**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of personal property when Dietary Aide (DA) 1 agreed to withdraw cash and purchase cigarettes with the use of the resident's debit card for one of three sampled residents (Resident 1). This failure resulted in $8,000 worth of unauthorized cash withdrawals from Resident 1's bank account within a four-day span. This failure also violated Resident 1's right to be free from misappropriation and placed other residents at risk for similar exploitation. Cross-reference F609 and F610. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent feeling of sadness). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of the effort) for toileting hygiene, bathing, and required supervision when performing oral hygiene, dressing, and personal hygiene. During a review of Resident 1's History and Physical (H&P), dated 5/29/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of the facility's SOC 341 (a report of suspected dependent adult or elder abuse), dated 7/7/2025, the form indicated the facility reported an allegation of elderly financial abuse on 7/7/2025. The form indicated Resident 1 reported he gave his debit card with the pin number written on an envelope to somebody to withdraw money from his account. The form indicated Resident 1 reported more funds were withdrawn than originally requested and were missing. During a review of Licensed Vocational Nurse (LVN) 1's written statement, dated 7/9/2025, the written statement indicated on 6/28/2025, Resident 1 came out of his room yelling, That motherfuck-- stole my money! The statement indicated LVN 1 followed Resident 1 to the kitchen and Resident 1 pointed at Dietary Aide (DA) 1 and stated, It was that guy! The statement indicated DA 1 stated, It wasn't me, my car has been in the shop! Resident 1 explained that he lent his debit card to DA 1 about a week ago so that DA 1 could buy cigarettes for him, and the card was supposed to be returned the same day. The statement indicated DA 1 repeatedly stated his car had been in the shop for a week. The statement indicated LVN 1 proceeded to assist Resident 1 to speak with a bank representative as LVN 1 hand wrote the amounts withdrawn from Resident 1's bank account (as dictated by the bank representative). The statement indicated RN 1 informed the Director of Nursing (DON) of the situation. The statement indicated RN 1 informed LVN 1 that the DON would notify the Administrator (ADM). During an interview on 7/8/2025 at 10:30 a.m. with ADM, the ADM stated DA 1 was suspended on 7/7/2025. During an interview on 7/8/2025 at 10:47 p.m. with Resident 1, Resident 1 stated on 6/25/2025, he provided DA 1 with his debit card and the pin number in an envelope. Resident 1 stated he asked DA 1 to withdraw $100 and buy him (Resident 1) a pack of cigarettes. Resident 1 stated DA 1 returned with two packs of cigarettes and $50. Resident 1 stated when he asked DA 1 for his card back, DA 1 replied the card was in his vehicle. Resident 1 stated he did not report the incident on 6/25/2025 but attempted to speak with DA 1 (6/26/2025), but DA 1 was off duty. Resident 1 stated on 6/27/2025, DA 1 told the resident the debit card was inside of his vehicle. Resident 1 stated DA 1 finally returned the debit card on 6/28/2025. Resident 1 stated he immediately called the bank with the help of LVN 1 to verify the funds in his account. Resident 1 stated he was surprised to learn that $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, which totaled $8,000. Resident 1 stated this made him so mad that he went to the kitchen, confronted DA 1, and yelled. Resident 1 stated DA 1 remained silent, refused to provide an explanation, and wore a dumb look on his face. Resident 1 stated LVN 1 and RN 1 told him to address the matter on 6/30/2025. Resident 1 stated on 6/30/2025, he made Social Services Director (SSD) 1 aware of the situation and SSD 1 helped Resident 1 file a claim with the bank. Resident 1 stated SSD 1 helped call the police on 7/1/2025. During an interview on 7/8/2025 at 11:13 a.m. with SSD 1, SSD 1 stated on 6/30/2025, Resident 1 reported he provided his debit card and pin number to DA 1 and money was missing. SSD 1 stated she assisted Resident 1 file a claim for the missing money. SSD 1 stated on 7/1/2025, she called the police. SSD 1 stated staff were not allowed to accept a resident's personal debit card to perform cash withdrawals or to purchase items without the presence of the resident. SSD 1 stated she expected staff to defer the request to her and she would verify if the resident had a family member or a representative party that could perform the transaction or assist the resident. SSD 1 stated another option was to arrange a qualified staff member to accompany the resident to the bank or the automated teller machine (ATM). SSD 1 stated the incident was considered misappropriation or financial abuse. During a telephone interview on 7/8/2025 at 11:57 p.m. with DA 1, DA 1 stated Resident 1 provided him a thick envelope with Resident 1's debit card and pin number. DA 1 stated Resident 1 requested for him to withdraw $100 and purchase a pack of cigarettes. During an interview on 7/8/2025 at 12:17 p.m. with LVN 1, LVN 1 stated on 6/28/2025, Resident 1 was angry and hurriedly made his way out of his room towards the kitchen. LVN 1 stated she followed Resident 1. LVN 1 stated DA 1 came out of the kitchen to explain Resident 1 gave DA 1 his personal debit card and pin number to buy Resident 1 cigarettes. LVN 1 stated Resident 1 alleged DA 1 kept his debit card for about a week. LVN 1 stated DA 1 explained the debit card was inside of his car which had been at the mechanic shop. LVN 1 stated at that point, RN 1 intervened and told both Resident 1 and DA 1 to stop. LVN 1 stated she assisted Resident 1 back to his room and called the bank. LVN 1 stated she transcribed the amount of money withdrawn from Resident 1's account from 6/25/2025 through 6/28/2025 (total of $8,000). LVN 1 stated staff were not allowed to accept resident's debit cards for any purpose because it had the potential to lead to financial abuse and situations like this. LVN 1 stated DA 1's possession of Resident 1's debit card and the confirmation of missing funds from Resident 1's bank account constituted suspicion of financial abuse. During an interview on 7/8/2025 at 12:57 p.m. with RN 1, RN 1 stated on duty on 6/28/2025 Resident 1 and DA 1 had a confrontation in the doorway of the kitchen. RN 1 stated she intervened and asked DA 1 to step away and stop. RN 1 stated she proceeded to call and text the DON to inform him Resident 1 gave his debit card to DA 1 to buy cigarettes, and when Resident 1's bank was contacted money was missing. RN 1 stated DA 1 should have never taken Resident 1's debit card because funds can go missing and there was a potential for financial abuse. RN 1 stated Resident 1's allegation was suspicious for misappropriation of funds. During an interview on 7/8/2025 at 1:30 p.m. with the ADM, the ADM stated DA 1's actions did not align with the facility's policy because staff were not permitted to handle personal banking transactions with a resident's debit card. The ADM stated it was the facility's responsibility to ensure residents' property was not misplaced or stolen. The ADM stated staff were not permitted to take resident's debit cards in order to protect the resident from any form of financial abuse and to make sure instances like this do not happen again. During an interview on 7/9/2025 at 11:40 a.m. with a representative from Resident 1's bank (Bank Representative 1), Bank Representative 1 confirmed $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, totaling $8,000. During a review of the facility's Policy and Procedure (P&P), titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, the P&P indicated residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. During a review of the facility's P&P, titled, Resident Rights, revised 2/2021, the P&P indicated the facility would ensure the resident would remain free from abuse, neglect, misappropriation of property and exploitation. During a review of the Dietary Aide Job Description (undated), indicated the following: 1. The dietary aide would be committed to always doing the right thing.2. The dietary aide would adhere to all facility policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 reported to the California Department of Health (CDPH), ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local authorities within 2 hours on 6/28/2025, after being made aware Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 dollars was withdrawn from Resident 1's bank account without Resident 1's knowledge. 2. Ensure Social Services Designee (SSD) 1 reported to the CDPH, ombudsman, and local authorities on 6/30/2025, when she was first made aware of Resident 1's allegation of misappropriation (illegal use of someone else's money for purposes other than those intended by the rightful owner) of personal funds.3. Ensure Registered Nurse (RN) 1 reported a suspicion of misappropriation of personal funds within 2 hours to the CDPH, ombudsman, and local authorities on 6/28/2025, when RN 1 was made aware Resident 1's funds were missing. These failures resulted in a delay of investigation by CDPH and law enforcement and had the potential to lead to further financial abuse by DA 1 to other residents.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent feeling of sadness). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of the effort) for toileting hygiene, bathing, and required supervision when performing oral hygiene, dressing, and personal hygiene. During a review of the facility's SOC 341 (a report of suspected dependent adult or elder abuse), dated 7/7/2025, the form indicated the facility reported an allegation of elderly financial abuse on 7/7/2025. The form indicated Resident 1 reported he gave his debit card with the pin number written on an envelope to somebody to withdraw money from his account. The form indicated Resident 1 reported more funds were withdrawn than originally requested and were missing. 1. During a review of Licensed Vocational Nurse (LVN) 1's written statement, dated 7/9/2025, the statement indicated on 6/28/2025, Resident 1 came out of his room yelling That motherfuck-- stole my money! The statement indicated LVN 1 followed Resident 1 to the kitchen and Resident 1 pointed at Dietary Aide (DA) 1 and stated, It was that guy! The written statement indicated DA 1 stated, It wasn't me my car has been in the shop! Resident 1 explained that he lent his debit card to DA 1 about a week ago so that DA 1 could buy cigarettes for him, and the card was supposed to be returned the same day. The statement indicated DA 1 repeatedly stated his car had been in the shop for a week. The statement indicated RN 1 informed the Director of Nursing (DON) and informed LVN 1 that the DON would notify the Administrator (ADM). During an interview on 7/8/2025 at 10:47 p.m. with Resident 1, Resident 1 stated on 6/25/2025, he provided DA 1 with his debit card and the pin number in an envelope. Resident 1 stated he asked DA 1 to withdraw $100 and buy him (Resident 1) a pack of cigarettes. Resident 1 stated DA 1 returned with two packs of cigarettes and $50. Resident 1 stated the other $50 was missing and when Resident 1 asked DA 1 for his card back, DA 1 responded by stating the card was in DA 1's vehicle. Resident 1 stated DA 1 did not return Resident 1's debit card and the remaining $50. Resident 1 stated he did not report the incident on 6/25/2025 and attempted to speak with DA 1 the following day (6/26/2025) but DA 1 was off duty. Resident 1 stated on 6/27/2025, DA 1 stated the debit card was inside of his vehicle and returned on 6/28/2025. Resident 1 stated he immediately called the bank with the help of LVN 1 to verify the funds in his account. Resident 1 stated he was surprised to learn that $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, which totaled $8,000. Resident 1 stated this made him so mad that he went to the kitchen, confronted DA 1, and yelled. Resident 1 stated DA 1 remained silent, refused to provide an explanation, and wore a dumb look on his face. Resident 1 stated LVN 1 and RN 1 told him to address the matter on 6/30/2025. Resident 1 stated on 6/30/2025, he made Social Services Director (SSD) 1 aware of the entire situation the morning of 6/30/2025 and SSD 1 helped Resident 1 file a claim with the bank. Resident 1 stated SSD 1 helped call the police on 7/1/2025. 2. During an interview on 7/8/2025 at 11:13 a.m. with SSD 1, SSD 1 stated on 6/30/2025, Resident 1 reported he provided his debit card and pin number to DA 1 and money was missing. SSD 1 stated for any instances of alleged or suspected financial abuse or misappropriation, the expectation was to report to the ombudsman, local authorities, the ADM, and CDPH. SSD 1 stated the incident had the potential to be considered as financial abuse. SSD 1 stated on 6/30/2025, SSD 1 reported the allegation to the ADM, but did not notify the local authorities until 7/1/2025, and did not notify the ombudsman or CDPH. SSD 1 stated all staff were mandated reporters, and she should have reported the incident to the ombudsman, CDPH, and local authorities 6/30/2025. SSD 1 stated she did not do so because she thought the ADM would notify the proper agencies. SSD 1 stated it was important to notify the local authorities, the ombudsman, and CDPH right away to prevent further potential financial abuse from occurring. During a telephone interview on 7/8/2025 at 11:57 p.m. with DA 1, DA 1 stated Resident 1 provided him a thick envelope with Resident 1's debit card and pin number. DA 1 stated Resident 1 requested for him to withdraw $100 and purchase a pack of cigarettes. During an interview on 7/8/2025 at 12:17 p.m. with LVN 1, LVN 1 stated on 6/28/2025, Resident 1 was angry and hurriedly made his way out of his room towards the kitchen. LVN 1 stated she followed Resident 1. DA 1 came out of the kitchen to explain Resident 1 gave DA 1 his debit card and pin number to buy cigarettes. LVN 1 stated Resident 1 alleged DA 1 kept his debit card for about a week. LVN 1 stated DA 1 explained the debit card was inside of DA 1's car, which had been at the mechanic shop. LVN 1 stated she assisted Resident 1 back to his room and assisted Resident 1 with calling the bank. LVN 1 stated she transcribed the amounts of money that was withdrawn each day from 6/25/2025 through 6/28/2025 (total of $8,000). LVN 1 stated DA 1's possession of Resident 1's debit card and the confirmation of missing funds from Resident 1's bank account constituted suspicion of financial abuse, which should have been reported to the local authorities, the ombudsman, and CDPH within two hours on 6/28/2025. LVN 1 stated all staff were considered mandated reporters and she should have reported to the local authorities, the ombudsman, and CDPH as soon as possible, but did not do so because she was under the impression that RN 1 or the DON would report to the proper agencies. 3. During an interview on 7/8/2025 at 12:57 p.m. with RN 1, RN 1 stated on 6/28/2025 Resident 1 and DA 1 had a confrontation in the doorway of the kitchen. RN 1 stated she intervened and asked DA 1 to step away and stop. RN 1 stated she proceeded to call and text the DON to inform him Resident 1 gave his debit card to (DA 1) to buy cigarettes and when Resident 1's bank was contacted, money was missing. RN 1 stated DA 1 should have never taken Resident 1's debit card because funds can go missing and there was a potential for financial abuse. RN 1 stated all staff members were mandated reporters and for any allegation or suspicion of financial abuse or misappropriation, the local authorities, CDPH and the ombudsman should be notified immediately. RN 1 stated Resident 1's allegation was suspicious for misappropriation of funds, and she should have reported the allegation to the local authorities, CDPH and the ombudsman. RN 1 stated she did not do so because she notified the DON, and the DON informed her that he would notify the ADM. RN 1 stated she told Resident 1 that SSD 1 would handle the matter on 6/28/2025. During an interview on 7/8/2025 at 1:30 p.m. with the ADM, the ADM stated the normal process for reporting any allegation of abuse was to report to CDPH, ombudsman, the police and complete the SOC 341 within two hours. The ADM stated it was important to report timely so an investigation could start, and to prevent further instances of abuse. The ADM stated LVN 1 informed RN 1 of the incident, and RN 1 informed the DON on 6/28/2025. The ADM stated she did not report the incident because she was out of the country on vacation and did not view the DON's message on 6/28/2025. The ADM stated she was made aware of the complete details of the situation on 7/7/2025 after Resident 1 reported the incident to her. The ADM stated LVN 1 and RN 1 should have reported the incident on 6/28/2025 to CDPH, the ombudsman, and the police. The ADM stated the delay in the reporting of the incident led to a delay in the initiation of an investigation. The ADM stated the lack of timely reporting placed Resident 1 at risk for further financial abuse by DA 1 (from 6/28/2025 through 7/7/2025). During an interview on 7/8/2025 at 3:08 p.m. with the DON, the DON stated he was out of the country on 6/28/2025 and returned to work on 6/30/2025. The DON stated RN 1 informed him of Resident 1's missing funds. The DON stated the police were notified on 7/1/2025. The DON stated immediate actions should have been taken to report to CDPH and the ombudsman of the incident. During a review of the facility's Policy and Procedure (P&P), titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2022, the P&P indicated the following: 1. All reports of resident abuse (including injuries of unknown origin) or theft or misappropriation of resident property are reported to local, state- and federal agencies (as required by current regulations).2. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.3. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility;b. The local/state ombudsman;c. The resident's representative;d. Adult protective services (where state law provides jurisdiction in long-term care);e. Law enforcement officials;f. The resident's attending physician; andg. The facility medical director.4. Immediately is defined as:a. within two hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, for one out of three sampled residents (Resident 1) by failing to initiate and conduct a timely investigation into an allegation of misappropriation of resident property and missing funds when the following occurred: 1. Licensed Vocational Nurse (LVN) 1 was made aware on 6/28/2025, of an allegation that Dietary Aide (DA 1) was in possession of Resident 1's debit card from 6/25/2025 through 6/28/2025 and a total of $8,000 in unauthorized cash withdrawals from Resident 1's bank account occurred from 6/25/2025 through 6/28/2025. 2. Registered Nurse (RN) 1 was made on 6/28/2025 Resident 1's debit card and funds were missing. 3. Social Services Designee (SSD) 1 was made aware, on 6/30/2025, Resident 1's funds were missing. These failures resulted in a delay of protective measures for Resident 1. This failure also resulted in a delay of disciplinary action against DA 1 which had the potential to lead to further financial abuse by DA 1 to other residents.Cross reference F602 and F609Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following a cerebral infarction (an interruption in blood flow to the brain), muscle weakness, and depression (persistent feeling of sadness) During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 required partial to moderate assistance (helper does less than half of the effort) for toileting hygiene, bathing, and required supervision when performing oral hygiene, dressing, and personal hygiene. During a review of the facility's SOC 341 (a report of suspected dependent adult or elder abuse), dated 7/7/2025, the form indicated the facility reported an allegation of elderly financial abuse on 7/7/2025. The form indicated Resident 1 reported he gave his debit card with the pin number written on an envelope to somebody to withdraw money from his account. The form indicated Resident 1 reported more funds were withdrawn than originally requested, and the funds were missing. 1. During a review of Licensed Vocational Nurse (LVN) 1's written statement, dated 7/9/2025, the written statement indicated, on 6/28/2025, Resident 1 came out of his room, yelling, That motherfuck-- stole my money! The statement indicated Licensed Vocational Nurse (LVN) 1 followed Resident 1 to the kitchen and Resident 1 pointed at Dietary Aide (DA) 1 and stated, It was that guy! The statement indicated DA 1 replied, It wasn't me, my car has been in the shop! Resident 1 explained that he lent his debit card to DA 1 about a week ago so that DA 1 could buy cigarettes for him, and the card was supposed to be returned the same day. The statement indicated DA 1 repeatedly stated his car had been in the shop for a week. The statement indicated LVN 1 proceeded to assist Resident 1 to speak to a representative from his bank and LVN 1 hand wrote the amounts withdrawn from Resident 1's bank account (as dictated by the bank representative). The statement indicated RN 1 made the Director of Nursing (DON) aware of the situation and RN 1 informed LVN 1 that the DON would notify the Administrator (ADM). During an interview on 7/8/2025 at 10:47 p.m. with Resident 1, Resident 1 stated on 6/25/2025, he provided DA 1 with his debit card and the pin number in an envelope. Resident 1 stated he asked DA 1 to withdraw $100 and buy him (Resident 1) a pack of cigarettes. Resident 1 stated DA 1 returned with two packs of cigarettes and $50. Resident 1 stated when he asked DA 1 for his card back, DA 1 responded by stating the card was in DA 1's vehicle. Resident 1 stated DA 1 did not return Resident 1's debit card and the remaining $50. Resident 1 stated he did not report the incident on 6/25/2025. Resident 1 stated he attempted to speak with DA 1 the following day (6/26/2025), but DA 1 was on duty. Resident 1 stated on 6/27/2025, DA 1 stated the debit card was inside of his vehicle. Resident 1 stated DA 1 finally returned the debit card on 6/28/2025. Resident 1 stated he immediately called the bank with the help of LVN 1 to verify the funds in his bank account. Resident 1 stated he was surprised to learn that $2,000 was withdrawn each day from 6/25/2025 through 6/28/2025, which totaled $8,000. Resident 1 stated this made him so mad that he went to the kitchen, confronted DA 1, and yelled. Resident 1 stated DA 1 remained silent, refused to provide an explanation, and wore a dumb look on his face. Resident 1 stated LVN 1 and RN 1 told him to address the matter on 6/30/2025. Resident 1 stated, on 6/30/2025, he made Social Services Director (SSD 1) aware of the entire situation and SSD 1 helped Resident 1 file a claim with his bank. Resident 1 stated SSD 1 helped call the police on 7/1/2025. 2. During an interview on 7/8/2025 at 11:13 a.m. with SSD 1, SSD 1 stated on 6/30/2025, Resident 1 reported he provided his debit card and pin number to DA 1 and was missing money. SSD 1 stated she proceeded to assist Resident 1 with filing a claim for the missing money with the bank. SSD 1 stated she called the police on 7/1/2025.SSD 1 stated staff were not allowed to accept a resident's debit card to perform a cash withdrawal or to purchase items without the presence of the resident. SSD 1 stated she expected staff to defer the request to SSD 1 and she would verify if the resident had a family member or a responsible party that could perform the transaction or assist the resident. SSD 1 stated another option was to arrange a qualified staff member to accompany the resident to the bank or the automated teller machine (ATM). SSD 1 stated for any instances of alleged or suspected financial abuse or misappropriation, the expectation was to report to the ombudsman, local authorities, the ADM, and California Department of Public Health (CDPH). SSD 1 stated the incident had the potential to be considered as financial abuse. SSD 1 stated on 6/30/2025, SSD 1 reported the allegation to the ADM, but did not notify the local authorities until 7/1/2025, and never notified the ombudsman or CDPH. SSD 1 stated every staff member of the facility was a mandated reporter, and she should have reported the incident to the ombudsman, CDPH, and local authorities as soon as she gained knowledge of the incident on 6/30/2025. SSD 1 stated she did not do so because she thought the ADM would notify the proper agencies. SSD 1 stated it was important to notify the local authorities, the ombudsman, and CDPH right away to prevent further potential financial abuse from occurring. 3. During an interview on 7/8/2025 at 12:57 p.m. with RN 1, RN 1 stated on 6/28/2025 Resident 1 and DA 1 had a confrontation in the doorway of the kitchen. RN 1 stated she intervened and asked DA 1 to step away and stop. RN 1 stated she did not suspend DA 1 for the remainder of his shift. RN 1 stated she proceeded to call and text the DON to inform him Resident 1 gave his debit card to DA 1 to buy cigarettes and money was missing after contacting Resident 1's bank. RN 1 stated all staff members were mandated reporters and for any allegation or suspicion of financial abuse or misappropriation, the local authorities, CDPH and the ombudsman should be notified immediately because the incident needed to be investigated. During an interview on 7/8/2025 at 1:30 p.m. with the ADM, the ADM stated the normal process for reporting any allegation of abuse was to report to CDPH, ombudsman, the police and complete the SOC 341 within two hours. The ADM stated it was important to report timely so an investigation could start, and to prevent further instances of abuse. The ADM stated she was made aware of the complete details of the situation on 7/7/2025 after Resident 1 reported the incident to her. The ADM stated the delay in reporting the incident led to a delay in the initiation of an investigation and the suspension of DA 1. The ADM stated all staff members that had knowledge of Resident 1's allegation of misappropriation should have reported to her directly so that she could have initiated a timely investigation. The ADM stated the lack of a timely investigation placed Resident 1 and other residents at risk for further financial abuse by DA 1 (from 6/28/2025 through 7/7/2025). During an interview on 7/8/2025 at 3:08 p.m. with the DON, the DON stated he was out of the country on 6/28/2025 and returned to work on 6/30/2025. The DON stated RN 1 made him aware Resident 1 was missing funds from his bank account. The DON stated he should have ensured the ADM received his message about the incident so that a timely investigation could have been initiated to identify and suspend the staff involved in the allegation. During a review of the facility's P&P, titled, Personal Property, revised 8/2022, the facility promptly investigates any complaints of misappropriation of property. During a review of the facility's Policy and Procedure (P&P), titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2022, the P&P indicated all reports of resident abuse (including injuries of unknown origin) or theft or misappropriation of resident property are and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one out of eight sampled residents (Resident 9) when: 1. Certified Nursing Assistant (CNA) 3 failed to assist Resident 9 with grooming prior to a medical appointment. 2. Resident 9 was not fed prior to leaving the facility for his medical appointment. These deficient practices had the potential to cause a negative physiological outcome for Resident 9, and resulted in Resident 9 being hungry. Findings: During an observation on 1/13/2025 at 1:05 p.m., in Resident 9's room, Resident 9 was observed being picked up for a medical appointment. Resident 9's food tray was untouched and placed on the food cart. Resident 9 was not feed before he left to his medical appointment. During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). During a review of Resident 9's History and Physical (H&P) dated 6/13/2024, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS), a mandated resident assessment tool), dated 11/22/2024, the MDS indicated Resident 9's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 9 was dependent on staff for dressing, toileting hygiene, putting and taking off footwear, showering/bathing self, personal hygiene, and oral hygiene. During a review of Resident 9's Order Summary Report dated 8/7/2024, the order summary report indicated Resident 9 had an order to feed Resident 9 for every meal, three times a day for feeding assistance. During a review of Resident 9's Order Summary Report dated 1/3/2025, the order summary report indicated Resident 9 had an order for a follow up appointment on 1/13/2025, pick up time was at 12:55 p.m. During an interview on 1/13/2025 at 12:25 p.m. with Resident 9, in Resident 9's room, Resident 9 stated he had not eaten yet and he was hungry. During an interview on 1/16/2025 at 12:01 p.m. with CNA 3, CNA 3 stated staff were notified when a resident had an appointment through morning huddles. CNA 3 stated a Registered nurse (RN) or a licensed Vocational Nurse (LVN) would perform the morning huddles and inform staff which resident would be leaving the facility for an appointment, their pickup time, and mode of transportation. CNA 3 stated the purpose to inform staff which residents had an appointment was for CNAs to get that resident ready for that appointment. CNA3 stated CNAs must change the resident's clothes, diaper, and make sure they eat before they leave the facility. CNA 3 stated her charge nurse did not inform her that Resident 9 had an appointment on 1/13/2025. CNA 3 stated Resident 9 was a resident that received his meal tray at the end because he needed to be feed by staff. CNA 3 stated Resident 9 should have received his food earlier so he could have eaten before he left to his appointment. CNA 3 stated it was not acceptable to send a resident out for an appointment without feeding him, and it was not fair to the resident and the right thing to do was to feed Resident 9 first. CNA 3 stated there was a potential for a resident to get sick for not eating, they could feel weak and their blood sugar may drop. CNA 3 stated she did not get Resident 9 ready for his appointment because she did not know he had an appointment. During an interview on 1/16/2025 at 12:22 p.m. with CNA 4, CNA 4 stated CNAs were supposed to get residents ready for their appointments. CNA 4 stated for residents with appointments, CNAs must change the resident's clothes, comb their hair, and make sure the residents eat before they leave the facility. CNA 4 stated she was assigned to feed Resident 9 but did not get a chance to feed the resident because he was picked up. CNA 4 stated she did not know resident 9 had an appointment. CNA 4 stated it was important to feed residents before they leave to an appointment because they have medical health issues and they could potentially feel weak and faint. During an interview on 1/16/2025 at 12: 44 p.m. with RN 1, RN 1 stated during morning huddles she informed staff which residents had an appointment for that day. RN 1 stated CNAs must make sure residents with an appointment were taken care of first and must be groomed and fed prior to leaving to their appointment. RN 1 stated the assigned CNA should have told Resident 9's feeder that he had an appointment so Resident 9 could have been fed first. RN 1 stated residents must eat before their appointments, especially Resident 9 because he needed to be fed and could not take a sacked lunch due to the type of diet ordered. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated all residents should be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self-worth and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedure) for four of 16 sampled residents (Residents 77, 24, 81, and 85) by failing to: 1. Ensure Resident 77 gave informed consent for the continuation of olanzapine (a psychotropic medication [medication that affect the mind, emotions, and behavior]) after his readmission from the general acute care hospital (GACH) on 10/27/2024. 2. Ensure to obtain informed consent from the residents and/or responsible party (RP) before the use of physical restraints (a physical or mechanical device) for Resident 24, 81, and 85. This deficient practice resulted in Resident 77 being unaware of the risks, benefits, and indications of his use of olanzapine, therefore, unable to make an informed decision about his care, and violated Resident 22, 81, and 85's right to make an informed decision regarding the use of physical restraints. Findings: 1. During a review of Resident 77's admission Record (Face Sheet), the Face Sheet indicated Resident 77 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 77's Minimum Data Set ([MDS], a resident assessment tool), dated 12/27/2024, the MDS indicated Resident 77's cognition (process of thinking) was intact. The MDS indicated Resident 77 required set up assistance with eating, oral hygiene, and upper body dressing. The MDS indicated Resident 77 required supervision with toileting, bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 77 was receiving an antipsychotic medication (medication to treat symptoms of schizophrenia). During a review of Resident 77's History and Physical (H&P), dated 10/29/2024, the H&P indicated Resident 77 had the capacity to understand and make decisions. During a review of Resident 77's general acute care hospital (GACH) After Visit Summary, dated 9/23/2024, the After Visit Summary indicated to stop taking olanzapine 15 milligrams (mg, unit of measurement). During a review of Resident 77's Psychiatric Follow Up Note, dated 10/14/2024, the Psychiatric Follow Up Note indicated olanzapine was removed from Resident 77's medication regimen and Resident 77 was not observed with worsening agitation (feeling of fear, dread, and uneasiness). During a review of Resident 77's GACH Psychiatric Progress Note, dated 10/26/2024, the Psychiatric Progress Note indicated Resident 77 felt his medication regimen was helpful and continued improvement in his anxiety and depression. During a review of Resident 77's GACH Medication List, dated 10/27/2024, the Medication List indicated to continue taking olanzapine 2.5 mg, half a tablet, by mouth, two times a day. During a review of Resident 77's Psychiatric Follow Up Note, dated 11/22/2024, the Psychiatric Follow Up Note indicated Resident 77 was restarted on olanzapine due to having delusional thinking (having false or unrealistic beliefs), increased paranoia (unjustified suspicion and mistrust of other people or their actions), and resistance to care. During an interview on 1/16/2025 at 8:25 a.m., with Resident 77, Resident 77 stated when he was readmitted to the facility in October 2024, he did not recall anyone speaking to him about any new medications from the GACH. During an interview on 1/16/2025 at 9:43 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the licensed nurses were responsible for verifying informed consent with the resident or their responsible party before a new order for psychotropic medication was administered or any change in the medication's dosage or frequency. LVN 1 stated verifying informed consent was important to ensure the resident understood the treatment they would receive, and the risks and side effects associated with the treatment. LVN 1 stated verifying the resident was provided with the education of the treatment would allow the resident to make an informed decision to accept or refuse the ordered medication. During a concurrent interview and record review on 1/16/2024 at 9:45 a.m., with LVN 1, Resident 77's Order Recap Report dated 1/1/2024 through 1/31/2025 was reviewed. The Order Recap Report indicated the following: a. Give olanzapine 15 mg, by mouth at bedtime, for psychosis (a severe mental condition in which though, and emotions are so affected that contact is lost with reality) as manifested by agitation. Order started on 9/2/2024 and was discontinued on 9/20/2024. b. Give olanzapine 1.25 mg, by mouth, two times a day for schizophrenia, bipolar mania (a period of extreme mood elevation and increase energy). Order started on 10/27/2024 and discontinued on 11/8/2024. c. Give olanzapine 1.25 mg, by mouth, two times a day for schizophrenia. Order started on 11/8/2024 and discontinued on 11/22/2024. d. Give olanzapine 1.25 mg, by mouth, two times a day for schizophrenia as manifested by delusional thinking and poor regards to his health. Order started on 11/22/2024. LVN 1 stated Resident 77's olanzapine was discontinued on 9/20/2024, when the resident was transferred to the GACH and upon readmission to the facility. LVN 1 stated olanzapine was not continued into Resident 77's medication regimen. LVN 1 stated Resident 77 was not administered olanzapine for over a month, from 9/20/2024 until 10/27/2024. During an interview on 1/16/2025 at 9:50 a.m., with LVN 1, Resident 77's medical record was reviewed. LVN 1 stated Resident 77 did not have an informed consent in his medical record and the resident was not informed of the risks, side effects, nor indication of use for olanzapine. LVN 1 stated because Resident 77 had approximately a month gap from when olanzapine was initially discontinued on 9/20/2024 then restarted from the GACH on 10/27/2024, Resident 77 was required to have an informed consent for the olanzapine treatment. LVN 1 stated because Resident 77 was not informed of the risks, benefits, and indications for the use of olanzapine, Resident 77 was unable to make a true informed decision regarding his care. During a concurrent interview and record review on 1/26/2025 at 9:53 a.m., with LVN 1, Resident 77's Medication Administration Records (MAR) for the months of October 2024, November 2024, December 2024, and January 2025 were reviewed. The MARs indicated: a. Resident 77 received olanzapine 1.25 mg, by mouth, every day at 5 p.m. and 9 a.m., which started on 10/27/2024 through 11/1/2024. b. Resident 77 received olanzapine 1.25 mg, by mouth, every day from 11/1/2024 through 11/30/2024, at 9 a.m. and 5 p.m. c. Resident 77 received olanzapine 1.25 mg, by mouth, every day from 12/1/2024 through 12/31/2024, at 9 a.m., and 5 p.m. d. Resident 77 received olanzapine 1.25 mg, by mouth, every day from 1/1/2025 through 1/16/2025, at 9 a.m. and 5 p.m. LVN 1 stated Resident 77 received olanzapine twice a day over the course of approximately three months. LVN 1 stated Resident 77 should have been informed of the use of olanzapine and its risk before he was administered the first dose on 10/27/2024. During a concurrent interview and record review on 1/16/2025 at 9:58 a.m., with LVN 1, the facility's policy and procedure (P&P) titled, Psychotropic Medication Use/Informed Consent, dated 3/2024, was reviewed. The P&P indicated, The signed written consent must be recorded in the resident's medical record . For a prescription written prior to facility admission, the facility staff must verify that the resident or the resident's representative gave informed consent and make notation in the resident's records. LVN 1 stated when a medication was continued from the GACH, the licensed nurse had to verify informed consent was given and notated on the facility's paper or electronic informed consent verification form. LVN 1 stated the facility's P&P was not followed because informed consent for the use of olanzapine was not verified with Resident 77 prior to the first administration. 2. During a concurrent observation and interview on 1/13/2024 at 9:25 a.m., with Resident 24, in Resident 24's room, Resident 24's bed was observed against the wall. Resident 24 stated the facility did not discuss the risks and benefits prior to placing the bed against the wall. During a review of Resident 24's Face Sheet, the Face Sheet indicated Resident 24 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) , muscle weakness (loss of muscle strength), depression (loss of interest in activities), difficulty walking, and anxiety (feeling fear). During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24's cognitive skills for daily decision making was intact. The MDS indicated Resident 24 was dependent on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 24's H&P, dated 5/20/2024, the H&P indicated Resident 24 had the capacity to understand and make decisions. During a review of Resident 24's order summary report, dated 10/24/2024, the order summary report indicated per Resident 24's request the facility would place the bed against the wall. During a concurrent interview and record review on 1/16/2025 at 1:23 p.m., with LVN 2, Resident 24's electronic medical record (eMAR) was reviewed. LVN 2 stated Resident 24's care plan with a focus of Potential for injury, dated 10/25/2024, indicated Resident 24's bed would be placed against the wall per the resident's request. LVN 2 stated the care plan intervention indicated the facility would obtain informed consent. LVN 2 stated he could not find documented evidence the licensed nursing staff informed Resident 24 and obtained informed consent prior placing the resident's bed against the wall. 3. During a concurrent observation and interview on 1/13/2025 at 11:37 a.m., with Resident 81, in Resident 81's room, Resident 81's bed was observed against the wall. Resident 81 stated she did not know why her bed was placed against the wall. Resident 81 stated facility did not explain the reason the bed was placed against the wall. Resident 81 stated she did not like her bed against the wall. During a review of Resident 81's Face Sheet, the Face Sheet indicated Resident 81 was admitted to the facility on [DATE] with diagnoses including collapsed (a break) vertebra (a bone in the spine that support weight and protect the spine), depression, and chronic (constantly) pain. During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's cognitive skills for daily decision making was intact. The MDS indicated Resident 81 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for ADLs. During a review of Resident 81's physician order, dated 10/24/2024, the physician order indicated to place Resident 81's bed against the wall per the resident's request. During a concurrent interview and record review on 1/16/2025 at 2:23 p.m., with LVN 1, Resident 81's eMAR was reviewed. LVN 1 stated Resident 81's care plan with a focus of Potential for injury, dated 10/25/2024, indicated Resident 81's bed would be placed against the wall per Resident 81's request. LVN 1 stated the care plan intervention indicated the facility would obtain informed consent. LVN 1 stated he could not provide documentation the licensed nursing staff informed Resident 81 and obtained informed consent prior to placing the resident's bed against the wall. LVN 1 stated it was Resident 81's right to make an informed decision regarding her care and treatment at the facility. 4. During an observation on 1/13/2025 at 10:18 a.m., in Resident 85's room, Resident 85's bed was observed against the wall. During a review of Resident 85's Face Sheet, the Face Sheet indicated Resident 85 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety, diabetes mellitus, muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 85 required moderate (helper does less than half the effort) assistance from staff for ADLs. During a review of Resident 85's H&P dated 10/14/2024, the H&P indicated Resident 85 did not had the capacity to make medical decisions. During a review of Resident 85's care plan with a focus of Potential for injury, dated 11/14/2024, the care plan indicated Resident 85's bed would be placed against the wall per Resident 81's responsible party's request. During a telephone interview on 1/13/2025 at 3:11 p.m., with Resident 85's Responsible Party (RP) 1, RP 1 stated the facility placed Resident 85's bed against the wall without any explanation and/or reason. RP 1 stated there was no informed consent obtained prior to placing Resident 85's bed against the wall. During a concurrent interview and record review on 1/15/2025 at 3:45 p.m., with the Director of Nursing (DON), Resident 85's eMAR was reviewed. The DON stated the care plan with a focus of Potential for injury, dated 11/14/2024, indicated Resident 85's bed would be placed against the wall per RP 1's request. The DON stated the care plan intervention indicated the facility would obtain informed consent. The DON stated he was not able to provide documented evidence staff informed RP 1 of the risks and benefits prior to placing Resident 85's bed against the wall and obtained informed consent as indicated in the care plan. The DON stated without sufficient documentation and without and informed consent, Resident 85's bed against the wall would be considered a physical restraint. During a review of the facility's P&P titled Use of Restraints, revised 4/2017, the P&P indicated restraints shall only be used for the safety and well-being of the residents and never for staff convenience. During a review of the facility P&P titled Resident Rights, revised 2/2021, the P&P indicated residents would be informed in their care planning and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of eight sampled residents (Resident 81) by failing to ensure the call light (a device that residents use to request assistance from staff) was within reach. This deficient practice had the potential to negatively impact the Resident 81's psychosocial well-being and/or result in delayed provision of care and services. Findings: During an observation on 1/13/2025 at 10:57 a.m., in Resident 81's room, Resident 81 was observed lying in bed. Resident 81's call light was on the floor on the left side of Resident 81's bed. During a review of Resident 81's admission record, the admission record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses including collapsed (a break) vertebra (a bone in the spine that support weight and protect the spine), depression (loss of interest in activities), and chronic (constantly) pain. During a review of Resident 81's Minimum Data Set ([MDS]- a resident assessment tool), dated 12/17/2024, the MDS indicated Resident 81's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 81 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 81's care plan with a focus of Resident at risk for falls, initiated on 4/10/2024, the care plan indicated Resident 81 was at risk for falls related to limited mobility (inability to move around easily without pain) and impaired function (difficulty performing daily tasks). The care plan interventions indicated staff would ensure Resident 81's call light was within reach and encourage use as needed for assistance. During a concurrent observation and interview on 1/14/2025 at 7:52 a.m., in Resident 81's room, Resident 81 was observed lying in bed in a semi-Fowler's position (head of the bed elevated 30-45 degrees). Resident 81's call light was on the floor on the left side of Resident 81's bed. Resident 81 was observed calling for nurse assistance asking for water. Resident 81 was not able to locate her call light. During a concurrent observation and interview on 1/16/2025 at 11:00 a.m., in Resident 81's room, with Certified Nursing Assistant (CNA 1), observed Resident 81's call light on the left side of the bed, not within reach. CNA 1 stated Resident 81's call light should have been attached to the resident's bed and within reach. CNA 1 stated it was important for Resident 81 to be able to reach the call light and use it for assistance during emergencies. During an interview on 1/16/2025 at 2:00 p.m., with the Director of Nursing (DON), the DON stated the call light should be placed within Resident 81's reach at the residents' bedside. The DON stated the call light was important for residents' to be able to communicate with staff. The DON stated the facility's licensed staff were responsible for checking the residents' call lights and placing the call lights within reach at the bedside. The DON stated if the call light was not within reach, the residents would not be able to call for help. The DON stated not having the call light within reach placed the residents' safety at risk and placed the residents at risk for falls, and injury. During a review of the facility's policy and procedure (P&P), titled Call Light, revised 1/2024, the P&P indicated the facility would provide a call light system that would enable residents to alert the nursing staff from their rooms. The P&P indicated the call light would be placed within resident's reach in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up and obtain a copy of an Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) for one of six sampled Residents (Resident 11). This deficient practice had the potential to result in the facility not honoring Resident 11's medical care directive in the event Resident 11 was to become incapacitated (unable to make informed decisions or care for themselves). Findings: During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (a chronic condition where the heart does not provide adequate blood flow to meet the body's needs), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 11's Minimum Data Set ([MDS], a resident assessment tool), dated 11/15/2024, the MDS indicated Resident 11's cognition (process of thinking) was intact. The MDS indicated Resident 11 required moderate assistance (helper does less than half the effort) with oral hygiene and upper body dressing. The MDS indicated Resident 11 required maximal assistance (helper does more than half the effort) with toileting, lower body dressing, and personal hygiene. During a review of Resident 11's History and Physical (H&P), dated 5/14/2024, the H&P indicated Resident 11 had the capacity to understand and make decisions. During an interview on 1/15/2025 at 8:49 a.m., with the Social Services Director (SSD), the SSD stated upon admission, residents were asked if they formulated an Advance Directive in the past or if they were interested in formulating one. The SSD stated once it was determined a resident has an Advance Directive in place, the facility would request a copy to ensure the facility would follow and respect their wishes if they were unable to speak for themselves. During a concurrent interview and record review on 1/15/2025 at 8:53 a.m., with the SSD, Resident 11's Advanced Healthcare Directive Acknowledgement Form, dated 5/8/2023, was reviewed. The Form indicated Resident 11 formulated an Advance Directive. Resident 11's Physician Orders for Life-Sustaining Treatment (POLST), dated 5/8/2023, was reviewed. The POLST indicated Resident 11 had an Advance Directive formulated on 12/26/2019. Resident 11's POLST, dated 5/14/2024, was reviewed. The POLST indicated Resident 11 had an Advance Directive formulated. The SSD stated Resident 11's Advanced Healthcare Directive Acknowledgement Form and POLSTs all indicated Resident 11 formulated an Advance Directive on 12/26/2019. The SSD stated a follow-up with Resident 11 should have occurred on 5/8/2023 and 5/14/2024, to obtain a copy of her Advance Directive. During a concurrent interview and record review on 1/15/2024 at 8:55 a.m., with the SSD, Resident 11's Progress Notes were reviewed. The Progress Notes did not indicate a follow-up with Resident 11 occurred to obtain a copy of her Advance Directive. The SSD stated she did not have a copy of Resident 11's Advance Directive and none of her records indicated anyone followed up with Resident 11 to obtain a copy. The SSD stated obtaining a copy of Resident 11's Advance Directive was important to ensure Resident 11's medical care wishes were upheld in the event she was unable to make medical decisions for herself. The SSD stated without a copy of Resident 11's Advance Directive, the facility could potentially provide medical care that went against Resident 11's wishes and Resident 11 had the right to receive the care she wants. During a review of the facility's policy and procedure (P&P) titled, Advance Directives revised 9/2023, the P&P indicated, If a resident or resident's representative has executed one or more advance directive(s), or executes upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff.

**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) was accurately coded for one of eight sampled residents (Resident 40) to reflect Resident 40's oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 40's dentures (oral appliances that replace missing teeth) and had the potential to negatively affect Resident 40's plan of care and delivery of necessary care and services. Findings: During a review of Resident 40's admission Record, the admission record indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN]- high blood pressure). During a review of Resident 40's Minimum Data Set ([MDS]- a resident assessment tool), dated 12/20/2024, the MDS indicated Resident 40's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 40 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 40 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 1/16/2025 at 3:00 p.m., with the MDS Nurse (MDSN 1), in Resident 40's room, Resident 40's dentures were observed on top of the resident's bedside table. MDSN 1 stated Resident 40 did not have her upper and bottom teeth. During a concurrent interview and record review on 1/16/2025 at 3:20 p.m., with MDSN 1, Resident 40's MDS, dated [DATE] section L (oral and/or dental status) was reviewed. MDSN 1 stated she was responsible for completing the MDS. MDSN 1 stated Resident 40's MDS section L was coded incorrectly as it did not reflect the resident's actual oral and/or dental status. MDSN 1 stated Resident 40's use of dentures should have been coded. MDSN 1 stated accuracy of the MDS assessment was important for quality measures that help measure healthcare process, outcomes, resident perceptions, and care for the resident. MDSN 1 stated inaccuracy of the MDS assessment had the potential to result in not meeting Resident 40's care needs and services. During a review of the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment', revised 11/2019, the P&P indicated qualified professionals who have completed the MDS resident assessment are to certify the accuracy of the section they have completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for three of 21 sampled residents (Residents 24, 40, and 42) by failing to: 1. Develop and implement a care plan for Resident 42's use of side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility). 2. Initiate and implement a comprehensive care plan for Resident 40 who was using dentures (oral appliances that replace missing teeth). 3. Initiate and implement a comprehensive care plan for Resident 24 Restorative Nurse Assistant ([RNA]- a healthcare professional who help residents regain or maintain their mobility) program. These deficient practices had the potential to negatively affect Residents 24, 40, and 42's physical well-being and had the potential to result in injury and insufficient provision of care and services. Findings: a. During a review of Resident 42's admission Record (Face Sheet), the Face Sheet indicated Resident 42 was admitted to the facility with diagnoses that included fracture (a break or crack in the bone) of the right femur (bone of the thigh), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left knee, and acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of the deep vein of the right lower extremity (leg). During a review of Resident 42's Minimum Data Set ([MDS], a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 42's cognition (process of thinking) was intact. The MDS indicated Resident 42 had impairment on one side of the lower extremity. The MDS indicated Resident 42 required supervision with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 42 required moderate assistance (helper does less than half the effort) with lower body dressing and rolling left and right. During a review of Resident 42's History and Physical (H&P), dated 12/11/2024, the H&P indicated Resident 42 had the capacity to understand and make decisions. During a review of Resident 42's Side Rail Utilization Assessment, dated 1/2/2025, the Side Rail Utilization Assessment indicated Resident 42 requested to have quarter side rails for assistance in transfers and bed mobility. The Side Rail Utilization Assessment indicated Resident 42's plan of care was reviewed and updated to reflect the side rail use. During a concurrent observation and interview on 1/13/2025 at 10:36 a.m., with Resident 42, in Resident 42's room, Resident 42 was observed lying in bed and had quarter side rails on the left and right side of the bed. Resident 42 stated she used the side rails to assist her in moving left and right while in bed. During a concurrent observation and interview on 1/15/2025 at 1:59 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 42's room, Resident 42 was observed lying in bed and had quarter side rails on the left and right side of the bed. LVN 1 stated Resident 42 had bilateral side rails on her bed as a mobility aide. During an interview on 1/15/2025 at 2:05 p.m., with LVN 1, LVN 1 stated when side rails were used as a mobility aide, the resident should have a care plan developed. LVN 1 stated the care plan would indicate the reason for the side rails, the individualized goals, and interventions to be implemented. LVN 1 stated the purpose of the care plan was to continuously assess the resident's need for the side rails, the appropriateness, and to monitor the resident's safety. During a concurrent interview and record review on 1/15/2025 at 2:21 p.m., with LVN 1, Resident 42's Care Plans were reviewed. The Care Plans did not indicate Resident 42 used side rails as a mobility aide. LVN 1 stated Resident 42 did not have a care plan developed that indicated her use of bed rails nor how to properly care and monitor Resident 42's safety. LVN 1 stated without a care plan for Resident 42, a goal was not set for Resident 42's safety and need for the bed rails. LVN 1 stated without a care plan, the licensed nurses would be unable to determine Resident 42's necessity and appropriateness for the bed rails and would not have the guidance on how to care for her. During an interview on 1/16/2025 at 11:40 a.m., with the Director of Nursing (DON), the DON stated a care plan was developed when a resident used side rails. The DON stated the care plan would outline the plan of care, the problem, the goals, and interventions to be implemented. The DON stated for Resident 42, the goals for her use of side rails would include no decline in her physical functionality and independence, and to continue using the side rails safely. The DON stated interventions would include continuous education for the proper use of side rails and monitoring that Resident 42 was safe. The DON stated the care plan was a communication tool between all nurses and other departments of the resident's conditions. The DON stated without a care plan on Resident 42's side rail use, the nursing staff would not have guidance on how to properly care and monitor her. b. During a review of Resident 40's Face Sheet, the Face Sheet indicated Resident 40 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN]-high blood pressure) During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's cognitive skills for daily decision making was intact. The MDS indicated Resident 40 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 40 was assessed as not having any oral and/or dental issues During a concurrent observation and interview on 1/16/2025 at 3:00 p.m., with the Minimum Data Set Nurse (MDSN 1) in Resident 40's room, Resident 40's dentures were observed on top of the resident's bedside table. MDSN 1 stated Resident 40 had no upper and bottom teeth. During a concurrent interview and record review on 1/16/2025 at 3:20 p.m., with MDSN 1, Resident 40's electronic medical record (eMAR), was reviewed. MDSN 1 was not able to locate a care plan for Resident 40's use of dentures. MDSN 1 stated there was no care plan for the use of dentures and there should have been a care plan initiated upon Resident 40's admission to the facility. MDSN 1 stated care planning served as a communication tool among facility staff who provided care for resident at the facility. MDSN 1 stated if there was no care plan, the facility staff would not be able to provide quality of care to residents. c. During a review of Resident 24's Face Sheet, the Face Sheet indicate Resident 24 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, muscle weakness (loss of muscle strength), depression (loss of interest in activities), difficulty walking, and anxiety (feeling fear). During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24's cognitive skills for daily decision making was intact. The MDS indicated Resident 24 was dependent from staff for ADLs During a review of Resident 24's H&P, dated 5/20/2024, the H&P indicated Resident 24 had the capacity to understand and make decisions. During a review of Resident 24's order summary report, dated 11/6/2024, the order summary report indicated to provide RNA program three times a week (3x/wk) for ambulation (walking). The order summary report indicated to provide RNA program omni cycle (motorized rehabilitation system that helps resident exercise) for both upper extremities (BUE, arms) 3x/wk. During a review of Resident 24's order summary report, dated 11/10/2024, the order summary report indicated the facility would provide RNA program omni cycle (motorized rehabilitation system that helps resident exercise) for both lower extremities (BLE, legs) 3x/wk. During a concurrent interview and record review on 1/15/2025 at 10:30 a.m., with LVN 1, Resident 24's active care plan was reviewed. LVN 1 stated there were no care plan addressing the resident's RNA program. LVN 1 stated Resident 24's the RNA program should be care planned. LVN 1 stated a care plan was an important communication for staff providing care to Resident 24. LVN 1 stated without care plan interventions, Resident 24 had the potential to not received needed care and services. During an interview on 1/16/2025 at 3:00 p.m., with the Director of Nursing (DON), the DON stated it was important for the facility licensed staff to develop a comprehensive care plan for each resident for continuity of care and services, based on resident needs and interventions. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated comprehensive, person-centered care plan would include measurable objectives and timeframes, services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain appropriate grooming and personal hygiene for one of eight sampled residents (Residents 18) by failing to keep Resident 18's fingernails clean and neat. This failure had the potential to result in a negative impact on Resident 18's quality of life and self-esteem and had the potential for the development of an infection. Findings: During a review of Resident 18's admission Record, the admission record indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease ([ESRD] -irreversible kidney failure), muscle weakness (loss of muscle strength), and hypertension ([HTN]- high blood pressure). During a review of Resident 18's's Minimum Data Set ([MDS]- a resident assessment tool), dated 10/25/2024, the MDS indicated Resident 18's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 18 was dependent (helper does all the effort) on staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 1/14/2025 at 1:24 p.m., with Resident 18, in Resident 18's room, observed Resident 18's fingernails. Resident 18's fingernails were long and had a black substance underneath. Resident 18 stated did not remember the last time her fingernails were cleaned or cut. Resident 18 stated her fingernails were long and would like the staff to cut and clean her fingernails. During an interview on 1/15/2025 at 8:28 a.m., with Certified Nursing Assistant (CNA 2), CNA 2 stated the CNAs were responsible for cleaning the residents' fingernails daily and trim them as needed. CNA 2 stated it was important to keep Resident 18's fingernails clean and trimmed to prevent the growth of bacteria (infection). CNA 2 stated long, dirty fingernails had the potential for residents to scratch themself and if Resident 18 scratched herself hard enough, it could create an open wound and increased risk of infection. CNA 2 stated having dirty fingernails was not sanitary because the resident used her hands to hold utensils when eating and any bacteria could transfer into the body. During an interview on 1/16/2025 at 10 a.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated it was the CNAs' responsibility to make sure the residents' fingernails were cleaned daily and trimmed as needed. LVN 2 stated residents should be provided with care and services necessary to maintain good personal hygiene. During a review of the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care, revised 2/2018, the P&P indicated facility would provide nails cleaning daily. The P&P indicated facility would trim residents' nails regularly to prevent resident from accidently scratching and injuring his or her skin. During a review of the facility's P&P titled Activities of Daily Living (ADLs), Supporting, revised 3/2018, the P&P indicated residents would be provided with care, treatment, and services necessary to maintain good grooming and personal hygiene.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for use of quarter side rails (short rails on one or both sides of the bed that can be used to assist in bed mobility) for one of two sampled residents (Resident 42), when Resident 42 used bilateral (left and right) quarter side rails for transfer assistance and bed mobility. This deficient practice had the potential to result in the unsafe use of side rails that could result in entrapment (becoming stuck between the bed and railing) and physical harm. Findings: During a review of Resident 42's admission Record (Face Sheet), the Face Sheet indicated Resident 42 was admitted to the facility with diagnoses that included fracture (a break or crack in the bone) of the right femur (bone of the thigh), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left knee, and acute embolism (a blood clot that enters the blood stream and blocks blood flow) and thrombosis (a blood clot that forms in a blood vessel, partially or completely blocking blood flow) of the deep vein of the right lower extremity (leg). During a review of Resident 42's Minimum Data Set ([MDS], a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 42's cognition (process of thinking) was intact. The MDS indicated Resident 42 had impairment on one side of the lower extremity. The MDS indicated Resident 42 required supervision with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 42 required moderate assistance (helper does less than half the effort) with lower body dressing and rolling left and right. During a review of Resident 42's History and Physical Examination (H&P), dated 12/11/2024, the H&P indicated Resident 42 had the capacity to understand and make decisions. During a review of Resident 42's Side Rail Utilization Assessment, dated 1/2/2025, the Side Rail Utilization Assessment indicated Resident 42 requested to have quarter side rails for assistance in transfers and bed mobility. During a concurrent observation and interview on 1/13/2025 at 10:36 a.m., with Resident 42, in Resident 42's room, Resident 42 was observed lying in bed and had quarter side rails on the left and right side of the bed. Resident 42 stated she used the side rails to assist her in moving left and right while in bed. During a concurrent observation and interview on 1/15/2025 at 1:59 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 42's room, Resident 42 was observed lying in bed and had quarter side rails on the left and right side of the bed. LVN 1 stated Resident 42 had bilateral side rails on her bed as a mobility aide. During an interview on 1/15/2025 at 2:05 p.m., with LVN 1, LVN 1 stated prior to installing side rails onto the bed, a licensed nurse would conduct an assessment to determine the appropriateness and safety of the side rails. LVN 1 stated after the assessment was completed, the resident's physician would be contacted to obtain an order to utilize the side rails. LVN 1 stated a physician's order was necessary because the order would prove that the resident's physician deemed it safe for the resident to have side rails. During a concurrent interview and record review on 1/15/2025 at 2:10 p.m., Resident 42's current Orders on 1/15/2025, were reviewed. The Orders did not indicate a physician's order for Resident 42 to have bilateral side rails. LVN 1 stated Resident 42 did not have a physician's order to allow side rails on Resident 42's bed. LVN 1 stated because there was no physician's order for Resident 42's side rails, there was no proof that Resident 42's physician permitted the use of side rails safely. LVN 1 stated Resident 42 was at risk for injury from the side rails such as entrapment or hitting any body part against the side rails. During an interview on 1/16/2025 at 11:40 a.m., with the Director of Nursing (DON), the DON stated a physician's order was required prior to the installation of side rails. The DON stated obtaining an order ensured the resident's physician was aware and determined the use of side rails was safe. The DON stated because Resident 42 did not have an order for the side rails, she was at risk of avoidable injury. During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, revised 8/2022, the P&P indicated, The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met; including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff practiced safe and effective medication administration practices for one out of eight sampled residents (Resident 90) by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN) administered medication to Resident 90 per the doctor's order. 2. Ensure LVN 3 did not falsely document she administered medication to Residents 90. 3. Ensure LVN 3 reordered medication for Resident 90. 4. Ensure LVN 3 did not administer another resident's medication to Resident 90. 5. Inform Resident 90 's doctor a medication was not administered as ordered. These deficient practices caused Resident 90 to have an interruption with medication therapy and pain control and exposed Resident 90 to a potential of a medication error and an adverse effect to their medications. Findings: During an observation on 1/15/2025 at 2:45 p.m., in the hallway, Resident 90 was observed asking staff to be wheeled to the front desk because her back hurt and she could not physically wheel herself. During an observation on 1/15/2025 at 3:11 p.m., in the hallway, Resident 90 was observed asking LVN 4 for pain medication. LVN 4 was observed telling Resident 90 that she had already given her pain medication. During an observation on 1/15/2025 at 3:27 p.m., in Resident 90's room, LVN 4 removed a Lidocaine (substance used to relieve pain by blocking signals at the nerve endings in skin) patch from Resident 90's mid back and placed another lidocaine patch 5 percent (%) on Resident 90's mid back. During a review of Resident 90's admission Record, the admission record indicated Resident 90 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood) and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 90's History and Physical (H&P) dated 11/22/2024, the H&P indicated Resident 90 had fluctuating capacity to understand and make decisions. During a review of Resident 90's Minimum Data Set (MDS), a mandated resident assessment tool), dated 11/25/2024, the MDS indicated Resident 90's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 90 required setup or clean up assistance for eating. The MDS indicated Resident 90 partial assistance (helper does less than half the effort) for upper body dressing, oral hygiene, and personal hygiene. During a review of Resident 90's Order Summary Report, dated 1/13/2024, the order summary report indicated Resident 90 had an order for Lidocaine HCL external patch 4 % for pain management, apply to mid lower back topically one time a day and remove per schedule. During a review of Resident 90's Medication Administration Record (MAR), dated 1/1/2025 - 1/31/2025, the MAR indicated Resident 90 was to receive Lidocaine external patch 4 % for pain management, apply to mid lower back topically one time a day and remove per schedule. The MAR indicated on 1/15/2025 Resident 90's lidocaine patch 4% was removed at 8:59 a.m. and a new lidocaine patch 4% was placed at 9:00 a.m. During a review of Resident 90's Care Plan for alteration of comfort related to pain, the care plan indicated Resident 90's goal was to display a decrease in behaviors of inadequate pain control and Resident 90 will verbalize adequate relief of pain. The care plan interventions indicated to administer analgesia (the absence of pain) as ordered, anticipate Resident 90's need for pain relief, and respond immediately to any complaints of pain. During an interview on 1/15/2025 at 2:48 p.m. with Resident 90, in the hallway, Resident 90 stated she needed assistance to be taken to the front desk because she could not propel (drive, push, or cause to move in a particular direction) her legs because her back hurt. Resident 90 stated she had asked LVN 3 for pain medication that morning but she had not received her medication. Resident 90 stated she was in a lot of pain and needed help. During a concurrent observation and interview on 1/15/2025 at 3:15 p.m. with LVN 4, in Resident 90's room, Resident 90 was observed with a patch on her mid back dated with 1/14/2025 and timed at 8:00 a.m. LVN 4 stated she thought she had given Resident 90 her lidocaine patch that morning. LVN 4 stated she should have removed the patch and placed a new patch on Resident 90. LVN 4 stated she documented she gave Resident 90 her lidocaine patch at 9:00 a.m. but she did not. LVN 4 stated it was not acceptable to document she administered a medication when she did not because it was not true. LVN 4 stated this practice would cause Resident 90 to become restless and her pain would not be managed. LVN 4 stated she did not report to anyone that she did not administer pain medication to Resident 90. LVN 4 stated she was supposed to notify the Registered Nurse (RN) supervisor and Resident 90's doctor about not administering the medication and about falsely documenting that she did. During an interview on 1/15/2025 at 4:22 p.m. with LVN 5, LVN 5 stated she relieved LVN 4, they both did rounds together and LVN 4 did not inform her that she did not give Resident 90 her medication patch. LVN 5 stated Resident 90 did not have a box of patches in the medication cart and she did not know from where LVN 4 got the lidocaine patch from. LVN 5 stated LVN 4 gave Resident 90 a lidocaine patch 5% that was ordered for another resident because that was not what Resident 90's doctor ordered. LVN 5 stated that it needed to be documented that Resident 90 received a Lidocaine patch 5% instead of the 4% and Resident 90's doctor must be informed. During an interview on 1/16/2025 at 8:33 a.m. with LVN 4, LVN 4 stated she grabbed another resident's lidocaine patch to give to Resident 90. LVN 4 stated it was not an acceptable practice because she gave Resident 90 a lidocaine patch 5% and her order was for a lidocaine patch 4%. LVN 4 stated she did not give Resident 90 pain medication because it was not on hand. LVN 4 stated she was supposed to call the pharmacy and reorder the medication but did not. LVN 4 stated she did not document that Resident 90 did not get the lidocaine patch, she did not document that Resident 90 received the wrong lidocaine patch, and she did not notify Resident 90's doctor. LVN 4 stated she did not follow the doctors order and Resident 90 could potentially have an adverse effect to the medication. During an interview on 1/16/2025 at 1:22 p.m. with RN 1 stated if a medication was not available to administer to a resident, the nurse must document that medication was not given, call the pharmacy to reorder the medication and inform the doctor. RN 1 stated nurses must sign that they administered a medication after administration because they must first witness that the resident took the medication. RN 1 stated nurses must notify their supervisor that a medication was not given because it was not available and their supervisor could assist by reordering the medication. RN 1 stated a nurse must notify the doctor that medication was not available and that a different patch percent was given to Resident 90. RN 1 stated giving Resident 90 another resident's medication was an unsafe practice and was not following the doctor's orders. RN 1 stated it was important to administer the correct medication to residents because medications are a plan of treatment for health issues, diagnosis and helps the residents' quality of life. During a review of facility's Policy and Procedure (P&P) titled Administering Medications, dated 4/2023, the P&P indicated medications were administered in a safe and timely manner and as prescribed. The P&P indicated medications were administered in accordance with prescriber orders, including any required time frame. The P&P indicated if a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the refusal, given at another time or the withholding of a medication. The P&P indicated the individual administering the medication initials the resident's MAR on the appropriate line on the MAR after giving each medication and before administering the next one. The P&P indicated medications ordered for a particular resident may not be administered to another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow and implement the pharmacist recommendation in the Medication Regimen Review (MRR) for one out of three sampled residents (Resident 9). This deficient practice had the potential to place Resident 9 at risk for complications due to bleeding. Findings: During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). During a review of Resident 9's History and Physical (H&P) dated 6/13/2024, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS), a mandated resident assessment tool), dated 11/22/2024, the MDS indicated that Resident 9's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 9 was dependent on staff for dressing, toileting hygiene, putting and taking off footwear, shower/bathe self, personal hygiene, and oral hygiene. During a review of Resident 9's Order Summary Report, dated 10/9/1014, the order summary report indicated Resident 9 had an order for Apixaban (medication used to treat and prevent blood clots) oral tablet 2.5 milligrams ([mg] metric unit of measurement) for atrial fibrillation (irregular and often very rapid heart rhythm), 1 tablet by mouth every 12 hours. The order summary report indicated Resident 9 had an order for aspirin (blood thinner) 81 mg for cerebrovascular accident ([CVA] when the blood supply to part of the brain is blocked or reduced) prophylaxis, give 1 tablet by mouth in the evening. During a review of Resident 9's electronic medical record, unable to locate an order to monitor Resident 9 for signs of bleeding. During a review of Resident 9's electronic medical record, unable to locate to in the MAR to monitor Resident 9 for signs of bleeding. During a review of Resident 9's Medication Regimen Review (MRR), dated 10/1/10/2024 - 10/22/2024, the MRR indicated to monitor bleeding on the MAR due to Aspirin and Apixaban. During a concurrent interview and record review on 1/16/2025 at 2:18 p.m. with Registered Nurse (RN) 1, Resident 9's order summary was reviewed. The order summary report indicated there was no order to monitor Resident 9 for bleeding. RN 1 stated the pharmacist recommendation was not in Resident 9's electronic medical record and it should be. RN 1 stated RNs were responsible for reviewing the MRR and adding the pharmacist recommendation in the resident's electronic medical record. RN 1 stated nurses should know to monitor residents for the risk of bleeding when administering the medications that Resident 9 receives. RN 1 stated it was important to monitor for bleeding when residents take blood thinners because they might bleed out through their feces or urine and these signs would be missed and the resident would not get the care they need. During a review of the facility's Policy and Procedure (P&P) titled Medication Regimen Reviews, dated 5/2019, the P&P indicated the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for three out of five sampled residents (Resident 1, 143, and 144) by failing to ensure: 1. Licensed nurses documented the dates/times residents left and returned to the facility. 2. The Leave of Absence form (form licensed nurses fill out to clear resident to temporarily leave facility) was completed prior to residents leaving and returning to the facility. These deficient practices had the potential to create a miscommunication of the residents' location, whether the residents were cleared to leave the facility, and also created a safety concern. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and pulmonary edema (condition where fluid accumulates in lung tissues, causing shortness of breath, wheezing and coughing up blood). During a review of Resident 1's History and Physical (H&P) dated 6/8/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a mandated resident assessment tool), dated 11/21/2024, the MDS indicated that Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required setup or clean up assistance for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) for toileting hygiene, lower body dressing, and putting on/taking off footwear. During a review of the Leave of Absence form, dated 1/13/2025, the form indicated Resident 1 left the facility at 10:00 a.m., and returned at 12:14 p.m. During a review of Resident 1's electronic medical record, unable to locate nursing progress notes indicating Resident 1 left the facility and returned to the facility on 1/13/2025. During an interview on 1/15/2025 at 8:28 a.m. with Resident 1, Resident 1 stated he left the facility for appointments and errands. Resident 1 stated the staff did not check on him when he returned. Resident 1 stated he gives the leave of absence form to the receptionist prior to leaving the facility. 2. During a review of Resident 143's admission Record, the admission record indicated Resident 143 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease (COPD, group of chronic lung diseases that block airflow and make it harder to breathe air out of the lungs). During a review of Resident 143's H&P dated 12/27/2024, the H&P indicated Resident 143 had the capacity to understand and make decisions. During a review of Resident 143's MDS, dated [DATE], the MDS indicated Resident 143's cognitive skills for daily decision making was intact. The MDS indicated Resident 143 required setup or clean up assistance for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 143's Leave of Absence form, dated 1/6/2025, the form indicated Resident 143 left the facility at 12:50 p.m. and returned at 4:40 p.m. The form did not indicate who Resident 143 left the facility with and what was Resident 143's outing plan. During a review of Resident 143's Leave of Absence form, dated 1/7/2025, the form indicated Resident 143 left the facility at 10:40 a.m. and returned at 4:13 p.m. The form did not indicate who Resident 143 left the facility with and what was Resident 143's outing plan. During a review of Resident 143's electronic medical record, unable to locate nursing progress notes that indicated Resident 143 left the facility and returned to the facility on 1/6/2025 and 1/7/2025. 3. During a review of Resident 144's admission Record, the admission record indicated Resident 144 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and lower extremity (legs) thrombosis (a blood clot within blood vessels that limits the flow of blood). During a review of Resident 144's H&P dated 1/9/2025, the H&P indicated Resident 144 had the capacity to understand and make decisions. During a review of Resident 143's Leave of Absence form, dated 1/6/2025, the form indicated Resident 143 left the facility at 12:50 p.m. and returned at 4:40 p.m. The form did not indicate who Resident 143 left the facility with and what was Resident 143's outing plan. During a review of Resident 144's Leave of Absence form, dated 1/9/2025, the form indicated Resident 144 left the facility at 10:45 a.m. and returned at 5:00 p.m. The form did not have the signature of the nurse that cleared Resident 144 to leave the facility. During a review of Resident 144's electronic medical record, unable to locate nursing progress notes that indicated Resident 143 left the faciity on 1/9/2025. During an interview on 1/15/2025 at 1:00 p.m. with the Receptionist, the Receptionist stated residents must talk to the charge nurse prior to leaving the facility and fill out the Leave of Absence form. The Receptionist stated the Leave of Absence form must be completely filled out before residents leave the facility. The Receptionist stated if the Leave of Absence form did not have a nurse signature, it meant the charge nurse did not clear the resident to leave the facility and that resident should have not left the facility. The Receptionist stated he did not know why the form was missing the charge nurse signature. During an interview on 1/16/2025 at 12:44 p.m. with Registered Nurse 1 (RN), RN 1 stated a licensed nurse must sign the Leave of Absence form to indicate the resident was cleared to leave the facility. RN 1 stated if a licensed nurse did not clear a resident to leave the facility it would be an unsafe practice and staff would not know resident's whereabouts. RN 1 stated the Leave of Absence form must be completely filled out to allow the resident to leave the facility. RN 1 stated license nurses must sign the Leave of Absence form and document in the nursing progress notes the resident left the facility. RN 1 stated licensed nurses must document when a resident leaves the facility and when the resident returns to the facility. RN 1 stated licensed nurses must document the condition of the resident when leaving the facility and the condition of the resident when they returned to the facility. During a review of the facility's policy and procedure (P&P) titled Signing Residents Out, dated 8/2006, the P&P indicated all residents leaving the premises must be signed out. The P&P indicated the expected time to return to the facility must be documented on the form. During a review of the facility's P&P titled Charting and Documentation, dated 7/2027, the P&P indicated information to be documented in the resident medical record was all services provided to the resident and objective observations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for five of eight sampled residents (Resident 19, 8, 76, 90, and 15) by: 1. Failing to ensure Resident 19's nasal cannula (device used to deliver supplemental oxygen placed directly on the resident's nostrils) and humidifier (a medical device that adds water vapor to oxygen to help relieve dryness and irritation by oxygen therapy) were changed every seven days. 2. Failing to ensure a multiuse bottle of blood glucose (BG, a type of sugar) test strips used for multiple residents was not taken into and out of each of the following residents rooms (Residents 8, 76, 90, and 15) which increased the risk of cross-contamination, infection, and the spread of disease between residents whose blood was being tested during BG level checks (a test that measures the amount of glucose in the blood). These deficient practices had the potential to place Residents 19, 8, 76, 90, and 15 at risk for infection. Findings: 1. During a review of Resident 19's admission Record (a document containing medical and demographic information), the admission record indicated Resident 19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD]- a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscle strength), and dysphagia (difficulty swallowing). During a review of Resident 19's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/17/2024, the MDS indicated Resident 19's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 19 required maximal (helper does less more than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 19's care plan with a focus of Oxygen Therapy related to (r/t) COPD, dated 11/8/2024, the care plan interventions indicated to administer oxygen as ordered. During a review of Resident 19's order summary report, dated 12/26/2024, the order summary report indicated to administer oxygen at two (2) liter (a metric unit) per minute (2 liter/min) as needed (PRN) for shortness of breath. During an observation on 1/13/2025 at 10:26 a.m., in Resident 19's room, observed Resident 19's oxygen humidifier was dated 12/14/2024. Resident 19's oxygen tubing and nasal cannula were touching the floor and undated by Resident 19's bedside. During a concurrent observation and interview on 1/16/2025 at 2:30 p.m., with the Director of Nursing (DON), the DON stated the oxygen humidifier on Resident 19's oxygen concentrator was dated 12/14/2024. The DON stated the tubing and nasal cannula were undated. The DON stated the oxygen tubing and nasal cannula should be changed and dated every seven days. The DON stated the oxygen humidifier should be changed every seven days and/or as needed. The DON stated the licensed staff were responsible for changing the oxygen tubbing, nasal cannula, and humidifier every seven days. The DON stated the oxygen supplies might accumulate dirt, dust, and not work properly. The DON stated not changing the oxygen tubing, nasal cannula, and humidifier placed Resident 19 at risk for a respiratory infection. The DON stated the purpose of changing the oxygen supplies every seven days was for infection control purposes and it was a standard of nursing practice. During a review of the facility's policy and procedure (P&P) titled Cleaning and Disinfection of Environmental Surfaces, revised 8/2019, the P&P indicated respiratory therapy equipment should be free from all microorganisms. During a review of the facility's' P&P titled Policies and Practices-Infection Control, revised 10/2018, the P&P indicated facility would maintain a sanitary environment to help prevent and manage transmission of diseases and infections. During a review of the facility's P&P titled Oxygen Administration, revised 2/2024, the P&P indicated the facility would provide safe oxygen administration. 2. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to DM with hyperglycemia (high blood glucose [BG]/blood sugar [BS]). During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 was sometimes able to be understood and understand others. The MDS indicated Resident 8 cognition was severely impaired. The MDS indicated Resident 8 required set up assistance with eating. The MDS indicated Resident 8 required substantial assistance for oral hygiene and upper body dressing. The MDS indicated Resident 8 was dependent upon facility staff assistance for bathing, toileting, and lower body dressing. During a review of Resident 8's undated care plan with a focus of Diabetes Mellitus, potential for hypoglycemia (low blood glucose), hyperglycemia (high blood glucose), the care plan indicated the interventions indicated to blood sugar check as ordered and to administer insulin per sliding scale. During a review of Resident 8's Order Summary Report, the Order Summary Report included an order for Insulin Lispro (medication used to treat high blood glucose) Injection Solution 100 units (unit of measurement) per milliliter ([ml] - a unit of measure for volume), indicated, inject subcutaneously (just under the skin) as per sliding scale if 70 milligrams (mg, unit of measure of weight) per deciliter (dL, unit measure of volume) - 150 = 0 If BS<70 to give glucose gel if able to swallow and Notify MD.; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 If BS>400 give 12 units of insulin and Notify MD., subcutaneously before meals and at bedtime related to Type 2 diabetes mellitus with hyperglycemia, administration times 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM, order date 12/6/2024. During a blood glucose monitoring observation on 1/14/2024 at 11:54 a.m. with Licensed Vocational Nurse (LVN) 4 on Nursing Station/Medication Cart 1, LVN 4, put on personal protective equipment (PPE, that include a gown, gloves, and mask) to enter Resident 8's room that had a sign on the door that indicated, Enhanced Barrier Precautions (EBP is an approach to the use of PPE to reduce transmission of Multidrug-Resistant Organisms (MDROs) between residents). LVN 4 took a multiuse bottle of Assure Platinum Blood Glucose (BG) Test Strips with an open date of 1/13/2025 into Resident 8's room placed the multiuse bottle of test strips on Resident 8's bedside table opened the container removed a test strip, pricked Resident 8's finger to obtain a blood sample and tested the resident's BG level. LVN 4 collected all the supplies, disposed of the lancet used to prick the resident's finger, and the used test strip and then returned the unused portion of the multiuse bottle of BG test strips to the medication cart. 3. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to DM. During a review of Resident 76's MDS dated [DATE], the MDS indicated Resident 76 was sometimes able to be understood and understand others. The MDS indicated Resident 76 cognition was intact. The MDS indicated Resident 76 was able to be understood and understand others. The MDS indicated Resident 76 required set up or supervision for ADLs. During a review of Resident 76's undated care plan with a focus of Diabetes Mellitus, potential for altered blood sugar level - at risk for skin breakdown due to insulin administration and blood sugar monitoring, the care plan indicated the interventions indicated to administer diabetes medications as ordered by doctor and monitor/document for side effects and effectiveness. During a review of Resident 76's Order Summary Report, the Order Summary Report included an order for Insulin Lispro (0.5 Unit Dial) Subcutaneous Solution Pen-injector (a medical device used to administer individualized doses of insulin) 100 UNIT/ML, indicated to Inject as per sliding scale: if 201 mg/dL - 250 = 2 units BS less than 201= No insulin; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units BS greater than 400 = Give 6 units and Call MD, subcutaneously before meals and at bedtime for DM, administration times 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM, order date 10/22/20244 During a concurrent blood glucose monitoring observation and interview on 1/14/2024 at 12:07 PM with LVN 4 on Nursing Station/Medication Cart 1, LVN 4 stated the EBP sign outside of Resident 76's door was for a different resident inside the same room and she was not required to put on a gown to check Resident 76's BG level. LVN 4 took the multiuse bottle of Assure Platinum BG Test Strips into Resident 76's room placed the multiuse bottle of test strips on Resident 76's bedside table opened the container removed a test strip, pricked Resident 76's finger to obtain a blood sample and tested the resident's BG level. LVN 4 collected all the supplies, disposed of the lancet used to prick the resident's finger, and the used test strip and then returned the unused portion of the multiuse bottle of BG test strips to the medication cart. 4. During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was admitted to the facility on [DATE] with diagnoses that included but not limited to DM with hyperglycemia. During a review of Resident 90's MDS dated [DATE], the MDS indicated that Resident 90 was sometimes able to be understood and understand others. The MDS indicated Resident 90 cognition was moderately impaired. The MDS indicated Resident 90 was able to be understood and understand others. The MDS indicated Resident 90 required set for eating and partial to substantial assistance for the ADLs, that included bathing or showering, dressing, getting in and out of bed or a chair, walking, and toileting. During a review of Resident 90's undated care plan with a focus of Diabetes Mellitus, potential for hypoglycemia and hyperglycemia, the care plan indicated the interventions indicated to administer diabetes medications as ordered by doctor and monitor/document for side effects and effectiveness. During a review of Resident 90's Order Summary Report, the Order Summary Report included an order for Insulin Regular Human (medication used to treat high blood glucose) Injection Solution 100 units per ml, indicated, inject subcutaneously as per sliding scale: if 151 mg/dL - 200 = 0 units, if BS is less than 60=Give juice or oral glucose gel; 201 - 250 = 3 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 399 = 9 units; 400+ = 12 [NAME] if BS is greater than 400, give 12 units and notify MD, subcutaneously before meals and at bedtime for DM, administration times 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM, order date 1/2/2025 During a concurrent blood glucose monitoring observation and interview on 1/14/2024 at 12:14 PM with LVN 4 on Nursing Station/Medication Cart 1, LVN 4 stated Resident 90 was under EBP, after putting on PPE (a mask, gown, and gloves), LVN 4 took the multiuse bottle of Assure Platinum BG Test Strips into Resident 90's room placed the multiuse bottle of test strips on Resident 90's bedside table opened the container removed a test strip, pricked Resident 90's finger to obtain a blood sample and tested the resident's BG level. LVN 4 collected all the supplies, disposed of the lancet used to prick the resident's finger, and the used test strip and then returned the unused portion of the multiuse bottle of BG test strips to the medication cart. 5. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to DM and pressure ulcer (a localized area of skin damage caused by prolonged pressure on the skin) of sacral region (lower spine), Stage III (sore deepens and looks like a crater). During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15 was sometimes able to be understood and understand others. The MDS indicated Resident 15 cognition was moderately impaired. The MDS indicated Resident 15 was usually understood and usually able to understand others. The MDS indicated Resident 15 required set for eating and partial assistance for oral hygiene. The MDS indicated Resident 15 substantial assistance to total dependency on facility staff for bathing or showering, dressing, getting in and out of bed or a chair, walking, and toileting. During a review of Resident 15's undated care plan with a focus of Diabetes Mellitus, potential for altered blood sugar, the care plan indicated interventions indicated to administer diabetes medications as ordered by doctor and monitor/document for side effects and effectiveness. During a review of Resident 15's Order Summary Report, the Order Summary Report included an order for Insulin Lispro, indicated, inject subcutaneously as per sliding scale: if 0 - 200 = 0 units, if BS is less than 201, no insulin; 201 - 250 = 2 units ; 251 - 300 = 3 units ; 301 - 350 = 4 units; 351 - 400 = 5 units if bs greater than 400 give 6 units and call MD, subcutaneously before meals and at bedtime for diabetes, administration times 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM, order date 11/26/2024. During a concurrent blood glucose monitoring observation and interview on 1/14/2024 at 12:22 PM with LVN 4 on Nursing Station/Medication Cart 1, LVN 4 took the multiuse bottle of Assure Platinum BG Test Strips into Resident 15's room placed the multiuse bottle of test strips on Resident 15's bedside table opened the container removed a test strip, pricked Resident 15's finger to obtain a blood sample and tested the resident's BG level. LVN 4 collected all the supplies, disposed of the lancet used to prick the resident's finger, and the used test strip and then returned the unused portion of the multiuse bottle of BG test strips to the medication cart. LVN 4 stated the Assure Platinum BG Test Strips inside the bottle are used for multiple residents and should not go into the room with the residents because of infection control. During an interview with the Director of Nursing on 1/16/2025 at 3:12 PM, the DON stated the multiuse bottle of BG/BS test strips used for multiple residents should stay at the medication cart for infection control. The DON stated the licensed nurse should only carry the supplies that they need into the resident's room and not take additional material or equipment because the supplies become unclean and increase the risk of infection toward other residents. According to Center for Disease Control for Injection Safety under, Considerations for Blood Glucose Monitoring and Insulin Administration dated 8/2024, indicated, Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment .Hand hygiene indicated . Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. Discard gloves in appropriate receptacles (containers). Perform hand hygiene immediately after removing gloves and before touching other medical supplies intended for use on other persons . If healthcare providers use blood glucose testing or insulin administration devices on more than one patient, equipment and supplies may become contaminated. Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus, hepatitis C virus, HIV, and other infections. During a review of the facility's P&P titled, Policies and Practices - Infection Control, revised 10/2018, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission or diseases and infections. During a review of the facility's P&P tiled, Obtaining a Fingerstick Glucose Level, revised 10/2021, the P&P indicated, the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Assemble equipment and supplies needed. During a review of an undated P&P Titled, Charge Nurse, the P&P indicated, Assist in training department personnel in identifying tasks that involve potential exposure to blood/body fluids . Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was in the facility for at least eight consecutive hours on 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025. This deficient practice had the potential to result in initial assessment to be delayed or missed and a potential to result in an overall decrease in the quality of care for the residents. Findings: During a review of the facility's Licensed Nurse Staffing, dated 12/1/20/24 through 12/31/2024, the Licensed Nurse Staffing indicated there was no RN scheduled during the 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, nor the 11 p.m. to 7 a.m. shift on 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025. During an interview on 1/15/2025 at 8:23 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the RN who worked weekends was on sick leave and to fill the RN shift, one of the Minimum Data Set Nurses (MDSN), who were licensed RNs, would come in during the 7 a.m. to 3 p.m. shift. During an interview on 1/15/2025 at 1:42 p.m., with MDSN 1, MDSN 1 stated he usually worked Monday through Friday, however, he had worked extra on some weekends to provide RN coverage. During a concurrent interview and record review on 1/16/2025 at 11:58 a.m., with the Director of Nursing (DON), the facility's Timecard Reports dated 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025 were reviewed. The Timecard Reports indicated the following hours MDSN 1 and MDSN 2 worked: a. On 12/7/2024, MDSN 2 worked 5.97 hours. b. On 12/8/2024, MDSN 2 worked 4 hours. c. On 12/15/2024, MDSN 1 worked 4.18 hours. d. On 1/4/2025, MDSN 2 worked 4.17 hours. The DON stated the facility had RN coverage on 12/7/2024, 12/8/2024, 12/15/2024, and 1/4/2025, however, the RNs on shift did not work the required eight hours. The DON stated having an RN in the facility for eight consecutive hours ensured assessments upon admission were completed timely. The DON stated RNs were used as a resource during an emergency due to the additional experience. The DON stated without an RN on shift for the required eight hours, there could be a delay or missed admission or general assessments. The DON stated because RNs were utilized during an emergency, the RN would take charge, therefore, without an RN, the resident involved in an emergency may not receive the best care possible. During a review of the facility's Job Description for Registered Nurse (RN) Supervisor, undated, the Job Description indicated the RN Supervisor was to supervise day-to-day activities of the facility in accordance with current federal, state, and local standards that govern the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of five sampled Residents (Resident 77 and 79)'s drug regiment was free of unnecessary medications by failing to: 1. Monitor the specific target behaviors for Resident 79's Zyprexa (olanzapine, an antipsychotic medication used to treat mental illness), Ativan (lorazepam, used to treat anxiety [excessive and persistent feelings of worry, fear, dread, and uneasiness that interfere with daily life), Desyrel (trazodone, antidepressant used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety disorders), Cymbalta (duloxetine, used to treat depression and anxiety), and Depakene (valproic acid, used to treat seizure (is a sudden rush of abnormal electrical activity in your brain) disorders, mental/mood conditions) and attempt nonpharmacological (without drugs) intervention prior to the initiation and during the use of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications and document the effectiveness of the nonpharmacological interventions. 2. Monitor Resident 77 for specified behavior of poor regard to his health while receiving olanzapine. This deficient practice had the potential to result in Resident 77's behavior of poor regard to his health being undetected and mismanaged and had the potential to cause adverse effects (side effects, unwanted undesirable effects that are possibly related to a drug) to Residents 79 due to the possible administration of unnecessary psychotropic medications. Findings: 1. During a review of Resident 79's admission Record (a document containing medical and demographic information), the admission Record indicated Resident 79 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a stroke, a serious condition that occurs when blood flow to the brain is blocked), dementia (memory loss that gets worse over time, Alzheimer's), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), altered mental status (AMS, a general term for a change in a person's mental function, consciousness, or awareness), depression, unspecified psychosis (commonly used if there is inadequate information to make the diagnosis of a specific psychotic disorder [a mental illness that causes a person to lose touch with reality]), and cognitive communication deficit (a communication difficulty caused by a cognitive impairment) During a review of Resident 79's Minimum Data Set (MDS, a standardized resident assessment and care-planning tool), dated 10/29/2024, the MDS indicated Resident 79 rarely or never was able to make self-understood and rarely or never had the ability to understand others. The MDS indicated Resident 79 had severe impairment in cognition (ability to think, process, and recall information). The MDS indicated under potential indicators for psychosis (hallucinations [see things that are not there] and/or delusions [having false or unrealistic beliefs]) that Resident 79 had, None of the above. The MDS indicated Resident 79 required set up assistance with eating, partial assistance with oral hygiene, and substantial assistance with lower body dressing. The MDS indicated Resident 79 was dependent on facility staff with toileting, bathing, upper body dressing, and personal hygiene. During a review of Resident 79's History and Physical Examination (H&P), dated 5/3/2024, the H&P indicated Resident 79 had fluctuating capacity to understand and make decisions. During a review of Resident 79's general acute care hospital (GACH) Progress Note, dated 4/27/2024, the GACH Progress Note indicated Resident 79's medications included duloxetine 60 milligram ([mg] - unit of measurement) once a day, memantine 10 mg twice a day, quetiapine (Seroquel (an antipsychotic medication used to treat mental illness) 25 mg twice a day, and lorazepam (Ativan) 0.5 mg/tablet, one tablet every 6 (six) hours as needed. The GACH Progress Note indicated Resident 79's admission was for agitation on dementia and that the resident May be overly sedated on above regiment, discuss with psych. Progress Note for Resident 79 indicated, Other specified personal risk factors, not elsewhere classified (due to chronic immobility). During a review of Resident 79's Psychiatric Skilled Nursing Facility (SNF) Initial Evaluation, dated 5/7/2024, the Psychiatric SNF Initial Evaluation indicated Resident 79, Today, the patient was alert but not oriented .strengths: ability to verbalize concerns and needs .Diagnosis: mood disorder, unspecified and generalized anxiety disorder. Resident 79's Psychiatric SNF Initial Evaluation indicated Assessment and Plan: Patient is currently not experiencing worsening symptoms of disease. Safety: Patient is not currently a danger to self or others . Medication Management: We will start Ativan 1 milligram ([mg] - unit of measure of weight) by mouth (PO) every 6 (six) hours as needed (PRN) for anxiety manifested by (m/b) increasing restlessness, NTE (Not to exceed) 2 mg per 24 hours, start trazodone 25 mg PO nightly at bedtime for depression m/b inability to sleep, and start Zyprexa 2.5 mg daily for psychosis m/b auditory hallucinations .encouraged to cease medication and report side effects should they occur .Continue participation in group and milieu therapies (a structured group treatment method that uses everyday activities to help people with mental health issues) as possible. During a review of Resident 79's Psychiatric SNF Follow-Up Note, dated 9/19/2024, the Psychiatric SNF Follow-Up Note indicated, follow up for depression and mood .Mental Status Exam, under Thought Content: No suicidal ideation, no homicidal ideation, no auditory or visual hallucinations expressed. During a review of Resident 79's Psychiatric SNF Follow-Up Note, dated of dictation 11/20/2024, the Psychiatric SNF Follow-Up Note indicated, We will increase Zyprexa 10 mg by mouth twice daily for psychosis manifested by auditory and visual hallucinations. We will continue Cymbalta (duloxetine) 60 mg by mouth daily for depression manifested by decrease in motivation, memantine 5 mg by mouth at bedtime for memory enhancement, trazodone 50 mg by mouth at bedtime for depression manifested by inability to sleep, temazepam 15 mg by mouth as needed at bedtime for insomnia for 14 days and we will assess to see the need to continue the medication after 14 days. We will also continue Ativan 1 mg by mouth every six hours as needed for anxiety manifested by restlessness for 30 days and we will assess the need to continue the medication after 30 days . Patient is not currently a danger to self or others . encouraged to cease medication and report side effects should they occur . Continue participation in group and milieu therapies as possible. During a review of the facility's Consultant Pharmacist Medication Regimen Review (MRR) between 10/2024 through 12/2024 the following recommendations were made for Resident 79: a. MRR for the months of 10/2024 and 11/2024 indicated, Please f/u (follow-up) to evaluate monitoring of all indicated behavior (s) and side effect (s) for valproic Acid on the Medication Administration Record (MAR, a written record of all medications given to a resident). b. MRR for the month of 12/2024 indicated, Please f/u to evaluate monitoring of all indicated behavior (s) and side effect (s) for all psychotropic orders on the MAR. During a review of Resident 79's Order Summary Report, the Order Summary Report included the following physician orders: a. Duloxetine HCL Oral Capsule Delayed Release Particles 60 MG, Give 1 capsule by mouth one time a day for Major Depression manifested by (m/b) labile activity related to depression, order date 9/1/2024. b. Lorazepam Oral Tablet 1 MG, Give 1 mg by mouth every 8 hours as needed for Anxiety m/b restlessness for 30 days, order date 01/07/2025 end date 2/6/2025. c. Memantine HCI Oral Tablet 5 MG, Give 1 tablet by mouth at bedtime related to dementia with agitation, order date 9/1/2024. d. Olanzapine Oral Tablet 10 MG, Give 1 tablet by mouth at bedtime for pshychosis m/b auditory hallucinations related to unspecified psychosis, order date 10/15/2024. e. Olanzapine Oral Tablet 5 MG, Give 1 tablet by mouth one lime a day related to unspecified psychosis m/b auditory hallucinations, order date 10/14/2024. f. Trazodone HCI Oral Tablet 100 MG, Give 1 tablet by mouth at bedtime for depression m/b inability to sleep, order date 12/23/2024. g. Valproic Acid Oral Solution 250 MG/5 milliliter ([ml] - a unit of measure for volume), Give 15 ml (750 mg) by mouth at bedtime related to unspecified psychosis m/b increased restlessness, order date 12/23/2024. h. Valproic Acid Oral Solution 250 MG/5ML, Give 20 ml (1000 mg) by mouth one time a day related to unspecificed psychosis m/b increased restlessness, order date 12/23/2024. i. May participate in activities not in conflict with treatment plan. j. Monitor behaviors of labile activity every shift for use of duloxetine, order date 9/1/2024. k. Monitor behaviors of psychosis m/b auditory hallucinations every shift for use of olanzapine, order date 9/1/2024. l. Monitor for anxiety m/b restlessness every shift, order date 9/1/2024. m. Monitor for depression m/b inability to sleep every shift for trazodone, order date 9/1/2024. n. Monitor S/E (side effects) and adverse reaction for antipsychotic medications .cognitive/behavior impairment (decrease mental status), akathisia (inability to sit still), frequent falls, depression, suicidal ideation, social isolation, blurred vision, fatigue, insomnia .every shift for olanzapine, order date 9/1/2024. o. Monitor S/E for anti-anxiety Ativan (lorazepam): drowsiness, lack of energy, confusion and disorientation, depression, dizziness, impaired thinking and judgement, memory loss, forgetfulness .Paradoxical side effects (when the opposite outcome of a drug occurs, rather than the expected outcome) included hallucinations, increased confusion, amnesia, cognitive impairment that looks like dementia, falls .every shift for Ativan use, order date 9/1/2024. p. Monitor S/E for anti-depressant (trazodone) .insomnia, dizziness, drowsiness, fatigue .and increased risk for fall every shift for trazodone, order date 9/1/2024 . q. Monitor Valproic Acid S/E .drowsiness, confusion, ataxia (poor muscle control that causes clumsy movements) .every shift, order date 11/9/2024. r. Non-RX (nonpharmacological/ without drugs) Behavioral Interventions indicated, Pick the intervention (s) that best works to alleviate the behavior .every shift for intervention document the corresponding number of all interventions attempted. Document effectiveness of intervention (s) Y/N, order date 9/1/2024. Intervention key: 0 - No Intervention attempted 2 - Redirect 3 - Remove from situation/Ensure resident safety 4 - Provide calm environment (low lighting, quiet) 5 - Meaningful activity 6 - Reapproach 7 - 1:1 8 - Offer food/drink 9 - Toilet 10 - Provide comfort (message, reposition, heat/cold) 11 - Relaxation techniques 12 - Resident refused During a review of Resident 79's undated care plans with a focus of: a. The resident uses anti-anxiety medications: Lorazepam r/t Anxiety disorder, the care plan intervention indicated, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Antianxiety side effects: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. Paradoxical side effects: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations. Resident 79's care plan included a caution, The resident is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety. b. The resident has impaired physical mobility r/t (related to) Alzheimer's disease, history of CVA (cerebrovascular accident, stroke). The care plan intervention indicated, invite the resident (Resident 79) to activity programs that encourage activity, physical mobility, such as exercise group .monitor/document/report to MD (physician) PRN s/sx (signs and symptoms) of immobility .provide supportive care, assistance with mobility as needed .Document assistance as needed. c. Resident with altered sleep pattern due to depression as m/b inability to sleep. The care plan interventions indicated, monitor causes of altered sleep pattern such as medication .encourage resident to get up during the day and attend activity as tolerated .administer medication as ordered, re-evaluate effectiveness of interventions. d. The resident uses antidepressant medication: duloxetine HCL and trazodone HCL r/t depression. The care plan interventions indicated, monitor/document side effects and effectiveness. Antidepressant side effects .anxiety, insomnia, dizziness, drowsiness, fatigue .and increased risk for falls. e. The resident uses psychotropic medications r/t behavior management, olanzapine for psychosis. The care plan interventions indicated administer medications as ordered. Monitor/document for side effects and effectiveness monitor/document/report to MD side effects and adverse reactions of psychoactive medications .frequent falls .depression .social isolation .fatigue, insomnia. The care plan included a Boxed warnings (formerly known as Black Box Warnings, are the highest safety-related warnings that medications can have assigned by the Food and Drug Administration [FDA]) which indicated, Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. f. Psychosis, dementia ., The care plan interventions included, encourage the resident to participate to the fullest extent possible with each interaction. g. The resident has impaired cognitive function or impaired thought process r/t Alzheimer's Dementia, psychosis and history of cerebral infarction. The care plan interventions indicated, communication .identify yourself at each interaction .engage the resident in simple structured activities that avoid overly demanding tasks .provide a program of activities that accommodates the resident's abilities. During a review of Resident 79's Medication Administration Record (MAR) for the months of 10/2024, 11/2024, 12/2024, and 1/2025 indicated Resident 79 was administered PRN lorazepam 1 mg a total of 87 times for restlessness or altered mental status (AMS) as follows: 28 times between 10/1/2024 - 10/30/2024 25 times between 11/1/2024 - 11/30/2024 22 times between 12/1/2024 - 12/31/2024 12 times between 1/1/2025 - 1/15/2025 During a review of Resident 79's MAR for monitoring behavior (s) of anxiety m/b restlessness every shift for the months of 10/2024, 11/2024, 12/2024, and 1/2025. Resident 79's MARs indicated by documentation and initialed by licensed nurses across three nursing shifts (7 AM - 3 PM, 3 PM - 11 PM, and 11 PM - 7 AM) that the resident experienced: Zero (0) episodes of restlessness between 10/1/2024 - 10/31/2024, but was administered 28 doses of lorazepam for restlessness. Three (3) episodes of restlessness between 11/1/2024 - 11/302024, and was administered 25 doses of lorazepam for restlessness. Three (3) episodes of restlessness between 12/1/2024 - 12/31/2024, and was administered 22 doses of lorazepam for restlessness. Six (6) episodes of restlessness between 1/1/2025 - 1/15/2025, and was administered 12 doses of lorazepam for restlessness. During a review of Resident 79's MAR for monitoring behavior (s) of psychosis m/b auditory hallucinations every shift for the use of olanzapine for the months of 10/2024, 11/2024, 12/2024, and 1/2025. Resident 79's MARs indicated by documentation and initialed by licensed nurses across three nursing shifts (7 AM - 3 PM, 3 PM - 11 PM, and 11 PM - 7 AM) that the resident experienced, zero (0) behaviors of psychosis m/b auditory hallucinations for the months of 10/2024, 11/2024, and 12/2024; with three behaviors documented on the 1/1/2025 MAR for 1/2/2025, 1/3/2025, and 1/8/2025. During a review of Resident 79's MAR for monitoring behavior (s) of depression m/b inability to sleep every shift for trazodone, for the months of 10/2024, 11/2024, 12/2024, and 1/2025. Resident 79's MARs indicated by documentation and initialed by licensed nurses across three nursing shifts (7 AM - 3 PM, 3 PM - 11 PM, and 11 PM - 7 AM) that the resident experienced, Zero (0) behavioral episodes of inability to sleep for the months of 10/2024, 11/2024, 12/2024, and 1/2025. Resident 79's starting dose of trazodone 25 mg nightly at bedtime, dated 5/7/2025, was increased on 9/1/2024 to trazodone 50 mg nightly at bedtime, and the order was increased again on 12/23/2024 to trazodone 100 mg for the same indication of depression m/b inability to sleep. During a concurrent observation and interview on 1/15/2025 at 9:58 AM, with Resident 79's Sitter (RS) 1 inside of the resident's room, Resident 79 was observed sleeping in bed. RS 1 stated that she was a 1:1 sitter for Resident 79 because the resident was a fall risk. RS 1 stated that the resident sleeps a lot and that she wakes Resident 79 up for meals and snacks. RS 1 stated that she works with Resident 79 daily from 7 AM - 3 PM and the resident sleeps most of the time she is with the resident. RS 1 stated Resident 79 is easy to work with and is cooperative. During an interview on 1/15/2025 at 10:03 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 79 was confused and did not know where she was. LVN 1 stated that Resident 79 slept quite a bit at times and tried to not get out of bed as much. LVN 1 stated Resident 79 used to be an artist and could talk to you about her art, as the resident used to paint. LVN 1 stated that he administered the PRN lorazepam 1 mg to Resident 79 on the morning of 1/15/2025 because the resident was restless. LVN 1 stated after the lorazepam Resident 79 calmed down a lot. LVN 1 stated Resident 79 did not show signs of depression, she was always willing to get up and says, okay, okay. During a concurrent interview and record review on 1/15/2024 at 10:34 AM with LVN 1, Resident 79's progress notes, 1/2025 MAR, and care plan for the use of lorazepam and trazodone was reviewed. LVN 1 stated he did not document nonpharmacological interventions attempted or indicate if the interventions were effective or not prior to administering the PRN medication lorazepam to Resident 79. LVN 1 stated he did not document or describe the behavior he observed that resulted in the resident being administered lorazepam. LVN 1 stated Resident 79's care plan did not include any nonpharmacological interventions to attempt prior to the administration of psychotropic medications for restlessness, depression, or inability to sleep. LVN 1 stated Resident 79 sleeps quite a bit during the day and was administered trazodone nightly for depression and inability to sleep. LVN 1 stated that there was no documentation that the resident was being monitored or documented hours of sleep daily. LVN 1 stated that Resident 79 was cooperative, talks about her art, and would smile frequently, but was confused and disoriented at times and did not know where she was. During a concurrent interview and record review on 1/15/2025 at 10:52 AM, with Registered Nurse (RN) 1, Resident 79's MARs and nursing progress notes were reviewed. RN 1 stated Resident 79's MAR indicated the resident was administered lorazepam on 1/10/2025 and there was no documentation that nonpharmacological interventions was attempted prior to the administration of lorazepam. RN 1 stated there should have been documentation of the nonpharmacological intervention and the effectiveness of the intervention for Resident 79. RN 1 stated there was no documentation that Resident 79 was being monitored for hours of sleep during the day, evening, or nighttime hours. RN 1 stated licensed nurses should have been monitoring Resident 79 for hours of sleep which was the triggered behavior for the use of trazodone, depression m/b inability to sleep, but they were not. During a concurrent an interview on 1/15/2025 at 2:29 PM, with RS 1, inside of Resident 79's room, RS 1 stated Resident 79 was sleeping, and she woke Resident 79 up for lunch and the resident went back to sleep. RS 1 stated that she has not seen Resident 79 talking to herself. RS 1 stated Resident 79 woke up today, 1/15/2025, when Responsible Party (RP) 2, came to visit, but went back to sleep once RP 2 left. During an observation on 1/15/2025 at 2:47 PM, inside of Resident 79's room, Resident 79 was observed sleeping on her back. During a concurrent observation and interview on 1/16/2025 at 11:10 AM, with RS 1, inside of Resident 79's room, Resident 79 was observed sleeping. RS 1 stated Resident 79 was sleeping. During an interview on 1/16/2025 at 11:11 AM with RP 2, RP 2 stated Resident 79 usually have her eyes closed when he arrives. RP 2 stated Resident 79 began hallucinating after admission to the facility. RP 2 stated was aware of the medications Resident 79 was on but was not aware of the side effects of the medications. RP 2 stated 79 continues to decline and is getting more confused and forgetful and cannot make a full sentence now. RP 2 stated before Christmas 2024, Resident 79 was able to sing a full verse of Jingle Bells. RP 2 stated Resident 79's physician initially wanted to wean the resident off of olanzapine and start the resident on a different medication for dementia due to Alzheimer's disease, but the medication was too expensive. RP 2 stated when he looks at Resident 79 now, there are times the resident just stares as if she is here, but nobody is home. During a concurrent observation and interview on 1/16/2025 at 2:59 PM, with Certified Nurse Assistant (CNA) 5, Resident 79 was observed sleeping, CNA 5 confirmed and stated, Resident 79 is sleeping now. During a concurrent interview and record review on 1/16/2025 at 3:30 PM, with the Director of Nursing (DON) in the presence of the facility's Administrator, Resident 79's clinical records for Resident 79 was reviewed, that included the nursing progress notes, MARs between 10/2024 through 1/2025, MRRs, and resident's psychiatric evaluations for 5/7/2024 and 9/19/2024. The DON stated the licensed nurses should document the specific behaviors observed and the nonpharmacological interventions attempted. The DON reviewed Resident 79's clinical records and stated there was no documentation to describe the behavior exhibited by the resident or documentation to indicate that the resident was evaluated for underlying cause of restlessness. The DON stated there was no documentation of nonpharmacological interventions attempted to alleviate the restlessness prior to the administration of lorazepam for the months of 10/2024, 11/2024, 12/2024, and 1/2025. The DON reviewed the monitoring for trazodone for the month of 12/2024 when trazodone was increased from 50 mg to 100 mg for depression m/b inability to sleep. The DON stated the trazodone dose increase does not correlate with the documentation of monitoring for sleep that indicated zero (0) across three nursing shifts between 10/2024 through 1/2025. The DON stated there was no documentation from the psychiatrist after 9/19/2024 to show that lorazepam 1 mg was reevaluated after 30 days. The DON stated there was no documentation that the facility evaluated the monitoring of behaviors and side effects of all psychotropic medications for Resident 79 as recommended by the facility's Consultant Pharmacist MRRs between 10/2024 through 12/2024. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring revised 3/2019, the P&P indicated Behavioral or Psychological Symptoms of Dementia (BPSD) describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. Appropriate assessment and treatment of behavioral symptoms requires differentiating between behavioral symptoms that can be managed by treating the underlying factors, and those that cannot. Current guidelines recommend the use of nonpharmacological interventions for BPSD .Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes . 1. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms. 2. The rationale for the interventions and approaches. 3. Specific and measurable goals for target behaviors. 4. How staff will monitor for effectiveness of the interventions. 5. Nonpharmacological approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. 6. The IDT (Interdisciplinary Team (brings together knowledge from different health care disciplines to help people receive the care they need) will monitor for side effects and complications related to psychoactive medications for example, lethargy (a condition marked by drowsiness and an unusual lack of energy and mental alertness). 2. During a review of Resident 77's admission Record, the admission record indicated Resident 77 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77's cognition was intact. The MDS indicated Resident 77 required set up assistance with eating, oral hygiene, and upper body dressing. The MDS indicated Resident 77 required supervision with toileting, bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 77 received an antipsychotic medication (medication to treat symptoms of schizophrenia). During a review of Resident 77's History and Physical Examination (H&P), dated 10/29/2024, the H&P indicated Resident 77 had the capacity to understand and make decisions. During a review of Resident 77's GACH Psychiatric Progress Note, dated 10/26/2024, the Psychiatric Progress Note indicated Resident 77 felt his medication regimen was helpful and continued improvement in his anxiety (feeling of fear, dread, and uneasiness) and depression. During a review of Resident 77's GACH Medication List, dated 10/27/2024, the Medication List indicated to continue taking olanzapine 2.5 milligram (mg, unit of measurement), half a tablet, by mouth, two times a day. During a review of Resident 77's Psychiatric Follow Up Note, dated 11/22/2024, the Psychiatric Follow Up Note indicated Resident 77 was restarted on olanzapine due to having delusional thinking (having false or unrealistic beliefs), increased paranoia (unjustified suspicion and mistrust of other people or their actions), and resistance to care. During a concurrent interview and record review on 1/16/2025 at 10:34 a.m., with Registered Nurse (RN) 1, Resident 77's Order Recap Report, dated 1/1/2024 through 1/31/2025 was reviewed. The Order Recap Report indicated: a. Give olanzapine 1.25mg, by mouth, two times a day for schizophrenia, bipolar mania (a period of extreme mood elevation and increase energy). Order started on 10/27/2024 and discontinued on 11/8/2024. b. Give olanzapine 1.25mg, by mouth, two times a day for schizophrenia. Orders started on 11/8/2024 and discontinued on 11/22/2024. c. Give olanzapine 1.25mg, by mouth, two times a day for schizophrenia as manifested by delusional thinking and poor regards to his health. Order started on 11/22/2024. d. Monitor every shift for depression as manifested by delusional thinking. Order started on 11/27/2024. e. Monitor every shift for behavior(s) of agitation for use of olanzapine. Order started on 12/16/2024. RN 1 stated Resident 77 received olanzapine because he had behaviors of delusional thinking and had poor regard to his health. RN 1 stated Resident 77 was only monitored for behaviors of agitation and delusional thinking. RN 1 stated Resident 77 was not monitored for any behaviors of poor regard to his health. RN 1 stated because Resident 77 was being treated for specific behaviors, all indicated behaviors had to be monitored by the licensed nurses. During a concurrent interview and record review on 1/16/2025 at 10:36 a.m., with RN 1, Resident 77's Medication Regimen Review (MRR), dated 11/1/2024 through 11/20/2024 and 12/1/2024 through 12/17/2024 were reviewed. The MRR indicated the Pharmacist's Consultant recommended to follow up to evaluate monitoring for all indicated behavior(s) and side effect(s) for olanzapine on the [Medication Administration Record]. RN 1 stated the purpose of the MRR was for the Pharmacist Consultant to review the resident's medication list and make recommendations to better monitor and care for the resident. RN 1 stated in November 2024 and December 2024, the Pharmacist Consultant recommended to follow up to monitor for all of Resident 77's indicated behaviors. RN 1 stated Resident 77's indicated behaviors for the use of olanzapine were delusional thinking and poor regard to his health. RN 1 stated the Pharmacist Consultant recommended the monitoring two times; however, the recommendations were not followed. RN 1 stated there was a discrepancy between Resident 77's orders for monitoring and the indicated behaviors for olanzapine. RN 1 stated Resident 77 was not being properly monitored as his behavior for poor regard to his health was not being monitored every shift. RN 1 stated Resident 77 was not being monitored properly for the effectiveness of olanzapine and Resident 77 was at risk of having his behavior being undetected. During an interview on 1/16/2025 at 12:13 p.m., with the DON, the DON stated Resident 77 was on a psychotropic medication, which required an indication of use for the behaviors the medication was treating. The DON stated all behaviors that were indicated must be monitored. The DON stated monitoring for all the behaviors ensured proper monitoring of the effectiveness of the behavior and to allow Resident 77's physician to adjust the dosage if needed. The DON stated because Resident 77's behavior of poor regard to his health was not being monitored, Resident 77 was at risk of having his behavior mismanaged and undetected. During a review of the facility's P&P titled, Behavioral Assessment, Intervention, and Monitoring revised 3/2019, the P&P indicated Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. The P&P indicated when a medication was prescribed for behavioral symptoms, the documentation would include the rational for use, specific target behaviors and expected outcomes, and monitoring for efficacy and adverse consequences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure opened boxes of nebulizer solution (Ipratropium and albuterol combination, is used to treat chronic obstructive pulmonary disease (COPD, a condition that blocks airflow and make it hard to breathe) and other lung conditions, such as asthma [wheezing, difficulty breathing], chronic bronchitis [swelling of the air passages that lead to the lungs], and emphysema [damage to the air sacs in the lungs]) had an open date and was stored in accordance with manufacturer's specification for five of five residents (Residents 15, 35, 74, 19, and 12) inside of two of two Medication Carts (Medcart Station 1 and Medcart Station 2). The deficient practice of failing to label nebulizer solutions, Ipratropium and albuterol combination per the manufacturers' requirements increased the risk that residents with lung diseases could have received ineffective medication necessary to treat or prevent shortness of breath, breathing difficulties, chest pain, and coughing, which could result in health complications or hospitalization. Findings: 1. During a concurrent interview and medication area inspection on 1/15/2025 at 2:48 PM of Medcart Station 1 with Licensed Vocational Nurse (LVN) 3, inside of Medcart Station 1, two boxes of Ipratropium-Albuterol Inhalation Solution labeled for Residents 15 and Resident 35 respectively were observed inside of the medication box with vials of inhalation solution stored outside of the foil pouch. LVN 3 stated there was no open date written or indicated on the boxes for Resident 15 or Resident 35. LVN 3 stated there was 2 vials of Ipratropium-Albuterol Inhalation Solution stored outside of the foil with a prescription fill date of 11/26/2024. LVN 3 stated that she administered a dose of Ipratropium-Albuterol Inhalation Solution to Resident 15, today, 1/15/2025 at 11:15 AM. LVN 3 stated there was four vials of Ipratropium-Albuterol Inhalation Solution stored outside of the foil pouch for Resident 35 and the prescription fill date was 11/8/2024. a. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to COPD and Asthma. During a review of Resident 15's Order Summary Report, the Order Summary Report included an order for Ipratropium-Albuterol Inhalation Solution 0.5-3 (2.5) milligram (mg, unit of measure of weight) per 3 milliliters (ml, unit of measure of volume), instructions indicated to inhale 3 ml orally (by mouth) every 6 (six) hours for SOB (shortness of breath)/ wheezing, order date 11/26/2024. b. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to COPD. During a review of Resident 35's Order Summary Report, the Order Summary Report included an order for Ipratropium-Albuterol Inhalation Solution 0.5 mg -3 (2.5) mg per 3 ml, instructions indicated to inhale 3 ml orally (by mouth) every 6 (six) hours as needed (PRN) for SOB/ wheezing/ Congestion, order date 11/22/2024. 2. During a concurrent interview, medication area inspection, and record review on 1/15/2025 at 3:02 PM of Medcart Station 2, with LVN 2, inside of Medcart Station 2, were three boxes of Ipratropium-Albuterol Inhalation Solution labeled for three individual residents, Resident 74, Resident 19, and Resident 12. The vials of Ipratropium-Albuterol Inhalation Solution was observed poured out and stored loosely inside of the boxes labeled for Resident 74, Resident 19, and Resident 12 and there was no foil pouch inside of the boxes. LVN 2 stated for Resident 74 and Resident 12 that there was no open date on the boxes and the date first stored loosely in the boxes was unknown. LVN 2 counted the vials and stated for Resident 74 there was 24 vials of Ipratropium-Albuterol Inhalation Solution stored outside of the foil pouch and the prescription fill date was 12/2/2024. LVN 2 stated for Resident 19 the open date was 12/27/2024 and there was 10 vials of Ipratropium-Albuterol Inhalation Solution stored outside of the foil pouch. LVN 2 stated for Resident 12 there was 11 vials of Ipratropium-Albuterol Inhalation Solution stored outside of the foil pouch and the prescription fill date was 12/18/2024. LVN 2 stated that Resident 12 was administered three doses of Ipratropium-Albuterol Inhalation Solution today, 1/15/2025, from the vials that was stored outside of a foil pouch for an unknown period of time. LVN 2 stated that he administered a dose of Ipratropium-Albuterol Inhalation Solution to Resident 12 today, 1/15/2025 and should have caught it. LVN 2 stated that he did not know who, when, or why the vials of Ipratropium-Albuterol Inhalation Solution was taken out of the foil pouch. a. During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to COPD, Acute Respiratory Failure (occurs when the lungs cannot release enough oxygen into the blood), and Emphysema. During a review of Resident 74's Order Summary Report, the Order Summary Report included an order for Ipratropium-Albuterol Inhalation Solution 0.5 mg -3 (2.5) mg per 3 ml, instructions indicated to inhale 3 ml orally every 6 (six) hours for SOB/ wheezing, order date 12/2/2024. b. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to COPD. During a review of Resident 19's Order Summary Report, the Order Summary Report included an order for Ipratropium-Albuterol Inhalation Solution 0.5 mg -3 (2.5) mg per 3 ml, instructions indicated to inhale 3 ml orally every 4 (four) hours for COPD exacerbation (worsening), order date 1/2/2025. c. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to COPD, Acute and Chronic (long-term) Respiratory Failure, Pulmonary Fibrosis (is a lung disease that causes scarring in the lungs, making it difficult to breathe), During a review of Resident 12's Order Summary Report, the Order Summary Report included an order for Ipratropium-Albuterol Inhalation Solution 0.5 mg -3 (2.5) mg per 3 ml, instructions indicated to inhale 3 ml orally every 6 (six) hours related to COPD, order date 10/6/2024. During an interview on 1/15/2025 at 3:30 PM with a Registered Nurse (RN) 1, RN 1 stated, the Ipratropium-Albuterol Inhalation Solution should be protected from light and remain in the foil pouch. RN 1 stated the light will effect the potency of the medication. RN 1 stated if the strength of the for Ipratropium-Albuterol Inhalation Solution is altered it may not be as effective for the residents to threat their breathing conditions. During an interview on 1/16/2025 at 3:12 PM with the Director of Nursing (DON), the DON read the manufacturer's package labeling for Ipratropium-Albuterol Inhalation Solution and stated the instructions indicated once the vial was removed from the foil pouch, the vial should be used within two weeks. DON stated the boxes of Ipratropium-Albuterol Inhalation Solution should have been dated with an open date. During a review of the manufacturer's labeling Instruction on the outside of the manufacturer's box for Ipratropium Bromide and Albuterol Sulfate Inhalation Solution 0.5 mg/3mg per 3 ml, the manufacturer's labeling indicated, For Oral Inhalation Only, Storage Conditions: Protect From Light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. A container of apple sauce and jelly were not labeled with the product name, the open date, and the use-by date. 2. An opened container of chocolate crème pie was not labeled with the open date and the use-by date. These deficient practices had the potential to result in harmful bacteria growth that could lead to foodborne illness (transfer of bacteria from one object to another). Findings: During a concurrent observation and interview on 1/13/2025 at 8:12 a.m., with the Dietary Supervisor (DS), in the kitchen, Refrigerator 5 was observed to have two unlabeled containers of food items. The DS stated one container The DS stated one container contained apple sauce and the second container contained jelly. The DS stated the apple sauce and jelly were transferred from their original packaging and into the kitchen safe containers. The DS stated both containers were not labeled with the product name, the open date, nor the use-by date. The DS stated there was no indication how long the apple sauce and the jelly were in the refrigerator. During a concurrent observation and interview on 1/3/2025 at 8:25 a.m., with the DS, in the kitchen, Freezer 1 was observed to have an opened container of chocolate crème pie. The DS stated the pie was served during lunch the previous day. The DS stated the opened container of chocolate crème pie was not labeled with the open day nor the use-by date. During an interview on 1/3/2025 at 8:30 a.m., with the DS, the DS stated when a food item was transferred to another container, the container must be labeled with the product name, the open date, and the use-by date. The DS stated when a food item was kept in its original packaging and opened, the container must be labeled with the open date and the use-by date. The DS stated proper labeling would ensure the freshness of the food item and would ensure the kitchen staff only used the food item within the correct dates. The DS stated if a food item went beyond its use-by date, the food item could grow bacteria and become a food safety hazard. The DS stated serving food items past its use-by date could cause foodborne illnesses to the residents served. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised 11/2022, the P&P indicated, All foods stored in the refrigerator or freezer are covered, labeled, and dated (us by date). The P&P indicated, Refrigerated food are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the intervention, as indicated in one of five sampled residents' (Resident 1) care plan titled, Resident has excessive tendencies of crawling and climbing out her bed, was impelmented. This deficient practice had the potential cause injury to Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a medical condition that occurs when blood flow to the brain is blocked, causing brain cells to die), alzheimer's disease (a brain disorder that destroys memory, thinking, and the ability to carry out daily tasks), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 1's History and Physical (H&P), dated 5/3/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2024, the MDS indicated Resident 1 rarely understood others and was rarely understood by others. The MDS indicated Resident 1 had severe cognitively impairment. The MDS indicated Resident 1 required set up assistance from staff for activities of daily living such as eating, partial assistance from staff for oral and personal hygiene and upper and lower body dressing, and substantial assistance from staff for toileting hygiene, showering, and putting on and taking off footwear. The MDS indicated Resident 1 required partial assistance from staff for rolling left and right, sitting to lying, lying to sitting on side of bed, and sitting to standing and chair to bed and toilet transfer and walking were not attempted due to medical condition or safety concerns. During a review of Resident 1's care plan, titled Resident has excessive tendencies of crawling and climbing out her bed, sitting on the floor, and crawling on the floor in her room. May be related to history of alzheimer's dementia, and anxiety (intense, excessive, and persistent worry and fear about everyday situations) manifested by restlessness and inability to stay still. The resident is at increased risk of falling, dated 9/26/2024, the intervention indicated to place mattress on floor next to bed, on one side of bed, for fall and safety precautions, due to resident's tendency of repetitivel climbing and crawling out of bed and crawling on floor, in her room, and to assist resident back to bed or her wheelchair once seen on floor crawling. During a review of Resident 1's order summary report (MD orders), dated 11/27/2024, the MD orders indicated to place mattress on floor, next to bed on one side of bed, for fall and safety precautions, due to Resident 1's tendencies of excessive and repetitive climbing and crawling out of bed and crawling on floor, in her room. During a concurrent observation and interview on 11/27/2024 at 2:42 p.m. with the Director of Nursing (DON), Resident 1 was observed on the floor underneath a bed by the window. The DON called Licensed Vocational Nurse (LVN 1) to the room to help assess and lift Resident 1 from the floor to a chair. The mattress on by Resident 1's bed was leaned against the curtain separating Resident 1 from her roommate. The DON stated Resident 1 tended to try and crawl out of bed. During a concurrent interview and record review on 11/27/2024 at 4:45 p.m. with the DON, Resident 1's care plan, titled Resident has excessive tendencies of crawling and climbing out her bed, sitting on the floor, and crawling on the floor in her room. May be related to history of Alzheimer's Dementia, and anxiety manifested by restlessness and inability to stay still. The resident is at increased risk of falling, dated 9/26/2024 was reviewed. The DON stated the mattress was leaning against Resident 1's nightstand and was not on the floor next to Resident 1's bed. The DON stated having the mattress on the floor next to Resident 1's bed was for safety. The DON stated the mattress on the floor as indicated in the care plan intervention was not followed. The DON stated, Resident 1 could get hurt. During a review of the facility's policy and procedure (P&P), titled Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated the staff should identify and implement relevant interventions to minimize serious consequences of falling. During a review of the facility's P&P, titled Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated a comprehensive care plan should include timetables to meet the resident's physical, psychosocial and functional needs, should be implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to report to the California Department of Public Health (CDPH), one of three residents (Resident 4), who was positive of Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection). This failure resulted to the delay in investigation by the CDPH and had the potential for COVID-19 virus to spread infecting other residents, staffs and visitors in the facility. Findings: During a review of Resident 4 ' s admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnosis that included epilepsy (disorder of the brain characterized by repeated seizures.), [NAME] ' s paralysis (seizure is followed by a brief period of temporary paralysis), and muscle weakness (loss of muscle strength) During a review of Resident 4 ' s history and physical (H&P) dated 8/7/2024, the H&P indicated Resident 4 had the mental capacity to understand and make medical decisions. During a review of Resident 4 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 7/8/2024, the MDS indicated Resident 4 could understand and be understood by others. The MDS indicated Resident 4 required substantial/maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) During a review of Resident 4 ' s undated care plan for positive for COVID-19, the care plan indicated Resident 4 tested positive for COVID-19 respiratory infection potential for respiratory distress. During a review of Resident 4 ' s COVID-19 lab results dated 7/9/2024 at 1:55 a.m., the COVID-19 antigen test result indicated Resident 4 had tested positive for COVID-19. During an interview on 7/19/2024 at 4:15 p.m., with Infection Preventionist (IP), the IP stated the COVID-19 case was not reported to CDPH. The IP stated, it was very important to report the COVID-19 outbreak to the CDPH so that CDPH can conduct the investigation and make sure the facility is following the correct procedures to prevent the spread of COVID-19. During an interview on 7/19/2024 at 4:45 p.m., with Director of Nursing (DON), the DON stated, COVID-19 outbreak and other unusual occurrence such as infections, should be reported to the CDPH. During a concurrent interview and record review on 7/23/2024 at 12:18 p.m., with the IP, the All Facilities Letter ([AFL] a letter from the Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C with information that include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) 23-08 (Requirements to Report Outbreaks and Unusual Infectious Disease Occurrences) was reviewed. The IP stated COVID-19 is categorized as unusual infection and should be reported to the CDPH. During a review of the facility ' s policy and procedure (P&P) titled Coronavirus Disease (COVID-19) – Identification and Management of Ill Residents, dated 5/2023, the P&P indicated, the health department should be notified of any residents or staff with suspected or confirmed COVID-19 infection. During a review of the facility ' s P&P titled, Unusual Occurrence Reporting, dated 12/2007, the P&P indicated the facility would report unusual occurrences or other reportable events which affect the health, safety or welfare of the residents, employees, or visitors. The P&P indicated unusual occurrence should be reported via telephone to appropriate agencies as required by current law and/ or regulations within 24 hours of such incident or as otherwise required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to appoint a responsible party and/or representative for one of 18 sampled residents (Resident 67), who did not have medical decision-making capacity. The above failure put Residents 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also prevented Resident 67's from exercising his rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F552 Findings: During a review of Resident 67's admission Record, the record indicated the facility originally admitted Resident 67 on 2/3/2023. Resident 67's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work), psychosis (a collection of symptoms that affect the mind, with some loss of contact with reality), and major depressive disorder (a distinct type of depressive illness accompanied by either delusions [a false belief or judgement], hallucinations [seeing things that are not real], or both). During a review of Resident 67's History and Physical (H&P), dated 2/6/2023, the H&P indicated Resident 67 had fluctuating capacity to understand and make decisions. During a review of Resident 67's medical record titled [Skilled Nursing Facility (SNF)] Follow Up Note, dated 6/14/2023, the record indicated Psychiatric-Mental Health Nurse Practitioner (PMHNP) 1 evaluated Resident 67 for anxiety (feeling of unease, excessive worry), delusion, depression, and confusion. The record indicated Resident 67 had a disorganized thought process, poor insight and judgement, and poor fund of knowledge (orientation to reality). The record indicated Resident 67 had been refusing medication and would continue to be off psychotropic medication due to [Resident 67] refusing medication. During a review of Resident 67's social services progress note, dated 6/14/2023, the progress note indicated [Resident 67] stated [he] will not take any medication from any doctor other than his primary physician that has been seeing .for over 15 years. Resident stated does not trust any other doctor. Resident stated, 'It's my choice if I decide to take medication.' During a review of Resident 67's electronic medical record (EMR), the EMR indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. During a review of Resident 67's medical record titled SNF Initial Evaluation, dated 7/19/2023, the record indicated PMHNP 1 evaluated Resident 67 following his 5150 hospitalization (the involuntarily detainment/hospitalization of an adult experiencing a mental health crisis, who has been evaluated as a danger to others, themselves, or gravely disabled). The record indicated that at the time of the evaluation, Resident 67 had a disorganized thought process, paranoid delusions (feelings that someone or some group is out to mistreat, harm, and sabotage you), and poor insight and judgement. The note indicated Resident 67 would be started on 0.5 milligrams (mg, a unit of measuring medication dosage) of Risperidone (a medication used to improve mood, thoughts, and behaviors in people with schizophrenia, bipolar disorder, and autism). The note indicated PMHNP 1 discussed the treatment plan with Resident 67 and facility staff and indicated benefits of these medications outweigh the risks for this patient given the patient's degree of mental illness. During a review of Resident 67's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/26/2023, the MDS indicated a Brief Interview For Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score of 10, which indicated Resident 67 had moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday). During a review of Resident 67's discontinued physician orders, dated 7/19/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 7/20/2023. During a review of Resident 67's Medication Administration Records (MAR), dated 7/2023, 8/2023, 9/2023, 10/2023, and 11/2023, the MARs indicated Resident 67 received the Risperidone from 7/2023 to 11/2023. During a review of Resident 67's Multidisciplinary Care Conference (MCC) notes, dated 10/17/2023, the notes indicated Resident 67 was unable to make medical decisions, and indicated per primary physician [Resident 67] able to make needs known, but unable to make medical decisions. During a review of Resident 67's EMR, the EMR indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. During a review of Resident 67's discontinued physician orders, dated 11/24/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 11/24/2023, and indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's medical record titled Facility Verification of Informed Consent, dated 11/24/2023, the record indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's MARs, dated 11/2023 and 12/2023, the MARs indicated Resident 67 received 0.5 mg of Risperidone, twice a day, from 11/2023 to 12/2023. During a review of Resident 67's MDS, dated [DATE], the MDS indicated a BIMS score of 9, indicating moderate cognitive impairment. During a review of Resident 67's medical record titled [Interdisciplinary Team (IDT)] Behavior Management, dated 12/8/2023, the record indicated Resident 67 was having increased erratic behavior (behavior that is unpredictable, or may be considered irregular or illogical for the situation, or not keeping with the standards of behavior for a given set of circumstances). The record further indicated the IDT (professionals from various disciplines who work in collaboration to address a patient's needs) reviewed Resident 67's medications and recommended an increase in his psychotropic medication dose. During a review of Resident 67's active physician orders, dated 12/8/2023, the orders indicated Resident 67 was now on 0.5 mg of Risperidone, once a day, for psychosis, and started on 0.75 mg of Risperidone at bedtime for psychosis. During a review of Resident 67's medical record titled SNF Initial Evaluation, dated 12/11/2023, the record indicated PMHNP 2 evaluated Resident 67 and indicated that at the time of the evaluation, Resident 67 had paranoia and delusion, poor insight, and poor judgement. The note indicated Resident 67 would be continued on 0.5 mg of Risperidone once a day in the morning and reflected the new order of 0.75 mg once a day at bedtime. The note indicated PMHNP 1 discussed the treatment plan, including the medications, with Resident 67 and facility staff. During a review of Resident 67's medical records titled Facility Verification of Informed Consent, both dated 12/8/2023, the documents indicated that informed consent for Risperidone 0.5 mg once a day, and Risperidone 0.75 mg at bedtime, were obtained from [Resident 67]. During an interview, on 1/25/2024 at 12:50 PM, with Medical Doctor (MD) 1, MD 1 stated he was Resident 67's primary physician in the facility and was familiar with the resident. MD 1 stated Resident 67 had fluctuating capacity to make medical decisions, and stated Resident 67 was not capable to provide informed consent. MD 1 stated potential side effects of Risperidone included worsening psychosis, mood disorders, and hallucinations. During a review of Resident 67's care plans, the care plans indicated [Resident 67] has impaired cognitive function or impaired thought processes [related to history of] metabolic encephalopathy and psychosis. The care plans further indicated Resident 67 was at risk for movement disorder, discomfort, low blood pressure, gait disturbance, constipation, or cognitive/behavioral impairment from use of Risperidone. During a review of Resident 67's Multidisciplinary Care Conference (MCC) notes, dated 1/5/2024, the notes were documented by the Social Services Director (SSD) and indicated per primary physician [Resident 67] able to make needs known, but unable to make medical decisions. During an interview on 1/25/2024 at 3:23 PM, with the Director of Nursing (DON), the DON stated informed consent was supposed to be obtained from the resident or responsible party/representative upon admission or re-admission to the facility, even if the resident received the medication in the hospital. The DON stated determination of whether the resident has capacity to provide informed consent based on the MDS and the H&P. The DON stated the resident should have an MDS BIMS score of 12 or higher, which indicated a resident had no cognitive impairments, and stated the H&P should specify the resident had capacity to make medical decisions. During a concurrent record review and interview, on 1/26/2024 at 11:10 AM, with the Social Services Director (SSD), the SSD reviewed Resident 67's EMR, including multidisciplinary care conference (MCC) notes, IDT conference notes. The SSD stated there was supposed to be someone with medical decision-making capacity present on Resident 67's behalf during the conferences because Resident 67 did not have medical decision-making capacity. The SSD stated Resident 67 was able to independently make decisions or speak for himself due to his cognitive impairment. The SSD stated Resident 67 should have been referred to the Office of Representatives to appoint a resident representative to make medical decisions on Resident 67's behalf, including informed consent. The SSD stated that not appointing a responsible party was a violation of Resident 67's rights. The SSD stated there was no documentation in Resident 67's medical record to indicate the facility had attempted to identify a resident representative or make the necessary referrals for Resident 67. During a review of the undated facility job description document titled Director of Social Services, the document indicated that responsibilities of the SSD included to implement policies and procedures for the identification of medically related social and emotional needs of the residents and refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. During a review of the facility policy and procedure (P&P) titled Resident Rights, dated 2/2021, the P&P indicated resident rights included: appointing a legal representative of his or her choice, in accordance with state law, being informed of, and participating in, his or her care planning and treatment, and participating in decision-making regarding his or her care. During a review of the facility P&P titled Health, Medical Condition and Treatment Options, Informing Residents of), dated 2/2021, the P&P indicated each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendation and prognosis, in advance of treatment and on - going basis. If a resident has an appointed representative, the representative is also informed. During a review of the facility P&P titled Resident Representative, dated 2/2021, the P&P defined a resident representative as: a. an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage financial matters; or receive notifications; b. a person authorized by state or federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage financial matters; or receive notifications; c. legal representative, as used in section 712 of the Older Americans Act; or d. the court-appointed guardian or conservator of a resident. The P&P further indicated If the resident is determined to be incompetent under the laws of the state by a court of competent jurisdiction, the rights of the resident will devolve to and will be exercised by the resident representative appointed to act on the resident's behalf and The court-appointed resident representative will exercise the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with state law. During a review of the facility P&P titled Psychotropic Medication Use, dated 10/2017, the P&P indicated facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services for three of 18 sampled residents (Resident 36, 47, and 84) when: 1. Certified Nurse Assistant (CNA) 3 did not change Resident 36's diaper in a timely manner. 2. Resident 47 was not repositioned every 2 hours or as needed per the physician's order. 3. Resident 84 was not repositioned every 2 hours or as needed per the physician's order. These deficient practices had the potential to cause a negative impact on Resident's 36, 47, and 84's health and psychosocial well-being by not meeting resident's needs. Findings: 1. During a review of Resident 36's admission Record, the admission record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including Parkinson's (a progressive disorder that affects the parts of the body controlled by the nerves) and generalized muscle weakness (lack of muscle strength). During a review of Resident 36's History and Physical (H&P), dated 12/28/2023, the H&P indicated Resident 36 had the capacity to understand and make decisions. The H&P indicated Resident 36 had a history of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/21/2023, the MDS indicated Resident 36's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 36 required partial/moderate assistance with oral hygiene and personal hygiene. The MDS indicated Resident 36 was dependent on staff for toileting hygiene. During an observation on 1/23/2024 at 8:12 a.m., in Resident 36's room, CNA 3 told Resident 36 she needed to wait to get her diaper changed because CNA 3 was collecting food trays and then had to go get her (CNA 3) linen cart. During an interview on 1/23/2024 at 8:19 a.m. with CNA 3, in Resident 36's room, CNA 3 stated Resident 36 had to wait to get a diaper change because CNA 3 was busy collecting food trays. CNA 3 stated she did not know how long Resident 34 had to wait to get her diaper changed. During an interview on 1/23/2024 at 8:22 a.m. with Resident 36, in Resident 36's room, Resident 36 stated she had been waiting to get her diaper changed since the night shift (11 p.m. to 7 a.m.). Resident 36 stated she kept asking to have her diaper changed but staff kept telling the resident to wait. Resident 36 stated she did not know why the CNAs did not change her diaper. Resident 36 stated she asked the CNAs to change her and to put her on her wheelchair because she did not want to be in bed. Resident 36 stated she felt sad the CNAs had her wait to get her diaper changed. 2. During a review of Resident 47's admission Record, the admission record indicated Resident 47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including left-sided hemiplegia (a condition caused by a brain injury, that results in a varying degrees of weakness, stiffness, and lack of control in one side of the body) and pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (tailbone). During a review of Resident 47's H&P dated 3/25/2023, the H&P indicated Resident 47 had the capacity to understand and make decisions. The H&P indicated Resident 47 had a diagnosis of cortical blindness (abnormal visual responses not caused by the eyes themselves). During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 47 was dependent on staff for oral and toileting hygiene, and required maximal assistance for eating and personal hygiene, and with rolling from lying on the back to the left and right side and return to lying on back on the bed. During a review of Resident 47's order summary dated 10/18/2023, the order summary indicated there was an order for Resident 47 to be repositioned and offloaded as needed every shift. The order summary indicated to monitor and report to the physician any skin changes. During a review of Resident 47's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Wound Management note, dated 12/26/2023, the IDT note indicated Resident 47's plan for pressure management was with the specialized turning program and off-loading. During an observation on 1/22/2024 at 9:16 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/22/2024 at 12:35 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 8:56 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 9:50 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 2:08 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/23/2024 at 3:49 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. During an observation on 1/24/2024 at 7:58 a.m. in Resident 47's room, CNA 6 was observed standing over Resident 47 and feeding him. Resident 47 was on his bed, head of the bed up and with his body leaning to the right against the wall. During an interview on 1/24/2024 at 8:00 a.m. with CNA 6, in Resident 47's room, CNA 6 stated she did not sit to feed Resident 47 because it was easier for her to feed him in this position. CNA 6 stated she knew she was supposed to sit while feeding the residents but could not find a chair. CNA 6 stated she was supposed to sit during mealtimes for the comfort of the resident and her comfort. CNA 6 stated she did receive an in-service about feeding residents and she was told that she could sit or stand while feeding. CNA 6 stated she did not reposition Resident 47 in bed because the resident had arthritis and it would hurt to reposition the resident. During an observation on 1/24/2024 at 8:22 a.m. in Resident 47's room, Resident 47 was lying on his back, right side of body leaning against the wall. During an observation on 1/24/2024 at 10:40 a.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of his body leaning against the wall. Resident 47 did not have a pillow under his head. Resident 47's call light was under a pillow. Resident 47 was screaming out for a nurse. Resident 47 did not stop scratching his right side of his stomach and back. Observed Resident 47 attempt to straighten himself out in bed. During an interview on 1/24/2024 at 10:44 a.m. with Resident 47, in Resident 47's room, Resident 47 stated the right side of his body was hurting and itching. Resident 47 stated he was screamed for a nurse but no one helped him. Resident 47 stated he did not use the call light because he was blind and did not know where the call light was. Resident 47 stated the right side of his body hurt and felt sweaty. During an observation on 1/24//2024 at 10:48 a.m. in Resident 47's room, observed CNA 7 changing Resident 47's gown and drying off the sweat from the resident's body. CNA 7 attempted to straighten out Resident 47's body in the bed. During an interview on 1/24/2024 at 11:00 a.m. with CNA 7, in Resident 47's room, CNA 7 stated Resident 47 stayed in bed all day. CNA 7 stated Resident 47 got repositioned in bed but that Resident 47 liked to lay on his right side. CNA 7 stated she did not know why Resident 47 liked to lay on his right side and liked to lean against the wall. CNA 7 stated she repositioned Resident 47 that morning (1/24/2024). CNA 7 stated resident 47 did not have a pillow behind his back to keep him in position because CNA 7 did not have a pillow. CNA 7 stated she repositioned Resident 47 on his left side facing the door. CNA 7 stated if she did not put a pillow behind the resident, to keep the resident in that position, it was not considered positioning the resident because he needed a pillow behind his back and between his legs. CNA 7 stated Resident 47 did not have skin issues and repositioning him often would prevent skin breakdown. CNA 7 stated Resident 47's call light was not assessable because it was under the pillow and if he needed help, he would not be able to call for help. During an observation on 1/24/2024 at 3:09 p.m. in Resident 47's room, Resident 47 was observed lying on his back, with the right side of the body leaning against the wall. 3. During a review of Resident 84's admission Record, the admission record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). During a review of Resident 84's H&P dated 12/23/2023, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions. During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84's cognitive skills for daily decision was moderately impaired. The MDS indicated Resident 84 required moderate assistance with personal hygiene and oral hygiene. During a review of Resident 84's IDT Wound Management Note, dated 12/26/2023, the IDT note indicated Resident 84 was bedfast (confined to bed). The IDT note indicated Resident 84's ability to change and control body position was very limited. The IDT note indicated friction and shear was a problem for Resident 84 and the resident was at high risk for developing pressure sores. During an observation on 1/22/2024 at 10:16 a.m., in Resident 84's room, Resident 84 was observed lying on his back. During an observation on 1/22/2024 at 12:13 p.m. with Resident 84, in Resident 84's room, Resident 84 was observed lying on his back. During an observation on 1/23/2024 at 8:43 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/23/2024 at 9:35 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/23/2024 at 1:44 p.m., in Resident 84's room, the Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/23/2024 at 3:32 p.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/24/2024 at 8:15 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/24/2024 at 11:18 a.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an observation on 1/24/2024 at 3:17 p.m., in Resident 84's room, Resident 84 was observed lying on his back with no pillows off-loading the body. During an interview on 1/25/2023 at 1:22 p.m. with Registered Nurse (RN) 1, in Resident 84's room, RN 1 stated all bedridden residents must be repositioned every 2 hours. RN 1 stated Resident 47 and Resident 84 must be repositioned in bed every 2 hours to prevent skin breakdown. RN 1 stated repositioning bedridden residents prevent pressure areas. During an interview on 1/26/2024 at 3:10 p.m. with Treatment Nurse (TN) 1, in the hallway, TN 1 stated Resident 47 and Resident 84 must be repositioned every 2 hours or as needed because they were both bedridden. TN 1 stated it was important to reposition residents to prevent pressure ulcers or sores. TN 1 stated Resident 47 received skin treatments and the repositioning the residents would prevent the residents from getting worse. TN 1 stated she had not noticed that residents were not repositioned throughout the day. During an interview on 1/26/2024 at 3:25 a.m. with the Director of Nursing (DON), in the hallway, the DON stated residents that do not have proper mobility, needed help with off-loading. The DON stated residents that were bedridden needed to be repositioned in bed every 2 hours or as needed. The DON stated if residents do not get repositioned, it increased the likelihood of a pressure injury. During a review of the facility's policy and procedure (P&P) titled, Repositioning, dated 5/2013, the P&P indicated repositioning was a common, effective, intervention for preventing skin breakdown, promotes circulation, and provides pressure relief. The P&P indicated repositioning was a critical for a resident who is immobile or dependent upon staff for repositioning. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, the P&P indicated care and services would be provided for residents who are unable to carry out ADLs independently. The P&P indicated residents will receive assistance with mobility, elimination (toileting) and with dining.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 45) received glasses as recommended and prescribed by the optometrist (healthcare provider who specializes in caring for the eyes). This failure created the potential for Resident 45 to suffer from avoidable physical harm related to injury from inability to see, and psychosocial harm related to inability to watch television, which was her preferred activity in the facility. Cross Reference: F-tag 656 Findings: During a review of Resident 45's admission Record, the admission record indicated the facility originally admitted Resident 45 on 6/4/2020 and readmitted Resident 45 on 1/7/2022. Resident 45's admitting diagnoses included hemiplegia (paralysis [inability to move] one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke (damage to the brain from interruption of its blood supply), and aphasia (language disorder that affects a person's ability to communicate) following a stroke. During a review of Resident 45's Minimum Data Set (MDS, comprehensive resident assessment and care screening tool), dated 11/22/2023, the MDS indicated Resident 45 had moderately impaired vision, and severely impaired cognition (ability to think and reason). During a review of Resident 45's care plans, the care plans indicated Resident 45 had impaired visual function. The goals of care included Resident 45 maintaining optimal quality of life. Staff's interventions indicated staff were to arrange consultation with eye care practitioner as required and ensure appropriate visual are available to support the resident's participation in activities. During a review of Resident 45's active physician orders, dated 1/7/2022, the orders indicated optometrist consult per family request. During a review of Resident 45's medical record titled, Optometric Consultation, dated 4/5/2023, the record indicated Resident 45 was seen by an optometrist and the optometrist recommended glasses. During a concurrent observation and interview, on 1/24/2024 at 10:51 AM, with Certified Nursing Assistant (CNA) 2, at Resident 45's bedside, CNA 2 checked Resident 45's bedside belongings for any corrective lenses or glasses. CNA 2 stated Resident 45 did not have any glasses. During a concurrent interview and record review, on 1/24/2024, with Licensed Vocational Nurse (LVN) 2, Resident 45's undated medical record titled, Resident's Clothing and Possessions was reviewed. LVN 2 stated the document indicated Resident 45 did not have glasses in her possession. LVN 2 stated that if a resident received glasses after initial completion of the record titled Resident's Clothing and Possessions, the document would be updated to reflect any new items in the resident's possession. During a concurrent interview and record review, on 1/24/2024 at 11:37 AM, with the Director of Social Services (DSS), the facility document titled, Summary Sheet 2023 was reviewed. The DSS stated Resident 45 was seen by an optometrist on 4/5/2023. The DSS stated the document indicated the optometrist recommended glasses for Resident 45. The DSS stated it would typically take a month for glasses to be delivered to the facility, and stated that upon delivery, the glasses would be documented on the resident's inventory list. During an interview on 1/24/2024 at 2:15 PM, with the optometrist's office, the optometrist's office stated an invoice (a list of goods sent, or services provided, with a statement of the sum due for these) was sent to the DSS on 4/25/2023. The office stated the invoice indicated the remaining payment due for the glasses, and stated that once payment was received, the glasses would be delivered to Resident 45. The optometrist's office stated the facility was supposed to provide the invoice to Resident 45 or her family member/responsible party. During an interview on 1/24/2024 at 2:36 PM, with Resident 45's family member (FM) 2, FM 2 stated the facility did not send her an invoice for the glasses. During an interview on 1/24/2024 at 2:40 PM, with Resident 45's responsible party FM 1, FM 1 stated the facility did not send him an invoice for glasses. FM 1 stated he communicated multiple times with the facility staff to inform them Resident 45 needed glasses. FM 1 stated that if the facility had sent the invoice, he would have paid right away, stating he really wanted Resident 45 to be able to see. During a concurrent interview and record review, on 1/24/2024 at 3:14 PM, with the DSS, the DSS reviewed her emails and located the invoice from the optometrist's office. The DSS stated she received the invoice on 4/25/2023 and stated she did not send it to FM 1 or FM 2. The DSS stated this failure to send the invoice to Resident 45's responsible parties for completion of payment led to a delay in Resident 45 receiving the glasses she needed. During a review of Resident 45's medical record titled, Activity Participation Review, dated 12/13/2023, the record indicated [Resident 45] likes to watch TV. The record further indicated it was very important to Resident 45 to do her favorite activities. During an interview on 1/24/2024 at 3:26 PM, with the Activity Director (AD), the AD stated it was important for residents to participate in activities that they enjoy, increasing their quality of life and comfort in the facility. The AD stated Resident 45 enjoyed watching television, and stated Resident 45 would not be able to watch TV and participate in her preferred activity if she was unable to see. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated Resident safety and .assistance to prevent accidents are facility-wide priorities. The P&P further indicated The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's P&P titled, Social Services, dated 9/2021, the P&P indicated the DSS was responsible for ensuring medically related social services are provided to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment . The P&P further indicated that social services staff were responsible for making referrals and obtaining needed services from outside entities. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions, and further indicated that services provided for or arranged .and outlined in the comprehensive care plan are provided by qualified persons. During a review of the facility's P&P titled, Resident Self Determination and Participation, dated 8/2022, the P&P indicated Residents are provided assistance as needed to engage in their preferred activities on a routine basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that precautions were maintained to prevent the development or worsening of pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure) for two of two sampled residents (Resident 51 and Resident 11) when the following occurred: 1. Resident 51's weight was not accurately set on her low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown). 2. The Treatment Nurse (TN 1) was unaware of Resident 11's weight measurement to monitor accuracy of the LALM settings. The above failures had the potential to cause the avoidable development of skin breakdown for Resident 51 and the complications associated with impaired skin integrity. The above failures also increased the potential for Resident 11 to suffer an avoidable worsening in condition of her existing Stage IV PU (full-thickness skin and tissue loss extending to the muscle, tendon, ligament, cartilage, or bone). Findings: 1. During a review of Resident 51's admission Record, the record indicated the facility originally admitted Resident 51 on 12/22/2020 and re-admitted Resident 51 on 6/6/2023. Resident 51's admitting diagnoses included hemiplegia and hemiparesis (weakness and/or inability to move one side of the body) following a stroke (when the blood supply to part of the brain is blocked or reduced), muscle wasting and atrophy (a decrease in size of an organ or tissue), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 51's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 11/24/2023, the MDS indicated Resident 51 experienced cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 51 had impairment to the upper and lower extremities on one side of her body, which interfered with daily function and placed the resident at risk of injury. The MDS indicated Resident 51 was fully dependent on staff to move from side to side in bed, and to transition from a sitting position to lying position, and a lying position to a sitting position. The MDS further indicated Resident 51 was at risk for developing PUs, and used a pressure reducing device in her bed, and was being turned and repositioned while in bed by staff. During a review of Resident 51's medical record titled, Braden Scale for Predicting Pressure Sore Risk, dated 12/7/2023, the record indicated Resident 51 was at high risk for skin breakdown. During a review of Resident 51's care plans, the care plans indicated Resident 51 was at risk for developing PUs and experiencing skin breakdown. The goals of care included Resident 51 having intact skin free of breakdown. Staff's interventions indicated LALM to prevent wounds and LALM setting according to .weight of resident. During a review of Resident 51's weight measurements, the records indicated Resident 51's most recent documented weight was 112.2 pounds (lbs., a unit of measuring weight) on 1/1/2024. During an observation, on 1/22/2024 at 1:42 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an observation, on 1/23/2024 at 4:25 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an interview on 1/24/2024 at 8:17 AM, with Treatment Nurse (TN) 1, TN 1 stated LALMs were used to prevent a worsening condition of existing PUs, and to prevent the development of PUs in residents who were high risk. TN 1 stated the weight settings were supposed to reflect the resident's current weight. TN 1 stated that incorrect weight settings will prevent the healing of, and potentially cause a worsening in condition of, existing PUs. TN 1 stated incorrect settings could also cause the development of new PUs. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation and interview, on 1/24/2024 at 8:29 a.m., at Resident 51's bedside, TN 1 observed Resident 51's LALM settings. Resident 51 was observed lying on a [NAME] Medical brand Elite LALM, and the weight settings indicated the LALM was set for a resident that weighed 210 lbs. TN 1 stated, That's too high. TN 1 then stated she had not checked Resident 51's LALM settings on 1/23/2024 and stated Resident 51 had a history of PUs and the incorrect settings on the LALM increased her risk at re-developing PUs. 2. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 10/24/2020 and re-admitted Resident 11 on 7/14/2023. Resident 11's admitting diagnoses included Stage IV PU to the right hip. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had impairment to the upper extremities on one side of her body, and impairment to the lower extremities on both side of her body, which interfered with daily function and placed her at risk of injury. The MDS further indicated Resident 11 had an existing Stage IV PU, was at risk for developing PUs, and used a pressure reducing device in her bed. During a review of Resident 11's medical record titled Skin and Wound Evaluation, dated 1/18/2024, the record indicated Resident 11 had a Stage IV PU with slow wound healing. During a review of Resident 11's medical record titled [Interdisciplinary Team] Wound Management Update, dated 1/18/2024, the record indicated recommendations for continued PU care included a LALM for wound management. During a review of Resident 11's care plans, the care plans indicated Resident 11 was at risk for developing Pus. The goals of care included to minimize the risk for Resident 11 experiencing further skin breakdown. Staff's interventions indicated LALM setting according to .weight of resident. During a review of Resident 11's weight measurements, the records indicated Resident 11's most recent documented weight was 155.8 lbs. on 1/1/2024. During an interview on 1/24/2024 at 8:17 AM, with TN 1, TN 1 stated her normal practice was to document the resident's current weight by hand onto the pump for reference to ensure the settings were always accurate. TN 1 stated she reviewed the residents' weights on a weekly basis and updated the settings as needed. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation, interview, and record review, on 1/24/2024 at 8:26 AM, at Resident 11's bedside, Resident 11's weight measurements were reviewed. TN 1 observed Resident 11's LALM settings. Resident 11 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump indicated the LALM was set for a resident that weighed 140 lbs., which matched the handwritten weight of 140 that TN 1 documented on the pump itself. TN 1 stated Resident 11's weight of 155.8 lbs. did not match the weight she was using for the LALM settings. TN 1 stated Resident 11 had not weighed 140 lbs. since 10/2023. TN 1 stated incorrect settings could cause a delay in Resident 11's wound healing. During an interview on 1/25/2024 at 9:23 AM, with the MDS Nurse (MDSN), the MDSN stated the resident's care plans identified the resident's current problems and identified the goals of the care being provided. The MDSN stated there was the potential for the goals of care to be unmet if staff were not implementing the interventions on the care plan. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown, dated 4/2018, the P&P did not address the use of and/or operating requirements and guidelines for LALMs in the facility. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions, and further indicated that services provided for or arranged .and outlined in the comprehensive care plan are provided by qualified persons. During a review of the facility's job description document titled, Treatment Nurse, undated, the document indicated the treatment nurse was required to provide primary skin care to residents in accordance with their care plan and ensuring that all nursing care is provided .following facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents with a urinary catheter device (a flexible tube placed in the bladder used to collect urine by attaching to a drainage bag) received proper assessment and the urinary catheter and tubing were off the floor for two sampled residents (Resident 64 and Resident 84). These deficient practices had the potential for Resident 84 to have an undiagnosed urinary tract infection (UTI, bladder infection) and placed Resident 64's and Resident 84's urinary catheter drainage system at risk for possible exposure to infectious agents. Findings: 1. During a review of Resident 64's admission Record, the admission record indicated Resident 64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). During a review of Resident 64's History and Physical (H&P) dated 12/27/2023, the H&P indicated Resident 64 did not have the capacity to understand and make decisions. The H&P indicated Resident 64 had a supra pubic catheter (a medical device that enters the body through a small incision in the abdomen to drain urine). During a review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/19/2023, the MDS indicated Resident 64's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision was impaired. The MDS indicated Resident 64 required substantial assistance with activities of daily living (ADLs, self-care activities performed daily such as dressing, personal hygiene, and grooming). The MDS indicated Resident 64 had a history of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). During an observation on 1/23/2024 at 11:45 a.m. in Resident 64's room, observed Resident 47's urinary catheter tubing and draining bag touching the floor. During an observation on 1/23/2024 at 1:55 p.m. in Resident 64's room, observed Resident 47's urinary catheter tubing and draining bag touching the floor. 2. During a review of Resident 84's admission Record, the admission record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including psychosis and obstructive uropathy. During a review of Resident 84's H&P dated 12/23/2023, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 84 had a diagnosis of hypertension (high blood pressure). During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84's cognitive skills for daily decision was moderately impaired. The MDS indicated Resident 84 required moderate assistance with personal hygiene and oral hygiene. During a review of Resident 84's care plan addressing the resident's use of an indwelling catheter, dated 1/22/2024, the care plan indicated the staff's interventions were to check the tubing, monitor/record/report to the physician for signs and symptoms of a UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, and increased temperature. During an observation on 1/24/2024 at 1:24 p.m. in Resident 84's room, observed Resident 84's urinary catheter drainage bag and tubing on the floor. During an observation on 1/26/2024 at 9:11 am. in Resident 84's room, observed Resident 84's urinary catheter drainage bag not covered. During an observation on 1/26/2024 at 12:30 p.m. in Resident 84's room, observed Resident 84's urinary catheter drainage bag not covered. The urinary catheter tubing was observed with sediments and red tinged urine. During an interview on 1/26/2024 at 12:57 p.m. with Certified Nursing Assistant (CAN) 5, in Resident 84's room, CNA 5 stated Resident 84's urinary catheter drainage bag was not covered because Resident 84 moved a lot and pulled on his catheter tubing. CNA 5 stated the urinary catheter drainage bag was supposed to be covered to provide privacy to residents. CNA 5 stated he did not notice the sediments and red tinged urine in the catheter tubbing. CNA 5 stated he emptied out the bag earlier and had not noticed it. CNA 5 stated sediments in the urine and red tinged urine meant that it had contamination. CNA 5 stated he drained the urinary bag without notifying a licensed nurse because he did not know he had to notify them. CNA 5 stated he did not know this was a change in condition for Resident 84. During an interview on 1/26/2024 at 1:14 p.m. with Registered Nurse (RN) 1, in Resident 84's room, RN 1 stated sediments in the urine and red tinged urine was a change in condition for a resident and must be reported to a licensed nurse right away. RN 1 stated a urinary catheter drainage bag must be covered to provide privacy to the resident. RN 1 stated Resident 84 had a history of UTI and CNAs must closely monitor the appearance of the resident's urine. RN 1 stated the urinary catheter tubing and drainage bag must not touch the floor for infection prevention. During an interview on 1/25/2024 at 4:04 p.m. with the Director of Staff Development (DSD), the DSD stated the urinary catheter drainage bag and tubing should not touch the floor. The DSD stated the catheter drainage bag must be covered to provide privacy. The DSD stated the practice was to place the catheter drainage bag in a basin to prevent it from touching the floor. The DSD stated the catheter bag and tubing must not touch the floor for infection control, to prevent the spread of germs. During an interview on 1/26/2024 at 3:25 p.m. with the Director of Nursing (DON), the DON stated when a CNA observed a resident with a change of condition, they must fill out a stop and watch form (a form to report resident change of condition) and inform the charge nurse. The DON stated it was important to inform the charge nurse and physician to address the issue quickly. The DON stated his expectation was CNAs were to report any changes in urine, place privacy bags over the urinary catheter drainage bags, and drainage bags and tubing should not touch the floor. The DON stated the catheter drainage bag and tubing must not touch the floor because there were germs on the floor and which could contaminate the urinary drainage bag. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 8/2022, the P&P indicated the catheter tubing and drainage bag are kept off the floor for infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to connect the nasal cannula (device used to deliver supplemental oxygen or increased airflow through the nose) to the oxygen concentrator (a device that provides supplemental oxygen) when oxygen therapy was provided to one of three sample residents (Resident 60). This failure had the potential for Resident 60's oxygen saturation (amount of oxygen circulating in the blood, normal value 95 percent [%] to 100%) to decrease which could lead to shortness of breath and respiratory distress. Findings: During a review of Resident 60's admission Record (Face Sheet), the admission Record indicated Resident 60 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), type 2 diabetes mellitus condition that results in too much sugar circulating in the blood), and schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). During a review of Resident 60's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 12/22/2023, the MDS indicated Resident 60 was able to make herself understood and understood others. The MDS indicated Resident 60's cognition (process of thinking) was intact. The MDS indicated Resident 60 received oxygen therapy in the facility. During a review of Resident 60's Order Summary Report, dated 1/22/2024, the Order Summary Report indicated to administer continuous oxygen at 2 liters (unit of measurement) per minute (L/min) via nasal cannula, may titrate (change rate) up to 5L/min, every shift, for shortness of breath and COPD. During an observation on 1/23/2024 at 9:22 a.m., in Resident 60's room, Resident 60 was in the restroom and her nasal cannula was observed disconnected from the oxygen concentrator and the attachment piece was on the floor. During an observation on 1/23/2024 at 9:34 a.m., in Resident 60's room, Resident 60 returned to her bed and placed the nasal cannula to her nose. The nasal cannula remained disconnected from the oxygen concentrator. Licensed Vocational Nurse (LVN) 1 informed Resident 60 that she would prepare Resident 60's medications for administration. During an observation on 1/23/2024 at 9:38 a.m., in Resident 60's room, LVN 1 assisted Resident 60 with her nasal cannula, inserted the prongs into Resident 60's nostrils and looped the tubing over Resident 60's ears. LVN 1 administered medication to Resident 60 and began to walk away from Resident 60's bedside. During a concurrent observation and interview on 1/23/2024 at 9:40 a.m. with LVN 1, in Resident 60's room, LVN 1 was informed that Resident 60's nasal cannula was not connected to the oxygen concentrator. LVN 1 removed the nasal cannula from Resident 60 and requested for a new nasal cannula to be brought to Resident 60. LVN 1 stated she had assisted Resident 60 with her nasal cannula and did not realize that the nasal cannula was not connected to the oxygen concentrator. LVN 1 stated she was responsible for assessing Resident 60's oxygen administration by ensuring the nasal cannula was connected to its oxygen source. LVN 1 stated if Resident 60 had continued without oxygen therapy, Resident 60 was at risk of desaturation (decrease in oxygen saturation). During an interview on 1/24/2024 at 11:39 a.m., with Registered Nurse (RN) 1, RN 1 stated when placing the oxygen tubing onto the resident, the nurse was responsible for checking the physician's order, placing the nasal cannula properly on the resident, and ensuring the tubing was connected to the oxygen concentrator. RN 1 stated it was an issue that Resident 60 had the nasal cannula in her nose without any oxygen because the nasal cannula had the potential to block Resident 60's airway, which could cause respiratory issues. RN 1 stated Resident 60 was dependent on supplemental oxygen and without it, Resident 60 was at risk for respiratory distress. During an interview on 1/25/2024 at 4:30 p.m., with the Director of Nursing (DON), the DON stated all nurses were responsible for assessing residents who were receiving oxygen therapy. The DON stated nurses were responsible for assessing the placement of the nasal cannula on the resident, the integrity of the tubing whether it needed to be changed, and the connection between the nasal cannula tubing and the oxygen concentrator. The DON stated residents, who received oxygen therapy, required oxygen to maintain their oxygenation at the appropriate level. The DON stated without proper oxygen therapy, the resident was at risk of not reaching their optimal oxygenation status, which could result in desaturation. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated steps in oxygen administration that include to check the tubing connected to the oxygen cylinder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed staff failed to ensure the accurate and complete documentation of the administration of Lomotil (a controlled medication used to treat loose and watery stools, contains small quantities of narcotics) in the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) to account for all eight doses (16 tablets) for one of three sampled residents (Resident 10). This failure had the potential for Resident 10 to overdose, the doses of Lomotil to become missing or unaccounted for, drug diversion (the act of health care providers stealing prescription medicines or controlled substances such as opioids for their own use), and/or the potential for a medication error to occur. Findings: During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but not limited to diabetes (poor blood sugar control) and lack of coordination. During a review of Resident 10's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 11/1/2023, the MDS indicated Resident 10's cognition (mental action or process of acquiring knowledge and understanding) was intact. During a review of Resident 10's Order Summary Report, dated 1/23/2024, the Order Summary Report indicated that Resident 10 was prescribed Lomotil Oral Tablet 2.5 to 0.025 milligrams ([MG]- a unit of measurement) to be given two tablets by mouth, every eight hours, as needed for diarrhea (loose and watery stools). During a concurrent interview and observation, on 1/23/2024, at 11:40 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 10's bubble pack (a card used to store medications for the residents) for Lomotil was observed. LVN 2 confirmed that Resident 10's bubble pack housed 34 remaining doses of Lomotil and that eight (8) doses of Lomotil had been administered. During a concurrent interview and record review, on 1/23/2024, at 11:50 a.m., with Registered Nurse (RN) 1, Resident 10's Controlled Drug Record (CDR), dated 12/2023 to 1/2024, was reviewed. The CDR indicated there were 84 tablets of Lomotil dispensed to the facility (equivalent to 42 doses). The CDR indicated the licensed nurses signed for the administration of six doses of Lomotil, instead of eight doses on the following dates and times: Dose 42 administered on 1/15/24 at 9 p.m. Dose 41 was left blank. Dose 40 administered on 12/27/23 at 9:04 a.m. Dose 39 administered on 12/27/2023 at 7:00 p.m. Dose 38 administered on 1/1/2024 at 12:51 a.m. Dose 37 was administered 1/5/2024 at 5:57 p.m. Dose 36 was administered 1/11/2024 at 1:33 a.m. Dose 35 indicated the originally documented administration was crossed off and the administration was documented in error. RN 1 confirmed the CDR indicated doses 41 and 35 were left unaccounted for, and that there should have been signatures that indicated that the licensed nurse administered the medication to account for all eight administered doses. During a concurrent interview and record review, on 1/23/2024, at 11:50 a.m., with RN 1, Resident 10's Medication Administration Record (MAR), dated 12/2023 to 1/2024, was reviewed. The MAR indicated Resident 10 received six (instead of eight) doses of Lomotil on the following dates and times: 1 dose on 12/27/2023 at 9:04 a.m. 1 dose on 1/1/2024 at 12:51 a.m. 1 dose on 1/5/2024 at 5:57 p.m. 1 dose on 1/11/2024 at 1:33 a.m. 1 dose on 1/11/2024 at 4:40 p.m. 1 dose on 1/20/2024 at 5:35 p.m. RN 1 confirmed there were two signatures missing on the MAR to account for all eight doses administered. RN 1 stated, It is important to document in the MAR. If we do not document, that means the medication was not given. It is a form of communication amongst the nurses, it is our way of ensuring that we are keeping all [narcotic] the doses accounted for, and so the nurses do not overdose [the resident]. RN 1 also stated that it was best practice for the licensed nurses to accurately account of every narcotic medication by assigning each tablet, (not each dose) a number on the CDR, so that each tablet can be accounted for when administering the narcotic medication. During an interview, on 1/23/2024, at 11:58 a.m., with LVN 2, LVN 2 stated he did not recall noticing the discrepancy when he performed the narcotic count earlier that morning because there was a lot of stuff going on. LVN 1 stated that it was important to ensure that count was accurate, and that documentation of the narcotics are accurate and complete to limit the possibility of drug diversion, keep every dose accounted for, to ensure the resident actually gets the medication and to limit medication errors. During an interview, on 1/23/2024, at 2:29 p.m., with LVN 3, LVN 3 confirmed that she worked on 1/20/2023, during the night shift (3 p.m. to 11 p.m.). LVN 3 stated she administered the ordered Lomotil dose to Resident 10, signed the MAR, but failed to document the administration on the CDR. LVN 3 stated, I was in between patients, that is why I forgot. LVN 3 stated, If there is no documentation for the administration of the medication in the CDR, then we (the licensed nurses) can double dose (administer two doses), [there is a] potential for narcotic diversion, and it is not [considered] accurate and complete documentation. During a concurrent interview and record review on 1/24/2024, at 1:48 p.m., with the Director of Nursing (DON), Resident 10's Lomotil bubble pack, the CDR and MAR was reviewed. 1) Resident 10's Lomotil bubble pack had 34 out of 42 doses of Lomotil remaining. 2) The CDR indicated the licensed nurses signed off on six doses of Lomotil, instead of the eight administered doses. 3) The MAR indicated the licensed nurses signed off on six doses of Lomotil, instead of the eight administered doses. The DON stated that it was not acceptable to have missing documentation in both the MAR and CDR. The DON stated that LVN 4 and LVN 5 failed to document in the MAR for their administrations (of Lomotil), and LVN 3 failed to document in the CDR for her administration (of Lomotil). The DON stated that the expectation of the licensed nurses was to document the administration of the medications accurately and completely. The DON stated that it was also best practice for the licensed nurses to accurately account of every narcotic medication by assigning each tablet, (not each dose) a number on the CDR. The DON stated that if all narcotic medications and tablets are not accurately documented and accounted for in the CDR or the MAR, then there would be potential for an accidental overdose for a resident, a medication error and drug diversion to occur. During a review of the facility's Policy and Procedure (P&P), titled, Controlled Substances, dated 11/2022, the P&P indicated the facility was to comply with all federal laws, regulations and other requirements related to the documentation of controlled medications. The P&P also indicated the controlled substance inventory is monitored and reconciled to identify loss or potential diversion. During a review of facility's P&P, titled, Administering Medications, dated 11/2022, the P&P indicated the facility was to ensure that the individual administering the medications records the dosage, date, and time in the resident's medical record. During a review of the facility's P&P, titled, Documentation of Medication Administration, dated 11/2022, the P&P indicated the facility was to ensure that the medication administration record was used to document all medications administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five (5) percent (5%) when three medication errors out of 38 total opportunities contributed to an overall medication error rate of 7.89%, affecting one of ten residents (Resident 85), based on the following: 1. Resident 85's heart rate was not assessed prior to the administration of hydrochlorothiazide (a medication used to treat high blood pressure and fluid retention) 12.g milligrams (mg, a unit of measurement) and losartan potassium (a medication used to treat high blood pressure) 25 mg. 2. Resident 85 was not instructed to rinse their mouth after the administration of one puff of Fluticasone-Salmeterol (a medication used to treat breathing problems). These failures had the potential for Resident 85 to experience medical complications such as bradycardia (a slow heart rate) which could lead to dizziness, chest pain, and confusion. These failures also had the potential for development of oral thrush (a fungal infection of the mouth). Findings: During a review of Resident 85's admission Record (Face Sheet), Resident 85 was admitted to the facility on [DATE] with diagnoses included but not limited to asthma (a condition where the airways become inflamed, narrow, and swell, and produce extra mucus that makes it difficult to breathe), hypertension (high blood pressure), and hyperlipidemia (high levels of fat particles in the blood). During a review of Resident 85's History and Physical Examination (H&P), dated 10/28/2023, the H&P indicated Resident 85 had the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/3/2023, the MDS indicated Resident 85 was able to make himself understood and understood others. The MDS indicated Resident 85's cognition (process of thinking) was moderately impaired. During a review of Resident 85's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated to administer for the following medications: 1. Hydrochlorothiazide 12.5 mg tablet, by mouth, once a day for hypertension. Hold medication if the systolic blood pressure (SBP, the maximum blood pressure during contraction of the ventricles [the two lower chambers of the heart responsible for pumping blood out of the heart]) was less than 110 millimeters of mercury (mmHg, unit of measurement of pressure in blood vessels) or if the heart rate was less than 60 beats per minute (BPM). 2. Losartan potassium 25 mg tablet, my mouth, once a day for hypertension. Hold medication if the SBP was less than 110 mmHg or if the heart rate was less than 60 BMP. 3. Fluticasone-Salmeterol Inhalation Aerosol 45-21 microgram (mcg, unit of measurement) per actuation (act, the process of spraying medication) (mcg/act), one puff inhaled by mouth once a day for chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow). Rinse mouth with water after use. During an observation on 1/23/2024 at 9:41 a.m., in Resident 85's room, LVN 1 checked Resident 85's blood pressure, which was 122/80 mmHg. LVN 1 did not check Resident 85's heart rate. LVN 1 informed Resident 85 that she would prepare his medications. During a current observation and interview on 1/23/2024 at 9:43 a.m., outside of Resident 85's room, LVN 1 prepared a total of three medications for Resident 85. LVN 1 stated she prepared three medications that consisted of two tablets and one inhaler. LVN 1 entered Resident 85's room and two tablets were administered with water and LVN 1 provided one puff of the inhaler to Resident 85. The three medications administered were hydrochlorothiazide, losartan potassium, and Fluticasone-Salmeterol. LVN 1 expressed appreciation to Resident 85 and provided no other instruction. During an interview on 1/23/2024 at 9:49 a.m., with LVN 1, LVN 1 stated she did not check Resident 85's heart rate prior to administering the hydrochlorothiazide and losartan potassium. LVN 1 stated she was responsible to check the medication orders for any parameters (when a medication is not administered based on a specific condition) prior to administering any medication. LVN 1 stated it was important to assess the heart rate prior to administering those medication because they had the potential to decrease the resident's heart rate. LVN 1 stated if Resident 85's heart rate was to decrease, it could cause bradycardia which could lead to a decrease in blood pressure, dizziness, or headache. During an interview on 1/23/2024 at 11:45 a.m., with LVN 1, LVN 1 stated after administering a dose from an inhaler, she was supposed to instruct Resident 85 to rinse his mouth after. LVN 1 stated she did not instruct Resident 85 to rinse his mouth. LVN 1 stated Resident 85 was at risk of developing oral thrush. During an interview on 1/24/2024 at 11:21 a.m., with the interim Infection Preventionist Nurse (IPN), the interim IPN stated after administering medication from an inhaler, the resident must rinse their mouth after to remove any medication residue from their mouth. The interim IPN stated this was essential in preventing the development of oral thrush. During an interview on 1/25/2024 at 4:36 a.m., with the Director of Nursing (DON), the DON stated the nurses were responsible to check the medication order for any parameters they had to be aware of. The DON stated administering blood pressure medications without checking the ordered parameters could potentially lower the resident's heart rate and blood pressure. The DON stated if the resident were to experience a decrease in heart rate, they could experience lethargy and weakness. The DON stated the nurses were also responsible to check any additional instructions prior to administering medication. The DON stated after administering medication from an inhaler, the resident was supposed to rinse their mouth to prevent oral thrush. The DON stated if the resident did not rinse their mouth after receiving medication from an inhaler, they were at risk of developing an oral infection. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders . The following information is checked/verified for each resident prior to administering medications: allergies to medications and vital signs, if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medications in a proper storage room for two sampled Residents (Resident 1 and Resident 57) when: 1. Medicated ointment and another unidentified substance was stored in a resident restroom. 2. Medicated ointment and Vaseline was kept at Resident 1's and Resident 57's bedside. This deficient practice had a potential risk for a resident or residents ingesting the medications. Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic kidney disease (gradual loss of kidney function) and cardiomegaly (enlargement of the heart). During a review of Resident 1's History and Physical (H&P) dated 10/10/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care planning tool), dated 12/22/2023, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision was intact The MDS indicated Resident 1 required moderate assistance with activities of daily living (ADLs, daily self-care activities such as grooming, personal hygiene, and dressing). During a concurrent observation and interview on 1/23/2024 at 10:44 a.m. with Resident 1, in Resident 1's room, observed 1 closed container with ointment and 1 cup with ointment at Resident 1's bedside. Resident 1 stated the container and cup contained medicated Vaseline to put on his buttocks. Resident 1 stated a nurse gave him the ointment so he could apply it every time he used the restroom. Resident 1 stated he kept the ointments at his bedside all the time. 2. During a review of Resident 57's admission Record, the admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including kidney failure (occurs when kidneys suddenly become unable to filter waste products from the blood, kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and blood's chemical makeup may get out of balance), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 57's H&P dated 10/10/2023, the H&P indicated Resident 57 had a history of alertness with episodes of confusion. During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skills for daily decision was severely impaired. The MDS indicated Resident 57 was dependent on staff for ADLs. The MDS indicated Resident 57 had a history of functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). During an observation on 1/22/2024 at 9:18 a.m., observed 3 opened containers of A& D ointment with zinc (medication used to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations, such as diaper rash, skin burns from radiation therapy) in the medicine cabinet in a resident restroom. Observed 2 unlabeled disposable cups with white substance in them and a tongue depressor. During an observation on 1/23/2024 at 9:45 a.m., in Resident 57's room, observed a medicine cup with yellowish-colored ointment at Resident 57's bedside. During an interview on 1/23/2024 at 9:50 a.m. with Certified Nursing Assistant (CNA) 3, in Resident 57's room, CNA 3 stated she had not noticed the ointment at Resident 57's bedside and did not know what the ointment was for. CNA 3 stated it looked like an ointment that a treatment nurse (TN) used to treat the resident's skin. CNA 3 stated only licensed nurses deal with that ointment because it was a prescribed medication. CNA 3 stated that ointment should not be kept at the bedside because any resident could take it and possibly eat it. During an interview on 1/23/2024 at 9:58 a.m. with Resident 57, in Resident 57's room, Resident 57 stated he did not know the ointment was at the bedside. Resident 57 stated that was not a good place to have the ointment because another resident could take it and use it. During an interview on 1/25/2024 at 8:48 a.m. with TN 1, TN 1 stated A&D and A&D with Zinc medication needed a physician's order. TN 1 stated that medication should not be left at a resident's bedside and should be discarded. TN 1 stated that licensed nurses were the only ones that have access to that medication and it was kept under lock and key. TN 1 stated the medication should not be kept at a resident's bedside or restroom because a resident might think it was food and they might want to eat it. TN 1 stated she did not know who put the medication in the restroom or who left the medicine cup with medicated ointment at Resident 1's and Resident 57's bedside. TN 1 stated that was not a safe practice and leaving it behind increased the risk of a resident ingesting the ointment. TN 1 stated she was the only one that dealt with medications on that side of the facility and was not aware that the ointments were missing from her medication cart. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated the facility would store all medications and biologicals in locked compartments under proper temperature, humidity, and light controls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 6 and Resident 62) were provided the opportunity to make an informed decision prior to entering into a binding arbitration agreement (the submission of a dispute to a neutral party who hears the case and makes a decision) when the following occurred: 1. Facility staff did not inform Resident 6's responsible party about what a binding arbitration entailed, or that entrance into a binding arbitration agreement was optional. 2. Facility staff did not contact Resident 62's responsible party and power of attorney (POA, a legal document that allows someone else to act on your behalf), prior to Resident 62 signing a binding arbitration agreement. This failure caused Resident 6 and Resident 62, and/or their responsible parties, to unknowingly forfeit their right to resolve any disputes with the facility in court, with a judge and/or jury. Findings: 1. During a review of Resident 6's admission Record, the record indicated the facility originally admitted Resident 6 on 1/5/2024. Resident 66's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 6's Minimum Data Set (a standardized assessment and screening tool), dated 1/9/2024, the MDS indicated Resident 6 had severely impaired cognition (loss of the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). During a review of Resident 6's progress notes, dated 1/8/2024, the progress note indicated Resident 6 responds to her name, but otherwise she mumbles incoherently in Spanish and doesn't make any sense. The progress notes also indicated Resident 6 did not have the ability to make medical decisions. During an interview, on 1/23/2024 at 12:29 PM, with Resident 6's Responsible Party (RP) 2, RP 2 stated he vaguely recalled signing documents upon Resident 6's admission to the facility. RP 2 stated he was told that the documents were related to billing, and stated he did not recall receiving any information related to binding arbitration agreements, and stated he did not know what a binding arbitration agreement meant. RP 2 further stated he was not explicitly informed that he was not required to sign the binding arbitration agreement. 2. During a review of Resident 62's admission Record, the record indicated the facility originally admitted Resident 62 on 8/21/2023. Resident 62's admitting diagnoses included metabolic encephalopathy, cognitive communication deficit (difficulty with thinking and language), and dementia. During a review of Resident 62's Minimum Data Set, dated [DATE], the MDS indicated Resident 62 had severely impaired cognition. During a review of Resident 62's progress note, dated 8/21/2023, the progress note indicated Resident 62 was admitted to the facility by ambulance on 8/21/2023, was only oriented to his name, and was very forgetful. The progress notes further indicated Resident 62's responsible party (RP 1) had been called by telephone but did not answer. During a review of Resident 62's Minimum Data Set, dated [DATE], the MDS indicated Resident 62 had severely impaired cognition. During an interview, on 1/25/2024 at 12:02 PM, with RP 1, RP 1 stated facility staff had not spoken to him about binding arbitration agreements. RP 1 stated he had been Resident 62's responsible party and POA since prior to Resident 62's admission to the facility. RP 1 stated Resident 62 was confused when admitted to the facility, and stated Resident 62 would not have had the capacity to make the decision to enter into a binding arbitration agreement. During a review of the undated facility document titled, Resident-Facility Binding Arbitration Agreement, the document indicated by signing this contract, you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. The document indicated Resident 62 digitally signed the document on 8/22/2023. The signature line labelled Signature on behalf of the resident was left blank. The document was also signed by the Social Services Assistant (SSA). During a concurrent interview and record review, on 1/25/2024 at 2:26 PM, with the SSA, the undated facility document titled, Resident-Facility Binding Arbitration Agreement was reviewed. The SSA stated she witnessed Resident 62 sign the document himself. The SSA stated she did not know Resident 62 had a responsible party. The SSA stated that if a resident was not self-responsible, it was not appropriate for them to consent to entering into a binding arbitration agreement. The SSA further stated residents and/or their responsible parties were supposed to be educated about binding arbitration agreements in a manner they understand. The SSA stated residents and/or their responsible parties had the right to make an informed decision prior to entering into a binding arbitration agreement and stated that they should not be required to sign.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement effective infection prevention measures for three of 11 sampled residents (Resident 23, 49, and 74) when the facility failed to: 1. Ensure Treatment Nurse (TN) 1 performed hand hygiene (a way of cleaning one's hands that substantially reduces the potential germs on the hands) throughout Resident 23's wound treatment. 2. Ensure Licensed Vocational Nurse (LVN) 2 donned (to put on) personal protective equipment (PPE, protective garments or equipment such as gowns, gloves, masks, eye wear that is designed to protect the wearer's body from infection) when providing care to Resident 49 and Resident 74 who were on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of infection. Findings: 1. During a review of Resident 23's admission Record (Face Sheet), the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 23's History and Physical Examination (H&P), dated 11/23/23, the H&P indicated Resident 23 had the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/14/2023, the MDS indicated Resident 23 was able to make herself understood and understood others. The MDS indicated Resident 23's cognition (process of thinking) was intact. The MDS indicated Resident 23 had cellulitis (skin infection that spreads rapidly) and moisture associated skin damage (MASD, inflammation and erosion of the skin that resulted from prolonged exposure to different sources of moisture such as feces or urine). During a review of Resident 23's Progress Notes, dated 1/25/2024, the Progress Notes indicated fungal dermatitis was found on Resident 23's lower back on 1/3/2024 and the physician was notified. During a review of Resident 23's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated the following daily wound care orders: 1. Cleanse with normal saline (NS, solution made of salt and water), pat dry, apply Nystatin-Triamcinolone External Cream (medicated cream to treat fungal skin infections) 100000-0.1 unit per gram (GM, unit of measurement) to the lower back, and keep open to air, once a day for 21 days. 2. Cleanse with NS, pat dry, apply Zinc Oxide Ointment 20 percent (%) (medicated cream that treats or prevents skin irritation such as cuts, burns, or diaper rash) to the left buttock, once a day for 21 days. 3. Cleanse with NS, pat dry, apply Zinc Oxide Ointment 20 percent to the right buttock, once a day for 21 days. During an observation on 1/24/2024 at 9:02 a.m., with TN 1 in Resident 23's room, TN 1 explained that she would be doing Resident 23's wound treatment. Resident 23 stated she did not have any pain and consented for TN 1 to continue with the wound treatment. TN 1 prepared her supplies, performed hand hygiene, and applied gloves. Resident 23 was lying on her left side, previous dressing removed prior to wound treatment. TN 1 cleansed the right and left buttock with NS, patted dry, removed her gloves, and applied new gloves. TN 1 applied Zinc Oxide Ointment with a wooden spatula applicator (small, broad, flat, blunt instrument, can also be called a tongue depressor) to the right buttock. TN 1 applied Zinc Oxide Ointment with a new wooden spatula applicator to the left buttock. TN 1 applied a padded dressing on the buttock, removed her gloves, and applied new gloves. TN 1 cleansed the lower back with NS, patted dry, and applied Nystatin-Triamcinolone Cream to the lower back. TN 1 cleaned her area, removed her gloves, and performed hand hygiene. During an interview on 1/24/2024 at 9:19 a.m., with TN 1, TN 1 stated she was supposed to perform hand hygiene throughout Resident 23's wound treatment. TN 1 stated she was supposed to perform hand hygiene when she removed her gloves and before applying new gloves. TN 1 stated she was supposed to perform hand hygiene when she moved to a new wound area. TN 1 stated hand hygiene was done to prevent the spread of infection and prevent contamination of other wounds. During an interview on 1/24/2024 at 11:22 a.m., with the interim Infection Preventionist Nurse (IPN), the interim IPN stated staff had to perform hand hygiene after touching any surfaces, before, during, and after providing care to a resident because there was the potential of germs carried on their hands. The interim IPN stated staff were to perform hand hygiene before and after glove use and especially throughout a wound treatment. The interim IPN stated when a resident has multiple wound treatments to multiple areas, hand hygiene should be performed before after the completion of one site and before moving to the next site. The interim IPN stated not performing hand hygiene put the resident at risk of contamination of wounds and infection. During an interview on 1/25/2024 at 4:47 p.m., with the Director of Nursing (DON), the DON stated hand hygiene was performed to prevent infection by killing germs and bacteria on the hands. The DON stated during a wound treatment, after removing gloves and before moving to another area, hand hygiene was supposed to be performed. The DON stated the absence of hand hygiene throughout the wound treatment increased Resident 23's likelihood of infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections . Hand hygiene is indicated immediately before touching a resident; before performing an aseptic task; after contact with body, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. 2a. During a review of Resident 49's admission Record (Face Sheet), the admission Record indicated Resident 49 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to hemiplegia (one-sided weakness) and hemiparesis (inability to move one side of the body) following a cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area) affecting left non-dominant side, dysphagia (difficulty swallowing), and type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 23 was rarely able to make herself understood and rarely understood others. The MDS indicated Resident 23's cognition was severely impaired. The MDS indicated Resident 23 had a feeding tube (a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications). During a review of Resident 49's Order Summary Report, dated 1/25/2024, the Order Summary Report indicated Resident 49 was on Enhanced Standard Precautions due to use of a feeding tube, which was an indwelling device. During an observation on 1/23/2024 at 8:12 a.m., with Licensed Vocational Nurse (LVN) 2, in Resident 49's room, LVN 2 entered Resident 49's room without donning a gown and gloves. LVN 2 explained to Resident 49 that he would administer her medications after he checked her blood pressure. LVN 2 took Resident 49's blood pressure, which was 110/60 millimeters of mercury (mmHg, unit of measurement of pressure in blood vessels). LVN 2 performed hand hygiene and sanitized the blood pressure cuff and stethoscope (a medical instrument for listening to internal sounds of the human body). LVN 2 prepared Resident 49's medication by crushing the tablets and diluting with water. LVN 2 donned only gloves and assessed the placement of Resident 49's feeding tube by inserting air into the tube and listening to her stomach with the stethoscope. LVN 2 continued to administer Resident 49's medication through her feeding tube. LVN 2 reconnected Resident 49's enteral feeding (a special liquid food mixture containing protein, carbohydrates, fats, vitamins, and minerals) to her feeding tube and continued the infusion. LVN 2 removed his gloves and performed hand hygiene. During an interview on 1/23/2024 at 8:45 a.m., with LVN 2, LVN 2 stated he was supposed to wear gown and gloves when he provided care to Resident 49 by means of checking her blood pressure and administering her medications through her feeding tube. LVN 2 stated ESP was used for residents who were prone to infection and was implemented to protect them from infection. 2b. During a review of Resident 74's admission Record (Face Sheet), the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to end stage renal disease (a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), type 2 diabetes mellitus, and peripheral vascular disease. During a review of Resident 74's H&P, dated 12/15/2023, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 was able to make himself understood and understood others. The MDS indicated Resident 74's cognition was intact. The MDS indicated Resident 74 received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so). During a review of Resident 74's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated Resident 74 was on Enhanced Standard Precautions due to having a hemodialysis (type of dialysis where the blood is treated to filter wastes and water) catheter (access point for dialysis), which was an indwelling device. During an observation on 1/23/2024 at 8:54 a.m., with LVN 2, in Resident 74's room, LVN 2 donned a gown and gloves and entered Resident 74's room. LVN 2 explained to Resident 74 that he would administer his medications after he checked his blood pressure, heart rate, and blood glucose level (amount of sugar in the blood stream). LVN 2 checked Resident 74's blood pressure which was 110/80 mmHg, 6and his heart rate was 85 beats per minute (bpm). LVN 2 doffed (removed) his gown and gloves and performed hand hygiene. LVN 2 retrieved the glucometer (a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip), did not don a gown and only applied gloves and checked Resident 74's blood glucose level, which was 120 milligrams (mg, unit of measurement) per (/) deciliter (dL, unit of measurement). LVN 2 removed his gloves, performed hand hygiene, and sanitized the blood pressure cuff, stethoscope, and glucometer. LVN 2 prepared Resident 74's medications and administered Resident 74's medications with water. During an interview on 1/23/2024 at 9:10 a.m., with LVN 2, LVN 2 stated he was supposed to don a gown and gloves when he checked Resident 74's blood glucose level. LVN 2 stated Resident 74 was on ESP and donning PPE was required during any kind of invasive procedure, such as piercing Resident 74's skin to obtain his blood glucose level. LVN 2 stated this placed Resident 74 at risk for infection. During an interview on 1/24/2024 at 11:18 a.m., with the interim IPN, the interim IPN stated ESP was implemented as a special precaution for residents with dialysis access or other indwelling devices that put them at a higher risk for infections. The interim IPN stated donning PPE while providing care to residents on ESP reduced the risk of transfer of infection. The interim IPN stated any touch-based care with a resident on ESP required the staff member to don a gown and gloves. During an interview on 1/25/2024 at 4:43 p.m. with the DON, the DON stated ESP was implemented to prevent the spread of multi-drug resistant organisms to residents who were more susceptible due to the presence of indwelling devices or open wounds. The DON stated when a staff member provided direct care to the resident, they had to don a gown and gloves. The DON stated donning a gown and gloves was especially important when accessing the resident's indwelling device because those devices were a direct entry way to the resident. The DON stated not donning a gown and gloves when providing care to residents on ESP exposed them to germs and bacteria that could cause an infection. During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . EBPs employe targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gown and gloves are applied prior to performing the high contact resident care activity . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent prior to initiation and administration of psychotropics (medications that affect the mind, emotions, and behavior) to five of seven sampled residents (Residents 43, 52, 64, and 84, and 67). The above failure put Residents 43, 52, 64, 84, and 67 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failure also removed the Residents' rights to make decisions about the care and treatments they received in the facility. Cross Reference: F-tag F561 Findings: 1. During a review of Resident 67's admission Record, the record indicated the facility originally admitted Resident 67 on 2/3/2023. Resident 67's admitting diagnoses included metabolic encephalopathy (when another health condition makes it hard for the brain to work), psychosis (a collection of symptoms that affect the mind, with some loss of contact with reality), and major depressive disorder (a distinct type of depressive illness accompanied by either delusions, hallucinations, or both). During a review of Resident 67's History and Physical (H&P), dated 2/6/2023, the H&P indicated Resident 67 had fluctuating capacity to understand and make decisions. During a review of Resident 67's medical record titled [Skilled Nursing Facility (SNF)] Follow Up Note, dated 6/14/2023, the record indicated Psychiatric-Mental Health Nurse Practitioner (PMHNP) 1 evaluated Resident 67 for anxiety (feeling of unease, excessive worry), delusion (false belief or judgement about external reality), depression (feeling of sadness), and confusion. The record indicated Resident 67 had a disorganized thought process, poor insight and judgement, and poor fund of knowledge (orientation to reality). The record indicated Resident 67 had been refusing medication and would continue to be off psychotropic medication due to [Resident 67] refusing medication. During a review of Resident 67's social services progress note, dated 6/14/2023, the progress note indicated [Resident 67] stated [he] will not take any medication from any doctor other than his primary physician that has been seeing .for over 15 years. Resident stated does not trust any other doctor. Resident stated, 'It's my choice if I decide to take medication.' During a review of Resident 67's electronic medical record (EMR), the record indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. During a review of Resident 67's medical record titled, SNF Initial Evaluation, dated 7/19/2023, the record indicated PMHNP 1 evaluated Resident 67 following his 5150 hospitalization (the involuntarily detainment/hospitalization of an adult experiencing a mental health crisis, who has been evaluated as a danger to others, themselves, or gravely disabled). The record indicated that at the time of the evaluation, Resident 67 had a disorganized thought process, paranoid delusions (feelings that someone or some group is out to mistreat, harm, and sabotage you), and poor insight and judgement. The note indicated Resident 67 would be started on 0.5 milligrams (mg, a unit of measuring medication dosage) of Risperidone (a medication used to improve mood, thoughts, and behaviors in people with schizophrenia, bipolar disorder, and autism). The note indicated PMHNP 1 discussed the treatment plan with Resident 67 and facility staff and indicated benefits of these medications outweigh the risks for this patient given the patient's degree of mental illness. During a review of Resident 67's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/26/2023, the MDS indicated a Brief Interview For Mental Status (BIMS) score of 10, which indicated Resident 67 had moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday). During a review of Resident 67's discontinued physician orders, dated 7/19/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 7/20/2023. During a review of Resident 67's Medication Administration Records (MAR), dated 7/2023, 8/2023, 9/2023, 10/2023, and 11/2023, the MARs indicated Resident 67 received Risperidone from 7/2023 to 11/2023. During a review of Resident 67's Multidisciplinary Care Conference (MCC) notes, dated 10/17/2023, the notes indicated Resident 67 was unable to make medical decisions, and indicated per primary physician [Resident 67] able to make needs known, but unable to make medical decisions. During a review of Resident 67's EMR, the EMR indicated Resident 67 was hospitalized on [DATE] and was re-admitted to the facility on [DATE]. During a review of Resident 67's discontinued physician orders, dated 11/24/2023, the orders indicated Resident 67 was started on 0.5 mg of Risperidone, twice a day, for manic disorder on 11/24/2023, and indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's medical record titled, Facility Verification of Informed Consent, dated 11/24/2023, the record indicated consent obtained by [physician] from [Resident 67]. During a review of Resident 67's MARs, dated 11/2023 and 12/2023, the MARs indicated Resident 67 received 0.5 mg of Risperidone, twice a day, from 11/2023 to 12/2023. During a review of Resident 67's MDS, dated [DATE], the MDS indicated a BIMS score of 9, indicating moderate cognitive impairment. During a review of Resident 67's medical record titled, [Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident)] Behavior Management, dated 12/8/2023, the record indicated Resident 67 was having increased erratic behavior (behavior that is unpredictable, or may be considered irregular or illogical for the situation, or not keeping with the standards of behavior for a given set of circumstances). The record further indicated the IDT reviewed Resident 67's medications and recommended an increase in his psychotropic medication dose. During a review of Resident 67's active physician orders, dated 12/8/2023, the orders indicated Resident 67 was now on 0.5 mg of Risperidone, once a day, for psychosis, and started on 0.75 mg of Risperidone at bedtime for psychosis. During a review of Resident 67's medical record titled, SNF Initial Evaluation, dated 12/11/2023, the record indicated PMHNP 2 evaluated Resident 67 and indicated that at the time of the evaluation, Resident 67 had paranoia and delusion, poor insight, and poor judgement. The note indicated Resident 67 would be continued on 0.5 mg of Risperidone once a day in the morning and reflected the new order of 0.75 mg once a day at bedtime. The note indicated PMHNP 1 discussed the treatment plan, including the medications, with Resident 67 and facility staff. During a review of Resident 67's medical records titled, Facility Verification of Informed Consent, dated 12/8/2023, the documents indicated that informed consent for Risperidone 0.5 mg once a day, and Risperidone 0.75 mg at bedtime, were obtained from [Resident 67]. During an interview, on 1/25/2024 at 12:50 PM, with Medical Doctor (MD) 1, MD 1 stated he was Resident 67's primary physician in the facility and was familiar with the resident. MD 1 stated Resident 67 had fluctuating capacity to make medical decisions, and stated Resident 67 was not capable of providing informed consent. MD 1 stated potential side effects of Risperidone included worsening psychosis, mood disorders, and hallucinations. During a concurrent record review and interview, on 1/26/2024 at 11:10 AM, with the Director of Social Services (DSS), Resident 67's EMR, including multidisciplinary care conference (MCC) notes, IDT conference notes were reviewed. The DSS stated there was supposed to be someone with medical decision-making capacity present on Resident 67's behalf during the conferences because Resident 67 did not have medical decision-making capacity. The DSS stated Resident 67 was able to independently make decisions or speak for himself due to his cognitive impairment. The DSS stated Resident 67 should have been referred to the Office of Representatives to appoint a responsible party to make medical decisions on his behalf, including informed consent. The DSS stated that not appointing a responsible party was a violation of Resident 67's rights. The DSS stated there was no documentation in Resident 67's medical record to indicate the facility had attempted to identify a responsible party for Resident 67. 2. During a review of Resident 43's admission Record, the admission record indicated Resident 43 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). During a review of Resident 43's History and Physical (H&P) dated 12/27/2023, the H&P indicated Resident 43 had the capacity to understand and make decisions. The H&P indicated Resident 43 had a diagnosis of seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations, or states of awareness). During a review of Resident 43's Minimum Data, dated 1/15/2024, the MDS indicated that Resident 43's cognitive skills for daily decision was intact. The MDS indicated Resident 43 needed supervision for activities of daily living. The MDS indicated Resident had a history of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 43's Order Summary, dated 7/20/2022, the order summary indicated Resident 43 was to receive Quetiapine fumarate tablet 400 mg, 1 tablet at bedtime for psychosis. During a review of Resident 43's MAR, dated 7/1/2022 to 7/31/2022, the MAR indicated Resident 43's received 1 tablet of Quetiapine fumarate 400mg at bedtime from 7/20/2022 to 7/31/2022. During a review of Resident 43's informed consent for Quetiapine fumarate tablet 300 mg, 2 times a day, dated 12/10/2023, the form indicated Resident 43 gave consent to receive quetiapine fumarate. 3. During a review of Resident 52's admission Record, the admission record indicated Resident 52 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of schizophrenia and angina pectoris (severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart). During a review of Resident 52's H&P dated 1/19/2024, the H&P indicated Resident 52 had the capacity to understand and make decisions. The H&P indicated Resident 52 had a diagnosis of left femur fracture (a break in the thighbone). During a review of Resident 52's MDS, dated [DATE], the MDS indicated that Resident 52's cognitive skills for daily decision was intact. The MDS indicated Resident 52 required supervision for activities of daily living (ADLs, self-care activities performed daily such as grooming, dressing, and personal hygiene). During a review of Resident 52's Order Summary, dated 6/1/2022, the order summary indicated Resident 52 was to receive Escitalopram oxalate tablet 5mg one time day for anxiety. During a review of Resident 52's MAR, dated 6/1/2022 to 6/30/2022, the MAR indicated Resident 52 received 1 tablet of Escitalopram oxalate 5 mg on 6/2/2022, and 6/4/2022 to 6/9/2022 and from 6/15/2022 to 6/30/2022. During a review of Resident 52's medical records, unable to locate a consent for Escitalopram oxalate 5 mg. During a review of Resident 52's medical records, the records indicated a consent form for Escitalopram oxalate 10 mg, dated 6/1/2023, given by Resident 52. During a review of Resident 52's MAR, dated 11/1/2023 to 11/30/2023, the MAR indicated Resident 52 received Lorazepam injection 2mg/milliliter (ml, unit of measurement) for agitation on 11/2/2023. During a review of Resident 52's medical records, unable to locate a consent for Lorazepam injection 2mg/ml. During a review of Resident 52's medical records, the records indicated informed consent for Lorazepam, dated 4/27/2023, given by Resident 52 to receive Lorazepam 1mg by mouth. 4. During a review of Resident 64's admission Record, the admission record indicated Resident 64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of dementia and psychosis. During a review of Resident 64's H&P dated 12/27/2023, the H&P indicated Resident 64 did not have the capacity to understand and make decisions. The H&P indicated Resident 64 had a diagnosis of supra pubic catheter (a medical device that helps drain urine from the bladder, enters the body through a small incision in the abdomen). During a review of Resident 64's MDS, dated [DATE], the MDS indicated that Resident 64's cognitive skills for daily decision was impaired. The MDS indicated Resident 64 needed substantial assistance for ADLs. The MDS indicated Resident 64 had a history of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). During a review of Resident 64's Order Summary, dated 6/15/2023, the order summary indicated Resident 64 was to receive Quetiapine fumarate tablet 50 mg, two times day. During a review of Resident 64's MAR, dated 6/1/2023 to 6/30/2023, the MAR indicated Resident 64 received 2 tablets of Quetiapine fumarate 50 mg daily from 6/15/2023 to 6/30/2023. During a review of Resident 64's medical records, unable to locate a consent form for Quetiapine fumarate 50 mg. During a review of Resident 64's medical records, the records indicated Resident 64's responsible party (RP) gave consent for Quetiapine fumarate 25 mg two times a day on 12/6/2023. 5. During a review of Resident 84's admission Record, the admission record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of psychosis and obstructive uropathy. During a review of Resident 84's H&P dated 12/23/2023, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 84 had a diagnosis of hypertension (high blood pressure). During a review of Resident 84's MDS, dated [DATE], the MDS indicated that Resident 84's cognitive skills for daily decision was moderately impaired and Resident 84's BIMS was 8. The MDS indicated Resident 84 required moderate assistance for personal hygiene and oral hygiene. The MDS indicated Resident 84 had a history of heart failure (progressive heart disease that affects pumping action of the heart muscle). During a review of Resident 84's Order Summary, dated 10/14/2023, the order summary indicated Resident 84 was to receive Remeron oral tablet, 15 mg, 1 tablet at bedtime for depression. During a review of Resident 84's MAR, dated 10/1/2023 to 10/31/2023, the MAR indicated Resident 84 received 1 tablet of Remeron oral tablet, 15 mg daily from 10/14/2023 to 10/23/2023. During a review of Resident 84's medical records, unable to locate consent for Remeron oral tablet 15 mg. During a review of Resident 84's medical records, the records indicated Resident 84's RP gave consent for Remeron 15 mg at bedtime on 12/20/2023. During a review of Resident 84's informed consent for Buspirone HCI oral tablet 5 mg, 2 times a day for depression, dated 12/20/2023, the informed consent indicated the doctor obtained consent from Resident 84 for administration of Buspirone HCI medication. During a review of Resident 84's Baseline Care Plan, dated 12/20/2023, the care plan indicated Resident 84 was cognitively impaired. During a review of Resident 84's BIMS Evaluation, dated 12/26/2023, the BIMS evaluation indicated Resident 84 had a BIMS score of 7 (severe cognitive impairment). During an interview on 1/25/2024 at 2:12 p.m. with Registered Nurse (RN) 1, RN 1 stated all residents needed an informed consent for a medication before administering the medication. RN 1 stated all informed consents should be in the resident's paper chart and if they were not in the chart, it meant the resident did not have an informed consent. During an interview on 1/25/2024 at 3:25 p.m. with the Director of Nursing (DON), the DON stated all residents or their responsible parties must give their authorization to administer antipsychotic medications. The DON stated they determine whether the resident has the capacity to provide informed consent based on the MDS and the H&P. The DON stated a resident could authorize the administration of an antipsychotic medication if they had a BIMs score of 12 or higher and if a resident had the mental capacity to make medical decisions. The DON stated if a resident had a responsible party, the doctor must explain the medication to the responsible party and get their consent to administer the medication. The DON stated all parties sign the consent indicating they understood the use of the medication. The DON stated informed consent was obtained from the resident or responsible party upon admission or re-admission to the facility, even if the resident received the medication in the hospital. During an interview on 1/25/2023 at 4:19 p.m. with Medical Records Staff 1, Medical Records Staff 1 stated they did not have the initial medication informed consent for Resident 43, 52, 64 and 84. During a review of facility's policy and procedure (P&P) titled, Health, Medical Condition and Treatment Options, Informing Residents of, dated 2001, the P&P indicated each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendation and prognosis, in advance of treatment and on - going basis. If a resident has an appointed representative, the representative is also informed. During a review of the facility's P&P titled, Psychotropic Medication Use, dated 10/2017, the P&P indicated facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement the care plans (document that assists nurses and other team care members organize aspects of resident care) for four of 46 sampled residents (Resident 23, Resident 11, Resident 51, and Resident 45) when facility staff failed to: 1. Develop a care plan for Resident 23 who had fungal dermatitis (a skin infection that causes red, irritated, or scaly rash) to her lower back. 2. Implement Resident 51's care plans for skin breakdown and pressure ulcers (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure). 3. Implement Resident 11's care plans for skin breakdown and pressure ulcers. 4. Implement Resident 45's care plan for her impaired vision. These failures had the potential to negatively affect the delivery of necessary care and services for Residents 23, 11, and 45. Resident 23 was at risk for worsening fungal dermatitis; Resident 11 and Resident 51 were at risk for a worsening condition of existing PUs, or development of new PUs; and Resident 45 was at risk for suffering from an avoidable inability to see, and inability to participate in her preferred activities. Cross Reference: F-tag 685 and F-tag 686 Findings: 1. During a review of Resident 23's admission Record (Face Sheet), the admission Record indicated Resident 23 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to chronic obstructive pulmonary disease (a lung disease characterized by long-term poor airflow), atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 23's History and Physical Examination (H&P), dated 11/23/23, the H&P indicated Resident 23 had the capacity to understand and make decisions). During a review of Resident 23's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 11/14/2023, the MDS indicated Resident 23 was able to make herself understood and understood others. The MDS indicated Resident 23's cognition (process of thinking) was intact. The MDS indicated Resident 23 had cellulitis (skin infection that spreads rapidly) and moisture associated skin damage (MASD, inflammation and erosion of the skin that resulted from prolonged exposure to different sources of moisture such as feces or urine). During a review of Resident 23's Progress Notes, dated 1/25/2024, the Progress Notes indicated fungal dermatitis was found on Resident 23's lower back on 1/3/2024 and the physician was notified. During a review of Resident 23's Order Summary Report, dated 1/24/2024, the Order Summary Report indicated to cleanse with normal saline (NS, solution made of salt and water), pat dry, apply Nystatin-Triamcinolone External Cream (medicated cream to treat fungal skin infections) 100000-0.1 unit per gram (GM, unit of measurement) to the lower back, and keep open to air, once a day for 21 days. During a current interview and record review on 1/25/2024 at 8:25 AM, with Treatment Nurse (TN 1), Resident 23's Care Plans were reviewed. Resident 23 did not have a care plan that addressed her fungal dermatitis. TN 1 stated once the fungal dermatitis was assessed and treatment was ordered by the physician, a care plan should have been developed. TN 1 stated care plans were developed when there was any change to the residents' condition or status. TN 1 stated care plans allowed the staff to be updated with the residents' conditions and their interventions. TN 1 stated since Resident 23 did not have a care plan that addressed her fungal dermatitis, there was the potential that the condition could worsen because the staff would be unaware of Resident 23's treatment plan and required monitoring. During an interview on 1/25/2024 at 9:14 AM, with the Minimum Data Set Nurse (MDSN), the MDSN stated care plans were developed based on the condition of the resident when they were first admitted to the facility and any changes thereafter. The MDSN stated he would audit the residents' medical record to ensure they have care plans developed based on their conditions, medications, and physician orders. The MDSN stated care plans were essential for the staff to be aware of the residents' goals and how to treat them properly. The MDSN stated Resident 23 did not have a care plan for her fungal dermatitis and there was the potential that Resident 23's skin condition would not be communicated to all the staff who provided care to her. During an interview on 1/25/2024 at 4:23 PM, with the Director of Nursing (DON), the DON stated care plans were developed to create a goal for the residents and to communicate the interventions to be implemented to meet their goal. The DON stated Resident 23 should have had a care plan developed that addressed her fungal dermatitis which would have had a measurable goal and the interventions the staff would implement to rectify the issue. The DON stated there was the potential that Resident 23's treatment could be missed, and her skin condition could worsen. 2. During a review of Resident 51's admission Record, the record indicated the facility originally admitted Resident 51 on 12/22/2020 and re-admitted Resident 51 on 11/28/2022, and again on 6/6/2023. Resident 51's admitting diagnoses included: hemiplegia and hemiparesis (weakness and/or inability to move one side of the body) following a stroke (when the blood supply to part of the brain is blocked or reduced), muscle wasting and atrophy (a decrease in size of an organ or tissue), and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 experienced cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 51 had impairment to the upper and lower extremities on one side of her body, which interfered with daily function and placed her at risk of injury. The MDS further indicated Resident 51 was fully dependent on staff to move from side to side in bed, and to transition from a sitting position to lying position, and a lying position to a sitting position. The MDS further indicated Resident 51 was at risk for developing PUs, and used a pressure reducing device in her bed, and was being turned and repositioned while in bed by staff. During a review of Resident 51's medical record titled Braden Scale for Predicting Pressure Sore Risk, dated 12/7/2023, the record indicated Resident 51 was at high risk for skin breakdown. During a review of Resident 51's care plans, the care plans indicated Resident 51 was at risk for developing PUs and experiencing skin breakdown, and goals of care included reducing Resident 51 having intact skin free of breakdown. Staff's interventions included Low Air Loss Mattress (LALM, mattress used to distribute pressure) to prevent wounds and LALM setting according to .weight of resident. During a review of Resident 51's weight measurements, the records indicated Resident 51's most recent documented weight was 112.2 pounds (lbs., unit of measuring weight) on 1/1/2024. During an observation, on 1/22/2024 at 1:42 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an observation, on 1/23/2024 at 4:25 PM, at Resident 51's bedside, Resident 51 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump that inflated the LALM indicated the LALM was set for a resident that weighed 210 lbs. During an interview on 1/24/2024 at 8:17 AM, with TN 1, TN 1 stated LALMs were used to prevent a worsening condition of existing PUs, and to prevent the development of PUs in residents who were high risk. TN 1 stated the weight settings were supposed to reflect the resident's current weight. TN 1 stated that incorrect weight settings will prevent the healing of, and potentially cause a worsening in condition of, existing PUs. TN 1 stated incorrect settings could also cause the development of new PUs. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation and interview, on 1/24/2024 at 8:29 a.m., at Resident 51's bedside, TN 1 observed Resident 51's LALM settings. Resident 51 was observed lying on a [NAME] Medical brand Elite LALM, and the weight settings indicated the LALM was set for a resident that weighed 210 lbs. TN 1 stated, That's too high. TN 1 then stated she had not checked Resident 51's LALM settings on 1/23/2024 and stated Resident 51 had a history of PUs and the incorrect settings on the LALM increased her risk at re-developing PUs. 3. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 10/24/2020 and re-admitted Resident 11 on 7/14/2023. Resident 11's admitting diagnoses included Stage IV PU to the right hip. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had impairment to the upper extremities on one side of her body, and impairment to the lower extremities on both side of her body, which interfered with daily function and placed her at risk of injury. The MDS further indicated Resident 11 had an existing Stage IV PU, was at risk for developing PUs, and used a pressure reducing device in her bed. During a review of Resident 11's medical record titled Skin and Wound Evaluation, dated 1/18/2024, the record indicated Resident 11 had a Stage IV PU with slow wound healing. During a review of Resident 11's medical record titled [Interdisciplinary Team] Wound Management Update, dated 1/18/2024, the record indicated recommendations for continued PU care included a LALM for wound management. During a review of Resident 11's care plans, the care plans indicated Resident 11 was at risk for developing PUs and goals of care included minimizing the risk for Resident 11 experiencing further skin breakdown. Interventions included LALM setting according to .weight of resident. During a review of Resident 11's weight measurements, the records indicated Resident 11's most recent documented weight was 155.8 lbs. on 1/1/2024. During an interview on 1/24/2024 at 8:17 AM, with TN 1, TN 1 stated her normal practice was to document the resident's current weight by hand onto the pump for reference to ensure the settings were always accurate. TN 1 stated she reviewed the residents' weights on a weekly basis and updated the settings as needed. TN 1 stated she checked the LALM settings daily for all residents on a LALM, and stated she checked all residents on 1/23/2024, and stated all settings were accurate. During a concurrent observation, interview, and record review, on 1/24/2024 at 8:26 AM, at Resident 11's bedside, TN 1 observed Resident 11's LALM settings and reviewed Resident 11's most recent weight measurements. Resident 11 was observed lying on a [NAME] Medical brand Elite LALM. The weight settings on the pump indicated the LALM was set for a resident that weighed 140 lbs., which matched the handwritten weight of 140 that TN 1 documented on the pump itself. TN 1 reviewed Resident 11's most recent weight of 155.8 lbs. and stated it did not match the weight she was using for the LALM settings. TN 1 stated Resident 11 had not weighed 140 lbs. since 10/2023. TN 1 stated incorrect settings could cause a delay in Resident 11's wound healing. 4. During a review of Resident 45's admission Record, the record indicated the facility originally admitted Resident 45 on 6/4/2020 and readmitted Resident 45 on 1/7/2022. Resident 45's admitting diagnoses included hemiplegia and hemiparesis following a stroke and aphasia (language disorder that affects a person's ability to communicate) following a stroke. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 had moderately impaired vision, and severely impaired cognition. During a review of Resident 45's care plans, the care plans indicated Resident 45 had impaired visual function, and goals of care included Resident 45 maintaining optimal quality of life. Staff's interventions indicated staff were to arrange consultation with eye care practitioner as required and ensure appropriate visual are available to support the resident's participation in activities. During a review of Resident 45's medical record titled, Optometric Consultation, dated 4/5/2023, the record indicated Resident 45 was seen by an optometrist and the optometrist recommended glasses. During a concurrent observation and interview, on 1/24/2024 at 10:51 AM, with Certified Nursing Assistant (CNA) 2, at Resident 45's bedside, CNA 2 checked Resident 45's bedside belongings for any corrective lenses or glasses. CNA 2 stated Resident 45 did not have any glasses. During a concurrent interview and record review, on 1/24/2024, with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 45's undated medical record titled Resident's Clothing and Possessions. LVN 2 stated the document indicated Resident 45 did not have glasses in her possession. LVN 2 stated that if a resident received glasses after initial completion of the record titled Resident's Clothing and Possessions, the document would be updated to reflect any new items in the resident's possession. During a concurrent interview and record review, on 1/24/2024 at 11:37 AM, with the Director of Social Services (DSS), the DSS reviewed the facility document titled Summary Sheet 2023 and stated Resident 45 was seen by an optometrist on 4/5/2023. The DSS stated the document indicated the optometrist recommended glasses for Resident 45. The DSS stated it would typically take a month for glasses to be delivered to the facility, and stated that upon delivery, the glasses would be documented on the resident's inventory list. During an interview on 1/24/2024 at 2:15 PM, with the optometrist's office, the optometrist's office stated an invoice (a list of goods sent, or services provided, with a statement of the sum due for these) was sent to the facility, which the facility was supposed to provide to Resident 45 or her responsible party. The optometrist's office stated the invoice indicated the remaining payment due for the glasses to be made and delivered to Resident 45. The optometrist's office stated the invoice was sent to the DSS directly via email. During an interview on 1/24/2024 at 2:36 PM, with Resident 45's family member (FM) 2, FM 2 stated the facility did not send her an invoice for glasses. During an interview on 1/24/2024 at 2:40 PM, with Resident 45's FM 1, and responsible party, FM 1 stated the facility did not send him an invoice for glasses. FM 1 stated he communicated multiple times with facility staff to inform them that Resident 45 needed glasses. FM 1 stated that if an invoice had been sent, he would have paid, stating that he really wanted Resident 45 to be able to see. During a concurrent interview and record review, on 1/24/2024 at 3:14 PM, with the DSS, the DSS reviewed her emails and located the invoice from the optometrist's office. The DSS stated she received the invoice on 4/25/2023 and stated she did not send it to FM 1 or FM 2. The DSS stated this failure to send the email to Resident 45's responsible parties for completion of payment led to a delay in Resident 45 receiving the glasses she needed. During an interview on 1/24/2024 at 3:26 PM, with the Activity Director (AD), the AD stated it was important for residents to participate in activities that they enjoy to increase their quality of life and comfort in the facility. The AD stated Resident 45 enjoyed watching television, and stated Resident 45 would not be able to watch TV and participate in her preferred activity if she was unable to see. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions, and further indicated that services provided for or arranged .and outlined in the comprehensive care plan are provided by qualified persons.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' food was appealing, appetizing, and palatable (pleasant to taste) when the facility served pale-yellow, square-shaped egg bites for breakfast, when residents verbalized feelings of dissatisfaction of the facility's food due to the lack of palatability and appeal, and food served in disposable Styrofoam dinnerware which did not maintain temperature for nine out of nine sampled residents (Residents 29, 30, 68, 77, 82, 85, 90, 57 and 63). This deficient practice had the potential for the residents to experience poor meal intake and weight loss, and lack of dignity. Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the facility on [DATE]. Resident 29's diagnoses included but not limited to fracture of the humerus (broken arm bone), muscle wasting, and protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function). During a review of Resident 29's Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 12/18/2023, the MDS indicated Resident 29's cognition (mental action or process of acquiring knowledge and understanding) was moderately impaired. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included but not limited to diabetes (high blood sugar levels in the blood) and hypertension (high blood pressure). During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognition was intact. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was originally admitted to the facility on [DATE]. Resident 68's diagnoses included but not limited to diabetes and high blood pressure. During a review of Resident 68's MDS, dated [DATE], the MDS indicated Resident 68's cognition intact. During a review of Resident 77's admission Record, the admission Record indicated Resident 77 was originally admitted to the facility on [DATE] and readmitted [DATE]. Resident 77's diagnoses included but not limited to diabetes and obesity (abnormal or excessive fat accumulation that presents a risk to health). During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77's cognition was moderately impaired. During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was originally admitted to the facility on [DATE]. Resident 82's diagnoses included but not limited to muscle weakness, pressure ulcer (a wound caused by prolonged pressure over a bony prominence), and diabetes. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82's cognition was moderately impaired. During a review of Resident 85's admission Record, the admission Record indicated Resident 85 was originally admitted to the facility on [DATE]. Resident 85's diagnoses included but not limited to muscle wasting and high blood pressure. During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85's cognition was moderately impaired. During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was originally admitted to the facility on [DATE]. Resident 90's diagnoses included but not limited to diabetes and muscle weakness. During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90's cognition was moderately impaired. During a review of Resident 57's admission Record, the admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 57's History and Physical (H&P) dated 10/10/2023, the H&P indicated Resident 57 had a history of alertness with episodes of confusion. During a review of Resident 63's admission Record, the admission record indicated Resident 63 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses of kidney disease (advanced kidney damage) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 63's H&P dated 1/20/2024, the H&P indicated Resident 63 had the capacity to understand and make decisions. The H&P indicated Resident 63 had a history of end stage of renal disease (ESRD, 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 63's MDS, dated [DATE], the MDS indicated Resident 63's cognitive skills for daily decision making was intact. The MDS indicated Resident 63 required maximal assistance with ADLs. During an interview, on 1/22/2024, at 9:00 a.m., with Resident 29, Resident 29 stated that the food was usually tasteless and did not look good. During an interview, on 1/22/2024, at 10:25 a.m., with Resident 85, Resident 85 stated that the food was cold sometimes and there was no meat served with his breakfast, and that the food did not taste good. During an interview, on 1/22/2024, at 10:54 a.m., with Resident 82, Resident 82 stated that the food was usually tasteless and did not look good. During an observation and test tray tasting of a pureed diet (food that has a soft, easy to chew texture) test tray, on 1/22/2024 at 12:07 p.m., the test tray contained one scoop of orange pureed carrots, one scoop of ground white fish, and one scoop of pinto beans. All three items tasted bland (no flavor) and did not look appetizing. During an interview, on 1/22/2024, at 12:44 p.m. a.m., with Resident 30, Resident 30 stated she usually did not like the food that was served by the facility and usually ate a fruit plate instead. During a concurrent observation and interview, on 1/23/2024, at 7:35 a.m., with Resident 82, Resident 82's breakfast tray was observed. The breakfast tray had to two pieces of toast, one bowl of cereal and a pale-yellow egg shaped as a square with four pieces of a green vegetables cooked within the egg. Resident 82 stated that her breakfast was yucky and unappealing. During a concurrent observation and interview, on 1/23/2024, at 7:38 a.m., with Resident 85, Resident 85's breakfast tray was observed. The breakfast tray had to two pieces of toast, one bowl of white oatmeal, and a pale-yellow egg shaped square with four pieces of a green vegetables cooked within the egg. Resident 85 stated that the food was nasty and unappealing and that he did not like his breakfast. During a concurrent observation and interview, on 1/23/2024, at 7:44 a.m., with Resident 77, Resident 77's breakfast tray was observed. The breakfast tray had to two pieces of toast, one bowl of white oatmeal, and a yellow egg shaped as a square with four pieces of a green vegetables cooked within the egg. Resident 77 stated, I am scared to eat. I [have] never [eaten an] egg like that. It does not taste like anything. It tastes like powder eggs. During an interview, on 1/23/2024, at 7:49 a.m., with Resident 68, Resident 68 stated that his breakfast tray was not good, did not taste like anything, and that his tray needed a protein. During an interview, on 1/23/2024, at 7:53 a.m., with Resident 90, Resident 90 stated that he did not like the egg on his breakfast tray because it had no taste. During a concurrent observation and interview, on 1/23/2024, at 3:19 p.m., with Resident 90's family member (FM) 1 and Resident 90, inside of Resident 90's room, Resident 90's lunch meal tray was observed. The lunch meal tray remained untouched and intact. FM 1 stated that she bought Resident 90 food from outside because Resident 90 did not eat his lunch meal tray. Resident 90 stated he did not like the food at the facility because it tasted bad. During an interview and concurrent observation of a photo taken of Resident 85's breakfast tray (on 1/23/2024 at 7:38 a.m.), on 1/24/2024, at 9:13 a.m., with the Dietary Supervisor (DS), the photo revealed a breakfast tray that had two pieces of toasted bread, one bowl of oatmeal, one carton of milk, and a pale-yellow egg shaped as a square with four pieces of a green vegetables cooked within the egg. The DS stated the breakfast did not look appealing or palatable to her. The DS stated that if residents received meals that looked unappealing, residents would get mad, stop eating and it would place the residents at risk for weight loss. During an interview and concurrent observation of a photo taken of Resident 85's breakfast tray (on 1/23/2024 at 7:38 a.m.), on 1/24/2024, at 11:30 a.m., with Registered Nurse (RN) 1, the photo revealed a breakfast tray that had two pieces of toasted bread, one bowl of oatmeal, one carton of milk, and a pale-yellow egg shaped as a square with four pieces of green vegetables cooked within the egg. RN 1 stated that the breakfast did not look appealing to her, and that it was the residents' right to have palatable foods. RN 1 stated that there was a potential for weight loss for the residents if the residents did not like their food because of the taste or do not find the food appealing. During an interview, no 1/24/2024, at 2:16 p.m., with the Director of Nursing (DON), the DON stated that if the residents did not like the food, then there would a potential for the residents to exhibit weight loss. During an observation on 1/25/2024 at 8:13 a.m. in the hallway, observed staff passing out resident food trays. Observed food served in white Styrofoam to-go boxes. During an observation on 1/26/2024 at 8:00 a.m., in the hallway, observed all residents breakfast trays served in a white to-go box. During an interview on 1/26/2024 at 9:12 a.m. with Resident 57, in Resident 57's room, Resident 57 stated his breakfast was cold and he ate his food because he was hungry but the food was cold. Resident 57 stated the kitchen food was never good and it was worse when it was cold. During an interview on 1/26/2024 at 9:33 a.m. with Resident 63, in Resident 63's room, Resident 63 stated his breakfast was cold that morning (1/26/2024). Resident 63 stated he always ate the food but could not that day. Resident 63 stated the taste was bad because the food was cold. Resident 63 asked who liked to eat cold food. During an interview on 1/26/2024 at 1:47 p.m. with the Dietary Supervisor (DS), the DS stated residents received their meals in Styrofoam because the plate bases got destroyed. The DS stated the plate bases got destroyed because they were stacked on top of the toaster and they melted. The DS stated it was important not to serve residents food in disposable plates because it was a dignity issue. The DS stated this was residents' home and they should be treated with dignity and respect. The DS stated she had already ordered new plate bases and they should be arriving soon. The DS stated the to go boxes would not maintain the food temperature like the other plates but she could reheat the food if residents asked. During a review of the kitchen Order Form, dated 1/26/2024 at 2:19 p.m., the order form indicated the new plates bases had not been ordered. During a review of the facility's policy and procedure (P&P), titled Food and Nutrition Services, dated 10/2017, the P&P indicated the facility was to provide each resident with a palatable diet that meets his or her daily nutritional needs, taking into account his or her preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure kitchen staff adhered to menus approved by the Registered Dietician (RD), and their respective standardized recipes, while preparing meals for 86 out of 89 facility residents when the following occurred: 1. Resident 11 and Resident 40 received cheese and vegetable quesadillas that did not have vegetables. 2. The Dietary Supervisor (DS) did not make the Registered Dietitian (RD) and the residents of the facility aware of the menu substitution changes made on 1/23/2024 and 1/24/2024. The above failures had the potential for 86 out of 89 residents to not receive the expected calories, proteins, and other micronutrients (vitamins and minerals needed by the body in very small amounts) from the meals served by the facility. Findings: 1. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 10/24/2020 and re-admitted Resident 11 on 7/14/2023. Resident 11's admitting diagnoses included acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), hyperkalemia (high potassium levels in the blood), and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of Resident 11's History and Physical (H&P), dated 7/5/2023, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, standardized resident assessment and care screening tool) dated 1/16/2024, the MDS indicated Resident 11's cognition was intact (ability to think and reason). During a review of Resident 11's physician orders dated 9/2/2023, the orders indicated Resident 11 was receiving a regular diet (a diet that does not include any dietary restrictions) with no added salt. During a review of Resident 11's care plans, the care plans indicated Resident 11 had a nutritional risk and increased nutrient needs. Staff's interventions indicated to provide diet/supplements [as ordered]. During a concurrent observation and interview on 1/23/2024 at 12:41 PM, at Resident 11's bedside, observed resident sitting up at the right edge of her bed with a lunch tray in front of her. Resident 11 stated she ordered the cheese and vegetable quesadilla. The plate had a quesadilla, shredded lettuce topped with diced tomato, and black beans. Resident 11 separated the tortilla to show the contents of the quesadilla and stated there were no vegetables in the quesadilla. No vegetables observed in the quesadilla. Resident 11 stated she did not plan to eat the quesadilla and stated she ate food brought in by another facility resident instead. During an interview on 1/23/2024 at 12:52 PM, with Resident 11, Resident 11 stated that in the last two to three months, the trays delivered have not matched the menu. Resident 11 stated facility residents brought this up to facility staff, and facility staff told them that the ingredients required for the recipe had not been delivered. 2. During a review of Resident 40's admission Record, the record indicated the facility admitted Resident 40 on 1/30/2019 and readmitted Resident 40 on 11/12/2019, and again on 1/30/2021. Resident 40's admitting diagnoses included hypokalemia (low levels of potassium in the blood), high blood pressure, and heart failure (a condition where your heart doesn't pump enough blood for your body's needs). During a review of Resident 40's H&P, dated 5/11/2023, indicated Resident 40 was oriented to person, place, and time. During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's cognition was intact. During a review of Resident 40's physician orders dated 3/13/2021, the orders indicated Resident 40 was receiving a regular diet with no added salt. During a review of Resident 40's care plans, the care plans indicated Resident 40 was at risk for potential malnutrition due to her medical conditions, and goals of care included Resident 40 being adequately nourished and hydrated. Staff's interventions indicated to provide, serve diet as ordered. During a concurrent observation and interview, on 1/23/2024 at 12:39 PM, at Resident 40's bedside with Resident 40, Resident 40 was observed sitting in a wheelchair eating lunch. Resident 40 stated she ordered the cheese and vegetable quesadilla and stated there were no vegetables in the quesadilla. Resident 40 had a small piece of quesadilla remaining on her plate, and observation of the quesadilla showed there were no vegetables. Resident 40 stated she had ordered the cheese and vegetable quesadilla in the past, and it did not have vegetables. During an interview on 1/24/2024 at 1:08 PM, with the Registered Dietician (RD), the RD stated she had not been notified that the facility was serving cheese and vegetable quesadillas without vegetables. The RD stated she was supposed to be notified by the Dietary Supervisor (DS) that the cheese and vegetable and quesadilla recipe was not being followed. The RD stated she would have instructed the kitchen staff to substitute alternative vegetables if the original vegetables required in the recipe were not available. The RD stated that the vegetables in the quesadilla recipe added nutritional value, and omitting the vegetables would decrease its nutritional value. During a review of the undated facility document titled, DT Cheese and Veggie Quesadilla, the document indicated the recipe and instructions for preparation of the cheese and vegetable quesadilla. The document indicated prepare the filling: .combine the zucchini, corn, onions, jalapenos, beans . and add the cheese. The document then indicated place filling on one half of each tortilla .place quesadillas on the griddle and cook. 3. During a review of the facility's Menu, dated 1/21/2024 to 1/27/2024, the Menu indicated the facility was to serve seasoned broccoli florets for lunch on 1/23/2023, and French toast for breakfast on 1/24/2024. During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with a fracture of the humerus (broken arm bone). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29's cognition was moderately impaired. During a review of Resident 29's Diet order, dated 12/14/2023, the diet order indicated Resident 29 was to have a regular consistency, no added salt, and reduced sweets diet. During an observation, on 1/23/2024, at 12:44 p.m., of Resident 29's meal tray, the meal tray had a scoop of zucchini, a scoop of white rice, and a serving of chicken. During an observation, on 1/24/2024, at 8:03 a.m., of Resident 29's meal tray, the meal tray had one waffle, one scoop of ground meat, a bowl of oatmeal, and a cup of coffee. During a review of the Menu Substitution Log, dated 11/13/2023 to 1/24/2024, the log indicated the broccoli for lunch (1/23/2024) was replaced by zucchini, and the French toast for breakfast (1/24/2023) was replaced by waffles. The log indicated that the broccoli was missing in [the] order and the French toast was unavailable. During a concurrent review and interview, on 1/24/2023, at 9:13 a.m., with the DS, the Diet Type Report, dated 1/24/2023, was reviewed. The report indicated 86 out of 89 residents were recipients of meals (any diet types) prepared by the kitchen. The report had indicated the remaining three residents had a nothing-by-mouth diet order (not able to eat food by mouth). The DS stated that all 86 recipients were supposed to receive broccoli (instead of zucchini) for lunch 1/23/2024 and waffles (instead of French toast) for breakfast on 1/24/2024. During an interview, on 1/24/2023, at 9:13 a.m., with the DS, the DS stated that the food delivery was missing broccoli, which was why the kitchen staff had to use zucchini to replace the broccoli. The DS stated that the Kitchen [NAME] (KC) had notified her that there would not be enough French toast for the residents the day before it was supposed to be served and did not know why there was inadequate supply for the residents. The DS stated that she did not inform the Registered Dietitian and the residents about the substitution of the food items (the broccoli and the French toast) on both dates (1/23/2024 and 1/24/2024) because she did not have enough time. The DS stated that it was important to tell the RD of the change so that the RD can approve the changes and ensure the substituted food items meet the nutritional value of the originally planned food items. The DS stated that it was important to let the residents know about the substitutions because it was their right to know about the meals that were served. During an interview, on 1/24/2024, at 12:11p.m., with the RD, the RD stated that the normal process for substituting food items was that the DS would inform her (the RD) of the specific food item change and the RD would approve of the substitution. The RD stated that she was not aware of any menu food item substitutions made on 1/23/2024 and 1/24/2024. The RD stated that it was important that the RD knew of the substitution to ensure that the food item was an appropriate substitution and had the same nutritional value. The RD stated that failing to make her aware of the food substitutions could result in the residents not receiving the intended amount of nutrients that he or she needs. During an interview, on 1/24/2024, at 2:16 p.m., with the Director of Nursing (DON), the DON stated that it was important that the DS made the RD aware of any food changes to ensure that it each substitution was adequate to ensure that the residents' caloric needs are met. During a review of the facility policy and procedure (P&P) titled, Menus, dated 10/2017, the P&P indicated the dietician reviews and approves all menus, menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal, and input from the residents is considered when menu planning. During a review of the facility job description document titled Dietary Supervisor, undated, the job description indicated essential duties and responsibilities of the Dietary Supervisor included partnering with the Dietician to ensure diet is in accordance with the resident's nutritional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 3) were treated with respect and dignity by failing to knock and request permission before opening the curtain in the residents ' room. This deficient practice had the potential to violate the rights to privacy and negatively affect the psychosocial wellbeing of Resident and Resident 3. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) of right side, end-stage renal disease ([ESRD], the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), type 2 diabetes mellitus (abnormal blood sugar). During a review of Resident 1 ' s History and Physical (H&P), dated 12/27/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool) dated 12/19/2023, the MDS indicated Resident 1 was independent for activities of daily living (ADL ' s) including bathing, dressing, and using the toilet. During a review of Resident 3 ' s admission Record, the admission record indicated Resident 3 was initially admitted on [DATE] with diagnoses including respiratory failure (condition in which the lungs could not get enough oxygen and makes it difficult to breathe), and ataxia (impaired balance or coordination). During a review of Resident 3 ' s H&P dated 8/15/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 needed partial assistance from staff for ADL ' s including bathing, dressing, and using the toilet. During an interview on 1/17/2024 at 9:04 a.m. with Resident 1, Resident 1 stated while she was taking a bath, housekeeping (HK) 1 opened the curtain to her living area without knocking or announcing himself. Resident 1 stated she felt uneasy and stated her privacy was important to her. During an observation on 1/17/2024 at 10:14 a.m., HK 2 was observed entering Resident 3 ' s room without knocking or announcing herself. During an interview on 1/18/2024 at 11:12 a.m. with HK1, HK1 stated that he did not knock nor announce himself before looking in the curtain of Resident 1. HK1 stated he should have knocked for the privacy of the residents. During an interview on 1/18/2024 at 12:30 p.m. with Director of Nursing (DON), DON stated staff should knock at the door before entering the room and if the curtain was closed, staff should also knock and announce themselves to the resident before looking in or entering the curtain. DON also stated (failure to knock or announce themselves) affects the resident and the residents right to privacy. During a review of the facility ' s Policy and Procedure (P&P) titled, Dignity, dated February 2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff are expected to knock and request permission before entering residents ' rooms.

Based on observation, interview and record review, the facility failed to follow their Infection Prevention and Control Policy and Procedures (P&P) by failing to ensure visitors and staff entering the facility completed screening for signs and symptoms (s/s) of Coronavirus Disease ([Covid-19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person). This deficiency practice had the potential to result in the spread of Covid-19 amongst facility staff, residents and the community. Findings: During an observation on 11/21/2023 at 9:35 a.m., two visitors walked into the facility and were asked by Receptionist to sign in and check their temperature. The visitors proceeded to enter the facility without staff validating Covid-19 screening was done and that visitors had no s/s of Covid-19. During a review of the facility's Employee Daily Monitoring Log dated 11/2/2023 to 11/21/2023, the Log indicated sections for temperature, validation whether staff exhibited s/s of Covid-19 including fever, cough, shortness of breath, sore throat or whether staff has had contact with anyone positive for Covid-19 were left blank/incomplete greater than 15 times. During a review of the facility's Visitor Monitoring Log dated 11/3/2023 to 11/21/2023, the Log indicated sections for temperature, validation whether staff exhibited s/s of Covid-19 including fever, cough, shortness of breath, sore throat or whether staff has had contact with anyone positive for Covid-19 were left blank/incomplete greater than 45 times. During an interview on 11/21/2023 at 11:10 a.m. with the Receptionist, the Receptionist stated he did not validate staff or visitor screening before entrance into the facility. During an interview on 11/21/2023 at 12:20 p.m., with the Director of Staff Development (DSD), DSD stated, the facility encouraged visitors and staff to perform the self-screening for COVID-19 before entering the facility. DSD stated visitors and staff screening should be validated by the receptionist before allowing them into the facility. DSD also stated visitors and staff with fever and signs and symptoms of COVID-19 should not be allowed to enter the facility to help prevent spread of Covid-19. During an interview on 11/21/2023 at 2:00 p.m. with the DON, DON stated self-screening for s/s of Covid-19 by the visitors and employees should be validated by staff before they are allowed into the facility. During a review of the facility's P&P titled, Infection Control dated 10/2018, the P&P indicated the facility would maintain a safe, sanitary, and comfortable environment to help prevent and manage transmission of diseases and infections. During a review of the facility's P&P titled, Coronavirus Disease (Covid-19)- Infection Prevention and Control Measures dated 9/2022, the P&P indicated, the infection prevention and control measures that were implemented to address the Covid 19 pandemic were incorporated into the facility infection prevention and control plan which included identifying and managing ill residents and staff; process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following criteria: a positive viral test for Covid-19; symptoms of covid-19 or close contact with someone with covid-19 infection or a high risk exposure. During a review of the facility's P&P titled, Coronavirus Disease (Covid-19)-Visitors and Communal Activities dated 5/2023, the P&P indicated residents were permitted to receive visitors of their choice as long as the visit occurred in a manner that did not place residents at risk. The P&P indicated core principles of covid-19 prevention and best practices to reduce covid-19 transmission were always adhered to including guidance for visitors who had a positive viral test for covid-19, symptoms of covid-19 or had close contact with someone with covid-19 infection. The P&P also indicated visitors with confirmed covid-19 infection or compatible symptoms should defer non-urgent in-person visitation until they meet Centers of Disease Control and Prevention (CDC) criteria for healthcare settings to end isolation.

Based on observation, interview, and record review, the facility failed to ensure 26 of 28 coffee mugs were cleaned, washed, and sanitized before the coffee mugs were taken out of the kitchen and placed on the coffee cart A for use and to distribute coffee to the residents in the facility. This failure had the potential to cause cross contamination (transfer of bacteria or any organisms) and illness to the affected residents in the facility. Findings: During a concurrent observation and interview, on 10/17/2023, at 7:33 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 was wheeling the coffee cart A in Hallway A, and stated she was going to distribute coffee to the residents. The orange plastic coffee mugs (coffee mugs) were examined. CNA 1 stated 26 out of 28 coffee mugs were stained with brown residue and stated that the coffee mugs were not clean. CNA 1 stated if a resident had drunk from any of the 26 stained coffee mugs, then it could potentially cause the resident to get sick. During an interview on 10/17/2023, at 7:46 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated serving coffee in dirty coffee mugs was unacceptable and could lead to cross contamination and could cause the residents to get sick. During an interview, on 10/17/2023, at 8:53 a.m., with Dish Washer (DW) 2, DW 2 stated the morning dishwasher was supposed to load the coffee cart and check if the coffee mugs were clean. DW 2 stated, It could have been my fault because I did not check if the coffeemugs were clean. When the nurses push the coffee carts into the kitchen, the nurses put the coffee mugs back on the tray [open side down] on the coffee cart, and they look like they are clean. It was my responsibility to check if they were clean or not after they were returned to the kitchen. The protocol is that the morning dishwasher is supposed to check the coffee carts before they get pushed out. During an interview, on 10/17/2023, at 9:15 a.m., with DW 1, DW 1 stated he was the morning dish washer, and he did not check both coffee carts (Coffee Cart A and Coffee Cart B) and the cleanliness of the coffee mugs before they were released from the kitchen. DW 1 stated it was his responsibility. During an interview, on 10/17/2023, at 9:18 a.m., with Dietary Supervisor (DS), DS stated there was a possibility that all the coffee mugs on both coffee carts were not washed if no one had washed or checked the cleanliness of the coffee mugs. During an interview, on 10/17/2023, at 9:30 a.m., with CNA 2, CNA 2 stated she was assigned to distribute coffee on coffee cart B. CNA 2 stated that she had distributed 20 of the coffee mugs. CNA 2 stated even though the coffee mugs may have looked clean, there may have been a possibility that they were not washed nor sanitized. During an interview, on 10/17/2023, at 10:50 a.m., with the Director of Nursing (DON), the DON stated, The potential harm of serving dirty coffee cups to residents is that the residents could get sick, develop an infection and it could increase the likelihood of cross contamination. The DON stated infection prevention was the responsibility of the staff and the distribution of the dirty coffee mugs had the potential to affect all the residents that requested coffee that morning. During a review of the facility's Policy and Procedure (P&P) titled, Policies and Practices- Infection Control , dated 10/2018, the P&P indicated the facility was to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. During a review of the facility's Policy and Procedure (P&P) titled, Sanitization , dated 11/2022, the P&P indicated the facility was to ensure all food contact surfaces and utensils are cleaned and sanitized . During a review of the facility's Policy and Procedure (P&P) titled, Homelike Environment , dated 2/2021, the P&P indicated the facility was to maintain a clean, sanitary and orderly environment . During a review of the facility's Policy and Procedure (P&P) titled, Dignity , dated 2/2021, the P&P indicated the facility was to provide a dignified dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a room that was assessed and equipped to prevent the resident from eloping (to run away unnoticed) for one of four sampled residents (Resident 1) who was assessed as a high risk for elopement. This deficient practice resulted in Resident 1 eloping from the facility on 9/6/2023 and was missing for three (3) days. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 1's History and Physical (H&P) dated 4/14/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had a history of a colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen. A colostomy may be temporary or permanent). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/25/2023, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 needed limited assistance for dressing and personal hygiene. The MDS indicated Resident 1 had liver disease (any of several conditions that can affect and damage the liver, over time causing cirrhosis [scarring]. As more scar tissue replaces healthy liver tissue, the liver can no longer function properly) and hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone, disrupting such things as heart rate, body temperature, and all aspects of metabolism). During a review of Resident 1's care plan for elopement, undated, the care plan indicated Resident 1 was at risk for elopement due to cognitive impairment, poor decision-making skills, and schizophrenia. The Care Plan indicated the goal for Resident 1 was for him to remain within the facility thru the next review and that he would not have incidents of elopement. The Care Plan indicated the staff's interventions included to monitor Resident 1's whereabouts frequently, redirect Resident 1 as needed, encourage to attend activities of choice, and to place a wander guard bracelet (bracelet with sensors that residents wear, has a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts caregivers) on the left wrist and the wander guard bracelet must be checked every shift. During an interview with Resident 2 (Resident 1's roommate) on 9/8/2023 at 11:27 a.m., in Resident 2's room, Resident 2 stated he was aware his roommate (Resident 1) left the faciity on 9/6/2023. Resident 2 stated Resident 1 waited for the nurse to leave the room and 5 minutes later he climbed out of the window. Resident 2 stated staff came into the room looking for Resident 1 an hour after he had left. During a review of Resident 2's H&P, dated 9/7/2023, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During an interview with the Administrator (Admin) on 9/8/2023 at 12:20 p.m., in the admin office, the Admin stated Resident 1 left the faciity on 9/6/2023, through the window of his room because the window screen was off. The Admin stated an intervention for a resident with a risk for elopement was a wander guard bracelet. Admin stated Resident 1 had a bracelet on when he left the facility but the alarm did not go off because he did not leave through a door. During an interview with Licensed Vocational Nurse (LVN) 1 on 9/8/2023 at 12:52 p.m., in the conference room, LVN 1 stated she worked the night Resident 1 left facility (9/6/2023). LVN 1 stated she heard the code yellow for elopement and LVN 1 went to check exit doors and Resident 1 was not found. LVN 1 stated she observed the window screen off the window from Resident 1's room. LVN 1 stated Resident 1 had a previous history of attempting to elope from the facility. During an interview with the Social Services Assistant (SSA) on 9/8/2023 at 1:58 p.m., in the conference room, the SSA stated in April 2023, she noticed Resident 1 in the lobby by the exit door. The SSA stated she observed Resident 1 multiple times close to the exit door, but the resident never attempted to open the door. The SSA stated that in April 2023, she decided to do an elopement risk assessment for Resident 1. The SSA stated that she notified nursing staff that Resident 1 scored high on the elopement risk assessment. During an interview with the Director of Nursing (DON) on 9/8/2023 at 4:02 p.m., in the conference room, the DON stated Resident 1 could make decisions for himself, and Resident 1 had a history of elopement in year 2022. The DON stated interventions for a resident on elopement risk were a wander guard bracelet and visual checks. The DON stated visual checks were nothing official where documentation was needed, and the facility had no proof that staff were doing visual checks. The DON stated it was acceptable to assign a resident with an elopement risk to a room that was next to an exit. The DON stated Resident 1 was not placed on extra precautions after his first elopement on 10/10/2022. During an interview with Resident 1 on 9/11/2023 at 11:50 a.m., in the lobby, Resident 1 stated he left the facility through the window of his room. Resident 1 stated he left the facility because he needed space from this place . Resident 1 stated he kept walking until he got tired. Resident 1 stated that he walked all the way to another city (approximately 8 miles away from the facility) became very tired, and felt stressed out and decided to return to the facility. Resident 1 stated he had a good time away from the facility. Resident 1 stated he made some friends out on the streets and they gave him some beer. During an interview with Certified Nurse Assistant (CNA) 3 on 9/12/2023 at 1:54 p.m., CNA 3 stated at approximately 11:10 p.m. on 9/6/2023 she did not see Resident 1 in his bed and notified her charge nurse. CNA 3 stated when she returned to Resident 1's room she noticed the screen was off the window. CNA 3 stated during the middle of the night Resident 1 usually walked the hallways and after a while they redirected him back to his room. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements , dated March 2019, the P&P indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report resident to resident abuse within 2 hours for two out of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in failure to protect residents from abuse. Findings: During a review of Resident 1's admission Record, dated 9/5/2023, the admission Record indicated Resident 1 was admitted on [DATE] with admission diagnosis that included vascular dementia (memory loss and cognitive difficulty with reasoning and judgment), diabetes mellitus (a disease that results in too much sugar in the blood), hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following a cerebral infarction (brain tissue death). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 8/17/2023, the MDS indicated Resident 1 was moderately cognitively impaired, and required extensive assistance (resident involved in activity; staff provide weight-bearing support) with personal hygiene and total dependence (full staff performance) for bathing. During a review of Resident 1's Progress Note, dated 8/30/2023, at 11:33 p.m., written by Licensed Vocational Nurse (LVN) 5, the Progress Note indicated Resident 1 and Resident 2 were observed arguing and swinging their hands at each other. The Progress Note indicated LVN 5 reported the incident to Registered Nurse (RN) 5. During a review of Resident 2's admission Record, dated 9/5/2023, the admission Record indicated Resident 2 was admitted on [DATE] with admission diagnosis that included metabolic encephalopathy (a chemical imbalance in the blood which affects the brain, and can lead to personality changes), schizophrenia (a mental illness that affects how a person thinks, feels, and behaves accompanied by hallucinations), depression (a mood disorder), and anxiety disorder (symptoms of intense anxiety or panic). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was moderately cognitively impaired, required supervision (oversight, encouragement or cueing) with personal hygiene, and extensive assistance for bathing. During a review of a facility report titled Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 8/31/2023, the SOC 341 indicated the abuse that occurred on 8/30/2023 between Resident 1 and Resident 2 was faxed at 8/31/2023 at 7:32 p.m. over to the state department. During an interview on 9/5/2023, at 8:32 a.m., with Resident 1, Resident 1 stated she complained to Resident 2 that the television was too loud and told her to turn it off, but Resident 2 became mad and went up to her and hit her on the right shoulder, so she hit Resident 2 back. During an interview on 9/5/2023, at 9:45 a.m., with the Director of Nursing (DON), the DON stated the resident-to-resident altercation between Resident 1 and Resident 2 occurred 8/30/2023 around 10:30 p.m., but he did not fax the abuse report to the state until the evening of 8/31/2023 after interviewing Resident 1, who informed him that Resident 2 hit her. DON stated abuse should be reported to the state within 2 hours, and Licensed Vocational Nurse (LVN) 1, and Registered Nurse (RN) 5 were suspended because the incident of abuse between Resident 1 and Resident 2 occurred on their shift and they did not report to the state timely. DON stated RN 5 and LVN 1 received training on abuse reporting. During an interview on 9/5/2023, at 11:12 p.m., with Resident 2, Resident 2 stated the reason her and Resident 1 were fighting was because Resident 1 got to talking and Resident 1 hit her for no reason on the upper left arm. During an interview on 9/5/2023, at 1:01 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated when abuse is suspected she would report it to the administrator right away, and if the administrator is not available, she would report it to the next in command. LVN 2 stated if she cannot contact any of her superiors such as the administrator, DON, or registered nurse supervisor, she would send a report to the state within 2 hours. During an interview on 9/5/2023, at 1:30 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated on 8/30/2023 around 10:30 p.m. to 10:45 p.m., when she was clocking in, she overheard Resident 1 and Resident 2 arguing, so LVN 5 went in the room and witnessed both Resident 1 and Resident 2 swinging at each other but not making physical contact. LVN 5 stated she separated Resident 1 and Resident 1and took Resident 1 out of the room via wheelchair. LVN 5 stated she reported the altercation between Resident 1 and Resident 2 to RN 1 and LVN 1, and suggested to RN 1 she should initiate a room change. During review of facilities policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating , dated 9/2022, the Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating policy indicated reporting allegations to the administrator and authorities should be immediately reported within 2 hours.

Based on interview and record review, the facility failed to provide education to one of five sampled residents (Resident 9) on the potential side effects, risks, and benefits of receiving pneumococcal (pertaining to pneumonia [infection of the lungs]) and COVID-19 (highly infectious respiratory virus spread from person to person) vaccines. This deficient practice failed to allow Resident 9 to exercise her right to make an informed choice to accept or refuse three different vaccine doses. Findings: A review of Resident 9's electronic immunization records (EIR) indicated the facility administered three different immunizations to Resident 9. On 1/13/2022, the infection preventionist nurse (IPN) administered one dose of pneumococcal vaccine. On 11/30/2022, the IPN administered one dose of a COVID-19 vaccination. On 5/4/2023, Resident 9 received a second dose of the COVID-19 vaccine in the facility. Further review of Resident 9's EIR indicated the IPN confirmed that Resident 9 had consented to all three vaccinations but did not indicate that any education was provided to Resident 9 or her family/responsible party. During a review of Resident 9's progress notes dated 1/13/2023 and 5/4/2023, the progress notes indicated Resident 9 agreed to receive the vaccinations but did not indicate that education was provided prior to Resident 9 prior to Resident 9 providing consent to receive the vaccines. During an interview on 8/23/2023 at 11:58 AM, following review of Resident 9's electronic medical record (including the EIR and progress notes), the IPN stated she verified that informed consent had been obtained for all three vaccines Resident 9 received in the facility. The IPN stated she could not locate documentation that vaccine education had been provided to Resident 9 prior to Resident 9 consenting to receive the vaccines. The IPN also could not locate documentation that teaching was provided any time prior to vaccine administration. The IPN stated that the purpose of educating residents prior to obtaining consent for a vaccine was to ensure the resident made an informed choice to either accept or refuse the vaccine. The IPN stated the administration of the three vaccines to Resident 9, without providing education first, was not respectful of Resident 9's rights to make informed choices regarding her medical care. During an interview on 8/23/2023 at 12:43 PM, with Resident 9, Resident 9 stated she made decisions for herself and stated she recalled receiving pneumococcal and COVID-19 vaccinations in the facility. Resident 9 stated she did not receive any education related to either of the vaccines prior to providing consent, or at the time the vaccines were administered. Resident 9 stated, [Facility staff] just told me that they were giving me the vaccine and did not explain anything about potential side effects, or the risks and benefits. During a review of Resident 9's History and Physical (H&P), dated 8/17/2023, the H&P indicated Resident 9 was alert and could verbalize her needs. During an interview on 8/24/2023 at 11:32 AM, with the Director of Nursing (DON), the DON stated all residents, or their family member/responsible party, were supposed to receive education prior to providing consent to receive a vaccine. The DON stated vaccine education was supposed to be provided by the person administering the vaccine and whoever was obtaining the informed consent. The DON stated that providing education was a part of obtaining informed consent and stated that resident's rights were not respected if a resident received a vaccine without having received education about the vaccine first. The DON stated the resident would not be able to make an informed choice to accept or refuse the vaccine because they had not been provided with all the necessary information. During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, dated 6/2022, the P&P indicated: 1. The resident (or resident representative) has the opportunity to accept or refuse a COVID-19 vaccine 2. Before the COVID-19 vaccination is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. 3. The resident's medical record includes documentation that indicate, at a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine, including: i. Samples of the educational materials used ii. The date the education took place iii. The name of the individual who received the education During a review of the facility's P&P titled, Pneumococcal Vaccine, dated 3/2022, the P&P indicated before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine .Provision of such education is documented in the resident's medical record.

Based on interview and record review, the facility failed to develop and implement an effective infection prevention and control program (IPCP) based on the following: 1. The Infection Preventionist Nurse (IPN) was unable to provide proof of a system for monitoring and surveilling infectious diseases in the facility, other than infections where antibiotics had been prescribed to the resident. 2. The IPN was unable to furnish an infection prevention and control program or policy that clearly outlined who would be responsible for infection prevention and control tasks in the event the IPN was unavailable and failed to ensure the individual covering her responsibilities in her absence had the necessary training. 3. The IPN performed infection control and prevention duties while not in the facility. This failure created the potential for vulnerable facility residents to suffer from avoidable infections, such as COVID-19 (a disease caused by a virus named SARS-CoV-2, that can be very contagious and spreads quickly), while the facility was experiencing an active outbreak of COVID-19 amongst facility staff and residents. Findings: 1. During a concurrent interview and record review on 8/23/2023 at 3:03 PM, with the IPN, the IPN showed a copy of an electronic spreadsheet. The IPN stated the spreadsheet was used for infection surveillance in the facility and only included residents receiving antibiotics. The IPN stated that not all infections require antibiotics. The IPN stated there was no current system in place for surveilling, tracking, or monitoring infections that were not being treated with antibiotics. The IPN stated the spreadsheet data was reported to the Quality Assurance Committee (QAC) monthly because the QAC was responsible for maintaining the quality of care and quality of life in the facility, including prevention of the spread of infection. The IPN stated that the current system she was using was not comprehensive and would not be effective in ensuring the early detection and control of all potential infections in the facility. The IPN stated it was important to have a comprehensive surveillance plan in place because ineffective infection surveillance could lead to the avoidable spread of infection from one resident to another. A review of the facility's policy and procedure (P&P) titled, Surveillance for Infections, dated 9/2017, the P&P indicated, the [IPN] will conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The P&P further indicated that the purpose of conducting this surveillance was to identify infections, guide appropriate interventions, and prevent future infections. 2. During an interview on 8/23/2023 at 3:03 PM, the IPN stated she was not aware of an IPCP in the facility and stated she had not been involved in developing or revising one. During an interview on 8/24/2023 at 8:42 AM, with the IPN, the IPN stated she was primarily responsible for all infection prevention and control tasks in the facility. The IPN stated there was no IPCP for the facility to follow in the event she was unavailable or unable to work. The IPN stated she was sick from 8/12/2023 to 8/22/2023 and was unable to come onsite to supervise infection control and prevention tasks. The IPN stated the Director of Nursing (DON) provided onsite coverage in her absence. The IPN stated she was unsure if the DON had completed any training in infection prevention and control. During an interview on 8/24/2023 at 9:29 AM, the IPN stated there was increased risk for the spread of infection in the facility if there was no IPCP available for facility staff to follow if she was unavailable. The IPN provided a copy of a facility P&P titled, Infection Control Program, dated 12/2009, and stated it was the most recent copy of the policy available. A review of the facility's P&P titled, Infection Control Program, dated 12/2009, the P&P indicated the Director of Staff Development (DSD) was the designated infection control nurse, and a member of an Infection Control Committee whose responsibility was to [establish] and [implement] all policies and procedures necessary for .controlling and preventing infection. During an interview on 8/24/2023 at 10:06 AM, the DSD stated he was not the designated IPN, and that the DON was the primary person responsible for covering the IPN's responsibilities if she was unavailable. The DSD stated this coverage plan was not explicitly outlined in a facility policy or documented IPCP, but it was the plan that was followed in the facility. The DSD stated the individual responsible for covering the IPN should be equally qualified and should have training related to infection control to effectively ensure the unnecessary spread of infection among facility staff and residents. The DSD stated he was unaware of an IPCP in the facility, and stated there should be one, but he did not know if there was one. The DSD stated that not having an IPCP in place could affect the facility residents because the guidance and responsibilities would not be clearly outlined, and if the IPN was unavailable, whoever was covering for her would not know what to do. During an interview on 8/24/2023 at 11:32 AM, with the DON, the DON stated he was responsible for covering the IPN's responsibilities if she was unavailable. The DON stated this coverage plan was not explicitly outlined in a facility policy or documented IPCP. The DON stated he had started an infection control training but had not yet completed it or obtained a certificate for it, despite being responsible for covering the IPN's role while she was unavailable. The DON stated he was unaware of an IPCP in the facility and relied heavily on calling the IPN for guidance and assistance while she was unavailable to be onsite in the facility. The DON stated that not having an IPCP in place could affect the facility residents because there was no system in place to prevent further spread of infection. 3. During an interview on 8/24/2023 at 8:42 AM, with the IPN, the IPN stated she was unable to work onsite in the facility from 8/12/2023 to 8/22/2023. The IPN stated that in her absence, she worked remotely to perform infection prevention and control tasks but was never onsite. During a concurrent interview and record review on 8/24/2034 at 10:00 AM, with the Administrator (ADM), the ADM provided a copy of the IPNs payroll timesheets. After reviewing the timesheets, the ADM confirmed that the IPN was documented as having worked full eight-hour shifts from 8/14/2023 to 8/18/2023. During an interview on 8/24/2023 at 11:32 AM, with the DON, the DON stated the IPN had not been onsite from 8/14/2023 to 8/18/2023 but had been performing IPN duties. The DON also stated that an infection prevention consultant had been contacted, and had provided guidance to the facility, but was never onsite in the facility while consulting and working with the facility. A review of the facility document titled, Positive [COVID-19] Residents, undated, provided by the DON on 8/23/2023, indicated all residents who had been infected with COVID-19 for the month of August 2023. The document indicated the first residents with COVID-19 were identified on 8/15/2023. The document further indicated that between 8/15/2023 and 8/22/2023, the number of residents infected with COVID-19 went from three residents on 8/15/2023 to 18 residents as of 8/22/2023. A review of the California Department of Public Health's All Facilities Letter (AFL) 20-84, dated 11/2020, indicated that the function of the IPN within the SNF included consulting in the development and implementation of the facility's infection prevention program. The AFL further indicated the IPN's functions also included developing an annual surveillance plan.

Based on observation, interview, and record review, the facility staff failed to implement and/or maintain infection control measures when the following occurred: Staff did not perform hand hygiene prior to or after providing direct patient care to three of six sampled residents (Resident 1, Resident 5, and Resident 7). Staff did not don (put on) the required personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) in rooms where residents were suspected of having COVID-19 (a disease caused by a virus named SARS-CoV-2 that can be very contagious and spreads quickly). Three licensed staff (Licensed Vocational Nurse 1 [LVN 1], LVN 2, and Registered Nurse Supervisor 1 [RNS 1]) wore N95 respirators (a filter mask that, if fitted properly, provides protection from biological particles such as bacteria and viruses) that they were not approved to use. These deficient practices had the potential to spread disease-causing pathogens from one resident to another, and from facility staff to residents, causing avoidable infection in both residents and staff. Findings: 1. During an observation on 8/18/2023 at 8:25 AM, signage outside of Room A indicated staff needed to adhere to enhanced standard precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) and everyone must perform hand hygiene before entering the room . Licensed Vocational Nurse 1 (LVN 1) placed medication into a cup outside of Room A, then entered Room A to administer the medication to Resident 1. LVN 1 did not perform hand hygiene prior to entering Room A or prior to handing the medication cup to Resident 1. After taking the medication, Resident 1 handed the empty medication cup to LVN 1, which LVN 1 disposed of in the room. LVN 1 then exited Resident 1's room without performing hand hygiene. During an observation on 8/18/2023 at 8:35 AM, LVN 1 then entered Room B, and touched Resident 7's arm and placed a re-usable blood pressure measuring device onto Resident 7's wrist to measure the resident's blood pressure. LVN 1 did not perform hand hygiene prior to entering Room B or prior to approaching Resident 7's bedside and providing direct patient care. During an interview on 8/18/2023 at 8:40 AM, LVN 1 stated that she did not perform hand hygiene prior to or after providing direct patient care in Room A and Room B. LVN 1 stated the purpose of hand hygiene was for infection control and stated that not performing hand hygiene was an infection risk to the residents. During an observation on 8/18/2023 at 9:01 AM, signage posted outside of Room C indicated the residents in Room C were on novel respiratory precautions requiring staff to clean their hands and don the required PPE prior to entering the room. During an observation on 8/18/2023 at 9:07 AM, Certified Nurse Assistant 1 (CNA 1) entered Room C without performing hand hygiene. Once inside the room, CNA 1 donned a pair of gloves and proceeded to assist Resident 5 with morning care (care provided in the morning that included, but was not limited to, bathing, dressing, and linen changes). During an observation on 8/18/2023 at 9:17 AM, CNA 1 removed and disposed of her gloves while inside Room C. CNA 1 then exited Room C and did not perform hand hygiene prior to or upon exiting the room. With ungloved hands, CNA 1 pushed a dirty linen collection cart to Room C's doorway. CNA 1 then re-entered Room C without performing hand hygiene. Inside the room, CNA 1 donned a pair of gloves, placed dirty linens from Room C into the collection cart, then removed and disposed of her gloves while in Room C. CNA 1 then donned a new pair of gloves without performing hand hygiene first and proceeded to assist Resident 5 to a wheelchair. During an observation on 8/18/2023 at 9:26 AM, CNA 1 removed and disposed of her gloves while inside Room C. CNA 1 then exited Room C, pushing Resident 5 in a wheelchair. CNA 1 did not perform hand hygiene in Room C after removing her gloves, or upon exiting Room C. During an interview on 8/18/2023 at 9:37 AM, CNA 1 stated she did not perform hand hygiene prior to and after providing direct patient care to Resident 5 or between glove changes. CNA 1 stated that the purpose of hand hygiene was to remove bacteria from the surface of the hands. CNA 1 stated that not performing hand hygiene created the potential for her to transmit bacteria from one resident to another and was an infection risk to the residents. During an interview on 8/18/2023 at 4:41 PM, the Director of Nursing (DON) stated that the purpose of hand hygiene was to reduce the risk of spreading infection from one resident to another. The DON stated that hand hygiene should be performed before and after any patient care activities, as well as prior to entry and upon exit from a resident's room. The DON stated that if hand hygiene was not performed, it posed an infection control risk to the facility residents and staff. A review of the facility policy and procedure (P&P) titled Handwashing/Hand Hygiene , dated 8/2019, indicated [the] facility considers hand hygiene the primary means to prevent the spread of infections . Further review of the P&P indicated the use of gloves does not replace handwashing/hand hygiene and that hand hygiene should be performed prior to donning gloves, as well as: Before and after direct contact with residents After contact with objects in the immediate vicinity of the resident After removing gloves Before and after entering isolation precaution settings 2. During an observation on 8/18/2023 at 9:01 AM, signage posted outside of Room C indicated the residents in Room C were on novel respiratory precautions , which required staff don a gown, gloves, N95 respirator, and a face shield (or goggles) prior to room entry. During an observation on 8/18/2023 at 9:07 AM, Certified Nurse Assistant 1 (CNA 1) entered Room C wearing an N95 respirator and face shield. CNA 1 did not don a gown or gloves prior to entering the room. Once inside the room, CNA 1 donned a pair of gloves and proceeded to assist Resident 5 with morning care (care provided in the morning that includes, but was not limited to, bathing, dressing, and linen changes). During an observation on 8/18/2023 at 9:17 AM, CNA 1 removed her gloves and disposed of them while inside Room C, then exited Room C. CNA 1 then returned to Room C with a dirty linen collection cart, and re-entered Room C wearing an N95 respirator and a face shield. CNA 1 did not don a gown or gloves. During an interview on 8/18/2023 at 9:37 AM, CNA 1 stated she did not don the required PPE prior to entering Room C. CNA 1 stated the PPE was required to prevent the spread of infection in the facility because the residents in Room C were being monitored for possible COVID-19 infection. CNA 1 stated that not donning the required PPE created the risk of spreading infection to other residents in the facility. During an observation on 8/18/2023 at 9:41 AM, signage posted outside of Room D indicated the residents in Room D were on novel respiratory precautions , requiring staff to don a gown, gloves, N95 respirator, and a face shield (or goggles) prior to room entry. Observed housekeeping staff 1 (HKS 1) mopping the floor in Room D wearing an N95 respirator, a face shield, and gloves. HKS 1 was not wearing a gown. During an interview on 8/18/2023 at 9:49 AM, HKS 1 stated the novel respiratory precaution signage outside of Room D indicated that staff needed to don PPE prior to entering the room, and HKS 1 stated she did not wear the required PPE while in Room D. HKS 1 stated that the purpose of the novel respiratory precautions and usage of PPE was to prevent the spread of infection. HKS 1 stated that by not wearing the required PPE, there was the risk that she could spread infection to other residents in other rooms. During an interview on 8/18/2023 at 4:41 PM, the DON stated that novel respiratory precautions were being implemented for facility residents who had COVID-19 or suspected of having COVID-19. The DON stated the purpose of the precautions was to reduce the risk of spreading respiratory infection from one resident to another. The DON stated that if novel respiratory precautions were not adhered to, including donning the required PPE, it was an infection control risk to the facility residents and staff. 3. During an observation on 8/18/2023 at 8:10 AM, observed a box of Honeywell brand DF300N95 model N95 respirators at the facility entrance. During an interview on 8/18/2023 at 8:19 AM, RNS 1 stated that the facility entrance was used by staff at the start and end of their shifts. During a concurrent observation and interview on 8/18/2023 at 3:15 PM, LVN 2 stated she recalled completing a fit test (a test conducted to verify that an N95 fits the wearer's face to provide the wearer with the expected protection) but could not remember the model of N95 respirator she was approved to use. LVN 2 stated she used whatever model of N95 respirator was available at the nurse's station and stated she was currently using the N95 model available at nurse's station 2. Observation of the N95 model at nurse's station 2 indicated it was the Honeywell brand DC300N95 model respirator. A review of the facility's document titled, Qualitative Respiratory Fit Record , dated 3/21/2023, indicated LVN 2 was fit tested and approved to use a 3M brand N951860S model N95 respirator. During a concurrent observation and interview on 8/18/2023 at 3:29 PM, observed RNS 1 wearing a Honeywell brand DC300N95 model N95 respirator. RNS 1 stated she had just changed [her] N95 respirator not long ago and was previously wearing a different N95 model earlier in the day. RNS 1 stated she grabbed whatever N95 respirator model was available at the main entrance when she came in for her shift, then changed it to the model she was currently wearing because the previous model was uncomfortable . Stated that the model of N95 she was currently wearing was more comfortable which is why she chose it. Stated that she knew which N95 model respirator she was fit tested for but didn't know where to get it from. A review of the facility's document titled, Qualitative Respiratory Fit Record , dated 5/2/2023, indicated RNS 1 was fit tested and approved to use a model Honeywell brand DC365N95HC model N95 respirator. During a concurrent observation and interview on 8/18/2023 at 3:31 PM, observed LVN 1 wearing a Honeywell brand DF300N95 model N95 respirator. LVN 1 stated she recalled being fit tested in 2023 and stated she could not recall which N95 model she had been approved to use. LVN 1 stated she just [wore] one that fit but did not check to ensure it was the N95 model that she was fit tested for. A review of the facility's document titled, Qualitative Respiratory Fit Record , dated 6/30/2023, indicated LVN 1 was fit tested and approved to use a Honeywell brand DC300N95 model N95 respirator. During a concurrent observation and interview on 8/18/2023 at 4:23 PM, the DON accessed the PPE storage room and multiple boxes of various models of N95 respirators observed. The DON stated the following N95 models were stocked and available for staff use: 3M brand N951860S model, Honeywell brand DC365N95HC model, and Honeywell brand DC300N95 model. During an interview on 8/18/2023 at 4:41 PM, the DON stated that the facility currently had an active COVID-19 outbreak, requiring staff to don whichever N95 model they were individually fit tested for and approved to use. The DON stated the purpose of a fit test was to ensure the N95 model fit the wearer and prevented infectious particles from entering or exiting from behind the N95 respirator. The DON stated that if staff used an N95 model they were not fit tested for and approved to use, the N95 respirator would not be effective in protecting from infection, or as a method of source control (the use of masks to cover a person's mouth and nose, helping to reduce the spread of large respiratory droplets to others and helping reduce the spread of COVID-19). The DON stated staff donning an N95 respirator they were not fit tested for increased the risk for infection to spread from resident to staff, staff to residents, and staff to staff. A review of facility's document titled, [Facility] COVID 19 Mitigation Plan , not dated, indicated when there is an outbreak [in the facility], all staff should wear a surgical/procedure mask or higher (e.g., N95 respirator) for source control . Further review of the document indicated all staff must wear fit tested .N95 respirators per transmission-based precautions (precautions implemented for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission) for COVID-19 . A review of facility's P&P titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, dated 9/2022, indicated the facility follows infection prevention and control practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility, including implementing source control measures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain management that was in accordance to the physician ' s order and care plan for one of four sampled residents ' (Resident 1) pain by failing to ensure the resident ' s pain medication was readily available and administered to the resident. This deficient practice had the potential to result in Resident 1 experiencing unnecessary, unrelieved pain and had the potential to negatively affect the resident ' s psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses (dx) that included hemiplegia (paralysis of one side of the body), aphasia (a disorder that affects how you communicate), and intervertebral disc degeneration (breakdown of one or more of the discs that separate the bones of the spine, causing pain in the back or neck and frequently in the legs and arms). During a review of Resident 1 ' s History and Physical (H&P), dated 5/7/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 5/28/2023, the MDS indicated Resident 1 required supervision to extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADL) such as locomotion (how the resident moves between locations), eating, transferring, bed mobility, dressing, toilet use, and personal hygiene. During a review of Resident 1's Care Plan for alteration of comfort related to pain due to dx of cerebrovascular accident ([CVA], damage to tissues in the brain due to a loss of oxygen) and Osteoarthritis ([OA], the wearing down of the protective tissue at the end of bones that causes pain and stiffness) initiated on 6/10/2021 and revised on 3/19/2023, the Care Plan indicated interventions for nursing to administer analgesia Norco [hydrocodone and acetaminophen, a narcotic for pain relief], Acetaminophen [a non-opioid pain medication], and Lidocaine [a pain medication]). The Care Plan interventions also included to anticipate the resident ' s need for pain relief, respond immediately to any complaints of pain and to monitor any signs of non-verbal pain such as changes in breathing, grunting, irritability, aggressiveness, and crying. During a review of Resident 1 ' s Physician Order Summary, the Summary indicated that Resident 1 had the following medication orders to be administered to the resident for pain: Acetaminophen tablet 325 milligrams ([mg], unit of measurement) 2 tablets (tabs) by mouth every 4 hours for mild pain (pain rating reference range: 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10 severe pain). Norco Oral Solution 7.5-325 mg per 15 milliliters (mL, a unit of measurement), give 10mL by mouth every six hours as needed for moderate pain. Norco Oral Solution 10-325 mg/15 ml, give 15 ml every six hours as needed for severe pain. During a review of Resident 1 ' s Nursing Notes (Notes), dated 6/6/2023 at 7:10 a.m., the Notes indicated Resident 1 complained of pain rated 8/10 however Norco was not available, and the resident was administered Acetaminophen 325 mg. 2 tabs while the facility was awaiting pharmacy to deliver the Norco medication refill. The Notes also indicated on 6/6/2023 at 7:40 a.m., Resident 1 ' s follow-up pain rating was 5. During a phone interview on 6/12/2023 at 3:20 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1 ' s Norco was not available for the resident when he complained of pain and the resident became upset about not receiving his pain medication. During an interview on 6/14/2023 at 1:28 p.m. with the Director of Nursing (DON), the DON stated medication should have been reordered from pharmacy 3 days before the last dose was to be administered and Resident 1 should not have run out of pain medication. The DON also stated if pain medication was not given to the resident as ordered by the physician, the resident ' s pain may be uncontrolled, and the resident could become frustrated. During a review of the facility ' s policy and procedure (P&P) titled, Medication and treatment Orders, dated 7/2016, the P&P indicated drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. During a review of the facility ' s P&P titled, Pain Assessment and Management dated 10/2022, the P&P indicated the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident ' s choices related to pain management. The P&P also indicated medication regiment was implemented as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 1), by failing to document the administration of Norco (narcotic pain medication) in the Medication Administration Record (MAR) for the resident. This deficient practice had the potential to result in medication errors and placed Resident 1 at risk for not receiving appropriate pain management due to incomplete and inaccurate medication administration documentation. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses (dx) that included hemiplegia (paralysis of one side of the body), aphasia (a disorder that affects how you communicate), and intervertebral disc degeneration (breakdown of one or more of the discs that separate the bones of the spine, causing pain in the back or neck and frequently in the legs and arms). During a review of Resident 1 ' s History and Physical (H&P), dated 5/7/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 5/28/2023, the MDS indicated Resident 1 required supervision to extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADL) such as locomotion (how the resident moves between locations), eating, transferring, bed mobility, dressing, toilet use, and personal hygiene. During a review of Resident 1 ' s Physician Order Summary, the Summary indicated that Resident 1 had the following medication orders to be administered to the resident for pain: Norco Oral Solution 7.5-325 mg per 15 milliliters (mL, a unit of measurement), give 10mL by mouth every six hours as needed for moderate pain (pain rating reference range: 0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10 severe pain). Norco Oral Solution 10-325 mg/15 ml, give 15 ml every six hours as needed for severe pain. During a review of Resident 1's Control Drug Record, dated 5/2023 and 6/2023, the Control Drug Record indicated Norco was administered to Resident 1 on: 5/27/23 at 4 a.m., 10:30 a.m., 4:30 p.m., 10:30 p.m. 5/28/23 at 5:02 a.m., 12:55 p.m., 7 p.m. 5/29/23 at 2:44 a.m., 10:00 a.m., 6:36 p.m. 5/30/23 at 12:59 a.m., 07:00 a.m., 1:25 p.m., 7:25 p.m. 6/4/23 at 10:29 a.m., 5:30 p.m., 11:50 p.m. A total of 17 times. During a review of Resident 1 ' s MAR, dated 5/2023 and 6/2023, the MAR indicated Norco was administered to Resident 1 on: 5/27/23 at 4 a.m. and 10:30 a.m. 5/28/23 at 5:02 a.m. and 12:55 p.m. 5/29/23 at 2:44 a.m. and 6:36 p.m. 5/30/23 at 12:59 a.m., 1:25 p.m., and 7:25 p.m. 6/4/23 at 10:29 a.m. and 11:50 p.m. A total of 11 times. During an interview and concurrent record review on 6/14/2023 at 1:28 p.m. with the Director of Nursing, Resident 1 ' s Antibiotic or Controlled Drug Record for Liquids Only (Control Drug Record), dated 5/2023 and 6/2023, and Medication Administration Record (MAR), dated 5/2023 and 6/2023 were reviewed. DON stated there were six instances when the administration of Norco medication to Resident 1 were not reflected on the MAR. The DON also stated nurses should document administration of narcotics to residents on both the MAR and Control Drug Record. During a review of the facility ' s policy and procedure (P&P) titled, Documentation of Medication Administration, dated 11/2022, the P&P indicated, a nurse or certified medication aide (where applicable) documented all medications administered to each resident on the resident ' s MAR and should be documented immediately after the medication was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan addressing falls that included measurable objectives, interventions, and timeframes on how staff would meet the needs for one of three sampled residents (Resident 1). This deficient practice had a potential for Resident 1 to be at increased risk for further falls. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1's original admission date to the facility was on 1/11/2023, and was readmitted on [DATE] with diagnoses that included chronic osteomyelitis (bone infection) in the left ankle and foot, acute and subacute infective endocarditis (inflammation of the inner lining of the heart), type 2 diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), abnormalities of gait and mobility (when the body systems that control the way a person walks do not function in the usual way), and acquired absence of right foot (when one or more limbs are amputated). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/18/2023, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required limited assistance from staff with bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene, and bathing. During a review of Resident 1's Change of Condition (COC) Evaluation, dated 2/26/2023, the COC indicated Resident 1 was found sitting next to her bed. The COC indicated Resident 1 stated she used the bathroom and her legs got weaker, so she sat on the floor. The COC indicated, Pain and neurological status evaluation were documented as not clinically applicable to the change in condition being reported. The COC indicated the primary care physician ' s recommendations were to monitor Resident 1. During a review of Resident 1's Post-Fall Review dated 2/26/2023, the Post-Fall Review indicated Resident 1 tried to walk back to her bed after using the bathroom, but her legs gave out, so she sat on the floor and started to crawl until she got to her bedside. Section 4 of the Post-Fall Review, entitled, The Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Review and Summary of Root Cause, indicated the IDT members participating in the review were one licensed vocation nurse, the director of nursing and the administrator. The primary care physician is not noted as attending the review. The Post-Fall Review also indicated Resident 1's care plan was updated. During a review of Resident 1's Progress Note, dated 2/26/2023 at 2:03 p.m., the note indicated Licensed Vocational Nurse (LVN) 1 was notified Resident 1 was laying on her back next to the foot of her bed, while housekeeping was cleaning the floor. The note indicated Resident 1 stated she felt weak and dizzy. Resident 1 complained of pain on the lower back and head. LVN 1 called 911 and Resident 1 was taken to the emergency room for further evaluation. During a review of Resident 1's Order Summary Report dated 3/1/2023, the report indicated there was a physician's order dated 2/26/2023, to transfer the resident to a general acute care hospital (GACH) via 911 due to altered level of consciousness (ALOC), headache, tachycardia (irregular fast heart beat), status post (s/P) fall. During a review of Resident 1's Nursing Admission, dated 3/6/2023, the admission note indicated Resident 1 was noted to have lower extremity weakness and used a wheelchair. The admission note also indicated Resident 1 had a history of 1 to 2 falls within the last six months. During a review of Resident 1's Post-Fall Review dated 3/11/2023, the Post-Fall Review indicated Resident 1 fell on her way back to her bed after using the bathroom. The review indicated Resident 1 was not using her walker and lost her balance. Section 4 of the post-fall review, entitled, The Interdisciplinary Team (IDT) Review and Summary of Root Cause, indicated the IDT members participating in the review were the administrator, the director of nursing, the social services director, activities director and director of rehabilitation. The primary care physician is not noted as attending the review. The Post-Fall Review also indicated Resident 1's care plan was updated. During a review of Resident 1's Fall Risk assessment dated [DATE], the assessment indicated Resident 1 had recent falls in less than 3 months and multiple falls within the last six months. The assessment Resident 1 was at risk for falls. During a review of Resident 1's undated Care Plan titled, Risk for falls related to status post right metatarsal amputation, chronic foot ulcer, hypothyroidism, MRSA endocarditis, impulsivity, forgetfulness, episodes of refusal of assistive device use (walker or wheelchair) and call light use for assistance, the care plan indicated the goals were: 1. Resident 1 would be free of falls through the review date; 2. Resident 2 would be compliant with safety measures e.g. assistive device use (walker/wheelchair), use of call light for any assistance. The care plan did not indicate the following: initiation date, goal date, or target date. The care plan indicated there were multiple interventions; however, there were no target dates indicated to use to evaluate the effectiveness of the nursing interventions. During a telephone interview with the MDS Nurse on 3/20/2023 at 1:30 p.m., the MDS Nurse stated for resident falls, the IDT reviewed the fall incident the next business day. The MDS Nurse stated the licensed nurse could update the resident ' s care plan. The MDS Nurse stated each resident's care plan had an initiated date, a goal date and a target date. The MDS Nurse stated the care plan dates were important for evaluation of goals and nursing interventions. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment, revised 3/2018, the P&P indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other will seek to identify and document resident risk factors and establish a resident-centered falls prevention plan based on relevant assessment information. The P&P indicated assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). The P&P indicated the staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. The P&P also indicated the staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. The P&P also indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident ' s condition, when the desired outcome is not met, and when the resident has been readmitted to the facility from a hospital stay. During a review of the facility's P&P titled, Care Planning-Interdisciplinary Team (IDT), revised 3/2022, the P&P indicated the IDT includes, but is not limited to: a. The resident ' s attending physician; b. A registered nurse with responsibility for the resident; c. A nursing assistant with responsibility for the resident; d. A member of the food and nutrition services staff; e. To the extent practicable, the resident and/or the resident ' s representative; and f. Other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. Based on interview and record review, the facility failed to develop a comprehensive and resident-centered care plan addressing falls that included measurable objectives, interventions, and timeframes on how staff would meet the needs for one of three sampled residents (Resident 1). This deficient practice had a potential for Resident 1 to be at increased risk for further falls. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1's original admission date to the facility was on 1/11/2023, and was readmitted on [DATE] with diagnoses that included chronic osteomyelitis (bone infection) in the left ankle and foot, acute and subacute infective endocarditis (inflammation of the inner lining of the heart), type 2 diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), abnormalities of gait and mobility (when the body systems that control the way a person walks do not function in the usual way), and acquired absence of right foot (when one or more limbs are amputated). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/18/2023, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required limited assistance from staff with bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene, and bathing. During a review of Resident 1's Change of Condition (COC) Evaluation, dated 2/26/2023, the COC indicated Resident 1 was found sitting next to her bed. The COC indicated Resident 1 stated she used the bathroom and her legs got weaker, so she sat on the floor. The COC indicated, Pain and neurological status evaluation were documented as not clinically applicable to the change in condition being reported. The COC indicated the primary care physician's recommendations were to monitor Resident 1. During a review of Resident 1's Post-Fall Review dated 2/26/2023, the Post-Fall Review indicated Resident 1 tried to walk back to her bed after using the bathroom, but her legs gave out, so she sat on the floor and started to crawl until she got to her bedside. Section 4 of the Post-Fall Review, entitled, The Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Review and Summary of Root Cause, indicated the IDT members participating in the review were one licensed vocation nurse, the director of nursing and the administrator. The primary care physician is not noted as attending the review. The Post-Fall Review also indicated Resident 1's care plan was updated. During a review of Resident 1's Progress Note, dated 2/26/2023 at 2:03 p.m., the note indicated Licensed Vocational Nurse (LVN) 1 was notified Resident 1 was laying on her back next to the foot of her bed, while housekeeping was cleaning the floor. The note indicated Resident 1 stated she felt weak and dizzy. Resident 1 complained of pain on the lower back and head. LVN 1 called 911 and Resident 1 was taken to the emergency room for further evaluation. During a review of Resident 1's Order Summary Report dated 3/1/2023, the report indicated there was a physician's order dated 2/26/2023, to transfer the resident to a general acute care hospital (GACH) via 911 due to altered level of consciousness (ALOC), headache, tachycardia (irregular fast heart beat), status post (s/P) fall. During a review of Resident 1's Nursing Admission, dated 3/6/2023, the admission note indicated Resident 1 was noted to have lower extremity weakness and used a wheelchair. The admission note also indicated Resident 1 had a history of 1 to 2 falls within the last six months. During a review of Resident 1's Post-Fall Review dated 3/11/2023, the Post-Fall Review indicated Resident 1 fell on her way back to her bed after using the bathroom. The review indicated Resident 1 was not using her walker and lost her balance. Section 4 of the post-fall review, entitled, The Interdisciplinary Team (IDT) Review and Summary of Root Cause, indicated the IDT members participating in the review were the administrator, the director of nursing, the social services director, activities director and director of rehabilitation. The primary care physician is not noted as attending the review. The Post-Fall Review also indicated Resident 1's care plan was updated. During a review of Resident 1's Fall Risk assessment dated [DATE], the assessment indicated Resident 1 had recent falls in less than 3 months and multiple falls within the last six months. The assessment Resident 1 was at risk for falls. During a review of Resident 1's undated Care Plan titled, Risk for falls related to status post right metatarsal amputation, chronic foot ulcer, hypothyroidism, MRSA endocarditis, impulsivity, forgetfulness, episodes of refusal of assistive device use (walker or wheelchair) and call light use for assistance, the care plan indicated the goals were: 1. Resident 1 would be free of falls through the review date; 2. Resident 2 would be compliant with safety measures e.g. assistive device use (walker/wheelchair), use of call light for any assistance. The care plan did not indicate the following: initiation date, goal date, or target date. The care plan indicated there were multiple interventions; however, there were no target dates indicated to use to evaluate the effectiveness of the nursing interventions. During a telephone interview with the MDS Nurse on 3/20/2023 at 1:30 p.m., the MDS Nurse stated for resident falls, the IDT reviewed the fall incident the next business day. The MDS Nurse stated the licensed nurse could update the resident's care plan. The MDS Nurse stated each resident's care plan had an initiated date, a goal date and a target date. The MDS Nurse stated the care plan dates were important for evaluation of goals and nursing interventions. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment, revised 3/2018, the P&P indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other will seek to identify and document resident risk factors and establish a resident-centered falls prevention plan based on relevant assessment information. The P&P indicated assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). The P&P indicated the staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. The P&P also indicated the staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P also indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, and when the resident has been readmitted to the facility from a hospital stay. During a review of the facility's P&P titled, Care Planning-Interdisciplinary Team (IDT), revised 3/2022, the P&P indicated the IDT includes, but is not limited to: a. The resident's attending physician; b. A registered nurse with responsibility for the resident; c. A nursing assistant with responsibility for the resident; d. A member of the food and nutrition services staff; e. To the extent practicable, the resident and/or the resident's representative; and f. Other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the coronavirus disease ([COVID 19]) a respiratory illness caused by a virus that can easily spread from person to person) per the facility's infection control policies as evidenced by: a. Failure to ensure one of five randomly selected staff (Licensed Vocational Nurse [LVN] 1 performed hand hygiene prior to entering and after exiting a resident room (Resident 1). b. Failure to ensure three of six randomly sampled staff sampled (LVN 1, Director of Staff Development Assistant [DSDA], and the dietary aide [DA]) was screened for COVID-19 prior to entrance to the facility. c. Failure to ensure one of three randomly selected residents (Resident 2) was monitored for signs and symptoms of COVID-19. These deficient findings had the potential to result in the continued spread of COVID-19 in the facility and cause undue harm to residents' health and well-being. Findings: a. During a record review of Resident 1's admission record dated 10/22/2022, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar) and a history of COVID-19 on 5/5/2020. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/12/2022, the MDS indicated Resident 1's cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 1 required supervision with eating, and required limited one person assistance with personal hygiene and extensive assistance with transfer, bed mobility, dressing, and toilet use. During an observation in front of Nursing Station 1 on 12/28/2022 at 9:53 a.m., LVN 1 was observed prepping medications for Resident 1. LVN 1 walked into Resident 1's room without performing hand hygiene. LVN 1 was observed administering oral medications to Resident 1 then walking out of the room without performing hand hygiene. During an interview with LVN 1 on 12/28/2022 at 9:58 a.m., LVN 1 stated she did not perform hand hygiene prior to entering and after exiting Resident 1's room. LVN 1 stated she should have performed hand hygiene to help prevent the spread of COVID-19. During an interview with the Infection Preventionist (IP) Nurse on 12/28/2022 at 1:50 p.m., the IP stated before entering and after exiting a resident's room, staff needed to perform hand hygiene to prevent the spread of infections. During a review of the facility's COVID-19 Mitigating Plan (12/28/2022), the document indicated it was the facility's policy to protect residents', staff, and others from harm during emergency events. To accomplish this, procedures were developed for infection prevention control to manage COVID 19 outbreaks. The document indicated the IP will follow the Los Angeles Health Department, California Department of Public Heath, and Centers for Disease Control. During a record review of facility's Guideline for preventing and Managing COVID-19 Skilled Nursing Facilities (printed 12/29/2022]), the document indicated healthcare personnel (HCP) and all other staff members should perform hand hygiene before and after all resident encounters, regardless of a resident's COVID-19 status. All staff should perform hand hygiene frequently including every time they enter and exit the resident rooms. b. During a record review of LVN 1's Timecard Report for 12/25/2022 to 1/7/2023, (printed 12/28/2022), the report indicated LVN 1 clocked in to work at the facility on 12/28/2022 at 8:06 a.m. During a record review of the Director of Staff Development Assistant's (DSDA) Timecard Report for 12/25/2022 to 1/7/2023 (printed 12/28/2022), the report indicated the DSDA clocked in to work at the facility on 12/28/2022 at 8:49 a.m. During a record review of the Dietary Aide's (DA) Timecard Report for 12/25/2022 to 1/7/2023 (printed 12/28/2022), the report indicated the DA clocked in to work at the facility on 12/28/2022 at 5:30 a.m. During a record review of the facility's Employee Daily Monitoring Log, (dated 12/28/2022), the log indicated employees will document date, name, and temperature at the start of shift, and report the following: a recent diagnosis of COVID-19, symptoms of COVID-19 infection, close contact exposure, or recent travel to a state or country with high COVID-19 transmission levels prior to entrance to the facility. The log dated 12/28/2022, indicated the DSDA, LVN 1, and DA was not screened prior to entering the facility. During an interview with the IP and concurrent review of the Employee Daily Monitoring Log, on 12/28/2022 at 2:14 p.m., the IP stated the DA, DSDA, and LVN 1 was not screened prior to entering the facility on 12/28/2022 and they should have been. The IP stated the staff was supposed to check their temperature and then answer the questionnaire at the start of the shift. The IP stated screening was to ensure staff was not sick and to mitigate the spread of infections in the facility. During a review of the facility's document titled, COVID 19 Mitigating Plan, (12/28/2022), the plan indicated it was the facility's policy to protect residents', staff, and others from harm during emergency events. To accomplish this, procedures were developed for infection prevention control to manage COVID-19 outbreak. The plan indicated the IP was responsible for overseeing the screening of all individuals entering the facility and will maintain records that all screening occurred. The plan indicated staff were screened upon entry by asking pertinent questions and taking of temperature before coming to work. c. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia (condition in which the blood does not have enough healthy red blood cells), and hypertension (high blood pressure). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was sometimes understood and sometimes understood others. The MDS indicated Resident 2 required extensive two-person assistance with bed mobility, eating, personal hygiene, and total dependence on staff for transfer, toilet use, dressing and bathing. During a record review of Resident 2's COVID-19 laboratory test result, collected on 12/19/2022, the test result indicated COVID-19 was detected. During a review of Resident 2's Change of Condition evaluation (COC) dated 12/22/2022 at 2:49 p.m., the COC indicated on 12/22/2022, Resident 2 tested positive for COVID-19. During a review of Resident 2's Medication Administration Record (MAR) for the month of December 2022, the MAR indicated Resident 2 was scheduled for monitoring for signs and symptoms of COVID-19 such as fever or shills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, or runny nose, nausea or vomiting, and diarrhea every shift. The MAR indicated no monitoring was completed from 12/22/2022 to 12/28/2022. During an interview with the IP and concurrent review of Resident 2's MAR, for the month of December 2022, on 12/28/2022 at 1:54 p.m., the IP stated Resident 2 had no documented evidence of COVID-19 symptom screening for the month of December 2022. The IP stated the screening was to ensure the resident was not getting worse and to mitigate complications of COVID-19. During a review of Resident 2's care plan titled, Risk for transmissible respiratory disease such as COVID-19, the staff's interventions indicated Resident 2 would be monitored every shift for signs and symptoms of respiratory illnesses such as cough, shortness of breath, sore throat, fever, and oxygen saturation (how much oxygen is in the blood). During a review of the facility's COVID 19 Mitigating Plan (12/28/2022), the plan indicated it was the facility's policy to protect residents', staff, and others from harm during emergency events. The plan indicated to accomplish this, procedures were developed for infection prevention control to manage COVID-19 outbreaks. The plan indicated the IP will follow the Los Angeles Health Department, California Department of Public Heath, and Centers for Disease Control. During a record review of the facility's Guideline for preventing and Managing COVID-19 Skilled Nursing Facilities, (printed 12/29/2022 by the administrator [ADM]), the document indicated all asymptomatic residents should be assessed for symptoms at least every 24 hours, with more frequent monitoring recommended for residents who are suspect cases, for example every shift, and especially for residents with confirmed Covid-19 for example every 4 hours. The document indicated records should be kept of resident symptoms and temperature checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess the residents for eligibility and failed to ensure residents were offered the pneumococcal vaccination (vaccine to help prevent one from getting pneumonia [infection of the lungs]) and the influenza vaccination (Flu, vaccine to prevent one from getting the flu) for five of five sampled residents (Residents 2, 3, 4, 5, and 6). This deficient practice placed Residents 2, 3, 4, 5, and 6 at a higher risk of acquiring and transmitting pneumonia and/or the flu to other vulnerable and immunocompromised residents in the facility. Findings: a. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia (a condition in which the blood does not have enough healthy red blood cells), and hypertension (a condition in which the force of the blood against the artery walls is too high). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/17/22, the MDS indicated Resident 1 had clear speech, and was sometimes able to be understood or sometimes understand others. The MDS indicated Resident 1 required extensive two-person assistance with bed mobility, eating, personal hygiene, and total dependence on staff for transfer, toilet use, dressing and bathing. During a record review of Resident 2's Immunization Record, the record indicated the pneumococcal and flu vaccine were not administered or offered to Resident 2. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included anemia, dysphagia (difficulty swallowing), tuberculosis of the lung (serious infection caused by the bacterium mycobacterium tuberculosis [MTB] that involves the lungs but may spread to other organs)type 2 diabetes mellitus without complications (high levels of sugar in the blood). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had clear speech, and was able to be understood and could understand others. The MDS indicated Resident 2 required extensive two-person assistance with bed mobility, and total dependence with locomotion on and off the unit, dressing, toilet use, eating, personal hygiene, transfer, and bathing. During a record review of Resident 3 Immunization Record, the record indicated the pneumococcal vaccine was not administered or offered to Resident 3. During a record review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart with heart failure and stage 1 through stage 4, chronic kidney disease or unspecified chronic kidney disease (medical condition referring to damage to the kidney due to chronic high blood pressure), chronic respiratory failure with hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and anemia. During a record review of Resident 4's MDS dated [DATE], the MDS indicated the resident had clear speech, and was able to be understood and had the ability to understand others. The MDS indicated Resident 4 required extensive assistance from one staff with bed mobility, dressing, personal hygiene, and total dependence on staff for toilet use and bathing. During a record review of Resident 4's Immunization Record, the record indicated the pneumococcal vaccine was not offered to Resident 4. During a review of Resident 5's admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (inadequate blood supply to an organ or brain), chronic obstructive pulmonary disease with acute exacerbation (COPD, a group of lung disease that block airflow and make it difficult to breathe), and hypertension. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had clear speech, and was able to be understood and had the ability to understand others. The MDS indicated Resident 5 required extensive assistance from one staff for bed mobility, during transfer, dressing, personal hygiene, bathing and locomotion on and off the unit, and supervision with eating. During a record review of Resident 5's Immunization Record, the record indicated the pneumococcal vaccine was not administered or offered to Resident 5. During a review of Resident 6's admission Record, the admission record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included COVID-19 (highly infectious respiratory virus), COPD, and anemia. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had clear speech, and was usually able to be understood and usually had the ability to understand others. The MDS indicated Resident 6 required extensive assistance from staff with bed mobility, transfer, dressing, personal hygiene, bathing, and eating, and total assistance on staff for locomotion on and off the unit. During a record review of Resident 6's Immunization Record, the record indicated the pneumococcal vaccine was not administered or offered to Resident 6. During an interview with the Infection Preventionist (IP) Nurse on 12/28/2022 at 11:30 a.m. and record review of Residents 2, 3, 4, 5, and 6's immunization records, the IP stated she was the responsible person overseeing the flu and pneumococcal vaccine administration in the facility. The IP stated she asked for the resident consent, and administered both vaccines. The IP stated it was important to get vaccinated because it protected the resident from getting the disease or lessened the symptoms. The IP stated the elderly were most likely to get infected due to their immune systems. The IP stated the pneumococcal vaccine should have been offered to Residents 2, 3, 4, 5, and 6 but she did not have a chance to offer it just yet to the residents. The IP stated Resident 2 was not offered the vaccine because the Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal for a resident) were responsible for making the decision on the resident's behalf. The IP stated there were no care plans found for the resident's refusals of the vaccines. During an interview with the Administrator (Admin) on 12/28/2022 at 12:25 p.m., the Admin stated it was the IP's responsibility to check and make sure the flu and pneumococcal vaccine were being offered to all residents. The Admin stated the IP was catching up with all the infection control updates and vaccines. The Admin stated there was no excuse for not offering the vaccines because the elderly are the ones who got infected and they need to get vaccinated. During a record review of the facility's policy and procedure (P&P) titled, Pneumonia Vaccine, dated 12/2012, the P&P indicated all residents are offered pneumococcal vaccines to aid in preventing pneumococcal infections. The P&P indicated the pneumococcal vaccines are administered to residents per our facility's physician- approved pneumococcal vaccination protocol. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumovax (pneumococcal vaccine) and when indicated, will be offered the vaccine within thirty days of admission to the facility unless medically contraindicated or the resident has been vaccinated. Assessment of pneumococcal vaccination status will be conducted within fourteen working days of the resident's admission if not conducted prior to admission. During a record review of the facility's P&P titled, Influenza Vaccine, dated 12/2012, the P&P indicated all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccination against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or residents legal representative) for examples, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. The Infection Preventionist will maintain surveillance data on influenza vaccine coverage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Conduct response testing after a COVID-19 outbreak (highly infectious respiratory illness caused by the SARS virus] positive staff or resident) was identified in the facility in a manner that was consistent with the current standards of practice for conducting COVID-19 testing regardless of vaccination status. 2. Document staff testing was completed, and the results were documented for each of 113 staff tested. These deficient practices placed all 87 in-house residents (75 of which were in the green zone, and 12 in the red zone), staff members, and the community at risk for the transmission and spread of COVID-19. Findings: During a review of Resident 12's admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included anemia (condition in which the blood does not have enough healthy red blood cells), hypertension (high blood pressure), and atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart). During a review of Resident 12's Minimum Data Set (MDS), a resident assessment and care-screening tool), dated 12/14/2022, the MDS indicated Resident 12 had clear speech, and was able to be understood and understood others. The MDS indicated Resident 12 required extensive two-person staff assistance with bed mobility, transfer, dressing, personal hygiene, toilet use, dressing and bathing. During a record review of Resident 12's COVID-19 laboratory test results, collected on 12/14/2022, the results indicated Resident 12 was positive for COVID-19. During a review of Resident 12's progress note dated 12/14/2022, the progress note indicated Resident 12 tested positive for COVID-19 after being tested with a rapid antigen test. During an interview with the Infection Preventionist (IP) Nurse on 12/28/2022 at 11:4 0 a.m., the IP stated response testing was initiated when there was a staff or resident that tested positive for COVID-19. The IP stated line listing was used to keep track of the COVID positive staff and/or residents and indicated when symptoms started and the kind of test used. The IP stated she used the line listing every time there was an outbreak. The IP stated the first positive resident (Resident 12) complained of a runny nose and cough, and that was when she started swabbing everyone in the facility, both staff and residents. During an interview with the IP and concurrent record review of the testing record for staff on 12/29/2022 at 9:30 a.m., the IP stated unvaccinated staff were not tested until 12/27/2022. The IP stated she did not remember why it was not done sooner. During a record review of the line list for the week of 12/12/2022 to 12/18/2022, the line list indicated there was no testing done for Certified Nursing Assistant (CNA) 45. During a record review of the facility's document titled, Response Testing, the document indicated if a single positive COVID-19 case is identified among either staff or residents, the facility must conduct comprehensive testing of all residents and staff regardless of vaccination status to identify potential asymptomatic infections. All residents and staff should be tested on ce every 3 to 7 days. The document indicated if testing capacity is limited, testing may be prioritized for the residents and staff in the same area (e.g., nursing station, floor, etc.) as the COVID-19 positive individual. Any close contact and exposed residents of confirmed COVID-19 cases will need to be quarantined. Individuals who are asymptomatic, close contacts or exposed, and within 31 to 90 days of recent COVID-19 infection, then point-of-care antigen tests are preferred over molecular tests, e.g., RT-PCR. All residents and staff who test negative will need to be included in response testing until there are at least 2 weeks with no additional infections identified. After 2 weeks of negative testing for residents, the facility could restart routine testing for residents as outlined below, in consultation with local Public Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) was offered the influenza (flu, common viral infection that can be deadly, especially in high-risk groups), pneumococcal (pneumonia, infection that inflames air sacs in one or both lungs, which may fill with fluid), and COVID-19 (a highly infectious respiratory illness caused by a coronavirus) vaccination. This deficient practice placed Resident 2 at risk to acquire serious infections such as the flu, pneumonia and COVID-19. Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia (blood does not have enough healthy red blood cells), and hypertension (high blood pressure). During a review of Resident 2's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 11/17/22, the MDS indicated Resident 2 was sometimes understood and sometimes understood others. The MDS indicated Resident 2 required extensive two-person assistance for bed mobility, eating, and personal hygiene, and total dependence with transfer, toilet use, dressing and bathing. During a record review of Resident 2's Immunization Records, the records indicated there was no indication the flu, pneumonia, and COVID-19 vaccines were offered or administered to Resident 2. During a record review of Resident 2's COVID-19 laboratory test, the test indicated a sample was collected on 12/19/2022 and indicated Resident 2 was positive for COVID-19. During a review of Resident 2's Change of Condition evaluation (COC), dated 12/22/2022 at 2:49 p.m., the COC indicated on 12/22/2022 Resident 2 tested positive for COVID-19. During an interview on 12/28/2022 at 11:40 a.m. with the Infection Preventionist (IP) Nurse, the IP stated Resident 2 did not have the capacity to make decisions. The IP stated she did not have the consent to administer Resident 2's vaccines. The IP confirmed it was the Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal for a resident) who would give the consent on Resident 2's behalf. During an interview with the Administrator (ADMIN) on 12/29/2022 at 12:45 p.m., the ADMIN stated the vaccines were not offered because Resident 2 did not have the capacity to make decisions. The ADMIN stated the IDT should have a meeting completed within 14 days of the resident's admission assessment with the MDS assessment by the Social Services Director (SSD). During a record review of the facility's provided guidance from the Los Angeles County Department of Public Health dated 12/9/2022, the guidance indicated to immediately assess all residents on admission and at regular intervals during their time in the facility, for their COVID-19 vaccination and booster status. The guidance indicated if a resident is not up to date with the COVID-19 vaccines immediately contact the Long term care (LTC) pharmacy to schedule an appointment or delivery of the vaccine to get the resident vaccinated. The guidance indicated if the resident is unvaccinated, the first dose should be administered within a week of admission.

Based on interview and record review, the facility failed to ensure two of two randomly selected direct-care contracted staff (Physical Therapist [PT] 1 and Occupational Therapist [OT] 1) had documented evidence of their COVID-19 (a highly contagious respiratory illness caused by a virus that can easily spread from person to person) vaccination status (treatment with a vaccine to produce immunity to a particular infectious disease). This deficient practice had the potential to result in the spread of COVID-19 in the facility. Findings: During a record review of the facility's Rehabilitation Department's Assignment Board Report for the week of 12/26/2022, the report indicated PT 1 provided 495 minutes of direct resident care to 12 residents in the facility, and OT 1 provided 440 minutes of direct resident care to nine residents in the facility. During a record review of the facility's COVID-19 staff vaccination matrix (document listing COVID vaccination status of all staff), last edited 12/28/2022, the record indicated that no Rehabilitation Department (Rehab Dept) staff were on the list. The record did not indicate PT 1 and OT 1's COVID-19 vaccination status. During an interview with the Infection Preventionist (IP) Nurse on 12/28/2022 at 12:15 p.m., the IP stated she did not have PT 1 and OT 1's COVID-19 vaccination status. The IP stated PT 1 and OT 1 worked for the Rehabilitation Department (Rehab Dept) and provided direct resident care. The IP stated the Rehab Dept staff were within 6 feet and spent more than 15 minutes with the residents when providing treatment and activities of daily living (ADLs, self-care activities performed daily such as personal hygiene and grooming) training to the residents. The IP stated she did not receive the Rehab Dept staff's vaccination record and did not know which of the staff were vaccinated and/or unvaccinated. The IP stated it was important to know the staff's vaccination status, and if a staff vaccination status was not verified, they were considered unvaccinated. During a concurrent interview with the IP and record review of the staff COVID-19 vaccination matrix on 12/28/2022 at 12:15 p.m., the IP stated none of the contracted staff were included in the matrix and they did not know their COVID-19 vaccination status. During an interview with the Administrator (ADM) on 12/28/2022 at 12:30 p.m., the ADM stated the facility did not check the contracted staff's COVID-19 vaccination status, which also included physicians, nurse practitioners, and registered dieticians. During a record review of the facility's policy and procedure (P&P), dated 6/2022 and titled Coronavirus Disease (COVID-19)- Vaccination of Staff, the P&P indicated all staff are required to be fully vaccinated for COVID-19. The P&P indicated staff meant individuals who provide any care, treatment, or other services for the facility and/ or its residents, regardless of clinical responsibility or resident contact, including individuals under contract or other arrangement, for example therapy personnel. The P&P indicated the IP maintained a tracking worksheet of staff members and their vaccination status. The tracking worksheet provided the most current vaccination status of all staff who provide any care, treatment, or other services for the facility and/ or residents. The worksheet included staff name, initial start of employment or service, termination of employment or service, job title or role, assigned work area, a brief description of how they interact with residents, vaccination status, exemption status, delays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) received care with respect and dignity by: 1. Allowing Resident 1 to sit on a wet diaper for over 5 hours. 2. Allowing Resident 2 to sit on a wet diaper for over 8 hours. This deficient practice had the potential to negatively affect Resident 1's and Resident 2's physical comfort, skin integrity, and psychosocial wellbeing. Cross reference F684. Findings: a. During a review of Resident 1's admission Record (face sheet) for Resident 1, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included respiratory failure (serious condition that makes it difficult to breathe on your own, lungs can not get enough oxygen into the blood) and atrial fibrillation (irregular heartbeat). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 10/24/2022, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 was totally dependent on staff for toilet use and personal hygiene tasks. During a concurrent observation and interview with Resident 1 on 11/29/2022 at 10:24 a.m., Resident 1 was observed laying in bed, on her back. A foul smell was noted. Resident 1 stated her diaper (incontinent brief) was dirty and if you got close to her, you would smell her dirty diaper. Resident 1 stated the last time her diaper was changed was at 5:00 a.m. (on 11/29/2022). Resident 1 stated she has been waiting for a certified nurse assistant (CNA) to come to her room, but no one had shown up. Resident 1 stated no staff from the day shift had come to check on her and she feels that other residents were more important than her. Resident 1 stated she did not get repositioned and was in the same position all day. During an interview with CNA 1 and Resident 1 on 11/29/2022 at 10:38 a.m., in Resident 1's room, CNA 1 stated she had checked on Resident 1 at 7:10 a.m. (on 11/29/2022) and the resident's diaper was dry. Resident 1 stated CNA 1's statement was not true, and the resident had not seen CNA 1 before until that moment and did not even know CNA 1 was the resident's assigned CNA. Resident 1 told CNA 1 the last time her diaper was changed was at 5:30 a.m., on 11/29/2022. During an interview with CNA 1 on 11/29/2022 at 2:29 p.m., CNA 1 stated after our conversation she changed Resident 1's diaper and the resident had a bowel movement (BM). CNA 1 stated she repositioned dependent residents that were in bed all day. CNA 1 stated she did not reposition Resident 1 that day (11/29/2022) and did not take the resident out of bed because she had been busy. CNA 1 stated her shift was not over and might move Resident 1 later. b. During a review of Resident 2's admission Record (face sheet), the face sheet indicated Resident 2 was originally admitted to facility on 8/19/2022 and readmitted on [DATE], with diagnoses which included chronic kidney disease (impairment of kidney function, causing kidney damage to worsen over several months or years) and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should, and can occur if the heart cannot pump [systolic] or fill [diastolic] adequately). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact however, the resident needed cueing to recall words and for orientation. The MDS indicated Resident 2 required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff for toilet use. During a review of Resident 2's care plan, dated 10/18/2022, and titled, Activities of daily living (ADL), the care plan indicated Resident 2 was totally dependent on staff for assistance with repositioning and turning in bed, and required total assistance with personal hygiene. The staff's interventions indicated Resident 2 must be kept clean and dry to prevent skin breakdown. During an interview with Resident 2 on 11/29/2022 at 12:23 p.m., Resident 2 stated the last time her diaper was changed was at 4:00 a.m., on 11.29/2022. Resident 2 stated no staff had come to her room to introduce themselves or offer their help. Resident 2 stated her diaper was wet and would like someone to change it. Resident 2 stated this happened often and it makes her feel ignored. Resident 2 stated she would like more help and felt helpless. Resident 2 stated she did not get repositioned every 2 hours, and was on her back all day. During an interview with CNA 2 and Resident 2 on 11/29/2022 at 12:45 p.m., in Resident 2 room, CNA 2 stated she had not attended to Resident 2 because she had been busy. CNA 2 stated when she passed by Residents 2 room, the resident was asleep and did not want to wake her up. Resident 2 told CNA 2 to wake her up because she did not want to be sitting on a wet diaper all day. CNA 2 stated it was not right Resident 2 had to wait all day to get her diaper changed. CNA 2 stated it was important to change the residents' diaper often to prevent skin breakdown. CNA 2 stated she did not reposition Resident 2 because she had not been told to reposition the resident. During an observation on 11/29/2022 at 1:00 p.m., in Resident 2's room, CNA 2 was observed changing Resident 2 diaper. Resident 2 was observed with redness on her bilateral (both sides) buttocks, inner thighs, and groin (area between the abdomen and the thigh on either side of the body). Resident 2 stated it was painful when CNA 2 wiped her. During an interview with the Director of Staff Development (DSD) on 11/29/2022 at 2:05 p.m., the DSD stated CNA's must reposition bed bound residents every 2 hours and change their diapers during repositioning and as needed. The DSD stated it was important to change residents diapers as often as possible to prevent skin rashes, skin infections, and for residents dignity. The DSD stated no resident should be sitting on their urine and BM for long periods of time. The DSD stated all CNAs have been trained when reposition residents and change diapers, and have received training on skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated residents are treated with dignity and respect at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) received treatment and care in accordance with professional standards of practice by not: 1. Changing Resident 1's incontinent brief (diaper) timely and repositioning the resident every two hours. 2. Changing Resident 1's diaper timely and repositioning the resident every two hours. This deficient practice had the potential to negatively affect Resident 1's and Resident 2's physical comfort, skin integrity, and psychosocial wellbeing. Findings: a. During a review of Resident 1's admission Record (face sheet) for Resident 1, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included respiratory failure (serious condition that makes it difficult to breathe on your own, lungs can not get enough oxygen into the blood) and atrial fibrillation (irregular heartbeat). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 10/24/2022, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 was totally dependent on staff for toilet use and personal hygiene tasks. During a concurrent observation and interview with Resident 1 on 11/29/2022 at 10:24 a.m., Resident 1 was observed laying in bed, on her back. A foul smell was noted. Resident 1 stated her diaper (incontinent brief) was dirty and if you got close to her, you would smell her dirty diaper. Resident 1 stated the last time her diaper was changed was at 5:00 a.m. (on 11/29/2022). Resident 1 stated she has been waiting for a certified nurse assistant (CNA) to come to her room, but no one had shown up. Resident 1 stated no staff from the day shift had come to check on her and she feels that other residents were more important than her. Resident 1 stated she did not get repositioned and was in the same position all day. During an interview with CNA 1 and Resident 1 on 11/29/2022 at 10:38 a.m., in Resident 1's room, CNA 1 stated she had checked on Resident 1 at 7:10 a.m. (on 11/29/2022) and the resident's diaper was dry. Resident 1 stated CNA 1's statement was not true, and the resident had not seen CNA 1 before until that moment and did not even know CNA 1 was the resident's assigned CNA. Resident 1 told CNA 1 the last time her diaper was changed was at 5:30 a.m., on 11/29/2022. During an interview with CNA 1 on 11/29/2022 at 2:29 p.m., CNA 1 stated after our conversation she changed Resident 1's diaper and the resident had a bowel movement (BM). CNA 1 stated she repositioned dependent residents that were in bed all day. CNA 1 stated she did not reposition Resident 1 that day (11/29/2022) and did not take the resident out of bed because she had been busy. CNA 1 stated her shift was not over and might move Resident 1 later. b. During a review of Resident 2's admission Record (face sheet), the face sheet indicated Resident 2 was originally admitted to facility on 8/19/2022 and readmitted on [DATE], with diagnoses which included chronic kidney disease (impairment of kidney function, causing kidney damage to worsen over several months or years) and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should, and can occur if the heart cannot pump [systolic] or fill [diastolic] adequately). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was intact however, the resident needed cueing to recall words and for orientation. The MDS indicated Resident 2 required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff for toilet use. During a review of Resident 2's care plan, dated 10/18/2022, and titled, Activities of daily living (ADL), the care plan indicated Resident 2 was totally dependent on staff for assistance with repositioning and turning in bed, and required total assistance with personal hygiene. The staff's interventions indicated Resident 2 must be kept clean and dry to prevent skin breakdown. During an observation Resident 2 on 11/29/2022 at 10:19 a.m., Resident 2 was observed in bed, lying on her back. During an interview with Resident 2 on 11/29/2022 at 12:23 p.m., Resident 2 stated the last time her diaper was changed was at 4:00 a.m., on 11.29/2022. Resident 2 stated no staff had come to her room to introduce themselves or offer their help. Resident 2 stated her diaper was wet and would like someone to change it. Resident 2 stated this happened often and it makes her feel ignored. Resident 2 stated she would like more help and felt helpless. Resident 2 stated she did not get repositioned every 2 hours, and was on her back all day. During an interview with CNA 2 and Resident 2 on 11/29/2022 at 12:45 p.m., in Resident 2 room, CNA 2 stated she had not attended to Resident 2 because she had been busy. CNA 2 stated when she passed by Residents 2 room, the resident was asleep and did not want to wake her up. Resident 2 told CNA 2 to wake her up because she did not want to be sitting on a wet diaper all day. CNA 2 stated it was not right Resident 2 had to wait all day to get her diaper changed. CNA 2 stated it was important to change the residents' diaper often to prevent skin breakdown. CNA 2 stated she did not reposition Resident 2 because she had not been told to reposition the resident. During an observation on 11/29/2022 at 1:00 p.m., in Resident 2's room, CNA 2 was observed changing Resident 2 diaper. Resident 2 was observed with redness on her bilateral (both sides) buttocks, inner thighs, and groin (area between the abdomen and the thigh on either side of the body). Resident 2 stated it was painful when CNA 2 wiped her. During an interview with the Director of Staff Development (DSD) on 11/29/2022 at 2:05 p.m., the DSD stated CNA's must reposition bed bound residents every 2 hours and change their diapers during repositioning and as needed. The DSD stated it was important to change residents diapers as often as possible to prevent skin rashes, skin infections, and for residents dignity. The DSD stated no resident should be sitting on their urine and BM for long periods of time. The DSD stated all CNAs have been trained when reposition residents and change diapers, and have received training on skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Repositioning, dated 5/2013, the P&P indicated repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The P&P indicated residents that are in bed should be on at least every two-hour repositioning schedule. During a review of the facility's P&P titled, Activities of daily living, supporting, dated 3/2018. The P&P indicated for residents who are unable to carry out activities of daily living (ADLs) independently, they will receive the services necessary to maintain good nutrition, grooming, and personal and oral care. The P&P indicated care and services will be provided to residents who are unable to carry ADLs independently, staff will provide assistance with mobility and elimination (toileting).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of potential sexual abuse for one of four samples residents (Resident 1), according to the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting . This deficient practice delayed the investigation of the sexual abuse allegation and increased the potential risk for Resident 1 and other residents to be sexually abused in the facility. Findings: During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra), adult failure to thrive (a decline seen in older adults resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression, and decreasing functional ability), and dementia (condition characterized by impairment of brain functions, such as memory loss and judgement). During a review of Resident 1's History and Physical (H&P), dated 5/3/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 8/26/2022, the MDS indicated Resident 1's cognition was severely impaired (ability to think and reason) and did not have the capacity to understand and make decisions. The MDS indicated Resident 1 required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Change of Condition (COC a sudden clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional domains), dated 11/14/2022, the COC indicated Resident 1 had vaginal bleeding times three episodes and the primary care clinician ordered to transfer Resident 1 to a general acute care hospital (GACH) for further evaluation. During a record review of Resident 1's GACH records, dated 11/15/2022, the GACH records indicated Resident 1 presented to the emergency room (ER) on 11/14/2022 due to blood in the urine. The records indicated Resident 1's urinalysis (urine test used to detect and manage a wide range of disorders) resulted positive for trichomonas (a sexually transmitted infection caused by a parasite). During a record review of Resident 1's GACH records, dated 11/15/2022, the GACH records indicated Resident 1's night nurse filed an Adult Protected Services ([APS] agency that provides social services to abused, neglected, or exploited older adults) report due to possible abuse. The GACH records indicated Resident 1's nurse and primary care physician were concerned about Resident 1 being discharged back to the facility. The GACH records indicated the Social Worker (SW) called the facility on 11/15/2022, at 11:04 a.m., to obtain collateral information (information gathered from a patient's known contacts) and spoke with the facility's Social Services Director (SSD). During a record review of the GACH records, dated 11/15/2022, the GACH records indicated the SW called the facility and spoke with the facility's Director of Nursing (DON) regarding the concerns/potential abuse allegations made by the GACH's nurse and Medical Doctor (MD). The GACH records indicated the DON stated it was unclear if Resident 1's bleeding in her adult brief was in her urine and due to her UTI. The GACH records indicated that due to the contact made with the DON and the APS and SOC 341 (a form used to report suspected abuse or neglect of an elder or dependent adult) filed and to be investigated from their standpoint, Resident 1 would return to the facility. During an interview on 11/23/2022, at 2:00 p.m., with the Administrator (ADM), the ADM stated trichomonas was a sexually transmitted disease. The ADM stated Resident 1 was a long-term resident of the facility and has lived there since 2019. During an interview on 11/23/2022, at 4:40 p.m., with the DON, the DON stated he spoke with the GACH SW on 11/15/2022 and told the GACH SW Resident 1 was transferred to the hospital for further evaluation due to the bleeding in her brief. The DON stated the GACH SW told him sexual abuse was being ruled out due to the nature of why Resident 1 was sent to the hospital. The DON read aloud the facility's P&P titled Abuse Investigation and Reporting. The DON stated the sexual abuse allegation for Resident 1 should have been reported to the Department of Public Health (DPH) and he did not know why it was not reported. The DON stated the police was called and came to the facility on [DATE] to speak with Resident 1. The DON stated there was no police case number given to the facility. During an interview on 11/23/2022, at 4:58 p.m., with the ADM, the ADM stated the sexual abuse allegation should have been reported. The ADM stated it was his responsibility and his mistake that he did not report the suspicion of sexual abuse to the DPH. The ADM stated, To be honest, the facility did not call the police, the police showed up on Saturday, 11/19/2022 and he was not sure who sent the police to the facility. The ADM stated maybe it was the hospital. The ADM stated the Ombudsman (an advocate for residents of nursing homes, board and care homes, and assisted-living facilities) was not made aware of the sexual abuse allegation for Resident 1 and they should have been. The ADM stated it was important to report a sexual abuse allegation to the DPH, the police and the Ombudsman, to investigate the allegation, and prevent the risk of Resident 1 and other residents being abused. During a review of the facility's P&P titled, Abuse Investigation and Reporting, dated as revised 7/2017, the P&P indicated, All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor of Record); d. Adult protective Services; e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. The P&P further indicated, An alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the investigation for the alleged sexual abuse of one of four sampled residents (Resident 1) according to the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting . This deficient practice potentially increased the risk for Resident 1 and other residents in the facility to be sexually abused. Findings: During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder, or urethra), adult failure to thrive (a decline seen in older adults resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression, and decreasing functional ability), and dementia (condition characterized by impairment of brain functions, such as memory loss and judgement). During a review of Resident 1's History and Physical (H&P), dated 5/3/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 8/26/2022, the MDS indicated Resident 1's cognition was severely impaired (ability to think and reason) and did not have the capacity to understand and make decisions. The MDS indicated Resident 1 required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional domains), dated 11/14/2022, the COC indicated Resident 1 had vaginal bleeding times three episodes and the resident's physician ordered to transfer Resident 1 to a general acute care hospital (GACH) for further evaluation. During a record review of Resident 1's GACH records, dated 11/15/2022, the GACH records indicated Resident 1 presented to the emergency room (ER) on 11/14/2022 due to blood in the urine. The records indicated Resident 1's urinalysis (urine test used to detect and manage a wide range of disorders) resulted positive for trichomonas (a sexually transmitted infection caused by a parasite). During a record review of the GACH records, dated 11/15/2022, the GACH records indicated Resident 1's night nurse filed an Adult Protected Services ([APS] agency that provides social services to abused, neglected, or exploited older adults) report due to possible abuse. The GACH records indicated Resident 1's nurse and physician were concerned with Resident 1 being discharged back to the facility. The GACH records indicated the Social Worker (SW) called the facility on 11/15/2022, at 11:04 a.m., to obtain collateral information (information gathered from a patient's known contacts) and spoke with the facility's Social Services Director (SSD). During a record review of the GACH records, dated 11/15/2022, the GACH records indicated the SW called the facility and spoke with the Director of Nursing (DON) regarding the concerns/potential abuse allegations made by the nurse and physician. The GACH records indicated the DON stated it was unclear if Resident 1's bleeding in her adult brief was in her urine and due to her UTI. The GACH records indicated that due to the contact made with the DON, APS report, and SOC 341 (a form used to report suspected abuse or neglect of an elder or dependent adult) filed and to be investigated from their standpoint, Resident 1 would return to the facility. During an interview on 11/23/2022, at 4:40 p.m., with the DON, the DON stated he spoke with the GACH SW on 11/15/2022 and told the SW that Resident 1 was transferred to the hospital for further evaluation due to the bleeding in her brief. The DON stated the SW told him sexual abuse was being ruled out due to the nature of why Resident 1 was sent to the hospital. The DON read aloud the facility's P&P titled Abuse Investigation and Reporting. The DON stated the sexual abuse allegation for Resident 1 should have been reported to the Department of Public Health (DPH) and he did not know why it was not reported. The DON stated the facility's P&P for reporting abuse indicated the investigation should have been completed within five days of the sexual abuse allegation and the investigation report should have been submitted by 11/21/2022. The DON stated he was not sure why the investigation was not completed on time. During an interview on 11/23/2022, at 4:58 p.m., with the Administrator (ADM), the ADM stated the sexual abuse allegation should have been reported. The ADM stated it was his responsibility and his mistake that he did not report the suspicion of sexual abuse to the DPH. The ADM stated the facility began the investigation for the sexual abuse allegation regarding Resident 1 on 11/16/2022 and it should have been completed on 11/21/2022 according to the facility's P&P for reporting abuse. The ADM stated it was important to report a sexual abuse allegation to the DPH, the police and the Ombudsman and to investigate the abuse allegation to prevent the risk of Resident 1 and other residents being abused. During a review of the facility's P&P titled, Abuse Investigation and Reporting, dated as revised 7/2017, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse ) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The P&P further indicated, The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sample resident (Resident 1) was free of mental anguish and emotional distress when the resident was not discharged according to facility's policy and procedure (P&P) titled, Discharge Summary and Plan. This deficient practice resulted in Resident 1 feeling rushed to be discharged because he was not ready to go, scared and frustrated because he did not receive help with transferring in and out of his bed at an unlicensed transitional living facility (UTLF), and depressed (persistent feeling of sadness and loss of interest) because he missed his friends at the skilled nursing facility (SNF) which he considered his home. Findings: During a review of Resident 1's admission Record (facesheet), the facesheet indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] . Resident 1's diagnoses included type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), long-term use of insulin (medication used to treat high blood sugar), difficulty in walking, hemiplegia (loss of ability to move on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left non-dominant side, chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing problems), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure resulting in the heart not pumping blood as well as it should), and pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid). During a review of Resident 1's History and Physical (H&P), dated 10/15/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 10/27/2022, the MDS indicated Resident 1 required extensive assistance with bed mobility, transfers between surfaces including to and from bed, chair, wheelchair and standing position, dressing, toilet use, personal hygiene, and was completely dependent for bathing assistance. During an interview on 11/7/2022 at 3:00 p.m., with the Social Services Director (SSD), the SSD stated Resident 1 was not able to self-administer his insulin (medication to treat high blood sugar) and was not able to check his own blood sugar. The SSD stated Resident 1 required moderate assistance for his toileting needs. The SSD stated Resident 1 was discharged to a facility that could not meet his needs and it was unsafe to discharge him there. The SSD stated she should have researched the facility before transferring Resident 1. The SSD stated if a resident was sent to a facility that could not meet their needs, the resident may not feel safe there and may not get the care they need. The SSD stated Resident 1 may also feel unhappy and it may negatively affect their psychosocial well-being. During a telephone interview with Resident 1 on 11/15/2022 at 12:40 p.m., Resident 1 stated when the facility told him he was being discharged on 10/27/2022. Resident 1 stated he was told the transportation was on their way and would arrive in five minutes. Resident 1 stated he did not have time to gather all his belongings and was missing his sweatpants and some shirts. Resident 1 stated he arrived to UTLF 1 and was there for less than 20 minutes and was taken to UTLF 2 where there was a bunch of crazy people. Resident 1 stated he was there for a day and a half, and he did not check his blood sugar and did not receive insulin because he was not able to do it himself. Resident 1 stated the facility did not send him with his glucose monitor (device used to check the blood sugar level). Resident 1 stated the left side of his body was weak and it was very hard to transfer himself in and out of the bed because no one helped him and that made him feel frustrated and was scared he might fall and hurt himself, but he had no other choice. Resident 1 stated after two days, he was taken to the hospital because he had chest pain and UTLF 2 informed him he could not return because they could not provide him the help he needed. Resident 1 stated the facility did not explain the plan for discharge and had not given him discharge and medication instructions prior to being discharged to UTLF 1. Resident 1 stated no one from UTLF 2 visited or called him while he was in the facility prior to his discharge. Resident 1 stated he felt depressed because he was taken away from his friends in the facility and he missed them. Resident 1 stated he was not ready to leave the facility and felt he was discharged so fast because they needed his bed for someone else. Resident 1 stated he did not let the facility know he did not want to leave because he felt rushed out of the facility. Resident 1 stated he felt he was not given a choice whether he wanted to leave the facility because he was just told he was being transferred. Resident 1 stated it made him feel sad and felt he was not treated right by the facility. Resident 1 stated his discharge from the facility had been very hard for him because it affected his depression and it really hurt him to leave his friends. Resident 1 stated he would like to return to the facility if he could. During a review of the facility's policy and procedure (P&P) titled, Discharging the Resident , dated 12/2016, the P&P indicated, 1. The resident should be consulted about the discharge; 2. Discharges can be frightening to the resident. Approach the discharge in a positive manner; 3. Reassure the resident that all of his or her personal effects will be taken to his or her place or residence; 5. If the resident is being discharged home, ensure that resident and/or responsible party received teaching and discharge instructions. During a review of facility's P&P titled, Discharge Summary and Plan, dated 12/2016, the P&P indicated when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The P&P indicated every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. The P&P indicated the discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. The P&P indicated a member of the IDT will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 8/2021, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a resident's discharge plan of care according to the facility's policy titled, Discharge Summary and Plan , which indicated every resident would be evaluated for his or her discharge needs and would have an individualized post-discharge plan, for one of three sampled residents (Resident 1) when the facility failed to: a. Ensure Resident 1 was involved in his discharge planning process. b. Follow up on Resident 1's request to be discharged to his family members (FM 1) home. This deficient practice led to Resident 1's unsafe discharge to an unlicensed transitional living facility (UTLF) which could not meet the resident's needs and resulted in Resident 1 feeling rushed to be discharged , depressed (persistent feeling of sadness and loss of interest), frustrated, and felt he was not treated with dignity. Findings: a. During a review of Resident 1's admission Record (facesheet), the facesheet indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), long-term use of insulin (medication used to treat high blood sugar), difficulty in walking, hemiplegia (loss of ability to move on one side of the body) and hemiparesis weakness on one side of the body) affecting the left non-dominant side, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing problems), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure resulting in the heart not pumping blood as well as it should), and pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid). During a review of Resident 1's History and Physical (H&P), dated 10/15/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 10/27/2022, the MDS indicated Resident 1 required extensive assistance with bed mobility, transfers between surfaces including to and from bed, chair, wheelchair and standing position, dressing, toilet use, personal hygiene, and was completely dependent for bathing assistance. During an interview on 11/7/2022, at 3:00 p.m., with the Social Services Designee (SSD), the SSD stated Resident 1 was discharged to the UTLF because he was accepted to the facility based on the resident's clinical information sent to the facility and she assumed they could provide the care Resident 1 required. The SSD stated Resident 1 was not given any details about UTLF 1 except for the address. The SSD stated she should have researched the UTLF, and she should have known the services offered because Resident 1 was discharged to a facility that could not meet his needs. The SSD stated it was unsafe to send Resident 1 to UTLF 1 because it led to the resident not receiving the proper care and assistance which may have led to hospitalization and Resident 1 not feeling safe which may have affected his psychosocial well-being. During a review of Resident 1's care plan, dated as closed 10/30/2022, there was no discharge care plan to review. During an interview on 11/10/2022, at 5:16 p.m., with the SSD, the SSD stated Resident 1 did not have an Interdisciplinary Team (IDT, professional medical team plan, coordinate and deliver personalized health care) meeting for his discharge plan because it must have been missed. The SSD stated it was important to have an IDT for discharge planning so the resident and the IDT could be on the same page and ensure the resident had a safe discharge. During a review of Resident 1's Social Service Review , dated 10/7/2022, the record indicated Resident 1's discharge plan was to transfer to a board and care (a home in a residential neighborhood equipped and staffed to care for a small number of residents) and the resident's discharge needs indicated a wheelchair was needed. The record indicated Resident 1 was currently appropriate for that level of care and had no active discharge planning to return to the community at that time. During a review of Resident 1's Multidisciplinary Care Conference , dated 10/7/2022, the record indicated Resident 1 was admitted to the facility for long-term care. The record indicated Resident 1 was to continue to gain strength with physical therapy services, and had no active discharge planning to return to the community at that time. During a telephone interview on 11/15/2022, at 12:40 p.m., with Resident 1, Resident 1 stated when he left the facility, he was taken to UTLF 1, and he was there for less than 20 minutes and was taken to UTLF 2 where there was a bunch of crazy people. Resident 1 stated he was taken to the hospital after a day and a half because he complained of having chest pain. Resident 1 stated when he left UTLF 2, he was told he could not return to UTLF 2 because they could not give him the help he required. Resident 1 stated he required a lot of assistance to change his brief. Resident 1 stated the left side of his body is weak, so it was very hard to transfer himself in and out of the bed because no one helped him and that made him feel frustrated and was scared he might fall and hurt himself, but he had no other choice. Resident 1 stated he did not get the help he needed at UTLF 2, and it was hard and frustrating. Resident 1 stated he was not ready to leave the facility and felt he was discharged so fast because they needed his bed for someone else. Resident 1 stated he did not let the facility know he did not want to leave because he felt rushed out of the facility. Resident 1 stated he felt he was not given a choice whether he wanted to leave the facility because he was just told he was being transferred. Resident 1 stated it made him feel sad and felt he was not treated right by the facility. Resident 1 stated his discharge from the facility had been very hard for him because it affected his depression and it really hurt him to leave his friends. Resident 1 stated he would like to return to the facility if he could. During an interview on 11/16/2022, at 2:00 p.m., with the Director of Nursing (DON), the DON stated discharge planning should start upon admission and should be care planned to meet the needs and goals of the resident. The DON stated an IDT meeting should be done as soon as possible and the resident's discharge should be discussed and reviewed by the IDT as needed. During an interview on 11/16/2022, at 4:20 p.m., with the Administrator (ADM) and the DON, the DON stated he checked Resident 1's medical record and the discharge IDT notes and the discharge care plan (personalized discharge plan for a resident) was not done, and it should have. The ADM stated the purpose of discharge planning, and the IDT was to discuss the discharge plan for the resident and stated it was important to have a discharge care plan and the IDT to ensure the resident was placed in the appropriate facility. The ADM stated Resident 1 was discharged to a facility that did not meet his needs for toileting, insulin administration and blood sugar checks and that it had the potential to cause harm to the resident. b. During an interview on 11/7/2022, at 3:00 p.m., with the SSD, the SSD stated she did not have any recent documentation that a discharge plan was discussed with Resident 1. The SSD stated Resident 1 informed her FM 1 offered the resident to move in with him. The SSD stated she reached out to FM 1, but he never returned her telephone call, and she did not follow up on Resident 1's request to be discharged home with FM 1. The SSD stated it was important to follow-up with FM 1 to honor the request and preference of the resident to be discharged to his brother's home. During a record review of Resident 1's social services progress notes, dated 9/7/2022, the note indicated the SSD contacted FM 1 regarding the discharge plan because per Resident 1, FM 1 offered for him to live with him. The note indicated the SSD left a voicemail with FM 1 and was waiting for her call to be returned. During a record review of Resident 1's social services progress notes, dated 3/18/2022 through 10/27/2022, the notes indicated the SSD contacted FM 1 one time, on 9/7/2022, regarding Resident 1's request to the discharged to FM 1's home. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, dated 12/2016, the P&P indicated, Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. The P&P indicated, The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services; c. A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. The P&P indicated, The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a resident's discharge plan of care according to the facility's policy titled, Discharge Summary and Plan, which indicated every resident would be evaluated for his or her discharge needs and would have an individualized post-discharge plan, for one of three sample residents (Resident 1). The facility failed to: a. Ensure Resident 1 was instructed about his discharge medications including self-administering insulin (medication used to manage high blood sugar) and using a blood glucose meter (device used to measure the blood sugar level in the body). b. Set up the home-health referral for medication management and safety. c. Develop a plan for discharge to meet the needs of Resident 1. d. Ensure Resident 1 was transferred to a setting where his medical and ADLs (Activities of Daily, including bathing, dressing, getting in and out of bed, walking, and using the toilet) needs could be met. e. Contact the physician for a discharge order. These deficient practices resulted in Resident 1 not monitoring his blood sugar and did not receive insulin for two days which increased the resident's risk of developing high or low blood sugar levels. Resident 1 was admitted to a general acute care hospital (GACH) two days after being discharged with a complaint of chest and abdominal pain and lack of a safe discharge location. Resident 1 was discharged to an unlicensed transitional living facility (UTLF) 1 without any care givers (a person who provides direct care to another), and was sent to UTLF 2 after 20 minutes because UTLF 1 could not meet Resident 1's needs, which increased the risk of Resident 1 having an accident and suffering an injury and not being able to complete his ADLs. As a result of the deficient practices, Resident 1 felt rushed to be discharged , depressed (persistent feeling of sadness and loss of interest), frustrated, and felt he was not treated with dignity. Findings: a. During a review of Resident 1's admission Record (facesheet), the facesheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), long-term use of insulin (medication used to treat high blood sugar), difficulty in walking, hemiplegia (loss of ability to move on one side of the body) and hemiparesis weakness on one side of the body) affecting the left non-dominant side, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing problems), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure resulting in the heart not pumping blood as well as it should), and pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid). During a review of Resident 1's History and Physical (H&P), dated 10/15/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 10/27/2022, the MDS indicated Resident 1 required extensive assistance with bed mobility, transfers between surfaces including to and from bed, chair, wheelchair and standing position, dressing, toilet use, personal hygiene, and was completely dependent for bathing assistance. During a review of Resident 1's Order Summary Report, dated 12/14/2022, the report indicated Resident 1 was receiving the following medications: 1. Amlodipine Besylate (medication to treat high blood pressure). 2. Atorvastatin Calcium (medication used to treat high cholesterol). 3. Clopidogrel Bisulfate (a medication used to thin the blood to prevent a heart attack and stroke (brain damage caused by a blockage of blood to the brain). 4. Docusate Sodium (medication used to prevent constipation). 5. Levemir Flex Touch pen injector (insulin medication used to treat high blood sugar). 6. Lisinopril (medication used to treat high blood pressure). 7. Montelukast Sodium (medication used to treat COPD). 8. Seroquel (medication used to treat schizophrenia [a disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly), 9. Sertraline HCl (medication used to treat depression). 10. Budesonide Aerosol Powder (medication used to treat COPD). 11. Carvedilol (medication used to treat high blood pressure), Cogentin (medication used to prevent muscle spasms and tremors). 12. Cyclobenzaprine HCl (medication used to treat muscle spasms). 13. Famotidine (medication used to decrease stomach acid production). 14. Lasix (medications used to reduce extra fluid in the body caused by a condition such as heart failure). 15. Metformin (medication used to treat high blood sugar). 16. Gabapentin (medication used to manage pain). 17. Valacyclovir HCl (medication used to treat shingles). 18. Insulin Lispro Solution (medication used to treat high blood sugar). 19. Ipratropium-Albuterol Aerosol Solution (medications used to treat COPD). 20. Acetaminophen (medication used to treat pain). 21. Bisacodyl Suppository (medication used to treat constipation). 22. Magnesium Hydroxide Suspension (medication used to treat constipation). 23. Melatonin (medication used to treat inability to sleep). 24. Nitroglycerin (medication used to treat chest pain). 25. Zolpidem Tartrate (medication used to treat inability to sleep). The report indicated Resident 1 had an order to check the blood glucose level before meals and at bedtime. During an interview on 11/7/2022, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not complete the discharge medication reconciliation for Resident 1 because he was very busy passing the afternoon medications and Resident 1 was leaving the facility in an hour. LVN 1 stated he was responsible for completing the medication reconciliation but gave the medications to the Social Services Director (SSD) and she completed the medication reconciliation form. LVN 1 stated he did not review the medications with Resident 1, he did not teach him how to check his blood sugar and did not teach him how to self-administer insulin because he did not have time to do it, but stated he was supposed to. LVN 1 stated it was important to reconcile the medications to ensure all the medications were accounted for and it was important to teach Resident 1 how to check his blood sugar so he could administer the correct insulin dose. LVN 1 stated it was important to teach the resident about his medications to ensure the resident took his medications correctly because it could lead to Resident 1 under or overmedicating himself, which may lead to complications such as high or low blood sugar and may lead to hospitalization. During an interview on 11/15/2022, at 12:40 p.m., with Resident 1, Resident 1 stated the facility did not teach him about his medications, how to check his blood sugar and how to self-administer insulin prior to being discharged to UTLF 1. Resident 1 stated his blood sugar was not checked and he did not get insulin at UTLF 1 and UTLF 2 for two days. During an interview on 11/16/2022, at 2:00 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was a diabetic who was receiving insulin. The DON stated Resident 1 was not able to perform his own blood sugar monitoring and administer his own insulin. The DON stated he was not sure if UTLF 1 offered the service of blood sugar monitoring and administration of insulin to the resident if he was not able to do it himself, but it was important to know for the safety of the resident. During a concurrent interview and record review on 11/18/2022, at 4:26 p.m., with the DON, Resident 1's progress notes, dated 3/18/2022-10/27/2022 were reviewed. The DON stated there was no medication education documented for Resident 1, which indicated it was not done. The DON stated Resident 1 should have been taught about his medications for safe self-administration, taught how to check his blood sugar and returned demonstration to ensure the resident could self-monitor their blood sugar correctly. The DON stated not teaching the resident about his medications and how to monitor his blood sugar may lead to harm of the resident including complications such as high or low blood sugar which may lead to hospitalization. During a telephone interview on 12/9/2022, at 3:43 p.m., with Resident 1's Primary Medical Doctor (PMD), the PMD stated he did not remember Resident 1 so he could not speak on him directly, but he expected that before a resident was discharged to a lower level of care, the nurses were supposed to teach the resident about their medications, how to check their blood sugar, and how to self-administer insulin. The PMD stated the nurses were supposed to teach the resident what is a high-level and low-level blood sugar level and when and how much insulin they were supposed to take. During an interview on 12/13/2022, at 1:37 p.m., with the SSD, the SSD stated she could not recall if Resident 1 was discharged with a glucometer (device to monitor blood sugar). The SSD stated she should have included it as equipment Resident 1 needed on the Post Discharge Plan of Care form, but she did not. During a record review of Resident 1's Post Discharge Plan of Care form, dated 10/27/2022, the form indicated the glucometer was not included as equipment needs for Resident 1. During an interview on 12/13/2022, at 2:01 p.m., with the Administrator (ADM), the ADM stated the medication reconciliation should have been completed by the licensed nurse to ensure its accuracy and safety of the resident. The ADM stated it used to be the practice of the facility to have the licensed nurse or the designee complete the medication reconciliation, but it has been changed to only the licensed nurse completing it. b. During a review of Resident 1's physician telephone order, dated 10/27/2022, the telephone order indicated to discharge Resident 1 to UTLF 1 with home health for medication management and safety. During an interview on 11/8/2022, at 12:24 p.m., with Marketing (MAR) 1, [DATE] stated the SSD was responsible for setting up Resident 1's home health referral. During a telephone interview on 11/10/2022, at 10:40 a.m., with the office manager (OM) of the home health center, the OM stated she had no record of Resident 1's referral for home health. During a concurrent interview and record review on 11/10/2022, at 5:16 p.m., with the SSD, Resident 1's physician order, dated 10/27/2022, was reviewed. The SSD confirmed the physician ordered home health for medication management and safety. The SSD stated she did not carry out the order for the home health referral because she thought the marketer who assisted her with the placement of Resident 1 had done it. The SSD stated she did not follow up to ensure the referral was made for home health because she assumed it was done. The SSD stated it was important to ensure the referral for home health was done because Resident 1 was discharged without the services he needed and that may lead to health problems for the resident and may result in hospitalization. During an interview on 11/16/2022, at 2:00pm, with the DON, the DON stated the home health referral for Resident 1 should have been done before the resident was transferred. The DON stated the risk to the resident for not having the home health set up was the resident not receiving safe medication management which may have led to hospitalization. During a telephone interview on 12/9/2022, at 3:43 p.m., with the PMD, the PMD stated the purpose for a home health order for medication management and registered nurse (RN) safety was for a nurse to ensure the resident understood what their medications were for, how to take their medications as prescribed, and to explain the side effects of the medications. c. During an interview on 11/10/2022, at 5:16 p.m., with the SSD, the SSD stated Resident 1 did not have an Interdisciplinary Team (IDT, professional medical team plan, coordinate and deliver personalized health care) meeting for his discharge plan because it must have been missed. The SSD stated it was important to have an IDT for discharge planning so the resident and the IDT could be on the same page and ensure the resident had a safe discharge. During a review of Resident 1's Social Service Review , dated 10/7/2022, the record indicated discharge plan was to go to a board and care (a home in a residential neighborhood equipped and staffed to care for a small number of residents) and discharge needs was a wheelchair. The record indicated resident was currently appropriate for level of care and had no active discharge planning to return to the community at that time. During a review of Resident 1's Multidisciplinary Care Conference , dated 10/7/2022, the record indicated resident was at facility for long-term care, resident to continue to gain strength with physical therapy services, and had no active discharge planning to return to the community at that time. During an interview on 11/15/2022, at 12:40 p.m., with Resident 1, Resident 1 stated the facility provided him the address to UTLF 1 but did not explain the plan for discharge and had not given him discharge and medication instructions prior to being discharged to UTLF 1. During an interview on 11/16/2022, at 2:00pm, with the DON, the DON stated discharge planning should start upon admission. The DON stated an IDT meeting should be done as soon as possible and the resident's discharge should be discussed and reviewed by the IDT as needed. During an interview on 11/16/2022, at 4:20 p.m., with the ADM and the DON, the DON stated he checked Resident 1's medical record and the discharge IDT and the discharge care plan (personalized discharge plan for a resident) was not done, and it should have. The ADM stated the purpose of discharge planning, and the IDT was to discuss the discharge plan for the resident and stated it was important to have a discharge care plan and the IDT to ensure the resident was placed in the appropriate facility. The ADM stated Resident 1 was discharged to a facility that did not meet his needs for toileting, insulin administration and blood sugar checks and that it had the potential to cause harm to the resident. d. During an interview on 11/7/2022, at 1:55 p.m., with LVN 1, LVN 1 stated Resident 1 was incontinent (inability to control) of bladder and bowel and needed a lot of assistance for incontinent brief changes. LVN 1 stated Resident 1 required assistance to get on and off the bed and onto his wheelchair. LVN 1 stated Resident 1 required a Hoyer lift (mechanical lift used to transfer a resident from the bed to a wheelchair) to be moved. LVN 1 stated Resident 1 was completely dependent on staff to get in and out of bed. LVN 1 stated he did not know why Resident 1 was being discharged from the facility. During a concurrent interview and record review on 11/7/2022, at 2:39 p.m., with the Director of Rehabilitation (DOR), Resident 1's physical therapy Discharge summary, dated [DATE]-[DATE] and Resident 1's occupational therapy note, dated 10/19/2022-10/26/2022 was reviewed. The DOR stated Resident 1 required moderate assistance for upper body dressing and minimal-to-moderate assistance for personal hygiene and required moderate assistance to transfer from the bed to the wheelchair. The DOR stated Resident 1 required caregivers that would assist with ADLs and getting up to his wheelchair for his safety. LVN 1 stated Resident 1 was not a total care (person completely dependent on staff for ADLs) resident but would have needed a board and care that offered the service of assisting the resident to get out of bed, to sit in his wheelchair, and with his ADLs. During an interview on 11/7/2022, at 3:00 p.m., with the SSD, the SSD stated Resident 1 was discharged to UTLF 1 because he was accepted to the facility based on the clinical information sent to the facility and she assumed they could provide the care Resident 1 required. The SSD stated Resident 1 was not given any details about UTLF 1 except for the address. The SSD stated she should have researched the UTLF, and she should have known the services offered because Resident 1 was discharged to a facility that could not meet his needs. The SSD stated it was unsafe to send Resident 1 to UTLF 1 because it led to the resident not receiving the proper care and assistance which may have led to hospitalization and Resident 1 not feeling safe which may have affected his psychosocial well-being. During a telephone interview on 11/8/2022, at 12:24 p.m., with [DATE], [DATE] stated a resident had to be cleared for discharge/transfer by the physician. [DATE] stated once the resident was cleared for discharge, the facility would look for placement of the resident. [DATE] stated the resident's clinical documents (facesheet, H&P, laboratory reports, wound notes, COVID-19 status, nursing and social service notes, and POLST ([physician orders for life-sustaining treatment] form which indicates a person's wishes for end-of-life treatment) is sent to the facility being considered for transfer of the resident to be reviewed and determine if facility can meet the needs [DATE] stated of the resident. [DATE] stated she did not know why Resident 1 had been taken from UTLF 1 to UTLF 2 because everything was set up for Resident 1 to go to UTLF 1. During an interview on 11/8/2022, at 1:50 p.m., with the SSD, the SSD stated she received a call from the GACH's Social Worker (SW) regarding Resident 1. The SSD stated the SW told her Resident 1 had been dumped in the emergency room (ER). During a review of Resident 1's GACH records, the Discharge summary, dated [DATE], indicated Resident 1 was admitted to the GACH on 10/29/2022 and discharged on 11/4/2022. The discharge summary indicated Resident 1 was admitted with abdominal pain and lack of safe discharge location. The discharge summary indicated Resident 1 reported he was told he could not return to the board and care. The discharge summary indicated Resident 1 endorsed chest, abdominal, and back pain, underwent CT (computerized tomography that combines a series of X-ray images) imaging of his abdomen, which demonstrated a large stool burden and a small left kidney stone. During an interview on 11/15/2022, at 12:05 p.m., with the GACH Social Worker (SW), the SW stated Resident 1 reported to her that he was sent by Uber (driving service) to the GACH from UTLF 2 and was dropped off one block away from the GACH. The SW stated Resident 1 was basically dumped at the GACH's ER. The SW stated Resident 1 was discharged and transferred to a skilled nursing facility on 11/4/2022. During a telephone interview on 11/15/2022, at 12:40 p.m., with Resident 1, Resident 1 stated when he left the facility, he was taken to UTLF 1, and he was there for less than 20 minutes and was taken to UTLF 2 where there was a bunch of crazy people. Resident 1 stated he was taken to the hospital after a day and a half because he complained of having chest pain. Resident 1 stated when he left UTLF 2, he was told he could not return to UTLF 2 because they could not give him the help he required. Resident 1 stated he required a lot of assistance to change his brief. Resident 1 stated the left side of his body is weak, so it was very hard to transfer himself in and out of the bed because no one helped him and that made him feel frustrated and was scared he might fall and hurt himself, but he had no other choice. Resident 1 stated he did not get the help he needed at UTLF 2, and it was hard and frustrating. Resident 1 stated he was not ready to leave the facility and felt he was discharged so fast because they needed his bed for someone else. Resident 1 stated he did not let the facility know he did not want to leave because he felt rushed out of the facility. Resident 1 stated he felt he was not given a choice whether he wanted to leave the facility because he was just told he was being transferred. Resident 1 stated it made him feel sad and felt he was not treated right by the facility. Resident 1 stated his discharge from the facility had been very hard for him because it affected his depression and it really hurt him to leave his friends. Resident 1 stated he would like to return to the facility if he could. During a telephone interview on 11/15/2022, at 2:06 p.m., with the PMD, the PMD stated he was sorry, but he did not remember Resident 1. The PMD asked what type of medical insurance Resident 1 had and stated his insurance should have covered the home health referral. The PMD stated he had to go and hung up the telephone. During a concurrent interview and record review on 11/16/2022, at 2:00 p.m., with the DON, Resident 1's physical therapy and occupational therapy evaluation dated 10/26/2022 and 10/30/2022, was reviewed. The DON stated Resident 1 required moderate assistance for bathing and toileting. The DON stated the SSD should have called the facility being considered for Resident 1 to ensure the facility was able to safely care for and provide the services the resident required. The DON stated UTLF 1 should have come to the facility and assessed Resident 1 to see if they could safely care for the resident. The DON stated he did not know the services offered by UTLF 1 . The DON stated Resident 1 was accepted to UTLF 1 based on the clinical information sent to them and he assumed UTLF 1 could provide the care the resident required but he should not have assumed. The DON stated there were things the facility could have done differently such as investigating UTLF 1 prior to transferring Resident 1. The DON stated the process was for the UTLF to visit Resident 1 prior to accepting him, but that did not happen. During a phone interview on 11/18/2022, at 8:06 a.m., with the ADM 1 of UTLF 1, ADM 1 stated residents must be independent to live in a UTLF. ADM 1 stated a resident must be independent for toileting needs and medication administration. ADM 1 stated a resident must be able to self-administer insulin and check their blood sugar because that service was not offered at their establishment. During a phone interview on 11/18/2022, at 9:23 a.m., with ADM 2 of UTLF 1, ADM 2 stated a resident could be supported at their home if they required minimal assistance with ADLs, such as verbal cues because they were not allowed to provide physical assistance to change a resident and they were not allowed to administer medications, so resident had to self-administer their medication, check their blood sugars, and do their own ADLs. ADM 2 stated a resident had to be able to self-transfer from the bed to the wheelchair. ADM 2 stated Resident 1 may have been sent to UTLF 2 because UTLF 1 did not accommodate residents who could not transfer themselves to the second floor and UTLF 2 was suited for a resident in a wheelchair. ADM 2 stated UTLF 2 had the same business model as UTLF 1. ADM 2 stated he was the person responsible for approving a resident's transfer to his UTLF but stated he did not remember Resident 1. ADM 2 stated he could not speak specifically about Resident 1 but the information he usually received for a resident included a facesheet (record with a patient's brief medical history), H/P (record with a patient's allergies, past surgeries, current symptoms, and medical history), and medication list and he would have asked the resident was independent with his ADLs and if they were independent to transfer in and out of their wheelchair. ADM 2 stated if Resident 1's medical records indicated he required moderate assistance with ADLs to him that could have just meant the resident needed a verbal prompt. During a telephone interview on 11/23/2022, at 2:20 p.m., with [DATE], [DATE] stated for a resident to qualify to be transferred to UTLF 1, the resident had to be able to transfer from the bed to the wheelchair on their own. [DATE] stated she did not know the services offered at UTLF 1, but she spoke with [DATE] about Resident 1 so she could help her find the proper placement for him. During a telephone interview on 12/9/2022, at 3:43 p.m., with the PMD, the PMD stated he did not remember Resident 1 so he could not speak about him directly, but stated a resident discharged to a lower level of care had to be mostly independent. The PMD stated if a resident was not self-transferring from his wheelchair to the bed and could not clean themselves after having a bowel movement and required a lot of assistance for ADLs, it was not appropriate to send the resident to a board and care that did not help with ADLs and transferring in and out of the wheelchair. During an interview on 12/13/2022, at 2:39 p.m., [DATE] stated UTLF 1 did not offer the service of medication administration and she was not sure if assistance with ADLs was offered. [DATE] stated UTLF 1 was wheelchair accessible according to when [DATE] communicated with the UTLF. [DATE] stated the facility was given the wrong address and that is why Resident 1 was sent to UTLF 2 owned by the same owner of UTLF 1. [DATE] stated there was an option for the UTLF to assess a resident in person prior to accepting them, but Resident 1 was not visited by the UTLF and was accepted based on the clinical information sent to ADM 2. During a telephone interview on 12/15/2022, at 8:55 p.m., Resident 1 stated he was doing okay at the Skilled Nursing Facility (SNF) 1. Resident 1 stated he was sleeping okay but he felt sad because he had no one to talk to because he had no friends at SNF 1. Resident 1 stated he felt bored because he did not like the activities at the SNF 1. Resident 1 stated he wished he could return to the facility because it was like a family atmosphere. Resident 1 stated the GACH tried to send him back to the facility, but the SW stated she was told by the facility's SW that he could not return to the facility and resident stated he did not know why. e. During a review of Resident 1's physician telephone order, dated 10/27/2022, the telephone order indicated to discharge to UTLF 1 with home health for medication management and safety. A review of the telephone order entered by LVN 1 indicated the physician had not signed the discharge order. During an interview on 12/14/2022, at 12:46 p.m., with LVN 1, LVN 1 stated he entered the telephone discharge order for Resident 1 after the SSD told him she had spoken with the PMD, and Resident 1 could be discharged . LVN 1 stated the SSD asked him to enter the discharge order and he entered it. LVN 1 stated he or the SSD could contact the PMD for a discharge order. LVN 1 stated he did not contact the PMD because the SSD had called him. LVN 1 stated he did not consult with the PMD about what medications to continue for Resident 1's discharge. LVN 1 stated he normally gives discharged residents all their medications except for the narcotic medications. During an interview on 12/14/2022, at 1:06 p.m., with the DON, the DON stated the SSD, or the licensed nurse was responsible for getting the discharge order from the physician. The DON stated if the SSD got the order, she would have the licensed nurse enter the order in the computer. The DON stated a fax was supposed to be sent to the physician with the current medications for the resident prior to the resident's discharge to ensure the resident was sent with the correct medications. The DON stated not confirming the discharge medications may lead to harm to the resident if they do not have the correct medications. The DON stated it should have been documented in the progress notes if the PMD was faxed the current medications for Resident 1 and the notification of the location the resident was discharged to. The DON stated if the documentation was not in the progress notes, then it was not done. During a record review of Resident 1's nursing progress notes, dated 10/16/2022-10/27/2022, no documentation was noted which indicated the PMD was sent a fax of Resident 1's current medication list and that he was notified of the location the resident would be discharged to. During an interview on 12/14/2022, at 3:40 p.m., the SSD stated she gave LVN 1 the address of UTLF 1 and the home health agency information for the discharge of Resident 1 and asked LVN 1 to contact the PMD for a discharge order. The SSD stated she did not tell LVN 1 that she had spoken with the PMD and obtained a discharge order> the SSD stated she never contacted the PMD to inform him of Resident 1's discharge plan. The SSD stated it was the responsibility of the licensed nurse to call the physician for a discharge order. The SSD stated there must have been a miscommunication between her and LVN 1. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan , dated 12/2016, the P&P indicated, When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The P&P indicated, The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge .As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. The P&P indicated, The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan .The resident or representative (sponsor) should provide the facility a minimum of a seventy-two (72) hour notice of a discharge to assure that an adequate discharge evaluation and pot-discharge plan can be developed. A member of the IDT will review the final post-discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. During a review of the facility's P&P titled, Telephone Orders , dated 2/2014, the P&P indicated, Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.) .Telephone orders must be countersigned by the physician during his or her next visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to completely fill out the discharge forms including the Post Discharge Plan of Care , Physician's Discharge Summary , and Discharge Summary/Comprehensive Assessment for three of three sample residents (Resident 1, 2, and 3). This deficient practice had the potential to harm to Residents 1, 2, and 3 due to the residents being discharged with incomplete medication lists and resident information needed to ensure a safe transfer. Findings: a. During a review of Resident 1's admission Record (facesheet), the facesheet indicated Resident 1 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses [NAME] included type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), long-term use of insulin (medication used to treat high blood sugar), difficulty in walking, hemiplegia (loss of ability to move on one side of the body) and hemiparesis weakness on one side of the body) affecting the left non-dominant side, chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing problems), hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure resulting in the heart not pumping blood as well as it should), and pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid). During a review of Resident 1's History and Physical (H/P), dated 10/15/2022, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 10/27/2022, the MDS indicated Resident 1 required extensive assistance with bed mobility, transfers between surfaces including to and from bed, chair, wheelchair and standing position, dressing, toilet use, personal hygiene, and was completely dependent for bathing assistance. During a record review of Resident 1's Post Discharge Plan of Care, dated 10/27/2022, the record indicated section number 5 for special training/instructions was blank and section 6 for medications was incomplete, including frequency of medications and special instructions. During a record review of Resident 1's undated Physician's Discharge Summary, the physician's discharge summary was incomplete including the section for final diagnosis which indicated the diagnosis during stay and discharge diagnosis. The section addressing Resident 2's prognosis was left blank. The physician's discharge summary was not signed by a facility representative and was not signed and dated by Resident 1's physician. During a record review of Resident 1's undated Discharge Summary/Comprehensive Assessment, the Discharge Summary/Comprehensive Assessment was incomplete including the sections for recapitulation (summary) of stay, medical status and history, nutritional status, physical impairments, and allergies. The record does not indicate who completed the form and if a copy was provided to the resident. During an interview on 11/7/2022, at 1:55 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not complete the discharge medication reconciliation for Resident 1 because he was very busy passing the afternoon medications and Resident 1 was leaving the facility in an hour. LVN 1 stated he was responsible for completing the medication reconciliation but gave the medications to the Social Services Director (SSD) and she completed the medication reconciliation form. LVN 1 stated he did not review the medications with Resident 1, he did not teach him how to check his blood sugar and did not teach him how to self-administer insulin because he did not have time to do it, but stated he was supposed to. LVN 1 stated it was important to reconcile the medications to ensure all the medications were accounted for and stated it was important to teach Resident 1 how to check his blood sugar so he could administer the correct insulin dose. LVN 1 stated it was important to teach the resident about his medications to ensure the resident took his medications correctly because it could lead to the resident under or overmedicating himself, which could lead to complications such as high or low blood sugar and may lead to hospitalization. During a concurrent interview and record review on 11/7/2022 at 3:00 p.m., with the SSD, Resident 1's Post Discharge Plan of Care , dated 10/27/2022 was reviewed. The SSD confirmed the medication reconciliation was not filled out completely and was missing the medications' frequency and special instructions. The SSD stated she filled out the medication reconciliation for Resident 1, but the licensed nurse was supposed to reconcile the medications. The SSD stated the nurse did not fill out the medication reconciliation because the transfer happened so quick. The SSD stated she got the phone call that the resident was accepted to the board and care home and the transportation was available, so the transfer paperwork was done quickly, and she missed filling out the paperwork completely. The SSD stated it was important to completely fill out the medication reconciliation to ensure the receiving facility knew what medications the resident was taking and the frequency. The SSD stated the result of sending incomplete information may lead to the new facility not having all the information to meet the needs of the resident. During a concurrent interview and record review on 11/16/2022, at 2:00 p.m., with the Director of Nursing (DON), Resident 1's Post Discharge Plan of Care , dated 10/27/2022, Discharge Summary/Comprehensive Assessment , undated, and Physician's Discharge Summary , undated, was reviewed. The DON confirmed all three forms were not filled out completely. b. During a review of Resident 2's facesheet, the facesheet indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included toxic encephalopathy (indicates brain dysfunction caused by toxic exposure), acute respiratory failure (occurs when fluid builds up in the lungs and keeps lungs from filling with enough air) with hypoxia (not getting enough oxygen), and pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). During a review of Resident 2's H/P, dated 9/16/2022, the H/P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and was unable to understand and make decisions. The MDS indicated Resident 2 required limited assistance with bed mobility, transfers between surfaces such as from the bed to the chair, and walking, and required extensive assistance for dressing, toilet use, and personal hygiene. During a record review of Resident 2's Post Discharge Plan of Care, dated 10/20/2022, the post discharge plan of care was incomplete. Sections 1 for physician visit, Section 2 for post discharge plans/community agencies, Section 3 for equipment needs, Section 4 for special observations, Section 5 for special training/instructions, and Section 6 for medications was left blank. During a record review of Resident 2's undated Discharge Summary/Comprehensive Assessment, the discharge summary/comprehensive assessment was incomplete and the recapitulation of stay, medical status and history, nutritional status, drug therapy, skin condition was blank. The record did not indicate who completed the form and if a copy was provided to Resident 2. During a review of Resident 2's undated Physician's Discharge Summary, the physician's discharge summary was incomplete including the section for final diagnosis which indicated the diagnosis during stay and discharge diagnosis. The section addressing Resident 2's prognosis was left blank. The physician's discharge summary was not signed by a facility representative and was not signed and dated by Resident 2's physician. During a concurrent interview and record review on 11/7/2022 at 4:21 p.m., with the SSD, Resident 2's Post Discharge Plan of Care , dated 10/20/2022, the Physician's Discharge Summary , undated, and the Discharge Summary/Comprehensive Assessment , undated, was reviewed. The SSD confirmed the three forms were not filled out. The SSD stated all discharge forms should have been completed so the receiving facility had the history of the resident and to ensure a safe transfer. During a concurrent interview and record review on 11/16/2022, at 2:00 p.m., with the Director of Nursing (DON), the DON reviewed Resident 2's Post Discharge Plan of Care , dated 10/20/2022, the Physician's Discharge Summary , undated, and the Discharge Summary/Comprehensive Assessment , undated, and confirmed all three forms were not filled out completely. c. During a review of Resident 3's facesheet, the facesheet indicated Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses including hypertension (high blood pressure), COPD, and absence of left leg above the knee. During a review of Resident 3's H/P, dated 6/11/2022, the H/P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 required extensive assistance with bed mobility, toilet use, and personal hygiene, required limited assistance for transfers between surfaces, and was independent with dressing, eating, and locomotion (moving) on and off the unit. During a review of Resident 3's undated Physician's Discharge Summary, was incomplete including the section addressing the resident's final diagnosis which indicated the diagnosis during the resident's stay and discharge diagnosis. The section addressing Resident 2's prognosis was left blank. The physician's discharge summary was not signed by a facility representative and was not dated. During a record review of Resident 3's Discharge Summary/Comprehensive Assessment, dated 8/30/2022, the discharge summary/comprehensive assessment was incomplete. Sections for recapitulation (summary) of stay, medical status and history, vital signs, nutritional status, physical impairments, allergies, and skin condition was blank. The record did not indicate who completed the form and if a copy was provided to the resident. During a concurrent interview and record review on 11/16/2022, at 2:00 p.m., with the Director of Nursing (DON), the DON reviewed Resident 3's Physician's Discharge Summary , undated, and the Discharge Summary/Comprehensive Assessment , dated 8/30/2022 and confirmed both forms were not filled out completely. The DON stated Resident 3's Post Discharge Plan of Care was missing from the chart. The DON stated it was important to fill out the discharge forms completely to ensure the receiving facility had all the information for the resident and ensure a safe discharge. During a review of the facility's policy and procedure (P&P) titled, Transfer of Discharge Documentation, dated 12/2016, the P&P indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. The P&P indicated, Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: a. The basis for the transfer or discharge; b. Contact information of the practitioner responsible for the care of the resident; c. Resident Representative information including contact information; d. Advance directive information; e. all special instructions or precautions for ongoing care, as appropriate; f. Comprehensive care plan goals; and g. All other necessary information, including a copy of the residents' discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. During a review of the facility's P&P titled, Discharge Summary and Plan , dated 12/2016, the P&P indicated, When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The P&P indicated, The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge . The discharge summary shall include a description of the resident's: a. current diagnosis; b. medical history; c. course of illness, treatment and/or therapy since entering the facility; e. physical and mental functional status; g. sensory and physical impairments; h. nutritional status and requirements; i. special treatments and procedures; j. mental and psychosocial status; p. medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update the medical records for one of four sampled residents (Resident 1) to indicate Resident 1 was conserved (a court ordered person is granted powers over a person that cannot care for themselves) by a public guardian (a person legally assigned to a person unable to properly care for themselves and/or who are unable to manage their finances). This deficient practice resulted in Resident 1 being allowed to leave the facility against medical advice (AMA) without his conservator's knowledge or permission, exposing him to extremes in weather, accidents, medical complications, hunger, injury and possible death. Resident 1 was found on 9/1/2022 (five days after leaving the facility AMA), less than 1 mile away from the facility and was transported to a General Acute Care Hospital 1 (GACH 1) by emergency services for evaluation and treatment. While admitted at GACH 1, Resident 1 was treated for dehydration (dangerous loss of body fluids), illicit (forbidden by laws rules or custom) drug use, drug withdrawal, tachycardia (abnormally fast heart rate), and altered mental status ([AMS] a change in mental function that stems from illnesses, disorders and injuries affecting the brain). Findings: During a review of Resident 1's admission records (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including but not limited to paraplegia (inability to use legs), Stage 4 pressure ulcer of the right buttock (most severe and painful form of a wound caused by pressure, usually from lying or sitting in one position for extended amounts of time. The wound reaches muscles, ligaments [connective tissue that attaches bone to bone] and bones and often becomes infected) and paranoid schizophrenia (a mental disorder where the mind does not agree with reality). The face sheet indicated Resident 1 was self-responsible but was conserved. Per the face sheet Resident 1's responsible party's (Conservator) information was not updated until 8/18/2022 (35 days after Resident 1 was admitted to the facility). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 7/18/2022, the MDS indicated Resident 1 was able to make independent decisions that were consistent and reasonable. The MDS indicated Resident 1 had a functional limitation in range of motion ([ROM] the distance and direction a joint can move to its full potential) to both his lower extremities and used a wheelchair for mobility. During a review of Resident 1's Conservatorship documents dated 2/16/2022, the Conservatorship documents indicated Resident 1 was placed under temporary conservatorship from 3/10/2022-3/10/2023. The Conservatorship documents indicated Resident 1 was gravely disabled (unable to provide basic care to oneself to sustain his/her health and safety) and a Los Angeles Public Guardian was given the authority to detain and treat him. During a review of Resident 1's physician's orders for the month of August 2022, the physician's orders indicated Resident 1 was able to go out on pass on: 1. 8/1/2022 for 3 hours 2. 8/12/2022 for 4 hours 3. 8/21/2022 for 4 to 6 hours 4. 8/26/2022 for 6 hours During a review of Resident 1's Physician's Orders, the Physician's Orders indicated Resident 1 was prescribed the following medication/wound treatment on: 1. 7/15/2022- Buspirone HCl tablet- 10 mg, 2 tablets, 3 times a day for anxiety (a mental disorder characterized by feelings of worry and fear) manifested by inability to relax in chair or bed 2. 7/13/2022 - Benazepril HCl- 10 mg, 1 tablet daily for hypertension ([HTN] high blood pressure) 3. 7/13/2022 - Metoprolol Tartrate- 25mg, 1 tablet, twice daily for HTN 4. 7/14/2022 - Remeron- 15mg, 1 tablet at bedtime for depression manifested by lack of appetite 5. 8/15/2022- Risperidone- 3mg, 1 tablet, 2 times a day for schizophrenia manifested by visual and/or auditory hallucinations During a review of Resident 1'S Medication Administration Record (MAR), dated 8/2022, the MAR indicated, Resident 1 last received: 1. Benazepril HCl 10 mg on 8/27/2022 at 9 a.m. 2. Buspirone HCl 20 mg on 8/27/2022 at 9 a.m. 3. Metoprolol Tartrate 25 mg on 8/27/2022 at 9 a.m. 4. Remeron 15mg on 8/26/2022 at 9 p.m. 5. Risperidone 3mg on 8/27/2022 at 9 a.m. During a review of Resident 1's laboratory results dated [DATE], the laboratory results indicated Resident 1 had a normal potassium level of 4.7 millimoles per liter ([mmol/L] a unit of measurement). During a review of Resident 1's Weekly Nursing Progress Note (WNPN) dated 8/27/2022 and timed at 8:40 a.m., the WNPN indicated Resident 1 was alert and oriented x4 (level of awareness to person, place, time and event) and able to make his needs know. The WNPN indicated Resident 1 ate approximately 75% or greater of each meal and Resident 1's skin was clean and dry. During a review of Resident 1's Progress Notes (discharge summary) dated 8/27/2022 and timed at 12:13 p.m., the Progress Notes indicated the director of nursing (DON) and licensed vocational nurse 1 (LVN 1) spoke to Resident 1 regarding an issue reported to them that Resident 1 had cocaine in his possession. The Progress Note indicated Resident 1 refused a search of his belongings and wanted to leave AMA. The Progress Note indicated Resident 1 was alert and oriented, self-responsible and independent with activities of daily living ([ADLs] activities related to personal care) and Resident 1's physician ordered to discharge Resident 1 AMA. During a review of Resident 1's Release from Responsibility for Discharge Against Medical Advice form dated 8/27/2022, the AMA form indicated Resident 1 left the facility AMA at 12:25 p.m. The AMA form was signed by Resident 1 and witnessed by two staff members. During an interview on 9/1/2022 at 10:05 a.m., a subsequent interview on the same day at 3 p.m., and on 9/2/2022, at 10:35 a.m., the administrator (ADM) stated per his investigation, Resident 1 was admitted to the facility from a GACH (7/13/2022) and per the GACH's admission records, Resident 1 was self-responsible. The ADM stated he nor the facility staff were aware Resident 1 was conserved when Resident 1 left the facility (8/27/2022) AMA. The ADM stated Resident 1 left the faciity on pass on 8/26/2022, the day prior to him (Resident 1) leaving the facility AMA (8/27/2022) and stated Resident 1 had left the faciity on pass on several occasions. The ADM stated he was made aware of Resident 1's conservatorship when Resident 1's Conservator called and spoke to him (8/31/2022), stating their social service director (SSD) left her (the Conservator) a message informing her (the Conservator) that Resident 1 was no longer in the facility. The ADM stated he then called Law Enforcement to file a missing person's report when he learned Resident 1 was conserved. The ADM stated the SSD should have reported at their stand-up meeting that Resident 1 was conserved and/or conducted an IDT meeting. The ADM stated good communication by the team is important to ensure residents are not hurt and, in this case, it could have prevented Resident 1 from leaving the facility AMA when he was not authorized to do so. The ADM stated Resident 1 was picked up by ambulance on 9/1/2022 (five days after leaving the facility AMA), at a nearby intersection less than one mile away from the facility. The ADM stated he called law enforcement to inform them that Resident 1 had been spotted but they (law enforcement) did not want to look for Resident 1. The ADM stated he (the ADM) went to go look for Resident 1 and located him in front of a fast-food restaurant sitting in his wheelchair with messy hair. The ADM stated he approached Resident 1 and told him his Conservator was looking for him. The ADM stated, Resident 1 began wheeling himself away from him, so he (the ADM) kept his distance, called 911 and stayed until he witnessed Resident 1 being picked up by ambulance. The ADM stated Resident 1 was taken to a local GACH and per the Conservator, she (the Conservator) was going to work with the GACH to locate a locked psychiatric facility to place Resident 1, due to Resident 1's diagnoses and history of AWOL. During an interview on 9/1/2022 at 10:30 a.m., the Conservator stated she was recently assigned to Resident 1's case (8/1/2022) and on 8/16/2022 she informed the facility's SSD that she was Resident 1's Conservator. The Conservator stated all information regarding the conservatorship was given to the SSD at that time. The Conservator stated she was upset to learn Resident 1 left the facility AMA because he was under an LPS ([[NAME]-Petris-Short] a legal means used to provide for the care and treatment of persons who cannot properly care for themselves because of a mental disorder) mental health conservatorship and Resident 1 did not have the authority or capacity to make that decision. The Conservator stated all discharges for conserved residents needed to go through the conservator and stated she would never have agreed to let Resident 1 leave the facility on his own because Resident 1 was deemed incapable of making decisions by a judge. The Conservator stated, the office of public guardian is open 24 hours a day, seven days a week and someone is always available if consents are needed. The Conservator stated Resident 1 had a court appointed conservator since 2013 but had a history of going AWOL (absent without leave) from their system. The Conservator stated, in March of this year (2022) Resident 1 was found and placed under conservatorship again. The Conservator stated she was surprised to learn Resident 1 was leaving the facility on pass because that should have been approved by the conservator and permission for out on pass would have been denied because of Resident 1's history of AWOL. During an interview on 9/1/2022 at 11:29 a.m., LVN 1 stated the day Resident 1 left the facility AMA (8/27/2022), he was acting strange and displaying erratic (unpredictable or irregular) behavior. LVN 1 stated Resident 3 reported to him (LVN 1) and the DON that Resident 1 had illegal drugs in the facility. LVN 1 stated they confronted Resident 1 but Resident 1 denied having illegal drugs and refused to be searched. LVN 1 stated because of Resident 1's erratic behavior, they called Resident 1's physician who ordered Resident 1 be transferred to a GACH for evaluation. LVN 1 stated Resident 1 refused to be transferred but instead requested to leave the facility AMA. LVN 1 stated Resident 1's physician was informed Resident 1 left the facility AMA, however, at that time Resident 1's physician did not know Resident 1 was conserved. LVN 1 stated when Resident 1 was admitted to the facility, they were under the impression he was self-responsible with no family. LVN 1 stated if he had known Resident 1 was conserved, he would not have let Resident 1 sign the discharge paper allowing him to leave the facility AMA, instead he (LVN 1) would have called the conservator regarding the transfer to the GACH. During an interview on 9/1/2022 at 11:52 a.m., LVN 2 stated they were not aware Resident 1 was conserved. LVN 2 stated Resident 1 was alert, able to make his needs known and could make decisions. LVN 2 stated when Resident 1 requested an out on pass she would call his physician to obtain an order. LVN 2 stated if she had been aware Resident 1 was conserved, she would have gone through the conservator for consent before calling Resident 1's physician. During a concurrent record review of Resident 1's face sheet with LVN 2, she stated the face sheet never indicated Resident 1 was conserved and someone must have updated Resident 1's face sheet because the conservator information currently documented was not there before. LVN 2 stated Resident 1's face sheet previously indicated Resident 1 was self-responsible. LVN 2 stated the facility has issues with communication that needs to change to ensure residents are safe. During an interview on 9/1/2022 at 2 p.m., the SSD stated when Resident 1 was first admitted to the facility the admission records from the GACH where Resident 1 was transferred from did not provide documentation indicating Resident 1 was conserved. The SSD stated the Conservator called and spoke to her (date unknown) a few weeks ago and it was at that time that she (the SSD) was made aware of Resident 1's conservatorship and she (the SSD) updated Resident 1's contact list with the conservator's information when the conservator provided her with the appropriate documents. The SSD stated she did not inform anyone at the facility that Resident 1 was conserved, nor did she place an updated admission record in Resident 1's physical chart. The SSD stated when she became aware of Resident 1's conservatorship she should have entered a progress note in Resident 1's chart, an interdisciplinary team (IDT) meeting should have been conducted so the department heads would all be on the same page and Resident 1's plan of care should have been updated accordingly, but stated she did not do any of that. The SSD stated she has a lot on her plate and did not realize how important it was to communicate the conservatorship information to the team at the time. The SSD stated if staff had been aware that Resident 1 was conserved, they would have informed Resident 1's Conservator prior to Resident 1 leaving the facility. The SSD stated it is very important to communicate new information with the team so everyone involved can be on the same page. The SSD stated Resident 1 was not able to make decisions for himself and being on the street alone was dangerous and placed him at risk of being lost. During a Review of GACH 1's emergency room records (History and Physical [H&P]) dated 9/1/2022, the H&P indicated Resident 1 was brought in via ambulance for AMS and was only oriented to his name. The H&P indicated, Resident 1 was not answering questions and was only able to follow basic commands. The H&P indicated Resident 1 was found to be tachycardic with a heart rate of 130 bpm (beats per minute) (normal range 60-100 bpm). The H&P indicated Resident 1 was hypertensive with a blood pressure of 160/107 (normal blood pressure less than 120/80). The H&P indicated, Resident 1's toxicology (measurement and analysis of banned substances and prescription medications present in a person's body) report revealed Resident 1 was positive for amphetamines (addictive, mood-altering drugs), Phencyclidine ([PCP] a drug that causes hallucinations), cannabinoid ([marijuana] a psychoactive drug), and opiates (pain relieving drug). The H&P indicated, Resident 1 was diagnosed with AMS and dehydration and was to be admitted to the hospital for further care. During a review of GACH 2's admission records (H&P) dated 9/2/2022, the H&P indicated Resident 1 was admitted to GACH 2 after being transferred from GACH 1's emergency room for psychiatric care with diagnoses of AMS, drug withdrawal and tachycardia and was started on a Clonidine patch (blood pressure lowering medication). The H&P indicated Resident 1 was weak and disheveled (messy, untidy appearance) and deconditioned (loss of physical functions and decrease in mental status). A review of GACH 2's Psychiatric Initial Evaluation notes ([NAME]) dated 9/2/2022, the [NAME] indicated Resident 1 was alert and oriented x1 (to self only). The [NAME] indicated Resident 1 was withdrawn, hyperverbal (fast, increased speech) and was making nonsensical statements. The [NAME] indicated Resident 1's speech was pressured (talking faster than usual) and slurred, Resident 1 had difficulty making his needs known, it was difficult making out what Resident 1 stated and he (Resident 1) could only answer yes or no questions. The [NAME] indicated Resident 1 was talking and mumbling to himself, was unable to provide a logical plan to care for himself, was unable to function outside of a structured setting and had poor safety awareness. The [NAME] indicated Resident 1 was unkempt (not tidy) and malodorous (smelling unpleasant) after being homeless for the past 4 days. During an interview on 9/7/2022 at 9:50 a.m., Resident 1's physician stated he was informed Resident 1 left the facility AMA (8/27/2022) but at that time everyone believed Resident 1 was self-responsible and he (Resident 1's physician) was not aware the SSD had received information that Resident 1 was conserved. During a review of the weather report from accuweather.com for [NAME], California from 8/27/2022 to 9/1/2022, the weather report indicated the daily high temperatures ranged from 79 degrees Fahrenheit([F] a unit of measurement) to 96 degrees F and the daily low temperatures ranged from 64 degrees F to 75 degrees F. https://www.accuweather.com/en/us/[NAME]/90262/august-weather/337140 During a review of the violent crime statistics for [NAME], California on crimegrade.org, the crime statistic indicated [NAME] had a crime grade of (F), meaning violent crime was much higher than the average United States (US) city. The crime statistic indicated [NAME] was in the 3rd percentile for safety, meaning 97% of cities are safer and 3% of cities are more dangerous and the chance of being a victim of violent crime in [NAME] may be as high as 1 in 33. https://crimegrade.org/violent-crime-[NAME]-ca/ A review of the facilities undated job description summary titled Director of Social Services , indicated the SSD was to: - Relate all pertinent information concerning a resident to the charge nurse when required. - Complete all required social services charting, psychosocial evaluations, assessments, quarterlies, updates as needed and patient care plan entries to meet federal/ state licensing requirements, facility policies and procedures and to accurately reflect Resident needs. A review of the facilities policy and procedure (P/P) titled Resident Representative dated 2/2021, the P/P indicated: - If a resident is determined to be incompetent under the laws of the state by a court of competent jurisdiction, the rights of the resident will devolve (transfer powers from one person to another) to and will be exercised by the resident representative appointed to act on the resident's behalf.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the medical records upon written request from an authorized representative (Rep 1) for one of three sampled residents (Resident 1). This deficient practice violated the rights of Rep 1 to obtain a copy of Resident 1 ' s medical records within 2 working days. Findings: During a review of Resident 1 ' s admission Record, dated 9/28/2022, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included campylobacter enteritis (a common intestinal infection caused by eating raw or undercooked poultry or eating something that touched it), antineoplastic chemotherapy induced pancytopenia (due to bone marrow suppression caused by the administration of cancer drugs), type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), 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). A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 9/14/2022, indicated Resident 1 had moderately impaired skills for daily decision-making. During an interview on 10/24/2022 at 10:33 a.m. with the Social Services Director (SSD), the SSD stated the medical records requestor was asked to complete an authorization form and bring in person or send by e-mail. THe SSD stated the timeframe to receive the medical records was 1 or two weeks (14 days). The SSD stated Medical Records would let the SSD know when to contact the requestor and inform him/her the records were ready for pick up. The SSD stated for the resident ' s request it was the same process, 1 to 2 weeks before the resident received the medical records. The SSD stated requestors were verbally told it would take 1 to 2 weeks before receiving medical records. The SSD stated she only took requests and guides those requests to Medical Records for processing. A review of the facility ' s form titled, Authorization for the Release of Medical Information (HIPAA Compliant) indicated there was no timeframe on the form identifying how long it took to process the medical records request. During a telephone interview with Rep 1 on 10/24/2022 at 10:45 a.m., Rep 1 stated she sent a letter of request for medical records, then was informed by the facility she had to complete an authorization form. Rep 1 stated she requested records on 9/22/2022. Rep 1 stated she was called to pick-up the records on 9/30/22 after Rep 1 made many inquiries about when the medical records would be ready. Rep 1 stated during the time she was waiting to pick-up the medical records, no one from the facility called her to inform her that there would be a delay in receiving the records. During a concurrent interview and record review on 10/24/2022 at 12:22 p.m. with the Administrator (ADMIN), the facility ' s policy titled, Release of Information, dated November 2009 was reviewed. The policy indicated A resident may have access to his or her records within (the space for number of hours is left blank) hours, excluding weekends or holidays, of the resident ' s written or oral request. The ADMIN stated the policy was from the facility's Corporate office and he would find out why there was a blank space for the number of hours. During an interview with the ADMIN on 10/24/2022 at 12:48 p.m., the ADMIN provided another copy of the facility's Release of Information policy with the facility's name and the blank space now indicated 72 written with black ink. The policy now indicated, A resident may have access to his or her records within 72 hours (excluding weekends or holidays) of the resident ' s written or oral request. During an interview with the ADMIN on 10/24/22 at 1:15 p.m., the ADMIN stated his Medical Records Director resigned on 10/20/22. The ADMIN stated at that time he was responsible for coordinating all medical records requests. The ADMN stated he was unable to provide a copy of the medical records request log for the months of September and October 2022. During a record review of Rep 1 ' s signed form titled, Authorization for the Release of Medical Information (HIPAA Compliant) provided by the facility, the form indicated Rep 1 requested Resident 1 ' s medical records on 9/22/22. During a review of the facility ' s policy titled, Release of Information, dated November 2009, the policy indicated all information contained in the resident ' s medical record is confidential and may only be released by the written consent of the resident or his/her legal representative (sponsor), consistent with state laws and regulations. The policy indicated the resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor). The policy further indicated a resident may obtain photocopies of his or her records by providing the facility with at least forty-eight (48) hour (excluding weekends and holidays) advance notice of such request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to notify the primary physician (MD) 1 of a very high blood sugar laboratory result (test result) for one of two sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for delay in care and services. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), chronic venous hypertension with ulcer of right lower extremity (High blood pressure in the leg veins over a long time, due to sitting or standing for prolonged periods; Lack of exercise; Smoking), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), localized edema (a disorder characterized by swelling due to excessive fluid accumulation at a specific anatomic site), disorders and injuries affecting your brain). During a review Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 9/15/22, the MDS indicated Resident 1 was severely impaired with his cognitive level for daily decision-making. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility, transferring, dressing, eating, toileting and personal hygiene. During a review of Resident 1 ' s History and Physical (H/P), dated 9/14/22, the H/P indicated Resident 1 didnot have ability to make medical decisions. During a review of Resident 1 ' s Lab Result Report collected on 9/14/22 and reported to the facility on 9/15/22, at 11:25am, the lab result indicated Resident 1 had a critical high glucose (blood sugar) level of 580 milligrams/per deciliter ([mg/dl] unit of measurement). The lab result report indicated normal glucose level was between 70-99. During a review of Resident 1 ' s eInteract Change in Condition Evaluation, (COC) dated 9/15/22 signed by Licensed Vocational Nurse (LVN) 2, the COC indicated Resident 1 had an altered mental status, was lethargic, with a high glucose level. The COC indicated, the primary care clinician, was notified at 4:41pm., on 9/15/22, approximately 5 hours after the facility obtained the results from the lab. The COC also indicated Resident 1 was transferred to a general acute care hospital (GACH) due to worsening condition. During a concurrent telephone interview and record review on 10/27/22 at 2:59 p.m., with the Director of Nursing (DON) 2, of Resident 1 ' s lab result dated 9/15/22, the DON 2 stated the facility ' s process was to report critical high results to the physician immediately and as soon as the results were obtained. The DON 2 stated Resident 1 ' s critically high glucose level was not reported to the resident ' s physician immediately. The DON 2 also stated Resident 1 ' s results were reported to the physician 5 hours after the results were received. The DON 2 stated not notifying the resident ' s physician of abnormal results could worsen the resident ' s condition. During a review of Resident 1 ' s Progress Notes, dated 9/15/22 and timed at 5:25 p.m., the progress notes indicated Resident 1 was lethargic, awake, verbally unresponsive, with a very high blood sugar, labored breathing, respiration rate of 33-38 beats per min., and a heart rate of 114. The progress notes indicated; Resident 1 was transferred to the GACH at 5:20 p.m., for a decline in health. During a review of the facility's undated policy and procedure (P/P), titled, Change in Resident ' s Condition or Status, the P/P indicated, the facility promptly notified the resident, his or her attending physician, and the resident ' s representative of changes in the resident ' s medical/mental condition and/or status. The P/P indicated, the facility ' s nurses will notify the resident ' s attending physician on call when there was a significant change in the resident ' s physical/emotional/mental condition, a need to alter the resident ' s medical treatment significantly, and when there was a need to transfer the resident to a hospital/treatment center. The P/P indicated a significant change of condition was a major decline or improvement in the resident ' s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, except in medical emergencies. The P/P indicated notifications will be made within twenty-four (24) hours of a change occurring in the resident ' s medical/mental condition or status. The P/P indicated if a significant change in the resident ' s physical or mental condition occurred, a comprehensive assessment of the resident ' s condition will be conducted as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of non-coverage, and Notice of Medicare Provider Non-coverage (NOMNC) form to three of 3 residents (4. 12, 30). The deficient practice of not providing advanced notice for last day of coverage ABN-SNF form, and notice of Medicare part A non-coverage indicating Medicare was about to end, did not give Resident 4, 12, and 30 the right to appeal, which could result in denial of right and discharge from the facility. Findings: A review of Resident 4's admission Face sheet indicated the resident was originally admitted to the facility on [DATE] and re-admitted [DATE], and discharged [DATE]. Resident 4's diagnoses included type 2 diabetes mellitus (adult onset of elevated blood sugar levels) , muscle weakness, other abnormalities of gait and mobility. A review of Resident 12's admission Face sheet indicated the resident was originally admitted to the facility on [DATE], and discharged [DATE]. Resident 12's diagnoses included,abnormal posture, urinary tract infection (UTI) Infection of the bladder, other abnormalities of gait and mobility. A review of Resident 30's admission Face sheet indicated the resident was originally admitted to the facility on [DATE], and discharged [DATE]. Resident 30's diagnoses included type 2 diabetes mellitus (adult onset of elevated blood sugar levels) , other abnormalities of gait and mobility, and muscle weakness. On 5/8/21 at 10:54 A.M., during and interview and review of SNF Beneficiary Notification for Residents 4, 12, and 30 did not have supporting evidence to show the residents were notified of their rights. During an interview the Business Office Assistant and Accounts Receivable Resource personnel stated we have searched everywhere and could not locate NOM-NOC/ABN for the three residents, and we do not have any other evidence available to prove. A review of facility's undated policy and procedure titled Form Instructions of the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, indicated a. A medicare provider or health plan must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrolles receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. b. The NOMNC must be delivered at least two calendar days before Medicare covered services end, or the second to last day of service if care is not being provided daily. c. The provider must ensure that the beneficiary or representative sign and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disrupted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise and update the care plan for one of three sampled Residents (Resident 18) after the Resident was transferred to the General Acute Care Hospital (GACH) for chest pain and subsequently readmitted to the facility. This deficient practice had the potential for Resident 18 to not have her care plan goals met, not have additional interventions implemented to prevent further incidences of chest pain or to experience a decline in physical and mental health. Findings: During a review of Resident 18's admission Record, it indicated the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 18's diagnoses included unstable angina (condition which the heart does not get enough blood flow and causes unexpected chest pain), chronic obstructive pulmonary disease (COPD[group of diseases that block airflow and make it difficult to breathe]), and cardiomegaly (condition in which the heart is enlarged). During a review of Resident 18's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 3/26/2021, it indicated Resident 18 had no cognitive (thought) impairment. During a review of Resident 18's progress notes dated 3/26/2021 at 2:28 p.m. , the progress notes indicated Resident 18 was transferred to GACH via 911 for complaints of chest pain radiating to the left arm. The progress notes indicated Resident 18 stated it feels like sharp pain. The progress notes indicated three Nitroglycerin (medication given to treat and prevent chest pain) tablets were administered to Resident 18 but were ineffective. During a review of the facility's Nursing Home to Hospital Transfer Form dated 3/26/2021, the form indicated Resident 18 was transferred to GACH for com plaints of chest pain on 3/26/2021. During a review of Resident 18's GACH Discharge summary dated [DATE], the summary indicated Resident 18's admission diagnosis on 3/26.2021 was unstable angina and chest pain. The summary indicated Resident 18's discharge diagnosis on 3/28/2021 was atypical (unusual) chest pain, COPD, and persistent cough. During a review of Resident 18's physician orders dated 3/29/2021, the physician orders indicated Resident 18 to be readmitted to facility. During a review of Resident 18's care plan titled Risk for irregular pulse and chest pains secondary to history of hypertension(high blood pressure) and chronic heart failure (the heart does not pump blood as it should) indicated the care plan was initiated on 11/18/2020 and revised on 11/18/2020. The care plans goal risk for onset of chest pain will be minimized every day for 3 months was initiated on 11/18/2020 and revised on 5/3/2021. The care plan indicated the interventions to be implemented were initiated on 11/18/2020 and revised on 11/18/2020. During a interview and record review on 5/11/2021, at 11:09 a.m., LVN 5 stated We are supposed to update and revise care plans upon readmission, if there is a change of condition of a resident, new behavior, or a new medication for a Resident. LVN 5 acknowledged there were no updates or revisions to Resident 18's Risk for Chest Pain care plan after 3/26/2021. A review of the facility's policy and procedure (P/P),titled Care Plans, Comprehensive Person-Centered, revised December 2016, indicated the care plans are revised as information about the residents and the residents' condition change. The policy indicates the Interdisciplinary team (IDT[ team of physicians , nurses, dietary, social services, and staff who work together the address the resident's needs]) must review and update the care plan when there has been a significant change in the Resident's condition, when the desired outcome is not met, when the Resident has been readmitted to the facility from a hospital stay, and at least quarterly. Based on interview and record review the facility failed to ensure care plan for Fall risk Prevention, was revised with measurable objective and time frame after Resident 59 sustained a fall with head pain. This deficient practice had the potential of resulting to Resident 59 having another fall with serious harm or death. Findings: A review of Resident 59'S admission Record (Face Sheet) indicated the resident was initially admitted to the facility on [DATE] and readmitted with diagnoses that included but were not limitted to Chronic Kidney disease (inability of the kidney to function) and Hyperkalemia ( high potassium levels). A review of Resident 59's Fall Risk Data Collection dated 2/5/2016, indicated a score 14 (a score of 10 or above represents high risk for falls. 8/10/2016, score of 13, 11/9/2016, score of 17 and 5/4/2021. The Fall Risk Datas indicated Resident 59 reuired assist in mobility with bowel and blader eliminations. It also indicated Resident 56 was on Diuretic (medication that increase uring out put), Narcotic's (pain medication) and antihypertensives (medication for blood pressure). A review of Resident 59's Minimum Data Set (MDS), an assessment and care-screening toolk, dated 4/16/2021, indicated Resident 59 had moderately impaired cognition skill (thought process) and totaly depended on staff for activities of daily living (ADLs). A review of Resident 59's Post care plan for Fall risk Prevention, dated 5/4/2021, indicated a discription on how the resident fell. Facility failed to indicate interventions that will address subsequent falls. Areview of Resident 59's nursing progress note dated 5/3/2021 at 23: 25 indicated the resident was found on the floor next to her bed on her right side (fetal position with her head resting upon the base of the bedside table. No indicated no injury but with previous multiple skin discolorations. Note indicated the facility did not complete the 72 hours charting, 72 hours even thogh the writer requested for but the facility did not provide and no x-ray of the head was ordered. On 05/06/21, 01:22 P. m., during an interview with LVN 7 stated interventions such as placing call light within resident reach, bed in a lower position, monitoring resident frequently due to resident having behavior, placing on 72 hours charting, obtaining x- ray, assess for pain and medicate but failed torevised the plan of care to reflict resident's needs. The facility's policy an procedure Care Plan revised 2016 indicated a person -centered care plan shall be developed that includes measureable objective and timetables to meet the resident's physical, psychosocial and functional needs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure laboratory test for potassium (a substance found in some foods and medications that help the body to work properly ) was obtained as ordered by the physician for one of one resident (Resident 59). This deficient practice had the potential to result in low or high levels of potassium in Resident 59's blood. Findings: On 05/11/21, at 11:38 a. m., during an interview, the Director of Staff Development (DSD) stated not following Resident 59's physician's order for potassium levels every 6 months placed the resident at risk of potassium toxicity and confusion. On 05/11/21, at 12 p. m., during a concurrent interview and review of Resident 59's Medication Regimen Review (MRR) dated 3/1/2021 to 3/31/2021, the Quality Assurance Nurse (QAN) stated the pharmacist's indicated lab work was not found in the chart as ordered for the resident's potassium to be drawn every six months. QAN stated the staff failed to follow Resident 59's physician's routine order. QAN also stated this failure could cause Resident 59 to have a heart attack. A review of Resident 59's Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] Resident 59's diagnoses included Chronic Kidney disease (inability of the kidney to function like they normally should) and Hyperkalemia ( high potassium levels). A review of the physician's order summary dated 5/6/2021, indicated Resident 59's potassium level will be checked every six months. A review of Resident 59's physician's order dated 5/6/2021, indicated potassium chloride extended release 10 milliequivalent. ([mEq] unit of measurement), Give one tablet by mouth (PO) one time a day (QD) for supplement, with food and a full glass of water. A review of Resident 59's medical records dated 2/17/2020 indicated the resident had a potassium blood level of 4.8 mEq /per liter (unit of measurement).

Based on observation, interviews, and record review facility failed to ensure one of one sampled residents (Resident 60) had the call light within reach. This deficient practice had the potential for accidents, including falls, and resulted in the delay of assisting Resident 60 with a drink of water. Findings: A review of Resident 60's undated admission record indicated the facility admitted Resident 60 on 4/11/21. Resident 60's diagnoses included acquired absence of right leg below knee, muscle weakness, gangrene (tissue death caused by lack of blood supply), sepsis (A life-threatening complication of an infection). A review of Resident 60's Minimum Data Set (MDS), an assessment and care-screening tool, dated 4/18/21, indicated the Resident 60 had impaired cognition (does not have full capacity to understand or to be understood by others). Resident 60 required extensive assistance from staff with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use, and personal hygiene. A review of care plan for activities of daily living (ADL - activities necessary for independent living), dated 4/12/21, indicated Resident 60 had a self-care deficit. The care plan indicated Resident 60 required extensive assistance from staff for ADLs. There care plan indicated that staff were to encourage the use of the call light for assistance and to extensively assist Resident 60 with eating and hydration needs. On 5/5/21, at 11:35 A.M., during the facility tour, Resident 60 was observed raising their right hand. During a concurrent interview with Resident 60, Resident 60 stated he needed help getting up and needed to drink water. Resident 60's call light was observed behind the head of bed. Resident 60 stated he did not know where the call light was. Following a subsequent observation and concurrent interview with a director of nursing (DON 1), DON 1 confirmed that Resident 60's call light was placed behind Resident 60's head of bed and was not within reach. Resident 60 verbalized to DON 1 that he could not reach the call light and needed a drink of water. DON 1 was observed to move the call light within reach for Resident 60 allowing Resident 60 to use the call light. Once a certified nurse assistant (CNA 2) responded, CNA 2 acknowledged that Resident 60's call light was supposed to be placed within reach to avoid accidents and resident been frustrated calling for help. Review of the policy and procedure titled, Answering Call Light, dated 3/2021, indicated to ensure 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** b. During a review of Resident 18's admission Records indicated the resident was initially admitted on [DATE] and readmitted on [DATE]. The admission Records indicated Resident 18's diagnoses included unstable angina (condition which the heart does not get enough blood flow and causes unexpected chest pain), chronic obstructive pulmonary disease (group of diseases that block airflow and make it difficult to breathe), and cardiomegaly (condition in which the heart is enlarged). During a review of Resident 18's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 3/26/2021 indicated Resident 18 had no cognitive (thought) impairment for daily decision making. During a review of the Resident Council minutes dated 3/9/2021 indicated Resident 18 voiced grieved regarding her call lights not being answered in a timely manner. During an interview on 05/06/21 at 09:02 a.m. Resident 18 stated I have access to my call light. When I use the call light, sometimes the nurses come in and tell me they will come back because they are helping someone else. This problem happens on all shifts. I usually need my diaper change because I'm incontinent. Sometimes I wait about 30 minutes because the nurses forget to comeback. During a concurrent interview and observation on 05/06/21 at 10:05 a.m., Resident 18 pressed her call light. During the observation a green light above Resident 18's room turned on. However, there was no audible alarm sound to alert the staff. During the observation seven staff members were observed passing Resident 18's room without responding to the call light. During the same observation at 10:15 a.m. the call light was answered by a Restorative Nurse Assistant (RNA). The RNA stated Everyone is responsible for answering the call light. There's a light that goes off at the nurse's station and a beeping noise. If someone passes a resident's room and the green light is on then they are supposed to answer the call light. We answer the light and we try to assist them but if we are busy with other residents we are supposed to ask for assistance. We should not tell the resident to wait. We should take care of them right away. c. During a review of Resident 2's admission Records indicated the resident was initially admitted on [DATE] and readmitted on [DATE]. The admission Records indicated Resident 2's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis of one side of the body), muscle weakness, type 2 diabetes (abnormal blood sugar levels), and seizures (bursts of uncontrolled electrical activity in the brain that causes abnormalities in muscle tone or movements). During a review of Resident 2's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 4/25/2021 indicated Resident 18 had no cognitive (thought) impairment with daily decision making. During a review of the Resident Council minutes dated 4/13/2021 indicated Resident 2 commented her call lights were not being answered in a timely manner. During an interview on 05/06/21 at 10:38 a.m., Resident 2 stated My call lights are still not answered on time. This happens on all the shifts. I waited about an hour 3 times this week for the nurses to come. I had to use my phone to call the receptionist. I need help to move from the bed to the bedside commode. They come in and shut off the light like if they helped me. All of my CNA's do this. They come in I tell them I have to use the bathroom and they turn off the light and then go find the nurse. At night they sit at the desk and don't answer the call light. During an interview on 05/07/21 at 10:38 a.m., CNA 9 stated We are short CNA's about 3 to 4 times a week in general. We need more CNA's because we end up getting extra patients. It effects the residents care at times. Today we have 9 CNA's and we are good but sometimes we have 5 CNA's and that is not enough. Any staff can answer a call light. If a call light is going off any staff who sees it should enter the resident's room and check. Sometimes when we are short nurses, we can not answer the call light on time. Sometimes I am busy and I answer the call light I let the resident know I will come back because I am busy. If I'm busy I must ask to for help. It only takes about 5 or 10 min to come back, but when we do not have enough nurses we really can not get to everyone. During an interview on 05/07/21 at 11:12 a.m., CNA 8 stated Anyone can answer a call light. No one should pass up a call light. Sometimes I see nurses pass up call lights. They will answer the lights now just because you are here. The LVN's do not answer the call lights. Some do. Residents complain about call lights not being answered. This is the first time I see the nurses doing their job. I don't ask for help because no one wants to help. We don't have enough CNA's. We use registry at times. This is the first week all of the nurses have all been here. Sometimes when I come in the mornings the schedule is not ready so we don't always know who our residents are. The LVNs make the schedule. When we are fully staffed, we should have 10 CNA's sometimes we have from 4 to 7 CNAs working. During an interview on 05/10/21 at 10 a.m., the Director of Staff Developer (DSD) stated We have complaints of residents not having call lights answered at times. All staff should answer call light. No one should pass up a call light. The resident's issue should be addressed right away. If the staff is busy, they should call someone else to help. The residents should not have to wait at all. They should be assisted right away. No one should have to wait 5 to 10 minutes for a call light to be answered. During an interview on 05/10/21 at 12:15 p.m., CNA 10 stated I feel overwhelmed at times. Sometimes I need help but can't get it. It effects answering call lights because we don't have enough nurses to answer the call lights. Sometimes the residents complain that it takes too long to get help. At times I have seen nurses walk pass call lights without checking on the Residents. A review of the facility's policy and procedure (P/P) titled Answering the Call Light, revised March 2021 indicated When answering call lights, if the resident needs assistance, indicate the approximate time it will take for you to respond. If the residents request is something you can fulfill, complete the task in less than 5 minutes if possible. If you are uncertain as to whether a request can be fulfilled or if you cannot fulfill the resident's request. Ask the nurse supervisor for assistance. If assistance is needed when you enter the room, summon help by using the call signal. Based on observation, interview, and record review facility failed to treat three of 4 residents (2, 18, 173) with respect and dignity. Resident 2 and 18, who needed assistance from staff for activities of daily living (a term used in healthcare to refer to people's daily self-care activities) were not assisted and their call lights either were tuned off without it being answerer or not answered in a timely manner. The deficient practice of turning off the call lights without answering them or not answering them in a timely manner for Resident 2 and 18 could result in the residents not receiving the assistance they needed. Resident 173, used urinals (a plastic bottle that male residents uses to urinate) but the two half full urinals were stored on the resident's bedside table, close to the water pitcher. The deficient practice of not storing urinals away from the bedside table and away from the water pitcher had the potential for Resident 173 to mistakenly drink the urine, spill it on the beside table, which could result in cross contaminations. Findings: a. A review of Resident 173's admission Face sheet indicated the resident was originally admitted to the facility on [DATE], the admission Face sheet indicated Resident 173's diagnoses included type 2 diabetes mellitus (abnormal blood sugar levels), mild cognitive impairment, and altered mental status. A review of Resident 173's Minimum Data Set (MDS), an assessment and care-screening tool, dated 4/28/21, indicated the resident had mildly impaired cognitive (do not have full capacity to understand or to be understood by others) status for daily decision making. The MDS assessment indicated Resident 173 required assistance from staff with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. A review of Care Plans dated 4/22/21, failed to indicate a formulated plan of care for Resident 173 that addressed the needs for assistance from staff for activities of daily living (ADL) specifically targeted to resident's care in the facility. A review of Resident 137's History and Physical assessment dated [DATE] indicated the resident had the capacity to understand and make decisions. A review of Resident 173's Bowel and Bladder Assessment form dated 4/22/21, indicated Resident 173 was occasionally incontinent (did not have control) of bladder function. The assessment indicated the resident continued to utilize the urinal at bedside, accidents and spillage of urine at times and able to feel the urge when needed to urinate. A review of Resident 173's physicians order dated 4/22/21, indicated Furosemide (medicine that increases urination) tablet 40 milligram (mg) 1 tablet by mouth one time a day for heart failure. A review of Resident 173's Medication Administration Record dated 5/2021, indicated the resident was actively receiving furosemide tablet 40 mg, 1 tablet by mouth one time a day for heart failure. On 5/7/21 at 12:04 P.M., during facility tour and observation there were two half full urinals were placed on Resident 173's bedside table, close to the water pitcher. During an interview with the director of nursing (DON) present in the resident's room who confirmed the urinals on the bedside table. The DON stated the urinals were not supposed to be there because it could spill or the resident could accidentally drink urine in place of water, which could cause infections. The DON stated Certified Nursing Attendants (CNA) were supposed to conduct rounds every hour to check on the residents. The DON stated by placing the urinals on the bedside table meant no body had checked on the residents. During interview Resident 173 stated the urinals were not supposed to be placed on his table but he needed to urinate and could not hold it any longer. The resident stated either that or he would have to wet the bed because the medications made him urinate more frequently. On 5/7/21 at 1:44 P.M. during observation and interview CNA 2 stated the residents urinal were not supposed to be left on the bedside table to avoid spills, and cross contamination. CNA 2 stated it was the duty of all staff to ensure they made rounds every hour to check on the resident's care area. CNA 2 stated I was not able to make rounds on Resident 173 on time. On 5/10/21 at 01:35 P.M. during interview the Infection Preventionist (IP) nurse stated the urinals were supposed to be kept on the bed rails and not on the bedside table. IP nurse stated I have witnessed urinals placed on bedside table in the residents room. I replaced it on the bedside rails and informed resident that it is cross contamination putting urinals on bedside table. If it is full resident can call the nurses to empty it. A review of facility's policy and procedure titled Quality of Life-Dignity, dated 2/2020, indicated the residents are treated with dignity and respect at all times. The policy indicated the staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment. The policy indicated demeaning practices and standards of care that compromise dignity are prohibited. staff are expected to promote dignity and assist residents. The policy indicated to promptly responding to a resident's request for toileting assistance. A review of facility's policy and procedure titled Activities of Daily living, dated 3/2018, indicated the residents will be provided with care, treatment and services to ensure that their maintain or improve activities of daily living do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADLs are unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to provide a homelike environment for two of 2 residents (8, 56). Resident 8, who was using a low air loss mattres ([LALM] designed to prevent and treat pressure wounds) was soaked and stained with dark brown material and had an odor of concentrated urine. The deficient practice resulted in an unpleasant odor that permeated in Resident 8's room. Resident 56 had boxes on top of boxes filled with personal belongings, which was placed on the floor close to the bed. The deficient practice created a harzadous environment for Resident 56. Findings: a. On 05/05/21 at 11:53 a.m., observed Resident 8, awake and oriented to name, place, and time. The resident was lying in a bed that was covered with a LALM. The LALM was soaked and stained with dark brown material and had an odor of concentrated urine. During interview Resident 8 stated the LALM had never been cleaned or changed. The resident stated she had asked the maintenance department to clean or replace the existing LALM with a new one. A review of Resident 8's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included pressure ulcer (sores extend below the subcutaneous fat into your deep tissues like muscle, tendons, and ligaments) of the right hip stage 4 (full thickness tissue loss with exposed bone, tendon or muscle with slough or eschar may be present on some parts of the wound bed). A review of of Resident 8's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/14/2021, indicated the resident had no cognitive impairment (ability to think, understand and make daily decisions) with daily decision making. On 05/06/21 at 11:06 a.m., during an interview with the Housekeeping Supervisor (HS) stated curtains and LALM had to be washed once a month but deep cleaning had not been performed due to Covid-19 pandamic. HS stated individual rooms were cleaned but there were no documented evidence. HS stated LALM had to be disinfected for 5 to 10 minutes and left to air dry which was done on a monthly or as needed basis if soiled but could not provide any documented evidence. b. On 05/06/21 at 10:19 a.m., during observation Resident 56 was in bed awake and oriented. The resident had boxes on top of boxes filled with personal belongings, which was placed on the floor close to the bed. According to the Resident 56 her belongings should have been properly arranged into her closets but no one was willing to do it. The observation of the cluster and hazardous environment was acknowledged and confirmed by the maintenance supervisor who said I agreed the belongings should have been arranged into boxes to create home like environment A review of Resident 56's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure). A review of of Resident 56's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/22/2021 indicated the resident had no cognitive impairment (ability to think, understand and make daily decisions) for daily decision making.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident's Care Plans (a document outlining a detailed approach to care customized to an individual resident's need) include measurable objectives and timeframe to meet 12 of 21 residents (2, 7, 11, 25, 26, 32, 41, 42, 56, 57, 172, 173) resident's medical, nursing, and mental and psychosocial needs. Resident 2, 7, 11, 25, 26, 32, 41, 56, 57, 172, 173 who were prescribed insulin (a medication used to treat and regulate abnormal blood sugar) therapy were not adequately monitored for glycated hemoglobin ([HgA1c] blood test that tells the average level of blood sugar over the past 2 to 3 months) to ensure the Interdisciplinary Team ([IDT] involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) in managing the resident's diabetes. Residents 2, 7, 11, 25, 26, 41, 57, 172, and 173 did not have routine HgA1c levels ordered to monitor the resident's goals and outcomes for the diagnosis of diabetes (a condition characterized by high levels of blood sugar which damage the heart, eyes and kidneys [pair of organs responsible for filtering waste materials out of the blood and passing them out of the body as urine, and regulating blood pressure of the body]) as per standard of practice. These deficient practices had the potential to cause Residents 2, 7, 11, 25, 26, 41, 57, 172, 173, to receive suboptimal (less than the highest standard or quality) care related to diabetes, to not know how their blood sugar (BS) levels were managed and if the current insulin therapy was adequate could lead to serious health complications such as damage to important organs such as the heart, kidneys, eyes and the nervous system. Residents 32 and 56, did not have resident centered Care Plans for hospice services or end of Life (palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life). The deficient practice could lead to Resident 32 and 56 not receive the person-centered care needed. Resident 42, who was refusing the administration of Lovenox (blood thinner) did not have Care Plan formulated to address the refusals and to perform blood laboratory as ordered and report to the primary physician. However, the facility did not perform any labs during the duration of Lovenox therapy. Findings: On 05/11/21 at 10:33 AM, during a phone interview the Consultant Pharmacist (CP) stated she completes the Medication Regimen Review ([MRR] a thorough evaluation of the medication regimen) for all of the residents. The CP stated for the residents who were diagnosed with diabetes she made sure there were HgA1c blood levels ordered by the physician. CP stated she would make recommendations to the physician if the HgA1c were not ordered. The CP stated HgA1c levels should be ordered every three months and when the residents showed stable blood sugar levels then the blood test could be reduced to every six months. The CP stated that ordering HgA1c levels every three months was standard of practice, and a diagnostic tool to evaluate the effectiveness of therapy for the resident to determine if changes in medication therapy were necessary. The CP stated HgA1c levels above 8 percent (%) should be evaluated closely and routinely. On 05/11/21 at 11:02 AM, during an interview the Minimal Data Set Coordinator (MDS) stated HgA1c should be documented on how it need to be monitored as part of the residents' Care Plan. The MDS stated medical records department had not been tracking to ensure the residents had HgA1c orders but will do so going forward. The MDS stated diabetic (persons with diabetes) residents on insulin should have HgA1c levels checked every three months. The MDS stated HgA1c was important because it shows if the insulin therapy was effective for the resident and if any changes to the medications need to be made based on the levels obtained. The MDS stated that it was important to have the right medications for diabetic residents to make sure their BS levels are stabilized so that they do not have complications such as coma (a period of prolonged unconsciousness brought on by illness or injury), get hospitalized or die. The MDS stated all diabetic residents should have a baseline HgA1c when admitted to the facility and laboratory services did not stop working even during COVID-19 (highly contagious respiratory infection) pandemic (an infectious disease that has spread across a large region, for instance multiple continents or worldwide, affecting a substantial number of people). On 5/11/21 at 11:51 AM, during an interview the Director of Nursing (DON 2) stated HgA1c should be ordered at admission for diabetic residents and re-ordered every three months to know if the medications were working. The DON 2 stated the care plan for diabetes should include the monitoring for HgA1c. The DON 2 stated if BS levels were not checked and insulin doses not given then the residents could have low or high BS levels, which could lead to coma, hospitalization, sustain ketoacidosis (serious diabetes complication where the body produces excess blood acids), and even die. On 5/11/21 at 12:40 PM, during a phone interview the Medical Doctor (MD 1) stated she usually orders HgA1c levels and when she overlooks to order the level, she gets reminded by the CP. The MD 1 stated HgA1c should be ordered every three months and for stable residents it could be reduced to every six months or yearly thereafter. The MD 1 stated BS levels are not enough to determine effectiveness of the insulin medications that was why HgA1c level was needed to determine if changes in the insulin medications were needed. The MD 1 stated not having HgA1c levels for residents was a concern and should be part of their diabetes care plan. The MD 1 stated it was harmful for the residents when the BS level was not checked, or insulin orders not administered. a. During a review of Resident 2's admission Record, dated 5/10/21, indicated that resident was initially admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 2's Medication Administration Record (MAR) for April and May 2021, indicated the resident was prescribed Insulin Lantus (type of insulin) 20 units (a measure of dosage for insulin) in the morning. The order indicated to hold if BS was less than 100 milligram per deciliter (mg/dL), on 4/7/21. The order indicated to administer Insulin Regular (type of insulin) as per sliding scale (insulin dose dependent on the BS level) subcutaneous (under the skin) before meals and at bedtime on 10/13/18. A review of Resident 2's undated Care Plan indicated to give diabetes medications as ordered by doctor and check fasting serum (liquid part of blood) BS as ordered by doctor. However, the Care Plan did not contain a plan on how and when to monitor the HgA1c levels. A review of Resident 2's clinical chart did not contain a record for HgA1c level physician order or laboratory results since admission on [DATE]. On 5/11/21 at 4:00 PM, during an interview, MDS stated that, after a thorough search, Resident 2's HgA1c level physician order and lab results could not be found. b. A review of Resident 7's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE]. A review of Resident 7's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Glargine (type of insulin) 5 units subcutaneous one time a day and to hold if BS was less than 100 mg/dL dated 3/18/21. The order indicated to administer Insulin Regular (type of insulin) as per sliding scale subcutaneous three times a day before (AC) meals and bedtime (HS) dated 4/6/21. A review of Resident 7's Care Plan dated 1/21/21 indicated to give diabetes medications as ordered by doctor. However, the Care Plan did not contain a plan to monitor for HgA1c levels. A review of Resident 7's clinical chart did not contain a record for HgA1c level physician order or lab results since admission 1/21/21. On 5/11/21 at 4 PM, during an interview MDS stated after a thorough search Resident 7's HgA1c level physician order and lab results could not be found. c. A review of Resident 11's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 11's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Basaglar Kwikpen (type of insulin) 20 units subcutaneous two times a day and to hold for BS less than 100 mg/dL dated 12/9/20 until 5/6/21. The order indicated to administer Lantus 20 units subcutaneous two times a day and to hold if BS was less than 100 mg/dL dated 5/6/21. The order indicated to administer Insulin Regular (type of insulin) as per sliding scale subcutaneous before meals and at bedtime dated 12/12/20. A review of Resident 11's Care Plan dated 10/10/20 indicated to give diabetes medications as ordered by doctor and to check fasting serum BS as ordered by doctor. However, the Care Plan did not contain a plan to monitor for HgA1c levels. A review of Resident 11's clinical chart did not contain a record for HgA1c level physician order or lab results since admission. On 5/11/21 at 4 PM, during an interview MDS stated after a thorough search, Resident 11's HgA1c level physician order and lab results could not be found. d. A review of Resident 25's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 25's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Humulin R (type of insulin) as per sliding scale subcutaneous three times a day dated 3/2/21. A review of Resident 25's Care Plan dated 11/20/20 indicated to give diabetes medications as ordered by the doctor and to check the fasting serum BS as ordered by doctor. However, the Care Plan did not contain a plan to monitor for HgA1c levels. A review of Resident 25's clinical chart did not contain a record for HgA1c level physician order or lab results since admission. On 5/11/21 at 4 PM, during an interview the MDS stated after a thorough search, Resident 25's HgA1c level physician order and lab results could not be found. e. A review of Resident 26's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 26's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Lispro (type of insulin) as per sliding scale subcutaneous before meals and at bedtime dated 4/7/21. A review of Resident 26's Care Plan dated 4/7/21 indicated to give diabetes medications as ordered by doctor and check fasting serum BS as ordered by the doctor. However, the Care Plan did not contain a plan to monitor for HgA1c levels. A review of Resident 26's clinical chart did not contain a record for HgA1c level physician order or lab results since admission. On 5/11/21 at 4 PM, during an interview MDS stated after a thorough search, Resident 26's HgA1c level physician order and lab results could not be found. f. A review of Resident 41's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE] with diagnoses including diabetes. A review of Resident 41's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Glargine (type of insulin) 5 unit subcutaneous two times a day and to hold if BS less than 100 mg/dL dated 9/14/20. A review of Resident 41's Care Plan on 1/2/21 indicated to monitor BS by finger stick as per orders, notify MD of significant changes, and to administer oral medication and/or insulin per orders. However, the Care Plan did not contain a plan to monitor for HgA1c levels. A review of Resident 41's clinical chart did not contain a record for HgA1c level physician order or lab results since admission. On 5/11/21 at 4 PM, during an interview the MDS stated after a thorough search, Resident 41's HgA1c level physician order and lab results could not be found. g. A review of Resident 57's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 57's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Glargine (type of insulin) 15 units subcutaneous two times a day and to hold for BS less than 100 mg/dL dated 1/10/21. A review of Resident 57's Care Plan, dated 7/7/20 indicated to give diabetes medications as ordered by doctor. However, the Care Plan did not contain a plan to monitor for HgA1c levels. A review of Resident 57's clinical chart did not contain a record for HgA1c level physician order or lab results since admission. On 5/11/21 at 4 PM, during an interview the MDS stated after a thorough search, Resident 57's HgA1c level physician order and lab results could not be found. h. A review of Resident 172's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 172's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Glargine (type of insulin) subcutaneous at bedtime and to hold if BS less than 100 mg/dL dated 4/3/21. A review of Resident 172's clinical chart did not contain a record for HgA1c level physician order or lab results since admission. On 5/11/21 at 4 PM, during an interview the MDS stated after a thorough search, Resident 172's HgA1c level physician order and lab results could not be found. i. A review of Resident 173's admission Record, dated 5/10/21, indicated the resident was initially admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 173's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Humulin R (type of insulin) as per sliding scale subcutaneous before meals and at bedtime dated 4/22/21. A review of Resident 173's Care Plan dated 4/22/21 indicated to give diabetes medications as ordered by doctor. However, the Care Plan did not contain a plan to monitor for HgA1c levels. A review of Resident 173's clinical chart did not contain a record for HgA1c level physician order or lab results since admission. On 5/11/21 at 4 PM, during an interview the MDS stated after a thorough search, Resident 173's HgA1c level physician order and lab results could not be found. A review of the facility's policy and procedure document titled Diabetes - Clinical Protocol, dated November 2020 indicated that: 1. For residents who meet the criteria for diabetes testing, the physician will order pertinent screening; for example, A1C, fasting plasma glucose, or 2-hour plasma glucose with oral glucose load. 2. As indicated, the Physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters a. Examples of blood glucose monitoring 1) . 2) . 3) For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin .; monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale insulin; . Monitor A1C on admission .or when diabetes is diagnosed, and every 6 months thereafter. 3. The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record and care plan.l. A review of Resident 42's admission Face sheet indicated the resident was originally admitted to the facility on [DATE], The admission Face sheet indicated Resident 42's diagnoses included laceration of unspecified part of colon, muscle weakness (generalized), other abnormalities of gait and mobility, and hypotension (low blood pressure). A review of Resident 42's Minimum Data Set (MDS), an assessment and care-screening tool, dated 3//21 indicated the resident had intact cognitive (had full capacity to understand or to be understood by others) skills for daily decision making. Resident 42 required supervision from staff with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. A review of Resident 42's History and Physical assessment notes dated 3/3/21 indicated the resident had the capacity to understand and make decisions. A review of Resident 42's Physician order dated 3/3/21, indicated to administer Aspirin enteric coated (barrier applied to oral medication that prevents its dissolution or disintegration in the gastric environment) tablet delayed release 81 milligram (mg), give 1 tablet by mouth one time a day for cerebral vascular accident (stroke) prophylaxis (prevention). The physician order dated 3/3/21, indicated to inject subcutaneous (under the skin) the Lovenox 30 mg/0.3 ml, inject 30 mg. A review of the Care Plans dated 3/3/21, indicated Resident 42 did not have Care Plan for the use of anticoagulant (blood thinner) therapy, Aspirin 81 milligram (mg) by mouth one time a day. A review of Care Plan dated 3/3/21, for Lovenox (blood thinner) therapy for deep vein thrombosis (a blood clot in a deep vein, usually in the legs) prophylaxis (prevention) indicated blood laboratory works as ordered, and monitor, document and report to the primary physician. However, the facility did not perform any labs during the duration of Lovenox therapy. On 5/8/21 at 10:17 A.M., during observation and interviews, Resident 42 stated the only issue I have in the facility is about the blood thinners I have been receiving since after my abdominal surgery. I do not know how long I am intended to take these medications and no one had explained to me. I have tried calling the doctor to explain the process but no answer. I spoke to the nurses and they do not answer my question. On 5/8/21 at 10:25 A.M., during interview Registered Nurse (RN 1) stated Resident 42 receives Lovenox and Aspirin therapy as result of abdominal surgery. RN 1 stated the resident refused the Lovenox most times and questions reason why and how long the therapy was to continue. During interview RN 1 stated the facility had not yet informed the prescribing physician about the resident's refusals. On 05/11/21 at 10:08 A.M., during record review of Pharmacy Medication Regimen Review (MRR) dated 4/1/21 and 4/29/21, indicated Resident 42 had been receiving Lovenox subcutaneous every 12 hours along with Aspirin 81 mg. The MRR notes indicated the Consultant Pharmacist recommended to re-evaluate the need for both Lovenox and Aspirin. The notes indicated this combination may lead to increased risk for bleeding and increasing clotting time. On 05/11/21 at 10:08 A.M., during MRR review the Pharmacy Consultant recommended Resident 42 Lovenox be monitored by conducting basic metabolic panel ([BMP] a group of 8 tests that measures several substances in the blood) and complete blood count ([CBC] a group of tests that evaluate the cells that circulate in blood) every 2 weeks while on the medication. However, the recommendations were not Care Planed as part of the goals and interventions. On 5/11/21 at 11:59 A.M. during record review and intermittent interview Licensed Vocational Nurse (LVN 1) stated the consultant pharmacist visits the facility at the beginning of each month to review every resident's medication, and the RN was supposed to follow up with those recommendations by notifying the physician. LVN 1 stated once the physician agreed with the recommendations the staff would follow up and ensure the order was carried out. LVN 1 stated in this case, there was no follow up of any kind and nothing had been done for Resident 42. The recommendations for BMP and CBC every 2 weeks while on Lovenox recommended by the Consultant Pharmacist had not been incorporated in the residents treatment. LVN 1 acknowledge that even though Resident 42 was receiving Lovenox and Aspirin at the same time, there were no Care Plan formulated for the use of Aspirin therapy. On 5/11/21 at 12:25 P.M., during interview Case manager (CM) stated the Pharmacy Consultant visits the facility beginning of the month and made recommendations. The CM stated she printed all recommendation and hand them over to the DON, and RN for follow up. CM stated she did not understand reason why there was no follow up with Resident 42's primary physician regarding the recommendations made by the Pharmacy Consultant. 05/11/21 at 12:35 PM during interview and record review MDS nurse stated I do the MDS and Care Plans. I omitted to Care Plan for the use of this medication for Resident 42. A review of facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 12/2016, indicated the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. b. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. c. The comprehensive person centered care plan will identify the professional services that are responsible for each element of care. j. A review of Resident 32's admission Record Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cancer, and hypertension (high blood pressure). A review of Resident 32's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/12/2021 indicated the resident did not have the capacity to understand and make decision. A review of the Hospice recertification form dated 4/5/2021 to 6/3/2021 indicated Resident 32 was readmitted to Hospice services due to cerebral infarction (stroke). A review of the Hospice binder for Resident 32 had blank care plan forms and blank comprehensive care plan forms. On 05/10/21 at 12:15 p.m., during an interview with the Director of Nursing (DON) stated the Hospice agency and the facility had to develop a an individualized care plan because care plan drove Resident 32's care. k. A review of Resident 59's admission Record (Face Sheet) indicated the resident was initially admitted to the facility on [DATE] and readmitted with diagnoses that included but were not limited to chronic kidney disease (inability of the kidney to function) and hyperkalemia (high potassium levels). A review of the Hospice recertification form dated 4/6/2021 to 6/4/2021 indicated Resident 59 was readmitted to Hospice services due to the diagnosis of chronic kidney disease (inability of the kidney to function). A review of the Hospice binder for Resident 59 had blank care plan forms and blank comprehensive care plan forms. On 05/10/21 at 11:26 a.m., in a concurrent interview and record review with the MDS nurse stated the facility and Hospice agency did not develop a plan of care. The MDS nurse further stated not developing a plan of care for Hospice services could lead to the staff not be able to provide personalize care. The facility's policy an procedure titled Care Plan revised 2016 indicated a person-centered care plan shall be developed that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident's call light was withing reach and promptly attempt to her needs for one of one sampled resident (Resident 59). This deficient practice resulted in Resident 59 falling and hitting her head on the side table and the base of the bed resulting in pain and bruising. Findings: During a review of Resident 59's admission Record (Face Sheet) indicated the resident was initially admitted to the facility on [DATE]. Resident 59 diagnoses included Chronic Kidney disease (inability of the kidney to function) and Hyperkalemia (high potassium levels). During a review of Resident 59's Minimum Data Set (MDS), an assessment and care-screening tool, dated 4/16/2021, the MDS indicated Resident 59 was able to make herself understood and understood others and was moderately impaired of cognition skills (thought process). The MDS indicated Resident 59 was totally depended on staff for activities of daily living (ADLs). During a review of Resident 59's Fall Risk Data Collection (FRD), dated 11/9/16, the FRD indicated a score of 14 (score of 10 or above represents high risk for falls). The FRD indicated Resident 59 required assist in mobility with bowel and bladder eliminations. During a review of Resident 59's care plan titled, Fall Risk Prevention, dated 10/19/17, the care plan indicated the facility will provide a safe environment, free of any clutters, kept call light within reach and answer promptly. During a review of Resident 59's Nursing Progress Notes (NPN), dated 5/3/2021 at 11:25 p.m., the NPN indicated Resident 59 was found on the floor next to her bed on her right side in a fetal position with her head resting on the base of the bedside table. The NPN indicated no injuries noted. The NPN indicated the facility staff did not complete the 72 hours neurological assessment charting post fall as indicated in the facility's policy. During an observation and interview on 05/06/21 at 11:50 a.m., in the presence and translation of Licensed Vocational Nurse 5 (LVN 5), Resident 59 stated she fell on 5/3/2021 while trying to reach for the call light when suddenly she lid off the mattress hitting her head on the base of the bedside table while her legs were hanging. Resident 59 stated she had pain in her head and all over her body. Resident 59 was observed with discolorations to bilateral lower arms which according to the resident, the discolorations were sustained by the staff rough handling her while picking her up from the floor. LVN 5 confirmed the call light was placed on the bed side lamp table further away from Resident 59's reach. During an interview on 5/06/21, at 1:31 p.m., Director of Staff Development (DSD) stated she was informed by LVN 6 Resident 59 was found on the floor on her side without any injury on 5/3/2021 at 11 p.m. During an interview on 5/06/21, at 4:01 p.m., LVN 6 stated on 5/3/21 at 11: 10 p.m., she heard Resident 59 calling out for help. LVN 6 stated upon entering the room, Resident 59 was on the floor in a fetal position with her head resting on the base of the bed side table. LVN 6 stated Resident 59 denied any pain at that time. LVN 6 stated there was no 72 hours charting or assessment initiated, or x ray (image of a body part) order obtained. During a review of the facility's policy and procedures (P/P) titled, Falls and Falls Risk Managing, revised 2018, the P/P indicated the staff would monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. (how about assessment post fall and physician notification).

Based on observation, interview, and record review the facility failed to implement its policy and procedures (P/P), Controlled Medication Disposal, and include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Consultant Pharmacist ([CP] specialist trained to assist with long-term care residents with special medications needs and educate both residents and healthcare providers) on the Antibiotic or Controlled Drug Record (Controlled Substance [CS]- medications that have the potential for abuse and dependency) logs for the final disposition (process of returning and/or destroying unused medications) of the CS for 3/2021 and 4/2021. This deficient practice had the potential for CS diversion (transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and risk for residents and staff in the facility to accidentally be exposed to harmful medications than can lead to physical harm and hospitalization. Findings: During a concurrent interview and review of the CS logs for 3/2021 through 4/2021, on 5/6/21 at 1:38 p.m., the CS logs were inconsistent some having only one staff signature and other days no signatures noted. DON 1 stated the final CS disposition process was conducted by her and any available Licensed Vocational Nurse (LVN) or RN. The DON 1 stated she and the Licensed Nurse disposing a CS would sign the CS log to verify count. DON 1 stated, she then would lock the CS in a cabinet located in her office and wait for final disposition. The DON 1 stated only she had access to the locked cabinet, and once a month, or as needed, she would dispose of the CS's in a white and blue pharmaceutical waste bucket (containers for disposing medications) with an RN or with the CP. The DON 1 stated the disposed medications in the bucket were for the CS from the month of April 2021. The DON 1 stated she was unable to locate the CP signature log for the CS logs for 3/2021 through 4/2021. The DON 1 stated the final CS disposition had to be done in the presence of an RN or DON and the CP logs signed by them upon the disposition of the CS. The DON 1 acknowledged the understanding of accountability involved with CS's, and stated she understood the potential for diversion of CS's, safety, and accidental exposure to harmful medications for the residents and staff. The DON 1 stated she failed to follow the facility policy to dispose of the CS's and sign the Antibiotic or Controlled Drug Record (CS) logs in the presence of the CP. During an interview on 5/7/2021 at 9:40 a.m., the Administrator (ADM) stated the final CS disposition should be done with an RN or DON and the CP and should not be done with only an LVN or RN. The ADMIN stated the facility failed to dispose of the CS according to policy with the DON and CP. During an interview on 5/11/2021 at 11:51 a.m., the DON 2 stated upon the discharge of a resident or discontinuation of a resident's CS, the CS was surrendered to the DON. The DON 2 stated at the time of surrendering of the CS, the licensed nursing staff and the DON would account for all the remaining doses and sign the CS log. The DON 2 stated once a month or as needed, the final CS disposition was done with the DON and CP and both would sign the CS log. The DON 2 stated CS should have been supervised disposition to avoid diversion, have accountability and prevent accidental exposure of harmful medications to residents and staff. During a review of facility's P/P titled, Controlled Medication Disposal, dated 4/2008, the P/P indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. The P/P indicated the DON and the CP were responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Also, schedule II-V controlled substances remining in the facility after a resident had been discharged , or the order discontinued, were disposed of in the facility by the DON or designated facility RN in conjunction with the CP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility failed to follow up with consultant Pharmacist monthly Medication regimen review (MRR) and the recommendations for the prescribing physician towards resident's care on two of four sampled residents (Residents 42 and 60) This deficient practice resulted in Residents 42 and 60, who were on anticoagulant (chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time) medications, not having laboratory works done every two weeks as ordered by the physician to ensure the residents were receiving their therapeutic dose. Findings: During a review of Resident 42's admission (Face Sheet) indicated the resident was originally admitted to the facility on [DATE]. Resident 42's diagnoses included laceration of unspecified part of colon (longest part of the large intestine [a tube-like organ connected to the small intestine at one end and the anus at the other]), muscle weakness (generalized), other abnormalities of gait and mobility, and hypotension (low blood pressure). During a review of Resident 42's Minimum Data Set (MDS), an assessment and care-screening tool, dated 3/21, the MDS indicated Resident 42 had intact cognitive (had full capacity to understand or to be understood by others) in thought process. During a review of Resident 42's physician's order, dated 3/3/21, indicated Aspirin (anticoagulant and fever reducer) tablet delayed release 81 milligrams ([mg] units of measurement), give one (1) tablet by mouth one time a day. During a review of Resident 42's physician order, dated 3/3/21, indicated Lovenox (anticoagulant) 30 mg/0.3ml, inject 30mg subcutaneous. During a review of Resident 42's care plan, dated 3/3/21, the care plan indicated no care plan was crated for the use of the anticoagulant Aspirin 81 mg by mouth once a day. During a review of Resident 42's care plan, dated 3/3/21, for Lovenox therapy for Deep Vein Thrombosis ([DVT] blood clot in a deep vein, usually in the legs) indicated lab works as ordered, monitor, document and report to primary physician any changes. During a review of Resident 42's MRR, the facility pharmacist recommended Resident 42 to have lab work monitored every two weeks while the resident is on Lovenox. The record of Resident 42's labs did not indicate it was done or monitored. During a review of Resident 42's laboratory work starting 3/3/21, there was no laboratory work found in the clinical chart. During a review of Resident 60's Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 60's diagnoses included acquired absence of right leg below knee, muscle weakness, gangrene (dead of body tissue). During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60 had impaired cognitive in thought process. During a review of Resident 60's care plans, dated 5/5/21, the care plans did not indicate Resident 60's use of two types of antiplatelet (medication that works by preventing platelets [clopidogrel and Apixaban]) at the same time. During a concurrent interview and review of the MRR, on 5/11/21 at 11:59 a.m., LVN 1 stated the consultant pharmacist came to the facility at the beginning of each month to review every resident's medication, and the Registered Nurse (RN) was supposed to follow up with any recommendations and notify the physicians of any recommendation by the Consultant pharmacy (CP), if the physician agreed with the recommendation, the staff followed up with it. LVN 1 stated there was no follow-up with the CP recommendations for Residents 42 and 60. During an interview on 5/11/21 at 12:25 p.m., the Case manager (CM) stated CP's recommendations were given to the Director of Nursing (DON), and RN for follow up. CM confirmed there was no follow up with the CP's recommendations for Residents 42 and 60 done with the primary physicians. During a review of facility's Policy and Procedure(P/P), titled Medication Regimen Reviews, dated 5/2019, the P/P indicated the CP performed a medication regimen review (MRR) for every resident in the facility receiving medication to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication such as duplicative therapies or omissions of ordered medications. The P/P indicated if the physician did not provide a timely response, or the consultant Pharmacist identified no action had been taken, it was the duty of the pharmacist to contact the Medical Director, and the Administrator.

Based on observation, interview, and record review the facility failed to: 1. Remove and discard from use one expired medication bubble pack (a medication package that holds individual medication pills in separate sealed compartments) for Resident 59, one insulin (a medication used to treat and regulate high blood sugar levels) vial (glass medication storage container) for Resident 41, one insulin pen (insulin injection device) for Resident 61, and one bronchodilator (medication used to prevent symptoms of Asthma [a condition that makes breathing difficult]) for Resident 52, from the medication cart, in one of two inspected medication carts (Medication Cart Station 3). 2. Label one insulin vial for Residents 61, with an open date in accordance with the manufacturer's requirements, in one of two inspected medication carts (Medication Cart Station 3). 3. Store one insulin pen for Resident 61, in the refrigerator, in accordance with the manufacturer's requirements in one of two inspected medication (Medication Cart Station 3). 4. Remove and discard from use one expired medication bubble pack for Resident 39, from the medication cart, in one of two inspected medication carts (Medication Cart Station 1). 5. Label one insulin pen for Residents 11, with an open date in accordance with the manufacturer's requirements, in one of two inspected medication carts (Medication Cart Station 1). 6. Store one insulin vial for Resident 10, in the refrigerator, in accordance with the manufacturer's requirements, in one of two inspected medication (Medication Cart Station 1). 7. Remove and discard from use three expired antibiotic (medication used to treat infections) intravenous (medication that is given through the veins) bags (type medication storage device) for Resident 51, and one expired antibiotic intravenous bag for Resident 172 from the refrigerator, in one of two inspected medication rooms (Medication room station 3). 8. Monitor the temperature of the second medication refrigerator, in one of two inspected medication rooms (Medication room station 3). 9. Remove and discard from use one expired emergency medication kit ( storage container for emergency use medications) for facility stock from the medication room, and one expired vaccine vial for facility stock, one expired insulin vial for Resident 324, from the refrigerator, in one of two inspected medication rooms (Medication room yellow zone). These deficient practices increased the risk that Residents 10, 11, 39, 41, 51, 52, 59, 61, 172, and 324 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: On 5/5/21 at 10:14 AM, during an observation of Medication Cart Station 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored and labeled contrary to facility policies: 1. One open and expired Lantus (a brand name for a type of insulin) vial for Resident 41 was found stored at room temperature and labeled with an open date of 3/13/21. According to the manufacturer's product storage and labeling, opened Lantus insulin vials can be stored at room temperature below 86 degrees Fahrenheit or refrigerated between 36 to 46 degrees Fahrenheit and used or discarded within 28 days of opening vial. 2. One open and expired Humalog Kwikpen (a brand name for a type of insulin injection device) vial for Resident 61 was found stored at room temperature and labeled with an expiration date of 4/3/21. According to the manufacturer's product storage and labeling, opened Humalog Kwikpens can be stored at room temperature below 86 degrees Fahrenheit and discarded within 28 days of opening pen even if the pen still contains Humalog. 3. One open and expired Advair HFA (a brand name for a bronchodilator) oral inhaler (portable device for administering medication by breathing in) for Resident 52, was found stored at room temperature with the device medication dose counter reading 000. According to the manufacturer's product storage and labeling, opened Advair HFA inhalers can be stored at room temperature between 68 and 77 degrees Fahrenheit and should be discarded when the medication dose counter reads 000. 4. One Hydrocodone/APAP (combination opioid [narcotic] medication for treating pain) 5-325 (strength of medication) mg ([mg]-unit of measure of mass) tablet medication bubble pack for resident 59 was found stored at room temperature labeled with an expiration date of 3/21. According to manufacturer's specifications, facility policy, and pharmacy label, expired medications should not be used and discarded by the labeled expiration date. 5. One open Humulin R (a brand name for a type of insulin) vial for Resident 61 was found stored at room temperature and not labeled with a date on which use at room temperature began. According to the manufacturer's product storage and labeling, opened Humulin R insulin vials can be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 31 days of opening vial or once they've been stored at room temperature. 6. One unopened Humulin N Kwikpen (a brand name for a type of insulin injection) for Resident 61 was found stored at room temperature and not labeled with a date on which use at room temperature began. According to the manufacturer's product storage and labeling, unopened Humulin N Kwikpens can be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 14 days when storage at room temperature began. On 5/5/21 at 11:11 AM, during an interview, Licensed Vocation Nurse (LVN)1 stated that the insulin vials and pens are not stored properly and not labeled with an open use date to know when they should be discarded and therefore considered expired. LVN1 stated the insulin vials are good for 28 days once opened. LVN1 stated these insulins should not be administered to residents since the insulins have lost their potency and the residents blood sugars will not be controlled. LVN1 stated the residents blood sugar can end up being high or low and cause them to go to the hospital and possibly have life threatening conditions like coma and eventually death when using expired insulin. LVN1 stated that the pain medication had expired end of March according to the pharmacy label on the bubble pack and using this medication would not be effective in treating the resident's pain. LVN1 stated that the resident would continue to have pain that can get worse, possibly causing psychosocial harm and inability to continue with normal daily activities. LVN1 stated when nurses come across unlabeled or expired medications, they should dispose of the medication. LVN1 stated that the Advair HFA medication dose counter reads 000, which means the device no longer contains medication. LVN1 stated if the resident does not receive this medication then the resident may have adverse breathing complications, asthma attacks and get hospitalized . On 5/6/21 at 11:56 AM, during an observation of the facility Station 3 medication room, the following was found: 1. Three unopened Vancomycin (an antibiotic) 750 mg intravenous (within a vein) bags (storage container for medication) for Resident 51 in the refrigerator labeled with an expiration date of 4/14/21, 4/30/21, and 4/30/21. According to manufacturer's specifications, facility policy, and pharmacy label, expired medications should not be used and discarded by the labeled expiration date. 2. One unopened Penicillin G (an antibiotic) 15 MU ([million units] - unit of measure) intravenous bags for Resident 172 in the refrigerator labeled with an expiration date of 4/22/21. According to manufacturer's specifications, facility policy, and pharmacy label, expired medications should not be used and discarded by the labeled expiration date. 3. One refrigerator, stored with medications, without a temperature monitoring log. According to facility policy and manufacturer's specifications, medication requiring refrigeration need to be stored at specific refrigerator temperatures. On 05/6/21 at 12:13 PM, during an interview, Registered Nurse (RN)1 stated that antibiotic bags stored in the refrigerator are expired. RN1 stated the LVN's and the Consultant Pharmacist (CP) check for expired medications and dispose of them in the white and blue buckets (containers indicated for disposing medications). RN1 stated that giving expired antibiotics to residents will not help with their treatment because the antibiotic is not effective, and the residents can become septic (life threatening condition when the body's response to an infection damages its own tissues), go to the hospital or die. RN1 stated that the refrigerator temperature should be checked every morning and evening and documented on the refrigerator monitoring log. RN1 stated there is no refrigerator monitoring log on the second refrigerator. RN1 stated it is unknown what temperature the medications in the second refrigerator have been stored at. RN1 stated the temperature of both refrigerators should be monitored to ensure the medications are kept at certain temperature ranges according to the manufacturer guidelines and their facility policy. RN1 stated the medications in the second refrigerator will not be effective for the residents, and they should be considered expired and disposed of. On 5/6/21 at 1:06 PM, during an observation of the facility yellow zone medication room, the following was found: 1. One open Fluzone (brand name of influenza [flu - a viral infection of the lungs, nose and throat that can be deadly specially in high risk people]) vaccine multidose vials ([MDV]-vials containing more than one dose of medication) was found stored in the refrigerator and not labeled with a date when the vial was used/opened. According to the manufacturer's product storage and labeling, open Fluzone MDV's should be stored between 36 to 46 degrees Fahrenheit and discarded within 28 days of opening or using the vial. 2. One open and expired Humalog (type of insulin) insulin vial for Resident 324 in the refrigerator labeled with an open date of 1/6/20. According to the manufacturer's product storage and labeling, opened Humalog insulin vials can be stored at room temperature below 86 degrees Fahrenheit or refrigerated between 36 to 46 degrees Fahrenheit, and used or discarded within 28 days of opening vial. 3. One expired emergency medication kit labeled with an expiration date of 4/21. According to pharmacy label and facility policy, expired emergency medication kits should not be used and discarded by the labeled expiration date. On 05/6/21 at 1:12 PM, during an interview, LVN3 stated flu vaccine was not labeled when it was opened, and that it was past 28 days since the Humalog vial was opened. LVN3 stated both medications are considered expired and should be discarded. LVN3 stated all nursing shifts should check for expired medications and emergency kits and dispose them. LVN3 stated the facility failed to dispose of expired medications and emergency kits. LVN3 stated expired insulin has low potency (full power) and giving expired insulin to residents means they will not receive the full dose and not help with their blood sugars, have low or high blood sugars, get hospitalized , and possibly die. LVN3 stated the influenza vaccine is considered expired and if used for residents will not give them the protection they need against the flu. LVN3 stated if not protected then the residents will be vulnerable to getting the flu, having complications and adverse effects from the flu, and possibly dying. LVN3 stated the emergency medication was expired since the end of April and it should have been replaced with a new kit from the pharmacy. LVN3 stated emergency medications are needed in emergency situations and used from the emergency medication kits. LVN3 stated giving residents expired medications during emergency situations will only make the situation worse and lead to resident death. On 05/7/21 at 9:40 AM, during an interview, the Administrator (ADMIN) stated the emergency medication kits should be checked daily for expiration dates, and if the kits are opened or expired should be addressed the same day by replacing with new ones from the pharmacy. The ADMIN stated that medication refrigerator temperature logs should be checked twice daily to make sure the temperature is in the appropriate range for the medications, so they maintain their effectiveness. The ADMIN stated the facility failed to check the expiration dates and dispose of expired emergency medication kits from the medication room. The ADMIN acknowledged the second refrigerator in Station 3 medication room did not have a record or log for the monitoring of the temperatures and stated that the medications should be discarded. On 5/7/21 at 11:43 AM, during an observation of Medication Cart Station 1, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored and labeled contrary to facility policies: 1. One unopened Humulin R (A brand name for a type of insulin injection) vial for Resident 10 was found stored at room temperature and not labeled with a date on which storage at room temperature began. According to the manufacturer's product labeling, unopened Humulin R insulin vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded within 31 days of opening or once they've been stored at room temperature. 2. One open Lantus Solostar pen (a brand name for a type of insulin injection device) for Resident 11 was found stored at room temperature and not labeled with a date on which storage at room temperature began. According to the manufacturer's product labeling, open Lantus Solostar pens should be stored at room temperature up to 86 degrees Fahrenheit and used or discarded within 28 days of opening or storing at room temperature. 3. One Hydrocodone/APAP 5-325 mg tablet medication bubble pack for resident 39 was found stored at room temperature labeled with an expiration date of 12/08/20. According to manufacturer's specifications, facility policy, and pharmacy label, expired medications should not be used and discarded. On 5/7/21 at 12:12 PM, during an interview, LVN4 stated that the insulin vials and pens are not stored properly and are expired because they are not labeled with an open use date to know when they should be discarded and not used. LVN4 stated she should not administer expire insulin to residents because they will not be effective and will not work to stabilize the residents blood sugar levels. LVN4 stated the expired insulins will cause the resident to have adverse effects such as low or high blood sugar levels, coma, and hospitalizations. LVN4 stated that the pain medication had expired on 12/8/20 and using this medication would not relieve the resident's pain. LVN4 stated that the resident would continue to have pain that can get worse, causing the resident harm. On 05/11/21 at 11:51 AM, during an interview, DON2 stated that expired narcotic medications have lost their potency. The DON2 stated that administering expired narcotic to residents will not control their pain, cause them more suffering from the pain, and potentially require them to have to take more potent narcotics to relieve their pain. The DON2 stated that uncontrolled pain will get in the way of residents' quality of life. The DON2 stated that the insulin vial and pens found in Medication 1, 3 and yellow zone medication room were stored inappropriately, and they are considered expired. The DON2 stated that MDV are good for 28 days, and when used beyond the 28 days their potency is not maintained and will not be effective controlling the residents' BS levels. The DON2 also stated that MDV used beyond 28 days can leads to contamination and infection for the residents. The DON2 stated that the Advair with a medication dose counter showing 000 indicates there is no more medication left in the device. The DON2 stated that a new Advair should be ordered from pharmacy. The DON2 stated that Advair is a long acting medication needed for Asthma (a condition that makes breathing difficult). The DON2 stated administering a medication that potentially not delivering the full dose to the resident will not work to treat the breathing difficulty and lead the resident to have an asthma attack and get hospitalized . The DON2 stated that the Vancomycin and Penicillin G antibiotics were expired and not effective in treating the residents' infection, which will make the infection worse, possibly lead to sepsis (a life-threatening complication of an infection), hospitalization and death. The DON2 stated that expired influenza vaccines will not provide protection against the flu and put the residents at risk of getting the flu and potentially dying. The DON2 stated that the emergency medication kit found in the yellow zone medication room indicates it is expired. The DON2 stated that the medications in the emergency kit are used during emergency situations and administering expired medications to residents during an emergency can make the situation worse, possibly causing the resident to get hospitalized and die. The DON2 stated that the second refrigerator in Medication Room station 3 does not have a log to monitor the temperature of the medications that are stored inside. The DON2 stated that if there are no temperature monitoring logs then it will not be known if the medications were being maintained at the temperature ranges specified by the medication manufacturer. The DON2 stated that if the temperature of the refrigerator is below or above the designated range then the potency and quality of the medications will be affected. The DON2 stated that if the temperature of the medications are not being monitored then they are considered expired and should not be administered to residents, because giving expired medications will not be effective in treating the residents condition and possibly make the condition worse and harm the resident. Review of facility's policy titled Administering Medications, dated April 2019, indicated that The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of facility's policy titled Storage of Medication, dated April 2008, indicated that 1. Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. 2. Medications requiring storage at 'room temperature' are kept at temperature ranging from 15 degrees Celsius (59 degrees Fahrenheit) to 30 degrees Celsius (86 degrees Fahrenheit). 3. Medications requiring 'refrigeration' or 'temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit)' are kept in a refrigerator with a thermometer to allow temperature monitoring. 4. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Review of facility's policy titled Labeling of Medication Containers dated April 2019 indicated that: 1. Labels for individual resident medications include all necessary information, such as .the expiration date when applicable 2. Labels for stock medications include all the necessary information, such as .the expiration date when applicable . Review of facility's document titled Insulin Administration, dated September 2014, indicated to Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening. Review of facility's undated document titled Guide for Special Handling of Medications indicated: 1. insulin products (except Levemir, Novolin R, Novolin N, Novolin 70/30) to store unopened vials in the refrigerator. May store opened vials at room temperature or in the refrigerator. Discard 28 days after opening or removed from refrigeration. 2. Insulin pens and cartridges to store at room temperature and do not refrigerate after opening. Expiration dates vary by manufacturer. Multi dose vials for injection to discard 28 days after opening. 3. Multi dose vials for injection to discard 28 days after opening. Review of facilities policy titled Emergency Medications, dated April 2007, indicated that The Consultant Pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit. Review of facility's policy titled Emergency Pharmacy Service and Emergency Kits, dated April 2008, indicated that The kits are checked by a pharmacist at least monthly.

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety and prepare foods free of visible signs of insects or rodents, when the following was observed: 1. Potatoes with green sprouts 2. One molded orange 3. Three oranges with dry brown dark spots. 4. An entire bundle of bananas with dark brown spots. 5. Gnats were flying on one sunken cantaloupe. 6. Old wilted fruit (multiple oranges, bananas and cantaloups) and vegetables (brown and red potatoes) were observed in a box under the storage cabinet. 7. Three old potatoes under the fruit and vegetable storage cabinet on the floor This deficient practice had the potential to cause a wide spread of foodborne illness and bacterial infections among resident's receiving food services in the facility. Findings: During kitchen observations, on 5/5/21 at 10:36 a.m., the following was observed and confirmed by DS the following observations: 1. Potatoes with green sprouts 2. One molded orange 3. Three oranges with dry brown dark spots. 4. An entire bundle of bananas with dark brown spots. 5. Gnats were flying on one sunken cantaloupe. 6. Old wilted fruit (multiple oranges, bananas and cantaloups) and vegetables (brown and red potatoes) were observed in a box under the storage cabinet. 7. Three old potatoes under the fruit and vegetable storage cabinet on the floor During an interview with the Dietary Supervisor (DS) on the same day at 10:38 a.m., stated when shown and asked what was the issue with the cantaloupe, he states that's mold, when asked about the appearance of the oranges he states that's old. DS was asked to describe the potatoes and he states that they are also old. DS stated, he has a responsibility to supervise food service for patients, employees, and visitors in a nursing home environment. Reviews menus and supervises the handling, preparation, and storage of food and assign work schedules for food services employees. The DS stated that residents could become sick if they were to be served fruits and vegetables that are old and have mold on them. A review of the facility's pest control service report, dated 5/3/21, showed a pest management service had rendered services to the facility for gnats on 3/1/21,3/23.21,4/5/21,4/27/21 and 5/3/21. The DS stated they had been having issues and have been receiving pest control services for the gnats. During a review of the facility's policy and procedure titled Preventing Foodborne Illness-Safety and dated disclosed the facility strives to minimize the risk of foodborne illness to the resident's, by maintaining clean food storage at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement its quality assurance, planning and implementation policy (QAPI) by: 1. Not identifying residents receiving insulin (medication to reduce or prevent high blood sugar). 2. Not monitoring and documenting blood sugar levels for residents on insulin therapy. 3. Not administering and documenting insulin administration for 21 residents. 4. Not obtaining physician orders for monitoring hemoglobin A1C (blood test that measures blood sugar levels over the past 3 months) for 9 out of 21 residents (Residents 2, 7, 11, 25, 26, 41, 57, 172, and 173). 5. Not implementing a physician's order for monitoring routine laboratory test every six months for 1 out of one resident (Resident 59). 6. Not acting on pharmacy consultant recommendations on medication regimen review irregularities for several months. 7. Not investigating a resident who had an unwitnessed fall. These deficient practices placed residents at risk for injuries, comma or death. Findings: On 5/11/21 at 4 PM, during an interview the Minimum Data Set Nurse (MDS) stated after a thorough search Resident 2, 7, 11, 25, 26, 41, 57, 172, and 173's medical records, there were no physicians' orders and lab results for HgA1c. a.A review of Resident 2's admission Record, dated 5/10/21, indicated the resident was admitted to the facility on [DATE] with a diagnosis including diabetes (high blood sugar). A review of Resident 2's Medication Administration Record (MAR) for April and May 2021, indicated the resident was prescribed insulin Lantus (medication to decrease blood sugar levels) 20 units (a unit of measurement) in the morning, and Regular insulin per sliding scale (insulin dose dependent on the BS level) subcutaneous ([SQ] under the skin) before meals (AC) and at bedtime (HS). A review of Resident 2's clinical chart did not contain a record for HgA1c level physician order or laboratory results since admission on [DATE]. b. A review of Resident 7's admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses including diabetes. A review of Resident 7's Order Summary Report, dated 5/10/21, indicated the resident was prescribed Glargine (type of insulin) 5 units subcutaneous daily. The order also indicated to administer Regular insulin per sliding scale SQ three times a day AC and HS. d. A review of Resident 11's admission record indicated the resident was initially admitted to the facility on [DATE] with a diagnosis including diabetes. A review of Resident 11's order summary report dated 5/10/21, indicated the resident was receiving Basaglar Kwikpen (type of insulin) 20 units subcutaneous two times a day (BID), Lantus 20 units SQ BID and Regular insulin as per sliding scale SQ AC and HS. e. A review of Resident 25's admission record indicated the resident was admitted to the facility on [DATE] with diagnosis including diabetes. A review of Resident 25's order summary report, dated 3/2/21, indicated the resident was prescribed Humulin R (type of insulin) per sliding scale SQ three times a day (TID). f. A review of Resident 26's admission record indicated the resident was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of Resident 26's order summary report, dated 4/7/21, indicated the resident was prescribed Lispro (type of insulin) per sliding scale SQ, AC and HS. g. A review of Resident 41's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes. A review of Resident 41's order summary report dated 9/14/20 indicated the resident was prescribed Glargine 5 units SQ BID. h. A review of Resident 57's admission record indicated the resident was admitted to the facility on [DATE] with diagnosis including diabetes. A review of Resident 57's order summary report dated 1/10/21 indicated the resident was prescribed Glargine 15 units SQ BID. i. A review of Resident 172's admission record indicated the resident was admitted to the facility on [DATE] with a diagnosis including diabetes. A review of Resident 172's order summary report dated 4/3/21 indicated the resident was prescribed Glargine SQ at HS. j. A review of Resident 173's admission record indicated the resident was admitted to the facility on [DATE] with a diagnosis including diabetes. A review of Resident 173's order summary report dated 4/22/21, indicated the resident was prescribed Humulin R (type of insulin) per sliding scale SQ and HS. 5. A review of Resident 59's Face Sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 59's diagnoses included Chronic Kidney disease (inability of the kidney to function like they normally should) and Hyperkalemia ( high potassium levels). On 05/11/21, at 12 p. m., during a concurrent interview and review of Resident 59's Medication Regimen Review (MRR) dated 3/1/2021 to 3/31/2021, the Quality Assurance Nurse (QAN) stated the pharmacist's indicated lab work was not found in the chart as ordered for the resident's potassium to be drawn every six months. QAN stated the staff failed to follow Resident 59's physician's routine order. QAN also stated this failure could cause Resident 59 to have a heart attack. A review of the physician's order summary dated 5/6/2021, indicated Resident 59's potassium level will be checked every six months. A review of Resident 59's physician's order dated 5/6/2021, indicated potassium chloride extended release 10 milliequivalent. ([mEq] unit of measurement), Give one tablet by mouth (PO) one time a day (QD) for supplement, with food and a full glass of water. A review of Resident 59's medical records dated 2/17/2020 indicated potassium blood level of 4.8 mEq /per liter (unit of measurement). On 05/11/21, at 1:28 p. m., during a QAPI interview, the Administrator (ADM) stated the facility used a spread sheet to track all identified issues such as falls, antibiotic use, and in-house pressure ulcers. The ADM also stated the QAPI team met monthly and the Director of Nursing (DON) discussed all nursing issues. The ADM stated he had only working in the facility for a month and was still looking into critical concerns. According to the ADM, not monitoring blood sugar levels, administering insulin for several residents could result in serious harm. The ADM added that the Quality Assurance Nurse (QAA) did not identify these issues until yesterday 5/10/2021, after surveyors brought it to the facility's attention. A review of the facility's undated QAPI policy indicated it shall focus on systems and processes on identifying system gaps and follow-up on areas of opportunities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility to provide food at a palatable, attractive, and appetizing temperature for four of four sampled Residents by: a. Ensuring Resident 222's vegetable and grilled cheese sandwich were not served cold. b. Ensuring Resident 2 was not served food that was ugly and looked like dog food and is rubbery. c. Ensuring Resident 18's daily meals for breakfast, lunch, and dinner were not served cold. d. Ensuring Resident 31's breakfast was not served cold. This deficient practice had the potential to result in decreased nutritional intake resulting in the development of pressure injuries (damage to skin and underlying tissue over bony areas), and delayed recovery from illness. Findings: a. A review of Resident 222's undated admission record indicated the facility originally admitted Resident 222 on 3/9/2016 and readmitted on [DATE]. Resident 2's diagnosis included chronic obstructive pulmonary disease (COPD [group of diseases that block airflow and make it difficult to breathe]), diabetes mellitus (condition that effects the way the body processes blood sugar), and non-pressure chronic ulcer (open sore resulting from breakdown of the skin and tissues.) A review of Resident 222's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 2/12/2021, indicated Resident 18 had no cognitive (understanding and knowledge) impairment. During an interview on 05/06/21 at 10:50 a.m., Resident 222 stated, The food is sometimes not cooked all the way. My food is served lukewarm. It is like this for all of my meals. During an observation and a concurrent interview on 05/06/21 at 12:42 p.m., Resident 222 received her food tray. Resident 222 touched her vegetables and grilled cheese sandwich and stated the food is cold. During an observation and a concurrent interview on 05/07/21 at 09:06 a.m., Resident 222 stated her eggs were cold, but she did not tell anyone because she is used to eating cold food. During an interview on 05/07/21 at 10:38 a.m., a certified nurse assistant (CNA 9) acknowledged that CNAs are responsible for delivering the food trays to the residents. CNA 9 stated the food cart is brought to the end of the hallway and no trays are delivered until a licensed vocational nurse (LVN) verifies each tray for correctness. The CNA stated the LVN compares the diet order with the tray and the Resident name to verify they match. The CNA stated it takes approximately 15 to 20 minutes to deliver the food to all the Residents rooms in this hallway. During an interview on 5/7/21 at 11:12 a.m., CNA 8 stated Some residents do not like the eggs. When I pass out the trays, they are hot but sometimes the trays sit awhile. It might take about 7 min to get the food to the residents. During an observation and a concurrent interview on 05/07/21 at 12:35 p.m., Resident 222's cheese quesadilla was observed being placed on food cart in kitchen. At 12:36 p.m., a grilled cheese and potato tot sample tray was prepared. At 12:44 p.m. Resident 222's food tray is taken out of kitchen. At 12:45 p.m. Resident 222's food tray arrived at the end of the hallway and had to be verified for correctness by a LVN. An LVN passes trays but does not verify the trays. At 12:49 p.m., two CNAs attempt to locate an LVN to verify the residents' food trays. At 12:51 p.m. the LVN returns to verify the residents' food trays for correctness. The LVN completes the verification at 12:56 p.m. At 1:05 p.m, Resident 222's food tray is delivered. Resident 222 touches her cheese quesadilla and states Everything is cold, but I will eat anyway. b. A review of Resident 2's undated admission record indicated the facility originally admitted Resident 2 on 6/21/2017 and readmitted on [DATE]. Resident 2's diagnosis included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis of one side of the body), muscle weakness, type 2 Diabetes (a condition that effects the way the body processes blood sugar), and seizures (bursts of uncontrolled electrical activity in the brain that causes abnormalities in muscle tone or movements). A review of Resident 2's MDS dated [DATE], indicated Resident 18 had no cognitive impairment. A review of Resident 2's physician's Orders dated 10/13/2018, indicated the physician ordered a reduced concentrated sweets (RCS), no added salt, and regular texture diet. A review of Resident 2's dietary profile/preferences form dated 4/14/21, indicated Resident 2 had not been served food to her liking. The dietary profile indicated that Resident 2 stated, At times I don't like the food, but I ask for a substitute and I get it all the time. During an interview on 05/06/21 at 10:38 a.m., Resident 2 stated, The food is ugly It looks like dog food and is rubbery. They will only replace it with peanut butter. I just eat it because I'm tired asking for different food. I see them bring my roommate's food and just leave the food without feeding her. During an observation and a concurrent interview on 05/07/21 at 1:16 p.m., Resident 2 stated, My food is hard as a rock. It is warm but inedible. It's too hard. This is chicken, a biscuit and veg (vegetables). The biscuit is wet. Upon observation, the chicken patty appears to be dry and hard. Resident 2 tries to cut chicken the patty and has difficulty. The biscuit is wet and appears mushy at the bottom. During an interview on 05/10/21 at 1:01 p.m., the Dietary Supervisor (DS) acknowledged that Resident 2 requests different food frequently and the facility provides alternatives. The DS could not verbalize whether the alternatives were acceptable to Resident 2. c. A review of Resident 18's undated admission record indicated the facility originally admitted Resident 18 on 10/16/2019 and was readmitted on [DATE]. Resident 18's diagnoses included unstable angina (condition which the heart does not get enough blood flow and causes unexpected chest pain), COPD, and cardiomegaly (condition in which the heart is enlarged). A review of Resident 18's MDS, dated [DATE], indicated Resident 18 had no cognitive impairment. A review of Resident 18's physician's orders dated 3/31/2021, indicated the physician ordered a RCS with a regular texture, thin consistency, and no salt added diet. A review of the Resident Council Minutes dated 3/9/2021, indicated Resident 18 stated, the food is cold. During an interview on 05/06/21 at 09:02 a.m., Resident 18 stated My food is cold for all three meals and I don't eat cold food. d. A review of Resident 31's undated admission record indicated the facility originally admitted Resident 31 on 12/1/2020 and was readmitted on [DATE]. Resident 31's's diagnoses included cellulitis (bacterial infection involving the inner layers of the skin) of the right lower limb, difficulty walking, type 2 diabetes, and necrotizing fasciitis (a bacterial infection that destroys tissue under the skin.) A review of Resident 31's MDS, dated [DATE], indicated Resident 31 had no cognitive impairment. During an interview on 05/07/21 at 09:09 a.m., Resident 31 stated My food was fine this morning but its normally cold. Most people would send it back. Lunch is okay and dinner is okay but in the mornings my eggs and food are always cold. The trays sit outside for a long time. Breakfast is served at 7:30 a.m. but we don't get it until about 20 min after they put the tray out on the cart and I'm right across from the kitchen. Sometimes I get it from the cart myself because I am tired waiting. They have the food on the cart and it just sits there. A review of the facility's policy and procedure (P/P) titled, Food and Nutrition Services, revised October 2017, indicated, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.