**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure that a care plan related to food preference for one resident (#17) was implemented. The deficient practice could place resident at risk for malnutrition. Findings include: Resident #17 was admitted [DATE] with diagnoses of fractured right femur with closed fracture with routine healing, type 2 diabetes mellitus, and cognitive communication deficit. The physician order dated July 13, 2024 included for a diet order of regular diet, regular texture and thin consistency. The social history note dated July 15, 2024 included that the resident appeared to be alert, oriented to person, place, time and situation. The nutrition assessment dated [DATE] revealed the resident followed a gluten free diet. The nutrition care plan dated July 19, 2024 included the resident had a potential and/or was at risk for inability to maintain nutrition. Interventions included resident food preferences, food selections, portion sizes honored via selective menu per resident request and to provide food in a form that is acceptable and culturally acceptable. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment did not code for any nutritional approaches; and, nutritional status did not trigger for care planning. The social services progress note dated July 25, 2024 included the resident had a BIMS score of 15 indicating the resident had intact cognition. A late entry physician progress note dated July 25, 2024 included the resident was alert and oriented. Plan was to maximize nutrition and mobility. The diet roster by wing dated August 15, 2024 revealed that resident #17 had regular diet and regular texture. Despite documentation of a gluten-free diet preference, the clinical record revealed no evidence that this diet preference was implemented. During an interview conducted on August 14, 2024 at 9:41 a.m. resident #17 stated that he was gluten free but would pasta and bread. he resident stated that the facility should have gluten free food. An interview was conducted on August 15, 2024 at 2:15 p.m. with the kitchen manager (staff #56) who stated that they have the diet order from the speech therapist or the hospital printed out. from their dietary printer. He stated that the dietician evaluates the residents' preferences and allergies, sends the information to the kitchen printer and it gets printed to their diet roster, which was a sheet of paper that tells him the residents' food textures, allergies, preferences, and dislikes. In an interview with the registered dietician (RD/staff #400) conducted on August 15, 2024 at 2:23 p.m., the RD that the residents are interviewed for food preferences by their dietary technicians who would then communicate this to the dietary staff/department and the RD. She stated that the MNA or nutritional assessment was followed up by the dietician; and that, if a resident had a gluten free diet, this will be communicated to the dietary and nursing department; and, the dietary and nursing department can update the diet order. An interview was conducted on August 15, 2024 at 2:47 pm with registered nurse (RN/staff #401) who stated that the appropriate diet order or information for a new resident was taken from the hospital verbal report, discharge orders, packet received from the hospital and from the speech therapist. The RN stated that resident preferences and/or allergies were reported to the kitchen, as soon as staff finds out about it; and, the resident's diet order/information will be updated in the clinical record. Further, the RN stated that nutrition assessment was done during admission of the resident. Regarding resident #17, the RN stated that the nutrition assessment for resident #17 initiated on July 15, 2024 revealed that the resident followed a gluten free diet; however, the RN stated that the diet order for resident #17 was for a regular diet. The facility policy on Diets Available on the Menu revealed that diet will be offered as ordered by the physician or his/her designee. If the RDN or designee finds through nutritional assessment that the diet order is not appropriate for the resident, she/he will recommend and/or, as designated by the physician, order a more appropriate diet. In an effort to individualized diets and provide residents with their preferences, these preferences can be combined with the main diet order to achieve desired results. Review of facility policy on Patient rights: Planning and Implementation Care with revision date of February 8, 2021 revealed the facility honors the resident's rights to receive services included in the plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews and facility policy review, the facility failed to ensure that the preference for a gluten free diet for one resident (#17) was honored. The deficient practice could result in resident's food preferences not accommodated and places the resident at risk for nutritional complications. Findings include: Resident #17 was admitted [DATE] with diagnoses of fractured right femur with closed fracture with routine healing, type 2 diabetes mellitus, and cognitive communication deficit. The physician order dated July 13, 2024 included for a diet order of regular diet, regular texture and thin consistency. The nutrition assessment dated [DATE] revealed the resident followed a gluten free diet. Review of the clinical record revealed no evidence of a physician order for a gluten-free diet for resident #17. The nutrition care plan dated July 19, 2024 included the resident had a potential and/or was at risk for inability to maintain nutrition. Interventions included resident food preferences, food selections, portion sizes honored via selective menu per resident request and to provide food in a form that is acceptable and culturally acceptable. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The MDS assessment did not code for any nutritional approaches; and, nutritional status did not trigger for care planning. The social services progress note dated July 25, 2024 included the resident had a BIMS score of 15 indicating the resident had intact cognition. A late entry physician progress note dated July 25, 2024 included the resident was alert and oriented. Plan was to maximize nutrition and mobility. Review of the diet roster by wing dated August 15, 2024 revealed that resident #17 had regular diet and regular texture. During an interview conducted on August 14, 2024 at 9:41 a.m. resident #17 stated that he was gluten free but would pasta and bread. he resident stated that the facility should have gluten free food. An interview was conducted on August 15, 2024 at 11:00 a.m. with cook (staff #93) who stated that if a resident had a preference or was on a gluten free diet, this will be honored. The cook stated that in order to honor the resident's preference, the kitchen staff must be made aware by either the nursing staff or the RD (Registered Dietitian). The cook stated that the dietician evaluates the resident's preferences and allergies; and, this information is then sent to the kitchen and it gets printed out to the kitchen's diet roster, which is a sheet of paper that tells him their residents' food textures, allergies, preferences, and dislikes. An interview was conducted on August 15, 2024 at 2:47 pm with registered nurse (RN/staff #401) who stated that the appropriate diet order or information for a new resident was taken from the hospital verbal report, discharge orders, packet received from the hospital and from the speech therapist. The RN stated that resident preferences and/or allergies were reported to the kitchen, as soon as staff finds out about it; and, the resident's diet order/information will be updated in the clinical record. Further, the RN stated that nutrition assessment was done during admission of the resident. Regarding resident #17, the RN stated that the nutrition assessment for resident #17 initiated on July 15, 2024 revealed that the resident followed a gluten free diet; however, the RN stated that the diet order for resident #17 was for a regular diet. The facility policy on Diets Available on the Menu revealed that diet will be offered as ordered by the physician or his/her designee. If the RDN or designee finds through nutritional assessment that the diet order is not appropriate for the resident, she/he will recommend and/or, as designated by the physician, order a more appropriate diet. In an effort to individualized diets and provide residents with their preferences, these preferences can be combined with the main diet order to achieve desired results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of facility documentation and policy, the facility failed to ensure sufficient preparation was provided to one resident ( #1) to ensure a safe and orderly discharge. The deficient practice could affect the resident's continuity of care. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included urinary tract infection, pneumonia, difficulty in walking, acute myocardial infarction, congestive heart failure and dependence on supplemental oxygen. The care plan dated May 5, 2023 included the resident wished to return home when the highest optimal level of care was achieved. Additional care plan dated May 6, 2023 included the provision of occupational therapy and physical therapy services due to decreased ability to transfer, decreased ADL (activities of daily living) ability, decreased balance and physical assistance needed with gait and transfer. Interventions included the resident will receive neurological re-education, therapeutic exercise, and gait/ and or transfer training. Review of the Discharge Summary and Post-Discharge Plan of Care dated May 30, 2023 at 10:39 p.m. with a locked date of June 1, 2023 at 8:03 p.m. revealed the resident was discharged to the community/home. The social services section indicated occupational therapy, physical therapy, and medication management would continue after the resident was discharged to home. The social services indicated that a home health agency had been set up to provide services. The therapy section recommended home health services to follow up as needed. The physician orders included the following orders: -5/30/2023: Home Health SNV (skilled nursing visit), CP assess, medication management, PT (physical therapy), OT (occupational therapy) evaluation and treat home safety. -6/1/2023: OK to discharge home with Home Health in place, RX ' s (prescriptions) in hand, medications on hand, provider aware. Patient to dc (discharge) home today with on hand narcotics. However, record review revealed no evidence that home health agencies and/ or outpatient rehabilitation services were arranged for the resident upon discharge. A facility document, Discharge Notice, dated May 31, 2023 revealed that the resident 's anticipated discharge date was June 1, 2023. The document indicated that home health care would be ordered for the resident by the social services/discharge planner prior to discharge that included PT, OT, and nursing. The document also indicated that the home health agency the resident had chosen is outpatient. A discharge MDS (Minimum Data Set) assessment dated [DATE] included the resident required supervision (oversight, encouragement or cueing) with transfer, walk in room/corridor, dressing, eating, toilet use, and personal hygiene. Per the MDS, there was an active discharge plan in place for the resident to return to the community. On June 14, 2023 at 9:50 a.m., resident 's (#1) family expressed frustration with the discharge plan because the resident was discharged and no proper services were set up. The resident 's family stated that the facility was contacted for home health orders and the facility told her to do outpatient PT (physical therapy). The family member stated resident (#1) was too weak for outpatient PT and that home health was needed. The family member stated that home health did not come until a week after the resident was discharged from the facility. During an interview with a social services director (SSD/staff #3) conducted on June 26, 2023 at 1:40 p.m., he stated that when a resident is discharged with a home health agency (HHA), the resident is put on the discharge calendar. He stated his assistant would be the one to discuss the discharge plan including home health services. He stated the encounter is documented in the resident 's electronic health record. He stated the HHA has 48 hours to assess after a resident was discharged home. A joint interview was conducted with the SSD (staff #3) and assistant social services (staff # 5) on June 26, 2023 at 2:20 p.m. Staff #5 stated she spoke to the resident about HHA and that the resident has chosen an outpatient HHA on May 31, 2023. She stated according to her HHA tracker, she failed to notify the home health agency because she did not know there was an order written on June 1, 2023. Staff #3 stated he did not communicate with his assistant (staff #3) about the home health order and that he did not know that the resident had chosen an outpatient HHA. During an interview with the director of rehabilitation (DOR/staff #10) on June 26, 2023 at 2:27 p.m., she stated that she recommended PT (physical therapy) and occupational therapy (OT) at home for safety due to balance issues. A facility policy titled Discharge Policy and Procedures with a revision date of August 20, 2022, included that it is their policy to provide the resident with a safe and successful transition from the facility. The procedure included an interdisciplinary team approach to determine that discharge is appropriate, and each discipline addresses certain aspects of the discharge process. The procedure also included that the case manager will facilitate the arrangements for home care nursing and/or therapy services, non-skilled home care services, and outpatient rehabilitation if the patient's benefits plan includes these services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and facility documentation, family/staff interviews and policy and procedure, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for one resident (#84). Findings include: -Resident #84 was admitted to the facility on [DATE] with diagnoses that included palliative care, secondary malignant neoplasm of unspecified lung, and malignant neoplasm of bladder. Review of the facility record titled, Nursing Comprehensive admission Data Collection, dated [DATE], stated resident was admitted for GIP (general inpatient) care under hospice services. The neurological assessment included a level of consciousness (LOC) that indicated resident was in a coma. Per the Minimum Data Set assessment dated [DATE], the resident expired in the facility on [DATE]. On [DATE] at 7:20 a.m., the State Agency received a facility reported incident related to personal property/missing personal items after death for resident #84. A complaint investigation was conducted on February 6, 2023 in which the facility provided the documents titled, Reportable Event/Record/Report, dated [DATE] at 8:00 a.m. Record review included an undated statement from a certified nursing assistant (CNA/ staff #45). Review of staff #45's statement revealed that on [DATE], the resident was admitted with a bag, that was light in weight. Per the statement, staff #45 placed the brown bag in the drawer, and that there were no hospice staff or family present at that time. An interview was conducted on February 7, 2023 at 11:13 a.m., with a family member who stated the family was with the resident in the acute hospital prior to transfer of resident #84 to the facility. The family member stated, the resident was unconscious, and that they did not think about picking up the belongings at that time because they were dealing with death and dying. She said the hospital told her the patient's belongings were sent with the resident to the facility. She stated on [DATE], around 2:00 p.m., she called the Director of Nursing (DON) and notified her that she wanted to pick up the personal items that included I-phone, I-PAD, stylus, 2 zippered wallets, and other small items. However, the facility was denying that the resident was admitted to the facility with his personal belongings that included IPAD, stylus, I-phone, 2 zippered wallets and other small items. She stated after the resident's death, the 3 credit cards and a debit card that were in the wallet were used for purchases totaling over $4000 dollars. She stated she was told by the facility that the bag was not found and did not arrive in the facility. She stated she made many additional phone calls but the facility was ignoring her calls and would not speak to her. During an interview with a licensed practical nurse (LPN/ staff # 27) conducted on February 8, 2022 at 10:44 a.m., staff #27 stated after the removal of resident's remains, on [DATE], she checked the contents of the duffle bag with another license practical nurse (#47). She stated the military print duffle bag contained nick-nacks, IPAD, long stylus, I-phone in a case of some sort, and two little zipped wallets. She stated the mortuary driver refused to take the duffle bag, and left the facility without the duffle bag. She stated after the mortuary driver left the facility, she checked the contents of the duffle bag with staff #47, and placed the bag on the top of the desk located under the television. She stated she exited the room with staff #47 and shut the door. She stated, the following morning, [DATE] at approximately 6:30 a.m., a licensed practical nurse (LPN/ staff #7) took over for the morning shift. She stated she provided a change of shift report to staff #7 that included the duffle bag that was still in the resident's room. She stated she told staff #7 the contents of the duffle bag. An interview was conducted on February 8, 2023 at 11:21 a.m. with a certified nursing assistant (CNA/ staff #91). She stated when she arrived for her shift on [DATE], the resident had already passed. She stated the resident was included in her assignment, and that she entered the resident's room and the remains was still in the room. She stated when she was in the resident's room, she saw a bag on the desk across the foot of the bed under the television. She stated she never touch the bag, but she called the nurse and reported her finding. She stated the mortuary driver entered the resident's room on [DATE] between 10:00 a.m. to 12:00 p.m. She stated the mortuary staff exited the room looking for the charge nurse (staff #27) to let her know there are high priced items, like IPAD and I-watch, in the resident's belongings. She stated, she stayed with the mortuary staff for about 15 minutes at the nurse's station waiting for the charge nurse. She stated when staff #27 came to the nurse's station, the mortuary staff notified staff #27 of the high-priced items, including the IPAD and the I-watch, and that he need the information for the next of kin. She stated the mortuary staff left the facility with only the remains of the resident, and did not take the bag. An interview was conducted on February 8, 2023 at 11:58 a.m. with a licensed practical nurse (LPN/ staff #47). She stated she remember the mortuary came to pick up the remains and was asking about the resident's belongings. She stated after the mortuary staff left the facility, staff #27, the charge nurse, asked her to witness the inventory of the resident's belongings. She stated the belongings were in the military-like, medium duffle bag that contained an I-phone, black electronics, square black IPAD, and shaving staff. She stated after looking at the items, they placed the items in the duffle bag, left the bag in the room, exited the room, and closed the resident's door. Staff #47 stated the process when a resident is admitted with expensive items, included calling the family to pick up the items. She stated if the family is not available, she would lock up the expensive valuables in the medication cart. She stated she would do her best to ensure the resident's valuables are safe. She stated if she places patient's valuables in the medication cart, she would report it to the oncoming shift because she does not want the patient's valuables to get lost. An interview was conducted on February 8, 2023 at 12:54 p.m. with a licensed practical nurse (LPN/ staff #7). He stated he only remembered the resident because there was a big stink about some valuables belonging to the resident that went missing. He stated the resident passed during the prior shift, and staff #27 told him during the change of shift report that there was an I-phone and other valuable items packed in the bag in the resident's room. He said staff #27 told him that someone is going to pick up the belongings, but he never heard anything more about it. He stated he never saw the bag, but he was not specifically looking for the bag until the director of nursing (DON/staff #158) told him to look for the bag. He stated he did not find the bag. Staff #7 stated the facility process when a new admission enters the facility, the CNA takes an inventory, write the belongings on the inventory form, and signs it and give the form to the nurse which is added in the admission pocket to be uploaded in the PCC. He stated, if a resident is admitted with valuables, he would put the items in the narcotic box, then later give it to the management to be placed in the safe. He stated part of the process is that someone would call the family member to pick up the valuables. He stated if there is no family member, the valuable is kept in the safe until somebody claims it. However, the facility failed to exercise reasonable care for the protection of the resident's property from loss of theft. An interview was conducted with the social services director (SSD/staff #15) on February 8, 2023 at 1:35 a.m. He stated when a new admission enters the facility an inventory of the resident's personal belongings is completed. He stated from what he understands, everybody is to get an inventory list and the document is loaded in the PCC (point click care). He stated the process included two staff looking at the valuables together, list the valuables, and signed by two staff. He stated the resident's valuable is taken and placed in the safe for safe keeping, and is documented in the PCC. He stated everybody has a stake in keeping the resident's valuable safe. He stated he has to do what is necessary to protect the resident's property. A joint interview was conducted on February 8, 2023 at 2:01 p.m. with the director of nursing (DON/ staff #158) and the administrator (staff #5). She stated, On [DATE] at about 3:00 p.m., the family of the resident brought to her attention that the resident has missing valuables. Staff #158 stated she contacted all the staff that worked in the room and conducted interviews. She stated based on her investigation, it was unsubstantiated because it was only the mortuary staff who saw the belongings and reported it to the family. She stated the facility did not find the resident's belongings, and that she informed the family member. Staff #158 stated it is her expectation after resident's death, or discharge that valuables is to be kept locked in the medication cart. She stated it is her expectation for resident's belongings are taken to the storage area, and the valuables is kept in the safe, the following business day. Staff #5 stated he agrees on staff #158's statement. The facility policy, Abuse and Neglect Prohibition, revised on [DATE], revealed each resident has the right to be free from abuse including the misappropriation of resident property. The facility included the definition of misappropriation of resident's property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The abuse prevention included the facility will address all concerns in accordance with Grievance Policy, and residents/families and staff will be able to report incidents and concerns without fear of retribution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, staff interviews, family interview and policy and procedures, the facility failed to ensure that allegations of misappropriation of resident property were reported to the State Agency and that the results of the investigations were submitted to the State Agency within the required time frame for one resident (#84). Findings include: -Resident #84 was admitted to the facility on [DATE] with diagnoses that included palliative care, secondary malignant neoplasm of unspecified lung, and malignant neoplasm of bladder. Review of the facility record titled, Nursing Comprehensive admission Data Collection, dated [DATE], stated resident was admitted for GIP (general inpatient) care under hospice services. The neurological assessment included a level of consciousness that indicated the resident was in a coma. Per the Minimum Data Set assessment dated [DATE], the resident expired in the facility on [DATE]. On [DATE] at 7:20 a.m., the State Agency received a facility reported incident (FRI) related to personal property. The FRI details included missing personal items after the death of resident #84. A complaint investigation was conducted on February 6, 2023 in which the facility provided the documents titled, Reportable Event/Record/Report, dated [DATE] at 8:00 p.m. Record review included statements from staff and residents dated [DATE] and [DATE]. Review of an undated statement that was included in the facility investigation from a certified nursing assistant (CNA/ staff #45), revealed that on [DATE], the resident was admitted with a bag that was light in weight. Per the statement, staff #45 placed the brown bag in the drawer, and that there were no hospice staff or family present at that time. An interview was conducted on February 7, 2023 at 11:13 a.m., with a family member who stated she was with the resident in the acute hospital prior to transfer to the facility. She stated the resident was unconscious, and that she did not think about picking up the belongings at that time because she was dealing with the death and dying process of the resident. She stated the hospital told her the patient's belongings were sent with the resident. She stated on [DATE], approximately after 2:00 p.m., she called the DON and notified her that she wanted to pick up the personal items that included I-phone, I-PAD, stylus, 2 zippered wallets, and other small items. However, she stated the facility denied the resident was admitted to the facility with his personal belongings. She stated after the resident's death, the 3 credit cards and a debit card that were in the wallet were used for purchases totaling over $4000 dollars. She stated she was told by the facility that the bag was not found and did not arrive in the facility. However, record review revealed no evidence that the facility notified the State Agency of the allegation of misappropriation of resident property after the Director of Nursing (DON) received the allegation on [DATE], and no evidence that a 5-day report was submitted to the State Agency as required. During an interview with a licensed practical nurse (LPN/ staff # 27) conducted on February 8, 2022 at 10:44 a.m., staff #27 stated after the removal of the resident's remains on [DATE], she checked the contents of the duffle bag with another licensed practical nurse (#47). She stated the military print duffle bag contained nick-nacks, IPAD, long stylus, I-phone in a case of some sort, and two little zipped wallets. An interview was conducted on February 8, 2023 at 11:58 a.m. with a licensed practical nurse (LPN/ staff #47). She stated after the mortuary staff left the facility, staff #27, the charge nurse, asked her to witness the inventory of the resident's belongings. She stated the belongings were in the military-like, medium duffle bag that contained an I-phone, black electronics, square black IPAD, and shaving staff. A joint interview was conducted on February 8, 2023 at 2:01 p.m. with the director of nursing (DON/ staff #158) and the administrator (staff #5). She stated, On [DATE] at about 3:00 p.m., the family of the resident brought to her attention that the resident had missing valuables. The DON stated this was her first knowledge that valuable items belonging to resident #84 were missing. Staff #158 stated, following the family's phone call, she contacted all the staff that worked in the room and conducted interviews. She stated based on her investigation, it was unsubstantiated because it was the mortuary staff who saw the belongings and reported it to the family. She stated the facility did not find the resident's belongings, and that she informed the family member. Further, the DON stated on [DATE], the State Attorney General entered the facility to investigate the missing valuables. The DON stated she decided to report the missing items to the State Agency on this date ([DATE]), to show the Attorney General that the facility was doing something to investigate the missing items. The DON stated she did not report the missing items on [DATE] because the mortuary staff was the one who told the family about the valuables and that there was no evidence the valuables arrived in the facility with the resident upon admission. The DON stated she did not complete a 5-day report because there was no proof that the items were stolen in the facility. The facility policy, Abuse and Neglect Prohibition, revised on [DATE], revealed each resident has the right to be free from abuse including the misappropriation of resident property. The facility included the definition of misappropriation of a resident's property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Per the policy State reporting obligations, the facility will report all allegations and substantiated occurrences of abuse including misappropriation of property to the administrator, State Agency, law enforcement officials and adult protective services, in accordance with Federal and State laws through established procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#13) was treated with dignity and respect. The sample size was 3. The deficient practice could result in residents not being treated with dignity and respect. Findings include: Resident #13 was readmitted to the facility on [DATE] with diagnoses that included a pleural effusion, not elsewhere classified, acute bronchospasm, and hypoxemia. An alteration in neurological status related to neuropathy care plan dated 12/09/21 had a goal to have no complications. Interventions included to give medications as ordered and to monitor/document/report to medical doctor as needed: signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness, or slurred speech. On 12/17/21, the resident was discharged with return anticipated. The resident was subsequently readmitted to the facility on [DATE]. A Nursing Comprehensive admission Data Collection dated 01/14/22 revealed the resident was alert and oriented to person, place, time, and situation. The resident was assessed to be verbally appropriate. A physician progress note dated 01/18/22 at 9:38 p.m. included that the resident was alert and oriented to time, place, person, and situation and had appropriate mood and affect. Review of the 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 14 on the Brief Interview for Mental Status, indicating intact cognition. The resident was assessed to have no behaviors and required extensive 2+ person physical assistance for most activities of daily living. The assessment included depression as a diagnosis and that the resident received an antidepressant for 7 out of 7 days in the look back period. During an observation conducted on 02/01/22 at 9:30 a.m., resident #13 was observed to be moaning and calling out incoherently. A Certified Nursing Assistant (CNA/staff #46) was observed to be seated at the desk across from the resident's doorway. Staff #46 did not look in on the resident, inquire as to whether or not the resident was in pain, or whether the resident needed anything. The staff member got up from the desk and walked to the opposite end of the hall at approximately 9:45 a.m. On 02/01/22 at 9:55 a.m., an activities staff (staff #95) was observed to enter the resident's room and give the resident an activity calendar. The resident was heard to say thank you and the staff member replied that the resident was welcome. Staff #95 left the resident's door partially closed when she left the room. At 10:04 a.m. on 02/01/22, resident #13 was observed laying in the bed, nude from the waist up, tugging at her brief. The resident speech was incoherent. The CNA (staff #46) was seated at the desk across the hall from resident #13's room. The resident was easily observed from the hallway. Staff #46 did not intervene on the resident's behalf. At 10:06 a.m., a resident who resided further down the hallway had 3 visitors leave and as they walked down the hall past resident #13's room, all 3 were observed to look into the resident #13's room and then quickly look away. At 10:09 a.m., a Licensed Practical Nurse (LPN/staff #93) nurse walked down the hallway past resident #13's room. He was observed to look into the resident's room, but continued walking down the hallway without stopping. At 10:15 a.m., an observation was conducted of the resident in the resident's room. A provider (staff #160) entered the resident's room. The resident stated she was dying and needed some love. The resident's gown had been pulled up to cover her breasts, but the gown was not placed over her arms or tied at the neck. The resident was not wearing her oxygen. The area around her lips was noted to be a dusky bluish color. Staff #160 attempted to reposition the resident and put the nasal cannula back onto the resident's nose. Staff #160 asked the resident if she would like another antidepressant. The resident stated that sounded good. An interview was conducted on 02/01/22 at 10:21 a.m. with staff #160. She stated she was not aware that the resident's gown had been off, or that the resident could easily be observed from the hallway. Staff #160 stated that she has been the provider for this resident for a long while and that the resident had some cognitive deficits which included dementia, and was very confused. On 02/01/22 at 10:25 a.m., staff #160 was observed to speak with resident #13's nurse (staff #93). The LPN told staff #160 that he had not noticed that the resident had taken her gown off. He stated that she was confused. Staff #160 asked staff #93 to run a urinalysis (UA) and urine culture on the resident. Staff #160 stated that she would send the speech therapist into the resident's room to ensure that her speech was not more slurred or garbled. At 10:35 a.m., a speech therapist came to the nurses' station and stated that the resident speech did sound a little slurred. Staff #160 instructed staff #93 to obtain a stat UA and Complete Blood Count (CBC). On 02/01/22 at 1:10 p.m., resident #13 was observed in her room with her door wide open. The resident was easily observed as she lay on her bed. Her nightgown had been removed and her chest was bare from the waist up. The nurse (staff #93) was observed to walk past the resident's room, look in, and continue walking down the hall. At 1:21 p.m. on 02/01/22 as the lunch trays were being delivered, a dietary assistant was overheard to ask the CNA (staff #46) if resident #13 was a feeder. Staff #46 answered no'' as they entered the room. Before the resident's door was fully closed, staff #46 was overheard to state that the resident had been kind of crazy that day. On 02/03/22 at 11:17 a.m., Emergency Medical Technicians (EMTs) were observed to enter resident #13's room. After several minutes, the EMTs were observed transporting the resident out of the facility. An interview was conducted with an LPN (staff #53) on 02/03/22 at 11:36 a.m. She stated that the resident could not breath. She said that when she repositioned the resident the resident oxygen saturation dropped. She stated that she had not noticed the resident having a change in mental status within the past few days. The LPN stated that she did not know for sure whether or not the resident had a urinary tract infection. The LPN stated that it was not unusual for the resident to take off her gown and to try to put it back on again. On 02/07/22 at 8:30 a.m., an interview was conducted with a CNA (staff #89). She stated that she usually worked on the hallway and became very familiar with the residents as some stayed about 90 days. She stated that, in general, she was aware of how alert her residents were. She stated that when resident #13 was admitted the last time, she would describe her as declining physically but that she was alert cognitively. Staff #89 said resident #13 was a sharp lady. Staff #89 stated that she remembered the resident as regularly taking off her gown throughout her stays. The LPN said the resident preferred to be dressed in her own clothing, but that the resident's family had not brought her any clothing yet. The LPN said that if the resident were undressed, she would open the bathroom door to block the view from the hallway. She said that she would remind the resident that there were visitors in the building. She said that there was really not a whole lot she could do as the resident has the right to take off her clothes. An interview was conducted on 02/09/22 at 1:38 p.m. with the Director of Nursing (DON/staff #149) and the Assistant DON (ADON/staff #17). Staff #149 stated that if a resident was confused and taking off their gown, she would expect that staff would cover the resident up, educate the resident, call the resident's family, perform frequent checks and monitoring, request a psychiatric evaluation, and maybe request a UA. The DON stated that she would expect the resident's care plan to be updated if it became a pattern. She stated that if the resident could be viewed from the door, she would maybe close the door. The DON stated that she would have expected that staff would have intervened to protect the resident's dignity, and that not addressing it did not meet her expectations. Staff #17 stated that she did not recall the resident ever disrobing in the manner described. The facility policy titled Your Rights as a Nursing Home Resident included that residents will keep all of their fundamental civil or human rights and liberties when they are admitted to a nursing home. The policy stated the resident has the right to receive care in a manner which promotes and enhances the quality of life. The policy included the resident has the right to receive services necessary to attain or maintain their highest practicable level of functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified as ordered when one resident's (#39) blood sugar level was outside parameters. The sample size was 5. The deficient practice could result in delayed medical care. Findings include: Resident #39 was admitted on [DATE] with diagnoses that included long-term use of insulin, diabetes mellitus, acute pyelonephritis, and infection of the intervertebral disc. A review of orders-administration notes dated January 1, 2022 revealed an order for insulin- Lispro Solution Pen-injector 100 UNIT/ML (milliliter) inject subcutaneously per sliding scale before meals and at bedtime as follows: If 0-70 give high protein/carbs. Recheck blood sugar and call the physician; 71-149, no intervention; 150-200, give 2 units; 201-250, give 4 units; 251-300, give 6 units; 301-350, give 8 units; 351-400, give 10 units; If greater than 400, call the physician. A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident's cognition was moderately impaired. The assessment included the resident received insulin injections for 7 days during the 7 days lookback period. Review of the January 2022 Medication Administration Record (MAR) revealed the resident's blood sugar level was greater than 400 on January 11, 14, 15, 17, 19, 20, and 29, 2022. Continued review of the MAR for January 2022 revealed the resident's blood sugar level was 62 on January 11, 2022 at 5:15 p.m., and 54 on January 23, 2022 at 12:15 p.m. Review of orders-administration notes for January 11, 2022 did not reveal a note regarding the blood sugar level 62. The note dated January 23, 2022 at 5:39 p.m. stated low blood sugar 54, snack was given. Further review of the clinical record did not reveal any documentation that the physician was notified of the abnormal blood sugar levels. An interview was conducted on February 10, 2022 at 11:45 a.m. with a Licensed Practical Nurse (LPN/staff #130), who stated checking the blood sugar before meals and at bedtime is the standard order in the facility. She said if the blood sugar result is abnormal, below 60 or greater than 400, the MAR will prompt to document a progress note for a new order. The LPN reviewed the January 2022 MAR for resident #39 and stated that the physician should have been notified of the abnormal blood sugar levels according to the physician's order. The LPN reviewed the MAR progress notes and stated that there was no documentation that the physician had been informed of the abnormal blood glucose levels. An interview was conducted on February 10, 2022 at 3:47 p.m. with the Director of Nursing (DON/staff #149). The DON stated that it is her expectation that the physician orders be followed including physician notification when the blood sugar levels were outside the parameters. The facility's policy Change of Condition stated the nurse shall evaluate and document/report recent labs and will notify the physician for any significant changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one of two sampled residents (#129) was reported to the State Agency. The deficient practice could result in allegations of abuse not being reported as required. Findings include: Resident #129 was admitted to the facility on [DATE], with diagnoses of Major Depressive Disorder, Cognitive Communication Deficit and Vascular Dementia without behavioral disturbance. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated that the resident was cognitively intact. The MDS also included the Resident Mood Interview (PHQ-9) score of 9, which indicated that the resident had mild depression. A review of a discharge note dated May 22, 2020 revealed the resident was discharged at 3:30 PM on May 22, 2020. A Grievance Report Form dated May 25, 2020 revealed a letter dated May 22, 2020 was received from a family member of resident #129. The letter included that the resident had told the family member that a male nurse who was in the resident's room the night before, exposed his penis and told the resident if she wants to feel better she will have to suck on this. The letter stated that after contacting staff, the family member was told the nurse had been suspended and that there would be an investigation. Review of the investigative report revealed the allegation was unsubstantiated. However, further review of the facility's investigation revealed no evidence that the allegation of abuse was reported to the State Agency. An interview was conducted with the Executive Director (staff #71) on February 8, 2022 at 8:56 AM, who stated that he was not notified of the allegation until after the resident had been discharged and he had not reported it. An interview was conducted with a Certified Nurse Assistant (CNA/staff #76) on February 9, 2022 at 10:51 AM, who said that if she witnessed abuse that she would notify the supervisor right away, and that there was always a supervisor on duty. She said that she received training on abuse from the facility and that she had not heard of abuse occurring in the facility. An interview was conducted with a Licensed Practical Nurse (LPN/staff #26) on February 9, 2022 at 11:04 AM. The LPN said that if she was seeing abuse herself that she would ask them to leave the room and hopefully they do. She said that she would call 911, notify administration, call authorities, and that she would do so even if it was theft or if she had just heard an allegation, even if she did not see the abuse, even if she did not know if it really happened. The LPN said that she had not heard of abuse happening in the building. During an interview with the Director of Nursing (DON/staff #149) conducted on February 10, 2022 at 3:47 PM, the DON stated that her method for abuse reporting would be to interview, investigate, and to report it immediately, and within 24 hours if there were no signs of harm. A facility policy titled Abuse and Neglect Prohibition revealed that the facility will make referrals to the appropriate state agencies as necessary, to ensure the protection of the resident or resident's property. This policy included that state reporting obligations included the facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and adult protective services (where state law provides for jurisdiction in long-term care facilities) in accordance with Federal and State law through established procedures. Timeline for reporting is as follows: If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of policy and procedure and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two residents (#138 and #81). The sample size was 24. The deficient practice could result in additional MDS assessments that do not accurately reflect residents' status and could result in data that is not accurate for quality monitoring. Findings include: -Resident #138 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included occlusion and stenosis of unspecified carotid artery, encounter for surgical aftercare following surgery on the circulatory system, and end stage renal disease (ESRD). A potential for complications related to ESRD care plan initiated on 12/10/21 had a goal for no complications related to dialysis or disease process. Interventions included to notify the physician as needed of any changes in condition. Review of the physician orders dated 01/12/22 included checking the dialysis site for signs and symptoms of infection every shift and if the resident has a fistula, check the site for positive bruit every shift, and no blood pressures to the left upper extremity. A daily skilled nursing note dated 01/12/2022 revealed the resident returned from dialysis with no issues. A physician order dated 01/14/22 revealed for dialysis treatments on Monday, Wednesday, and Fridays; and to ensure a snack/sack lunch is sent with the resident to dialysis. A daily skilled nursing note dated 01/14/22 included the resident returned from dialysis and had a positive bruit and thrill to the arm fistula. However, review of the admission MDS assessment dated [DATE] revealed the resident did not receive dialysis services. -Resident #81 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, gangrenosum, and complete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic. A discharge care plan dated 12/02/21 related to the resident's desire to establish goals for self and to be in the discharge planning process had a goal to be discharged at the highest optimal level of care over the next 90 days. Interventions included to discharge home. A Social Services progress note dated 01/06/22 at 10:33 a.m. included that the current discharge was estimated for one more week. The resident will return back to prior living arrangements with home health services. Review of a discharge progress note dated 01/12/22 at 12:14 p.m. revealed the resident was discharged from the facility at 11:30 a.m. with spouse to home. However, review of the discharge MDS assessment dated [DATE] revealed the resident was discharged to an acute hospital. On 02/10/22 at 10:49 a.m., an interview was conducted with the MDS Coordinator (staff #78). She stated that both of the MDS coordinators input MDS information. Staff #78 stated that she reviews the progress notes, therapy notes, hospital notes, Medication Administration Records, Treatment Administration Records, flow sheets, immunization and admission records for resident information. She stated that if the information is documented, it is considered accurate. She said that the department heads are responsible to certify that the information contained in their individual sections is accurate, and attest to the accuracy. Staff #78 reviewed the MDS assessments for residents #138 and #81 and stated that the data was inaccurate. She stated that she would input a modification and correct the inaccurate data. An interview was conducted on 02/10/22 at 3:05 p.m. with the Director of Nursing (DON/staff #149). She stated that ensuring MDS assessments are accurate involves staff double-checking what they are documenting. The DON stated that a Registered Nurse checks them off as a second check and that her expectation is that the MDS assessment is coded correctly. The facility's policy MDS stated all involved staff members are responsible for accurate and timely completion of the MDS in accordance with the MDS RAI instruction manual. The RAI manual instructs to review the resident's clinical record to determine whether or not the resident received dialysis within the last 14 days and code peritoneal or renal dialysis which occurred at the nursing home or at another facility. The RAI manual also stated to review the clinical record including discharge plan and discharge orders for documentation of discharge location and code the 2-digit code that corresponds to the resident's discharge status.

**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 one resident (#24) was provided incontinence care in accordance with professional standards of practice. The sample size was 3. The deficient practice could result in residents' not receiving incontinence care timely. Findings include: Resident #24 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction affecting the left non-dominant side, hemiplegia, hemiparesis, and generalized muscle weakness. Review of the care plan dated December 17, 2021, revealed the resident was incontinent of bowel and bladder. Interventions included staff assistance with incontinence care following incontinent episodes. Review of the Activity of Daily Living (ADL) care plan dated December 19, 2021 revealed the resident had ADL performance deficit. Interventions included staff assistance with grooming, bathing and personal hygiene, and occupational/physical therapy services. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status score was 14 which indicated the resident was cognitively intact. The assessment included the resident was frequently incontinent of bowel and bladder function. The MDS also revealed the resident needed the assistance of two staff for personal hygiene. During an interview conducted with the resident on February 1, 2022 at 1:48 p.m., resident #24 stated that about two weeks ago she told a certified nursing assistant (CNA) that she was soiled with feces but the CNA told her that she was too busy and did not have any help to change the resident. Resident #24 stated a second incident happened on January 31, 2022 during the night shift. The resident stated that after dinner, she told a CNA she needed help to go to bed and the brief needed to be changed. The resident stated the CNA told her that she was not going to be changed because the CNA did not have any help. An interview was conducted on February 3, 2022 at 10:00 a.m. with a Licensed Practical Nurse (LPN/staff #130). The LPN stated she was familiar with the resident and said the resident is alert and oriented, incontinent of bowel and bladder, and needed two staff assist for hygiene needs. The LPN stated a resident family member reported to her that on Monday night, January 31, 2022, no one changed the resident's brief through the night and that both the resident and family member were upset that the resident did not get the care needed. The LPN stated she reported the event to the Director of Nurses (DON/staff #149) on February 1, 2022 between 2:30 p.m. to 3:00 p.m. An interview was conducted on February 3, 2022 at 11:53 a.m. with a temporary nursing assistant (staff #14). She stated she was familiar with resident #24, but she was not assigned to this resident on January 31, 2022. The staff stated there were only two CNAs that Monday because they were working short of two CNAs. She stated no one was assigned to resident #24. She stated that after dividing the other sections, resident #24 was reassigned to another CNA (staff #23). Staff #14 stated on Monday, between 10:00 p.m. to 2:00 a.m., staff # 23 asked her help to change the incontinence brief of resident #24. She stated this was her only encounter with resident #24 because she was too busy caring for her own residents. An interview was conducted on February 3, 2022 at 12:24 p.m. with staff #23. She stated she worked on Monday night, January 31, 2022 and that there were only two CNAs. She stated she was familiar with resident #24 and that the resident was incontinent of bowel and bladder and totally dependent on personal hygiene. Staff #23 stated that she only changed the resident's brief at 3:00 a.m. with staff #14 assistance. An LPN (staff #15) was interviewed on February 7, 2022 at 9:13 a.m. She stated she worked on Monday night shift, January 31, 2022 with only two CNAs. She said she saw resident #24 at bedtime between 8:30 p.m. to 9:30 p.m. for a blood sugar check and saw the resident a second time at 5:00 a.m. for a blood sugar check. The LPN also stated that she provided perineal care and changed the resident's brief between 7:00 p.m. to 9:00 p.m. with the help of staff #14. However, staff #14 stated she has no recollection of any resident encounter between 7:00 p.m. to 9:00 p.m. An interview was conducted on February 10, 2022 at 3:47 p.m. with the Director of Nurses (DON/staff #149). The DON stated that it is her expectation that perineal care is provided by nursing staff every shift and as needed. A facility policy titled Incontinence Care stated the facility will provide the necessary incontinence care to patients that are incontinent of bowel and bladder and receive appropriate treatment. The policy also stated if a patient is found to become incontinent during stay, the patient will be triggered to use the toilet through shift, and if there is a trend that is noted, the patient will be put on a times schedule. The policy included nursing staff is to provide incontinent care every shift, after incontinent episodes and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident, family member and staff interviews, and policy and procedure, the facility failed to ensure one resident (#24) consistently received appropriate treatment and care as ordered by the physician for edema control. The sample size was 2. The deficient practice could result in residents with edema not being provided treatment and services ordered by the physician. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction affecting the left non-dominant side, hemiplegia, hemiparesis, and generalized muscle weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident required extensive assistance of two persons with transfer, bed mobility, dressing, toilet use and personal hygiene. The assessment included the resident had functional limitation in range of motion of the upper extremity and lower extremity, on one side. Review of physician orders dated December 26, 2021 revealed an order for a compression glove on the left hand at all times as tolerated. The order included the compression glove may be taken off at night for comfort and to elevate the left upper extremity on the pillow every shift for edema control. Review of the Treatment Administration Record (TAR) dated February 2022 revealed documentation that the resident was wearing a compression glove on the left hand. Review of a physician order dated February 7, 2022 revealed an order for left ½ lap tray while the resident was in the wheelchair to support the left upper extremity for edema control. A care plan dated February 8, 2022 revealed the resident uses a left sided ½ lap tray, when up in the wheelchair to support the resident's left upper extremity, and to help control edema. An intervention included placing a ½ left sided lap tray when the resident is up in the wheelchair to control edema. During an observation conducted on February 1, 2022 at 2:16 p.m., the resident was observed sitting in the wheelchair with no compression glove in place to the left hand. An observation was conducted of the resident on February 8, 2022 at 8:14 a.m. The resident was observed eating breakfast in bed. No compression glove was observed to the left hand. Following this observation, the resident was assisted to the wheelchair by staff. Following the transfer to the wheelchair, the resident was observed to not have a lap tray on the wheelchair, and no compression glove on the left hand. An interview was conducted with resident #24's family member on February 9, 2022 at 9:27 a.m. The resident's family member (responsible party) stated that the resident was supposed to wear a compression glove on the left upper extremity to help with the swelling. The family member stated that the resident only had the compression glove on for a couple of days, and it was off more than on. During an interview conducted with the resident on February 9, 2022 at 10:03 a.m., the resident was observed sitting in the wheelchair with no lap tray in place watching television. The resident's left hand was observed dangling on the side of the wheelchair with no compression glove on the left hand. The resident stated the nurses knew about the left arm edema that the tight glove they put on sometimes helps with the swelling. The resident stated the nurses have not been putting the glove on lately. The resident further stated a lap tray was not in place while she was in the wheelchair yesterday or today, but that the staff placed a table in front of the wheelchair during meal times. An interview was conducted on February 10, 2022 at 12:18 p.m. with a Licensed Practical Nurse (LPN/staff #130). Staff #130 reviewed the resident's clinical record and stated that there was a physician order for a compression glove. The LPN stated that she had attempted to order a new glove from the therapist (staff #126) because the old one was so tight, it caused the resident to scream when it was put on. The LPN also stated the resident did not have a lap tray when she saw the resident during breakfast, and that there was no lap tray in the resident's room. The LPN stated a speech therapy (ST/staff #106) might have ordered the lap tray but it was not communicated to the nursing staff. In an interview conducted with staff #106 on February 10, 2022 at 2:30 p.m., the ST stated that ordering a lap tray was outside her scope of practice and she did not write the order for it. On February 10, 2022 at approximately 2:35 p.m., an interview was conducted with the Director of Rehab (staff #116). Staff #116 reviewed the resident's clinical record and stated the physician ordered the lap tray on February 7, 2022. She stated that nursing did not notify the therapy department of the order. Staff #116 also stated the therapy department has a lap tray available and she would offer it to nursing at this time. An interview was conducted on February 10, 2022 at 3:06 p.m. with the therapist (staff #126). He stated that he did not have any knowledge or notification from nursing to order a compression glove. Staff #126 stated that a compression glove is medically managed, and nursing is the one who puts in the order for that type of equipment. An interview was conducted on February 10, 2022 at 3:47 p.m. with the Director of Nursing (DON/staff #149). The DON stated a physician order is required for a compression glove or lap tray. She stated the wound nurse will order the compression glove from the central supply and the nursing staff will put on the glove. The DON stated a lap tray is ordered based on therapy recommendation. She stated therapy will verbally notify nursing of the order and will document the recommendation. The DON stated that it is her expectation that the physician order regarding the compression glove and lap tray will be implemented by nursing. A facility policy, Specialized Therapeutic Equipment, stated the purpose of the policy included the use of splints, orthotics, and other specialized equipment to protect and promote the healing of muscles and joints, facilitate appropriate alignment, and facilitate improved function mobility and independence. The facility will facilitate proper utilization of such devices in order to promote safe mobility and increased functional independence. The policy stated braces, splints, orthotics, positioning devices, and other equipment will be utilized as medically necessary. Facility staff will don/doff and utilize these devices as deemed medically necessary while providing care. Upon admission to the facility, orders for equipment/braces will be entered. Orders/changes to orders for these devices will be communicated to appropriate staff. The policy included staff will facilitate patient utilization of such equipment, as tolerated by the patient, at rest and during mobility as deemed medically necessary in order to promote optimal patient outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure timely assessments and consistent treatments were provided to one resident (#56) with pressure ulcers. The sample size was 2. The deficient practice could result in worsening of pressure ulcers. Findings include: Resident #56 was admitted on [DATE] with diagnoses that included stage 4 pressure ulcer of the left heel, stage 4 pressure ulcer to sacral region, cellulitis of left lower limb, and diabetes mellitus type 2. A nursing admission note dated January 7, 2022 at 8:00 p.m. stated that the resident arrived at the facility with admitting diagnoses that included pressure injury to sacrum, pressure injury to left heel, and cellulitis to bilateral lower extremities. Review of hospital transfer orders dated January 7, 2022, included the following wound care: -Cleanse left heel with carraklenz wound cleanser, apply gauze wet with ¼ strength Dakin's solution, cover with ABD and wrap with cast padding. -Cleanse the sacral stage 4 ulcer with carraklenz, fill the wound with gauze wet with ¼ strength Dakin's solution, and cover with aquacel foam or ABD. A nursing comprehensive admission data collection dated January 8, 2022 at 9:04 a.m. revealed the resident was admitted with the coccyx packed with gauze and covered with a dressing and Unna boots in place to the left and right lower leg. Review of physician orders dated January 9, 2022 stated to clean the sacral injury with wound cleanser, fill wound with gauze wet with ¼ strength Dakin's solution, cover with aquacel foam two times a day; and to cleanse the left plantar heel injury with wound cleanser, apply gauze wet with ¼ strength Dakin solution to wound, cover with dry gauze, ABD and wrap with cast padding every 3 days. Review of the Treatment Administration Record (TAR) for January 2022 revealed the code 9 for the treatment of the sacral injury on January 9 at 8:00 p.m. which meant other/see nurse notes. The TAR also revealed the area to document the treatment for the left heel was blank for January 9, 2022. A review of the nurse notes for January 9, 2022 did not reveal documentation regarding the treatment to the sacral injury. Further review of the clinical record revealed an admission assessment of the wounds and treatment was not conducted until January 10, 2022. An admission MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident was admitted with one stage 3 pressure ulcer. A care plan initiated on January 13, 2022 revealed the resident had a pressure injury to the coccyx. Interventions included to administer treatments as ordered and for weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of physician orders revealed the treatment to the left heel was discontinued on January 13, 2022. Further review of the clinical record did not reveal any evidence that a new physician order for treatment was obtained for the left heel wound. Review of the TAR for January did not reveal evidence of treatments being provided to the left heel. However, review of the Wound Care Evaluation documentation revealed the left heel wound was assessed and treatment was provided on January 14, 21, and 28, 2022. An interview was conducted with the wound nurse (staff #52) on February 10, 2022 at 10:10 a.m. Staff #52 stated that when a resident is admitted to the facility with wounds, the admitting nurse completes a body check, obtains treatment orders, and provides the treatments. She stated the wounds are reassessed by her for the appropriateness of treatment within 24-hours or the following business day. Staff #52 also stated that new wounds are communicated by nursing via text, but if a resident is admitted on the weekend, the admission nurse or the provider can contact her for treatment recommendation. Staff #52 reviewed the clinical record for resident #56, and stated the treatment for the left heel was first written on January 9, 2022 and the treatment was not provided. She stated the pressure ulcers were not assessed until January 10, 2022, three days after the admission. Staff #56 stated there is no treatment order for the left heel wound. An interview was conducted on February 10, 2022 at 3:37 p.m. with the Director of Nursing (DON/ staff #149). Staff #149 stated when a resident is admitted to the facility with a pressure ulcer, the pressure ulcer assessment must be done the same day, and the treatment must be done on that day. The DON also stated the nursing staff was responsible to address the pressure ulcer on admission and communicate the findings to the wound nurse. A facility policy, Pressure Ulcer, stated that upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin. The policy included that in addition, they shall describe and document a full evaluation of the pressure sore including description of the wound, pain evaluation, and current treatment (if applicable); and the physician will authorize pertinent orders related to wound treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident family and staff interviews, and policy and procedure, the facility failed to ensure one resident (#38) received the necessary assessments related to urinary catheters to restore bladder continence. The sample size was 4. The deficient practice could result in possible urinary complications and bladder continence not being restored. Findings include: Resident #38 was admitted on [DATE], with diagnoses that included left femur fracture, fracture of shaft of humerus, and urinary retention. A physician order dated January 1, 2022 revealed an order for an indwelling Foley catheter 16 French 10 cc (cubic centimeters) balloon with diagnosis of acute urinary retention. The Nursing Comprehensive admission Data Collection dated January 1, 2022 included the resident had a 16 French catheter. An admission Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 04 which indicated the resident had severe cognitive impairment. Per the MDS, the resident had an indwelling catheter and required extensive one-person assistance with toilet use. Review of a daily skilled nursing note dated January 3, 2022 at 9:43 p.m., revealed the resident was alert to person, place, time, and situation. A urinary care plan dated January 3, 2022, revealed the resident has a catheter related to acute urinary retention. The goal was that the resident would have no complications related to the catheter. Interventions included bladder training/bag clamping per physician orders with discontinue use of the indwelling urethral Foley catheter. A physician order dated January 4, 2022 stated consultation was confirmed with in-house urology regarding the resident being admitted with a Foley due to acute urinary retention. Review of the urology consult note dated January 5, 2022 at 2:51 p.m. stated the resident was admitted to the facility with a Foley and there has not been any void trial attempted. The urologist stated the patient was relatively confused and difficult to understand speech-wise and the resident was not able to provide an accurate history picture of how the resident ended up with the catheter. The note included that because the resident was unable to communicate well, Foley will be left in for now. The resident can follow up with the clinic when the resident improves in order to determine the plan of care. The note also included that if the resident improves between now and then, a void trial is appropriate, and does not foresee a need for re-consultation. Review of physician progress notes dated January 30, 2022 at 1:00 p.m., stated the resident was feeling much better and has improved pain control. It also included the resident was progressing with therapy. Review of physician progress notes dated February 3, 2022 at 10:26 a.m., stated the resident was feeling much better and has improved pain control. The note included the resident was participating in therapy without issue. An order administration note dated February 10, 2022 at 12:16 p.m. revealed the Foley catheter was changed. Review of daily skilled nurses' notes revealed no assessments of the Foley catheter. Further review of the clinical record revealed no evidence that the resident was assessed for removal of the catheter or that a voiding trial was attempted. During an interview conducted with the resident's family member on February 1, 2022 at 10:20 a.m., the family member stated that prior to admission to the facility, resident #38 was continent of bowel and bladder function. The family member stated the Foley catheter was placed in the hospital because of hip surgery. The family member stated the resident never had a history of urinary retention and that the resident fell at home while toileting self. An interview was conducted on February 10, 2022 at 11:45 a.m. with a Licensed Practical Nurse (LPN /staff #130). The LPN stated that when a resident is admitted to the facility with a Foley catheter, an assessment should be performed that includes the color of the urine, the type of the Foley catheter, how long it should stay, and proper diagnosis. She stated the facility did not have a separate form for a comprehensive assessment related to a Foley catheter. She stated for those residents who were admitted with a Foley catheter, the facility policy is to do a voiding trial, which starts with clamping the Foley catheter every two hours, depending on the physician order. The LPN stated the order might also include an order for a bladder scan. The Director of Nurses (DON/staff #149) was interviewed on February 11, 2022 at 9:36 a.m. The DON stated that her expectations related to the use of a Foley catheter is there must be orders and an appropriate diagnosis. She stated the nurses must assess the appropriateness of the Foley catheter and document the assessments on the progress notes. The DON also said the nurses can call the physician to ask for voiding trials or to discontinue a Foley if needed. The DON stated the in-house urologist does rounds and can also recommend voiding trials. A facility policy titled Foley Catheter stated when possible, all Foley catheters should be removed prior to admission unless an appropriate diagnosis exists. If a resident requires an indwelling catheter, the facility will follow routine Foley catheter care orders. Discontinue all Foley catheters as soon as possible, per physician order, if the resident does not have a qualifying diagnosis. The policy included bladder training, if ordered by the physician, should begin prior to discontinuation of the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure interventions were implemented timely for one resident (#77) with malnutrition and weight loss. The sample size was 4. The deficient practice places residents at risk for nutritional decline. Findings include: Resident #77 was admitted on [DATE], with diagnoses of unspecified protein-calorie malnutrition, cognitive communication deficit, dementia with behavioral disturbances, and UTI (Urinary Tract Infection). The hospital discharge orders dated January 10, 2022 at 8:43 a.m. included the resident's weight of 104.9 pounds (47.627 kilogram), and height of 62 inches (157.48 centimeters). Review of a document titled, Nursing Comprehensive admission Data Collection, dated January 10, 2022 at 1:55 p.m. indicated the resident's height was 64 inches. The resident's weight was not included. Review of the document, Nutrition Assessment MNA, dated January 14, 2022 at 9:43 a.m. stated the resident weighed 105 pounds and was 64 inches tall. The assessment revealed a score 3 on the nutritional screening which indicated the resident was malnourished. The assessment included an estimated energy needs of 1410-1645 kcal per day, and protein needs of 47-56 grams/day. Based on the weight of 105 pounds, the assessment concluded that the resident's oral food intake was likely adequate to meet needs, and recommended a magic cup twice daily for lunch and dinner for nutritional support. Review of the vital signs and weight documentation revealed the resident was weighed on January 14, 2022 at 10:10 a.m., 4 days after admission, and weighed 105 pounds using a bed scale. However, the weight entry was crossed out by staff #114 and stated, incorrect documentation. On January 14, 2022 at 3:16 p.m. a new weight of 82.2 pounds was entered in the vital signs and weight documentation for the resident. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2 which indicated the resident had severe cognitive impairment. The MDS assessment also revealed the resident required extensive assistance with eating. A nutrition care plan dated January 18, 2022 revealed the resident had potential risk for inability to maintain nutrition due to nutritional screening score of 3, underweight and Body Mass Index (BMI) of 18. Interventions included magic cup, and for the Registered Dietician (RD) to evaluate and make recommendations as needed. However, further clinical record review revealed no additional nutritional assessment to address the resident's caloric/protein needs related to the negative weight discrepancy of 22.8 pounds (-21.71%); and no physician's order for magic cup twice daily for nutritional support that was recommended on January 14, 2022. The weight summary included weights of 90 pounds on January 21, 2022, and 87.4 pounds on January 28 and 29, 2022. An interview was conducted with the RD on February 8, 2022 at 1:49 p.m. The RD stated that during the nutritional assessment, the resident weighed 105 pounds and the caloric needs were calculated based on that. She accessed the resident's clinical record and stated a magic cup was recommended on January 14, 2022, and confirmed that there was no physician order found for the magic cup. The RD also stated that the weight entered on January 14, 2022 at 105 pounds was an error. She said the resident was reweighed on the same day and it was 82.2 pounds. The RD stated that the nutritional/caloric needs for a resident who weighs 105 pounds and height is 64 inches are not the same for a resident who weighs 82.2 pounds and height is 64 inches. She stated that the resident caloric/nutritional needs should have been re-assessed based on the adjusted weight of 82.2 pounds. She stated that the resident was discussed in the WINS nutrition committee which included a certified nursing assistant, physical therapy, nursing, dietary supervisor and speech pathologist (if needed). She stated that those who are in attendance are not an expert or have training in calculating the resident's caloric/nutritional needs. The RD stated that she was the only expert in evaluating the resident's caloric/nutritional needs and she should have re-assess the resident. An interview was conducted on February 10, 2022 at 3:47 p.m. with the Director of Nurses (DON/staff #149). The DON stated that it is her expectation that a resident is weighed upon admission. She also stated that if a nutritional supplement was recommended, it is her expectation that nursing staff will obtain a physician order for the supplement on the same day. A facility policy Weight Loss Assessment and Intervention, stated the multidisciplinary team may strive to prevent, monitor, and intervene for undesirable weight loss for the residents. The nursing staff may measure residents' weights on admission and the next day or as ordered by the providers. If no weight concerns, weights may be performed on a monthly basis. Interventions for care planning for weight loss may include the use of supplementation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that one resident (#70) was assessed for pain in accordance with the physician's orders. The sample size was 5. The deficient practice could result in residents' pain not being assessed. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses of arteriovenous malformation of the digestive system vessel, gastrointestinal hemorrhage, and cognitive communication deficit. A physician's order dated January 7, 2022 included to evaluate pain per shift and document every shift for Routine Screening of Pain. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Review of the Treatment Administration Record for January 2022 revealed this resident was not evaluated for pain 12 times during this month. An interview was conducted on February 10, 2022 at 11:44 AM with a Licensed Practical Nurse (LPN/staff #130), who said that if a resident is in pain, she would assess the resident's level of pain with either the 1-10 pain scale or the pain faces scale. The LPN stated that monitoring is important. She reviewed the clinical record and said that the blanks indicate the area was not assessed but that the resident could have been out for those days. An interview was conducted on February 10, 2022 at 3:55 PM with the Director of Nursing (DON/staff #149), who said that pain medications must be monitored for effectiveness and must have a pain scale. The missing monitoring was reviewed and the DON said this does not meet her expectations. An interview was conducted on February 11, 2022 at 11:27 AM with the Assistant Director of Nursing (ADON/staff #17), who said that the facility does not have a policy on following physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure that an antibiotic medication was obtained and available timely for one sampled resident (#132). The deficient practice could result in medications not being available for residents. Findings include: Resident #132 admitted to the facility on [DATE] with diagnoses that included methicillin resistant staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere, cellulitis of left lower limb, and abscess of tendon sheath, left ankle and foot. Review of a physician's order dated 01/22/22 included daptomycin solution reconstituted (antibiotic) 350 milligrams (mg), use 350 mg intravenously one time a day for MRSA for 23 days. The start date was listed as 01/23/22. Review of the 01/23/22 Medication Administration Record (MAR) revealed that the code 9 had been documented in the space provided for administration of daptomycin. Review of the chart codes key contained in the MAR indicated that 9 meant Other/See Nurse Note. However, review of the nurse notes dated 01/23/22 did not include an entry related to daptomycin. The order was discontinued on 01/24/22. Another physician order dated 01/24/22 revealed for daptomycin solution reconstituted 350 mg, use 368 mg intravenously (IV) one time a day for MRSA for 23 days. A MRSA care plan dated 01/24/22 had goals to be free from MRSA infection and for MRSA infection to resolve with minimal complications as evidenced by negative culture, vital signs within normal limits, and no signs or symptoms of acute infection. Interventions included to give antibiotic therapy as ordered. Review of the January 2022 MAR included that daptomycin was administered in accordance with the physician order from 01/24/22 through 01/29/22. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The assessment included the resident being administered antibiotics for 6 out 7 days in the look back period. Continued review of the January 2022 MAR revealed the antibiotic medication was administered on 01/30/22 MAR but no evidence to indicate whether or not the resident received daptomycin on 01/31/22. A nursing progress note dated 01/31/22 at 3:11 p.m. included the intravenous antibiotic was to be delivered that afternoon. The medication was unavailable when scheduled. However, the nursing documentation did not indicate whether or not the physician had been notified of the delay. On 02/01/22 at 12:35 p.m., an interview was conducted with resident #132. The resident stated that the medication did not arrive until midnight of the previous night (early morning of 02/01). She stated that she was supposed to receive the medication at 2:00 p.m. of the previous day. She said that nurses told her it just was not here yet. The resident stated that her first day in the facility, her medication was late as well. She stated that she arrived at the facility at about 10:30 a.m. on 01/22/22, but that her medication did not arrive until 01/24/22 at about 2:30 or 3:00 p.m. She stated that she was told by nursing that the pharmacy only delivers 2 IVs at a time because the medication is so expensive. Review of the MAR for February 2022 revealed a code 9 for daptomycin administration on February 2, 2022. An orders administration note dated 02/02/22 at 2:09 p.m. revealed that daptomycin may be given when it arrived from the pharmacy. The note indicated that the physician was aware. An interview was conducted on 02/08/22 at 11:26 a.m. with a Licensed Practical Nurse (LPN/staff #10). She stated that when she admits a new resident, she will obtain the admission packet and type the admission orders into the electronic record. She stated that she can take the hospital orders and send them directly to the pharmacy as telephone orders received by (TORB) and then she will add the physician's name and her name. The LPN stated that she compares the admission packet with the hospital packet to make sure everything matches. She said the pharmacy delivers once or twice per dayshift. The LPN stated that once the orders are put in, the resident's medications should be delivered that day. Staff #10 stated that if medications are not delivered in time she will get the medications from the PYXIS so the resident does not miss a dose. Staff #10 said that in rare cases, nursing will call the resident's home to have someone to bring a home supply. She stated that medications are available normally and that it would be unusual if they were not delivered. The LPN stated that if medications did not arrive, she would call the pharmacy first to see what the holdup is. She stated that she would let the physician and the resident know if the medication was not available and/or when it would arrive. On 02/09/22 at 10:46 a.m., an interview was conducted with the Director of Nursing (DON/staff #149). She stated that when a resident is admitted to the facility, the orders are sent to the pharmacy, but a first-dose backup could be obtained from the PYXIS. She stated that if medications were not available, the process would include notifying the resident that they are waiting for the medication to arrive, bringing in their home medications, or could also include calling the physician and getting an order for something else. She stated that she would expect the nurse to call the pharmacy, the provider, and family, and to document that in the clinical record. The DON stated that not having the medication on hand would not meet her expectations. The facility policy titled Unavailable Medications included that the pharmacy staff shall call or notify nursing staff that the ordered product(s) is/are unavailable, notify nursing when it is anticipated that the drug(s) will become available, suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available, which is covered by the resident's insurance. Nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability, and optional therapy/therapies that are available. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the DON or designee and contact the facility Medical Director for orders and/or new direction. The licensed nurse will obtain a new order and cancel/hold or discontinue the order for non-available medication. The new order will be sent to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure consistent monitoring was conducted for one resident (#70) receiving a psychotropic medication. The sample size was 5. The deficient practice could result in residents receiving psychotropic medications not being monitored for side effects and effectiveness. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses of arteriovenous malformation of the digestive system vessel, gastrointestinal hemorrhage, and cognitive communication deficit. A review of physician orders dated January 10, 2022 included for Escitalopram Oxalate 20 milligrams by mouth one time a day for depression as evidenced by verbalizing sadness; for anti-depression medication use to monitor every shift for S/S (signs/symptoms) of sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain with charting to indicate P = Problem and 0 = No Problems; Did resident have any mood disturbances this shift related to anti-depression medication use? (i.e. sadness, tearfulness, excessive crying, verbalizing depression, etc.) and to notify social services if mood disturbances were observed. Review of the care plan initiated on January 10, 2022 revealed the resident could experience adverse reactions or side effects from taking anti-depressant medications. Interventions included monitoring every shift for signs and symptoms of sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), and excess weight gain. A Medication and Treatment Administration Record for January 2022 included that Escitalopram was administered as ordered. However, monitoring for side effects and effectiveness was not performed 10 times during January 2022. An interview was conducted on February 10, 2022 at 11:44 AM with a Licensed Practical Nurse (LPN/staff #130), who said that when a resident is receiving antidepressants she would note that the resident was exhibiting symptoms if they are isolating themselves or not eating, refusing therapy or showers, or if they just tell you that they are depressed. The LPN reviewed the clinical record and said that monitoring for side effects and mood for antidepressants was on the Treatment Administration Record. She said that the markings on the record were y for yes, n for no. She said that on the days that had nothing entered could be that the resident was out for those days because the record should say yes, no, or not applicable on the days that the resident was in the facility. This LPN was not able to find that the resident was out for those days. An interview was conducted on February 10, 2022 at 3:55 PM with the Director of Nursing (DON/staff #149), who said that her expectations for antidepressants were that they must have a proper diagnosis, behavior monitoring, adverse effects monitoring, care plan, and consents. The DON said that blanks in the monitoring did not meet her expectations. A facility policy titled Psychotropic Medication Use revealed that this facility will ensure that a behavioral monitoring order will be initiated for anti-anxiety and anti-psychoactive medications, and that any psychoactive medication that requires behavioral monitoring will be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, observation, and policy review, the facility failed to ensure that one sampled resident's food preferences were honored (#70). The deficient practice could result in residents' food preferences not being honored. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses of arteriovenous malformation of the digestive system vessel, gastrointestinal hemorrhage, and cognitive communication deficit. A physician order dated January 7, 2022 revealed an order for a regular diet. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated that the resident was cognitively intact. An interview was conducted with the resident on February 1, 2022 at 10:25 AM, who said that the food was poor. The resident said that the residents are provided a meal sheet and that they can circle their choices on it, but that they may or may not get that item. He said that tonight he had one slice of bread and one little thing of margarine, and one jelly, but that he had requested a biscuit and 2 or 3 jellies and butters. A Meal Request Ticket dated February 10, 2022 revealed that the resident wanted a garden salad with ranch dressing, green beans, carrot cake with cream cheese frosting, milk, a hamburger with pickles and tomatoes and a large diet Pepsi. An observation was conducted on February 10, 2022 at 1:18 PM of this resident's meal. This resident had a burger, a salad with ranch, a carrot cake, a large ice tea, and a diet Pepsi. In an interview conducted immediately after this observation, this resident said that this was what he had been talking about. He said that he had not wanted the ice tea and that he had wanted milk. An interview was conducted on February 10, 2022 at 1:28 PM with a Registered Nurse (RN/staff #115), who stated that trays and drinks are normally passed out by management and the CNAs. She stated that sometimes she helps out and that residents' beverages are all done in the residents' hall, pretty much. She said that the kitchen does not give the residents milk. The RN said that the reason the resident did not have milk is that he may have refused, and that the CNA that passed the tray might know. During an interview conducted on February 10, 2022 at 1:34 PM with a Certified Nursing Assistant (CNA/staff #37), the CNA stated that this resident had two sodas at lunchtime. Staff #37 said that he was not aware if the resident had milk during lunch as he was not the one to give the resident the lunch tray. The CNA stated the resident normally wants milk in the morning and a soda in the afternoon. An interview was conducted on February 11, 2022 at 8:52 AM with the Executive Chef (staff #114), who said that the kitchen staff loads the cart, takes it to the front of the hall, and then the nursing staff distributes the meal. He said that if a resident requests food, they circle it on the sheet. He stated that they honor the request if they can or try to come close to it. Staff #114 said that the facility only has 2 percent milk but that the kitchen was not out of milk. He said that the nursing staff put the milk on the tray and that it was located on the top of the cart. The Executive Chef stated the only drinks that the kitchen staff get ready for the residents are the fountain drinks. Staff #114 stated that if the resident did not receive milk, it was an error on behalf of nursing. A facility policy titled Food Policy: Resident Preferences revealed that the facility will accommodate the foods and beverages requested and that if unavailable a substitute will be offered to the resident. This document included that food service will offer a variety of meals and snacks available 24/7 to the resident and that reasonable effort will be made to accommodate special requests.

Based on facility documentation, interviews, and policies, the facility failed to inform two residents/representatives (#74 and #7) that a resident had tested positive for COVID-19 within the required time frame and failed to provide evidence other residents and their families/representatives were informed. The deficient practice could result in residents and their families/representatives not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission. Findings include: Review of COVID-19 notification documentation dated January 25, 2022 at 9:58 p.m. revealed a resident had a positive COVID-19 test result and was placed on a 10-day quarantine. Review of facility documentation revealed no evidence that other residents in the facility and/or their families/representatives had been notified of the new positive COVID-19 case by 5 p.m. the next calendar day following this occurrence. In addition, the facility was unable to provide any evidence that other residents in the facility or their families/representatives were notified of the new positive case of COVID-19. An interview was conducted on February 1, 2022 at 8:49 a.m. with resident #74. Resident #74 stated no one had informed her that there was COVID in the facility. The resident stated that she had noticed last week that the staff were putting on a gown when entering one of the resident's the room. The resident stated she asked a Certified Nursing Assistant (CNA) if there was COVID in the building, and the CNA stated she was not allowed to tell. During an interview conducted on February 1, 2022 at 9:04 a.m. with resident #7, a family member was visiting (contact person for resident #7). The family member stated she was not informed that there was COVID in the facility. Resident #7 also stated that he was not notified that there was COVID in the facility. An interview was conducted on February 7, 2022 at 10:17 a.m. with the Infection Control Preventionist (ICP/staff #100). Staff #100 stated that the facility uses Cliniconex to communicate if there is a new COVID positive resident in the facility. The ICP stated she is responsible for sending out the robot phone call to all residents and families. She also stated the business office sends out emails, and each department is notified via staff or department meetings. The ICP stated the COVID notification is done the same day, and that on the weekend, the nurse in charge is responsible for sending out the notifications. The ICP stated the facility's last COVID positive result was on January 31, 2022, and that all residents and families were notified by 2/1/2022. However, no evidence was revealed that other residents in the facility and/or their families/representatives had been notified of the new positive COVID-19 case by 5 p.m. the next calendar day following this occurrence. An interview was conducted on February 11, 2022 at 9:36 a.m. with the Director of Nurses (DON/staff #149). The DON stated it is her expectation that if a resident is positive for COVID, the facility would notify the family as soon as the facility learned of the COVID positive result. The DON stated the facility uses Cliniconex to communicate any new positive COVID result to the families. Review of a facility policy titled, Notification of Positive COVID-19 Test Results, stated the facility ensures to keep the patients, families and staff safe and informed of positive COVID-19 test results. The policy included that the facility follows the CDC (Centers for Disease Control and Prevention), CMS (Centers for Medicare & Medicaid Services), and county health and state guidelines. The policy also included the facility will inform all patients, their representatives/families and staff by 5:00 p.m. the next calendar day following the occurrence of a single confirmed COVID-19 infection or of three or more patients or staff with new onset of respiratory symptoms that occurred within 72 hours of each other.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #70 was admitted to the facility on [DATE] with diagnoses of arteriovenous malformation of the digestive system vessel, gastrointestinal hemorrhage, and cognitive communication deficit. A physician's order dated January 7, 2022 included for Apixaban (Anticoagulant) Tablet 5 mg, Give 5 mg by mouth two times a day for coronary artery disease. A Care Plan dated January 7, 2022 included the resident is at risk for bleeding related to the use of anticoagulant/blood thinner medication. Interventions included administering blood thinner per physician orders and monitoring frequently for signs and symptoms of bleeding (extensive bruising, tarry stools, bloody stools, bloody urine, nose bleed, bleeding gums, etc.). A physician's order dated January 10, 2022 included for Anticoagulation Medication Monitoring: Monitor every shift for signs and symptoms of bleeding (black tarry stools, increased or new bleeding of gums, blood in urine, etc.) and that if complications were noted to notify the Medical Doctor. Charting is to indicate P =Problems, 0 = No Problems every shift. A Medication and Treatment Administration Report for January 2022 included that this resident received Apixaban as ordered. However, further review of the reports revealed this resident did not receive monitoring for signs and symptoms of bleeding for 10 days. An interview was conducted on February 10, 2022 at 11:44 AM with an LPN (staff #130), who said that there are different types of anticoagulants and that she would observe bleeding for all of them. This nurse was not able to find that the resident was out of the facility for those days that monitoring was not done. An interview was conducted on February 10, 2022 at 3:55 PM with the DON (staff #149), who said that her expectations for anticoagulant medications is that there must be monitoring for signs and symptoms of bleeding and that the anticoagulant is included on the care plan. She said that blanks for the monitoring did not meet her expectations. A facility policy titled Anticoagulation Policy and Procedure revealed that the risk of bleeding exists in any patient that is on any anticoagulant. The policy included their goal is to avoid exposing patients to unnecessary risks or to unnecessarily withhold any beneficial treatments. Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure that two residents (#140 and #77) were administered medications according to physician orders, and that one resident (#70) receiving an anticoagulation medication was consistently monitored for signs and symptoms of bleeding. The sample size was 5. The deficient practice could result in residents receiving medications that are not necessary. Findings include: -Resident #140 was admitted to the facility on [DATE] with diagnoses that included an encounter of surgical aftercare following surgery on the circulatory system, hypotension, and anxiety disorder, unspecified. A physician order dated 01/14/22 included for midodrine HCl (anti-hypotensive) 5 milligrams (mg); give 1 tablet three times a day for hypotension. Hold for systolic blood pressure (SBP) greater than or equal to 120. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 12 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. The assessment stated the resident required extensive 2-person physical assistance for most activities of daily living. Review of the clinical record did not include a hypotension care plan. Review of the January 2022 Medication Administration Record (MAR) revealed the resident received midodrine HCl on 7 occasions when the SBP was greater than or equal to 120: 01/14 - for a BP of 120/64 01/18 - for a BP of 121/67 01/19 - for a BP of 120/61 Twice on 01/23 - for BPs of 150/71 and 128/76 01/25 - for a BP of 128/72 01/27 - for a BP of 130/72 An interview was conducted with a Licensed Practical Nurse (LPN/staff #60) on 02/09/22 at 1:18 p.m., who stated that prior to giving an anti-hypotensive medication he will check the resident's blood pressure. He stated that he has to look at the orders every time because every order is different, and the parameters might be different for the medication. The LPN stated in the case of midodrine, sometimes the parameter for SBP is 140, sometimes it is 110. The LPN stated that the risk for giving midodrine when the resident's blood pressure is too high is that the medication might increase the resident's blood pressure and make the resident hypertensive. He reviewed the resident's MAR and stated that the medication administrations would absolutely be medication errors. -Resident #77 admitted to the facility on [DATE] with diagnoses that included urinary tract infection, dementia with behavioral disturbance, and primary hypertension. A physician order dated 01/10/22 included for atenolol (antihypertensive) 25 mg; give 1 tablet one time a day for hypertension. Hold if SBP is less than 100 or for heart rate (HR) less than 60. The admission MDS assessment dated [DATE] revealed the resident scored 2 on the BIMS assessment, indicating severely impaired cognition. The assessment also revealed the resident required extensive 2-person physical assistance for most activities of daily living. Review of the January 2022 MAR revealed atenolol was administered on two occasions when the resident's HR was lower than 60: 01/27 - for a HR of 51 01/28 - for a HR of 58 A high blood pressure care plan dated 02/01/22 had a goal for no complications related to high blood pressure. Interventions included to administer medications per physician orders (hold per ordered parameters). On 02/09/22 at 1:11 p.m., an interview was conducted with an LPN (staff #93). He stated that before giving an antihypertensive medication, the first thing he will do is check the resident's blood pressure and pulse. He stated that if an antihypertensive was given in error, he would call the physician right away and monitor the blood pressure. The LPN reviewed the resident's MAR and stated that the medication should have been held. An interview was conducted on 02/09/22 at 1:53 p.m. with the Director of Nursing (DON/staff #149). She stated that her expectation was that nurses will check the updated blood pressure and pulse before medication administration, and follow the parameters on the medication. The DON stated that it would not meet her expectation for medications to be administered when the resident's blood pressure or pulse was outside of the ordered parameters. The facility policy titled Medication Administration included that it is the policy of the facility that medications are to be administered as prescribed by the attending physician. Procedures included that medications must be administered in accordance with the written orders of the prescribing physician.

-A breakfast dining observation was conducted on February 1, 2022 at 8:38 a.m. on the second-floor hallway. A Certified Nursing Assistant (CNA/staff #18) was observed pouring coffee and juices from the meal cart parked in front of a room located near the nurses' station. Staff #18 was observed to place the uncovered beverages on the meal tray, walk the entire length of the hallway, enter a resident's room and serve the tray to the resident. -Additional dining observations were conducted on February 1 and 8, 2022 between 8:30 a.m. and 8:45 a.m. on the 200 hallways at breakfast. Several staff who were helping to serve the breakfast trays were observed to pour milk, orange juice, coffee, apple juice and cranberry juice from the meal cart parked in front of one resident's room, and deliver the uncovered beverages on the tray to residents' rooms located at the end of the hall. An interview was conducted on February 8, 2022 at 2:03 p.m. with the dietary manager (staff #114). Staff #114 stated dietary prepares the food carts for the meal service and nursing delivers the foods. He stated that if a beverage is to be served directly outside the resident's room, it would be acceptable for the beverage to be uncovered. The dietary manager stated that it is not acceptable for the uncovered beverages to be carried down the hallway. An interview was conducted on February 10, 2022 at 12:44 p.m. with a Certified Nursing Assistant (CNA/staff #21). The CNA stated that if he has to walk a distance to deliver the food tray, the beverage cups will have lids. He said there are lids on the cart. An interview was conducted on February 10, 2022 at 3:47 p.m. with the Director of Nursing (DON/staff #149). The DON stated that her expectations when serving meals included hand hygiene prior to serving the meals and that beverages must have lids when the staff is walking in the hallway with trays. Based on observations and staff interviews, the facility failed to ensure food was served in accordance with professional standards for food service safety. The deficient practice could result in contamination placing residents at risk for foodborne illness. Findings include: -On 02/01/22 at 1:16 PM, an observation of meal delivery on the 2C unit was conducted. The meal cart was parked at the end of the 2C unit hallway. Staff were observed to deliver trays into resident rooms. The cart was moved down the hallway as the meals were delivered. The beverage pitchers, including milk, juices, and iced tea were not dated. The beverages were poured into glasses and placed onto the meal trays. The beverages were not covered. The trays, including the uncovered beverages, were carried into the resident rooms for delivery.

Based on observations, staff interviews, facility documentation, and review of policies and procedures, the facility failed to ensure that one staff (#14) and one vendor (#1) were consistently screened for COVID-19 upon entry to the facility, and that one staff (#52) performed appropriate hand hygiene during wound care. The deficient practice could result in the spread of infection. Findings include: Regarding COVID-19 screening: -Review of the timesheet for staff #14, a nursing assistant, for January 2022 revealed that the staff member worked January 6, 10, 11, 12, 13, and 16, 2022. On request, the facility was able to provide individual COVID-19 screening documents for staff #14 for January 2022. However, review of facility individual COVID-19 screening documents provided revealed no evidence that staff #14 was screened for COVID-19 prior to or at the beginning of the shift on January 6, 10, and 13, 2022. -Review of the vendor screening sign-in sheet dated January 2022, revealed vendor #1, a phlebotomist, provided resident services on January 15, 16, 20, 22, 23, and 29, 2022. On request, the facility provided COVID-19 screening documents for January 2022. However, review of facility documents provided for COVID-19 vendor screening revealed no evidence that vendor #1 was screened for COVID-19 prior to providing services to the residents on January 15, 16, 20, 22, 23, and 29, 2022. An interview was conducted on February 7, 2022 at 10:17 a.m. with the infection control nurse (staff #100). Staff #100 stated the facility's COVID-19 screening process included all staff and visitors being screened upon entry or at the beginning of their shift. She stated the screening process includes review of the signs and symptoms of illness including fever. She also stated that the facility documents the signs and symptoms of COVID-19 according to the facility surveillance plan. Review of the facility COVID-19 screening document updated on August 11, 2020, stated to remind staff, vendor, and visitor to wash hands and use hand sanitizer frequently. It also included screening each person for symptoms prior to entering patient care areas, and to circle yes or no for each symptom on the document. Regarding handwashing: A wound care observation was conducted on February 9, 2022 at 11:10 a.m. with the wound care nurse (staff #52). The wound nurse was observed to provide wound treatments to a resident that had coccyx, left lower extremity, right lower extremity, and left heel wounds. The nurse was not observed to wash her hands in between donning and doffing a pair of gloves including when going from dirty to clean procedure of the wound care. The nurse did not wash hands before donning a new pair of gloves or when transitioning the wound care from dirty (old dressing removal) to clean (applying new treatment) throughout the process. An interview was conducted on February 10, 2022 at 10:10 a.m. with staff #52. The nurse stated that she is supposed to wash her hands before and after providing wound care, before and after direct contact with a resident, after removing an old dressing, before putting on a new pair of gloves, and after disposing of the resident's trash. The nurse stated she should have washed her hands between glove changes during the wound care. An interview was conducted on February 10, 2022 at 3:47 p.m. with the Director of Nursing (DON/staff #149). The DON stated it is her expectation that hand washing must be done in between glove changes, when going from a dirty area to a clean area, when providing treatments to the wounds. A facility policy, Hand Hygiene, included the use of alcohol-based hand sanitizer that contains at least 60% alcohol. The policy stated a hand sanitizer should be applied every time staff enter a patient room, and after removing gloves.