**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Informed Consent, for the use of wander guard alarm (a system of wearable bracelets and sensors that helps keep residents safe in healthcare facilities) for one of three sampled residents (Resident 59). This failure violated Resident 59's right and placed Resident 59 at risk for psychological distress related to the discomfort from wearing the alarm and the sound of the alarm. Findings: During a review of Resident 59's admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), unsteadiness (pattern of walking that's unstable) on feet, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 59's Elopement Risk (ER), dated 12/22/2024, the ER indicated Resident 59 was at risk for elopement. During a review of Resident 59's Minimum Data Sheet (MDS, a resident assessment tool), dated 1/6/2025, the MDS indicated, Resident 59 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 59 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing; and partial/moderate assistance (helper did less than half the effort) with toileting, shower, lower body dressing and personal hygiene. During an observation on 2/18/2025 at 10:47 am in the dining room, Resident 59 was sitting on his wheelchair with wander guard alarm bracelet on his right wrist. During a concurrent interview and record review on 2/20/2025 at 10:51 am with Licensed Vocational Nurse 4 (LVN 4), Resident 59's medical records (chart) and PointClickCare (PCC, a cloud-based software platform) were reviewed. LVN 4 stated there was no documented evidence that consent was obtained before the application of a wander guard. LVN 4 stated consent should be obtained to make sure the resident or his responsible party was informed and purpose on the use of wander guard was explained. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, the use of a wander guard alarm system involved a prolonged use of a device and should be consented before its application. DON stated the risks and benefits of using the device should be explained to prevent causing anxiety and discomfort from wearing the device and its sound. During a review of the facility's policy and procedure (P&P) titled, Resident Alarms, revised 12/19/2022, the P&P indicated, The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary. During a review of the facility's P&P titled, Informed Consent, revised 12/19/2022, the P&P indicated, When situations arise that involve complex decisions, the facility will verify that informed consent had been obtained prior to any medical intervention or treatment is initiated, including, but not limited to, administration of psychotherapeutic medications, application of a physical restraint or the prolonged use of a device that may lead to the inability to regain use of a normal body function and for transfer and discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call light was within reach for one of one sampled resident (Resident 89). This failure had the potential for Resident 89 not to received necessary care and services and put Resident 89 at risk for fall. Findings: During a review of Resident 89's admission Record (AR), the AR indicated Resident 89 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss on interest or pleasure in activities) and unsteadiness on feet (gait instability). During a review of Resident 89's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2025, the MDS indicated, Resident 89 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 89 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and toileting hygiene, shower, upper, lower body dressing and personal hygiene. During a revie w of Resident 89's undated Care Plan (CP), the CP indicated Resident 89 was at risk for falls. The CP interventions included to place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. The CP indicated Resident 89 needed prompt response to all requests for assistance. During a concurrent observation and interview on 2/18/2025 at 10:09 am with Certified Nurse Assistant 1 (CNA 1) inside Resident 89's room, Resident 89 was lying in bed with the call light hanging on the wall. Resident 89 stated she did not know where the call light was. CNA 1 stated Resident 89's call light should be placed next to Resident 89 where the resident could see the call light and able to call staff when Resident 89 needs help. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, call light should be within easy reach of the resident. by the bedside to be utilized when needed and needs could be addressed immediately. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised 12/19/2022, the P&P indicated, The purpose of this policy is to assure the facility is adequately equipped with a call lights. The P&P indicated staff will ensure the call light is within reach of residents and secured, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the Level I Pre-admission Screening and Resident Review (PASRR) for one of 21 sampled residents (Resident 5) that were in the facility for more than 30 days. This failure had the potential to place the resident at risk for delayed care and to not receive care and services for a mental or intellectual disability. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility readmitted Resident 5 to the facility on 1/27/25 with diagnoses that included malignant neoplasm of esophagus (cancer of the tube that runs from the throat to the stomach) and bipolar disorder (episodes of mood swings from depressive lows to manic highs). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 2/3/25, the MDS indicated Resident 5 was severely cognitively impaired (ability to understand and process thoughts), and was totally dependent in lower body dressing and personal and toileting hygiene. During a record review of Resident 5's clinical record, Resident 5's clinical record indicated on 6/13/23, Resident 5's Pre-admission Screening and Resident Review I (PASARR- a federal requirement to determine need and appropriate setting for services) evaluation result was positive, and Resident 5 required a PASARR II evaluation. During an interview, on 2/21/25, at 12:21 p.m., with Admissions Coordinator (AC), the AC stated the AC completes admission and screens resident for PASARR I. The AC stated the AC usually receives the patient from the hospital so AC requests PASARR I from the hospital and AC gives PASARR I to the Minimum Data Set Assistant (MDS A). The AC stated MDS A is responsible for PASARR II. During an interview and record review of Resident 5's PASARR I, on 2/21/25, at 12:34 p.m., with MDS A, MDS A stated the PASARR I is triggered for residents with psychiatric diagnosis or medication or mentally disabled. The PASARR Department (PD) contacts MDS A for additional information or may interview resident, review medications, and confirm if on 5150 hold (involuntary psychiatric detention) of if on any lockdown. After the PASARR I is reviewed by the PD, the PD will update the facility, and a screen letter and determination letter are entered in the PASARR system. The MDS A stated if the resident discharges and returns, a new PASARR I screening is completed by MDS A to trigger another PASARR II and the resident is treated like a new admission because they may have a different diagnosis or medication. The MDS A stated another PASARR I evaluation should have been completed for Resident 5 upon readmission by Admissions, MDS A, or from the hospital to determine if a PASARR II was still needed. MDS A stated PASARR is used to determine if the resident needs the services, psychiatric evaluation or psychiatric services. MDS A stated there should have been a PASARR I screening completed between 6/13/23 and 1/28/25 for Resident 5 due to Resident 5 was readmitted and in facility for more than 30 days. MDS A stated Resident 5 was readmitted to the facility on [DATE] and 5/6/24 from the hospital and there was no PASARR I completed for Resident 5. During a record review of the facility's Policy and Procedure (P&P), titled, Resident Assessment-Coordination with PASARR Program, dated 2022, the policy and procedure indicated all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. Exceptions to the preadmission screening program include those individuals who: a. Are admitted directly from a hospital. b. Are admitted directly from the hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to develop a care plan (CP) for the use of Zoloft (medication used to treat depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities]) for one of one sampled resident (Resident 41). This failure had the potential for inconsistency of care for Resident 41 and risk for unnecessary psychotropic medication use. Findings: During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder and hypertension (high blood pressure). During a review of Resident 41's History and Physical (H&P) dated 11/2/2023, the H&P indicated Resident 41 had the capacity to understand and make decisions. During a review of Resident 41's Order Summary Report (OSR) dated 10/24/2024, the OSR indicated Resident 41 had an active order for Zoloft 50 milligrams (mg, unit of measurement) once a day for depression, manifested by verbalization of sadness. During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment tool) dated 12/5/2024, the MDS indicated Resident 41's had moderately impaired cognitive abilities (ability to think, learn and process information). During a concurrent interview and record review on 2/20/2025 at 10:59 AM with Registered Nurse Supervisor 2 (RN 2), Resident 41's medical record was reviewed. RN 2 stated there was no CP for the use of Zoloft and stated there should be a CP so that staff can monitor if the medication was working and to guide the staff on consistently implementing specific interventions for Resident 41. During an interview on 2/20/2025 at 2:47 PM with the Director of Nursing (DON), the DON stated there was no CP for Zoloft use for Resident 41. The DON stated there should be a CP so that staff would implement interventions for monitoring the effectiveness of the medication for Resident 41. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Plans revised 12/19/2022, the P&P indicated the comprehensive CP will include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. The objectives will be utilized to monitor the resident's progress and alternative interventions will be documented as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident with management for constipation for five days (2/15/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25) for one of one sampled resident (Resident 142). This failure resulted in a delay in receiving necessary care & services to manage Resident 142 constipation and had the potential to result in adverse consequences for Resident 142. Findings: During a review of Resident 142's admission Record (AR), the AR indicated the facility admitted the resident on 7/1/24 and readmitted on [DATE] with diagnoses that included othopedic aftercare following surgical amputation (care provided following a medical procedure that involves removal of a body part) and obesity (excessive accumulation of body fat). During a review of Resident 142's History & Physical (H&P) dated 2/16/25, the H&P indicated Resident 142 had the capacity to make medical decisions. During a review of Resident 142's Minimum Data Set (MDS, a resident assessment tool) dated 2/18/25, the MDS indicated Resident 142 had moderately impaired cognition (ability to understand and process thoughts) and required supervision or touching assistance with upper body dressing, dependent for lower body dressing and toileting hygiene. During an interview on 2/18/25, at 10:54 a.m., with Resident 142, Resident 142 stated Resident 142 had constipation. Resident 142 stated Resident 142 did not have bowel movement (BM) since the previous Wednesday, 2/12/25 while in the hospital. Resident 142 stated Resident 142 was taking Norco but does not want Norco because of the side effects of constipation. During a concurrent interview and record review on 2/20/25 at 10:47 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 142 complained of constipation and LVN 2 administered Milk of Magnesia (MOM) on 2/19/25 at 12:00 p.m. with no bowel movement (BM) result. LVN 2 stated residents were rechecked/reassessed in about an hour after medications are given to determine medication effectiveness. LVN 2 stated LVN 2 did not document effectiveness of MOM on Resident 142's MAR. LVN 2 stated LVN 2 was assigned to Resident 142 on 2/18/25 and 2/19/25. LVN 2 stated LVN 2 saw in the resident's medical record that Resident 142 did not have a BM for three days. LVN 2 stated, usually there was a standing Physician's Order (MDO) that if MOM was ineffective, licensed staff needed to give a suppository or maybe enema but Resident 142 did not have this order. LVN 2 stated, for Resident 142, if the medication was ineffective, the physician should have been notified. Resident 142's MAR and Progress Notes indicated there was no follow up or additional medication given for constipation for Resident 142 on 2/19/25 and LVN 2 did not call the physician to report medication ineffectiveness. LVN 2 stated, constipation would affect Resident 142's health and could result in complications and patient discomfort. During a review of Resident 142's MAR for 2/1/25 -2/28/25, the MAR indicated Resident 142's last BM was on 2/14/25. The MAR indicated MOM was not given on 2/15/25, 2/16/25, 2/17/25, and 2/18/25. During a review of Resident 142's Pain Management Care Plan (CP) undated, the CP indicated for staff to monitor, document, and report adverse reaction to analgesic therapy. During a review of the facility's Policy and Procedure (P&P), titled, Provision of Quality Care, dated 2022, the P&P indicated each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility's policy on foley catheter (FC, thin flexible tube that is inserted into the bladder to drain urine) care for one of one sampled resident (Resident 50) by failing to ensure the FC port was changed when visibly soiled and ensure a FC securement device was placed as ordered. These failures had the potential to put Resident 50 at risk for infection and injury. Findings: During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH, medical condition which the prostate grows making it difficult to urinate) and sepsis( life-threatening condition that arises when the body's response to infection injures its own tissues and organs). During a review of Resident 50's History and Physical (H&P) dated 8/11/2024, the H&P indicated Resident 50 did not have the capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set (MDS, a standardized assessment tool) dated 12/2/2024, the MDS indicated Resident 50 had severely impaired cognitive abilities (ability to learn, think, and process information). The MDS indicated Resident 50 had an indwelling catheter (FC). During a review of Resident 50's untitled and undated Care Plan (CP), the CP indicated Resident 50 had an indwelling catheter and indicated to apply the catheter stabilization device to ensure the FC was in place and to place a secure device immediately if not on. During a review of Resident 50's Order Summary Report (OSR) dated 12/11/2024, the OSR indicated an order for licensed staff to apply a catheter stabilization device to ensure the FC was in place. During a concurrent observation and interview on 2/18/2025 at 11:16 AM with the Infection Prevention Nurse (IPN), Resident 50s' FC port was observed with brown substance and the FC did not have a securement device. The IPN stated the brown substance looked like feces on the FC port. The IPN stated there was no FC securement device. The IPN stated the visibly soiled FC could put the resident at risk for infection. The IPN stated, without a securement device, the resident could be at risk of injury because the FC could be pulled out by accident. During an interview on 2/19/2025 at 3:13 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated licensed nurses needed to ensure a securement device was on for a FC. LVN 4 stated FC could be pulled out by accident if there was no securement device. LVN 4 stated if the FC becomes soiled, it should be changed immediately because it would put the resident at risk for infection because the tube goes directly to the bladder. During an interview on 2/20/2025 at 2:50 PM with the Director of Nursing, the DON stated if the FC was visibly soiled staff should inform the Registered Nurse Supervisor to change it as soon as possible. The DON stated if the FC was not changed, it could put the resident at risk for infection. The DON stated if the FC securement device was not on as ordered by the physician, the FC could be pulled by accident and cause injury to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Catheter Care revised 12/19/2022, the P&P indicated the facility will ensure residents with indwelling catheters receive appropriate catheter care and maintain dignity and privacy when indwelling catheters are in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 16) who was receiving tube feeding (TF, liquid form of nutrients given to people who cannot eat or drink by mouth safely) through a gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach, can be used to give nutrition and/or drugs), did not have the TF running while the resident was being changed in the supine (lying horizontally on the back with face and torso upward) position. This failure had the potential to result in Resident 16 aspirating (when small particles of food or drops of liquid are breathed into the lungs), which could cause aspiration pneumonia (an infection that occurs in the lungs due to aspiration) and other serious complications. Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was readmitted on [DATE] with diagnoses that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 16's Care plan (CP), revised on 12/13/2023, indicated Resident 16 required TF related to dysphagia (difficulty swallowing), swallowing problems, cerebral palsy, and intestinal obstruction which required surgery. The CP indicated, Resident 16 was at high risk for multiple complications including nausea, vomiting, and aspiration. The CP indicated, the HOB should be elevated at least 30-45 degrees during and thirty minutes after TF. During a review of Resident 16's History and Physical (H&P), dated 2/20/2024, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 11/20/2024, the MDS indicated Resident 16 was rarely/never understood and while a resident (performed while a resident of the facility and within the last 7 days) Resident 16 had a feeding tube. During a review of Resident 16's Braden Scale for Predicting Pressure Ulcer Risk Evaluation (BS -tool used for assessing residents' risk of development of pressure ulcers-localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), dated 11/20/2024, the BS indicated Resident 16 's mobility (ability to change and control body position) was assessed as completely immobile and the resident did not make even slight changes in body or extremity position without assistance. During a review of Resident 16's Nutritional Assessment (NA), dated 2/10/2025, the NA indicated Resident 16's type of TF was a gastrostomy tube (GT) needed for dysphagia. During a review of Resident 16's Physician Orders Summary Report (PO), dated 2/19/2025, the PO indicated Resident 16 had an active order for a continuous TF of Fibersource HN (a feeding containing fiber that is nutritionally complete) or the equivalent, to infuse at rate of 45 milliliters per hour (ml/hr.) for 20 hours, to start at 2 pm and continue until the dose is infused, ordered on 2/12/2025. During a concurrent observation and interview on 2/18/2025 at 11:46 am with Licensed Vocational Nurse 1 (LVN 1), Resident 16's TF was infusing while the CNA was changing the resident. The resident was lying in the supine position. LVN 1 stated, she paused the TF pump for 7-10 minutes and it restarted. LVN 1 stated, the TF should be paused when changing the resident to prevent her from choking or aspirating, which could lead to difficulty breathing and further complications to the resident. During an interview on 2/18/2025 at 12:18 pm with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated he changed Resident 16 and asked them to pause it for 10 minutes and the TF started running again, stating sometimes they need more time. CNA 2 stated, he cleaned Resident 16 frequently, approximately every two hours. During an interview on 2/21/2025 at 10:23 am with the Director of Nursing (DON), the DON stated the TF needs to be turned off by the licensed nurse when changing a resident. The DON stated, receiving a TF while a resident was supine could cause aspiration of the TF and could lead to something more serious. During a review of the facility's policy and procedure (P&P) titled, Verifying Placement of Feeding Tube, last revised 12/19/2022, the P&P indicated, the resident's head-of-bed (HOB) should be kept elevated a minimum of 30 degrees at all times during the administration of feedings or medications to prevent aspiration and pneumonia, unless otherwise specified in medical orders or contraindication for other reasons.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 22) had pharmacy recommendations that were signed and dated by the attending physician. This deficient practice had the potential to result in a delay in necessary services, poor continuity of care, and a delay in follow-up on the resident's status. Findings: During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was readmitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 22's History and Physical (H&P), dated 7/12/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 12/31/2024, the MDS indicated Resident 22 had severely impaired cognition and used a wheelchair for mobility. During a concurrent interview and record review on 2/19/2025 at 11:22 am with the Medical Record Director (MRD), Resident 22's Skilled Nursing Pharmacy Recommendations (SNPR) for September 2024 and December 2024 that were flagged in the medical record needing physician signing were reviewed. The September 2024 SNPR indicated, the physician response was undated by Resident 22's attending physician, and the December 2024 SNPR physician response lacked a physician signature and date. The MRD stated, the pharmacy recommendations should be signed and dated by the doctor by the end of the month to indicate if they want to continue or discontinue the pharmacy recommendations. The MRD stated, she believed the physician visited in January 2025 but was unable to find a record of the visit. The MRD further stated, Resident 22's last attending physician note in the medical record was dated 12/28/2024. During an interview on 2/21/2025 at 10:18 am with the Director of Nursing (DON), DON stated during physician visits, the physician should sign the patient's pharmacy recommendations. DON further stated, a signed SNPR was important to indicate physician's evaluation and acknowledgement of their pharmacy recommendations. During a review of the facility's policy and procedure (P&P) titled, Physician Services, last revised 12/19/2022, the policy indicated it was the facility's policy that the medical care of each resident to be under the supervision of a licensed physician. The P&P indicated, physician orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy.

Based on observation, interview, and record review, the facility failed to ensure staffing information on the Nurse Staffing Sheet (posted information that contains the facility's current resident census and total number and actual hours worked by licensed and unlicensed nursing staff) was posted in a prominent place readily accessible to residents and visitors for one of two nursing stations. This failure resulted in nurse staffing information being inaccessible to other residents at the opposite side of the facility. Findings: During observations on 2/18/2025 at 9:10 am, 2/19/2025 at 11:15 am, and 2/20/2025 at 10:30 am, the Nurse Staffing Sheet was only posted at the reception desk near the entrance in the facility across from Nursing Station A. During an interview on 2/20/2025 at 11:30 am with the Director of Staff Development (DSD), the DSD stated staffing was only posted in the reception area and there were no other postings within the facility. The DSD stated, the posting was accessible to visitors and residents who visited the front lobby, but wasn't readily accessible to residents at the other side of the facility by Nursing Station B. During an observation on 2/21/2025 10:01 am, staffing information was only posted at the reception desk near the entrance in the facility. During an interview on 2/21/2025 11:19 am with the DSD, DSD stated the staffing posting was only at the reception desk, and it should also be posted at Nursing Station B to make it more visible and accessible to the other residents. During a review of the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, last revised 9/16/2024, the policy indicated it was the policy of the facility to make nurse staffing information was posted in a prominent place readily accessible to residents and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the informed consent was signed for the use of Trazodone 50 milligrams (mg, unit of measurement) every night for insomnia (difficulty falling asleep) for one of five sampled residents (Resident 31). This failure had the potential for unnecessary psychotropic medication (drug affecting how the brain works and causes changes in mood, feelings and behavior) for Resident 31. Findings: During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (persistent pain that lasts for at least three months and significantly impacts a person's life) and low back pain. During a review of Resident 31's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31's Order Summary Report (OSR) dated 12/10/2024, the OSR indicated Resident 31 had an active physician's order for Trazodone 50 mg at night for insomnia. During a review of Resident 31's Minimum Data Set (MDS, a standardized assessment tool) dated 1/2/2025, the MDS indicated Resident 31 had intact cognitive abilities (ability to think, learn, and process information). During a concurrent interview and record review on 2/18/2025 at 11:40 AM with Registered Nurse Supervisor 1 (RN 1), Resident 31's Physician Document of Informed Consent (PDIC) form for Trazodone dated 12/10/2024 was reviewed. RN 1 stated Resident 31 did not sign the PDIC form for Trazodone. RN 1 stated if the PDIC was not signed, the risks and benefits of Trazodone were not discussed with the resident and placed the resident at risk for unnecessary medication use. During an interview on 2/20/2025 at 2:33 PM with the Director of Nursing (DON) the DON stated the PDIC form for Trazodone was not signed by Resident 31. The DON stated the PDIC form needed to be signed by the resident to indicate the resident understood the risk and benefits of the medication and if there were any alternatives the resident would want to try first. During a review of the facility's Policy and Procedure (P&P) titled, Use of Psychotropic Medication revised on 12/19/2022, the P&P indicated residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing traumatic event). During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated, Resident 17 had a moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 17 required substantial/maximal assistance (helper did more than half the effort) with oral and toileting hygiene, shower, and personal hygiene. During a concurrent interview and record review on 2/19/2025 at 12:11 pm with the Social Services Director (SSD), Resident 17's Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life), dated 11/3/2021, and Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgement Form, dated 7/4/2024 were reviewed. The SSD stated the POLST indicated Resident 17 had no AD. The SSD stated the ADA Form indicated Resident 17 had not executed an AD. The ADA Form had a written note that Resident 17 wished to have an AD in place. The SSD stated there were no records indicated that Resident 17's family member was followed up on an AD or arrangement was done to formulate an AD. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated AD should be in Resident 17's chart (medical record) upon Resident 17's admission. The DON stated the AD helped staff to determine Resident 17's wishes and preferences regarding care in the facility. During a review of the facility's policy and procedure (P&P) titled, Resident Rights Regarding Treatment and Advance Directives, revised 12/19/2022, the P&P indicated, On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Based on interview and record review, the facility failed to follow the facility's policy on Advance Directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three of three sampled residents (Residents 17, 28 and 31) by failing to: 1. Ensure Residents 28 and 31's Advance Directive Acknowledgement Form (ADA) was filled out. 2. Ensure a copy of Resident 17's AD was in the medical chart. These failures had the potential for Residents 17, 28 and 31's preferences not carried out by the facility staff, affecting the residents quality of life. Findings: a. During a review of Resident 31's admission Record (AR), the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and lower back pain. During a review of Resident 31's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 4/18/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a concurrent interview and record review on 2/18/2025 at 11:43 AM with the Social Services Director (SSD), Resident 31's ADA form dated 4/15/2024 was reviewed. The SSD stated the ADA form was not filled out completely and stated there should be a check mark on the form if Resident 31 did or did not have an AD. The SSD stated the risk of not completing the ADA form was that the facility could provide services that were not in accordance with the resident's AD if the resident had formulated an AD. During an interview on 2/20/2025 at 2:30 PM with the Director of Nursing (DON), the DON stated the ADA forms should be filled out completed to indicate the facility inquired if the resident had an AD. The DON stated, the resident would receive the wrong services and the facility would not know the resident's preferences in receiving care during emergency if the ADA form was not filled out. c). During a review of Resident 28's admission Record (AR), the AR indicated Resident 28 was originally admitted into the facility on 9/14/2024 and readmitted into the facility on [DATE] with diagnoses that included depression (a mood disorder that may cause persistent sadness or loss of interest in activities) and chest pain. During a review of Resident 28's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated 9/23/2024, the POLST indicated Resident 28 had a legally recognized decision maker. During a review of Resident 28's History and Physical (H&P), dated 9/30/2024, the H&P indicated Resident 28 was awake, alert, and followed commands. During a review of Resident 28's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 2/4/20245, the MDS indicated Resident 28 had severely impaired cognition and used a wheelchair for mobility. During a concurrent interview and record review on 2/18/2025 at 11:45 am with the Social Services Director (SSD), Resident 28's Advanced Directive Acknowledgment (ADA) Form, dated 9/23/2024 was reviewed. The ADA Form did not indicate (by checking one of the following statements) that Resident 28 had or had not executed an advance directive. The SSD stated, the ADA form should have been completed on admission and was not complete, making it invalid. During an interview on 2/20/2025 at 2:30 pm with the Director of Nursing (DON), the DON stated the ADA Form should be entirely filled out to indicate if the resident had an Advance Directive. The DON further stated, this allows them to know the resident's wishes, preferences and prevent the risk of the resident receiving the wrong services. During a review of the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives, last revised 12/19/2022, indicated it was the facility's policy to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. The P&P indicated, on admission the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive. The P&P indicated, in the event the resident is unable to formulate an advance directive due to cognitive impairment the facility will provide information and education to the resident's representative about the right to refuse medical or surgical treatment and formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 54's admission Record (AR), the AR indicated the facility readmitted Resident 54 into the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD- mental health condition caused by an extremely stressful or terrifying event) and spinal stenosis (spaces inside the bones of the spine get too small). During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/25, the MDS indicated Resident 54 was cognitively intact (ability to understand and process thoughts), and required supervision or touching assistance with upper body dressing and personal hygiene and partial/moderate assistance with lower body dressing and toileting hygiene. During a record review of Resident 54's clinical record and Care Plans, Resident 54 did not have a Care Plan for Resident 54's PTSD diagnosis. During a concurrent interview and record review, on 2/20/25, at 10:37 a.m., of Resident 54's Care Plans, with LVN 2, LVN 2 stated Yes, Resident 54 has a PTSD diagnosis. LVN 2 stated Resident 54's behavior can be non-compliant, such as when Resident 54 does not want tray removed, does not adhere to schedules, and hoarding tendencies. LVN 2 stated PTSD is caused by flashbacks (sudden, involuntary re-experiences of a past event). LVN 2 stated LVN 2 knows Resident 54 is a veteran (served in the armed forces of their country), and maybe has bad memories of things that happened. LVN 2 stated Resident 54 did not have a specific Care Plan for PTSD, but there should be one because of the diagnosis and there should be a specific Plan of Care for PTSD. During an interview, on 2/20/25, at 3:02 p.m. with the Director of Nursing (DON), the DON stated that Resident 54 has a diagnosis of PTSD and is a Vietnam Veteran (served in the United States Armed Forces during the Vietnam War). The DON stated Resident 54 had discussed his experiences with DON. The DON stated per facility policy, Resident 54 requires a Care Plan specific to PTSD. The DON stated it is important to develop an individualized Care Plan for a resident with PTSD to manage symptoms and triggers. During a record review of the facility's Policy & Procedure (P&P), titled, Trauma Informed Care, dated, 2022, the policy indicated it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Based on interview and record review, the facility failed to develop a specific and individualized person-centered care plan to meet the needs of trauma (a psychological and physiological response to an overwhelming, distressing, or life-threatening event or series of events) survivor residents for two of two sampled residents (Residents 17 and 54). These failures had the potential for Residents 17 and 54 not to receive the necessary care, treatment, and services. Findings: a. During a review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing traumatic event). During a review of Resident 17's Trauma Informed Care Screener (TICS, a tool or process that helps identify if someone had experienced trauma), dated 7/5/2024, the TICS result indicated Resident 17 had positive trauma screen. During a review of Resident 17's History of Present Illness (HPI), dated 8/11/2024, the HPI indicated Resident 17 had history of PTSD. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated, Resident 17 had a moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 17 required substantial/maximal assistance (helper did more than half the effort) with oral and toileting hygiene, shower, and personal hygiene. During a concurrent interview and record review on 2/19/2025 at 3:00 pm with the Registered Nurse Supervisor 1 (RN 1), Resident 17's Care Plans (CP) were reviewed. RN 1 stated, Resident 17 was a veteran and had a diagnosis of PTSD. RN 1 stated there was no care plan developed for Resident 17 to address the diagnosis of PTSD. RN 1 stated care plan should be developed for the staff to know the resident's triggers, and to developed interventions specific for the resident to prevent re-traumatization (experiences where past traumatic memories were triggered). During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, Resident 17 who had diagnosis of PTSD should had a care plan specific for the needs of the resident to identify Resident 17's triggers and address his symptoms to prevent relapse of an old trauma. During a review of the facility's policy and procedure (P&P) titled. Trauma Informed Care, revised 12/19/2022, the P&P indicated, Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivors' need to be respected, informed, connected, and hopeful regarding their own recovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure for infection control and prevention for three of five sampled residents (Residents 10, 59, and 74), by failing to: a. Ensure Staff wore the appropriate Personal Protective Equipment (PPE- minimizes exposure to hazards) while providing care five residents on Enhanced Barrier Precautions (EBP- infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) while providing care to Resident 74. b. Ensure an appropriate signage indicating Resident 59's transmission-based precaution (TBP, set of infection control guidelines used in healthcare settings to prevent the spread of infectious diseases than can be transmitted through contact with an infected person) was posted outside the resident's room. c. Ensure Certified Nursing Assistant 4 (CNA 4) wore the required PPE when changing Resident 10's linen. These deficient practices had the potential to result in cross contamination and the spread of infection. Findings: a. During a review of Resident 74's admission Record (AR), the AR indicated the facility readmitted Resident 74 on 1/26/25 with diagnoses that included COVID 19 (virus), methicillin resistant staphylococcus aureus (MRSA- bacteria resistant to many antibiotics), immunodeficiency (condition that weakens or eliminates the immune system's ability to fight disease and infection). During a review of Resident 74's Minimum Data Set (MDS, a resident assessment tool), dated 1/30/25, the MDS indicated Resident 74 was severely cognitively impaired (ability to understand and process thoughts) and was on isolation or quarantine for active infectious disease. During a review of Resident 74's History & Physical (H&P), dated 2/2/25, the H&P indicated Resident 74 did not have the capacity to make medical decisions. During a concurrent observation and interview, on 2/18/25, at 3:58 p.m., Certified Nurse Assistant (CNA 5) was observed changing Resident 74's diaper. Resident 74 was on Enhanced Barrier Precautions (EBP). CNA 5 was observed wearing gloves and not wearing a gown while changing Resident 74. CNA 5 stated CNA 5 was changing Resident 74 and CNA 5 should be wearing a gown, mask, and gloves when changing Resident 74. CNA 5 stated CNA 5 was not wearing a gown while CNA 5 was changing Resident 74's diaper. CNA 5 stated CNA 5 should wear a gown. CNA 5 stated it was important because it's EBP you don't want to get sick and Personal Protective Equipment (PPE) protects her and the resident. During an interview, 2/19/25, at 3:10 p.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated EBP was used mostly when the resident has a gastrointestinal tube (delivers liquid nutrition directly to the stomach or small intestine) (G-tube- delivers liquid nutrition directly to the stomach or small intestine), multidrug-resistant organism (MDRO- resistant to multiple antibiotics or antifungals), or a wound. LVN 4 stated the resident is vulnerable to anything and we want to protect them. LVN 4 stated during cleaning and changing residents, it is very important, and staff need to wear a gown and gloves when a resident is on EBP and wearing only gloves is not the right way. The staff have to gown up and put your gloves on. During an interview, on 2/20/25, at 12:23 p.m., CNA 3 stated EBP is for our protection and the residents' protection. When a resident has a G-tube, catheter (a tube inserted into your bladder to freely drain urine), intravenous line (IV- a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein), it is easier for them to get infection or spread infection to us. CNA 3 stated there are signs near the front of the door and stickers by the door that let us know if a resident is on EBP. CNA 3 stated the appropriate PPE to be worn when providing care to an EBP resident includes gloves, gowns, mask, and a face shield, depending on the kind of condition they have. CNA 3 stated using the proper PPE is important because it provides protection for us, the resident and other residents from any kind of infection or illness. During an interview, on 2/20/25, at 1:54 p.m., with the Infection Preventionist (IP), the IP stated not using the proper PPE affects the resident's safety and presents a risk for infections. The IP stated the PPE to be worn when providing care to EBP residents is gown and gloves. The IP stated If staff is wearing only gloves and no gown while changing a resident on EBP, the staff is not wearing proper PPE. During a record review of the facility's Policy & Procedure (P&P), titled, Enhanced Barrier Precautions, dated 2024, the policy indicated Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include changing briefs or assisting when toileting. b. During a review of Resident 59's admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), unsteadiness (pattern of walking that's unstable) on feet, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 59's Minimum Data Sheet (MDS, a resident assessment tool), dated 1/6/2025, the MDS indicated Resident 59 had a severely impaired cognition (ability to understand and process information). The MDS indicated Resident 59 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing; and partial/moderate assistance (helper did less than half the effort) with toileting, shower, lower body dressing and personal hygiene. During a review of Resident 59's Specimen Preliminary Report (SPR), dated 2/3/2025, the SPR indicated Resident 59 had resistance to Extended-spectrum beta lactamase (ESBL, a bacterial infection resistant to many antibiotics making them harder to treat) in the urine. During a review of Resident 59's Order Summary Report (OSR), dated 2/10/2025, the OSR indicated Resident 59 was on contact isolation related to ESBL of the urine. During a concurrent observation and interview on 2/18/2025 at 10:47 am with the Treatment Nurse (TN) outside Resident 59's room. The TN stated Resident 59 was on Enhanced Barrier Precaution (EBP, a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs]) because Resident 59 had a positive ESBL in the urine. During a concurrent interview and record review on 2/18/2025 at 3:25 pm with the Infection Prevention Nurse (IPN), Resident 59's medical records (chart) and PointClickCare (PCC, a cloud-based software platform) were reviewed. IPN stated, there was no documented evidence that Resident was cleared out of contact isolation (a type of infection control precaution used to prevent the spread of infectious diseases that are transmitted through direct contact with an infected person or their environment) and infection was colonized (when microorganism, like bacteria or fungi, lives on or inside the body without causing a disease). The IPN stated Resident 59 should be maintained on contact isolation until cleared to prevent spread of infection to the other residents. During an interview on 2/20/2025 at 12:09 pm with the Director of Nursing (DON), the DON stated, Resident 59 who was on transmission-based precautions should be reassessed and cleared out of infection for the safety of the other residents in the facility and cohorted properly. During a review of the facility's P&P titled, Transmission-Based (Isolation) Precautions, revised 7/18/2023, the P&P indicated, Cohorting residents with the same pathogen. The order for transmission-based precautions/isolation will specify the type of precaution and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside of the resident's room, wing, or facility wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. c. During a review of Resident 10's AR, the AR indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia (paralysis of both arms and legs) and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks). During a review of Resident 10's H&P dated 4/30/2024, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report (OSR) dated 6/21/2024, the OSR indicated an active physician's order for EBP related to risk for multidrug resistant organism infection (MDRO, bacteria that is resistant to antibiotics) due to presence of a gastrostomy tube (G-tube, thin flexible tube that is inserted into the stomach). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had problems with short-term and long-term memory and was dependent on staff for rolling left and right. During a review of Resident 10's undated and untitled care plan (CP), the CP indicated Resident 10 was on EBP as of 5/31/2023. The CP indicated for staff to wear gown and mask when changing contaminated linen. During a concurrent observation and interview on 2/18/2025 at 10:43 AM with Certified Nursing Assistant 4 (CNA 4) in Resident 10's room, an EBP sign was posted outside Resident 10's room. CNA 4 was inside Resident 10's room and was changing Resident 10's linen. CNA 4 was only wearing gloves. CNA 4 stated CNA 4 was not wearing the full PPE when changing Resident 10's linen and should have worn a gown and gloves. CNA 4 stated wearing the required PPE would prevent the transmission or microorganisms (germs). CNA 4 stated, gown and gloves should have been worn when changing the resident's linens because it was considered a high contact activity. During an interview on 2/20/2025 at 1:52 PM with the Infection Prevention Nurse (IPN), the IPN stated staff needed to wear the required PPE prior to entering an EBP room and when changing the resident's linen. The IPN stated, not wearing PPE would put the resident at risk for infection. During an interview on 2/20/2025 at 2:41 PM with the Director of Nursing (DON), the DON stated staff needed to wear the required PPE for direct and high contact activity in EBP rooms. The DON stated changing linens would be considered a high contact activity. The DON stated not donning the required PPE could spread infection. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions revised 6/17/2024, the P&P indicated PPE for EBP was necessary when performing high-contact care activities which included changing linens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of one sampled resident (Resident 1). Resident 1 was hit by Family Member 1 (FM1- Resident 1's brother) during visitation on 5/21/24. This deficient practice resulted in discoloration of Resident 1's right lower lip and left temporal (side) area of the face. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 2/22/24 and readmitted on [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and bipolar disorder (mental disorder with periods of depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities] and periods of elevated mood.) During a review of Resident 1's Progress Notes dated 5/21/24 at 3:20 pm, the Progress Notes indicated Resident was on 1:1 monitoring (providing continuous observation for a period of time) due to agitation and aggressiveness. The Progress Notes indicated a staff (unidentified) left Resident 1 because Resident 1's FM1 came to visit him. The Progress Notes indicated according to the staff, both Resident 1 and FM1 were calm and after 5-10 minutes later, Resident 1 was heard yelling loud saying Nurse, Nurse. Resident 1 was sitting on his wheelchair, pointed at FM1, and stated He (FM1) hit me. During a review of Resident 1's Progress Notes dated 5/21/24 at 4:02 pm, the Progress Notes indicated assessment was done on Resident 1, neurocheck (examination of the brain, nerve, and spinal cord functioning) was started and Resident 1 was given Tylenol (medication for pain) for complaint of 6/10 pain (0= no pain and 10=worst pain based on pain scale) on the left temporal area. During a review of Resident 1's Progress Notes dated 5/21/24 at 10:37 pm, the Progress Notes indicated Resident 1 arrived back to the facility from General Acute Care Hospital 1 (GACH 1) with discoloration on his right lower lip and left temporal area of the face related to an incident prior to his transfer to GACH 1. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/22/24, the MDS indicated Resident 1 had severely impaired cognition (ability to understand). The MDS indicated Resident 1 was using a manual wheelchair for ambulation. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with chair/bed-to-chair transfers. During an interview on 6/3/24 at 1:45 pm with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was verbally aggressive but not physically aggressive towards staff. During an interview on 6/3/24 at 2:28 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated during the two days she was assigned to Resident 1 ( 5/20/24 and 5/21/24), Resident 1 was easily agitated and he would yell . LVN 1 stated the SSD was sitting with Resident 1 on 5/21/24 at around 9 am to 9:30 am and Resident 1 calmed down. LVN 1 stated the SSD was sitting with Resident 1 before FM1 came to the facility on 5/21/24 at 2:38 pm. During an interview on 6/3/24 at 2:39 pm, CNA 2 stated it was around 3 pm on 5/21/24 when she heard a resident yelling Nurse, Nurse and CNA 2 saw FM1 came out of Resident 1's room. CNA 2 stated when she checked Resident 1, Resident 1 had a scratch on the side of the left eye and CNA 2 went out to get an ice pack and applied the ice pack to the side near Resident 1's left eye. During an interview on 6/3/24 at 3:05 pm, Resident 1's roommate who was alert and coherent, stated on 5/21/24, he could see both Resident 1 and FM1 talking by the doorway inside the room Resident 1's roommate stated FM1 told Resident 1 not to cause a ruckus and to quiet down and FM1 reassured Resident 1 that the family supports him. Resident 1's roomate stated Resident 1 started cursing and said to FM1 I'm not going to change, I'll do what I want. Resident 1's roommate stated FM1 hit Resident 1 after hearing Resident 1's statement. During an interview on 6/3/24 at 3:47 pm with the Social Services Director (SSD), the SSD stated she stayed with Resident 1 on 5/21/24 from 9 am to 3 pm when FM1 came. SSD stated she left Resident 1's room to go to the bathroom after observing Resident 1 was welcoming of FM1. The SSD stated she later heard Resident 1 screaming he (FM1) hit me. The SSD stated when she interviewed FM1, FM1 stated FM1 hit Resident 1 because Resident 1 was verbally aggressive. During a phone interview with Resident 1's FM2 on 6/3/24 at 5:20 pm, FM2 stated FM1 had intact cognition and was not confused. During a review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect and Exploitation revised 12/19/22, the P&P indicated abuse means the willful infliction of injury .with resulting physical harm, pain, or mental anguish.

Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced the resident's dignity and respect, by standing in front of the resident while assisting a meal for one of one sampled resident (Resident 49) in accordance with facility's policy on Promoting/Maintaining Resident Dignity During Mealtimes. This deficient practice had the potential to affect Resident 49's self-esteem and self-worth. Findings: During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on 5/25/2018 with diagnoses that included cataract (clouding of the lens in the eye leading to a decrease in vision) and hypertensive retinopathy (damage of retinas [inner back lining of your eyes] from long-term high blood pressure). During a review of Resident 49's History and Physical (H&P), dated 10/31/2023, the H&P indicated Resident 49 did not have the capacity to understand and make decision. During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/20/2023, the MDS indicated, Resident 49 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) with eating. The MDS indicated Resident 49 required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. During an observation on 2/13/2024 at 1:12 pm, Resident 49 was sitting in a wheelchair next to Resident 49's bed with uncovered hot plate on the food tray without staff assisting Resident 49 to eating. During an observation on 2/13/2024 at 1:14 pm, Certified Nurse Assistant 1 (CNA 1) stood in front of Resident 49 talking and assisting Resident 49 while eating. During a concurrent observation and interview on 2/13/2024 at 1:21 pm, with CNA 1, CNA 1 stated she needed to sit down next to Resident 49 and needed to be at eye level while assisting Resident 49 during mealtime to provide respect to Resident 49. During an interview on 2/15/2024 at 1:30 pm with Director of Nursing (DON), the DON stated, staff needed to sit and assist Resident 49 in a dignified manner to be able to see or observed Resident 49 while eating. During a review of the facility's Policy and Procedure (P&P) titled, Promoting/Maintaining Resident Dignity During Mealtimes, revised on 12/19/2022, the P&P indicated, staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes and all staff will be seated, if possible, while feeding a resident.

Based on observation, interview, and record review, the facility failed to ensure safety during self-administration of medications for one of one sampled resident (Resident 19.) This deficient practice had the potential to result in unsafe medication use. Findings: During a review of Resident 19's admission Record, the admission record indicated the facility admitted the resident on 3/28/2022, with diagnoses that included diabetes mellitus (high blood sugar,) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning.) During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/1/2024, the MDS indicated the resident had moderate cognitive (ability to understand) impairment. The MDS indicated the resident required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and dependent with toileting and showers. During an observation in Resident 19's room and interview with Resident 19 on 2/13/2024 at 10:52 am, there was one bottle of topical (applied to the skin) medication of fluocinolone acetonide on top of Resident 19's table. Resident 19 stated he had informed the licensed nurses (unidentified) who administer medications to him that he had been using the medicine for his scaly skin on his eyebrows and on top of his head. During an observation in Resident 19's room on 2/15/2024 at 11:20 am, there was one bottle of fluocinolone acetonide on the table in front of Resident 19. Licensed Vocational Nurse 4 (LVN 4) checked the bottle, which had an expiration date of July 2023. LVN 4 removed the medication from the table and stated she will get an order for the medication. During an interview on 2/16/2024 at 10:01 am, the Director of Nursing (DON) stated the family should not bring medications to the resident if not ordered by the physician. The DON stated it could have a negative effect to the resident. During a review of the facility's Policy and Procedure (P&P) titled Self-Administration of Medication dated 12/19/2022, the P&P indicated it was the policy of the facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 83) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Call Lights: Accessibility and Timely Response and the resident's care plan. This deficient practice had the potential for Resident 83 not to receive or received delayed care. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). During a review of Resident 83's untitled care plan initiated on 10/25/2023, the care plan indicated Resident 83 was at risk for falls and injuries. The care plan interventions indicated for nursing staff to place Resident 83's call light within reach and encourage the resident to use the call light for assistance as needed. The care plan indicated Resident 83 needed prompt response to all requests for assistance. During a review of Resident 83's Fall Risk Assessment (method of assessing a patient's likelihood of falling), dated 11/1/2023, the assessment indicated Resident 83 was assessed as at high risk for fall due to being disoriented, decreased muscular coordination, systolic blood pressure dropped between lying and standing, taking three or more medications currently and predisposing disease condition. During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make decision. During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated, Resident 83's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated, Resident 83 required total dependence with eating, oral hygiene, toileting, showering, upper or lower body dressing and personal hygiene. During a concurrent observation and interview on 2/13/2024 at 9:09 am, with Registered Nurse 1 (RN 1), Resident 83 was lying in bed with call pad on the right upper side of the bed. RN 1 stated Resident 83 was unable to reach the call pad. RN 1 stated Resident 83 was high risk for fall and the call pad needed to be within reach of Resident 83, to maintain the resident's safety. During an interview on 2/15/2024 at 1:19 pm, with Director of Nursing (DON), the DON stated, Resident 83's call light needed to be within reach of the resident at all times, in order to attend Resident 83's needs. The DON stated the call light was one of the modes of communication between the residents and staff and was the way of telling staff the resident needed assistance. During a record review of the facility's Policy and Procedure (P&P) titled, Call Lights: Accessibility and Timely Response revised on 12/19/2022, the P&P indicated, staff will ensure the call light is within reach of the resident and secured as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan for one of one sampled resident (Resident 239) with edema (swelling caused by fluid retention) of the left leg. This deficient practice had the potential to result in worsening of edema for Resident 239. Cross Reference: F684 Findings: During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/26/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. Resident 239 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and sitting to lying and required maximal assistance (helper lifts, holds, or supports trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and toilet transfers. During an observation on 2/13/2024 at 11:45 am, Resident 239 was sitting in a wheelchair with both legs on the ground. Resident 239's left leg appeared swollen and red in color. During an observation on 2/15/2024 at 12:55 pm, Resident 239 was sitting in a wheelchair inside her room with left leg swollen and the resident's left leg was not elevated. During a concurrent observation and interview with the Director of Nursing (DON) on 2/16/2024 at 9:28 am, Resident 239 was sitting on a chair inside her room with both feet on the ground. The DON stated the left leg looked swollen and pinkish in color and moist. Resident 239 stated the left leg was moist because of water oozing due to the swelling. During a review of Resident 239's Skilled Evaluation Notes dated 2/13/2024, 2/24/2024 and 2/15/2024 on 2/16/2024 at 9:35 am, the nurse's notes did not indicate swelling on the left leg. During a concurrent interview with the DON, DON stated there were no notes indicating Resident 239's left leg edema was assessed and addressed. The DON stated based on the documentation, the DON was unable to determine when Resident 239's left leg edema started. The DON stated if Resident 239's left leg edema was identified, the nurses would make a plan of care for edema and the plan of care would include interventions such as monitoring the edema, measuring the edema, elevation of the affected part, medication regimen review and diet review. The DON stated measuring the edema was important to determine the baseline and if there was worsening or improvement of the edema. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Care Plans dated 12/29/2022, the P&P indicated the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to set up the lunch tray for one of one sampled resident (Resident 44) with severely impaired vision. This failure had the potential to result in Resident 44 losing weight and becoming dehydrated (when the body does not have enough fluid to function properly) due to the inability to feed himself. Findings: During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (when the body's metabolism causes brain dysfunction), blindness in one eye, low vision in the other eye, and glaucoma (a group of eye conditions that cause blindness). During a review of Resident 44's Care Plan, revised on 10/7/2022, the care plan indicated Resident 44 had an activity of daily living (ADL) self-care performance deficit related to his conditions and required supervision by one staff member for eating. During a review of Resident 44's Care Plan, revised on 8/16/2023, the care plan indicated Resident 44 had impaired visual function related to glaucoma, cataracts (cloudiness on the eye lens that obstructs vision) and diabetic retinopathy (an eye disease from uncontrolled sugar that can cause blindness) and would bump into objects while in his wheelchair, grab for drinks that were not there and had a history of multiple falls related to his impaired vision. During a review of Resident 44's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 44 had moderately impaired cognition (thinking), had highly impaired vision (eyes are able to follow an object, but identifying an object is questionable) in adequate lighting, and needed substantial or maximal assistance during eating when the meal was placed before the resident. During a review of Resident 44's Care Plan, revised on 2/13/2024, the care plan indicated Resident 44 had potential nutritional problems and malnutrition related to his multiple diseases and required assistance at meals as needed. During a concurrent observation and interview on 2/13/2024 at 1:09 pm with Resident 44 in Resident 44's room, Resident 44 was seated in his wheelchair with the bedside table end facing the resident with a covered lunch tray that was not within reach. Resident 44 stated he had poor vision and needed assistance to eat lunch. During a concurrent observation and interview on 2/13/2024 at 1:13 pm with Licensed Vocational Nurse 2 (LVN 2) in Resident 44's room, Resident 44 was seated in his wheelchair with the bedside table end facing the resident with a covered lunch tray that was not within reach. LVN 2 stated, that is not considered a proper meal setup and the nursing assistant should have provided the resident with feeding assistance. LVN 2 further stated it is important to help feed him for nutritional and quality of life purposes. During a review of Resident 44's Breakfast, Lunch, and Dinner Meal Tickets (food planned for that day's mealtime), dated 2/14/2024, the breakfast, lunch, and dinner meal tickets indicated Resident 44's feeding ability required a partial assist (setup of the meal) and supervision during the meal.

Based on observation, interview, and record review, the facility failed to ensure the nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) was placed properly by placing both nasal prongs in the resident's nostrils for one of one sampled resident (Resident 83) in accordance with the facility's policy titled Oxygen Concentrator. This deficient practice placed Residents 83 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues). Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included acute respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) unspecified with hypoxia or hypercapnia (high levels of carbon dioxide [waste product that the body gets rid of when a person exhales]). During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make decision. During a review of Resident 83's Physician Order's, dated 11/15/2023, the order indicated Resident 83 needed to receive oxygen at four (4) liters per minute (L/min) via nasal cannula and to maintain resident's oxygen saturation (amount of oxygen carried in blood) above or equal to 92 percent (%) every shift. During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated, Resident 83's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 83 required total dependence with eating, oral hygiene, toileting, shower, upper or lower body dressing and personal hygiene. During an observation on 2/13/2024 at 9:04 am, with Registered Nurse 1 (RN 1), Resident 83 was observed awake, lying in bed. Resident 83's nasal cannula was observed with only one prong in resident's right nostril and the left prong was out of the nostrils. The nasal cannula was not delivering oxygen to both nostrils. RN 1 stated the nasal cannula needed to be inside both nostrils of Resident 83 to receive the desired oxygen needed. During an interview on 2/15/2024 at 1:20 pm with the facility's DON, the DON stated the nasal cannula needed to be placed inside Resident 83's both nostrils when in use to ensure the desired oxygen needed by Resident 83 was administered as ordered. During a record review of the facility's Policy and Procedure (P&P) titled, Oxygen Concentrator, revised on 12/19/2022, the P&P indicated to place the nasal cannula on the resident, adjusting to fit resident and achieve comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct reassessment after a routine pain medication was administered for one of two sampled residents (Resident 239.) This deficient practice resulted in Resident 239 to continue to experience pain, affecting the resident's quality of life. Findings: During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/25/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. The MDS indicated Resident 239 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and sitting to lying and required maximal assistance (helper lifts, holds, or supports trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and toilet transfers. During a review of Resident 239's risk for pain care plan, initiated on 1/11/2024, the care plan indicated to evaluate effectiveness of pain interventions (30 minutes after medication administration). During an observation on 2/14/2024 at 11:25 am, Resident 239 informed the staff she was in pain at 9/10 level on pain scale (0=no pain; 10=worst pain). During a medication pass administration observation on 2/15/2024 at 9:16 am, Licensed Vocational Nurse 4 assessed Resident 239's pain to be 10/10, described as burning pain on both legs. Resident 239 stated she was shaking because of the pain. LVN 4 administered Lyrica 100 milligrams (mg) and Morphine Sulfate (MS Contin)15 mg. LVN 4 informed Resident 239 Lyrica was for neuropathic pain. During an interview on 2/15/2024 at 11:10 am, Resident 239 stated she was still experiencing pain at 8/10 on her legs. Resident 239 stated LVN 4 did not come back to reassess her pain level after giving her the scheduled medications. During an interview on 2/15/2024 at 11:15 am, LVN 4 stated she did not go back to reassess Resident 239's pain level. LVN 4 stated if Resident 239 still had pain, LVN 4 could try non-pharmacological interventions such as repositioning, distractions with TV. LVN 4 stated she did not do the non-pharmacological interventions since she failed to go back to reassess Resident 239. During a review of the facility's Policy and Procedure (P&P) titled Pain Management, dated 12/19/2022, the P&P indicated the facility staff will reassess resident's pain management regularly for effectiveness and/or adverse consequences.

Based on interview and record review, the facility failed to ensure the irregularities of the Medication Regimen Review (MRR) identified by the facility's Pharmacy Consultant was acted upon for one of five sampled residents (Resident 83) in accordance with facility's policy and procedure titled, Consultant Pharmacist Reports. This deficient practice had the potential for harm due to missed opportunity by the physician and the licensed staff to act upon the reported irregularities. Findings: During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 10/24/2023 with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). During a review of Resident 83's History and Physical (H&P), dated 11/2/2023, the H&P indicated Resident 83 did not have the capacity to understand and make decision. During a review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated Resident 83's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated, Resident 83 required total dependence with eating, oral hygiene, toileting, shower, upper or lower body dressing and personal hygiene. During a review of Resident 83's Physician's Order dated 11/1/2023, the order indicated to administer to Resident 83, Insulin Aspart subcutaneously (to inject a medication into the tissue layer between the skin and the muscle) solution Pen-injector 100 unit per milliliter, inject per sliding scale (variable scale for insulin dose based on blood sugar level) before meals and at bedtime for diabetes mellitus. During a review of a facility document titled, Consultant Pharmacist's Medication Regimen Review dated 11/17/2023, completed by the facility's Pharmacy Consultant, the document indicated to add to inject insulin within 5 to 10 minutes before meal to the Insulin Aspart (rapid-acting insulin [medication used to help the body turn food into energy and control blood-sugar/glucose levels] that helps lower mealtime blood-sugar spikes) order. During a concurrent record review and interview with Registered Nurse 1 (RN 1) on 2/15/2025 at 12:51 pm, Resident 83's medical record was reviewed. RN 1 stated Aspart needed to be injected within 5 to 10 minutes before breakfast and dinner. RN 1 stated, there were no other clinical documentation that the recommendation from the Pharmacy Consultant was carried out. During an interview on 2/15/2024 at 1:32 pm, with the facility's Director of Nursing (DON), the DON stated, I do not know why the pharmacy recommendation was missed. The DON stated, Medication Regimen Review (MRR) was a monthly recommendation that staff needed to carry out. During a review of the facility's Policy and Procedure (P&P), titled, Consultant Pharmacist Reports, dated 06/2021, the P&P indicated recommendations are acted upon and documented by the facility staff and or prescriber and physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. The P&P indicated the director of nursing or designated licensed nurse addressed and documents recommendations that do not require a physician intervention, e.g., monitor blood pressure.

Based on interview and record review, the facility failed to ensure one of five sampled staff (Licensed Vocational Nurse 3 [LVN 3]) was aware to report an allegation of abuse to the Long-Term Care Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care) as required by State and Federal regulations. This deficient practice had the potential for facility staff not to report an abuse incident to the Long-Term Care Ombudsman, which could lead to possible harm and risk of further abuse of the residents. Findings: During an interview on 2/15/2024 at 12:06 pm, with LVN 3 (Charge Nurse), LVN 3 stated, I don't know what is an Ombudsman when asked about reporting agencies if an abuse allegation occurred. LVN 3 stated the two agencies to report allegation of abuse were the State Agency and the local law enforcement. LVN 3 stated LVN 3 received abuse in-service training last month. During an interview on 2/15/2024 at 12:21 pm, with Director of Staff Development (DSD), DSD stated any allegation of abuse should be reported in a timely manner to the State, local law enforcement and the Long-Term Care Ombudsman. DSD stated abuse reporting to the Long-Term Care Ombudsman was required by the State and the Federal regulations. DSD stated the Long-Term Care Ombudsman was an agency who advocate and help residents in nursing homes for their care, health, and safety. During a review of the facility's Inservice Training Report dated 1/27/2024 and attached Lesson Plan titled Prevention, Recognizing, and Reporting abuse dated 7/16/2018, the training indicated, To call the Long-Term Care Ombudsman as soon as practically possible, after the telephone is made, the SOC341 (Report of Suspected Dependent Adult/Elder Abuse) form is completed and must be sent within 24 hours to the Ombudsman Office and if injury occurs report in 2 hours. During a review of the facility's Policy and Procedure (P&P), titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revised 12/19/2022, the P&P indicated The Administrator or designee will notify the appropriate agencies immediately, as soon as possible, but no later than 24 hours after discovery of the incident. During a review of the facility's P&P, titled Training Requirements, revised 12/19/2022, the P&P indicated All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program. Training requirements should be met prior to staff and volunteers independently providing services to resident, annually, and as necessary based on the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain written informed consent for three of five sampled residents (Residents 81, 85 and 5) for the use of psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication. These deficient practices had a potential for Residents 81, 85 and 5 to not receive adequate information regarding the use of psychotropic medication, necessary to make an informed decision. Findings: a. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted on [DATE] with diagnoses that included hypertensive chronic kidney disease (high blood pressure caused by damaged kidneys), dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), major depressive disorder or depression (a persistent sadness and loss of interest in activities that interferes with daily life) and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). During a review of Resident 81's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 81 had severely impaired cognition (thinking), was taking an antidepressant (a high-risk medication used to treat depression that can cause harm if not taken correctly) and used a wheelchair for mobility. During a review of Resident 81's Physician Documentation of Informed Consent (PDIC). (undated), the PDIC indicated a physical restraint (all devices and practices used by the facility that restrict freedom of movement or normal access to one's body) order for half-length bed side rails to be in place and a psychoactive medication (a drug that affects brain function and mental processes) order for escitalopram oxalate (a medication used to treat depression) five milligrams (mg, a measure of solid weight. One thousandth of a gram) by mouth once daily with consent obtained from Resident 81's surrogate (an individual who makes decisions for someone who is no longer able to make their own health care decisions). The PDIC did not indicate a date when it was signed by the physician. During a review of Resident 81's Physician Documentation of Informed Consent (PDIC) (undated), the PDIC indicated a psychoactive medication order for trazodone HCL (a medication used to treat depression) 50 mg tablet at bedtime for depression and inability to sleep with consent obtained from Resident 81's surrogate. The PDIC did not indicate a date when it was signed by the physician. During a review of Resident 81's Physician Documentation of Informed Consent (PDIC) (undated), the PDIC indicated a psychoactive medication order for quetiapine fumarate (a medication used to treat symptoms of psychosis) 12.5 mg by mouth at bedtime for psychosis or verbal aggression toward others with consent obtained from Resident 81's surrogate. The PDIC did not indicate a date when it was signed by the physician. b. During a review of Resident 85's admission record, the record indicated the facility admitted Resident 85 on 1/11/20234 with diagnoses that included major depressive disorder (a feeling of severe sadness or hopelessness) and dementia (decline in mental ability severe enough to interfere with daily life). During a review of Resident 85's History and Physical (H&P), dated 1/12/2024, the H&P indicated Resident 85 had fluctuating capacity to understand and make a decision. During a review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/15/2024, the MDS indicated, Resident 85's cognition (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 85 required moderate physical assistance with eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 85's Physician's Order, dated 1/25/2024, the order indicated to administer Remeron (a medication to treat depression [a feeling of severe sadness or hopelessness]) tablet 7.5 milligram (mg) one tablet by mouth at bedtime for depression, manifested by poor intake. During a concurrent record review and interview on 2/16/2024 at 10:31 am with Licensed Vocational Nurse 1 (LVN 1), Resident 85's medical record was reviewed. The LVN 1 stated, Physician Documentation of Informed Consent for Remeron was not signed by Resident 85's physician. LVN 1 stated there was no documented evidence that informed consent was obtained for Resident 85 for the use of Remeron. LVN 1 stated, if it was not documented, it was not done. LVN 1 stated psychotropic medications needed to be discussed to the resident or residents responsible party to be aware of the side effects (harmful effects) of the medication. During a concurrent record review and interview on 2/16/2024 at 10:36 am with Registered Nurse 1 (RN 1), RN 1 stated Physician Documentation of Informed Consent for Resident 85's use of Remeron was not signed by the physician. RN 1 stated, the physician needed to call Resident 85's responsible party to obtain informed consent for the use of Remeron. RN 1 stated, there was no other clinical documentation that consent was obtained for Resident 85 who received Remeron. RN 1 stated, it was important to have an informed consent for residents receiving psychotropic medications because the risks and benefits needed to be discussed with Resident 85 or Resident 85's responsible party. During an interview on 2/16/2024 at 11:03 am with Resident 85's Responsible Party (RP 1), RP 1 stated, RP 1 did not receive a call from Resident 85's physician discussing and obtaining a consent for Remeron for Resident 85. RP 1 stated, RP 1 did not speak to Resident 85's doctor nor the facility licensed nurse to discuss the risk and benefits of Remeron on Resident 85. c. During a review of Resident 5's admission record, the record indicated the facility admitted Resident 5 on 4/2/2023 with diagnoses that included major depressive disorder (a feeling of severe sadness or hopelessness) and anxiety (emotion characterized by feelings of tension, worried thoughts, and physical changes). During a review of Resident 5's H&P dated 4/5/2023, the H&P indicated Resident 5 had the capacity to understand and make decision. During a review of Resident 5's Physician's Order, dated 11/27/2023, the order indicated to administer Temazepam (used to treat insomnia [trouble with sleeping]) oral capsule 30 mg. one capsule by mouth at bedtime for insomnia manifested by inability to sleep. During a review of Resident 5's MDS, dated [DATE], the MDS indicated, Resident 5's cognition for daily decision making was intact. The MDS indicated Resident 5 required moderate physical assistance with toileting, shower, and upper body dressing. During a review of Resident 5's Physician's Order, dated 1/5/2023, the order indicated to administer Lexapro (antidepressant - a medication that change the way the brain regulate mood and behavior) one tablet 15 mg for depression manifested by verbalization of sadness over medical condition. During a concurrent record review and interview on 2/14/2024 at 2:07 pm with RN 1, RN 1 stated Physician Documentation of Informed Consent for Lexapro and Temazepam were not dated. RN 1 stated, RN1 would not be able to determine when the consent was obtained. RN 1 stated informed consent needed to be obtained when the medication was ordered, and medication dose was increased. RN 1 stated, there was no other clinical documentation that consent was initiated for Resident 5 to receive Lexapro and Temazepam. During a concurrent record review and interview on 2/15/2024 at 1:38 pm with the Director of Nursing (DON), the DON stated Physician Documentation of Informed Consent should be dated and signed by the physician. The DON stated it was important to have a valid informed consent for residents receiving psychotropic medications because the risks and benefits needed to be discussed with the residents or resident's responsible party. During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent, dated 12/19/2022, the P&P indicated, the facility will verify that informed consent has been obtained prior to any medical intervention or treatment is initiated. The P&P indicated the prescribing physician shall seek the consent of the resident to inform the resident's family of a prescription, order or increase of an order for psychotherapeutic medication within 48 hours of the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 49's admission Record, the admission record indicated the facility admitted Resident 49 on 5/25/2018 with diagnoses that included cataract (clouding of the lens in the eye leading to a decrease in vision) and hypertensive retinopathy (damage of retinas [inner back lining of your eyes] from long-term high blood pressure). During a review of Resident 49's Nutrition Progress Notes dated 3/1/2023 at 3:08 pm, the notes indicated staff needed to encourage Resident 49 during meals and supplement intake. During a review of Resident 49's History and Physical (H&P), dated 10/31/2023, the H&P indicated Resident 49 did not have the capacity to understand and make decision. During a review of Resident 49's untitled care plan revised on 12/18/2023, the care plan indicated Resident 49 had nutritional problem. The care plan indicated Resident 49 needed assistance with personal care. The care plan interventions indicated for nursing staff to encourage Resident 49 to consume at least 60 percent (%) of meals. The care plan interventions indicated Resident 49 needed feeding assistance program for lunch by Certified Nurse Assistant (CNA). During a review of Resident 49's MDS dated [DATE], the MDS indicated, Resident 49 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) with eating. The MDS indicated, Resident 49 required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. During an observation on, 2/13/2024 at 9:33 am, Resident 49 was asleep, seated upright in bed. Resident 49's breakfast tray was in front of the resident with uncovered plate containing breakfast of pureed egg, juice, milk, and pancake. Resident 49 ate 20% of the meal. There was no staff observed assisting or encouraging Resident 49 to eat or drink. During a concurrent observation and interview on 2/13/2024 at 9:35 am, with Registered Nurse 1 (RN 1), RN 1 stated, Resident 49 took a long time to eat and did not need assistance during mealtime. RN 1 stated breakfast was served at 7:30 am. During a concurrent interview and record review with RN 1, on 2/13/2024 at 10:29 am, Resident 49's medical records were reviewed. RN 1 stated, Resident 49 needed supervision, assistance, verbal cues from staff during eating. RN 1 stated there was no staff assisting Resident 49 during breakfast and that was the reason why Resident 49 did not finish eating breakfast. RN 1 stated, if Resident 49 was not supervised during mealtime, Resident 49's food would get cold, and the resident would not be getting enough nutrition that could lead to weight loss. During a concurrent observation and interview on 2/13/2024 at 1:21 pm, with CNA 1, CNA 1 stated Resident 49 was on feeding assistance program to remind and encourage Resident 49 to eat. CNA 1 stated, CNA 1 needed to stay and check Resident 49 and give verbal cues during mealtime until Resident 49 consumed the meal. During an interview on 2/15/2024 at 1:23 pm, with the Director of Nursing (DON), the DON stated, staff needed to be with Resident 49 during mealtime to encourage the resident to eat. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL's), revised on 12/19/2022, the P&P indicated, care and services may consist of the following activities of daily living: eating to include meals and snacks. The P&P indicated a resident who is unable to carry out activities of daily lining will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. b. During a review of Resident 48's admission Record, the admission record indicated the facility admitted the resident on 1/25/2023, with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body). During a review of Resident 48's MDS dated [DATE], the MDS indicated the resident had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 48 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort,) for rolling left and right, sitting to lying, toileting and showers. During a concurrent observation and interview on 2/13/2024 at 11:35 am, Registered Nurse 1 (RN 1) attempted to use the language translator to speak with Resident 48, the resident shook her head and spoke in her language. The translator failed to translate what Resident 48 said. RN 1 looked for the communication tool to communicate with Resident 48 and found it inside Resident 48's drawer inside her room. RN 1 stated the communication tool was in Vietnamese and not in Mandarin. RN 1 stated they could not use the communication tool to communicate with Resident 48. During an interview on 2/14/2024 at 2:05 pm, Occupational Therapist (OTR) stated Resident 48 spoke Mandarin. OTR stated there were two mandarin speaking staff at the facility and would usually work Monday to Friday from 9:00 am to 5:00 pm. During a review of the facility's Policy and Procedure (P&P) titled Effective Communication dated 7/17/2023, the P&P indicated effective communication ensures that information provided to the resident is provided in a form and manner that the resident can access and understand, including in a language that the resident can understand. Based observation, interview, and record review the facility failed to provide the necessary care and services to assist resident's activities of daily living for three of three sampled residents (Residents 18, 48 and 49) by failing to: a. Ensure Resident 18 was provided a communication device with the language that the resident understood. b. Ensure Resident 48 was provided a communication device with the language that the resident understood. These deficient practices had the potential for Residents 18 and 48 to not be able to express their needs and receive the necessary care and services. c. Assist Resident 49 who required assistance, encouragement and cueing with eating, during mealtime, in accordance with facility's policy titled Activities of Daily Living (ADL's). This deficient practice had the potential to result in a decline in Resident 49's activities of daily living, including the ability to eat which could lead to weight loss. Findings: a. During a review of the Resident 18's admission record, the admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Hypertensive Chronic Kidney Disease (high blood pressure caused by damage to the kidneys), Type II Diabetes Mellitus (high levels of sugar in the blood because of a problem in the way the body regulates and uses sugar ), Unspecified Psychosis (symptoms that happen when a person is disconnected from reality) not due to a substance or known physiological condition, and Anxiety Disorder (involves a persistent feeling of anxiety or dread, which can interfere with daily life). During a review of Resident 18's care plan for communication problem related to language barrier, dated 9/14/2023 and revised on 9/19/2023, the care plan indicated Resident 18's primary language was Vietnamese but can make minimal needs known in English. The care plan also indicated Resident 18 had a diagnosis of Aphasia (a language disorder caused by damage in a specific area of the brain that controls language, causing the person unable to communicate). The goal of the care plan included for the resident to improve communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, and writing messages. The care plan intervention indicated Resident 18 preferred to communicate in Vietnamese language and required Vietnamese assistance in communication. The interventions listed also that Resident 18 required phone verbal translator assistive device to communicate, and to ensure availability and functioning of adaptive communication equipment. During a review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 1/2/2024, the MDS indicated Resident 18 had the ability to make self understood and understand others. The MDS indicated Resident 18 had clear speech, and adequate hearing with no difficulty in normal conversation, social interaction, or listening to television (TV). The MDS indicated Resident 18 had range of motion limitations on both lower extremities and dependent on staff for toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. The MDS also indicated Resident 18 had frequent urinary incontinence. During a review Resident 18's History & Physical (H&P) dated 1/16/2024, the H&P indicated Resident 18 had the capacity to understand and make decisions. During observation of Resident 18 and concurrent interview with Registered Nurse 1 (RN 1) on 2/13/24 at 10:43 a.m., Resident 18 was observed lying in bed, awake, with call light within reach. RN 1 ask how Resident 18 was and Resident 18 answered RN1 in Vietnamese language, and RN 1 could not figure out what Resident 18 said or what Resident 18 needed. RN 1 the facility used a phone translator to communicate with non-English speaking resident. RN 1 went to the nurse station and came back to Resident 18's room with the phone translator. RN 1 spoke on the phone translator to communicate with Resident 18 but there was no translation coming out of the phone. RN 1 tried several times to communicate with Resident 18 through the phone translator but was unable to, because no sound was coming out of the phone. RN 1 stated the facility had staff who speaks Vietnamese and could translate what Resident 18 tried to say. RN 1 stated the phone translator needed to be in good working condition and functional, because the staff who speak Vietnamese were not always available. During a review of the facility's Policy and Procedure (P&P) titled Effective Communication, revised on 7/17/2023, the P&P indicated it is the facility's policy to accommodate needs when communicating with residents who have difficulties with communication to promote dignity, understanding, and safety. The policy indicated that direct care staff will be educated on effective communication that reflects the needs of the resident population and needs of the staff and correspond with the Facility Assessment. The policy also indicated that staff would communicate with the resident using techniques identified in their plan of care, and in accordance with his/her established routine for communication, as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide needed care and services to two of two sampled residents (Residents 239 and 73) that will meet each resident's physical, mental, and psychological needs, when the facility failed to: a. Address Resident 239's edema of the left leg by elevating the leg or provided measures to elevate the affected leg. b. Address elevated blood glucose levels for Resident 73. These deficient practices had the potential to result in negative outcome to Residents 239 and 73, affecting the residents' quality of life. Findings: a. During a review of Resident 239's admission Record, the admission record indicated the facility admitted the resident on 5/26/2022 and readmitted on [DATE], with diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder that affects the blood vessels outside of the heart) and venous insufficiency (when the veins have trouble sending blood from the limbs back to the heart, causing blood to pool in the veins on the legs.) During a review of Resident 239's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/8/2024, the MDS indicated the resident had no cognitive (ability to understand) impairment. Resident 239 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right and sitting to lying and required maximal assistance (helper lifts, holds, or supports trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfers and toilet transfers. During an observation on 2/13/2024 at 11:45 am, Resident 239 was sitting in a wheelchair with both legs on the ground. Resident 239's left leg appeared swollen and red in color. During an observation on 2/15/2024 at 12:55 pm, Resident 239 was sitting in a wheelchair inside her room with left leg swollen and the resident's left leg was not elevated. During a review of Resident 239's Skilled Evaluation Notes dated 2/13/2024, 2/24/2024 and 2/15/2024 on 2/16/2024 at 9:35 am, the nurse's notes did not indicate swelling on the left leg. During a concurrent interview with the DON, DON stated there were no notes indicating Resident 239's left leg edema was assessed and addressed. The DON stated based on the documentation, the DON was unable to determine when Resident 239's left leg edema started. During a review of the facility's Policies and Procedures (P&P), there was no P&P for the management of edema. b. During a review of Resident 73's admission Record, the admission record indicated Resident 73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Type II Diabetes Mellitus ( a condition that happens because of a problem in the way the body regulates and uses) with hyperglycemia (high blood sugar), Cerebral Palsy (a group of lifelong conditions that affect movement and co-ordination), and Quadriplegia (paralysis that affects all of a person's limbs and body from the neck down). During a review of Resident 73's History and Physical, dated 4/16/2023, the H&P indicated Resident 73 does not have the capacity to understand and make decisions. During a review of Resident 73's Minimum Data Set (MDS, a standardized assessment and care panning tool), dated 12/12/2023, the MDS indicated Resident 73 does not have the ability to make self understood and understand others. The MDS indicated Resident 73's cognitive (ability to understand) skills for daily decision making were severely impaired and Resident 73 was dependent on staff for his functional abilities (activities of daily living). The MDS indicated Resident 73 was always incontinent of bowel and bladder. The MDS also indicated Resident 73 had a diagnosis of Diabetes Mellitus. During a review of Resident 73's undated care plan for Type II Diabetes Mellitus with Hyperglycemia, the care plan indicated a goal for Resident 73 to be free of any signs and symptoms of hyperglycemia. The care plan interventions included to monitor, document, report as needed (PRN) any signs and symptoms of hyperglycemia. During a review of Resident 73's Physician Orders indicated a stat (now or immediately) order, dated 2/16/2024, for Complete Blood Count (CBC- a blood test that measures many different parts and features of the blood), Comprehensive Metabolic Panel (CMP- a blood test that gives doctors information about the body's fluid balance, levels of electrolytes and how well the kidneys and liver are working), and HgbA1C (blood test that shows the average blood sugar [glucose] level over the past two to three months). There was no other active blood sugar monitoring ordered or medication ordered for Resident 73's Diabetes Mellitus. During a review of Resident 73's laboratory blood test results, the results indicated Resident 73's blood Glucose level was 181 milligrams/dilution (mg/dl) on 1/29/2024; 121 mg/dl on 12/22/2023; 160 mg/dl on 12/14/2023 and 201 mg/dl on 12/5/2023. The reference (normal) level for glucose level was 65 - 99 mg/dl. Resident 73's HgbA1C laboratory blood test result on 12/5/2023 was 6.8 percent (%). The reference level for HgbA1C was less than (<) 6.0%. During a review of Resident 73's Medication Administration Record (MAR) for the month of December 2023, January 2024, and February 2024, the MAR indicated Resident 73 did not have any medication that was administered for Resident 73's Diabetes Mellitus and Hyperglycemia. During an interview with Registered Nurse 1 (RN 1) on 2/16/2024 at 12:26 p.m., after reviewing the nurse's progress notes and physician's orders for Resident 73, RN 1 stated there was no documentation that Resident 73's 201 mg/dl blood Glucose level on 12/5/2023 was addressed. RN1 stated Resident 73 needed to be assessed for signs and symptoms of hyperglycemia and the physician needed to be notified. RN 1 stated that the documentation on the progress notes needed to have specific documentation that Resident 73 was assessed for hyperglycemia and that the physician was notified specifically about the high glucose level of Resident 73.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL, a bed that alternates pressure to help heal and prevent pressure injuries) was set accurately for two of three sampled residents (Residents 84 and 11) reviewed for pressure ulcers (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure). This failure had the potential for Resident 84's and Resident 11's skin conditions to worsen or develop further skin breakdown. Findings: a. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included necrotizing fasciitis (a bacterial infection that cause skin, tissue and muscle death), type II diabetes (DM2- a condition that happens because of a problem in the way the body regulates and uses sugar as fuel) with skin ulcer (an open sore caused by poor blood flow) and methicillin resistant staphylococcus aureus infection (an infection caused by a bacteria that is resistant to antibiotics). During a review of Resident 84's care plan revised on 11/17/2023, the care plan indicated that Resident 84 had potential/actual impairment to skin integrity and was at high risk for further development of skin problems, nonhealing, infection and or deterioration of wounds. During a review of Resident 84's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 84 had severely impaired cognition (thinking), was completely dependent on helpers to change position in bed, had five venous and arterial ulcers present, a diabetic foot ulcer (an open sore on the foot caused by poor circulation from diabetes), a surgical wound, moisture associated skin damage (skin irritation or damage caused by prolonged exposure to moisture) and had a pressure reducing device for his bed as one of the treatments. During a review of Resident 84's Order Summary Report dated 1/30/2024, the order summary report indicated Resident 84 had an active order for a LAL mattress (LAL, a pressure reducing bed that alternates pressure to help heal and prevent skin breakdown) for skin management and settings and functions were to be checked every shift. During a review of Resident 84's Skin Only Evaluation dated 2/7/2024, the evaluation indicated the interventions for Resident 84's documented pressure ulcer was to provide skin care per facility guidelines and wound care per treatment order. During a concurrent observation and interview on 2/13/2024 at 10:02 am with the Treatment Nurse (TN), in Resident 84's room, the low air loss mattress control unit was on the static (firm pressure) setting while the resident was lying in bed. TN stated Resident 84 was on the LAL mattress to relieve pressure on a surgical wound located on his back. TN further stated the static setting means the bed won't move and it shouldn't be on that setting. During a review of Proactive medical products: Operation Manual for Protekt Aire 2000, (undated), the manual indicated it provides low air loss pressure redistribution therapy, but when in static mode it will provide a firm surface. During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, revised 9/12/2023, indicated, the facility would provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries by providing appropriate, pressure-redistributing, support surfaces as an intervention for prevention and to promote healing.b. During a review of Resident 11's admission record, the admission record indicated Resident 11 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness or the inability to move on one side of the body), pressure ulcer ( lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) of the sacral region stage 4 (very deep, big, and painful open sore caused by pressure at the bottom of the spine), Type II Diabetes Mellitus (high levels of sugar in the blood because of a problem in the way the body regulates and uses sugar) with Hyperglycemia (high blood glucose level), and Morbid (severe) Obesity (a complex disease involving having too much body fat). During a review of Resident 11's care plan for stage 4 pressure injury on the Sacro Coccyx (tailbone), dated 7/19/2023, the care plan indicated a goal for Resident 11's wound to show signs of improvement. The care plan interventions included to monitor placement and function of the LAL mattress. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had clear speech and had the ability to make self understood and understand others. The MDS indicated Resident 11 was dependent on staff for toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, and mobility. The MDS indicated Resident 11 required substantial/maximal assistance for oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 11 was at risk for developing pressure ulcers, and at the time of the MDS assessment, Resident 11 had one stage 3 (ulcer extending through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) and one stage 4 pressure ulcer. The MDS indicated Resident 11 has a pressure reducing device for his bed. During a review of Resident 11's History and Physical (H&P) dated 1/24/2024, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a review of Resident 11's Physician's Order Summary, the summary indicated an order dated 1/25/2024 for a Low Air Loss Mattress (LAL mattress-- tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float) for skin management and to check setting and function every shift. During a review of Resident 11's Weights and Vitals form, the form indicated the resident's weight on 2/5/2024 at 9:57 a.m. was 248.0 pounds (lbs.). During an observation of Resident 11 on 2/13/2024 at 12:41 p.m., Resident 11 was observed in bed, awake, and alert. Resident 11's LAL mattress was set on 160. During an interview with the Treatment Nurse (TXN 1) on 2/14/2024 at 3:38 p.m., TXN 1 verified the setting for Resident 11's LAL mattress was set at 160. TXN 1 stated the setting was according to the Resident 11's latest weight. TXN 1 verified Resident 11's weight in the resident's medical record and stated Resident 11's latest weight was 248 lbs. and not 160 lbs. TXN 1 stated that he made a mistake and thought the resident's weight was 148 lbs. TXN1 stated Resident 11's LAL mattress setting needed to be at 240 which was the closest setting to the resident's weight. TXN 1 stated it was important for the setting to be accurate because if it was too soft, the pressure would not be appropriate for Resident 11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the bed was at the lowest position for two of six sampled residents (Residents 39 and 69) who were assessed as high risk for falls. This deficient practice had the potential to result in injury secondary to falls. Findings: During a review of Resident 39's admission Record, the admission record indicated the facility admitted the resident on 8/17/2018, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and hemiplegia and hemiparesis (weakness and paralysis on one side of the body.) During a review of Resident 39's Fall Risk assessment dated [DATE], the assessment indicated the resident was at risk for falls due to intermittent confusion, required assistance with elimination, poor vision, balance problem while standing and required the use of assistive devices. During a review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/19/2023, the MDS indicated the resident had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 39 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half effort) for rolling left to right, sit to lying mobility and dependent with toileting and showering needs. During an observation on 2/14/2024 at 10:00 am, with the MDS Nurse. Resident 39's bed was 28 inches from the floor. The MDS Nurse maneuvered the bed to its lowest position (when the bed stops moving down while pressing the bed control) and the top of the mattress was 21 inches from the floor. During a concurrent interview, the MDS Nurse stated the bed needed to be low so the risk for injury will be lower in case of a fall. During a review of Resident 69's admission Record, the admission record indicated the facility admitted the resident on 11/14/2023, with diagnoses that included dementia and a history of falling. During a review of Resident 69's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment. The MDS indicated Resident 69 was dependent with rolling left to right, sit to lying, lying to sitting sit to stand and chair/bed-to-chair transfers, toileting, and showers. During an observation on 2/15/24 at 8:20 am, Resident 69's bed was not at its lowest position, the top of the mattress was at upper thigh level. The RN Supervisor maneuvered the bed to its lowest position and the top of the mattress was at the level above the knee. During a concurrent interview, the RN Supervisor stated the bed needed to be at the lowest position because the risk for injury would be lessened if the bed was low. During a review of the facility's Policy and Procedure (P&P) titled Fall Prevention Program dated 12/28/2023, the P&P indicated the resident will be assessed for fall risk and will receive care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted on [DATE] with diagnoses that included rhabdomyolysis (muscle breakdown that can be life-threatening), difficulty in walking, and dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). During a review of Resident 78's Order Summary Report dated 1/5/2024, the order summary report indicated Resident 78 had an active order for bilateral (on both sides) side (bed) rails with length to be at one quarter (1/4- rails at the head of the bed that are less restrictive for movement) use as an enabler (bedrails used to aid movement). During a review of Bed Rails-V 2, dated 1/6/2024, the Bed Rails-V 2 indicated the use of bed rails for Resident 78 was assessed with recommendations for one quarter bedrails bilaterally to be used for mobility and transferring purposes. It also indicated the resident or resident representative was educated and provided informed consent, however the field for the name of the resident or resident representative that was educated and provided informed consent was blank. During a review of Resident 78's quarterly Minimum Data Set (MDS, a standardized resident assessment and care screening tool) assessment dated [DATE], the MDS indicated Resident 78 had severely impaired cognition (thinking), required partial or moderate assistance (helper provides less than half the effort and lifts or holds trunk or limbs of resident) for changing positions in bed, and needed substantial or maximal assistance (helper provides more than half the effort and lifts or holds trunk or limbs of resident) for transferring to the toilet. During a concurrent observation and interview on 2/13/2024 at 9:30 am with Resident 78 in Resident 78's room, the resident was lying in bed with both bedrails at the half position (rails that are horizontal and directly in the middle of the bed; more restrictive for movement). Resident 78 stated he cannot get out of bed with the rails in that position. During a concurrent observation and interview on 2/14/2024 at 9:21 am with Certified Nurse Assistant 2 (CNA 2) in Resident 78's room, Resident 78's bedrails were at the half position. CNA 2 stated the bedrails are up to prevent him from falling and getting out of bed. CNA 2 stated the resident moves a lot and doesn't always listen to directions. During a concurrent observation and interview on 2/14/2024 at 9:37 am with Registered Nurse 2 (RN 2) in Resident 78's room, RN 2 showed surveyors both bedrails were at the half position on Resident 78's bed. RN 2 stated there was no consent to have them at the half position. RN 2 further stated, if the bedrails are at the half position it restricts the resident, the resident could try to get out of bed and get hurt. During a review of Facility Verification of Informed Consent, (undated), the Facility Verification of Informed Consent indicated a prolonged use of a device order for one quarter bilateral side rails for Resident 78 and did not indicate a signature and date on the consent form from Resident 78 or Resident 78's representative. During a review of the facility's policy and procedure (P&P) titled, Proper Use of Bed Rails, dated 12/19/2022, indicated, Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. Based on observation, interview, and record review, the facility failed to: 1. Attempt appropriate alternatives prior to installing side (bed) rail for two of six sampled residents (Residents 65 and 85). 2. Follow the physician's order for bilateral (on both sides) side rails with length to be at one quarter (rails at the head of the bed that are less restrictive for movement) use as an enabler (bedrails used to aid movement) for one of six sampled residents (Resident 78). These deficient practices had the potential to present a safety hazard and risk of entrapment to Residents 65, 85 and 78. Findings: 1.a. During a review of Resident 65's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2022 and readmitted on [DATE] with diagnoses that included epilepsy (brain disorder in which a person has repeated seizures [convulsions] over time. During a review of Resident 65's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 1/26/2024, the MDS indicated the resident had severe cognitive (ability to understand) impairment. The MDS indicated Resident 65 was dependent with all activities of daily living. During a review of Resident 65's document titled Bedrails Assessment dated 1/4/2024, the assessment indicated to provide visual and verbal reminders to use the call light. The assessment indicated the reason why alternative was ineffective was due to right sided weakness. During an observation on 2/13/2024 at 11:27 am, Resident 65 was lying in bed, awake, with bilateral side rails up. Resident 65 was moving her left arm and her right arm was bent towards the left side of her chest. During a concurrent record review and interview with the MDS Nurse on 2/14/24 at 3:10 pm, bedrails assessment was reviewed. The MDS Nurse stated the bedrails assessment indicated no appropriate alternatives attempted prior to the use of the side rails. 1.b. During a review of Resident 85's admission Record, the admission Record indicated the facility admitted the resident on 1/11/2024, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and history of falling. During a review of Resident 85's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment. The MDS indicated the resident required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with rolling left to right, sit to lying and lying to sitting on the side of the bed mobility and toileting needs. During an observation on 2/14/2024 at 8:30 am, Resident 85 was awake in bed and both side rails were up. During an interview on 2/14/2023 at 8:59 am, Resident 85 stated he remembered he had a history of a fall but could not remember when it occurred. Resident 85 pointed to the siderail and stated the siderail was the problem; because of the siderail he had to move down the bed, and he fell. Resident 85 stated he did not have any injury from the fall. During a review of the Resident 85's document titled Bedrails Assessment dated 1/11/2024, the assessment indicated the following alternatives were attempted: lowered the bed to the floor, provided frequent staff monitoring, and provided visual and verbal reminders to use the call light. The assessment indicated the reason why the alternatives were ineffective was due to cognitive and physical mobility deficit due to left above the knee amputation and dementia. During an interview on 2/14/2024 at 2:45 pm, the MDS Nurse stated the indicated reason why the alternatives failed did not explain how the alternatives failed. The MDS Nurse stated there were no other alternatives attempted after the low bed failed. During an interview on 2/16/2024 at 8:52 am, the Director of Nursing (DON) stated the use of siderails would put the resident at risk for entrapment and injuries. During a review of the facility's Policy and Procedure (P&P) titled Proper Use of Bed Rails dated 12/19/2022, the P&P indicated to utilize a person - centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. The P&P indicated alternatives include, but are not limited to; roll guards, foam bumpers, lowering the bed and concave mattress. If no appropriate alternatives are identified, the medical record should include evidence of the following: evidence that alternatives were tried and were not successful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 241's admission Record, the admission record indicated the facility admitted the resident on 2/8/2024, with diagnoses that included Methicillin Resistant Staphylococcus Aureus (MRSA). During a review of Resident 241's Medication Administration Record (MAR) for 2/1/2024 to 2/29/2024, the MAR indicated an order for Resident 241 for fluconazole (antifungal medication) 200 milligrams (mg- unit of measurement) one tablet by mouth, one time a day for MRSA of the sputum for seven (7) days. During a review of Resident 241's General Acute Hospital's (GACH) microbiology report dated 1/10/2024 to 1/26/2024, the report indicated Resident 241 had MRSA of the nares and tracheal aspirate (secretion from the tubes to the lungs). During a review of Resident 241's GACH medication record, the medication record did not indicate the indication for the use of fluconazole. During an interview on 2/15/2024 at 4:39 pm, the Infection Prevention Nurse (IPN) stated there was a documentation the physician was notified of the medication Resident 241 was taking at GACH and the physician to continue medications. The IPN stated fluconazole was not for MRSA. The IPN stated there was no communication to the physician to clarify the use of fluconazole for Resident 241. Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 140 and 241) reviewed for the use of antibiotics (medication to treat infection), received the medication with adequate indication for its use. a. Resident 140 did not meet the criteria to receive Cefazolin (an antibiotic medication) intravenously (IV, a way of giving a drug or other substance through a needle or tube inserted into a vein), which started on 2/6/2024, and Maxipime (Cefepime HCl, an antibiotic medication) intravenously, which started on 2/13/2024 for Resident 140's right forearm cellulitis (skin infection) in accordance with the facility's antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). b. For Resident 241, the medication criteria was not met for the use of fluconazole (medication to treat and prevent fungal infection) as treatment of Methicillin Resistant Staphylococcus Aureus (MRSA - form of bacterial infection that is resistant to numerous antibiotics) of the sputum. These failures had the potential for adverse (harmful) consequences for Residents 140 and 241. Findings: During a review of Resident 140's admission record (face sheet), the admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included cellulitis of the right upper limb, Type II Diabetes Mellitus (high levels of sugar in the blood because of a problem in the way the body regulates and uses sugar), and obesity (abnormal or excessive fat accumulation). During a review of Resident 140's History and Physical (H&P) dated 2/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During an observation and concurrent interview with Resident 140 on 2/13/2024 at 10:24 a.m., Resident 140 was in bed awake, alert, oriented, with ongoing IV antibiotic, Maxipime Injection Solution, running through a Peripherally Inserted Central Catheter line (PICC line, a long flexible thin tube or catheter inserted into a vein in the upper arm for long term IV infusion) on the left arm. Resident 140 stated the treatment was for the cellulitis on her right arm. Resident 140 stated Resident 140 was admitted from the acute hospital and was given antibiotics there for seven days and when she was admitted at the facility, the facility gave her another IV antibiotic for seven days which was completed today (2/13/2024). Resident 140 stated the facility started another antibiotic today because her cellulitis did not get any better and the drainage on her cellulitis did not stop. Resident 140 was observed with a bandage on her right forearm which was wet with clear/watery drainage. During a review of Resident 140's Physician's Order dated 2/6/2024, the order indicated to administer Cefazolin Sodium Injection Solution 1 gm (gram) intravenously every 12 hours for seven days for the resident's right forearm cellulitis. The physician's order indicated Cefazolin was started on 2/6/2024 and was completed on 2/13/2024. The physician's order indicated another antibiotic of Maxipime Injection Solution Reconstituted 2 gm intravenously every 12 hours for 10 days for the resident's right forearm cellulitis. The physician's order for Maxipime indicated it is an active order which started on 2/13/2024. A review of Resident 140's Infection Screening Evaluation (ISE, facility's screening assessment form to determine presence of infection) dated 2/14/2024, the evaluation indicated Resident 140 had no pain, no new or marked increase symptom, and had redness on the skin. The ISE did not indicate if Resident 140 had an infection, and the infection analysis section of the ISE was not completed. During a review of Resident 140's Antibiotic Time Out Form (a reassessments tool to review a patient's antimicrobial [antibiotics] therapy) for the use of Maxipime, dated 2/24/2024, the form indicated the antibiotic was being given for the resident's cellulitis of the right upper limb. Resident 140's presenting clinical symptom was redness and swelling. Resident 140 was afebrile (no fever) and there was no diagnostic testing that was ordered. The Antibiotic Time Out Form indicated the prescribing provider was notified of Resident 140's current clinical status, and the provider determined to continue with the current antibiotic therapy for 10 days. During an interview with the Infection Prevention Nurse (IPN) on 2/16/2024 at 9:29 a.m., the IPN stated the Infection Surveillance Assessment indicated Resident 140 did not meet the criteria for the use of the antibiotic. The IPN stated, the doctor's response on the Antibiotic Time Out Form, which was done because the resident did not meet criteria for the use of the antibiotic, was to continue giving the antibiotic. The IPN stated Resident 140 did have enough symptoms to meet the criteria for the use of the antibiotics, and the culture and sensitivity test (C&S, a laboratory test done to help diagnose an infection and decide what antibiotic to give) from the acute hospital indicated no growth (no organism grew in the culture from the wound). During a review of the facility's Policy and Procedure (P&P), dated reviewed/revised on 12/19/2022, titled Antibiotic Stewardship Program, the P&P indicated the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with the antibiotic use. The P&P indicated Nursing staff would monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48 to 72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.

Based on observation, interview and record review, the facility failed to ensure two of two bags of meat in a plastic box were not placed directly on the floor in the kitchen preparation area in accordance with facility's Policy and Procedure (P&P), titled Food Storage. This deficient practice had the potential for food borne illnesses (infections caused by ingesting contaminated food or beverages). Findings: During an initial tour of the kitchen on 2/13/2024 at 8:32 am, together with the facility's Assistant Director of Nutrition Services (ADNS), two bags of meat in a plastic box were placed directly on the floor in the meal preparation area. During a concurrent observation and interview on 2/13/2024 at 8:32 am, the ADNS stated, food and food containers should not be placed directly on the floor. ADNS stated, the floor was dirty and putting food directly on the flow can cause food contamination and sickness if eaten by the residents. The ADNS stated food or food containers needed to be placed on a rack. During a concurrent observation and interview on 2/13/2024 at 8:34 am, with the Director of Nutrition Services (DNS), the DNS stated food or food containers needed to be stored six (6) inches off the floor and should be placed on a rack to prevent food contamination. During a review of the facility's P&P titled, Food Storage, revised on 8/29/2023, the P&P indicated, all foods should be stored away from the walls, off the floor and clear of ceiling sprinkles, sewers/waste disposal pipes and vents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff wear required Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.) when assisting two of three residents (Resident 33 and Resident 240) with meal. These deficient practices had the potential for the spread of infection. Findings: During a review of Resident 33's admission Record, the admission record indicated the facility admitted the resident on 8/25/2023 with diagnoses that included multiple fracture (broken bone) of ribs. During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/16/2023, the MDS indicated the resident had moderate cognitive (ability to understand) impairment and required supervision with rolling left and right and sit to lying mobility. During a review of Resident 240's admission Record, the admission record indicated the facility admitted the resident on 2/6/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow). During a review of Resident 240's MDS dated [DATE], the MDS indicated the resident had moderate cognitive (ability to understand) impairment and required supervision with eating and moderate assistance with toileting, oral hygiene and shower. During an interview on 2/14/2024 at 9:30 am, the Director of Staff Development (DSD) stated, if the staff (in general) did not have close contact with the residents, isolation gown is not needed when entering the room designated as Novel Respiratory Precautions for exposure to a roommate diagnosed with COVID-19 (a respiratory illness that can spread from person to person). During an observation on 2/15/24 at 12:35 pm, Certified Nursing Assistant 3 (CNA 3) and CNA 4 entered Room A (on Novel Respiratory Precautions). CNA 3 and CNA 4 did not wear an isolation gown upon entering the room. CNA 3 assisted Resident 33 with meal set-up, CNA 3 removed lids from the cups and cut up food into small pieces. CNA 4 assisted Resident 240 with meal set-up, removed lids from cups and fed the resident. During an interview on 2/15/2024 at 3:32 pm, the Infection Prevention Nurse (IPN) stated Room A was designated as Novel Respiratory Precautions room. The IPN stated each time a staff enter Room A, staff needed to wear an isolation gown, gloves, N95 (respiratory protective device designed to achieve a very close facial fit) and face shield. During a review of the local guidelines for preventing and managing COVID-19 in Skilled Nursing Facilities, updated 1/25/2024, the guidelines indicated for close contacts, asymptomatic residents, staff needed to wear full PPE per COVID transmission-based precautions when providing care or entering a room where the resident is (resident room, shower room, rehab gym, etc.). During a review of the facility's COVID-19 outbreak line list, the roommate (Resident 86) of Resident 33 and Resident 240 tested positive for COVID -19 on 2/8/2024.

Based on observation, interview, and record review, the facility failed to provide personal privacy for one of 20 sampled residents (Resident 77). Resident 77 was visible from the hallway with the lower part of the resident's body uncovered, exposing her adult brief and legs while in bed. This deficient practice had the potential to violate Resident 77's right to privacy and negatively affect Resident 77's psychosocial well-being. Findings: A review of Resident 77's admission Record indicated the facility admitted the resident on 6/11/2022, with diagnoses that included epilepsy (a brain disorder that causes recurring, unprovoked seizures), profound intellectual disabilities (individuals who cannot live independently, and require close supervision and help with self-care activities for having very limited ability to communicate and physical limitations), quadriplegia (paralysis that affects all a person's limbs and body from the neck down), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), and unspecified anxiety disorder (a mental health condition which interferes with the ability to function). A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/6/2022, indicated the resident did not have the ability to make self understood and understand others, and was severely impaired in her cognitive skills (core skills the brain uses to think, read, learn, remember, reason, and pay attention) for daily decision making. The MDS indicated the resident was totally dependent on the staff for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident was always incontinent of bowel and bladder. During an observation on 3/14/23 at 9:09 am, Resident 77 was observed awake, lying in a low bed, with bilateral 1/4 side rails up and a floor mat on the right side of the bed. Resident 77 was moving her lower extremities sideways left and right with the lower part of her body uncovered, and the resident's adult brief and legs exposed. The resident's privacy curtain was partially closed, and the resident's lower part of the body including her adult brief was visible from the hallway outside her room. During an interview with the Director of Staff Development (DSD) on 3/14/2023 at 9:09 am, the DSD confirmed that Resident 77's lower part of the body including her adult brief was visible from the hallway. The DSD proceeded to cover the resident's lower part of the body with the resident's blanket. The DSD stated that Resident 77 moved a lot and was a fall risk. The DSD stated the staff needed to monitor the resident closely that was why the staff could not completely close the resident's privacy curtain. The DSD stated that the staff could close the privacy curtain a little bit more to cover Resident 77 and prevent the resident's body from being exposed from the hallway. A review of the facility's policy and procedures titled, Promoting/Maintaining Resident Dignity, revised on 9/2/2022, indicated it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life. The policy indicated all staff will maintain resident privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and care planning tool) for one of 20 sampled residents (Residents 57) accurately reflected the resident's bladder (organ that stores urine) function. This deficient practice had the potential to result in inconsistencies and delay of individualized care and services for Residents 57. Findings: A review of Resident 57's admission Record indicated the facility admitted Resident 57 on 5/25/2018, with diagnoses of difficulty in walking, repeated falls, and gastro-esophageal reflux disease (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus). A review of Resident 57's MDS dated [DATE], indicated Resident 57 had severely impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 57 required extensive assistance with one person physical assist for transfer, dressing, and toilet use. The MDS indicated Resident 57 had an indwelling catheter (a tube inserted into the bladder used to drain urine from the bladder to the tube and the drainage bag) and was always continent (able to control) of bladder. During a concurrent observation and interview with Resident 57 on 3/14/2023 at 11:10 am, Resident 57 was sitting in her wheelchair in the activity room without an indwelling urinary catheter. Resident 57 stated she never had an indwelling urinary catheter in place while in the facility. During an interview on 3/14/2023 at 11:12 am, RN 2 stated, Resident 57 did not have an indwelling urinary catheter. RN 2 stated, Resident 57 was continent of bladder. During an interview on 3/15/2023 at 9:33 am, the MDS Nurse (MDSN) stated, she saw Resident 57 physically and stated the resident did not have an indwelling urinary catheter currently and in 2/2023. The MDSN stated, she miscoded the resident's MDS dated [DATE] under the bladder section. The MDSN stated the MDS was the resident's assessment and needed to be accurate. A review of the facility's policy and procedures (P&P) titled, MDS 3.0 Completion, dated 9/2/2022, indicated that according to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate services to maintain activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) for one of five sampled residents (Resident 62) with mobility and range of motion concerns. This deficient practice resulted in Resident 62's decreased mobility, including transfers to a wheelchair and assistance to go out of Resident 62's room. Findings: A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Census List (record of hospitalizations, room changes, and payer source changes) indicated Resident 62 did not leave the facility since admission on [DATE]. A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/17/2021, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 responded it was somewhat important to do things with groups of people, do favorite activities, and go outside to get fresh air when the weather was good. The MDS indicated Resident 62 was totally dependent (full staff performance every time) for transfers between surfaces and locomotion on unit (how resident moves between locations in the room and adjacent corridor). The MDS indicated Resident 62 participated in locomotion off unit (how resident moves to and from distant areas in the facility) only once or twice during the seven-day assessment period. A review of Resident 62's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Progress and Discharge summary, dated [DATE], indicated Resident 62 met short-term goals which included sitting upright in a chair/wheelchair with proper positioning for 60 minutes. The PT Discharge Plan indicated to use a mechanical lift when transferring Resident 62 into the assigned wheelchair. A review of Resident 62's care plan for ADL self-care performance, dated 7/13/2021 and revised on 7/8/2022, indicated an intervention to provide Resident 62 with total assistance with transfers requiring two person assist using a mechanical lift. Resident 62's care plan for ADLs did not include interventions to address locomotion off unit and locomotion on unit. A review of Resident 62's admission Order, dated 1/12/2022, indicated Resident 62 was admitted to hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) with a diagnosis of Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life). Resident 62's hospice admission Order indicated an activity order for transfers from bed to chair. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 responded it was somewhat important to do favorite activities and to go outside to get fresh air when the weather was good. The MDS indicated Resident 62 was totally dependent for transfers between surfaces, locomotion on unit, and locomotion off unit. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 was totally dependent for transfers between surfaces, locomotion on unit, and locomotion off unit. A review of Resident 62's Documentation Survey Report (electronic record of care) for 12/2022 indicated locomotion off unit was NA (not applicable) for Resident 62 for the entire month (31 days). The Documentation Survey Report for 12/2022 indicated Resident 62 was totally dependent for locomotion on unit on 12/25/2022 and 12/28/2022 but was not applicable for all other dates in the month (29 days). A review of Resident 62's Documentation Survey Report for 1/2023 indicated locomotion off unit and locomotion on unit was not applicable for the entire month (31 days). A review of Resident 62's Documentation Survey Report for 2/2023 indicated Resident 62 was totally dependent for locomotion on unit and locomotion off unit on 2/18/2023 and 2/19/2023. Resident 62's Documentation Survey Report indicated locomotion on unit and locomotion off unit was not applicable for all other dates in the month (26 days). A review of Resident 62's Activity Attendance Record for 2/2023 indicated Resident 62 participated in room visits for music, sensory stimulation, and watching television or a movie. Resident 62's Activity Attendance Record did not indicate Resident 62 participated in activities in the activity room for the entire month. A review of Resident 62's Documentation Survey Report for 3/2023 indicated Resident 62 required limited assistance (resident highly involved in activity, staff provided guided assistance) for locomotion on unit and locomotion off unit on 3/13/2023. Resident 62's Documentation Survey Report indicated locomotion on unit and off unit was not applicable from 3/1/2023 to 3/12/2023 and 3/14/2023 to 3/16/2023. A review of Resident 62's Activity Attendance Record for 3/2023 indicated Resident 62 participated in room visits for music, sensory stimulation, video calls, and watching television or a movie. Resident 62's Activity Attendance Record did not indicate Resident 62 participated in activities in the activity room for the entire month. During an observation on 3/14/2023 at 10:37 am in Resident 62's room, Resident 62 was sleeping while lying in bed. During an observation and interview on 3/15/2023 at 2:20 pm in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. Resident 62 reached forward with slight movement at the right shoulder joint and slight extension of the right elbow. Resident 62's right wrist was completely bent downward, and Resident 62's thumb and fingers on the right hand were bent around a rolled-up hand towel. Resident 62 did not have any active movement in the left arm. Resident 62's left shoulder was positioned in neutral (arm positioned parallel to the body), the left elbow was slightly bent, the left wrist was bent in a downward position, and the left thumb and fingers were bent around a rolled-up hand towel. Resident 62 stated the facility staff did not assist Resident 62 out of bed. There was no wheelchair observed in Resident 62's room. During an observation and interview on 3/16/2023 at 9:19 am in Resident 62's room, Resident 62 was awake, alert, and verbal. Resident 62 was lying in bed with the HOB elevated almost upright and wore a hospital gown. Resident 62 stated Resident 62 would love to go to the activity room but did not have a wheelchair. There was no wheelchair observed in Resident 62's room. During an interview on 3/16/2023 at 10:14 am, Certified Nursing Assistant 2 (CNA 2) stated Resident 62 did not take showers in the shower room and only received bed baths because Resident 62 was on hospice care. CNA 2 stated Resident 62 was usually repositioned in bed and did not get out of the bed. CNA 2 stated Resident 62 did not have visitors often but was transferred to the gerichair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) for visits. During an observation on 3/16/2023 at 11:29 am, Resident 62's bathroom did not have any wheelchair for Resident 62. During an interview and record review on 3/17/2023 at 3:40 pm, the Director of Nursing (DON) reviewed Resident 62's PT Discharge Summary and stated PT recommended a mechanical lift to transfer Resident 62 into a wheelchair. The DON reviewed Resident 62's Documentation Survey Report for locomotion off unit and locomotion on unit and confirmed the report indicated not applicable for Resident 62. The DON stated Resident 62 had no restrictions to get out of bed. During a telephone interview on 3/17/2023 at 4:16 pm, the Hospice Registered Nurse (HRN 1) stated HRN 1 had never seen Resident 62 out of bed. HRN 1 stated Resident 62 could transfer into a gerichair which would improve Resident 62's quality of life, make Resident 62 happy, and allow Resident 62 to have something to look forward to. A review of the facility's policy and procedures titled, Activities of Daily Living (ADLs), revised on 9/2/2022, indicated assisting with transfers was part of the care and services the facility may provide for ADLs.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 83) with pressure ulcers (areas of damaged skin caused by staying in one position for too long) had the resident's low air loss mattress (LAL, a mattress designed to prevent and treat pressure ulcers) set at the correct setting based on the resident's weight. Resident 83 weighed 100 pounds and Resident 83's LAL mattress was set at 160 pounds. This deficient practice had the potential to result in worsening and/or delay in healing of Resident 83's pressure ulcers. Findings: A review of Resident 83's admission Record indicated the facility initially admitted Resident 83 on 1/19/2023, and re-admitted the resident on 1/29/2023, with diagnosis that included respiratory failure (the lungs failed to exchange gas effectively), cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), quadriplegia (paralysis of all four limbs) and multiple pressure ulcers (painful wound caused as a result of pressure or friction). A review of Resident 83's Order Summary Report dated 1/19/23, indicated a physician's order for LAL mattress for wound management and for the staff to monitor LAL placement and function every shift. A review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/2/2023, indicated the resident had moderate impairment in cognitive (ability to think and process information) skills, had multiple pressure ulcers (areas of damaged skin caused by staying in one position for too long) and required total dependence (full staff performance every time) from staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 83's Skin Only Evaluation dated 3/13/2023, indicated the resident had stage 3 (full thickness skin loss) pressure ulcers/injuries on the sacrococcyx (pertaining to both the sacrum and coccyx [the tailbone]), right heel, right midback, and right ear. During an observation, on 3/14/2023 at 9:58 am, Resident 83's low air loss mattress was set at 160 pounds. During a concurrent observation and interview with the Infection Prevention Nurse (IPN), on 3/14/2023 at 10 am, the IPN stated that Resident 83 was at high risk for pressure ulcers to the back and that the resident was unable to move independently in bed. The IPN confirmed that the Resident 83's LAL was set at 160 pounds. The IPN stated, the treatment nurse (TXN 1) was responsible for checking the resident's LAL mattress setting. During an interview with TXN 1, on 3/14/2023 10 am, TXN 1 stated that she was not aware that Resident 83's LAL mattress was at the wrong setting. TXN 1 stated that the resident weighed 100 pounds and not 160 pounds. TXN 1 stated that it was important to set the LAL mattress based on manufacturer recommendation which was to set the LAL mattress according to the resident's weight to promote wound healing. TXN 1 stated that the LAL mattress should not be set too soft or too hard because the pressure ulcer could worsen. During a follow-up interview and concurrent review of Resident 83's weight log, on 3/14/2023 at 10: 10 am, the TXN 1 stated that Resident 83 weighed 100 pounds on 3/13/2023. A review of the facility's policy and procedures dated 9/2/2022 titled, Use of Support Surfaces, indicated Support surface refers to a specialized mattress, mattress overlay, or chair cushion designed to manage pressure, shear, microclimate, or friction forces on tissue. The policy indicated support surfaces will be utilized in accordance with manufacturer recommendations. A review of the Operation Manual for Resident 83's LAL mattress, undated, indicated users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 48) with indwelling catheter (a tube inserted into the bladder used to drain urine from the bladder to the tube and the drainage bag) was assessed and monitored for cloudiness and presence of white sediments (substances or particles present in the urine) in the urine as indicated on the facility's policy and procedure titled, Indwelling Catheter Use and Removal, and Resident 48's care plan. This deficient practice had the potential to result in delay of care and treatment for a possible urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder) and/or dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in) for Resident 48. Findings: A review of Resident 48's admission Record indicated the facility admitted the resident on 9/24/2021, with diagnoses of benign prostatic hyperplasia (BPH - enlarge prostate gland that can cause uncomfortable urinary symptoms), acute kidney failure (an abrupt decline in renal function) and obstructive and reflux uropathy (a disorder involving the urinary tract). A review of Resident 48's care plan dated on 3/28/2022, indicated Resident 48 was at risk for UTI. The care plan goal indicated Resident 48 will show no signs and symptoms of infection. The interventions included for the staff to monitor the resident for signs and symptoms (s/sx) of UTI such as confusion, dark concentrate urine, and foul urine. A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/27/2023, indicated Resident 48 had severely impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 48 required extensive assistance with one person physical assist for bed mobility, transfer, dressing, and toilet use, and required total dependence (full staff assistance all the time) for bathing. A review of Resident 48's care plan revised on 3/14/2023, indicated Resident 48 had an indwelling suprapubic catheter (a hollow flexible tube that is inserted into the bladder through a cut in the tummy, used to drain urine from the bladder) related to obstructive uropathy secondary to BPH and was at risk for recurrence of catheter-associated urinary tract infection (CAUTI). The interventions included for the staff to record/report to the resident's physician s/sx of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. During a concurrent observation and interview with Registered Nurse 2 (RN 2), on 3/14/2023 at 9:34 am, Resident 48 was lying in bed with a suprapubic catheter draining cloudy urine with white sediments. RN 2 stated there should be no cloudiness and white sediments in the catheter tubing. RN 2 stated, cloudiness and sediments in the catheter tubing or urine could be signs of infection and needed to be reported to the resident's physician for a possible laboratory test. During a concurrent interview and review of Resident 48's medical record with RN 2, on 3/15/2023 at 10:14 am, RN 2 stated there was no documentation that Resident 48 was monitored for signs and symptoms of UTI. During an interview with the Director of Nursing (DON) on 3/15/2023 at 12:48 pm, the DON stated, it was important to monitor Resident 48 for signs and symptoms of UTI for early detection and avoid complications of infection. A review of the facility's policy and procedures (P&P) titled, Indwelling Catheter Use and Removal, dated 9/2/2022, indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with professional standards of practice and resident care policies and procedures that include but are not limited to: ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting, and addressing such changes. The P&P indicated additional care practices include: recognition and assessment for complications and their causes, and maintaining a record of any catheter-related problems.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 29) reviewed for the use of oxygen was administered oxygen in a safe and sanitary condition in accordance with the standard of care and the facility's policy and procedure. Resident 29's oxygen tubing was not labeled with the date it was changed. This deficient practice placed Resident 29 at risk for respiratory infection by possible contaminants (something that makes an item no longer suitable for use) in the tubing that was being used for an extended period of time. Findings: A review of Resident 29's admission Record indicated the facility initially admitted the resident on 11/16/2014, and readmitted the resident on 7/28/2020, with diagnoses that included obstructive sleep apnea (a condition in which individuals experience pauses in breathing during sleep associated with partial or complete closure of the throat or the upper airway), chronic atrial fibrillation (a condition in which the upper two chambers of the heart beat quickly and irregularly), and hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure). A review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/21/2023, indicated resident had the capacity to make self understood and understand others. The MDS indicated Resident 29 required extensive assistance from the staff for bed mobility, transfer, walking in room and corridor, dressing, toilet use, and personal hygiene, required limited assistance from the staff for locomotion on and off the unit, and required supervision for eating. The MDS indicated Resident 29 received oxygen therapy. A review of Resident 29's care plan dated 7/5/2022, indicated the resident had altered respiratory status/difficulty breathing related to the resident's obstructive sleep apnea. The interventions included for the staff to administer oxygen at two liters per minute (2 LPM) via nasal cannula (a flexible tubing with two prongs on one end placed under the nose to administer oxygen) as ordered. A review of Resident 29's physician order dated 7/26/2022, indicated for the resident to receive oxygen at 2 LPM via nasal cannula as needed for shortness of breath, and to maintain the resident's oxygen saturation (SpO2, the measurement of how much of oxygen is being carried by red blood cells) greater or equal to 92%. During an observation and concurrent interview with Resident 29 on 3/14/23 at 10:49 am, Resident 29 was in his room sitting on his wheelchair by his bed. Resident 29 was receiving oxygen at 2 LPM via nasal cannula. The nasal cannula was not labeled with the date it was changed. Resident 29 stated that he did not use the oxygen all the time and only used the oxygen when he was having breathing problems. During an interview with the Director of Staff Development (DSD) in Resident 29's room, on 3/14/23 at 10:52 am, the DSD confirmed that the resident's nasal cannula tubing was not labeled with the date it was changed. The DSD stated that the staff would change the tubing every week and the tubing needed to be dated so the staff would know when it was time to change the tubing. A review of the facility's policy and procedures titled, Oxygen Administration, revised on 9/2/2022, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goal and preferences. The policy indicated staff shall change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on observation, interview, and record review, the facility failed to ensure the routine pain medication was administered to one of 20 sampled residents (Resident 13) as ordered by the physician. Resident 13's Methadone (severe pain reliever) was not administered as ordered for six days in 1/2023 and 2/2023. This deficient practice had the potential to cause ineffective pain management for Resident 13. Findings: A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021, with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's care plan for acute/chronic pain, revised on 4/25/2022, indicated the intervention to administer Methadone 30 milligrams as ordered. A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), but he was able to understand others and express ideas and wants. The MDS indicated Resident 13 required limited one-person assistance with bed mobility, transfer, walking, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS indicated Resident 13's worst pain intensity over the last five days was 6. A review of Resident 13's Physician's Progress Notes, dated 1/6/2023, indicated Resident 13 had stasis dermatitis (skin inflammation due to fluid buildup related to poor blood circulation) in his lower extremities and was receiving wound care due to a big toe wound. A review of Resident 13's physician's orders from 1/2022 to 2/2023 indicated the order to give 15 milliliters of Methadone HCl solution 10 milligrams/5 milliliter orally in the morning for pain management, hold if respiratory rate less than 12, last reordered on 12/9/2022. A review of Resident 13's Medication Administration Records (MARs) from 1/2023 to 2/2023 indicated the following: 1. Methadone was coded as 6 on 1/8/2023, 1/9/2023, 1/10/2023, and 1/11/2023. 2. Methadone was not signed as administered by the licensed nurse on 2/27/2023 and coded 6 on 2/28/2023. During an observation and interview on 3/14/2023 at 9:21 am, Resident 13 stated his medication (unidentified) was missed about a month ago. Resident 13 was alert and oriented, with no evidence of pain or any distress while sitting in his wheelchair, and on supplemental oxygen at two liters per minute. During an interview on 3/16/2023 at 9:12 am, Licensed Vocational Nurse 3 (LVN 3) stated Resident 13 had a routine Methadone to be administered daily at 6 am as ordered by the physician. During a concurrent review of the MAR for 2/2023, LVN 3 stated the medication was not administered on 2/27/2023 and 2/28/2023. LVN 3 stated there was no documented evidence on the progress notes or MAR indicating the reason for not administering the medication on the two dates. LVN 3 stated if the medication was held for any reason, it must be coded 2 with a reason documented on the resident's chart. LVN 3 stated medication administration must be coded accurately and timely to prevent possible missed medication or medication overdose. During an interview and concurrent review of Resident 13's MAR for 1/2022 on 3/16/2023 at 11:31 am, Registered Nurse 2 (RN 2) stated Methadone was not administered on 1/8/2023, 1/9/2023, 1/10/2023, and 1/11/2023. RN 2 stated there were no notes in 1/2023 indicating why Methadone was coded 6. RN 2 stated on 1/10/2023, the licensed nurse documented she called the pain management physician's office about the Methadone order and endorsed to the incoming shift. RN 2 stated the licensed nurse must call the physician or pharmacy about four to five days before the medication ran out to ensure continuity of care. RN 2 stated medication unavailability would lead to delayed treatment and inadequate pain management. A review of the facility's policy and procedures, titled Pain Management, dated 9/2/2022, indicated pain management must be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A review of the facility's policy and procedures, titled Medication Reordering, dated 9/2/2022, indicated the facility must utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. The policy indicated acquisition of medications must be completed in a timely manner to ensure medications are administered in a timely manner. The policy indicated each time a nurse is administering medications, the nurse must observe how many doses are left and reorder the medications when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and provide assistance for one of one sampled resident (Resident 14) reviewed for nutrition, to ensure the resident was able to use the special eating equipment and utensils provided to the resident when eating his meals. This deficient practice placed Resident 14 at risk for malnutrition (lack of sufficient nutrients in the body) and further weight loss. Findings: A review of Resident 14's admission Record indicated the facility originally admitted the resident on 4/24/2019, and readmitted the resident on 1/4/2023, with diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar as a fuel and characterized by having high blood sugar level) with diabetic polyneuropathy (a complication of diabetes mellitus characterized by progressive damage of the nerve fibers usually of the arms and legs), muscle wasting and atrophy (thinning or loss of muscle tissue), and dysphagia (difficulty swallowing). A review of Resident 14's physician order dated 1/6/2023, indicated for the staff to provide the resident with built up utensils (eating utensils designed with molded plastic handles to assist individuals with limited or weakened grasping strength) and plate guard (prevent food from accidentally being pushed off the plate while eating) daily for all meals to promote self feeding tasks. A review of Resident 14's physician order dated 1/9/2023, indicated for the resident to have Controlled Carbohydrate - No Added Salt (CCHO - NAS) diet, mechanically altered texture (food are altered by whipping, blending, grinding, chopping, or mashing so food are easy to chew and swallow) and nectar consistency liquid (easily pourable and comparable to apricot nectar or thicker cream soups) for dysphagia. A review of Resident 14's dietary progress notes dated 1/9/2023, indicated Resident 14 was in the acute care hospital from [DATE] until 1/4/2023 because of respiratory failure (occurs when not enough oxygen passes from the lungs to the blood) and urinary tract infection (condition in which bacteria invade and grow in the urinary tract which includes the kidneys, ureters, bladder, and urethra). The dietary progress notes indicated Resident 14 had a 20 pounds (lbs.) or 10% weight loss in 30 days due to hospitalization. The dietary progress notes indicated Resident 14 had good oral intake and was fed by staff. A review of Resident 14's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/11/2023, indicated resident had the ability to make self understood and understand others. The MDS indicated Resident 14 required extensive assistance from the staff for bed mobility, dressing, eating, and personal hygiene. A review of Resident 14's care plan dated 1/18/2023, indicated the resident had activities of daily living (ADLs) self-care performance deficit. The interventions included for one staff to provide extensive assistance with eating and to continue to assist the resident with ADLs daily. During a dining observation on 3/14/23 at 12:30 pm, Resident 14 was lying in his bed with the head of the bed elevated. Resident 14 was eating lunch by himself, and was using an adaptive spoon and fork and a plate guard to eat. There was no staff in the room to monitor and assist the resident to eat. Resident 14's right hand was shaking and the food on the spoon was falling off before the resident could put the spoon in his mouth. During an interview with Resident 14 on 3/14/23 at 12:39 pm, Resident 14 stated that he was done eating. Resident 14 stated that his food kept falling off the spoon and the resident could not see what he was eating. Resident 14 stated that he needed help with eating. During an interview with Certified Nursing Assistant 5 (CNA 5) in Resident 14's room, on 3/14/23 at 12:45 pm, CNA 5 stated he was assigned to Resident 14. CNA 5 stated Resident 14 did not need assistance with eating and the resident could eat by himself. CNA 5 checked the resident's food tray and stated that Resident 14 ate 20% of his food, almost nothing. A review of the facility's policy and procedures titled, Use of Assistive Devices, revised on 9/2/2022, indicated facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for two of 20 sampled residents (Resident 48 and 87) by failing to ensure the resident's call light was within reach as indicated on the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response, and the resident's plan of care. This deficient practice had the potential for Resident 48 and 87 to not receive the needed care and services due to Resident 48 and 87's inability to call staff for assistance. Findings: a. A review of Resident 48's admission Record indicated the facility admitted Resident 48 on 9/24/2021, with diagnoses of unspecified dementia (memory loss which interferes with daily functioning) and repeated falls. A review of Resident 48's Care Plan, dated on 9/1/2021, indicated Resident 48 was at high risk for fall. The interventions included for the staff to place the resident's call light within reach and encourage Resident 48 to use it for assistance. A review of Resident 48's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 2/27/2023, indicated Resident 48 had severely impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 48 required extensive assistance with one person physical assist for bed mobility, dressing, and toilet use and total dependence (full staff assistance all the time) for bathing. During an observation on 3/14/2023 at 9:34 am, with Registered Nurse 2 (RN 2), Resident 48 was lying in bed with the call light hanging on the left side rails. During an interview on 3/14/2023 at 9:36 am, RN 2 stated, Resident 48's call light needed to be within reach, so that Resident 48 could use the call light if she needed help or assistance. During an interview on 3/14/2023 at 9:56 am, the Director of Nursing (DON) stated, Resident 48's call light needed to be within reach so the resident could use the call light to call for assistance. A review of the facility's policy and procedures (P&P) titled, Call light: Accessibility and Timely Response, dated 9/2/2022, indicated, the staff will ensure the call light is within reach of resident and secured, as needed. The P&P indicated the call light system will be accessible to residents while in their bed or other sleeping accommodations within the residents' room. b. A review of Resident 87's admission Record indicated the facility admitted Resident 87 on 1/8/2023, with diagnoses that included muscle wasting and atrophy (muscle shrinking), Alzheimer's disease, (progressive disorder that causes brain cells to waste away and die) and history of falling. A review of Resident 87's MDS dated [DATE], indicated Resident 87 had severely impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 87 required limited assistance with one person physical assist for transfer, walking, locomotion on and off unit, dressing, and toilet use and required extensive assistance with personal hygiene and bathing. A review of Resident 87's Care Plan, undated, indicated Resident 87 was at risk for falls. The nursing interventions included for the staff to place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. During an observation on 3/14/2023 at 10:12 am, with RN 2, Resident 87 was sitting at the edge of the bed with the call light hanging on the right side rails next to the head board. Resident 87 stated, she could not use her call light and was unable to reach it. During an interview on 3/14/2023 at 10:12 am, RN 2 stated, Resident 87 needed to have her call light within reach. RN 2 stated, Resident 87 needed to visibly see her call light so that she could use the call light to call for help. A review of the facility's policy and procedure titled Call light: Accessibility and Timely Response, dated 9/2/2022, indicated, the staff will ensure the call light is within reach of resident and secured, as needed. The P&P indicated the call light system will be accessible to residents while in their bed or other sleeping accommodations within the residents' room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Census List (record of hospitalizations, room changes, and payer source changes) indicated Resident 62 did not leave the facility since admission on [DATE]. A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 12/15/2022, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition. The MDS indicated Resident 62 was totally dependent (full staff performance every time) for eating, dressing, and personal hygiene. The MDS also indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's Clothing and Possessions, dated 8/10/2021, indicated two pajamas and one pair of gray pants. During an observation on 3/15/2023 at 2:20 pm in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. During an observation on 3/16/2023 at 9:19 am in Resident 62's room, Resident 62 was awake, alert, and verbal. Resident 62 was lying in bed with the HOB elevated almost upright and wore a hospital gown. During an interview on 3/16/2023 at 10:14 am, Certified Nursing Assistant 2 (CNA 2) stated Resident 62 wore a gown because Resident 62 did not have any clothes to wear. CNA 2 stated Resident 62's family did not provide any clothes. CNA 2 stated Resident 62 wore borrowed clothes from the facility's laundry when Resident 62 had visitors which were returned to the laundry. During an observation on 3/16/2023 at 5:46 pm in Resident 62's room, Resident 62 was lying in bed with the HOB elevated and wore a hospital gown. During a telephone interview on 3/17/2023 at 10:27 am, Resident 62's Responsible Party (RRP 1) stated Resident 62 had many clothes upon admission to the facility. RRP 1 stated the facility staff used to tell RRP 1 that Resident 62 was overdressed. RRP 1 stated Resident 62 had at least four shirts, four dresses, four pairs of pants to match every shirt, and white fluffy house shoes. RRP 1 stated the facility never informed RRP 1 that Resident 62 did not have any clothes. During an interview on 3/17/2023 at 11:31 am, the Hospice Certified Nursing Assistant (CHHA 1) stated Resident 62 wore a hospital gown since Resident 62 did not have any clothes. CHHA 1 stated Resident 62 used to have long sleeve blouses. CHHA 1 opened Resident 62's closet, two drawers located below the closet, and three drawers of the bedside drawers. Resident 62 did not have any clothing in these locations. During a concurrent interview and record review on 3/17/2023 at 3:19 pm, the Director of Nursing (DON) reviewed Resident 62's Clothing and Possessions inventory, dated 8/10/2021. The DON stated these were items added to Resident 62's inventory and should have another inventory upon admission to the facility. In a concurrent interview, the Director of Medical Records (DMR) stated DMR reviewed Resident 62's entire clinical record and did not locate Resident 62's inventory from admission. During a follow-up telephone interview on 3/17/2023 at 3:34 pm, RRP 1 stated Resident 62 had too many items and good clothes upon admission to the facility. RRP 1 did not take an inventory of Resident 62's clothes upon admission since RRP 1 could not enter the facility due to the Coronavirus-19 (COVID-19, infectious viral disease that can cause respiratory illness) restrictions. A review of the facility's policy and procedures titled, Resident Personal Belongings, revised on 9/2/2022, indicated All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. Based on observation, interview, and record review, the facility staff failed to follow their policy and procedures to accurately document the personal belongings/possessions of two of 20 sampled residents (Residents 9 and 62). a. For Resident 9, the facility staff did not update the resident's inventory sheet to include (two) electric-powered wheelchairs (EPWs) that were brought in and stored at the facility during the resident's admission to the facility. b. For Resident 62, the facility failed to record Resident 62's personal inventory upon admission to the facility on 3/11/2021. These deficient practices had the potential to cause a negative impact on Resident 9 and Resident 62's psychosocial well-being. Findings: a. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including difficulty in walking, severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and hypertensive heart disease (heart problems due to high blood pressure over a long period of time) with heart failure. A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 required limited, one-person assistance with transfers, walking, and locomotion on and off unit. The MDS indicated Resident 9 normally used walker and wheelchair for mobility devices. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. During an interview on 3/14/2023 at 9:56 am, Resident 9 stated he had brought (two) EPWs to the facility, but he did not know where they were stored. Resident 9 stated he was concerned the EPWs were not being recharged or maintained. During an interview on 3/15/2023 at 2:59 pm, the Director of Social Services (DSS) stated Resident 9 was admitted to the facility with two EPWs that were stored in the facility's storage room. The DSS stated she did not update Resident 9's inventory sheet to include the EPWs. During an interview on 3/15/2023 at 4:03 pm, the Maintenance Supervisor (MS) stated Resident 9 was admitted to the facility with two EPWs. The MS stated Resident 9 asked if the batteries of the EPWs could be recharged every two weeks. The MS stated there was no company that regularly serviced the units. During a concurrent observation, two EPWs, one of which would not turn on, were observed in the outside storage room. During an interview on 3/16/2023 at 10:47 am, the Infection Prevention Nurse (IPN) stated the admitting nurse or the staff who received the EPWs should have documented the EPWs in the inventory of belongings to ensure an accurate inventory necessary to protect the resident's belongings. During a concurrent review of Resident 9's inventory sheet titled, Resident's Clothing and Possessions, (undated), it indicated, No belongings upon admission. A review of the facility's policy and procedures titled, Resident Personal Belongings, dated 9/2/2022, indicated the following: 1. The facility must protect the resident's right to possess personal belongings and assure they would be rightfully returned to the resident or to the resident's representative in the event of the resident's death or discharge from the facility. 2. All resident personal items would be inventoried at the time of admission by the social services designee or another designated staff member and documentation retained in the medical record. 3. Additional possessions brought in during the duration of the resident's stay must be added to the existing personal belongings inventory listing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop care plans for four of 20 sampled residents (Resident 13, 62, 1, and 9). a. For Resident 13, the facility did not develop a care plan for a Restorative Nursing Program [RNP, nursing program that uses restorative nursing aides (RNAs) to help residents maintain their function and joint mobility] for ambulation (walking) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge recommendation on 6/17/2022. This deficient practice prevented Resident 13 from walking for nine months since discharge from PT. b. For Resident 62, who had impaired range of motion [ROM, full movement potential of a joint (where two bones meet)] in both arms and both legs, the facility did not develop a care plan to address Resident 62's decreased ROM and mobility. This deficient practice had the potential for Resident 62 to develop ROM limitations, including the development of contractures (chronic loss of joint motion associated with deformity and joint stiffness). c. For Resident 1, who had impaired ROM in both arms and both legs, the facility did not develop a care plan to address Resident 1's decreased ROM and mobility. This deficient practice had the potential for Resident 1 to develop ROM limitations, including the development of contractures. d. For Resident 9, the facility staff did not develop a care plan for the resident's inability to sleep for which Melatonin (supplement to induce sleep) and Trazodone (antidepressant medication that can induce sleep) were ordered. This deficient practice had the potential to cause excessive sleep for Resident 9. Findings: a. A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021, with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's PT Treatment Encounter Note(s), dated 6/17/2022, indicated Physical Therapist 1 (PT 1) discussed with Resident 13 about Resident 13's discharge from PT. The PT Treatment Encounter Note indicated Resident 13 agreed to transition to the Restorative Nursing Program (RNP) for ambulation. A review of Resident 13's PT Discharge summary, dated [DATE], indicated Resident 13 was safely ambulated on level surfaces for 60 feet using a two-wheeled walker with minimum assistance from the staff on 6/17/2022. The Discharge Summary indicated Resident 13 had a good prognosis to maintain Resident 13's current level of functioning with consistent staff follow-through. A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), understood others, and expressed ideas and wants. The MDS indicated Resident 13 required limited one-person assistance and/or guided maneuvering of limbs with walking. The MDS indicated Resident 13's balance during transitions and walking was not steady and only able to stabilize with staff assistance. During an interview on 3/15/2023 at 2:44 pm, the Director of Rehabilitation (DOR) stated the residents on RNP did not have any physician's orders for RNP services since the facility transitioned to paperless electronic documentation. The DOR stated RNP services were implemented in a resident's care plan. The DOR stated the DOR and the MDS Assistant (MDSA) had RNP meetings with the RNAs once per month. During an interview on 3/15/2023 at 2:52 pm, the DOR and MDSA stated a resident's RNP care plan included an RNP task in the electronic documentation system, which allowed the RNA to document the RNP session. The DOR and MDSA stated RNP services were important to maintain a resident's functional status. During an interview and concurrent review of Resident 13's clinical records on 3/16/2023 at 6:01 pm, the MDSA stated RNA was recommended for ambulation when Resident 13 was discharged from PT on 6/17/2022. The MDSA stated MDSA reviewed Resident 13's entire clinical record and did not locate a care plan for RNA after discharge from PT on 6/17/2022. The MDSA stated the task for RNA was not created since Resident 13 did not have a care plan for RNA. The MDSA stated there was no documented evidence Resident 13 was seen for ambulation with RNA after discharge from PT on 6/17/2022. During an interview on 3/17/2023 at 11:49 am, the Director of Nursing (DON) stated care plans were important because it guided the resident's care. A review of the facility's policy and procedures titled, Comprehensive Care Plans, revised on 9/2/2022, indicated the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Cross reference F688 b. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/17/2021, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 required limited assistance (resident highly involved in activity) for eating and required extensive assistance (resident involved in activity while staff provide weight-bearing support) for dressing and personal hygiene. The MDS indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in both arms and both legs), dated 3/11/2021, indicated Resident 62 had limited ROM in the left shoulder, left elbow, left wrist, left hand/fingers, both knees, and both ankles. The JMA indicated Resident 62's ROM in the right shoulder was above shoulder height, the right elbow had full ROM (straighten and bend without limitations), the right wrist had full ROM, the right hand/fingers had full ROM, and both hips bent to hip height. A review of Resident 62's Change of Condition JMA, dated 1/12/2022, indicated Resident 62 had limited ROM in the right ring finger and right little finger, left hand/finger, both knees, and both ankles. The JMA indicated Resident 62's ROM in both shoulders was above shoulder height, the right elbow had full ROM, the left elbow had nearly full ROM, ROM in both wrists moved from a slightly bent position to a fully bent position, and both hips bent to hip height. A review of Resident 62's MDS, dated [DATE], 6/30/2022, 9/26/2022, and 12/15/2022, indicated Resident 62 had functional ROM limitations in both arms and both legs. During an observation on 3/15/2023 at 2:20 pm in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. Resident 62 reached forward with slight movement at the right shoulder joint and slight extension of the right elbow. Resident 62's right wrist was completely bent downward, and Resident 62's thumb and fingers on the right hand were bent around a rolled-up hand towel. Resident 62 did not have any active movement in the left arm. Resident 62's left shoulder was positioned in neutral (arm positioned parallel to the body), the left elbow was slightly bent, the left wrist was bent in a downward position, and the left thumb and fingers were bent around a rolled-up hand towel. During an observation on 3/15/2023 at 2:27 pm in Resident 62's room, Certified Nursing Assistant 8 (CNA 8) had Resident 62's permission to remove the blanket over both legs. Resident 62 lifted the right leg very slightly at the hip joint but did not have any other active movement in the right leg and throughout the left leg. Both of Resident 62's ankles were bent away from the body. During an interview on 3/17/2023 at 11:49 am, the Director of Nursing (DON) stated care plans were important because it guided the resident's care. During an interview on 3/17/2023 at 12:48 pm, the DON and the DOR reviewed Resident 62's MDS assessments. Both the DON and DOR stated Resident 62 did not have an active care plan to address Resident 62's ROM limitations. A review of the facility's policy and procedures titled, Comprehensive Care Plans, revised on 9/2/2022, indicated the facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Cross reference F688 c. A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 8/1/2008, and readmitted the resident on 2/15/2023. Resident 1's diagnoses included but was not limited to kidney failure, dysphagia (difficulty swallowing), attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding), history of transient ischemic attack (brief stop of blood supply to the brain) and cerebral infarction (brain damage due to a loss of oxygen to the area) without residual deficits. A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 2/21/2023, indicated Resident 1 had unclear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 was totally dependent (full staff performance every time) for bed mobility, transfers between surfaces, dressing, eating, hygiene, toileting, and bathing. The MDS indicated Resident 1 had functional ROM limitations in both arms and both legs. A review of Resident 1's re-admission Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in both arms and both legs), dated 2/16/2023, indicated Resident 1 raised both arms at the shoulder joint to shoulder height and had full ROM in both elbows (straighten and bend without limitations), full ROM in both wrists, nearly full ROM in both hands, full ROM in both hips, full ROM in both knees, and full ROM in both ankles. During an observation on 3/15/2023 at 8:23 am in Resident 1's room, Resident 1 was lying in bed with the HOB elevated. Resident 1 was awake and had both hands interlocked in the middle of Resident 1's body. There was blanket over both of Resident 1's legs. During an observation on 3/15/2023 at 8:57 am, Treatment Nurse 2 (TXN 2) came out of Resident 1's room after changing the G-tube dressing. TXN 2 returned to Resident 1's room to remove the blanket over Resident 1's legs. Resident 1 had a pillow placed in-between both legs. Resident 1's left leg was crossed above the right leg. During an interview on 3/16/2023 at 10:42 am, Certified Nursing Assistant 3 (CNA 3) stated Resident 1 moved both arms but did not move both legs. CNA 3 stated Resident 1 required a pillow between Resident 1's legs since Resident 1 tended to cross the legs. During an interview on 3/17/2023 at 11:49 am, the Director of Nursing (DON) stated care plans were important because it guided the resident's care. The DON stated Resident 1 did not have an active care plan to address Resident 1's ROM limitations. A review of the facility's policy and procedures titled, Comprehensive Care Plans, revised on 9/2/2022, indicated the facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Cross reference F688 d. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), obstructive sleep apnea (sleep-related breathing disorder), hypertensive heart disease (heart problems due to high blood pressure over a long period of time) with heart failure, major depressive disorder (persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (developed by individuals who experienced a shocking, scary, or dangerous event with symptoms like trouble sleeping and nightmares). A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 had sleeping problems nearly every day. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. A review of Resident 9's active physician orders from 3/1/2023 through 3/17/2023 indicated the following orders: 1. Give 1 tablet of Melatonin tablet 5 milligrams orally at bedtime for sleep. 2. Give 1 tablet of Trazodone HCl 100 milligrams orally at bedtime for depression manifested by inability to sleep. During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 9:39 am, Licensed Vocational Nurse 3 (LVN 3) stated the licensed nurse must clarify the order with the physician if it was necessary to administer two different medications to treat the sleeping problem. LVN 3 stated all licensed staff must be aware of the care plan and ensure Resident 9's safety. During an interview on 3/16/2023 at 9:50 am, Registered Nurse 2 (RN 2) stated Melatonin and Trazodone were both ordered as a sleep aid for Resident 9. RN 2 stated by administering both medications at the same time, the licensed nurse would be unable to determine the effectiveness of each medication or identify which medication was causing an adverse effect. RN 2 stated administering both medications could cause a drug interaction, which could potentially lead to falls or oversedation. During a follow-up interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 11:03 am, RN 2 stated there were no notes or a care plan addressing Resident 9's sleeping problem to address the administration of both Resident 9's Melatonin and Trazodone at the same time. RN 2 stated the licensed nurse must initiate a care plan to address Resident 9's inability to sleep, verify the orders with the physician, and clarify for any possible drug interactions and inform Resident 9. A review of the facility's policy and procedures, titled Comprehensive Care Plans, dated 9/2/2022, indicated the following: 1. The facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. 2. The resident comprehensive care plan must describe the resident-specific interventions that reflect the resident's needs and preferences. 3. The comprehensive care plan must be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 4. The physician, other practitioner, or professional must inform the resident and/or resident representative of the risks and benefits of the proposed care, of treatment, and treatment alternatives/options. 5. Qualified staff responsible for carrying out interventions specified in the care plan must be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to three of five sampled residents (Residents 62, 1, and 13) with mobility (ability to move) and range of motion [ROM, full movement potential of a joint (where two bones meet)] concerns. a. For Resident 62, the facility failed to: 1. Perform an annual Joint Mobility Assessment (JMA, brief assessment of a resident's range of motion in both arms and both legs) since 1/12/2022 (over one year) in accordance with the facility's policy. 2. Provide passive range of motion (PROM, movement of a joint through the ROM with no effort from the resident) or any splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both arms and both legs since 4/5/2022 (over 11 months) in accordance with the facility's policy for Restorative Nursing Programs [RNP, nursing program that use a restorative nursing aide (RNA) to help residents maintain their function and joint mobility]. These deficient practices had the potential for Resident 62 to experience a decline in range of motion, including the development and worsening of contractures (deformity and joint stiffness) in both arms and both legs, making it difficult to dress Resident 62 in normal clothes. These deficient practices also had the potential to cause Resident 62 increased pain with movement and contribute to the development of pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin). b. For Resident 13, the facility did not provide RNP services with the RNA for ambulation (walking) after discharge from Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 6/17/2022 (nine months). This deficient practice had the potential to cause a decline in Resident 13's ability to walk. c. For Resident 1, the facility failed to provide ROM exercises to both arms and both legs in accordance with the facility's policy for RNP since 3/9/2023. This deficient practice had the potential for Resident 1 to develop ROM limitations, including the development of contractures. Cross reference F656. Findings: a. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Census List (record of hospitalizations, room changes, and payer source changes) indicated Resident 62 did not leave the facility since admission on [DATE]. A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/17/2021, indicated Resident 62 had clear speech, sometimes expressed ideas, and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 required limited assistance (resident highly involved in activity) for eating and required extensive assistance (resident involved in activity while staff provide weight-bearing support) for dressing and personal hygiene. The MDS also indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's JMA, dated 3/11/2011, indicated Resident 62 had limited ROM in the left shoulder, left elbow, left wrist, left hand/fingers, both knees, and both ankles. The JMA indicated Resident 62's ROM in the right shoulder was above shoulder height, the right elbow had full ROM (straightened and bent without limitations), the right wrist had full ROM, the right hand/fingers had full ROM, and both hips bent to hip height. A review of Resident 62's Occupational Therapy [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] Plan of Care, dated 3/11/2021, indicated Resident 62 had more ROM limitations in the left arm than the right arm. The OT Plan of Care indicated the left arm had spasticity (increased muscle stiffness) which positioned the elbow in extension (straight), fingers in flexion (bent), neutral shoulder (arm positioned parallel to the body), and neutral wrist (straight with the palm in line with the wrist). The OT Plan of Care included OT treatment five times a week for four weeks. A review of Resident 62's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Plan of Care, dated 3/11/2021, indicated Resident 62 had ROM limitations both legs. The PT Plan of Care indicated both of Resident 62's knees bent to five degrees of motion (normal is 140 degrees of motion) and both hips had 20 degrees of limited flexion (hips bent to hip height). The PT Plan of Care indicated Resident 62 had 10 out of 10 (severe) pain in both thighs. The PT Plan of Care included PT treatment five times a week for four weeks. A review of Resident 62's OT Progress and Discharge summary, dated [DATE], indicated Resident 62 met a short-term goal to tolerate the application of a left-hand splint for three hours. The OT Progress and Discharge Summary also indicated Resident 62 met a long-term orthotic (splint) goal which indicated the RNP applied and removed the left-hand splint and monitored Resident 62's skin condition for effective contracture prevention and joint protection. The OT Discharge Plan indicated Resident 62 was referred to the RNP for application of the left-hand splint and PROM program. A review of Resident 62's PT Progress and Discharge summary, dated [DATE], indicated Resident 62 met short-term goals which included sitting upright in a chair/wheelchair with proper positioning for 60 minutes, reporting decreased pain in both knees and hip joints to moderate pain, and improved PROM of both knees to 60 degrees of flexion. The PT Progress and Discharge Summary also indicated RNP training included education to the nurses for proper positioning and techniques to inhibit extensor tone (prevent excessive straightening) in both of Resident 62's legs. The PT Discharge Plan indicated Resident 62 was referred to RNP with an exercise program and to use a mechanical lift when transferring Resident 62 into the assigned wheelchair. A review of Resident 62's Restorative Administration Record (record of RNA sessions) for 4/2021 indicated Resident 62 received the following RNA services: - 4/5/2021 to 4/30/2021: RNP for PROM to both legs one time per day, every day, three times per week - 4/5/2021 to 4/30/2021: RNP for PROM on the left arm one time per day, every day, three times per week - 4/5/2021 to 4/6/2021: RNP splinting program one time per day, every day, three times per week - 4/7/2021 to 4/30/2021: Refer to RNP for splinting program one time a day, every day, three times per week to apply the inflatable hand roll (hand splint placed in the palm with an inflatable air bladder to apply a low stretch to contracted fingers) for up to three hours to the left hand. A review of Resident 62's Restorative Administration Record for 5/2021 indicated Resident 62 received the following physician's orders and RNA services from 5/1/2021 to 5/31/2021: - 4/6/2021: RNP for PROM exercises to both legs, one time a day, every day, three times per week - 4/6/2021: RNP for PROM program for the left arm, one time a day, every day, three times per week - 4/8/2021: RNP for splinting program to apply an inflatable hand roll to the left hand for up to three hours, one time a day, every day, three times per week A review of Resident 62's Restorative Administration Record indicated Resident 62 continued to receive RNA services in accordance with the physician's orders from 6/2021 to 2/2022. A review of Resident 62's Change of Condition JMA, dated 1/12/2022, indicated Resident 62 had limited ROM in the right ring finger and right little finger, left hand/finger, both knees, and both ankles. The JMA indicated Resident 62's ROM in both shoulders was above shoulder height, the right elbow had full ROM, the left elbow had nearly full ROM, ROM in both wrists moved from a slightly bent position to a fully bent position, and both hips bent to hip height. A review of the OT Evaluation and Plan of Treatment (OT Evaluation), dated 1/12/2022, indicated Resident 62's primary physician referred Resident 62 to OT services to evaluate the ROM in both arms due to a specific decline in finger extension in the ring finger and little finger of the right hand. The OT Evaluation indicated Resident 62 had the following ROM: - Right shoulder: Within functional limits (WFL, sufficient joint movement without significant limitation) - Right elbow/forearm: WFL - Right wrist: Impaired - Right hand: Impaired - Right thumb: WFL - Right index finger: WFL - Right middle finger: WFL - Right ring finger: Impaired - Right little finger: Impaired - Left shoulder: WFL - Left elbow/forearm: WFL - Left wrist: WFL - Left hand: Impaired - Left thumb: Impaired - Left index finger: Impaired - Left middle finger: Impaired - Left ring finger: Impaired - Left little finger: Impaired. The OT Evaluation indicated Resident 62 already had an inflatable hand roll splint for the left-hand contractures to prevent further decline and indicated Resident 62 was developing contractures to the right hand ring finger and little finger. The OT recommendation for Resident 62 included placement of hand roll splints in both hands to maintain joint mobility. The OT clinical impression indicated Resident 62 presented with functional decline and indicated nursing referred Resident 62 to hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible). The OT Evaluation did not recommend further therapy services. A review of Resident 62's admission Order, dated 1/12/2022, indicated Resident 62 was admitted to hospice care with a diagnosis of Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life). Resident 62's hospice admission Order indicated Resident 62 may continue all routine medications and treatments. A review of Resident 62's electronic record for RNP included the following RNP tasks: - 2/24/2022: PROM to both arms, daily, three times per week, as tolerated - 2/25/2022: splint/care assistance to left hand, daily, three times per week, as tolerated - 3/2/2022: PROM to both legs, daily, three times per week, as tolerated. Resident 62's RNP record, dated 2/25/2022, did not indicate the amount of time to apply the left-hand splint. Resident 62's RNP record did not include a right-hand splint in accordance with the OT Evaluation recommendation on 1/12/2022. A review of Resident 62's RNP Documentation Survey Report (electronic record of RNA sessions) for 3/2022 indicated Resident 62 received RNP services three times per week for PROM to both arms, left hand splint application, and PROM to both legs from 3/2/2022 to 3/30/2022. A review of Resident 62's RNP Documentation Survey Report for 4/2022 indicated Resident 62 received RNP services for PROM to both arms, left hand splint application, and PROM to both legs on 4/1/2022 and 4/4/2022. A review of Resident 62's electronic record for RNP indicated the RNP tasks for PROM to both arms, application of the left splint/care, and PROM to both legs were resolved (discontinued) on 4/5/2022. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 had clear speech, sometimes expressed ideas, and wants, sometimes understood verbal content, and had severely impaired cognition. The MDS indicated Resident 62 was totally dependent (full staff performance every time) for eating, dressing, and personal hygiene. The MDS also indicated Resident 62 had functional ROM limitations in both arms and both legs. During an observation and interview on 3/15/2023 at 2:20 PM in Resident 62's room, Resident 62 was awake, alert, and spoke in short sentences. Resident 62 was lying in bed with the head-of-bed (HOB) elevated almost upright and wore a hospital gown. Resident 62 reached forward with slight movement at the right shoulder joint and slight extension of the right elbow. Resident 62's right wrist was completely bent downward, and Resident 62's thumb and fingers on the right hand were bent around a rolled-up hand towel. Resident 62 did not have any active movement in the left arm. Resident 62's left shoulder was positioned in neutral (arm positioned parallel to the body), the left elbow was slightly bent, the left wrist was bent in a downward position, and the left thumb and fingers were bent around a rolled-up hand towel. Resident 62 stated Resident 62 did not remember if any facility staff member provided any exercises to both arms and both legs. During an observation on 3/15/2023 at 2:27 PM in Resident 62's room, Certified Nursing Assistant 8 (CNA 8) had Resident 62's permission to remove the blanket over both legs. Resident 62 lifted the right leg very slightly at the hip joint but did not have any other active movement in the right leg and throughout the left leg. Both of Resident 62's ankles were bent away from the body. During an interview on 3/15/2023 at 2:44 PM, the Director of Rehabilitation (DOR) stated the residents on RNP did not have any physician's orders for RNP services since the facility transitioned to paperless electronic documentation. The DOR stated RNP services were implemented in a resident's care plan. The DOR stated the DOR and the MDS Assistant (MDSA) had RNP meetings once per month. During an interview on 3/15/2023 at 2:52 PM, the DOR and MDSA stated a resident's RNP care plan included an RNP task in the electronic documentation system, which allowed the RNA to document the RNP session. The DOR and MDSA stated RNP services were important to maintain a resident's ROM and to maintain a resident's functional status. The DOR stated residents who did not move at all or had weakness were at risk for developing contractures. During an observation and interview on 3/16/2023 at 9:19 AM in Resident 62's room, Resident 62 was awake, alert, and verbal. Resident 62 was lying in bed with the HOB elevated almost upright and wore a hospital gown. A rolled-up hand towel was resting on top of Resident 62's left hand instead of inside the left palm. Resident 62 stated the hand towel sometimes came out of the left hand. Resident 62 continued to have minimal active movement in the right shoulder and right elbow to reach forward. Resident 62 was unable to move the right wrist, which was positioned in a completely bent position, and the right fingers, which were positioned into a fist. Resident 62 continued to have no movement in the left arm and both ankles were bent away from the body. Restorative Nursing Aide 1 (RNA 1) walked into Resident 62's room. In a concurrent interview, RNA 1 stated Resident 62 did not receive RNA services for ROM but assisted Resident 62 with feeding. During a follow-up interview on 3/16/2023 at 9:35 AM, RNA 1 stated Resident 62 did not receive RNA for ROM since Resident 62 was on hospice. During an interview on 3/16/2023 at 10:50 AM, Restorative Nursing Aide 2 (RNA 2) stated RNA 2 did not work with Resident 62 since Resident 62 was on hospice. During an interview on 3/16/2023 at 11:47 AM, the Director of Nursing (DON) stated the facility's nurses provided nursing care for hospice residents and the hospice company provided additional services. The DON stated residents on hospice were treated the same as any other resident in the facility. During a follow-up interview on 3/16/2021 at 4:15 PM, the DON stated residents on hospice received the same care provided to all other residents, including medication management, pain management, activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), and RNA services for ROM. The DON stated some families did not want the resident on hospice to receive RNA services. The DON stated the facility coordinated care with the hospice company if the family did not want a resident to receive RNA services. During an interview and record review on 3/16/2023 at 3:09 PM, the DOR reviewed Resident 62's PT Progress and Discharge summary, dated [DATE], which included recommendations for RNP exercises. The DOR reviewed Resident 62's OT Progress and Discharge summary, dated [DATE], which included recommendations for a left-hand roll splint and RNP for PROM. The DOR stated Resident 62 received another OT evaluation on 1/12/2022 which included a recommendation for a right-hand roll splint. In a concurrent interview and observation, the Assistant Director of Rehabilitation (ADOR) provided a demonstration of an inflatable hand roll splint. The ADOR stated PROM should be performed prior to applying the splint. The ADOR brought out a blue colored splint which had an internal plastic air pocket that could be inflated. The ADOR connected a small manual pump to the plastic air pocket to inflate the splint. The ADOR stated the inflatable hand roll splint was secured to the hand with a Velcro strap. The ADOR stated the inflatable hand roll splint prevented further contractures to the hand and provided skin protection to the palm. During an interview and record review on 3/16/2023 at 5:09 PM, the DOR reviewed Resident 62's initial JMA, dated 3/11/2021. The DOR stated Resident 62 had the following ROM in both arms and both legs: - Right shoulder: WFL - Right elbow: WFL - Right wrist: WFL - Right hand: WFL - Right hip: WFL - Right knee: 20-30 degrees (10 degrees of motion, normal 0-140 degrees) - Right ankle: 0-10 degrees into plantarflexion (ankle bent with toes pointing away from the body, normal 0-50) - Left shoulder: 0-10 degrees (normal 0-180 degrees) - Left elbow: 0-10 degrees (normal 0-140 degrees) - Left wrist: 20-30 degrees (normal 0-80 degrees) - Left hand: positioned in flexion (bent) - Left hip: WFL - Left knee: 20-30 degrees - Left ankle: 0-10 degrees into plantarflexion The DOR reviewed Resident 62's Change in Condition JMA, dated 1/12/2022. The DOR stated Resident 62 had the following ROM in both arms and both legs: - Right shoulder: WFL - Right elbow: WFL - Right wrist: 20-80 degrees - Right hand: contractures of the ring fingers and little fingers - Right hip: WFL - Right knee: 20 degrees of motion - Right ankle: 0-10 degrees into plantarflexion - Left shoulder: WFL - Left elbow: WFL - Left wrist: 20-80 degrees - Left hand: contractures of the fingers - Left hip: WFL - Left knee: 10 degrees of motion - Left ankle: 0-10 degrees into plantarflexion The DOR stated Resident 62 did not receive another JMA after 1/12/2022 since Resident 62 was on hospice. The DOR stated the therapists did not perform any screening for ROM once a resident was placed on hospice services. During an observation and interview on 3/16/2023 at 5:46 PM in Resident 62's room, the DOR observed Resident 62's ROM. Resident 62 was lying in bed with the HOB elevated and wore a hospital gown. Resident 62 was awake, alert, and stated, I want therapy for all my problems because I can't move stuff. The DOR asked Resident 62 to move both arms. Resident 62 slightly lifted the right arm at the shoulder joint and slightly extended the right elbow. Resident 62 was unable to move the left arm. The DOR lifted the blankets to observe both of Resident 62's legs and stated, Oh my God. The DOR stated Resident 62 had contractures to both ankles into plantarflexion. The DOR walked out of Resident 62's room and stated Resident 62 declined since the last JMA on 1/12/2022. The DOR stated Resident 62 had increased contractures in both ankles, both wrists, and both hands/fingers. The DOR stated the DOR could not touch Resident 62 since Resident 62 was on hospice services. The DOR stated the facility discontinued RNA services when residents were placed on hospice. During an interview and record review on 3/17/2023 at 7:37 AM, the DOR compared Resident 62's JMA from 3/11/2021 and 1/12/2022. The DOR stated Resident 62 was discharged from PT and OT services on 4/2/2021 with recommendations for ROM with RNA and application of a left-hand splint. The DOR stated Resident 62's ROM in the left shoulder, left elbow, left wrist, and left hand improved on the JMA, dated 1/12/2022, because Resident 62 received RNA services for ROM and application of the left-hand splint. The DOR stated Resident 62 currently had contractures to both ankles, both wrists, and both hands. The DOR did not know the reason for Resident 62's decline in ROM and Resident 62's contracture development. During an interview on 3/17/2023 at 9:33 AM, the Hospice Certified Nursing Assistant (CHHA 1) stated Resident 62 received a bed bath, oral care, nail care, body lotion application, and perineal care (genital and rectal cleaning). CHHA 1 stated providing ROM was not part of the assignment. CHHA 1 stated CHHA 1 moved Resident 62's legs if Resident 62 did not complain of pain. CHHA 1 stated Resident 62 did lift the legs during care, and CHHA 1 would move Resident 62's legs if Resident 62 wanted to move them for comfort. CHHA 1 stated CHHA 1 did not move Resident 62's arms since Resident 62 was stiffer in both hands. During an interview on 3/17/2023 at 9:40 AM, Certified Nursing Assistant 7 (CNA 7) stated CNA 7 provided Resident 62 with ADL care, including dressing, bathing, changing the linen, changing positions every two hours, feeding, and oral care. CNA 7 stated Resident 62's wrists, hands, and ankles were bent and did not move. CNA 7 stated both of Resident 62's elbows and knees were very stiff. CNA 7 stated CNA 7 moved Resident 62's arms and legs during care but did not provide ROM. CNA 7 stated the RNAs provided ROM to the residents. CNA 7 stated Resident 62 wore a hospital gown because Resident 62 did not have any clothes. CNA 7 stated it would be difficult to dress Resident 62 in regular clothes because Resident 62 cannot bend both arms to get through sleeves which would likely hurt Resident 62 unintentionally. During a telephone interview on 3/17/2023 at 10:27 AM, Resident 62's Responsible Party (RRP 1) stated Resident 62 did not walk anymore but moved both arms and both legs upon admission to the facility. RRP 1 stated the facility did not inform RRP 1 of Resident 62's ROM limitations in both arms and both legs. RRP 1 stated RRP 1 would never prevent the facility from performing exercises with Resident 62. RRP 1 stated Resident 62 used to exercise every day. During an observation and interview on 3/17/2023 at 11:31 AM in Resident 62's room, Resident 62 was sleeping with the HOB elevated and wearing a hospital gown. Both of Resident 62's wrists and hands were in a bent position while sleeping. CHHA 1 slightly bent the right elbow but stated CHHA 1 could not straighten Resident 62's right wrist and right fingers. CHHA 1 slightly lifted Resident 62's left arm at the shoulder joint and stated CHHA 1 could not bend the elbow because the bone felt very tight. CHHA 1 also stated CHHA 1 could not straighten Resident 62's left wrist and left fingers because they felt very contracted. CHHA 1 stated CHHA 1 has worked with Resident 62 for the past year and stated Resident 62 looked more fragile and developed more contractures. During an interview and record review on 3/17/2023 at 12:48 PM, the DON stated Resident 62 was originally admitted to the facility on [DATE] and remained at the facility since admission. The DON reviewed Resident 62's OT Progress and Discharge summary, dated [DATE], which indicated a recommendation for a RNP to apply the left-hand splint and provide PROM to both arms. The DON reviewed Resident 62's PT Progress and Discharge summary, dated [DATE], which indicated a recommendation to use a mechanical lift to transfer Resident 62 to a wheelchair and a RNP for ROM. The DON reviewed Resident 62's RNP documentation. The DON stated Resident 62 received RNA services from 4/6/2021 to 4/4/2022. The DON stated Resident 62's RNA task for PROM to both legs, PROM to both arms, and application of the inflatable left hand splint was discontinued on 4/5/2022. The DON reviewed Resident 62's clinical record, including but not limited to interdisciplinary team meetings and nursing progress notes. The DON stated Resident 62's clinical record did not indicate the reason for discontinuing Resident 62's RNA services. The DON stated the facility did not have any documented evidence Resident 62 received any PROM to both arms, PROM both legs, and splint application to either arm from 4/5/2022 to now, which the DON stated was a total of 11 months. A review of the facility's policy and procedure titled, Joint Mobility Screening and Assessment, revised on 11/2017, indicated a resident who enters the facility without limited range of motion and/or limited range of motion receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. The facility further indicated a Joint Mobility Assessment form will be completed by the rehabilitation staff upon initial assessment, annual assessment, and change of condition. A review of the facility's policy and procedure titled, Restorative Nursing Programs, revised on 9/2/2022, indicated it was the facility's policy to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The policy indicated Residents, as identified during the comprehensive assessment process, will receive services from restorative aids (RNAs) when they are assessed to have a need for restorative nursing services, which included providing PROM and splint or brace assistance. During an interview and record review on 3/17/2023 at 12:48 PM with the DON and DOR, the DOR stated Resident 62 did not receive another JMA after 1/12/2022 since Resident 62 was on hospice. Both the DON and DOR reviewed the facility's policies tilted, Joint Mobility Screening and Assessment and Restorative Nursing Programs. Both the DON and the DOR stated the facility's policies did not indicate residents placed on hospice care were excluded from receiving a JMA and RNP/RNA services. During a telephone interview on 3/17/2023 at 2:15 PM, the Hospice Registered Nurse (HRN 1) stated Resident 63 had contractures to both wrists, both hands, and both feet. HRN 1 stated the hospice company only provided ROM during normal care to keep Resident 62 comfortable. HRN 1 stated the hospice staff did not provide ROM services. HRN 1 stated the hospice company would not prevent Resident 62 from receiving ROM exercises from the facility if the facility had a nursing program to perform ROM. During an interview on 3/17/2023 at 3:34 PM, the DOR stated contracture development should be avoided to prevent the development of pressure sores. The DOR stated it would be difficult to dress Resident 62 in regular clothes since the nurse would have to lift Resident 62's arms and bend the elbows. A review of the facility's policy titled, Prevention of Decline in Range of Motion, revised on 9/2/2022, indicated the facility shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. The policy further indicated the facility will provide intervention, exercises and/or therapy to maintain or improve range of motion. b. A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021 with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's care plan related to Resident 13's limited physical mobility, revised on 4/25/2022, indicated the following: 1. The goal was for Resident 13 to remain free of complications related to immobility, including contractures, thrombus formation (blood clot formation that limits the natural flow of blood), skin breakdown, and fall-related injury. 2. Interventions included ambulation (walking) with one staff required to assist Resident 13, provision of gentle ROM as tolerated with daily care, and assistance with mobility as needed. A review of Resident 13's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Treatment Encounter Note(s), dated 6/17/2022, indicated Physical Therapist 1 (PT 1) discussed with Resident 13 about Resident 13's discharge from PT. The PT Treatment Encounter Note indicated Resident 13 agreed to transition to the Restorative Nursing Program (RNP) for ambulation. A review of Resident 13's PT Discharge summary, dated [DATE], indicated Resident 13 was able to safely ambulate on level surfaces 60 feet using a two-wheeled walker with minimum assistance from the staff on 6/17/2022. The Discharge Summary indicated Resident 13 had good prognosis to maintain current level of functioning with consistent staff follow-through. A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), was able to understand others, and was able to express ideas and wants. The MDS indicated Resident 13 required limited one-person assistance and/or guided maneuvering of limbs with walking. The MDS indicated Resident 13's balance during transitions and walking was not steady and only able to stabilize with staff assistance. A review of Resident 13's Physician's Progress Notes, dated 1/6/2023, indicated Resident 13 had stasis dermatitis (skin inflammation due to fluid buildup related to poor blood circulation) in Resident 13's lower extremities (legs) and was receiving wound care due to a big toe wound. During an observation and interview on 3/14/2023 at 9:21 AM, Resident 13 stated the desire to participate in exercises because Resident 13 used to walk with a walker upon admission to the facility. Resident 13 was alert and oriented, with no evidence of pain or any distress while sitting in the wheelchair and received supplemental oxygen at 2 liters/minute. During an interview on 3/16/2023 at 8:42 AM, Certified Nursing Assistant 6 (CNA 6) stated CNA 6 did not know if Resident 13 could walk, because CNA 6 has not seen Resident 13 walk. During an interview on 3/15/2023 at 2:44 PM, the Director of Rehabilitation (DOR) stated the residents on RNP did not have any physician's orders for RNP services since the facility transitioned to paperless electronic documentation. The DOR stated RNP services were implemented in a resident's care plan which created a RNP task. The DOR stated the DOR and the MDS Assistant (MDSA) had RNP meetings once per month. During an interview on 3/15/2023 at 2:52 PM, the DOR and MDSA stated a resident's RNP care plan included an RNP task in the electronic documentation system, which allowed the RNA to document the RNP session. The DOR and MDSA stated RNP services were important to maintain a resident's ROM and to maintain a resident's functional status. D[TRUNCATED]

b. A review of Resident 54's admission Record indicated the facility admitted Resident 54 on 9/13/2022, with diagnoses of orthostatic/postural hypotension (form of low blood pressure that happens when standing after sitting or lying down), history of falling, and unspecified dementia (memory loss which interferes with daily functioning). A review of a facility document titled, Consultant Pharmacist's Medication Regimen Review, dated 12/17/2022, completed by the facility's consultant pharmacist, indicated for the facility to review Resident 54 for falls. The consultant pharmacist recommendations included for the staff to screen Resident 54 for postural hypotension at lying and standing position. A review of Resident 54's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/6/2023, indicated Resident 54 had moderately impaired memory and cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 54 required limited assistance with one person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. During a concurrent review of Resident 54's medical record and interview with the Infection Preventionist Nurse (IPN) on 3/16/2023 at 9:12 am, the IPN stated there was no documentation that Resident 54 was screened or monitored for postural hypotension. The IPN stated, Resident 54's blood pressure needed to be monitored at lying and standing position to assess for fall risk and prevent fall. During an interview on 3/16/2023 at 12:20 pm, the Director of Nursing (DON) stated there was no specific time frame indicated in the facility policy to act upon the consultant pharmacist's recommendations during the monthly Medication Regimen Review. The DON stated it could take between 30 to 45 days, but the registered nurse could prioritize and address the most important recommendation/s as soon as possible. A review of the facility's policy and procedures (P&P) titled, Medication Regimen Review, dated 9/2/2022, indicated facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Based on interview and record review, the facility failed to develop a policy that specified the time frames for acting upon the facility's consultant pharmacist's recommendation during the monthly regimen review (MRR, thorough evaluation of the resident's medication regimen to promote positive outcomes and minimize risks or adverse effects) for two of 20 sampled residents (Resident 9 and 54). a. For Resident 9, the facility staff did not act upon the MRR recommendation, dated 2/8/2023, to review with the physician the necessity of the routine and as needed (PRN) Melatonin (supplement to induce sleep) until 3/16/2023. b. For Resident 54, the facility staff did not act upon the MRR recommendation, dated 12/17/2022, to screen the resident for postural hypotension (form of low blood pressure that happens when standing after sitting or lying down). These deficient practices had the potential to cause a decline in the residents' physical and psychosocial well-being related to a delay in the necessary treatment and services. Cross Reference with F757 Findings: a. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), obstructive sleep apnea (sleep-related breathing disorder), hypertensive heart disease (heart problems due to high blood pressure over a long period of time) with heart failure, major depressive disorder (persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (developed by individuals who experienced a shocking, scary, or dangerous event with symptoms like trouble sleeping and nightmares). A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 had sleeping problems nearly every day. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. A review of Resident 9's Consultant Pharmacist's MRR, dated 2/8/2023, indicated the following: Resident has an order for Melatonin 5 milligrams at bedtime for sleep. Please also review with MD if resident needs both routine and prn melatonin at bedtime. A review of Resident 9's active physician orders from 3/1/2023 through 3/17/2023 indicated the following orders: 1. Give 1 tablet of Melatonin tablet 5 milligrams orally at bedtime for sleep. 2. Give 1 tablet of Melatonin tablet 5 milligrams orally PRN at bedtime for supplement to regulate circadian rhythm, for inability to sleep. During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 9:39 am, Licensed Vocational Nurse 3 (LVN 3) stated Resident 9 had active orders for routine and PRN Melatonin. LVN 3 stated the licensed nurse must clarify the order with the physician if it was necessary to administer two different medications to treat the inability to sleep. LVN 3 stated, if determined both medications were necessary, Resident 9 must either have the routine or as needed Melatonin order, and not both, to prevent overmedicating the resident. LVN 3 stated, if Melatonin was ordered to be administered routinely and was ineffective, the licensed nurse must call the physician to obtain any new orders. During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 11:03 am, Registered Nurse 2 (RN 2) stated routine and PRN Melatonin must not be ordered at the same time due to possible overmedication. RN 2 stated the licensed nurse must call the physician to increase the routine Melatonin dosage if ineffective. RN 2 stated if she was assigned to follow through with the physician regarding a MRR recommendations, it must be done within 24 hours. RN 2 stated Resident 9's PRN Melatonin was discontinued on 3/16/2023. During an interview on 3/16/2023 at 12:20 pm, the Director of Nursing (DON) stated there was no specific time frame indicated in the facility's policy to act upon the pharmacy consultant's recommendations during the monthly MRR. The DON stated it could take between 30 to 45 days, but the registered nurse could prioritize and address the most important recommendation/s as soon as possible. A review of the facility's policy and procedures, titled Medication Regimen Review, dated 9/2/2022, indicated the monthly MRR includes a review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The policy indicated the facility staff must act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on interview and record review, the facility failed to ensure the medication regimen of two of 20 sampled residents (Residents 9 and 10) were free of any duplicate medication therapy and had adequate indications for its use. a. For Resident 9, the facility failed to clarify with the physician whether the active orders for routine Melatonin (supplement to induce sleep) 5 milligrams at bedtime and as needed (PRN) Melatonin 5 milligrams at bedtime were both necessary in addition to an order for Trazodone 100 milligrams at bedtime, to address Resident 9's inability to sleep. b. For Resident 13, the facility failed to ensure PRN acetaminophen (used to treat minor aches and pain) 650 milligrams was only administered for mild pain as ordered, and PRN Percocet (controlled medication to treat moderate to severe pain) 5-325 milligrams was only administered for severe pain as ordered. These deficient practices had the potential to cause a decline in the residents' physical and psychosocial well-being. Cross Reference with F756 Findings: a. A review of Resident 9's admission Record indicated the facility initially admitted the resident on 12/5/2022, with multiple diagnoses including severe obesity (excessive body fat), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), obstructive sleep apnea (sleep-related breathing disorder), hypertensive heart disease (heart problems due to high blood pressure over a long period of time) with heart failure, major depressive disorder (persistent feeling of sadness and loss of interest), and post-traumatic stress disorder (developed by individuals who experienced a shocking, scary, or dangerous event with symptoms like trouble sleeping and nightmares). A review of Resident 9's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/9/2022, indicated the resident did not have an impairment in cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 9 had sleeping problems nearly every day. A review of Resident 9's History & Physical, dated 2/29/2023, indicated Resident 9 had the capacity to understand and make decisions. A review of Resident 9's active physician orders from 3/1/2023 through 3/17/2023 indicated the following orders: 1. Give 1 tablet of Melatonin tablet 5 milligrams orally at bedtime for sleep. 2. Give 1 tablet of Melatonin tablet 5 milligrams orally PRN at bedtime for supplement to regulate circadian rhythm (natural internal process that regulates the sleep-wake cycle), for inability to sleep. 3. Give Trazodone HCl 100 milligrams orally at bedtime for depression manifested by inability to sleep. During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 9:39 am, Licensed Vocational Nurse 3 (LVN 3) stated the licensed nurse must clarify the order with the physician if it was necessary to administer two different medications to treat the inability to sleep. LVN 3 stated, if determined both medications were necessary, Resident 9 must either have the routine or as needed Melatonin order, and not both, to prevent overmedicating the resident. LVN 3 stated, if Melatonin was ordered to be administered routinely and was ineffective, the licensed nurse must call the physician to obtain any new orders. During an interview and concurrent review of Resident 9's clinical records on 3/16/2023 at 11:03 am, Registered Nurse 2 (RN 2) stated routine and PRN Melatonin must not be ordered at the same time due to possible overmedication. RN 2 stated the licensed nurse must call the physician to increase the routine Melatonin dosage if ineffective. RN 2 stated the licensed must call the physician to inform about Resident 9's condition and verify the Trazodone and Melatonin orders related to any possible drug-to-drug interactions. A review of the facility's policy and procedures titled, Consulting Physician/Practitioner Orders, dated 9/2/2022, indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner must call the attending physician to verify the order and document the verification order by entering the order, time, date and signature on the physician order sheet. The policy indicated if orders were received via telephone, the nurse must document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order, and call the attending physician to verify the order. b. A review of Resident 13's admission Record indicated the facility initially admitted the resident on 5/11/2021, with multiple diagnoses including chronic respiratory failure with dependence on supplemental oxygen and chronic peripheral venous insufficiency (damaged leg veins causing problems moving blood back to the heart). A review of Resident 13's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 1/5/2023, indicated the resident had moderate impairment in cognition (mental action or process of acquiring knowledge and understanding), but he was able to understand others and express ideas and wants. The MDS indicated Resident 13 required limited one-person assistance with bed mobility, transfer, walking, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS indicated Resident 13's worst pain intensity over the last 5 days was 6. A review of Resident 13's Physician's Progress Notes, dated 1/6/2023, indicated Resident 13 had stasis dermatitis (skin inflammation due to fluid buildup related to poor blood circulation) in his lower extremities and was receiving wound care due to a big toe wound. A review of Resident 13's physician's orders from 11/2022 to 3/2023 indicated the following active orders as of 3/17/2023: 1. Monitor for pain: 0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, 10 = very severe pain (ordered on 6/16/2021). 2. Give two tablets of acetaminophen tablet 325 milligrams orally every six hours PRN for mild pain, not to exceed three grams in 24 hours (ordered on 5/11/2021). 3. Give one tablet of Percocet tablet 5-325 milligram orally every six hours PRN for severe pain, not to exceed three grams in 24 hours (ordered on 4/7/2022). During an interview and concurrent review of Resident 13's clinical records on 3/16/23 at 9:12 am, Licensed Vocational Nurse 3 (LVN 3) stated Resident 13 was given Tylenol as needed for mild pain or pain level of 1-3. LVN 3 stated Resident 13 was given Percocet as needed for severe pain or pain level of 7-10. LVN 3 stated if Resident 13 complained of moderate pain or pain level of 4-6, the physician must be notified to obtain a specific pain medication order for moderate pain to target the effectiveness of the pain medications without giving too much or too little. During an interview and concurrent review of Resident 13's clinical records on 1/2022 on 3/16/2023 at 11:31 am, Registered Nurse 2 (RN 2) stated she was not aware of the new pain scale (0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, 10 = very severe pain) indicated in Resident 13's physician orders. RN 2 stated she would call the physician to obtain/clarify the pain medication order for moderate pain to ensure all licensed nurses consistently administered Resident 13's pain medications as ordered. The MARs from 11/2022 to 3/2023 indicated the following: 1. On 11/2022 - Resident 13 had moderate level of pain (6-7) and Percocet 5-325 milligrams was administered on 11/4/2022, 11/9/2022, 11/11/2022 (x2), 11/12/2022, 11/13/2022, 11/14/2022, 11/16/2022, 11/18/2022, 11/19/2022, 11/20/2022, 11/23/2022, 11/24/2022, and 11/29/2022 (total of 14 times). 2. On 1/2023 - Resident 13 had moderate pain (7) and Percocet 5-325 milligrams was administered on 1/2/2023, 1/3/2023, and 1/24/2023 (total of three times). Resident 13 had moderate pain (5) and acetaminophen 650 milligrams was administered on 1/6/2023 (total of one time). 3. On 2/2023 - Resident had moderate level of pain (7) and Percocet 5-325 milligrams was administered on 2/24/2023 (total of one time). 4. On 3/2023 - Resident had moderate level of pain (7) and Percocet 5-325 milligrams was administered on 3/9/2023 and 3/14/2023 (total of 2 times). A review of the facility's policy and procedures titled, Pain Management, dated 9/2/2022, indicated pain management must be provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The policy indicated the facility must use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain.

Based on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) to three of five residents (Resident 62, 66, and 1) receiving hospice care. The facility failed to: 1. Officially designate the facility's staff member responsible for coordinating hospice services in the facility's policy. 2. Ensure the facility's coordinator for hospice care coordinated and communicated with the hospice company to ensure the provision of hospice services. 3. Ensure the facility's licensed staff were aware of the facility's designated coordinator for hospice care. 4. Ensure the Hospice Certified Nursing Assistant (CHHA - nursing aide who are trained specifically for hospice care) provided timely care on designated dates and communicated the hospice visits with detailed notes in the residents' clinical record binder specifically for hospice care (hospice binder). These failures prevented Resident 66, 62, and 1 from receiving well-coordinated and comprehensive hospice services. Findings: A review of the facility's policy and procedures titled, Hospice Services Facility Agreement, revised on 9/2/2022, indicated it was the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The policy indicated the facility had designated (the Assistant Director of Nursing, or specify the member from the interdisciplinary team) to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff. During an interview on 3/15/2023 at 9:30 am, Registered Nurse 2 (RN 2) stated the facility did not have a designated contact person for hospice residents. RN 2 stated if the hospice staff had any concerns, additional physician's orders, or questions, then the hospice staff would contact the charge nurse or RN supervisor assigned to the specific hospice resident. During an interview on 3/16/2023 at 11:03 am, Licensed Vocational Nurse 2 (LVN 2) stated LVN 2 did not know who the hospice coordinator was for the facility. LVN 2 stated the hospice personnel alerted the charge nurse if they were in the facility for a resident. LVN 2 stated the facility's hospice coordinator was supposed to be ensuring the residents on hospice were receiving services according to the hospice contract, but LVN 2 did not know who the facility's hospice coordinator was. During an interview on 3/16/2023 at 11:35 am, LVN 1 stated any nursing supervisor could be the hospice coordinator. During an interview and record review on 3/16/2023 at 11:47 am, the Director of Nursing (DON) and the Director of Social Services (DSS) stated the hospice coordinator was the DON. The DON reviewed the facility's policy for hospice services and stated the facility did not designate a staff member in charge of coordinating hospice services in the facility's hospice policy. During a follow-up interview on 3/17/2023 at 11:49 am, the DON stated the DON was the official coordinator for hospice but delegated all the tasks related to hospice to the DSS since the DSS initiated hospice services. a. A review of Resident 66's admission Record indicated the facility originally admitted Resident 66 on 4/2/2021. Resident 66's diagnoses included alcoholic cirrhosis of liver (final phase of liver disease) with ascites (abdominal swelling caused by accumulation of fluid related to liver disease), acute respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), and acute ischemic heart disease (hardening of blood vessels preventing blood flow and oxygen to the heart). A review of Resident 66's census list (record of hospitalizations, room changes, and payer source changes) indicated Resident 66 was readmitted to the facility from the hospital on 2/2/2023. A review of Resident 66's admission Order, dated 2/2/2023, indicated Resident 62 was admitted to hospice care. A review of Resident 66's Physician's Certification for Hospice Benefit, dated 2/2/2023 to 4/2/2023, indicated Resident 66's primary hospice diagnosis included alcoholic cirrhosis of liver with ascites. A review of Resident 66's clinical record in Resident 66's hospice binder included a calendar, which indicated the dates hospice staff would provide services to Resident 66. A review of Resident 66's hospice calendar for 2/22/2023 to 2/28/2023 and 3/2023 did not clearly indicate the dates Resident 66 would receive CHHA services. Resident 66's hospice binder also included a Hospice Staff Sign-In Sheet. Resident 66's Hospice Staff Sign-In Sheet did not include a CHHA. Further review of Resident 66's hospice binder did not include CHHA communication sheets (note indicating the CHHA provision of care) from 2/2023 to 3/2023. The latest CHHA communication entry was dated on 12/22/2022. A review of Resident 66's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 3/1/2023, indicated Resident 66 had clear speech, clear expression of ideas and wants, clear understanding of verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 66 required extensive assistance (resident involved in activity with staff providing support) for bed mobility, transfers between surfaces, dressing, toileting, and hygiene. During an interview and record review on 3/16/2023 at 11:47 am, the DON stated Resident 66 had intermittently revoked hospice services to allow Resident 66 to be hospitalized for treatment. The DON stated Resident 66 was re-admitted to hospice care on 2/2/2023. The DON reviewed the Hospice Staff Sign-In Sheet, calendar, and CHHA notes. The DON stated the last CHHA note was dated in 12/2022. The DON stated there was no documented evidence the hospice CHHA provided care to Resident 66 in 2/2023 and 3/2023. b. A review of Resident 62's admission Record indicated the facility admitted Resident 62 on 3/10/2021. Resident 62's diagnoses included unspecified atrial fibrillation (irregular and often very rapid heart rate), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and hypertension (abnormally high blood pressure). A review of Resident 62's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 12/15/2022, indicated Resident 62 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 62 was totally dependent (full staff performance every time) for eating, dressing, and personal hygiene. The MDS indicated Resident 62 had functional ROM limitations in both arms and both legs. A review of Resident 62's admission Order, dated 1/12/2022, indicated Resident 62 was admitted to hospice care with a diagnosis of Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life). A review of Resident 62's clinical record in Resident 62's hospice binder included a calendar, which indicated the dates hospice staff would provide services to the Resident 62. Resident 62's hospice calendar indicated the CHHA was scheduled to provide care to Resident 62 on 2/7/2023, 2/9/2023, 2/14/2023, 2/16/2023, 2/21/2023, 2/23/2023, 2/28/2023, 3/7/2023, 3/9/2023, 3/14/2023, and 3/16/2023. Further review of Resident 62's hospice binder indicated the CHHA communication sheet (note indicating the CHHA provision of care) did not have any entries for 2/7/2023, 2/9/2023, 2/14/2023, and 3/7/2023. During an interview and record review on 3/16/2023 at 11:47 am, the DON reviewed Resident 62's hospice binder. The DON confirmed the hospice binder did not include a communication sheet for the provision of CHHA care to Resident 62 on 2/7/2023, 2/9/2023, 2/14/2023, and 3/17/2023. The DON stated the facility did not have documented evidence Resident 62 received CHHA care on 2/7/2023, 2/9/2023, 2/14/2023, and 3/17/2023. c. A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 8/1/2008, and readmitted the resident on 2/15/2023. Resident 1's diagnoses included but was not limited to kidney failure, dysphagia (difficulty swallowing), attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding), history of transient ischemic attack (brief stop of blood supply to the brain) and cerebral infarction (brain damage due to a loss of oxygen to the area) without residual deficits. A review of Resident 1's Physician's Certification for Hospice Benefit, dated 2/15/2023 to 5/15/2023, indicated Resident 1's primary hospice diagnosis was diffuse (spread out) traumatic brain injury (injury that affects how the brain works) with loss of consciousness of unspecified duration. A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 2/21/2023, indicated Resident 1 had unclear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 was totally dependent (full staff performance every time) for bed mobility, transfers between surfaces, dressing, eating, hygiene, toileting, and bathing. A review of Resident 1's clinical record in Resident 1's hospice binder included a calendar, which indicated the dates hospice staff would provide services to Resident 1. Resident 1's hospice calendar indicated the CHHA was scheduled to provide care to Resident 1 on 3/2/2023, 3/7/2023, 3/9/2023, 3/14/2023, and 3/16/2023. Further review of Resident 1's hospice binder indicated the CHHA communication sheet (note indicating the CHHA provision of care) did not have an entry for 3/2/2023. Resident 1's CHHA notes on 3/7/2023, 3/9/2023, and 3/14/2023 included a single, handwritten note for each date on the blank side of the CHHA communication sheet. During an interview and record review on 3/16/2023 at 11:47 am, the DON reviewed Resident 1's hospice binder. The DON confirmed the clinical record did not include a communication sheet for the provision of CHHA care to Resident 1 on 3/2/2023. The DON stated the facility did not have documented evidence Resident 62 received CHHA care on 3/2/2023. The DON also stated the CHHA notes on 3/7/2023, 3/9/2023, and 3/14/2023 were incomplete and did not indicate the care provided to Resident 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the physical space and equipment in the Rehabilitation Gym, including one box containing five lidocaine (medication for local pain relief) patches, two of two boxes of menthol (medication for minor muscle and joint aches and pain) patches, three of three packages with electrode (conductor through which electricity enters or leaves an object) preparation pads for skin preparation, and one container of ultrasound gel. This failure had the potential to prevent the provision of a functional and sanitary environment. Findings: During an observation on [DATE] at 9:05 am in the rehabilitation gym, a box with five unopened lidocaine pain relief patches expired on 11/2022. Two packages of unopened menthol medication patches expired on 8/2022. Three packages of electrode preparation pads for skin preparation expired on 6/2021. A container of ultrasound gel expired on [DATE]. During an observation and interview on [DATE] at 9:21 am in the rehabilitation gym, the Director of Rehabilitation (DOR) stated the rehabilitation department received a new ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) machine which was being calibrated (setting a measuring device to confirm with a reference standard). The DOR stated ultrasound gel was used as a conductor for ultrasound but would not be effective since the ultrasound gel expired on 3/2021. The DOR stated the electrode preparation pads were used to clean and prevent the skin from damage prior to applying electrodes on the skin. The DOR stated the electrode preparation pads were likely dry and unusable since they expired on 6/2021. The DOR observed the lidocaine and menthol patches and stated being unaware the patches were stored in the rehabilitation department. A review of the facility's policy and procedures titled, Rehab Equipment Maintenance & Safety, revised on [DATE], indicated preventative maintenance shall be performed on all rehab equipment to prolong the rehab equipment life and to ensure efficient operation and reliability of the equipment.