**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure discharge planning needs were met for one out of two sampled residents (Resident 1) when: 1. Resident 1 and his wife (CG, caregiver) were not provided required instructions or education on how to properly care for a wound; and 2. Resident 1 was not discharged from the facility with home health services (care provided in the home to include a nurse who would perform wound care, assessments, and education on wound care and dressing changes). This failure had the potential for the wound to worsen and become infected. Findings: 1. A review of the facility's policies and procedures (P&P) titled, Discharging the Resident, dated 9/1/24, indicated, the resident and/or responsible party would receive discharge instructions. A review of the undated document titled, Resident-Based Competencies (demonstrated skills that ensured an individual had the ability to provide adequate care), indicated, when a resident was discharged from the facility, the discharge would be safe and effective (successful). A review of the admission Record, dated 6/1/25, indicated resident 1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia C5-C7, incomplete (messages from the brain to the nerves that made arms and legs move did not always work, which caused a total loss of arm and leg movement at times. C5-C7 was the cervical spinal area in the neck), fusion of the spine cervical region (a surgical procedure that permanently joined two or more moving pieces of the spine together), and bacteremia (bacteria in the blood stream). Resident 1 was his own RP (responsible party, made own decisions). A review of the admission MDS, dated [DATE], indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 1 scored 15 out of 15, which indicated intact memory. The admission MDS indicated, Resident 1 required substantial assistance to dress his lower body, rolling in bed from left to right, and both arms and legs were impaired (limited ability to use). A review of the Admission/readmission Evaluation/Assessment (admission assessment), dated 6/1/25, indicated, Resident 1 did not have any open wounds upon admission to the facility. The admission assessment indicated Resident 1 had discoloration between both buttocks (butt cheeks). The admission assessment indicated, Resident 1 had an old pressure scar (the color and thickness of a pressure scar could indicate the stage of healing after a pressure ulcer was no longer open) and skin discoloration to the right buttock. A review of the Initial Wound Evaluation and Management Summary, dated 6/5/25, indicated, Resident 1 had a wound to the coccyx (also known as the tailbone, located between the buttocks) and the wound doctor performed a surgical debridement (removal of dead tissue) that resulted in dead muscle being removed from the coccyx wound. The Initial Wound Evaluation and Management Summary, indicated, there was a new diagnosis of stage 4 pressure wound of the right coccyx, and a new wound care treatment was required to manage and heal the wound. A review of the Physician's Orders, dated 6/5/25, indicated, a new wound care treatment to Resident 1's coccyx area included: cleaning the wound with normal saline (sterile salty water), pat dry and apply zinc oxide (a medicated cream that promoted wound healing) to the peri-wound (the intact skin that surrounded a wound), apply silver alginate (a medicated dressing) to the wound bed and cover with a foam dressing. During an interview on 6/25/25 at 9:41 am, Resident 1 stated, I did not have any open wounds when I was admitted to the facility. No one taught me or CG how to care for my wound before and I've been to the emergency room three times since I was discharged [from the facility] due to my wound worsening. Resident 1 stated, the emergency room sent me home with wound care supplies and set me up with home health. CG joined the phone call with Resident 1's permission and stated, I was not present during the discharge instructions, we were not given any [wound care] supplies, and I was not given any instruction or education on caring for the wound. CG confirmed that Resident 1 would not be able to perform his own wound care and required CG to perform wound care and dressing changes the coccyx. During a concurrent interview and record review on 6/25/25 at 10:01 am, with Wound Certified Registered Nurse (WCRN) Resident 1's Progress Note, dated 6/6/25 was reviewed. WCRN confirmed, the Progress Note, indicated, Resident 1 was discharged from the facility on 6/6/25, WCRN was the nurse that performed the discharge, and WCRN had provided wound care education. WCRN confirmed Resident 1's wound was located on the coccyx and Resident 1 would not be able to perform his own wound care. WCRN stated, education provided included education on treatments and signs and symptoms of infection. WCRN stated an inability to recall if Resident 1's care giver had been provided with education and instruction on how to perform wound care per the physician's order. WCRN confirmed, the Progress Note, did not indicate who the wound care education was provided to, the supplies needed for wound care, or that a return demonstration (showing someone how to perform wound care and observing them perform the wound care) had been performed with Resident 1's caregiver (CG). During a concurrent interview and record review on 6/25/25 at 10:37 am, with Director of Nursing, (DON) Progress Note, dated 6/6/25 and written by WCRN was reviewed. DON stated, if the patient is alert and oriented [their own responsible party], and able to perform a return demonstration, the wound care education is provided to them. DON confirmed, Resident 1's wound was located on his coccyx and Resident 1 would not be able to perform his own wound care. DON stated, if Resident 1's CG would perform wound care, the CG should have been provided the education. DON confirmed, the Progress Note did not indicate that CG was instructed on wound care or performing dressing changes. During a review of Resident 1's Discharge Summary, dated 6/5/25, indicated, Resident 1 would be discharged home on 6/6/25 and WCRN completed the Nursing Services section. The section labeled Skin Condition Upon Discharge (where the nurse documented any skin concerns, including wounds, and the physician ordered wound care was described) did not include the stage 4 pressure wound of the coccyx and there was no instruction on how to care for it. 2. A review of the facility's P&P titled, Discharging the Resident, dated 9/1/24, indicated, the facility would assist the resident with coordinating care that was required after discharging from the facility such as home health or needed equipment. A review of the Discharge Planning care plan (a document that described resident goals and care required to reach goals), dated 6/6/25, indicated, Resident 1 preferred to be discharged home, would be assessed for discharge needs and would be provided education related to discharge needs. During an interview on 6/20/25 at 3:00 pm, Registered Nurse (RN) confirmed, RN was the nurse who performed Resident 1's admission to the facility on 6/1/25. RN stated, Resident 1 did not want to be in the facility, wanted to go home, and I had to convince him to stay and complete his antibiotic therapy. During an interview on 6/25/25 at 9:41 am, Resident 1 stated, I don't remember anyone offering me home health. No one taught me or CG how to care for my wound and I've been to the emergency room three times since I was discharged [from the facility] due to my wound worsening. Resident 1 stated, the emergency room sent me home with wound care supplies and set me up with home health. Resident 1 confirmed he did not want to be in the facility and RN had convinced him to stay and complete his antibiotic therapy. During a review of Resident 1's Discharge Summary, dated 6/5/25, indicated, the Social Services Director (SSD) completed the section titled, Social Services. The SSD's section indicated that Resident 1 would be discharged home on 6/6/25. The section labeled discharge services and referrals, indicated Resident 1 was not ordered home health services and would need to be seen by his primary care physician within seven days after discharge. During a telephone interview on 6/25/25, at 3:33 pm, SSD stated, There was a case conference note that indicated Resident 1's understanding of leaving the facility unplanned, education was provided, and Resident 1 was notified that he would be required to make a follow up appointment with the doctor after discharge. SSD confirmed, the note would be provided via secured email. SSD confirmed that Resident 1 did not want to be in the facility and wanted to be discharged after the antibiotic therapy was completed on 6/6/25. On 6/27/25 at 7:00 am, Resident 1's provided an IDT Conference Note,, dated 6/5/25 and locked (after a note was written the writer locked it, indicating the note was complete) on 6/19/25, was reviewed. The IDT Conference Note indicated that SSD completed the form, this was an admission conference, and an active discharge plan was being developed for Resident 1 to discharge from the facility the next day (6/6/25). The IDT Conference Note,' indicated, SSD would follow up with any needed appointments and home health. The note indicated, Resident 1 declined home health and understood the risks of leaving unplanned. The IDT Conference Note did not include education provided regarding the dangers associated with declining home health for wound care, that wound care supplies would be needed, or where the wound care supplies could be obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the discharge Minimum Data Set (MDS, a resident assessment tool) was accurate for one out of two sampled residents (Resident 1) when the discharge MDS did not reflect Resident 1's stage 4 (a deep wound that could expose muscle, tendon, or bone) coccyx (also known as the tailbone, located between the buttocks) wound at discharge. This caused an inaccurate reflection of Resident 1's health status and skin condition at discharge and had the potential to impact the discharge planning process. Findings: A review of the Long-Term Care facility Resident Assessment Instrument 3.0 User's Manual (RAI, a manual that provided clear guidance about how to complete the MDS), dated [DATE], indicated, when a resident was discharged from the facility, an assessment was required. The RAI indicated the intent of Section M: Skin Conditions, was to document the presence of wounds. A review of the admission Record, dated 6/1/25, indicated resident 1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia C5-C7, incomplete (messages from the brain to the nerves that made arms and legs work did not always reach the nerves, which caused a total loss of arm and leg movement sometimes. C5-C7 was the spinal area in the neck), fusion of the spine cervical region (a surgical procedure that permanently joined two or more moving pieces of the spine together, cervical region was in the neck area), and bacteremia (bacteria in the blood stream). Resident 1 was his own RP (responsible party, made own decisions). During a concurrent interview and record review on 6/20/25 at 12:30 pm, with MDS Coordinator, Resident 1's admission MDS, Section M: Skin Conditions was reviewed. MDS Coordinator confirmed, the admission MDS indicated, Resident 1 was admitted with two unstageable pressure injuries (a wound that cannot be fully seen) that presented as deep tissue injuries (intact skin that appeared to be discolored due to damage of underlying soft tissue pressure). A review of the Admission/readmission Evaluation/Assessment (admission assessment), dated 6/1/25, indicated, upon the admission assessment, Resident 1 did not have any open wounds. The admission assessment indicated Resident 1 had discoloration between both buttocks (butt cheeks). The admission assessment indicated Resident 1 had an old pressure scar (the color and thickness of a pressure scar indicated the stage of healing after a pressure ulcer was no longer open) and skin discoloration to the right buttock. A review of the Progress Note, dated 6/2/25, indicated, Resident 1 had an open area to the coccyx. A review of the Initial Wound Evaluation and Management Summary, dated 6/5/25, indicated that the wound doctor performed a surgical debridement (removal of dead tissue) of the right coccyx and removed dead tissue and muscle. The Initial Wound Evaluation and Management Summary, indicated a new diagnosis of stage 4 pressure wound of the right coccyx. During a concurrent interview and record review on 6/24/25 at 11:35 am, with MDS Coordinator, Resident 1's discharge MDS, dated [DATE], was reviewed. MDS Coordinator confirmed, the discharge MDS, Section M: Skin Conditions, indicated, Resident 1 was discharged with two unstageable pressure injuries that were present upon admission and did not include the physician diagnosed stage 4 pressure ulcer to the coccyx. During an interview on 6/24/25 at 3:04 pm, the MDS Coordinator confirmed the discharge MDS, dated [DATE], should have reflected Resident 1's stage 4 pressure ulcer to the coccyx and it did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their wound prevention, maintenance, and wound care policies and procedures (P&P) for three out of three sampled residents (Residents 1, 2, and 3) when: 1A. Resident 1 was provided wound care without a physician's order; and 1B. Skin assessments did not consistently reflect the condition of the skin or wound, and the discharge skin assessment was not completed; and 1C. A change of condition was not documented; and 2. Residents 1, 2, and 3 were not provided with repositioning every two hours. These failures contributed to Resident 1's wound development and placed residents at an increased risk for a delay in wound healing, decline in health status, and could negatively impact their psychosocial well-being. Findings: 1A. A review of the facility's P&P titled, Wound Care, indicated, a physician's order was required prior to wound care being provided. A review of the admission Record, dated 6/1/25, indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia C5-C7 incomplete (messages from the brain to the nerves that made arms and legs move did not always work, which caused a total loss of arm and leg movement at times. C5-C7 was the cervical spinal area in the neck), type 2 diabetes mellitus with diabetic neuropathy (inability to control blood sugar that caused nerve damage), muscle weakness, and anemia (decreased amount of red blood cells resulting in a lack of oxygen being carried to the body's tissues.) Resident 1 was his own RP (responsible party, made own decisions). During a concurrent interview and record review on 6/20/25 at 3:00 pm, with Registered Nurse (RN), Resident 1's Nursing Admission/readmission Evaluation/Assessment (admission assessment), dated 6/1/25 was reviewed. RN confirmed performing the admission assessment and stated, the admission assessment indicated, there was no open areas to Resident 1's skin. RN reviewed a progress note, titled Alert Note, dated 6/1/25, and confirmed, the Alert Note, indicated, RN changed dressing (a material that was applied over skin or a wound) on Resident 1's coccyx (also known as the tailbone, located between the buttocks). RN stated, Resident 1 came to the facility with a foam dressing (a padded dressing) on, I applied a new foam dressing for an intervention of safety and skin integrity. There is no order needed. During a concurrent interview and record review on 6/20/25 at 3:27 pm, with Director of Nursing (DON), Resident 1's Physician's orders were reviewed. DON confirmed, a Physician's order was required for nursing to perform dressing changed and confirmed there was no physician order for a dressing change present on 6/1/25. 1B. A review of the facility's (P&P) titled, Prevention of Pressure Injuries, revised 4/1/20, indicated, facility staff would perform skin assessments upon admission, daily, and at discharge. The P&P indicated, Identify any signs of developing pressure injuries (i.e. non-blanchable [discolored skin that did not turn white when pressed] erythema (reddening of the skin]). A review of the P&P titled, Pressure Ulcer Management, revised 7/1/23, indicated, the assessment of a pressure sore included a description of the wound, the stage classification [staging a wound was how the wound was classified, based on the appearance, size, and weather it was an open or closed wound], and appearance of drainage or necrotic [dead] tissue. A review of the Job Description: Treatment Nurse [TN] RN/LPN [Registered Nurse/Licensed Nurse], dated 10/1/16, indicated the TN was responsible for documenting informative and descriptive nursing notes (progress notes), as well as the resident's response to the care. A review of the Job Description: Registered Nurse/RN, dated 2/1/24, indicated the RN was responsible for documenting informative and descriptive nursing notes (progress notes), as well as the resident's response to the care. During a concurrent interview and record review on 6/20/25 at 3:00 pm, with RN, Resident 1's admission assessment, dated 6/1/25 was reviewed. RN confirmed, the section titled, L. Skin Evaluation, indicated, Resident 1 had excoriation (red, raw, or superficial scratches to the skin) near the peri area (skin that surrounded your private parts), discoloration between both buttocks (butt cheeks), and the right buttock had an old pressure scar (thick skin that remained after an open wound had closed) and the skin was discolored. RN confirmed, the section of the admission assessment labeled 1c. Resident has wounds or skin integrity concerns present on admission, was marked as no. RN confirmed, selecting no was inaccurate, and RN should have selected yes due to skin integrity concerns. RN reviewed a progress note titled, Alert Note, dated 6/1/25 and confirmed, the Alert Note, contained additional skin assessment documentation that included Resident 1 arriving to the facility with a coccyx dressing in place and that RN had replaced the old dressing with a new one. RN confirmed, the assessment did not include a description of the coccyx area. During a concurrent interview and record review on 6/25/25 at 10:16 am, with Unit Manager/Licensed Nurse (UN/LN), Resident 1's progress note, titled, Nurses Note, dated 6/2/25 and time stamped at 9:49 am, was reviewed. UM/LN confirmed that the Nurses Note indicated, UN/LN assessed a 3.1 centimeter (cm) in length, opened area to Resident 1's skin, next to the coccyx area on the right buttock that contained slough (dead tissue). UN/LN confirmed the open wound was not staged and stated, if there was a RN here, I would have asked the RN to assess and stage the wound. I don't recall if there was an RN here or not. UM/LN confirmed, when the treatment nurse was not working, UM/LN would perform wound care treatments and stated, I can't stage [wounds], the RN has to. (Resident 1's assigned nurse on 6/2/25 was a RN) A review of the Nursing-Weekly Summary, dated 6/2/25 and time stamped at 10:01 am, indicated, Wound Certified Registered Nurse (WCRN) performed an assessment on Resident 1. The skin assessment section indicated that Resident 1 had excoriation near the peri area, discoloration between both buttocks, and the right buttock had an old pressure scar and the skin was discolored. The documentation was identically written to RN's admission skin assessment. The skin assessment section indicated that there were no new skin issues. The Nursing-Weekly Summary included an area for additional notes. The additional note section indicated that Resident 1 declined having a skin assessment performed. A review of the Nursing-Daily Skilled Charting Form, dated 6/2/25 and time stamped 10:12 am, indicated WCRN documented a second skin assessment, indicating Resident 1 had excoriation near the peri area, discoloration between both buttocks, and the right buttock had an old pressure scar and the skin was discolored. The documentation was identically written to RN's admission skin assessment and the Nursing-Weekly Summary (what WCRN had documented at 10:01 am). There was no additional note that indicated Resident 1 had declined a skin assessment. A review of the Nursing-Daily Skilled Charting Form, dated 6/3/25, indicated Resident 1 did not have any wounds, the skin color was normal, and interventions were in place to aid in wound healing. A review of the Nursing-Daily Skilled Charting Form, dated 6/4/25, indicated, Resident 1 did not have any wounds, the skin color was normal, interventions were in place to aide in wound healing, and teaching was provided regarding treatment for a linear (in the shape of a straight line) open area to the coccyx. A review of the Skin & Wound Evaluation, dated 6/4/25, indicated that TN B had performed a wound assessment. TN B documented her wound assessment as an unstageable deep tissue injury (DTI, deep tissue injuries are not open wounds) to the right gluteus (the big muscle inside the butt cheek), and it was present upon admission. The Skin & Wound Evaluation, indicated, Resident 1's wound measured 7.6 cm in length and 4.2 cm in width. The wound bed contained slough. TN B did not indicate on the Skin & Wound Evaluation that Resident 1's wound was on the coccyx or had increased in size. A review of the Initial Wound Evaluation and Management Summary, dated 6/5/25, indicated that the wound doctor performed a surgical debridement (removal of dead tissue) of the right coccyx and removed dead tissue and muscle. The Initial Wound Evaluation and Management Summary, indicated a new diagnosis of stage 4 pressure wound of the right coccyx, full thickness (extended beyond the first two layers of skin and extended into muscle, fat, or bones and was considered a severe wound). The Initial Wound Evaluation and Management Summary, indicated the wound doctor's plan for treatment was to apply a primary dressing (applied directly onto the wound) calcium alginate with silver (a sterile antimicrobial dressing that absorbed drainage) once a day and as needed if the dressing became soiled or damaged. The Initial Wound Evaluation and Management Summary, indicated, the wound doctor's plan for treatment was to apply gauze island dressing (a padded dressing) as a secondary dressing (applied over the primary dressing). A review of the Physician's Orders, dated 6/5/25, indicated, Treatment: unstageable DTI to right gluteus extending to coccyx: Cleanse with normal saline [sterile, salty water], pat dry and apply zinc oxide [medicated cream to promote wound healing] to peri wound [intact skin that surrounded the wound], silver alginate to wound bed and cover with foam dressing. The directions were to change the dressing every day and as needed. A review of the Discharge Summary, dated 6/5/25, signed and dated 6/6/25 by WCRN, indicated, Resident 1 was being discharged home (per Resident 1's request). The section titled, Skin Condition Upon Discharge, indicated Resident 1 had a deep tissue injury to the right gluteus extending to the coccyx and Resident 1 was to monitor for .increase in size, shape, skin breakdown, and/or signs and symptoms of infection until resolved. There was no review or assessment of the stage 4 pressure ulcer to the coccyx or information regarding the treatment plan that the wound doctor initiated. During a concurrent interview and record review on 6/25/25, at 10:37 am, with Director of Nursing (DON), admission assessment, dated 6/1/25, progress note, titled, Nurses Note, dated 6/2/25 and time stamped at 9:49 am, Nursing-Weekly Summary, dated 6/2/25 and time stamped at 10:01 am, Nursing-Daily Skilled Charting Form, dated 6/2/25 and time stamped 10:12 am, Nursing-Daily Skilled Charting Form, dated 6/3/25, Nursing-Daily Skilled Charting Form, dated 6/3/25, Skin & Wound Evaluation, dated 6/4/25, Initial Wound Evaluation and Management Summary, dated 6/5/25, and Discharge Summary, dated 6/5/25 was reviewed. DON confirmed wound care assessments and documentation did not consistently reflect the condition of the skin, the location of the wound, or appearance of the wound, and confirmed the discharge skin assessment was not completed. DON confirmed, none of the skin assessments included the stage of the wound and stated, the nurse assessing the wound is responsible for staging it. During the interview, WCRN joined and confirmed being Resident 1's assigned nurse on 6/2/25 and stated, I don't remember if I was notified that Resident 1's wound had changed. WCRN confirmed, both skin assessments that WCRN had documented on 6/2/25 were identically typed when compared to RN's admission skin assessment on 6/1/25, appeared to be copied and pasted, and was not able to recall if WCRN documented or copied and pasted the assessment. WCRN confirmed that there were two separate assessments documented on 6/2/25, one daily and one weekly. WCRN confirmed both documents contained a skin assessment and stated, I didn't assess his skin, he refused. 1C. A review of the facility's P&P titled, Prevention of Pressure Injuries, revised 4/1/25, indicated, facility staff would Evaluate, report, and document potential changes in the skin. A review of Resident 1's admission MDS, dated [DATE], indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 1 scored 15 out of 15, which indicated intact memory. The admission MDS indicated Resident 1 required substantial assistance to roll in bed from left to right and both arms and legs were impaired (limited ability to use). During a concurrent interview and record review on 6/20/25 at 3:00 pm, with RN, Resident 1's admission assessment, dated 6/1/25 was reviewed. RN confirmed, the section titled, L. Skin Evaluation (the assessment of the skin), indicated Resident 1 did not have any open wounds upon admission. During a concurrent interview and record review on 6/25/25 at 10:16 am, with UN/LN, Resident 1's admission assessment, dated 6/1/25 was reviewed. UN/LN confirmed, the admission assessment did not indicate Resident 1 had an open wound. Resident 1's progress note, titled, Nurses Note, dated 6/2/25, was reviewed. UM/LN confirmed that the Nurses Note indicated, UN/LN assessed a 3.1 cm in length, opened area to Resident 1's skin, next to the coccyx area on the right buttock that contained slough. UN/LN confirmed, prior to performing a skin assessment, UN/LN should review the previous skin assessment and could not recall if she had. UN/LN stated, it would be considered a change of condition and confirmed, the required change of condition documentation was not completed. During an interview on 6/25/25 at 10:37 am, with DON, Resident 1's admission assessment and progress note, titled, Nurses Note, dated 6/2/25 was reviewed. DON confirmed, the assessments indicated a change of condition and there was no change of condition present in the chart. 2. A review of the facility's P&P titled, Pressure Ulcer Management, revised 7/1/23, indicated, CNAs will attestate [prove, usually through documentation] for their shift that their residents were repositioned at lease every two hours. During a concurrent interview and record review on 6/20/25, with Certified Nurse Assistant (CNA) C, Resident 1's task schedule (POC, the area of the electronic medical record where the CNAs documented care provided to residents), dated 6/1/25 through 6/6/25 was reviewed. CNA C confirmed the POC indicated Resident 1 was to be repositioned every shift, not every two hours. CNA C stated, residents are repositioned every two hours and we only chart once a day. Director of Staff Development (DSD) joined the interview and was asked how the CNAs documented that residents were provided with repositioning every two hours. DSD stated, if your resident required repositioning every two hours, then it should be documented every two hours. DSD confirmed, residents with wounds required to be repositioned every two hours and the POC indicated, Resident 1 was repositioned once a shift. A review of the admission Record, dated 4/29/25, indicated that Resident 2 was admitted to the facility on [DATE] with the diagnoses of severe protein-calorie malnutrition (unintended weight loss caused by disease processes or inadequate food consumption), generalized muscle weakness, and difficulty in walking. A review of Resident 2's admission/ 5-day MDS assessment, dated 5/5/25 indicated, a BIMS score of 12 out of 15 (moderately impaired) and required partial/moderate assistance with rolling from side to side in bed. A review of the Wound Evaluation & Management Summary, dated 5/29/25, indicated, Resident 2 had a stage 4 pressure wound of the left coccyx, full thickness. A review of the Physician's Order indicated, facility staff would encourage repositioning every two hours and as needed. A review of the POC, dated 6/1/25 through 6/25/25, indicated CNAs would turn and reposition Resident 1 every shift, not every two hours. A review of admission Record, dated 3/25/25, indicated Resident 3 was admitted to the facility on [DATE] with the diagnosis of muscle weakness and difficulty with walking. A review of Resident 3's admission/ 5-day MDS assessment, indicated that Resident 3 was dependent upon staff to roll from side to side in bed. A review of the Wound Evaluation & Management Summary, dated 4/29/25, indicated Resident 2 had a stage 4 pressure wound of the coccyx, full thickness and required to be repositioned per the facility's protocol. A review of the POC, dated 6/1/25 through 6/25/25, indicated CNAs would turn and reposition Resident 3 every shift, not every two hours. During an interview on 6/25/25 at 9:41 am, Resident 1 stated, they [facility staff] didn't turn me every two hours and confirmed, Resident 1 required assistance with repositioning. During a concurrent interview and record review on 6/25/25 at 2:00 pm, with DON, Resident 2 and 3's POC, dated 6/1/25 through 6/25/25 was reviewed. DON confirmed the POC did not indicate that Residents 2 and 3 were being repositioned every two hours and the POC indicated they were being repositioned every shift. During an interview on 6/25/25 at 2:29 pm, Resident 3 stated, they don't offer to reposition me, I have to ask, and I only get repositioned, maybe three to four times a day.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that 1 (Resident #38) of 4 residents reviewed for medication administration was assessed for their ability to self-administer medications. Specifically, Resident #38 expressed a desire to self-administer their medications, and without first assessing the resident to determine if they were clinically appropriate and safe to do so, the facility allowed the resident to self-administer a nebulizer treatment while unsupervised by staff and denied the resident the right to self-administer their inhaler. Findings included: A facility policy titled, Self-Administration of Medications, reviewed 10/2024, indicated, Residents have the right to self-administer medications when it is clinically appropriate and safe for the resident to do so. The policy specified, 1. As part of their overall evaluation, resident's mental and physical abilities will be considered to determine whether self-administering medications is clinically appropriate for the resident. Resident #38's admission Record indicated the facility admitted the resident on 05/21/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, acute and chronic respiratory failure with hypoxia (low oxygen level), and muscle weakness. Resident #38's Care Plan Report included a focus area, initiated 05/21/2024 and revised 02/23/2025, that indicated the resident had an alteration in their respiratory system with acute symptoms and had a high risk for the development of cardio-pulmonary symptoms, respiratory distress, and functional decline related to a diagnosis of COPD. Interventions dated 05/21/2024 directed staff to administer medications and nebulizer treatments as ordered. Resident #38's Care Plan Report did not include any focus areas addressing the resident's ability to self-administer medications. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2025, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #38 did not have a functional limitation in range of motion in their upper or lower extremities. Resident #38's Order Summary Report revealed the following orders: - an order dated 02/11/2025 for ipratropium-albuterol solution 0.5-2.5 milligrams per 3 milliliters (mg/3mL) to be inhaled via a nebulizer every 6 hours as needed for shortness of breath or wheezing; -an order dated 02/04/2025 for Xopenex nebulization solution 0.63 mg/3mL to be inhaled via a nebulizer every 6 hours for COPD or wheezing; - an order dated 02/04/2025 for Spiriva HandiHaler inhalation capsule 18 micrograms (mcg) inhaled orally one time a day for COPD; and - an order dated 03/24/2025 for Breo Ellipta inhalation aerosol powder 100-25 micrograms per actuation (mcg/act) inhaled orally one time a day for COPD. The Order Summary Report did not contain orders addressing the resident's ability to self-administer medications. An observation on 03/31/2025 at 10:28 AM revealed Resident #38 had a nebulizer treatment in progress. No staff member was present in Resident #38's room. During an interview on 03/31/2025 at 1:45 PM, Resident #38 stated that they had an inhaler ordered, and they wanted to be able to keep it with them so they could administer it when needed, but the facility would not allow them to keep the medication and administer it themselves. Resident #38 stated when staff provided their nebulizer treatment, staff handed the treatment to the resident and left the room. During an interview on 04/02/2025 at 1:44 PM, Licensed Vocational Nurse (LVN) #1 stated that if a resident requested to self-administer medications, he would tell them that per the facility's policy, medications had to be administered by a nurse and that it was not possible for the resident to keep their medications themselves. LVN #1 stated that no resident in the facility self-administered medications. During an interview on 04/02/2025 at 3:40 PM, LVN #2 stated that if a resident wanted to self-administer medications, the nurse still gave the medications and stayed with the resident to supervise the resident while they administered the medications. LVN #2 stated residents could not keep medications in their room and take the medications themselves. LVN #2 further stated there were no residents in the facility that had orders for self-administration of their medications. During an interview on 04/02/2025 at 3:53 PM, the Respiratory Therapist (RT) stated the nurses administered inhalers and nebulizers. The RT stated a nurse was supposed to stay in the room with a resident while administering a nebulizer treatment to monitor for any adverse reactions. The RT stated she would not be surprised to hear that Resident #38 was administering their own nebulizer treatment, but had not seen the resident self-administer their nebulizer very often. The RT stated Resident #38 had requested to self-administer medications, but it was not allowed. The RT further stated they did not make the rules, they just followed them. During an interview on 04/03/2025 at 9:05 AM, the Director of Nursing (DON) stated that due to having residents who were confused and wandered, the facility tried not to have any residents self-administer medications. The DON stated that there were currently no residents in the facility that self-administered their medications. During an interview on 04/03/25 at 9:24 AM, the Administrator stated self-administration of medications was a clinical issue that he expected nursing staff to manage.

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurately coded for pressure ulcers and restraints for 1 (Resident #62) of 21 sampled residents. Findings included: A facility policy titled, Resident Assessments, revised 10/2024, revealed, A comprehensive assessment of each resident is completed at intervals designated by OBRA [Omnibus Budget Reconciliation Act] regulations and PPS [Perspective Payment Plan] requirements. The section of the policy titled, Policy Interpretation and Implementation included 6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated 10/2024, revealed, M0210: Unhealed Pressure Ulcers/Injuries, specified Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. - Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers. Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. The manual further revealed Section P: Restraints and Alarms, defined Physical Restraints as Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual, Appendix PP). The manual revealed the Coding Instructions, directed staff to After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back period or it was used but did not meet the definition. Code 1, used less than daily: if the item met the definition and was used less than daily during the observation period. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. Resident #62's admission Record indicated the facility admitted the resident on 10/10/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, essential hypertension (high blood pressure), depression, and anxiety. A quarterly MDS, with an Assessment Reference Date (ARD) of 02/20/2025, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident required partial/moderate assistance with rolling left and right while in bed. The MDS revealed M0210 was coded to indicate the resident had one or more unhealed pressure ulcers/injuries, however, M0300 A through M0300 G indicated the resident did not have any pressure ulcers/injuries. The MDS indicated that the resident used bed rails as a restraint daily. Resident #62's Care Plan Report included a focus area initiated on 10/11/2023, that indicated the resident was at risk for activity of daily living (ADL)/mobility decline and required assistance related to cognitive impairment. Interventions indicated the resident used one-quarter length bilateral bed rails (initiated 10/11/2023 and revised 06/20/2024). The Care Plan Report revealed a focus area initiated on 02/21/2025, which was after the MDS ARD, that indicated Resident #62 had a pressure ulcer to their left heel and was at risk for further breakdown and/or slow, delayed healing. During an interview on 04/02/2025 at 1:47 PM, the MDS Coordinator stated she had been working at the facility for eight years. She stated the MDS should be accurate and stated that it was her responsibility to ensure the MDS was accurate. She stated Resident #62's side rails were used for mobility and should not have been marked as a restraint on the MDS; it was an error . The MDS Coordinator stated she could see on the resident's MDS that it had been coded to indicate Resident #62 had existing pressure ulcers, but each type of pressure ulcer had been marked to indicate the resident did not have any. The MDS Coordinator stated the resident's MDS was not correct. During an interview on 04/03/2025 at 9:21 AM, the Director of Nursing (DON) stated her expectation was for the MDS assessments to be accurate. She stated the nurse who was completing the MDS needed to go section by section to ensure the assessment was correct before it was transmitted. During an interview on 04/03/2025 at 9:45 AM, the Administrator stated his expectation for the MDS process going forward was for the MDS Coordinator to review each MDS section by section to ensure the accuracy prior to transmitting them to Center for Medicare and Medicaid Services (CMS).

Based on interview, record review, and facility policy review, the facility failed to provide a bed-hold notice upon transfer to the hospital or within 24 hours following an emergency transfer, which affected 2 (Resident #7 and Resident #47) of 3 residents reviewed for hospitalizations. Findings included: An undated facility document titled, Bed Hold Policy and Notification revealed, It is the policy of this facility to provide any resident that is transferred to a general acute care hospital the right to exercise the bed hold provision. 1. Resident #7's admission Record indicated the facility admitted the resident on 05/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and type two diabetes mellitus. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #7's Care Plan Report included a focus area, revised on 05/06/2024, that indicated the resident required long-term care related to increased activities of daily living (ADL) care needs, medical needs, and clinical needs. The Care Plan Report also included a focus area, revised on 05/01/2024, that indicated the resident had impaired cognitive function/impaired thought process. Interventions directed staff to administer medications as ordered and to monitor/document for side effects and effectiveness (initiated 05/01/2024). Resident #7's Progress Notes revealed a Nurse's Note, dated 01/06/2025 at 10:44 AM, that revealed Resident #7 had increased confusion and increased lethargy. The note indicated orders were received from the physician to send the resident to the emergency room. Resident #7's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. Resident #7's Progress Notes revealed an Admission/re-admission Summary Note, dated 01/12/2025 at 1:58 PM, that revealed Resident #7 was readmitted to the facility after being hospitalized for a diagnosis of sepsis. Resident #7's Progress Notes revealed an Alert Note, dated 01/20/2025 at 3:14 AM, that revealed Resident #7 complained of not feeling right and became anxious about possibly having a stroke. The note indicated orders were received to send the resident to the emergency room. Resident #7's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. Resident #7's Progress Notes revealed an Admission/re-admission Summary Note, dated 01/27/2025 at 4:00 PM, that revealed Resident #7 was readmitted to the facility after being hospitalized for a diagnosis of metabolic encephalopathy. Resident #7's Progress Notes revealed a Nurse's Note, dated 03/21/2025 at 3:30 PM, that revealed the physician gave an order for Resident #7 to be sent to the emergency room for further evaluation related to the abnormal laboratory results. Resident #7's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. 2. Resident #47's admission Record indicated the facility admitted the resident on 07/05/2021. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, essential hypertension (high blood pressure), and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2025, revealed Resident #47 had short- and long-term memory problems and severely impaired cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). Resident #47's Care Plan Report included a focus area, initiated 01/08/2023 and revised on 06/27/2023, that indicated the resident had impaired cognition due to having had a stroke with cognitive changes and aphasia. Resident #47's Progress Notes revealed a Nurse's Note, dated 01/24/2025 at 7:10 PM, that indicated Resident #47 had a fever of 101.6, a cough, and was fatigued and drowsy. The note indicated an order was received to send the resident to the hospital for further evaluation. Resident #47's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. During an interview on 04/03/2025 at 9:18 AM, the Director of Nursing (DON) stated that going forward, the nurses would be the process holders for the bed-holds. She stated they were to call the family and notify them of the resident being transferred to the hospital, and then, while the nurse had the family on the phone, they were to ask the family if they wanted the resident's bed held. She stated that the nurse would then initiate and complete the bed-hold/transfer form and enter progress notes in the electronic health record. The DON stated the Admissions Coordinator would follow up with the resident/representative afterward to ensure the bed-hold stayed in place for seven days, and the Business Office Manager was responsible, going forward, to ensure there was a signature from the resident/representative on the bed-hold form as soon as possible, in addition to the verbal acceptance or refusal of the bed-hold. The DON stated the facility was not following the process of notifying a resident of the bed-hold policy upon transfer until it was brought to their attention, during the survey. The DON stated her expectation was for the process of obtaining permission for a bed-hold to be done timely. During an interview on 04/03/2025 at 9:40 AM, the Administrator stated his expectation of the bed-hold process was that staff completed the notifications and paperwork within the timeframes designated in the regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three residents sampled for patient rights (Resident 1) was treated with dignity and respect when the Marketing Director (MD) had spoken with Resident 1 on the phone with the hospice nurse (HN) available and stated, What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here, This resulted in Resident 1 becoming tearful and had the potential to result in psychosocial harm. Findings: A review of a facility policy titled, Resident Rights, with a revised date of [DATE], indicated, Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. A review of the facility's records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), obstructive sleep apnea (sleep disorder with recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing), other abnormalities of gait and mobility, generalized muscle weakness, acquired absence of right leg above knee, chronic pain syndrome, and unspecified depression (symptoms of depression). During an interview on [DATE] at 2:45 PM with Resident 1's power of attorney (POA), she stated the Marketing Director (MD) had spoken with Resident 1 on the phone with the hospice nurse (HN) available and stated, What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here, which caused Resident 1 to cry. POA stated that after speaking to Resident 1 he stated he did not have a POLST filled out but did not want to die, but did not want full Cardiopulmonary Resuscitation (CPR), so he had picked selective treatment. She stated that she requested for a POLST form and was met with comments that stated Resident 1 is supposed to go onto hospice, and he would not need a POLST. POA stated that once Resident 1 was sent to the hospital on [DATE] at 5:50 AM, the facility informed POA that Resident 1 had his POLST sent to the hospital with him; however, upon arrival to the hospital she found Resident 1 intubated and being transferred to the ICU. POA stated, How is it that days later they didn't have that signature on the POLST. During an interview on [DATE] at 2:30 PM with the hospice liaison (HL), she stated the MD was on the phone with Resident 1 and stated, The only reason I brought you back was because you said you were going to go on hospice, and further stated that the hospice staff took the phone away from Resident 1 because it was not okay to speak with him that way. HL stated after she spoke with Resident 1 he did agree to hospice after a consult, but did not want to start hospice at the facility because he did not feel safe, we then updated his POLST. HL stated the POLST was never signed by his provider, and he had a medical emergency that resulted in CPR and being intubated. HL stated that the staff was not helpful and unprofessional and initially refused to give him a POLST to fill out and stated he needs to go on hospice and not deal with a POLST. During an interview on [DATE] at 11:45 AM with Licensed Vocational Nurse (LVN) 1, she stated the, POLST was not signed, by the medical provider, but it was signed by the resident as DNR selective. It wasn't signed on the 20th, and stated how she has expressed her concerns to the medical provider. LVN 1 stated the EMT's that arrived said Resident 1 will be considered full code (full resuscitation attempt) due to the POLST not being signed by the medical provider. LVN 1 stated, Yes, they should, sign the POLST immediately in some form, especially since Resident 1 had been declining. LVN 1 stated there was a lack in the quality of care for Resident 1. During an interview on [DATE] at 12:15 PM with MD, stated Resident 1 was supposed to be admitted to hospice; however, according to them (the hospice nurse) determined that he was alert and oriented (of sound mind) and he refused hospice at that time. MD, who confirmed she was a marketer with no medical background, stated when she talked to him he seemed confused and not oriented. MD stated she felt that Resident 1 needed hospice even though he was of sound mind at the time he refused hospice care. MD stated she was talking to the hospice nurse over the phone on speaker with Resident 1 present and stated that he was supposed to be on hospice as it was the plan and she did not want hospice to leave without him signing up for hospice. MD stated she was upset that hospice left and didn't follow through with Resident 1 and she did not feel that hospice offered all that they were supposed to offer him. During an interview on [DATE] at 1:25 PM with Director of Nursing (DON), she stated that the resident had a right to determine he did not want to go on hospice as he was oriented, which she had also verified. DON stated that someone without a medical background should not be able to determine if a resident was confused and not oriented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement resident-directed care consistent preferences and rights for one of three residents sampled for patient rights (Resident 1) when the facility did not maintain a valid copy of Physician Orders for Life-Sustaining Treatment (POLST- a voluntary option for people to use to communicate their end-of-life decisions) in Resident 1's medical record when transfer from the facility via ambulance was made. This failure resulted in Resident 1's right to decline specific treatment in the event of a medical emergency to not be followed. Findings: A review of a facility policy titled Advance Directives, with a revised date of [DATE], indicated, The director of nursing services or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care . The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive . The nurse supervisor is required to inform emergency medical personnel of a residents advance directive regarding treatment options and provide such personnel with a copy of the advance directive or Physician orders for life-sustaining treatment (POLST) when transfer from the facility via ambulance or other means is made. A review of a facility policy titled, Resident Rights, with a revised date of [DATE], indicated, Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. A review of a facility policy titled, Do Not Resuscitate Order, with a revised date of [DATE], indicated, Do not resuscitate (DNR, allow natural death) orders must be signed by the resident's attending physician . State specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include: POLST . A review of the facility's records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), obstructive sleep apnea (sleep disorder with recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing), other abnormalities of gait and mobility, generalized muscle weakness, acquired absence of right leg above knee, chronic pain syndrome, and unspecified depression (symptoms of depression). A review of the facility's record POLST for Resident 1 indicated selective treatment (do not intubate, avoid intensive care (ICU), comfort-focused care) was selected for Resident 1 with a DNR. The date the form was prepared was on [DATE], and it was signed by Resident 1 on [DATE]. This form indicated that the Physician (DR) signed the POLST on [DATE]. A review of the facility's progress note dated [DATE] at 7:51 AM, indicated, Resident was sent with face sheet, medication summary, and POLST of DNR selective however it had pending provider's signature of DNR elective. Emergency Medical Technician (EMT) stated, provider's signature is required, therefore resident is considered full code. He left the facility . at 0550. POA was notified at 5:54 AM. A review of the facility's calendar for the physician and nurse practitioner schedule for [DATE], indicated, the nurse practitioner and physician did not enter the clinic to see residents [DATE]th, 18th, 19th of 2025. The nurse practitioner did enter the clinic to see residents on [DATE] and the physician did not enter the clinic until [DATE]. During an interview on [DATE] at 2:45 PM with Resident 1's power of attorney (POA), she stated the Marketing Director (MD) had spoke with Resident 1 on the phone with the hospice nurse (HN) available and stated, What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here, which caused Resident 1 to cry. POA stated that after speaking to Resident 1 he stated he did not have a POLST filled out but did not want to die, but did not want full Cardiopulmonary Resuscitation (CPR), so he had picked selective treatment. She stated that she requested for a POLST form and was met with comments that stated Resident 1 is supposed to go onto hospice, and he would not need a POLST. POA stated that once Resident 1 was sent to the hospital on [DATE] at 5:50 AM, the facility informed POA that Resident 1 had his POLST sent to the hospital with him; however, upon arrival to the hospital she found Resident 1 intubated and being transferred to the ICU. POA stated, How is it that days later they didn't have that signature on the POLST. During an interview on [DATE] at 11:45 AM with Licensed Vocational Nurse (LVN) 1, she stated the, POLST was not signed, by the medical provider, but it was signed by the resident as DNR selective. It wasn't signed on the 20th, and stated how she has expressed her concerns to the medical provider. LVN 1 stated the EMT's that arrived said Resident 1 will be considered full code (full resuscitation attempt) due to the POLST not being signed by the medical provider. LVN 1 stated, Yes, they should, sign the POLST immediately in some form, especially since Resident 1 had been declining. LVN 1 stated there was a lack in the quality of care for Resident 1. During an interview on [DATE] at 1:25 PM with Director of Nursing (DON), she stated, No, it wasn't appropriate, for the physician to sign the POLST with a date of [DATE] when they were not there to sign it that day and stated that nobody should be backdating documentation. DON stated it is not fair that the resident had to be intubated (to insert a tube for breathing) if he did not want to be intubated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review, the facility did not meet this requirement when it failed to provide evidence of incontinent (no ability to control one's bowels or bladder and requires staff to clean), care for two of 17 sampled residents (Resident 1 and 2). This resulted in the potential for skin breakdown and a loss of dignity for both residents, who were dependent on staff for care. Findings: Resident 1 was admitted to the facility on [DATE] for conditions that included rhabdomyolysis (a breakdown of muscle), spondylosis (abnormal wear of the spinal cartilage), history of stroke and difficulty walking. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment tool that measures health and mental status in nursing home patients), dated 6/4/24 indicated that her ability to use the restroom, Toilet Hygiene, was rated at 2 or Substantial/Maximal Assist. During an interview and observation on 7/24/24 at 11:20 AM, Resident 1 ' s room smelled strongly of stale urine. Resident 1 was observed seated at the edge of her bed and in an interview, concurrently stated that she was waiting for assistance because she was wet. Resident 1 stated that she had pressed the call light at 11:00 AM and had been at the edge of the bed waiting for an unidentified CNA (Certified Nursing Assistant) who said they would return, I ' ve been waiting 20 minutes here, I looked at the clock. Resident 1 stated that she had also been left wet the night before: a CNA changed her at 10:10 PM, the next shift took over, and Resident 1 stated that the CNA from registry (a temporary help agency) who did not check on her the entire shift until it was time for the next shift to come on and changed her at 5:25 AM. She stated this happens all the time, and that it also happened on 7/15/24 when she was left wet for at least six hours. Resident 1 stated that on 7/22/24 and 7/23/24, her sheets were wet and she was not changed which made her uncomfortable. Resident 2 was admitted to the facility on [DATE] for conditions that included leg cellulitis (inflammation of the leg), diabetes, congestive heart failure, legal blindness, muscle weakness and unsteadiness on her feet. A review of Resident 2 ' s MDS dated [DATE], indicated that her ability to use the restroom, Toilet Hygiene, was rated at 1 or Dependent, Helper does all the work. In an interview and observation on 7/24/24 at 11:42 AM, Resident 2 stated, I'm getting left wet all night long. I can't tell you which CNA was here because I never saw her. I get changed before the evening shift leaves, and I don't see anyone until morning. Resident 2 had a large cast on her right foot and stated that she previously had a boot with bolts in it that seemed to intimidate the newer or registry CNAs who were not sure how to handle her. She stated, I think they avoided changing me because they didn't know how to handle me at night. In an interview on 7/24/24 at 11:48 AM, CNA C acknowledged that CNA D was a registry staff member and that her shift followed CNA D ' s coming off of the night shift of 7/23/24 and she had been assigned to Residents 1 and 2 and began doing resident care at 6:45 AM. CNA C stated that she arrived on shift to find Resident 1's bed saturated by urine. CNA C stated that she had arrived at 6:15 am and began her shift at 6:45 following report. CNA C stated that CNA D reported to her that she had taken Resident 1 to the restroom at 5:30 AM, and that CNA D, was supposed to do a time stamp on her work if she had done it. CNA C stated that residents are to be rounded on every two hours or more frequently as needed, per policy. In an interview on 7/24/24 at 11:50 AM, Licensed Vocational Nurse (LVN) A stated that she had been assigned as Unit Manager on the night shift. LVN A stated, I can tell if a CNA is rounding every two hours. If they're not, the bed will soak through, that ' s how I can tell if they ' re changing residents. Residents don't usually urinate enough every two hours to soak the bed. LVN A stated that she was familiar with Resident 1, whom she stated was alert, oriented, and credible. She keeps track of things. If she said it happened, it happened. LVN A stated that CNAs are trained to round every two hours, standard care, and that CNAs are also supposed to do walking rounds to check on residents being taken over by next shift, when a wet resident would be evident. In an interview and record review on 7/24/24 at 12:15 PM, Director of Staff Development (DSD) B confirmed that registry CNA D had been assigned to Resident 1 on 7/23/24, and that had been CNA D ' s first assignment at the facility. DSD B further stated that she received a text at 6:52 AM from unit manager LVN A on the morning of 7/24/24 regarding CNA D, Came in early, left at 6:50 [am], didn't give report and Nothing's done. In a concurrent record review of the facility ' s document titled, Point of Care Audit Report dated 7/24/24, reflected that CNA D had not charted that she gave any care to residents or indicated in any way that care had been done. DSD B also stated that she had received a report from staff on 7/15/24, the night that Resident 1 stated she had been left wet. DSD B provided the text for review, Whoever worked last night didn't give me a report. Some residents weren't changed. DSD B stated that registry CNAs come and go, they don't have a boss so it's hard to supervise them. They work for themselves. A review of the facility ' s policy titled, Activities of Daily Living, Supporting, (undated), provided by DSD B, indicated as follows: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including support and assistance with Elimination (toileting) q 2 hours and prn. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Total Dependence requires full staff performance of an activity with no participation of the resident for any aspect of the ADL activity. Finally, the policy indicated, The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 2) was treated with dignity and respect during direct patient care. This deficient practice had the potential to negatively affect Resident 2's psychosocial well-being and did cause Resident 2 to become angry. Findings: During a review of the facility's policy revised 2/2021, titled, Dignity, indicated each resident shall 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. This policy also indicated residents are treated with respect and dignity at all times. During a review of the facility's policy revised 2/2021, titled, Resident Rights, indicated each resident is to be treated with respect, kindness, and dignity; and to be supported by the facility in exercising his or her rights. A review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included injury of lower spine and pelvis, sequela (an after effect of a disease, condition, or injury), Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease), difficulty walking, chronic pain, heart disease, and a history of falls. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 4/10/24, indicated that Resident 2 was cognitively intact (able to think and reason) and made her own decisions, and is her own responsible party (RP). A review of a care plan dated 4/8/24, indicated Resident 2 is dependent on staff for activities for daily living (ADLs-hygiene, toileting, grooming, dressing, and bathing) related to limited physical mobility and a history of falls with injury. This care plan indicated Resident 2 needed assistance of one staff member with transfers and ambulation related to pelvis fracture, pain, and weakness. During an interview on 5/3/24 at 2:30 pm, Resident 2 stated, I get tired of waiting on the Certified Nursing Assistants, (CNA)s. [CNA F] made me wait for 30 minutes to get help to the bathroom and I wet myself. [CNA F] was not supposed to come back in here. They promised me I would not have to see [CNA F] again. I am angry, I do not want an apology, I don't ever want to see her again. During an interview on 5/3/24 at 3:10 pm, Licensed Nurse (LN) A confirmed CNA F was not supposed to go back in Resident's 2 room after she discussed a complaint made by Resident 2. LN A stated, I think there might be a language barrier, and CNA F has received corrective action. I will also be providing more education to CNA F; she has only been a nurse assistant for less than 90 days. During an interview on 5/3/24 at 3:15 pm, Assistant Director Of Nursing stated, Yes, I agree CNA F did cause Resident 2 to become angry and this is a dignity issue for the resident, she needs to be monitored and put on alert charting. Even though she is her own RP, we will call the family. During an interview on 5/3/24 at 3:20 pm, the Director of Nursing (DON) confirmed she was aware of the complaint by Resident 2 about CNA F and this CNA was not supposed to have the assignment to help Resident 2 per request. DON stated, I will follow up with [CNA F] and tell her even if she is scheduled in error, she is not allowed to go into the room of Resident 2. We will monitor Resident 2 for any new behaviors since this mistake happened today.

Based on observation, interview, and record review the facility failed to follow its Administrating Medications policy and procedure (P&P) for one out of one resident (Resident 53) when Resident 53 was provided a suppository (a meltable medication placed into the rectum) for self-administration. This failure had the potential for incorrect medication administration and could cause Resident 53 negative clinical outcomes. Findings: During a review of the facility's P&P titled, Administrating Medications, revised 12/1/22, indicated, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the undated record titled admission Record indicated Resident 53 was admitted to the facility with the diagnosis of morbid (severe) obesity (more than 80 to 100 pounds over the ideal body weight) and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breath). The admission Record indicated Resident 53 had good cognition (ability to think and recall information) and was her own responsible party (had the ability to make own medical decisions). During a concurrent observation and interview on 11/13/23 at 9:57 am, Licensed Nurse F (LN) was observed walking into Resident 53's room with a suppository. Resident 53 stated LNs did not administer the suppository and that Resident 53 would self-administer the suppository. LN F handed a suppository to Resident 53 and left the room. Resident 53 placed the suppository in a box on top of the bedside table and stated Resident 53 would administer the suppository later. During an interview on 11/14/23 at 2:47 pm, LN F stated being registry staff (a travel nurse that worked at the facility and was employed by a third party), it was LN F's first day at the facility, and was not familiar with the residents. LN F confirmed handing a suppository to Resident 53 and stated, another staff member told me that Resident 53 always administered her own suppositories. LN F stated unawareness if there was a physician's order for the suppository or if Resident 53 had been assessed for self-administration of medication. LN F confirmed LN F should have reviewed Resident 53's medical records prior to handing Resident 53 the suppository and did not. During a concurrent interview and record review on 11/14/23 at 4:10 pm, with Director of Nurses (DON), Resident 53's Orders was reviewed. DON stated the Orders indicated the physician had not provided an order for Resident 53 to self-administer medication. DON reviewed all IDT Meeting Notes that had been entered into Resident 53's medical record and stated there was not an IDT Meeting Note present that indicated the IDT team had assessed Resident 53 for safety of self-administration of medication and there should have been.

Based on observation, interview, and record review, the facility failed to maintain the facility in a safe and operable manner and provide a homelike environment when: 1. A handrail at the end of Hall 3 was not attached securely to the wall, sections of the ceiling had missing and peeling popcorn texture (a sprayed on bumpy texture that was applied to the ceiling) on Hall 3 and near the nurse station. 2. Five of 13 sampled residents (Residents 18, 75, 46, 55, and 27) expressed that their belongings were missing. This failure had the potential to cause resident harm and resulted in residents' inability to access their own belongings and had the potential to foster an environment that was not home-like. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 10/1/09, indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P indicated maintenance personnel were responsible for Maintaining the building in good repair. During a review of the facility's P&P titled, Homelike Environment, revised 5/1/22, indicated, Residents are provided with a safe, comfortable, and homelike environment During a concurrent observation and interview on 11/15/23 at 10:23 am with Maintenance Supervisor (MS) the handrail at the end of Hall 3 to the left was observed. MS stated maintenance staff performed daily rounding of the facility and would shake the handrails to assure they were attached securely to the wall. MS observed the handrail and confirmed it was no longer attached to the metal wall fastener and was not safe for resident use. MS observed an area of the ceiling, located on Hall 3, in-between the fire sprinkler and a light fixture, and confirmed a section of the popcorn texture on the ceiling was peeling and missing. MS observed a large section of the ceiling near the nurse's station and stated the popcorn texture was missing and the edges had a visible gap of space between the popcorn texture and the ceiling. MS stated over a year ago there had been a water leak from the facility's air conditioning unit that was located on the roof. MS stated the water leak had caused damage to the ceiling where the popcorn texture was missing near the nurse's station. MS stated the popcorn texture had been peeling in different sections throughout the facility, the plan was to replace the all the popcorn texture, and a company had been contacted to obtain a quote for the cost of the repair. A request was made to review a copy of the quote, MS stated there was no documentation and the quote was provided over the phone. 2. A review of the facility's policy titled, Resident Rights, revised October 2022, indicated that residents have the right to retain and use personal possessions A review of the facility's record titled discharge notes for resident 75, dated 11/14/23, indicated that resident 75's cell phone was missing upon discharge. In an interview on 11/13/23 at 9:15 AM, Resident 18 stated that he had brought in three shirts and two pair of pants that were laundered and misplaced by the facility. In a group resident interview on 11/15/23 at 1:45 PM, three of 11 sampled residents (Residents 46, 55, and 27) stated they were missing belongings. Resident 55 stated that she was missing two pairs of pants because there was another resident in the facility with the same name, so they get mixed up. Resident 46 stated that the facility lost her pair of purple sweatpants a week ago and she then saw a male resident wearing them. A family member of Resident 27 stated in the group interview that Resident 27 was given two beautiful blankets, and we've never been able to find them. I walk down the hallway and find other people wearing the things I brought for my mother. In an interview on 11/15/23 at 3:52 PM, Social Services Director (SSD) acknowledged that there had been quite a few residents who had missing items because families don't label them. The facility has been working on finding a way to ensure everything families bring in gets labeled and that they are working on ways to improve the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sufficient staffing that met the needs of the residents when: 1. Two out of 11 residents (Resident 45 and 50) stated they did not receive a shower due to the facility not having enough staff. 2. Eight out of 11 residents stated they experienced long call light wait time due to the facility not having enough staff. This failure had the potential to result in resident inability to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Staffing, revised 4/1/21, indicated, Our facility provides adequate staffing to meet needed care and services for our resident population. The P&P indicated, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. 1. During a review if the facility's P&P titled Shower, revised 5/1/18, indicated, The purposes of this procedure are to promote self-determination and facilitate resident choice regarding shower and bathing to ensure cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The P&P indicated Staff will honor shower and/or bathing preferences such as frequency of shower schedule. During an interview on 11/14/23 at 12:18 pm, CNA L stated on 11/12/23, there was only three CNAs working in the facility. CNA L stated, when the facility was short staffed, the residents did not get their assigned showers, there were long call light wait times, and stated feelings of sadness and concern due to the residents not getting the care they should. CNA L stated, documenting NA (not applicable) in the resident's medical records, when a shower was not provided to a resident due to the facility being short staffed. A review of Resident 45's record titled Bathing, dated 10/19/23 and 10/30/23, indicated, the shower response of NA was selected. During a review of Resident #50's clinical record it indicated admission was on 6/19/23, with diagnoses Unspecified Heart Failure, Diabetes Mellitus (DM), Benign Prostatic Hyperplasia (BPH, enlarged prostate blocking the flow of urine), and bipolar disorder (mental health condition causing extreme mood swings of extreme highs (mania) and lows (depression)). The facility's MDS dated [DATE], rated Resident #50's cognition 12/15, moderately impaired. During a concurrent observation and interview on 11/13/23 at 11:40 am with Resident #50 and family member (FM), Resident #50 was observed to have a full moustache and beard and was lying in bed with clothing that had food remnants noted on the front of the shirt. Resident #50 stated, they are short staffed. I may get one shower a week. I have never been shaven since I have been here, and I like to be clean shaven. FM stated the only things we have problems with are related to getting the resident's clothes changed regularly and sometimes the clothes have had evidence of being soiled with food or even feces. The same clothes have been worn for several days. The resident does wear a brief and has a foley catheter, the brief can leak onto the clothes. We think they are short on staff, across the board short staffed for days and nights. First thing I did today was go to the nurse station and told them I wanted Resident #50 to be changed into the clean clothes I have brought in, and we are still waiting. I just want Resident #50 clean. They must have shaven at some point, but they have not shaven Resident #50 very often, and the preference is clean shaven. I am here every other day, and this is a continuous issue. During a review of Resident #45's clinical record, indicated that Resident 45 was admitted to the facility on [DATE] with diagnoses which included stroke, affecting left non-dominant side, type 2 diabetes (high blood sugar) and muscle weakness. He was his own healthcare decision maker. During a review of Resident #45's MDS, dated [DATE], the MDS indicated that Resident #45 had a BIMS score of 15, at section C Cognitive Patterns indicating that his cognition was intact. During an interview on 11/13/2023 at 12:15 pm in Resident #45's room, with Resident #45, Resident # 45 stated Today is my shower day. They told me that I cannot have my shower because there were only two CNAs on the floor today . During an interview on 11/13/2023 at 12:32 pm with LN A, LN A acknowledged that she was aware that Resident #45 was told that he could not have his shower. LN A said Ya, that was earlier, we had short staff. We have registry now; we can give him shower. I'll go and tell him. During a concurrent observation and interview with HA F on 11/14/23 at 10:00 am regarding the whiteboard of roommates, Resident #34's whiteboard indicated the resident is to be shaven with hygiene and is clean shaven, Resident #50's whiteboard does not have a shaving designation and has a full beard and moustache. HA F stated, there is a shortness of CNAs that is why I am sitting for Resident #34. Typically, this would not be my job. I understand the CNA that was supposed to be here called in or something. We have a lot of call ins. I feel like we are short staffed often. I do feel like our residents suffer. I think the staffer quit last weekend. It didn't matter because staffing is bad at this building anyway. We are assigned [NAME]-nilly kind of. Some days there is a lot of CNAs and some days there's hardly any. Like the other day we only had two CNAs to cover the day. This place is very understaffed. We used to use Registry, but they stopped because we had some bad registry people that did not care for our residents adequately. But we are running so short, people are getting tired and overwhelmed. They have been offering incentives like money to pick up shifts, especially since state is here. We only had two aids on yesterday until you guys showed up then they start calling to recruit. We cannot do a really good job with the lack of staff. As a Hospitality Aid, we are directed to turn lights off and ask what the person wants and help if we can. We cannot often-times and we need to get a nurse or aid and sometimes they aren't available. The lights are timed, so when we turn them off it breaks the time. People for the most part get showered. I mean, sometimes they refuse, or we can't get to them. Shaving should be done as part of a shower, but it does not always happen unless there is a specific reminder written on the resident's white board. There are some residents that don't want a shave, but others that probably do but don't get them because they haven't been put on the list and have the shaving designation written on the white board. We just can't provide what is best for our residents. 2. During a review of the facility's P&P titled, Answering the Call Light, revised 10/2/22, indicated, The purpose of this procedure is to respond to the residents' requests and needs. The P&P indicated staff would Answer the resident's call light as soon as possible and that when staff answered a call light with the intent to come back with an item of information, do so promptly. A review of the undated Admissions Record, indicated Resident 22 was admitted to the facility on [DATE] with the diagnosis of hypertension (high blood pressure) and unsteadiness on feet. Resident 22's cognition (ability to remember, recall information, and think) was intact. During an interview on 11/13/23 at 9:24 am, Resident 22 stated Resident 22's roommate, Resident 14 vomited. Resident 22 stated pressing the call light, along with Resident 14 at approximately 4:30 am and it took one and a half hour for staff to respond to the call light. Resident 22 stated after 15 minutes with no staff response to the call light, Resident 22 turned on a timer, located on Resident 22's personal cell phone. The timer indicated, a time of one hour and 15 minutes, was dated 11/23/23 and the time indicted the personal cell phone timer started 4:45 am. A review of the undated Admissions Record indicated, Resident 55 was admitted to the facility on [DATE] with the diagnosis of repeated falls, muscle weakness, and difficulty in walking. Resident 55 had good cognition and was her own responsible party (RP, made own decisions). During an interview on 11/13/23 at 10:33 am, Resident 55 stated sometimes the facility was short staffed. Resident stated on the night of 11/12/23 at 9:45 pm, pressing the call light. Resident 55 stated, Resident 55 had urinated in the brief (adult diaper) and needed to be cleaned up. Resident 55 stated an hour and a half had passed before facility staff responded to the call light. During an interview in 11/14/23 at 5:22 am, Certified Nurse Assistant H (CNA) stated staffing in the facility had been a challenge due to staff being sick. CNA H stated last week, there were three CNAs for the NOC (nighttime) shift. CNA H stated resident outcomes that could occur when the facility was short staffed included longer call light wait times. During an interview on 11/14/23 at 5:28 am, Licensed Nurse I (LN) stated staffing the facility could be a challenge when you had unforeseen call offs and staff members who just don't show up for their shift. LN I stated normally the NOC shift had two LN and four CNAs. LN I stated one night, recently, only two CNAs had arrived to work the NOC shift. During an interview on 11/14/23 at 5:34 am, with CNA J and CNA K, CNA J stated, on 11/11/23, there were two CNAs on the NOC shift and on 11/12/23 there was three CNAs. CNA J and CNA K both stated when the facility was short staffed on the NOC shift, it was not possible to perform good resident care, there was an inability to perform every two-hour rounding (checking residents to see if they were incontinent of urine or stool and repositioning a resident to prevent wounds), and call light wait times were longer. During an interview on 11/14/23 at 5:41 am, LN M confirmed working a NOC shift with only two CNAs recently. A review of the undated Admissions Record indicated Resident 14 was admitted to the facility 3/12/18 with the diagnosis of chronic obstructive pulmonary disease (a lung disease that caused difficulty in breathing). A review of the record titled, Cognitive Patterns, dated 10/28/23, indicated, Resident 14 had good cognition. A review if the record titled, Functional Abilities and Goals, dated 10/28/23, indicated, Resident 14 was dependent (helper does all the work) with bathing, rolling from side to side in the bed, and was not able to sit up in bed without assistance from facility staff. During an interview on 11/14/23 at 8:15 am, Resident 14 stated around 4:30 am on 11/13/23, Resident 14 vomited all over self. Resident 14 stated pressing the call light for staff assistance and it took over an hour and half for staff to respond to the call light. Resident 14 stated, one time Resident 14 wanted out of bed and needed assistance getting into the chair. Resident 14 stated it took a long time before staff responded to the call light and I never got to sit in my chair. Resident 14 stated when staff did not respond to the call light it made me feel like I wasn't worth much and they don't care about me. Resident 14's roommate, Resident 22, stated feeling the same way when staff did not respond to the call lights in a timely manner. Resident 133 was admitted to the facility on [DATE] with a diagnosis including arthritis and muscle weakness. Resident 133 (R133) was at the facility for strengthening and rehabilitation for returning to her home. On 11/13/23 at 8:50 AM Resident 133 was observed having physical therapy. Resident 133 was interviewed regarding care and staffing in the facility. Resident 133 stated, There are slow responses to call lights. It takes up to 30 minutes before they come to answer them. I can hear them helping others and I don't need anything urgent. So, I just wait. Resident 133 denies having incontinence due to waiting for staff to answer her call light. Resident 136 was admitted to the facility on [DATE] with a diagnosis including Vertigo (Dizziness) and falling. Resident 136 needed assistance to get out of bed due to her history of falling and dizziness. On 11/13/23 at 9:04 AM Resident 136 was observed lying in bed at 9:04 AM with distinct odor of urine present in her room. Resident 136 was questioned of needing staff to assist with toileting. Resident 136 said, I have a wet bed and need changed. Resident 136 answered questions regarding incontinence and lying in a wet bed by stating, it happens all the time. Resident 136 turned on her call light and waited for staff to answer her call for help. It took 2 minutes 40 seconds for the call light to be answered by a hospitality aid (HA). The HA asked what Resident 136 needed. Resident 136 answered, My bed is wet, and I need to go to the restroom. The HA replied that she would send someone to help and left the room. An additional 39 minutes and 11 seconds passed before a CNA returned to provide incontinent care and change bedding. Resident 136 stated, This happens all the time. My bottom is getting sore. During a review of Resident #6's clinical record, indicated that Resident #6 was admitted to the facility on [DATE] with diagnoses which included stroke, affecting left non-dominant side, chronic pain, right below-knee amputation (a surgery to remove the right leg below the knee), and muscle weakness. She was her own healthcare decision maker. During a review of Resident #6's Minimum Data Set (MDS - an assessment and care screening tool),, dated 8/29/2023, the MDS indicated that Resident #6 had a brief interview for mental status (BIMS) score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During an interview on 11/13/2023 at 9:27 am in Resident #6's room, Resident #6 stated they took forever to come her, they didn't have enough help .I pushed the bottom, waited for a long time to be changed. It's horrible. During a review of Resident #70's clinical record it indicated admission was on 9/22/23, with diagnoses of Systolic and Diastolic Congestive Heart Failure (CHF, heart works less efficiently pumping blood, oxygen, and nutrients), and Chronic Pulmonary Edema (long term and progressive fluid collecting in the air sacs of the lungs making it difficult to breathe). The facility's MDS (minimum data set, a standardized assessment tool) dated 9/26/23 rated Resident #70's cognition 13/15, cognitively intact. During an interview on 11/13/23 at 11:00 am with Resident #70, who stated, occasionally, it looks like they don't have enough staff, it takes a while for them to answer the call light. During a review of Resident # 8's clinical record it indicated admission was on 2/13/23, with diagnoses Acute and Chronic Respiratory Failure (condition that makes it difficult to breathe by oneself, which develops when the lungs cannot get enough oxygen in the blood and retain carbon dioxide), Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease with respiratory difficulty and airflow limitations), and DM. The facility's MDS dated [DATE] rated Resident #8's cognition 13/15, cognitively intact. During an interview on 11/13/23 at 12:15 pm with Resident #8, who stated, On the day shift it is better for answering the call light. I always look at the clock when I push the button. I have waited up to an hour for the call light, mostly nights. There are Hospitality Aids during the day to help buffer the staff. I will press my light and the helpers will come in and ask what I need. I will say I need my CNA and they will turn my light off and say they will go get them, but never return. I just turn my light back on. During a review of Resident # 11's clinical record it indicated admission was on 5/20/23, with diagnoses COPD, Rectal Prolapse (part of the large intestine bulges outside the anus), right lower leg Cellulitis (RLL Cellulitis, bacterial infection involving inner layers of the skin causing redness, warmth, pain, and swelling). The facility's MDS dated [DATE], rated Resident #11's cognition 14/15, cognitively intact. During an interview on 11/14/23 at 09:00 am with Resident #11, who stated, two weekends in a row we were so short staffed, one CNA to 40 residents, today there were only two CNAs on. It happens on the weekend and mostly at nighttime. I stay awake at night worried when we are so short staffed. I have watched the clock and there was a time it took two hours. There was a time that I was sitting in liquid shit for an hour, I had the call light on for a hour. I had to call a FM to call the Nurse's station to have someone come help me. I do not feel safe with the lack of staff available to take care of me. When it takes a lot of time to answer the light, they usually will say that they are short staffed. I was told they have a special machine that keeps track of how long the lights were on. They hired a few Hospitality Aids that I have been told cannot touch me, but they come in and turn out the call light and ask me what I need. This stops the light timing. They will not do anything for me, they say they will tell the CNA or the nurse. They always turn the call light off, but don't always get back to me with the CNA or nurse timely. I will wake up covered in poop and then call the nurse, but it takes a long time for them to get to the call light to help me. During a review of Resident # 18's clinical record it indicated admission was on 11/28/15, with diagnoses Metabolic Encephalopathy (Chemical imbalance in the blood that causes problems in the brain), COPD, and Parkinson's Disease (Progressive central nervous system disorder affecting parts of the body controlled by nerves such as movement, often including tremors). The facility's MDS dated [DATE], rated Resident #18's cognition 15/15, cognitively intact. During an interview on 11/13/23 at 1:00 pm with Resident #18's family member, who stated, my only concerns is that they have such a turnover of workers and they do not know Resident 18's diagnoses or how to respond to symptoms, they do not know what is going on because they do not know the residents. Oftentimes, they seem very short staffed. During a review of the facility's P&P titled, Resident Council, revised 12/1/06, indicated, A Resident Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible to address the item(s) of concern. During a confidential interview on 11/15/23 at 1:50 pm, one out of 11 residents stated not receiving a scheduled shower and three out of 11 residents stated they experienced long call light wait times due to the facility not having enough staff. Residents expressed feelings of frustration, inability to sleep, and a burning sensation on the inner thighs due to sitting in a brief full of urine that was not changed in a timely manner. A review of the record titled, Resident Council Minutes, dated 9/14/23, indicated, old business (review of last month's meeting minutes) of call lights not answered timely (all shifts) had not been resolved. A review of the record titled Resident Council Minutes, dated 10/19/23, indicated, old business (review of last month's meeting minutes) of call light concerns had not been resolved. A review of the record titled Resident Council Minutes, dated 11/9/23, indicated, old business (review of last month's meeting minutes) of call light concerns had not been resolved. During a concurrent observation and interview on 11/15/23 at 3:23 pm, with Director of Nursing (DON), DON stated call light wait time expectancy was for staff to answer the call light within three to five minutes. DON stated all staff employed in the facility were expected to answer call lights. DON stated there was a display screen at the nurse station that showed which room had a call light on and for how long the call light had been ringing. DON walked over to the nurse station, where four staff members were sitting in chairs and one staff member was standing, using a cell phone. DON stated the call light display monitor indicated the resident in room 110B had pressed the call light 10 minutes ago. DON requested staff to respond to the call light. DON stated barriers for timely call light answering could be due to lack of staff urgency, staff were caught up with other resident care, and when the facility was short staffed. DON stated it was a challenge to staff PM (evening) and NOC shifts. DON stated facility staffing ratios (the number of residents assigned to one LN or CNA) was dependent on resident census (number of residents that lived in the facility) as follows: AM (morning) shift required three LN and five to eight CNAs, PM shift was three LN, five to seven CNAs, NOC shift was two LN and three to five CNAs. DON clarified the number of CNAs required per shift did not include the Restorative Nursing Assistants. During an observation on 11/15/23 at 3:48 pm, located in hall 2, the call light for room [ROOM NUMBER] was on upon arrival. A housekeeper, the Social Services Director, and the DON were observed to walk past the call light without answering it. During a concurrent record review and interview on 11/16/23 at 9:20 am, with Human Resources (HR), an untitled record with the date 11/11/23 was reviewed. HR stated the untitled record was time punches for the staff members who worked on 11/11/23. HR stated the untitled record indicated, on 11/11/23, the PM shift had two LN, and two CNAs. The untitled record indicated there were no LN working the NOC shift and there were three CNAs. HR stated the facility would have utilized registry (travel nurse, employed by a third party) LN for NOC shift on 11/11/23. A request for registry time sheets had been made. HR reviewed the untitled record with the date of 11/12/23, and stated the untitled document indicated, the AM shift had three LN, the PM shift had two LN and three CNAs, the NOC shift had 1 LN. A review of the facility record titled Daily Census, dated Saturday, 11/11/23, indicated, the facility had 81 residents. A review of the facility record titled Daily Census, dated Sunday, 11/12/23, indicated the facility had 80 residents. On 11/16/23 at 1:15 pm, a second request was made for registry time sheets. During an interview on 11/16/23 at 1:26 PM, the facility's Administrator (ADMIN) stated when the facility had a census of 80, the staffing expectancy was as follows: the AM shift would have four LN and seven CNAs, the PM shift would have four LN and seven CNAs, the NOC shift would have two LN and four CNAs. ADMIN stated when facility staff called in, the expectation was to utilize the facility's own staff to cover the needed shifts and staff currently working would be asked to work a double (two, eight hour shifts in a row). ADMIN stated if the facility's staff was not able to work the extra hours, a registry service would be utilized. ADMIN stated if the facility was not able to obtain registry staff, a last resort would be for the facility would utilize department heads (DON, Social Services Director, Director of Staff Development, and Admissions Coordinator) to float (answer call lights, pick up meal trays, wiping down a bedside table, and provide water if needed). ADMIN stated the department heads being utilized as floaters were not required to change diapers and performed tasks as requested by the CNA who was responsible for direct resident care. ADMIN stated there had been low staffing on some weekends; when three to five CNAs do not show up for work, weekends were tough to staff, and confirmed low staffing could contribute to long call light wait times and showers not being provided to the residents. Registry time sheets were requested a third time and not provided.

Based on observation, interview, and record review the facility did not post daily staffing for public viewing as required by regulation. This failure created the potential for staffing issues including, short staffing, staffing and workload misinformation leading to decreased quality of care and adverse clinical outcomes. Findings: During a concurrent Interview and record review on 11/14/23 at 3:42 PM, the Director of Nursing (DON) attempted to locate the daily staffing posting. When the document for 11/14/23 was not available and determined not to exist the DON stated, It is not here. I will check and see if I can find it and left the DON's office. The DON approached the Assistant Director of Nursing (ADON), asked if the ADON was familiar with the form and had a current copy. The ADON did not have knowledge of the form and did not have a copy. Neither the ADON nor DON had the regulation required documents for the last 18 months. At 3:50 PM on 11/14/23 during a concurrent interview and document review the Facility Administrator (Admin) was not familiar with the requirement for posting daily staffing in a public location and the 18-month retention requirement. The Admin stated, My staffing probably has that but she walked off the job last Sunday. No daily staffing posting document was provided on request. No posting was observed during the survey. The regulatory requirement was provided to the Admin via email. The Admin affirmatively responded, Obviously we haven't been posting it . and affirmed the facility would publicly post the required information for future compliance.

Based on observation, interview, and record review, the facility failed to ensure the five rights of medication administration had been followed for one resident (Resident 53) when Licensed Nurse (LN) F did not know the name or dosage of a medication that LN F provided to Resident 53 and LN F did not document the medication had been given. This failure had the potential for incorrect medication administration, duplication for medication administration, and could cause Resident 53 negative clinical outcomes. Findings: During a review of the facility's policy and procedure (P&P) titled, Administrating Medications, revised 12/1/22, indicated, The individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. The P&P indicated the Individual administering the medication will record in the resident's medical record: the date, time, dose, and sign record. A review of the undated record titled admission Record indicated Resident 53 was admitted to the facility with the diagnosis of morbid (severe) obesity (more than 80 to 100 pounds over the ideal body weight) and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breath). The admission Record indicated Resident 53 had good cognition (ability to think and recall information) and was her own responsible party (had the ability to make own medical decisions). During a concurrent observation and interview in 11/13/23 at 9:57 am, LN F was observed walking into Resident 53's room with a suppository. Resident 53 stated LNs did not administer the suppository and that Resident 53 would self-administer the suppository. LN F handed a suppository to Resident 53 and left the room. Resident 53 placed the suppository in a box on top of the bedside table and stated Resident 53 would administer the suppository later. During an interview on 11/14/23 at 2:47 pm, LN F stated Resident 53 requested a suppository, an unknown staff member handed LN F a suppository, and was told that Resident 53 administered her own suppositories. LN F stated not looking at the suppository prior to handing it to Resident 53. LN F stated not being aware if the suppository LN F provided to Resident 53 was the suppository that the physician ordered, if it was the right medication, or the right dose. LN F confirmed not signing the Medication Administration Record and stated LN F thought the nurse who gave LN F the suppository signed it out on the Medication Administration Record (MAR). LN F stated LN F did not review Resident 53's order to ensure a different medication was to be used prior to administering the suppository. During a concurrent interview and record review on 11/14/23 at 4:10 pm, with Director if Nurses (DON), Resident 53's MAR, dated 11/1/23 through 11/30/23 was reviewed. DON stated the MAR indicated a suppository had not been signed out by a LN on 11/13/23. DON stated the MAR indicated the physician had ordered a Dulcolax suppository 10 milligrams insert 1 suppository rectally every 24 hours as needed for constipation if milk of magnesia was ineffective. Record if taken. DON stated medication administration expectancy was for LN know the five rights of medication administration which included: LN were to not administer a medication that the LN did not prepare, LN should follow the physician order's, LN are required to know what medication and dose was being given to a resident, and LN needed to sign the MAR to indicate the medication was given to the resident. DON confirmed LN F did not follow facility expectancy or policies for medication administration. A copy of the MAR was requested. The MAR provided had been updated after the record request to include May self-administer this medication by keeping at bedside.

Based on observation, interview, and record review the facility failed to have or follow policies and procedures for Quality Assurance and Performance Improvement (QA/PI) nor any formalized QAPI projects as required. This failure demonstrated a lack of quality and performance improvement that could lead to a decrease in Resident quality of life, enjoyment and happiness, causing adverse clinical outcomes. Findings: On 11/16/23 at 10:30 AM during a concurrent interview and record review the Facility Administrator (Admin) was interviewed regarding facility administration functions. The Admin was not able to provide regulation required policies and procedures on Quality Assurance and Performance Improvement (QA/PI). The QA/PI processes assist a facility in recognizing issues potentially affecting residents adversely, guiding the facility in monitoring and improving issues to reduce or prevent adverse outcomes. The Admin stated he did not have a policy for QA/PI processes available. The Admin did not have any documented formalized regulatory required QA/PI projects with planning, review, data analysis and outcome progress. The Admin verbalized understanding of the process and need for ongoing QA/PI initiatives stating he would be sure these will be done in the future.

Based on observation, interview and record review the facility failed to have records of Quality Assurance and Performance Improvement (QA/PI) meetings to obtain feedback, use data, and take action in conducting structured, systematic investigations and analysis of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility failing to have a structured, functional QA/PI process addressing potentially harmful and preventable issues creates the potential for resident harm and adverse clinical outcomes. Findings: During a concurrent record review and interview on 11/16/23 at 9:56 AM, with the Facility Administrator (Admin) when questioned about monthly and quarterly Quality Assurance and Performance Improvement (QA/PI) meetings the Admin stated the facility has, Daily quality meetings with department by department issues the managers select. The Admin was not able to print a report. Observed the form and it appears to be a day by day (not a formal monthly or quarterly) account of departmental quality assessments and improvement but not in the format of a QA/PI meeting. The Admin provided Quality Assurance (QA) sign in sheets for the months of June, July, August, September, October and November 2023. The Admin reviewed and acknowledged the Medical Director did not attend nor sign the attendance sheets on a quarterly basis (as required). The Admin provided a document set titled, Welcome November 13, 2023 Quality assurance monthly meeting consisting of six double sided pages containing a list format of usual Quality Assurance/Performance Improvement (QA/PI) functions. From the documents there are no discussions seen as would be expected resulting from a QA/PI meeting. The Admin acknowledged the list format provided does not include discussions of the items present; meeting minutes do not include meaningful information upon which an improvement plan or process can be monitored and assessed. The Admin stated, We do work on issues like falls and they are improving. The document provided does not have any feedback for results as would be an expected result from a QA/PI meeting such as improving the current status of items present. There is no discussion of adverse events, whether or not they occurred. In addition, there were no prioritization, development or action plans of any QA/PI activities discussed. When asked the Admin was not able to produce a copy of a policy/procedure on QA/PI program activities. At 11/16/23 12:41 PM, the Admissions Coordinator (AC) member was interviewed. When asked if the AC attended monthly QA/PI meetings the AC replied, Yes, daily in stand-up (a daily status meeting) I go. The AC identified her names and signatures on the QA/PI meeting attendance sign in sheets. The AC was not able to elaborate on any discussion of quality or performance issues discussed in the QA/PI meetings. At 11/16/23 12:52 PM, The Assistant Director of Nursing (ADON) was interviewed regarding attendance at QA/PI meetings. The ADON was not familiar with the meeting frequency and stated, We talk about it in the daily stand-up. When asked specifically regarding when the QA/PI meeting is held the ADON replied, I think Quarterly. It has been some time. I'm thinking October? The ADON did not state any QA/PI projects when asked though he offered, We go over things in stand-up. The ADON signature appears on the October QA/PI attendance sheet. At 11/16/23 12:56 PM, the Director of Nursing (DON) was interviewed regarding the QA/PI meeting. The DON replied, Quarterly when asked how often the QA/PI meeting was held. The DON's signature appears on monthly sign in sheets for June, July, August, October and November 2023. The DON has signed he attends the QA/PI meetings consistently on a monthly basis (with exception of September 2023) but states the meetings are only held quarterly. The DON offered that a QA/PI project is fall reduction and that the falls have decreased. The ADON and AO were not aware of falls being a QA/PI project. At 11/16/23 01:49 PM, The Medical Records Director (MRD) member was interviewed as the MR's name appears on the sign in sheets. We have meetings monthly. We work on falls, yes we go over the numbers. Every manager attends. Yes, the Medical Director attends monthly. The Medical Director signature does not appear on the monthly sign in sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 8/1/19, indicated This facility considers hand hygiene the primary means to prevent the spread of infection. The P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures . and hand hygiene would be performed, Before and after direct contact with residents. During an observation on 11/13/23 at 12:12 pm, in the social dining room, located on hall 4, Hospitality Aide (HA) was observed touching Resident 41's head with bare hands. HA touched HA's face, eyeglasses, hair, and while readjusting the N95 mask (a mask that filtered 95 percent of airborne particles) HA placed uncleansed fingers into the N95. HA was observed placing a kiss on top of Resident 66's head while touching Resident 66's shoulders. HA walked over to Resident 52 and touched the arm rest and handles of Resident 52's wheelchair. HA placed hands on Resident 62's shoulders and was rubbing HA hands back and forth. HA walked across the social dining room and hugged Resident 15. HA was observed readjusting N95 mask, placing fingers on the inside of the N95. HA had not performed hand hygiene before or after coming into direct contact of each resident with bare hands or touching self. During an interview on 11/14/23 at 12:01 pm, HA confirmed not performing hand hygiene during 11/13/23's observations in the dining hall, confirmed touching five residents and self without performing hand hygiene, and stated importance of hand hygiene in between direct resident contact was to protect self and residents from getting sick. HA stated being an employee of the facility since May 2023 and received training about hand hygiene upon hire and had not attended any in-services provided by the facility. HA stated the in-services were for the Certified Nursing Assistants and not the HA. During a concurrent interview and record review on 11/14/23 at 4:15 pm, with Director of Staff Development (DSD), Inservice-Sign in Sheet and Education Program Lesson Plan, dated 11/6/23 was reviewed. DSD stated the Education Program Lesson Plan indicated, hand hygiene was required Before and after direct contact with residents. DSD stated the In-Service Sign in Sheet indicated, HA wad been present for the in-service. Based on observation, interview and record review, the facility failed to ensure infection control program was properly maintained or implemented to reduce the spread of infection when: 1. Personal protective equipment (PPE, gloves, gowns, eye protection, and masks) was not consistently and correctly used by staff when providing care for Coronavirus disease (COVID-19: an infectious disease caused by the SARS-CoV-2 virus) positive residents; and 2. Tuberculosis (TB-a bacterial infection that mainly attacks the lung. A tuberculosis screening test checks to see if a person has the bacteria (germs) that cause TB in the body) screen was not done per the facility's policy for one out of six sampled employees. 3. Hospitality Aide (HA) did not perform hand hygiene (wash hands or use hand sanitizer) before or after direct resident contact with five out of five residents (Resident 41, 66, 52, 62, and 15) including contact with self. These failures had the potential to result in the development and transmission of infectious diseases that could lead to significant adverse consequences to residents, staff, and visitors. Findings: A review of Centers for Disease Control and Prevention (CDC)'s guideline titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/2023, the guideline indicated, Healthcare Personnel (HCP) who enter the room of a patient with suspected or confirmed COVID infection should adhere to Standard Precautions and use a The National Institute for Occupational Safety (NIOSH)-approved particulate respirator (a type of air-purifying respirators protects by filtering particles out of the air the user is breathing) with N95 filters (N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). During a concurrent observation and interviewed on 11//13/2023, at 8:30 am, at Hall 100, observed an unidentified staff (Staff C) coming out of room [ROOM NUMBER] without wearing a face shield. Staff 1 stated we don't need to wear an eye shield . During a concurrent observation and interviewed on 11/13/23 at 12:08 pm outside room [ROOM NUMBER], a sign of airborne precautions (for patients known or suspected to be infected with pathogens transmitted by the airborne route) was posted at the door of room [ROOM NUMBER], a 3-drawer plastic storage for PPE was placed outside the room. Observed a Certified Nursing Assistant (CNA) B providing care to Resident 29 without wearing gloves and a face shield. Observed CNA B coming out of room [ROOM NUMBER], opening the top drawer of the PPE storage without sanitizing her hands. CNA B stated, You don't need gloves if you don't contact the resident . CNA B stated that she just attended an infection control in-service couple weeks ago and she was taught that she didn't need gloves. During a concurrent observation and interviewed on 11/14/2023 at 8:31 am, outside room [ROOM NUMBER], CNA D was observed coming out of room [ROOM NUMBER] without wearing N 95 mask and a face shield. CNA stated Yeah, we do need to wear N 95, I just did not do it . During an interview on 11/14/2023 at 9:02 am at the Infection Preventionist (IP)'s office, the IP consultant stated that the facility followed CDC guideline which indicated that the staff should wear gown, gloves, eye protection, and mask while taking care of COVID-19 positive residents. The IP consultant said, The staff were expected to wear gloves and face shield. 2. A review of the facility policy, titled Employee Health Records, revised 11/2019, the policy indicated that A health record for each employee will contain associate TB screening Record. During a concurrent interview and record review on 11/15/2023 at 4:31 pm at the Director of Staff Development's (DSD) office. The DSD stated that the facility followed CDC guidelines for employee TB screen which was two-step skin test for new hire. Staff E's Health record was reviewed, indicated that Staff E was hired on 6/17/2023, and Staff E's TB screening record was missing. The DSD stated that she could not find Staff E's TB screening record and that's why she asked Staff E to do TB skin test on 11/8/2023.

Findings: Review of a facility policy titled Bath; Bed Bath, No-Rinse Sponge Bath (undated) indicated baths were to be given to residents to provide cleanliness, comfort, and to prevent body odors. The policy indicated, All residents are given baths unless contraindicated (not advised). The policy indicated bath water should be comfortably warm (between 95- and 110-degrees Fahrenheit) and should be changed intermittently throughout the process when the water becomes too cool or dirty. During review of record titled Resident Council Minutes, dated 7/20/2023 at 1:45 pm, shower was indicated as a concern regarding nursing care. During observational tour of the facility on 10/13/2023 at 8:50 am, overheard Resident 8 ask Director of Nursing (DON) when hot water for showers would be available. DON stated, That was fixed Wednesday (10/11/2023). Resident 8 stated, It ' s been out for like a week. DON restated that maintenance staff had resolved the issue. During observation on 10/13/2023 at 12:30 pm, a facility staff member handed this surveyor a note indicating, the facility has not been giving residents showers due to no hot water! They do not have any shower caps for alternatives. -Anonymous (sic). During record review of Shower Day Skin Inspection for 19 residents, the records indicated: On 10/6/2023, Resident 17 refused a bath or shower. On 10/10/2023, the record did not indicate a shower or bath had been provided for Resident 5. On 10/11/2023, Residents 9 and 20 refused a bath or shower. On 10/12/2023, Resident 11 refused shower or bath. On 10/16/2023, Resident 8 refused [shower] due to water pressure. The form did not indicate a shower or bath had been provided for Resident 21. On 10/18/2023, Resident 9 refused a bath or shower. During an interview on 10/19/2023 at 9:05 am with Administrator (ADM 1), ADM 1 stated the facility had purchased a bunch of wipes for bed baths because the facility had no hot water since last night. ADM 1 stated the facility planned to bring in an extra Certified Nurse Assistant (CNA) when hot water was back to catch up on showers. ADM 1 stated one of two water heaters was shut off yesterday (10/18/2023) for repair, but since that time a new water leak had been discovered. During a concurrent interview on 10/19/2023 at 9:05 am with Maintenance Supervisor (MS), MS stated a water leak had been discovered in the dining room at 6:00 am, and water to the facility had been shut off shortly thereafter so the leak could be fixed. During an interview on 10/19/2023 at 9:20 am, CNA 3 stated water in the facility runs warm but cools quickly, which has caused residents to decline showers. CNA 3 stated the hot water had been an issue since last Friday. During an interview on 10/19/2023 at 9:35 am, CNA 5 stated the DON was not admitting to residents there was no hot water. During an interview on 10/19/2023 at 9:37 am, Resident 14 stated she hadn ' t had a shower and the water was cold. During an interview on 10/19/2023 at 9:38 am, Resident 25 stated it had been about a week with no shower or bed bath. During an interview on 10/19/2023 at 9:40 am, Resident 8 stated she had asked DON on 10/13/2023 about no hot water for showers. Resident 8 stated the hot water had been out about a week at that time, but now it's been two weeks. Resident 8 stated showers had been offered by staff, but the resident refused because showers were cold. Resident 8 stated wipes had been offered for bed baths, but that's not going to get me clean, either. Resident 8 stated she had refused wipes. During an interview on 10/19/2023 at 9:45 am, Resident 26 stated, It ' s about time you got here. I want a hot shower. It ' s been 15 days. Resident 26 stated he was very frustrated and had a fit about it. During an interview on 10/19/2023 at 9:50 am, Resident 9 stated there had not been hot water in the facility for 15 days. Resident 9 stated, That's close to elder abuse. Resident 9 stated her home was near the facility and that she was able to go home to shower, but she feels awful and is pissed she can't wash her hair at the facility. Resident 9 stated it has been a long time with no accommodation. Resident 9 stated, I feel left behind. I ' m pretty independent, so they don ' t check on me very much. During an interview on 10/19/2023 at 9:50 am, Housekeeper (HK) stated residents had been complaining about no hot water and not getting showers, particularly Resident 16. During an interview on 10/19/2023 at 11:10 am, CNA 1 stated the facility had no hot water for almost three weeks. CNA 1 stated a family complained about lack of bathing their bedbound family member and reported she heated water in a microwave to do a bed bath. CNA 1 reported another resident wanted a shower prior to dialysis. CNA 1 stated she reported the issue to Staffing Coordinator (SC) and was told to use a shower cap with soap in it to wash the resident's hair. CNA 1 stated, Residents are complaining about showers. I was told just do what you can. Based on observation, interview, and record review, the facility did not provide routine showers and/or baths consistent with the residents' needs and choices for 11of 23 (Resident 5, 8, 9, 10, 11, 14, 16, 17, 20, 25, and 26) sampled residents. This failure had the potential to result in depression, poor self-esteem, skin breakdown, infection, and denial of resident rights, all of which could lead to negative clinical outcomes for all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the supervision required to keep all residents free from potential accidents and hazards when: 1. One of seven residents (Resident 1) eloped unsupervised (left without notice) from the facility without staff being aware he was gone. 2. Wanderguard alarms (prevent wander-prone residents from leaving unattended) were not working at two of four facility exit doors. These failures had the potential to compromise the safety and well-being of all residents from unsupervised wandering/elopement with the potential for accident or harm. Findings: Review of facility policy titled, Safety and Supervision of Residents, revised 10/2022, indicated the facility would strive to make the environment as free from accident hazards as possible based on individual resident need. The policy indicated the facility would monitor the effectiveness of interventions by (a) ensuring that interventions are implemented correctly and consistently, (b) evaluate the effectiveness of interventions, and (c) modify interventions as needed. Review of facility policy titled, Wandering and Elopements, revised 3/2019, indicated that 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. 1.Review of Resident 1's admission record indicated he was admitted to the facility on [DATE], with diagnoses which included heart disease and muscle weakness. Review of Minimum Data Set (MDS) record, dated 2/25/2023, indicated Resident 1 had a Brief Interview for Mental Status (tool used to identify the mental capacity of residents) score of 12 out of 15. The record indicated Resident 1 required limited staff guidance (guided maneuvering of limbs or other non-weightbearing assistance) for moving about on and off the unit. The record indicated Resident 1 was not steady, but able to stabilize without staff assistance when walking and turning around. The record indicated Resident 1 used a walker and/or wheelchair for mobility following a stroke, and a wander/elopement alarm was not used. The record indicated care areas triggered for care planning included cognitive (mental capacity) loss/dementia, activities of daily living functional/rehabilitation potential, and falls. Review of an Interdisciplinary Team (IDT - a group of professionals from different disciplines who meets to discuss resident care) Note for Resident 1, dated 3/16/2023 at 9:05 am, indicated that staff was alerted by a civilian that Resident 1 was seen outside of the facility. The note indicated staff searched surrounding areas to locate Resident 1, who was known to have exit-seeking behaviors with a risk for fall. The note indicated Resident 1 had moderately impaired cognition (the ability to acquire and process information). Resident 1's description of the event was that he went out for a walk. During an interview on 10/13/2023 at 12:10 pm with Administrator (ADM 1) and Director of Nursing (DON), ADM 1 and DON could not confirm Resident 1 ' s 3/16/2023 elopement had been reported to SA. ADM 1 stated he did not work for the facility until 4/2023 and was not present in the facility at the time of elopement. During an interview with DON on 10/13/2023 at 1:25, DON stated he had just called ADM 2 (administrator in 3/2023) who reported he can ' t remember if they called SA or not. DON stated ADM 2 reported to him that if there was proof of a report to SA, it would have been on the computer. ADM 1 and DON were unable to produce an unusual occurrence report. During an interview on 10/19/2023 at 12:15 pm with Director of Social Services (DSS), DSS stated Resident 1 was his own Responsible Party and wanted to go out at the time of elopement on 3/16/2023. DSS stated Resident 1 didn't sign out and got to the park before it was noticed he was not in the facility. DSS stated, Someone brought him back, she thought possibly the DON. DSS stated Resident 1 was not wearing a Wanderguard bracelet at the time of elopement, but Wanderguard bracelet was placed on Resident 1 after the elopement to prevent further incidents. 2. Review of documents titled RF Technologies Down Payment Requisition, dated 09/28/2023, indicated a request for purchase of Code Alert 9450 Wander Management (WM) System components. During an observational tour of the facility 16 days later on 10/13/2023 at 8:45 am with Director of Nursing (DON), two of four alarms did not sound at Wanderguard-monitored exit doors located (a) between rooms [ROOM NUMBERS] and (b) between the storage shed and outside storage. During an interview on 10/13/2023 at 9:00 am with DON, DON stated a log of Wanderguard alarm system checks did not exist but that he had checked the alarm system a couple days ago and it was working at that time. DON stated he checked the alarm system about once or twice a week for my peace of mind. During a concurrent observation and interview with DON on 10/13/2023 at 12:35 pm, the Wanderguard at exit door between rooms [ROOM NUMBERS] was again tested. A very loud alarm sounded. DON verified that the Wanderguard was still not working but that a universal door alarm had been turned on. DON stated a new Wanderguard unit had been ordered. Record review was performed for a sample of seven residents (Residents 1-7), each of whom was identified as being at risk for elopement:.Residents 2-7 had orders for Wanderguard, signed consents, and elopement care plans in place and updated. Each resident had orders for battery function of Wanderguard documented checked nightly and placement checked each shift. Review of Minimum Data Set (MDS) record, dated 9/20/2023, indicated Resident 2 exhibited wandering behaviors 1 to 3 times on admission. The record indicated Resident 2 required limited staff guidance (guided maneuvering of limbs or other non-weightbearing assistance) for moving about in his room and on and off the unit. The record indicated Resident 2 was not steady, but able to stabilize without staff assistance when walking and turning around. The record indicated Resident 1 used a wheelchair for mobility due to impairment in his lower extremity (legs) function related to diagnoses of Parkinson's disease and history of stroke. The record indicated Resident 2 had had a fall since admission and was on an alarm to prevent wander/elopement daily. Review of an IDT Note for Resident 2, dated 10/12/2023 at 1:41 pm, indicated, Resident 2 walked out back door of facility pushing his wheelchair in front of him. The note indicated Resident 2 became combative and resisted assistance when staff attempted to redirect him back into the building. The plan was to monitor for further elopement attempts. Root cause analysis indicated Resident 2 has a history of exit-seeking behavior looking for his wife with a baseline cognition level of severe impairment. The note indicated Resident 2 was at risk for wandering, elopement, fall or accident. Interventions prior to Resident 2's elopement on 10/12/2023 were an elopement prevention care plan and Wanderguard. The note indicated the facility planned to increase safety checks, provide calm reassurance that his wife knows where he is, and encourage family to visit more often. During an interview on 10/19/2023 at 9:35 am, CNA 4 confirmed Resident 5 is a wanderer and seeks to exit the facility enough for staff to monitor him. During an interview on 10/19/2023 at 11:00 am with Maintenance Supervisor (MS), MS stated he did not keep a log of weekly checks of the Wanderguard, so there was no proof, and to his knowledge DON was not doing checks of the Wanderguard system. During a concurrent interview on 10/19/2023 at 11:00 am with ADM 1, ADM 1 stated Both Wanderguard systems on Hall 1 and Hall 2 near laundry and kitchen aren ' t working. During an interview on 10/19/2023 at 12:15 pm with Director of Social Services (DSS), DSS stated Resident 2 had a witnessed elopement on 10/12/2023. DSS stated he made it out the front door. Staff saw him and followed him out.

Based on observation, interview, and record review, the facility failed to ensure residents' linens were being clean and sanitized using infection control standards. This failure resulted in residents' linens not being cleaned and sanitized properly and had the potential to spread disease and infection throughout the facility. Findings: A review of a facility policy titled, Infection Prevention and Control, revised 10/2021, indicated, An infection prevention and control program (ICPC) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation on 10/13/2023 at 8:50 am, overheard Director of Nursing (DON) inform Resident 8 an issue with no hot water in the facility was fixed Wednesday (10/11/2023). Resident 8 stated the hot water had been out for like a week. DON again replied that maintenance staff had resolved the issue two days prior. During a review of Plumbing Doctor Invoice #24467745, dated 10/17/2023, the invoice indicated it was an estimate to replace a gas control valve, thermostat, temperature and pressure valve, and drain valve on a 100-gallon water heater. During a review of Plumbing Doctor Estimate #24523298, dated 10/17/2023, the estimate indicated This estimate is to remove old leaking 100-gallon water heater and install a new 100-gallon water heater up to state and city code. This will include an expansion tank and seismic straps. During an interview on 10/19/2023 at 9:05 am, Maintenance Supervisor (MS) stated one of two facility water heaters was out. MS stated a plumber had been called to replace parts, but a decision had been made to replace the broken water heater. MS stated he knows hot water temperatures should be between 106- and 120-degrees Fahrenheit, but we don't have that now. During an interview on 10/19/2023 at 10:30 with Housekeeper (HK), HK stated the laundry has been dirtier. HK stated they were having to rewash the laudry often. During an interview on 10/19/2023 at 11:10 am with Administrator (ADM 1), ADM 1 stated he was unaware of the laundry issues. ADM 1 stated he did not know where to find the Ecolab (manufacturer) operating manual for washing machines but would look for it. During a concurrent observation in the laundry room and interview with MS on 10/19/2023 at 11:43 am, MS stated Ecolab maintains facility washing machines. When asked how often machines were maintained, MS stated Ecolab had been in the facility 2 to 3 days ago to check the dishwashers but could not state when washing machines were last maintained. MS stated he was aware residents were complaining about the laundry and things aren't getting clean. MS stated he did not know where to find the manufacturer operating manual for facility washing machines. MS confirmed the two of two washing machines were overfilled with blankets and articles of clothing; this did not allow water to agitate or cleaning chemicals to circulate properly through laundry items. During an interview on 10/19/2023 at 12:40 pm, ADM 1 stated he could not locate the manufacturer operating manual for washing machines. ADM 1 stated he had called Ecolab and confirmed the facility washing machines require low temperature at a minimum of 120-degrees Fahrenheit for proper cleaning and sanitizing with the detergent. Despite two requests on 10/19/2023 and 11/6/2023, Ecolab operating manuals were not provided to SA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain essential equipment necessary to ensure resident safety and activities of daily living needs were met when: 1 The Wanderguard Alarm System (prevents wander-prone residents from leaving the facility unattended) did not work for three weeks or more. This failure led to the potential for unsupervised resident elopement (leaving without notice), leading to the potential for harm and preventable accidents/hazards for all residents. 2. One of two facility water heaters did not work for two weeks or more. This failure led to residents not getting baths or showers due to no hot water in the facility with the potential to result in poor self-esteem, depression, denial of resident rights, contribution to skin breakdown, infection, and negative clinical outcomes for all residents. Findings: 1. Review of a facility policy titled, Wandering and Elopements, revised 3/2019, indicated that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of facility policy titled, Safety and Supervision of Residents, revised 10/2022, indicated the facility will strive to make the environment as free from accident hazards as possible based on individual resident need. The policy indicated the facility will monitor the effectiveness of interventions by (a) ensuring interventions are implemented correctly and consistently, (b) evaluate the effectiveness of interventions, and (c) modify interventions as needed. Review of documents titled RF Technologies Down Payment Requisition, dated 09/28/2023, indicated request for purchase of Code Alert 9450 Wander Management (WM) System components. During an observational tour of the facility 16 days later on 10/13/2023 at 8:45 am with Director of Nursing (DON), a test was performed to the Wanderguard alarm system. The Wanderguard alarm did not sound at two of four Wanderguard-monitored exit doors: (a) between rooms [ROOM NUMBERS] and (b) near the laundry room. During an interview on 10/13/2023 at 9:00 am with DON, DON stated he had checked the alarm system a couple days ago and it was working at that time. DON stated he did not keep a log of checks performed to the Wanderguard system but stated he checked the system about once or twice a week for my peace of mind. During a concurrent observation and interview with DON on 10/13/2023 at 12:35 pm, the Wanderguard at exit door between rooms [ROOM NUMBERS] was again tested. A very loud alarm sounded. DON stated that a universal door alarm had been turned on but confirmed Maintenance Supervisor (MS) had been unable to fix the Wanderguard. DON stated a new Wanderguard unit had been ordered. During an interview on 10/19/2023 at 11:00 am with MS, MS stated he did not keep a log of his weekly checks of the Wanderguard so there was no proof, and DON was not doing the checks to his knowledge. During a concurrent interview on 10/19/2023 at 11:00 am with Administrator (ADM 1), ADM 1 stated Both Wanderguard systems on Hall 1 and Hall 2 near laundry and kitchen aren ' t working. 2. During observation on 10/13/2023 at 8:50 am, overheard Resident 8 ask DON when hot water for showers would be available again. DON stated, That was fixed Wednesday (10/11/2023). Resident 8 stated the hot water had been out for like a week. DON again stated maintenance staff had resolved the issue two days prior. During observation on 10/13/2023 at 12:30 pm, a facility staff member handed this surveyor a note indicating, the facility has not been giving residents showers due to no hot water! They do not have any shower caps for alternatives. -Anonymous (sic). During a review of Plumbing Doctor Invoice #24467745, dated 10/17/2023, the invoice indicated it was an estimate to replace a gas control valve, thermostat, temperature and pressure valve, and drain valve on a 100-gallon water heater. During a review of Plumbing Doctor Estimate #24523298, dated 10/17/2023, the estimate indicated This estimate is to remove old leaking 100-gallon water heater and install a new 100-gallon water heater up to state and city code. This will include an expansion tank and seismic straps. During an interview on 10/19/2023 at 9:05 am, Administrator (ADM 1) stated the facility had been without hot water since last night. ADM 1 stated the facility bought a bunch of wipes for bed baths and planned to bring in an extra Certified Nurse Assistant (CNA) when the hot water is back to catch up on showers. During a concurrent interview on 10/19/2023 at 9:05 am, MS stated one of two facility water heaters was out. MS stated the water heater had a known leak and a plumber was called for parts, however getting the parts was a problem. MS stated it had been decided to replace the water heater. MS stated he understood water needs to be between 106- and 120-degrees Fahrenheit for proper cleaning and sanitizing, but we don't have that now. MS stated a water leak had been discovered in the dining room at 6:00 am, and water to the facility had been shut off shortly thereafter so the leak could be fixed. During an interview on 10/19/2023 at 11:10 am, CNA 1 stated the facility had no hot water for almost three weeks. CNA 1 stated a family complained about lack of bathing their bedbound family member and reported she heated water in a microwave to do a bed bath. CNA 1 reported another resident wanted a shower prior to dialysis. CNA 1 stated she reported the issue to Staffing Coordinator (SC) and was told to use a shower cap with soap in it to wash the resident's hair. CNA 1 stated, Residents are complaining about showers. I was told just do what you can. During observation on 10/19/2023 at 12:30 pm, overheard MS tell ADM 1 running water had been restored to the facility that was turned off for 6 1/2 hours. During an concurrent interview and record review with MS on 10/19/2023 at 11:00 am, MS stated he had not checked facility water temperatures after fixes to the water heaters. MS stated he was unaware water was still not hot. MS stated he did not have a regular system for checking water temperatures. MS stated he was also only checking water temperature in random resident rooms, not in common areas nor shower rooms in the facility. MS provided the Daily Maintenance Rounds log that indicated on 9/18/2023, Rooms 109, 209, 302, and 402 had hot water temperatures between 110- and 112-degrees Farhenheit and on 9/19/2023, Rooms 109, 209, 304, and 404 had hot water temperatures between 109- and 111-degrees Farhenheit. MS confirmed these were the only recorded water temperatures he had for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the Care Plan for two of nine sampled residents (Resident 1 and 8) when: 1. Frequent safety checks ordered by the physician were not added to Resident 1's Care Plan. Resident 1 had a prior history of being the initiator of two physical altercations with two other male residents (Refer to F600). 2. Resident 8's Care Plan was not updated after a verbal and physical altercation with Resident 1. This failure had the potential to put Resident 8 and other residents at risk of threats to their health and well-being. Findings: A facility policy, titled, Safety and Supervision of Residents, revised 7/1/17, was reviewed. The policy indicated that the facility strove to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. As part of an individualized, resident-centered approach to safety, the interdisciplinary care team (IDT-a group of professionals from different disciplines that met to discuss the residents' care) should have identified any specific accidents hazards or risks for individual residents. The care team should have targeted interventions to reduce individual risks related to hazards in the environment, including adequate supervision. 1. A review of Resident 1's admission record indicated they were admitted to the facility on [DATE]. Resident 1's diagnoses included vascular dementia (impaired blood supply to the brain that caused confusion and memory loss) with psychotic disturbance (loss of touch with reality), cognitive communication deficit (difficulty with thinking and use of language), and depression. A review of Resident 1's record showed a physician's order, dated 9/6/22, for risperidone (an antipsychotic medication) 2 milligrams (a metric unit of weight) by mouth every morning and at bedtime. The medication's indication was for, behavioral and psychological symptoms of dementia as evidenced by physically aggressive behavior towards others that is not easily redirectable during activities of daily living care. A review of Resident 1's record showed a physician's order, dated 2/10/23, for 15 minute safety checks on resident to ensure safety of all residents. During an observation, on 3/2/23, at 1:44 pm, Resident 1 walked independently and briskly around the facility with a walker, to the front entrance, back to his room, and to the dining room. During a concurrent interview and record review, on 3/2/23, at 5 pm, the Director of Nursing confirmed the checks that had been ordered to be done every 15 minutes were not on Resident 1's Care Plan. 2. A review of Resident 8's admission record indicated they were admitted to the facility on [DATE]. Resident 8's diagnoses included a stroke, dementia (a mental disorder that caused confusion and memory loss), and hemiplegia and hemiparesis (paralysis and weakness on one side of the body) the stroke, affecting the right dominant side. A review of Resident 1's admission record indicated they were admitted to the facility on [DATE]. Resident 1's diagnoses included vascular dementia (impaired blood supply to the brain that caused confusion and memory loss) with psychotic disturbance (loss of touch with reality), cognitive communication deficit (difficulty with thinking and use of language), and depression. A Summary of Incident note, dated 3/23/23, by the administrator (ADMIN), was reviewed. ADMIN wrote, Around 3 pm on 3/23/23 a Certified Nursing Assistant (CNA) was taking vitals (such as pulse and blood pressure readings) for [Resident 8]. [Resident 1] was walking down the h [sic] when [Resident 8] and [Resident 1] locked eyes. [Resident 1] walked closer to [Resident 8]. [Resident 8] was heard CNA [sic] that he was going to kick his ass. At this point [Resident 8] leaned forward and [Resident 1] flinched [Resident 8] then repeated that he would kick [Resident 1]'s ass. [Resident 1] then struck [Resident 8]. [Resident 8] back [sic] and struck [Resident 1]. During a concurrent interview and record review, on 3/29/23, at 1:35 pm, the Director of Nursing confirmed there was nothing written in Resident 8's Care Plan about any verbal or physical altercation with Resident 1, or any other resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect three of nine sampled residents (Residents 2, 5 and 8) from physical abuse when Resident 1 was the initiator of two physical altercations with two other male residents. 1. Resident 1 held Resident 2 down and punched him in the face four times. 2. Resident 1 came up behind Resident 5 and shoved him. 3. Resident 1 struck Resident 8 after a verbal altercation. This failure had the potential to cause serious physical injury and threaten Resident 2, 5 and 8's health and well-being. Findings: A facility policy, titled, Abuse Prevention Program, revised 12/1/16, was reviewed. The policy indicated that residents had the right to be free from abuse, including mental or physical abuse. As part of the resident abuse prevention, administration would have protected residents from abuse by anyone, including other residents. Administration would have established and implemented a Quality Assurance and Performance Improvement review and analysis of abuse incidents and implemented changes to prevent future occurrences of abuse. A facility policy, titled, Safety and Supervision of Residents, revised 7/1/17, was reviewed. The policy indicated that the facility strove to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. As part of an individualized, resident-centered approach to safety, the interdisciplinary care team (IDT-a group of professionals from different disciplines that met to discuss the residents' care) should have identified any specific accidents hazards or risks for individual residents. The care team should have targeted interventions to reduce individual risks related to hazards in the environment, including adequate supervision. 1. A review of Resident 2's admission record indicated they were admitted to the facility on [DATE]. Resident 2's diagnoses included Alzheimer's disease (a long-term disease that caused a loss of intellectual function), depression, and high blood pressure. A review of Resident 1's admission record indicated they were admitted to the facility on [DATE]. Resident 1's diagnoses included vascular dementia (impaired blood supply to the brain that caused confusion and memory loss) with psychotic disturbance (loss of touch with reality), cognitive communication deficit (difficulty with thinking and use of language), and depression. A review of Resident 1's record showed a physician's order, dated 9/6/22, for risperidone (an antipsychotic medication) 2 milligrams (a metric unit of weight) by mouth every morning and at bedtime. The medication's indication was for, behavioral and psychological symptoms of dementia as evidenced by physically aggressive behavior towards others that is not easily redirectable during activities of daily living care. A handwritten note, undated, by the Activities Assistant (AA), was reviewed. The note described an incident that occurred on 2/9/23. AA wrote, At approx. [sic] 11:00 am, [Resident 2] and [Resident 1] were sitting next to each other, drinking coffee, in the dining room. They were sitting quietly while listening to music. Unprovoked, [Resident 1] stood up, held [Resident 2] down with his left arm & punched him four times with his right. I ran to stop [Resident 1] & [Resident 1] continued to try to punch [Resident 2] unsuccessfully. [Resident 2] did not retaliate. A review of Resident 1's record showed a Social Service Note, dated 2/10/23, at 12:49 pm, by the Social Services Director (SSD). SSD wrote, SSD in to see patient for res-res [resident-to-resident incident]. PT [sic] hit another resident [Resident 2] sitting next to him, unprovoked. PT acknowledged doing this, stated, ' He was making noises.' A review of Resident 2's record showed an IDT Note, dated 2/13/23, at 1:15 pm, by the Assistant DON (ADON). ADON wrote of the incident that occurred on 2/9/23, Root cause analysis: Resident [1] has history of aggression. Both residents are demented and this incident was unprovoked. 2. A review of Resident 5's admission record indicated they were admitted to the facility on [DATE]. Resident 5's diagnoses included fracture of the T11 - T12 vertebra (broken bones in the middle-lower part of the spine), anxiety, and generalized weakness. A review of Resident 1's admission record indicated they were admitted to the facility on [DATE]. Resident 1's diagnoses included vascular dementia (impaired blood supply to the brain that caused confusion and memory loss) with psychotic disturbance (loss of touch with reality), cognitive communication deficit (difficulty with thinking and use of language), and depression. A review of Resident 1's record showed a physician's order, dated 9/6/22, for risperidone (an antipsychotic medication) 2 milligrams (a metric unit of weight) by mouth every morning and at bedtime. The medication's indication was for, behavioral and psychological symptoms of dementia as evidenced by physically aggressive behavior towards others that is not easily redirectable during activities of daily living care. Review of Resident 5's record showed a Nurse's Note, dated 12/7/22, at 3:51 pm, by the Director of Nursing (DON). DON wrote, [Resident 5] was standing at the nurses station speaking to staff when [Resident 1] approached. It appeared [Resident 1] thought [Resident 5] had his walker. [Resident 1] attempted to pull the walker away from [Resident 5], who was not using it for support at the time. [Resident 5] then pull [sic] his walker back away from [Resident 1] and then turned around and resumed speaking to staff. [Resident 1] then walked up behind [Resident 5] and shoved him in the back. At that time staff intervened and separated the two residents. [Resident 1] was redirected and brought to his room when his walker was given to him. Review of Resident 5's record showed an IDT note, dated 12/9/22, at 2:50 pm, by the DON. DON wrote of the incident that happened on 12/7/22, Root cause analysis: [Resident 1] was confused and thought [Resident 5]'s walker was his. When [Resident 5] pulled it away, [Resident 1] pushed [Resident 5]. 3. A review of Resident 8's admission record indicated they were admitted to the facility on [DATE]. Resident 8's diagnoses included a stroke, dementia (a mental disorder that caused confusion and memory loss), and hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following the stroke, affecting the right dominant side. A review of Resident 1's admission record indicated they were admitted to the facility on [DATE]. Resident 1's diagnoses included vascular dementia (impaired blood supply to the brain that caused confusion and memory loss) with psychotic disturbance (loss of touch with reality), cognitive communication deficit (difficulty with thinking and use of language), and depression. A review of Resident 1's record showed a physician's order, dated 9/6/22, for risperidone (an antipsychotic medication) 2 milligrams (a metric unit of weight) by mouth every morning and at bedtime. The medication's indication was for, behavioral and psychological symptoms of dementia as evidenced by physically aggressive behavior towards others that is not easily redirectable during activities of daily living care. During an observation, on 3/2/23, at 1:44 pm, Resident 1 walked independently and briskly around the facility with a walker, to front entrance, back to his room, and to the dining room. A Summary of Incident note, dated 3/23/23, by the administrator (ADMIN), was reviewed. ADMIN wrote, Around 3 pm on 3/23/23 a Certified Nursing Assistant (CNA) was taking vitals (such as pulse and blood pressure readings) for [Resident 8]. [Resident 1] was walking down the h [sic] when [Resident 8] and [Resident 1] locked eyes. [Resident 1] walked closer to [Resident 8]. [Resident 8] was heard [sic] CNA that he was going to kick his ass. At this point [Resident 8] leaned forward and [Resident 1] flinched [Resident 8] then repeated that he would kick [Resident 1]'s ass. [Resident 1] then struck [Resident 8]. [Resident 8] back [sic] and struck [Resident 1]. A review of Resident 1's record showed an IDT note, dated 3/24/23, at 8:46 am, by the Director of Nursing (DON). DON wrote of the incident that occurred on 3/23/23, Root cause analysis: Resident has history of aggressive behavior. Other resident [Resident 8] made eye contact with him [Resident 1] and made a lunging action from his chair. This caused [Resident 1] to react by hitting the other resident [Resident 8].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Registered Dietitian (RD) carried out the functions of the food and nutrition services to assess the nutritional needs for one of three sampled residents (Resident 1). This failure had the potential for the residents to not receive proper therapeutic diets based on their medical diagnoses and may result in putting the residents at nutritional risk, and further compromising the medical status of the residents. Findings: A review of the facility's policy titled, Food and Nutrition Services , revised in 10/2017, indicated: 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. A resident-centered diet and nutrition plan will be based on this assessment. A review of Resident 1's record indicated she was admitted to the facility on [DATE], with diagnoses which included heart problems with surgery on the circulatory system, lung problems, end stage renal disease (a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis to maintain life), dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 1's Minimum Data Set (an assessment and care screening tool), dated 12/16/2022, indicated that Resident 1 had a brief interview for mental status (BIMS) score of 14, at section C Cognitive Patterns indicating she was cognitively intact. She was her own health care decision maker. A review of Resident 1's MDS, dated [DATE], at section V – Care Area Assessment (CAA) Summary (a process provided guidance on how to focus on key issues identified during a MDS assessment), indicated that Resident 1's Nutritional Status was triggered and was addressed in Resident 1's care plan. A review of Resident 1's Nutritional Care Plan showed the resident had nutritional problem or potential nutritional problem. A nutritional care plan was then initiated on 12/21/2022, and interventions/tasks indicated that Registered Dietitian (RD) was to evaluate the resident . During a concurrent interview and record review with the Director of Nursing (DON), on 1/31/2023 at 2:20 pm, Resident 1's RD evaluation and assessment reports/notes were not found. The DON stated the medical record personnel was on vacation and he would try to locate the documents. However, the facility was not able to provide request records even after given three weeks to locate the record (since 1/31/2023). During an interview with Administrator (ADMIN) 1 on 2/9/2023 at 9:02 am, the ADMIN stated that the facility had contracted with a Nutrition Consulting company – N 1, which provided Registered Dietitian Consultation Services. ADMIN stated that RD 1 would come to the facility, twice a week, on every Tuesday and Thursday. Resident 1 was admitted to the facility on [DATE], which was Monday. Her dialysis schedule was every Monday, Wednesday, and Friday. RD 1 was given six opportunities in December 2022, and four opportunities in January 2023 to assess and evaluate the resident before Resident 1 was admitted to acute hospital on 1/14/2023. There were no such documents/reports to be found in Resident 1's medical record. A review of the facility's documentation, titled, Agreement for Registered Dietitian Consultation Services , dated, 9/1/2021, signed by ADMIN 2 (former Administrator of the facility) and Registered Dietitian Supervisor (RDS) from N 1 company, showed: 1. The terms of Agreement indicated that Professional services of the Company registered dietitian will be contracted for 64-80 hours per month . 2. The Responsibilities of the Consultant Dietitian include: · Charts nutritional information in accordance with the policies of the Facility and accepted professional practice. Participates in development and review of individual resident care plans and discharge plans where applicable. Counsels the resident, staff, and family with regard to the resident's nutritional needs. · Maintains and provides written reports of each consultation visit including date and hours, observation, comments, goals and /or recommendations, and staff conferences. 3. The Responsibilities of The Facility included: Sufficient consultation hours per month to assure that the food and nutrition services and resident nutritional care regulations are met. A review of the facility's documentation, titled, Job Description: Registered Dietician , dated, 9/2017, indicated: 1. The general purpose of RD was to Complete nutritional initial, quarterly, annual, and significant change reviews on residents according to federal and state guidelines. Assist in coordination of nutrition care services with Dietary Supervisor. Complete nutritional reviews monthly on high-risk residents (significant weight loss/gain, pressure ulcer, hemodialysis, and tube fed). 2. The Essential Duties of RD included: · Ability to meet all health, compliance, and competency requirements. · Assess nutritional needs, diet restrictions and current health plans in order to develop and implement dietary care plans and provides nutritional counseling as needed. · Monitor food services operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as State and Federal regulations. During an interview with Dietary Manager (DM) on 2/16/2023 at 12:32 pm, DM stated that the dietary department, had 48 hours to speak to the residents, interview them for their preference, and chart it on the computer . During an interview with the DON on 2/23/2023 at 9:13 am, the DON confirmed that Resident 1 did not have RD assessments and RD progress notes. The DON stated We had been having issues with this consultant company. Obviously, [RD 1] was not showing up enough . The DON stated that for food and nutrition services, RD 1 had 48 hours to assess and evaluate a new admission resident. During an interview with ADMIN 1 on 2/23/2023 at 10:03 am, ADMIN 1 stated that a new RD from N1 company – RD 2 started last week, and he had a long talk with RD 1's supervisor (RDS). ADMIN 1 stated, [RDS] said it won't happen again . ADMIN 1 indicated that the facility had better communication with RD 2, and they continued working on finding their own RD .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, this requirement was not met when four of 11 residents (Residents 1, 2, 3 and 4) stated they were not bathed as scheduled. This resulted in a reduced quality of life, a less home like environment and potential for infection and skin issues, and resulted in reduced self esteem for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] for conditions including chronic heart failure, difficulty walking, diabetes, muscle weakness, chronic obstructive pulmonary disease (a lung disease that blocks the lungs) and morbid obesity. A review of Resident 1's shower sheets (a working document to record bathing) for December 2022 indicated that her scheduled bathing days were Mondays and Thursdays, and that there were nine scheduled bathing dates that month. Further review of the record indicated that bathing was documented for Resident 1 on 12/5, 12/8, 12/11, 12/15, 12/25 and 12/28/22, only six of nine bathings had been documented, including a four-day gap in documentation from 11/30/22 to 12/5/22 and a nine-day gap in documentation from 12/16/22 to 12/25/22 with no documentation of refusing bathing provided for these gaps. Resident 2 was admitted to the facility on [DATE] for conditions that included Parkinson's Disease (a nerve disease that causes tremors and unstable movement), morbid obesity, heart failure, and neurocognitive disorder (decline in brain function due to bodily illness), and history of stroke. A review of Resident 2's shower record for December 2022 indicated that her scheduled bathing days were Mondays and Thursdays and that there were nine scheduled bathing dates for that month. Further review of provided shower sheets indicated that bathing was documented for Resident 2 on 12/12, 12/15, 12/19, and 12/22; four of nine bathing opportunities, including an eight-day gap in documentation from 12/1/22 to 12/9/22 and a six-day gap between 12/16 and 12/21/22, with no documentation of refusal during those gaps. Resident 3 was admitted to the facility on [DATE] and had conditions including an antibiotic resistant infection, diabetes, kidney failure, muscle weakness, and cellulitis (swollen tissue) on a lower limb (leg). A review of Resident 3's shower record for December 2022 indicated that her scheduled shower days were Tuesday and Friday and that there were nine scheduled bathing days for that month. Further review of provided shower sheets indicated that bathing was documented for Resident 3 on 12/1, 12/6, 12/13, 12/16, 12/20, 12/23 and 12/27/22, seven of nine bathing opportunities, including a four-day gap in documentation between 12/2 and 12/6/22; a six-day gap between 12/7 and 12/12/22, and a four-day gap in documentation between 12/28 and 12/31/22, with no documented refusal during those gaps. Resident 4 was first admitted to the facility on [DATE], and again admitted on [DATE], for obesity, asthma, diabetes, kidney disease and breast cancer. A review of Resident 4's shower sheets for December 2022 indicated that her scheduled shower days were and Wednesday and Saturday. Of nine scheduled bathing days that month, Resident 4's record indicated that bathing was documented on shower sheets on 12/8, 12/10, 12/13, 12/17, 12/21 and 12/24/22, six of nine scheduled shower dates, with a seven-day gap between 12/1 and 12/8/22 where no documented bathing was given to the resident and no refusals were recorded. A review of the facility's Shower Policy and Procedure, (undated), indicated that Staff will honor shower and/or bathing preferences such as frequency of shower schedule, and, under Documentation, The following information should be recorded on the resident's ADL record (Activities of Daily Living) and/or in the resident's medical record: 1) The staff will document the date the shower was performed; 2) The signature and title of the person recording the data. In written correspondence on 1/4/23 at 9:12 AM, the Director of Nursing (DON) A indicated that shower sheets that he had provided represented the most complete record of residents' bathing. In an interview on 12/27/22 at 11:02 AM, with Visitor (VIS) 1, she stated that she was informed by Resident 1 that CNAs (Certified Nursing Assistants) and maybe some nurses keep telling her, ' I'll be back in 20-30 minutes,' when she requests a shower and they never come back. VIS 1 further stated that Resident 1 is incontinent and quite heavy so it's hard for her to reach some areas to clean herself and she can't physically do it. VIS 1 stated that when she visited, Resident 1's hair was greasy and flat many times. In an interview on 12/28/22 at 12:19 PM, Resident 2 stated, I do not always get what I need. The CNAs say, ' I have to help another resident, but they never come back. I do not always get my showers. I went nine days without a shower recently. In a confidential interview with Resident 10 on 12/28/22 at 1:40 PM, he stated that he observed Resident 1 asking for a shower earlier in the week and they never showed up. Resident 10 further stated that Resident 1 had requested a bath the previous night, but asked that the male CNA find a female CNA to give the bath. Resident 10 stated that the male CNA tried to get assistance from two female CNAs who could be heard in the distance laughing and chatting. Resident 10 further stated that the female CNAs refused to help because they were too busy, and that an LVN (Licensed Vocational Nurse) had to intervene to make the bath possible. In an interview on 12/28/22 at 2:10 PM, Resident 3 stated that she didn't always get her showers as requested, sometimes they say they are too busy. In an interview on 12/28/22 at 2:14 PM, CNA A stated that shower sheets were the way staff documents showers which should always be used, even if the resident refuses a shower. In an interview on 12/28/22 at 2:20 PM, Wound Nurse (WN) A stated that Resident 1 had a wound on her foot and was followed by a podiatrist who instructed to keep the wound clean and dry, and acknowledged the importance of bathing, and stated, it is very important to keep the wound clean to promote healing and prevent infection. In an interview on 12/29/22 at 10:38 AM, CNA B, stated that Resident 1 had told him that on the previous night, 12/28/22, she requested a bath, but not by a male CNA. CNA B stated that he then asked CNA C if she could assist, and that she replied she was too busy and was unable to help. CNA B stated that CNA C then instructed CNA A to, tell her we'll have to skip today, but that the resident ultimately received a bath because a night nurse intervened. In an interview on 12/29/22 at 11: 37 AM, Resident 1 became tearful and upset and stated, There's always an excuse from CNAs. I hear them coming down the hall laughing and giggling in the lobby, playing games, not working. Just last night, two CNAs refused to give me a bed bath when I needed a female. I get the feeling like I'm garbage to them. Not good enough to get a shower. They seem to treat everyone else like gold here, but not me.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet this requirement when four of four sampled residents' (Resident's 1, 2, 3 and 4), bathing records were incomplete, not readily available, and not part of a reportable medical record. This resulted in potentially missed showers, infection, skin breakdown and reduced quality of life. Findings: Resident 1 was admitted to the facility on [DATE] for conditions including chronic heart failure, difficulty walking, muscle weakness, chronic obstructive pulmonary disease (a lung disease that blocks the lungs) and morbid obesity. A review of Resident 1's shower record for December 2022 indicated that her scheduled shower days were Mondays and Thursdays, and that there were nine scheduled bathing days that month. Further review of the record indicated that bathing was documented for Resident 1 on 12/5, 12/8, 12/11, 12/15, 12/25 and 12/28/22, only six of nine bathing opportunities had been documented, and documentation was missing for a nine-day gap from 12/16/22 to 12/25/22, and a four-day gap in documentation from 11/30/22 to 12/5/22; and there were no documented refusals. A review of an electronic report of bathing activity titled, Documentation Survey Report v2 for December, 2022 indicated that on 12/22/22, Resident 1 was totally dependent, physical help was provided for the resident to receive a bath in bed. No further record of this activity was provided, although the Director of Nursing (DON) A stated previously that the shower sheets (an informal, internal working document), not the electronic medical record, were the most complete documentation. He acknowledged that shower sheets provided were the totality of that record, however, there was no shower sheet for 12/22/22, but one was recorded in the electronic medical record. Resident 2 was admitted to the facility on [DATE] for conditions that included Parkinson's Disease (a nerve disease that causes tremors and unstable movement), morbid obesity, heart failure, and neurocognitive disorder (decline in brain function due to bodily illness), and history of stroke. A review of Resident 2's shower record for December 2022 indicated that her scheduled shower days were Mondays and Thursdays and that there were nine scheduled bathing days for that month. Further review of provided shower sheets indicated that bathing was documented for Resident 2 on 12/12, 12/15, 12/19, and 12/22; four of nine bathing opportunities, and no documentation was recorded for an eight-day gap in from 12/1/22 to 12/9/22, and a six-day gap between 12/16 and 12/21/22. Resident 3 was admitted to the facility on [DATE] and had conditions including an antibiotic resistant infection, diabetes, kidney failure, muscle weakness, and cellulitis (swollen tissue) on a lower limb (leg). A review of Resident 3's shower record for December 2022 indicated that her scheduled shower days were Tuesday and Friday and that there were nine scheduled bathing days for that month. Further review of provided shower sheets indicated that bathing was documented for Resident 3 on 12/1, 12/6, 12/13, 12/16, 12/20, 12/23 and 12/27/22, seven of nine bathing opportunities, with no documentation for a four-day gap in between 12/2 and 12/6/22, a six-day gap between 12/7 and 12/12/22, and a four-day gap between 12/28 and 12/31/22. A review of the facility's provided shower record indicated that two residents' records were often recorded on one sheet in many instances, requiring the facility to hand-cut the sheets into two to compile, for instance, Resident 1's record by itself. The sheets were cut apart after the surveyor requested them, indicating that the facility had not previously compiled a single, complete record of bathing for Resident 1 that was part of the permanent medical record. A review of the facility's, Shower Policy and Procedure, (undated), indicated that, Staff will honor shower and/or bathing preferences such as frequency of shower schedule, and, under Documentation, The following information should be recorded on the resident's ADL record (Activities of Daily Living) and/or in the resident's medical record: 1) The staff will document the date the shower was performed; 2) The signature and title of the person recording the data. A review of Resident 2's shower sheets for December 2022 indicated that Mondays and Thursdays were designated shower days. Of nine scheduled days on Mondays and Thursdays in December; only on four instances of bathing were documented: 12/12, 12/15, 12/19 and 12/22/22. Review of that record indicated a gap of nine days in documentation between 12/16 and 12/24/22. No refusals of showers were documented during those dates. Further review indicated that a nine-day gap in documentation occurred between 12/1 and 12/9/22, when no documentation, including refusals, was provided by the facility. A review of Resident 3's shower sheets for December 2022 indicated that her scheduled shower days were Tuesday and Friday and that there were nine designated shower days that month. Of those nine, bathing was documented only on seven dates: 12/1, 12/6, 12/13, 12/16, 12/20, 12/23 and 12/27/22. Further review indicated a six-day gap in documentation between 12/6 and 12/13/22 and a four-day gap between 12/1 and 12/6/22 in documented showers or refusals. A record review of written correspondence on 1/4/23 at 9:12 AM, indicated that the Director of Nursing (DON) A stated at that time that shower sheets represented the most complete record of residents' bathing. After concurrent review of an electronic report of residents' bathing, DON A determined the electronic record not to be the best record and provided informal shower sheets. Resident 4 was first admitted to the facility on [DATE], and again admitted on [DATE], for obesity, asthma, diabetes, kidney disease and breast cancer. A review of Resident 4's shower sheets for December 2022 indicated that her scheduled shower days were and Wednesday and Saturday. Two shower sheets for December 2022 (12/13 and 12/26/22) were provided by DON A on 12/28/22 at 1:50 PM, presented as the entire record at that time. In correspondence on 1/9/22, DON A acknowledge that Resident 4 had only two shower sheets for December 2022, and stated he would revisit the record to see if any were missing, but that she had often refused that month, although previously stated that refusals also required documentation, and were not present in the record. Resident 4's shower sheets indicated nine shower opportunities for December 2022, and was showered only on 12/13 and 12/26/22, two of nine scheduled shower days. In correspondence on 1/9/23, DON A was asked again if this represented the resident's entire record for December showers. DON A responded on that date that he would check his files. On 1/10/23, DON A provided an additional four shower sheets (13 days for the dates 12/8, 12/10, 12/17, and 12/21 that had not previously been provided to surveyor, indicating that the record had not been complete when initially requested. Of nine scheduled bathing days that month, Resident 4's record indicated that bathing was documented on shower sheets on 12/8, 12/10, 12/13, 12/17, 12/21 and 12/24/22, six of nine scheduled shower dates. In an interview on 12/28/22 at 2:14 PM, Certified Nursing Assistant (CNA) A stated that shower sheets were the place he had been instructed to document bathing, and that even refused showers should be documented. In an interview on 12/29/22 at 11:37 AM, Resident 1 stated that she was untrustworthy about CNAs documentation on shower sheets or whether they were used accurately. I have asked them to see the shower sheets they fill in when they're offering showers. The staff says they're confidential, but they can write whatever they want on them, refused, declined, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe infection control practices to prevent spread of infection when: 1. The blood pressure (BP) cuff was not effectively sanitized in-between resident care use on two out of two sampled residents (Resident 16 and Resident 19). 2. Licensed Nurse H (LN) touched medications with bare hands on two out of two sampled residents (Resident 16 and Resident 19). 3. a. Oxygen tubing was found on floor, outdated, and or undated for one out of two residents (Resident 43). b. Oxygen tubing was undated for one out two residents (Resident 38). c. Oxygen tubing was unlabeled for one out of one resident (Resident 77) while using a portable oxygen tank. 4. Staff failed to wear the required Personal Protective Equipment (PPE, face shield or goggles, gloves, gown) in the facility's yellow zone (area used to quarantine new admissions who require isolation) These failed practices may pose health and infection risk to facility's residents potentially leading to negative clinical outcomes. Findings: 1. During an observation, in Unit Three, on 8/10/22, at 8:14 am, LN F used a BP cuff sitting on top of the medication cart to check Resident 16's BP. After checking Resident 16's BP, LN F wiped the BP cuff with two alcohol pads and did not wear gloves. Not all areas of the BP cuff had been cleaned. LN F placed the BP cuff on top of the medication cart. During an observation, in Unit Three, on 8/10/22, at 8:48 am, LN F used a BP cuff sitting on top of the medication cart to check Resident 19's BP. LN F was observed walking out of Resident 19's room with the BP cuff on top of a clip board and the unclean BP cuff was resting against LN F's chest. LN F wiped the BP cuff with two alcohol pads and did not wear gloves. Not all areas of the BP cuff had been cleaned. LN F placed the BP cuff on top of the medication cart. During an interview on 8/10/22, at 9:00 am, LN F confirmed placing dirty BP cuff against chest, not properly sanitizing the BP cuff in between resident use, not wearing gloves, and stated the expectation is to clean with a bleach wipe and let sit for two minutes prior to next resident use. During an interview on 8/10/22 at 10:49 am, Director of Nurses (DON) stated the expectation for cleaning the BP cuff was to use a bleach wipe and let BP cuff sit for three minutes between resident use. DON stated staff should not use alcohol wipes to clean BP cuff. A review of the Clorox disinfectant wipes, indicated a three-minute wait time between each resident use. During a review of the facility's policies and procedures (P&P) titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, the P&P indicated medical equipment must be cleaned and disinfected before reuse by another resident. 2. During an observation, in Unit Three, on 8/10/22, at 8:14 am, LN H was preparing Resident 16's medications. LN H cut a medication in half, broke open a capsule, and touched each of Resident 16's medications without using gloves. During an observation, in Unit Three, on 8/10/22, at 8:48 am, LN H was counting Resident 19's medications prior to administering. LN H began touching the pills without using gloves and then stopped. LN H retrieved a spoon and used the spoon to remove the remaining pills being counted. During an interview on 8/10/22, at 10:49 am, DON confirmed nursing should not touch medications without wearing gloves. A review of the facility's policies and procedures (P&P) titled: Administering Medications, revised 3/22/18, the P&P indicated Staff shall follow established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. 3. (a) A review of Resident 43's record indicated admission to the facility on 3/26/21 and a readmission on [DATE]. Resident 43 had the diagnosis of chronic obstructive pulmonary disease (COPD, lung disease that makes breathing difficult). Resident 43 did not make her own medical decisions. A review of the record titled General Order, dated 4/7/22, indicated Resident 43 had an order for oxygen at 3 liters/min via nasal cannula (NC, oxygen tube that is placed in the nostrils) (continuous) for COPD. Requested all oxygen orders including an order to change oxygen tubing was made on 8/10/22. The order to change oxygen tubing weekly was not provided. During an interview and observation on 8/8/22, at 9:53 am, the NC including entire oxygen tubing was observed to be laying on the floor of Resident 43's room. The yellow sticker on the oxygen tubing was dated 7/11/22 with a time of 5:00 am. The oxygen tubing had been in use for 28 days. The oxygen tubing and face mask used for Resident 43's breathing treatments (medication that is placed in a nebulizer machine and inhaled into lungs) was not dated. The face mask, medication holder (place to insert liquid medication), and oxygen tubing was in separate pieces laying on a dirty, cluttered table. Resident 43 stated using the nebulizer and equipment daily and did not know if or when the tubing had been changed. During an interview and observation on 8/8/22, at 11:46 am, LN L confirmed the sticker on Resident 43's oxygen tubing was dated 7/11/22, the oxygen tubing on the nebulizer did not have a sticker, and that night shift should change and date all oxygen tubing every Sunday. LN L stated it was everyone's responsibility to make sure the tubing was labeled for their residents. It was observed that Resident 43 was wearing the oxygen tubing on her face. LN L stated no knowledge of who placed the tubing on the resident and was not aware the tubing was on the floor. LN L stated that the tubing would be replaced right away and confirmed the oxygen tubing found on the floor should be replaced and not used on residents. During an interview on 8/9/22, at 3:13 pm, DON confirmed nursing staff is expected to change and date all oxygen and nebulizer tubing every Sunday on the night shift. (b) A review of Resident 38's record indicated admission to the facility on 2/18/22 with a readmission on [DATE]. Resident 38 had the diagnosis of COPD and did not make his own medical decisions. A review of the Physician Order Report indicated Resident 38 had an order for oxygen, dated 5/11/22 that reads: Oxygen at 2 liters/min via nasal cannula. A review of the Physician Order Report indicated Resident 38 had an order for oxygen, dated 8/8/22 that read: change nasal cannula and nebulizer tubing every week and PRN (as needed) once a day on Sun; NOC (every Sunday on night shift). During an interview and observation on 8/8/22, at 10:49 am, Resident 38's oxygen and nebulizer tubing did not have a sticker and was not dated. Resident 38 stated I don't know if they ever change the tubing and staff is busy and doesn't always have time to do their job. During an interview and observation on 8/8/22, at 11:46 am, LN L confirmed the oxygen and nebulizer tubing did not have a sticker, was not dated, and that night shift should change and date all oxygen tubing every Sunday. LN L stated it was everyone's responsible to make sure the tubing was labeled for their residents. During an interview on 8/9/22, at 3:13 pm, Director of Nurses confirmed nursing staff was expected to change and date all oxygen and nebulizer tubing every Sunday on the night shift. (c) During an observation and interview on 8/8/22, at 12:05 pm, Resident 77 was observed in the dining room with a portable oxygen tank. Restorative Nurse Assistant confirmed there was no label or date on Resident 77's oxygen tube. During an interview on 8/9/22, at 3:13 pm, Director of Nurses confirmed nursing staff is expected to change and date all oxygen and nebulizer tubing every Sunday on the night shift. 4. A record review indicated that Resident 63 was placed on Covid - 19 (SARS-CoV-2 or Covid-19 is a viral infection that affects the respiratory system) quarantine for possible exposure on 8/9/22. Resident 63 was admitted to the facility with diagnoses that included after surgical care on digestive system, muscle weakness and respiratory failure with hypoxia (low oxygen level). Resident 63 was placed in a yellow zone to indicate she was on Covid-19 precautions for an exposure. During an observation on 8/10/22 at 9:30 am, a staff member was noted to be going into a marked isolation room. No eye protection was noted. Signage on the wall outside of the room, indicated N95 mask, gown, gloves and eye protection were to be worn. During an interview with Licensed Nurse (LN) E, the staff member observed, on 8/10/22 at 9:35 am when she exited the room of Patient 63, LN E stated the resident was in isolation for Covid precautions. LN E stated she had been wearing gown, gloves and mask when in the room. She confirmed she was not wearing eye protection. The facility Infection Preventionist (IP) was in the hallway and verified LN E should have been wearing eye protection. IP verified that Resident 63 had recently had a possible exposure to Covid -19 and was not vaccinated for Covid 19 requiring precautions for Covid-19. Guidance written by the Centers for Disease Control and Prevention titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 2/2/22 read, Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection .Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered .Guidance addressing duration and recommended PPE when caring for residents in quarantine is described in Section: Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection.

Based on observation, interview and record review, the facility failed to provide full visual privacy to one out of two sampled residents (Resident 67) when a privacy curtain had been missing for one month. This failure had the potential to cause a decline in Resident 67's mental health and cause psychosocial harm. Findings: A review of the records indicated Resident 67 was admitted to the facility 1/29/21 with the diagnoses of generalized anxiety disorder (extreme worrying that interferes with daily activities), cognitive communication impairment (inability to interact meaningfully with others), and bipolar disorder, current episode mixed, moderate (mood disorder that can cause rapid speech, racing thoughts, and agitation). Resident 67 was her own responsible party and could make her own medical decisions. During a concurrent interview and observation on 8/9/22, at 9:24 am, Resident 67 was sitting in a wheelchair in the hallway, had rapid speech, an elevated tone (variations in speech), and was waving arms in the air. Resident 67 stated being upset because the privacy curtain in her room had been missing. Resident 67 stated staff knew the privacy curtain had been missing and while trying to verbalize feelings, Resident 67 's speech became more rapid with an even higher elevation of tone. At 9:30 am Housekeeper Director (HD) came into room upon hearing Resident 67 from hallway. Resident 67 became louder, pointing finger at ceiling where the privacy curtain was missing. Resident 67 was observed to have exaggerated body movements, slanted eyebrows, a creased forehead, squinting eyes, and down turned lips. After several moments, Resident 67 was able to verbalize frustration without rapid speech to HD about the missing privacy curtain. HD stated awareness about the missing privacy curtain and had been trying to purchase the correct hooks needed for one month. During an interview on 8/9/22, at 3:02 pm, HD stated two staff members took extra hooks off of tracks in other rooms today to get the privacy curtain up in Resident 67's room. When asked what the plan was to provide privacy for other rooms (if there was a privacy curtain concern) while needed hooks were unavailable to purchase, HD stated the facility would need to purchase new tracks. Social Services Assistant walked up during interview and stated no knowledge of anyone offering Resident 67 a new room that provided privacy. During an interview on 8/9/22, at 3:27 pm, HD stated a new track for the privacy curtain had been ordered. During a concurrent interview and record review on 8/9/22, at 4:21 pm, Social Services Director was not able to produce documentation that Resident 67 had been offered a new room with privacy curtains. A review of the facility's policy and procedure (P&P) titled Dignity, revised 10/17, indicated the resident has the right to use of privacy curtains.

Based on interview and record review, the facility failed to address and resolve Resident Council identified issues and concerns for the past four months This failure resulted in pain management needs not to be met, call lights remained being unanswered for an extended amount of time, nutritional needs not to be met and residents felt their grievances were not listened to. Findings: The facility used a form titled Resident Council Minutes that kept attendance of the participants in resident council and tracked their grievances. This form also discussed old business, and new business, including resolutions the facility department related to any issues were responsible for addressing the concerns. Review of Resident Council Minutes, dated 06/23/2022, had a section titled Old Business - Any new business identified at the last council meeting must be addressed here - either as resolved or unresolved. Five out of six items in this list are marked as resolved, with one unresolved. The unresolved items are as follows - Food comes out cold sometimes. However, PM janitor could use more training especially with using the floor machine, is deemed as resolved. There is no indication, nor documentation, between the two resident council meetings in May and June that this was in fact resolved. It is placed on the Resident Council Attendance, that there is no group resident council due to Covid-19. Residents were interviewed individually in their room. No follow up was done with residents regarding their concerns. No signatures or dates of implementation and completion were noted. Review of Resident Council Minutes, dated 07/15/2022, indicated there were 2 unresolved concerns from May resident council meeting, food comes out cold sometimes. Upon review of May Resident Council Minutes, dated 05/19/2022, it is indicated the two unresolved issues remain as, food sometimes comes out cold. The department response from dietary in relation to cold food was marked as unresolved with a new plan in progress. The department response with no date indicating the new plan to be implemented stated, DSS ordered new dome lids for plates. Will continue to monitor tray pass for timely delivery. No more paper on isolation. PM janitor could use more training, especially with using the floor machine. The department response was, Will have PM janitor use mop and bucket instead of auto scrubber. Also talk to him about checking rooms, bathrooms, and employee bathrooms and stocking. This has been marked unresolved due to a new plan in progress, per department head of housekeeping. No further follow up was observed or completed with residents regarding their concerns. During a confidential resident group interview on 08/09/2022 at 10:07 am, six out of eight residents reported the food was still cold, stating We get the same food a lot. The taste is not good. Four out of eight residents stated the food was not in the form of their preference - in reference to palatability. Six out of eight residents complained of the taste. Seven out of eight residents stated their wait time for call light response is more than 5-15 minutes, which they deemed 5-15 minutes is reasonable. Six out of eight residents have explained having issues with receiving showers at appropriate times, while three out of eight residents complained of cold showers. Six out of eight residents complain, It is too cold, which was observed with residents wearing blankets and/or several layers of clothing. Per resident, Ice machine has been a problem here for years. Goes up and down, up and down. The ice machine has been broken. It's been a few weeks. Four out of eight residents did not get ice when they wanted. Resident stated, Takes them an hour and a half to get me a pain pill sometimes. One resident stated sometimes grievances are not responded to. Like answering call bells. The group was asked how many have had issues with call lights. Seven of the eight raised their arms in response. During an interview on 08/10/2022 at 11:16 am, Administrator (ADMIN), voiced understanding of the need for better written communication between departments for issues that arise in resident council. ADMIN stated currently bringing in ice physically for residents; however, residents stated they have not had ice recently. ADMIN explained he was unaware of multiple problems with food (in reference to palatability, temperature). ADMIN not aware of lack of pain medications being given to residents, in regard to hospice residents. ADMIN did not see official report of minutes, was told by other staff of the issues that arose during resident council at morning stand up. Requested for call light audits several times, did not receive. ADMIN unaware of call lights being turned off and having such a long response time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of eighteen smoking residents (Resident 74 and 49) smoked safely in the designated supervised area, securing smoking supplies, and use of safety equipment. This resulted in unsupervised smoking, hazards including cigarettes not properly being disposed of, lack of safety equipment, and had a potential to put all residents at risk for fire hazard and injuries. Findings: 1. A review of the facility's policy titled, Smoking Policy - Residents, revised in April 2012, it is listed under Policy Interpretation and Implementation, that smoking is only permitted in designated resident smoking areas, which are located outside of the building. It also states that all residents will have a smoking agreement signed upon admission and quarterly - which includes a statement saying that residents who had smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision of staff. The facility maintained the right to confiscate smoking articles found in violation of the smoking policies. A review of Resident 74's record indicated he was admitted to the facility on [DATE], with diagnoses which included heart failure, lung disease, and palliative hospice (end of life) care. Resident 74 was able to make his own health care decisions. During an interview on 8/8/22 11:30 am, Resident 74 stated they smoked. Resident 74 stated they, do not have a can to put cigarettes in but keeps cigarette butts in one place. Explains that they will go out to smoke a couple of times a day (regardless of the set smoking schedule) and keeps cigarettes and supplies in room. Resident 74 confirmed they smoked on their patio, which was supported with observation of approximately thirty cigarettes on the ground in resident's patio in the bark under a tree approximately two feet away from dry brush. A record review of a Quarterly Clinical Assessment Review, dated with an observation date of 7/13/22, Resident 74 agreed to smoke in designated area, place cigarettes in proper receptacle, and agreed to have smoking items stored by staff with supervised smoking times. A review of the medical record titled Safe Smoking Risk, included an observation on 6/24/22 at 2:41 PM, indicated Resident 74 was not currently on oxygen. There is a prompted question stating, Does resident understand and agree that smoking materials will be secured by facility staff? with an answer of No - patient prefers holding cigarettes. For the IDT template note it states, Resident demonstrated safe smoking per policy. Activities staff will observe and assist supervised smoking. In the care plan, it was noted with a problem start date of 6/24/22, Resident 74 had a history of long-term smoking - with a long-term goal for having resident smoke in designated area, practice safe smoking, will participate with smoking schedule, and will have reduce episodes of smoking related injuries daily. During a concurrent observation and interview dated 8/8/22 at 1:35 pm, with the Director of Nursing (DON) and Administrator (ADMIN), both individuals stated they were unaware that Resident 74 smoked; however, upon further investigation it was noted in social workers notes, care plans, assessments, and this individual's name was written on the smoking list provided by the facility. Both ADMIN and DON were shown the list provided by the facility of the smoking list and they were able to identify two out of eighteen residents that they were aware that smoked on their patio, an undesignated area, without staff or proper safety equipment present. During interview on 8/9/22 at 9:10 am, DON stated he was now aware of Resident 74 who does not smoke in the designated smoking area and instead smoked on his patio off his room. DON agreed that the patio area behind resident room, have dry brush throughout. DON stated Resident 74 does keep own smoking supplies in room and smokes on back patio. DON states there are some residents that are independent smokers that were deemed so, but they must smoke by the gazebo a designated smoking area which had the appropriate safety equipment, including a fire extinguisher, fire blanket, and smoking apron. When asked for any interventions that were done for this resident that was smoking on their own in the back patio, DON stated that education had been done towards this resident several times, but the resident does not listen. With review of the policy, it stated that the facility maintains the right to confiscate smoking articles found in violation with the policy. It is determined that the policy and procedure titled, Smoking Policy, A review of a progress note dated 8/9/22 at 5:22 pm, that was written by Social Service Director (SSD) stated that, Patient agrees to smoke in designated areas, understands safety related to smoking. Resident 74 understood that smoking is a privilege and if smoking policy is not followed smoking privileges can be taken away. Resident comments: I am not putting my signature anywhere; you can put verbal. I am going to start looking for a place to go if that's the case. Resident was not happy with conversation and hospice was notified as well of patient's comments to assist if needed. Resident 74 did not allow Social Services Assistant (SSA) to go through his belongings. During an interview on 8/10/22 at 11:43 am, Administrator (ADMIN) stated the resident was spoken to in regards to smoking at designated gazebo area. Stated all residents are now out to the gazebo during arranged smoking times. Upon later observation during smoking schedule breaks, it was noted that Resident 74 was not participating in set smoke breaks. 2. A review of the record indicated Resident 49 was admitted to the facility 2/20/22 with diagnoses of cerebral infarction, unspecified (stroke, disrupted blood flow to the brain), other sequelae of cerebral infarction, (side effects from a stroke that can occur minutes to years after a stroke occurred) and muscle weakness. Resident 49 was his own RP and can make his own medical decisions. A review of the smoking assessment, dated 2/23/22, an assessment section titled smoking materials will be secured by facility staff, indicated Resident 49 prefers holding own cigarettes. A review of the smoking assessment, dated 5/27/22, an assessment section titled smoking materials will be secured by facility staff, indicated Resident 49 prefers holding own cigarettes. A review of the record titled Functional Status, Section G, dated 6/17/22, indicated Resident 49 required one-person physical assist while dressing, using the toilet, and performing personal hygiene (combing hair, brushing teeth, shaving, washing/drying face and hands). During an interview on 8/8/22, at 10:33 am, Resident 49 stated the facility had four smoking times, located outside at the smoking area, but will smoke just outside of his room when he wants a cigarette. Resident 49 pointed to a patio area just past the sliding glass door in his room. During an observation on 8/9/22, at 9:40 am, an empty pack of cigarettes was observed in a garbage can. The garbage can was against the building, directly in between Resident 49 and Resident 67's doors that lead to an adjoined patio area. The patio area that belongs to Resident 67 had dirty linen scattered on the ground and the area was cluttered with miscellaneous items including trash. Resident 67 had an overgrown garden area with wooden planks on the ground. This posed as a fire danger due to Resident 49 not having a receptacle to extinguish his cigarettes when smoking outside on the patio.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician orders when the pain management needs for one of four sampled Hospice (supportive care to terminally ill residents that focuses on their comfort, quality of life, and being pain free) residents when; Resident 281 received a lower than the ordered dose of morphine (a strong pain medication) on 12 of 20 occasions. This failure had the potential for Resident 281 to have uncontrolled moderate or severe pain. Findings: 1. A review of Resident 281's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included prostate (a small gland in men) cancer, brain cancer, spine cancer and palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure). Resident 281 expired on [DATE]. A review of Resident 281's Minimum Data Set (MDS, a standardized resident assessment), dated [DATE], indicated Resident 281's Brief Interview for Mental Status (BIMS, a number value between 00-15 with 13-15 cognitively intact, 08-12 moderately impaired, and 00-07 severe impairment) score was 0 (severe impairment). Resident 281 was not able to make his own healthcare decision. A review of Resident 281's physician order, dated, [DATE] - [DATE], showed Pain-Monitor for presence of pain, every shift, using scale 0-10. 0 = no pain; 1-2 = least pain; 3-4 = mild pain; 5-6 = moderate pain; 7-8 = severe pain; 9-10 very severe/horrible/worst pain. A review of Resident 281's Medication admission Records (MARS) for Pain-Monitor for presence of pain, every shift, using scale 0-10, from [DATE] to [DATE], a total of 69 shifts, showed: 1). Pain level was assessed as 0 for 63 times. 2). Pain level was assessed as 5 in the afternoon (PM) shift on [DATE]. 3). Pain level was assessed as 5 in the morning (AM) shift and7 in the night (NOC) shift on [DATE]. 4). Pain level was assessed as 4 in AM shift and 6 in PM shift on [DATE]. 5). Pain level was assessed as 7 in PM shift on [DATE]. A review of Resident 281's Pain-Monitor for presence of pain, every shift, using scale 0-10, from [DATE] to [DATE], a total of 8 shifts, showed 1). Pain level was assessed as 0 for 7 times. 2). Pain level was assessed as 5 in AM shift on [DATE]. A review of Resident 281's physician order, dated, [DATE] - [DATE], Morphine concentrate - Schedule II solution (a concentrated liquid morphine), 20 milligram (mg)/milliliter (ml), amount to administer: 0.25 ml, oral, every 2 hours as needed, give 0.25 ml as needed for mild pain (pain level = 3-4) was ordered. A review of the resident's MARS from [DATE] - [DATE], showed that this medication was only given once on [DATE], at 4:57 am on NOC shift, for a pain level of 6 (moderate pain). The resident was given a dose pain medication which was ordered to be given for a mild pain when he had a moderate pain. A review of Resident 281's physician order, dated, [DATE], Lorazepam (a medication to relieve anxiety) 2 mg/ml, not to exceed 10 mg daily, give 0.25 ml, oral, every 4 hours as needed for mild anxiety, shortness of breath; give 0.5 ml, every 4 hours as needed for moderate/severe anxiety, shortness of breath. A review of Resident 281's progress note on [DATE] at 3:27 pm by LN U, indicated that Resident 281 complained of pain, pain level 8, given PRN Lorazepam 0.5. This pain level was identified in a progress note, but not recorded in the resident's pain assessment monitoring sheet. A review of Resident 281's physician order, dated, [DATE] - [DATE], Morphine concentrate - Schedule II solution, 20 mg/ml, amount to administer: 1 ml, oral, every 2 hours as needed, give 1 ml as needed for severe pain seven to ten out of ten was ordered. A review of Resident 281's physician order, dated, [DATE] - [DATE], Morphine concentrate - Schedule II solution, 20 mg/ml, amount to administer: 0.5 ml, oral, every 2 hours as needed, give 0.5 ml as needed for moderate pain four to six out of ten was ordered. A review of the resident's MARS from [DATE] - [DATE], indicated: 1). Morphine concentrate 0.5 ml was given on [DATE], at 4:43 pm, in PM shift, the resident's pain level was 8, not 4-6. 2). Morphine concentrate 0.5 ml was given twice on [DATE]. Once at 12:01 pm, in AM shift, the resident's pain level was 8; once at 4:28 pm, in PM shift, the resident's pain level was 8. The resident's pain level was at a severe level, but he was given a medication that was ordered for moderate pain. 3). Morphine concentrate 0.5 ml was given on [DATE], at 1:49 pm, in AM shift, the resident's pain level was 9, per physician pain assessment order, a pain level at 9-10 was rated as very severe/horrible/worst pain. But the resident was again, given a medication that was ordered for moderate pain. 4). Morphine concentrate 0.5 ml was given on [DATE] at 9:29 am, the resident's pain level was 9. He had a severe/horrible/worst pain and was given a medication that was ordered for moderate pain. 5). Morphine concentrate 0.5 ml was given on [DATE] at 8:54 am, in AM shift, the resident's pain level was 9. He had a severe/horrible/worst pain and was given a medication that was ordered for moderate pain. 6). Morphine concentrate 0.5 ml was given on [DATE], at 5:37 pm, in PM shift, the resident's pain level was 9. He had a severe/horrible/worst pain and was given a medication that was ordered for moderate pain. A review of Resident 281's physician order, dated, [DATE] - [DATE], Morphine concentrate - Schedule II solution, 20 mg/ml, amount to administer: 0.25 ml, oral, every 2 hours as needed, give 0.25 ml as needed for mild pain 1-3/10 was ordered. A review of the resident's MARS from [DATE] - [DATE], it showed: 1). Morphine concentrate 0.25 ml was given on [DATE], at 5:31 pm, in PM shift, the resident's pain level was 8. He had a severe pain and was given a medication that was ordered for mild pain. 2). Morphine concentrate 0.25 ml was given on [DATE], at 1:08 pm, in PM shift, the resident's pain level was 8. He had a severe pain and was given a medication that was ordered for mild pain. 3). Morphine concentrate 0.25 ml was given on [DATE], at 10:39 am, in AM shift, the resident's pain level was 6. He had a moderate pain and was given a medication that was ordered for mild pain. During an interview with RP on [DATE] at 4:05 pm, stated my chief complaint is that they did not follow the orders from the Hospice order . HN S said that she met with Director of Nursing (DON) and to discuss the issues of Resident 281 not being given pain medication. RP said DON told me that [Resident 281] was over medicated. They could not sedate [Resident 281], so he won't be falling. DON said to RP Your idea of medicating [Resident 281] and let him fall is not going to happen. During an interview with DON on [DATE] at 2:38 pm, He admitted that Staff is fearful of overmedicating and killing the residents. I told them that you aren't overmedicating them, you need to make sure their pain is covered. DON stated that Resident 281 attempted to self-transfer a lot when he was agitated. Pain was not identified as a root cause of [Resident 281's] falls. During an interview on [DATE] at 10:15 am, DON stated his expectation would be a nursing progress note denoting post pain assessments. DON confirmed a problem with residents' getting pain medications timely (CNAs tell the nurse and it takes too long), he stated registry nurses and new nursing staff were hesitant to give too much narcotic medication (morphine) due to fear of overmedicating them and was not aware residents were receiving a lower incorrect dose for severe pain levels. During an interview on [DATE] at 9:30 am, ADMIN was aware back in 4/2022, about the pain issues for Resident 281, SSD informed him of the Resident 281's family member's concerns, they did an in-service just surrounding this particular resident, it mainly focused on non-pharmacy interventions, not the pain medication administration and assessment, wrong medication issues, they did not address the entire program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. A review of Resident 27 record indicates upon admission on [DATE] at 6:48 PM, Resident 27 had admitting diagnoses of lung disease, Type 2 Diabetes, high blood pressure, and difficulty with walking. During an interview on 8/8/22 at 10 am, Resident 27 stated it takes 1.5 hours to get changed. Resident was in tears and upset in regard to not being changed on time. 12. During confidential resident interviews on 8/9/22 at 10:07 AM, one resident stated, Takes them an hour and a half to get me a pain pill sometimes. One resident stated sometimes grievances are not responded to. Like answering call bells. The group was asked how many have had issues with call lights not being answered timely more than 20 minutes, seven of the eight raised their arms in response. Another resident stated sometimes I say, forget it. they don't pay attention to me anyhow. 7. A review of the records indicated Resident 67 was admitted to the facility 1/29/21 with the diagnoses of generalized anxiety disorder (extreme worrying that interferes with daily activities), cognitive communication impairment (inability to interact meaningfully with others), and bipolar disorder, current episode mixed, moderate (mood disorder that can cause rapid speech, racing thoughts, and agitation). Resident 67 was her own responsible party and made her own medical decisions. During a concurrent interview and observation on 8/8/22, at 9:18 am, Resident 67 stated asking Certified Nurse Assistant I (CNA) for a shower this morning and was told no because it was not Resident 67's shower day. Resident 67's was observed to be disheveled, wearing dirty clothes, and had oily hair. CNA I confirmed Resident 67 asked for a shower and had been denied. When asked why Resident 67 could not have a shower, CNA I placed a hand on her hip, rolled her eyes and stated, we have other showers to do and today is not Resident 67's shower day. CNA I was not aware if there was a policy that spoke to shower requests and stated the need to seek out clarification. Resident 67 became agitated, speaking with a rapid rate, threw her hands in the air, stated no one listens, then went back to her room. During an interview on 8/8/22, at 9:48 am, CNA I stated, the Director of Staff Development (DSD) was unaware of policy and since another resident refused a shower, Resident 67 could have a shower. During a concurrent interview and observation on 8/8/22, at 10:47 am, Resident 67 was observed sitting in room, eating an apple, wearing clean clothes, and had wet hair. Resident 67 stated feeling better since CNA I had provided a shower and if you had not been here, she would not of received a shower. During an interview on 8/8/22, at 12:26 pm, DSD stated residents have scheduled shower days and it was not Resident 67's shower day. DSD stated CNA I should not decline giving Resident 67 a shower. DSD confirmed staff should honor resident preferences, staff needed to provide scheduled residents with shower first then work in requested showers if able. During an interview on 8/9/22, at 10:13 pm, Director of Nurses (DON) stated if a resident requested a shower, it was a preference, and should be accommodated. DON stated if staff was not able to provide the resident with a shower that morning, staff should work with resident and offer a different time during the day that the resident agrees on. A review of the policies and procedures (P&P) titled Dignity, revised 10/17, indicated individual needs, preferences and dignity shall be accommodated to the extent possible. 8. A review of the records indicated Resident 19 was admitted to the facility on [DATE] with the diagnoses of end stage renal disease (kidney failure), hypertensive urgency (emergent, elevated blood pressure), and major depressive disorder (sad mood). Resident 19's preferred language is Panjabi/[NAME] and Resident 19's daughter was her responsible party (medical decision maker). During a concurrent interview and observation on 8/10/22, at 8:48 am, Licensed Nurse H (LN) was administering Resident 19's morning medication with LN F in attendance. LN F was providing training to LN H who was a new nurse to the facility. During the medication administration LN H was speaking English to Resident 19. Resident 19 was speaking in broken English and [NAME] (preferred language). Resident 19 and LN H were observed to be frustrated and not understanding each other. Resident 19 continued to attempt communication and LN H continued to offer Resident 19 medication. LN F left the room approximately four to five minutes later and returned with a nurse who spoke [NAME] to translate. LN F stated Resident 19's usual nurse speaks [NAME]. LN F and LN H confirmed there was a communication barrier, and a translator should be used. During an interview on 8/11/22, at 11:46 pm, Director of Nurses (DON) stated translator services should be utilized when staff is not present to translate for residents and there are staff members available who speak [NAME]. During a concurrent interview and record review on 8/12/22, at 3:30 pm, Social Services Director (SSD) confirmed Resident 19 needed assistance with communication. SSD confirmed a care plan was in place and additional communication methods were available in Resident 19's room to assist with communication between resident and staff. SSD stated there was a picture board, staff that spoke [NAME], and a translator line. SSD confirmed multiple interventions were in place for communication and staff did not always utilize them. A review of the facility's policy and procedure titled Translation and/or Interpretation of Facility Services, revised 3/18, indicated The facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 5. Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with diagnoses that included, Parkinson's disease (uncontrollable tremors, stiffness, and difficulty with balance and coordination), and history of falling. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 6/9/22, indicated that Resident 39 was cognitively intact. During a review of Resident 39's MDS section G, Functional status dated 6/9/22, The MDS indicated, Resident 39 requires one-person physical assist with dressing. During an interview on 8/8/22, at 11:06 a.m., with Resident 39, Resident 39 stated, They never answer my call light when I turn it on, so I just don't use it. In the morning when I try to get dressed, I get my shirt on halfway then I must go out into the hallway with my shirt half on and try to wave someone down to help me. There are a lot of males around and its embarrassing to be in the hall half naked. 6. Resident 50's record was reviewed. Resident 50 was admitted to the facility on [DATE], with a diagnosis that included, Fractured hip, hearing loss, and unsteadiness on feet. The most recent MDS dated [DATE] indicated that Resident 50 was cognitively intact. During a review of Resident 50's MDS section G Functional status, dated 6/17/22, The MDS indicated, Resident 50 requires one-person physical assist with toileting. During an interview on 8/8/22, at 11:30 a.m., with Resident 50, Resident 50 stated, I turn my call light on, but they never answer it. It somehow gets turned off and I have too repeatedly push it repeatedly, about 5 or 6 times until someone comes and finally answers it. I need a little help to get up to go to the bathroom and sometimes I don't make it. It is very embarrassing. Based on observation, interview and record review the facility failed to provide direct care staff to meet the needs of the residents when call lights were not answered timely. This resulted in dependent residents not to receive the assistance they need for activities of daily living, resident felt their dignity was not honored during care, communication was not provided in their native language, and pain management needs were not met. Findings: 1. A review of Resident 66's record indicated diagnoses that include low back pain, difficulty walking, and hypertension. Resident 66 had a Brief Interview for Mental Status (BIMS) score (a number value between 00-15 with 13-15 cognitively intact, 08-12 moderately impaired, and 00-07 severe impairment) of 15 on 6/24/22 and Section G of the MDS indicated one-to-two-person assistance with most activities and one person assistance for setup for eating and drinking. During an interview on 8/8/22 at 11:20 am, Resident 66 stated it can sometimes be difficult to get help from staff. She stated call bells take a long time to be answered and sometimes this leaves her sitting in her own urine. She stated she now calls the nurses station on her telephone to get someone to at least answer her call light. She stated last night, 8/7/22, she called the nurses station 15 times on her telephone with no answer. She stated a CNA came in and she stated what had happened. The CNA stated to call again, and she would go to desk to see what the issue was. She called and the CNA answered the phone. The CNA informed Resident 66 that the ringer was turned off of the telephone at the nurse's station. 2. A review of Resident 44's record indicated diagnoses that include transient cerebral ischemic attack (a stroke - damage to the brain from interruption in its blood supply), difficulty walking, respiratory failure with hypoxia. Resident 44 had a BIMS score of 15 on 6/9/22 and Part G on the facility Minimum Date Set (MDS) (provides a comprehensive assessment of the resident's functional capabilities. (Section G is specific to Functional Status) of the MDS indicated Resident 44 needed supervision for activities. During an interview on 08/08/22 at 10:20 am, Resident 44 stated she frequently has pain and will ask for pain medications. Stated it takes a long time to get the medications. She stated the pain will sometimes be much worse because the wait time is so long. 3. A review of Resident 76's record indicated diagnoses that include hydronephrosis with renal and ureteral calculous obstruction (blockage in the tube that connects the kidney to the bladder), difficulty walking, heart failure (heart is unable to pump blood to meet the body's need). Resident 76 had a BIMS score of 14 on 7/20/22 and Section G of the MDS indicated one-to-two-person assistance with most activities and one person assistance for setup for eating and drinking. During an interview on 8/8/22 at 10:29 am, resident 76 stated she has poor pain control. She stated that she will ask for pain medication and sometimes it takes up to 2 hours to get the medications. Sometimes it will be time for the next dose before you get the one you are waiting for. 4. A review of Resident 56's record indicated diagnoses that include convulsions (a sudden, violent movement of the body), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), and respiratory failure with hypoxia (failure to provide body with enough oxygen to the body). Resident 56 had a BIMS score of 14 on 6/20/22. Section G on MDS on 6/20/22 indicated Resident 56 needed two people to assist with bed mobility and transfers and one person assistance to setup for eating and drinking. During an interview on 8/8/22 at 3:16 pm, Resident 56 complained of a long wait time to receive pain medication. 9. During a concurrent observation and interview on 8/8/22 at 11:30 am, Resident 74 stated pain medications are late and looked in his journal and gave examples. On 8/1/22 at 9:30 am, CNA showed up at 10 am, then another correct CNA comes at 10:19 am, then he called another CNA at 10:40 am then by 11:50 am, he received his pain medication. On 8/5/22, Resident 74 called CNA at 10:40 am due to reporting pain level was a 7/10 (severe) and by 11:50 am he received his pain medication. Resident 74 stated his pain level right now was a 7/10. Resident 74 stated it makes him feel not happy, frustrated and causes anxiety. Resident 74 stated his pain level after receiving medication is usually a level of 4-5 and was tolerable at that level. Resident 74 stated I'm not the waiting type and stand in the hallway. Resident 74 stated The Hospice nurse was aware. Resident 74 stated Timeliness could be improved; they should hire more people. 10. During an interview on 8/9/22 2:53 pm, CNA Y stated she works with Resident 57 often and Be as gentle as I can. We try to get her out as much as we can because she gets depressed. CNA Y stated, I can tell by the way she talks (wants to talk to son etc) when in pain. CNA Y stated she has to remind nurses often that Resident 57 was due for pain medication. CNA Y stated, nurses get super overwhelmed and get super behind. CNA Y described that Resident 57 grinds her teeth and scratches her arm when in pain, and it gave her skin tears from rubbing too hard. CNA Y stated LN Z and LN AA take 20-30 mins

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a concurrent interview and record review on 8/18/22, at 9:33 am, Director of Staff Development (DSD) stated an in-service for Hospice, Death and Dying was provided to each shift on 11/22/21. (Hospice is a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-liming illness. Hospice care provides compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible) A review of the record titled: Education Program Lesson Plan, dated 11/22/21, indicated the in-service provided education on: Why plan for hospice, More care, not total care from hospice, Staff working with outside companies to provide resident care, Dying process, and stages of grief. A review of the record titled In-Service Sign In Sheet, dated 11/22/21, indicated five Certified Nurse Assistants (CNA) attended the in-service. DSD confirmed in-services are open for Licensed Nurses (LN) to attend; however, was not required. DSD stated pain was discussed during the in-service and confirmed pain was not listed under course content (bullet point list of education provided). During a concurrent interview and record review on 8/18/22, at 9:33 am, DSD stated on 12/9/21 an in-service for Hospice, Death and Dying was provided to each shift. DSD stated a hospice representative (someone who worked for hospice) provided the in-service to help make aware of the peaceful, comfort aspect of hospice. A review of the record titled: Education Program Lesson Plan, dated 12/9/21, indicated in-service provided education on Dying Process, Stages of Grief, and Respecting Family Wishes. A review of the record titled Continuing Education Sign-In Sheet indicated 13 CNAs attended the in-service along with the Social Services Director (SSD). DSD confirmed in-services are open for Licensed Nurses (LN) to attend; however, was not required. DSD stated pain was discussed during the in-service and confirmed pain was not listed under course content (bullet point list of education provided). A review of the power point (method of teaching, utilizes pictures and words), DSD confirmed that pain was discussed, but the power point was not specific for treating end of life pain. During a concurrent interview and record review on 8/18/22, at 9:33 am, DSD provided two additional in-services titled: Behavioral Management-Aggressive Behavior in Aging Adult, dated 11/11/21 and Change of Condition & Reporting, dated 11/30/21. DSD stated pain was discussed during these two in-services; however, pain was not listed under the course content section. Requested in-services for pain/pain control requested, no in-services were provided. During a concurrent interview and record review on 8/18/22, at 9:33 am, DSD and surveyor reviewed course content for an in-service provided to facility staff on 4/26/22 titled: PRN Medications/Hospice and Pain (PRN means as needed). DSD confirmed the record titled PRN Medications/Hospice/Pain, dated 4/26/22 had extensive bullet points that reviewed non-pharmacological pain interventions (trying alternate methods to relieve pain before providing pain medication) and extensive bullet points that reviewed: hospice patients, communication and assessing. DSD confirmed the section titled PRN MEDS had one sentence, indicating that a PRN medication should be given if non-pharmacological approaches and scheduled pain medication did not work. DSD stated pain management was discussed during the in-service, the education was patient specific and use of Morphine (narcotic to treat moderate to severe pain, usually given to hospice patients for end of life pain management) was reviewed with staff. During a concurrent interview and record review on 8/18/22, at 10:32 am, Minimum Data Set (MDS) stated involvement with the in-service titled: PRN Medications/Hospice and Pain. MDS stated there was only one place for the instructor to sign the form, so MDS signed in the space provided for staff who attended the in-service. MDS stated the agenda is a cue card, and pain was discussed in more detail than the agenda suggested. MDS stated SSD asked MDS to perform the hospice in-service due to concerns about a resident and wanted to make sure everything was in place for the resident. MDS stated barriers for nursing staff who care for hospice residents included nurses not wanting to give that dose that kills a patient. MDS state education is ad-lib, happens continuously, as issues arise, and is not documented. MDS confirmed the facility's policy and procedure (P&P) titled Pain Assessment and Management, revised 3/15, was provided during the in-service and did not address specific hospice pain management. During a concurrent interview and record review on 8/18/22, at 11:43 am, Director of Nurses (DON) stated the DSD provided most of the in-services for LN and DON provided more on-the-spot in-services if there is an issue. DON stated on-the-spot in-services (an informal educational conversation) are not documented. DON stated to assure staff understood the education provided about pain, the DON will check resident Medication Administration Records (MARS) daily to assess if LN are providing pain medication adequately and keeping resident pain under control. DON stated if the residents are not being provided pain medication, DON will follow up with LN and provide additional education. DON stated LN meetings are mandatory and as far as I know they are attending. Inservice sign in sheets reviewed with DON. DON stated unawareness that LN had not been attending in-services. DON stated, pain assessments are nursing basic 101, if you can't manage pain, you shouldn't be a nurse. DON and surveyor reviewed course content for an in-service provided 4/26/22 titled: PRN Medications/Hospice and Pain. DON stated CNA will alert LN when residents are having pain, the LN will assess pain and use their nursing judgement if the pain medication should be given. DON used Resident 281 as an example to clarify nursing judgement. DON stated resident 281 was confused, he was not really in pain, and Resident 281's daughter insisted he get morphine. DON stated the need to provide nursing staff more education to alleviate the fear of causing resident death from administering pain medication. DON stated the in-service was provided to staff on 4/26/22 to educate staff on how to deal with Resident 281's family, what needed to be done to provide care for Resident 281, and the in-service was focused on one resident, not how to care for all hospice residents or how to treat all hospice resident's pain. DON reviewed sign in attendance log and stated the sheet was accurate, looked like 44 signatures. DON was asked why non direct care staff attended (the facility housekeeper, business office manager, admissions, etc). DON stated, they were in the building. A review of the three-page record titled: In-Service Sign In Sheet, dated 4/26/22, indicated 45 staff members attended the PRN Medications/Hospice and Pain in-service. 14 out of 45 staff members who attended the in-service did not provide direct patient care, 7 Licensed Nurses who provide direct care staff attended, two of those nurses signed the record twice (resulting in 9 Licensed Nurse signatures), 16 Certified Nursing Assistants attended the in-service, and 6 Nurse Assistants (student CNA). 67.44 % (percent) of staff that attended the in-service did not provide direct patient care. Based on observation, interview, and record review the facility failed to ensure nursing staff had appropriate competencies and skills sets for assessing and implementing plan of care for four of four sampled residents (Resident 281, 58, 74 and 57). Refer to F 697, F 849 This resulted in 1. a Resident 281 was given wrong dosage, wrong pain medication for the wrong pain level. Refer to F 697, F 849. 1. b Resident 281 wasn't provided with Oxygen concentrator on 4/15/22, 4/22/22 and 4/23/22 per physician ordered and hospice plan of care. 2. Resident 58 wasn't given his pain medication per physician order when he asked for it. Resident 58 was upset and had to suffer a longer pain. 3. Resident 74 was given incorrect dose of medication for severe pain, pain medications were administered late, and medications available for anxiety/cough were not given when symptoms present. 4. Resident 57 pain management program was not adjusted when she reported it was ineffective, when her swallowing was declining, and medications were not available for administration. 5. Nursing leadership and Medical Director did not evaluate staff skills levels and provide individualized competency based training to deliver quality of care. Finding: 1.a. A review of Resident 281's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included prostate cancer, brain cancer, spine cancer and palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure). The resident expired on 5/3/2022. A review of Resident 281's Minimum Data Set (MDS - an assessment and care screening tool), dated 4/15/2022, indicated Resident 281's Brief Interview for Mental Status (BIMS) scored was 0 (severe impairment). Resident 281 was not able to make his own healthcare decision. A review of Resident 281's Hospice Skilled Nursing visit note on 4/22/22 at 4:30 pm by HN R, indicated that the resident's pain level was not acceptable to the resident, it showed Resident appeared to be experiencing more pains on his abdomen (the part of the body between the chest and the hips), right upper abdomen, both feet and his back this time. Pain intensity was 5 - medium. PRN (pain medication given as needed) not being given . The note also indicated that a verbal education was provided to LN U about end-of-life sign/symptoms, respiratory distress and use of oxygen and/or morphine to relieve symptoms of distress. HN R discussed the resident's recent falls with LN U. A review of Resident 281's Hospice Skilled Nursing visit note on 4/24/22 at 3:30 pm by HN S, indicated that Responsible Party (RP) was present and distressed. The note indicated RP stating patient is not being medicated appropriately. Patient resting quietly. Staff requested PRN opioid frequency to be increased to every two hours. Upon review PRN, opioid already scheduled every two hours as needed. Agency nurse practitioner informed. A review of Resident 281's Hospice Skilled Nursing visit notes and progress notes indicated that the resident fell on 4/10/22, 4/22/22, 4/25/22 and 4/29/22. A review of Resident 281's physician pain medication orders and Medication admission Records (MARS) from 4/8/22 to 5/3/22, indicated: 1. The resident was given wrong pain medication with wrong pain level on 4/10/22 at 4:47 am. 2. The resident was given Lorazepam (ordered for anxiety) when his pain level was 8 on 4/10/22 at 3:27 pm. 3. The resident was given wrong pain medication with wrong pain level on 4/17/22 at 5:31 pm. 4. The resident was given wrong pain medication with wrong pain level on 4/19/22 at 12:01 pm and 4:28 pm. 5. The resident was not given prn pain medication when his pain level was assessed on 4/25/22 and 4/28/22. 6. The resident was given wrong pain medication with wrong pain level on 4/25/22 at 12:10 am. 7. The resident was given wrong pain medication with wrong pain level on 4/25/22 at 1:08 pm. 8. The resident was given wrong pain medication with wrong pain level on 4/26/22 at 10:39 am . 9. The resident was given wrong pain medication with wrong pain level on 4/27/22 at 1:49 pm. 10. The resident was given wrong pain medication with wrong pain level on 4/28/22 at 9:29 am. 11. The resident was given wrong pain medication with wrong pain level on 4/29/22 at 8:54 am. 12. The resident was given wrong pain medication with wrong pain level on 4/30/22 at 5:37 pm. 1.b. A review of Resident 281's Hospice initial admission assessment record, dated, 3/31/22, indicated that Resident 281 was dyspneic (difficult, painful breathing or shortness of breath) or noticeably Short of Breath with minimal exertion (e.g. while eating, talking, or performing other ADLs (activities of daily living) ) or with agitation. A review of Resident 281's physician order, dated 4/11/22 - 5/3/22, indicated Oxygen (O2) - @ 2-5 Liters/Min via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). Goal to maintain Oxygen saturation (Sats) above 90%. Monitor O2 Sats every shift, NOC (night shift), AM (morning, day shift), PM (afternoon shift). (Oxygen saturation is the measure of how much oxygen is traveling through the body. Normal oxygen saturation for healthy adults is usually between 95% and 100%. Low oxygen level, also called hypoxemia (is low levels of oxygen in your blood. It causes symptoms like headache, difficulty breathing, anxiety, rapid heart rate and bluish skin) is considered a reading between 90% and 92%.) A review of Resident 281's Hospice Skilled Nursing visit note on 4/15/22 at 7:20 pm by HN R, indicated that the resident's O2 Sats level was down to 88 % due to no concentrator. The note showed Patient is pale with pallor (an unhealthy pale appearance). Skin is cool and dry. There was not an oxygen concentrator (a type of medical device used for delivering oxygen to a patient with breathing issues) in patient's room. This nurse notified the Charge nurse about the patient's oxygen Sats level, and she said she couldn't get a concentrator, and she would let patient's assigned nurse know when she came back from lunch After visiting all of my patients, circled back to speak with patient's assigned nurse and she had not been notified about patient's oxygen Sats level. HN R indicated on her note that a verbal instruction to charge nurse and assigned nurse regarding shortness of breath, O2 Sats parameters and when to apply O2 . A review of Resident 281's Hospice Skilled Nursing visit note on 4/22/22 at 4:30 pm by HN R, indicated that the resident's O2 Sats level was 86% and there was no O2 concentrator in his room. The note showed skin was dry and cool with pallor .Spoke with his assigned nurse and requested that she obtain the oxygen concentrator and placed patient on 2 Liter via nasal cannula . HN R indicated on her note that a verbal instruction to assigned nurse about End-Of-Life signs and symptoms. Respiratory distress and use of Oxygen and /or Morphine to relieve symptoms of distress. A review of Resident 2281's Hospice Skilled Nursing visit note on 4//23/22 at 11:15 am by HN R, indicated that the resident's O2 Sats level was 85 % and he was wearing a NC (nasal cannula) that was attached to an empty back-up cylinder (an oxygen tank that containing oxygen under pressure. It often was used for transporting patients or was provided when there was a power outage or problems with the O2 concentrator). HN R indicated on her note that a verbal instruction to assigned nurse regarding importance of making sure patient has an oxygen concentrator, as opposed to a back-up tank which is unsafe . The note also indicated that the need for comfort care for the resident, the staff needed to minimize adverse effects of .dyspnea, and to relieve the symptoms of dyspnea, O2 Sats level needed to be maintained greater than 88%. During an interview with HN R on 8/4/22 at 8:21 am, stated I remembered that I told the nurse just take me to where I can get the concentrator for him. At that point, the nurse did know where to find the concentrator. HN R stated my expectation was if they noticed that he needed oxygen, they should have it done! I was told, well sometimes, the CNA(Certified Nursing Assistant) came in, they put the person on Oxygen and they did not check. I told them, You guys are responsible to check and see whether the CNAs know there's Oxygen running to the patients. 2. A review of Resident 58's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included amputation of left leg below knee, kidney problem, stroke and palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure). A review of Resident 58's MDS, dated [DATE], indicated Resident 58's Brief Interview for Mental Status (BIMS) scored was 15 (intact cognitive response). He was not able to make his own healthcare decision. A review of Resident 58's physician order and MARS from 4/2022 and 7/2022, indicated that he had prn (as needed) Morphine concentrate orders for pain medication every hour and he was only given one time for his prn pain medication for the entire months of April and July in 2022. 3. A review of Resident 74's record indicated he was admitted to the facility on [DATE], with diagnoses which included heart failure, lung disease, and palliative hospice (end of life) care. Resident 74 was able to make his own health care decisions. A review of physician order dated 4/13/22, Morphine Sulfate Continuous release (MS Contin- a strong, long-acting narcotic pain medication) 15 milligrams (mg) every 12 hours for chronic pain. Morphine concentrate (liquid) 100 mg/5 milliliter (ml), administer 0.25 ml every 2 hours for mild pain (1-3 on pain scale), 0.5 ml orally every 2 hours for moderate pain (pain scale 4-6) and 1 ml every 2 hours for severe pain (pain scale number 7-10). A review of the MAR History dated 4/1-4/30/22, indicated Morphine Concentrate 0.5 ml for moderate pain levels 4-6 was administered 16 opportunities when Resident 74 reported severe pain levels at 7-8 out of ten. On 4/19/22 late administration was documented for the as needed dose. On 4/28/22 at 1:06 am, the post pain assessment for Resident 74 was reported at a level 6 moderate pain, all the other 15 post pain assessment (one hour post pain medication administration) indicated a 0 or no pain. A review of a Hospice Skilled Nursing visit note dated 7/16/22, indicated Resident 74 reported having some pain, it's usually my ribs and my back but lately my hips and my shoulder. I have been having little spells of shortness of breath but that's now how I felt when I went into the hospital. I felt like I was suffocating/drowning. HN R reminded Resident 74 that the morphine liquid (pain) and Lorazepam (anxiety) can be taken together to when needed to alleviate the feelings of shortness of breath/suffocation. Resident 74 told HN R that sometimes more often than not, he has trouble getting his pain medication. He will request it, then he is told they are at lunch. During an interview on 7/28/2022 at 12:41 pm, SSD stated she did not know Resident 74 had issues about his pain medication. SSD stated Registry (contract) nursing staff have some issues, because they aren't familiar with the residents. A review of a Hospice Skilled Nursing visit note dated 7/30/22, indicated, upon entering Resident 74's room, he slammed the door, as HN R was entering the room. He was very agitated, when asked if everything was OK, he stated nothing is OK! Life is not OK! I guess I just have to deal with this! Resident 74 stated he was having severe pain, 7 out of 10, and wanted his morphine. HN R asked Resident 74 if he had taken any Lorazepam for his anxiety, he stated I did not know that I had any available. HN R spoke with LN L about the orders for Lorazepam. LN L could not find the as needed order for Lorazepam in the system, only the routine. HN R pulled up the original hospice admission orders and then LN L was able to add this, as needed Lorazepam, to the medication administration system and was able to give it to the agitated resident. A review of a Hospice Skilled Nursing visit note dated 8/4/22, indicated Resident 74 was not receiving pain medications, making pain worse, and reported pain level at 7, a severe level. The pain level was not acceptable to resident. HN R documented that Resident 74's needs were not being met. Resident 74 stated He is not feeling as angry as last time, but would like to know Why I cannot get my pain medication and the one you said I can have for anxiety. Resident 74 informed HN R that he requested the cough medicine and was told it was not ordered. HN R went to speak with LN L about the orders for cough medicine and anxiety. LN L informed HN R that the order for the cough medicine had an end dated for 3 days and the Lorazepam as needed order was no longer in the system, although HN R had reviewed this on 7/30/22 and had LN L correct the orders in the system. LN L explained she tried to add the orders back, for cough medication and Lorazepam, but her tablet battery went dead. During an interview on 8/4/22 at 8:21 am, HN R explained that she texted the SSD at the facility and reported that Resident 74 had multiple complaints about not getting his pain medication and had other issues about pain medications. HN R stated she explained to Resident 74 I want you to talk to the social worker and Director of Nursing. Resident 74 told HN R that happened a lot, that the nurse did not know his medications. HN R stated this made Resident 74 really angry. He said he wasn't getting his medication. I told him that I would talk to his nurse. About the as needed Lorazepam. We checked the order, it was there. It was in the system. Wherever she was showing me. It was not there. But I have access to their system, I can check on my end, I have done the reconciliation, it was there. I pulled the order that I faxed to the facility, it was there. I just did the reconciliation. A review of Resident 74's physician orders dated 4/11/22 open ended, indicated Lorazepam (antianxiety) 0.5 mg tablet every eight hours for anxiety as exhibited by (AEB) terminal agitation. A review of the MARs for July 2022, indicated Resident 74 was given Lorazepam late on 16 opportunities. The MAR had monitoring for Resident 74 related to Lorazepam for anxiety related to terminal agitation, the number of episodes charted were 0 for the entire month. A review of the Resident 74's physician order dated 4/11/22 open ended, indicated Resident 74 could have Lorazepam 0.5 mg one tablet every four hours as needed for anxiety. A review of the MAR for August 2022 indicated Resident 74 received one dose of as needed Lorazepam on 8/5/2022 at 1:35 am. A review of Resident 74's physician orders dated 8/1/22 with an end date of 8/3/22, indicated he received one dose of Robitussin (cough chest congestion) 5 ml as needed four times a day for cough/chest congestion on 8/3/22 at 3:40 pm. 4. A review of Resident 57's record indicated she was admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome, lung disease, aftereffects of stroke and was on palliative hospice care (end of life). A review of the physician order report dated 6/1-8/10/22, indicated an order for morphine tablet extended release 7.5 mg oral for moderate to severe pain (4-10) hold for sedation and respiratory rate less than 12 (low) every eight hours, nothing to indicated to not crush the medication. There were no pain medications in liquid form indicated on the physician orders. A review of Lexicomp, an online drug reference guide indicated, morphine extended-release formulations are to be swallowed whole, chewing, crushing, or dissolving any of these extended-release preparations (including capsule beads or pellets) could result in rapid release and absorption of a potentially fatal dose of morphine. A review of Resident 57's nursing progress notes indicated: On 7/14/22, IDT note reviewed resident weight loss. No medication reviews. A goal of resident was needs for comfort. On 7/28/22 at 11:29 am, resident complained of pain ten out of 10 (worst pain), routine medication 15 mg given, ineffective, offered as needed morphine 7.5 mg, resident refused stated 7.5 mg does not help me, I need my 15 mg morphine. On 7/28/22 at 10:30 pm, resident having difficulty swallowing big pills and notified Hospice. A new physician order to crush medications related to difficulty swallowing. On 7/31/22, LN noted resident was annoyed because her routine pain medication was held earlier today, held due to respiration and heart rate low, and she was hallucinating. On 8/2/22, LN noted resident refusing to be changed during shift and repositioned in bed, stated I feel too much pain to move. On 8/5/22, resident assessed by Hospice and LN, her breathing slow, oxygen given, improved, hard to arouse, and morning medication held due to condition. New orders were for diet only. No medication order changes to liquid form. On 8/9/22, LN noted resident having difficulties swallowing medication, no medication changes for a liquid morphine. A review of a Hospice plan of care review dated 8/10/22, indicated Resident 57's pain management was scheduled morphine extended release 15 mg six hours and Morphine 7.5 mg as needed every eight hours for breakthrough pain. Resident 74 put on schedule Methadone (pain medication) 5 mg daily for severe pain in July 2022. Resident 74 had a hard time swallowing whole medication and food, in July 2022 medication orders were to crush medications. During an interview on 8/09/22 2:53 pm, CNA Y stated she works with Resident 57 often and Be as gentle as I can. We try to get her out as much as we can because she gets depressed. CNA Y stated, I can tell by the way she talks (wants to talk to son etc.) when in pain. CNA Y stated she has to remind nurses often that Resident 57 was due for pain medication. CNA Y stated, nurses get super overwhelmed and get super behind. CNA Y described that Resident 57 grinds her teeth and scratches her arm when in pain, and it gave her skin tears from rubbing too hard. CNA stated LN Z and LN AA take 20-30 mins to get pain medications to Resident 57. CNA Y stated Resident 57's pain affects her sleep and caused depression. CNA Y stated Resident 57 was always on her call light if she was in pain. CNA Y stated one day Resident 57 was acting strange, she told the nurse, the nurse said, well she just received medications. CNA Y had not participated in an IDT meeting related to Resident 57's pain and hospice care needs. During an interview on 8/9/22 at 3:17 pm, LN AA explained there were many medication changes for Resident 57 and she was still in pain, mainly in her back, but all over. LN AA stated as needed morphine did not help. LN AA stated Resident 57 wanted a stronger pain medication, she believed Percocet was better just started on methadone and morphine, but it is more of a short-term relief. LN AA stated Resident 57 said 7.5 mg of morphine was not working. LN AA stated DON was aware of any changes with Resident 57. LN AA was asked if medications were given timely and stated, if taking care of one resident and this one asks for pain medications, may have to wait, we do our best to be timely with pain medications. During an observation on 8/10/22 at 3 pm, Resident 57 was observed sleeping in bed, laying at an angle. Resident 57 was observed to be moaning (sign of pain) while asleep, this continued for a minute, and she continued to appear more uncomfortable. During an interview on 8/11/22 at 10:15 am, DON confirmed he was responsible for the hospice clinical nursing coordination, recently added a Quality Assurance Performance Improvement (QAPI) issue for late medication administration issues, had difficulty reaching some of the hospice nurses, they currently have 3 different contracts. DON confirmed when asked about the multiple entries on post pain medication assessments being a 0 for residents, he stated that was his error in instructing staff nurses to just put a 0 (no pain) when pain was under control after pain medication administration, not the actual pain level they report, to the nurse. Asked DON how does Nursing staff, Hospice nursing, and IDT evaluate the effectiveness of the pain medication if all entries are 0? DON stated there would be no way to know, the hospice medications are entered into the MAR as routine even though they are as needed and do not require a post assessment. DON stated his expectation would be a nursing progress note denoting post pain assessments. DON confirmed a problem with residents' getting pain medications timely (CNAs tell the nurse and it takes too long), he stated registry nurses and new nursing staff were hesitant to give too much narcotic medication (morphine) due to fear of overmedicating them and was not aware residents were receiving a lower incorrect dose for severe pain levels. DON stated no recent IDT team meetings have been held to discuss the varied issues of residents surrounding coordinating hospice care. DON stated Hospice was responsible for educating nurses. DON stated the changes in MD 1 who left June 2022, MD 2 picked up recently. DON stated Resident 57 was complicated and sometimes did not want to take some of her pain medications or changed her mind about her regimen. DON stated Resident 57 will go back and forth on what medications she wants. Resident 57 only wanted the liquid form of morphine or only Percocet, etc. DON just recently became aware that Resident 57 had trouble swallowing, so now Resident 57 will proceed to liquid medications. During an interview on 8/18/22 at 9:30 am, ADMIN explained the issues around implementing the hospice program at the facility, he stated accessibility to a medical director/physician coverage, new DON, the previous DON not effective, consistent IDT meetings, and communication amongst the facility nursing staff and hospice staff. ADMIN was aware back in April 2022, about the hospice management and pain issues for Resident 281, SSD informed him of the daughter's concerns, they did an in-service just surrounding this particular resident, it mainly focused on non-pharmacy interventions, not the pain medication administration and assessment, wrong medication issues, they did not address the entire program. ADMIN brought and met with hospice agencies to correct communication issues. Hospice coordination was not in QAPI. The last education provided by hospice was 12/2021, no education was provided to registry staff. During an interview on 8/18/22 at 10:45 am, SSD was asked about the issues with hospice care coordination and setting goals. SSD stated it was hard to coordinate hospice care when there was no consistent staff, issues with communication and competencies. SSD stated new nursing staff, short direct care staffing, registry staff, SSD informed the ADMIN of the family issue with Resident 281. SSD was listed as the instructor of the education about pain management, inquired if she was qualified to present, she indicated that the MDS nurse was present, not DON or DSD. During an interview on 8/18/22 at 12:20 pm, Medical Director (MD 2) stated the Hospice program was responsible for educating staff, inquired if he or DON could educate, yes of course, and agreed ultimately implementing the plan of care was the responsibility of the facility staff. MD 2 stated The nursing staff, and the Interdisciplinary care team should have provided me with a change of condition or issues surrounding pain or other symptom management.

Based on observation, interview, and record review the facility failed to ensure: 1. Accurate accountability and disposition of the medications awaiting final disposition (means destroying the unused medications to render it ineffective and prevent abuse or diversion) in the facility with a census of 76, 2. The facility's Consultant Pharmacist (CP) documented medication refrigerator temperatures were checked and logged for three out of three months (April, May, and June) when the facility temperature logs had missing data. 3. Routine medications (medications given daily) were not available for use for three out of four residents. These failed practices could contribute to unsafe medication use and prevention of drug diversion in the facility which could lead to negative outcomes. Findings: 1. During a concurrent interview, observation and review on 8/9/22, 2:30 pm, of the facility's medication destruction binder, accompanied by the Director of Nurses (DON), narcotic sheets (documentation with name of narcotic, resident name, instructions for use, and the total number of individual pills remaining) were provided for review. DON stated narcotic sheets were the official destruction record, signed and dated by both DON and CP when a narcotic is destroyed. Three out of seven narcotic sheets were missing one out of two required signatures. The receptacle containing narcotics awaiting final disposition had eight or more loose narcotic pills on the top that were available for use. No free-flowing liquid was observed on are around the loose narcotics. DON confirmed the findings. During a concurrent observation and interview at the nurse's station on 8/10/22, at 10:46 am, a review of the binder that contained more than 100 consolidated delivery sheets (CDS, an itemized list of medication being delivered to the facility for resident use, including narcotics) was not signed or dated by a Licensed Nurse (LN) accepting the delivery. LN C stated there were two CDS sheets provided during medication delivery. One CDS would be signed by staff and returned to the facility's pharmacy and the facility's copy of the CDS was placed in the binder at the nurse's station. LN C stated if there was a discrepancy and we need to know who accepted the medication, someone can call the pharmacy and request a copy of the signed document. During a concurrent record review and interview on 8/10/22, at 10:49 am, DON stated expectations were for staff to sign both CDS. DON confirmed missing signatures, dates, and lack of accountability for receiving all medication including narcotics. A review of the facility's policies and procedures (P&P) titled Discarding and Destroying Medications, revised 10/2014, indicated The receiving pharmacist and a Registered Nurse employed by the facility sign a separate log . and the medication disposition will contain the following information .reason for disposition and signature of witness. 2. During a concurrent observation, interview and record review in the facility's locked medication supply room, on 8/9/22, at 10:29 am, LN E confirmed the medication refrigerator log was missing temperature entries for: 3/26/22, 3/27/22,4/2/22, 4/3/22, 4/16/22, 4/17/22, 4/23/22, 4/24/22, 5/1/22, 5/20/22-5/22/22, 7/25/22, and 7/26/22. DON arrived at medication storage room and confirmed missing temperature entries. DON stated the expectation was that the night shift nurses monitored and entered the refrigerator temperatures onto the log nightly. A review of the records titled Consulting Services Provided this Month, completed by the facility's CP, dated 4/22, 5/22, and 6/22, indicated the medication refrigeration log was reviewed and temperatures were logged. A review of the facility's policies and procedures (P&P) titled: Storage of Medications, revised 11/17, indicated Drugs shall be stored in appropriate temperatures and Drugs requiring refrigeration shall be stored in a refrigerator between 36 degrees Fahrenheit (F) and 46 degrees F. 3a. During a concurrent observation and interview on 8/10/22, at 8:14 am, LN H was being trained by LN F during the facility's morning medication administration round. LN H was not able to find Resident 16's morning dose of Keppra (seizure medication) in the medication cart. LN H stated this was not the first time the facility was out of Keppra. LN F and LN H confirmed Resident 16 did not receive the morning dose of Keppra. LN F stated sometimes the pharmacy does not send medication when requested. A review of the Medication Administration History indicated two orders for Keppra: Keppra 1,000 milligrams (mg, unit of measure), 1 tablet, once a day, staring 9/17/21 and Keppra 500 mg, one tablet, at bedtime, starting 5/14/22. A review of a Pharmacy's record titled Refill Order Form indicated the facility requested a refill for Keppra 1,000 mg on 12/20/21 for Resident 16. A note from the pharmacist, faxed back to the facility, indicated it was too soon to order Keppra 1,000mg. A review of Pharmacy's record titled Refill Order Form dated 5/5/22 indicated the pharmacy faxed the facility seeking clarification for Resident 16's Keppra doses. During a concurrent record review and interview on 8/10/22, at 1:45 pm, Pharmacist (PHAR) consultant from the facility's pharmacy, stated the facility requested Keppra 1,000mg on 8/10/22, PHAR stated the last request for Keppra 1,000mg was made on 12/21/21. PHAR stated due to the facility not requesting Keppra 1,000 mg for a period of time, the pharmacy sent the facility a request to clarify Resident 16's Keppra order. PHAR stated the facility replied with an order for Keppra 500mg to be administered at bedtime. This led PHAR to believe the Keppra 1,000 mg order had been discontinued. PHAR stated that the facility will often request Keppra 500mg early and could see a trend that the medication had been ordered earlier and earlier over the last several months. PHAR stated, if Resident 16's Keppra 500mg dose was being used for the 1,000mg dose, the nurse would need to administer two every morning and one at bedtime to receive the ordered doses. PHAR stated that would explain why the facility was running out of Keppra 500mg so early. PHAR stated there should be two blister packs (package medication is in), one blister pack with Keppra 1,000mg to be administered in the morning and one blister pack for Keppra 500 mg to be administered at bedtime. PHAR stated a one-month supply is sent to the facility at a time. During a concurrent record review and interview on 8/11/22, at 11:46 am, DON confirmed both Keppra orders and doses for Resident 16 and stated the blister pack label should match the physician's order. DON unaware that staff had been using Keppra 500mg tablets and not ordering Keppra 1,000mg dose from the facility's pharmacy. DON confirmed facility inability to provide Resident 16 with ordered Keppra on 8/10/22 could be a result of not having both ordered doses on hand. 3b. During a concurrent observation and interview on 8/10/22, at 8:48 am, LN H was being trained by LN F during the facility's morning medication administration round. LN H was not able to find Resident 19's Eliquis (blood thinner) and megestrol (appetite stimulant). The blister pack for Resident 19's Eliquis and megestrol was missing. LN F stated, when the sticker is missing, it means the medication has been requested. LN F stated having a difficult time administering medications due to the pharmacy not sending medication when requested. A review of the facility's record titled Refill Order Form indicated Eliquis for Resident 19 was requested on 7/30/20. A review of Pharmacy's CDS indicated a 14-day supply of Eliquis had been delivered to the facility for Resident 19 on 7/31/22. A review of Pharmacy's CDS indicated a 14-day supply of Eliquis had been delivered to the facility for Resident 19 on 8/10/22. A review of Pharmacy's Refill Order Form indicated megestrol for Resident 19 was requested on 7/17/22. A review of Pharmacy's CDS indicated a 10-day supply of megestrol had been delivered to the facility for Resident 19 on 7/18/22. A review of Pharmacy's CDS indicated a 10-day supply of megestrol had been delivered to the facility for Resident 19 on 8/10/22. During an interview on 8/10/22, at 10:49 am, DON stated medications were not always being provided to the facility on time. DON stated a known issue with missing medications was the medication might have been ordered from the facility's pharmacy too early. DON stated if a nurse ordered the medication and it was too early to fill the prescription, the pharmacy would notify the facility when the medication can be ordered. The DON stated, then it falls off and the medication never shows up. A review of Resident 56's record indicated diagnoses that include convulsions (a sudden, violent movement of the body), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), and respiratory failure with hypoxia (failure to provide body with enough oxygen to the body). Resident 56 had a Brief Interview for Mental Status (BIMS) score (a number value between 00-15 with 13-15 cognitively intact, 08-12 moderately impaired, and 00-07 severe impairment) of 14 on 6/20/22. Section G on the facility Minimum Date Set (MDS) (provides a comprehensive assessment of the resident's functional capabilities. Section G is specific to Functional Status) on 6/20/22 indicated Resident 56 needed two people to assist with bed mobility and transfers and one person assistance to setup for eating and drinking. During a record review of Resident 56's Medication Administration Record (MAR), it was noted that Resident 56 was taking Renvela every day with meals (three times per day). The medication was due to be given at 9 am, 1 pm and 5 pm with food. Renvela is given to control phosphorus levels in the blood in adults/children who were on dialysis. It was noted that the 1 pm doses were not being given on dialysis days. On further review, from 6/1/22 through 8/10/22, the resident was not given 30 doses in a 71-day period. During an observation and interview on 8/10/22 at 9:45 am, Licensed Nurse (LN) H was medicating residents with their morning medications with LN F orienting her. Resident 56 was waiting for her medications while sitting in her wheelchair. Transportation was waiting to take Resident 56 to dialysis. LN F stated that the Renvela was not currently available. LN F agreed that the MAR indicated that 1 pm dose has not been being given on dialysis days and that the order does state that resident can self-administer and that today resident will not receive 9 am or 1 pm dose as medication is not available. During an interview on 8/10/22 at 12:15 pm, LN C agreed he cared for Resident 56 on 8/8/22. He agreed he did not send 1 pm dose with Resident 56 to dialysis as she does not bring food and it is to be given with food. He stated that the prior Medical Doctor (MD) was aware that 1 pm doses were not being given, but he doesn't know if current MD has been informed. During an interview on 8/10/22 at 2:30 pm with LN's F and H, LN F stated that Resident 56 was given her 9 am dose of Renvela before she left for dialysis. LN H indicated how medication was in an overflow drawer on the medication cart that she did not look in originally. LN F stated they did not give the 1 pm dose to the resident to take with her. During an interview with the Director of Nursing (DON) on 8/10/22 at 2:40 pm, DON agreed that the 1 pm dose is being charted as not being administered because the staff sends the medication to dialysis in a Ziplock bag. DON stated that nursing does not chart that they gave it, as the resident gives it to herself. Asked if she is sent with food to dialysis, and DON stated that dialysis gives her food to take with the medication. During a telephone interview on 8/10/22 at 3:03 pm, Dialysis Staff (DS) stated that Resident 56 does not take medication while at dialysis. DS stated that clients are not allowed to eat or drink at dialysis and haven't been allowed to that she is aware of since at least October 2021. She stated clients are not supplied food and that some medications can be given by staff with a MD order but stated that Renvela is not one of them. She stated that she has never seen Resident 56 attempt to take a medication while she is receiving dialysis. During a telephone interview on 8/10/22 at 4:15 pm, MD stated he was not aware that Resident 56 was not receiving her 1 pm dose of Renvela on dialysis days. A review of the facility policy titled, Administering Medications with a revision date of 3/22/2018, read, Medications must be administered in accordance with the orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility had a 17.24 % (percent) medication error rate, when five medication errors out of 29 opportunities were observed during medication pass for two out of three residents (Resident 16 and Resident 19). These failures resulted in four medications not given and one medication administered at an incorrect dose, which did not follow physician orders. This had the potential for residents to have a decrease of therapeutic medication effects (symptoms the medication is treating), a decline in health status, and negative psychosocial outcomes. Findings: During a concurrent observation and interview on 8/10/22, at 8:14 am, Licensed Nurse (LN) F was orientating LN H on medication cart #3 (a locked cart on wheels, resident medications were stored in). LN H was not able to locate the blister pack (medication storage device) for Keppra (seizure medication). LN H stated, this is not the first time we were out of Keppra. LN H stated, if a surveyor was not watching the medication pass, LN H would borrow the medication from another resident. LN H and LN F confirmed Resident 16 received all morning medications except for the 9:00 am dose of Keppra. A review of Resident 16's record indicated admission to the facility on [DATE] with the diagnoses of hypertension (high blood pressure) and epilepsy, unspecified, not intractable, without status epilepticus (seizures). Resident 16's son was listed as the responsible party (person who makes medical decisions). A review of the record titled Prescription Order, dated 9/17/21, indicated the physician wrote an order for Keppra 1,000 milligrams (mg, unit of measure) to be given once a day, at 9:00 am for seizure disorder. During a concurrent observation and interview on 8/10/22, at 8:48 am, LN F was orientating LN H on medication cart #3. LN H was preparing morning medications for Resident 19. During the medication preparation, LN H was not able to find the morning dose of Eliquis (blood thinner to prevent blood clots) and megestrol (appetite stimulation). LN H counted each medication provided to Resident 19 prior to administration. There were 11 pills, two liquid medications and one topical pain patch. Each medication prepared for Resident 19 was photographed using the surveyors State iPhone. Both LN F and LN H confirmed Resident 19 did not receive Eliquis and megestrol during the morning medication pass. A review of Resident 19's record titled Medication Administration History (MAR), dated 8/10/22, Indicated Resident 19 had an order for Eliquis 5 milligrams (unit of measure), one tablet every 12 hours for clot prevention. The MAR indicated the medication was given at 9:00 am. A review of Resident 19's MAR, dated 8/10/22, indicated Florajen Acidophilus (supplement), 20 billion cell, one capsule to be given once a day. The MAR indicated the medication had been provided to Resident 19. A review of the photographs taken 8/10/22, at 8:48 am, during LN H's medication pass, indicated Florajen Acidophilus was not administered to Resident 19. A review of the MAR, dated 8/10/22, at 9:00 am, indicated Florajen Acidophilus was not administered because the medication was not available. A review of Resident 19's MAR, dated 8/10/22, indicated megestrol suspension 400 mg/10 milliliters (ml, unit of measure), (40 mg/ml) give 200 mg, once a day was not administered: drug unavailable. A review of Resident 19's MAR, dated 8/10/22, indicated Prozac (medication to treat depression/sadness) 60 mg, one tablet, was to be given once a day. A review of the instructions located on the blister pack (device that contains medication with the medication order and instructions) containing Prozac, indicated fluoxetine HCL (generic name for Prozac) 20 mg caps, take three (3) capsules (60 mg) daily. A review of the photograph containing all medications administered to Resident 19, showed one capsule of Prozac, not three, per the label's instructions. Resident 19 received 20 mg of Prozac, not the ordered 60 mg. During a concurrent interview and record review, on 8/10/22, at 10:49 am, Director of Nurses (DON) stated missing meds happen. DON stated the expectation is for the nurses to tell the DON when medications are missing or not ordered. DON reviewed photographs taken of medications prepared and administered for Resident 19 and confirmed Prozac was not administered at the correct dose, and Florajen Acidophilus was not provided to Resident 19. DON confirmed LN F informed him of missing medications for Resident 16 and Resident 19. DON stated the pharmacy had been called and all missing medications would be administered to Residents 16 and 19 when the pharmacy delivers them. DON stated the physician had been notified and a one-time order had been placed, allowing staff to administer the medications late. DON was not able to provide documentation for medication administration in-services. DON stated expectation is for nursing to compare the medication label on the blister pack to the order in the computer. DON confirmed the order in the computer should match the label on the medication's blister pack. During an interview on 8/11/22, at 10:40 am, Quality Assurance Nurse (QAN, nurse who works for facility's pharmacy, can observe medication pass and provide unbiased insight on deficient practices), stated the facility had not requested QAN services in over a year. A review of the document titled: Consulting Services Provided this Month, dated 4/22, 5/22, and 6/22, indicated the facility's Consultant Pharmacist (CP) recommended the facility utilize the QAN for a more thorough review and in-depth medication pass audit. During an interview on 8/11/22, at 11:46 pm, DON confirmed knowledge of access to pharmacy's QAN and not utilizing QAN services. A review of the facility's policies and procedures (P&P) titled Medication Administration, revised 3/22/18, the P&P indicated when staff administered medications, The individual administering the medication must check the label to verify the right medication, right dose, right time, right method .before giving the medication. The P&P indicated Medications ordered for a particular resident may not be administered to another resident.

Based on observations, interviews, and record reviews, the facility failed to provide safe storage and labeling of medications and medical supplies when: 1a. the refrigerator and room temperatures were not consistently monitored in one out of one medication storage rooms. 1b. an unlabeled medication with wet, deteriorated packaging located in medication refrigerator was available for use. 2a. expired medication stored in one out of four medication carts (a locked cabinet on wheels where resident medication is stored). 2b. one out of four medication carts where medication was stored contained loose debris and was dirty. 2c. Expired and unlabeled medication were stored in one out of one treatment cart. These failures had the potential for unsafe medication use, and the use of medical supplies which would no longer be effective, which could lead to negative clinical outcomes. Findings: 1a. During a concurrent observation and interview on 8/9/22, at 10:29 am, Director of Nurses (DON) and Licensed Nurse H (LN) confirmed medication refrigerator temperature logs were missing temperature entries on: 3/26/22, 3/27/22,4/2/22, 4/3/22, 4/16/22, 4/17/22, 4/23/22, 4/24/22, 5/1/22, 5/20/22-5/22/22, 7/25/22, and 7/26/22. DON stated the expectation was that LN working the night shift monitored and entered refrigerator temperatures onto the temperature log nightly. A review of the facility's policies and procedures (P&P) titled: Storage of Medications, revised 11/17, indicated Drugs shall be stored in appropriate temperatures and Drugs requiring refrigeration shall be stored in a refrigerator between 36 degrees F and 46 degrees F. 1b During a concurrent observation and interview on 8/9/22 at 10:29 am, DON and LN H confirmed a metal box with liquid Lorazepam (medication used to treat anxiety and restlessness) was missing the resident's name on the medication packaging, the packaging was wet and deteriorated. There was ice and liquid inside the metal storage box the Lorazepam was stored in. The DON confirmed findings and stated the Lorazepam package should not look like that and instructed LN H to call the pharmacy and reorder the medication. DON placed the metal lock box back into the medication refrigerator after removing the ice, leaving the liquid inside the metal box. A review of the facility's P&P titled Medication Labels, dated 3/18, the P&P indicated the labels are permanently affixed to the outside of the prescription container and Medication containers having soiled, incomplete, illegible .labels are returned to the dispensing pharmacy for re-labeling or destroyed in accordance with the medication destruction policy. A review of the facility's P&P titled Storage of Medication, revised 11/17, the P&P indicated The nursing staff shall be responsible for maintaining storage .areas in a clean, safe, and sanitary manner. 2a During a concurrent interview and observation of Unit Three's medication cart (locked cart on wheels containing resident medication) on 8/9/22, at 2:51 pm, LN J confirmed a bottle of Prostate Formula (men's health, supplement) had been expired. LN J stated the medication belonged to a resident who had recently been discharged and someone forgot to give the medication back to the resident. LN J stated it was every nurse's responsibility to maintain the medication carts and remove expired medications. During an interview on 8/9/22, at 3:13 pm, DON stated the expectation was for nursing to inspect the medication carts weekly. DON stated the medication carts had been inspected by himself, this week, and DON checked medication carts routinely every other week. DON confirmed the expired medication should have been removed and not available for use. A review of the facility's P&P titled Storage of Medication, revised 11/17, the P&P indicated The facility shall not use discontinued, outdated, or deteriorated drugs or biological's and All such drugs shall be returned to the dispensing pharmacy or destroyed as soon as possible. 2b. During a concurrent interview and observation of Unit Three's medication cart on 8/9/22, at 2:51 pm, LN J confirmed 2 of the drawers that medications were stored in had loose debris, dirty, and had loose medication. LN J stated it was every nurse's responsibility to maintain the medication carts and keep them cleaned. LN J confirmed the medication cart should be clean, free of debris and not contain loose pills. During an interview on 8/9/22, at 3:13 pm, DON stated the expectation was for nursing to inspect the medication carts weekly. DON stated the medication carts had been inspected by himself, this week, and DON checked medication carts routinely every other week. DON confirmed the medication cart should be clean, free of debris and not contain loose pills A review of the facility's P&P titled Storage of Medication, revised 11/17, the P&P indicated The nursing staff shall be responsible for maintaining storage .areas in a clean, safe, and sanitary manner. 2.c During a concurrent observation and interview on 8/9/2022, at 2:33 pm, of the facility's treatment cart (a locked cart that contains wound care supplies and medication), LN K confirmed an open bottle of saline (used to clean wounds) had been dated 8/4. LN K was not able to state how long the saline was able to be used once opened. LN K confirmed two open bottles of acetic acid (used to clean wounds) had been missing pharmacy labels due to the labels being removed. LN K stated the resident no longer used the medication and the acetic acid was being saved incase another resident needed it. LN K confirmed 20 dressings, with the brand name Gentell, Hydrogel Saturated Gauze (used in wound care) had expired 7/2022. LN K confirmed one package with the brand name Gentell, Hydrogel Saturated Gauze had expired 12/2020, and was available for use. LN K stated all staff, including the treatment nurse was responsible for the monitoring of expired medication and supplies in the treatment cart. During an interview on 8/9/22, at 3:13 pm, DON stated the expectation for LN was to inspect the treatment cart weekly. DON confirmed that open saline found in treatment cart was no longer available for use. DON stated once saline had been opened, it needed to be dated and discarded 24 hours after it was opened. DON confirmed resident labels on acetic acid should not have been removed, stating the medication was to be used on the resident it was ordered for and cannot be used for another resident. DON confirmed the expired Hydrogel dressings should have been removed from the treatment cart and not available for use. A review of the facility's P&P titled Storage of Medication, revised 11/2017, the P&P indicated The nursing staff shall be responsible for maintaining storage .areas in a clean, safe, and sanitary manner. A review of the facility's P&P titled Storage of Medication, revised 11/2017, the P&P indicated The facility shall not use discontinued, outdated, or deteriorated drugs or biological's and All such drugs shall be returned to the dispensing pharmacy or destroyed as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of Resident Council Minutes, dated 6/23/22 had a section titled Old Business - Any new business identified at the last council meeting must be addressed here - either as resolved or unresolved. Five out of six items in this list are marked as resolved, with one unresolved. The unresolved items are as follows - Food comes out cold sometimes. Review of Resident Council Minutes, dated 7/15/22, indicated there were 2 unresolved concerns from May resident council meeting, food comes out cold sometimes. Upon review of May Resident Council Minutes, dated 5/19/22, it was indicated the two unresolved issues remained as, food sometimes comes out cold. The department response from dietary in relation to cold food was marked as unresolved with a new plan in progress. The department response with no date indicating the new plan to be implemented stated, DSS ordered new dome lids for plates. Will continue to monitor tray pass for timely delivery. During a confidential resident group interview on 8/9/22 at 10:07 am, six out of eight residents reported the food was still cold, stating We get the same food a lot. The taste is not good. Four out of eight residents stated the food was not in the form of their preference - in reference to palatability. Six out of eight residents complained of the taste. During an interview on 8/10/2022 at 11:16 am, Administrator (ADMIN), voiced understanding of the need for better written communication between departments for issues that arise in resident council. ADMIN stated currently bringing in ice physically for residents; however, residents stated they have not had ice recently. ADMIN explained he was unaware of multiple problems with food (in reference to palatability, temperature). 4. A review of the records indicated Resident 21 was admitted to the facility on [DATE] with the diagnoses of type two diabetes and hypertension (high blood pressure). Resident 21 was not her own decision maker. During an interview on 8/8/22, at 10:12 am, Resident 21 stated the kitchen staff did not know how to cook and the food was not good at all. Resident 21 stated the vegetables were not fully cooked and the meat was dry. Resident 21 stated that sometimes meals were not eaten due to the poor quality and staff did not always offer anything else to eat. 5. A review of the records indicated Resident 33 was admitted to the facility on [DATE] and had a return admission on [DATE]. Resident 33 had the diagnoses of contracture of left hand and left knee (inability to move) and major depressive disorder (a sad mood). Resident 33 was her own responsible party and made her own decisions. During an interview on 8/8/22, at 11:29 am, Resident 33 stated the food was lousy, strawberries and cantaloupe were never ripe. Resident 33 stated the kitchen gets my tray and food preferences mixed up a lot. 6. A review of the records indicated Resident 49 was admitted to the facility on [DATE] and had a readmission on [DATE]. Resident 49 had the diagnoses of cerebral infarction (stroke) and muscle weakness and was his own decision maker. During an interview on 8/8/22, at 10:33 am, Resident 49 stated, food is what it is and does not eat breakfast at the facility because it is never good. Resident 49 stated asking for other food when the provided meal was not appealing. When asked if alternate meals were provided, Resident 49 stated good luck, they don't give it. 8. Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with a diagnosis that included, Parkinson's disease (uncontrollable tremors, stiffness, and difficulty with balance and coordination), and history of falling. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 6/9/22, indicated that Resident 39 was cognitively intact. During an interview on 8/8/22, at 11:10 a.m., with Resident 39, Resident 39 stated, The food here is terrible and cold most of the time. They serve the same bland stuff every day, and sometimes I just don't eat it. I didn't even know I could ask for something else than what was brought out on my tray. 9. Resident 50's record was reviewed. Resident 50 was admitted to the facility on [DATE], with a diagnosis that included, Fractured hip, hearing loss, and unsteadiness on feet. The most recent MDS dated [DATE] indicated that Resident 50 was cognitively intact. During an interview on 8/8/22, at 11:40 a.m., Resident 50 stated, the food is unappetizing and tastes terrible and was always cold. I usually only eat a few bites of the lunch and dinner because it is so bland. They just come and grab the tray whether I have eaten any of it or not and have never offered me anything different to eat. Based on interview and record review the facility did not ensure the food service met resident needs as evidenced by unresolved food complaints surrounding the form, taste and temperature of the food that was served. These failures had the potential to result in decreased resident meal intakes, negatively impact their nutritional health status and quality of life. Findings: 1. A review of Resident 44's record indicated diagnoses that include transient cerebral ischemic attack (a stroke - damage to the brain from interruption in its blood supply), difficulty walking, respiratory failure with hypoxia. Resident 44 had a Brief Interview for Mental Status (BIMS) score (a number value between 00-15 with 13-15 cognitively intact, 08-12 moderately impaired, and 00-07 severe impairment) score of 15 on 6/9/22 and Part G of the facility's Minimum Data Set (MDS) (provides a comprehensive assessment of the resident's functional capabilities. Section G is specific to Functional Status) on 6/20/22 indicated Resident 44 needed supervision for activities. During an interview on 8/8/22 at 10:20 am, Resident 44 stated that the food stinks and that sometimes it is cold and just doesn't taste good. She stated, I wished they had better food. 2. A review of Resident 76's record indicated diagnoses that include hydronephrosis with renal and ureteral calculous obstruction (blockage in the tube that connects the kidney to the bladder), difficulty walking, heart failure (heart is unable to pump blood to meet the body's need). Resident 76 had a BIMS score of 14 on 7/20/22 and Section G of the MDS indicated one-to-two-person assistance with most activities and one person assistance for setup for eating and drinking. During an interview on 08/08/22 at 10:31 am, resident 76 stated the food is lousy. She stated that they frequently are not given what is on the menu. 3. A review of Resident 56's record indicated diagnoses that include convulsions (a sudden, violent movement of the body), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), and respiratory failure with hypoxia (failure to provide body with enough oxygen to the body). Resident 56 had a BIMS score of 14 on 6/20/22. Section G on MDS on 6/20/22 indicated Resident 56 needed two people to assist with bed mobility and transfers and one person assistance to setup for eating and drinking. During an interview on 8/8/22 at 3:13 pm, resident 56 stated that the food is terrible and that sometimes it is cold. The food is bad.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 27 record indicated upon admission on [DATE] at 6:48 pm, Resident 27 had admitting diagnoses of lung disease, Type 2 Diabetes, high blood pressure, and difficulty with walking. A review of a physician order report dated 5/27-8/10/22, indicated Resident 27's diet order had no added salt. Upon an interview with Resident 27 on 8/8/22 10:00 am, Resident 27 stated they did not like the food that was offered. Resident 27 stated if they request a different meal due to not liking the current meal, she was always given sandwiches - no variety seen with the substitutions. Resident 27 explained she does not like fish and still received fish often, regardless of having it written in her chart as a dislike. Resident 27 explained she had other staff members verify it was still on her chart as a dislike, Resident 27 complained on never having enough salt. According to Resident 27, each of these issues lead made her feel depressed and upset, as observation, visible tears were in Resident 27's eyes. Upon record review, Resident 27 had lost weight since admission. Resident 27 was admitted to the facility on [DATE] with a weight of 281 pounds. The most current weight taken was on 8/0/22, at 266 pounds. This equated to a weight loss of 15 pounds over a span of approximately two months. During a concurrent interview and record review on 8/11/22 at 9:50 am with the Registered Dietician (RD) and Dietary Manager (DM) weights of Resident 27 were reviewed. It was concluded Resident 27 had lost 15 pounds since admission and dietary staff did not trigger for weight loss. RD and DM confirmed Resident 27 was not at risk for issues related to sodium packets and could have a liberalized diet and will ask physician for new order. Both RD and DM confirmed not having alternatives and salt packets could have contributed to her weight loss and depression surrounding her food preferences. Resident 27's intake was less than 75 percent. Resident 27 had told many staff about wanting salt and alternatives, not just sandwiches, and no changes were made. They now have a new form developed to give to residents to request alternatives so now the communication will get to the kitchen. DM stared using a new form for alternative requests this week for direct care staff to give to kitchen when residents meal change request. An observation and interview were conducted on 8/11/22 at 3:00 pm, CNA X stated Resident 27 now had alternative food request slips in her room in reach to request for different food. CNA X stated resident requested food with more salt and for lunch today received a hamburger with tomatoes and no bun. 4. A record review of a Skilled Nursing Hospice Note dated 8/4/22, Resident 74 stated the ice machine was broken so the staff here do not see a need to bring water anyhow and bring ice, why does it take four days to get the ice machine fixed? During a confidential resident group interview on 8/9/22 at 10:07 am, one resident, stated Ice machine has been a problem here for years. Goes up and down, up and down. The ice machine has been broken. It's been a few weeks. Four out of eight residents did not get ice when they wanted. During interview on 8/9/22 at 4:07 pm, ADMIN stated ice machine down, due to project for laundry room, which has been almost a year ago. The electrical panel for the ice machine was being used for the mobile laundry room outside. ADMIN stated ice was ordered and being brought in for staff to use and distribute. 9. A review of the records indicated Resident 67 was admitted to the facility 1/29/21 with the diagnoses of generalized anxiety disorder (extreme worrying that interferes with daily activities), cognitive communication impairment (inability to interact meaningfully with others), and bipolar disorder, current episode mixed, moderate (mood disorder that can cause rapid speech, racing thoughts, and agitation). Resident 67 was her own responsible party and made her own medical decisions. During an interview on 8/8/22, at 9:18 am, Resident 67 stated the ice machine was not working. Resident 67 pointed to the end of the hall where an ice chest sat and stated, before you came, they didn't have ice for 10 days. Resident 67 stated when asking for ice, she was told they do not have any. 10. A review of the records indicated Resident 21 was admitted to the facility on [DATE] with the diagnoses of type two diabetes and hypertension (high blood pressure). Resident 21 was not her own decision maker. During an interview on 8/8/22, at 10:12 am, Resident 21 stated the kitchen staff did not know how to cook and the food was not good at all. Resident 21 stated the vegetables were not fully cooked and the meat was dry. Resident 21 stated that sometimes meals were not eaten due to the poor quality and staff did not always offer anything else to eat. 11. A review of the records indicated Resident 33 was admitted to the facility on [DATE] and had a return admission on [DATE]. Resident 33 had the diagnoses of contracture of left hand and left knee (inability to move) and major depressive disorder (a sad mood). Resident 33 was her own responsible party and made her own decisions. During an interview on 8/8/22, at 11:29 am, Resident 33 stated the food was lousy, strawberries and cantaloupe were never ripe. Resident 33 stated the kitchen gets my tray and food preferences mixed up a lot. 12. A review of the records indicated Resident 49 was admitted to the facility on [DATE] and had a readmission on [DATE]. Resident 49 had the diagnoses of cerebral infarction (stroke) and muscle weakness and was his own decision maker. During an interview on 8/8/22, at 10:33 am, Resident 49 stated food is what it is and does not eat breakfast at the facility because it is never good. Resident 49 stated asking for other food when the provided meal was not appealing. When asked if alternate meals were provided, Resident 49 stated good luck, they don't give it. During a review of the facility's policy and procedure (P&P) titled, Food Preferences, dated 2018, the P&P indicated, Resident food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. Food preferences can be obtained from the resident, family, or staff members. Updating of food preferences will be done as residents' needs change and/or during the quarterly review. Based on interview and record review, the facility failed to ensure that resident preferences were honored and offered substitutes of similar nutritive value for 10 of 10 sampled residents (Residents 21, 33, 39, 44, 49, 50, 56, 66, 67, and 76) and four out of eight confidential resident interviews. This failure not to provide food in accordance with resident preferences may result in decreased meal satisfaction and overall caloric intake. Findings: 1. Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with a diagnosis that included, Parkinson's disease (uncontrollable tremors, stiffness, and difficulty with balance and coordination), and history of falling. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 6/9/22, indicated that Resident 39 was cognitively intact. During an interview on 8/8/22, at 11:10 a.m., with Resident 39, Resident 39 stated, The food here is terrible and cold most of the time. They serve the same bland stuff every day, and sometimes I just don't eat it. I didn't even know I could ask for something else than what was brought out on my tray. 2. Resident 50's record was reviewed. Resident 50 was admitted to the facility 7/18/22, with a diagnosis that included, fractured hip, hearing loss, and unsteadiness on feet. The most recent MDS dated [DATE] indicated that Resident 50 was cognitively intact. During an interview on 8/8/22, at 11:40 a.m., with Resident 50, Resident 50 stated, The food is unappetizing and tastes terrible and is always cold. I usually only eat a few bites of the lunch and dinner because it is so bland. They just come and grab the tray whether I have eaten any of it or not and have never offered me anything different to eat. During an interview on 8/9/22, at 10:00 a.m., with Certified Nursing Assistant (CNA N), CNA N stated, if a resident doesn't like the food I would just go to the kitchen and get them a sandwich, I don't know what else there is for them to pick. During an interview on 8/9/22, at 10:15 a.m., with CNA O, CNA O stated, No one has ever asked me for something different but if they did, I guess I would go to the kitchen and ask them for a sandwich. During an interview on 8/9/22, at 10:30 a.m., with CNA P, CNA P stated, If a resident didn't like the food I would just go to the kitchen and get them something else. I have never heard of an alternate ticket. During an interview on 8/9/22, at 11:00 a.m., with CNA Q, CNA Q stated, I guess I would just go to the kitchen and ask them for a substitute, I don't know what an alternative ticket is. During a concurrent interview and record review on 8/10/22, at 3:30 p.m., with Dietary supervisor (DS), the facility's alternate meal ticket was reviewed. The Alternate meal ticket indicated the staff were supposed to circle lunch or dinner, indicate room number, diet texture, date and mark which substitute the resident wanted out of the four offered, chicken breast, grilled cheese, hamburger, or a chef salad. DS stated, The staff get an alternative ticket and fill it out, depending on which substitute they want according to the meal choices on the ticket. The staff know to do this if they don't like the food or if they eat less than half. 5. A review of Resident 44's record indicated diagnoses that include transient cerebral ischemic attack (a stroke - damage to the brain from interruption in its blood supply), difficulty walking, respiratory failure with hypoxia. Resident 44 had a Brief Interview for Mental Status (BIMS) score (a number value between 00-15 with 13-15 cognitively intact, 08-12 moderately impaired, and 00-07 severe impairment) score of 15 on 6/9/22 and Part G of the facility's Minimum Data Set (MDS) (provides a comprehensive assessment of the resident's functional capabilities. Section G is specific to Functional Status) on 6/20/22 indicated Resident 44 needed supervision for activities. During an interview on 8/8/22 at 10:20 am, Resident 44 stated that the food stinks and that sometimes it is cold and just doesn't taste good. She stated, I wished they had better food. 6. A review of Resident 76's record indicated diagnoses that include hydronephrosis with renal and ureteral calculous obstruction (blockage in the tube that connects the kidney to the bladder), difficulty walking, heart failure (heart is unable to pump blood to meet the body's need). Resident 76 had a BIMS score of 14 on 7/20/22 and Section G of the MDS indicated one-to-two-person assistance with most activities and one person assistance for setup for eating and drinking. During an interview on 8/8/22 at 10:31 am, resident 76 stated the food is lousy. She stated that they frequently are not given what is on the menu. 7. A review of Resident 66's record indicated diagnoses that include low back pain, difficulty walking, and hypertension. Resident 66 had a BIMS score of 15 on 6/24/22 and Section G of the MDS indicated one-to-two-person assistance with most activities and one person assistance for setup for eating and drinking. During an observation and interview on 8/8/22 at 11:20 am, Resident 66 stated she didn't have any ice in her water. Her water cup was observed to just have water. Resident 66 stated she has difficulty swallowing and needs water to facilitate swallowing. Resident 66 stated she does not like room temperature water, and she needs ice for the water. Resident 66 stated the facility ice machine has not worked for a while and getting ice can be very difficult. She stated that staff will either say they do not have any or that it is not available. She stated that night shift is most difficult as they state they can't get into the kitchen to get her any ice. 8. A review of Resident 56's record indicated diagnoses that include convulsions (a sudden, violent movement of the body), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), and respiratory failure with hypoxia (failure to provide body with enough oxygen to the body). Resident 56 had a BIMS score of 14 on 6/20/22. Section G on MDS on 6/20/22 indicated Resident 56 needed two people to assist with bed mobility and transfers and one person assistance to setup for eating and drinking. During an interview on 8/8/22 at 3:13 pm, resident 56 stated that the food is terrible and that sometimes it is cold. The food is bad.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement Hospice agreements and Hospice program ((a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) policy and procedures, and collaborate in the development of a coordinated plan of care, to ensure the physical, psychosocial, spiritual, and emotional needs were meet for four of four sample residents (Resident 57, 58, 74 and 281) when: 1.a. Resident 281 was given wrong dosage, wrong pain medication for the wrong pain level. This resulted in agitation and four falls. 1.b. Resident 281 wasn't provided with Oxygen concentrator on 4/15/22, 4/22/22 and 4/23/22 per physician ordered and hospice plan of care. This could potentially cause respiratory distress for Resident 281. 2. Resident 58 wasn't given his pain medication per physician order when he asked for it. Resident 58 was upset and had to suffer a longer pain. 3. Resident 74 was given incorrect dose of medication for severe pain, pain medications were administered late, and medications available for anxiety/cough were not given when symptoms present. This resulted in Resident 74 to have severe pain, anger, anxiety, and feelings of suffocation/drowning. 4. Resident 57 pain management program was not adjusted when she reported it was ineffective, when her swallowing was declining, and medications were not available for administration. This resulted in severe pain, depression, feeling miserable and sleep disturbances (moaning in her sleep). This failure resulted in Hospice residents not receiving the quality of care to meet their physical, psychosocial and emotional needs at end of life. Refer to F 697 and F 726. Findings: A review of the Hospice Agreement between the facility and Advanced Hospice, Inc., title Hospice Service Agreement, signed in 3/2016, indicated that the facility will provide Residents who have elected Hospice care with the following basic services that includes: a. Pharmacy Services: Prescription and non-prescription drugs that are not for treatment of the terminal illness and related conditions as determined by the Hospice Interdisciplinary Team (IDT). Pharmacy Service provided by the Facility will be available on a 24 hour a day 7 days a week basis. b. Durable medical equipment (DME) Services: Supervision and assistance in the use of any durable medical equipment and prescribed therapies that are not related to the terminal illness and related conditions. c. Supervision of Facility staff providing services under the plan of care established by Hospice team. A review of the facility's policy, titled Hospice Program, revised in 7/2017, indicated that it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's need. There included: a. Twenty-four-hour room and board care. b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of are. A review of the facility's policy, titled Hospice Program, revised in 7/2017, indicated: a. In general, it is the responsibility of the facility to meet the residents' personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. b. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. c. The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative, including: - Palliative goals and objectives. - Palliative interventions . 1.a. A review of Resident 281's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included prostate cancer, brain cancer, spine cancer and palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure). The resident expired on 5/3/2022. A review of Resident 281's Minimum Data Set (MDS - an assessment and care screening tool), dated 4/15/2022, indicated Resident 281's Brief Interview for Mental Status (BIMS) scored was 0 (severe impairment). Resident 281 was not able to make his own healthcare decision. A review of Resident 281's Hospice initial admission assessment record, dated, 3/31/2022, indicated that his pain was an active problem for the patient. A comprehensive pain assessment was performed and indicated that his primary pain was from his head and was intermittent. It increased by pressure and could be relieved by medication. A plan of care for pain was initiated and the goal was to improve in pain level to be 0/10 (no pain) on the pain scale. A fall assessment was also performed and indicated that his pain was affecting his level of function - Pain often affects the resident's desire or ability to move or pain can be a factor in depression or compliance with safety recommendations. A review of Resident 281's Hospice Skilled Nursing Visit note on 4/8/22 at 7:48 pm by Hospice Nurse (HN) R, indicated that the resident was disoriented, forgetful and lethargic. He had generalized pain and his pain was interfering with his activity/ movement daily. It could be managed by prn (as needed) medication. The care plan for his pan was the same as the date it was initiated on 3/31/22, as to improve in pain level to be 0/10 (no pain). A review of Resident 281's Hospice Skilled Nursing visit note on 4/22/22 at 4:30 pm by HN R, indicated that the resident's pain level was not acceptable to the resident, it showed Resident appeared to be experiencing more pains on his abdomen (the part of the body between the chest and the hips), right upper abdomen, both feet and his back this time. Pain intensity was 5 - medium. PRN (pain medication given as needed) not being given . The note also indicated that a verbal education was provided to LN U about end-of-life sign/symptoms, respiratory distress and use of oxygen and/or morphine to relieve symptoms of distress. HN R discussed the resident's recent falls with LN U. A review of Resident 281's Hospice Skilled Nursing visit note on 4/24/22 at 3:30 pm by HN S, indicated that Responsible Party (RP) was present and distressed. The note indicated RP stating patient is not being medicated appropriately. Patient resting quietly. Staff requested PRN opioid frequency to be increased to every two hours. Upon review PRN, opioid already scheduled every two hours as needed. Agency nurse practitioner informed. A review of Resident 281's Hospice Skilled Nursing visit notes and progress notes indicated that the resident fell on 4/10/22, 4/22/22, 4/25/22 and 4/29/22. A review of Resident 281's physician pain medication orders and Medication admission Records (MARS) from 4/8/22 to 5/3/22, indicated: 1. The resident was given wrong pain medication with wrong pain level on 4/10/22 at 4:47 am. 2. The resident was given Lorazepam (ordered for anxiety) when his pain level was 8 on 4/10/22 at 3:27 pm. 3. The resident was given wrong pain medication with wrong pain level on 4/17/22 at 5:31 pm. 4. The resident was given wrong pain medication with wrong pain level on 4/19/22 at 12:01 pm and 4:28 pm. 5. The resident was not given prn pain medication when his pain level was assessed on 4/25/22 and 4/28/22. 6. The resident was given wrong pain medication with wrong pain level on 4/25/22 at 12:10 am. 7. The resident was given wrong pain medication with wrong pain level on 4/25/22 at 1:08 pm. 8. The resident was given wrong pain medication with wrong pain level on 4/26/22 at 10:39 am . 9. The resident was given wrong pain medication with wrong pain level on 4/27/22 at 1:49 pm. 10. The resident was given wrong pain medication with wrong pain level on 4/28/22 at 9:29 am. 11. The resident was given wrong pain medication with wrong pain level on 4/29/22 at 8:54 am. 12. The resident was given wrong pain medication with wrong pain level on 4/30/22 at 5:37 pm. 1.b. A review of Resident 281's Hospice initial admission assessment record, dated, 3/31/22, indicated that Resident 281 was dyspneic (difficult, painful breathing or shortness of breath) or noticeably Short of Breath with minimal exertion (e.g. while eating, talking, or performing other ADLs (activities of daily living) ) or with agitation. The treatment for shortness of breath was initiated on 3/31/22 and the resident needed Oxygen 2 - 5 Liter /Min for comfort, symptom control and dyspnea (difficult breathing). A review of Resident 281's physician order, dated 4/11/22 - 5/3/22, indicated Oxygen (O2) - @ 2-5 Liters/Min via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). Goal to maintain Oxygen saturation (Sats) above 90%. Monitor O2 Sats every shift, NOC (night shift), AM (morning, day shift), PM (afternoon shift). (Oxygen saturation is the measure of how much oxygen is traveling through the body. Normal oxygen saturation for healthy adults is usually between 95% and 100%. Low oxygen level, also called hypoxemia (is low levels of oxygen in your blood. It causes symptoms like headache, difficulty breathing, anxiety, rapid heart rate and bluish skin) is considered a reading between 90% and 92%.) A review of Resident 281's Hospice Skilled Nursing visit note on 4/15/22 at 7:20 pm by HN R, indicated that the resident's O2 Sats level was down to 88 % due to no concentrator. The note showed Patient is pale with pallor (an unhealthy pale appearance). Skin is cool and dry. There was not an oxygen concentrator (a type of medical device used for delivering oxygen to a patient with breathing issues) in patient's room. This nurse notified the Charge nurse about the patient's oxygen Sats level, and she said she couldn't get a concentrator, and she would let patient's assigned nurse know when she came back from lunch After visiting all of my patients, circled back to speak with patient's assigned nurse and she had not been notified about patient's oxygen Sats level. HN R indicated on her note that a verbal instruction to charge nurse and assigned nurse regarding shortness of breath, O2 Sats parameters and when to apply O2 . A review of Resident 281's Hospice Skilled Nursing visit note on 4/22/22 at 4:30 pm by HN R, indicated that the resident's O2 Sats level was 86% and there was no O2 concentrator in his room. The note showed skin was dry and cool with pallor .Spoke with his assigned nurse and requested that she obtain the oxygen concentrator and placed patient on 2 Liter via nasal cannula . HN R indicated on her note that a verbal instruction to assigned nurse about End-Of-Life signs and symptoms. Respiratory distress and use of Oxygen and /or Morphine to relieve symptoms of distress. A review of Resident 2281's Hospice Skilled Nursing visit note on 4//23/22 at 11:15 am by HN R, indicated that the resident's O2 Sats level was 85 % and he was wearing a NC (nasal cannula) that was attached to an empty back-up cylinder (an oxygen tank that containing oxygen under pressure. It often was used for transporting patients or was provided when there was a power outage or problems with the O2 concentrator). HN R indicated on her note that a verbal instruction to assigned nurse regarding importance of making sure patient has an oxygen concentrator, as opposed to a back-up tank which is unsafe . The note also indicated that the need for comfort care for the resident, the staff needed to minimize adverse effects of .dyspnea, and to relieve the symptoms of dyspnea, O2 Sats level needed to be maintained greater than 88%. During an interview with HN R on 8/4/22 at 8:21 am, stated I remembered that I told the nurse just take me to where I can get the concentrator for him. At that point, the nurse did know where to find the concentrator. HN R stated my expectation was if they noticed that he needed oxygen, they should have it done! I was told, well sometimes, the Certified Nursing Assistant (CNA) came in, they put the person on Oxygen and they did not check. I told them, You guys are responsible to check and see whether the CNAs know there's Oxygen running to the patients. 2. A review of Resident 58's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included amputation of left leg below knee, kidney problem, stroke and palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure). A review of Resident 58's MDS, dated [DATE], indicated Resident 58's Brief Interview for Mental Status (BIMS) scored was 15 (intact cognitive response). He was not able to make his own healthcare decision. A review of Resident 58's physician order and MARS from 4/2022 and 7/2022, indicated that he had prn (as needed) Morphine concentrate orders for pain medication every hour and he was only given one time for his prn pain medication for the entire months of April and July in 2022. 3. A review of Resident 74's record indicated he was admitted to the facility on [DATE], with diagnoses which included heart failure, lung disease, and palliative hospice (end of life) care. Resident 74 was able to make his own health care decisions. A review of a physician order dated 4/8/22, indicated Resident 74 was admitted to Hospice service with a terminal diagnosis of heart failure. A review of Resident 74's MDS dated [DATE], indicated he had pain, occasionally, and on a pain scale at a 7 (severe pain). MDS dated [DATE], Resident 74 indicated he had pain frequently at a moderate level. A review of a hospice/palliative care plan dated 4/7-7/28/22, indicated Resident 74 was to have optimal relief from pain and to coordinate all plans of care with the Hospice team. Observe for efficacy of pain regimen. A review of physician order dated 4/13/22, Morphine Sulfate Continuous release (MS Contin- a strong, long-acting narcotic pain medication) 15 milligrams (mg) every 12 hours for chronic pain. Morphine concentrate (liquid) 100 mg/5 milliliter (ml), administer 0.25 ml every 2 hours for mild pain (1-3 on pain scale), 0.5 ml orally every 2 hours for moderate pain (pain scale 4-6) and 1 ml every 2 hours for severe pain (pain scale number 7-10). A review of the MAR History dated from 4/1-4/20/22, indicated the MS Contin was administered late 8 times, from one to one and one/half hours. A review of the MAR History dated 4/1-4/30/22, indicated Morphine Concentrate 0.5 ml for moderate pain levels 4-6 was administered 16 opportunities when Resident 74 reported severe pain levels at 7-8 out of ten. On 4/19/22 late administration was documented for the as needed dose. On 4/28/22 at 1:06 am, the post pain assessment for Resident 74 was reported at a level 6 moderate pain, all the other 15 post pain assessment (one hour post pain medication administration) indicated a 0 or no pain. A review of the pain monitoring by shift from 4/7-4/30/22, indicated Resident 74, reported severe pain 43 times, moderate pain 7 times, and mild or no pain 22 times. A review of a quarterly clinical observation detail report dated 7/13/22, indicated Resident 74 had pain frequently at a level 6 (moderate) aching pain. Resident 74 indicated his pain comes and goes. Resident 74 verbally identifies pain and anxiety may affect his pain. A review of a Hospice Skilled Nursing visit note dated 7/16/22, indicated Resident 74 reported having some pain, it's usually my ribs and my back but lately my hips and my shoulder. I have been having little spells of shortness of breath but that's now how I felt when I went into the hospital. I felt like I was suffocating/drowning. HN R reminded Resident 74 that the morphine liquid (pain) and Lorazepam (anxiety) can be taken together to when needed to alleviate the feelings of shortness of breath/suffocation. Resident 74 told HN R that sometimes more often than not, he has trouble getting his pain medication. He will request it, then he is told they are at lunch. A review of a Hospice Skilled Nursing visit note dated 7/21/22, indicated Resident 74 had pain in his wrist, back and hips sometimes shoulders, he rated his pain level to be severe, 8 out of ten. Resident 74 requested pain medication but stated he was having a hard time getting it. A review of a Hospice Skilled Nursing visit note dated 7/26/22, Resident 74 indicated, what makes pain worse, was the time between doses. Resident 74 had a productive cough and HN R received a new physician order for Robitussin DM 10 mg/200 ml, 5 ml every four hours as needed for cough. During an interview on 7/28/2022, 10:49 am, Resident 74, stated I told a CNA that I was in pain, I needed my pain medicine. The CNA said OK, she would tell the nurse. A half hour after, no one came. I pushed the call light again and a CNA stated she would tell the nurse, and still no one came. I had to push the call light 3 times and I finally got my pain medicine. The longest wait was about 2 hours. I told the Hospice nurse, they said they will look into it . During an interview on 7/28/2022 at 12:41 pm, SSD stated she did not know Resident 74 had issues about his pain medication. SSD stated Registry (contract) nursing staff have some issues, because they aren't familiar with the residents. A review of a Hospice Skilled Nursing visit note dated 7/30/22, indicated, upon entering Resident 74's room, he slammed the door, as HN R was entering the room. He was very agitated, when asked if everything was OK, he stated nothing is OK! Life is not OK! I guess I just have to deal with this! Resident 74 stated he was having severe pain, 7 out of 10, and wanted his morphine. HN R asked Resident 74 if he had taken any Lorazepam for his anxiety, he stated I did not know that I had any available. HN R spoke with LN L about the orders for Lorazepam. LN L could not find the as needed order for Lorazepam in the system, only the routine. HN R pulled up the original hospice admission orders and then LN L was able to add this, as needed Lorazepam, to the medication administration system and was able to give it to the agitated resident. A review of a Hospice Skilled Nursing visit note dated 8/4/22, indicated Resident 74 was not receiving pain medications, making pain worse, and reported pain level at 7, a severe level. The pain level was not acceptable to resident. HN R documented that Resident 74's needs were not being met. Resident 74 stated He is not feeling as angry as last time, but would like to know Why I cannot get my pain medication and the one you said I can have for anxiety. Resident 74 informed HN R that he requested the cough medicine and was told it was not ordered. HN R went to speak with LN L about the orders for cough medicine and anxiety. LN L informed HN R that the order for the cough medicine had an end dated for 3 days and the Lorazepam as needed order was no longer in the system, although HN R had reviewed this on 7/30/22 and had LN L correct the orders in the system. LN L explained she tried to add the orders back, for cough medication and Lorazepam, but her tablet battery went dead. During an interview on 8/4/22 at 8:21 am, HN R explained that she texted the SSD at the facility and reported that Resident 74 had multiple complaints about not getting his pain medication and had other issues about pain medications. HN R stated she explained to Resident 74 I want you to talk to the social worker and Director of Nursing. Resident 74 told HN R that happened a lot, that the nurse did not know his medications. HN R stated this made Resident 74 really angry. He said he wasn't getting his medication. I told him that I would talk to his nurse. About the as needed Lorazepam. We checked the order, it was there. It was in the system. Wherever she was showing me. It was not there. But I have access to their system, I can check on my end, I have done the reconciliation, it was there. I pulled the order that I faxed to the facility, it was there. I just did the reconciliation. A review of Resident 74's physician orders dated 4/11/22 open ended, indicated Lorazepam (antianxiety) 0.5 mg tablet every eight hours for anxiety as exhibited by (AEB) terminal agitation. A review of a Nurse Practitioner (NP) progress note dated 5/9/22, indicated Resident 74 was on hospice, he reported fatigue, no shortness of breath and reported a cough. Resident 74 reported pain managed. There were no other NP or MD progress notes found in the record. A review of the MARs for July 2022, indicated Resident 74 was given Lorazepam late on 16 opportunities. The MAR had monitoring for Resident 74 related to Lorazepam for anxiety related to terminal agitation, the number of episodes charted were 0 for the entire month. A review of the Resident 74's physician order dated 4/11/22 open ended, indicated Resident 74 could have Lorazepam 0.5 mg one tablet every four hours as needed for anxiety. A review of the MAR for August 2022 indicated Resident 74 received one dose of as needed Lorazepam on 8/5/2022 at 1:35 am. A review of Resident 74's physician orders dated 8/1/22 with an end date of 8/3/22, indicated he received one dose of Robitussin (cough chest congestion) 5 ml as needed four times a day for cough/chest congestion on 8/3/22 at 3:40 pm. During a concurrent observation and interview on 8/8/22 at 11:30 am, Resident 74 stated pain medications were late and looked in his journal and gave examples. On 8/1/22 at 9:30 am, CNA showed up at 10 am, then another correct CNA comes at 10:19 am, then he called another CNA at 10:40 am then by 11:50 am, he received his pain medication. On 8/5/22, Resident 74 called a CNA at 10:40 am due to reporting pain level was a 7/10 (severe) and by 11:50 am he received his pain medication. Resident 74 stated his pain level right now was a 7/10. Resident 74 stated it made him feel not happy, frustrated and caused anxiety. Resident 74 stated his pain level after receiving medication is usually a level of 4-5 and was tolerable at that level. Resident 74 stated I'm not the waiting type and I stand in the hallway. Resident 74 stated the Hospice nurse was aware. Resident 74 stated timeliness could be improved, they should hire more people. There were no Interdisciplinary team (IDT, a group of multidisciplinary staff who meet to discuss resident plan of care) meeting notes found in the record related to Resident 74's Hospice plan of care since April 2022. 4. A review of Resident 57's record indicated she was admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome, lung disease, aftereffects of stroke and was on palliative hospice care (end of life). A review of Resident 57's MDS dated [DATE], indicated she was cognitively intact. Resident 57 had a decision maker for health care concerns. A review of a NP progress note dated 6/16/22, indicated Resident 57 had chronic pain, continue to use Percocet (strong narcotic medication) and will work with hospice for better pain management. There were no other NP or MD progress notes found in the record. A review of the physician order report dated 6/1-8/10/22, indicated an order for morphine tablet extended release 7.5 mg oral for moderate to severe pain (4-10) hold for sedation and respiratory rate less than 12 (low) every eight hours, nothing to indicated to not crush the medication. There were no pain medications in liquid form indicated on the physician orders. A review of Lexicomp, an online drug reference guide indicated, morphine extended-release formulations are to be swallowed whole, chewing, crushing, or dissolving any of these extended-release preparations (including capsule beads or pellets) could result in rapid release and absorption of a potentially fatal dose of morphine. A review of Resident 57's nursing progress notes indicated: On 7/14/22, IDT note reviewed resident weight loss. No medication reviews. A goal of resident was needs for comfort. On 7/28/22 at 11:29 am, resident complained of pain ten out of 10 (worst pain), routine medication 15 mg given, ineffective, offered as needed morphine 7.5 mg, resident refused stated 7.5 mg does not help me, I need my 15 mg morphine. On 7/28/22 at 10:30 pm, resident having difficulty swallowing big pills and notified Hospice. A new physician order to crush medications related to difficulty swallowing. On 7/31/22, LN noted resident was annoyed because her routine pain medication was held earlier today, held due to respiration and heart rate low, and she was hallucinating. On 8/2/22, LN noted resident refusing to be changed during shift and repositioned in bed, stated I feel too much pain to move. On 8/5/22, resident assessed by Hospice and LN, her breathing slow, oxygen given, improved, hard to arouse, and morning medication held due to condition. New orders were for diet only. No medication order changes to liquid form. On 8/9/22, LN noted resident having difficulties swallowing medication, no medication changes for a liquid morphine. A review of the Hospice Care visit note dated 7/29/22 and 8/5/22, indicated Resident 57 stated her pain medications are ineffective. HN documented upon interviewing the staff they are giving all pain medications as ordered and does not complain in between doses. HN noted Case Manager and DON notified. A review of a Hospice Care visit note dated 8/6/22, HN indicated Resident 57 was out of Lorazepam and morphine, refills were requested and I picked up the medication from a local pharmacy and delivered them to the facility. During a concurrent observation and interview on 8/8/22 at 10:01 am Resident 57 stated her pain was depressing and terrible. Resident 57 was lying on her right side with the head of her bed elevated. Resident 57 stated I have throbbing pain to my stomach (both sides). A review of a Hospice plan of care review dated 8/10/22, indicated Resident 57's pain management was scheduled morphine extended release 15 mg six hours and Morphine 7.5 mg as needed every eight hours for breakthrough pain. Resident 74 put on schedule Methadone (pain medication) 5 mg daily for severe pain in July 2022. Resident 74 had a hard time swallowing whole medication and food, in July 2022 medication orders were to crush medications. During an interview on 8/09/22 2:53 pm, CNA Y stated she works with Resident 57 often and Be as gentle as I can. We try to get her out as much as we can because she gets depressed. CNA Y stated, I can tell by the way she talks (wants to talk to son etc.) when in pain. CNA Y stated she has to remind nurses often that Resident 57 was due for pain medication. CNA Y stated, nurses get super overwhelmed and get super behind. CNA Y described that Resident 57 grinds her teeth and scratches her arm when in pain, and it gave her skin tears from rubbing too hard. CNA stated LN Z and LN AA take 20-30 mins to get pain medications to Resident 57. CNA Y stated Resident 57's pain affects her sleep and caused depression. CNA Y stated Resident 57 was always on her call light if she was in pain. CNA Y stated one day Resident 57 was acting strange, she told the nurse, the nurse said, well she just received medications. CNA Y had not participated in an IDT meeting related to Resident 57's pain and hospice care needs. During an interview on 8/9/22 at 3:17 pm, LN AA explained there were many medication changes for Resident 57 and she was still in pain, mainly in her back, but all over. LN AA stated as needed morphine did not help. LN AA stated Resident 57 wanted a stronger pain medication, she believed Percocet was better just started on methadone and morphine, but it is more of a short-term relief. LN AA stated Resident 57 said 7.5 mg of morphine was not working. LN AA stated DON was aware of any changes with Resident 57. LN AA was asked if medications were given timely and stated, if taking care of one resident and this one asks for pain medications, may have to wait, we do our best to be timely with pain medications. During an observation on 8/10/22 at 3 pm, Resident 57 was observed sleeping in bed, laying at an angle. Resident 57 was observed to be moaning (sign of pain) while asleep, this continued for a minute, and she continued to appear more uncomfortable. During an interview on 8/11/22 at 10:15 am, DON confirmed he was responsible for the hospice clinical nursing coordination, recently added a Quality Assurance Performance Improvement (QAPI) issue for late medication administration issues, had difficulty reaching some of the hospice nurses, they currently have 3 different contracts. DON confirmed when asked about the multiple entries on post pain medication assessments being a 0 for residents, he stated that was his error in instructing staff nurses to just put a 0 (no pain) when pain was under control after pain medication administration, not the actual pain level they report, to the nurse. Asked DON how does Nursing staff, Hospice nursing, and IDT evaluate the effectiveness of the pain medication if all entries are 0? DON stated there would be no way to know, the hospice medications are entered into the MAR as routine even though they are as needed and do not require a post assessment. DON stated his expectation would be a nursing progress note denoting post pain assessments. DON confirmed a problem with residents' getting pain medications timely (CNAs tell the nurse and it takes too long), he stated registry nurses and new nursing staff were hesitant to give too much narcotic medication (morphine) due to fear of overmedicating them and was not aware residents were receiving a lower incorrect dose for severe pain levels. DON stated no recent IDT team meetings have been held to discuss the varied issues of residents surrounding coordinating hospice care. DON stated Hospice was responsible for educating nurses. DON stated the changes in MD 1 who left June 2022, MD 2 picked up recently. DON stated Resident 57 was complicated and sometimes did not want to take some of her pain medications or changed her mind about her regimen. DON stated Resident 57 will go back and forth on what medications she wants. Resident 57 only wanted the liquid form of morphine or only Percocet, etc. DON just recently became aware that Resident 57 had trouble swallowing, so now Resident 57 will proceed to liquid medications. During an interview on 8/18/22 at 9:30 am, ADMIN explained the issues around implementing the hospice program at the facility, he stated accessibility to a medical director/physician coverage, new DON, the previous DON not effective, consistent IDT meetings, and communication amongst the facility nursing staff and hospice staff. ADMIN was aware back in April 2022, about the hospice management and pain issues for Resident 281, SSD informed him of the daughter's concerns, they did an in-service just surrounding this particular resident, it mainly focused on non-pharmacy interventions, not the pain medication administration and assessment, wrong medication issues, they did not address the entire program. ADMIN brought and met with hospice ag[TRUNCATED]

Based on interview and record review, the facility failed to ensure care and services met accepted standards of quality when the Quality Assurance and Performance Improvement (QAPI) did not identify and correct quality deficiencies when: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility. Refer to F 689 This failure resulted in substandard quality of care and had the potential to put all residents at risk for safety and decreased quality of care and life. Findings: A Review of the facility's policy, titled 2022 Quality Assurance and Performance Improvement (QAPI) Plan, updated on 7/28/2022, showed: - Guiding: a. The organization uses quality assurance and performance improvement to make decisions and guide their day-to-day operations. b. The outcome of QAPI in the organization is to improve the quality of care and the quality of life of the residents. c. In this organization, QAPI includes all employees, all departments, and all services provided. d. The organization makes decisions based on data, which includes the input and experience of caregivers, residents, health care practitioners, families, and other stakeholders. - Scope: The scope of the QAPI program encompasses all segments of care and services provided by the facility that impact clinical care, quality of life, resident choice, and care transitions with participation from all departments. a. Clinical Care Services: We provide comprehensive clinical care to resident with acute and chronic disease, rehabilitative needs, as well as end-of-life care. All care is resident-centered and focused around choice and individualized treatment plans. b. Dietary: We provide nutrition's meals under the supervision of a licensed dietician. The facility considers resident choices and preferences by providing several options for meals and embrace open dinning hours. c. Pharmacy Services: We provide supervision and collaborate with the medical and nursing team at the facility by reviewing, dispensing, and monitoring medication effectiveness to ensure therapeutic goals are maintained for each resident. d. Plant Operations and Maintenance: We provide comprehensive building safety, repairs, and inspections to ensure all aspects of safety are enforced, assuring the safety and well-being for each resident, visitor, and staff who enters the building. The facility's governing body is ultimately responsible for overseeing the QAPI Committee. The Administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. During a concurrent interview and QAA meeting minutes record review with Administrator (ADMIN) on 8/11/22 at 2 pm, stated that the members of QAA are ADMIN, Director of Nursing (DON), Medical Director (MD), and three others, typically are the heads of the department, such as Social Service Director (SSD), dietary - Registered Dietitian (RD), Director of Staff Development (DSD), Infection Preventionist (IP), Pharmacist, Medical Records, depends on what issues were identified and what needed to be discussed during the meeting. ADMIN stated that the meeting minutes showed call light answering issue was identified, and he explained that a plan to audit the call light issues was under development. There was no meeting minutes record indicating that the issues with Pain management and Hospice services, Pharmacy services, Dietary services, Resident Council and Unsafe smoking practices were ever been identified or discussed. 1. The staff did not coordinate and implement the person-centered hospice care plan and follow the physician orders that met the needs for four of four sampled Hospice (a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness during last phases of incurable disease) residents (Residents 57, 58, 74 and 281) when Resident 281's pain level was not properly assessed. He was given wrong dosage, wrong pain medication for the wrong pain level. The staff did not follow the physician order to provide pain medication to Resident 58 when he was asking. The order indicated that Resident 58 could have pain medication every one hour, but the staff told him that it was for every four hours. Resident 74 was given incorrect dose of medication for severe pain, pain medications were administered late, and medications available for anxiety/cough were not given when symptoms present. Resident 57 pain management program was not adjusted when she reported it was ineffective, when her swallowing was declining, and medications were not available for administration. During an interview on 8/11/22 at 10:15 am, DON confirmed he was responsible for the hospice clinical nursing coordination, recently added a Quality Assurance Performance Improvement (QAPI) issue for late medication administration issues, had difficulty reaching some of the hospice nurses, they currently have 3 different contracts. DON confirmed when asked about the multiple entries on post pain medication assessments being a 0 for residents, he stated that was his error in instructing staff nurses to just put a 0 (no pain) when pain was under control after pain medication administration, not the actual pain level they report, to the nurse. Asked DON how does Nursing staff, Hospice nursing, and IDT evaluate the effectiveness of the pain medication if all entries are 0. DON stated there would be no way to know, the hospice medications are entered into the MAR as routine even though they are as needed and do not require a post assessment. DON stated his expectation would be a nursing progress note denoting post pain assessments. DON confirmed a problem with residents' getting pain medications timely (CNAs tell the nurse and it takes too long), he stated registry nurses and new nursing staff were hesitant to give too much narcotic medication (morphine) due to fear of overmedicating them and was not aware residents were receiving a lower incorrect dose for severe pain levels. DON stated no recent IDT team meetings have been held to discuss the varied issues of residents surrounding coordinating hospice care. DON stated Hospice was responsible for educating nurses. DON stated the changes in MD 1 who left June 2022, MD 2 picked up recently. DON stated Resident 57 was complicated and sometimes did not want to take some of her pain medications or changed her mind about her regimen. DON stated Resident 57 will go back and forth on what medications she wants. Resident 57 only wanted the liquid form of morphine or only Percocet, etc. DON just recently became aware that Resident 57 had trouble swallowing, so now Resident 57 will proceed to liquid medications. During an interview on 8/18/22 at 9:30 am, ADMIN explained the issues around implementing the hospice program at the facility, he stated accessibility to a medical director/physician coverage, new DON, the previous DON not effective, consistent IDT meetings, and communication amongst the facility nursing staff and hospice staff. ADMIN was aware back in April 2022, about the hospice management and pain issues for Resident 281, SSD informed him of the daughter's concerns, they did an in-service just surrounding this particular resident, it mainly focused on non-pharmacy interventions, not the pain medication administration and assessment, wrong medication issues, they did not address the entire program. ADMIN brought and met with hospice agencies to correct communication issues. Hospice coordination was not in QAPI. The last education provided by hospice was 12/2021, no education was provided to registry staff. During an interview on 8/18/22 at 10:45 am, SSD was asked about the issues with hospice care coordination and setting goals. SSD stated it was hard to coordinate hospice care when there was no consistent staff, issues with communication and competencies. SSD stated new nursing staff, short direct care staffing, registry staff, SSD informed the ADMIN of the family issue with Resident 281. SSD was listed as the instructor of the education about pain management, inquired if she was qualified to present, she indicated that the MDS nurse was present, not DON or DSD. During an interview on 8/18/22 at 12:20 pm, Medical Director (MD 2) explained the Hospice program goal was symptom management, if pain control was not attainable, hospitalize. MD 2 stated that MD 1 left on June 13-14, 2022, he was not aware that there were any problems with the hospice program related to implementing the plan of care. MD 2 confirmed he was late in getting his monthly assessments and notes in the system for the past couple of months due to transitioning medical directors. MD 2 stated the Hospice program was responsible for educating staff, inquired if he or DON could educate, yes of course, and agreed ultimately implementing the plan of care was the responsibility of the facility staff. MD 2 stated The nursing staff, and the Interdisciplinary care team should have provided me with a change of condition or issues surrounding pain or other symptom management. 2. Five medication errors out of 29 opportunities during medication administration observation, resulting in a medication error rate of 17.24 %. The facility's medication refrigerator temperatures logs had missing data for 3 months. Routine medications were not available for three residents. Failed to accurately dispose unused medications. Expired and unlabeled medications were found in medication cart. 3. Resident Council identified issues and concerns had not been addressed and resolved for the past four months when call lights being remained unanswered for an extended amount of time, nutritional needs not to be met (cold and bland food), preferences not honored and did not offer alternative with similar nutritive value. Residents felt their grievances were not listened and resolved. During an interview with ADMIN on 08/10/2022 at 11:16 am, stated that he understood the need for better written communication between departments for issues that arise in Resident Council. ADMIN admitted that he was unaware of multiple problems with food (in reference to palatability, temperature). ADMIN stated that he did not see the official report of minutes and he was told by other staff of the issues that arose during Resident Council at morning stand up. Requested for call light audits several times, did not receive. ADMIN unaware of call lights being turned off and having such a long response time. 4. Two of eighteen smoking residents (Resident 74 and 49) admitted that they smoked on their patio and there were approximately thirty cigarettes found on the ground in the resident's patio in the bark under a tree approximately two feet away from dry brush. During a concurrent observation and interview dated 8/8/22 at 1:35 PM, with the Director of Nursing (DON) and Administrator (ADMIN), both individuals stated they were unaware that this Resident 74 smoked; however, upon further investigation it was noted in social workers notes, care plans, assessments, and this individual's name was written on the smoking list provided by the facility. Both ADMIN and DON were shown the list provided by the facility of the smoking list and they were able to identify two out of eighteen residents that they were aware that smoked on their patio, an undesignated area, without staff or proper safety equipment present. During an observation on 8/9/22, at 9:40 am, an empty pack of cigarettes was observed in a garbage can. The garbage can was against the building, directly in between Resident 49 and Resident 67's doors that lead to an adjoined patio area. The patio area that belongs to Resident 67 had dirty linen scattered on the ground and the area was cluttered with miscellaneous items including trash. Resident 67 had an overgrown garden area with wooden planks on the ground. This posed as a fire danger due to Resident 49 not having a receptacle to extinguish his cigarettes when smoking outside on the patio. During an interview on 8/10/2022 at 11:43 AM, Administrator (ADMIN) stated the resident was spoken to in regard to smoking at designated gazebo area. Stated all residents are now out to the gazebo during arranged smoking times. Upon later observation during smoking schedule breaks, it was noted that Resident 74 was not participating in set smoke breaks.

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to develop and implement plans of action to correct identified facility issues related to: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility. Refer to F 689 Findings: A Review of the facility's policy, titled 2022 Quality Assurance and Performance Improvement (QAPI) Plan, updated on 7/28/2022, showed: a. QAPI Plan: The QAPI plan guides the facility's performance improvement efforts. b. The QAPI team will review the sources of information to determine if gaps or patterns exist in the systems of care that could result in quality problems; or if there are opportunities to make improvements. The facility's governing body is ultimately responsible for overseeing the QAPI Committee. The Administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. During a concurrent interview and QAA meeting minutes record review with Administrator (ADMIN) on 8/11/2022 at 2 pm, stated that the members of QAA are ADMIN, Director of Nursing (DON), Medical Director (MD), and three others, typically are the heads of the department, depends on what issues were identified and what needed to be discussed during the meeting. ADMIN stated that the meeting minutes showed call light answering issue was identified, and he explained that a plan to audit the call light issues was underdevelopment. There was no meeting minutes record indicated that the issues with Pain management and Hospice services, Pharmacy services, Dietary services, Resident Council and Unsafe smoking practices were ever been identified or discussed. The staff did not coordinate and implement the person-centered hospice care plan and follow the physician orders that met the needs for four of four sampled Hospice (a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness during last phases of incurable disease) residents (Residents 57, 58, 74 and 281) when Resident 281's pain level was not properly assessed. He was given wrong dosage, wrong pain medication for the wrong pain level. The staff did not follow the physician order to provide pain medication to Resident 58 when he was asking. The order indicated that Resident 58 could have pain medication every one hour, but the staff told him that it was for every four hours. Resident 74 was given incorrect dose of medication for severe pain, pain medications were administered late, and medications available for anxiety/cough were not given when symptoms present. Resident 57 pain management program was not adjusted when she reported it was ineffective, when her swallowing was declining, and medications were not available for administration. During an interview on 8/11/22 at 10:15 am, DON confirmed he was responsible for the hospice clinical nursing coordination, recently added a Quality Assurance Performance Improvement (QAPI) issue for late medication administration issues, had difficulty reaching some of the hospice nurses, they currently have 3 different contracts. DON confirmed when asked about the multiple entries on post pain medication assessments being a 0 for residents, he stated that was his error in instructing staff nurses to just put a 0 (no pain) when pain was under control after pain medication administration, not the actual pain level they report, to the nurse. Asked DON how does Nursing staff, Hospice nursing, and IDT evaluate the effectiveness of the pain medication if all entries are 0. DON stated there would be no way to know, the hospice medications are entered into the MAR as routine even though they are as needed and do not require a post assessment. DON stated his expectation would be a nursing progress note denoting post pain assessments. DON confirmed a problem with residents' getting pain medications timely (CNAs tell the nurse and it takes too long), he stated registry nurses and new nursing staff were hesitant to give too much narcotic medication (morphine) due to fear of overmedicating them and was not aware residents were receiving a lower incorrect dose for severe pain levels. DON stated no recent IDT team meetings have been held to discuss the varied issues of residents surrounding coordinating hospice care. DON stated Hospice was responsible for educating nurses. DON stated the changes in MD 1 who left June 2022, MD 2 picked up recently. DON stated Resident 57 was complicated and sometimes did not want to take some of her pain medications or changed her mind about her regimen. DON stated Resident 57 will go back and forth on what medications she wants. Resident 57 only wanted the liquid form of morphine or only Percocet, etc. DON just recently became aware that Resident 57 had trouble swallowing, so now Resident 57 will proceed to liquid medications. During an interview on 8/18/22 at 9:30 am, ADMIN explained the issues around implementing the hospice program at the facility, he stated accessibility to a medical director/physician coverage, new DON, the previous DON not effective, consistent IDT meetings, and communication amongst the facility nursing staff and hospice staff. ADMIN was aware back in April 2022, about the hospice management and pain issues for Resident 281, SSD informed him of the daughter's concerns, they did an in-service just surrounding this particular resident, it mainly focused on non-pharmacy interventions, not the pain medication administration and assessment, wrong medication issues, they did not address the entire program. ADMIN brought and met with hospice agencies to correct communication issues. Hospice coordination was not in QAPI. The last education provided by hospice was 12/2021, no education was provided to registry staff. During an interview on 8/18/22 at 10:45 am, SSD was asked about the issues with hospice care coordination and setting goals. SSD stated it was hard to coordinate hospice care when there was no consistent staff, issues with communication and competencies. SSD stated new nursing staff, short direct care staffing, registry staff, SSD informed the ADMIN of the family issue with Resident 281. SSD was listed as the instructor of the education about pain management, inquired if she was qualified to present, she indicated that the MDS nurse was present, not DON or DSD. During an interview on 8/18/22 at 12:20 pm, Medical Director (MD 2) explained the Hospice program goal was symptom management, if pain control was not attainable, hospitalize. MD 2 stated that MD 1 left on June 13-14, 2022, he was not aware that there were any problems with the hospice program related to implementing the plan of care. MD 2 confirmed he was late in getting his monthly assessments and notes in the system for the past couple of months due to transitioning medical directors. MD 2 stated the Hospice program was responsible for educating staff, inquired if he or DON could educate, yes of course, and agreed ultimately implementing the plan of care was the responsibility of the facility staff. MD 2 stated The nursing staff, and the Interdisciplinary care team should have provided me with a change of condition or issues surrounding pain or other symptom management. 2. Five medication errors out of 29 opportunities during medication administration observation, resulting in a medication error rate of 17.24 %. The facility's medication refrigerator temperatures logs had missing data for 3 months. Routine medications were not available for three residents. Failed to accurately dispose unused medications. Expired and unlabeled medications were found in medication cart. 3. Resident Council identified issues and concerns had not been addressed and resolved for the past four months when call lights being remained unanswered for an extended amount of time, nutritional needs not to be met (cold and bland food), preferences not honored and did not offer alternative with similar nutritive value. Residents felt their grievances were not listened and resolved. During an interview with ADMIN on 08/10/2022 at 11:16 am, stated that he understood the need for better written communication between departments for issues that arise in Resident Council. ADMIN admitted that he was unaware of multiple problems with food (in reference to palatability, temperature). ADMIN stated that he did not see the official report of minutes and he was told by other staff of the issues that arose during Resident Council at morning stand up. Requested for call light audits several times, did not receive. ADMIN unaware of call lights being turned off and having such a long response time. 4. Two of eighteen smoking residents (Resident 74 and 49) admitted that they smoked on their patio and there were approximately thirty cigarettes found on the ground in the resident's patio in the bark under a tree approximately two feet away from dry brush. During a concurrent observation and interview dated 8/8/22 at 1:35 PM, with the Director of Nursing (DON) and Administrator (ADMIN), both individuals stated they were unaware that this Resident 74 smoked; however, upon further investigation it was noted in social workers notes, care plans, assessments, and this individual's name was written on the smoking list provided by the facility. Both ADMIN and DON were shown the list provided by the facility of the smoking list and they were able to identify two out of eighteen residents that they were aware that smoked on their patio, an undesignated area, without staff or proper safety equipment present. During an observation on 8/9/22, at 9:40 am, an empty pack of cigarettes was observed in a garbage can. The garbage can was against the building, directly in between Resident 49 and Resident 67's doors that lead to an adjoined patio area. The patio area that belongs to Resident 67 had dirty linen scattered on the ground and the area was cluttered with miscellaneous items including trash. Resident 67 had an overgrown garden area with wooden planks on the ground. This posed as a fire danger due to Resident 49 not having a receptacle to extinguish his cigarettes when smoking outside on the patio. During an interview on 8/10/2022 at 11:43 AM, Administrator (ADMIN) stated the resident was spoken to in regard to smoking at designated gazebo area. Stated all residents are now out to the gazebo during arranged smoking times. Upon later observation during smoking schedule breaks, it was noted that Resident 74 was not participating in set smoke breaks.

Based on observation, interview, and record review, the facility failed to provide consistent administrative oversight to ensure the residents received the care and services to meet their needs when: 1. Pain management and Hospice services were not coordinated and monitored to meet the needs of residents. Refer to F 697, F 726 and F 849. 2. Pharmacy services related to administration, labeling, and storage did not meet standards. Refer to F 755, F 759, F 880 3. Resident council complaints were unresolved. Refer to F 565 4. Ensure safe smoking practices in the facility. Refer to F 689 Findings: A review of the facility's job description, titled Administrator, revised on 3/1/2014, indicated: a. The Administrator (ADMIN) assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees in the provision of care and services rendered in accordance with professional standards, and in compliance with county, state and federal laws and regulations, as applicable. Collaborates with consultants, contractors, referring physicians, facility resources, government agencies and advocacy groups. Implements operational and financial objectives of the Government Body and allocates resources in an efficient and economical manner to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. b. The essential job functions: - Oversee daily facility operations and coordinates departmental organization, management and resource, allocation to provide care and services to residents and meet organizational objectives for revenue and growth. - Communicate directly with residents, families, medical staff, nursing staff, interdisciplinary team members and Department Heads to coordinate care and services, improve organization and implementation of plans of care, to maintain quality of care, quality of life and a homelike environment for all residents. - Ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. Able to foster interdisciplinary cooperation and coordination of quality assurance and quality improvements goals. - Carry out all duties in accordance with facility/home office policy and procedure. 1. A review of the facility's police, titled Pain Assessment and Management, revised in 3/2015, indicated The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The guidelines also indicated that The pain management program is based on a facility-wide commitment to resident comfort. The monitoring and modifying approaches indicated that .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated A review of the facility's policy, titled Hospice Program, revised in 7/2017, indicated In general, it is the responsibility of the facility to meet the residents' personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. The policy also indicated that a member of the Interdisciplinary Team (IDT, team members include Administrator, Director of Nursing, Social Services Director, Medical Director, etc.) with clinical and assessment skills who is operating within the State scope of practice. He or She is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family. c. Ensuring that the Long-Term Care facility communicates with the hospices medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians. The staff did not coordinate and implement the person-centered hospice care plan and follow the physician orders that met the needs for four of four sampled Hospice (a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness during last phases of incurable disease) residents (Residents 57, 58, 74 and 281) when Resident 281's pain level was not properly assessed. He was given wrong dosage, wrong pain medication for the wrong pain level. The staff did not follow the physician order to provide pain medication to Resident 58 when he was asking. The order indicated that Resident 58 could have pain medication every one hour, but the staff told him that it was for every four hours. Resident 74 was given incorrect dose of medication for severe pain, pain medications were administered late, and medications available for anxiety/cough were not given when symptoms present. Resident 57 pain management program was not adjusted when she reported it was ineffective, when her swallowing was declining, and medications were not available for administration. During an interview on 8/18/22 at 9:30 am, ADMIN explained the issues around implementing the hospice program at the facility, he stated accessibility to a medical director/physician coverage, new DON, the previous DON not effective, consistent IDT meetings, and communication amongst the facility nursing staff and hospice staff. ADMIN was aware back in April 2022, about the hospice management and pain issues for Resident 281, SSD informed him of the daughter's concerns, they did an in-service just surrounding this particular resident, it mainly focused on non-pharmacy interventions, not the pain medication administration and assessment, wrong medication issues, they did not address the entire program. ADMIN brought and met with hospice agencies to correct communication issues. Hospice coordination was not in QAPI. The last education provided by hospice was 12/2021, no education was provided to registry staff. 2. Five medication errors out of 29 opportunities during medication administration observation, resulting in a medication error rate of 17.24 %. The facility's medication refrigerator temperatures logs had missing data for 3 months. Routine medications were not available for three residents. Failed to accurately dispose unused medications. Expired and unlabeled medications were found in medication cart. 3. Resident Council identified issues and concerns had not been addressed and resolved for the past four months when call lights being remained unanswered for an extended amount of time, nutritional needs not to be met (cold and bland food), preferences not honored and did not offer alternative with similar nutritive value. Residents felt their grievances were not listened and resolved. During an interview with ADMIN on 08/10/2022 at 11:16 am, stated that he understood the need for better written communication between departments for issues that arise in Resident Council. ADMIN admitted that he was unaware of multiple problems with food (in reference to palatability, temperature). ADMIN stated that he did not see the official report of minutes and he was told by other staff of the issues that arose during Resident Council at morning stand up. Requested for call light audits several times, did not receive. ADMIN unaware of call lights being turned off and having such a long response time. 4. Two of eighteen smoking residents (Resident 74 and 49) admitted that they smoked on their patio and there were approximately thirty cigarettes found on the ground in the resident's patio in the bark under a tree approximately two feet away from dry brush. During a concurrent observation and interview dated 8/8/22 at 1:35 PM, with the Director of Nursing (DON) and Administrator (ADMIN), both individuals stated they were unaware that this Resident 74 smoked; however, upon further investigation it was noted in social workers notes, care plans, assessments, and this individual's name was written on the smoking list provided by the facility. Both ADMIN and DON were shown the list provided by the facility of the smoking list and they were able to identify two out of eighteen residents that they were aware that smoked on their patio, an undesignated area, without staff or proper safety equipment present. During an observation on 8/9/22, at 9:40 am, an empty pack of cigarettes was observed in a garbage can. The garbage can was against the building, directly in between Resident 49 and Resident 67's doors that lead to an adjoined patio area. The patio area that belongs to Resident 67 had dirty linen scattered on the ground and the area was cluttered with miscellaneous items including trash. Resident 67 had an overgrown garden area with wooden planks on the ground. This posed as a fire danger due to Resident 49 not having a receptacle to extinguish his cigarettes when smoking outside on the patio. During an interview on 8/10/2022 at 11:43 AM, Administrator (ADMIN) stated the resident was spoken to in regard to smoking at designated gazebo area. Stated all residents are now out to the gazebo during arranged smoking times. Upon later observation during smoking schedule breaks, it was noted that Resident 74 was not participating in set smoke breaks.