**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an injury of unknown origin (any injury without a reason the injury could have or did occur) in accordance with their abuse policy and procedure (P&P) for one of three sampled residents (Resident 1) when Resident 1 was found with discoloration (a different color than normal) around his right eye on 4/12/25 and the injury was not reported to the California Department of Public Health (CDPH) and adult protective services until 4/14/25. This failure led to the delay of the investigation into the cause of Resident 1 ' s injury to rule out the potential for abuse. Findings: During an interview on 4/30/25 at 1:29 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had Huntington ' s Disease (causes nerve cells in the brain to decay over time affecting a person ' s movements, thinking ability and mental health) with involuntary body movement (abnormal, random muscle movements) and confused at times. During an observation on 4/30/25 at 1:43 p.m., Resident 1 was groomed and dressed sitting in a wheelchair in his room. Resident 1 had involuntary movements in his body, head, arms and legs. Resident 1 was asked if he remembered what happened to his eye and appeared to shake his head no. Resident 1 attempted to speak but his words were not clear. During a review of Resident 1 ' s admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including Huntington ' s Disease and dementia (decline in thinking, memory and reasoning). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS – assessment of cognitive status for memory and judgement) scored 04 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had a severe cognitive impairment. During an interview on 4/30/25 at 1:57 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 had a black eye (bruise caused by a collection of blood under the skin) a couple of weeks ago. CNA 1 stated she had asked Resident 1 what happened to his eye, and he laughed. CNA 1 stated Resident 1 was on every 15-minute checks by staff before the black eye happened. CNA 1 stated a black eye could be a potential sign of abuse and needed to be reported to the charge nurse and Administrator (ADM) as soon as possible. During an interview on 4/30/25 at 2:28 p.m. with CNA 2, CNA 2 stated he frequently took care of Resident 1. CNA 2 stated when he started his shift on 4/12/25 at 6:30 a.m., he found Resident 1 with a black eye. CNA 2 stated he thought another CNA had reported the black eye to the charge nurse, so he did not tell the nurse himself. During a concurrent interview and record review on 4/30/25 at 2:34 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/12/25 around 8:00 a.m., LVN 2 notified her Resident 1 had discoloration around his right eye. LVN 1 stated LVN 2 had administered Resident 1 ' s morning medication and discovered the skin around his eye was discolored. Resident 1 ' s Progress Note, dated 4/12/25 at 10:05 a.m. was reviewed. The note indicated, During med pass, writer noted that resident has a black eye around right eye. The resident stated he doesn ' t know how he got the black eye .There were no reports of falls or accidents in the recent past that could explain the injury . LVN 1 stated the ADM was the facility ' s abuse coordinator and he should have been notified immediately because an unwitnessed injury of a bruised, discolored eye could indicate abuse. LVN 1 stated LVN 2 had notified the DON but was unable to locate documentation indicating when the DON was notified. LVN 1 was unable to locate documentation indicating the ADM had been notified. Resident 1 ' s IDT (Interdisciplinary team- team from different healthcare disciplines who work together to provide compressive patient care) note dated 4/14/25 at 12:39 p.m. was reviewed, the note indicated, . Resident was observed with red and blue discoloration around the right eye. No evidence of fall, physical altercation, or abuse was found . Per staff he was agitated on Friday [4/11/25] in dining room, he was redirected to his room until he was calm. Per staff interview there was no physical contact made with resident at that time . LVN 1 stated she had asked Resident 1 how he got the black eye, and he was unable to state how it happened. LVN 1 stated she had not suspected abuse, but the incident was unwitnessed, and Resident 1 was not able to report what happened, so it should have been treated as abuse. During an interview on 4/30/25 at 2:55 p.m. with LVN 2, LVN 2 stated she was Resident 1 ' s nurse on 4/12/25 and had gone into Resident 1 ' s room between 8:30 and 9:00 a.m. to administer his medications and noticed the discoloration around his eye. LVN 2 stated she had finished passing the other resident ' s medications before she notified the DON around 10:00 a.m. LVN 2 stated she did not notify the ADM. LVN 2 was unable to state who the facility ' s abuse coordinator was. LVN 2 was unable to locate documentation indicating she had notified the DON of Resident 1 ' s discolored eye. LVN 2 stated she did not call the police department, but she should have since a black eye could be a sign or abuse. During an interview on 4/30/25 at 3:05 p.m. with the DON, the DON stated LVN 2 had notified her immediately after Resident 1 ' s discolored eye was found, receiving the call around 10:00 a.m. The DON stated she thought the ADM had reported the incident to the police department but was unable to provide supporting documentation. The DON stated suspected abuse needed to be reported within two hours to the abuse coordinator and 24 hours to CDPH. The DON stated Resident 1 had been on 15-minute checks at the time of the discolored eye and she was unsure why the staff had not noticed his eye sooner. The DON stated there was no documentation in the electronic medical record indicating when the state licensing agency or ombudsman were notified. The DON stated she was unsure if the ADM had reported the incident to law enforcement. The DON stated Resident 1 ' s discolored eye could have been the result of abuse, but the IDT did not suspect abuse had caused it. During a concurrent telephone interview and P&P review on 5/5/25 at 9:55 a.m. with the ADM, the ADM stated he had a copy of the facility ' s abuse P&P. The facility ' s P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 4/2021, was reviewed and indicated, . If resident abuse . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . The ADM stated Resident 1 ' s discolored eye was an injury of unknown source because it was unwitnessed, and the resident could not state what happened. The ADM stated he notified the state licensing agency and ombudsman by fax on 4/14/25. The ADM stated the P&P indicated suspicion of abuse should have been reported within two hours according to the facility ' s P&P. The ADM stated the P&P was not followed. During a telephone interview with the Ombudsman (OMB-advocate who works to ensure the health, safety and well-being of nursing home residents), the OMB stated they received the report of Resident 1 ' s injury on 4/15/25. During a review of an e-mail provided by the ADM, indicated he sent the report regarding Resident 1 ' s injury to CDPH on 4/14/25 at 4:03 p.m. During a review of the State Operations Manual, dated 8/8/2024, the SOM indicated, . Injuries of unknown source-An injury should be classified as an injury of unknown source when all of the following criteria are met . source of injury was not observed by any person . source of injury could not be explained by the resident . injury is suspicious because of the extent of the injury or location of the injury . During a review of the facility ' s P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 4/2021, . All reports of resident abuse (including injuries of unknow origin) . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management . If resident abuse . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . administrator or the individual making the allegation immediately . to the following persons or agencies . state licensing/certification agency responsible for surveying/licensing the facility . local/state ombudsman . Law enforcement officials . Immediately is defined as . within two hours of an allegation involving abuse .

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of five sampled residents (Resident 1) when the facility ' s boiler system (a system of vessels and tubes, in which water is heated) was not functional, Certified Nursing Assistant (CNA) 2 gave Resident 1 a bed bath with cold water. This failure violated Resident 1 ' s right to a homelike environment and caused him to feel uncomfortable and chilled during the bed bath. Findings: During an interview on 3/18/25 at 10:00 a.m. with the Administrator (ADM), the ADM stated he received a phone call from the Director of Maintenance (DOM) on the morning of 3/18/25 because the boiler to the facility ' s water supply was not working. The ADM stated the Vendor (VDR) came out and replaced the ignition control module (electronic panel that manages the ignition process, ensuring the boiler is lit safely) on the boiler but discovered a gas valve (essential to control the flow of gas to the boiler) had also failed. The VDR did not have the gas valve in stock and could not order it until Monday 3/17/25. During an interview on 3/18/25 at 10:29 a.m. with Resident 1, Resident 1 stated he was notified there was no hot water on Saturday (3/15/25). Resident 1 stated his scheduled shower days were Tuesdays and Fridays. Resident 1 stated he was given a bed bath earlier in the day and the CNA had not been notified there was an alternate source to get hot water for a bed bath. Resident 1 stated, she gave me a cold bed bath. It was like biting a bullet. Resident 1 stated he was expecting warm water, then was washed with cold water which gave him chills throughout the bed bath and was not a thorough cleaning. During a concurrent observation and interview on 3/18/25 at 11:22 a.m., the sink temperature in Resident 1 ' s room was measured and registered 65.8 degrees (°) Fahrenheit (°F- a unit of temperature measurement- 212° F is boiling, and 32° F is freezing). During an interview on 3/18/25 at 11:54 a.m. with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated when she arrived at work, she was notified the boiler was not working, so there was no hot water. CNA 2 stated she gave Resident 1 a cold bed bath because she was not aware there was an alternate source for hot water available in the breakroom. CNA 2 stated, I felt so bad. CNA 2 stated Resident 1 was chilled and asked her during the bed bath when the facility would have hot water again. CNA 2 stated she should have used warm water for Resident 1 ' s bed bath. During an interview on 3/18/25 at 1:41 p.m. with CNA 3, CNA 3 stated he used hot water from the dispenser in the breakroom for resident bed baths. CNA 3 stated it was important to use warm water when providing a bed bath to make sure the resident was comfortable. During an interview on 3/18/25 at 1:47 p.m. with the Director of Staff Development (DSD), the DSD stated the hot water heater stopped working on Saturday 3/15/25. The DSD stated she and the Director of Nursing (DON) provided in-services to the staff over the weekend regarding the alternate hot water source and hand hygiene. The DSD stated the CNAs were offering the residents bed baths since there was no hot water for showering. The DSD stated the CNAs were instructed to use the hot water available in the breakroom for bed baths. The DSD stated the expectation for bed baths was for the CNA to test the water temperature themselves and have the resident check the water temperature before giving the resident a bed bath because it was important to make sure the resident was comfortable. The DSD stated a resident should not have a bed bath with cold water because it could be a shock to the resident ' s system and the residents would become easily chilled because their body temperature was not always functioning correctly due to chronic illnesses. The DSD stated, they [the CNAs] would not take a cold bath themselves. During an interview on 3/18/25 at 1:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the staff received texts over the weekend notifying them the facility did not have hot water. LVN 1 stated the staff were instructed there was a hot water source from a dispenser in the breakroom to use for resident baths. During an interview on 3/18/25 at 2:28 p.m. with the DON, the DON stated she and the DSD had been giving the staff in-services and instructed the staff to use the hot water dispenser in the breakroom for resident bed baths. The DON stated her expectation was for the staff to use warm water at the resident ' s preferred temperature for bed baths. The DON stated the residents should not receive a cold bed bath because they were at higher risk for hypothermia (a significant and dangerous drop body temperature) due to their age or health conditions. During an interview on 3/18/25 at 2:45 p.m. with the ADM, the ADM stated the expectations for bed baths was for the staff to provide warm water to fill the basin. The ADM stated the water temperature should be checked on the arm prior to bathing the resident and he would hope a resident did not have a cold bed bath. During a review of the facility ' s policy and procedure (P&P) titled Bed Baths, dated 9/2/22, the P&P indicated, . It is the practice of this facility to assist residents with bed bathing to maintain proper hygiene and prevent skin issues . Fill the basin halfway with warm water to the touch (between 98.6 °F to 103°F). Have the resident feel the water to ensure it is comfortable for them . During a review of the facility ' s P&P titled Resident Rights, dated 2/2021, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to . a dignified existence . be treated with respect, kindness, and dignity . self-determination . During a review of the facility ' s P&P titled Homelike Environment, dated 2/2021, the P&P indicated, . Residents are provided with a safe, clean, comfortable and homelike environment . Staff provides person-centered care that emphasizes the residents ' comfort, independence and personal needs and preferences .

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when one of two facility boiler systems (a device that heats the facility ' s water and/or ventilation system) stopped working and the laundry was washed in temperatures below the minimum water temperatures according to the facility ' s policy and procedure (P&P). This failure placed the 117 residents at risk for cross contamination from laundry not properly washed and sanitized according to the P&P. Findings: During an interview on 3/18/25 at 10:00 a.m. with the Administrator (ADM), the ADM stated he received a phone call from the Director of Maintenance (DOM) on the morning of 3/18/25 because the boiler to the facility ' s water supply was not working. The ADM stated the Vendor (VDR) came out and replaced the ignition control module (electronic panel that manages the ignition process, ensuring the boiler is lit safely) on the boiler but discovered a gas valve (essential to control the flow of gas to the boiler) had also failed. The VDR did not have the gas valve in stock and could not order it until Monday 3/17/25. During a concurrent observation and interview on 3/18/25 at 10:15 a.m. with Laundry Aide (LA) 1, LA 1 was in the clean linen area folding clothes. LA 1 stated when she came to work on 3/17/25, she was notified there was no hot water. LA 1 stated she washed the clothing and linens in cold water since no hot water was available. During a concurrent observation and interview on 3/18/25 at 10:20 a.m., with the Housekeeping Supervisor (HKS), the HKS stated she was also the supervisor for laundry. The HKS stated the facility washed clothing and linens in chemicals designed for low temperature washing. The HKS reviewed the laundry detergent label and stated it could be used at low temperatures, the recommended temperature was 130 degrees (°) Fahrenheit (°F-unit of temperature measurement on which water freezes at 32 ° and boils at 212°) to 150° F. The HKS stated the temperature was only recommended. There was a chemical dispenser on the wall next to the washers, the HKS stated it housed chlorine bleach, detergent and laundry sanitizer. The HKS stated the chemicals were automatically mixed to the wash by the dispenser. The HKS stated only white linens used bleach. During a concurrent observation and interview on 3/18/25 at 11:22 a.m. with the DOM, the laundry room sink water temperature was tested at 66.9°F. The DOM stated sink ' s water temperatures should be approximately 105 deg F. The DOM stated the water temperature in the washing machine would be the same as the sink because they were on the same water line. During a concurrent interview and record review on 3/18/25 at 1:30 p.m. with the HKS, the facility ' s policy and procedure (P&P) titled, Departmental (Environmental Services)-Laundry and Linen, dated 1/2014 was reviewed. The P&P indicated, . Washing Linen and other Soiled Items . Laundry may be processed in either low-temperature or high-temperature cycles . For low-temperature processing, wash linen in water that is at least 71-77°F and use a . chlorine bleach rinse if the material can withstand bleach and remain intact . The HKS stated she was unsure if 66.9°F met the facility ' s P&P of 71-77°F. The HKS stated the DOM would be in charge of the water temperatures. The HKS stated there was no way to know if the washer water met the minimum temperature according to the facility P&P. The HKS stated the facility used chlorine bleach only for the whites and linens, but not on the colored laundry. During an interview on 3/18/25 at 1:33 p.m. with the DOM, the DOM stated he did not deal with laundry, and it would be up to the HKS to know if the laundry temperature P&P was followed. During a concurrent interview and record review on 3/18/25 at 2:28 p.m. with the Director of Nursing (DON), the DON stated the Infection Preventionist was on vacation. The DON stated the IP would usually oversee the infection prevention practices of the laundry department. The DON reviewed the facility ' s P&P titled Departmental (Environmental Services)-Laundry and Linen, and stated the P&P indicated for low temperature wash, the laundry should be washed at a minimum temperature of 71-77°F. The DON stated if the water temperature was below the 71°F, it did not follow the P&P. During an interview on 3/18/25 at 2:45 p.m. with the ADM, the ADM stated when the IP was off, the DSD would normally take her place. The ADM reviewed the P&P for laundry and stated he would have to check the water temperature in the laundry room to see if the 71-77°F was met. The ADM stated if the laundry room water temperature was in the 60 ' s then the policy was not followed. During a review of a professional reference found at https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html#:~:text=Several%20studies%20have%20demonstrated%20that,are%20carefully%20monitored%20and%20controlled. Titled G. Laundry and Bedding, dated 2003, the reference indicated, . Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient apparel . Several studies have demonstrated that lower water temperatures of 71°F-77°F . can reduce microbial contamination when the cycling of the washer, the wash detergent, and the amount of laundry additive are carefully monitored and controlled .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain essential equipment in a safe operating condition when one of two boiler systems (a device that heats the facility ' s water and/or ventilation system) was not monitored, maintained and failed to operate from 3/15/25 to 3/18/25. This failure resulted in a non-functioning boiler system, unable to heat water throughout the facility including the laundry, kitchen, showers and sink faucets and placed the residents at risk for poor hygiene, infectious disease and discomfort. The facility ' s residents were unable to shower for three days, had to eat with disposable flatware and Styrofoam trays, and clothing and linens were washed in subpar (below normal) temperatures according to the facility policy and procedure (P&P). (cross reference F880, F584) Findings: During an interview on 3/18/25 at 10:00 a.m. with the Administrator (ADM), the ADM stated he received a phone call from the Director of Maintenance (DOM) on the morning of 3/18/25 because the boiler to the facility ' s water supply was not working. The ADM stated the Vendor (VDR) came out and replaced the ignition control module (electronic panel that manages the ignition process, ensuring the boiler is lit safely) on the boiler but discovered a gas valve (essential to control the flow of gas to the boiler) had also failed. The VDR did not have the gas valve in stock and could not order it until Monday 3/17/25. During a concurrent observation and interview on 3/18/25 at 10:15 a.m. with Laundry Aide (LA) 1, LA 1 was in the clean linen area folding clothes. LA 1 stated when she came to work on 3/17/25, she was notified there was no hot water. LA 1 stated she washed the clothing and linens in cold water since no hot water was available. During a concurrent observation and interview on 3/18/25 at 10:20 a.m., with the Housekeeping Supervisor (HKS), the HKS stated she was also the supervisor for laundry. The HKS stated the facility washed clothing and linens in chemicals designed for low temperature washing. The HKS reviewed the laundry detergent label and stated it could be used at low temperatures, the recommended temperature was 130 degrees (°) Fahrenheit (°F-unit of temperature measurement on which water freezes at 32 ° and boils at 212°) to 150° F. The HKS stated the temperature was only recommended. There was a chemical dispenser on the wall next to the washers, the HKS stated it housed chlorine bleach, detergent and laundry sanitizer. The HKS stated the chemicals were automatically mixed to the wash by the dispenser. The HKS stated only white linens used bleach. During an interview on 3/18/25 at 10:29 a.m. with Resident 1, Resident 1 stated he was notified there was no hot water on Saturday (3/15/25). Resident 1 stated his scheduled shower days were Tuesdays and Fridays. Resident 1 stated he showered on Friday (3/14/25) and the facility had hot water at that time. Resident 1 stated he was given a bed bath earlier in the day and the CNA had not been notified there was an alternate source to get hot water for a bed bath. Resident 1 stated, she gave me a cold bed bath. It was like biting a bullet. Resident 1 stated he was expecting warm water, then was washed with cold water which gave him chills throughout the bed bath and was not a thorough cleaning. Resident 1 stated because there was no hot water to wash dishes, the meals were coming in Styrofoam containers with disposable utensils. During an interview on 3/18/25 at 10:35 a.m. Resident 2 stated his shower days were Saturdays and Wednesdays. Resident 2 stated he did not receive a shower or a bed bath on Saturday (3/15/25). Resident 2 stated he did not want a bed bath and had not bathed for 6 days. During an interview on 3/18/25 at 10:37 a.m. with Resident 3, Resident 3 stated he was scheduled for showers on Wednesdays and Saturdays. Resident 3 stated he did not receive a shower or bed bath on 3/15/25 and washed himself using cold water in the sink. During an interview on 3/18/25 at 10:40 a.m. with Resident 4, Resident 4 stated he was not told about the hot water outage until he had washed his face and brushed his teeth with cold water on 3/15/25. Resident 4 stated he asked a CNA and was told the hot water was not working. Resident 4 stated his shower days were Wednesdays and Saturdays. Resident 4 stated on Saturday he just cleaned himself up with cold water and did not get a bed bath. During a concurrent observation and interview on 3/18/25 at 11:00 a.m. with the DOM, the facility ' s hot water boiler was observed and there was no heat coming from the boiler. The boiler for the facility ' s heater ventilation system was working and heat could be felt standing next to it, its thermometer read 160°F. The DOM stated the water boiler system supplied the entire facility ' s hot water, and the module had stopped working on Saturday (3/15/25). The DOM stated the VDR came out and replaced the module but discovered gas valve was not working. The DOM stated the VDR did not provide routine maintenance to the boilers but would come out when there was a transition in season requiring a change between the air conditioner and heater. The DOM stated they call the VDR when there is issue, but no routine maintenance was scheduled. During a concurrent observation and interview on 3/18/25 at 11:05 a.m. with the DOM in the kitchen, there were three sinks observed, a dish washing sink, a hand washing sink and food preparation sink. The water temperatures were checked and indicated: Dish sink-61.7 deg F Food prep sink-64.6 deg F Hand wash sink-63.3 deg F During an interview on 3/18/25 at 11:10 a.m. with [NAME] (CK) 1, CK 1 stated she used the hand washing sink with cold water and soap to clean her hands while working in the kitchen and would then use hand sanitizer to ensure she had clean hands. CK 1 stated the dishwasher was still able to reach the correct temperature for sanitizing dishes, so they were able to wash the items they cooked with in hot water. CK 1 stated there was a dispenser for hot water which they used to make coffee, and they used the hot water from there for any needs for hot water such as dish washing by hand and the sanitation bucket. CK 1 stated their hands and dishes had to be sanitized correctly and if they were not then, that is bad for residents, they could get sick from the food. CK 1 stated the lack of hot water placed the resident ' s food at risk for cross contamination. During an interview on 3/18/25 at 11:15 a.m. with CK 2, CK 2 stated he washed his hands in cold water and soap then used gloves while cooking. CK 2 stated it was important to sanitize hands and dishes to prevent food borne illness (illness that comes from eating contaminated food). During an interview on 3/18/25 11:20 a.m. with Resident 5, Resident 5 stated he had been washing his hands in cold water. Resident 5 stated he was a new admit and was not notified the facility did not have hot water. During a concurrent observation and interview on 3/18/25 at 11:22 a.m. with the DOM, the sink temperature in Resident 5 ' s room was checked. The temperature read 64.8. The DOM stated the sink temperatures should be approximately 105 deg F. Several water temperatures were checked throughout the facility as follows: room [ROOM NUMBER]-bathroom sink- 65.8°F Station 2 shower- 64.9°F Station 1 shower- 66.0°F Station 4 shower 66.4°F Station 3 shower 60.4°F room [ROOM NUMBER]-bathroom sink-65.8°F room [ROOM NUMBER]-bathroom sink-65.8°F Laundry room sink- 66.9°F The DOM stated the water temperature, and the washing machine water temperature would be the same (66.9) because they were on the same water line. During an interview on 3/18/25 at 11:48 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when she worked on Sunday, she was told the water heater was not working. CNA 1 stated they were instructed there was a hot water dispenser in the breakroom to get water for bed baths. CNA 1 stated they were using hand wipes to clean the residents ' hands as needed and before meals. During an interview on 3/18/25 at 11:54 a.m. with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated when she arrived at work, she was notified the boiler was not working, so there was no hot water. CNA 2 stated she gave Resident 1 a cold bed bath because she was not aware there was an alternate source for hot water available in the breakroom. CNA 2 stated, I felt so bad. CNA 2 stated Resident 1 was chilled and asked her during the bed bath when the facility would have hot water again. CNA 2 stated she should have used warm water for Resident 1 ' s bed bath. During a telephone interview on 3/18/25 at 2:06 p.m. with the VDR, the VDR stated they were called out on Saturday 3/15/25 because the water heater boiler was not working. The VDR stated he sent a technician out to fix the problem. The VDR stated the ignition control module was replaced, and it was then discovered the gas valve was not functioning. The VDR stated the module was the brains of the system and the gas valve was controlled by the module. The VDR stated both parts had to work together for the boiler to work correctly. The VDR stated the company was not scheduled for routine, preventative maintenance of the boiler and were only called out for emergencies and twice a year when contacted, to switch the heater to air conditioning and the air conditioning back to the heater as the weather changed. During a review of the Vendor ' s invoice to the facility dated 3/17/25, the invoice indicated, . pressure regulating gas V [valve-device for controlling passage] . Quantity 1 . IGN [ignition-firing something up] Module . Quantity 1 . During a review of the facility ' s policy and procedure (P&P) titled Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order . Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . During a review of the facility ' s P&P titled Unusual Occurrence Reporting, dated 12/2007, the P&P indicated, . our facility reports unusual occurrences or other reportable events which affect the heath, safety, or welfare of our residents, employees or visitors . Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed and transmitted for 1 (Resident #30) of 2 residents reviewed for discharges. Findings included: A facility policy titled, MDS [Minimum Data Set] Completion and Submission Timeframes, revised 07/2017, indicated, Policy Interpretation and Implementation 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' [Centers for Medicare and Medicaid Services] QIES [Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare and Medicaid Services - Long term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024, revealed, Discharge Assessment-Return Not Anticipated - Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. - Must be completed (item Z0500B [MDS Assessment Completion Date]) within 14 days after the discharge date (A2000 [discharge date ] + 14 calendar days). - Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). An admission Record revealed the facility admitted Resident #30 on 03/17/2024. According to the admission Record, the resident had a medical history included a diagnosis of type 2 diabetes. According to the admission Record, Resident #30 discharged from the facility to an acute hospital on [DATE]. The MDS data records for Resident #30 revealed the last completed MDS was a quarterly assessment on 09/24/2024, and there was no discharge assessment. During an interview on 02/06/2025 at 8:07 AM, the MDS Coordinator stated Resident #30 did not have a discharge assessment completed. The MDS Coordinator stated a discharge assessment should have been completed, but she had overlooked it. During an interview on 02/06/2025 at 8:42 AM, the Director of Nursing (DON) revealed the discharge assessments were completed by the MDS Coordinator. The DON stated she expected the discharge assessments to be completed once the facility was aware of the discharge. During an interview on 02/06/2025 at 9:04 AM the Administrator stated discharge assessments should be completed by the MDS Coordinator.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure reusable resident care equipment was cleaned and disinfected after use and failed to ensure enhanced barrier precautions (EBP) were used for 1 (Resident #64) of 1 resident observed during wound care. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 09/27/2024, specified, Definitions: 'Enhanced barrier precautions' refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi-drug resistant organism] as well as those at increased risk of MDRO acquisition (e.g. [exempli gratia, for example], residents with wounds or indwelling medical devices). The policy revealed the section titled, Policy Explanation and Compliance Guidelines, included, c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions - a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers). The policy also indicated, 3. Implementation of Enhanced Barrier Precautions - a. Make gowns and gloves available PRIOR TO PERFORMING TASKS. A facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, specified, d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). An admission Record indicated the facility readmitted Resident #64 on 01/10/2025. According to the admission Record, the resident had a medical history that included diagnoses of acquired absence of other right toe(s) and an encounter for orthopedic aftercare following surgical amputation. A 5-day scheduled assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2025, revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #64 had a surgical wound. Resident #64's care plan included a focus area initiated 01/12/2025, that indicated the resident had altered non-pressure skin integrity related to a surgical wound to the right foot. Interventions directed staff to provide treatments as ordered (initiated 01/12/2025). Resident #64's Order Summary Report, with active orders as of 02/05/2025, revealed an order dated 01/30/2025, to cleanse the resident's right foot transmetatarsal amputation (TMA) with normal saline, pat dry, and apply Medihoney when wrap with a gauze bandage every other day for surgical wound care. An observation on 02/03/2025 at 9:10 AM, revealed Resident #64 had a dried bloody dressing to the right foot. The observation revealed no EBP signage inside the room or outside the room in the hallway, and there was no PPE, including gowns, available in the room or in the hallway outside the room. An observation on 02/05/2025 at 1:16 PM, revealed Licensed Vocational Nurse (LVN) #2, who was also the treatment nurse, and LVN #3 entered Resident #64's room to provide wound care. LVN #2 and LVN #3 entered the resident's room after performing hand hygiene and donned gloves. LVN #2 and LVN #3 did not don a gown. LVN #2 was observed cutting off the resident's old dressing on their right foot with scissors. After providing wound care, LVN #2 was observed taking the scissors to the treatment cart and putting them in the drawer without cleaning or sanitizing them. During an interview conducted immediately after the provision of wound care, LVN #2 stated there was no signage up on the doorway and there were no PPE supplies available, so she did not think about EBP. LVN #2 stated that since the resident did have a wound that required a dressing, they should have put on gowns while providing the wound care. LVN #2 stated Resident #64 should have been put on EBP by the Infection Preventionist (IP) when the wound opened up and started requiring a dressing change. LVN #2 stated the scissors should have been cleaned and disinfected after using them. LVN #2 stated she should have placed them on a paper towel on the cart to prevent contamination and then cleaned them before they were put back in the drawer, but she was nervous and forgot. During an interview on 02/05/2025 at 2:29 PM, LVN #3 stated EBP should be used when a resident had an open wound that required a dressing to help prevent the spread of infection. LVN #3 stated she went into the room with LVN #2 as the interpreter and did not think about needing to put on a gown for EBP. During an interview on 02/05/2025 at 2:46 PM, the IP stated they started doing EBP in November (2024) for residents with chronic wounds, MDROs, dialysis access, gastrostomy tubes, catheters, colostomies, and intravenous (IV) access. The IP stated if the resident had an ulcer or open wound then they would need the EBP to prevent them from getting an infection. The IP stated she was the person responsible to put the precautions in place. The IP stated Resident #64 had a surgical incision that was an open wound that needed a dressing, and they should have been on EBP. The IP stated the nurses should have notified her, and they should have caught that EBP was needed. The IP stated training had been done on EBP at least every two weeks, and it was ongoing. The IP stated any reusable equipment used during wound care needed to be cleaned and disinfected after use, and the scissors should not have been put back into the cart without being cleaned first. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated reusable equipment should be disinfected immediately after the wound care was provided. The DON stated EBPs should be used on all residents with wounds, chronic pressure wounds, and when the staff had any contact with bodily fluids. The DON stated the IP was responsible to ensure that the EBPs were in place. The DON stated the staff had been educated, and the treatment nurse and the nurse assisting should have been using the gown and gloves. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated staff should clean and disinfect reusable equipment after use for infection control reasons. The Administrator stated EBPs should be used with residents that had open wounds, dialysis access, and IV access sites. The Administrator stated staff should be aware of who was on the precautions, the proper signage should be up, and the cart with the PPE should be available. The Administrator stated Resident #64 had a change in condition with the wound, and the treatment nurse did not communicate it with the IP to update the information. During an interview on 02/06/2025 at 9:39 AM, the IP stated she was not aware that Resident #64's wound opened up and EBP was required. The IP stated it was a lack of communication between her and the treatment nurse.

Based on interview, record review, and facility policy review, the facility failed to ensure resident Minimum Data Set (MDS) assessments were accurate for 4 (Residents #19, #64, #68, and #217) of 28 residents reviewed for MDS accuracy. Findings included: A facility policy titled, MDS Error Correction, revised 09/2010, indicated, The assessment coordinator and/or the interdisciplinary assessment team will follow the established procedures for making corrections to the MDS. The policy revealed, 6. If an error is discovered in a record that has already been accepted by the QIES [Quality Improvement and Evaluation System] ASAP [Assessment Submission and Processing] system, implement procedures for either modification or inactivation of the information in the system within 14 days of the discovery of the error. 1. An admission Record indicated the facility admitted Resident #217 on 01/21/2025. According to the admission Record, the resident had a medical history that included a diagnosis of bacteremia. An admission MDS, with an Assessment Reference Date (ARD) of 01/27/2025, revealed Resident #217 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS revealed the resident was receiving intravenous (IV) medications on admission and while a resident within the last 14 days prior to the assessment. The MDS revealed the resident received IV antibiotics on admission. The MDS did not indicate the type of IV access site. Resident #217's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 01/22/2025, for a central veinous catheter (CVC), with instructions to flush with 10 milliliters (ml) of normal saline, infuse medication, then flush with 10 ml of normal saline five times a day. On 02/05/2025 at 11:06 AM, the MDS Coordinator stated that when a resident was admitted to the facility, the staff completed an admission assessment. She stated an IV line and medication would be documented in the MDS assessment. She reviewed the admission MDS completed for Resident #217 and stated there was a section which should have indicated the type of IV line, and it was not coded. On 02/06/2025 at 8:43 AM, the Director of Nursing (DON) stated Resident #217 had a central line (central veinous catheter) on admission. She reviewed Resident #217's admission MDS and stated that the central line section on the MDS should have been coded. She stated the MDS was coded incorrectly. On 02/06/2025 at 9:07 AM, the Administrator stated the MDS coordinator's job was to ensure the MDS assessments were accurate. He stated he expected MDS assessments to be accurate, and communication needed to improve to ensure the accuracy of the MDS assessments. 2. An admission Record indicated the facility admitted Resident #19 on 05/18/2018. According to the admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea. A quarterly MDS, with an Assessment Reference Date (ARD) of 12/20/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS did not indicate that the resident used a non-invasive mechanical ventilator. Resident #19's care plan included a focus area revised 05/06/2024 that indicated the resident was at risk for an alteration in respiratory status related to obstructive sleep apnea. Interventions directed staff to use a BiPAP (bilevel positive airway pressure) machine (a non-invasive mechanical ventilator). Resident #19's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 07/20/2024 for a BIPAP with an inhalation positive airway pressure of 24 centimeter of water (cmH20), exhalation positive airway pressure of 8 cmH20, with 24% fraction of inspired oxygen (FI02) with a goal of 88% blood oxygen saturation (Sp02) level. An observation on 02/03/2025 at 9:41 AM, revealed Resident #19 was in bed. A BiPAP machine was on the resident's nightstand with tubing in a black bag. During an interview on 02/06/2025 at 8:06 AM, the MDS Coordinator stated that information for the MDS came from interviews with the resident and family, observation, her own assessment to gather information, and she looked at other assessments and progress notes from all departments. She stated it was important for the MDS to be accurate for an appropriate care plan to be developed so that they could provide the proper care for the resident. The MDS Coordinator stated the BiPAP should have been coded on Resident #19's MDS. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated it was important for the MDS to be accurate because it was the communication to the Centers for Medicare and Medicaid (CMS), and it determined the proper care for the resident. She stated it also determined their numbers on the quality measures report. She stated the information for the MDS should come from the resident's record. The DON stated Resident #19's BiPAP should have been coded on the MDS. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated it was important for the MDS to be accurate because it affected the care provided and accurately reflected the resident's needs. He stated the information for the MDS came from the assessments from all departments, and it was the MDS Coordinator's responsibility to ensure the accuracy of the assessments. He stated it was his expectation that the MDS was accurate. He stated Resident #19's BiPAP should have been coded. 3. An admission Record revealed the facility readmitted Resident #64 on 01/10/2025. According to the admission Record, the resident had a medical history that included type 2 diabetes mellitus with a foot ulcer, and an acquired absence of the right toe(s). A 5-day scheduled assessment MDS, with an Assessment Reference Date (ARD) of 01/14/2025, revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident received injections three days during the assessment look-back period. The MDS did not indicate that the resident received insulin injections and antibiotics during the assessment look-back period. Resident #64's care plan included a focus area revised 08/30/2024, that indicated the resident was at risk for hypo/hyperglycemia (low/high blood sugar) related to type 2 diabetes mellitus. Interventions directed staff to administer diabetes medication as ordered by the doctor and monitor and document for side effects and effectiveness (initiated 08/21/2024). The care plan included a focus area revised 01/12/2025, that indicated the resident had an infection and was at risk for adverse reaction to antibiotic therapy. Interventions directed staff to administer antibiotics per the medical doctor's orders (initiated 01/10/2025). Resident #64's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 01/10/2025 for Augmentin (an antibiotic) 500 - 125 milligrams (mg) with instructions to give one tablet by mouth every eight hours for prophylactic foot surgery for 28 days. The Order Summary Report revealed an order dated 01/10/2025 for Humalog (insulin lispro) 100 units per milliliter (ml) with instructions to inject per sliding scale subcutaneously before meals. Resident #64's January 2025 Medication Administration Record [MAR], revealed staff documented that they administered Augmentin 500 - 125 mg once on 01/10/2025, three times a day on 01/11/2025, 01/12/2025, and 01/14/2025, and twice on 01/13/2025, during the MDS look-back period. The MAR revealed staff documented that they administered Humalog insulin during the MDS look-back period on 01/11/2025 at 4:30 PM, 01/13/2025 at 12:00 PM, and 01/14/2025 at 12:00 PM. During an interview on 02/06/2025 at 8:06 AM, the MDS Coordinator stated that information for the MDS came from interviews with the resident and family, observation, her own assessment to gather information, and she looked at other assessments and progress notes from all departments. She stated it was important for the MDS to be accurate for an appropriate care plan to be developed so that they could provide the proper care for the resident. The MDS Coordinator stated Resident #64 received insulin and after reviewing Resident #64's MDS she confirmed that it was not coded on the MDS but should have been. She stated she documented three injections but did not code the actual insulin. She also confirmed that the MDS should have been coded for the resident taking an antibiotic. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated it was important for the MDS to be accurate because it was the communication to the Centers for Medicare and Medicaid (CMS), and it determined the proper care for the resident. She stated it also determined their numbers on the quality measures report. She stated the information for the MDS should come from the resident's record. She stated they should look under the active orders to determine what medications the resident was taking. She stated Resident #64 was receiving an antibiotic and insulin, and the medications should have been properly coded on the MDS. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated it was important for the MDS to be accurate because it affected the care provided and accurately reflected the resident's needs. He stated the information for the MDS came from the assessments from all departments, and it was the MDS Coordinator's responsibility to ensure the accuracy of the assessments. He stated it was his expectation that the MDS was accurate. He stated Resident #64's medications should have been coded on the MDS. 4. An admission Record indicated the facility admitted Resident #68 on 12/14/2024. According to the admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. An admission MDS, with an Assessment Reference Date (ARD) of 12/20/2024, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was taking an antipsychotic medication with the indication noted. However, the section titled N0450. Antipsychotic Medication Review revealed it was incorrectly coded to indicate that antipsychotics were not received, and this caused the assessment to skip information related to gradual dose reduction (GDR). Resident #68's care plan included a focus area revised 12/17/2024, that indicated the resident received an antipsychotic medication for bipolar disorder. Interventions directed staff to administer medication as ordered and consult with the physician to consider dose reduction at least every three months. Resident #68's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 12/14/2024, for quetiapine fumarate 50 milligrams (mg) with instructions to give one tablet by mouth two times a day for bipolar disorder. Resident #68's December 2025 Medication Administration Record [MAR], revealed staff documented that the resident received quetiapine fumarate 50 mg twice a day during the MDS look-back period from 12/15/2024 through 12/20/2024. During an interview on 02/06/2025 at 8:06 AM, the MDS Coordinator stated that information for the MDS came from interviews with the resident and family, observation, her own assessment to gather information, and she looked at other assessments and progress notes from all departments. She stated it was important for the MDS to be accurate for an appropriate care plan to be developed so that they could provide the proper care for the resident. The MDS Coordinator stated Resident #68 was taking an antipsychotic medication and after reviewing the MDS she confirmed that section N0450 was coded incorrectly. She stated it should have indicated that the resident was taking an antipsychotic. She stated it was overlooked. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated it was important for the MDS to be accurate because it was the communication to the Centers for Medicare and Medicaid (CMS), and it determined the proper care for the resident. She stated it also determined their numbers on the quality measures report. She stated the information for the MDS should come from the resident's record. She stated they should look under the active orders to determine what medications the resident was taking. The DON stated Resident #68's MDS should have been coded to reflect the use of the antipsychotic on all parts of the MDS to ensure the accuracy of the assessment. She confirmed that section N0450 of the MDS was coded incorrectly. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated it was important for the MDS to be accurate because it affected the care provided and accurately reflected the resident's needs. He stated the information for the MDS came from the assessments from all departments, and it was the MDS Coordinator's responsibility to ensure the accuracy of the assessments. He stated it was his expectation that the MDS was accurate. He stated Resident #68's medication should have been coded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure licensed nurses (LN) administered medications in accordance with professional standards of practice for one of seven sampled residents (Resident 5), when: 1. Resident 5's morning medications were left at the bedside unattended and not administered as prescribed by the physician on 9/16/24. This failure resulted in Resident 5 not receiving the medications as prescribed by the physician, which had the placed Resident 5 at risk for thrombosis (clotting of the blood), embolism (obstruction or blockage in a blood vessel) and had the potential for other facility residents to ingest the medications that were left unattended. 2. One of Two Licensed Nurses failed to lock the medication cart when the cart was out of the nurse ' s sight, according to the facility ' s policy and procedure (P&P). This failure had the potential for staff, visitors, or residents to access medications from the unlocked medication cart. Findings: During a concurrent observation and interview on 9/16/24 at 12:09 p.m. with Resident 5, in Resident 5 ' s room, a small, clear plastic cup was on Resident 5 ' s bedside table and contained four medications, a round white tablet, a round dark red tablet, a small yellow tablet, and a dark capsule. Resident 5 stated the nurse brought his medication in around 9:00 a.m. and left them on the table so he could take them later. Resident 5 stated he usually preferred to take his morning medication around lunchtime. During a review of Resident 5 ' s admission Record, undated, the admission record indicated, Resident 5 was admitted to the facility on [DATE] with diagnosis of paraplegia (paralysis [loss of ability to move] of the legs and lower body), malignant neoplasm of the right testis (cancer in the testicle), malignant neoplasm of spinal cord (cancer spread to the spine [backbone]) and acute (sudden onset) embolism and thrombosis of the iliac vein (blood vessel in the pelvis). During a review of Residents 5 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 5 ' s Brief Interview of Mental status assessment (BIMS – assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 5 was cognitively intact. During a concurrent observation and interview on 9/16/24 at 12:12 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 5 ' s room, the cup of medication was observed on Resident 5 ' s bedside table. LVN 1 stated the medication was apixaban (medication to treat blood clots), magnesium (dietary supplement), multiple vitamin (dietary supplement), and vitamin D (dietary supplement). LVN 1 stated, I shouldn ' t have done that [left medication at bedside]. LVN 1 stated Resident 5 did not want to take his medication during the 8:00 a.m. medication pass, so she left the medication on his table. LVN 1 stated medication should never be left at bedside because there was no way to be sure the resident took the medication. LVN 1 stated medications left at bedside placed other residents at risk because they could wander in and take medication not prescribed to them. LVN 1 stated apixaban was a blood thinner and could place a resident at risk for bruising and bleeding if they it was not prescribed to them. During a concurrent interview and record review on 9/16/24 at 12:35 p.m. with LVN 2, Resident 5 ' s Order Summary Report, (OSR), dated September 2024 were reviewed. The OSR indicated, . [brand name for apixaban] Oral Tablet 2.5 mg [milligrams-unit of measurement] (Apixaban) Give 1 tablet by mouth two times a day . Magnesium Oxide Oral Tablet 400 mg (Magnesium Oxide) Give 1 tablet by mouth three times a day . Multiple Vitamin Tablet Give 1 tablet by mouth one time a day . Ergocalciferol [a form of vitamin D] Oral Capsule 1.25 MG . Give 1 capsule by mouth one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for vitamin D supplement . LVN 2 stated the medication should have been consumed within an hour of the scheduled 8:00 a.m. medication time. LVN 2 stated it was not safe to leave a medication unattended at bedside because another resident could consume the medication. LVN 2 stated if a resident took a blood thinner not prescribed to them it could cause bleeding. During an interview on 9/16/24 at 12:50 p.m. with LVN 3, LVN 3 stated another resident could have taken the medication left at bedside. LVN 3 stated it could cause adverse side effects and there would be no way to know if the resident took the medication which could affect the therapeutic level (maintain a certain level in the blood to work properly) if it is a medication needing a consistent blood level. During a review of the facility ' s P&P titled Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time . Residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely . During a telephone interview and P&P review on 9/24/24 at 3:32 p.m., with the Director of Nursing (DON), the DON stated medication should never be left at bedside. The DON stated if a resident wanted to self-administer medication there was a process to follow including an assessment, care plan and a doctor ' s order. The DON stated Resident 5 had not been assessed for self-administration and the medication should not have been left. The DON stated Resident 5 was on a blood thinner, so it was important for the nurse to verify he had taken the medication. The DON stated it was a safety issue if a resident with dementia had wandered in the room and taken the medication. The DON stated the P&P was to administer a medication within an hour of the scheduled time and the P&P was not followed. During a professional reference review of Lippincott Manual of Nursing Practice 10th Edition, dated 2014, indicated, .Standards of Practice .General Principles .Common Departures from the Standards of Nursing Care .Legal claims most commonly made against professional nurses include the following departures from appropriate care .failure to .follow physician orders .adhere to facility policy or procedure .administer medications as ordered . 2. During a concurrent observation and interview on 9/16/24 at 12:12 p.m. with LVN 1, the medication cart was observed with the lock pulled all the way out which indicated it was unlocked. LVN 1 took out the keys of her pocket and went to unlock the cart, did not put the key in the lock and placed the keys back into her pocket. LVN 1 stated, it [the medication cart] might have been left open. LVN 1 opened the drawer and took out the glucometer, then pushed the lock in locking the cart. LVN 1 stated the cart should be locked when she was not in front of the cart because anybody could access the medication. During an interview on 9/16/24 at 12:35 p.m. with LVN 2, LVN 2 stated she always locked the medication cart anytime she was not directly in front of it. LVN 2 stated the cart should never be unlocked if unattended. LVN 2 stated anyone including residents would be able to access the medication. During an interview on 9/16/24 at 12:50 p.m. with LVN 3, LVN 3 stated the medication cart needed to be locked anytime it was unattended. LVN 3 stated anybody could access the medication and narcotics were supposed to be kept under two locks, if one lock was undone the narcotics were not stored appropriately. During a telephone interview on 9/24/24 at 3:32 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the medication cart to be locked unless the nurse was actively working with it. The DON stated an unlocked medication cart was a safety issue because confused residents and visitors could access the medication. The DON stated it could also cause an issue with HIPPA (Health Insurance Portability and Accountability Act-a federal law that sets a national standard to protect medical records and other personal health information). During a review of the facility ' s P&P titled Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed . During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . The cart must be clearly visible to the personnel administering medications . During a review of a professional reference retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and Reports/Reports/downloads/lewingroup.pdf, titled, CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services Long-Term Care Pharmacy Primer, dated December 30, 2004, the professional reference review indicated, .C. Administration of Medications by Nursing Facility Personnel . Nursing facility personnel administer medications pursuant to the prescription order. The personnel designated to administer medications must be trained by the nursing facility . Medication Carts . The carts contain locked, non-removable drawers for each resident's medications . Medication carts must be supervised at all times by the nurse administering medications. When medication carts are not in use, they must be stored in a designated locked area with all drawers locked .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1's call light was removed from the wall and taken away from her on 2/20/2024. This failure violated Resident 1's right to have her call light accessible and within reach and resulted in Resident 1 to feel isolated and alone and without the ability to call staff for assistance. Findings: During a review of Resident 1 ' s admission Record (AR), dated 3/7/24, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a history of Alzheimer (a brain disease that causes memory loss and other cognitive impairment), Right femur (upper leg bone) fracture (broken bone), Right Artificial Hip Joint (a surgical procedure in which an orthopaedic surgeon removes the diseased parts of the hip joint and replaces them with a new prosthesis), Muscle weakness, and Abnormal gait and mobility (unable to walk in a typical way). During a review of Resident 1's Minimum Data Set (MDS – an evaluation of a resident's cognitive and functional status), dated 2/16/24, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for memory recall) was 9 (a score of 0 – 7 indicated severe impairment, 8 – 12 indicated moderate impairment, and 13 – 15 indicated minimal to no impairment). During a review of Resident 1's MDS for Functional Abilities And Goals (FAAG) dated 2/16/24, the FAAG indicated Resident 1 required assistance to complete activities of daily living (eating, toileting, bathing, transferring, etc.) During an interview on 3/7/24 at 9:15 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 stated Certified Nursing Assistant (CNA) 1 came to her room on 2/20/24 around 12 o ' clock a.m. to check her briefs (an adult diaper). Resident 1 stated, CNA 1 threw the blanket off me, pushed and shoved me. I had a right hip incision from a hip replacement. I tried to cover my hip because it was hurting, she grabbed my hand and pulled it away. Then she took my call light away for no reason. Resident 1 stated, I like my call light on my bed so I can reach it to call staff for assistance. Resident 1 stated she used the call light to call staff for pain medication and when she soils her briefs. Resident 1 stated without the call light there was no way of calling staff for help. During an interview on 3/7/24 at 10:21 a.m. with CNA 2, CNA 2 stated she worked during the night shift on 2/20/24. CNA 2 stated Resident 1 was pushing her call light all night long. CNA 2 stated CNA 1 was assigned to provide care to Resident 1 that night and CNA 1 stated Resident 1 was crazy and CNA 1 was not going answer Resident 1 ' s call light. CNA 2 stated CNA 1 was instructed by Registered Nurse (RN) 1 to take Resident 1 ' s call light away. CNA 2 stated it was not acceptable to take call lights away from residents under any circumstances. During an interview on 3/7/24 at 10:30 a.m. with LVN 1, LVN 1 stated she worked during the night shift on 2/20/24. LVN 1 stated RN 1 was assigned to provide care to Resident 1. LVN 1 stated Resident 1 was alert and cooperative most of the time, sometimes confused during the night, and particular about care. LVN 1 stated Resident 1 pushed the call light excessively (more than three times an hour). LVN 1 stated Resident 1 would push the call light when she was not happy with how staff folded her blanket. LVN 1 stated it was not acceptable to take away the call light from the resident even if the resident was confused. LVN 1 stated if the resident pushed the call light 100 times, staff must answer the call light 100 times. During an interview on 3/7/24 at 12:14 p.m. with the Director of Nursing (DON), DON stated staff was not allowed to take anything away from the resident. DON stated call lights should be placed on the bed with the resident when the resident is in bed. DON stated it was unacceptable to take away the call light even if the resident is confused or have behavioral issues. During an interview on 3/7/24 at 12:20 p.m. with the Administrator (ADM), ADM stated Resident ' 1 son reported that Resident 1 ' s call light was removed from the wall on 2/20/24. ADM stated an investigation was completed on 2/20/24 and concluded that Resident 1 ' s call light was not removed from the wall but RN 1 did instruct CNA 1 to place Resident 1 ' s call light on Resident 1 ' s bedside table to minimize Resident 1 from pushing the call light. ADM stated RN 1 and CNA 1 were placed on suspension during the investigation on 2/20/24 and terminated on 2/26/24. During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated 12/2016, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident ' s symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility . During a review of the facility ' s policy and procedure (P&P) titled, Answering the Call Light, dated 3/2021, the P&P indicated, Purpose: The purpose of this procedure is to ensure responses to the resident ' s requests and needs. General Guidelines: .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions. Findings: During an interview on 9/29/23, at 2:05 p.m., with Resident 1, inside Resident 1's room, Resident 1 stated, On 8/18/23, the Social Services Director (SSD) 1 and Business Manager (BM) came to my room and gave me a copy of the Discharge Notice and they told me that the facility found a Residential Care Facility (RCFE, a homelike environment designed to promote resident independence and self-direction to the greatest extent possible in a residential, non-medical setting.) that is willing to care for me and I will be discharged on September 17, 2023. I told them that I have an on-going Workers Compensation claim against my former employer and they should be responsible in paying for my nursing home expenses. I got injured while at work. My next Workers Compensation hearing is on October 26, 2023. I am paraplegic (inability to voluntarily move the lower parts of the body), diabetic (elevated blood sugar), hypertensive (high blood pressure), chronic pain (persistent pain that lasts for months to years) and depressed (a persistent feeling of sadness and loss of interest). I need nursing care 24/7. I am bedbound During a concurrent interview and record review on 9/29/23, at 2:20 p.m., with the Social Services Director (SSD) 2, Resident 1's Interdisciplinary Team Note (IDT), dated 8/18/23 was reviewed. The IDT note indicated, . IDT REVIEW OF 30-DAY NOTICE OF DISCHARGE . [Resident 1] was given a notice of discharge secondary to non-payment . IDT recommendations: Social Services and Activities support visits x [for] 72 hours starting next business day, nursing to monitor x 72 hours for psychological distress . refer for psychological evaluation . IDT attendees: SSD 1, DON, Activity Director, and Business Office Manager . SSD 2 stated Resident 1 refused to participate in planning his discharge to a RCFE. SSD 2 stated there was no record of psychological evaluation being completed. SSD stated without the psychological evaluation completed by a qualified provider, Resident 1's psychological condition and readiness for discharge was not determined and discharge to another health care setting could be unsafe. During an interview with the Acting Director of Nursing (ADON) on 10/4/23, at 3:00 p.m., the ADON stated Resident 1 should have a psychological evaluation by a qualified provider to determine his psychological condition and readiness for discharge to another level of care. The ADON stated Resident 1 was bedbound with chronic medical conditions including Major Depression, Paraplegia, Diabetes, Chronic Pain, and High Blood Pressure. The ADON stated Resident 1's discharge to another health care setting without a psychological evaluation could result to an unsafe discharge and could lead to preventable re-admissions. During a review of Resident 1's admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 9/29/23, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Major Depression, Paraplegia, Type 2 Diabetes Mellitus, and Chronic Pain. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 7/7/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's MDS Mood and Behavior, dated 7/7/23, the MDS indicated, . Mood .Total Severity Score 0 [no symptoms] . Behavior . Potential Indicator of Psychosis . 0 [Behavior of hallucination or delusions are not exhibited] . During a review of Resident 1's Nursing Care Plan (CP), dated 10/9/23, the CP indicated, . At risk for mood and behavior changes related to diagnosis of major depressive disorder recurrent, unspecified without medication use. Date initiated: 12/07/23 . During a review of Resident 1's Nursing Care Plan (CP), dated 10/9/23, the CP indicated, . Needs pain management and monitoring related to: history of chronic back pain syndrome. Date initiated: 2/25/22 . During a review of the Department of Health Care Services Office of Administrative Hearings and Appeals (a government entity that handles discharge appeals for long-term care residents) document titled, Decision and Order, dated 9/26/23, the document indicated, . SUMMARY . The appeal is GRANTED. [Facility] has not complied with the legal requirements to involuntary discharge [Resident 1] in that it did not provide Resident with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. Therefore, the discharge is improper, and Resident shall be permitted to remain in Facility . During a review of the facility's P&P titled, Transfers and Discharges, undated, the P&P indicated, . Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and family in accordance with federal and state specific regulations .

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had her personal belongings accurately inventoried at the time of admission. This failure resulted in Resident 1 ' s loss of personal belongings and the right to have an accurate inventory of personal possessions. During an interview on 5/2/23, at 9:25 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 had a small television sitting on the table with pictures. CNA 1 stated, Resident 1 ' s closet was full of clothing, two pairs of shoes. CNA 1 stated, We are responsible to complete a inventory sheet and list all [residents] belongings on admission. CNA 1 stated the inventory sheet should be done for all residents to keep track of their belongings. During an observation and interview on 5/2/23, at 11:30 a.m., with Social Services Director (SSD) 1, inside Resident 1 ' s room, SSD 1stated, there was a television sitting on the table. SSD 1, stated, I am not sure who ' s television it is. SSD 1, stated, there was no name or markings on the television to indicate who it belonged to. SSD 1 stated, Resident 1 ' s inventory sheet of personal possessions was blank upon admission. SSD 1 stated, the inventory sheet should indicate Resident 1 did come into the facility with belongings. SSD 1 stated the blank inventory sheet showed Resident 1 did not have belongings when admitted . SSD 1 stated, when Resident 1 was discharge from the facility, the inventory sheet was not completed and there was no record of her belongings. SSD 1 stated, We have no way of knowing what Resident 1 had while here. SSD 1 stated, if Resident 1 reported items missing, the facility had no way of tracking or verifying her belongings. During an interview and record review, with on 5/2/23 at 11: 45 a.m., with SSD 2, SSD 2, stated, Resident 1 ' s family members contacted her to report Resident 1 ' s television was missing. SSD 2, stated she was not sure what belongings Resident 1 had or is missing at this time because the inventory sheet was incomplete. SSD 2 stated, This is not the correct process to care for residents ' belongings. SSD 2, stated the inventory of personal possessions should have been completed on admission for Resident 1. During a review of Resident 1 ' s admission Record (AR) , (a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/2/23, the AR indicated, Resident 1 was admitted from the general acute care hospital (GACH) on 9/27/18 to the facility, with diagnosis which included Diabetes Mellitus (chronic condition that affects the way the body process blood sugar), Dementia(characterized by progressive or persistent loss of intellectual functioning), Hypertension (Elevated Blood Pressure), and Diverticulitis( inflammation of the colon). During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities) , dated 3/29/23, the MDS indicated Resident 1 ' s Brief Interview for Mental Status (BIMS) score was 11 of points which indicated Resident 1 had moderate cognitive impairment. During a review of Resident 2 ' s, AR, AR indicated Resident 2 was admitted from an acute care hospital on 8/30/22to the facility, with diagnosis which included, Dysphagia (difficulty swallowing foods or liquids), Morbid Obesity, Congestive Heart Failure, and History of falling. During an interview on 5/2/23, at 12:30 p.m., with Administrator (ADM), the ADM stated, [Resident 1] was admitted to the facility in 2018 and the inventory of personal possessions is blank and was not completed on admission. The staff are responsible to complete the inventory document . The ADM stated Resident 1 did not had a complete inventory sheet on admission. The ADM stated the process was to complete the admission inventory sheet per facility Policy and Procedure. The ADM stated the Medical Records and Social Services Department were responsible to ensure the inventory sheet was accurately completed on admission and whenever family members would bring in new items for the resident. The ADM, stated the facility was responsible for residents ' belonging. The ADM stated, We are not following the process to address the rights of the residents to have all their belongings returned when discharged . During a concurrent telephone interview and record review, on 5/4 /23, at 2:05 p.m., with Medical Records Director, (MRD), Resident 1's Inventory of Personal Possessions, undated, was reviewed. The Inventory of Personal Possessions, indicated, . Instructions: Upon admission, identify the resident ' s personal belongings by indicating quantity of those items listed . MRD stated, there was no belongings listed, no date, or signatures of Resident 1,2, and 3 ' s personal belongings accurately inventoried on admission. MRD stated, facility staff should indicate in the inventory sheet any personal belongings brought in at the time of admission and update as necessary throughout the resident's stay in the facility. MRD stated, the staff failed to follow the facility's policy on Personal Property. During a review of the facility's policy and procedure (P&P) titled, Personal Property, dated 3/2021, the policy indicated, . Resident belongings are treated with respect by facility staff, regardless of perceived value . The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 75) personal eyeglasses were not inventoried upon admission. This failure resulted in Resident 75's loss of personal eyeglasses. Findings: During an observation and interview on [DATE], at 10:41 a.m., with Resident 75, inside Resident 75's room, Resident was observed sitting on the edge of her bed and watching TV. Resident 75 stated her prescription eyeglasses was missing since yesterday and staff was not able to find her eyeglasses. Resident stated she use her eyeglasses for reading and watching TV. Resident 75 stated, The eyeglasses meant a lot for me. My husband bought it for me before he died. I want it back. During an interview on [DATE], at 10:39 a.m., with Social Services Director (SSD) 2, SSD 2 stated, Resident 75's missing prescription eyeglasses was reported missing on [DATE]. SSD stated, she was aware Resident 75's prescription eyeglasses were last seen on [DATE]. During a concurrent interview and record review, on [DATE], at 10:39 a.m., with SSD 2, Resident 75's Inventory of Personal Possessions, dated [DATE], was reviewed. The Inventory of Personal Possessions, indicated, . Instructions: Upon admission, identify the resident's personal belongings by indicating quantity of those items listed . Prosthetic Devices . Eyewear [unmarked] . Date: [DATE] . SSD 2 stated, there was no record of Resident 75's eyewear in the inventory list. SSD 2 stated, facility staff should indicate in the inventory sheet any personal belongings brought in at the time of admission and update as necessary throughout the resident's stay in the facility. SSD 2 stated, the staff failed to follow the facility's policy on Personal Property. During an interview on [DATE], at 11 a.m., with the Acting Director of Nursing (DON),DON stated, Resident 75's missing prescription eyeglasses was unfortunate and the facility was responsible in replacing Resident 75's eyeglasses. DON stated, Resident 75's personal belongings should be accounted for at the time of admission and updated as needed. DON stated, staff failed to follow the facility's policy on resident's belongings. During a review of Resident 75's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated [DATE], the AR indicated, Resident 75 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus), Hypertension (elevated blood pressure), and End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 75's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated [DATE], the MDS indicated Resident 75's Brief Interview for Mental Status (BIMS) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of the facility's document titled, Inventory of Personal Possessions for Resident 75, dated [DATE], the Inventory of Personal Possessions indicated, Resident 75's brought several personal belongings to the facility. Resident 75's listed items on the inventory included a purple and pink pajamas, two black sweaters, one white underwear, one hairbrush, a bottle of perfume, an eye shadow, a lipstick, two make up brushes and one eyeliner. During a review of the facility's policy and procedure (P&P) titled, Personal Property, dated 3/2021, the policy indicated, . Resident belongings are treated with respect by facility staff, regardless of perceived value . The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing activity program to meet the needs, for one of six sampled residents (Resident 89) when Resident 89, who was identified as needing exercise-focused activities due to morbid (severe) obesity (overweight) related to depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and physical sedentary (way of life characterized by too much sitting, lying in bed, and having little or no physical exercise), was not provided with exercise-focused activities as recommended by the Registered Dietitian (RD, a health professional trained in diet and nutrition to help people improve their health and well-being through healthy diet, good eating habits, and exercises for weight control). This failure had the potential to result in Resident 89 to continue to gain more weight that could interfere with breathing, walking, or in performing basic activities of daily living (ADL); and placed Resident 89 at risk to experience weakness, generalized pain, skin breakdown, complications to chronic and compromised health condition, and fewer social opportunities to interact with other persons at the facility. Findings: During a concurrent observation and interview on 3/21/23, at 9:30 a.m., with Resident 89, in her bedroom, Resident 89 was observed lying in bed on her right side. Resident 89 was receiving oxygen per nasal cannula (flexible tube with 2 prongs to deliver oxygen into the nose). Resident 89 pointed at the television and stated, I stay in bed all day and just watch television. Resident 89 stated, she was overweight, on a diet, and needed to exercise to lose weight. During an interview on 3/21/23 at 10 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 89 had not been out of her bed for out-of-room activities. CNA 1 stated Resident 89 spends the day in bed where she eats breakfast, lunch, and dinner watching television. During a review of Resident 89's admission Record (AR), undated, the AR indicated, Resident 89 was admitted to the facility on [DATE], with diagnoses which included Morbid Obesity, polyneuropathy (a condition that causes a decreased ability to move and feel sensation because of nerve damage), chronic (constant and re-occurring) obstructive pulmonary disease (COPD, a long-term lung disease that makes it hard to breathe), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from the body), chronic pulmonary embolism (a condition that occur when a clump of blood clot, gets stuck in an artery in the lungs, blocking the flow of blood), and major depressive disorder. During a review of Resident 89's Minimum Data Set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs), Resident 89's MDS - Brief Interview for Mental Status (BIMS) score on 3/24/23, was 10, which indicated, Resident 89 had moderately impaired cognitive ability to think, reason, or remember). Resident 89's functional status for locomotion (movement) to and from off-unit locations such as dining, or activity areas was coded 8 which indicated Activity did not occur. During a review of Resident 89's Weights, dated 3/13/22 to 3/1/23, the Weights indicated, Resident 89's ideal body weight range was 108-132 pounds (lbs., a unit of weight measurement). Resident 89's weight gains were as follows: 03/01/23: 324 lbs. 01/01/23: 330 lbs. 12/08/22: 325 lbs. 09/01/22: 319 lbs. 06/01/22: 310 lbs. 03/13/22: 305 lbs. During a review of Resident 89's Progress Notes (PN), dated 2/5/23 at 11:22 a.m., the PN indicated Resident on monitor for 10 lbs. weight gain in a month, no edema noted. Resident consumed 100% of all meals, will snack couple times a day. Resident is obese, she does not get up of bed or exercise. During a review of Resident 89's Nutritional Assessment (NA),dated 10/10/22, by the RD, the NA indicated Morbid Obesity as related to Consumption of excessive portions of food, Depression, Increased skinfold thickness, Obese with BMI (Body Mass Index, a medical screening tool that measures a person's body fat based on one's height and weight) > (over) 50 (BMI of over 40 kilogram [kg, a unit of weight measurement] indicate morbid/severe obesity), Physical inactivity- sedentary . Nutrition intervention .Encourage to attend exercise-focused activities and do exercises in bed as tolerated .Resident would like to lose weight but no goal stated .Stated she does not get up much because it is painful for her to be in her wheelchair . Gradual weight loss beneficial to resident health due to obesity. During a concurrent interview and record review, on 3/23/23 at 8:28 a.m., with the Activity Director (AD) and Assistant Administrator (AADM) 1, the AD stated, Resident 89 was only provided with in-room activities. The AD stated, I provide (Resident 89) with the facility news (chronicle) to read and give her coloring packets to color . I invite her to Bingo, movies, coffee social and she declines. The AD stated, Resident 89 had told her, that if staff could get her up in a wheelchair, then she would go and attend these activities. The AD stated, since I started working here in January 2023, Resident 89 had not been gotten up to attend activities in the activity room. The AD and AADM were unable to provide documented evidence of Resident 89's Activities care plan developed and implemented by the facility. The AD and AADM were both unable to find ACTIVITIES plan of care from the resident's electronic or paper health record. The AD and AADM 1 stated, Resident 89 did not have an Activities care plan and the care plan intervention initiated by the RD to encourage Resident 89 to attend exercise-focused activities was not followed. The AD stated, If we don't develop and implement care plans to address resident needs, we (staff) would not know how to help them go through with their daily lives. During a concurrent interview and record review, on 3/23/23 at 2:37 p.m., with the RD, the RD stated, Staff must encourage Resident 89 to attend and participate in exercise focused activities . staff must get Resident (89) out of bed and into her wheelchair and go outside . if resident declines, this must be documented . Staff should explain to the resident the benefits of exercise and the risks for not exercising .Sedentary /bedbound/no exercise can contribute to more weight gain .skin breakdown for Resident 89. During a review of the March 2023 ACTIVITY CALENDAR (AC), the AC indicated, the following weekly exercise activities were provided in the Activity room: 1. Gentle Yoga (a gentler style of yoga practice that is performed at a slower pace, with less intense positions, and usually includes extended time for meditation, breathing and relaxation) and 2. Stretch Tai Chi (a series of gentle physical exercises and stretches). During an interview with the AD, on 3/24/23 at 8:40 a.m., the AD stated, Resident 89 had not been offered nor have attended any of these exercise activities since January 2023. During a concurrent observation and interview, with Resident 89 (with AD as interpreter), on 3/24/23 at 8:43 a.m., Resident 89 was observed in bed watching television. Resident 89 stated, The lady (RD) talked to me yesterday about getting up to exercise and to eat less food so I could lose weight .somebody comes in . the one in Physical Therapy (a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) I think . I raise my arms, she moves my leg, raise it, bends, to help me get stronger . But I only get out of bed for shower. My back hurts a lot from lying down . I would like to be gotten up, go outside my room or just outside . I need a bigger wheelchair . my wheelchair is too small . hurts my sides .maybe exercise . diet could help me lose weight . During a review of Job Description - Activities Director, dated 6/1/21, the Job Description indicated, Position Summary: To plan, organize, develop, and direct the overall operation of the Activities Department in accordance with current federal, state, and local standards, guidelines, and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident . ESSENTIAL DUTIES . Plan, develop, implement, evaluate, and direct the activities programs of this facility . Assists in the development of resident centered care plans . During a review of the facility's Policy and Procedure (P and P) titled, Activity Evaluation), with a revision date of 5/2013, the P and P indicated, In order to promote the physical, mental, and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident . conducted by Activity Department personnel, in conjunction with other staff .evaluate related factors such as functional level . medical conditions that may affect resident's participation in activities (for example . level of pain, need for supplemental oxygen so that a resident with pulmonary or heart disease can participate more comfortably in an activity involving movement) . each resident's activities care plan . should reflect his/her individual needs . the activity evaluation and activities care plan will identify if a resident is capable of pursuing activities without intervention from the facility . care plan shall relate to his/her individual needs . During a review of the facility's P and P titled, Care Plans, Comprehensive Person-Centered (CPCPC), revision date of 12/2016, the CPCPC indicated, .The interdisciplinary team (IDT, a group of healthcare professionals who work together to assess, develop, implement, and evaluate each resident's treatment plan), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The CPCPC will include measurable objectives and timeframes, describe the services that are to be furnished . interventions address the underlying sources of the problem area(s), not just addressing only symptoms or triggers, identify the professional service that are responsible for each element of care . During a review of an article titled, Class III Obesity (Formerly Known as Morbid Obesity), dated 2023, retrieved from https://my.clevelandclinic.org/health/diseases/21989-class-iii-obesity-formerly-known-as-morbid-obesity, indicated, the complications of morbid obesity include diabetes (elevated blood sugar levels), heart diseases, high blood pressure, atherosclerosis (plaque buildup in the arteries), sleep apnea (breathing momentarily stops while sleeping), breathing difficulty, osteoarthritis (wear and tear of joints), and depression. During a review of an article titled, The Harmful Effects of Not Getting Enough Physical Activity in the Elderly, dated 9/8/22, retrieved from https://www.cdc.gov/chronicdisease/resources/publications/factsheets/physical, indicated, .Class III obesity, formerly known as morbid obesity, is a complex chronic condition that can lead to several serious health issues. Not getting enough physical activity can lead to heart disease-even for people who have no other risk factors. It can also increase the likelihood of developing other heart disease risk factors, including obesity, high blood pressure, and high blood cholesterol. Not getting enough physical activity can raise a person's risk of developing type 2 diabetes. Physical activity helps control blood sugar (glucose), weight, and blood pressure and helps raise good cholesterol and lower bad cholesterol. Adequate physical activity-at least 150 minutes of moderate activity a week-can also help reduce the risk of heart disease and nerve damage, which are often problems for people with diabetes. Getting the recommended amount of physical activity can lower the risk of many cancers, including cancers of the breast, colon, and uterus. Regular physical activity is one of the most important things people can do to improve their health. Moving more and sitting less have tremendous benefits for everyone, regardless of age, sex, race, ethnicity, or current fitness level. Physical activity is one of the best things people can do for their health. The Physical Activity Guidelines for Americans, 2nd Edition presents new findings on the benefits of regular physical activity/exercises, which include Improved sleep, Increased ability to perform everyday activities, improved cognitive ability and a reduced risk of dementia, Improved bone, and muscle health, and may help immune systems protect the bodies from infection and disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity consistent with enhancing each resident's quality of life for three of 10 sampled residents (Residents 1, 366, and 21) when: 1. Resident 1 and Resident 366's fingernails were long with black and brown matter under the fingernails. 2. Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. These failures resulted in the facility not promoting the rights of Resident 1, 366 and 21 to a dignified and respectful existence and had the potential to compromise their health and well-being. Findings: 1. During a concurrent observation and interview on 3/22/23, at 9:00 a.m., with Certified Nurse Assistant (CNA) 8, Resident 1 was sitting in her wheelchair outside her room. CNA 8 stated, Resident 1 was a total care and requires assistance with Activities of Daily Living (ADLs), including during meals. CNA 8 stated, Resident 1's fingernails on both hands were long with black and brown matter under the fingernails. CNA 8 stated, CNAs were responsible in keeping resident's fingernails clean at all times. CNA 8 stated, the facility failed to keep Resident 1's fingernails clean. CNA 8 stated, Resident 1 uses her hands to eat her meals, and the dirty fingernails could cause skin infection and stomach problems such as nausea, vomiting, and diarrhea. CNA 8 stated, the facility failed to maintain Resident 1's dignity. During a concurrent observation and interview on 3/22/23, at 9:34 a.m., with Licensed Vocational Nurse (LVN) 6, in Resident 366's room, Resident 6 was lying in bed and with both hands on top of the bedsheet cover. LVN 6 stated Resident 366 was dependent on staff for her ADLs and requires assistance during meals. LVN 6 stated, Resident 366's fingernails on both hands were long with black and brown matter under the fingernails. LVN 6 stated, Resident 366 was diabetic and licensed nurses were responsible in keeping resident's fingernails clean at all times. LVN 6 stated, the facility failed to keep Resident 366's fingernails clean. LVN 6 stated, Resident 1's dirty fingernails could cause infection. LVN 6 stated, the facility failed to maintain Resident 366's dignity. During an interview on 3/22/23, at 9:45 a.m., with LVN 6, LVN 6 stated, Resident 1 and Resident 366's dirty fingernails were unacceptable, a dignity and infection control issue. LVN 6 stated, cleaning of Resident 1 and Resident 366's fingernails were part of the Activities of Daily Living (ADLs) care plan. LVN 6 stated Resident 1 and Resident 366 should be treated with kindness, respect, and dignity at all times. During an interview on 3/22/23, at 3:51 p.m., with the Director of Nursing (DON), DON stated, Resident 1 and Resident 366's dirty fingernails were an infection control and dignity issue. DON stated, Resident 1 and Resident 366's ADL care plan was not followed. DON stated, staff should have cleaned Resident 1 and Resident 366's fingernails according to the care plan. DON stated, Resident 1 and Resident 366's dirty fingernails could cause skin infection and stomach problems such as nausea, vomiting, and diarrhea. The DON stated Resident 1 and Resident 366 should be treated with respect and dignity at all times. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/24/23, the AR indicated, Resident 1 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Chronic Obstructive Pulmonary Disease (COPD - is a chronic inflammatory lung disease that causes obstructed airflow of the lungs). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 3/24/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 3 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's ADL Care Plan (CP), dated 3/22/23, the CP indicated, . Focus . I require limited to total assist with one to two-person assistance with most ADLs . Interventions . 1 to 2 staff members to assist with ADLs . Date Initiated: 3/7/22 . During a review of Resident 366's AR, dated 3/22/23, the AR indicated, Resident 366 was admitted from an acute care hospital on 3/14/23 to the facility with diagnoses which included Heart Failure (weakness in the heart where fluid accumulates in the lungs), Cerebral Infarction (stroke), Dysphagia (swallowing difficulty), and Type 2 Diabetes Mellitus Type 2 (a disorder in which blood sugar or glucose levels are abnormally high). During a review of Resident 366's MDS, dated [DATE], the MDS indicated Resident 366's BIMS score was 9 out of 15. (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 366's ADL Care Plan (CP), dated 3/22/23, the CP indicated, . Focus . At Risk for Altered ADL Self Care . Interventions . Check nail length and trim and clean on bath day and as necessary . Date Initiated: 3/14/23 . During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2016, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . During a review of the facility's P&P titled, Care of Fingernails/Toenails, dated 2/2018, the P&P indicated, . The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . 1. Nail care includes regular cleaning and trimming . 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease . During a review of the facility's document titled, Certified Nurse Assistant (CNA) Job Description, dated 11/2016, the Certified Nurse Assistant (CNA) Job Description indicated, . Essential Duties and Responsibilities . Promptly assists residents with Activities of Daily Living (ADL) and daily nursing care needs as directed in nursing care plan, including bathing, grooming, dressing, transferring . Will treat residents with respect, dignity, and compassion . During a review of the facility's document titled, Licensed Vocational Nurse (LVN) Job Description, dated 11/2016, the Licensed Vocational Nurse (LVN) Job Description indicated, . Essential Duties and Responsibilities . Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control . Provide information and instruction to residents and their families in areas such as resident rights . 2. During a concurrent observation and interview on 3/22/23, at 9:40 a.m., with Licensed Vocational Nurse (LVN) 6, in Resident 21's room, Resident 21 was lying in bed and awake. LVN 6 stated, Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. LVN 6 stated, Resident 21's oral care should be done every shift and it was not followed. LVN 6 stated, licensed and unlicensed personnel were responsible in keeping Resident 21's mouth clean at all times. LVN 6 stated, the facility failed to follow Resident 21's ADL care plan. LVN 6 stated, Resident 1's poor oral care could cause several issues including pain and oral infection. LVN 6 stated, the facility failed to maintain Resident 1's dignity. During an interview on 3/27/23, at 11 a.m., with the Director of Nursing (DON), DON stated, Resident 21's poor oral care were an infection control and dignity issue. DON stated, Resident 21's ADL care plan was not followed. DON stated, staff should have cleaned Resident 21's mouth according to the care plan. DON stated, Resident 21's dry lips and mouth could cause pain and mouth infection. DON stated, Resident 21 should be treated with respect and dignity at all times. During a review of Resident 21's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 21 was admitted from an acute care hospital on 1/24/23 to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Dementia (define), and Gastrostomy (an artificial external opening into the stomach for nutritional support). During a review of Resident 21's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 1/31/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 3 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 21's ADL Care Plan (CP), dated 3/22/23, the CP indicated, . Focus . I have a physical functioning deficit in my ADL's related to Dx [diagnosis] of Dementia and its progression . Interventions . Encourage choices with care . Nail care PRN . Date Initiated: 10/28/22 . During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2016, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . During a review of the facility's P&P titled, Activities of Daily Living (ADLs), dated 3/2018, the P&P indicated, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care . During a review of the facility's document titled, Certified Nurse Assistant (CNA) Job Description, dated 11/2016, the Certified Nurse Assistant (CNA) Job Description indicated, . Essential Duties and Responsibilities . Promptly assists residents with Activities of Daily Living (ADL) and daily nursing care needs as directed in nursing care plan, including bathing, grooming, dressing, transferring . Will treat residents with respect, dignity, and compassion . During a review of the facility's document titled, Licensed Vocational Nurse (LVN) Job Description, dated 11/2016, the Licensed Vocational Nurse (LVN) Job Description indicated, . Essential Duties and Responsibilities . Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control . Provide information and instruction to residents and their families in areas such as resident rights .

**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 resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for two of five sampled residents (Resident 75 and 59) when: 1. Resident 75's MDS assessment for hearing, speech and vision was not coded accurately. This failure had the potential for Resident 75 not being provided with the necessary care and services to meet her healthcare needs. 2. Resident 59's smoking status was not coded accurately in the MDS assessment. This failure had the potential for Resident 59's smoking safety and identified care needs to go unmet. Findings: 1. During an observation and interview on [DATE], at 10:41 a.m., with Resident 75, inside Resident 75's room, Resident 75 stated, her prescription eyeglasses was missing since yesterday and staff was not able to find her eyeglasses. Resident 75 stated, she uses her prescription eyeglasses for reading and watching TV. Resident 75 stated, The eyeglasses meant a lot for me. My husband bought it for me before he died. I want it back. During an interview on [DATE], at 10:39 a.m., with Social Services Director (SSD) 2, SSD 2 stated, Resident 75's missing prescription eyeglasses was reported missing on [DATE]. SSD 2 stated , she was aware Resident 75's prescription eyeglasses were last seen on [DATE]. During a concurrent interview and record review, on [DATE], at 9:15 a.m., with Minimum Data Set Nurse (MDS), Resident 75's MDS assessment Section B, dated [DATE] was reviewed. The MDS assessment, Section B indicated, . B1000. Vision . Ability to see in adequate light (with glasses or other visual appliances) . Enter Code [0] Adequate - sees fine detail, such as regular pint in newspapers/books . B1200. Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision . Corrective lenses [0] . MDS stated, Resident 75's MDS assessment Section B was not accurate and was coded incorrectly. MDS stated, she cannot recall if Resident 75 was wearing eyeglasses when she completed Resident 75's MDS Vision Assessment Section B on [DATE]. During an interview on [DATE], at 11:05 a.m., with the Director of Nursing (DON), DON stated the residents should have accurate MDS assessments. DON, stated the expectation from all staff completing the MDS assessments was to have an accurate assessment. DON stated, Resident 75's inaccurate assessment could potentially result in not meeting Resident 75's healthcare needs. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated, . 1. Any health care professional who participates in the assessment process is qualified to assess the medical, functional and /or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge . 3. The information captures on the assessment reflects the status of the resident during the observation (look-back) period for that assessment . 4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident . During a review of CMS's RAI Version 3.0 Manual dated [DATE], indicated, . SECTION B1000: VISION . A person's reading vision often diminishes over time. If uncorrected, vision impairment can limit the enjoyment of everyday activities such as reading newspapers, books, or correspondence, and maintaining and enjoying hobbies and other activities. It also limits the ability to manage personal business, such as reading and signing consent forms. Moderate, high or severe impairment can contribute to sensory deprivation, social isolation, and depressed mood . Steps for Assessment . Ask direct care staff over all shifts if possible about the resident's usual vision patterns . 2. Then ask the resident about his or visual abilities. 3. Test the accuracy of your findings: Ensure that the resident's customary visual appliance for close vision is in place (e.g., eyeglasses, magnifying glass) . 2. During a review of Resident 59's admission Record, undated, the admission record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage (a head injury causing bleeding in the brain), history of transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction. During a review of Residents 59's Minimum Data Set Assessment (MDS- a resident assessment tool used to identify resident cognitive and physical function), dated [DATE], the MDS indicated, Resident 59's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 06 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated, Resident 59's was severely cognitively impaired. During a concurrent observation and interview on [DATE], at 1:35 p.m., with Resident 59, in Resident 59's room, Resident 59 was sitting in her wheelchair at bedside. Resident 59 stated she was a smoker and had never missed a smoke break. During conversation the Activities Assistant (AA) came into the room and told Resident 59 it was time for her smoke break. During an observation on [DATE], at 2:20 p.m., Resident 59 was sitting out in the courtyard in a group of residents with a smoking apron on and smoked a cigarette. Resident 15's MDS assessment dated [DATE], indicated, . Section J . Section J1300. Current Tobacco Use reflected 0 [No Tobacco Use] . During an interview on [DATE], at 2:59 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, she assisted the MDS nurse with the MDS assessments. The ADON reviewed Resident 59's MDS assessment dated [DATE]. The ADON validated Resident 59 was a smoker and the MDS was not accurate. The ADON stated the MDS assessments should be accurate for the resident's safety and billing purposes. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated [DATE], the P&P indicated, .2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 82's admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 82 was admitted to the facility on [DATE]. Resident 82's diagnoses included .DYSPHAGIA (difficulty swallowing) FOLLOWING OTHER CEREBROVASCULAR DISEASE (condition that affects blood flow to the brain) .GASTROSTOMY STATUS . During a concurrent interview and record review, on 3/27/23, at 11:08 a.m., with Minimum Data Set Nurse (MDSN), Resident 82's Order Summary Report, dated 3/27/23, and Resident 82's Care Plans, undated, was reviewed. The Order Summary Report indicated, Cleanse g-tube (a tube surgically inserted through the abdomen into the stomach) insertion site with [normal saline], pat dry and cover with DD. every night shift. MDSN stated that there was no care plan found for the dressing change ordered on 8/10/22. During a review of Resident 84's admission Record (AR), the AR indicated, Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses included .DYSPHAGIA FOLLOWING CEREBRAL INFARCTION (damage to the tissues in the brain due to loss of oxygen to the area) .ENCOUNTER FOR ATTENTION TO GASTROSTOMY . During a concurrent interview and record review, on 3/27/23, at 11:08 a.m., with MDSN, Resident 84's Order Summary Report, dated 3/27/23, and Resident 84's Care Plans, undated, was reviewed. The Order Summary Report indicated, Change dressing to G-tube every day every night shift. MDSN stated that there was no care plan found for the dressing change ordered on 8/19/22. During a review of Resident 107's admission Record (AR), the AR indicated, Resident 107 was admitted to the facility on [DATE]. Resident 107's diagnoses included .DYSPHAGIA FOLLOWING CEREBRAL INFARCTION .GASTROSTOMY . During a concurrent interview and record review, on 3/27/23, at 11:08 a.m., with MDSN, Resident 107's Order Summary Report, dated 3/27/23, and Resident 107's Care Plans, undated, was reviewed. The Order Summary Report indicated, Cleanse G-tube insertion site with [normal saline], Pat dry and cover with T drain dressing (pre-cut dressing to provide a snug fit around a tube). every night shift Only use hypoallergenic (micropore) tape (paper tape to secure wound dressings that is unlikely to cause an allergic reaction) [due to] sensitivity. MDSN stated, there was no care plan found for the dressing change ordered on 2/20/23. During an interview on 3/27/23, at 11:11 a.m., with MDSN, MDSN stated, the importance of care planning is to identify the plan of care, to make sure the needs of the residents are being met, to establish a baseline and update as needed. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, 12/16, the P&P indicated, .A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered 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 . 3. During an observation on 3/21/23, at 10:10 a.m., in Resident 81's room, Resident 81 was lying in bed with the oxygen concentrator (a medical device that provides oxygen) connected to her nose via nasal cannula (a small, flexible tube that attaches to an oxygen source and intended to deliver a steady stream of oxygen to your nose). The oxygen concentrator flow rate was set to administer oxygen at 4 liters per minute (unit of measurement). During a concurrent observation and interview on 3/22/23, at 9:34 a.m., inside Resident 81's room, with Licensed Vocational Nurse (LVN) 7, LVN 7 verified the oxygen concentrator flow rate was set to deliver at 4 liters per minute of oxygen to Resident 81. LVN 7 stated, she will check Resident 81's physician's order for an Oxygen order. During a concurrent interview and record review, on 3/22/23, at 9:38 a.m., with LVN 7, Resident 81's Order Summary Report, dated 3/22/23 was reviewed. LVN 7 stated, Resident 81's physician's order for Oxygen was to administer oxygen at 2 liters per minute. LVN 7 stated, she did not follow the physician's order. LVN 7 stated, Resident 81 was under Hospice care and the oxygen was ordered to provide comfort. LVN 7 stated, the higher flow of oxygen could have a negative effect on Resident 81's health. During an interview on 3/27/23, at 11:35 a.m., with the Acting Director of Nursing (DON), DON stated, oxygen was considered a medication and physician's order should be followed to prevent oxygen toxicity for Resident 81. During a review of Resident 81's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 81 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During a review of Resident 81's Order Summary Report dated 3/22/23, the Order Summary Report indicated, . Oxygen via nasal canula 2 L/min [liters per minute] every shift for Shortness of breath related to end of life . Order Date 3/15/23 . During a review of the facility's document titled, Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . During a review of the facility policy and procedure (P&P) titled, Oxygen Administration dated 11/2020, the P&P indicated, . The purpose of this procedure is to provided guidelines for safe oxygen administration . Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration . During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 9/2013, the P&P indicated, . Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . The care plan is based on the resident's comprehensive assessment and is developed by Care Planning/Interdisciplinary Team . During a review of the professional reference tiled, Bench to bedside review: Oxygen as a drug retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688103/ dated 2/24/2009, indicated, .Oxygen is one of the most widely used therapeutic agents. It is a drug in the true sense of the word, with specific biochemical and physiologic actions, a distinct range of effective doses, and a well-defined adverse effects at high doses . Based on interview and record review, the facility failed to develop and implement a person-centered baseline care plan within 48 hours of resident admission in the facility for 6 of 12 sampled residents (Residents 60, 80, 81 82, 84, and 107) when: 1. Resident 60 was sent out to general acute care hospital (GACH) on 2/18/23 for a high blood sugar, returned the following day and was sent to the hospital again on 2/23/23 for a swelling and bruising to right elbow as a result of altercation with another resident; care plans were not developed to prevent rehospitalization and keep her safe. This failure had a potential for Resident 60's blood sugar level and right elbow's swelling and bruising to not be monitored. 2. Resident 80 did not have a care plan in place for a critical lab result and received blood transfusion. This failure had a potential for Resident 80 for potential adverse reaction to blood transfusion and laboratory value to not be monitored. 3. Resident 81's care plan for oxygen administration which indicated the administration oxygen via (through) nasal cannula (a small, flexible tube that attaches to an oxygen source and intended to deliver a steady stream of oxygen to your nose) was not implemented. This failure had the potential for Resident 81's oxygen needs to go unmet. 4. Residents 82, 84, and 107 did not have a care plan for gastrostomy (surgical opening from the abdomen into the stomach) dressing changes. This failure had the potential to result in Resident 82, 84 and 107's dressing change needs being unmet with the potential for an increased risk of infection. Findings: 1. During an observation on 3/21/23, at 10:08 a.m., in Resident 10's room, Resident was laying in bed, covered with blanket and eyes closed. Resident 10 did not respond to questions asked. During a review of Resident 60's admission Record (a document with personal identifiable and medical information) undated, indicated Resident 60 was re-admitted to the facility on [DATE], with diagnosis which included cerebral infarction (), Diabetes Mellitus (DM-high blood sugar) and anemia (low red blood count). During a review of Residents 10's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 10's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 9 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 10 was moderately cognitively impaired. During a concurrent interview and record review on 3/24/23, at 2:19 p.m., with Minimum Data Set Nurse (MDSN), Resident 60's clinical record was reviewed and stated, Resident 60 was sent out to GACH on 2/18/23 because of a high blood sugar. MDSN stated she was not able to find a care plan to address the high blood sugar. MDSN stated Resident 60 was sent out to GACH again on 2/23/23 for swelling and bruising to right elbow as a result of an altercation with another resident. MDSN stated she was not able to find a care plan to address the swelling an bruising of the right elbow. MDSN stated there should have been a care plan in place to monitor the right elbow and the high blood sugar. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 4 on 3/27/23, at 9:30 a.m., LVN 4 reviewed Resident 60's clinical record and stated Resident 10 was sent out to GACH for possible fracture (break in the bone) of right elbow. LVN 4 stated she was not able to find a care plan for the right elbow and there should have been a care plan 2. During a concurrent observation and interview on 3/21/23, at 8:55 a.m., in Resident 80's room, Resident 80 was laying in bed watching TV and putting make-up. Resident 80 stated she was in the hospital for three weeks because she needed a blood transfusion but did not remember when. During a review of Resident 80's admission Record (a document with personal identifiable and medical information) undated, indicated Resident 80 was re-admitted to the facility on [DATE], with diagnosis which included anemia (low red blood count), DM, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and arthropathy (joint disease). During a review of Residents 80's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 80's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) was independent with daily decision making. During a concurrent interview and record review on 3/24/23, at 2:35 p.m., with MDSN, she reviewed Resident 80's clinical record and stated, . I do not see documentation on why Resident 80 was sent out to GACH . MDSN stated she was not able to find a care plan why Resident 80 was sent out to GACH and there should have been a care plan in place. During a concurrent interview and record review on 3/27/23, at 9:50 a.m., with LVN 4, she reviewed Resident 80's clinical record and stated Resident 80 was sent out to GACH for blood transfusion on 1/14/23 and returned in the facility on 2/4/23. LVN 4 stated there was no care plan in place for the blood transfusion. LVN 4 stated there should have been a care plan to monitor Resident 80 for possible reaction to the blood transfusion. During an interview on 3/27/23, at 4 p.m., with the Assistant Director of Nursing (ADON), she stated her expectation was for all residents returning from GACH to have an updated care plan. ADON stated licensed nurses including the ADON and the Director of Nursing (DON) are to initiate a care plan and medical records to audit residents' charts to make sure there was care plan in place. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident . The interdisciplinary team must review and update the care plan: . when the resident has been readmitted to the facility from a hospital stay .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for two of four sampled residents (Resident 13 and 84) when: 1. Resident 13's nutrition care plan was not revised with seven days to include significant weight losses on 12/18/22 or 2/1/23. This failure placed Resident 13 at risk for complications due to care needs not being planned by licensed nurses and the interdisciplinary team to determine if interventions needed to be added, changed or completed. 2. Resident 84's care plan was not revised within seven days to reflect the physician's order for diet and oral intake. This failure had the potential for Resident 84's nutritional needs to go unmet. Findings: 1. A review of Resident 13's medical record (MR) was initiated on 3/22/23. Resident 13 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing), type 2 diabetes mellitus (a disease when the body's ability to produce insulin [a hormone] was impaired resulting in abnormal metabolism of carbohydrates and elevated levels of glucose [blood sugar] in the blood), and thrombophilia (the tendency for blood clots to form). During a concurrent interview and record review on 3/22/23 at 9:32 a.m., with the Registered Dietitian (RD), the RD reviewed the document titled Weights and Vitals Summary (WVS) for Resident 13, dated 5/20/2022 to 2/1/2023. The RD confirmed, the WVS indicated the following weights and dates for Resident 13: 5/20/22: 204 pounds (lbs), 12/18/22 160 lbs, 10% severe weight loss from comparison weight dated 7/1/22 196 lbs, [-36 lbs, 18.4%], 7.5% severe weight loss from comparison weight dated 10/4/22 178 lbs, [-18 lbs, 10.1%] and 5% significant weight loss from comparison weight dated 11/13/22 169 lbs [-9 lbs, 5.3%], 2/1/23 154 lbs, 10% severe weight loss from comparison weight dated 9/5/22 186 lbs, [-32 lbs, 17.2%], and 7.5% severe weight loss from comparison weight dated 11/6/22 170 lbs, [-16 lbs, 9.4%]. The RD stated either nursing or RD was responsible to update the nutrition care plan with significant weight changes. The RD confirmed Resident 13's nutrition care plan did not reflect the above significant weight losses. During a concurrent interview and record review for Resident 13 on 3/22/23 at 2:40 p.m., with the ADON, the ADON stated unplanned weight loss should be monitored. The ADON confirmed the nutrition care plan for Resident 13 did not reflect significant weight loss prior to 3/2/23. 2. During a review of Resident 84's admission Record, undated, the admission record indicated, Resident 84 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing foods or liquids), cerebral infarction (stroke-result of disrupted blood flow to the brain), encounter for attention to gastrostomy (PEG tube-a feeding tube placed through the abdomen directly into the stomach bypassing the mouth and throat), hemiplegia (paralysis on one side of body) and hemiparesis (inability to move on one side of the body) following cerebral infarction, hypertensive heart failure (heart problems due to chronic high blood pressure), and history of traumatic brain injury (a head injury causing bleeding in the brain). During a review of Residents 84's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 84's Brief Interview of Mental Status Assessment (BIMS - assessment of cognitive status for memory and judgement) scored 99 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 unable to complete interview). The BIMS assessment indicated Resident 84 was unable to participate in the assessment. During an observation on 3/21/23, at 1:04 p.m., Resident 84 had a mechanical soft (food texture designed for people who have difficulty chewing or swallowing) lunch on the bedside table in front of her. Resident 84 fed herself while a certified nursing assistant (CNA) sat at the bedside. The CNA stated she would assist the resident as needed. During an interview on 3/27/23, at 9:40 a.m., with CNA 5, CNA 5 stated Resident 84 had nothing by mouth and fed through PEG tube for as long as she could remember. CNA 5 stated approximately a month ago, Resident 84 had started an oral diet. CNA 5 stated Resident 84 was able to feed herself with occasional reminders to swallow. During a review of Resident 84's physician's order titled Order Summary Report, dated 3/27/23, the physician's order indicated, .Regular diet Mechanical Soft texture, Thickened Liquid Nectar (thickened liquids to prevent choking and stop fluid from entering the lungs) consistency . Enteral Feed (form of nutrition that is delivered directly into the digestive system as a liquid) Order every shift Check tube placement by gastric aspiration (testing amount of fluid left in the stomach through a PEG tube by removing contents with a syringe) of contents . Discharge [discontinue] PEG TUBE feedings. [Patient] started PO (oral) diet 2/7/23 . During a concurrent interview and record review on 3/27/23 at 11:46 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 84's physician's order and stated Resident 84's PEG tube feedings were discontinued on 2/7/23. The MDSN stated Resident 84 started a puree (food that is smooth with no lumps) diet and graduated to a mechanical soft diet on 3/7/23. Resident 84's care plans were reviewed. The diet alteration care plan dated 8/18/22, indicated, .PEG feeding as ordered . [brand name of liquid meal replacement] 1.5 cal [calorie-measurement of the energy content of food] at 70 [mL-milliliters a unit of measurement]/hour [for] 18 hours for a total of 1260 [mLs] and 1890 calories . Resident 84's swallowing care plan dated 1/31/23, indicated, .Pt has improved swallowing skills and may be able to safely resume a PO diet .2/7/23: Discharge peg tube feedings and started puree diet with nectar thick liquids TID (three times a day) . 3/7/23: Diet upgraded to mechanical soft with nectar thick liquids TID . The MDSN The MDSN stated care plans were used to ensure the correct interventions were in place to meet the resident's goals. The MDSN stated Resident 84's care plans contradicted each other and should have been updated and revised to avoid confusion and reflect the physician's order. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident . Receive the services and/or items included in the plan of care .The comprehensive, person-centered 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 .Reflect treatment goals, timetables and objectives in measurable outcomes .aid in preventing or reducing decline in the resident's functional status and/or functional levels .Reflect currently recognized standards of practice for problem areas and conditions .Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents condition change . During a review of a professional reference retrieved from https://www.healthit.gov/buzz-blog/interoperability/comprehensive-shared-care-plan-nursing titled, What Does The Comprehensive Shared Care Plan Mean For Nursing? dated 5/8/2017, the reference indicated, .Since unique resident needs may require particular care or services, the services needed to attaint this level of well-being are established in the individual's plan of care . Care plans help us document our assessment of patients' needs and goals, select appropriate interventions, and evaluate the impact of those interventions. But they are also evolving plans; they continue to be revised based on the patient's responses and progress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 82's admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 82 was admitted to the facility on [DATE]. Resident 82's diagnoses included .DYSPHAGIA (difficulty swallowing) FOLLOWING OTHER CEREBROVASCULAR DISEASE (condition that affects blood flow to the brain) .GASTROSTOMY STATUS . During a concurrent interview and record review, on 3/27/23, at 11:08 a.m., with Minimum Data Set Nurse (MDSN), Resident 82's Order Summary Report, dated 3/27/23, and Resident 82's Treatment Administration Record (TAR), dated 3/27/23, was reviewed. The Order Summary Report indicated, Cleanse g-tube (a tube surgically inserted through the abdomen into the stomach) insertion site with [normal saline], pat dry and cover with DD [sic]. every night shift .Order Date .08/10/2022. The TAR indicated, a check mark symbol to show that the physician's order was completed each corresponding day in the month of March. MDSN stated, there was a check mark missing on 3/1/23 and 3/21/23 which indicated that the physician's order for a dressing change was not completed on those days. MDSN stated, there was no further documentation from the nurse in the Resident 82's chart as to why there was not a dressing change completed on 3/1/23 and 3/21/23. During a review of Resident 84's admission Record (AR), the AR indicated, Resident 84 was admitted to the facility on [DATE]. Resident 84's diagnoses included .DYSPHAGIA FOLLOWING CEREBRAL INFARCTION (damage to the tissues in the brain due to loss of oxygen to the area) .ENCOUNTER FOR ATTENTION TO GASTROSTOMY . During a concurrent interview and record review, on 3/27/23, at 11:08 a.m., with MDSN, Resident 84's Order Summary Report, dated 3/27/23, and Resident 84's TAR, dated 3/27/23, was reviewed. The Order Summary Report indicated Change dressing to G-tube every day every night shift .Order Date .08/05/2022. The TAR indicated, a check mark symbol to show that the physician's order was completed each corresponding day in the month of March. MDSN stated, there was a check mark missing on 3/11/23, 3/17/23 and 3/21/23 which indicated that the physician's order for a dressing change was not completed on those days. MDSN stated, there was no further documentation from the nurse in the Resident 84's chart as to why there was not a dressing change completed on 3/11/23, 3/17/23 and 3/21/23. During a review of Resident 107's admission Record (AR), the AR indicated, Resident 107 was admitted to the facility on [DATE]. Resident 107's diagnoses included .DYSPHAGIA FOLLOWING CEREBRAL INFARCTION .GASTROSTOMY STATUS . During a concurrent interview and record review, on 3/27/23, at 11:08 a.m., with MDSN, Resident 107's Order Summary Report, dated 3/27/23, and Resident 107's TAR, dated 3/2723, was reviewed. The Order Summary Report indicated, Cleanse G-tube insertion site with [normal saline], Pat dry and cover with T drain dressing (pre-cut dressing to provide a snug fit around a tube). every night shift Only use hypoallergenic (micropore) tape (paper tape to secure wound dressings that is unlikely to cause an allergic reaction) [due to] sensitivity .Order Date .02/20/2023. The TAR indicated, a check mark symbol to show that the physician's order was completed each corresponding day in the month of March. MDSN stated, there was a check mark missing on 3/4/23 and 3/22/23 which indicated that the physician's order for a dressing change was not completed on those days. MDSN stated, there was no further documentation from the nurse in the resident's chart as to why there was not a dressing change completed on 3/4/23 and 3/22/23. During an interview on 3/27/23, at 1:55 P.M, with MDSN, MDSN stated, there is an increased risk of infection if Residents 82, 84 and 107 did not receive their dressing changes according to the physician's orders. During a review of facility document titled, .Job Description .Licensed Vocational Nurse . (Job Description), dated 7/29/16, the Job Description indicated, .POSITION SUMMARY .The primary purpose of your job position is to provide primary care to specific residents under the medical direction and supervision of the residents' attending physicians or the Medical Director of the facility, with an emphasis on assessment, illness prevention and health care management . During a profession reference retrieved from https://www.registerednursing.org/articles/does-nurse-always-follow-doctors-orders titled, Does a Nurse Always Have to Follow a Doctor's Orders?, indicated .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed neglect . 2. During an observation on 3/21/23, at 10:10 a.m., in Resident 81's room, Resident 81 was lying in bed with the oxygen concentrator (a medical device that provides oxygen) connected to her nose via nasal cannula (a small, flexible tube that attaches to an oxygen source and intended to deliver a steady stream of oxygen to your nose). The oxygen concentrator flow rate was set to administer oxygen at 4 liters per minute (unit of measurement). During a concurrent observation and interview, on 3/22/23, at 9:34 a.m., inside Resident 81's room, with Licensed Vocational Nurse (LVN) 7, LVN 7 verified the oxygen concentrator flow rate was set to deliver at 4 liters per minute of oxygen to Resident 81. LVN 7 stated, she will check Resident 81's physician's order for Oxygen. During an interview on 3/22/23 at 9:38 a.m., with LVN 7, LVN 7 stated, Resident 81's physician's order for Oxygen was to administer oxygen at 2 liters per minute. LVN 7 stated, she did not follow the physician's order. LVN 7 stated, Resident 81 was under Hospice care and the oxygen was ordered to provide comfort. LVN 7 stated, the higher flow of oxygen could have a negative effect on Resident 81's health. During an interview on 3/27/23, at 11:35 a.m., with the Acting Director of Nursing (DON), DON stated oxygen was considered a medication and physician's order should be followed to prevent oxygen toxicity for Resident 81. During a review of Resident 81's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 81 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During a review of Resident 81's Order Summary Report dated 3/22/23, the Order Summary Report indicated, . Oxygen via nasal canula 2 L/min [liters per minute] every shift for Shortness of breath related to end of life . Order Date 3/15/23 . During a review of the facility's document titled, Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . During a review of the facility policy and procedure (P&P) titled, Oxygen Administration dated 11/2020, the P&P indicated, . The purpose of this procedure is to provided guidelines for safe oxygen administration . Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration . During a review of the professional reference tiled, Bench to bedside review: Oxygen as a drug retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688103/ dated 2/24/2009, indicated, .Oxygen is one of the most widely used therapeutic agents. It is a drug in the true sense of the word, with specific biochemical and physiologic actions, a distinct range of effective doses, and a well-defined adverse effects at high doses . 3. During a concurrent observation and interview on 3/21/23, at 11:23 p.m., with Resident 38, near the facility's main entrance. Resident 38 was observed sitting on his wheelchair. Resident 38 was observed to have a contracted left upper extremity. Resident 38 stated, his transportation going to the dialysis was in the parking lot and waiting for him. Resident 38 stated, his lunch tray was not served today and it was supposed to be given to him an hour ago. Resident 38 stated, I don't want to be hungry. I sit in the dialysis chair for 4 to 5 hours and they don't have food in the dialysis center. Please help me get some food from the kitchen. During an interview on 3/21/23, at 11:27 a.m., with Certified Nurse Assistant (CNA) 9, CNA 9 stated, Resident 38 was a dialysis patient and goes to the Dialysis Center three times a week: every Tuesday, Thursday, and Saturday. CNA 9 stated, Resident 38's transportation pick up was around 11:30 a.m. CNA 9 stated, Resident 38's early lunch tray was supposed to be provided to him 30 minutes ago and it was not done. CNA 9 stated, The CNA assigned to him is responsible in obtaining his early lunch tray. We are all responsible in making sure that he gets his food on time. It's not good for him to go to dialysis on an empty stomach. He might lose weight if he will miss his lunch before going to the dialysis center. During a concurrent interview and record review on 3/21/23, at 11:30 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 38's Order Summary Report (OSR), dated 3/21/23 was reviewed. OSR indicated, . Dialysis Treatment days: Tuesday, Thursday and Saturday at 12:15 PM. Transportation . pick up time at 11:00 AM . Order Date 9/15/22 . LVN 4 stated, Resident 38's early lunch tray should be served 30 minutes before the transportation pick up time and failed to do so. LVN 4 stated, We need to give him enough time to eat. He's disable and unable to use his left arm and left hand. Between the licensed nurses and CNAs, we should get his early lunch tray on his dialysis days. Resident should eat before leaving for dialysis. During an interview on 3/27/23, at 11:35 a.m., with the Acting Director of Nursing (DON), the DON stated his expectation was for the Licensed Nurse (LN) and CNA assigned to Resident 38 to coordinate the delivery of early meal tray on dialysis days. The DON stated Resident 38 could potentially experience weight loss from missing his lunch. The DON stated, Resident could go hungry for hours and it's not acceptable. During a review of Resident 38's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, . admission Date 5/2/22 . Diagnosis Information . End Stage Renal Disease (ESRD - medical condition in which a person's kidneys stop functioning on a permanent basis and needing long-term dialysis) . During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 38's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 13 out of 15 indicating cognitively intact (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a review of the facility's document titled, Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . During a review of the facility policy and procedure (P&P) titled, Dialysis Guideline, dated 4/2016, the P&P indicated, . The following information will provide addition direction in assessment, planning and provision of care to our residents requiring hemodialysis . Whether residents receiving hemodialysis are transported out of the center, or receive dialysis in house, communication is essential for continuity of care . Pre-Dialysis Protocol . Be aware of any meals that may be missed and arrange for routine boxed lunches to be provided by the dietary if resident is transported off-site . Based on observation, interview and record review, the facility failed to meet professional standards of practice for seven of 12 sampled residents (Residents' 80, 82, 81, 83, 84, 38 and 107) when: 1. Licensed Nurse failed to follow the facility Change in a Resident's condition or status policy and procedure when Licensed Nurse did not conduct change in resident's condition assessment prior to sending Resident 80 out to general acute care hospital (GACH). This failure had the potential for Resident 80's change of condition to not being addressed by the nursing staff which could lead to delay of treatment and/or services. 2. Resident 81 was administered oxygen without following physician's order. This failure resulted in Resident 81 to receive a high dose of oxygen and had the potential to experience oxygen toxicity (a lung damage that happens from breathing too much supplemental oxygen; it can cause coughing and trouble breathing; in severe cases it can even cause death.) which can lead to difficulty in breathing and death. 3. Resident 38's early lunch tray was not served on 3/21/23 before leaving the facility for dialysis. This failure had the potential to result in Resident 81 leaving the facility hungry and could have a negative impact on his health and well-being. 4. Licensed Nurses failed to follow physician orders Resident 82, 84 and 107 when licensed nurses did not provide gastrostomy (surgical opening from the abdomen into the stomach) dressing changes. This failure had the potential for increased risk of infection for Residents 82, 84 and 107. Findings: 1. During a review of Resident 80's admission Record, undated, the admission record indicated, Resident 80 was re-admitted to the facility on [DATE] with diagnoses which included anemia (body does not have enough healthy red blood cells), arthropathy (joint disease), diabetes mellitus type 2 (too much sugar in the blood). During a review of Residents 80's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 80's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) indicated Resident 80 was independent with decisions regarding tasks of daily life. During a concurrent observation and interview on 3/21/23, at 8:55 a.m., in Resident 80's room, Resident 80 was laying in bed watching TV and putting make-up. Resident 80 stated she was in the hospital for three weeks because she needed a blood transfusion but did not remember when. During a concurrent observation and record review on 3/24/23, at 2:30 p.m., with Minimum Data Set Nurse (MDSN), she reviewed clinical record of Resident 80 and stated she was sent out to general acute care hospital (GACH) on 1/14/23 until 2/4/23. MDSN stated she did not find a change of condition (COC) and a transfer form when Resident 80 was transferred to GACH. MDSN stated there should have been a COC assessment and a transfer form because Resident 80 was sent out to GACH. During an interview on 3/27/23, at 4:15 p.m., with the Assistant Director of Nursing (ADON), she stated Resident 80 did not have a COC assessment prior to going to GACH. ADON stated residents who goes to GACH needed to have a COC. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/21, the P&P indicated, . The nurse will notify the resident's attending physician or physician on call when there has been a(an): .need to transfer the resident to a hospital/treatment center . Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR communication Form . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . During a review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, page 16-17 indicated, Standards of practice General Principles .failure to adhere to facility policy or procedural guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care, services and activities of daily living (ADLs -activities related to personal care: bathing, oral care, brushing hair, shaving) for four out of 11 residents (Residents 32, 59, 71 and 91) when the facility did not routinely provide personal hygiene assistance according to the residents needs and preferences. This failure had the potential to result in oral infections, loss of teeth, body odor and skin irritations and infections. Findings: During a resident council meeting (an organized group of people living in a long-term care facility that meets on a regular basis to discuss concerns, develop suggestions on improving services or resolve differences) on 3/22/23, at 11:05 a.m., Residents 32, 29, 72 and 91 stated they were not receiving routine personal hygiene. During a review of Resident 71's admission Record, undated, the admission record indicated, Resident 71 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors), Type 2 Diabetes Mellitus, edema (excess fluid trapped in the body's tissues), pruritis (itching skin), and cellulitis (potentially serious bacterial skin infection) of right lower limb. During a review of Resident 71's Minimum Data Set (assessment dated [DATE], indicated Resident 71's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 71 was not cognitively impaired. During a concurrent observation and interview on 3/22/23, at 8:42 a.m., with Resident 71, Resident 71 sat in a wheelchair at his bedside, dressed and hair combed. Resident 71 stated he had not been receiving showers routinely and he was supposed to shower twice weekly. Resident 71 stated, you can smell me if you take off your mask. During a concurrent observation and interview on 3/22/23, at 12:21 p.m., with Resident 71, Resident 71 stated, the nursing staff did not provide routine oral care. Resident 71 stated, it had been a few days since his teeth were brushed. Resident 71 showed his teeth, and no buildup of plaque or tartar was observed. Resident 71 stated, his teeth were cleaned by the dental hygienist at the facility a couple of weeks ago. Resident 71 stated, he had Parkinson's Disease, and it was difficult for him to brush his teeth. Resident 71 stated the staff would not offer oral care unless he asked for it. During a concurrent interview and record review on 3/27/23, at 10:12 a.m., with the Assistant Director of Nursing (ADON), Resident 71's Certified Nursing Assistant's (CNA) documentation titled Documentation Survey Report, dated March 2023 was reviewed. The CNA's ADL-Bathing documentation indicated, between 3/1/23 and 3/26/23 Resident 71 had a shower on 3/6/23 and 3/19/23. The ADON reviewed the document and stated Resident 71 was given a shower twice which was not enough. ADON enough. The ADON stated, the lack of bathing was a quality-of-care issue. The ADON stated, residents needed to bathe to prevent skin breakdown and dry flaky skin. The CNA's ADL-Personal Hygiene documentation indicated, on 2/27/23, 3/7/23, 3/9/23, 3/15/23 and 3/21/23 Resident 71 was provided personal hygiene care only one time. The ADON stated, personal hygiene should be provided two times per day at a minimum. The ADON stated, Resident 71's personal hygiene was not done frequently enough to meet the resident's needs. During a review of Resident 59's admission Record, undated, the admission record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses which included, traumatic subdural hemorrhage (a head injury causing bleeding in the brain), history of transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction (stroke-result of disrupted blood flow to the brain). During a review of Residents 59's Minimum Data Set assessment dated [DATE], indicated Resident 59's Brief Interview of Mental status assessment scored 06 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 59 was severely cognitively impaired. During a concurrent observation and interview on 3/21/23, at 12:45 p.m., with Resident 59, Resident 59 wore a gown and sat in a wheelchair next to her bed. Resident 59 stated, the facility staff did not help her with denture care. Resident 59 stated, the staff did not offer to help or provide reminders to clean her teeth. Resident 59 stated, my toothbrush and toothpaste keep disappearing so I can't brush them [her teeth] anyway. During a concurrent interview and record review on 3/27/23, at 10:21 a.m., with the ADON, Resident 59's CNA's documentation titled Documentation Survey Report, dated March 2023 was reviewed. The CNA's ADL-Bathing documentation indicated, between 3/1/23 and 3/26/23 Resident 59 had a shower once on 3/7/23. The CNA's ADL-Personal Hygiene documentation was reviewed and indicated, Resident 59 was provided personal hygiene one time on 3/11/23 and 3/17/23. ADON stated, personal hygiene needed to be performed at least two times per day. During a review of Resident 91's admission Record, undated, the admission record indicated, Resident 91 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis on one side of body) and hemiparesis (inability to move on one side of the body) following cerebral infarction, disorder or bone density, and history of falling. During a review of Residents 91's Minimum Data Set assessment dated [DATE], indicated Resident 91's Brief Interview of Mental status assessment was conducted through staff assessment and indicated Resident 91 memory was intact and moderately independent with decision making. During a concurrent observation and interview on 3/21/23, 12:35 p.m., Resident 91 sat in a wheelchair at her bedside. Resident 91 was dressed and groomed. Resident 91 stated, she kept extra washcloths at her bedside so she could wash her face when needed. During an interview on 3/24/23, at 2:05 p.m., with Resident 91, in her room, Resident 91 stated, she was mostly independent, but the CNAs had never asked about or offered to help her with oral care. Resident 91 stated, she also had missed showers at times due to low staffing but could not remember exact dates. During a concurrent interview and record review on 3/27/23, at 10:21 a.m., with the ADON, Resident 91's CNA documentation titled Documentation Survey Report, dated March 2023 was reviewed. The CNA's ADL-Bathing documentation indicated, between 3/1/23 and 3/26/23 Resident 91 had a shower once on 3/6, 3/9/23, 3/10/23 and 3/15/23. The ADON stated Resident 91 was not showered routinely and should have showered twice a week at a minimum. During a review of Resident 32's admission Record, undated, the admission record indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses which included sequelae of cerebral infarction, protein-calorie malnutrition (poor nutrition caused by not consuming enough protein and calories), muscular dystrophy (genetic diseases that cause progressive weakness and loss of muscle mass), quadriplegia (paralysis of all 4 limbs), and disorder of the skin and subcutaneous tissue ( group of conditions that causes inflammation of your subcutaneous [innermost layer of skin] fat). During a review of Residents 32's Minimum Data Set assessment dated [DATE], indicated Resident 32's Brief Interview of Mental status assessment scored 14 of 15. The BIMS assessment indicated Resident 32 was not cognitively impaired. During a concurrent observation and interview on 3/24/23, at 1:49 p.m., with Resident 32, in Resident 32's room, Resident 32 was lying in bed, dressed. Resident 32 stated, she was used to taking good care of her teeth before she had a stroke and became quadriplegic. Resident 32 stated, ever since I had the stroke, I had to depend on them. Resident 32 became visibly upset and stated she had to ask the staff to help her with oral care and the staff did not provide routine oral care. Resident 32 stated, about 3 weeks ago she had asked a CNA if she would brush her teeth after dinner and the CNA stated she only had time to help her before dinner because of staffing. Resident 32 stated, the CNA brushed her teeth before dinner, so she did not eat dinner because she did not want to go to bed with dirty teeth. During a concurrent interview and record review on 3/27/23, at 10:21 a.m., with the ADON, Resident 59's CNA documentation titled Documentation Survey Report, dated March 2023 was reviewed. The CNA's ADL-Personal Hygiene documentation was reviewed and indicated, Resident 59 was provided personal hygiene once on 3/11/23 and 3/17/23. The ADON stated personal hygiene needed to be performed at least two times per day. During a concurrent interview and record review on 3/27/23, at 10:19 a.m., with the ADON, Resident 32's CNA documentation titled Documentation Survey Report, dated March 2023 was reviewed. The CNA's ADL-Bathing documentation indicated between 3/1/23 and 3/26/23 Resident 32 was showered on 3/17/23. The ADON stated Resident 32 was dependent on staff for care. Resident 32's CNA's ADL-Personal Hygiene documentation was reviewed and indicated, there were two days personal hygiene was only performed one time, 3/2/2 and 3/3/23. The ADON stated personal hygiene should be done twice per day routinely and when the residents request it. During an interview on 3/24/23, at 11:25 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated the facility was supposed to provide a toothbrush, mouth wash and toothpaste for the residents. CNA 3 stated, all residents should receive oral care at least once per day. CNA 3 stated, showers were scheduled at least twice weekly for all residents. During an interview on 3/24/23, at 11:49 a.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated, all residents were scheduled for showers twice per week and should receive two or three showers per week depending on their preferences. CNA 7 stated, residents when the staff is shorthanded, it was difficult to give all residents their showers according to schedule. CNA 7 stated, the staff needed to provide oral care two to three times per day, after meals. CNA 7 stated, I feel like we [CNAs] have not been on top of it [oral care]. CNA 7 stated oral care was especially important for the residents who were on tube feedings. CNA 7 stated, she had noticed some residents do not even have the supplies for oral care available in their room. CNA 7 stated, thestated, the facility provided a toothbrush, toothpaste and mouthwash to residents. During an interview on 3/27/23, at 4:21 p.m., with the Assistant Director of Nursing (ADON), ADON stated the expectation for oral care was the nursing staff would provide oral care two times daily at a minimum. ADON stated, bathing should occur at least twice per week and as needed for resident requests. During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADLs), Supporting, dated March 2018, the P&P indicated, .Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Residents will be provided with care, treatment or services to ensure that their activities of daily living (ADLs) do not diminish . Appropriate care and services for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care .Hygiene (bathing, dressing, grooming, and oral care) .A resident's ability to perform ADLs will be measured using clinical tools, including the MDS .Independent-Resident completed activity with no help or staff oversight at any time during the last 7 days . Supervision-Oversight, encouragement or cueing provided 3 or more times . Limited Assistance-Resident highly involved in activity and received physical help in guided maneuvering of limb(s) . Extensive Assistance-[NAME] resident performed part of activity over the last 7 days, staff provided weight-bearing support . Total Dependence-Full staff performance of an activity with no participation by resident for any aspect of the ADL activity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) were provided to maintain good grooming for two of 10 sampled residents (Resident 1 and Resident 366) when: 1. Resident 1 and Resident 366's fingernails were long with black and brown matter under the fingernails. This failure resulted in Resident 1 and Resident 366's fingernails not being well groomed and the potential for harboring microorganisms (bacteria, virus, or fungus) or infection. 2. Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. This failure resulted in Resident 21's mouth not being clean and the potential for causing oral pain, harboring microorganisms or infection. 3. Facility staff did not provide personal hygiene to ensure Resident 47's fingernails and toenails were short, even, trimmed, and clean at all times, and staff did not trim Resident 47's long facial hair above her upper lip. This failure to provide necessary nail care and appropriate grooming resulted in Resident 47 to have self-inflicted scratches, dirty fingernails, toenails and an unkempt appearance. Findings: 1. During a concurrent observation and interview on 3/22/23, at 9:00 a.m., with Certified Nurse Assistant (CNA) 8, Resident 1 was sitting in her wheelchair outside her room, CNA 8 stated Resident 1 was a total care and requires assistance with Activities of Daily Living (ADLs), including during meals. CNA 8 stated Resident 1's fingernails on both hands were long with black and brown matter under the fingernails. CNA 8 stated CNAs were responsible in keeping resident's fingernails clean at all times. CNA 8 stated the facility failed to keep Resident 1's fingernails clean. CNA 8 stated Resident 1 uses her hands to eat her meals, and the dirty fingernails could cause skin infection and stomach problems such as nausea, vomiting, and diarrhea. CNA 8 stated the facility failed to follow Resident 1's ADL care plan. During a concurrent observation and interview on 3/22/23, at 9:34 a.m., with Licensed Vocational Nurse (LVN) 6, in Resident 366's room, LVN 6 stated Resident 366 was dependent on staff for her ADLs and requires assistance during meals. LVN 6 stated Resident 366's fingernails on both hands were long with black and brown matter under the fingernails. LVN 6 stated Resident 366 was diabetic and licensed nurses were responsible in keeping resident's fingernails clean at all times. LVN 6 stated the facility failed to keep Resident 366's fingernails clean. LVN 6 stated Resident 366's dirty fingernails could cause infection. LVN 6 stated the facility failed to follow Resident 366's ADL care plan. During an interview on 3/22/23, at 9:45 a.m., with LVN 6, LVN 6 stated Resident 1 and Resident 366's dirty fingernails were unacceptable, and a dignity and infection control issue. LVN 6 stated cleaning of Resident 1 and Resident 366's fingernails were part of the Activities of Daily Living (ADLs) care plan. LVN 6 stated Resident 1 and Resident 366 should be treated with kindness, respect, and dignity at all times. During an interview on 3/22/23, at 3:51 p.m., with the Director of Nursing (DON), the DON stated Resident 1 and Resident 366's dirty fingernails were an infection control and dignity issue. The DON stated Resident 1 and Resident 366's ADL care plan was not followed. The DON stated staff should have cleaned Resident 1 and Resident 366's fingernails according to the ADL care plan. The DON stated Resident 1 and Resident 366's dirty fingernails could cause skin infection and stomach problems such as nausea, vomiting, and diarrhea. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/24/23, the AR indicated, Resident 1 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Chronic Obstructive Pulmonary Disease (COPD - is a chronic inflammatory lung disease that causes obstructed airflow of the lungs). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 3/24/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 3 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's ADL Care Plan (CP), dated 3/22/23, the CP indicated, . Focus . I require limited to total assist with one to two-person assistance with most ADLs . Interventions . 1 to 2 staff members to assist with ADLs . Date Initiated: 3/7/22 . During a review of Resident 366's AR, dated 3/22/23, the AR indicated, Resident 366 was admitted from an acute care hospital on 3/14/23 to the facility with diagnoses which included Heart Failure (weakness in the heart where fluid accumulates in the lungs), Cerebral Infarction (stroke), Dysphagia (swallowing difficulty), and Type 2 Diabetes Mellitus Type 2 (a disorder in which blood sugar or glucose levels are abnormally high). During a review of Resident 366's MDS, dated [DATE], the MDS indicated Resident 366's BIMS score was 9 (moderate cognitive impairment) out of 15 . During a review of the facility's P&P titled, Activities of Daily Living (ADLs), dated 3/2018, the P&P indicated, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care . During a review of the facility's P&P titled, Care of Fingernails/Toenails, dated 2/2018, the P&P indicated, . The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . 1. Nail care includes regular cleaning and trimming . 6. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease . During a review of the facility's document titled, Certified Nurse Assistant (CNA) Job Description, dated 11/2016, the document indicated, . Essential Duties and Responsibilities . Promptly assists residents with Activities of Daily Living (ADL) and daily nursing care needs as directed in nursing care plan, including bathing, grooming, dressing, transferring . Will treat residents with respect, dignity, and compassion . During a review of the facility's document titled, Licensed Vocational Nurse (LVN) Job Description, dated 11/2016, the document indicated, . Essential Duties and Responsibilities . Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control . Provide information and instruction to residents and their families in areas such as resident rights . During a review of the Center for Disease Control (CDC) article titled, Nail Hygiene dated 7/15/22, the article indicated, . Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of some infections, such as pinworms. Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, longer fingernails can harbor more dirt and bacteria than short nails, thus potentially contributing to the spread of infection . 2. During a concurrent observation and interview on 3/22/23, at 9:40 a.m., with Licensed Vocational Nurse (LVN) 6, in Resident 21's room. Resident 21 was lying in bed and awake. LVN 6 stated Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. LVN 6 stated Resident 21's oral care should be done every shift and it was not followed. LVN 6 stated licensed and unlicensed personnel were responsible in keeping Resident 21's mouth clean at all times. LVN 6 stated the facility failed to follow Resident 21's ADL care plan. LVN 6 stated Resident 1's poor oral care could cause several issues including pain and oral infection. During an interview on 3/27/23, at 11:00 a.m., with the Director of Nursing (DON), the DON stated Resident 21's poor oral care were an infection control and dignity issue. The DON stated Resident 21's ADL care plan was not followed. The DON stated staff should have cleaned Resident 21's mouth according to the care plan. The DON stated Resident 21's dry lips and mouth could cause pain and mouth infection. The DON stated Resident 21 should be treated with respect and dignity at all times. During a review of Resident 21's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 21 was admitted from an acute care hospital on 1/24/23 to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and Gastrostomy (an artificial external opening into the stomach for nutritional support). During a review of Resident 21's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 1/31/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 3 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 21's ADL Care Plan (CP), dated 3/22/23 , the CP indicated, . Focus . I have a physical functioning deficit in my ADL's related to Dx [diagnosis] of Dementia and its progression . Interventions . Encourage choices with care . Nail care PRN . Date Initiated: 10/28/22 . During a review of the facility's P&P titled, Activities of Daily Living (ADLs), dated 3/2018, the P&P indicated, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care . During a review of the facility's document titled, Certified Nurse Assistant (CNA) Job Description, dated 11/2016, the document indicated, . Essential Duties and Responsibilities . Promptly assists residents with Activities of Daily Living (ADL) and daily nursing care needs as directed in nursing care plan, including bathing, grooming, dressing, transferring . Will treat residents with respect, dignity, and compassion . During a review of the facility's document titled, Licensed Vocational Nurse (LVN) Job Description, dated 11/2016, the document indicated, . Essential Duties and Responsibilities . Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control . Provide information and instruction to residents and their families in areas such as resident rights . 3. During a concurrent observation and interview on 03/21/23, at 12:44 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 47 was observed seated in her wheelchair, in the hallway, in front of the nursing station. Resident 47 was observed dressed in blouse and dark-color short pants (above the knee pants). Resident 47 was observed with many pinpoint scabbed areas and scratch marks on both legs. An open area on the left leg was observed bleeding, in addition to an open area above her right ankle which was pressed against the left metal footrest. LVN 1 stated, She (Resident 47) scratches herself . it is care-planned .I don't know why she is wearing shorts . she should be wearing pants . During a concurrent observation and interview, on 3/21/23 at 1:18 p.m., with the Infection Preventionist (IP, a professional who make sure healthcare workers and patients are doing all the things they should to prevent infections), inside Resident 47's room, Resident 47 was observed eating lunch with her fingers. Resident 47's fingertips and fingernails were observed with dried red and brown-color substances. The IP stated, It's blood . from when [Resident 47] scratched her left leg . which is still bleeding . The IP stated, she will inform the Treatment Nurse (TN) to take care of the new open area on the resident's left leg. During a review of Resident 47's admission RECORD (AR), undated, the AR indicated, Resident 47 was admitted to the facility on [DATE], with diagnosis which included excoriation skin-picking disorder (ESPD, a persistent and compulsive picking of one's skin resulting in skin lesions), pruritus (itching), type 2 diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic neuropathy (nerve damage that can occur in people with diabetes), and dementia (a condition characterized by loss of memory, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 47's Minimum Data Set for Functional Status (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs), dated 3/7/23, indicated, Resident 47 required extensive assistance of one person to get dressed and take off all items of clothing. During a review of Resident 47's MDS - Brief Interview for Mental Status (BIMS, an evaluation of attention, orientation, and memory recall) score of 3 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), which indicated Resident 47 had severe cognitive impairment. During a concurrent observation and interview, on 3/24/23, at 8:11 a.m., with Resident 47, accompanied by the Activity Director (AD), inside Resident 47's bedroom, Resident 47's right hand fingernails was observed with brown, black, and red color substances on the cuticle area and underneath the nails. Resident 47 stated, My fingernails are very dirty, I need scrubbing, I need a brush and help to scrub my fingernails. Resident 47 stated, I still itch, and my legs are painful down there . look at my feet and legs please. Resident 47's legs and feet were observed with many pinpoint and linear open areas consistent with being scratched. Resident 47's left big toenail was observed with long and jagged toenail. The left big toenail length was measured from the crescent top with a paper tape measure, and the length was 0.4 centimeter (cm-unit of measurement). The upper right corner of the nail was broken and jagged (rough and sharp). Resident's right foot was crossed and on top of the left foot. There were areas of 0.1 cm round open areas consistent with having been in contact with the jagged left big toenail. Resident 47's feet were observed to be dry and scaly, and her toenails were long and thick). During a concurrent observation and interview on 3/24/23, at 8:36 a.m., at Resident 47's bedside, with the Director of Nursing (DON), DON stated, The left-hand fingernails (left hand) needs scrubbing, I will let the Certified Nursing Assistant (CNA) know. The DON looked at Resident 47's toenails and stated, I don't know when the podiatrist could come to cut toenails and treat . During an interview, on 3/24/23 at 10:00 a.m., with Social Services Director (SSD) 2, SSD 2 stated, We have a podiatry (medical care and treatment of the human foot) contract, but there is no Podiatrist (a doctor who has special training in diagnosing and treating foot problems) available to come. SSD 2 stated, The last Podiatry visit was on 1/10/23 . Resident 47 was admitted to the facility on [DATE] . but she was not on the Podiatrist's list of residents to visit and treat . I don't know why she was not put in the list . During an interview on 3/24/23, at 10:15 a.m., with the Administrator (ADM) 1, ADM stated, We are in the process of getting a new contract with a Podiatry Group. Our current contract will expire on 3/31/23. During a concurrent observation and interview on 3/24/23, at 12 p.m., with assistant Administrator (AADM) 2, in Resident 47's room, Resident 47 stated, They just cleaned my toes, and it still stings. They cut my toenails and I feel a lot better! Look at it. Resident 47's toenails was observed trimmed and clean. The AADM 2 stated, staff called a Podiatrist who had come and trimmed and treated Resident 47's toenails. During an interview on 3/27/23, at 9:00 a.m., with Certified Nursing Assistant (CNA) 1, regarding standards of practice for daily grooming and hygiene to residents, CNA 1 stated, I don't know the answer to your question . I have to get back to you on that. CNA 1 stated, I have to change them (residents) if they are wet, make sure they are clean . we need to make sure we cut their nails or clean their hands . During a concurrent observation and interview on 3/27/23, at 9:05 a.m., with LVN 1, Resident 47 was observed with long facial hair above her upper lip. LVN 1 stated, Resident [47] has 'whiskers' (long and coarse facial hair in humans and animals) . need to remove them. During an interview on 3/27/23, at 9:10 a.m., with the Director of Staff Development (DSD), the DSD stated she would be giving an in-service to all CNAs regarding care. During a review of the facility Policies and Procedures (P&P) titled, Activities of Daily Living (ADLs), Supporting revision date 3/2018, the P&P indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain .grooming and personal and oral hygiene .with consent of the resident and in accordance with the plan of care, including appropriate assistance with bathing, dressing, grooming . If residents with dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate . During a review of an article titled Nail Hygiene (NH), dated 6/15/22, and retrieved from Centers for Disease Control and Prevention (CDC, a United States National Center for Injury Prevention and Control) website at https://www.cdc.gov/hygiene/personal-hygiene/nails.html, the NH article indicated, Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of some infections. Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, longer fingernails can harbor more dirt and bacteria than short nails, thus potentially contributing to the spread of infection. Before clipping or grooming nails, all equipment (for example, nail clippers and files) should be properly cleaned. Infections of the fingernails or toenails are often characterized by swelling of the surrounding skin, pain in the surrounding area, or thickening of the nail. In some cases, these infections may be serious and need to be treated by a physician. To help prevent the spread of germs and nail infections: Keep nails short and trim them often, Scrub the underside of nails with soap and water (or a nail brush), and clean any nail grooming tools before use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents remained free from accidents and accident hazards as is possible, for one of 12 sampled residents (Resident 47), when: 1. Resident 47 had an unwitnessed fall on 12/9/22, and the facility did not assess Resident 47's risk for falls; did not conduct a change in condition (CIC, a process of evaluation to identify and promptly report and communicate a resident's change of condition to appropriate healthcare personnel), and the interdisciplinary team (IDT, a group of healthcare professionals who work together to assess, develop, implement, and evaluate each resident's treatment plan) did not review or discuss the root cause of Resident 47's fall in order to make recommendations for appropriate resident-centered care plan interventions that could prevent further falls and injuries. This failure resulted in Resident 47 sustaining repeated falls on 2/23/23, 3/19/23, and 3/22/23, Resident 47 experienced pain, bruises and injuries. Findings: 1. During a concurrent observation and interview, on 03/21/23 at 1:18 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 47 was observed seated in her wheelchair, in the hallway, in front of the nursing station. When greeted, Resident 47 pointed at her legs and stated, I fell . my legs hurt. The LVN 1 stated, Resident 47 had unwitnessed falls . During a review of Resident 47's admission RECORD (AR), undated, the AR indicated Resident 47 was admitted to the facility on [DATE], with diagnosis which included generalized muscle weakness, lack of coordination, type 2 diabetes mellitus (a disease in which blood sugar levels are too high) with diabetic neuropathy (nerve damage that can occur in people with diabetes), dementia (a condition characterized by loss of memory, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and adult failure to thrive (AFT, a gradual decline in physical and/or cognitive function of an elderly patient, usually associated with weight loss and other illnesses). During a review of Resident 47's Minimum Data Set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs), Resident 47's MDS Functional Status dated 3/7/23, indicated, Resident 47 required extensive assistance of two or more persons to move and/or, reposition in bed, transfer to and from bed to a chair and the other way around, and to transfer to and from the toilet. Resident 47 also required extensive one-person to get dressed and undressed. Resident 47's MDS - Brief Interview for Mental Status (BIMS)score on 3/22/23, was 3, which indicated, Resident 47 had severely impaired cognitive ability to think, reason, or remember. During a review of Resident 47's Progress Notes dated 12/9/23 at 7:20 a.m., the Progress Notes indicated, Writer was on the hallway passing med (medication) . Resident (47) roommate came out 'my roommate is on the floor' . resident was on the floor face down next to the bed . assessed for any injury, vital signs are stable . grip both hand equal . started neurocheck (an assessment of the level of consciousness, mental status, vital signs, eye movement, arm, and leg movement to detect damage or injury) . The Care Plan initiated on 12/9/22, indicated Goal: Minimize falls and fall-related injuries by 3/28/23 . Interventions: Bed in low position . call light within reach. During a concurrent record review and interview, on 3/24/23 at 8:00 a.m., with the Director of Nursing (DON), the DON stated, that for Resident 47's fall on 12/9/22, a fall risk assessment was not done, a CIC was not completed, and there was no root cause review done by the IDT; and no recommendations for interventions that could prevent repeated falls. During a review of Resident 47's Progress Notes dated 2/23/23 at 1:55 p.m., the Progress Notes indicated, Notified that resident had fallen off bed . resident lying on her right side with blood surrounding her head . performed ROM (Range-of-Motion, refers to evaluating how a person's joints can move without causing pain) . 2 CNA helped resident back to bed . notified MD . order to transfer to hospital .ambulance arrived . resident left with EMS (emergency medical services provide urgent pre-hospital treatment) via gurney (a bed on wheels that is used for moving people who are sick or injured) . also notified hospital resident is COVID positive (COVID, an infectious disease caused by the corona virus). During a concurrent interview and record review, on 3/24/23 at 8:05 a.m., with the DON, of Resident 47's Assessment Outcomes (AO), dated 3/1/23 was reviewed., The DON stated, The IDT had reviewed Resident's 47's 2/23/23 fall upon her readmission to the facility on 3/1/23 . The AO dated 3/1/23, indicated Resident 47's Fall Risk Score was 9.0 - Low Risk for Falls. The Occupational Therapy (OT, a form of therapy that helps individuals maintain or recover the skills needed to do their activities of daily living) dated 3/1/23, indicated, . Due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for falls, further decline in function and mobility. During a review of Resident 47's Progress Notes dated 3/19/23 at 6:02 a.m. the Progress Notes indicated, Unwitnessed fall, found resident lying on side of her bed, assisted back to bed, no apparent injury this time, neuro check initiated . upper lower extremity without c/o pain, good motor strength lower and upper extremity but unable to bear weight on her feet . MD notified. The CP initiated on 3/19/23, indicated Goal: Minimize falls and fall-related injuries by 3/28/23 . Interventions: Follow up with labs (laboratory), monitor, refer to therapy as indicated. During a review of Resident 47's Progress Notes dated 3/22/23 at 8:15 a.m. the Progress Notes indicated, Resident is on Alert Charting due to S/P fall approximately 8 am . was assisted back to bed . evaluated resident . responsive and pupils and vitals WNL (within normal limits) . on neuro checks and besides the agitation for coffee, [NAME] (spelled incorrectly) checks have all been within normal limits. The CP initiated on 3/19/23, indicated Goal: Minimize falls and fall-related injuries by 3/28/23 . Interventions: Bedside floor mat (right side), medication regimen review, monitor for delayed injuries and neurochecks for 72 hours. During an observation and interview on 3/24/23 at 8:11 a.m., with Resident 47, Resident 47 was observed with a fading yellow-tinge, green and purple bruise from the middle temple down to the resident's left cheek. Resident 47 touched her forehead and stated, It does not hurt. During an interview on 3/24/23 at 2:11 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, If IDT, RCA, recommendations are not done, we won't be able to formulate a resident-centered care plan interventions to prevent the residents' repeated falls. During a concurrent record review and interview, on 3/24/23 at 3:20 p.m., with the [NAME] President of Clinical Services (VPCS), the VPCS stated, There was no care plan for Resident 47's fall on 2/23/23, and the care plans for 3/19/23 and 3/22/23 had to be upgraded with resident-specific interventions to prevent repeated falls . During a review of the facility document titled, FALL IDT REVIEW (FIR), undated, the FIR indicated, the following action items the IDT would be reviewing after a Fall: Resident Name, Event, Status Prior to Event, POTTY (toilet use), PAIN, POSITION, PERSONAL ITEMS, PHYSICAL ENVIRONMENT, Risk Factors, IDT Discussion Points, Root Cause Analysis (Witness/Where/Why), INTERVENTIONS, IDT attendees. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing (FFRM), revision date 3/2018, the FFRM indicated, Based on evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls . During a review of an online brochure published by the Centers for Disease Control and Prevention (CDC, a United States National Center for Injury Prevention and Control), dated 4/2015, retrieved from https//www.cdc.gov/_falls_in_older_patients_provider_pocket_guide_2015-04-a.pdf, the brochure indicated, Key Steps for Fall Prevention: 1. Be proactive, ask all patients 65+ if they've fallen in the past year, 2. Identify & address fall risk factors such as lower body weakness, gait and balance problems, psychoactive medications, postural dizziness, poor vision, and problems with feet and/or shoes, 3. Refer as needed to specialists .Key Fall Interventions: Educate patient, Enhance strength & balance, Modify medications, Manage hypotension, Supplement vitamin D, Address foot problems, Optimize vision, Optimize home safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met for one of four sampled residents (Resident 10) when Resident 10 did not have documentation of completed post-dialysis assessments of access sites (site used for dialysis) and monitoring for complications on multiple dates. This failure placed Resident 10 at risk for delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through the blood vessel) access sites. Findings: During a concurrent observation and interview on 3/22/23, at 9:15 a.m., in Resident 10's room, Resident 10 was observed seated up in bed eating and dressed appropriately for the weather. Resident 10 stated she goes to dialysis in Fresno and she gets picked up by a transport company. During a record review of Resident 10's, admission Record, undated, indicated, Resident 10 was re-admitted on [DATE], with a diagnosis that include End-Stage kidney disease (final permanent stage of kidney disease when kidneys no longer function, needing dialysis). During a concurrent interview and record review on 3/22/23, at 9:50 a.m., with Licensed Vocational Nurse (LVN) 5, she stated Resident 10 goes to dialysis three times a week and the licensed nurse on-duty was responsible to fill out the dialysis communication form. LVN 5 stated the licensed nurse was responsible in assessing resident upon return from dialysis, complete the dialysis communication form and contact the dialysis center if the nurse did not complete the assessment in the dialysis communication form. LVN 5 stated the incomplete dialysis communication forms were noted on the following dates: 1/10/23, 1/24/23, 1/25/23, 2/18/23, 2/23/23, 2/25/23, 2/28/23, 3/2/23, 3/4/23, 3/11/23, 3/16/23 and 3/21/23. During a concurrent interview and record review on 3/24/23, at 8:25 a.m., with Medical Records (MR), she stated she was responsible in auditing the dialysis communication forms. MR stated she checked all the resident dialysis binders to make sure the dialysis communication forms are completed for all the dialysis residents. MR reviewed Resident 10's dialysis communication forms for 1/10/23, 1/24/23, 1/25/23, 2/18/23, 2/23/23, 2/25/23, 2/28/23, 3/2/23, 3/4/23, 3/11/23, 3/16/23 and 3/21/23 and MR she stated they are incomplete and should have been completed. During an interview on 3/27/23, at 3:54 a.m., with the Assistant Director of Nursing (ADON), she stated the expectation was for licensed nurse to make sure dialysis communication forms to be completed and filed in residents charts. ADON stated licensed nurse are responsible in following up with the dialysis center for incomplete dialysis communication forms assessment. During a review of the facility's policy and procedure (P&P) titled, Dialysis (Renal), Pre and Post Care, dated 5/07, the P&P indicated, . Assess resident's blood pressure (in non-shunt arm) prior to being transported to the dialysis unit . Any concerns about resident's condition that may influence the dialysis treatment should be addressed prior to leaving skilled facility . Dialysis access should be assessed upon return to the facility for patency, and any unusual redness or swelling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 3/21/23, at 10:50 a.m., with Resident 366, in Resident 366's room, Resident 366 was resting in bed with two half bed rails raised up. Resident 366 stated, I don't know why I have a side rails. During a concurrent observation and interview on 3/21/23, at 11:30 p.m., with Certified Nursing Assistant (CNA) 9, in Resident 366's room, CNA 9 stated, she was the CNA for Resident 366 and has taken care of Resident 366 before. CNA 9 stated, Resident 366 had bed rails up on both sides of the bed. CNA 9 stated, Resident 366 was alert with confusion and needs moderate to extensive assistance from staff. During a concurrent interview and record review, on 3/21/23, at 11:35 a.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 stated, she was the nurse for Resident 366. LVN 6 stated, Resident 366 had two bed rails up. LVN 6 stated, there has to be an order, assessment, care plan and a consent from the resident or responsible party to use bed rails. LVN 6 reviewed Resident 366's clinical record and stated she was not able to find an order to use the bed rails. LVN 6 stated, she did not find an assessment, no consent, and no care plan for the bed rails. LVN 6 stated, there should have been an order, bed rail assessment, consent and a care plan prior to the bed rails installed in Resident 366's bed because bed rails were considered restraints. During a concurrent interview and record review, on 3/24/23, at 8:53 a.m., with Minimum Data Set Nurse (MDSN), MDSN stated, side rails are used for mobility and repositioning. MDSN stated, prior to installing the bed rails, a licensed staff will conduct a screening for appropriate use of bed rails, obtain a bed rail consent from the resident or the responsible party, notify the medical doctor to get an order, initiate a care plan then installed the side rails. MDSN reviewed Resident 366's electronic clinical record and stated she did not find an order to use the bed rails, no side rails assessment found, no signed consent found and no care plan found. MDSN stated, the facility did not follow the process prior to installing Resident 366's bed rails. During an interview on 3/27/23, at 10:25 a.m., with the Acting Director of Nursing (DON), DON stated, the facility has a policy and procedure (P&P) related to use of bed rails for facility residents. DON stated, the facility did not follow the P&P for Resident 366's use of bed rails. DON stated, there should have been a doctor's order for the use of the side rails, completed bed rail assessment, signed consent and care plan prior to installing the bed rails. DON stated, without the bedrails assessment, Resident 366's was placed at risk for entrapment, injury, or serious harm. During a review of Resident 366's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 366 was admitted from an acute care hospital on 3/14/23 to the facility with diagnoses which included Heart Failure (weakness in the heart where fluid accumulates in the lungs), Cerebral Infarction (stroke), Dysphagia (swallowing difficulty), and Type 2 Diabetes Mellitus Type 2 (a disorder in which blood sugar or glucose levels are abnormally high). During a review of Resident 366's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 366's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 9 out of 15 indicating moderate cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a review of facility's policy and procedure (P&P) titled, Bed Safety, undated, the P&P indicated, . To try to prevent deaths/injuries from the beds and related equipment . Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; Review that gaps within the bed system are within the dimensions established by the FDA (Food and Drug Administration) . The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use . Side rails may be used if assessment and consultation with the attending physician has determined that they are needed . the staff shall inform the resident and family about the benefits and potential hazards associated with side rails . During a review of professional reference from the FDA- Food and Drug Administration, titled A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-care-facts dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet . Based on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 212 and Resident 366) were assessed for bed rail risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed) prior to bed rail installation. Facility failed to obtain informed consent (form signed by resident or family explaining the risks of side rail use), physician order with indication for use, and care plan prior to the use of bed rails when Resident 212 and 366 had two raised upper bed rails. This failure had the potential to place Resident 212 and Resident 366 at risk for decreased freedom of movement, entrapment and/or injury. Findings: 1. During a concurrent observation and interview on 3/21/23, at 9:12 a.m., with Resident 212, in Resident 212's room, Resident 212 was laying in bed with two half bed rails raised up. Resident 212 stated she used the bed rails for positioning and turning. Resident 212 stated she did not remember signing a consent to use the bed rails. Resident 212 stated she did not remember any of the staff explained to her the risks and benefits of using the bed rails. During a review of Resident 212's, admission Record, undated, the admission record indicated, Resident 212 was admitted to the facility on [DATE] with diagnoses which included Malignant neoplasm of right female breast (cancer that can spread into or invade nearby tissues), morbid (severe) obesity and pain in right knee. During a review of Resident 212's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 212's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 indicating cognitively intact (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During an interview on 3/23/23, at 1:45 p.m., with Certified Nursing Assistant (CNA) 2, she stated she is the CNA for Resident 212 and had taken care of Resident 212 before. CNA 2 stated Resident 212 had bed rails up on both sides of the bed. During a concurrent interview and record review on 3/23/23, at 1:57 p.m., with Licensed Vocational Nurse (LVN) 3, he stated he was the nurse for Resident 212. LVN 3 stated Resident 212 had two bed rails up. LVN 3 stated there has to be an order, assessment, care plan and a consent from the resident or responsible party to use bed rails. LVN 3 reviewed Resident 212's clinical record and stated he was not able to find an order to use the bed rails. LVN 3 stated he did not find an assessment, no consent and no care plan for the bed rails. LVN 3 stated there should have been an order, bed rail assessment, consent and a care plan prior to the bed rails installed in Resident 212's bed because bed rails are considered restraints. During a concurrent interview and record review on 3/23/23, at 2:15 p.m., with LVN 5 and Minimum Data Set Nurse (MDSN), LVN 5 and MDSN stated side rails are used for mobility and repositioning. MDSN stated prior to installing the bed rails, therapy need to screen for appropriateness of the bed rails, side rails assessment, bed rail consent signed by resident or the responsible party, notify the medical doctor to get an order, initiate a care plan then the side rails was installed. LVN 5 and MDSN reviewed Resident 212's electronic clinical record and stated they did not find an order to use the bed rails, no side rails assessment found, no signed consent found and no care plan found. LVN 5 stated she did not find nursing documentation when the bed rails were installed and why the bed rails were installed. LVN 5 and MDSN stated the facility did not follow the process prior to installing the bed rails on Resident 212. During a concurrent observation and interview on 3/23/23, at 2:36 p.m., with the Maintenance Supervisor (MS), he inspected the bed rails of Resident 212 and stated Resident 212's bed rails are one half rails. The MS stated he installed the bed rails on Resident 212 but did not recall the date when it was installed. MS stated he remembered one of the nurse asked him to install the bed rails and the type of bed rails to install but did not recall who the nurse was. During an interview on 3/23/23, at 4: 15 p.m., with the Assistant Director of Nursing (ADON), she stated the facility had a process to follow to use a bed rails. ADON stated the facility did not follow the process for Resident 212's use of bed rails. The ADON stated there should have been a doctors order for the use of the side rails, bed rail assessment, signed consent and care plan prior to installing the bed rails. During a review of facility's policy and procedure (P&P) titled, Bed Safety, undated, the P&P indicated, . To try to prevent deaths/injuries from the beds and related equipment Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; Review that gaps within the bed system are within the dimensions established by the FDA (Food and Drug Administration) . The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use . Side rails may be used if assessment and consultation with the attending physician has determined that they are needed . the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. During a review of professional reference from the FDA- Food and Drug Administration, titled A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-care-facts dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: King-Rabetsimba, Nic Surveyor: [NAME], [NAME] Based interview and record review the facility failed to periodically and accurately reconcile controlled substances (CS-medication which can be easily abused and under strict government control) when nursing staff did not ensure accurate controlled substance accountability for two of three resident's CS records (Resident 75 and 211). This failure had the potential for Resident 75 and 211 not to be adequately treated for their pain and had a potential for diversion (used illegally) of controlled substance medication. Findings: During a review of Resident 211's Face Sheet (FS- a documented containing resident's personal information), dated 3/23/23, the FS indicated Resident 211 was , admitted [DATE]. The FS indicated, diagnosis Partial traumatic amputation (at least half the diameter of the injured extremity is severed at level between right hip and knee) .Encounter for orthopedic aftercare following surgical amputation. During a review of Resident 211's Order Summary Report (ORS), dated 2/9/23, the ORS indicated, Hydrocodone-Acetaminophen (pain medication to treat moderate to severe pain) Oral Tablet 5-325 MG [milligrams- measured dose] (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for moderate-severe pain (4-9/10) for 14 days .start date 2/9/23 .end date 2/23/23. During a review of Resident 211's ORS, dated 3/14/23, the ORS indicated, [hydrocodone-acetaminophen] Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain-Moderate for 14 days .start date 3/14/23 .end date 3/28/23. During a review of Resident 211's-controlled drug record count sheets (CDRCS), dated 2/10/23 and 3/20/23, the CDRCS indicated, hydrocodone-acetaminophen 5-325 mg dated 2/10/23 (Rx 3864857) and 3/20/23 (Rx 521315) had documentation of administration of a total of 8 tablets of hydrocodone-acetaminophen 5-325 mg from 3/9/23-3/21/23. The CDRCS indicated, administration dates of 3/9/23 at 4 p.m., 3/10/23 at 8:35 a.m., 3/13/23 at 8:30 a.m., 3/14/23 at 8:30 a.m., 3/15/23 at 8:30 a.m., 3/19/23 at 1:12 p.m., 3/20/23 at 4 p.m. and 3/21/23 at 6:30 p.m. During a review of Resident 211's Medication Administration Record (MAR), dated 3/1/23-3/31/23, the MAR indicated, no documentation for 3/20/23 administration of 5-325 mg hydrocodone-acetaminophen as indicated on the controlled drug record count sheet. During a review of Resident 75's FS, dated 9/17/22, the FS indicated, Resident 75 was , admitted [DATE]. The FS indicated diagnosis including , Age-related osteoporosis (bone loss), Foot drop (difficulty lifting the foot). During a review of Resident 75's ORS, dated 9/17/22, the ORS indicated, Hydrocodone-Acetaminophen Tablet 10-325 MG Give 1 tablet by mouth every 8 hours as needed for Moderate pain (4-7/10). During a review of Resident 75's CDRCS, dated 9/17/22 and 10/30/22, the CDRCS indicated, hydrocodone-acetaminophen 10-325 mg dated 9/17/22 (Rx 12814145) and 10/30/22 (Rx 12815194) had documentation of administration of a total of 11 tablets administered for 11/1-11/30/22. The CDRCS indicated administration dates of 11/2/22 at 4:36 p.m., 11/8/22 at 3:38 p.m., 11/14/22 at 4:53 p.m., 11/16/22 at 8:15 p.m., 11/18/22 8:20 p.m., 11/22/22 (x3 5:19 a.m., 4:45 p.m., 11:37 p.m.), 11/24/22 at 8 a.m., 11/26/22 at 7:12 p.m., 11/27/22 at 10 p.m. During a review of Resident 75's MAR, dated 11/1/22-11/30/22, the MAR indicated, no documentation for 11/24/22 administration of hydrocodone-acetaminophen as indicated on the controlled drug record count sheet. During a concurrent record review and interview on 3/22/23, at 2:40 p.m., with Licensed Vocational Nurse (LVN) 11 Resident 211 and 75's CDRC was reviewed. LVN 11 stated, the process for controlled drugs is for licensed staff to count control medications at the beginning of each shift to verify amount. During an interview on 3/23/23, at 8:51 a.m , with Interim Director of Nursing (IDON), the IDON stated reconciliation for control drugs should be done monthly when received. IDON stated, an audit should be done for controlled substances because there could be diversion (illegal distribution) and patients not receiving medication as ordered by a physician. IDON stated, there is no current system in place to accurately reconcile controlled drugs. During an interview on 3/27/23, at 10:30 a.m , with Pharmacist Consultant (PC), the PC stated it is important to have a reconciliation system in place to make sure residents are getting the medication appropriately. The PC stated, if there is no documentation on the MAR the resident may not be getting appropriate pain management. The PC stated, it is important for staff to accurately reconcile, if there is a discrepancy the facility will complete a thorough investigation of staff. During an interview on 3/27/23, at 1:30 p.m , with Assistant Director of Nursing (ADON), the ADON stated it is important to have a system in place to audit and track controlled drugs to keep accurate count. ADON stated, the expectation for nursing staff is to count control drugs in the beginning of shift and shift change. ADON stated, the staff sign once the controlled medication has been administered and should be entered into the MAR. The ADON stated there is a risk of uncontrolled pain if the resident does not get medication they need. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, dated 4/2019, the P&P indicated, .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .9. Upon Receipt:. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) The name of the resident receiving the medication .(5) quantity of the medication remaining .(6) signature of nurse administering medication .Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately .c. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator .d. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal action is indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 4, 73, 99, 261) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behaviors) medications including quetiapine (antipsychotic medication),olanzapine (antipsychotic medication for bipolar disorder, depression, and schizophrenia) and escitalopram(an antidepressant medication for depression, alcoholism, and schizophrenia) when: 1. Resident 73 was administered olanzapine with no resident specific non-pharmacological interventions were implemented prior to and during use of olanzapine, and no annual gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose of if the dose or medication can be discontinued) was attempted. 2. Resident 99 was administered quetiapine without an appropriate indication and/or clinical justification, no documentation of behaviors to support the use of quetiapine, no resident-specified non-pharmacological interventions were implemented prior to and during use of quetiapine, and manufacturer specified monitoring was not done during use of quetiapine. 3. Resident 4 was administered quetiapine without an appropriate indication and/or clinical justification, no documentation of behaviors to support the use of Seroquel, no resident-specified non-pharmacological interventions were implemented prior to and during use of quetiapine, and manufacturer specified monitoring was not done during use of quetiapine. 4. Resident 261 was administered quetiapine without an appropriate indication and/or clinical justification, no resident specified non-pharmacological interventions were implemented prior to and during use of quetiapine, manufacturer specified monitoring were not done during use of quetiapinel, and no annual GDR was attempted or resident clinical rationale for continuing the quetiapine and escitalopram medication. These failures resulted in unnecessary medications for Resident 73, 99, 4 and 261, which had the potential for medication interactions, adverse reactions and unidentified risks associated with the use of psychotropic medications that included but limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: 1. During a review of Resident 73's Face Sheet (FS-a documented containing resident's personal information), dated 3/23/23, the FS indicated Resident 73 admission date was 3/30/21 and readmitted on [DATE]. The FS indicated, diagnoses included Type 2 diabetes mellitus with diabetic chronic kidney disease (high blood sugar with decrease kidney function), schizophrenia, unspecified (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality and relates to others), major depressive disorder unspecified (depressed mood, loss of interest), and anxiety disorder (persistent worry and fear). During a review of Resident 73's Order Summary Report (OSR), dated 1/1/22-3/24/23, the OSR indicated, Olanzapine Tablet 5 [MG-milligram, a dosage measurement] Give 0.5 tablet [2.5 MG] by mouth two times a day related to SCHIZOPHRENIA, UNSPECIFIED M/B striking out at staff during ADLs care, putting self and others at risk for injury .dated 1/6/22 .Olanzapine Tablet 5 MG Give 1 tablet by mouth two times a day related to SCHIZOPHRENIA UNSPECIFIED .dated 2/4/22 .Olanzapine Tablet 5 MG Give 1 tablet by mouth two times a day related to SCHIZOPHRENIA UNSPECIFIED .dated 2/4/22 .(Seroquel) Quetiapine Give 1 tablet by mouth two times a day related to SCHIXOPHRENIA, UNSPECIFIED M/B angry/aggressive beahvior stiking out at staff duirng ADLs care, putting self and others at risk for injury .2/9/22 .Olanzapine Tablet 5 MG Give 1 tablet by mouth two times a day related to SCHIZOPHRENIA, UNSPECIFIED .dated 6/10/22. During a concurrent record review and interview on 3/23/23, at 10:51 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 73's Medical Administrative Record (MAR), dated 3/1/23-3/31/23 was reviewed. The MAR indicated, Olanzapine Tablet 5 MG Give 1 tablet by mouth two times a day related . The LVN stated, non-pharmacological interventions for [olanzapine are 1:1, Activity, adjust room temperature, back rub, change position. LVN 7 stated, the Resident 73's non-pharmacological interventions for olanzapine were general. LVN 7 stated it was important to have resident specific non-pharmacological interventions because they fit the needs of the residents, and could be used to lower dose of psychotropic medication. During a concurrent record review and interview on 3/23/23, at 1:45 P.M., with LVN 7, Resident 73's clinical record was reviewed. LVN 7 stated, he was unable to find a GDR attempt. During a concurrent record review and interview on 3/23/23, at 1:59 P.M., with Medical Records Clerk (MRC), Resident 73's OSR and Interdisciplinary Team (IDT-a team of health care workers from multiple disciplines) notes dated 6/10/22 to 3/23/23 was reviewed. MRC stated, she was unable to find any GDR attempt. During a concurrent record review and interview on 3/24/23, at 11:24 A.M, with Minimum Data Set Nurse (MDSN), Resident 73's Progress Note (PN), dated 2/4/22 was reviewed. MDSN stated, IDT note indicates Resident currently on Olanzapine 2.5 mg BID which was started 12/29/21. MD increased to Olanzapine tablet 5 MG .Continue to redirect resident as much as possible. IDT team reviewed and in agreement, continue to monitor. MDSN stated, no GDR was recommended. During a review of Resident 73's MAR, dated 1/1/23-3/31/23, the MAR indicated no behaviors of striking out at staff during ADLs care, putting self and others at risk for injury were documented. During an interview on 3/27/23, at 10:30 A.M., with Consultant Pharmacist (CP), CP stated, residents should have resident specific non-pharmacological interventions for behavior for psychotropic medications. CP stated, resident specific non-pharmacological interventions accommodate the needs of each resident and are specific to help that individual patient. CP stated, if resident specific non-pharmacological interventions work then resident may not need to be on medication. CP stated, it is important to monitor Thyroid Stimulating Hormone (TSH-stimulates the release of thyroid hormone) and labs to make sure there is no adverse effect from the medication. CP stated, it is expected residents receive a GDR annually to make sure residents are on the minimal effective dose. During an interview on 3/27/23, at 1:30 P.M., with Assistant Director of Nursing (ADON), stated it is important to have resident specific non-pharmacological interventions to see what is effective for residents' behaviors. ADON stated, implementing measures could support possibility for a GDR. ADON stated, psychotropics have more effects for elderly residents, like tardive dyskinesia [uncontrolled, abnormal, repetitive movements caused by long-term use of psychiatric drugs]. ADON stated, residents should be getting GDRs because they are at high risk of developing side effects. During a review of Dailymed.nlm.nih.gov, the manufacture for olanzapine indicated warnings and precautions for olanzapine, tardive dyskinesia .a syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs .the risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment .to the patient increase . During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2022, the P&P indicated, . Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident signs and symptoms in order to identify underlying causes .10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible .11. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications . 2. During a review of Resident 99 Face Sheet (FS), dated 3/23/23, the FS indicated Resident 99 was admitted [DATE], diagnoses included unspecified psychosis not due to a substance or known physiological condition (not specified mental condition where thoughts and emotions is lost with external reality), and dementia (group of thinking and social symptoms that interferes with daily functioning including memory loss). During a review of Resident 99's Order Summary Report (OSR), dated 3/23/23, the OSR indicated, QuetiapineFumarate Tablet 25 [MG-milligrams unit of dosage] Give 1 tablet by mouth in the evening related to UNSPECIFIED PSYCHOSIS (mental condition) NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION [manifested by] episodes of agitation, putting self and others at risk for injury .start date 9/10/22. During a review of Resident 99's Hospital Discharge Summary (HDS), dated 9/9/22, the HDS indicated, Do not administer these medications until re-evaluated by a provider at the next level of care .Quetiapine 25 mg Tab (Seroquel) 25 mg=1 tab, QPM (every night)[for] 30 days. The HDS indicated, Problems: hypertension, dementia .mental status: Alert, Confused. A diagnosis of psychosis was not documented on HDS. During a review of Resident 99's Minimum Data Set (MDS-a care area assessment and screening tool), dated 9/16/22, the MDS indicated resident's Section-I Active Diagnosis .Psychiatric/Mood Disorder (mental health condition affecting mood thinking and behavior) . Psychotic Disorder (other than schizophrenia) (mental disorder characterized by a disconnect with reality). During a concurrent record review and interview on 3/23/23, at 3:45 p.m., with Minimum Data Set Nurse (MDSN), Resident 99's clinical record, Medication Administration Record (MAR) dated 9/1/22-11/30/22 and current MAR dated 3/1/23-3/31/23 was reviewed. MDSN stated, no behaviors (episodes of psychosis m/b agitation, putting self and others at risk for injury) were documented. MDSN stated, she was unable to find documentation on behaviors of agitation in Resident 99's clinical records. During a concurrent record review and interview on 3/23/23, at 3:50 p.m., with MDSN, Resident 99's HDS, dated 9/9/22 was reviewed. MDSN stated, there was no diagnosis of psychosis in discharge summary orders from the hospital. MDSN stated, she was not sure where the diagnosis of psychosis came from. MDSN stated, it is important for resident to have an accurate diagnosis in order to be treated appropriately. MDSN stated, the facility needs to make sure they do not provide unneeded medication and put residents at harm for side effects of psychotropic medication. MDSN stated, we need to prevent them from having harm. During a concurrent record review and interview on 3/23/23, at 4:00 p.m , with MDSN, Resident 99's Clinical Record (CR)dated 9/9/22-3/23/23 was reviewed. MDSN stated, Thyroid Stimulating Hormone (TSH- stimulates the release of thyroid hormone) was not being monitored and no eye exam had been performed for Resident 99. During a concurrent record review and interview on 3/24/23, at 4:30 p.m., with Medical Records Clerk (MRC), Resident 99's MAR dated 9/1/22-11/30/22 and current MAR dated 3/1/23-3/31/23 was reviewed. The MRC stated, Resident 99's MAR indicated, there were no non-pharmacological interventions documented. MRC stated, there were no resident specific non-pharmacological interventions for quetiapine because there was no physicians order for non-pharmacological interventions for quetiapine. During an interview on 3/27/23, at 10:30 a.m., with Consultant Pharmacist (CP), CP stated, there should be documentation of monitored behaviors when there is an indication for psychotropic medication. CP stated, it is important to document behaviors to ensure the medication that is given is helping or not. CP stated, residents should have resident specific non-pharmacological interventions for behavior for psychotropic medications. CP stated, resident specific non-pharmacological interventions cater to the resident and are specific to help that individual patient. CP stated, if resident specific non-pharmacological interventions work then resident will not need to be on medication. CP stated it is important to monitor TSH and labs to make sure there is no adverse effect from the medication. During an interview on 3/27/23, at 1:30 p.m , with Assistant Director of Nursing (ADON), ADON stated, it is important to document resident behaviors who are on psychotropic medication to make sure the medication is effective. ADON stated, it is not appropriate for a resident to be on psychotropic medication if they do not have behaviors, if there is no history of behaviors, why would a resident be on medication for a diagnosis they do not have. ADON stated, it is important to have resident specific non-pharmacological interventions to see what is effective for residents' behaviors. ADON stated, implementing measures could support possibility for a GDR. ADON stated, it is important to follow manufacturer guidelines and monitor TSH due to effects of medication to resident thyroid. ADON stated, if not monitored residents may have abnormal labs. ADON stated, psychotropics have more effects for elderly residents, like tardive dyskinesia [uncontrolled, abnormal, repetitive movements caused by long-term use of psychiatric drugs]. During a review of Lexicomp, a nationally recognized drug database, the manufacturer for quetiapine [brand name] indicated, monitoring parameters blood chemistries (electrolytes, renal function, liver functions, TSH) annually . Obtain lens exam at start of therapy and then every 6 months. During a review of Lexicomp, the manufacture for quetiapine [brand name] indicated a black box warning for quetiapine [brand name], Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. During a review of Dailymed.nlm.nih.gov, the manufacture for quetiapine indicated warnings and precautions for quetiapine, tardive dyskinesia .a syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs .the risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment .to the patient increase. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2022, the P&P indicated, . Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident signs and symptoms in order to identify underlying causes .10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible .11. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications . 3. During a review of Resident 4's Face Sheet (FS), dated 3/23/23, the FS indicated Resident 4 was, admitted on [DATE]. The FS indicated, diagnosis including alzheimer's Disease (disease that causes memory loss), dysphagia (difficulty swallowing), dementia, and unspecified psychosis not due to a substance or known physiological condition. During a review of Resident 4's Order Summary Report (OSR), dated 3/23/23, the OSR indicated, . Quetiapine Oral Tablet 50 MG[MG-milligram, a dosage measurement] Give 1 tablet by mouth two times a day related to unspecified psychosis not due to a substance or known physiological condition [manifested by]continuous yelling causing impairment in functional capacity .start date 1/23/23. During a review of Resident 4's Minimum Data Set (MDS), dated [DATE], the MDS indicated, Section E-Behavior .E0100 Potential Indicator of Psychosis .None of the above .E0200 Behavioral Symptoms-Presence & Frequency .Behaviors not exhibited . Section I-Active Diagnosis: Psychotic Disorder (other than schizophrenia). During an interview on 3/23/23, at 1:52 p.m., with Licensed Vocational Nurse (LVN 7), LVN 7 stated quetiapine medication was for residents' psychosis for yelling, LVN stated resident yelled and was non-compliant at times. During a concurrent record review and interview on 3/23/23 at 2:05 p.m., with LVN 7, Resident 4's Medication Administration Record (MAR) dated 3/1/23-3/31/23 was reviewed. LVN 7 reviewed resident's non-pharmacological interventions for Seroquel. LVN 7 stated the non-pharmacological interventions included 1:1, Activity, Adjust room temperature, Backrub, Change position, Give fluids. LVN 7 stated, the non-pharmacological interventions are general and are not resident specific. LVN 7 state,d it is important to have resident specific non-pharmacological interventions because they fit the needs of the residents and are useful to help find what is effective in targeting specific needs and could be used to lower dose of medication. During a concurrent record review and interview on 3/23/23 at 2:10 p.m , with LVN 7, Resident 4's Clinical Record (CR) dated 3/26/21-3/23/23 was reviewed. LVN 7 stated, there were no Thyroid Stimulating Hormone (TSH- stimulates the release of thyroid hormone) lab results and no order to monitor TSH. LVN 7 stated, it is important to order labs to prevent physiological abnormalities due to medication side effects. LVN 7 stated, the medication could potentially harm the residents. LVN 7 stated, this medication has black box warning indicating this medication increases mortality in elderly with dementia related to psychosis. LVN 7 stated, this resident has a diagnosis of dementia. During a concurrent record review and interview on 3/24/23 at 11:01 a.m., with Minimum Data Set Nurse (MDSN), Resident 4's Discharge Summary (DS), dated 2/26/21 was reviewed. MDSN stated, psychosis diagnosis came from the hospice medication orders. MDSN stated, antipsychotic medication was not appropriate for residents with dementia and alzheimer's. MDSN stated, verified Seroquel has a black box warning and residents who have dementia have an increase mortality with this medication, increase death, suicide thoughts and behaviors. During a concurrent record review and interview on 3/24/23 at 11:05 a.m , with MDSN, Resident 4's clinical record, MAR, dated 3/1/21-3/31/21, and 1/1/23-3/31/23 were reviewed. The MDSN stated, there were no behaviors (continuous yelling causing impairment in functional capacity) documented. The MDSN stated, there was no evidence or documentation of resident yelling in Resident 4's clinical records when she was admitted [DATE]. During a concurrent record review and interview on 3/24/23 at 11:08 a.m., with MDSN, Resident 4's Interdisciplinary Team (IDT-a team of health care workers from multiple disciplines) note, dated 6/10/21 was reviewed. The IDT note indicated, IDT team met to review residents' psychotropic medications. Resident currently on Seroquel 100 mg once a day and 200 mg at bedtime for Behavior: continuous yelling causing impairment in functional capacity .writer called [name of hospice provider] and spoke with [Registered Nurse] on 6/9/21. Reviewed psychotropic medication. Stated Seroquel was started due to resident being irritable, irrational and having SI (suicidal ideation-thinking about or planning suicide) thoughts. Stated since she was admitted , she has noticed drastic change in resident .IDT reviewed medication. During an interview on 3/27/23, at 10:30 a.m , with Consultant Pharmacist (CP), CP stated there should be documentation of monitored behaviors when there is an indication for psychotropic medication. It is important to document behaviors to ensure the medication that is given is helping or not. CP stated, residents should have resident specific non-pharmacological interventions for behavior for psychotropic medications. CP stated resident specific non-pharmacological interventions accommodate resident needs and are used to help that individual patient. CP stated if resident specific non-pharmacological interventions work then resident will not need to be on medication. CP stated it is important to monitor TSH and labs to make sure there is no adverse effect from the medication. During an interview on 3/27/23, at 1:30 p.m , with Assistant Director of Nursing (ADON), stated it is important to document resident behaviors who are on psychotropic medication to make sure the medication is effective. ADON stated, it is not appropriate for a resident to be on psychotropic medication if they do not have behaviors, if there is no history of behaviors, why would a resident be on medication for a diagnosis they do not have. The ADON stated, it is important to have resident specific non-pharmacological interventions to see what is effective for residents' behaviors. ADON stated, implementing measures could support possibility for a GDR. ADON stated, it is important to follow manufacturer guidelines and monitor TSH due to effects of medication to resident thyroid. ADON stated if not monitored residents may have abnormal labs. ADON stated psychotropics have more effects for elderly residents, like tardive dyskinesia[uncontrolled, abnormal, repetitive movements caused by long-term use of psychiatric drugs]. During a review of Dailymed.nlm.nih.gov, the manufacture for quetiapine indicated warnings and precautions for quetiapine, tardive dyskinesia .a syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs .the risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment .to the patient increase. During a review of Lexicomp, a nationally recognized drug database, the manufacturer for quetiapine [brand name] indicated, monitoring parameters blood chemistries (electrolytes, renal function, liver functions, TSH) annually . Obtain lens exam at start of therapy and then every 6 months. During a review of Lexicomp, the manufacture for Seroquel indicated a black box warning for quetiapine [brand name], Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2022, the P&P indicated, . Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident signs and symptoms in order to identify underlying causes .10. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible .11. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications . 4. During a review of Resident 261's Face Sheet (FS), dated 3/23/23, the FS indicated, Resident 261 was , admitted on [DATE]. The FS indicated, diagnosis including aphasia following unspecified cerebrovascular disease (lack of blood flow to the brain, which results in the inability to express and understand written and spoken language), major depressive disorder, anxiety disorder and schizophrenia, unspecified psychosis(chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality and relates to others). During a review of Resident 261's Order Summary Report (OSR), dated 3/23/23, the OSR indicated (Seroquel) Quetiapine Tablet 25 MG [MG-milligram, a dosage measurement] Give 2 tablet by mouth at bedtime relate to BRIEF PSCYHOTIC DISORDER [manifiseted by] paranoia due to fear of closed doors, the dark, causing him distress, AEB becoming verbally aggressive and using derogatory language .start date 2/25/22 . Escitalopram Tablet 10 MG Give 1 tablet by mouth one time a day for aeb [as evidenced by] sad that his sister did not come related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED. During a review of Resident 261's Hospital Case Management Discharge Summary (CMD), dated 9/13/20, the HCMDS indicated, no psychiatric diagnosis for indication of quetiapine. During a concurrent record review and interview on 3/24/23, at 11:51 a.m., with Minimum Data Set Nurse (MDSN), Resident 261's MDS Section B,E, I dated 9/19/20 was reviewed. MDS indicated, Section B-Hearing, Speech, and Vision .B0600-Speech Clarity .clear speech-distinct intelligible words .B0700 .Makes self understood .sometimes understood-ability is limited to making concrete requests .B0800 Ability to understand others .sometimes understands- responds adequately to simple, direct communication only .Section E-Behavior .E0100 Potential Indicator of Psychosis .None of the above .E0200 Behavioral Symptoms-Presence & Frequency .Verbal behavioral symptoms directed towards others (threatening others, screaming) .Behavior occurred 1 to 3 days . Section I-Active Diagnosis .Psychiatric/Mood Disorder .no Psychotic disorder or Schizophrenia indicated. MDSN stated, she was aware Resident 261 had a diagnosis of aphasia. MDSN stated, Resident 261 can say yes and no clearly and was evaluated by speech therapy on 9/15/20. MDSN stated, she was unable to find a diagnosis of schizophrenia (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality and relates to others) on hospital documentation. During a review of Resident 261's Psychiatric Evaluation PE, dated 4/15/21, the PE indicated History of present illness .September 2020 of yelling out fearfully at night .and when the door to his room is closed .He will scream his sisters name out and cry into the hallway .he becomes fearful and will cry aloud until the door is open .throughout the interview the patient was only able to say 'thank you' and Jill .Unspecified psychosis not due to a substance or known physical condition .Patient has paranoid delusions which cause behaviors of yelling out for his sister serval times a shift .if the door closes he will cry .he is fearful when his closet door is open .He is unaware who staff is .He is being monitored for behaviors screaming Is that you Jill, I am sorry Jill. Please don't leave me Jill .[Resident 261] is agreeable (he states thank you, unclear if he comprehends) to a trial of Seroquel 25 mg BID. During a record review of Resident 261's Medication Administration Record (MAR), dated 1/1/23-3/31/23. The MAR indicated, no behaviors for [quetiapine] (causing distress [as evidenced by] becoming verbally aggressive and using derogatory language) were documented. During a concurrent record review and interview on 3/23/23, at 2:59 p.m., with MDSN, Resident 261's MAR, dated 3/1/23-3/31/23 was reviewed. The MDSN stated there were no resident specific non-pharmacological intervention for Seroquel. MDSN states they are not specific, the non-pharmacological interventions are general [one staff to resident], Activity, adjust temperature, back rub, change positions, give fluids .). MDSN stated, it is important for residents to have specific non-pharmacological interventions because everyone has different care needs and react differently. MDSN stated, it is important to implement resident specific non-pharmacological interventions as it relates top antipsychotics because we want to reduce the effects of antipsychotics. During a concurrent record review and interview on 3/23/23, at 3:10 p.m., with MDSN, Resident 261's IDT notes, dated 9/13/20 to 3/23/23 were reviewed. The MDSN was unable to provide documentation of a GDR attempts, and stated there have been no GDR attempts for [quetiapine and escitalopram]. During a concurrent record review and interview on 3/23/23, at 3:15 p.m , with MDSN, Resident 261's LR, dated 9/13/20 to 3/23/23 were reviewed. MDSN stated, there were no TSH monitoring and last eye exam was 7/19/21. MDSN stated, speech evaluation was noted as completed on 9/15/20; however, MDSN and Medical Records Clerk (MRC)were unable to locate documentation of speech evaluation. During an interview on 3/27/23, at 10:07 a.m , with Consultant Pharmacist (CP), CP stated, it is important to check for the appropriateness of indications of resident medications. CP stated quetiapine has a black box warning as it relates to dementia. CP stated, quetiapinel can increase mortality in elderly patients with dementia related psychosis. CP stated, there should be documentation of monitored behaviors when there is an indication for psychotropic medication. CP stated, it is important to document behaviors to ensure the medication that is given is helping or not. CP stated, resident specific non-pharmacological interventions accommodate resident needs and are used to help that individual patient. CP stated, if resident specific non-pharmacological interventions work then resident may not need to be on medication. CP stated, it is important to monitor TSH and labs to make sure there is no adverse effect from the medication. CP stated, GDR should be attempted annually to ensure the patient is on the minimal effective dose. During a concurrent record review and interview on 3/27/23 at 11:28 a.m., with Medical Director (MD), Resident 261's Electronic Medical Record (EMR) was reviewed. The MD acknowledged Resident 261 had a diagnosis of aphasia and stated the diagnosis of schizophrenia was a new diagnosis in the building as of 10/14/21. MD stated, there was no diagnosis of Schizophrenia found in the Electronic Medical Records for resident 261. MD stated, the facility needs to be monitoring for labs, lipids, eye exams. MD stated, there is an issue with not evaluating and monitoring a resident on psychotropic medications once they have been admitted . MD stated, Resident 261 needs to have a GDR. According to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition- handbook that contains criteria for diagnosing mental disorders and is used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders) indicates one of the criteria for schizophrenia as, .The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. During a review of Lexicomp, a nationally recognized drug database, the manufacturer for quetiapine indicated, monitoring parameters blood chemistries (electrolytes, renal function, liver functions, TSH) annually . Obtain lens exam at start of[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional standards of practice for a facility of 109 when: 1. Medications for Resident 1, 59, 74, 89, 96, 97, 411, 412 did not have patient identifiers. 2. Two tuberculin (used tuberculosis screening) 1 ml (milliliter- unit of measure) vials were found open, partially used and expired, and one Influenza vaccine (a vaccine that protects against the flu) 5 ml vial did not have an open or discard date. These failures had the potential for medication to be given to the incorrect resident which could cause adverse reactions (harmful, unintended result caused by a medication) and for expired tuberculin and influenza vaccine to be given to residents, decreasing the effectiveness of the tuberculin screening and influenza vaccine. Findings: 1. During an observation and concurrent interview on [DATE], at 2:15 p.m , with Licensed Vocational Nurse (LVN) 9, at Station 3 medication cart, Resident 89's fluticasone-salmeterol (a portable medication device used to improve lung function) 250/50 [mcg-micrograms per dose-mcg] medication was observed in its opened box with no appropriate patient identifier labels on the device. Resident 1's fluticasone-salmeterol 250-50 mcg medication was observed in its opened box with no appropriate patient identifier labels on the device. Resident 96's fluticasone-salmeterol 250-50 mcg and tiotropium bromide (medication to improve lung function) 18 mcg were observed in an opened box with no use by date or appropriate patient identifier labels on the device. Resident 411's Latanoprost Solution 0.005% (eye drop medication for glaucoma) was observed in its opened box with no appropriate patient identifier. LVN 9 stated, there was no patient identifiers on the inhalers or eye drops. LVN 9 stated, there is a potential for cross contamination and infection. LVN 9 stated, the medication could be given to the wrong patient. LVN 9 stated, there could be an allergic reaction or death if medications were given to the wrong patient. LVN 9 observed the Latanoprost bottle and stated she was not sure when the expiration date was. LVN stated, the eye drops had an expiration date of 6 weeks from the open date . LVN 9 stated the clear zip lock bag that held the Latanoprost had an open date of [DATE]. LVN 9 stated, this medication was expired. LVN 9 stated, expired Latanoprost could be less effective, and the eye drop formula could possibly make eye condition worse. During a review of Resident 89's, Order Summary Report (OSR), dated [DATE], the OSR indicated, [Fluticasone-Salmeterol]Aerosol Powder Breath Activated 250-50 mcg/dose . 1 puff inhale orally every 12 hours .start date [DATE]. During a review of Resident 1's OSR, dated [DATE], the OSR indicated, Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (Fluticasone-Salmeterol) 1 inhalation inhale orally every 12 hours .start date [DATE]. During a review of Resident 96's OSR, dated [DATE], the OSR indicated, Fluticasone-Salmeterol Aerosol Powder Breath Activated 250-50 mcg/act 1 puff inhale orally two times a day .start date [DATE] .(Tiotropium Bromide Monohydrate) Capsule 18 mcg 1 capsule inhale orally one time a day .start date [DATE]. During a review of Resident 411's OSR, dated [DATE], the OSR indicated, Latanoprost Solution 0.005% Instill 1 drop in both eyes at bedtime .start date [DATE]. During a review of Resident 59's OSR, dated [DATE]-[DATE], the OSR indicated, Budesonide-Formoterol Fumarate Aerosol 160-4.5 mcg/act 2 puff inhale orally two times a day .start date [DATE] .Tiotropium Bromide Monohydrate Capsule 18 mcg 1 capsule inhale orally one time a day .start date [DATE]. During a review of Resident 74's OSR, dated [DATE], the OSR indicated, Budesonide-Formoterol Fumarate Aerosol 160-4.5 mcg/act 2 puff inhale orally every 12 hours .start date [DATE]. During a review of Resident 97's OSR, dated [DATE], the OSR indicated, Budesonide-Formoterol Fumarate Aerosol 80-4.5 mcg/act 2 puff inhale orally two times a day .start date [DATE]. During a review of Resident 412's OSR, dated [DATE], the OSR indicated, Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 mcg/act (Fluticasone-Salmeterol) 1 puff inhale orally every 24 hours .start date [DATE]. During an observation and concurrent interview on [DATE], at 2:33 p.m., with LVN 10, at Station 4 medication cart, Resident 59's budesonide-formoterol fumarate (medication used to help control symptoms of asthma and improve lung function) 160-4.5 and tiotropium bromide 18 mcg was observed in its opened box, with no use by date or appropriate patient identifier labels on the devices. LVN 10 stated, the inhalers did not have patient identifiers on the devices themselves. LVN 10 stated, if the devices all look the same the medication could be used on the wrong patient. LVN 10 stated, there is a potential for cross contamination. LVN 10 stated, it is also important to put discard dates and patient identifiers just in case the box goes missing. During an observation and concurrent interview on [DATE], at 2:40 p.m., with LVN 11, at Station 1 medication cart, Resident 74's budesonide-formoterol fumarate 160-4.5 mcg/act was observed in its opened box, with no use by date or appropriate patient identifier labels on the device. Resident 97's budesonide-formoterol fumarate 80-4.5 mcg/act was observed in its opened box, with no use by date or appropriate patient identifier labels on the device. Resident 412's fluticasone-salmeterol 250-50 mcg was observed in its opened box, with no appropriate patient identifier labels on the device. LVN 11 stated, the inhalers need to be appropriately labeled. LVN 11 stated there is a possibility the box could go missing, there should be patient identifier label on both the box and inhaler. LVN 11 stated, if you do not have the box, you would not know who the medication is for. LVN 11 stated, if the medication is not appropriately labeled, there is a risk of giving the medication to another resident. During an interview on [DATE], at 9:20 a.m , with Interim Director of Nursing (IDON), IDON stated, the expectation is for medication, as with the inhalers, to be properly labeled and have specific patient identifiers on the devices itself, that way if the device comes out of the storage container we can still identify. IDON stated, if not properly identified it could be given to the wrong patient. During an interview on [DATE], at 9:53 a.m., with the Pharmacist Consultant (PC), PC stated there needs to be two patient identifiers on medication, this is standard. PC stated, if medication, like an inhaler, is not properly labeled, there is an increased risk of medication error, and the medication could be given to a different patient. PC stated, there is a potential for cross contamination. During an interview on [DATE], at 1:30 p.m., with Assistant Director of Nursing (ADON), ADON stated the expectation for staff is to ensure medication is properly labeled with two patient identifiers. ADON stated labeling will ensure the correct patient receive their medication and there wont be cross contamination. ADON stated, if resident received the incorrect medication the resident could be allergic. ADON stated should be labeled on the inhaler themselves with two patient identifiers. 2. )During an observation and concurrent interview on [DATE], at 3:35 p.m., with Licenced Vocational Nurse (LVN 8), Two tuberculin multidose 1 [mL-milliliters unit of measurement] vials were observed in a pouch with expiration date [DATE]-[DATE] stored in one medication refridgerator for Station 1 and 2. LVN 8 stated, if the tuberculin is expired it will not be effective to the resident. One Influenza vaccine 5 ml multidose vial was also observed, without a date open or discard date label, stored in the medication room [ROOM NUMBER] and 2 refrigerator. LVN 8 stated, he does not see an open date or expiration date on the influenza vial. LVN 8 stated, the vaccine expired after a certain amount of time and could not be as effective for the resident. During an interview on [DATE], at 9:20 a.m., with the Interim Director of Nursing (IDON), the IDON stated, it is the expectation that the facility has proper labeling of medication. IDON stated, the tuberculin multidose vial should have an open date, expiration date and be discarded appropriately. IDON stated, an expired medication could impact the resident by not getting the correct dosage strength of the medication. During an interview on [DATE], at 1:30 p.m., with Assistant Director of Nursing (ADON), ADON stated, the expectation of staff is to ensure medication will be labeled with date open and expiration stickers on vaccines and medications. ADON stated, once a medication is open, there should be a date open and expiration date. ADON stated, there is the potential for expired vaccines to be ineffective to the residents. During a review of the facility's Order Listing Report (OLR), dated [DATE]-[DATE], the OLR indicated, 7 residents had orders for tuberculin screening. During a review of the facility's Immunization Report (IR), dated [DATE]-[DATE], the IR indicated, 6 residents had the potential to receive the influenza vaccine. During a review of Lexicomp, a nationally recognized drug database, the manufacturer for tuberculin indicated, Opened vials should be discarded after 30 days. During a review of Lexicomp, the manufacturer for influenza vaccine indicated, Discard multiple-dose vials 28 days after initial entry During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, dated 4/2019, the P&P indicated, .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .Policy Interpretation and Implementation .1. Medication labels must be legible at all times .5. Labels for each single unit dose package include all necessary information, such as: .f. the name of the resident and physician. (Note: The names of the resident and physician do not have to be on each unit dose package, but they must be identified with the package in such a manner as to ensure that the drug is administered to the right resident). During a review of the facility's P&P titled, Storage of Medication, dated 11/2020, the P&P indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview and record review, the facility failed to ensure the menu was followed when: 1) the Fried [NAME] puree recipe for the lunch meal on 3/23/23 for 17 of 110 residents (Residents 1, 4, 13, 20, 22, 24, 42, 43, 50, 64, 68, 70, 77, 82, 366, 367, 368) was not followed. 2) the Stir Fry Vegetables puree recipe for the lunch meal on 3/23/23 for 17 of 110 residents (Residents 1, 4, 13, 20, 22, 24, 42, 43, 50, 64, 68, 70, 77, 82, 366, 367, 368) was not followed. This failure had the potential to result in not meeting the nutritional needs of the residents and further compromising their medical status. Findings: 1) During a review of the facility document titled, Spring Cycle Menus Week 3 Thursday (menu), dated 3/23/23, the menu indicated for the lunch meal on the puree (blend foods to make it easier to swallow) diet the following: .Szechuan Pork .P .Fried [NAME] .P .Stir Fry Vegetables .P #12 .Parsley Sprig .Flakes .Confetti Coleslaw .P- #12 .Tapioca Pudding .Plain Pudding .Milk .#8=1/2 [cup] (c-unit of measurement) .#12=1/3c .#16=1/4c .P=Pureed . During a review of the facility document titled, Recipe: Fried Rice, undated, the recipe indicated Pureeds/Dysphagia (difficulty swallowing) Recipe: Puree. Serve #12. (Small #16, large #8). During a review of the facility document titled, Recipe: Pureed Starch (Rice, Pasta, Potatoes), undated, the recipe indicated 1. Complete regular recipe. Measure out total number of portions .2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm milk. See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency . The recipe also indicated that for 24 servings of starch per recipe, 24 to 48 ounces of warm milk was to be added to puree the recipe. During a concurrent observation and interview on 3/23/23, at 11:23 a.m., in the kitchen, [NAME] 1 stated, she was preparing 20 servings of the pureed fried rice. [NAME] 1 added 20 scoops of regular fried rice into the blender using a #8 scoop, then blended on high. [NAME] 1 then added two cups of water to the blender, blended on high. [NAME] 1 stated, this was done because the recipe already had soy sauce in it so broth should not be added. [NAME] 1 added two cups of water to the blender and blended on high. [NAME] 1 added 1.25 cups of water to the blender for a total of 5.25 cups of water, blended on high and stated the consistency was pudding consistency. [NAME] 1 did not refer to Recipe: Puree Starch (Rice, Pasta, Potatoes) while she was completing this recipe. During an interview on 3/24/23, at 8:03 a.m., with Certified Dietary Manager (CDM), CDM stated, the puree recipes for the lunch meal on 3/23/23 were not followed. CDM stated, adding water instead of milk or low sodium broth would not maintain the nutritional value of the pureed food items. CDM stated, the expectation was the recipes were to be followed. During a review of the facility's policy and procedure (P&P) titled, Standardized Recipes, dated 4/07, the P&P indicated, .only tested, standardized recipes will be used to prepare foods . 2) During a review of the facility document titled, Spring Cycle Menus Week 3 Thursday (menu), dated 3/23/23, the menu indicated for the lunch meal on the puree (blend foods to make it easier to swallow) diet the following: .Szechuan Pork .P .Fried [NAME] .P .Stir Fry Vegetables .P #12 .Parsley Sprig .Flakes .Confetti Coleslaw .P- #12 .Tapioca Pudding .Plain Pudding .Milk .#8=1/2 [cup] (c-unit of measurement) .#12=1/3c .#16=1/4c .P=Pureed . During a review of the facility document titled, Recipe: Stir Fry Vegetables, undated, the recipe indicated Pureeds/Dysphagia (difficulty swallowing): Puree, #12 . During a review of the facility document titled, Recipe: Pureed Vegetables, undated, the recipe indicated 1. Complete regular recipe. Measure out the total number of portions .2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk) if needed. See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. The recipe indicated, for 24 servings of vegetables, 4 to 12 ounces of warm fluid such as milk or low sodium broth would be added to puree the recipe if liquid is needed. During a concurrent observation and interview on 3/23/23, at 11:23 a.m., in the kitchen, [NAME] 1 stated, she was preparing 20 servings of the pureed stir fry vegetables. [NAME] 1 added 20 scoops of regular stir fry vegetables into the blender using a #8 scoop, then blended on high. [NAME] 1 then added one cup of water, blended on high and stated, she used water to puree this recipe because the recipe contained butter. [NAME] 1 added one cup of water for a total of 2 cups of water, blended on high and stated, the consistency was pudding consistency. [NAME] 1 did not refer to Recipe: Pureed Vegetables while she was completing this recipe. During an interview on 3/24/23, at 8:03 a.m., with the Certified Dietary Manager (CDM), CDM confirmed that the puree recipes for the lunch meal on 3/23/23 were not followed. CDM stated, when water is added instead of milk or low sodium broth the recipe would not maintain the nutritional value of the pureed food items. CDM stated, the expectation was that the recipes were to be followed. During a review of the facility's policy and procedure (P&P) titled, Standardized Recipes, dated 4/07, the P&P indicated .only tested, standardized recipes will be used to prepare foods .

Based on observation, interview and record review, the facility failed to ensure professional standards for food safety guidelines were followed when: 1. The ice machine filter screen was on the floor with paper debris, gloves, and dirt; the filter was covered with off-white dirt residue, the ice machine's interior cover had light pink and off-white to light brown color substance in the interior cover; and one rectangular ice machine swithbox was on top of the counter next to a bowl of cut apples and a tray holding special drinking glasses to be used by residents requiring these special devices. 2. Thirty-two (32) cooking and serving utensils were stored inside a rubber lined wooden drawer that was covered with unidentified black spots, food debris, dirt and moist area. Some of the utensils had caked-in substances on its grooves and/or handles. The drawer emitted a rancid ( ) and bad odor. These failures had the potential to result in foodborne illnesses (illness caused by consuming contaminated food) from the growth of microorganisms (a germ that can only be seen through a microscope) for the 109 residents eating food prepared in the facility. Findings: 1. During an observation on 3/21/23, at 9:25 a.m., in the kitchen, the food prep sink located outside the walk-in refrigerator was observed to not have an air gap for drainage. During an interview on 3/21/23, at 9:43 a.m., with the Maintenance Supervisor (MS), MS stated, there was no air gap on the food prep sink. During an interview on 3/27/23, at 2:22 p.m., with Certified Dietary Manager (CDM), CDM stated, the importance of having an air gap in the food prep sink is to prevent back flow of used water back into the sink. During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 5-402.11 .a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed . 2. During a concurrent observation and interview on 3/21/23, at 9:41a.m., with Certified Dietary Manager (CDM), in the kitchen, a clean blender was stored on a shelf, the blender contained water and condensation underneath the closed lid. CDM stated, the blender needed to be upside down to allow it to air dry. During a concurrent observation and interview on 3/21/23, at 9:54 a.m., a clean [brand name] kitchen device used to puree food, was stored with water accumulated in the bottom of the device and condensation underneath a closed lid. CDM stated, [brand name] kitchen device used to puree food should have been air dried and that it would need to be cleaned again. During an interview on 3/27/23, at 2:22 p.m., with CDM, CDM stated, the importance of properly air-drying kitchen equipment is to prevent bacteria from growing and multiplying on a wet surface. During a review of the facility policy and procedure (P&P) titled, Sanitization, dated 10/08, the P&P indicated .Food preparation equipment and utensils that are manually washed will be allowed to air dry . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 4-901.11 .After cleaning and sanitizing, and utensils: equipment shall be air-dried . 3. During a concurrent observation and interview on 3/21/23 at 9:54 a.m., with Certified Dietary Manager (CDM), in the kitchen, two large frying pans were observed to have thick black residue on the cooking surface that were hung up on a rack and available to be used. CDM took both frying pans down to be discarded and stated, she will replace the frying pans. During an observation on 3/23/23, at 11:22 a.m., in the kitchen, two large cooking pots were observed to have thick black residue on the bottom of the pot, were stored on a covered rack and were available to be used. During an interview on 3/27/23, at 2:22 p.m., with CDM, CDM stated, the importance of keeping kitchen equipment free of the buildup of black residue is to prevent a potential fire. CDM stated, the black residue is not a cleanable surface, bacteria can breed on it. During a review of the facility policy and procedure (P&P) titled, Sanitization, dated 10/08, the P&P indicated .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 4-601.11 .Equipment food-contact surfaces and utensils shall be clean to sight and touch .The food- contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations . 4. During an observation on 3/21/23, at 9:54 a.m., in the kitchen, two rubber spatulas were observed to be cracked and chipped and were hanging from a rack ready to be used. Certified Dietary Manager (CDM) removed the spatulas and discarded both spatulas. During a review of the facility policy and procedure (P&P) titled, Sanitization, dated 10/08, the P&P indicated .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 4-202.11 .Multiuse food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections .

F813 Based on observation, interview, facility document and policy and procedure review, the facility failed to ensure a policy regarding use and storage of foods brought to residents by family and other visitors was followed to ensure safe and sanitary storage, handling, and consumption. This failure had the potential to limit the resident's rights and enjoyment of food brought in by family or visitors. Findings: On 3/22/23 at 10:34 a.m. an interview was conducted with the Infection Preventionist (IP) 1. When asked how the facility handled food brought to the residents from family or visitors, the IP 1 stated if food was brought to the residents from family or visitors, it must be consumed within two hours, or the food would be discarded. On 3/22/23 at 10:52 a.m. a review of the undated facility document titled, Important Rules Regarding Food and Beverages Not Prepared by Facility Staff, and concurrent interview was conducted with Administrator (ADM). The ADM stated the undated document titled Important Rules Regarding Food and Beverage Not Prepared by the Facility Staff was like a policy for the resident's family that the facility created. The ADM stated if they gave the resident's family a policy, they would not understand it. Review of the Important Rules Regarding Food and Beverage Not Prepared by the Facility Staff document showed, Rule #2: Perishable (foods that require refrigeration) foods must be eaten within two hours. We do NOT reheat or store food .Rule #5: Food/Beverages are NOT to be offered to other patients other than your loved one. The ADM stated the facility wanted to keep a safe environment therefore storing perishable food was not allowed. When asked if the Important Rules Regarding Food and Beverage Not Prepared by the Facility Staff was the facility policy, the ADM went to his office and returned a half an hour later with a policy revised March 2022 titled, Food Brought by Family/Visitors which showed, Food brought to the facility by visitors or family is permitted .2. Food brought by family/visitors for individual residents are not shared with or distributed to other residents. 3. Family/visitors are asked to prepare and transport food using safe food handling practices, including: a. safe cooling and reheating processes; b. holding temperatures; c. preventing cross contamination with raw and undercooked foods, and d. hand hygiene. 4. Safe food handling practices are explained to family/visitors in a language and format they understand. 5a. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use-by date . The ADM was asked why the facility did not follow the policy provided, the ADM replied the facility wanted to keep the resident's safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 4. During a review of Resident 71's admission Record, undated, the admission record indicated, Resident 71 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors), Type 2 Diabetes Mellitus (problem in the way the body regulates and uses sugar as a fuel), edema (excess fluid trapped in the body's tissues), pruritis (itching skin), and cellulitis (potentially serious bacterial skin infection) of right lower limb. During a review of Residents 71's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 71's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 71 was cognitively intact. During a concurrent interview and record review on 3/22/23 at 10:30 a.m., with Licensed Vocational Nurse (LVN) 10, Resident 71's POLST form was reviewed. The POLST form indicated in case of life sustaining treatment was needed, Resident 71 was to receive CPR (a lifesaving technique that is useful in many emergencies), full medical interventions, and artificially administered nutrition (allows a person to receive nutrition (food) and hydration (fluids) when they are no longer able to take them by mouth). LVN 10 reviewed the POLST form and stated it appeared that Resident 71 printed his name but did not sign the form where it indicated signature required. When asked why the resident did not initial the signature line or sign the form, LVN 10 responded, I don't know. During an interview on 3/24/23, at 2:56 p.m., with Resident 71, Resident 71 stated he did not sign a POLST form when he was admitted to the facility. Resident 71 stated due to Parkinson's Disease he was not capable of printing his name but was able to sign his initials. Resident 71 demonstrated with a pen and paper. Resident 71 stated if a staff member had asked for him to sign the POLST form he would have initialed it. During an interview on 3/24/23, at 8:27 a.m., with the Medical Records (MR), the MR stated the entire POLST form needed a resident or the responsible party's signature to be considered complete. Resident 71's POLST form was reviewed, and the MR stated she considered the POLST form incomplete. The MR stated the POLST form needed to be completed on admission. The MR stated her main responsibility was auditing for each residents' medical records for completion. The MR stated she had only worked for the facility for two months and did not have time to audit every resident's medical record. During an interview on 3/27/23, at 1:36 p.m., with LVN 1, LVN 1 stated a POLST form required a signature from the resident or responsible party to be considered complete. LVN 1 stated without a completed POLST form, there was no way to know what the resident's wishes were. LVN 1 stated without a complete signed POLST form, the nurses would perform the maximum treatment in case of an emergency. During an interview on 3/27/23, at 4:22 p.m., with the Assistant Director of Nursing (ADON), the ADON stated if a POLST form was not complete CPR would be done in case of an emergency. During a review of the facility's policy and procedure (P&P) titled, POLST and Advance Directives, dated 9/2022, the P&P indicated, The resident has the right to formulate an POLST and/or advance directive, including the right to accept or refuse medical or surgical treatment . The POLST should be completed by your doctor or another trained medical provider after you've had a a good conversation about the form's medical terms and options . The POLST form is not valid until it is signed by both you (or your designated decisionmaker) AND your physician, nurse practitioner, or physician assistant . During a professional reference retrieved from https://capolst.org/ titled POLST California, dated 2023, the reference indicated, .Physician Orders for Life-Sustaining Treatment (POLST) is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR. Printed on bright pink paper, and signed by both a patient and physician, nurse practitioner or physician assistant, POLST can prevent unwanted or ineffective treatments, reduce patient and family suffering, and ensure that a patient's wishes are honored. Based on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for four of 12 sampled residents (Residents 107, 108, 211 and 71) when: 1. Resident 107's copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was not signed and readily available as part of Resident 107's current medical records. 2. Resident 108's copy of Consent to Treat, Bed Hold Notification and Influenza-Pneumococcal Immunization Consent or Declination Form were not signed and readily available as part of Resident 108's current medical records. 3. Resident 211's copy of Informed Consent was not signed and readily available as part of Resident 211's current medical records. These failures had the potential risk for Residents' 107, 108 and 211's decisions regarding their healthcare and treatment options not being honored. 4. Resident 71's Physician Orders for Life-Sustaining Treatment (POLST--a form that indicates patient's decisions for end-of-life care) form was not signed by the resident. This failure had the potential for Resident 71's end-of-life care to not be followed in case of an emergency. Findings: 1.During a review of Resident 107's clinical record titled, admission Record (AR-document containing resident profiles) dated 3/23/23, the AR indicated, Resident 107 was admitted to the facility on [DATE], with diagnosis which included intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head) and dysphagia (swallowing difficulty). 2.During a review of Resident 108's clinical record titled, admission Record, dated 3/23/23, the AR indicated, Resident 108 was admitted to the facility on [DATE], with diagnosis which included arthropathy (joint disease) and muscle weakness. 3.During a review of Resident 211's clinical record titled, admission Record dated 3/23/23, the AR indicated Resident 211 was admitted to the facility on [DATE], with diagnosis which included muscled weakness and morbid (severe) obesity. During a concurrent interview and record review on 3/22/23 at 9:30 a.m., with Licensed Vocational Nurse (LVN) 5 and Assistant Director of Nursing (ADON), LVN 5 and ADON stated the facility practice was to make sure the forms are signed within 24 hours of admission and POLST forms signed within 72 hours. LVN 5 and ADON stated it was the responsibility of the admitting nurse and the nurse on duty to make sure consents are signed. During a concurrent interview and record review on 3/24/23, at 8:25 a.m., with Medical Records (MR), she stated she assumed the position as MR two months ago. MR reviewed clinical records for Residents' 107, 108 and 211. She stated Resident 107's POLST form was incomplete, and it should have been completed and signed. MR reviewed Resident 108's clinical records and stated Resident 108's Consent to Treat, Bed Hold Notification and Influenza-Pneumococcal Immunization Consent or Declination Form was incomplete and it should have been completed and signed. MR reviewed Resident 211's clinical record and stated Resident 211's Consent to Treat form was incomplete and should have been completed and signed. During an interview on 3/27/23, at 3:54 p.m., with the ADON, she stated, consent forms are to be done by admission date and to be completed no later than 72 hours. ADON stated interdisciplinary team (IDT-group of people working together and make decisions to set common goals) meets to discuss and review new admission and ensure all consents are completed and signed. ADON stated it was important to make sure all consent forms are complete and signed to ensure the staff are following the wishes of residents. During a review of facility document titled, Job Description, Medical Records, dated 11/16, the Job Description indicated, . Assist in establishing procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records . Review discharge and death records, as well as records on the nursing units . Ensure the incomplete records/charts are returned to nursing service for correction . During a review of the facility's policy and procedure (P&P) titled, POLST and Advance Directives, dated 9/2022, the P&P indicated, The resident has the right to formulate an POLST and/or advance directive, including the right to accept or refuse medical or surgical treatment . The POLST should be completed by your doctor or another trained medical provider after you've had a a good conversation about the form's medical terms and options . The POLST form is not valid until it is signed by both you (or your designated decisionmaker) AND your physician, nurse practitioner, or physician assistant . During a review of the facility's policy and procedure titled, Charting and Documentation, dated 7/17, the P&P indicated, . Documentation in the medical record may be electronic, manual or a combination . Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 413's Face Sheet (FS) (a documented containing resident's personal information), dated 2/23/23, the FS indicated, Resident 413diagnosis included hypertensive heart disease without heart failure (high blood pressure), and muscle weakness. During an observation on 3/21/23, at 8:47 a.m., with Licensed Vocational Nurse (LVN) 4 in, Resident 413's room, LVN 4 was observed using a blood pressure cuff that had not been sanitize prior to and after Resident 413's care. During an interview on 3/23/23, at 9:20 a.m., with Acting Director of Nursing (IDON), the DON stated, all equipment should be disinfected between resident care. The IDON stated, disinfecting equipment will decrease the changes of infection. During an interview on 3/27/23, at 10:30 a.m., with the Pharmacist Consultant (PC), the PC stated nursing staff should be cleaning blood pressure cuffs to prevent cross contamination (a process in which bacteria is transferred from one object to another). During an interview on 3/27/23, at 1:30 p.m., with Assistant Director of Nursing (ADON), the ADON stated, the expectation to sanitize blood pressure cuffs before and after every use. ADON stated, we do not want cross contamination. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/2018, the P&P stated, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) bloodborne pathogens standard .policy Interpretation and Implementation .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs .4. Reusable resident care equipment will be decontaminated and/or sterilize between residents according to manufactures' instructions . Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Two of six sampled residents' (Resident 14 and 81) oxygen concentrator (a device that concentrates the oxygen from the ambient air) were found covered with lint and dust. This failure placed Residents 14 and 81 at an increased risk to develop respiratory and healthcare-associated infections. 2. The Maintenance Supervisor (MS) failed to call pest control on 3/21/23 and 3/22/23 when pest were seen in the facility. This failure potentially placed facility residents at an increased risk for foodborne-related illness. 3. Licensed Vocational Nurse (LVN) 4 failed to properly disinfect resident shared blood pressure cuff (a device used to measure blood pressure) prior to and after resident care. This deficient practice had the potential for the development and the spread of infection to all residents. Findings: 1. During a concurrent observation and interview on 3/22/23, at 9:34 a.m., in Resident 81's room with Licensed Vocational Nurse (LVN) 6, LVN 6 observed Resident 81's oxygen concentrator and stated the concentrator was not clean and was covered with dust and lint. LVN 6 stated, facility residents who receive supplemental oxygen with dust and lint oxygen concentrator are at increased risk for respiratory infections. LVN 6 stated, using oxygen concentrator with dust and lint was not acceptable. During a concurrent observation and interview on 3/23/23, at 1:41 p.m., with Resident 14, in Resident 14's room. Resident 14 had an oxygen cannula (a device used to deliver supplemental oxygen) connected to an oxygen concentrator. The oxygen was operating at 2L/min (LPM-Liters Per Minute, unit of measurement). The oxygen concentrator was covered with white and gray material. Resident 14 stated, the dirty oxygen was not acceptable and possibly the reason for her not getting better. Resident 14 stated, she wanted the oxygen concentrator to be cleaned or replaced. During a concurrent observation and interview on 3/23/23, at 1:151 p.m., in Resident 14's room with the Infection Preventionist (IP), IP observed t Resident 14's oxygen concentrator and stated the concentrator was not clean and was covered with dust and lint IP stated, using a dirty oxygen concentrator was not acceptable. IP stated, Resident 14's respiratory condition could worsen. IP stated, maintaining the cleanliness of an oxygen concentrator is the responsibility of the licensed staff. During an interview with the on 3/27/23, at 10:30 a.m., with Acting Director of Nursing (DON), DON stated, using dirty supplemental oxygen concentrators was not acceptable and could potentially cause residents to become ill. DON stated, the purpose of the oxygen concentrator was to improve resident's oxygen level. DON stated, residents using dirty supplemental oxygen concentrators could have respiratory infection such as pneumonia (lung infection caused by bacteria) or bronchitis (inflammation of the airways). DON stated, he expects the oxygen concentrator to be cleaned weekly and as needed for the safety and well-being of all residents receiving supplemental oxygen. DON stated, Everyone is responsible in keeping our residents safe. I expect our staff to report dirty oxygen concentrator to the charge nurse immediately so she or he can notify the Housekeeping Staff or Maintenance Staff. During a review of Resident 81's admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 81 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Exposure to COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus), Palliative Care (specialized medical care to ease symptoms without curing the underlying disease for people living with a serious illness), and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 81's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 12/7/22, the MDS indicated Resident 81's Brief Interview for Mental Status (BIMS) score was 8 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 81's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Order Summary . Oxygen via nasal canula 2L/min [Liters Per Minute, unit of measurement] every shift for Shortness of breath related to [r/t] end-of-life care . Order Date 3/15/2023 . During a review of Resident 81's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Alteration in Respiratory Status r/t use of O2 (oxygen) supplement . Date Initiated 1/12/2023 . Interventions . Administer oxygen as needed per Physician order. Monitor oxygen flow rate and response . During a review of Resident 14's AR, dated 3/24/23, the AR indicated, Resident 14 was admitted from an acute care hospital on 8/24/22 to the facility, with diagnoses which included Guillain-Barre Syndrome (a disorder where the body's immune system damages nerve. The damage to the nerves causes muscle weakness and sometimes paralysis), Emphysema (a lung condition that causes shortness of breath) and Shortness of Breath. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's BIMS score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 14's OSR, dated 3/24/23, the OSR indicated, . Order Summary . Oxygen 1 LPM VIA NASAL CANNULA every shift related to PERSONAL HISTORY OF COVID-19; SHORTNESS OF BREATH . Order Date 3/15/2023 . During a review of Resident 14's CP, dated 3/24/23, the CP indicated, . Alteration in Respiratory Status related to dependence of supplemental oxygen . Date Initiated 8/25/2022 . Interventions . Administer oxygen as needed per Physician order . During a review of the facility's document titled, Job Description . Licensed Vocational Nurse, dated 11/2016, the document indicated, . Essential Duties . Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2016, the manual indicated, . Periodically clean the concentrator's cabinet as follows: 1. Use a damp cloth, or sponge, with a mild detergent such as dish washing soap to gently clean the exterior case. 2. Allow the concentrator to air dry, or use a dry towel, before operating the concentrator . To limit bacterial growth, air dry the humidifier thoroughly after cleaning when not in use . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, . The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure . 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened . 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments . During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, undated, the P&P indicated, . An effective infection prevention and control program is necessary to control the spread of infections and/or outbreaks . Undertaking process and/or outcome surveillance activities to identify infections that are causing, or have the potential to cause an outbreak . 2. During a concurrent observation and interview on 3/21/23, at 9:51 a.m., with Activity Assistant (AA), in the hallway near the kitchen and staff breakroom, AA observed the floor and stated, That is a water roach and it's moving [pointing to a bug on the floor], it's alive. AA stated, the water roach could go to the kitchen where resident food are prepared. AA stated, a water roach could cause foodborne illness to anyone consuming food from the kitchen. During a concurrent interview and record review, on 3/23/23, at 11:43 a.m., with Maintenance Supervisor (MS), , the facility's Pest Control Log (log), undated, was reviewed. The log indicated, . Date . 3/21/23 . Location of sighting . Hallway by kitchen . Type of Insect . water bug . Corrective action . [blank] . Date 3/22/23 . Location of sighting . Hallway by kitchen . Type of Insect . water bug . Corrective action . [blank] . MS stated, he was supposed to call the pest control company to report the sighting on 3/21/23 and 3/22/23 and failed to do so. MS stated, water roach could enter the food preparation area and cause foodborne related illness. During an interview on 3/27/23, at 10:23 a.m., with the Acting Director of Nursing (DON), DON stated, the facility should be free from pest and any sightings should be reported immediately to the pest control company. DON stated, it was not acceptable to have bugs in the facility especially near the kitchen or food preparation area. DON stated, pest could cause foodborne related illness to facility residents such as nausea, vomiting, diarrhea, and dehydration. During a review of the facility's document titled, Job Description . Director of Environmental Services, dated 11/2016, the document indicated, . Position Summary . Responsible for the building, the equipment and other materials located in and around the physical property. Implanting and planning an organized system to maintain the operations of the property and maintain it in good, clean, and safe order . During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Maintaining the building in compliance with current federal, stated, and local laws, regulations, and guidelines . Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments . During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, undated, the P&P indicated, . An effective infection prevention and control program is necessary to control the spread of infections and/or outbreaks . Undertaking process and/or outcome surveillance activities to identify infections that are causing, or have the potential to cause an outbreak .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a concurrent observation and interview on 3/23/23, at 1:41 p.m., with Resident 14, in Resident 14's room. Resident 14 had an oxygen cannula connected to an oxygen concentrator. The oxygen was being given at 2L/min. The oxygen concentrator filter was operating without the filter installed. Resident 14 stated, the absence of filter was not acceptable and possibly the reason for her not getting better. Resident 14 stated she wanted the oxygen concentrator to be replaced. During a concurrent observation and interview on 3/23/23, at 1:51 p.m., in Resident 14's room with with Infection Preventionist (IP),., IP observed at Resident 14's oxygen concentrator and stated the oxygen concentrator was operating without a dust filter and it should have one . IP stated, using the oxygen concentrator without a filter was not acceptable. The IP stated Resident 14's respiratory condition could worsen. The IP stated maintaining the cleanliness of oxygen concentrator is the responsibility of the licensed staff. During an interview on 3/27/23, at 10:35 a.m., with the Acting Director of Nursing (DON), DON stated, using supplemental oxygen concentrators without a filter was not acceptable and could potentially cause residents to become ill and damage to the machine. DON stated, the purpose of the oxygen concentrator was to improve resident's oxygen level. DON stated, residents using dirty supplemental oxygen concentrators could have respiratory infection such as Pneumonia or Bronchitis DON stated, Everyone is responsible in keeping our residents safe. I expect our staff to report dirty oxygen concentrator or missing filter to the charge nurse immediately so he or she can notify the Housekeeping Staff or Maintenance Staff. During a review of Resident 14's AR, dated 3/24/23, the AR indicated, Resident 14 was admitted from an acute care hospital on 8/24/22 to the facility, with diagnoses which included Guillain-Barre Syndrome (a disorder where the body's immune system damages nerve. The damage to the nerves causes muscle weakness and sometimes paralysis), Emphysema (a lung condition that causes shortness of breath) and Shortness of Breath. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14's BIMS score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 14's OSR, dated 3/24/23, the OSR indicated, . Order Summary . Oxygen 1 [liters per minute] VIA NASAL CANNULA every shift related to PERSONAL HISTORY OF COVID-19; SHORTNESS OF BREATH . Order Date 3/15/2023 . During a review of Resident 14's CP, dated 3/24/23, the CP indicated, . Alteration in Respiratory Status related to dependence of supplemental oxygen . Date Initiated 8/25/2022 . Interventions . Administer oxygen as needed per Physician order . During a review of the facility's document titled, Job Description . Licensed Vocational Nurse, dated 11/2016, the document indicated, . Essential Duties . Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2016, the manual indicated, . Caution! Risk of Damage . To avoid damage to internal components of the unit: DO NOT operate the concentrator without the filter installed or with a dirty filter . Cleaning the Cabinet Filter .1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to high dust, air pollutants, etc. 2. Clean the cabinet filter with a vacuum cleaner or wash with a mild liquid dish detergent and water. Rinse thoroughly. 3. Thoroughly dry the filter and inspect for fraying, crumbling, tears, and holes. Replace filter if any damage is found. 4. Reinstall the cabinet filter . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, . The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure . 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened . 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments . During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control, undated, the P&P indicated, . An effective infection prevention and control program is necessary to control the spread of infections and/or outbreaks . Undertaking process and/or outcome surveillance activities to identify infections that are causing, or have the potential to cause an outbreak . Based on observation, interview and facility policy and procedure review, the facility failed to ensure kitchen equipment was maintained in safe operating condition when: 1. The ice machine manufacturer cleaning instructions were not followed, 2. The walk-in refrigerator interior wall was not a cleanable surface, and 3. A food preparation sink was not in proper working order. These failures had the potential to affect the equipment not functioning in the way it was intended which could affect the health status of the residents. 4. One of six sampled residents' (Resident 14) oxygen concentrator was found operating without a filter. This failures placed Residents 14 at an increased risk to develop respiratory and healthcare-associated infections. Findings: 1. On 3/21/23 at 10:08 a.m. an observation of the facility ice machine located in the kitchen and concurrent interview with the Maintenance Supervisor (MS) was conducted. The MS was asked to describe how he cleaned the ice machine. The MS stated he turned the ice machine off and emptied the ice storage bin. The MS stated he removed the internal components of the ice machine and scrubbed them with a brush then ran the internal components through the dish machine. When asked if he used the ice machine cleaner and sanitizer to clean the internal components, he stated he did not. On 3/22/23 at 9:10 a.m., a review of the the ice machine manufacturer cleaning instructions and concurrent interview was conducted with MS. The MS confirmed the ice machine manufacturer instructions did not include washing the internal components of the ice machine in the dish machine. The MS stated he put the internal components of the ice machine in the dish machine so it is real clean. Review of the ice machine manufacturer cleaning instructions titled, Cleaning System Instructions indicated Step 6: Remove parts [internal] for cleaning . Step 7: Mix a solution of cleaner and warm water. Depending upon the amount of mineral buildup, a larger quantity of solution may be required. Use the ration in the table below to mix enough solution to thoroughly clean all parts. Step 8: Use [half] of the cleaner/water mixture to clean all components .use a soft-bristle nylon brush, sponge or cloth (not a wire brush) to carefully clean the parts. Soak parts for 5 minutes .Rinse all components with clean water .Step 10: Mix a solution of sanitizer and warm water. Step 11: Use [half] of the sanitizer/water solution to sanitize all removed components. Use a spray bottle to liberally apply the solution to all surfaces of the removed parts or soak the removed parts in the sanitizer/water solution. Do not rinse parts after sanitizing. The facility policy and procedure titled, Sanitation revised October 2008, indicated .12. Ice machines and ice storage containers will be cleaned, drained and sanitized per manufacturer's instructions and facility policy . 2. During the initial tour of the kitchen with the Certified Dietary Manager (CDM) on 3/21/23 at 8:50 a.m., an observation of the interior wall of the walk-in refrigerator located next to the walk-in door was conducted. The interior walk-in wall appeared soiled with a brown residue and multiple chips in the wall. The paint on the wall had peeled and was not a smooth surface. The CDM was asked how often the interior of the walk-in refrigerator was cleaned. The CDM stated the interior of the walk-in refrigerator was cleaned twice a week but confirmed the wall was not included in the cleaning. The CDM agreed the wall of the walk-in refrigerator was not clean and stated she had not informed maintenance of walk-in refrigerator wall. The facility policy and procedure titled Sanitization revised October 2008, indicated .2. All .equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . According to the USDA 2022 Food Code, Section 6-101.11 Surface Characteristics, (A) Except as specified in (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) Smooth, durable, and easily cleanable for areas where food establishment operations are conducted . 3. On 3/22/23 at 8:54 a.m. an observation of a food preparation sink in the kitchen and concurrent interview was conducted with the CDM. The CDM stated the garbage disposal was broken and the food preparation sink was not being used. On 3/23/23 at 8:33 a.m., an observation of a food preparation sink in the kitchen and concurrent interview was conducted with MS. When asked what was wrong with the food preparation sink, MS stated he was not aware the food preparation sink was a problem. MS stated problems were documented via a maintenance log located at the nursing station. He stated he checked the maintenance log every morning and confirmed the food preparation sink was not on the log. The MS was asked if the nursing station was the only place a maintenance log was kept. MS stated he was not sure if the kitchen had a maintenance log. On 3/23/23 at 8:44 a.m. an interview was conducted with the CDM. The CDM stated she documented maintenance issues on a log in the kitchen that was implemented in December 2022. The CDM confirmed the food preparation sink was not on the maintenance log located in the kitchen office. The CDM stated she spoke with the Maintenance Assistant (MA) on 3/22/23. The CDM stated she was not sure there was a maintenance log being used elsewhere. On 3/23/23 at 10:31 a.m. an interview was conducted with MA. MA confirmed the CDM informed him verbally about the broken garbage disposal on 3/22/23. MA stated the garbage disposal needed to be removed because it did not work. MA further stated the sink was clogged with food, so water was not able to drain from the sink. The facility policy and procedure titled Sanitation revised October 2008, indicated .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . According to the USDA Food Code 2022 Section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

Based on observation, interview and record review, the facility failed to contain garbage and refuse (nonhazardous solid waste) properly when two out of three dumpsters were found to not have securely closing lids. This failure had the potential to attract rodents, insects and flies and could spread infection which placed residents at risk for foodborne illness. Findings: During a concurrent observation and interview, on 3/21/23, at 10:51 a.m., with Maintenance Supervisor (MS), in the back parking lot near the dumpsters, three dumpsters were observed with two lids atop of each the dumpsters. Two of the three dumpsters had lids that would not close. Two of the three trashcans were observed to have a gaps in the lids where they should be closed. MS stated, there were gaps between the lids on the two dumpsters observed and that a raccoon could potentially get inside the dumpster because of the gaps. During an interview on 3/22/23, at 9:15 a.m., with Housekeeping Supervisor (HS), HS stated the dumpster should have lids that close and the lids should be closed in the middle without a gap. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, undated, the P&P indicated .All garbage and refuse containers are provided with lids or covers and must be kept covered when stored or not in continuous use .Outside dumpsters provided by garbage pickup services will be kept closed . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 5-501.113 . Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered . With tight-fitting lids or doors if kept outside the food establishment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for seven of seven sampled residents (Residents 1, 22, 24, 36, 64, 81, and 367) when: 1. Resident 81 was receiving hospice services without a written physician order. 2. Resident 22 , Resident 367 and Resident 64 were receiving hospice services with unsigned hospice agreement. 3. Hospice personnel caring for residents under hospice services were not provided orientation to the facility's policies and procedures. These failures had the potential to place Residents 1, 22, 24, 36, 64, 81, and 367 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: 1. During a concurrent interview and record review, on 3/22/23, at 2:08 p.m., with the Acting Director of Nursing (DON), Resident 81's Physician's Order (PO), dated 3/22/23 was reviewed. The PO indicated, . Notify [Name of Hospice Agency] of any changes . Order Date 12/03/2022 . DON stated, he was unable to find a valid Hospice order for Resident 81. DON stated, the physician order verbiage starts with a sentence such as admit to hospice services with a terminal diagnosis of [blank] and the name of the hospice agency. I can't find the hospice order. DON stated, without a specific physician order for hospice services, Resident 81 could potentially receive care against her wishes. During a review of Resident 81's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 81 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During a review of Resident 81's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Notify [Name of Hospice Agency] of any changes . Order Date 12/03/2022 . During a review of Resident 81's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Has a Terminal Prognosis/End Stage Condition with Less Than 6 Months to Live if Disease Follow It's Natural Course . Interventions . Work cooperatively with hospice team to ensure resident's spiritual, emotional, intellectual, physical and social needs are met . Date Initiated . 2/5/23 . During a review of the facility's P&P titled, Hospice Program, dated 7/2017, the P&P indicated, . 12. Our facility has designated the DON [Director of Nursing] to coordinate care provided to the resident by our facility staff and the hospice staff . Obtaining the following information from the hospice . Hospice physician and attending physician (if any) orders specific to each resident . 2. During a concurrent interview and record review, on 3/22/23, at 2:15 p.m., with the Acting Director of Nursing (DON), the facility's Hospice Agreement with [Name of Hospice Agency], dated 12/8/22 was reviewed. The hospice agreement indicated, . IN WITNESS WHEREOF, each of the undersigned has caused this Business Associate Agreement to be executed in its name and on its behalf by its duly authorized representative . DON stated, there was no signature from [Name of Hospice Agency] authorized representative. DON stated, the hospice agreement must be signed by both parties prior to initiating hospice services for Resident 22 and Resident 367's. DON stated, without the signature the hospice agreement was not valid. During a concurrent interview and record review on 3/22/23, at 2:20 p.m., with the Director of Nursing (DON), the facility's hospice agreement with [Name of Hospice Agency], dated 12/8/22 was reviewed. The document indicated, . IN WITNESS WHEREOF, each of the undersigned has duly executed this Agreement on behalf of the of the party and on the date set forth below . DON stated, there was no signature from the facility's authorized representative. DON stated, the hospice agreement must be signed by both parties prior to initiating Resident 64's hospice services. DON stated, without the signature the hospice agreement was not valid. During a concurrent interview and record review, on 3/23/23, at 9:30 a.m., with t Administrator (ADM), the facility's hospice agreement with [Name of Hospice Agency] and [Name of Hospice Agency] , dated 12/8/22 were reviewed. ADM stated, there were missing signatures on the two agreements and both should be signed prior to initiating hospice services to facility residents. ADM stated, without the signature of the authorized representative, the hospice agreement was not valid. During a review of Resident 22's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 22 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Heart Failure (weakness in the heart where fluid accumulates in the lungs), Chronic Pain (experiencing pain greater than 6 months), and Palliative Care (specialized medical care to ease symptoms without curing the underlying disease for people living with a serious illness). During a review of Resident 22's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] for End Stage Heart Disease . Order Date 11/17/2022 . During a review of Resident 22's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Patient is on Hospice care . Date Initiated . 12/1/22 . During a review of Resident 367's AR, dated 3/22/23, the AR indicated, Resident 367 was admitted from an acute care hospital on 2/20/23 to the facility, with diagnoses which included Alzheimer's Disease (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Heart Failure, and Palliative Care. During a review of Resident 367's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] . Order Date . 2/20/23 . During a review of Resident 367's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Has a Terminal Prognosis/End Stage Condition . Date Initiated . 2/12/23 . During a review of Resident 64's AR, dated 3/22/23, the AR indicated, Resident 64 was admitted from an acute care hospital on 9/20/22 to the facility, with diagnoses which included Protein Calorie Malnutrition, Dementia, Muscle Weakness, and Palliative Care. During a review of Resident 64's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit patient to [Name of Hospice Agency] . Order Date . 1/2/23 . During a review of Resident 64's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Patient is on Hospice related to: End of Life Care . Date Initiated . 3/15/23 . During a review of the facility's P&P titled, Hospice Program dated 7/2017, the P&P indicated, . Hospice services are available to residents at the end of life . 6. The agreement with the hospice provider will be signed by the facility representative and a representative from the hospice agency before hospice services are furnished to any resident . 3. The facility failed to ensure that hospice personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures. During an interview on 3/22/23, at 9:06 a.m., with Hospice Aide (HHA), in Station 3 hallway, HHA stated, she was the assigned Hospice Aide for Resident 1 for over two months. HHA stated, she provided bed bath and personal care once a week to Resident 1. HHA stated, she does not recall having an orientation on the facility's policy and procedures or meeting the facility's Hospice Coordinator. During a concurrent interview and record review, on 3/22/23, at 2:30 p.m., with the Acting Director of Nursing (DON), the facility's Hospice Program Policy and Procedure (P&P), dated 7/2017 was reviewed. The P&P indicated, . 12. Our facility has designated [name] RN/DON to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . DON stated, he does not have any record or proof that an orientation on the P&P of the facility to hospice staff caring for facility residents was done. DON stated, the facility failed to follow its own hospice policy. DON stated, the lack of orientation to the facility's policy and procedure to hospice personnel could potentially result to not meeting the medical, physical, psychosocial, and spiritual needs of Residents 1, 22, 24, 36, 64, 81, and 367. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/24/23, the AR indicated, Resident 1 was admitted from an acute care hospital on 11/14//20 to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Chronic Obstructive Pulmonary Disease (COPD - is a chronic inflammatory lung disease that causes obstructed airflow of the lungs). During a review of Resident 1's Order Summary Report (OSR), dated 3/24/23, the OSR indicated, . Admit patient to [Name of Hospice Agency] with terminal diagnosis COPD . During a review of Resident 22's admission Record (AR), dated 3/22/23, the AR indicated, Resident 22 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Heart Failure (weakness in the heart where fluid accumulates in the lungs), Chronic Pain (experiencing pain greater than 6 months), and Palliative Care (specialized medical care to ease symptoms without curing the underlying disease for people living with a serious illness). During a review of Resident 22's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] for End Stage Heart Disease . Order Date 11/17/2022 . During a review of Resident 24's admission Record (AR), dated 3/22/23, the AR indicated, Resident 24 was admitted from an acute care hospital on 4/24/20 to the facility, with diagnoses which included Heart Failure, Unspecified Joint Pain, and Palliative Care. During a review of Resident 24's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] . Order Date 2/23/2023 . During a review of Resident 36's admission Record (AR), dated 3/22/23, the AR indicated, Resident 36 was admitted from an acute care hospital on 6/13/22 to the facility, with diagnoses which included Cerebral Infarction (stroke), Epilepsy (a brain disorder that causes seizures), Hypertension (elevated blood pressure), and Palliative Care. During a review of Resident 36'sOrder Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] diagnosis of COPD . Order Date . 6/13/22 . During a review of Resident 64's admission Record (AR), dated 3/22/23, the AR indicated, Resident 64 was admitted from an acute care hospital on 9/20/22 to the facility, with diagnoses which included Protein Calorie Malnutrition, Dementia, Muscle Weakness, and Palliative Care. During a review of Resident 64's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit patient to [Name of Hospice Agency] . Order Date . 1/2/23 . During a review of Resident 81's admission Record (AR), dated 3/22/23, the AR indicated, Resident 81 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Protein-Calorie Malnutrition, Anxiety Disorder, Dementia, and Palliative Care. During a review of Resident 81's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Notify [Name of Hospice Agency] of any changes . Order Date 12/03/2022 . During a review of Resident 367's admission Record (AR), dated 3/22/23, the AR indicated, Resident 367 was admitted from an acute care hospital on 2/20/23 to the facility, with diagnoses which included Alzheimer's Disease (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Heart Failure, and Palliative Care. During a review of Resident 367's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] . Order Date . 2/20/23 . During a review of the facility's P&P titled, Hospice Program, dated 7/2017, the P&P indicated, . 12. Our facility has designated [name] RN/DON to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being .

Based on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when the facility's ATB stewardship and surveillance program was not conducted for January 2023 and February 2023. These failures had the potential to place residents at risk for an adverse effect of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate antibiotic use. Findings: During a concurrent interview and record review on 3/27/2023, at 1:32 p.m., with Infection Preventionist (IP) 2, IP 2 stated IP 1 assumed the position two weeks ago. IP 2 stated she is covering for IP 1. IP 2 reviewed the Order Listing Report for the month of January and February 2023. The IP 2 stated, .There are no surveillance line listings for antibiotic use for the month of January and February 2023 . IP 2 stated there should have been an infection surveillance log for antibiotic use to verify if antibiotic usage was appropriate for a resident. IP 2 stated the surveillance form line listing was important to determine if the infection was a healthcare associated infection (HAI-infection acquired when receiving care in a healthcare facility) or a community acquired infection (CAI- acquired in the general population). During an interview on 3/27/23, at 4 p.m., with Assistant Director of Nursing (ADON), ADON stated the expectation was for the IP to do the line listing to ensure residents on antibiotics meet the infection criteria. ADON stated IP should have been tracking the type of infections happening in the facility and one way to do it was completing a line listing of all the antibiotics used in the facility and the type of infections. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Policy, undated, the P&P indicated, .1. Resident will be evaluated for infection using standardized tools and criteria . 2. Nursing staff will review laboratory or other diagnostic testing and report abnormal results to the practitioner . 6. Review of laboratory culture reports to determine if the antibiotic remains indicated or if adjustments to therapy should be made . During a review of the facility's clinical document titled, Infection Prevention and Control, undated, indicated, .Monitoring and documenting infections, including tracking and analyzing outbreaks of infection as well as implementing and documenting actions to resolve related problems . Surveillance, including process and outcome surveillance, monitoring, data analysis, documentation and communicable diseases reporting . Antibiotic review including reviewing data to monitor appropriate use of antibiotics in the resident population . Documenting observations related to the causes of infection and/or infection trends; and Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure- related infections . Essential elements of a surveillance system include use of standardize definitions and listings of the symptoms of infections, use of surveillance tools such as infection surveys and data collection templates . During a review of a professional reference from CDC (Centers for Disease Control) found at www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html dated CDC (Centers for Disease Control) Professional Reference titled, The Core Elements of Antibiotic Stewardship for Nursing Homes (found at www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html) indicated, . Leadership Commitment . Nursing home leaders commit to improving antibiotic use. Facility leadership, both owners and administrators, as well as regional and national leaders if the facility is part of a larger corporation, can demonstrate their support in the following ways . Communicate with nursing staff and prescribing clinicians the facility's expectations about use of antibiotics and the monitoring and enforcement of stewardship policies . Create a culture through messaging, education . which promotes antibiotic stewardship . Accountability . Nursing homes identify individuals accountable for the antibiotic stewardship activities who have the support of facility leadership . Empower the Director of Nursing to set the practice standards for assessing, monitoring and communicating changes in a resident's condition by front-line nursing staff. Nurses and nurse aides play a key role in the decision-making process for starting an antibiotic . Therefore, the importance of antibiotic stewardship is conveyed by expectations set by nursing leadership in the facility . Infection program coordinator . Infection program coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility . Tracking and Reporting Antibiotic Use and Outcomes . Process Measures: Tracking how and why antibiotics are prescribed . Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians . Antibiotic use measures: tracking how often and how many antibiotics are prescribed . Track the amount of antibiotic used to review patterns of use and determine the impact of new stewardship interventions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment for 10 of 10 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9 and Resident 10), when on [DATE], the ambient (meaning inside the building) temperature levels in the residents rooms, exceeded 81 degrees Fahrenheit (F- a scale for measuring temperature in which water freezes at 32 degrees and boils at 212 degrees). The measured ambient room temperatures reached up to 91.2 degrees F. The facility staff were fully aware of the extreme hot weather and heatwave forecasts and warnings during the week of ([DATE] to [DATE]), and the facility failed to monitor, prepare, plan, implement interventions, and provide sufficient cooling equipment that would ensure each residents comfort and safety at all times. These failures placed Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 at risk for dehydration (a condition that occurs when the body loses too much water and other fluids caused by illness, not drinking enough water or other fluids, sweating too much during hot weather conditions, or taking certain medicines), heat related illnesses such as heat exhaustion (manifested by weakness, headache, vomiting, cramps, loss of consciousness) or heat-stroke (a serious heat-related illness manifested by high body temperature of 104 degrees F or higher, rapid breathing, increased heart rate); and reduced ability to participate in normal activities of daily living. Findings: During a concurrent observation and tour of the facility and interview, on [DATE], at 6:31 p.m., with the Maintenance Supervisor (MS), resident rooms were measured for ambient temperatures using the surveyor's infrared temperature gun (ITG, a tool that can measure temperatures from a distance). The measured temperature in the room occupied by Resident 1 and Resident 2 was 90.2 degrees F. Resident 1 and Resident 2 both stated, It ' s hot here. During a review of Resident 1 ' s clinical record, the face sheet (a document containing resident profile information) indicated Resident 1 was admitted to the facility with diagnoses which included hypertension (high blood pressure). During a review of Resident 1 ' s Minimum Data Set (a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1 ' s Brief Interview Mental Status (BIMS- assessment of cognitive status) indicated Resident 1 ' s BIMS score was 3 of 15 points which indicated Resident 1 had severe cognitive impairment. During a review of Resident 2 ' s clinical record, Resident 2 ' s face sheet indicated Resident 2 was admitted to the facility with diagnoses which included hypertension and chronic respiratory failure with shortness of breath. During a review of Resident 2 ' s MDS assessment dated [DATE], Resident 2 ' s MDS assessment indicated Resident 2 ' s BIMS score was 15 of 15 points which indicated Resident 2 had no cognitive impairment. During a concurrent observation and interview on [DATE], at 6:48 p.m., with the MS, the measured temperature in the room occupied by Resident 3 was 91.2 degrees F. Resident 3 laid in bed and stated, [It ' s] hot. The MS stated the ambient temperature should be between 71 to 81 degrees F. During a review of Resident 3 ' s clinical record, Resident 3 ' s face sheet indicated Resident 3 was admitted to the facility with diagnoses which included anxiety disorder (intense, excessive and persistent worry and fear characterized by fast heart rate, rapid breathing and sweating). During a review of Resident 3 ' s MDS assessment dated [DATE], Resident 3 ' s BIMS score was 13 of 15 points which indicated Resident 3 had no cognitive impairment. During a concurrent observation and interview on [DATE], at 6:53 p.m., with the MS, the measured temperature in the room occupied by Resident 4 and Resident 5 was 89.8 degrees F. Resident 4 stated, It ' s really hot, [air-conditioning] does not work, it blows out hot air. Resident 5 also stated, It ' s too hot, [air-conditioning] is not working. During a review of Resident 4 ' s clinical record, Resident 4 ' s face sheet indicated Resident 4 was admitted to the facility with diagnoses which included anxiety and hypertension. During a review of Resident 4 ' s MDS assessment dated [DATE], Resident 4 ' s BIMS score was 15 of 15 points which indicated Resident 4 had no cognitive impairment. During a review of Resident 5 ' s clinical record, Resident 5 ' s face sheet indicated Resident 5 was admitted to the facility with diagnoses which included muscle weakness and pain. During a review of Resident 5 ' s MDS assessment dated [DATE], Resident 5 ' s BIMS score was 8 of 15 points which indicated Resident 5 had moderate cognitive impairment. During a concurrent observation and interview on [DATE], at 6:57 p.m., with the MS, the measured temperature in the room occupied by Resident 6 was 85.6 degrees F. Resident 6 laid in bed and was asleep. The MS stated the ambient temperature should be between 71 to 81 degrees F. During a review of Resident 6 ' s clinical record, Resident 6 ' s face sheet indicated Resident 6 was admitted to the facility with diagnoses which included hypertension, dependence on supplemental oxygen and shortness of breath. During a review of Resident 6 ' s MDS assessment dated [DATE], Resident 6 ' s BIMS score was 15 of 15 points which indicated Resident 6 had no cognitive impairment. During a concurrent observation and interview on [DATE], at 7:05 p.m., with the MS, the measured temperature in the room occupied by Resident 7 and Resident 8 was 86.7 degrees F. Resident 7 stated, It ' s very uncomfortable and hot. Resident 8 stated, It ' s uncomfortable, too hot. I am scared of dying from the heat. My father died from heat. The MS stated the ambient temperature should be between 71 to 81 degrees F. During a review of Resident 7 ' s clinical record, Resident 7 ' s face sheet indicated Resident 7 was admitted to the facility with diagnoses which included hypertension and anxiety. During a review of Resident 7 ' s MDS assessment dated [DATE], Resident 7 ' s BIMS score was 3 of 15 points which indicated Resident 7 had severe cognitive impairment. During a review of Resident 8 ' s clinical record, Resident 8 ' s face sheet indicated Resident 8 was admitted to the facility with diagnoses which included hypertension and syncope (sudden temporary loss of consciousness). During a review of Resident 8 ' s MDS assessment dated [DATE], Resident 8 ' s BIMS score was 14 of 15 points which indicated Resident 8 had no cognitive impairment. During a concurrent observation and interview on [DATE], at 7:10 p.m., with the MS, the measured temperature in the room occupied by Resident 9 and Resident 10 was 84.8 degrees F. Resident 9 stated, It ' s hot every day. The [air-conditioning] does not work, it ' s so hot, I can ' t breathe. Resident 10 stated, It ' s too hot, it ' s affecting [my] health. It ' s not comfortable. During a review of Resident 9 ' s clinical record, Resident 9 ' s face sheet indicated Resident 9 was admitted to the facility with diagnoses which included emphysema (a lung condition that causes shortness of breath). During a review of Resident 9 ' s MDS assessment dated [DATE], Resident 9 ' s BIMS score was 15 of 15 points which indicated Resident 9 had no cognitive impairment. During a review of Resident 10 ' s clinical record, Resident 10 ' s face sheet indicated Resident 10 was admitted to the facility with diagnoses which included morbid (severe) obesity, hypertension and shortness of breath. During a review of Resident 10 ' s MDS assessment dated [DATE], Resident 10 ' s BIMS score was 15 of 15 points which indicated Resident 15 had no cognitive impairment. During an interview on [DATE], at 7:30 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, It ' s hot today. It ' s hot in the facility. The A/C is not working. CNA 1 stated there is a heatwave and it was not safe for the health of the residents and they could experience heat related illness such as dehydration. During an interview on [DATE], at 7:45 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, It ' s hot in the facility today. The air-conditioning is not working. LVN 1 stated residents could develop heat related illness such as dehydration, heat stroke and shortness of breath if the ambient temperatures are not maintained between 71 to 81 degrees F. During an interview on [DATE], at 7:59 p.m., with the MS, the MS stated the compressor was down and was not working. The MS stated the compressor cool down the air that comes in the building. The MS stated, No air was coming in from one of the vents last week. The MS stated he was not sure how long the compressor was down and not working to its full capacity. The MS stated it was important to maintain the ambient temperature between 71 to 81 degrees F in the facility especially there is a heatwave this week. The MS stated it was his responsibility to ensure all equipment ' s in the facility such as the HVAC is in working condition. During a review of the facility document titled, Job Description: Maintenance Director, the document indicated, General Purpose: Supervise the facility ' s day-to-day functions as it relates to the facility ' s interior and grounds . Essential Job Duties: Ensuring that all maintenance activities in a facility are appropriately carried out. Maintaining and upholding the quality and standards of an organization . Complying with all safety norms and regulations set by the industry . During an interview on [DATE], at 10:32 p.m., with LVN 2, LVN 2 stated, It was known issue for quite some time. The [air-conditioning] system is not working. It ' s really hot. LVN 2 stated it was not safe for residents especially of the ongoing heat wave this week. LVN 2 stated residents could get sick with heat related illness such as dehydration and heat stroke. During a concurrent interview on [DATE], at 10:55 p.m., with the Director of Nursing (DON) and the Administrator, the DON and ADM stated 91.2 degrees F was the highest temperature recorded today and it should be between 71 to 81 degrees F. The ADM stated it was an indication that the cooling units were not functioning to its full capacity and it was an issue especially of the heatwave this week which placed residents at an increased risk to develop heat related illness. The ADM stated it was important to ensure the HVAC and other equipment ' s in the facility were maintained and operating in its full capacity. During a review of the facility ' s policies and procedure (P&P) titled, Dangerous Temperature Level undated, the P&P indicated, . A dangerous temperature level is any temperature outside the acceptable range for a person's comfort and safety. All residents can be adversely affected by abnormal temperature levels, and all facilities should maintain temperatures in resident areas at comfortable and safe levels at all times. Comfortable and safe refers to the overall temperature that minimizes the resident's risk of hyperthermia, hypothermia, and susceptibility to respiratory ailments and colds. Heating, ventilation and air conditioning systems should be capable of maintaining an acceptable temperature range throughout resident areas. When the facility temperature is outside the acceptable range for a prolonged period of time, the facility will evaluate the situation, monitor all residents and take appropriate actions to ensure the health and maximize the comfort of the residents. If an emergency disrupts normal day-to-day operations, the executive director will notify the state health department, and the QA&A Committee will keep written documentation of notification for three years . During a review of the facility ' s P&P titled, Departmental Maintenance-HVAC undated, the P&P indicated, General Guidelines . 11. Inspect air-conditioning unit drains and filters weekly. Change filters at least monthly during use. Discard soiled filters. 12. Air-conditioning/cooling units should have major cleaning and maintenance performed in the spring and fall before the system is changed over. During the summer months check the unit daily for proper drainage of condensate. Promptly investigate reports of condensation appearing where it doesn't belong 13. Clean or discard filters in individual air-conditioning units in the resident rooms at least monthly during the summer. Vacuum and maintain units as necessary. 14. Clean air vents and air handling units at least annually. Maintain exhaust fans at least every six (6) months .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when: 1. Resident 1 ' s transfer and discharge notice did not include the location to which Resident 1 was to be discharged . This failure had the potential to result in Resident 1 ' s unsafe discharge and increased likelihood of preventable re-admissions. 2. The facility failed to send a copy of Resident 1 ' s transfer and discharge notification to the state Long-Term Care Ombudsman (resident advocacy agency) office. This failure resulted in the Long-Term Care Ombudsman not being aware of Resident 1 ' s discharge circumstances should appeals be filed by the resident or his representative. Findings: 1. During an interview on 1/11/23, at 10:06 a.m., with Resident 1, inside Resident 1 ' s room, Resident 1 stated, On 9/28/22, the former Social Services Director (SSD) and Business Manager (BM) came to my room and gave me a copy of the Notice of Transfer/Discharge and they told me that I have 30-days to find a new facility or I can apply for Medical (health insurance provided by the State of California), so I can stay in the facility. I told them that I have an on-going workers compensation claim against my former employer and they should be responsible in paying for my nursing home expenses. I got injured while at work. I am paraplegic (inability to voluntarily move the lower parts of the body), diabetic (elevated blood sugar) and hypertensive (high blood pressure). I need nursing care 24/7. I am bedbound During a concurrent interview and record review on 1/11/23, at 10:13 a.m., with the Acting Social Services Director (ASSD), Resident 1 ' s Notice of Transfer/Discharge (NTD), dated 9/28/22 was reviewed. The NTD indicated, . Transfer/Discharge to: [location] To be determine . ASSD stated the NTD was issued to Resident 1 on 9/28/22 to encourage him to apply for Medical insurance. ASSD stated, We were hoping that he will agree to apply for Medical, but he did not. ASSD stated the facility did not have a concrete plan on where Resident 1 was going when the facility served the Notice of Transfer/Discharge. ASSD stated the facility failed to follow its own policy on Transfer and Discharge. ASSD stated the facility failed to provide Resident 1 a written transfer/discharge notice that included the location to which Resident 1 was to be discharged . ASSD stated the facility was responsible in ensuring Resident 1 ' s safe discharge. During an interview with the Director of Nursing (DON) on 1/11/23, at 11:30 a.m., the DON stated Resident 1 should have a written transfer/discharge notice that included the location to which Resident 1 is to be discharged . The DON stated Resident 1 was bedbound with chronic medical conditions including Paraplegia, Diabetes, and High Blood Pressure. The DON stated Resident 1 required a care facility that can accommodate his medical needs. The DON stated Resident 1 ' s lack of proper discharge planning could result to unsafe discharge and could lead to preventable re-admissions. During a review of Resident 1's admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 2/7/23, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Type 2 Diabetes Mellitus (a disorder in which blood sugar or glucose levels are abnormally high) and Heart Failure (the heart cannot pump blood or fill adequately). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 8/9/22, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's MDS Functional Status, dated 7/5/22, the MDS indicated, . Bed Mobility extensive assistance . During a review of Resident 1 ' s Nursing Care Plan (CP), dated 2/25/22, the CP indicated, . Needs pain management and monitoring related to: history of back surgery, pain to neck, back and shoulders . Interventions . Repositioning every 2 hours . During a review of the facility's P&P titled, Transfers and Discharges, undated, the P&P indicated, . Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and family in accordance with federal and state specific regulations . Notification of Transfer or Discharge . This notification will include: Reason for and effective date of transfer or discharge . Location of transfer or discharge . 2. During an interview on 1/11/23, at 10:06 a.m., with Resident 1, inside Resident 1 ' s room, Resident 1 stated, On 9/28/22, the former SSD and BM came to my room and gave me a copy of the Notice of Transfer/Discharge and they told me that I have 30-days to find a new facility or I can apply for Medical insurance, so I can stay in the facility. I told them that I have an on-going workers compensation claim against my former employer and they should be responsible in paying for my nursing home expenses. I got injured while at work. I am paraplegic, diabetic and hypertensive. I need nursing care 24/7. I am bedbound. During a concurrent interview and record review on 1/11/23, at 10:13 a.m., with the ASSD, Resident 1 ' s NTD, dated 9/28/22 was reviewed. The NTD indicated, . If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal. The appeal can be filed in writing to or by calling the following . State LTC Ombudsman Office . ASSD stated the NTD was issued to Resident 1 on 9/28/22 and the section to document the date when the facility notified the State LTC Ombudsman Office was left blank. ASSD stated the facility failed to follow its own policy on Transfer and Discharge. ASSD stated the facility failed to send a copy of the Notice of Transfer/Discharge to the State LTC Ombudsman office. During an interview with the DON on 1/11/23, at 11:40 a.m., the DON stated the SSD did not notify the State LTC Ombudsman office when Resident 1 was given the Notice of Transfer/discharge on [DATE] and should have been notified. The DON stated the facility failed to follow its own policy on Transfer and Discharge. The DON stated without the knowledge of Resident 1 ' s discharge circumstances, the long-term care Ombudsman could not act promptly should appeals be filed by the resident or his representative. During a review of Resident 1's AR, dated 2/7/23, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Type 2 Diabetes Mellitus, and Heart Failure. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's BIMS score was 14 out of 15 which indicated Resident 1 had no cognitive impairment. During a review of Resident 1's MDS Functional Status, dated 7/5/22, the MDS indicated, . Bed Mobility extensive assistance . During a review of Resident 1 ' s CP, dated 2/25/22, the CP indicated, . Needs pain management and monitoring related to: history of back surgery, pain to neck, back and shoulders . Interventions . Repositioning every 2 hours . During a review of the facility's P&P titled, Transfers and Discharges, undated, the P&P indicated, . Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and family in accordance with federal and state specific regulations . The facility will send a copy of the notice of transfer or discharge to the representative of the Office of State Long Term Care (LTC) Ombudsman . During a review of Professional reference titled, CMS Issues Clarification of Notice Requirements to Long-Term Care Ombudsman when Resident is transferred or discharged from Long-Term Care Facility dated 7/24/17, (found at https://www.hallrender.com/2017/07/24/cms-issues-clarification-of notice requirements) indicated . On May 12, 2017, the Survey and Certification Group at Centers for Medicare and Medicaid Services (CMS) issued a memorandum, Implementation Issues, Long-Term Care Regulatory Changes . Clarification of Notice before Transfer or Discharge Requirements clarifying the requirements of the Final Rule regarding the timing for providing notice to the State Long-Term Care Ombudsman in the event a resident is transferred or discharged from the long-term care facility. Facilities must immediately review and revise their discharge and transfer notice practices, policies and procedures . Emergency Transfers, when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable . Copies of notices for emergency transfers must also still be sent to the Ombudsman .

Based on interview, and record review, the facility failed to ensure services provided meet professional standards of quality for one of four sampled residents (Resident 1) when the facility failed to arrange a reliable transportation provider to pick up Resident 1 from the dialysis center on 8/3/22 and 8/29/22. This failure resulted to Resident 1 sitting in his wheelchair in the dialysis center lobby for several hours after he completed his dialysis and placed Resident 1 at a potential risk of skin breakdown and muscle cramps. Resident 1 felt he was ignored and neglected by the facility. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/6/22, the AR indicated, . admission Date 6/2/22 . Diagnosis Information . End Stage Renal Disease (ESRD - medical condition in which a person's kidneys stop functioning on a permanent basis and needing long-term dialysis) . During a review of Resident 1's Order Summary Report (OSR), dated 9/6/22, the OSR indicated, . Dialysis . Days of Treatment: Monday, Wednesday, and Friday at 1:15 p.m. pick up:12:15 p.m. Order Date . 5/2/22 . During an interview on 9/2/22, at 10:10 a.m., with the Dialysis Social Worker (DSW), the DSW stated Resident 1 was not picked up on time on two occasions for the month of August 2022. DSW stated on 8/3/22, around 7:30 pm, Resident 1 was in the waiting room of the dialysis center by himself. DSW stated Resident 1 completed his dialysis around 5:30 p.m. DSW stated she called the facility ' s Assistant Administrator (AADM) on 8/3/22 and requested the facility to arrange a transportation to take Resident 1 back to the facility. DSW stated Resident 1 told her that he was hungry and felt ignored and neglected by the facility. DSW stated Resident 1 was picked up by the transportation company on 8/3/22 at 9:00 p.m. During an interview on 9/2/22, at 10:15 a.m., with the DSW, the DSW stated Resident 1 was not picked up on time on two occasions for the month of August 2022. DSW stated on 8/29/22, around 9:00 pm, Resident 1 was in the waiting room of the dialysis center by himself. DSW stated Resident 1 completed his dialysis around 5:30 p.m. DSW stated she called the facility ' s AADM on 8/29/22, at 8:00 p.m. and requested the facility to arrange a transportation to take Resident 1 back to the facility. DSW stated Resident 1 told her that he was hungry and felt ignored and neglected by the facility. DSW stated Resident 1 was picked up by the transportation company on 8/29/22 at 9:30 p.m. During an interview on 9/6/22, at 12:30 p.m., with Resident 1, inside Resident 1 ' s room. Resident 1 stated he was not pick-up on time on two occasions for the month of August 2022. Resident 1 stated the first incident occurred on 8/3/22 and the second incident occurred on 8/29/22. Resident stated on both occasions, he was sitting on his wheelchair for four hours in the dialysis center waiting area and was hungry. Resident stated he felt ignored and neglected by the facility. During a phone interview on 9/6/22, at 5:00 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the assigned Charge Nurse for Resident 1 on 8/29/22. LVN 1 stated on 8/29/22 at 7:00 p.m., she noticed that Resident 1 was not in the building but she forgot to call the dialysis center to check on Resident 1 ' s status. LVN 1 stated on 8/29/22 at 7:30 p.m., the facility receptionist informed her that the dialysis center called asking for Resident 1 to be picked up as soon as possible. LVN 1 stated the receptionist called the AADM and the DON. LVN 1 stated Resident 1 arrived to the facility between 9:30 p.m. and 9:45 p.m. on 8/29/22. LVN 1 stated she was responsible in ensuring that all residents were accounted for after dinner time, including Resident 1 and failed. During a phone interview on 9/19/22, at 1:30 p.m., with the AADM, the AADM stated Resident 1 was not picked up on time on two occasions for the month of August 2022, on 8/3/22 and 8/29/22. The AADM stated the transportation company failed to pick up Resident 1 on time but ultimately, the facility is responsible in ensuring Resident 1 ' s safe return to the facility after his dialysis treatment. The AADM stated the facility failed to provide Resident 1 a reliable transportation. During an interview on 9/19/22, at 5:45 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the Licensed Nurses (LN) to ensure that all residents were accounted for after dinner time and to call the dialysis center to check on the status of residents on dialysis and to call the DON or AADM for additional guidance. The DON stated Resident 1 ' s experience of sitting in his wheelchair and waiting in the dialysis center ' s lobby for several hours was unacceptable. The DON stated Resident 1 could develop skin breakdown or muscle cramps which could lead to harm or negative outcome. During a review of the facility's document titled, Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . During a review of the facility policy and procedure (P&P) titled, Dialysis Guideline, dated 4/4/16, the P&P indicated, . The following information will provide addition direction in assessment, planning and provision of care to our residents requiring hemodialysis . Whether residents receiving hemodialysis are transported out of the center, or receive dialysis in house, communication is essential for continuity of care . The following elements are in place for the center to demonstrate satisfactory compliance with the guide: Center has communication system/process with dialysis provider staff . Care plan inclusive of safety, assessment .

Based on interview and record review, the facility failed to ensure dialysis (treatment for people whose kidneys are failing) assessment form was completed for one offour sampled residents (Resident 1) when the facility did not perform a pre-dialysis and post-dialysis assessment (contains vital signs and assessment of access site of dialysis catheter [used for connecting to a machine that filters blood during treatment]) on 8/12/22, 8/15/22, 8/17/22, 8/22/22, 8/24/22, and 8/29/22. This failure placed Resident 1 at a potential risk of dialysis complications (low blood pressure, fluid overload, blood clots, muscle cramps, access site infection, itchy skin) to go unnoticed which could lead to harm or death. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/6/22, the AR indicated, . admission Date 6/2/22 . Diagnosis Information . End Stage Renal Disease (ESRD - medical condition in which a person's kidneys stop functioning on a permanent basis and needing long-term dialysis) . During a review of Resident 1's Order Summary Report (OSR), dated 9/6/22, the OSR indicated, . Dialysis . Days of Treatment: Monday, Wednesday, and Friday at 1:15 p.m. pick up:12:15 p.m. Order Date . 9/2/22 . During a review of Resident 1's OSR, dated 9/6/22, the OSR indicated, . Check AV fistula (a surgical connection and primarily use for dialysis) site dressing to LUE [Left Upper Extremity], leave intact for 4-8 hours following dialysis . if bleeding is noted from dialysis access site immediately apply pressure to stop bleeding . Order Date . 5/2/22 . During a review of Resident 1's Care Plan (CP), dated 2/2/22, the CP indicated, . I am at risk for alteration in Kidney Function due to ESRD, Dialysis dependent. Days of treatments: Monday, Wednesday, and Fridays . Goal . Resident will have no signs or symptoms of infection or bleeding at fistula site . Interventions . Observe for post-dialysis hang over – vital signs, mental status, excessive weight gain between treatments, nausea, vomiting, weakness, headache, severe leg cramps . During a concurrent interview and record review on 9/6/22, at 10:59 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 1 ' s Dialysis/Observation Communication Forms (DOCF), dated 8/2022 was reviewed. LVN 2 stated the DOCF were missing for the following dates: 8/12/22, 8/15/22, 8/17/22, 8/22/22, 8/24/22, and 8/29/22. LVN 2 stated the licensed nurses were expected to complete the DOCF with information including Resident 1 ' s vital signs (temperature, heart rate, respiration rate and blood pressure) before leaving the facility and upon returning to the facility. LVN 2 stated the DOCF was use by the dialysis center to communicate the outcome of the dialysis procedure, including vital signs before and during dialysis, pre-dialysis weight and post-dialysis weight, medications administered, new orders or procedural changes. LVN 2 stated the Licensed Nurses use the DOCF to document his or her observation of Resident 1 ' s dialysis access site for sign/symptoms of infection, bleeding and/or complications and any changes in orders after returning from the dialysis center. LVN 2 stated without proper assessment and documentation in DOCS, Resident 1 could experience dialysis complications such as low blood pressure, fluid overload, blood clots, muscle cramps, and access site infection. During an interview on 9/19/22, at 5:35 p.m., with the Director of Nursing (DON), the DON stated her expectation was for the licensed nurses (LN) to complete the pre and post-dialysis assessment and document in Resident 1 ' s DOCF. The DON stated the DOCF should be completed by the LN with all the vital signs and pertinent information. The DON stated that it was important to complete a pre and post-dialysis assessment on dialysis residents to ensure they were stable before and after dialysis treatments. The DON stated Resident 1 could have changes in his condition before or after dialysis that could go unnoticed due to lack of proper assessment and could lead to harm or death. During a review of the facility policy and procedure (P&P) titled, Dialysis Guideline, dated 4/4/16, the P&P indicated, . The following information will provide addition direction in assessment, planning and provision of care to our residents requiring hemodialysis . Written communication including review of daily weights, changes in condition or mood, response to the treatment, and evaluation of the vascular access site . Pre Dialysis Protocol: Be cognizant of medications ordered and timing of administration . Communicate/facility plan for preventive skin interventions . Post Dialysis Protocol: Review transfer forms .Observe for unusual symptoms as lethargy, chest pain, headache, unsteady gait or nausea .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided meet professional standard of practice for one of six sampled residents (Resident 1) when facility staff did not follow the physician's order to administer Carbidopa-Levodopa (medication use to treat Parkinson ' s disease, a medical condition that causes uncontrollable body movements, stiffness, and difficulty with balance and coordination). This failure had the potential to cause Resident 1 to experience negative outcomes such as uncontrollable body movements, stiffness, and difficulty with balance and coordination. Findings: During an interview on 11/7/22, at 1:11 p.m., with Resident 1, inside Resident 1 ' s room, Resident 1 stated, The facility nurses gave me the wrong dosage of my Carbidopa-Levodopa from 11/1/22 to 11/4/22, instead of receiving Carbidopa-Levodopa 25/250 milligram (mg, unit of measurement), I received Carbidopa-Levodopa 25/100 mg. The 25/100 mg. was a yellow [color] pill and the 25/250 mg. was a blue [color] pill. I thought it was just a different pill manufacturer so I just took the yellow pill for several days without questioning the nurse if it was the correct dose. The yellow pill did not alleviate my symptoms, I was having a hard time moving around. I talked to Nurse [LVN 2] on 11/4/22 and complained about the ineffectiveness of the yellow pill. Nurse [LVN 2] then called the pharmacy and they [pharmacy] confirmed that I was getting the wrong dose. I expect the nurses to check my medications for accuracy before giving it to me. During a concurrent interview and record review on, 11/7/22, at 1:23 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Note (PN), dated 11/4/22 was reviewed. The PN indicated, . 13:59 [1:59 p.m.] . Change of Condition . Medication error. Which Started on 11/4/22 in the morning . Resident was given one dose of Carbidopa/Levodopa 25 mg/100 mg during shift. [Current] Pharmacy was notified, spoke with pharmacist it was a medication error on [Former] Pharmacy end. Pharmacist notified their supervisor . LVN 2 [e-SIGNED] . LVN 1 stated the facility transitioned to a new pharmacy provider on 11/1/22 and the [former] pharmacy provider dispensed the wrong dose of Resident 1 ' s Carbidopa/Levodopa. LVN 1 stated Resident 1 received the wrong dose from 11/1/22 to 11/4/22. LVN 1 stated Resident 1 could experience worsening symptoms of his Parkinson ' s Disease such as uncontrolled body movements due to an incorrect dose of Carbidopa-Levodopa. LVN 1 stated Licensed Nurses were responsible in checking the accuracy of the medication prior to administering to facility residents. During an interview with the Director of Nursing (DON) on 11/7/22, at 2:30 p.m., the DON stated Resident 1 should have the correct dose of his Carbidopa-Levodopa available for administration according to the physician ' s order. The DON stated the [former] pharmacy provider dispensed the wrong dose of Resident 1 ' s Carbidopa-Levodopa. The DON stated Resident 1 received the wrong dose of Carbidopa-Levodopa from 11/1/22 to 11/4/22. The DON stated licensed nurses should check the medication for accuracy when receiving medication delivery from the pharmacy and before administering to facility residents. The DON stated Resident 1 could experience negative outcome such as uncontrollable body movements due to an incorrect dose of Carbidopa-Levodopa. During a review of Resident 1's admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 11/7/22, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Parkinson ' s Disease (a medical condition that causes uncontrollable body movements, such as shaking, stiffness, and difficulty with balance and coordination) and Anxiety Disorder ( (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 8/9/22, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's 0rder Summary Report (OSR), dated 11/7/22, the OSR indicated, . Carbidopa-Levodopa Tablet 25-250 mg. Give 1 tablet by mouth daily every two hours from 6:00 a.m. to 6:00 p.m. related to PARKINSON ' S DISEASE . Order date 1/1/22 . During a review of the document titled, Medication Error Reporting Form, dated 11/6/22, the document indicated, . [Resident 1] . Date(s)/Time(s) error occurred: 11/1, 11/2, 11/3/11/4 . Time(s) 6:00 am to 6:00 pm . What was the problem with the medication . [x] Wrong medication, including wrong dose, dosage form or packaging . Form Completed by DON . During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 4/2008, the P&P indicated, . Medications are labeled in accordance with facility requirements, state and federal laws . Each prescription medical label includes . 1. Resident ' s name . 2. Specific Directions for use . 3. Medication name . Strength of medication . During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 4/2008, the P&P indicated, . Receiving medications from the Pharmacy . A licensed nurse receives medications delivered to the facility and documents that the delivery was received . b. Verifies medications received and directions for use with the medication order form and/or physician ' s orders . c. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor . During a review of the facility's P&P titled, Medication Administration-General Guidance, dated 10/2017, the P&P indicated, . Medications are administered as prescribed in accordance with good nursing principles and practices . Personnel authorized to administer medications do so only after they have familiarized themselves with the medication . During a review of Pharmacy Services Agreement, dated 11/1/22, indicated, . This SEVICE AGREEMENT is made and entered into as of the 1st day of November 2022, by and between [Name of New Pharmacy], and Centerpointe Care Center . Pharmacy agrees to provide prescription and over-the-counter medications . Pharmacy will furnish and replenish, on a regular basis, an emergency and interim medication supply, the composition of which will comply with federal and state regulations . Pharmacy agrees to provide delivery services to Facility three (3) times daily on weekdays and two (2) times daily on weekends . and on emergency basis . During a review of the facility's document titled, Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort . During a review of Professional reference from https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed, titled, Why You Need to Take Your Medications as Prescribed or Instructed dated 2/16, indicated, . Sticking to your medication routine (or medication adherence) means taking your medications as prescribed - the right dose, at the right time, in the right way and frequency . not taking your medicine as prescribed by a doctor or instructed by a pharmacist could lead to your disease getting worse, hospitalization, even death .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of six sampled residents (Resident 1) when the facility did not administer Resident 1 ' s physician prescribed medication of Sertraline (medication used to treat depression and anxiety) from 11/4/22 to 11/5/22. This failure resulted in Resident 1 not being administered his prescribed Sertraline and Resident 1 experiencing anxiety and sleeplessness for two days. Findings: During an interview on 11/7/22, at 1:11 p.m., with Resident 1, inside Resident 1 ' s room, Resident 1 stated, I didn't have my medication for anxiety for two days. I was restless and unable to sleep for two nights. I need my medication but since [the facility] does not have it, I had to wait. The nurses told me that they have a new pharmacy and they [pharmacy] failed to deliver my anti-anxiety medication on time. During a concurrent interview and record review on, 11/7/22, at 1:30 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record [MAR], dated 11/1/22 to 11/30/22 was reviewed. The MAR indicated Resident 1's Sertraline 25 milligram (unit of measurement) for anxiety disorder was not administered from 11/4/22 to 11/5/22. LVN 1 stated Resident 1 ' s Sertraline was not administered due to the medication not being available. LVN 1 stated the facility transitioned to a new pharmacy provider on 11/1/22 and the new pharmacy provider was not able to deliver Resident 1 ' s Sertraline on time. LVN 1 stated Resident 1 could experience anxiety and sleeplessness for not receiving his Sertraline medication. During an interview with the Director of Nursing (DON) on 11/7/22, at 2:35 p.m., the DON stated Resident 1 should have his Sertraline available for administration according to the physician ' s order. The DON stated the new pharmacy provider was not able to dispense Resident 1 ' s medications in a timely manner. The DON stated licensed nurses should reorder medications according to the facility ' s medication reordering policy. The DON stated Resident 1 could experience increased anxiety due to a missed dose of Sertraline. During a review of Resident 1's admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 11/7/22, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Parkinson ' s Disease (a medical condition that causes uncontrollable body movements, such as shaking, stiffness, and difficulty with balance and coordination) and Anxiety Disorder ( (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 8/9/22, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's 0rder Summary Report (OSR), dated 10/5/22, the OSR indicated, . [Sertraline] Give 25 mg by mouth at bedtime related to ANXIETY DISORDER . During a review of Resident 1 ' s Progress Note (PN), dated 11/4/22, the PN indicated, . 11/4/22 . 22:04 [10:04 p.m.] . Sertraline tablet . Hold until delivery per MD . During a review of Resident 1 ' s Progress Note (PN), dated 11/5/22, the PN indicated, . 11/5/22 . 20:13 [8:13 p.m.] . Sertraline tablet . not available, order medication to [Pharmacy X] . During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 4/2008, the P&P indicated, . Reorder medication five days in advance of need to assure an adequate supply is on hand . During a review of the facility's P&P titled, Medication Administration-General Guidance, dated 10/2017, the P&P indicated, . Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) . During a review of Pharmacy Services Agreement, dated 11/1/22, indicated, . This SEVICE AGREEMENT is made and entered into as of the 1st day of November 2022, by and between [Name of New Pharmacy], and Centerpointe Care Center . Pharmacy agrees to provide prescription and over-the-counter medications . Pharmacy will furnish and replenish, on a regular basis, an emergency and interim medication supply, the composition of which will comply with federal and state regulations . Pharmacy agrees to provide delivery services to Facility three (3) times daily on weekdays and two (2) times daily on weekends . and on emergency basis . During a review of the facility's document titled, Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort . During a review of Professional reference from https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed, titled, Why You Need to Take Your Medications as Prescribed or Instructed dated 2/16, indicated, . Sticking to your medication routine (or medication adherence) means taking your medications as prescribed - the right dose, at the right time, in the right way and frequency . not taking your medicine as prescribed by a doctor or instructed by a pharmacist could lead to your disease getting worse, hospitalization, even death .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program for one of three sampled residents (Resident 1) when there were visible brown and reddish substances in Resident 1 ' s bathroom wall. This failure resulted in an unclean and unsanitary environment for Resident 1 and had the potential to result in cross contamination and infection. Findings: During an observation on 8/5/22, at 10:59 a.m., in Resident 1 ' s bathroom, there was a dried brown substance that was visible on the wall across from the toilet. There were multiple dried substances on the floor and the wall on the side of the toilet. There were also multiple droplets of dried brown substance on the wall behind the toilet and two reddish brown fried substances were visible on the floor under the sink. During a concurrent observation and interview on 8/5/22, at 11:16 a.m., with Certified Nurse Assistant (CNA), in Resident 1 ' s bathroom, the dry brown and reddish substances on the walls and floor in the were shown to CNA. CNA 1 stated the brown and reddish substances were either blood or feces. CNA stated the housekeeper should be notified immediately to clean the bathroom. During an interview on 8/5/22, at 11:50 a.m., with the Housekeeping Manager (HM), the HM stated there was feces in the walls and floor on Resident 1 ' s bathroom. The HM stated it was important for the feces to be cleaned and disinfected immediately because it was an infection control issue and placed residents ' at risk to develop an infection. During an interview on 8/5/22, at 2:32 p.m., with the DON, the DON stated if feces were not cleaned up immediately, there was a potential risk to spread infection to other residents ' . During an interview on 8/10/22, at 4:07 p.m., with the Infection Preventionist (IP), the IP stated other residents at the facility were at risk of becoming sick if feces were not cleaned up immediately. IP stated the feces had the potential to spread bacterial infections (a disease caused by microorganisms that invade tissue). During a review of the facility ' s policy and procedure (P&P) titled, Infection Prevention and Control, [undated], the P&P indicated, GUIDELINE STATEMENT: An effective infection prevention and control program is necessary to control the spread of infections and/or outbreaks .activities involved in program development and oversight may include but are not limited to: .Developing and implementing appropriate infection control policies and procedures . During a review of the facility ' s P&P titled, Cleaning and Disinfection of Environmental Surfaces, dated 8/2012, the P&P indicated, .Housekeeping surfaces ( .floors .) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .Environmental surfaces will be disinfected (or cleaned) on a regular basis .and when surfaces are visibly soiled .Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and functional environment when two of four door alarms were tested to ensure alarm functionality and the door alarms did not function (to alert staff). This failure had the potential for residents to leave the facility undetected by staff, which placed residents at risk for serious injury, accidents and/or death. Findings: During a concurrent observation and interview on 3/2/22, at 12:16 p.m., with the Infection Preventionist (IP), in the dining room near the kitchen area, the IP checked the alarm function of the door alarm by opening the door and the door alarm did not function. The IP stated the door alarm in the dining room was not functioning for several months. The IP stated the exit door in the dining room lead to the back parking lot and access to the main street. The IP stated residents who scored high in elopement risk could use the exit door in the dining room to leave the facility undetected and placed residents at risk for serious injury, accidents and/or death. The IP stated maintenance staff was responsible to ensure door alarms were working and door alarms were tested daily. During a concurrent observation and interview on 3/2/22, at 12:26 p.m., with the IP, in Station 2 hallway, adjacent to room [ROOM NUMBER] and the DSD's office, the IP checked the alarm function of the exit door alarm by opening the door, the door alarm did not function. The IP stated the door alarm in Station 2 hallway was not functioning for several days. The IPstated the exit door in Station 2 hallway led to the back parking lot and access to the main street. The IP stated residents who scored high in elopement risk could use the exit door in Station 2 hallway to leave the facility undetected and placed residents at risk for serious injury, accidents and/or death. The IP[DI9] stated maintenance staff was responsible to ensure door alarms were working and that door alarms were tested daily. During a concurrent observation and interview on 3/2/22, at 12:35 p.m., with the Maintenance Director (MAIND), in the dining room near the kitchen area, the MAIND checked the alarm function of the door alarm by opening the door, the door alarm did not function. The MAIND stated the exit door in the dining room led to the back parking lot and access to the main street. MAIND stated the purpose of the door alarm was to alert facility staff if a resident was trying to leave the facility and to keep residents safe at all times. The MAIND stated confused residents could get out of the exit door undetected and wander outside the facility, which placed residents at risk for injury or accidents. The MAIND stated door alarms should be tested daily. The MAIND stated maintenance staff was responsible in ensuring that door alarms are working and door alarms are tested daily. MAIND stated the permanent maintenance director for the facility was on leave. MAIND stated, I am covering for today. I am the Maintenance Director for another facility. During a concurrent observation and interview on 3/2/22, at 12:39 p.m., with the MAIND, in Station 2 hallway, adjacent to room [ROOM NUMBER] and DSD's office, the MAIND checked the alarm function of the exit door alarm by opening the door, the door alarm did not function. MAIND stated the exit door in Station 2 hallway lead to the back parking lot and access to the main street. MAIND stated confused residents could get out of the exit door undetected and wander outside the facility, placing residents at risk for injury or accidents. MAIND stated door alarms should be tested daily. On 3/2/22, at 12:42 p.m., a copy of the daily alarm log for the month of February 2022 and March 2022 was requested from the MAIND, and the MAIND was unable to provide a copy of the daily alarm log for the month of February 2022 and March 2022. During an interview on 3/2/22, at 5:45 p.m., with the Director of Nursing (DON), the DON stated exit doors should have functioning alarms at all times. The DON stated door alarms should be tested daily. The DON stated maintenance staff was responsible in ensuring that door alarms are working and door alarms are tested daily. The DON stated residents who scored high in elopement risk could use the exit door to leave the facility undetected and placed residents at risk for serious injury, accidents and/or death. The DON stated the facility's policy on preventing elopement was not followed. During an interview on 3/2/22, at 5:55 p.m., with the Administrator (ADM), the ADM stated exit doors should have functioning alarms at all times and door alarms should be tested daily by the Maintenance Director or his designee. The ADM stated the situation was unacceptable and the facility's policy on preventing elopement was not followed. On 3/2/22, at 5:59 p.m., a copy of the daily alarm log for the month of February 2022 and March 2022 was requested from the ADM, and the ADM was unable to provide a copy of the daily alarm log for the month of February 2022 and March 2022. During a review of the facility's document titled Job description of Maintenance Director, dated 2/2014, the Job Description indicated, . Ensuring that all maintenance activities in a facility are appropriately carried out . Keeping a record of all maintenance and service activities conducted and maintaining a cycle of the same . During a review of the facility's document titled, Elopement Guideline, dated 10/2015, the document indicated, . Door alarms and resident protection alarms . Door alarms are tested daily. The results of the tests are then recorded on designated log . Monitoring Compliance . Door alarms are checked and documented in Building Engines . During a review of the facility's P&P titled, Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance Department is responsible for maintaining the building, grounds and equipment in safe and operable manner at all times .

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of 69 sampled residents (Resident 41) when Resident 41's gastrostomy tube (g-tube) (a tube inserted through an incision in the abdomen that delivers nutrition directly to the stomach) was visible while Resident 41 was asleep in the facility's hallway. This practice failed to provide Resident 41 with privacy to ensure dignity and respect which resulted in Resident 41's g-tube to be visible to other residents and visitors in the facility and violated Resident 41's right to keep her nutritional status confidential. Findings: Review of Resident 41's clinical record, titled, Face sheet (a document containing resident profile information) indicated Resident 41 was admitted to the facility with diagnoses which included gastrostomy status. On 1/22/19 at 3:06 p.m., during an observation in the facility's hallway, Resident 41 sat in her wheelchair and was asleep. Resident 41's g-tube hung between Resident 41's blouse and pants and was visible to other residents and visitors in the facility. On 1/22/19 at 3:10 p.m., during a concurrent observation and interview, in the facility's hallway, Resident 41 sat in her wheelchair and was asleep. Social Service Director (SSD) 2 stated Resident 41's g-tube was visible and should not be visible for other residents and visitors to see. On 1/22/19 at 3:15 p.m., during an interview, Licensed Nurse (LN) 14 stated Resident 41's g-tube should not be visible to other residents and visitors. LN 14 stated, It's a dignity issue. On 1/23/19 at 8:17 a.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated it was a dignity issue for Resident 41's g-tube to be visible to other residents, staff and visitors. The facility policy and procedure titled, Dignity dated 2/26/15, indicated, . All residents will be treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality . Treating residents with dignity and respect maintains and enhances each resident's self-worth and improves his or her psychosocial well-being and quality of life . Maintaining dignity . Assisting residents in daily care in a dignified manner . covering appliances attached to resident, ensuring residents are not exposed .

Based on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for three of 69 sampled residents (Resident 10, Resident 51 and Resident 36) when: 1. Resident 10's physician did not provide, and licensed nurses did not clarify, the blood glucose (sugar) parameters for which to notify and alert the physician after elevated blood sugar values continued for over 30 days. 2. Licensed nurses did not clarify with Resident 51's physician the flow rate for supplemental oxygen (O2) administration and administered supplemental O2 without a complete physicians order. 3. Resident 36's Midrodine (a medication used to treat low blood pressure) was not administered to Resident 36 on 12/18/18 when Resident 36's blood pressure was 81/48 per physician's order and no blood pressure parameter was in place to determine when to administer the Midodrine medication. For Resident 10 this failure resulted in the administration of medication without parameters which could be harmful without the benefit of adequate monitoring and reporting parameters. For Resident 51 this failure resulted in the potential for Resident 51 to receive too high or too low supplemental oxygen. For Resident 36 this failure had the potential to result in Resident 36 to experience low blood pressure symptoms such as dizziness and blurred vision. Findings: 1. On 1/22/19 at 8:40 AM, during a concurrent interview and record review, Registered Nurse Assessment Coordinator (RNAC), stated Resident 10's blood sugar values ranged from 300 to 400 from 10/2018 through 1/2019. The RNAC reviewed Resident 51's clinical record but could not find parameters of blood sugar levels for which a nurse should call the physician. The RNAC reviewed nursing progress notes but could not find documentation of a nurse calling the doctor to inform him of Resident 10's blood sugar. The RNAC stated it should be documented when a nurse calls the doctor. RNAC stated licensed nurses should have notified the physician since [a blood glucose level between 300-400] was a high blood glucose value. On 1/22/19 at 8:50 AM, during an interview with Licensed Nurse (LN) 6, LN 6 stated, As nurses we should notify the doctor if the blood sugar is high. We should do an SBAR [Situation, Background, Assessment, Recommendation] document to communicate promptly with a physician].The doctor should be notified if he needs a sliding scale (a range of blood sugar values the MD orders a dose of Insulin to be administered based upon the value). A 400 plus blood sugar is too high and out of range in the sliding scale. It's nursing judgement that we notify the doctor if the blood sugar is high; in this case it is too high. We need a parameter. I don't see a parameter for the blood sugar. We need a parameter to know when to notify the doctor. I don't see a parameter [in the orders] for the blood sugar. On 1/22/19 at 9:20 AM, during an interview and record review, LN 8 reviewed Resident 10's blood sugar values from 10/1/18 through 1/22/19, and stated, Absolutely [we] should notify the MD [Medical Doctor] but we need a parameter of the blood sugar to know when to call a doctor. [A blood glucose value of ] 400 and 300 is too high and the patient might need additional insulin but the doctor should be notified and it needs to be documented in the progress notes that MD was notified. On 1/22/19 at 9:35 AM, during an interview and record review, LN 11 stated licensed nurses needed to notify the MD when a resident experienced high blood sugar values. LN 11 stated, nurses need a parameter of when to call the doctor for an increase in blood sugar because it may be necessary to get additional laboratory work done to determine if the current medication regimen was effective or not. On 1/22/19 at 10:05 AM, during a concurrent interview and record review, the Director of Nursing (DON) stated the nurses did not notify the physician to clarify and obtain parameters of blood sugar ranges. The DON stated Resident 10's clinical record did not indicate nurse documentation the MD was notified about the elevated blood sugar values. The DON stated it was the responsibility of the nurse to notify the MD when the resident's blood sugar was elevated. Review of the facility policy and procedure titled, Notification of Change in Resident Health Status dated 11/12/14, indicated, .To ensure that proper notifications are made when a resident has a change in health status .The center will consult the resident's physician, nurse practitioner or physician assistant .A. Acute illness or a significant change in the resident's physical, mental, or psychosocial status(i.e. deterioration in health .or clinical complications .C A need to alter treatment significantly (i.e. a need to discontinue an existing from of treatment due adverse consequence, or to commence a new form of treatment .Notification: Depending on the nursing evaluation appropriate notification may be immediate to 48 hours . 2. On 1/16/19 at 9 AM, during an observation, Resident 51 was in bed in a seating position receiving oxygen at 2 liters (L) per minute via nasal cannula. On 1/17/19 at 9:40 AM, during a concurrent interview and record review, the Director of Staff Development (DSD) stated the order for oxygen was not correct because it did not specify how many liters of oxygen to administer. On 1/17/19 at 11:45 AM, during a concurrent interview and record review, LN 11 stated, I don't know how many liters to put it because the order does not indicate how many liters. On 1/23/19 at 1:24 PM, during a concurrent joint interview and record review, with the DON and Director of Clinical Operations (DCO), the DCO stated oxygen orders were required to include how many liters of supplemental O2 to administer. Review of the facility policy and procedure titled, Oxygen Administration dated 6/20/16, indicated, .Procedure Details .1. Check Physician's order . Review of professional reference titled, COMPLETE GUIDE TO DOCUMENTATION second edition dated 2008, indicated, Clarify ambiguous orders with the practitioner. Document your efforts to clarify the order and document whether the order was carried out. 3. On 1/23/19 at 1:24 p.m., during a concurrent interview and record review, the DON reviewed Resident 36's clinical record and stated Resident 36's blood pressure was 81/48 on 12/18/18. The DON reviewed Resident 36's Medication Administration Record (MAR) dated 12/18 and could not find documented evidence LN administered the Midodrine medication to Resident 36 on 12/18/18. The DON stated, We usually know the [blood pressure] parameters. It should have been given when the blood pressure was 81/48. Midodrine medication should have been given when the blood pressure was low and the doctor should have been notified. The DON was unable to provide documented evidence LNs notify the physician Resident 36 had a low blood pressure of 81/48 on 12/18/18 and the Midodrine medication was not given.

Based on observation, interview and record review, the facility failed to report medication irregularities for one of 69 sampled residents (Resident 66) when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's ordered dose of 30 mg. daily. This failure resulted in Resident 66's receipt of a higher dose of medication than the physician ordered daily from 12/9/18 through 1/22/19 which placed the resident at risk of adverse reactions from the higher dosage. Findings: On 1/22/19 at 10:32 a.m., during an interview, Licensed Nurse (LN) 8 stated she administered Duloxetine to Resident 66 from the medication cart bubble pack (a card containing multiple doses of a medication, separated into individual doses). LN 8 stated she did not remember giving Resident 66 half a capsule of the Duloxetine. LN 8 stated if a physician's order did not match the directions on the bubble pack she should clarify with the physician. LN 8 stated the Duloxetine medication order did not match the directions on the bubble pack and she did not clarify the order with the doctor. On 1/22/19 at 11:33 a.m., during a concurrent observation and record review at Station 1's medication cart, the Director of Clinical Operations (DCO) reviewed Resident's 66's physician orders dated 12/9/18 in the computer and compared it with the instructions on the medication bubble pack. The medication bubble pack of Duloxetine indicated, . Duloxetine Cap 40 MG . Take one (1) capsule by mouth once daily . Swallow Whole, Do Not Chew Or Crush . The bubble pack had 11 doses removed from the pack . Resident 66's physician's orders dated 12/9/18 indicated, . Duloxetine 60 MG . Give 0.5 capsule daily . On 1/22/19 at 1:40 p.m., during a concurrent interview and record review, the DCO stated Resident 66's Electronic Medication Administration Record (eMAR) for January 2019 indicated an order for Duloxetine HCl [HydroChloric Acid] capsule Delayed Release Particles 60 MG [milligrams] Give 0.5 capsule by mouth . The DCO stated Resident 66 had received the wrong dose [from 12/9/18 to 1/22/19]. The DCO stated the daily check marks and initials in the eMAR indicated Resident 66 received the Duloxetine medication from 12/9/18 to 1/22/19. Review of Resident 66's eMAR dated 12/18, indicated, . Duloxetine HCl [HydroChloric Acid] capsule Delayed Release Particles 60 MG [milligrams] Give 0.5 capsule by mouth . The first medication dose was documented as administered on 12/9/18. Review of Resident 66's record review, titled, Order Summary Report dated 12/8/18 indicated, . Duloxetine HCl Capsule Delayed Release Particles 60 MG Give 0.5 capsule by mouth one time a day . During a concurrent interview and record review with the DCO, the pharmacy drug manifest (pharmacy delivery slip) dated 12/9/18 and 1/3/19 was reviewed and indicated, . [Resident 66] . Duloxetine [Capsule] 40 mg . medication was delivered to the facility. The drug manifest dated 1/3/19, indicated, . [Resident 66] . Duloxetine [Capsule] 40 mg . The DCO stated the pharmacy made a mistake in transcribing the order. Review of Resident 66's record, titled, Clinical Pharmacist Medication Regimen Review Summary dated 12/12/18 and 1/21/19 indicated Resident 66's clinical record was reviewed by the facility pharmacist with no recommendations. Review of the Duloxetine drug prescribing package insert information dated 2014, indicated, Duloxetine . Concerns related to adverse effects: [1] Bleeding risk: May impair platelet aggregation resulting in increased risk of bleeding events . use has been reported to range from relatively minor bruising . to life-threatening hemorrhage [an escape of blood from a ruptured blood vessel] .

Based on observation, interview and record review, the facility failed to report medication irregularities for one of 69 sampled residents (Resident 66) when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's order dose of 30 mg. This failure resulted in Resident 66 to receive more than the physican prescribed dose of Duloxetine medication daily from 12/9/18 through 1/22/19 which placed the resident at risk of side effects of a high dose of medication. Findings: On 1/22/19 at 10:32 a.m., during an interview, Licensed Nurse (LN) 8 stated she administered the Duloxetine to Resident 66 from the medication cart bubble pack (a card containing multiple doses of a medication, separated into individual doses). LN 8 stated she did not remember giving Resident 66 half a capsule of the Duloxetine. LN 8 stated if a physician's order did not match the directions on the bubble pack she would clarify with the physician. LN 8 stated the Duloxetine medication order did not match the directions on the bubble pack and she did not clarify the order with the doctor. On 1/22/19 at 11:33 a.m., during a concurrent observation and record review at Station 1's medication cart, the Director of Clinical Operations (DCO) reviewed Resident's 66's physician's order in the computer and compared it with the medication bubble pack. The medication bubble pack of Duloxetine indicated, . Duloxetine Cap 40 MG . Take one (1) capsule by mouth once daily . Swallow Whole, Do Not Chew Or Crush . The bubble pack had 11 doses removed from the pack . Resident 66's physician's orders dated 12/9/18 indicated, . Duloxetine 60 MG . Give 0.5 capsule daily . On 1/22/19 at 1:40 p.m., during a concurrent interview and record review, the DCO stated Resident 66's Electronic Medication Administration Record (eMAR) for January 2019 indicated an order for Duloxetine HCl [HydroChloric Acid] capsule Delayed Release Particles 60 MG [milligrams] Give 0.5 capsule by mouth . The DCO stated Resident 66 had received the wrong dose from 12/9/18 to 1/22/19. The DCO stated the daily check marks and initials in the eMAR indicated Resident 66 received the Duloxetine medication from 12/9/18 to 1/22/19. Review of Resident 66's record, titled eMAR dated 12/18, indicated, . Duloxetine HCl [HydroChloric Acid] capsule Delayed Release Particles 60 MG [milligrams] Give 0.5 capsule by mouth . The first medication dose was documented as administered on 12/9/18. Review of Resident 66's record, titled, Order Summary Report dated 12/8/18, indicated, . Duloxetine HCl Capsule Delayed Release Particles 60 MG Give 0.5 capsule by mouth one time a day . On 1/23/19 at 3 p.m., during a concurrent interview and record review with the DCO, the Pharmacy drug manifest (pharmacy delivery slip) dated 12/9/18 and 1/3/19 was reviewed and indicated, . [Resident 66] . Duloxetine [Capsule] 40 mg . medication was delivered to the facility. The drug manifest dated 1/3/19, indicated, . [Resident 66] . Duloxetine [Capsule] 40 mg . The DCO stated the pharmacy made a mistake in transcribing the order. Review of Resident 66's record, title, Clinical Pharmacist Medication Regimen Review Summary dated 12/12/18 and 1/21/19, indicated Resident 66's clinical record was reviewed by the facility pharmacist with no recommendations. Review of the facility policy and procedure titled, Administration Procedures For All Medications dated 12/17, indicated, Policy. To administer medications in a safe and effective manner . C. Review 5 Rights (3) times: 1. Prior to removing the medication package/container from the cart/drawer; 2. Prior to removing the medication from the container a. Check the label against the order on the MAR . 3) After the dose has been prepared and before returning the medication to storage . After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the Mar or TAR [Treatment Administration Record], . Review of the Duloxetine drug prescribing package insert information, dated 2014, indicated, Duloxetine . Concerns related to adverse effects: [1] Bleeding risk: May impair platelet aggregation (blood clotting mechanism) resulting in increased risk of bleeding events . use has been reported to range from relatively minor bruising . to life-threatening hemorrhage [an escape of blood from a ruptured blood vessel] .

Based on observation, interview and record review, the facility failed to ensure one of 69 sampled residents (Resident 66) was free from significant medication error when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's ordered dose of 30 mg daily. This failure resulted in Resident 66's receipt of a higher dose of medication than the physician ordered daily from 12/9/18 through 1/22/19 which placed the resident at risk of adverse reactions from the higher dosage. Findings: On 1/22/19 at 10:32 a.m., during an interview, Licensed Nurse (LN) 8 stated she administered Duloxetine to Resident 66 from the medication cart bubble pack (a card containing multiple doses of a medication, separated into individual doses). LN 8 stated she did not remember giving Resident 66 half a capsule of the Duloxetine. LN 8 stated if a physician's order did not match the directions on the bubble pack she should clarify with the physician. LN 8 stated the Duloxetine medication order did not match the directions on the bubble pack and she did not clarify the order with the doctor. On 1/22/19 at 11:33 a.m., during a concurrent observation and record review at Station 1's medication cart, the Director of Clinical Operations (DCO) reviewed Resident's 66's physician orders for what date in the computer and compared it with the instructions on the medication bubble pack. The medication bubble pack of Duloxetine indicated, . Duloxetine Cap 40 MG . Take one (1) capsule by mouth once daily . Swallow Whole, Do Not Chew Or Crush . The bubble pack had 11 doses removed from the pack . Resident 66's physician's orders dated 12/9/18 indicated, . Duloxetine 60 MG . Give 0.5 capsule daily . On 1/22/19 at 1:40 p.m., during a concurrent interview and record review, the DCO stated Resident 66's Electronic Medication Administration Record (eMAR) for January 2019 indicated an order for Duloxetine HCl [HydroChloric Acid] capsule Delayed Release Particles 60 MG [milligrams] Give 0.5 capsule by mouth . The DCO stated Resident 66 had received the wrong dose [from 12/9/18 to 1/22/19]. The DCO stated the daily check marks and initials in the eMAR indicated Resident 66 received the Duloxetine medication from 12/9/18 to 1/22/19. Review of Resident 66's eMAR dated 12/18, indicated, . Duloxetine HCl [HydroChloric Acid] capsule Delayed Release Particles 60 MG [milligrams] Give 0.5 capsule by mouth . The first medication dose was documented as administered on 12/9/18. Review of Resident 66's record review, titled, Order Summary Report dated 12/8/18 indicated, . Duloxetine HCl Capsule Delayed Release Particles 60 MG Give 0.5 capsule by mouth one time a day . During a concurrent interview and record review with the DCO, the pharmacy drug manifest (pharmacy delivery slip) dated 12/9/18 and 1/3/19 was reviewed and indicated, . [Resident 66] . Duloxetine [Capsule] 40 mg . medication was delivered to the facility. The drug manifest dated 1/3/19, indicated, . [Resident 66] . Duloxetine [Capsule] 40 mg . The DCO stated the pharmacy made a mistake in transcribing the order. Review of Resident 66's record, titled, Clinical Pharmacist Medication Regimen Review Summary dated 12/12/18 and 1/21/19 indicated Resident 66's clinical record was reviewed by the facility pharmacist with no recommendations. Review of the Duloxetine drug prescribing package insert information dated 2014, indicated, Duloxetine . Concerns related to adverse effects: [1] Bleeding risk: May impair platelet aggregation resulting in increased risk of bleeding events . use has been reported to range from relatively minor bruising . to life-threatening hemorrhage [an escape of blood from a ruptured blood vessel] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Ovanisyan, Suren Based on interview and record review, the facility failed to develop a comprehensive person centered care plan to establish care needs, interventions and measurable objectives for three of 69 sampled residents (Resident 78 and 302) when: 1. Resident 78 did not have a care plan with measurable goals and interventions for the diagnosis and treatment of pneumonia (lung infection). 2. Resident 302 did not have a care plan with measurable goals and interventions for the diagnosis of Clostridium difficile (C. diff) (infection of the colon-large intestine). 3. Resident 10's care plan for diabetes (abnormal metabolism of carbohydrates resulting in elevated levels of glucose in the blood and urine) was not revised to reflect individualized effective interventions or targeted blood sugar values which frequently ranged between 300 milligrams per deciliter (mg/dL) (a unit of measurement) to 400 mg/dL (normal blood sugar level on an empty stomach range between 70 and 99 mg/dL, normal blood sugar level two hours after eating is less than 140 mg/dL) This needs a resource, professional, rather than a stated opininion. This practice placed residents at risk for complications from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed or completed. Findings: 1. On 1/22/19 at 9:26 AM, during a concurrent interview and record review, Licensed Nurse (LN) 5 stated Resident 78 was on doxycycline (medication to treat an infection) 100 milligrams (mg) (dry unit of measurement) for pneumonia (lung infection). LN 5 stated Resident 78 came back from the hospital on [DATE]] with pneumonia. LN 5 stated residents who were diagnosed with pneumonia and who were on antibiotics required to have a care plan with interventions. LN 5 stated, There is no care plan in place for pneumonia. LN 5 stated, We need a care plan to know what we are monitoring for and to document our interventions. On 1/22/19 at 1:56 PM, during an interview, LN 5 stated a care plan should be initiated on the same day when a resident is diagnosed with pneumonia and on the same day an antibiotic is ordered. On 1/22/19 at 9:33 AM, during interview and record review, the Electronic Medical Records (EMR) validated there was no care plan in place for Resident 78's diagnosis of pneumonia and antibiotic treatment. 2. On 1/18/19 at 10:35 AM, during a concurrent interview and record review, LN 7 stated Resident 302 experienced pain, nausea and vomiting on 12/28/18 at the dialysis center and required to be hospitalized the same day. LN 7 stated Resident 302 returned to the facility on 1/15/19 with a diagnosis of C-diff. LN 7 stated Resident 302 was on Vancomycin 250 mg antibiotic (a medication to treat infection) capsules every six hours. LN 7 stated Resident 302's record required a care plan for C. diff because it was important [to reflect progress to treatment]. LN 7 reviewed Resident 302's medical record and stated, I don't see a care plan for C. diff for this resident. The care plan should be in place, it should include isolation precautions and interventions such as administering antibiotics. The care plan should have been [written] especially [when the residents ] are on specific medication for C. diff. On 1/18/19 at 3:47 PM, Assistant Director of Nursing (ADON) stated, When a resident is on antibiotics, vital signs, adverse affects, and how the resident is doing should be charted. When a resident completes their antibiotics [as ordered] there should be charting for 72 hours. If a resident has C. diff and is put on antibiotics they should have care plan for infection control, so everyone is providing the same care. On 1/22/19 at 1:56 PM, during an interview, LN 5 stated a care plan should be initiated on the same day when a resident is diagnosed with C. diff and on the same day an antibiotic is ordered. Review of Resident 302's revised care plan dated 1/18/18, indicated, Resident to remain on isolation precautions [related to] c-diff .Goal resolve without complications. Date initiated: 1/18/19 . 3. Review of Resident 10's face sheet (a document containing resident profile information) indicated Resident 10 was initially admitted to the facility on [DATE]. The document indicated Resident 10 was readmitted to the facility on [DATE], with diagnoses which included diabetes and pressure ulcer of the left heel. On 1/22/19 at 8:40 AM, during a concurrent interview and record review, Registered Nurse Assessment Coordinator (RNAC) stated Licensed Nurses (LN) should have notified Resident 10's Primary Care Physician (PCP) of Resident 10's elevated blood sugar levels. RNAC reviewed Resident 10's clinical record and was unable to find a documented assessment LNs performed when Resident 10 had episodes of elevated blood sugar levels. RNAC stated Resident 10 did not have a physician's order of blood sugar parameter for LNs to base their assessment in order to determine if a blood sugar level would warrant the LNs to call the PCP or document a change of condition. RNAC stated Resident 10's blood sugar results were high and the PCP should have been notified and a change of condition assessment should have been done by LNs. On 1/22/19 at 9:25 AM, during a concurrent interview and record review, LN 6 reviewed Resident 10's care plans dated January 2019, and stated she did not see a care plan initiated by LNs that addressed Resident 10's diabetes condition and elevated blood sugars. LN 6 stated, It [diabetes and episodes of elevated blood sugar levels] should be in the care plan because a care plan is important to plan the care for the resident and see if the interventions are working especially with a pattern of high blood sugars over the past months should be in the care plan. On 1/22/19 at 9:35 AM, during a concurrent interview and record review, LN 11 reviewed Resident 10's care plans and stated, [Resident 10] should have a care plan for his diagnosis of diabetes and episodes of elevated blood sugar levels but he does not, I do not see one. On 1/22/19 at 10:29 AM, during an interview, LN 9 stated, [Licensed Nurses] have to get an order to call MD [doctor] if [blood sugar level] is over 400 [mg/dl] and to recheck [blood sugar level] and notify MD. [Licensed Nurses] have to do a care plan and a change of condition [assessment and documentation] . On 1/23/19 at 8:29 AM, during a concurrent interview and record review, Director of Staff Development (DSD) reviewed Resident 10's clinical record and was unable to find a care plan for diabetes and the episodes of elevated blood sugar levels since Resident 10 was re-admitted back to the facility on what date. The DSD stated LNs should have done a care plan on diabetes and the elevated blood sugar levels. The DSD stated, All nurses are trained on orientation how to recognized signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) so I don't understand what is happening. They should know [to notify the MD for a change in condition] and [Licensed Nurses] have been in-serviced many times on documentation. The DSD stated Resident 10 had wounds on both heels and elevated blood sugar levels over a prolonged period of time could result in delayed wound healing. The facility policy and procedure titled, Care Planning Process dated 12/17, indicated, The interdisciplinary team shall prepare a comprehensive person centered care plan with the patient/resident and if applicable, the resident representative, to assist the patient/resident to reach his/her highest level. The care planning process will begin upon admission to the center . Procedure . 4. The care plan will be person centered and incorporate the patient/resident's goals of care and treatment . Professional reference titled, High Blood Sugar (Hyperglycemia) in Diabetes (retreived from www.summitmedicalgroup.com) undated, indicated, High blood sugar means that the level of sugar in your blood is higher than recommended for you. If you don't keep your blood sugar at a normal, healthy level most of the time, you will increase your risk of heart and blood vessel disease, stroke, kidney problems, and loss of vision . Very high blood sugar above 400 mg/dl can be a medical emergency. In many cases it must be treated right away with IV [intravenous] fluids and insulin . High blood sugar can be serious if it's not treated. If your blood sugar runs too high over time, it can cause problems with your heart, eyes, kidneys, nerves and blood vessels. A very high blood sugar can cause life-threatening problems, coma, or death . The facility document titled, Job Description Charge Nurse LVN dated 8/15, indicated, . Assess resident needs, develop individual care plans, administer nursing care, evaluate nursing care . Essential Job Duties . Assure that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process. Identify needs . Develop individualized plan of care in collaboration with the resident/responsible party and interdisciplinary care team . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . The facility policy and procedure titled, Care Planning Process dated 12/11/17, indicated, The interdisciplinary team [a group composed of a physician, a nurse, a social worker and additional appointed facility staff] shall prepare a comprehensive person centered care plan .to assist the patient/resident to reach his/her highest practicable level .The care planning process will begin upon admission to the center .1. Upon admission to the center, a baseline care plan will be developed within 48 hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and a comprehensive person-centered care plan for two of 69 sampled residents (Resident 10 and Resident 462) when: 1. Resident 10's physician did not provide, and licensed nurses did not clarify, the blood glucose (sugar) parameters for which to notify and alert the physician after elevated blood sugar values continued for three months. 2. Resident 10's care plan for diabetes (abnormal metabolism of carbohydrates resulting in elevated levels of glucose in the blood and urine) was not revised to reflect individualized effective interventions or targeted blood sugar values which frequently ranged between 300 milligrams per deciliter (mg/dL) (a unit of measurement) to 428 (normal blood sugar level on an empty stomach range between 70 and 99 mg/dL, normal blood sugar level two hours after eating is less than 140 mg/dL). 3. Resident 462's dilantin (a medication to treat seizure) level was 3 micrograms per milliliter (ug/ml-a unit of measurement), below the normal therapeutic range of 10 to 20 and the physician was not notified promptly per facility's policy and procedure. 4. Resident 462 had a possible episode of seizure (a sudden surge of electrical activity in the brain) as reported by Certified Nursing Assistant (CNA) 5 to Licensed Nurse (LN) 2 and there was no documented assessment performed by LN 2. 1. These failures placed Resident 10 at risk for a delay in wound healing of a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) and at risk for complications from diabetes. 2. These failures placed Resident 462 at increased risk for seizures. Findings: 1. Review of Resident 10's record, titled, Face sheet (a document containing resident profile information) indicated Resident 10 was initially admitted to the facility on [DATE]. The document indicated Resident 10 was readmitted to the facility on [DATE], with diagnoses which included diabetes and pressure ulcer of the left heel. On 1/22/19 at 8:40 AM, during a concurrent interview and record review, Registered Nurse Assessment Coordinator (RNAC) stated LNs should have notified Resident 10's Primary Care Physician (PCP) of Resident 10's elevated blood sugar levels. RNAC reviewed Resident 10's clinical record and was unable to find a documented assessment LNs performed when Resident 10 had episodes of elevated blood sugar levels. RNAC stated Resident 10 did not have a physician's order to include blood sugar parameters for LNs to inform the physician of blood sugar levels that may have warranted a call from the LNs. The RNAC stated Resident 10's blood sugar results were high and the PCP should have been notified and a change of condition assessment should have been done by LNs. On 1/22/19 at 8:50 AM, during a concurrent interview and record review, with Licensed Nurse (LN) 6, LN 6 reviewed Resident 10's blood sugar values for the month of January 2019 and stated, As nurses we should notify the doctor if the blood sugar is high. We should do an SBAR [Situation, Background, Assessment, Recommendation] document to communicate promptly with a physician].The doctor should be notified if he [resident] needs a sliding scale. A 400 plus blood sugar is too high .It's nursing judgement that we notify the doctor if the blood sugar is high; in this case it is too high. We need a parameter. I don't see a parameter for the blood sugar. We need a parameter to know when to notify the doctor. I don't see a parameter [in the orders] for the blood sugar. On 1/22/19 at 9:20 AM, during an interview and record review, LN 8 reviewed Resident 10's blood sugar values from 10/1/18 through 1/22/19, and stated, Absolutely [we] should notify the MD [Medical Doctor] but we need a parameter of the blood sugar to know when to call a doctor. [A blood glucose value of ] 400 and 300 is too high and the patient might need additional insulin but the doctor should be notified and it needs to be documented in the progress notes that MD was notified. On 1/22/19 at 9:35 AM, during an interview and record review, LN 11 stated licensed nurses needed to notify the MD when a resident experienced high blood sugar values. LN 11 stated, nurses needed a parameter of when to call the doctor for an increase in blood sugars because the physician may have wanted to order blood work to obtain laboratory values to determine if the current medication regimen was effective or not. On 1/22/19 at 10:05 AM, during a concurrent interview and record review, the Director of Nursing (DON) stated the nurses did not notify the physician to clarify and obtain parameters of blood sugar ranges. The DON stated Resident 10's clinical record had not indicated nurse documentation the MD was notified about the elevated blood sugar values. The DON stated it was the responsibility of the nurse to notify the MD when the resident's blood sugar was elevated. Review of Resident 10's Minimum Data Set Assessment (MDS) assessment (an evaluation of memory care and functional needs) dated 10/9/18, indicated, Resident 10 was at risk for developing pressure ulcers and indicated Resident 10 had a Stage 3 pressure ulcer (wound with full thickness tissue loss). Review of Resident 10's physician orders, dated 1/2019, indicated, . Insulin Lispro Solution 100 unit/milliliter (ml) [a unit of measurement] Inject 10 units subcutaneous before meals . Lancets (device used to poke the skin to obtain a drop of blood) 1 strip . in the morning every [Tuesday, Thursday and Sunday] related to type 2 diabetes mellitus . Resident 10's physician orders did not indicate an order for an insulin sliding scale (increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). Review of Resident 10's Medication Administration Record (MAR) reflect the following values: morning blood sugar values for the month of October 2018 indicated, blood sugar ranges were from 304 mg/dL to 367 mg/dL. Review of Resident 10's noon blood sugar values for the month of October 2018 indicated, blood sugar ranges were from 312 mg/dL to 400 mg/dL. Review of Resident 10's evening blood sugar values for the month of October 2018 indicated, blood sugar ranges were from 382 mg/dL to 425 mg/dL. Review of Resident 10's night blood sugar values for the month of October 2018 indicated, blood sugar ranges were from 303 mg/dL to 402 mg/dL. Review of Resident 10's morning blood sugar values for the month of January 2019 indicated, blood sugar ranges were from 295 mg/dL to 428 mg/dL. Review of Resident 10's noon blood sugar values for the month of January 2019 indicated, blood sugar ranges were from 248 mg/dL to 416 mg/dL. Review of Resident 10's evening blood sugar values for the month of January 2019 indicated, blood sugar ranges were from 227 mg/dL to 414 mg/dL. Review of Resident 10's night blood sugar values for the month of January 2019 indicated, blood sugar ranges were from 267 mg/dL to 400 mg/dL. 2. On 1/22/19 at 9:25 AM, during a concurrent interview and record review, LN 6 reviewed Resident 10's care plans dated January 2019 and stated she did not see a care plan initiated by LNs that addressed Resident 10's diabetes condition and elevated blood sugars. LN 6 stated, It [diabetes and episodes of elevated blood sugar levels] should be in the care plan because a care plan is important to plan the care for the resident and see if the interventions are working especially with a pattern of high blood sugars over the past months should be in the care plan. On 1/22/19 at 9:35 AM, during a concurrent interview and record review, LN 11 reviewed Resident 10's care plans and stated, [Resident 10] should have a care plan for his diagnosis of diabetes and episodes of elevated blood sugar levels but he does not, I do not see one. On 1/22/19 at 10:29 AM, during an interview, LN 9 stated,[Licensed Nurses] have to get an order to call MD [doctor] if [blood sugar level] is over 400 [mg/dl] and to recheck [blood sugar level] and notify MD. [Licensed Nurses] have to do a care plan and a change of condition [assessment and documentation] . On 1/23/19 at 8:29 AM, during a concurrent interview and record review, the Director of Staff Development (DSD) reviewed Resident 10's clinical record and was unable to find a care plan for diabetes and the episodes of elevated blood sugar levels since Resident 10 was re-admitted back to the facility. The DSD stated LNs should have done a care plan on diabetes and the elevated blood sugar levels. The DSD stated, All nurses are trained on orientation how to recognized signs and symptoms of hypoglycemia and hyperglycemia so I don't understand what is happening. They should know [to notify the MD for a change in condition] and [Licensed Nurses] have been in-serviced many times on documentation. DSD stated Resident 10 has wounds on both heels and elevated blood sugar levels over a prolonged period of time could result in delayed wound healing. Review of Resident 10's record, titled, Physician Orders dated 1/19, indicated, . Wound Vac [Vacuum assisted closure of a wound- is a type of therapy to help wounds heal. During the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly.] Apply to both heels topically every [Tuesday, Thursday, Saturday] for open wounds apply Black Foam to wound bed after cleansing, cover with drape and run at 125 mmhg [millimeters of Mercury- a measurement used to measure pressure] . On 1/23/19 at 1:24 PM, during an interview, the DON stated Resident 10 had wounds on bilateral (both sides) heels and his elevated blood sugar levels over a prolonged period of time could result in delayed wound healing. DON stated LNs should have performed an assessment and a change of condition charting when Resident 10 had elevated blood sugar levels. The DON stated LNs should notify Resident 10's PCP for any change in condition. The facility policy and procedure titled, Notification of Change in Resident's Health Status dated 11/14, indicated, . The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is . A .Significant change in the resident's physical . status . deterioration in health . or clinical complications . The facility policy and procedure titled, Care Planning Process dated 12/17, indicated, The interdisciplinary team shall prepare a comprehensive person centered care plan with the patient/resident and if applicable, the resident representative, to assist the patient/resident to reach his/her highest level. The care planning process will begin upon admission to the center . Procedure . 4. The care plan will be person centered and incorporate the patient/resident's goals of care and treatment . Professional reference titled, High Blood Sugar (Hyperglycemia) in Diabetes (found at www.summitmedicalgroup.com) undated, indicated, High blood sugar means that the level of sugar in your blood is higher than recommended for you. If you don't keep your blood sugar at a normal, healthy level most of the time, you will increase your risk of heart and blood vessel disease, stroke, kidney problems, and loss of vision . Very high blood sugar above 400 mg/dl can be a medical emergency. In many cases it must be treated right away with IV [intravenous] fluids and insulin . High blood sugar can be serious if it's not treated. If your blood sugar runs too high over time, it can cause problems with your heart, eyes, kidneys, nerves and blood vessels. A very high blood sugar can cause life-threatening problems, coma, or death . The facility document titled, Job Description Charge Nurse LVN dated 8/15, indicated, . Assess resident needs, develop individual care plans, administer nursing care, evaluate nursing care . Essential Job Duties . Assure that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process. Identify needs . Develop individualized plan of care in collaboration with the resident/responsible party and interdisciplinary care team . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . 3. Resident 462's face sheet indicated Resident 462 was admitted to the facility on [DATE] with diagnoses which included other seizures. Resident 462's BIMS score indicated 15 out of 15 points which indicated Resident 462 was cognitively intact (pertaining to memory, recall and judgemnent). Resident 462's physician orders dated 11/21/17 indicated, . Dilantin capsule 100 mg . Give 2 [capsules] in the evening and 3 [capsules] in the morning . Resident 462's physician orders dated 8/29/18 indicated, . Dilantin [level] one time a day every four months . Review of Resident 462's clinical record titled, [Name of Laboratory] Laboratories and Radiology dated 8/26/18 indicated Resident 462's dilantin level was 13.3 ug/ml. Review of Resident 462's clinical record titled, [Name of Laboratory] Laboratories and Radiology dated 1/14/19 indicated Resident 462's dilantin level was 3 ug/ml. On 1/23/19 at 9:36 a.m., during an interview in Resident 462's room, Resident 462 stated, Yes I had a seizure a week ago when I was in the courtyard smoking. I just go to sleep when I have a seizure. Resident 462 stated CNA 5 brought her inside the nurse's station and CNA 5 took her vital signs and told the nurse. Review of Resident 462's care plan dated 11/17/17 indicated, . Resident [462] at risk for imapired neurological status r/t seizures as evidenced by unresponsiveness . Resident [462] at risk for toxicity from anti-seizure medication . Dilantin . Dilantin levels will be within normal limits . Monitor dilantin level every four months . On 1/23/19 at 11:52 a.m., during a telephone interview, CNA 5 stated, We were on the courtyard patio and [Resident 462] was smoking. Her head dropped and she dropped her cigarette. I grabbed her and took her inside [the nurse's station]. [Resident 462] woke up when we got inside. I told the charge nurse, I think [Resident 462] had a seizure. The nurse checked her and took her vital signs and [Resident 462 was back to normal. On 1/23/19 at 3:46 p.m., during a concurrent interview and record review, LN 2 reviewed Resident 462's seizure care plan and stated Resident 462's seizure manifest as unconsciousness. LN 2 stated, CNA 5 took Resident 462 inside the nurse's station from the courtyard patio and informed her Resident 462 had a seizure [NAME] smoking. LN 2 reviewed Resident 462's clinical record and was unable to find documented evidence she assessed Resident 462's alleged seizure as reported to her by CNA 5. LN 2 was also unable to find documented evidence she notified the physician of Resident 462's episode of unresponsiveness and possible seizure. LN 2 stated, I should have documented my assessment on [Resident 462] and call the doctor. If it's not documented, it's not done. On 1/23/19 at 4:46 p.m., during an interview, the DON stated she was aware of Resident 462's dilantin level of 3 ug/ml. The DON stated, I'm not sure of the normal range of dilantin. The DON stated, Any [laboratory values] that comes back, the nurse should call the doctor for critical levels right away. If the nurse can't get a hold of the primary doctor, they should call the medical director. We should call the doctor right away and not just fax the result. The DON stated Resident 462 could have seizure episode due to the low dilantin level. The DON stated she was not aware of Resident 462's seizure episode. The DON stated LN 2 should have documented and assessed Resident 462 when CNA 5 reported about the seizure episode. The DON stated LN 2 should have notified the physician and Resident 462's family about the seizure incident. The facility policy and procedure titled, Notification of Change in Resident's Health Status dated 11/14, indicated, . The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is . A .Significant change in the resident's physical . status . deterioration in health . or clinical complications .

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (drugs that affect a person's mental state) drug use when: 1. Psychotropic medications were administered longer than 14 days as a PRN (as needed) designation rather than for a limited time period for one of 69 sampled residents (Resident 29). 2. There was no reduction done as ordered for one of 69 sampled residents (Resident 91) when Resident 91's physician order to reduce the medication Abilify (psychotropic medication) was not followed. These failures had the potential to result in Resident 29 and Resident 91 receipt of medications without the benefit of a physician assessment for the extended need. This failure placed Resident 29 and Resident 91 at potential risk of receiving unnecessary psychotropic medications. Findings: 1. On 1/22/19 at 10:47 a.m., during a concurrent interview and record review, Social Services Director (SSD) 1 reviewed Resident 29's physician orders dated 1/2019, which indicated, . Alprazolam (medication for anxiety) 0.25 milligrams (mg) (dry unit of measurement) to be given every 12 hours PRN anxiety, order start date 11/30/18 . SSD 1 stated the physician's order for Resident 29's Alprazolam was not limited to a 14 day duration period. SSD 1 reviewed Resident 29's clinical record and was unable to find documented evidence the attending physician assessed Resident 29's continued use of Alprazolam. SSD 1 stated she was responsible to initiate GDR for residents receiving psychotropic medications. On 1/22/19 at 10:55 a.m., during an interview, SSD 2 stated she was not aware the PRN psychotropic needed a duration end date. On 1/23/19 at 1:24 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated the physician has to assess the resident if they have a PRN order for psychotropic medications. The DON stated the physician should document they have seen the resident and why they chose to continue the PRN psychotropic medication. The DON stated, If there is a new order for [a psychotropic medication], the duration should be documented. The DON reviewed Resident 29's clinical record and was unable to find documented evidence Resident 29's physician assessed the resident for the continued use of Alprazolam. 2) On 1/22/19 at 11:33 a.m., during a concurrent interview and record review, SSD 2 reviewed Resident 91's medication regimen review dated 11/7/18 and indicated, . [Resident 91 . CURRENT ORDER: [aripiprazole] Tablet 5 MG Give 5 mg by mouth one time a day . RECOMMENDATION: Please consider reducing the current medication dose to stop [aripiprazole; an antipsychotic medication] Tablet 5 mg . Give 5 mg by mouth one time a day and start [aripiprazole] Tablet 2 mg . Give 2 mg by mouth one time a day . SSD 2 stated Resident 91's physician agreed to the pharmacy recommendation to decrease the Aripiprazole medication from 5 mg to 2 mg. SSD 2 stated the pharmacy recommendation and the physician order to decrease the Aripiprazole dose was not followed and should have been implemented. On 1/22/19 at 11:45 a.m., during an interview, SSD 1 stated after she initiates the GDR, she would discuss with the Interdisciplinary Team (IDT- a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) and the IDT team would discuss with the physician if he agreed to the GDR recommendation. On 1/23/19 at 1:24 p.m., during a concurrent interview and record review, the Director of Nursing (DON) reviewed Resident 91's clinical record and stated Resident 91's physician agreed with the pharmacy recommendation to decrease the dose of Aripiprazole from 5 mg to 2 mg daily but the physician order was not followed. The DON stated, It was somehow missed. The doctor should have been notified that it was missed . I don't see any side effect [when the Ariprazole medication 5 mg instead of 2 mg was given daily]. There was no behavior changes [with Resident 91]. In general, we should follow the doctor's recommendation. Review of Resident 91's Medication Administration Record (MAR) dated 11/1/18 to 11/30/18 indicated Aripiprazole 5 mg daily was given to Resident 91 by Licensed Nurses (LNs). Review of Resident 91's MAR dated 12/1/18 to 12/31/18 indicated Aripiprazole 5 mg daily was given to Resident 91 by LNs. Review of Resident 91's MAR dated 1/1/19 to 1/22/19 indicated Aripirazole 5 mg daily was given to Resident 91 by LNs. The facility policy and procedure titled, Behavior Management Guideline dated 3/30/16, indicated, . Guideline Statement: To develop behavior plans and medication regimens, when appropriate, to optimize the functional abilities of patients/residents while monitoring for adverse side effects and improved behaviors Unnecessary Drugs: Each patient's/resident's drug regimen will be free from unnecessary drugs. An unnecessary drug is any drug when uses: [1] In excessive dose .[2] For excessive duration .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional standards when: 1. Expired medications were found in the medication cart, and in the Automated Dispensing Unit (ADU; a drug storage device used to track drug distribution), 2. Medications that were required to be dated when opened were found in the medication cart opened and undated, 3. Resident's medications from home were found opened and unlabeled in the medication cart, and 4. A medication refrigerator temperature log was not completed. This failure resulted in four of 69 sampled residents, Residents 54, 27, 38, and 78, receiving expired and potentially expired medications; one of 69 sampled residents, Resident 19, not receiving medications as ordered, and multiple residents having the potential of receiving medication stored at incorrect temperatures. All of these failures had the potential to cause ineffective medication treatment. Findings: 1. On 1/17/19 at 9:20 AM, during a concurrent observation and interview with Director of Nurses (DON), a one-liter bag of 5% dextrose for IV use (a form of glucose in water given in a vein to replace lost fluids, treat low blood sugar, insulin shock, or dehydration) facility stock medication, was found in the ADU with an expiration date of 10/2018. The DON stated the dextrose 5% solution was expired. Review of the facility policy and procedure titled, Storage of Medications dated, 3/17, indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier Expiration Dating (Beyond-use dating) . C. d. When the original seal of a manufacturer's container or vial is initially broken, it is recommended that a nurse write the date opened on the medication container or vial . E. No expired medications will be administered to a resident. F. All expired medications will be removed from the active supply and destroyed in the facility On 1/17/19 at 3:51 PM, during a concurrent observation and interview, Resident 54's medications, ipratropium bromide and Albuteral inhaler (an inhaled spray that opens airways in the lungs) was found in the medication cart with an expiration date of 12/18. Licensed Nurse (LN) 12 stated the inhaler was expired. Review of the facility policy and procedure titled, Administration Procedures for All Medications dated 12/17, indicated, Policy. To administer medications in a safe and effective manner. Procedures . D. Check expiration date on package/container before administering any medication. When opening a multi-dose container, place the date on the container . 2. On 1/22/19 at 3:23 PM, during a concurrent observation and interview with Director of Clinical Operations (DCO), an opened umeclidinium inhaler (an inhaled spray that opens airways in the lungs) for Resident 27 was in a medication cart without an opened on date. A fluticasone and salmeterol diskus (an inhaled powder that opens airways in the lungs) for Resident 55 had no opened on date. The DCO stated she was not aware of the expiration dates required for the medications because there was no expiration date on the product. On 1/22/19 at 3:42 PM, during a concurrent observation and interview with Licensed Nurse (LN) 12, an opened bottle of latanoprost (eye drops) for Resident 38 was stored in the medication cart without an opened on date or expiration date. LN 12 stated medications are to be dated when opened. Review of Professional Reference .National Patient Safety Goals dated 1/1/15 indicated, Label all medications, medication containers . On 1/22/19 at 3:51 PM, during a concurrent observation and interview with LN 12, an open ipratropium bromide and olodaterol inhalation (a combination of medications inhaled to relax and open the airways for better breathing) medication for Resident 78 was found in the medication cart, opened, with no expiration date. LN 12 stated she did not know the expiration date of the medication because there was no expiration date label on the product. Review of the facility policy and procedure titled, Storage of Medications dated, 3/17, indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier Expiration Dating (Beyond-use dating) . C. d. When the original seal of a manufacturer's container or vial is initially broken, it is recommended that a nurse write the date opened on the medication container or vial . E. No expired medications will be administered to a resident. F. All expired medications will be removed from the active supply and destroyed in the facility 3. On 1/17/19 at 2:22 PM, during a concurrent observation and interview, a bottle of lantanoprost (a medication for the eyes, given as eye drops) was stored in a medication cart not labeled with a resident's name. LN 9 stated if the medication was not in a box the nurse would not know which resident it belonged to. She stated the name on the box indicated the lantanoprost belonged to Resident 19. The medication bottle was not labeled with a resident's name. Resident 19's MAR dated 1/19, indicated lantanoprost eye drops were administered from 11/9/18 to 1/22/19. Review of Professional Reference titled, .National Patient Safety Goals dated 1/1/15 indicated, . Label all medications, medication containers . 4. On 1/17/19 at 10:20 AM, during a concurrent interview and record review of the facility temperature logs for the medication storage refrigerator, Licensed Nurse LN 5 stated, There are temperature recordings missing on the log. LN 5 stated the temperature logs were recorded by the night shift and afternoon shift. On 1/17/19 at 11:45 AM, during a concurrent interview and record review, the DCO stated, Yes, there are missing temperatures on the log. The DCO stated the night night and afternoon shifts were to log the temperatures of the refrigerators on the logs. The DCO stated not having the temperatures recorded could result in medications not being stored at the correct temperatures. Review of medication refrigerator temperature logs indicated the missing temperature log entries: December 28-29, 2018. November 2, 7-10, 20-21, 27-28, 2018. October 31, 2018. September 30, 2018. July 27-29, 2018. June 12-13, 15-21, 26-30, 2018. May 1-2, 6, 9-31, 2018. April 1, 5-7, 11-14, 17-18, 29-30, 2018. March 1-3, 5-8, 12-14, 19-20, 24-27, 29-31, 2018. February 1, 5-20, 23, 28, 2018. January 3, 6, 9-10, 17-18, 23-24, 29-31, 2081. The facility policy and procedure titled, Storage of Medications dated, 3/17, indicated, Policy: Medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier Temperature .F. The facility should check the refrigerator or freezer .

Based on observation, interview and record review, the facility failed to maintain an effective infection control program for four of six sampled residents (Resident 51, Resident 86, Resident 77, and Resident 69) when: 1. Resident 51's nebulizer tubing (drug delivery device used to administer medication in the form of mist inhaled into the lungs through a mouth piece or face mask) was undated. Resident 51's Continuous Positive Airway Pressure (C-pap; forces air into the nasal passages at pressure high enough to overcome obstruction in the airway and stimulate normal breathing) face mask had brownish yellow residue. 2. Resident 86's shared bathroom had an unlabeled urinal; Resident 77 and Resident 69's urinals (portable receptacles used by men for urinating at bedside) were on top of the night stand unlabeled. 3. Medication syringe was found in the medication cart with pink colored liquid residue in the tip. These failures placed Resident 51, Resident 86, Resident 77, and Resident 69 at risk of exposure to healthcare-associated infection. Findings. 1. On 1/16/19 at 9 AM, during an observation in Resident 51's room, a C-pap facial mask with brownish yellow residue and a nebulizer tube was observed on top of the night stand, undated. On 1/16/19 at 9:03 AM, during an interview, Resident 51 stated he used the facial mask [for the nebulizer] at night when he slept. Resident 51 stated he received a nebulizer treatment every day. On 1/16/19 at 9:10 AM, during an interview, Licensed Nurse (LN) 6 stated, It [the C-pap face mask] doesn't look clean. LN 6 stated if the facial mask looked dirty it should be cleaned. LN 6 verified the nebulizer tubing was not dated. She stated the nebulizer tubing was changed every seven days and should be dated with the date the tubing was last changed. LN 6 stated when the tubing was not cleaned and disinfected the possibility of Resident 51 developing a respiratory infection was high if the C-pap facial mask was dirty and nebulizer tubing not changed on the schedule dated. On 1/23/19 at 9 AM, during an interview, the Director of Staff Development (DSD) stated, Nebulizer tubing and oxygen tubing are supposed to be dated. The face mask for C-pap machine are cleaned everyday by night shift, or any shift can clean it if it is dirty. On 1/23/19 at 1:24 PM, during an interview, the Director of Nursing (DON) and Director of Clinical Operations (DCO) stated the oxygen tubing and nebulizer tubing were changed every 7 days and should be dated. The C-pap face masks were cleaned every night and as needed if dirty. The facility policy and procedure titled, Bi-level (BiPap)-Basic/Routine dated 8/16/16, indicated, .care and cleaning, . facial device: clean with mild soap and water, rinse with sterile water. Air dry and store in perforated plastic bag . 2. On 1/16/19 at 8:25 AM, during an observation in Resident 86's shared bathroom, a urinal was observed unlabeled. On 1/16/19 at 8:50 AM, during an interview, LN 6 stated, Urinals are supposed to be labeled with room number and date. Urinals are changed every seven days on Sundays. If urinals are not dated they go in the trash. On 1/16/19 at 9:05 AM, during an observation in Resident 69's and Resident 77's room, two unlabeled urinals were found on top of bedside tables. On 1/16/19 at 9:15 AM, during an interview, the Certified Nursing Assistant (CNA) 1 stated, Urinals are supposed to be labeled with room number and date. Urinals are changed every seven days. On 1/23/19 at 1:24 PM, during an interview, the DON and the DCO stated the urinals were changed once a week and should be labeled with the room number and the date. Review of the facility policy and procedure titled, Cleaning and Disinfecting Non-Critical Resident-Care Items dated 11/23/15, indicated, .(1) Single-use items are cleaned/disinfected between uses by a single resident and disposed of after afterwards (e.g. bedpans, urinals). 3. On 1/17/19 at 10:45 AM, during a concurrent observation and interview with LN 5, a syringe was observed to have a pink substance inside its tip. LN 5 stated, Yes, there is pink colored liquid in the tip of the syringe. LN 5 stated the syringe was not cleaned and it should have been. LN 5 stated the syringe cleaning instruction was to rinse with warm water and let the syringe dry. On 1/17/19 at 10:45 a.m., during a concurrent observation and interview, the DCO stated, Yes there is pink colored liquid in the tip of the syringe and it should have been cleaned after every use. Review of the Manufacturer's guideline, Instructions for use with Adapter Cap and oral Syringe, indicated, .8. Rinse the oral syringe in warm water and leave to dry.

Based on observation, interview, record review, and manufacturer's guidelines for use, the facility failed to maintain sanitary conditions when preparing and distributing food in accordance with professional standards for food service safety when: 1. A bucket containing sanitizing solution used in the kitchen did not meet manufacturers guidelines and 2. Kitchen staff did not wash hands after touching food and prior to plating food in the tray line. These failures had the potential for food preparation and distribution to not occur under sanitary conditions. Findings: 1. On 1/16/19 at 8:30 AM, during a concurrent observation and interview, the Director of Dining Services (DDS) dipped a test strip into a red bucket which contained a cloudy cleaning solution. The DDS swirled the strip in the solution for approximately three seconds. The strip was pale green at the top and bottom and approximately three inches of beige color. She held the strip against the manufacturer's color scale (determines the amount of cleaning solution in the water; recommendation was for the strip to read between 200-400 parts per million [ppm]). The color of the strip matched the color of 150 ppm. The DDS stated manufacturers guidelines indicated the paper strip should remain in the solution for ten seconds and should match the color for between 200 and 400 ppm and that did not occur. Review of the Manufacturer's guidelines for use of the cleaning solution indicated, .Directions for use: .To sanitize food contact surfaces, food processing equipment and other hard surfaces in food processing locations . Use [cleaning product] to sanitize pre-cleaned hard non-porous surfaces . countertops . Apply a use-solution . of [product](200-400 ppm active quat . Review of the facility policy and procedure titled, Dining Services Policies and Procedures . Section 6: Sanitation . Cleaning Kitchen Areas . dated 1/11/18 indicated, Change sanitizing solution: . As it becomes cloudy or dirty 2. On 1/17/19 at 11:45 AM, during a concurrent observation and interview, [NAME] 1 removed her gloves after taking food temperatures prior to plating food (serving food on plates). [NAME] 1 put food on a plate without performing hand hygiene or donning (putting on) new gloves. She stated, Oh, you caught me. I have my gloves right there to put on. She stated she should wash her hands after removing gloves and before putting on clean gloves. On 1/17/19 at 11:50 AM, during a concurrent observation and interview, [NAME] 2 was standing at the steam table plating food. He touched the bridge of his glasses with his right thumb and continued plating food. He stated he did not realize he touched his glasses. On 1/17/19 at 12:10 PM, during a concurrent observation and interview, [NAME] 2 removed the glove from his right hand and applied a new glove without washing his hands. The Dietary Services Supervisor stated her expectation was that staff should wash their hands if gloves were removed. The facility policy and procedure titled Infection Control-Hand Washing dated 12/16/16, indicated, . When to wash hands . Before putting on disposable gloves. After removing disposable gloves . Any other time deemed necessary