Based on observation, interview, and record review, it was determined that the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for one (Resident #72) of one resident, whose comprehensive care plan was reviewed. Specifically, the facility failed to develop a comprehensive care plan that was correct for Resident #72 for restraints. The findings are: On 05/06/2025 at 12:40 PM, this surveyor observed Resident #72 in a wheelchair, with a seat belt restraint on. On 05/06/2025, a review of Medical Diagnosis indicated that Resident #72 had diagnoses, which included: rhabdomyolysis (breakdown of muscle tissue) and muscle spasms (involuntary contractions of muscles). On 05/07/2025, a review of a Nursing Restraint Evaluation completed on 04/04/2025, indicated that Resident #72 was admitted with a wheelchair that had a seat belt that the resident could unbuckle and buckle themselves. Resident #72 requested to use seat belt for safety, due to having muscle spasms, causing the resident to jump causing [pronoun] to fall out of the seat in the wheelchair. A review of Resident #72 ' s admission Minimum Data Set (MDS), completed on 03/26/2025, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognition was intact. A review of Medication admission Record (MAR) indicated that Resident #72 had an order for wheelchair with seatbelt per resident request when up related to muscle spasms. Check every shift for ability of resident to unbuckle self if needed that was done on 04/04/2025. A review of a Care Plan Report for Resident #72 did not reveal any reference to the seat belt being ordered and used as an intervention to prevent falls. During an interview on 05/06/2025 at 12:00 PM, Resident #72 indicated that they had a seatbelt in their wheelchair that held them in and kept them from falling out. Resident #72 indicated that the seatbelt was requested, due to having muscle spasms and jumping causing [pronoun] to fall out in the past. Resident #72 indicated they were able to move the upper half of their body, with no issues and had no issues buckling and unbuckling the seat belt. During an interview on 05/08/2025 at 9:38 AM, the MDS coordinator indicated that safety restraints or any type of restraints should be care planned accordingly, so staff could look in the system to know how to take care of a resident, such as checking on the restraints as needed. The MDS Coordinator also indicated, if care plans were not done correctly, the resident would not get the proper care.

Based on observation, interview, and record review, the facility failed to ensure oxygen use was included on the plan of care for 1 (Resident #21) of 1 sampled resident. The findings are: Resident #21 had diagnoses of Chronic obstructive pulmonary disease, Shortness of breath acute, and Chronic respiratory failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2024 documented a Brief Interview for Mental Status (BIMS) of 15 (13 to 15 indicates cognitively intact) and the resident received oxygen therapy. A Physician's Order dated 01/22/2024 documented, .O2 [oxygen] @ [at] 2L/M [2 liters per minute] via NC [nasal canula] prn [as needed]; if sat [oxygen saturation] is below 90% as needed for SOB [shortness of breath] . Review of Resident #21's Care Plan with a revision date of 2/13/24 did not address oxygen therapy. On 03/13/2024 at 02:59 PM, the MDS Coordinator was asked, Should oxygen use be included in a residents plan of care and why? The MDS Coordinator responded, Yes, it should be included to ensure continuity of care and to prevent the resident from becoming short of breath. The MDS Coordinator was then asked if Resident #21's care plan reflected oxygen use. After reviewing Resident #21's care plan the MDS Coordinator confirmed that it did not. The facility policy titled, Care Planning, obtained from the Administrator on 03/14/2024 at 09:50 AM documented, .comprehensive person-centered care plan are based on resident assessments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the walls were free of scrapes, blotchy and/or missing paint, and that the floors were clean and free of dead insects (roaches). The findings are: 1. On 03/11/2024 at 11:00 AM, during initial rounds and on 03/13/2024 at 9:10 AM, Rooms 13, 15, 26, 27, 29, 36, and 38's walls were bare of pictures and/or décor. 2. On 03/11/2024 at 11:20 AM, the following observations were made: a. In room [ROOM NUMBER] there were scratches beside the bed with paint and plaster missing and sheetrock exposed. b. In room [ROOM NUMBER], one and a half feet off the floor, the paint was scraped off the wall. c. In room [ROOM NUMBER], as you enter the room, scrapes were all the way down the left side of the room with paint missing. d. In room [ROOM NUMBER], behind the bed there were scrapes in the wall with paint and plaster missing and sheetrock exposed. e. In room [ROOM NUMBER], immediately to the right as you enter the room, there were holes in the wall beside the bed. f. In room [ROOM NUMBER], there were two areas of unpainted plaster above the air/heating unit. 3. On 03/13/2024 at 2:34 PM, the Maintenance Director was asked if he/she had noticed the resident's rooms having a lot of their belongings in boxes stacked up in their rooms. The Maintenance Director said, yes he/she was aware, but all of the storage areas in the storage buildings was taken and they are out of room to store anything else at this time. 4. On 03/14/2024 at 9:45 AM, the Administrator was asked how does the Maintenance Director become aware of environmental issues/needs? The Administrator described a notebook located at the nurse's station and they will write it in the book, and it's mentioned in the morning meetings. The Administrator was asked if she was aware of any rooms that need painted and plastered. The Administrator said the Maintenance Director is new and since he's been here, he's been going through plastering and will go back and paint the places that need it. The Administrator was asked if this was an ongoing process. The Administrator said that the Maintenance Director is new, and he has been coming out on the weekends to paint some. The Administrator was asked what are some of the things that you do to provide a homelike environment? The Administrator said the residents love to barbecue. If staff have a barbecue, the Dietary Manager (DM) changes the menu so they can have a barbecue as well. They have (smart TVs with quick access) so they can stream what they like, and they have Wi-Fi (internet). The Administrator was asked what about a resident's room that has nothing on the walls, is there an avenue for them to get decorations? The Administrator said that some residents say they don't want anything on the walls because they believe they will be going home. The Administrator said mirrors have been added for women who want to look at themselves. They get their own personalized shampoo of choice, combs, brushes, soap, shaving cream, etc. 1. On 03/11/2024 at 11:27 AM, in room [ROOM NUMBER] A there was scraped paint, and a white blotch of paint on the wall. a. On 03/11/2024 at 09:08 AM, in room [ROOM NUMBER] A there was scraped paint, and a white blotch of paint on the wall. b. On 03/12/2024 at 03:44 PM, in room [ROOM NUMBER] A there was scraped paint, and a white blotch of paint on the wall. c. On 03/13/2024 at 02:28 PM, the Maintenance Supervisor was asked, How long has the white paint and the scraped paint been on the wall in room [ROOM NUMBER]? The Maintenance Supervisor stated, About a month and a half. I've been working in maintenance for about two months. d. On 03/13/2024 at 03:44 PM, in room [ROOM NUMBER] A, there was scraped paint, and a white blotch of paint on the wall. 2. On 03/11/2024 at 11:12 AM a dead roach and dirt were on the floor beside the tube feeding pump in room [ROOM NUMBER]B. a. On 03/11/2024 at 01:19 PM, a dead roach and dirt were on the floor beside the tube feeding pump in room [ROOM NUMBER]B. b. On 03/12/2024 at 02:55 PM, a dead roach and dirt were on the floor beside the tube feeding pump in room [ROOM NUMBER]B. c. On 03/13/2024 at 02:14 PM, a dead roach and dirt were on the floor beside the tube feeding pump in room [ROOM NUMBER]B. d. On 03/13/2024 at 02:16 PM, Housekeeper #1 was asked, Can you tell me what you see beside the bed in room [ROOM NUMBER]? Housekeeper #1 looked beside the bed and stated, Trash. The Surveyor asked, How often are the rooms cleaned? Housekeeper #1 stated, Every day, but they probably missed that spot.

2. Resident #39 had diagnoses of Alzheimer's and Unspecified psychosis. The Quarterly MDS with and ARD of 12/06/2023 documented a BIMS score of 9 (8-12 indicates moderately cognitively impaired) and required supervision or touching assistance of staff with personal hygiene and partial/moderate assistance of staff with bathing. On 03/11/24 at 11:15 AM, Resident #39 was sitting at a table in the small Dining Room. The fingernails on both hands long were 1/2 inch long, jagged and had a dark brown substance underneath the nails. On 03/12/24 at 10:35 AM, Resident #39 was lying in bed, the fingernails on both hands remained jagged and long with a dark substance under the nails. 3. Resident #61's admission MDS with an ARD of 02/13/2024 documented a BIMS score of 15 (13-15 indicates cognitively intact) and was dependent on staff for personal hygiene and bathing and had diagnoses of Other fracture and Traumatic Brain Injury. On 03/11/2024 at 10:55 AM, Resident # 61 was lying in bed the fingernails on both hands were 1/2 inch long, jagged and had a brown substance underneath them. On 03/12/2024 at 09:08 AM, Resident #61 was lying in bed, the fingernails on both hands and the toenails on both feet, long, jagged, and dirty. Resident #61 voiced he/she would like to have the fingernails and toenails cut. On 03/12/2024 at 3:35 PM, CNA #1 was asked who was responsible for nail care. CNA #1 responded, We all are, the nurses do the diabetic. Activities have a nail activity, and the weekend nurse does a lot of nail care on Sunday. CNA #1 accompanied the Surveyor to Resident 61's rooms. When asked to describe the residents' finger and toes nails, CNA #1 described them as long, brittle and needing to be cleaned. CNA #1 then accompanied the Surveyor to Resident #39's room and again was asked to describe Resident #39's fingernails, CNA #1 stated, .they need to be trimmed and cleaned. On 03/12/2024 at 3:50 PM, Licensed Practical Nurse (LPN) #1 was asked who does nail care on the residents. LPN #1 responded the treatment nurse, but if we see someone who needs their nails trimmed, we all do it. LPN #1 then accompanied the Surveyor to Resident #39's and #61's rooms and was asked to describe their nails. LPN #1 confirmed both of the resident's nails were long, jagged, and looked dirty and needed cleaned and trimmed. On 03/12/2024 at 4:10 PM, the Assistant Director of Nursing (ADON) was asked who was responsible for nail care. The ADON confirmed the nurses do nail care on the diabetic residents and the CNAs do nail care on everyone else after showers or bathes and on an as needed basis. The Surveyor asked the ADON to describe Residents #39 and #61's nails. The ADON confirmed they were long, jagged, and dirty and needed trimmed and cleaned. The facility's policy titled, Care of fingernails/Toenails documented, .Nail care includes daily cleaning and regular trimming . Based on observation, interview, and record review, the facility failed to ensure facial hair was removed from 1 (Resident #1) of 7 sampled residents who were dependent on staff for shaving; failed to provide nail care for 2 (Residents #39 and #61) of 28 sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #1 had a diagnosis of Other recurrent depressive disorders. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/2024 documented Resident #1 scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). A Care Plan initiated 01/10/2023 documented, .The resident is totally dependent on staff for personal hygiene . On 03/11/2024 at 11:08 AM, Resident #1 had facial hair 1/2 inch long on the chin. On 03/12/2024 at 11:55 AM, Resident #1 had facial hair 1/2 inch long on the chin. On 03/13/2024 at 2:22 PM, Resident #1 had facial hair 1/2 inch long on the chin. Resident #1 was asked, How often does the staff shave the hair on your chin? Resident #1 stated, I asked them to shave them yesterday, but they said they didn't have any razors. On 03/14/2024 at 02:36 PM, Certified Nurse Assistant (CNA) #2 was asked, Can you tell me why [Resident #1] hasn't been shaved? CNA #2 stated, [Resident #1] gets shaved on [the resident's] bath days on Tuesdays, Thursdays, and Saturdays. On 03/14/2024 at 08:45 AM, the Director of Nursing (DON) was asked, Does the facility have razors? The DON walked to the storage closet on the secure unit and picked up a container that was filled with razors. The DON asked, Who needed shaved? This surveyor informed her that Resident #1 needed to be shaved. The DON stated, I'll make sure [the resident] gets shaved. On 03/14/2024 at 08:50 AM, Resident #1 had facial hair 1/2 inch long on the chin. On 03/14/2024 at 09:50 AM, Resident #1's bath sheet documented the resident had a bed bath on 03/12/2024. On 03/14/2024 at 9:50 AM, a policy titled, Shaving a Resident, was provided by the Administrator which documented, .The purpose of this procedure is to promote cleanliness and to provide skin care . Documentation The following information should be recorded in the resident's medical record. The date and time the procedure was performed . The name and title of the individual(s) who performed the procedure .

Based on observation, interview, and record review, the facility failed to follow physician orders and maintain oxygen concentrations in accordance with physician orders for one (Resident #21) of 8 sampled residents. The findings are: Resident #21 had diagnoses of Chronic obstructive pulmonary disease, Shortness of breath, and Acute and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2024 documented a Brief Interview for Mental Status (BIMS] of 15 (13-15 indicates cognitively intact) received continuous oxygen therapy. On 03/11/2024 at 11:30 AM, Resident #21 was lying in bed with oxygen on per oxygen concentrator via nasal canula, at 3.5 liters per minute. On 03/12/2024 at 10:29 AM, Resident #21 was lying in bed receiving oxygen at 3.5 liters per minute via nasal canula. A Physician's Order dated 01/22/2024 documented, .O2 [oxygen] @ [at] 2L/M [2 liters per minute] via NC [nasal canula] prn [as needed]; if sat (oxygen saturation) is below 90% as needed for SOB [shortness of breath]. Review of Resident #21's Care Plan with a revision date of 02/13/2024 did not address oxygen therapy. On 03/12/2024 at 3:42 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, How do you ensure oxygen settings are accurate on the residents who receive oxygen? LPN #1 replied, Everyone checks it, and the humidifier and tubing is changed out every Wednesday. The Surveyor asked who monitors and adjusts oxygen flow rates. LPN #1 confirmed the nurses. LPN #1 was asked if she knew what Resident #21's oxygen flow rate was supposed to be according to the physician's orders. LPN #1 replied, I believe it's two liters. LPN #1 accompanied the Surveyor to Resident #21's room and was asked to check the rate on Resident #21's oxygen. LPN #1 replied, It's on 4 liters, sometimes [Resident #21's family member] comes and may have messed with it. The facility policy titled, Oxygen Administration. Documented, .Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation Verify there is a physician's order . Review the physician's orders or facility protocol for oxygen administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record revealed the facility admitted Resident #66 on 11/18/2022 with a diagnosis of malignant neoplasm of the larynx (voice box). A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident required limited assistance for activities of daily living (ADLs). The MDS assessment indicated Resident #66 received hospice care while a resident. A review of the care plan revealed hospice services were not identified on the care plan for Resident #66. A review of the physician orders, dated 11/29/2022, revealed a physician's order to admit Resident #66 to hospice for malignant neoplasm of the laryngeal cartilage. An interview on 12/20/2022 at 1:20 PM with Licensed Practical Nurse (LPN) #14 revealed the resident was admitted to the facility already on hospice services. During an interview on 12/21/2022 at 6:41 AM, LPN #9 revealed the resident received hospice services and was admitted on hospice from the hospital. LPN #9 indicated the hospice company left their care plan, but hospice should also be addressed on the facility care plan for the resident. During an interview on 12/21/2022 at 7:45 AM, Minimum Data Set (MDS) Coordinator #19 revealed they had a hospice binder, and a care plan was in the binder on what services the hospice company provided to Resident #66. MDS Coordinator #19 revealed hospice services should be on the person-centered care plan. MDS #19 indicated hospice was not on the person-centered care plan, but it should have been. During an interview on 12/21/2022 at 10:15 AM, the Director of Nursing (DON) revealed it was expected that all services provided to Resident #66 should be addressed on the person-centered care plan. During an interview on 12/21/2022 at 1:08 PM, the Administrator revealed it was expected for hospice services to be identified on the care plan. Based on observations, interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for 2 (Resident #24 and Resident #66) of 19 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to develop a comprehensive care plan for Resident #24 to prevent pressure ulcers, which resulted in Resident #24 developing a pressure ulcer to a lower extremity. The facility failed to ensure the diagnoses of schizoaffective disorder, depression, long-term use of anticoagulants, pain, and edema were also addressed in Resident #24's care plan. Also, the facility failed to develop a care plan to address hospice services for Resident #66. Findings included: The facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1. A review of Resident 24's admission Record revealed the facility admitted the resident with diagnoses which included long-term use of anticoagulants, stroke, atrial flutter, chronic viral, heart disease, schizoaffective disorder, depression, hepatitis C, muscle wasting and atrophy, type 2 diabetes mellitus, hemiplegia and hemiparesis, congestive heart failure, peripheral vascular disease, pain in right hip, and edema. A review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS revealed diagnoses listed included coronary artery disease, heart failure, viral hepatitis, diabetes mellitus, stroke, depression, and schizophrenia. Per the MDS, Resident #24 was at risk for a pressure ulcer but did not have any during the time of the assessment. Further review of the MDS indicated Resident #24's medications included an antipsychotic, an anticoagulant, a diuretic, and insulin. A review of Resident #24's Care Plan, initiated on 09/08/2022, revealed the resident did not have a care plan for the prevention of pressure ulcers. Further review of the care plan revealed the care plan did not address identified areas of concern related to peripheral vascular disease, type 2 diabetes mellitus, depression, schizoaffective disorder, long-term use of anticoagulants, edema, and pain until 12/19/2022. During an interview on 12/20/2022 at 10:03 AM, LPN #12 stated she assessed the resident's feet and identified a stage 3 pressure ulcer to the resident's right heel. During an interview on 12/21/2022 at 8:23 AM, Licensed Practical Nurse (LPN)/Social Service Director (SSD) #10 stated the MDS Coordinator was responsible for updating the resident's care plan. She stated that all the nurses split up all of the resident's care plans to review them. She stated the facility did that time to time. That was what prompted the review of the resident's care plans, and the staff wanted to include anything that was left out of the care plan. She stated she did not know why Resident #24's care plan did not address peripheral vascular disease, type 2 diabetes mellitus, schizoaffective disorder, depression, long-term use of anticoagulants, pain, and edema in the resident's care plan prior to 12/19/2022, but the diagnoses should have been addressed. LPN/SSD #10 stated Case Manager (CSM) #8 and MDS Coordinator #19 completed the care plans for residents on admission. During an interview on 12/21/2022 at 8:58 AM, CSM #8 stated the staff member that admitted the resident was responsible for completing the resident's baseline care plan and she would review the care plan the following day to see if it needed to be updated. CSM #8 stated LPN/SSD #10 was responsible for updating the resident's care plan. CSM #8 stated the resident's care plan was not updated until 12/19/2022 due it to probably being caught in a care plan review. During an interview on 12/21/2022 at 9:07 AM, MDS Coordinator #19 stated both MDS Coordinator #19 and CSM #8 were responsible for updating the resident's care plan. MDS #19 stated the resident's diagnoses of peripheral vascular disease, type 2 diabetes mellitus, schizoaffective disorder, depression, long-term use of anticoagulants, pain, and edema should have been addressed on the resident's care plan prior to 12/19/2022. She stated the facility was behind on updating resident care plans. She stated that having a care plan that was not up to date could cause a communication issue with the Certified Nursing Assistants (CNAs). She stated the facility had a plan in place and were auditing care plans because she brought it to the attention of the Administrator that care plans were not up to date. During an interview on 12/21/2022 at 12:16 PM, the Director of Nursing (DON) stated the comprehensive care plan was completed by both MDS Coordinator #19 and CSM #8. The DON stated the resident's diagnoses of peripheral vascular disease, type 2 diabetes mellitus, schizoaffective disorder, depression, long-term use of anticoagulants, pain, and edema should have been addressed prior to 12/19/2022. She stated the Administrator had a meeting and care plans were discussed; however, she was not part of that meeting. The DON agreed that if the diagnoses of diabetes mellitus and peripheral vascular disease were identified on the care plan, the resident's newly identified pressure ulcer could have been prevented. During an interview on 12/22/2022 at 3:03 PM, the Administrator stated the resident's diagnoses of peripheral vascular disease, type 2 diabetes mellitus, schizoaffective disorder, depression, long-term use of anticoagulants, pain, and edema should have been addressed prior to 12/19/2022. The Administrator stated that if the diagnoses of diabetes mellitus and peripheral vascular disease were identified on the care plan, the pressure ulcer could have potentially been prevented.

Based on observation, record review, and interview, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing was changed weekly to prevent the potential for infection for 1 (Resident #49) of 1 sampled resident who had a PICC line in the last three months. The findings are: Resident #49 had diagnoses of Cancer, Septicemia, Heart Disease, Renal Failure and Pressure Ulcers. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons for bed mobility, transfer and toilet use, one person physical assistance for personal hygiene and bathing, was always incontinent of bowel and bladder and had two stage one, one stage three and two stage four pressure ulcers, and an unstageable and a deep tissue injury and was not on intravenous therapy. a. The Physician Order dated 11/30/22 documented, .Vancomycin HCl [Hydrochloride] Solution Reconstituted 750MG [Milligram] Use 250 ml/hr [milliliter/hour] intravenously [IV] one a day related to SEPSIS . PRESSURE ULCER . Hold Date from 12/15/2022 . D/C [Discontinued] Date 12/15/2022 . b. The Nsg (Nursing)-General Note dated 12/02/2022 at 10:30 AM documented, .APN [Advanced Practical Nurse] here at this time, gave order to send resident out for altered mental status change and her being lethargic . c. The Nsg-General Note dated 12/09/2022 at 3:52 PM documented, .hospital called to report that resident would be returning to facility today. reports she will be on IV vanc [Vancomycin] . d. The Physician Order dated 12/15/22 documented, .Vancomycin HCl Solution Reconstituted 750 MG Use 250 ml/hr intravenously every 48 hours related to SEPSIS . PRESSURE ULCER . until 12/19/2022 . e. The Care Plan dated 12/15/22 documented, .Resident admitted with sepsis . Maintaining PICC site per facility protocol . f. On 12/19/22 at 12:18 PM and on 12/20/22 at 7:22 AM, Resident #49 was resting in bed. The resident had a PICC line to her right upper arm, the dressing was dated 12/3. g. On 12/20/22 at 8:29 AM, the Surveyor asked the Director of Nursing (DON), When should a PICC line dressing be changed? The DON stated, Every 2-3 days. The Surveyor asked, Who is required to change the dressing? The DON stated, A Register Nurse. The Surveyor asked, Does [Resident #49] have a physician's order to have her PICC line dressing changed? The DON stated, No. The DON accompanied the Surveyor to the Resident #49's room. Resident #49 was resting in bed. The Surveyor asked the DON, What is the date on the resident's PICC line dressing? The DON stated, 12/3, the dressing was last changed when she was in the hospital. The Surveyor asked, The PICC line dressing, should it have been changed? The DON stated, Yes. The Surveyor asked, Who is responsible to ensure there was an order for the PICC line dressing change and that the dressing was changed? The DON stated, Me. h. The facility policy titled, Central Venous Catheter Care and Dressing Changes, provided by Consultant (CST) #11 on 12/20/22 at 9:07 AM documented, .The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressing . A physician's order is not needed for this procedure . Perform site care and dressing change at established intervals . Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all central vascular access devices . Change the dressing . at least every 7 days . Check expiration dates of the . dressing . Assess the integrity of securement devices with each dressing change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure care and services were provided to prevent new pressure ulcer development for 1 (Resident #24) of 3 residents reviewed for pressure ulcers and/or skin concerns. Specifically, the facility failed to monitor the resident's skin on the resident's right heel after the resident verbalized complaints of pain to the heel, and the resident developed a stage 3 pressure ulcer to the right outer heel. Findings included: The facility's policy titled, Prevention of Pressure Injuries, revised on 04/2020, indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. 3. Inspect skin on a daily basis when performing or assisting with personal care or ADLs [activities of daily living]. b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc. Further review indicated, 1. Evaluate, report and document potential changes in the skin. A review of Resident #24's admission Record revealed the facility admitted the resident with diagnoses that included abnormalities of gait and mobility, muscle wasting and atrophy, type 2 diabetes mellitus, hemiplegia and hemiparesis, difficulty in walking, peripheral vascular disease, and edema. A review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS revealed diagnoses listed included coronary artery disease and diabetes mellitus. Per the MDS, Resident #24 was at risk for pressure ulcers but did not have any during the time of the assessment. A review of Resident #24's Care Plan, initiated on 09/08/2022, revealed the resident did not have a care plan for the prevention of pressure ulcers. During an interview on 12/19/2022 at 10:39 AM, Resident #24 was sitting in a wheelchair in their bedroom. The resident stated the resident had a bruise on their right heel. Resident #24 stated the staff needed to check it because they were concerned it was an ulcer or a diabetes issue. During a record review on 12/20/2022 at 8:27 AM, Progress Notes were reviewed from 09/08/2022 through 12/20/2022, and there were no notes indicating the resident had any identified skin concerns to the right heel. A review of a Nsg [Nursing] Weekly Assessment/Note with Skin audit Other, dated 12/07/2022 and signed by Licensed Practical Nurse (LPN) #13, revealed, Skin audit completed no new skin breakdown noted will continue to monitor. A review of a Nsg [Nursing] Weekly Assessment/Note with Skin audit Other, dated 12/14/2022 and signed by LPN #9, revealed, No new skin issues. A review of the Medication Administration Record [MAR] revealed, Diabetic Nail Care by licensed professional every Tuesday and prn [as needed] every day shift, had been completed on 12/20/2022 as of 8:39 AM by LPN #12. During an interview on 12/20/2022 at 8:58 AM, LPN #12 stated she worked at a sister facility and was only working at this facility while the treatment nurse was on vacation. LPN #12 stated she went to trim the resident's fingernails that morning, but they had already been trimmed. She stated she did not look at the resident's feet, only the resident's hands/fingernails. She stated another staff member was assisting the resident with getting dressed when she went to assess the resident's fingernails and stated she would come back to assess the resident later. During a concurrent interview and observation on 12/20/2022 at 10:03 AM, LPN #12 stated she assessed the resident's feet and identified a stage 3 pressure ulcer to the resident's right heel. At this time, both LPN #12 and the surveyor went into the resident's room and was granted permission to look at the resident's heel. Upon removal of the resident's shoe and sock, there was a pressure ulcer to the resident's outer right heel, measuring approximately 2 1/4 inches by 1 1/4 inches. Slough was noted around approximated edges of the wound. There was a scant amount of yellow drainage noted to the resident's sock. LPN #12 stated she had placed bordered gauze on the wound until she received further orders. Resident #24 told LPN #12 the area to the heel had caused the resident pain at night, and the resident had notified nursing staff about the area to the heel for approximately two weeks. LPN #12 stated 12/20/2022 was her first day with the resident. During an interview on 12/20/2022 at 10:27 AM, Nursing Assistant (NA) #15 stated she provided ADL care to Resident #24, which included dressing the resident. NA #15 stated Resident #24 always requested not to tie the resident's shoes too tight, and an unknown staff member had placed a bandage on the resident's right heel last week. She was unsure of the exact date when she noticed the bandage. NA #15 stated she did not notify anyone of the bandage because she thought the treatment nurse was already aware, due to the resident having the bandage. She stated if a resident were to have a new skin concern, she would notify the treatment nurse. During an interview on 12/20/2022 at 10:36 AM, Certified Nursing Assistant (CNA) #17 stated Resident #24 had never complained to her regarding any issues with the resident's feet but had complained to another nurse and/or nursing assistant. CNA #17 stated she was unsure who the resident voiced concerns to or when. CNA #17 stated she thought the nurse addressed the concern. She stated she provided ADL care to the resident, which included dressing the resident. However, the resident was always dressed when she arrived on shift, and she had not seen any skin concerns to the resident's feet. CNA #17 stated if the resident had a new skin concern, she would notify the treatment and floor nurse. During an interview on 12/20/2022 at 12:45 PM, LPN #14 stated Resident #24 told her on 12/15/2022 that they had pain in their right heel. She stated she assessed the resident's right heel, and the skin was not open. She stated she provided the resident with an as-needed pain medication and notified the treatment nurse, LPN #16. LPN #14 stated she did not document the assessment of the resident's heel in the resident's medical record on 12/15/2022. A telephone interview was attempted on 12/20/2022 at 1:10 PM with LPN #16; however, LPN #16 was on vacation and not available during the survey. During an interview on 12/20/2022 at 2:24 PM, Advanced Practice Registered Nurse (APRN) #18 stated he was not notified of Resident #24's pressure ulcer until the morning of 12/20/2022, and he would be visually assessing it on 12/21/2022. APRN #18 stated if staff identified a new skin concern, he expected staff to notify him. During an interview on 12/21/2022 at 6:10 AM, LPN #9 stated she completed skin assessments on Resident #24 every week, and the resident had never complained of any pain to that area. LPN #9 stated she was not aware the resident had a pressure ulcer and was not sure of the date of the last skin assessment that she completed. LPN #9 stated if a resident had a new skin concern, she would notify the treatment nurse and put a note in the resident's medical record. During an interview on 12/21/2022 at 12:16 PM, the Director of Nursing (DON) stated staff assessed Resident #24's skin when the resident received a shower. The DON stated staff should inspect the resident's skin daily as they provide ADLs for the resident and the treatment nurse completed the weekly skin assessments. The DON stated she was made aware of Resident #24's pressure ulcer on 12/19/2022. The DON stated the resident had never made any complaints to her regarding foot pain and if staff noticed a new skin concern or a resident complained of pain in their foot, she expected staff to report it to the nurse and then the nurse should report it to the DON. The DON stated the resident should not have had a bandage on their heel without a physician's order. The DON stated the nurse (LPN #14) should have documented when the resident complained of pain and what her assessment was and also should have told another nurse in case the resident needed to be reassessed. The DON stated she had not assessed the resident's heel. During a follow-up interview on 12/21/2022 at 12:40 PM, the DON called APRN #18. APRN #18 stated the ulcer was on the resident's foot and was either a diabetic ulcer or a pressure ulcer. APRN #18 stated the resident was going to be seen by the medical doctor on 12/22/2022. APRN #18 stated, It may have started as a pressure ulcer and developed into a diabetic ulcer. It's probably a stage 3. APRN #18 stated the resident wore their shoes tight and it may have contributed to the pressure ulcer. APRN #18 stated he was not notified until 12/20/2022. After the phone call, the DON stated the APRN should have been notified on 12/19/2022. During an interview on 12/21/2022 at 3:03 PM, the Administrator stated Resident #24's skin should be assessed daily by CNAs and weekly by the treatment nurse. The Administrator stated the pressure ulcer was discovered this week and was not sure what day. The Administrator then stated it was discovered last Wednesday, 12/14/2022, by a CNA, but was not made aware of the pressure ulcer at that time. The Administrator stated the resident had not voiced any complaints or concerns related to their feet. The Administrator stated if a pressure ulcer was identified, he expected staff to get a physician's order to treat it and should notify the family member or responsible party. During a telephone interview on 12/28/2022 at 11:05 AM, LPN #13 stated Resident #24's skin was assessed weekly, and she was not sure of the exact date when she completed the resident's skin assessment. She stated Resident #24 stayed in bed mostly and had a rubbing area on their feet and she had placed a bootie on the resident's foot to protect it, which was not on the resident's MAR. She stated the resident did not have an open area to the right foot but did have bruising. She stated the bruising started approximately two weeks ago. She did not notify anyone about it but had noticed the resident's MAR had a physician's order to address the resident's heel. LPN #13 stated if a new skin concern was identified, staff should notify the doctor and the treatment nurse.

Based on observation, record review, and interview, the facility failed to ensure a resident performed safe practices while smoking and tobacco was stored and locked up to prevent potential injury for 1 (Resident #37) of 3 (Resident #24, #30 and #37) sampled residents who smoked. The findings are: Resident #37 had diagnoses of Left Below the Knee Amputation, Diabetes Mellitus and Schizophrenia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision for bed mobility, transfer, and locomotion. a. The Care Plan with a revision date of 05/20/22 documented, [Resident's name] is a smoker . The resident requires a smoking apron while smoking . The resident's smoking supplies are stored (Activity Director office) . b. The Nsg (Nursing) Smoking Safety Screen and Care Plan dated 11/11/22 documented, .Safe to smoke without supervision Score 1.0 . RESIDENT NEED FOR ADAPTIVE EQUIPMENT: Smoking apron (checked) . Does resident need facility to store lighter and cigarettes? Yes (checked) . Resident has shown safe practices with placing apron, lights own cigarette, and understands facility smoking policies/times . Safe to smoke without supervision . c. On 12/19/22 at 10:24 AM, Resident #37 stated he was able to smoke when he wants, keep his own cigarettes, does not have to wear an apron but needs to ask a nurse for a lighter. d. On 12/20/22 at 9:05 AM, Resident #37 wheeled his self-outside in his wheelchair to an enclosed smoking area. No staff or other residents were present. He reached into his backpack grabbed a pipe and tobacco. He packed his pipe, reached in his pocket retrieved a lighter and lit his pipe. He stated the lighter was his and must return it back to the nurse. There was an open cabinet with aprons, the resident did not put one on. e. On 12/20/22 at 10:09 AM, the Surveyor asked the Assistant Director of Nursing (ADON), When residents are assessed and can smoke unsupervised, what determines this? The ADON stated, They have to have a BIMS of 15, be assessed, monitored and need to wear an apron. The Surveyor asked, Are residents allowed to keep their tobacco products on them? The ADON stated, No. The nurses keep the cigarettes and/or tobacco and supplies. They need to ask the nurse and she will give the resident his/her cigarettes. The nurses will need to go outside and light their cigarettes. The Surveyor asked, Is [Resident #37] required to wear an apron? The ADON stated, Yes. The Surveyor asked, Are staff allowed to hand the residents a lighter to take outside to light their cigarettes and return it after they are done smoking? The ADON stated, No. The ADON was asked, Are unsupervised residents allowed to keep their own tobacco products? The ADON stated, No. The ADON accompanied the surveyor to Resident #37's room. When asked the resident stated, his tobacco was in his backpack, and a nurse had given him a lighter that he returned after he was done smoking. When asked if he wears an apron, he stated to the ADON, I don't have to wear one, never have worn one. f. The facility policy titled, Smoking, provided by the Consultant (CST) on was received 12/21/22 at 12:37 PM documented, .This facility shall establish and maintain safe resident smoking practices . The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: .ability to smoke safely with or without supervision) per a completed Safe Smoking Evaluation) . The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation .

Based on observations, interviews, and facility policy review, the facility failed to ensure medications were locked and secured properly on 1 of 2 medication carts reviewed for medication storage. Findings included: A review of a facility policy titled, Storage of Medications, revised November 2020, revealed, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Observation on 12/20/2022 at 8:55 AM revealed a medication cart sitting in the East Hallway unattended, with a medication card labeled for Resident #64 containing six pills of olanzapine (an antipsychotic medication that is used to treat psychotic conditions such as schizophrenia and bipolar disorder) 2.5 milligrams (mg). There were no staff observed in the East Hallway. On 12/20/2022 a continuous observation from 8:55 AM through 9:07 AM, revealed the medication cart/olanzapine medication remained unattended until 9:07 AM when Licensed Practical Nurse (LPN) #1 entered the East Hallway and approached the medication cart. During an interview on 12/20/2022 at 9:07 AM, LPN #1 revealed all medications should have been locked inside the medication cart or in the medication room. LPN #1 indicated she had obtained the medication from the cart, was called away, and forgot to lock the medication in the medication cart. LPN #1 reported medications should not be left on top of the medication cart accessible to residents or staff. During an interview on 12/21/2022 at 9:48 AM, the Director of Nursing (DON) revealed medications should always be locked inside the medication cart or the medication room. The DON reported she expected staff to lock up medications even in an emergency to ensure medications were stored safely and not accessible to residents. During an interview on 12/21/20222 at 1:02 PM, the Administrator revealed staff were expected to always keep all medications locked and secure from residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure medical records were accurate for 1 (Resident #66) of 1 residents reviewed for tracheostomy care. Observations and record review revealed Resident #66 had a tracheostomy, but a review of the record revealed no physician's order for the care of the tracheostomy. Findings included: A review of the policy titled, Tracheostomy Care, dated August 2013, revealed in the procedure guidelines to check physician order. A review of the admission Record revealed the facility admitted Resident #66 on 11/18/2022 with a diagnosis of malignant neoplasm of the larynx. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident required limited assistance for activities of daily living (ADLs). The MDS indicated Resident #66 had received tracheostomy care and suctioning while a resident in the facility. A review of the care plan, initiated 12/19/2022, revealed Resident #66 had a tracheostomy related to impaired breathing mechanics. Interventions for the tracheostomy included to observe/document respiratory rate, depth, and quality, and to document every shift as ordered. The care plan also indicated to suction as necessary. A review of the Order Summary Report, revealed an order for oxygen at three (3) liters per minute (LPM) via tracheostomy, dated 11/18/2022. There was no physician's order for the care of the tracheostomy. On 12/20/2022 at 1:02 PM, Resident #66 was observed to have a tracheostomy in place. Oxygen and a suction machine were observed at the bedside and an interview with Resident #66 at the time of the observation indicated the resident performed their own tracheostomy care. On 12/20/2022 at 1:21 PM, Licensed Practical Nurse (LPN) #1 revealed Resident #66 did not have any physician orders for the resident's tracheostomy care. She indicated there should be orders for cleaning, suctioning, and assessment, even if the resident preferred to clean the tracheostomy themself. On 12/20/2022 at 2:26 PM, Advance Practice Registered Nurse (APRN) #18 revealed he had given an order when Resident #66 was admitted to assess the tracheostomy every shift. He indicated he was aware Resident #66 performed their own care at times, but there should be an order for care and assessment every shift and as needed per the facility policy. During an interview on 12/21/2022 at 6:27 AM, LPN #9 revealed oxygen tubing and suction equipment was changed out on Wednesday but was not documented in the medical record. LPN #9 indicated there was no order for tracheostomy care, but there should have been at least an order for care as needed. During an interview on 12/21/2022 at 7:48 AM, Minimum Data Set (MDS) Coordinator #19 revealed the direct care nurses performed the tracheostomy care, and physician orders should have been in place and followed. During an interview on 12/21/2022 at 10:00 AM, the Director of Nursing (DON) revealed a physician order should have been in place for the care of the tracheostomy. The DON revealed it was expected for physician orders to be in place for tracheostomy care and assessment. During an interview on 12/21/2022 at 1:12 PM, the Administrator revealed he expected staff to have orders in the medical record for tracheostomy care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to ensure the privacy and confidentiality of residents' medical records was maintained on 2 of 3 wings of the facility. Observations revealed residents' personal health information (PHI) was not kept secure when computers containing the resident's electronic health record (EHR) were on and the screens were not locked when staff were not present. Findings included: Review of a facility policy titled, Confidentiality of Information and Personal Privacy, revised 10/2017, indicated, 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 4. Access to resident personal and medical records will be limited to authorized staff and business associates. During a concurrent observation and interview on 12/19/2022 at 9:45 AM, a facility desktop computer located in the dining room between East Wing and [NAME] Wing was observed on, and the computer screen was not locked. The screen displayed Resident #15's name, picture, date of birth , room number, allergies, code status, and current physician's orders, which included pressure ulcer care. The top right of the screen indicated Licensed Practical Nurse (LPN) #1 was logged in to the resident's EHR. There were four residents (cognitive status unknown) who were sitting in the dining room. Between 9:45 AM and 9:56 AM, LPN #3, Certified Nursing Assistant (CNA) #4, CNA #5, Dietary Manager (DM) #6, DM #7, CNA #2, LPN #1, Case Manager (CSM) #8, and the Administrator all walked by the computer displaying Resident #15's EHR and did not close or minimize the screen. At 9:56 AM, CNA #2 sat down at the computer and minimized the screen. In an interview at this time, CNA #2 stated LPN #1 was logged into the resident's EHR, and staff should log out of the EHR/computer before leaving the computer. During an interview on 12/19/2022 at 10:56 AM, LPN #1 stated that leaving the resident's EHR visible was an honest mistake, and she normally locked the screen. She stated she was in a rush. During a concurrent observation and interview on 12/20/2022 at 6:44 AM, a facility desktop computer located in the dining room between East Wing and [NAME] Wing was observed on and the computer screen was not locked. The screen displayed a list of residents that included their name, room number, admission date, and payor source. The residents on display were Residents #3, #6, #44, #40, #57, #28, #2, #39, #48, #31, #19, #72, #1, #20, #14, #60, #11, #35, #37, and #12. The top right of the screen indicated LPN #9 was logged in to the EHR. There were four residents (cognitive status unknown) who were sitting in the dining room. At 6:46 AM, LPN #3 approached the computer. In an interview at this time, LPN #3 stated the computer screen should be locked or the staff member should log out of the computer. She stated LPN #9 was working the medication cart down the hall. At 6:49 AM, LPN #9 stated she had provided LPN #12 with her login information because LPN #12 did not have a login to the EHR, and that LPN #12 should have locked the computer screen or logged out of the EHR. During an interview on 12/20/2022 at 8:58 AM, LPN #12 stated she had her own login credentials to the EHR and did not use any other staff's login credentials. She stated LPN #9 had logged in to the computer and showed LPN #12 a physician's order for a resident. LPN #12 stated staff should lock the computer screen before walking away. During a concurrent observation and interview on 12/20/2022 at 10:49 AM, the nurse's desk on [NAME] Hall, located next to a set of double doors and across the hall diagonally from room [ROOM NUMBER], contained a facility desktop computer that had an unlocked screen and was visible to passersby. The screen contained Resident #1's profile screen that included the resident's name, picture, date of birth , allergies, code status, and emergency contact's name and phone numbers. The top right of the screen indicated LPN #14 was logged in to the EHR. At 10:51 AM, LPN #14 approached the desk and stated she should have locked the screen before leaving the computer. During an interview on 12/21/2022 at 12:16 PM, the Director of Nursing (DON) stated if staff were logged into the EHR and walked away from the computer, they should either close out of the EHR or close the laptop to protect the resident's records so no one could see it. During an interview on 12/21/2022 at 3:03 PM, the Administrator stated if staff were logged into the EHR and walked away from the computer, they should lock the computer screen to ensure privacy of the resident's medical record.

Based on observation, record review, and interview, the facility failed to ensure residents fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 (Residents #49 and #16) of 4 (Residents #15, #16, #47 and #49) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #49 had diagnoses of Diabetes Mellitus and Dementia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required total physical assistance of one person with personal hygiene and bathing. a. The Care Plan with a revision date of 12/12/22 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . b. Resident #49's ADL bathing log documented the resident received a bed bath on 12/17/22. c. On 12/19/22 at 8:38 AM, Resident #49 was resting in bed. The fingernails on her left thumb, middle and pinkie finger were jagged and extended approximately 1/3 inch from her fingertip. The fingernails on her right hand were jagged and were approximately 1/3 inch long with a brown substance under the nail tips. d. On 12/20/22 at 8:12 AM, the Surveyor asked Certified Nursing Assistant (CNA) #21, Who performs the resident's nail care? CNA #21 stated, The CNAs, if diabetics the nurses have to file and trim them. The Surveyor asked, When is the resident's nail care completed? CNA #21 stated, Daily. e. On 12/20/22 at 8:19 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Who performs the resident's nail care? LPN #1 stated, The CNAs, nurses have to trim and file if diabetics. The Surveyor asked, When is the resident's nail care completed? LPN #1 stated, Shower days and as needed? f. On 12/20/22 at 8:21 AM, LPN #1 accompanied the Surveyor to Resident #49's room, the Surveyor asked, Can you describe her nails? LPN #1 stated, On her left hand her thumb, middle and little finger are approximately 1/3 inch long and jagged. On her right hand all nails are approximately 1/3 inch long, jagged and need to be cleaned. The Surveyor asked, What is that brown substance under her nail tips? LPN #1 stated, I do not know. The Surveyor asked, Is the resident in need of nail care? LPN #1 stated, Yes. The Surveyor asked, Who is responsible to ensure her nail care is completed as needed? LPN #1 stated, The weekend supervisor and treatment nurse. 2. Resident #16 had diagnoses of Dementia and Diabetes Mellitus. The Annual MDS with an ARD of 9/14/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and required total physical assistance of one person with personal hygiene and bathing. a. The Initial Care Plan dated 3/30/16 documented, The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Dementia . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . b. Resident #16's ADL log for bathing documented the resident received a shower on 12/17/22. c. On 12/19/22 at 9:42 AM, Resident #16 was resting in bed with his hands resting on his chest. His hands were contracted in a fist position with rolled wash cloths in them. The resident's thumb nails were visible and were approximately 1/3 inches long from the fingertip. d. On 12/20/22 at 8:24 AM, LPN #1 accompanied the Surveyor to Resident's #16's room. The resident was resting in bed, hands with wash clothes in place. The Surveyor asked LPN #1, Can you describe the resident's nails to me? LPN #1 stated, On the right hand they are approximately 1/2 inch long and jagged. Same for the left hand. They need to be trimmed. The Surveyor asked, Who is responsible to ensure his nail care is completed as needed? LPN #1 stated, The weekend supervisor and treatment nurse. e. On 12/21/22 at 1:34 PM, the Surveyor asked the Director of Nursing (DON), Who performs diabetic nail care on the residents? The DON stated, The treatment and floor nurses, the CNAs can clean their nails. The Surveyor asked, When is the resident's nail care completed? The DON stated, Shower days and as needed. The Surveyor asked, Who is responsible to ensure nail care is being completed as needed? The DON stated, The treatment nurse and me. f. On 12/21/22 at 12:37 PM, the facility policy titled, Fingernails/Toenails, Care of, provided by Consultant (CST) #11 on 12/21/22 at 12:37 PM documented, .The purpose of this procedure are to clean the nail bed, to deep nails trimmed, and to prevent infections . Nail care includes daily cleaning and regular trimming . Proper nail care can aid in the prevention of skin problems around the nail bed . Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin .

Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the medication error rate was not 5% or greater. Observations revealed there were 3 medication errors out of 28 opportunities for error observed for 3 (Resident #4, Resident #23, and Resident #26) of 3 residents, which resulted in a medication error rate of 10.71%. Findings included: A review of the facility policy titled, Administering Medications, revised April 2019, revealed, Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. 1. During a medication administration observation on 12/20/2022 at 7:10 AM, Licensed Practical Nurse (LPN) #14 prepared medications for Resident #4. The following medications were prepared and given to the resident: - aspirin 81 milligrams (mg) enteric coated, one tablet - atenolol 50 mg, one tablet - chlorthalidone 50 mg, one tablet - isosorbide ER 30 mg, one tablet - Jardiance 10 mg, one tablet - Lisinopril 20 mg, one tablet - metformin 500 mg, one tablet - Zyrtec 10mg, one tablet - stool softener, one capsule - multivitamin with minerals, one tablet - Novolin N 100 units/ml (milliliters), 23 units subcutaneous A record review of Resident #4's December 2022 medication administration record and physician Order Listing revealed a revised order, dated 01/02/2022, for an aspirin 81 mg chewable tablet instead of an aspirin 81 mg enteric-coated tablet. During an interview on 12/20/2022 at 12:44 PM with LPN #14, she revealed she had administered an enteric-coated aspirin to Resident #4, and the order was for chewable aspirin. LPN #14 reviewed the orders and confirmed the order was for a chewable aspirin. LPN #14 indicated the bottle for the chewable aspirin in the medication cart was empty, so she just administered an 81 mg tablet and did not realize it was enteric coated. 2. During a medication administration observation on 12/20/2022 at 7:37 AM, Licensed Practical Nurse (LPN) #1 prepared medications for Resident #23. The following medications were prepared and given to the resident: - Tylenol 325 milligrams (mg), two tablets - iron 325 mg, one tablet - folic acid 1 mg, one tablet - Celebrex 100 micrograms (mcg), one capsule - vitamin D 10 mg tablet equal to 400 units, two tablets - metoprolol ER 100 mg, one tablet A record review of Resident #23's December 2022 medication administration record and physician Order Listing revealed an order, dated 01/02/2022, for cholecalciferol tablet (vitamin D) 1000 units which directed staff to give two tablets for vitamin D deficiency. During the medication administration, Resident #23 received a total of 800 units of cholecalciferol (Vitamin D) instead of the 2000 units that were ordered. During an interview on 12/20/2022 at 1:33 PM, LPN #1 reviewed the physician order for cholecalciferol and revealed the order was for two tablets of 1000 units, one time a day. LPN #1 indicated she had only given 800 units and 1000-unit tablets were not available. 3. During a medication administration observation on 12/20/2022 at 8:15 AM, Licensed Practical Nurse (LPN) #14 prepared medications for Resident #26. The following medications were prepared and given to the resident: - bromodine tartrate eye drop, one drop in each eye - Celexa 20 mg (milligram), one tablet - Lasix 40 mg, one tablet - potassium ER 10 milliequivalents (mEq), one tablet - quetiapine 50 mg, one tablet - cranberry 450 mg, one tablet - Flonase, one spray in each nostril - MiraLAX 17grams, one capful - hydralazine 25 mg, one tablet - Incruse ellipta inhaler 62.5 mg, one inhalation - cholecalciferol (Vitamin D) 400 units, two tablets A record review of Resident #26's December 2022 medication administration record and physician Order Listing revealed an order, dated 01/01/2022, for cholecalciferol tablet (vitamin D) 1000 units which directed staff to give one tablet for vitamin D deficiency. During medication administration, Resident #26 received two tablets of the 400-unit Vitamin D to equal 800 units. During an interview on 12/20/2022 at 12:48 AM, LPN #14 revealed she administered two tablets of Vitamin D 10 mcg, equivalent to 400 units, which equaled 800 units to Resident #26. LPN #14 indicated the amount of medication that was given was not what the physician ordered, and orders should be followed to administer the correct amount of medication. During an interview on 12/21/2022 at 9:48 AM, the Director of Nursing (DON) revealed it was expected for staff to follow the five rights of medication administration and to ensure everything was correct by reading the orders and verifying the medication was the correct dosage as ordered by the physician. During an interview on 12/21/2022 at 1:02 PM, the Administrator revealed it was expected for the staff to follow the five rights of medication administration and to follow the physician orders as prescribed.

Based on record review and interview, the facility failed to ensure three partially vaccinated staff members completed their primary vaccination series in 60 days to prevent the potential spread of COVID-19. This failed practice had the potential to effect 64 residents according to the Resident Matrix provided by the Administrator on 12/19/22 at 11:05 AM. The findings are: 1. On 12/21/22 at 9:18 AM, The COVID-19 Staff Vaccination Status for Providers provided by the Consultant (CST) #11 on 12/21/22 at 9:18 AM documented, 4 staff members out of 169 were partially vaccinated. 2. The Healthcare Personnel COVID-19 Vaccination Cumulative Summary Tracking Worksheet provided by CST #11 on 12/21/22 at 9:18 AM documented, Licensed Practical Nurse (LPN) #9 was hired on 10/20/22 and was vaccinated with the Moderna Vaccine, dose #1 of on 10/18/22. Nursing Assistant (NA) #15 was hired on 9/21/22 and was vaccinated with the Moderna Vaccine, dose #1 on 8/26/22. Hospitality Aide #20 was hired on 11/23/22 and was vaccinated with the Moderna Vaccine, dose #1 on 9/20/22. 3. The COVID-19 Vaccination Record Cards for LPN #9, NA #15, and Hospitality Aide #20 provided by CST #11 on 12/21/22 at 10:15 AM documented, LPN #9, .1st Dose COVID-19 . Moderna . 10/18/22 . 2nd Dose was blank. NA #15, .1st Dose COVID-19 . Moderna . 8/26/22 . 2nd Dose was blank. Hospitality Aide #20, .1st Dose COVID-19 . Moderna . 9/20/22 . 2nd Dose was blank. 4. On 12/21/22 at 11:43 AM, The November 2022 and December 2022 staffing schedule provided by CST #11 documented the following: a. The November 2022 schedule documented Hospitality Aide #20 worked 4 days with the last day worked 11/30/22. b. The December 2022 schedule documented LPN #9 worked 11 days with the last day worked 12/20/22. NA #15 worked 13 days with the last day worked 12/20/22. 5. On 12/21/22 at 3:12 PM, the Surveyor asked CST #11, When are staff required to have their primary vaccination series completed? CST #11 stated, Within 60 days. The Surveyor asked, What will happen if staff do not comply? CST #11 stated, They are removed from the schedule until the primary vaccination series are completed. The Surveyor asked, According to the November and December staffing schedule, was LPN #9, Hospitality Aide #20, and NA #15, removed from the schedule when they did not complete their primary vaccination series in 60 days? CST #11 stated, No. 6. The facility policy titled, Coronavirus Disease (COVID-19) - Vaccination of Staff, provided by CST #11 documented, .All staff are required to be fully vaccinated for COVID- 19 . Phase 1: All staff are required no later than 30 days from the CMS [Centers for Medicare and Medicaid Services] Memorandum applicable to the state to: .have received a single dose of COVID-19 vaccine; or . have received the initial dose of a primary vaccination series; .Phase 2: All staff are required no later than 60 days from the CMS Memorandum applicable to the state to: .have completed a primary vaccination series; or . have been granted a qualifying exemption; .Staff who refuse to comply with these requirements are placed on unpaid administrative leave .When COVID-19 vaccines are administered in two (2) doses, individuals who receive the first vaccine are automatically scheduled for a second dose . The second dose of the Moderna vaccine is administered no sooner than 28 days after the first dose . Second doses . are given no later than 6 weeks (42 days) after the first dose .