**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for one of three sampled residents (Resident 1), who was admitted with a peripherally inserted central catheter (PICC line - a long flexible catheter inserted through a vein in the upper arm). This deficient practice resulted in Resident 1 not receiving appropriate care, monitoring and assessment specific to her PICC line. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (when excess fluid builds up in the brain, normal pathways that drain the fluid are blocked, often by a tumor, infection), type 2 diabetes mellitus without complications (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and malignant neoplasm of the brain (a dangerous growth of cancerous cells in the brain that invades and destroys health tissue). During a review of Resident 1's Skin Supplemental Assessment, dated 8/13/2025, the Skin Supplemental Assessment indicated Resident 1 had a right antecubital (the area of the forearm located in front of the elbow) PICC line, 5 French (Fr- unit of measurement for outer diameter of tubing), triple lumen, intact, no signs and symptoms (s/s) of infection noted, total length 41 centimeters (cm- unit of measurement for length). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 1 had moderately impaired cognitive skill (problems with thinking, memory, judgement) for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating and oral/personal hygiene. Resident 1 was dependent (helper does all of the effort and resident does none of the effort to complete the activity) with toileting hygiene, shower/bathe self, upper/lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 had a central line (PICC) on admission. During a concurrent interview and record review, on 9/4/2025, at 12:14 PM, with the Director of Nursing (DON), Resident 1's medical records were reviewed. The DON stated Resident 1 had a PICC line on her right antecubital area upon admission and could not find a baseline care plan in Resident 1's medical records regarding this care area. The DON stated licensed nurses, and the Minimum Data Set Coordinator (MDSC) were responsible for creating baseline care plans for residents. During an interview, on 9/4/2025, at 1:52 PM, the MDSC stated Resident 1 should have had a baseline care plan addressing the resident's dressing changes, site monitoring for infection, and assessment for the PICC line, since Resident 1 was assessed to have the PICC line upon admission. The MDSC stated baseline care plans were created within 48 hours of a resident's admission to the facility and it was important for Resident 1 to have the baseline care plan for the PICC line to provide quality care. During a follow up interview, on 9/4/2025, at 2:58 PM, the DON stated Resident 1 should have had a baseline care plan with initial interventions and goals for PICC line 48 hours after admission. The DON stated the facility's P&P for baseline care plan was not followed. During a review of the facility's policy and procedure (P&P) titled, Care Plans- Baseline, undated, the P&P indicated a baseline plan of care to meet the resident's immediate health and safety needs was developed for each resident within forty-eight (48) hours or admission. The baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the peripherally inserted central catheter (PICC line- a long flexible catheter that is inserted through a vein in the upper arm) care and dressing was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1). Resident 1's PICC line was not changed every seven days as indicated in the facility's policy. This deficient practice had the potential to result in Resident 1 developing an infection on the PICC line insertion site. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus (when excess fluid builds up in the brain, normal pathways that drain the fluid are blocked, often by a tumor, infection), type 2 diabetes mellitus without complications (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and malignant neoplasm of the brain (a dangerous growth of cancerous cells in the brain that invades and destroys health tissue). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (problems with thinking, memory, judgement) for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating and oral/personal hygiene. The MDS indicated Resident 1 had a central line (PICC) on admission. During a review of Resident 1's Skin Supplemental Assessment, dated 8/13/2025, the Skin Supplemental Assessment indicated Resident 1 had a right antecubital (the area of the forearm located in front of the elbow) PICC line, 5 French (Fr- unit of measurement for outer diameter of tubing), triple lumen, intact, no signs and symptoms (s/s) of infection noted, total length 41 centimeters (cm- unit of measurement for length). During a concurrent interview and record review, on 9/4/2025, at 12:14 PM, with the Director of Nursing (DON), Resident 1's medical records were reviewed. The DON stated it was the responsibility of the Treatment Nurse (TN) or the Registered Nurse (RN) Supervisor to change Resident 1's PICC line dressing at least every seven days. The DON stated Resident 1's PICC line should have been changed on 8/19/2025 and there was no documentation to indicate Resident 1's PICC line was changed on or before 8/19/2025. During an interview, on 9/4/2025, at 12:15 PM, with the DON and the Assistant DON (ADON), the ADON stated she changed Resident 1's PICC line but could not state the date it was changed. The ADON stated she did not document the PICC line dressing change in Resident 1's medical record. The DON stated if the PICC line change was not documented then it was considered not done. The DON stated the facility's policy for Central Venous Catheter Care was not followed. The DON stated it was important to change Resident 1's PICC line dressing to prevent complications like infections. During a review of the facility's policy and procedure (P&P) titled, Central Venous Catheter Care and Dressing Changes, undated, the P&P indicated to change the dressing if became, damp, loosened or visibly soiled and at least every 7 days. The P&P indicated that the purpose of this procedure was to prevent complications associated with intravenous (within or through a vein) therapy, including catheter-related infections that were associated with contaminated, loosened, soiled, or wet dressings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** S483.25(d) Accidents. The facility must ensure that - S483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) who was assessed as high risk for falls by failing to develop a comprehensive resident-centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) after Resident 1's fall on 8/10/2025. This deficient practice resulted in Resident 1's repeated fall on 8/12/2025 at 6:19 PM. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included non-traumatic intracerebral hemorrhage (the bleeding into the brain tissue that occurs without a physical injury or trauma), ataxia (a condition characterized by a lack of coordination and balance), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/6/2025, the MDS indicated Resident 1 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds the trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident 1 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with sit to lying, sit to stand, chair/bed-to-chair transfer, and walking 10 feet (ft- unit of measurement). During a review of Resident 1's Fall Risk Assessment, dated 8/10/2025, the Fall Risk Assessment indicated a score of 12 (a score of 10 or above represents high risk for falls). During a review of Resident 1's Progress Notes, dated 8/10/2025, timed at 2:30 PM, the Progress Notes indicated Resident was found sitting on the floor mat at the left (L) side of her bed. When asked the resident what happened, resident was not able to describe what happened. During a review of Resident 1's Interdisciplinary Team (IDT- a meeting where healthcare professionals from different disciplines collaborate to develop or review a resident's care plan) Progress Note, dated 8/11/2025, the IDT Progress Note indicated Resident 1 was found sitting on the floor on the left side of her bed. The IDT Recommendation indicated, Resident 1 remains at risk for falls due to impaired safety awareness. Education provided and reinforced regarding use of call light. Plan of care to continue with fall precautions and ongoing monitoring. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a document that provides a framework for communication between members of the health care team about a resident's condition), dated 8/12/2025, the SBAR indicated that on 8/12/2025, at 6:19 PM, an unknown resident's Responsible Party 1 (RP 1) saw Resident 1 trying to reposition self from her wheelchair and got up. Licensed Vocational Nurse 1 (LVN 1) stated heard a sound and got up and saw the Resident on the floor before he could catch her. SBAR indicated, per LVN, Resident 1 fell forward on the floor on her left side. Resident 1 was unresponsive to verbal and physical stimuli and loudly snoring as she was asleep. During a review of Resident 1's Progress Notes, dated 8/12/2025, timed at 6:37PM, the Progress notes indicated at 5:45PM, after dinner, Resident 1, while on the wheelchair was placed in front of the nurses' station with other residents. At 6:15PM, Resident 1 was in a wheelchair in front of the nurses' station while LVN (not specified) was passing medications. At 6:19PM, RP 1 saw Resident 1 trying to reposition self from the wheelchair and got up. The LVN (LVN 1) at the nurse's station heard the sound and got up but Resident 1 was already on the floor before LVN 1 could catch her. During an interview, on 8/27/2025, at 1:45 PM, with LVN 1, LVN 1 stated CNA 1 placed Resident 1 in the hallway across from Nurse's Station after dinner. LVN 1 stated Resident 1 was not confused but was not moving around in her wheelchair when CNA 1 left her by the hallway. LVN 1 stated he was not familiar with Resident 1's care but knew that she was in the Falling Star Program (a program that serves as a visual identifier and reminder system for staff to recognize residents who are determined to be at risk for falls). LVN 1 stated he did not know that Resident 1 had a history of falls or what type of supervision Resident 1 needed. LVN 1 stated he was inside the Nurse's Station assisting another family member with lab results when he saw Resident 1 try to get up from her wheelchair. LVN 1 stated he attempted to assist Resident 1 but by the time he got to Resident 1 she already fell on the floor. LVN 1 stated he saw Resident 1 fall face down and was in deep sleep when he got to her in the hallway. During an interview, on 8/27/2025, at 2:51 PM, with LVN 2, LVN 2 stated Resident 1 was found on the floor in her room on 8/10/2025. LVN 2 stated Resident 1 had poor safety awareness and was impulsive with her actions and needed to be supervised to prevent future falls. LVN 2 stated facility staff placed Resident 1 by the Nurse's Station so she can be supervised closely. LVN 2 stated it was important for Resident 1's care plan interventions to be specific and resident-centered and specific to her needs to prevent falls. During a concurrent interview and record review, on 8/27/2025, at 3:31 PM, with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy Evaluation and Plan of Treatment, with the certification period from 8/6/2025 to 9/1/2025 was reviewed. The DOR stated Resident 1 needed moderate assistance with transfer, bed mobility, and walking 10 ft. The DOR stated Resident 1 needed assistance from staff to stand up safely from a wheelchair. The DOR stated Resident 1 required prompts, had impaired safety awareness and had moderately impaired decision making. The DOR stated it would not be safe for Resident 1 to stand up from her wheelchair without assistance. The DOR stated Resident 1 needed supervision when left sitting in her wheelchair. The DOR stated that the facility staff supervising Resident 1 should have Resident 1 within his eye line to ensure she receives assistance when she tries to stand up. During an interview, on 8/28/2025, at 9:51 AM, with CNA 1, CNA 1 stated Resident 1 needed to be supervised because she was at risk for falls and was in the Falling Star Program. CNA 1 stated on 8/12/2025, Resident 1 turned and twisted in her wheelchair from time to time. CNA 1 stated on 8/12/2024, at around 6 PM, she placed Resident 1 in front of the Nurse's Station so Resident 1 can be supervised while CNA 1 assisted another resident in the dining room. CNA 1 stated she informed LVN 1 that Resident 1 was in her wheelchair in front of the Nurse's Station before leaving. CNA 1 stated she heard someone fall in the hallway while helping another Resident and ran to the nurse's station to check on Resident 1. CNA 1 stated she saw Resident 1 in front of the Nurse's Station snoring and face down on the floor. During a concurrent interview and record review, on 8/28/2025, at 10:09 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), Resident 1 care plan with focus on Resident 1's actual fall and risk for further falls, dated 8/10/2025 was reviewed. The DON stated Resident 1 was confused, had poor safety awareness, and tried to get out of bed numerous times. The DON stated on 8/12/2025 at approximately 6:15 PM, LVN 1 was charting on the computer inside the Nurse's Station when he heard a sound in the hallway. The DON stated LVN 1 stood up and saw Resident 1 on the floor. The DON stated LVN 1 was not able to catch Resident 1 before she fell on the floor. The DON stated Resident 1's care plan for fall did not include resident-specific interventions on how to supervise and what type of monitoring Resident 1 needed to prevent further falls. The DON stated the purpose of a care plan was to provide interventions for facility staff to follow in order to tackle residents' needs and meet specific goals. The DON stated the IDT recommendation from 8/11/2025 for ongoing monitoring of Resident 1 should have been included in Resident 1's interventions to prevent falls. During a concurrent interview and record review, on 8/28/2025, at 10:09 AM, with the DON and the ADON, Resident 1's care plan for risk for further falls and injuries related to (r/t) balance problem, gait abnormality (unusual pattern of walking), poor trunk control (difficulty maintaining upright posture, balance, and performing daily activities) , bowel/bladder incontinence (involuntary and unexpected passage of urine or stool), poor communication/comprehension, dated 8/10/2025 was reviewed. The DON stated the care plan was not resident-specific and did not and should have included supervision and monitoring as an intervention to prevent Resident 1 from falling. During a concurrent interview and record review, on 8/28/2025, at 10:50 AM, with the DON, the facility's Falling Star Program policy was reviewed. The DON stated the Falling Star Program did not indicate what type of supervision or monitoring a resident receives once added to the program. The DON stated both the facility's Falling Star Program and Resident 1's care plan for falls did not indicate what type of supervision and monitoring Resident 1 needed to prevent falls. During a review of the facility's undated Policy and Procedure titled, Falling Star Program, the P&P indicated The IDT is responsible for implementing individualized interventions for each resident's fall risks. During a review of the facility's P&P, titled, Managing Falls and Fall Risk, , revised 03/2018, the P&P indicated the following:1. The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. 2. The staff, with the input of the attending physician, will implement a Resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. During a review of the facility's P&P, titled, Safety and Assistance of Residents, revised 02/2021, the P&P indicated the following:1. Our facility strives to make the environment as free from accident hazards as possible. Our residents' safety and needs to prevent accidents are facility-wide priorities.2. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including assisting the residents as needed and assisting on any assistive devices. During a review of the facility's P&P, titled, Care Plans, Comprehensive Person-Centered, undated, the P&P indicated the following:1. A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan describes services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental, psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 126's admission Record, the admission Record indicated that Resident 126 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood), hypertensive (high blood pressure) heart disease, atrial fibrillation (an irregular and often very rapid heart rhythm), chronic kidney disease (a progressive damage and loss of function in the kidneys). During a review of Resident 126's History and Physical (H&P), dated 12/16/2024, the H&P indicated Resident 126 had the capacity to understand and make decisions. During a review of Resident 126's Care Plan, revised 12/16/2024, the Care Plan indicated Resident 126 has Activities of Daily Living (ADL) self-care and/or mobility performance deficit and needs the call light within reach to meet the resident's needs. During a concurrent observation and interview on 12/16/2024 at 10:39 AM with Resident 126 in his room, Resident 126 was lying in bed on his back with the head of bed elevated. Resident 126's call light was not on his bed. Resident 126 stated he cannot reach the call light. During a concurrent observation and interview on 12/16/2024 at 10:45 AM with Certified Nursing Assistant 1 (CNA1) in Resident 126's room, Resident 126's call light was under the bed. CNA 1 stated the call light was underneath Resident 126's bed and was not within Resident 126's reach. CNA 1 stated the facility should place the call light within resident's reach to ensure staff is able to provide resident's needs especially during emergencies. During an interview on 12/19/2024 at 9:40 AM with DON, the DON stated it was important to ensure the call light is within the resident's reach so the resident can get assistance on time to meet their needs. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, revised 03/2021, the P&P indicated the facility should ensure the remote control or task lighting are easily accessible. During a review of the facility's P&P titled, Answering the Call Light, revised 3/2022, the P&P indicated the facility should ensure that the call light is within reach and accessible to the resident all times. Based on observation, interview, and record review, the facility failed to accommodate the needs for two of 14 sampled residents (Residents 222 and 126) by failing to ensure the resident's call light (device used by residents to call staff) was within the resident's reach. This deficient practice had the potential for delayed provision of care to Residents 222 and 126, which could negatively affect the residents' overall wellbeing. Findings: 1. During a review of Resident 222's admission Record, dated 12/18/2024, the admission Record indicated Resident 222 was admitted to the facility on [DATE] with diagnosis of pneumonia (an infection that affects one or both lungs and causes them to fill up with fluid or pus), chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), and neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem). During a review of Resident 222's History and Physical, dated 12/5/2024, the H&P indicated Resident 222 had the capacity to understand and make decisions. During a concurrent observation and interview on 12/16/2024 at 10:09 AM with Resident 222 in the resident's room, Resident 222 was trying to position his pillow behind his head with his left arm but was struggling to get the pillow in place. Resident 222 stated he was trying to reach for his call light but could not reach it. During a concurrent observation and interview on 12/16/2024 at 10:11 AM with Certified Nursing Assistant 4 (CNA 4), in Resident 222's room, CNA 4 stated Resident 222's call light was on the floor and should have been on the bed, and in a position/ location where Resident 222 could reach it. CNA 4 stated it is important to keep residents' call lights within their reach so that they can call for the facility staff and ask for the help they need. The CAN 4 verified Resident 222 was unable to reach for his call light cord because it was on the floor. During an interview on 12/18/2024 at 9:16 AM with the Director of Nursing (DON), the DON stated, call lights should be within the resident's reach, and call lights on the floor are not an acceptable practice because it is important that residents can reach their call light to ask staff for assistance to meet resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 54), had the head of bed (HOB) elevated at minimum 30 degrees during tube feeding infusion in accordance with the facility policy. This deficient practice had the potential for Resident 54 aspirating (feeding could enter the windpipe and lungs) and result in complications such as aspiration pneumonia (an inflammation of the lungs and bronchial tubes that occurs after foreign matter was inhaled), hospitalization, and death. Findings: During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted on [DATE] with diagnosis of dysphagia (difficulty or discomfort in swallowing) and a gastrostomy tube (G-tube, tube inserted through the belly that brings nutrition directly to the stomach). During a review of Resident 54's History and Physical (H&P, a term used to describe a physician's examination of a resident), dated 11/8/2024, the H&P indicated Resident 54 does not have the capacity to understand and make decision. During a review of Resident 54's MDS, the MDS indicated Resident 54 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for oral hygiene, toileting, showering, upper and lower body dressing, personal hygiene, rolling left and right, sit to lying, and laying to sitting on side of bed. The MDS indicated Resident 54 had a feeding tube while not a resident of the facility and within the last seven days. During a review of Resident 54's Order Summary, dated 11/6/2024, the Order Summary indicated elevate head of bed 30 to 45 degrees during enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) and one hour after enteral feeding. During a concurrent observation and interview on 12/16/2024 at 2:27 PM with Licensed Vocational Nurse 4 (LVN 4) in Resident 54's room, Resident 54's tube feeding was observed to be infusing. LVN 4 stated, Resident's (Resident 54) head of bed seemed to be elevated at 20 degrees, but definitely not at the minimum 30 degrees as ordered by physician. The LVN 4 stated Resident 54 was at risk for aspiration, especially because Resident 54 required assistance from staff to turn. During an interview on 12/18/2024 at 9:26 AM with the Director of Nursing (DON), the DON stated it is important to follow physician's orders to elevate the HOB during tube feedings to prevent aspiration, and the best practice for positioning a resident receiving a feeding infusion is about 40 to 45 degrees of head elevation. During a review of the facility's policy titled, Enteral Feedings- Safety Precautions, dated 11/2024, the policy indicated to elevate the head of the bed at least 30 degrees during tube feeding and at least one hour after feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 34), received Apixaban (medication to prevent blood clots) as indicated on the physician's order. This deficient practice had the potential to cause Resident 34 serious problems such as heart attack (a condition when blood flow to the heart muscle is suddenly blocked), deep vein thrombosis (DVT- a condition where a blood clot forms in a deep vein, usually in the legs, leading to serious complications), pulmonary embolism (a condition where a blood clot travels to and blocks an artery in the lungs), and stroke. Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnosis of atrial fibrillation (A-fib, an abnormal heart rhythm characterized by rapid and irregular beating) and history of myocardial infarction (MI-a condition when blood flow to the heart muscle is suddenly blocked). During a review of Resident 34's History and Physical (H&P- a term used to describe a physician's examination of a resident), dated 9/11/2024, the H&P indicated Resident 34 had the capacity to understand and make decisions. During a review of Resident 34's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2024, the MDS indicated Resident 34 required partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 34 required maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for lower body dressing. The MDS indicated Resident 34 had an active diagnosis of atrial fibrillation or other dysrhythmias (irregular heartbeats), heart failure (a condition that occurs when the heart can't pump enough blood and oxygen to the body's organs), coronary artery disease (a condition where the arteries that supply blood to the heart muscle become narrowed or blocked), and hypertension (chronic changes in the left heart ventricle and atrium, and coronary arteries as a result of chronic raised blood pressure). The MDS indicated Resident 34 was taking and required use of an anticoagulant (medication used to decrease the body's ability to form blood clots). During a review of Resident 34's Order Summary, dated 10/8/2024, the Order Summary indicated give Apixaban five (5) milligram (mg- metric unit of measurement, used for medication dosage and/or amount) one tablet by mouth every 12 hours for A-fib blood clot prevention. During an interview on 12/16/2024 at 12:01 PM with Resident 34, in Resident 34's room, Resident 34 stated, she did not receive her Apixaban medication last week because the facility did not have it in stock. Resident 34 stated she was very concerned about not getting her medication because she had A-fib and needs to take it every day to treat her heart medical conditions. Resident 34 stated she had spoken to the Administrator verbalizing her concerns. During a concurrent interview and record review on 12/17/2024 at 4:11 PM with Licensed Vocational Nurse 3 (LVN 3), of Resident 34's Medical Administration Record (MAR), LVN 3 stated that on 12/6/2024, 12/7/2024, 12/8/2024, 12/9/2024, and 12/10/2024, Resident 34 did not receive her Apixaban medication due to awaiting delivery from pharmacy. LVN 3 stated there was no documentation indicating the facility physician was notified regarding the lack of Apixaban. LVN 3 stated Resident 34 was at high risk for developing blood clots, heart attack, pulmonary embolism, and DVT due to her A-fib and heart conditions, and not taking Apixaban increased the risk of Resident 34 to develop blood clots. LVN 3 stated the licensed nurses should have notified the physician immediately to find an alternate medication for Resident 34. During an interview on 12/17/2024 at 4:31 PM with the Director of Nursing (DON), the DON verified that Resident 34 did not receive Apixaban on the mentioned 5 days. The DON stated the licensed nurses should have notified the physician immediately to find an alternative medication to treat Resident 34's diagnosis since omitting Apixaban could result in Resident 34 getting a heart attack, MI, and stroke. The DON stated it is important that residents receive their prescribed medication to keep them in stable condition, and this incident should have been prevented by ensuring Apixaban was in stock at the facility at all times. During a review of the facility's policy titled, Pharmacy Services, dated 4/2022, the policy indicated residents have sufficient supply of their prescribed medications and receive medications in a timely manner. In collaboration with the dispensing pharmacy and the facility, the consulting pharmacist oversees the development of procedures for acquisition and availability of medications. The policy indicated pharmaceutical services consist of the process of identifying, evaluating, and addressing medication-related issues including the prevention and reporting of medication errors. During a review of the facility's policy titled, Administering Medications, dated 4/2019, the policy indicated medication errors are documented, reported, and reviewed by the facility staff to inform process changes and or the need for additional staff training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician addressed the medication regimen review (MRR/Drug Regimen Review - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) on 6/10/2024 to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (a medication used to treat psychosis) or document a clinical rationale as to why an attempt would be contraindicated for one of five sampled residents (Resident 52). The deficient practice increased the risk for Resident 52 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Seroquel therapy possibly leading to impairment or decline in the resident's mental, physical, and /or psychosocial status. Findings: During a review of Resident 52's admission Record (a document containing diagnostic and demographic information), dated 12/18/0224, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and psychosis (a mental disorder characterized by a disconnection from reality). During a review of Resident 52's Minimum Data Set (MDS- a standardized resident assessment tool), dated 11/8/2024, the MDS indicated Resident 52 was taking an antipsychotic in the last seven days or since admission on a routine basis, and a GDR had not been attempted, and a GDR had not been documented by a physician as clinically contraindicated. The MDS indicated Resident 52 did not have any potential indicators of psychosis. Resident 52 did not have mood or behavioral symptoms. The MDS indicated Resident 52 had severe cognitive skills (a condition that makes it difficult for a person to remember, learn, concentrate, or make decisions that affect their daily life) for daily decision making. The MDS indicated Resident 52 required partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) from staff for upper and lower body dressing, personal hygiene, putting on footwear, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and transfer from chair to bed. The MDS indicated Resident 52 required maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting and showering. During a review of Resident 52's Order Summary Report (a summary of all currently active physician orders), dated 3/28/2024, the Order Summary Report indicated Seroquel 25 milligrams (mg - a unit of measure for mass) by mouth at bedtime for psychosis manifested by responding to internal stimuli thinking she works in the facility. During a review of the consultant pharmacist's recommendation, dated 6/10/2024, the pharmacist's recommendation indicated a note to the attending physician to consider if a dose change for Resident 52's Seroquel 25 mg was warranted at this time due to psychoactive medications must undergo a psychotropic drug regimen review with evaluation for dose reduction every six months for the first year and annually thereafter. During a review of Resident 52's clinical record, there was no documentation found indicating the physician responded to the consultant pharmacist's request to consider a GDR for Seroquel or any other indication the dose of Seroquel had changed since 3/8/2024. During a concurrent interview and record review of Resident 52's Psychotropic (relating to or denoting drugs that affect a person's mental state) Summary Sheet (a monitoring log of behavioral episodes of residents who are on psychotropic medication) on 12/17/2024 at 12:21 AM with the Assistant Director of Nursing (ADON), the ADON verified that the Psychotropic Summary Sheet indicated Resident 52 had zero episodes of psychosis for the months of March, April, May, June, July, August, and September 2024. During an interview on 12/19/2024 at 10:46 AM, with the ADON, the ADON stated the facility failed to ensure the physician responded to the consultant pharmacist's request to decrease the dose of Seroquel for Resident 52. The ADON stated there is no record of a specific response to the pharmacist's request or any other record that addresses the dosage of Seroquel specifically and the resident has been on the same dose since March of 2024. The ADON stated the physician should have responded to the pharmacist's recommendations within one to two days from the pharmacist's written report. The ADON stated the facility failed to decrease the dose or document a resident-specific reason why a dosage reduction would be contraindicated. The ADON stated the failure to consider a GDR or respond to the pharmacist's request for GDR increased the risk that Resident 52 may experience adverse effects of Seroquel, such as tardive dyskinesia (a condition affecting the nervous system, such as uncontrollable jerky movements of the face and body often caused by long-term use of some psychiatric drugs), cognitive impairment, tremors, drooling, rigidity, due to using a higher dose than necessary which could have negatively impacted her quality of life. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review, revised May 2019, the P&P indicated copies of medication regimen review reports, note to attending physicians including physician responses are maintained as part of the permanent medical record, and medication regimen reviews are done upon admission and at least monthly thereafter, or more frequently if indicated. During a review of the facility's P&P titled, Tapering Medication and Gradual Drug Dose Reduction , revised April 2024, the policy indicated, The physician will review periodically whether current medication are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medication, or with a lower dose . The physician will order appropriate tapering of medication, as indicated . The policy indicated the staff and practitioner will consider tapering under certain circumstances, including when the resident's clinical condition has improved or stabilized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (a medication used to treat psychosis) or document a clinical rationale as to why an attempt would be contraindicated for one of five sampled residents (Resident 52.) The deficient practice increased the risk for Resident 52 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Seroquel therapy possibly leading to impairment or decline in the resident's mental, physical, and /or psychosocial status. Findings: During a review of Resident 52's admission Record (a document containing diagnostic and demographic information), dated 12/18/0224, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and psychosis (a mental disorder characterized by a disconnection from reality). During a review of Resident 52's Minimum Data Set (MDS- a standardized resident assessment tool), dated 11/8/2024, the MDS indicated Resident 52 was taking an antipsychotic in the last seven days or since admission on a routine basis, and a GDR had not been attempted, and a GDR had not been documented by a physician as clinically contraindicated. The MDS indicated Resident 52 did not have any potential indicators of psychosis. Resident 52 did not have mood or behavioral symptoms. The MDS indicated Resident 52 had severe cognitive skills (a condition that makes it difficult for a person to remember, learn, concentrate, or make decisions that affect their daily life) for daily decision making. The MDS indicated Resident 52 required partial assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs, but provides less than half the effort) from staff for upper and lower body dressing, personal hygiene, putting on footwear, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and transfer from chair to bed. The MDS indicated Resident 52 required maximal assistance (helper does more than half the effort to lift or hold trunk or limbs and provides more than half the effort) for toileting and showering. During a concurrent interview and record review of Resident 52's Psychotropic (relating to or denoting drugs that affect a person's mental state) Summary Sheet (a monitoring log of behavioral episodes of residents who are on psychotropic medication) on 12/17/2024 at 12:21 AM with the Assistant Director of Nursing (ADON), the ADON verified that the Psychotropic Summary Sheet indicated Resident 52 had zero episodes of psychosis for the months of March, April, May, June, July, August, and September 2024. During a review of Resident 52's Order Summary Report (a summary of all currently active physician orders), dated 3/28/2024, the Order Summary Report indicated Seroquel 25 milligrams (mg - a unit of measure for mass) by mouth at bedtime for psychosis manifested by responding to internal stimuli thinking she works in the facility. During a review of the consultant pharmacist's recommendation, dated 6/10/2024, the pharmacist's recommendation indicated a note to the attending physician to consider if a dose change for Resident 52's Seroquel 25 mg was warranted at this time due to psychoactive medications must undergo a psychotropic drug regimen review with evaluation for dose reduction every six months for the first year and annually thereafter. During a review of Resident 52's clinical record, there was no documentation found indicating the physician responded to the consultant pharmacist's request to consider a GDR for Seroquel or any other indication the dose of Seroquel had changed since 3/8/2024. During an interview on 12/19/2024 at 10:46 AM, with the ADON, the ADON stated the facility failed to ensure the physician responded to the consultant pharmacist's request to decrease the dose of Seroquel for Resident 52. The ADON stated there is no record of a specific response to the pharmacist's request or any other record that addresses the dosage of Seroquel. The ADON stated Resident 52 has been on the same dose since March of 2024. The ADON stated the facility failed to decrease Resident 52's Seroquel dose or document a resident-specific reason/s why a dosage reduction would be contraindicated. The ADON stated the failure to consider a GDR or respond to the pharmacist's request for GDR increased the risk that Resident 52 may experience adverse effects of Seroquel, such as tardive dyskinesia (a condition affecting the nervous system, such as uncontrollable jerky movements of the face and body often caused by long-term use of some psychiatric drugs), cognitive impairment, tremors, drooling, rigidity, due to using a higher dose than necessary which could have negatively impacted her quality of life. During a review of the facility's policy and procedure (P&P) titled, Tapering Medication and Gradual Drug Dose Reduction , revised April 2024, the policy indicated, The physician will review periodically whether current medication are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medication, or with a lower dose . The physician will order appropriate tapering of medication, as indicated . The policy indicated the staff and practitioner will consider tapering under certain circumstances, including when the resident's clinical condition has improved or stabilized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 273's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (a sudden loss of kidney function that occurs over a short period of time), and sepsis (a life-threatening blood infection). During a review of Resident 273's History and Physical (H&P), dated 12/14/2024, the H&P indicated Resident 273 had the capacity to understand and make decisions. During a review of Resident 273's Order Summary Report, dated 12/12/2024, the Order Summary Report indicated Resident 273 had an order for indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine). During a concurrent observation and interview on 12/16/2024 at 1:43 PM with Registered Nurse 1 (RN 1), Resident 273's indwelling catheter collection bag was observed touching the floor. RN 1 stated, The indwelling catheter collection bag is touching the floor. It shouldn't be touching the floor because it puts the resident at risk of getting an infection. During a concurrent interview and record review on 12/18/2024 at 11:56 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Catheter Care, Urinary dated 9/2014 was reviewed. The P&P indicated: 1. The purpose of this P&P is to prevent catheter associated urinary tract infections (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder, ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]). 2. Infection Control: be sure the catheter tubing and drainage bag are kept off the floor. DON stated that an indwelling catheter touching the floor can cause an infection to the resident and it should not be touching the floor. Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and /or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure for two of 14 sampled residents (Residents 126 and 273) in accordance with the facility policy by failing to ensure: 1. Resident 126's used urinal with urine was not placed next to the uncovered cup of water and a cup of oatmeal on the resident's bedside table. 2. Resident 273's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not touching the floor. This deficient practice placed the Resident 126 at risk for potential infection. Findings: 1. During a review of Resident 126's admission Record, the admission Record indicated Resident 126 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood) and hypertensive (high blood pressure) heart disease without heart failure. During a review of Resident 126's History and Physical Examination (H&P), dated 12/16/2024, the H&P indicated Resident 126 had the capacity to understand and make decisions. During an observation in Resident 126's room and interview on 12/16/2024 at 10:12 AM, Resident 126's used urinal with urine was observed next to an open/uncovered cup of water and an open/ uncovered cup of oatmeal on the bedside table. Resident 126 stated he asked the Certified Nurse Assistant (CNA) to empty the urinal around 9 AM. During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 12/16/2024 at 12:03 PM, LVN 2 stated Resident 126's urinal should have been emptied and not left by the resident's food. During an interview with Director of Nursing on 12/16/2024 at 12:02 PM, the DON stated the urinal should not be placed next to the resident's food. The DON stated staff should dedicate an area like the siderail (are adjustable metal or rigid plastic bars that attach to the bed ) that is within easy reach of the urinal but away from food. The DON also stated it was important to keep the urinal away from food to maintain hygiene and prevent potential contamination. During a review of facility's policy and procedure (P&P) titled, Infection Prevention Quality Control Plan, revised October 2023, the P&P indicated the facility shall provide guidelines for general infection control while caring for residents. Standard Precaution would be used in the care of all residents in all situations. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether they contain visible blood, non-intact skin, and/or mucous membranes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted on [DATE] with diagnoses including cerebrovascular disease (a condition that affects blood flow to the brain), dysphagia (difficulty swallowing), muscle weakness, Parkinson's disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements), type 2 diabetes (a disorder characterized by difficulty in blood sugar control), anxiety disorder (a mental health condition that causes excessive and uncontrollable feelings of fear and anxiety), quadriplegia (paralysis from the neck down, including legs and arms), abnormalities of gait and mobility, and chronic kidney disease. During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 10/18/2024, the MDS indicated Resident 11 had intact cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated Resident 11 needed supervision or touching assistance (a helper provides verbal sues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating. Resident 11 required partial assistance (help less than half the effort) with oral hygiene and maximal assistance (help more than half the effort) with upper body dressing and personal hygiene. During a review of Resident 11's Care Plan, initiated on 7/19/2024, the Care Plan indicated Resident 11 had limited physical mobility related to Parkinson's disease. The Care Plan indicated the facility needs to provide supervision assistance for Resident 11 during eating. During a concurrent observation and interview on 12/16/2024 at 12:43 PM in the dining room, Resident 11 was using her dominant (right) hand, which was trembling when observed scooping her food with a spoon. Resident 11 had clumps of cherry pie on her chest and on the table. There was no staff assisting Resident 11 with eating. Resident 11 stated she needed a little help with eating the cherry pie. During a concurrent observation and interview on 12/16/2024 at 12:55 PM with Restorative Nursing Assistant 1 (RNA 1) in the dining room, RNA 1 stated that Resident 11 had difficulty to hold the spoon, scoop the food out of the plate, and need help with eating. RNA 1 stated the facility should provide assistance to Resident 11 with eating. Resident 11 was observed with food crumbs on her shirt, by the chest area. RNA 1 stated food crumbs left on Resident 11's clothes will make her feel lose her dignity and could discourage Resident 11 from eating. During a review of the facility's policy titled, Dignity, dated February 2021, the policy indicated demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents, for example help the resident to keep urinary catheter bags covered. Based on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 222 and 11) were treated with respect and dignity in accordance with the facility policy by failing to ensure: 1. Resident 222 had a dignity bag (urine drainage bag holder to prevent public view) over the resident's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine). 2.Resident 11 did not have any food crumbs (small pieces of food that have broken off from a larger piece) on the resident's shirt on 12/16/2024. These deficient practices have the potential to negatively affect Residents 222 and 11's self-worth, self-esteem, and psychosocial well-being. Findings: 1. During a review of Resident 222's admission Record, the admission Record indicated Resident 222 was admitted to the facility on [DATE] with diagnosis of pneumonia (an infection that affects one or both lungs and causes them to fill up with fluid or pus), chronic obstructive pulmonary disease (COPD- lung disease causing restricted airflow and breathing problems), and neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem). During a review of Resident 222's History and Physical, dated 12/5/2024, the H&P indicated Resident 222 had the capacity to understand and make decisions. During a review of Resident 222's Order Summary, dated 12/6/2024, the Order Summary indicated an indwelling catheter was to be placed to prevent movement and urethral traction (a medical procedure where a catheter is inserted into the urethra and then gently pulled on to apply pressure on the bladder neck) for neurogenic bladder, and to change urinary drainage bag as needed. During an interview on 12/16/2024 at 10:09 AM with Resident 222, in Resident 222's room, Resident 222 stated seeing the drains from his body such as his feeding tube, and seeing his urine made him feel weak. Resident 222 stated he would prefer not to see his drains. During a concurrent observation and interview on 12/16/2024 at 10:11 AM with Certified Nursing Assistant 4 (CNA 4), in Resident 222's room, CNA 4 stated Resident 222 had a full bag of urine in his catheter bag and needed to be drained. CNA 4 stated the catheter bag did not have a dignity bag to cover the yellow urine to prevent Resident 222 and others from seeing it. CNA 4 stated it was important to use a dignity bag to cover the sight of urine to promote respect and dignity for residents, and to follow facility policy. During an interview on 12/18/2024 at 9:05 AM with the Director of Nursing (DON), the DON stated the facility's policy regarding dignity bags was to keep urinary catheter bags covered to promote dignity for residents, since urine is a waste product from the human body, and it is not pleasant to see.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two residents (Resident 70 and Resident 71) reviewed for closed records had a discharge care plan. This failure had the potential to result in Resident 70 and Resident 71 increasing their risk of preventable readmissions due to not focusing on their discharge plan and goals, not actively preparing and effectively transitioning to post discharge care. Findings: 1. During a review of Resident 70's admission Record, the admission Record indicated that the facility admitted Resident 70 on 8/22/2024 with diagnoses including type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), muscle weakness, abnormalities of gait and mobility, depression, hypertensive (high blood pressure) heart disease, atrial fibrillation (an irregular and often very rapid heart rhythm), congestive heart failure (a heart disorder causes the heart to not pump the blood efficiently), dysphagia (difficulty swallowing), and cognitive communication deficit. During a review of Resident 70's Minimum Data Set (MDS- a resident assessment tool), dated 8/29/2024, the MDS indicated Resident 70 had moderately impaired cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. The MDS indicated Resident 70 required partial physical assistance from staff to complete activities of daily living. During a review of Resident 70's Physician Order dated 10/19/2024, the Physician Order indicated Resident 70 could be discharge home on [DATE] under home health for physical therapy, occupational therapy, and nursing. 2. During a review of Resident 71's admission Record, the admission Record indicated that the facility admitted Resident 71 on 8/29/2024 with diagnoses including fracture of lower end of left ulna and radius (broken bone above the wrist on left hand), muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, anemia (the body does not have enough healthy red blood cells), dementia (a progress state of decline in mental abilities), disorders of right acoustic [NAME] (could cause the hearing and balance problem), osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), dysphagia, and history of falling. During a review of Resident 71's MDS dated [DATE], the MDS indicated Resident 71 had moderately impaired cognitive skills for daily decision making and required assistance from staff to complete activities of daily living. During a review of Resident 71's Physician Order dated 9/20/2024, the Physician Order indicated Resident 71 was to be discharged home on 9/24/2024 with home health for physical therapy, occupational therapy, nursing (registered nurse), and home health aide. During a concurrent interview and record review on 12/18/2024 at 10:28 AM with the Social Service Director (SSD), Resident 70's care plan, revised on 11/19/2024 and Resident 71's care plan, revised on 10/17/2024 were reviewed. There was no discharge care plan for Resident 70 and Resident 71. The SSD stated she was responsible for developing the discharge care plan and she had not made a discharge care plan for Resident 70 and Resident 71. The SSD stated she should develop a care plan of discharge, so the resident would know their goals and meet their needs after discharge. During an interview on 12/19/2024 at 9:40 AM with the Director of Nursing (DON), the DON stated it was important to have care plans for discharge, so the facility can let the resident know the goals for discharge and help the resident meet their needs to avoid preventable readmission. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, revised 12/2016, the P&P indicated, Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. and The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 122 and Resident 22) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) treatment received communication records from the hemodialysis center when the residents returned to the facility. This failure had the potential to result in Resident 122 and Resident 22's health status not being communicated in a timely manner and not receiving appropriate post dialysis care. Findings: 1. During a review of Resident 122's admission Record, the admission Record indicated the facility admitted Resident 122 on 12/3/2024 with diagnoses including chronic kidney disease (a progressive damage and loss of function in the kidneys), hyperkalemia (high potassium levels in blood), thrombocytopenia (low platelet count in blood), hypo-osmolality (levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia (low sodium levels in blood), end stage renal disease (ESRD-irreversible kidney failure), and dependence on renal (kidney) dialysis. During a review of Resident 122's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 12/4/2024, the H&P indicated, Resident 122 had the capacity to understand and make decisions. During a review of Resident 122's Minimum Data Set (MDS- a resident assessment tool), dated 12/7/2024, the MDS indicated Resident 122 had moderately impaired cognitive (ability to remember things, solve problems, or make decisions) skills for daily decision making. During a concurrent interview and record review on 12/17/2024 at 9:42 AM with the Director of Nursing (DON), Resident 122's Physician Order, dated 12/16/2024 was reviewed. The Physician Order indicated that Resident need to attend dialysis on Mondays, Wednesdays, and Fridays. The DON stated Resident 122 needed to go to dialysis on Mondays, Wednesdays, and Fridays which were 12/4/2024, 12/6/2024, 12/9/2024, 12/11/2024, 12/13/2024, and 12/16/2024. During a concurrent interview and record review on 12/17/2024 at 9:40 AM with the DON, Resident 122's Communication Record for Dialysis Residents (CRDR) were reviewed. The CRDR indicated there were no CRDR forms for dates 12/4/2024, 12/6/2024, 12/9/2024, 12/11/2024, and 12/16/2024. The DON stated there was no documentation in the CRDR indicating Resident 122 received the dialysis on 12/4/2024, 12/6/2024, 12/9/2024, 12/11/2024, and 12/16/2024. 2. During a review of Resident 22's admission Record, the admission Record indicated the facility admitted Resident 22 on 12/21/2021 with diagnoses including dependence on renal dialysis, chronic kidney disease, hyperosmolality and hypernatremia (high amount sodium in the blood). During a review of Resident 22's MDS, dated [DATE], the MDS indicated Resident 22 had moderately impaired cognitive skills for daily decision making. During a concurrent interview and record review on 12/18/2024 at 11:40 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 22's CRDR and Resident 22's Physician order, dated 12/29/2023 were reviewed. The CRDR indicated there were no CRDR forms for dates 11/6/2024 and 11/13/2024. The Physician order indicated Resident 22 needed to go to dialysis every Mondays, Wednesdays, and Fridays. LVN 2 stated there was no documentation in the CRDR indicating Resident 22 went to dialysis on 11/6/2024 and 11/13/2024, which were Wednesdays. LVN 2 stated resident should have the CRDR for every time when resident went to dialysis to communicate resident's condition and monitor side effects and complication from dialysis. During an interview on 12/19/2024 at 9:40 AM with the DON, the DON stated it was important to have communication forms for dialysis, in order for the facility staff to check and record any new orders, new medication, document post dialysis vital signs, and complications post dialysis. During a review of the facility's policy and procedure (P&P) titled, Long Term Care Facility Outpatient Dialysis Services Coordination Agreement, dated 12/2024, the P&P indicated the facility should ensure that there was documented evidence of collaboration of care and communication between the facility and the ESRD Dialysis Unit and maintain a copy. During a review of the facility's P&P titled, Hemodialysis Access Care, revised 9/2010, the P&P indicated the facility nurse should document any part of report from dialysis nurse after dialysis being given.

Based on observation, interview, and record review, the facility failed to ensure dry food items that had been removed from their original packaging were labeled with use by date, and refrigerated foods that had expired were discarded. This deficient practice resulted in exposing residents to expired food items, affecting the quality, taste, and texture of food, and potentially harming residents if they consumed expired food. Findings: During a concurrent observation in the facility's kitchen and interview on 12/16/2024 at 8:16 AM with the Dietary Supervisor (DS), the DS picked up a package of assorted sugar free beverage crystals and stated the package was not labeled with a use by date to indicate when the product expired/ will expire. The DS added, It was no longer good for human consumption. The DS stated the package had been taken out of its original packaging and should have been labeled with use by date by the person who removed it from the original package. The DS stated it was important to label the food with use by date to ensure it was safe for human consumption and expired items are discarded. The DS stated there are two staff in the kitchen responsible for labeling packages with a delivery date, open date, and expiration or use by date, and discarding expired food items twice a week, on Tuesdays and Thursdays. During a concurrent observation in the facility's dry food storage kitchen and interview on 12/16/2024 at 8:27 AM with the DS, a loaf of bread whole grain bread with expiration date of 12/14/2024. The DS stated the bread should have been discarded since it was past the expiration/ use by date, and if residents consumed it, it could cause gastrointestinal issues for residents or change the texture of the bread by making it stale. During a concurrent observation in the facility's dry storage room and interview on 12/16/2024 at 8:39 AM with the DS, the DS stated two jars of pear honey and ginger jelly were stored in the dry storage room without a label of use by date or expiration date. During a concurrent observation in the facility's kitchen and interview on 12/16/2024 at 8:45 AM with the DS, the DS stated there was a box of frozen bread in the freezer with a delivery date of 9/5/2024 and a use by date of 11/25/2024. DS stated the expired bread should not be in the refrigerator and should have been discarded to prevent anyone from eating expired bread. During a concurrent observation in the facility 's kitchen and interview on 12/16/2024 at 9:12 AM with the DS, DS stated the freezer contained a box of frozen crab cakes containing blue crab did not have a label with a use by date and did the DS does not know if the item was safe for human consumption. DS stated, the DS would need to call the company to obtain a use by date for the crab cakes. DS also stated she did not have this particular item listed on their kitchen food item guidelines to indicate how long the food was safe for consumption. During a review of the facility's policy titled, Food Receiving and Storage, dated November 2022, the policy indicated dry foods that are stored in bins are removed from original packaging, labeled, and dated with use by date. All foods stored in the refrigerator or freezer are covered, labeled, and dated with use by date, are monitored so they are used by their use by date or discarded.

Based on observation, interview, and record review, the facility failed to ensure garbage was disposed properly for one of two dumpsters as indicated on the facility policy. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. Findings, During a concurrent observation and interview on 12/17/2024 at 1:19 PM with Infection Prevention Nurse (IPN), there were two dumpsters in a corner outside the facility by the facility parking lot. One dumpster was observed not covered and another dumpster was not covered and was overflowing with garbage. IPN stated both dumpsters needed to be covered because the garbage could harbor pests. IPN stated it could cause the spread of infection and affect staff and the residents. During an interview on 12/18/2024 at 2:18 PM with the Administrator (ADM), ADM stated keeping the garbage area clean is the responsibility of the maintenance staff and kitchen staff. ADM stated dumpsters' cover should be kept closed and it should not be filled with garbage above the full line. ADM stated this had the potential for pest and other insects' infestation, which could affect the residents and staff's health. During a review of the facility's policies and procedures (P&P) titled, Food-Related Garbage and Refuse Disposal, revised date October 2017, indicated), the P&P indicated all garbage and refuse containers (moveable container for storing and disposing of waste such as garbage) are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. It also indicated garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement their policy and procedure for norovirus (also often called food poisoning. It is the most common cause of diarrhea [watery stool] and vomiting [throwing up]) prevention and control for three of three sampled residents (Resident 1, 2 and 3) when facility did not cohort (a group of people with a shared characteristic) their staff assignment after they received a positive norovirus result for Resident 1 on 10/27/2024. This deficient practice placed all the other residents in the facility, facility staff and visitors at risk for contacting (exposure to contagious disease) norovirus. Findings: 1. During a review of Resident 1's admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems), sepsis (a life-threatening blood infection). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/6/2024, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more the half the effort) with oral hygiene, toileting hygiene, and personal hygiene. The MDS also indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with eating, shower/bath, upper and lower body dressing, and putting on/taking off footwear. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents), dated 10/26/2024, entered at 5:08 AM, indicated the resident is exhibiting the following symptoms: Diarrhea: 3 or more liquid or watery stools above what is normal for the resident within a 24-hour period. Vomiting: 2 or more episodes in a 24-hour period. Abdominal pain Nausea (a feeling of discomfort or sickness in the stomach that can make you feel like you need to vomit) During a review of Resident 1's SBAR, dated 10/27/2024, entered at 5:39 PM, indicated nurse received laboratory reports from General Acute Care Hospital (GACH) indicating Resident 1 was positive for Norwalk agent (norovirus). During a review of Resident 1's laboratory results from GACH, dated 10/27/2024, timed 3:08 PM, indicated a detected result for norovirus. 2. During a review of Resident 2's admission Record, indicated Resident 2 was originally admitted to the facility on [DATE]. Resident 2's diagnoses included acute gastritis (occurs when the lining of your stomach is damaged or weak), dysphagia (difficulty swallowing), and muscle weakness. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 2 required setup or clean up assistance (helper sets ups or cleans up, resident completes activity) with eating, oral hygiene, and upper body dressing. The MDS indicated Resident 2 required supervision (helper provides verbal cues and/or touching as resident completes activity) with lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bath. During a review of Resident 2's SBAR, dated 10/26/2024, entered at 12:37 PM, indicated Resident 2 is exhibiting nausea and vomiting. 3. During a review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE]. Resident 3's diagnoses included muscle weakness, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and protein calorie malnutrition (PCM, is the state of inadequate intake of food.) During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 required supervision with eating. The MDS indicated Resident 3 required partial/moderate assistance with oral hygiene. The MDS indicated Resident 3 required substantial/maximal assistance with upper body dressing. The MDS indicated Resident 3 was dependent with toileting hygiene, shower/bath, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 3's SBAR, dated 10/27/2024, entered at 3:11 AM, indicated Resident 3 is exhibiting 2 or more episodes of vomiting in a 24-hour period. During a review of Certified Nurse Assistant (CNA) assignment form, dated 10/27/2024 for evening shift (3 PM to 11 PM shift), indicated CNA 1 was assigned the following rooms: Room M (asymptomatic [no symptoms of norovirus]) Room N (suspected with norovirus) Room O (asymptomatic) Room P (asymptomatic) Room Q (asymptomatic) The form indicated indicated CNA 2 was assigned the following rooms: Room D (asymptomatic) Room E (asymptomatic) Room A (confirmed norovirus) Room F (suspected with norovirus) Room B (suspected with norovirus) Room G (asymptomatic) Room H (asymptomatic) The form indicated CNA 3 was assigned the following rooms: Room I (asymptomatic) Room J (asymptomatic) Room K (asymptomatic) Room C (suspected with norovirus) Room L (asymptomatic) During a review of CNA assignment form, dated 10/27/2024 for night shift (11 PM to 7 AM shift), indicated CNA 4 was assigned the following rooms: Room M (asymptomatic) Room N (suspected with norovirus) Room O (asymptomatic) Room P (asymptomatic) Room E (asymptomatic) The form indicated CNA 5 was assigned the following rooms: Room Q (asymptomatic) Room D (asymptomatic) Room A (confirmed norovirus) Room F (suspected with norovirus) Room B (suspected with norovirus) Room R (asymptomatic) The form indicated CNA 6 was assigned the following rooms: Room K (asymptomatic) Room S (asymptomatic) Room C (suspected with norovirus) Room T (asymptomatic) During a review of CNA assignment form, dated 10/28/2024 for morning shift (7 AM to 3 PM shift), indicated CNA 7 was assigned the following rooms: o Room M (asymptomatic) o Room N (suspected with norovirus) o Room O (asymptomatic) o Room P (asymptomatic) o Room Q (asymptomatic) The form indicated CNA 8 was assigned the following rooms: Room Q (asymptomatic) Room D (asymptomatic) Room E (asymptomatic) Room A (confirmed norovirus) Room F (suspected with norovirus) Room R (asymptomatic) Room B (suspected with norovirus) The form indicated CNA 9 was assigned the following rooms: Room K (asymptomatic) Room C (suspected with norovirus) Room L (asymptomatic) Room T (asymptomatic) Room U (asymptomatic) During a review of CNA assignment form, dated 10/28/2024 for evening shift, indicated CNA 1 was assigned the following rooms: o Room M (suspected with norovirus) o Room N (suspected with norovirus) o Room O (asymptomatic) o Room P (asymptomatic) o Room Q (asymptomatic) The form indicated CNA 10 was assigned the following rooms: Room D (asymptomatic) Room E (asymptomatic) Room A (confirmed norovirus) Room F (suspected with norovirus) Room B (suspected with norovirus) Room G (asymptomatic) Room H (asymptomatic) Room V (asymptomatic) The form indicated CNA 11 was assigned the following rooms: Room C (suspected with norovirus) Room L (asymptomatic) Room T (asymptomatic) Room U (asymptomatic) Room X (asymptomatic) Room Y (asymptomatic) Room Z (asymptomatic) During a review of CNA assignment form, dated 10/28/2024 for night shift, indicated CNA 12 was assigned the following rooms: o Room M (suspected with norovirus) o Room N (suspected with norovirus) o Room O (asymptomatic) o Room P (asymptomatic) o Room Q (asymptomatic) The form indicated CNA 13 was assigned the following rooms: o Room D (asymptomatic) o Room E (asymptomatic) o Room A (confirmed norovirus) o Room F (suspected with norovirus) o Room R (asymptomatic) o Room B (suspected with norovirus) o Room G (asymptomatic) o Room H (asymptomatic) o Room W (asymptomatic) The form indicated CNA 14 was assigned the following rooms: o Room C (suspected with norovirus) o Room L (asymptomatic) o Room T (asymptomatic) o Room U (asymptomatic) o Room X (asymptomatic) o Room Y (asymptomatic) o Room Z (asymptomatic) During a review of CNA assignment form, dated 10/29/2024 for morning shift, indicated CNA 7 was assigned the following rooms: o Room M (suspected with norovirus) o Room H (asymptomatic) o Room O (asymptomatic) o Room P (asymptomatic) o Room Q (asymptomatic) The form indicated CNA 8 was assigned the following rooms: o Room N (asymptomatic) o Room D (asymptomatic) o Room E (asymptomatic) o Room A (confirmed norovirus) o Room F (suspected with norovirus) o Room R (asymptomatic) o Room B (suspected with norovirus) o Room V (asymptomatic) The form indicated CNA 15 was assigned the following rooms: o Room C (suspected with norovirus) o Room ZZZ (asymptomatic) o Room J (asymptomatic) o Room K (asymptomatic) o Room L (asymptomatic) During a concurrent record review of Resident 1's medical records on 10/29/2024 at 10 AM and interview with Infection Preventionist (IP), the IP stated facility received the positive norovirus result from GACH on 10/27/2024 evening shift. IP stated Registered Nurse (RN ) who was working that day informed her through telephone and gave RN instructions to place Resident 1 on contact isolation (staff members wear gloves and aprons when they come into contact with you), notify Doctor and family. IP verified she did not give instructions to designate a separate staff to take care Resident 1 who was tested positive for norovirus and to other residents with the same symptoms of vomiting and diarrhea and to ensure they are not assigned to asymptomatic residents. During a concurrent record review of Facility's Policy and Procedure (P&P), titled Norovirus Prevention and Control, revised on 10/2011, and interview with IP on 10/29/2024 at 10:30 AM, indicated in the event of an outbreak of norovirus gastroenteritis, staff will care for one resident cohort on their unit and will not move between resident cohorts (resident cohorts may include symptomatic, asymptomatic, exposed, or asymptomatic unexposed resident groups). IP stated facility should have changed the CNA assignment on 10/27/2024 evening shift when facility received Resident 1's positive result of norovirus. IP stated there should have been one CNA assigned to Resident 1 who was tested positive for norovirus and other residents with the same symptoms of vomiting and diarrhea. IP stated that staff taking care of mix cohorts (both with norovirus, symptomatic residents, and asymptomatic residents) has high potential of spreading the virus through direct contact resident care. During a concurrent record review of CNA assignments dated from 10/27/2024 to 10/29/2024 with Director of Staff Development (DSD) on 10/30/2024 at 1:40 PM, DSD verified Resident 1 who is in Room A, did not have a designated staff assigned to the resident and to other residents with similar symptoms of vomiting and diarrhea. DSD stated residents who were not having symptoms had high risk of contacting the norovirus because CNA assigned to Resident 1 had mixed cohorts and was assigned to take care of asymptomatic residents at the same time. DSD added not cohorting CNA assignments is not a good thing to other asymptomatic residents because they are exposed to the virus. During an interview on 10/30/2024 at 3:25 PM with RN, she verified that she did not receive instructions to cohort licensed nurse and CNA assigned to Resident 1 and other residents with the same symptoms of norovirus on 10/27/2024 from IP. RN stated she should have changed the CNA assignment that shift, to assign one (1) CNA to Resident 1 and to other suspected residents (residents with the same signs and symptoms) to avoid contamination and spread of infection to other residents that are asymptomatic. During an interview on 10/30/2024 at 4:25 PM with Assistant Director of Nursing (ADON), the ADON stated cohort means residents with the same symptoms or diagnosis. The ADON added they should have cohort the staffing assignment to residents with same symptoms from the reisdent without symptoms, to prevent further spread of infection or virus. During a review of Facility's P&P titled Norovirus Prevention and Control, revised on 10/2011, P&P indicated facility will implement strict infection control measures to prevent the transmission of norovirus infection. It also indicated the following interpretation and implementation: o Avoid exposure to vomitus or diarrhea. Place resident on contact precaution in a single occupancy room, if possible, when symptoms are consistent with norovirus gastroenteritis. o Approaches for Cohorting residents during outbreaks may include placing resident in multi-occupancy rooms or designating resident care areas within the facility for resident cohorts. o In the event of an outbreak of norovirus gastroenteritis, staff will care for one resident cohort on their unit and will not move between resident cohorts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) was not left unattended by facility staff while the resident is sitting on the bedside commode (a portable toilet) for long period of time. This deficient practice had a potential to result in skin breakdown and accidents that can lead to injury. Findings: During a review of the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but not limited to acquired deformities of left lower leg (any abnormality in the normal alignment of the leg occurring either within the bone or at the level of a joint), enterocolitis due to clostridium difficile (an inflammation of the colon caused by an overgrowth of the C. diff bacterium [a type of bacteria that can cause diarrhea and colitis, an inflammation of the colon]), abnormality of gait and mobility, severe protein-calorie malnutrition (a nutritional condition that occurs when someone doesn't consume enough protein and calories). During a review of Resident 1 Fall Risk assessment dated [DATE] indicated Resident 1 is low risk for fall. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/03/2024, indicated Resident 1 had intact cognition and needed substantial/maximal assistance (helper does more than half the effort) from the staff for the activities of daily living (personal care activities that are essential for independent living. They include basic tasks that people learn as children, like eating and walking) and was dependent (a person who depends on or needs someone or something for aid, support, favor) for toileting hygiene, showers, and dressing. During a review of Resident 1's Care Plan initiated 8/03/2024 indicated, At risk for falls secondary to antihypertensive (medicines that bring your blood pressure down in various ways), hypnotic (the use of medications to induce, extend, or improve sleep quality) use. Interventions indicated to answer call light in timely manner and assess and anticipate resident's needs such as toileting needs, comfort levels, and body positioning, etc. The care plan also indicated intervention to encourage resident to assume a standing position slowly, remind resident to walk slowly and rest adequately and keep environment free of clutter and safety hazards. During a review of Resident 1's Change in Condition document dated 8/12/2024 indicated, Female Caregiver (Certified Nurse Assistant [CNA] not specified) interviewed on 8/8/2024 at 3:35 pm and stated I saw the call light (a device used by patients to call for assistance from hospital staff) on, so I went to assist the patient (Resident 1). I assisted her to the bedside commode and told the daughter to use the call light when she was ready to get off the commode. I left the room to tend to another patient. I was not able to make it back to assist. During an interview with the facility Administrator (Admin) on 8/13/2024 at 7:46 am, Admin stated Family 1 talked to him about the Resident 1 being left sitting on the bedside commode for a long period of time on 8/8/2024. Admin stated, I made a grievance (an official statement of a complaint over something believed to be wrong or unfair) that same day. During an interview with CNA2 on 8/13/2024 at 8:05 am, CNA2 stated, I remember her (Resident 1) because I helped her that day (8/8/2024). CNA2 stated on 8/8/2024, Resident 1had the call light on, and went in to help the resident to the bedside commode. CNA2 also stated, CNA2 she instructed Resident 1 to use the call light when she was ready and left the resident's room. CNA2 also stated, after leaving Resident 1's room, CNA2 told the charge nurse that Resident 1 was left in the room while on the bedside commode and CNA2 got busy with other residents and did not go back to see if Resident 1 was done using the commode. During an interview with CNA1 on 8/13/2024 at 10:51 am, CNA1 stated, there was an incident with Resident 1, on 8/8/2024 when Resident 1 was placed on the bedside commode by another CNA and the CNA left the room while the resident is on the bedside commode. CNA1 stated, CNA1 was not aware at the time when Resident 1being placed on the bedside commode and was left without any supervisions by facility staff. During a concurrent interview with CNA1 on 8/13/2024 at 11:07 am, CNA1 stated, CNA2 left the patient on the bedside commode for a long period of time and from experience everyone takes a different time using the bedside commode, but 40 minutes is a long time to be on the bedside commode without facility staff's supervisions and/ or assistance and it was dangerous because the resident was not being monitored and the resident could have had a fall. CNA1 stated, the resident should not have been left alone while on the commode and should not have been left for long period of time. CNA1 stated this does place the resident at risk for accident such as fall. During an interview with the Director of Nursing (DON) on 8/13/2024 at 1:34 pm, per the DON, CNA2 just helped to put Resident 1 on the bedside commode and told the resident to use the call light when the resident was finished. The DON also stated, Resident 1 used the call light but we do not know for sure how long it was that she (Resident 1) was left sitting on the bedside commode. During a concurrent interview with CNA2 on 8/13/2024 at 1:45 pm, CNA2 stated she did not inform the residents assigned CNA (CNA1) that the resident was left on the bedside commode. CNA2 stated, she left the resident's room while Resident 1 while in the bedside commode. CNA2 stated I went and told my charge nurse that I left her (Resident 1) on the bedside commode. After that, I am not sure what happened or if the assigned CNA was made aware. CNA2 confirmed that she got busy and did not know for sure how long the Resident 2 was left sitting on the bedside commode without facility staff supervising the resident. During an interview with Charge Nurse (CN1) on 8/13/2024 at 1:57 pm, CN1 stated, Honestly, I do not really remember. I am not sure how long Resident 1was left on the bedside commode without facility staff present to supervise the resident in the room. During an interview with Family 1 on 8/13/2024 at 3:15 pm, Family 1 stated, There was a day last week when I went to visit my mom (Resident 1) at the facility, and she used the call light because she needed to use the bathroom. A CNA (unable to recall name) came in the room and assisted her to the bedside commode in the room. We used the call light and waited 10 to 15 minutes. I heard them say the call light was on and for someone to answer it, but nobody did. I ended up taking her (Resident 1) off the bedside commode myself and placed her back on the bed. When my watch hit the 40-minute mark from when we initially pressed the call light for assistance, I marched into the Administrators office and made him aware of what had happened. During a review of the facility's policy and procedure, Activities of Daily Living (ADLs), Supporting, revised 3/2018, indicated, 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. The policy also indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with elimination (toileting). During a review of the facility's policy and procedure titles Fall and Fall Risk Managing reviewed 3/2018 indicated, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated resident conditions that may contribute to the risk of falls include functional impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure for one of three (3) sampled residents (Resident 1) by failing to thoroughly investigate an allegation of sexual abuse (non-consensual sexual contact of any type with a resident. This deficient practice had the potential to place Resident 1 at risk for elder abuse. Findings: A review of Resident 1's admission Record indicated resident was admitted on [DATE] with the diagnoses of dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and aphasia (a language disorder that affects how a resident communicates). A review of Resident 1's History and Physical, dated 6/20/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 6/26/2024, indicated resident was moderately impaired with cognitive ((mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating and oral hygiene. MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a structured communication framework that can help teams share information about the resident's condition), dated 7/15/2024, indicated resident stated that she was felt up (to touch or fondle someone for sexual pleasure) by a male staff member and it occurred in the nighttime/ early morning on Saturday 7/13/24. A review of the Facility's Staff Assignment, dated 7/12/24 3 PM to 11 PM shift, indicated Certified Nursing Assistant 1 (CNA 1) was a male staff member assigned to Resident 1. During a concurrent record review of the facility's staff assignment on 7/12/2024 and interview on 7/25/2024 at 11:36 AM, the Director of Nursing (DON) confirmed that CNA 1 was assigned to Resident 1 on 7/12/2024 during the 3 PM to 11 PM shift. The DON stated the facility should have looked into the staffing on 7/12/2024 at 3 PM to 11 PM shift since Resident 1 mentioned it was a male staff member at nighttime. The DON also stated that the facility should have suspended CNA 1 until further investigation for the safety of Resident 1 and the other residents. During an interview on 7/25/2024 at 1:22 PM, Administrator (ADM) stated the facility should have looked into the staffing on 7/12/2024 at 3 PM to 11 PM shift and suspended CNA 1 until further investigation. A review of the facility's Policy and Procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/2021, indicated all allegations are thoroughly investigated. Policy also indicated any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare settings) were followed in accordance with the facility ' s policy and procedure by failing to ensure the Certified Nursing Assistant 3 (CNA 3) wore an isolation gown while passing water pitcher inside a residents room with a resident (Resident 2) who was positive for Coronavirus-19 (Covid-19, an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions). This deficient practice had a potential to spread infection to all residents, staff, and visitors in the facility. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included Klebsiella Pneumoniae (a type of bacteria that can cause many different infections that are more likely gets picked up while in the hospital) and resistance to multiple antimicrobial drugs (bacteria no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death). A review of Resident 2's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 7/2/24, indicated Resident 2 had moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene and shower, lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 2 required partial assistance (helper does less than half the effort) with oral and personal hygiene and upper body dressing. A review of Resident 2's Physician's Order, dated 7/11/24, timed at 2:47 PM, indicated an order for contact and droplet standard precautions (preventative steps needed to be taked by healthcare team to prevent the spread of infection) for ten (10) days every shift for COVID-19 positive. A review of Resident 2's Laboratory Report titled, Provider Report of Covid-19 Laboratory Results, collected on 7/11/24, indicated Resident 2 was positive for Covid-19. During a concurrent observation and interview on 7/11/24 at 4:30 PM, CNA 3 was seen with a cart full of water pitchers for the residents in the resident hallway. CNA 3 was then observed entering Resident 2's room with a pitcher of water from the cart without wearing an isolation gown. Outside Resident 2 ' s room had a Norovirus isolation sign and instructions indicating gloves, mask, gowns should be worn prior to entering. CNA 3 stated he was not aware the resident was positive for Covid-19 and stated he should have worn a gown to protect himself, other staff, and residents. CNA 3 also stated he did not pay attention to read the precaution sign by the door outside Resident 2's room. During an interview on 7/11/24 at 4:40 PM, the Licensed Vocational Nurse 2 (LVN 2) stated she should have informed CNA 3 who were the residents positive for Covid-19. LVN 2 stated CNA 3 should have used a gown before going inside Resident 2's room to prevent spread of germs to other residents. During an interview on 7/11/24 at 4:58 PM, the Director of Nursing (DON) stated CNA 3 should be educated on the use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) to protect himself and not spread the infection to other residents. During an interview on 7/11/24 at 5:45 PM, the Administrator (ADM) stated the staff should know their residents and what type of isolations they are on. The ADM also stated the staff should be aware of what isolation precaution and what PPE to use when providing care to the resident. A review of the facility's Policy and Procedure titled, Covid-19, Prevention and Control, revised 6/10/24, indicated as part of transmission-based precautions for Covid-19, gowns shall be worn prior to providing direct care or entering rooms/care areas where residents are in isolation (Covid-19 Cohort or isolating in place). Care areas include but are not limited to resident rooms, shower rooms, rehab gyms, etc.

Based on observation, interview, and record review the facility failed to follow infection prevention procedure during medication administration for one of two sampled residents (Resident 1) by failing to ensure Licensed Vocation Nurse (LVN) 1 washed hands before administering Resident 1's oral medication, washed hands before wearing gloves and administering ophthalmic (pertaining to eye) medications as indicated in the facility policy. This failure had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 1. Findings: During a review of Resident 1 ' s admission Record (Face Sheet) dated 5/20/2024, the Face Sheet indicated the facility admitted Resident 1 on 01/17/2019 with diagnoses which include history of falling, difficulty in walking, muscle weakness, hypertension (elevated blood pressure), glaucoma (eye disease that can cause vision loss and blindness by damaging a nerve in the back of the eye), hyperlipidemia (increased levels of lipids or fat in their blood), and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). During a review of Resident 1 ' s Minimum Data Set (MDS- standardized assessment and care screening tool), dated 02/05/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired. The MDS indicated Resident 1 had no impairment with range of motion in the upper and lower extremity. During an observation on 05/20/2024 at 10:03 AM, Licensed Vocational Nurse (LVN) 1 was observed entering Resident 1 ' s room without performing hand hygiene and administered the following medications to Resident 1. a. Furosemide (also called a water pill, that is commonly used to reduce edema (fluid retention) 40 milligrams (mg- unit measure for mass) oral tablet. b. Potassium Chloride (a supplement that can treat low potassium levels) extended release (ER- formulated so that the drug is released slowly over time) 10 milliequivalent ([meq]- a unit measure for the number of grams of a medication) oral tablet. c. Alfuzosin Hydrochloride (used in men to treat symptoms of an enlarged prostate) ER 10 mg oral tablet. d. Eliquis (medicine used to reduce the risk of stroke and blood clots) 5 mg oral tablet. During an observation on 05/20/2024 at 10:08 AM, LVN 1 was observed applying gloves in Resident 1 ' s room without performing hand hygiene and attempted to administer Resident 1 ' s eye drops, Tobramycin-Dexamethasone (used to treat bacterial eye infections) ophthalmic suspension 0.3-0.1% in Resident ' s eyes. Resident 1 requested a mirror and requested to self-administer the eye drops. LVN 1 was observed touching Resident 1 ' s bedside table and bed rail while looking for a mirror and then informed Resident 1 that there was no mirror. LVN 1 repositioned Resident 1 ' s head of the bed to 45 degrees. LVN 1 instructed Resident 1 to open resident ' s eyes, touched Resident 1 ' s face and eyes with both hands without washing hands, changed gloves, then proceeded to apply the eye drops to Resident 1 ' s left and right eyes. During an interview on 05/20/2024 at 12:33 PM, LVN 1 admitted she did not perform hand hygiene before entering Resident 1 ' s room and administering eye drops. LVN 1 stated that hand hygiene should be performed before and after medication administration. LVN 1 stated hand hygiene was important to prevent the spread of infection between residents. During an interview on 05/20/2024 at 3:33 PM, with the quality assurance nurse (QA), the QA stated staff should sanitize their hands before and after medication administration and should wash their hands when administering eye drops. The QA stated handwashing was important to prevent the spread of infection. During a review of facility ' s policies and procedure (P&P) titled Handwashing / Hand Hygiene revised date 08/2019 indicated under policy statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation indicated staff should use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before preparing and handling medications. Policy procedure indicated performing hand-hygiene before applying non-sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure to administer medication in a safe and timely manner for two of two sampled residents (Resident 1 and 2) by ensuring: 1a. Resident 1 did not receive Tobramycin-Dexamethasone ophthalmic suspension (used to treat bacterial eye infections) 30 days after the open date as indicated in their policy. 1b. Resident 1 received Timolol Maleate (a medication used to treat glaucoma [eye disease that can cause vision loss and blindness by damaging a nerve in the back of the eye]) in accordance with the physician ' s order. 2. To administer Tylenol (a medication used to treat pain) according to pain parameters as ordered by the physician for Resident 2. These failures had the potential to result in worsening of Resident 1's glaucoma, had the potential to negatively impact Resident 1 ' s health and well-being, and ineffective management of pain for Resident 2. Findings: 1a. During a review of Resident 1 ' s admission Record (Face Sheet) dated 5/20/2024, indicated the facility admitted Resident 1 on 01/17/2019 with diagnoses which include history of falling, difficulty in walking, muscle weakness, hypertension (elevated blood pressure), glaucoma, hyperlipidemia (increased levels of lipids or fat in their blood), and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). During a review of Resident 1 ' s Minimum Data Set (MDS- standardized assessment and care screening tool), dated 02/05/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired. The MDS indicated Resident 1 had no impairment on range of motion in the upper and lower extremity. During a review of Resident 1 ' s Medication Administration Record (MAR), date ordered 10/30/2023, indicated an order for Tobramycin-Dexamethasone ophthalmic suspension 0.3 %-0.1% instill two drops in both eyes every six hours as needed for eye redness. During an observation on 05/20/2024 at 10:03 AM, Licensed Vocational Nurse (LVN) 1 was observed administering Tobramycin-Dexamethasone ophthalmic suspension 0.3-0.1% two drops in Resident 1 ' s both eyes. During a concurrent interview and record review on 05/20/2024 at 12:37 PM, with LVN 1, Resident 1 ' s Tobramycin-Dexamethasone medication label was reviewed. The medication label indicated it was opened on 4/1/2024. LVN 1 stated that Resident 1 ' s Tobramycin-Dexamethasone ophthalmic suspension was opened on 04/1/2024 and based on the facility ' s policy, the Tobramycin-Dexamethasone expired on 05/01/2024 (30 days after opening). LVN 1 stated Resident 1 ' s Tobramycin-Dexamethasone ophthalmic suspension should have been discarded on the expiration date. LVN 1 stated it was important to check the open and expiration date to ensure the residents do not receive expired medications. During an interview on 05/20/2024 at 3:33 PM, with the quality assurance nurse (QA), the QA stated staff should verify every medication ' s expiration date before administering medication and the staff should remove expired medications from the cart and call the pharmacy. The QA further stated it was important for staff to discard expired medications because expired medications were not as effective and have the potential to cause harm to the resident. During a review of facility ' s pharmaceutical services policies and procedure (P&P) titled Medications Requiring Notation of Date Opened (undated), the P&P indicated to ensure potency (the ability or capacity to achieve or bring about a particular result), maintain efficacy, and avoid cross contaminations (the physical movement or transfer of harmful bacteria from one person, object or place to another), certain medications must be dated when first opened and discarded when the designated expiration time period or the manufacturers expiration date elapses. The P&P indicated all ophthalmic drops and ointments (except unit dose packages and Zilactin (used to relieve pain from minor problems in the mouth) which expires 6 weeks after opening unless refrigerated) expires one month after opening. 1b. During a review of Resident 1 ' s Order Summary Report (a summary of all current physician orders), dated 05/20/2024 indicated Resident 1 ' s physician prescribed Timolol Maleate one drop in both eyes two times a day for glaucoma on10/29/2023. During a concurrent interview and record review on 05/20/2024 at 12:40 PM, with LVN 1, LVN 1 stated she administered Tobramycin-Dexamethasone ophthalmic suspension 0.3-0.1% (medication used to treat eye redness) instead of the ordered Timolol Maleate (a medication for glaucoma). LVN 1 was observed inspecting her medication cart and stated there was no Timolol Maleate in the medication cart. During a concurrent observation and interview on 05/20/2024 at 12:52 PM, with LVN 1, LVN 1 confirmed there was no Timolol Maleate for Resident 1 in the medication refrigerator. LVN 1 stated there was only one medication refrigerator in the facility. LVN 1 stated it was important to follow physician orders and ensure the residents were getting all their scheduled medications. During an interview on 05/20/2024 at 3:33 PM. The QA stated it was important nurses follow the process to ensure that residents were receiving medications as ordered by the physician because it has the potential to negatively affect the resident ' s health. During a review of facility ' s policies and procedure (P&P) titled Administering Medications dated revised on 04/2019, indicated Medications are administered in a safe and timely manner, and as prescribed. The P&P indicated medications are administered in accordance with prescriber orders, including any requires timeframe and medications are administered within one hour of their prescribed time, unless otherwise specified. 2. During a review of Resident 2 ' s Face Sheet, indicated the facility admitted Resident 2 on 03/11/2019 with diagnoses which include history of falling, unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time, age related osteoporosis (condition that leads to loss of bone mass) and low back pain. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was cognitively intact. The MDS indicated Resident 2 had no impairment with range of motion in the upper extremity and had impairment on one side in the lower extremity. During a review of Resident 2 ' s Order Summary Report (a summary of all current physician orders), dated 5/20/2024 indicated an order of Tylenol (a medication for pain) 325 milligrams ([mg]- a unit of measure for mass) two tablets by mouth every eight hours as needed for moderate pain (pain 4-6) on 01/30/2024. During an observation on 5/20/2024 at 10:03 AM, Licensed Vocational Nurse (LVN) 1 was observed administering Tylenol 325 mg oral two tablets to Resident 2. Resident 2 was observed swallowing the Tylenol with a full glass of water. During a concurrent interview and record review on 05/20/2024 at 10:40 AM, with LVN 1, Resident 2 ' s Order Summary Report dated 5/20/2024 was reviewed. LVN 1 stated that Resident 2 reported pain level of two to three based on the numeric pain scale (pain screening tool used to assess pain severity using a 0–10 scale, zero for no pain and 10 highest level) on 5/20/2024. LVN 1 stated the order for Tylenol 325 mg two tablets for moderate of pain (4-6) was not appropriate for Resident 2 ' s reported pain of two to three. LVN 1 stated it was important to assess the resident ' s pain and follow physician orders. LVN 1 stated that giving a medication indicated for higher levels of pain has the potential for the resident to become dependent on the pain medication. During an interview on 05/20/2024 at 3:33 PM, the QA stated it was important nurses followed physician orders including the pain parameters to reduce the risk of addiction. The QA stated it was important to follow physician orders to determine the efficacy (the ability to produce a desired or intended result) of the medication for the ordered pain parameters. During a review of the facility ' s P&P, titled Administering Mediations, revised on 04/2019, the P&P indicated under policy statement that Medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation indicated that Medications are administered in accordance with prescriber orders, including any required timeframe.

Based on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was answered for one (1) of four 4 sampled residents (Resident 1). On 5/7/24, Resident 1's call light was on, and it was not answered by Licensed Vocational Nurse (LVN) 1 who was standing across the resident's room, Certified Nurse Assistant (CNA) 2 and Registered Nurse (RN) 1 who passed by the room. This had the potential to result in a delay in care for Resident 1 not to receive the necessary care and services which can lead to illness or serious injury. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 4/29/24 with diagnosis which include difficulty in walking, muscle weakness, hypertension (when the pressure in your blood vessels is too high). During a review of Resident 1's care plan date initiated 4/29/24 indicated Resident 1's at risk for fall. Care plan goal indicated Resident 1 will consistently use call light for assistance. The care plan intervention indicated answer call light in timely manner, encourage to call for assistance and keep call light within easy reach. A review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 05/3/24, indicated Resident 1's cognition was intact (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 1 was assessed to need set up or clean up assistance (helper set up or clean up) on eating and supervision or touching assistance (helper does verbal cues) on oral hygiene, toileting hygiene, shower bathe self and personal hygiene. During an observation on 5/7/24 at 5:57 AM, observed the call light at Room A (Resident 1's room) was on, the Certified Nursing Assistant (CNA 2) passed by Room A and did not answer the call light. Licensed Vocational Nurse (LVN) 1 was standing across Room A at the hallway and did not answer the call light. During concurrent observation and interview on 5/7/2024 at 6:03 AM with the CNA 1, CNA 1 saw surveyors standing outside Resident 1's room and saw the call light was on. CNA 1 went inside Room A. CNA 1 stated Resident 1 was asking for the urinal (portable receptacle into which one urinates) and blanket. During observation on 5/7/24 at 6:12 AM the call light at Room A was on. LVN 1 was at the hallway and did not answer the call light. Registered Nurse (RN1) passed by Room A and did not answer the call light. During interview on 5/7/24 at 6:17 AM with CNA 2, CNA 2 stated the call lights were connected to the nursing station and can be heard at the hallways, whoever sees it should have answered it as soon as possible for safety to prevent fall and to ensure we provide what the resident need. CNA 2 also stated everybody needs to answer the call light all the time. During an interview on 5/7/24 at 7:41 AM with RN 1, RN 1 stated who ever seen or heard the call light was on, the staff should answer it as soon as possible. RN 1 stated the call light of Resident 1 was not answered right away on 5/7/24 at 5:57 AM and 6:12 AM, it was possible for Resident 1 to have accident of fall. Resident 1 might not wait and will stand up to urinate. The RN 1 also stated it would affect the dignity of Resident 1 and Resident 1 will not feel comfortable and safe. During an interview on 5/7/2024 at 1:46 PM with Resident 1, Resident 1 stated he calls when needs his urinal and usually he waits 30 minutes to one hour before facility staff answers the resident's call light Resident 1 also stated, the day shift and evening shift is the worst and the resident have to wait long before staff answer's the resident's call light because they were busier. Resident 1 also stated he feels discouraged when the needs to wait for a long time for the facility staff to answer his call light. A review of the facility's policy and procedure (P&P) titled, Answering the Call Light revised date 10/2010 indicated the purpose of this procedure it's to respond to the resident's requests and needs. General guidelines indicated answer the call like as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure the safety and prevent fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) of two (2) of three (3) high fall risk sampled residents (Resident 2 and 3) by: 1. The facility failed to update care plan interventions and to reassess Resident 2's fall risk assessment after the resident's fall on 4/25/2024. 2. The facility failed to update Resident 3's care plan after resident had a fall on 4/9/2024. This deficient practice resulted to Resident 2 had another fall on 5/4/2024 and was sent to General Acute Care Hospital (GACH 1) and placed Resident 3 at risk for another fall incident. Findings: 1. A review of Resident 2's admission record indicated the facility admitted Resident 2 on 4/22/24 with diagnosis which include muscle weakness, difficulty in walking, traumatic subarachnoid hemorrhage (traumatic head injury, resulting in bleeding) A review of Resident 2's H&P dated 4/30 /24 indicated Resident 2 does not have the capacity to make decisions. A review of Resident 2's Minimum Data Set (MDS, standardized care and screening tool), dated 4/26/24, indicated Resident 2 was moderate impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS also indicated Resident 2 needs supervision or touching assistance (helper provides verbal cue and or touching steadily and or contact guard assistance as resident completes activity) on eating, oral hygiene, upper body dressing, personal hygiene, partial moderate assist (helper does less than half the effort) on toileting hygiene and personal hygiene. The MDS also indicated, the following activities was not attempted due to medical condition or safety concerns, walking 10 feet on uneven surfaces (ability to walk 10 feet) and picking up object. During concurrent interview 5/8/2024 at 5:47 PM and record review of Resident 2's fall risk assessment dated [DATE] indicated Resident 2 was high risk for fall. The Minimum Data Set Coordinator nurse (MDSC) stated there was no documented evidence of fall risk assessment was done after Resident 2's incident of fall on 4/25/2024. During a review of Resident 2's Progress Notes dated 4/25/24 at 9:46 AM indicated the charge nurse was alerted by the house keeping that Resident 2 was on the floor. The progress notes also indicated, the charge nurse rushed to Resident 2's bedside and Resident 2 was noted to have blood running down his face. Resident 2 was transferred to GACH 1 via ambulance at 12PM. During a review of Resident 2's Progress Notes dated 4/25/24 at 10:19 PM, indicated Resident 2 returned from GACH 1 at 8:30 PM with laceration on the scalp with stitches (also called sutures, are special types of thread that hold the edges of a wound together while it heals in place). During a review of Resident 2's Progress Notes dated 5/4/24 at 11:47 PM (late entry) indicated around 11:05 PM Resident 2 was found on the floor in right lateral recumbent position (lying on the right side) and making snoring sound. Resident 2 was unresponsive. The progress notes also indicated that the Resident 2 was transferred to GACH 1 via 911 (three-digit number anyone can dial on the telephone to get help when there is a life-threatening or in-progress emergency). During a review of Resident 2's GACH 1 ED notes dated 5/4/24 at 11:44 PM indicated Resident 2 was brought in by ambulance (BIBA) from the facility for unwitnessed fall. The GACH 1 ED notes also indicated Resident 2 was noted to have a gold- sized hematoma on right forehead. During concurrent interview and record review on 5/8/24 at 5:47 PM with the MDSC of Resident 2's Care Plan dated initiated 4/22/24, revised date 5/3/2024 indicated Resident 2 is at risk for fall related to gait balance problem, psychoactive drugs (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) use, unaware of safety needs, and wandering(a patient who goes beyond the view or control of staff without the intention of leaving the health care facility). The care plan goal indicated Resident 2 will be free of fall and will not sustain serious injury. The MDSC stated after Resident 2's fall on 4/25/24, the resident's care plan was not reviewed and updated to ensure interventions are in place to prevent another fall. The MDSC stated the licensed nurses should have updated the care plan as soon as there's a change of condition or fall and the licensed nurses should have been looking for new interventions to try to keep resident safe and prevent another fall. During the same interview on 5/8/24 at 5:47 PM with MDSC, MDSC stated on 4/26/24 Resident 2 was originally in Room A near the nursing station, then on 4/26/24 the resident was transferred to r Room B and Room B is far from the nursing station. MDSC also stated, based on the Resident 2's MDS dated [DATE], Resident 2 needs supervision with assistance on toileting and the resident should have a facility staff to assist the resident to the bathroom, from bed to standing up should have somebody assisting the resident. MDSC also stated, if the resident was provided with assistance on 4/25/24 and 5/4/24 the fall could have been prevented. 2. A review of Resident 3's admission record indicated the facility initially admitted Resident 3 on 2/6/24 and readmitted on [DATE] with the following diagnosis difficulty walking, muscle weakness, thrombocytopenia (a condition in which there is a lower-than-normal number of platelets in the blood. It may result in easy bruising and excessive bleeding from wounds or bleeding in mucous membranes and other tissues). A review of Resident 3's MDS, dated [DATE], indicated Resident 3 's cognition was intact skills for daily decision making. The MDS also indicated Resident 3 needs supervision or touching assistance (helper provides verbal cue and or touching steadily and or contact guard assistance as resident completes activity) on eating oral hygiene, substantial maximal assistance (helper does more than half of the effort) on toileting hygiene, shower bathe self-upper and lower body dressing. The MDS indicated toilet transfer chair to bed transfer was not attempted due to medical condition or safety concerns. During a review of Resident 3's Progress Notes dated 4/9/24 at 9:54 AM indicated Resident 3 was found on the floor on her back with a large laceration to her left elbow. The Resident 3 was transferred to GACH 1 via 911. During a concurrent interview with MDSC and record review on 5/8/24 at 6:39 PM, Resident 3's fall risk assessment dated [DATE] was reviewed and indicated Resident 3 was moderate risk for fall. The MDSC also stated, Resident 3's fall risk assessment dated [DATE] indicated the resident is moderate risk for fall and did not have history of fall. The MDSC stated the fall risk assessment for Resident 3 dated on 4/10/24 was not accurate because it indicated no history of fall, but resident fell on 4/9/24. MDSC stated, the fall risk assessment needs to be accurate to ensure the facility is providing interventions according to the resident's needs. During a concurrent interview and record review on 5/8/24 at 6:39 PM of the Resident 3's care plan dated from 4/9/24 to 5/2/24 the MDSC stated no care plan was initiated after the fall incident on 4/9/24. During an interview on 5/8/24 at 9:45 PM with the Director of Nursing (DON), the DON stated, no investigation and report was done for Resident 2's fall on 4/25/24 and on 5/4/24. The DON also stated, no investigation was conducted for Resident 3's fall on 4/9/24. The DON also stated, both residents (Resident 2 and 3) did not have any injuries after the fall that is why she did not conduct any investigation as to how or why the residents fell. During a review of facility's policies and procedure (P&P) titled Safety and Supervision of Resident revised date 7/2017 indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility -wide priorities. During a review of facility's (P&P) titled Safety and Supervision of Resident revised date 3/2018 indicated for an individual who has fallen, the staff and practitioner will try to identify possible cause within the 24 hours of fall. During a review of facility's (P&P) titled Assessing fall and their cause revised date 3/2018 indicated the purpose of this procedure is to provide guidance for assessing a resident after a fall and to assist staff in identifying cause of fall. Review the care plans to assess for any special needs of the resident. The P&P also indicates that falls are leading cause of morbidity and mortality among the elderly in nursing homes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote dignity and respect for one of one resident (Resident 293) for dignity care area as indicated on the facility's policy when staff changed the resident's brief when the resident stated she was dry and did not need to be changed. This deficient practice had the potential to result in Resident 293's feelings of decreased self-esteem, self-worth, and experiencing distress. Findings: A review of Resident 293's admission Record indicated Resident 293 was admitted to the facility on [DATE], with diagnoses of recurrent major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), insomnia (inability to sleep), and fracture (break in the bone) of unspecified part of neck of right femur (the long bone of the bind or lower limb extending from the hip to the knee). A review of Resident 293's History and Physical (H&P, the initial clinical evaluation and examination of the resident) dated 1/20/2024, indicated Resident 293 had the capacity to understand and make decisions. A review of Resident 293's Care Plans, dated 2/1/2024, indicated Resident 293 had bladder (a hollow organ in the lower abdomen that stores urine) incontinence (inability to control the flow or urine from the bladder) related to impaired mobility due to right hip hemiarthroplasty (partial hip replacement procedure that involved replacing half of the hip joint). A review of Resident 293's Activities of Daily Living (ADLs - activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) for the month of January 2024 indicated Resident 293 received care for bowel (a long tube which food travels while it is being digested after leaving the stomach) and bladder elimination. During an interview on 1/30/2024 at 9:49 AM in Resident 293's room, Resident 293 stated last night, 1/29/2024, around 8 PM two Certified Nursing Assistants (CNAs - CNA 2 and CNA 3) came in to change her. Resident 293 stated she informed CNA 2 and CNA 3 she did not need to be changed. Resident 293 stated CNA 2 and CNA 3 forced her and changed her briefs. Resident 293 stated during this time she told CNA 2 and CNA 3, I'm not wet, I'm not wet. Resident 293 stated she felt hopeless when she was changed. Resident 293 stated, It was very unpleasant. During an interview on 2/1/2024 at 10:40 AM with Resident 293's roommate, Resident 293's roommate stated the CNAs came to check on Resident 293 Monday night, 1/29/2024, unable to recall time. Resident 293's roommate stated she heard Resident 293 say she was okay, and she was dry. Resident 293's roommate stated the CNAs changed her anyway. Resident 293's roommate stated she could hear what happened and the CNAs said they had to change her. During an interview on 2/1/2024 at 10:41 AM with Resident 293, Resident 293 stated she heard the CNA laugh while the CNAs changed her briefs. Resident 293 stated, It made me very upset. During an interview on 2/1/2024 at 10:45 AM with CNA 4, CNA 4 stated she would explain to the resident to check their brief if they said they were dry and did not need to be changed. CNA 4 stated she would come back and ask the resident again if she could change their brief. CNA 4 stated staff cannot force the residents and change their briefs if they refused. During a telephone interview on 2/1/2024 at 10:52 AM with CNA 2, CNA 2 stated on 1/29/2024 she changed all her residents. CNA 2 stated, Sometimes the residents told me not to change them, but I could not listen to them. We would do whatever, but they gonna get changed. CNA 2 stated she would change the residents to freshen them up, even though they said they do not want to be changed. During an interview on 2/1/2024 at 10:59 AM with Registered Nurse (RN 1), RN 1 stated the resident should not be changed when the resident refused to be changed. RN 1 stated Resident 293 was able to communicate 100% when it came to continence (the ability to control the bladder and bowel) care. During an interview on 2/1/2024 at 11:03 AM with CNA 8, CNA 8 stated he usually worked during night shift. CNA 8 stated Resident 293 would call the nurses when she was wet at night to get changed. CNA 8 stated Resident 293 was alert and oriented and knew when she was wet or not wet. During an interview on 2/2/2024 at 10:09 AM with the Director of Nursing (DON), the DON stated when a resident does not want to be changed the CNA (general) should acknowledge the resident and return in ten minutes to follow up with the resident. The DON stated residents have their right for independence and autonomy. The DON stated staff cannot force residents to change their briefs. A review of the facility's policy and procedure titled, Resident Rights, revised 12/2016, indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to a dignified existence; to be treated with respect, kindness, and dignity; and to exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff) was within reach for one of two residents (Resident 292) for the environment care area. The call light was observed hanging on the back of the resident's bed, out of reach (more than the arm's length) of Resident 292. This failure had the potential to result in a delay in or in inability for Resident 292 to obtain necessary care and services. Findings: A review of Resident 292's admission Record indicated Resident 292 was admitted to the facility on [DATE], with diagnoses of central cord syndrome at 7th cervical vertebra (C7 - the largest and most inferior vertebra [the flexible column of bones extending neck to tail] in the neck region) level of cervical spinal cord (result of trauma that causes damage to the vertebrae in the neck leading to the spinal cord's ability to transmit some messages to or from the brain is damages or reduced below the site of injury to the spinal cord), history of falling, and difficulty in walking. A review of Resident 292's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 1/25/2024, indicated Resident 292 had the capacity to understand and make decisions. A review of Resident 292's Care Plan, dated 1/29/2024, indicated Resident 292 was dependent on staff for meeting physical needs. During a concurrent observation and interview on 1/31/2024 at 8:45 AM in Resident 292's room with Resident 292, Resident 292 was lying in bed and call light was looped and clipped on bed linen with call light dangling behind resident's head of bed. Resident 292's bed was elevated to a sitting position. Resident 292 looked around her bed and stated she did not know where her call light was. Resident 292 stated she was unable to find and reach for her call light. During a concurrent observation and interview on 1/31/2024 at 8:45 AM in Resident 292's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 292's call light was behind her bed. CNA 1 stated Resident 292 was not able to use her call light in the current location. CNA 1 sated call light should be within reach of the resident, so she could press on the call light when she needed help. During an interview on 1/31/2024 at 8:45 AM with Resident 292, Resident 292 stated she had Physical Therapy session earlier and the Physical Therapist (unknown) had moved the call light and did not place the call light within reach after therapy session. Resident 292 stated she felt afraid her call light was not within reach because she was not able to get a hold of the staff. Resident 292 stated she had a broken neck and was not able to move around to find and reach the call light. During an interview on 2/2/2024 at 10:09 AM with the Director of Nursing (DON), the DON stated the call lights were used for residents to call for assistance when necessary. The DON stated when resident's call lights were not within reach of the residents, the residents could not receive assistance within a timely manner. The DON also stated the residents could be distressed and needed assistance. The DON stated there could be a delay in assistance without the call light. A review of the facility's policy and procedure titled, Answering the Call Light, revised 10/2010, indicated when the resident is in bed be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one (1) of two (2) sampled residents (Resident 37) upon admission and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare (a federal health insurance for anyone age [AGE] and older/Medicaid (a joint federal and state program that gives health coverage to some people with limited income and resources) or by the facility's per diem (a payment rate determined for each day of the residents stay) rate, in accordance with the facility policy. This deficient practice resulted in payment of billed charges to Resident 37 which amounted to $21,420 prior to being discharged from the facility. Findings: A review of Resident 37's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (the immune system attacks the protective sheath that covers nerve fibers and cause communication problems between the brain and the rest of the body), generalized muscle weakness, and difficulty in walking. A review of Resident 37's Minimum Data Set (MDS, standardized assessment and care screening tool), dated 9/6/2023, indicated Resident 37 had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 37 required substantial assistance (helper does more than half the effort) with toileting, shower, lower body dressing, and putting on/taking off footwear and required partial assistance (helper does less than half the effort) with upper body dressing. The MDS also indicated Resident 37 required supervision (helper provides verbal cues) with eating, and oral hygiene. During an interview on 2/2/2024 at 5:44 PM, Resident 37 stated she was not notified by the facility that her stay at the was no longer covered. Resident 37 also stated that she was asked and had to write a check for $21,420 payable to the facility, before being discharged . Resident 37 expressed about not being thrilled with the way she left. Resident 37 further stated, she had told the facility early on during her stay that she had a private health insurance and not Medicare and was told the facility will take care of it. During an interview on 2/2/2024 at 6:43 PM, the Business Office Manager (BOM) stated, The facility assumed Resident 37 was on Medicare Part A (a hospital insurance inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care) instead of Managed Care (a healthcare insurance approach that integrates the financing of health care and the delivery of care and related services to keep the costs to the purchaser at a minimum while delivering what is appropriate for a given patient or population of patients). The BOM confirmed that the admission Coordinator (AC) collected $21,420 payment from Resident 37 instead of calling and obtaining authorization from the insurance company. The BOM also stated it was important to verify Resident 37's secondary insurance and the facility should have checked the Common Working File (CMF, a secure, cloud - based tool that permits health information to be exchanged between providers and patients) for alerts for potential secondary insurance and then verify the coverage. During an interview on 2/2/2024 at 7:55 PM, the Administrator (ADM) stated the AC was supposed to verify the primary insurance and if there was a problem with the insurance, they should have talked to Resident 37. During a concurrent interview and record review on 2/2/2024 at 9:35 PM, the BOM verified and confirmed there was no documentation from the AC that Resident 37 was made aware of her financial responsibility. The BOM also stated she was unable to provide documentation about any conversation the AC had with Resident 37 regarding insurance coverage. A review of the facility's policy and procedure titled, admission Agreement, revised August 2018, indicated that the admission agreement (contract) will reflect all charges for covered and non-covered items, as well as identify the parties that are responsible foe the payment of such services. A review of the facility's policy and procedure titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised September 2022, indicated that if the director of admissions or benefits coordinator believes (upon admission or during the resident's stay ) that Medicare (Part A of the Fee for Service Medicare program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for the payment of the non-covered service(s). The policy also indicated that the resident/beneficiary is not charged during the demand bill process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan within 48 hours of resident's admission for use of indwelling catheter (tube that drains urine from the bladder into a bag) for one of one sampled resident (Resident 13). This failure had the potential to result in Resident 13 not being provided with an effective and resident centered care which could result in urinary tract (urinary system) infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]). Findings: During a review of Resident 13's admission record, the admission Record, indicated Resident 13 was admitted on [DATE] with diagnosis of Extended Spectrum Beta-Lactamase (ESBL) (bacteria in the urine), and urine retention (inability to urinate) with an indwelling catheter in place. During a review of Resident 13's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 11/13/2023, the MDS indicated Resident 13 had severe cognitive impairment (problems with a person's ability to think, use judgment and make decisions). MDS indicated Resident 13 requires a helper to do more than half the effort to lift, hold trunk or limbs and provides more than half the effort to eat, clean teeth, upper body dressing, roll from lying to back to left and right side, and sit on the side of the bed with no back support. MDS indicated Resident 13 requires a helper to do all of the effort to complete toileting, showering, lower body dressing, and putting on socks and shoes. During a concurrent record review of Resident 13's care plan and interview on 1/31/2024 at 9:15 AM with Licensed Vocational Nurse (LVN 3), LVN 3 stated, Resident 13 did not have a baseline care plan to care for indwelling catheter. LVN 3 stated she was unable to determine what size catheter, or where the catheter was placed. During a concurrent observation and interview on 2/1/2024 at 9 AM with Resident 13, in Resident 13's room, Resident 13 had an indwelling catheter in place. Resident 13 stated she needed the catheter because she was unable to urinate on her own and was going to have surgery for her back soon. Resident 13 stated she had the catheter since she was admitted to the facility. During a concurrent record review of Resident 13's care plan and interview on 2/2/2024 at 2:44 PM with Minimum Data Set Coordinator 2 (MDS 2), MDS 2 stated, Resident 13, did not have a baseline care plan to address the care for indwelling catheter. MDS 2 stated Resident 13 should have a care plan in place to ensure that interventions are effective. MDS 2 stated the nurse who does the admission is responsible for creating the baseline care plan within 72 hours. MDS stated Resident 13 should have a care plan specifying type of catheter, and monitor interventions related to catheter intake, output, and care. During an interview on 2/2/2024 at 6:35 PM with the Director of Nursing (DON), the DON stated they do their best to complete the baseline care plans and does not have an answer to why some care plans are not complete. The DON stated, residents are supposed to have baseline care plans within 48 hours of admission. During a review of the facility's policy and procedure titled, Care Plan-Baseline, dated March 2022, Care Plan- Baseline, indicated, a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. A review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), difficulty in walking and muscle weakness. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/26/2024, indicated Resident 4 had severely impaired cognitive (thought process and ability to reason or make decisions) skills for daily decision making. Resident 4 was assessed as partial dependent/ moderate assistance (helper does less than half the effort) with eating, oral hygiene, upper body dressing, and personal hygiene. Resident 4 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. A review of Resident 4's Order Summary Report, dated 2/1/2024, indicated an order, dated 1/23/2024 as follows: a. Cleanse the sacrum (large, triangle shaped bone in the lower spine that forms the pelvis) with normal saline solution (NSS), pat dry and apply zinc oxide (used to treat or prevents skin irritation), every day for wound healing for 3 weeks, b. Cleanse left hip and right hip with NSS, pat dry and paint betadine (used to clean skin) on deep tissue injuries (DTI, injuries of the skin and/or underlying tissue over a bony prominence as a result of pressure or pressure in combination with shear), every day for wound healing for 3 weeks, and c. Low air loss (LAL) mattress for skin maintenance and resident comfort for wound healing. During a concurrent record review of Resident 4's medical records and interview with LVN 1 on 2/1/2024 at 11:22 AM, LVN 1 stated that Resident 4 has sacrum moisture-associated skin damage (MASD), right hip and left hip deep tissue injury. LVN 1 stated that wound care physician (MD) was consulted on 1/22/2024 and initial wound assessment by wound care MD was done on the same day. LVN 1 stated that wound care MD's notes indicated a recommendation to implement pressure relieving measures and offloading as tolerated. LVN 1 verified that care plan was not done to address Resident 4's MASD on the sacrum, and right hip and left hip deep tissue injury. LVN 1 stated it was important to develop a care plan so the staff could provide the necessary care and treatment for Resident 4's skin problem. LVN 1 stated the wound care MD's recommendation and treatment orders should have been reflected in Resident 4's care plan. During an interview with MDS Nurse 2 (MDS) 2 on 2/2/2024 at 8:42 AM, MDS 2 stated Resident 4 was assessed on 1/22/2024 as having sacral MASD, and right hip and left hip DTI. MDS 2 stated that treatment orders for Resident 4's sacral MASD, right hip and left hip DTI and LAL mattress were ordered on 1/23/2024 but it was not care planned. MDS 2 stated that Resident 4's sacral MASD, right hip and left hip DTI could get worse because there was no care plan. MDS 2 stated, The staff taking care of Resident 4 will not have a plan of care to follow. A review of facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised on December 2016, policy indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident' s physical, psychosocial, and functional needs is developed and implemented for each resident. 6. A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 15's diagnoses included liver cirrhosis (is permanent scarring that damages your liver and interferes with its functioning), cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right and left lower limbs, and urinary tract infection (UTI, is an infection in any part of the urinary system)/ Extended Spectrum. Beta-Lactamase (ESBL, are enzymes produced by some bacteria that may make them resistant to some antibiotics) of the urine. A review of Resident 15' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/21/2023, indicated Resident 15 had intact cognitive skills for daily decision making. The MDS indicated Resident 15 needed substantial/maximal assistance (helper does more than the effort helper lifts or holds trunk or limbs and provides more than half the effort) toileting hygiene, shower/bathe self, lower body dressing, and putting on and taking off footwear. Resident 15 needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides [NAME] than half the effort) toilet transfer, chair/bed-to-chair transfer and walk 10 feet (FT, unit of measurement). A record review of Resident 15's Physician's order dated, 12/15/2023, indicated Ertapenem Sodium (an antibiotic that is used to treat severe infections caused by bacteria in the skin, lungs, stomach, pelvis, and urinary tract) Solution Reconstituted 1 gram (GM, unit of measure). Use one (1) gram intravenously (refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) every 24 hours for ESBL of Urine for 13 Days and use 1 gram intravenously every 24 hours for UTI/ESBL Administer 1,000 MG IV Push every 24 hours for 13 days. A record review of Resident 15's Physician's order dated, 1/25/2024, indicated Ceftriaxone Sodium Solution Reconstituted (process of adding a liquid diluent to a dry ingredient to make a specific concentration of liquid)1 GM. Use 1 gram intravenously every 24 hours for Cellulitis of Left Lower Extremity for 7 days. A record review of Resident 15's Care plan did not show a care plan on Pain Management for the left leg cellulitis and Intravenous Antibiotic therapy. During an interview with the Director of Nursing (DON) on 2/2/2024 at 10:09 AM, DON stated, Care plans are a work in progress, not finished in one day, every shift adds what is necessary, dietary, therapy. It should be completed within 5 days and then a work in progress. The basic stuff can be done immediately then the resident's needs are addressed throughout their stay. It is important to adjust to resident's condition, guidelines, and improvements. If the resident has IV medications, the care plan for antibiotic should be in chart. During an interview with the Minimum Data Set Nurse (MDS) 2, on 2/2/2024 at 10:55 AM, MDS 2 stated, Care plans should be created when it was ordered so that everyone was aware of the plan of care. If resident has antibiotic, it should be included in care plan as well. Plan of care is important so everyone will know for continuity of care. The care plan should be initiated upon admission and continued. If there is Intravenous therapy, the IV Nurse should put it in. When we do comprehensive assessment, we also update the care plan at the same time. A review of facility's policy and procedure (P&P) titled, Care plans, Comprehensive Person Centered, dated 11/2016, P&P indicated identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. Assessments of the Residents are ongoing and care plans are revised as information about the residents and the resident's condition change. 7. A review of Resident 243's admission Record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 243's diagnoses included congestive heart failure (a long-term condition in which the heart cannot pump blood well enough to meet your body needs), pleural effusion (water on the lung, happens when fluid builds up in the space between your lungs and chest cavity), and hypertension (high blood pressure) A review of Resident 243' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/1/2024, indicated Resident 246 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 243 needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides [NAME] than half the effort) in toileting hygiene, shower/bathe self, upper body dressing, chair/bed-to-chair transfer and walk 10 feet (ft, unit of measurement). A review of Resident 243's Physician's order dated 1/26/2024, indicated oxygen at 2 liters per minute (LPM)via nasal cannula as needed for shortness of breath. During an observation in Resident 243's room on 1/30/2024 at 7:55AM, Resident 243's nasal cannula was observed on the resident's cheek and was not properly placed on her nostrils. During an observation in Resident 243's room on 1/30/2024 at 11 AM, Resident 243's nasal cannula was observed touching the floor and nasal cannula was left on top of the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings). A review of Resident 243's Care plan on 2/2/2024 at 8:40 AM, there was no care plan indicated for Resident 243's oxygen therapy. During an interview with the Director of Nursing (DON) on 2/2/2024 at 10:09 AM, DON stated, Care plans are a work in progress, not finished in one day, every shift adds what is necessary, dietary, therapy. It should be completed within 5 days and then a work in progress. The basic stuff can be done immediately then the resident's needs are addressed throughout their stay. It is important to adjust to resident's condition, guidelines, and improvements. If the resident has IV medications, the care plan for antibiotic should be in chart. During an interview with MDSN 1, on 2/2/2024 at 11:22 AM, MDSN 1 stated, the purpose of oxygen care plan is to have nursing interventions in place for the oxygen therapy. MDSN 1 did not know what can happen if there was no care plan for the resident. A review of facility's policy and procedure (P&P) titled, Care plans, Comprehensive Person Centered dated 11/2016, P&P indicated incorporate identified problem areas and reflect treatment goals, timetables, and objectives in measurable outcomes. 4. A review of Resident 289's admission Record indicated Resident 289 was admitted to the facility on [DATE] with diagnoses of methicillin resistant staphylococcus aureus infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA - infections caused by specific bacteria that are resistant to commonly used antibiotics), acute respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily function), pneumonia (lung inflammation caused by bacterial or viral infection), and adult failure to thrive (describes a state of decline and may be caused by chronic diseases and functional impairments, manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 289's Nurses Notes, dated 1/26/2024, indicated Resident 289 had a physician order for oxygen therapy (nasal cannula) at two (2) to three (3) liters/minute (LPM - flow of oxygen) to maintain an oxygen saturation (SpO2, measures how much oxygen is carried by the hemoglobin [Hgb- a protein in red blood cells that carries oxygen to the body's organs and tissues and transports carbon dioxide from your organs and tissues back to the lungs] in your blood or how well a person is breathing) at 92% or greater. The Nurses Notes also indicated Resident 289's mental status was alert and oriented times three (alert and oriented to person, place, and time), able to communicate verbally, speech clear, and was able to understand and be understood when spoken. A review of the Resident 289's Admit Screener dated 1/27/2024, indicated Resident 289 had a Stage 2 pressure ulcer located at the sacrum with no measurements of the pressure ulcer documented. A review of Resident 289's care plan, dated 1/27/2024, indicated the resident has pressure ulcer or potential for pressure ulcer with one approach. The care plan approach indicated the resident needs (encouragement, assistance, supervision) with use of bed rails, trapeze bar, etc. for resident to assist with turning. A review of Resident 289's Medication Administration Record for the Month of January and February 2024 indicated Resident 289 to receive oxygen at three LPM via nasal cannula continuously for shortness of breath. During an observation on 1/30/2024 at 8:34 AM in Resident 289's room, Resident 289 was lying in bed receiving oxygen at four LPM via nasal cannula. A concurrent interview with Resident 289, Resident 289 stated he was supposed to receive three liters of oxygen. A review of Resident 289's Braden Scale (tool used to Predict Pressure Ulcer Risk), dated 2/2/2024, indicated Resident 289 was at high risk for pressure ulcers Resident 289's activity was bedfast (confined to bed). Resident 289's had very limited mobility (makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently). It also indicated Resident 289 had a problem with friction and shear (requires moderate to maximum assistance in moving). During a concurrent interview and record review of Resident 289's care plan on 2/2/2024 at 10:55 AM with the Minimum Data Set Nurse (MDS 2), MDS 2 stated there was no care plan created for Resident 289 for oxygen. MDS 2 stated Resident 289 should have a care plan created for oxygen to ensure his continuity of care. During an interview on 2/2/2024 at 10:09 AM with the Director of Nursing (DON), the DON stated care plan for oxygen use should be added right away when resident arrives with the condition. During a concurrent record review of Resident 289's care plan, the DON stated a care plan was not created for Resident 289's oxygen use. The DON stated it was important to include the resident's condition in the resident care plan to monitor guidelines and goals. A review of Resident 289's Treatment Administration Record (TAR, a medical record used by healthcare providers to document the administration of a medication or treatment), start date 1/31/2024, indicated to cleanse the coccyx (the small bone at the bottom of the spine) stage two ulcer with normal saline and apply Medihoney (a wound and burn gel used to support the removal of necrotic [characterized by, or producing death of a usually localized area of living tissue] tissue and aids in wound healing) with dry dressing (a sterile pad applied to a wound to promote healing and protect the wound from further harm) daily for 21 days every shift. During an interview on 2/2/2024 at 10:55 AM with the Minimum Data Set Nurse (MDS 2), the MDS stated Resident 289 had a pressure ulcer and there needed to be a care planned so nurses were aware he had a pressure ulcer. MDS 2 stated the care plan for the pressure ulcer would ensure he received the necessary care for his pressure ulcer. During a concurrent interview and record review of Resident 289's care plan on 2/2/2024 at 11:22 AM with MDS 2, MDS 2 stated care plan for oxygen should had been created so the nurses know what interventions were put in place. During an interview on 2/2/2024 at 11:22 AM with MDS 1, MDS 1 stated a care plan was created for Resident 289's pressure ulcer but it was not specific for his pressure ulcer. MDS 1 stated interventions should include turning him and keeping him off his pressure ulcer, the treatment, monitoring to make sure the pressure ulcer does not get worse. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated the care plan will include measurable objectives and timeframes. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Incorporated identified problem areas, incorporate risk factors associated with identified problems, and reflect currently recognized standards of practice for problem areas and conditions. 5. Resident 290 did not have a care plan for the use of foley catheter (catheter inserted into a person's bladder to collect urine into a bag). This deficient practice had a potential to not provide specific care for Resident 290, which could result in a urinary tract infection (UTI). Findings: A review of Resident 290's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included gross hematuria, benign prostatic hyperplasia (BPH; enlargement of the prostate [male reproductive gland] that is not cancerous), retention of urine and acute kidney failure (when kidneys suddenly stop working properly). During a review of Resident 290's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/12/24, indicated Resident 290 had moderate impairment with cognitive (thinking and reasoning) skills for daily decision making. During a concurrent observation and interview on 2/1/2024 at 12:17 PM with Registered Nurse (RN) 1 in Resident 290's room, Resident 290's urine in foley bag was observed. RN 1 stated, The urine looks amber and cloudy with puss. This could signify infection and dehydration and it is important to notify the doctor immediately. During an interview on 2/1/2024 at 12:38 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, the care plan for residents with foley catheters should specifically indicate the need to monitor for signs and symptoms of infection such as smell, output and appearance of urine to prevent UTIs. During a concurrent interview and record review on 2/1/24 at 12:52 PM with Minimum Data Set Nurse (MDS) 2, Resident 290's Care Plans, dated 1/2024 to 2/2024, MDS 2 stated, Resident 290 does not have a care plan for his foley catheter. MDS 2 stated, Resident 290 should have a foley care plan that specifically indicated monitoring for signs and symptoms of UTI such as sediment in urine, hematuria (blood in urine that is visible to the naked eye) and pain. During an interview on 2/2/24 at 10:09 AM with Director of Nursing (DON), the DON stated, it is important to include the resident's condition in a resident's care plan to monitor guidelines and goals such as infection prevention. The DON stated, if a resident has a foley catheter, the resident should have a care plan for it. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated a comprehensive care plan will include measurable objectives and timeframes; describe services to maintain the resident's highest practicable physical, mental, and psychological needs; incorporate problem areas; and incorporate risk factors associated with identified problems. The P&P indicated, care plans will aid in preventing or reducing declines in the resident's functional status and or functional levels. The P&P indicated the interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition. A review of Resident 289's care plan, dated 1/27/2024, indicated the resident has pressure ulcer or potential for pressure ulcer with one approach. The care plan approach indicated the resident needs (encouragement, assistance, supervision) with use of bed rails, trapeze bar, etc. for resident to assist with turning. A review of Resident 289's Medication Administration Record for the Month of January and February 2024 indicated Resident 289 to receive oxygen at three LPM via nasal cannula continuously for shortness of breath. During an observation on 1/30/2024 at 8:34 AM in Resident 289's room, Resident 289 was lying in bed receiving oxygen at four LPM via nasal cannula. A concurrent interview with Resident 289, Resident 289 stated he was supposed to receive three liters of oxygen. A review of Resident 289's Braden Scale (tool used to Predict Pressure Ulcer Risk), dated 2/2/2024, indicated Resident 289 was at high risk for pressure ulcers Resident 289's activity was bedfast (confined to bed). Resident 289's had very limited mobility (makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently). It also indicated Resident 289 had a problem with friction and shear (requires moderate to maximum assistance in moving). During a concurrent interview and record review of Resident 289's care plan on 2/2/2024 at 10:55 AM with the Minimum Data Set Nurse (MDS 2), MDS 2 stated there was no care plan created for Resident 289 for oxygen. MDS 2 stated Resident 289 should have a care plan created for oxygen to ensure his continuity of care. During an interview on 2/2/2024 at 10:09 AM with the Director of Nursing (DON), the DON stated care plan for oxygen use should be added right away when resident arrives with the condition. During a concurrent record review of Resident 289's care plan, the DON stated a care plan was not created for Resident 289's oxygen use. The DON stated it was important to include the resident's condition in the resident care plan to monitor guidelines and goals. A review of Resident 289's Treatment Administration Record (TAR, a medical record used by healthcare providers to document the administration of a medication or treatment), start date 1/31/2024, indicated to cleanse the coccyx (the small bone at the bottom of the spine) stage two ulcer with normal saline and apply Medihoney (a wound and burn gel used to support the removal of necrotic [characterized by, or producing death of a usually localized area of living tissue] tissue and aids in wound healing) with dry dressing (a sterile pad applied to a wound to promote healing and protect the wound from further harm) daily for 21 days every shift. During an interview on 2/2/2024 at 10:55 AM with the Minimum Data Set Nurse (MDS 2), the MDS stated Resident 289 had a pressure ulcer and there needed to be a care planned so nurses were aware he had a pressure ulcer. MDS 2 stated the care plan for the pressure ulcer would ensure he received the necessary care for his pressure ulcer. During a concurrent interview and record review of Resident 289's care plan on 2/2/2024 at 11:22 AM with MDS 2, MDS 2 stated care plan for oxygen should had been created so the nurses know what interventions were put in place. During an interview on 2/2/2024 at 11:22 AM with MDS 1, MDS 1 stated a care plan was created for Resident 289's pressure ulcer but it was not specific for his pressure ulcer. MDS 1 stated interventions should include turning him and keeping him off his pressure ulcer, the treatment, monitoring to make sure the pressure ulcer does not get worse. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated the care plan will include measurable objectives and timeframes. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Incorporated identified problem areas, incorporate risk factors associated with identified problems, and reflect currently recognized standards of practice for problem areas and conditions. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive resident- centered care plan for eight (8) of 19 sampled residents (Residents 10, 13, 291, 289, 290, 15, 243, and 4), as indicated on the facility policy. 1. Resident 10 did not have a care plan to include non-pharmacological interventions (approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being) to address psychosis (a mental disorder characterized by a disconnection from reality). 2. Resident 13 did not have a care plan for the use of Abilify (medication used to treat mental illness) and use of indwelling catheter (tube that drains urine from the bladder into a bag). 3. Resident 291 did not have a care plan for the use of Melatonin (medication to regulate the body's wake-sleep cycle). 4. Resident 289 did not have a care plan for the use of oxygen therapy (a treatment that delivers oxygen for you to breathe) and Stage 2 pressure ulcer (partial thickness of loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough or bruising) This deficient practice had the potential for Resident 289 to not receive care and services to prevent further skin breakdown and respiratory complications. 5. Resident 290 did not have a care plan for the use of foley catheter (catheter inserted into a person's bladder to collect urine into a bag). 6. Resident 15 did not have a care plan for the left leg cellulitis and use of Ceftriaxone Sodium (third-generation cephalosporin antibiotic used for the treatment of a few bacterial infections) for infection. 7. Resident 243 did not have a care plan for oxygen therapy. 8. Resident 4's pressure injuries/skin problem and treatment orders were not reflected on the care plan. This deficient practice had the potential to not provide the specific interventions necessary for Residents 10, 13, 291, 289, 290, 15, 243, 4's well-being. Findings: 1. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted on [DATE] for subdural hemorrhage (bleeding in the brain, which can cause symptoms of aggression and confusion). During a review of Resident 10's MDS, dated 1/4/2024, the MDS, indicated Resident 10 had severe cognitive impairment (individual is incapable of living independently because of the inability to plan and carry out activities of daily living and apply judgment), and required maximal assistance from a helper for daily activities such as eating, bathing, toileting, and getting dressed. During a review of Resident 10's Orders Summary Report, dated 9/28/2023, the Orders Summary Report, indicated Seroquel 25 milligrams (MG, a unit of measurement of mass) for psychosis (a mental disorder characterized by a disconnection from reality) demonstrated by yelling out at staff. Orders indicated: Give 1 tablet by mouth two times a day for Psychosis. Start date 10/3/2023. During a concurrent record review of Resident 10's care plan and interview on 2/2/2024 at 2:50 PM with MDS 2 Coordinator (MDS 2), MDS 2 stated, Resident 10 was missing a comprehensive care plan to include use of non-pharmacological interventions to address psychosis. The MDS 2 stated the care plan should have been developed to avoid ineffective resident care. 2. During a review of Resident 13's admission record, the admission record, indicated Resident 13 was admitted on [DATE] with diagnosis of Extended Spectrum?Beta-Lactamase (ESBL) (bacteria in the urine that causes infection), and urine retention (inability to urinate) with an indwelling catheter (tube that drains urine from the bladder into a bag) in place. During a review of Resident 13's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 11/13/2023, the MDS indicated Resident 13 had severe cognitive impairment (problems with a person's ability to think, use judgment and make decisions). MDS indicated Resident 13 required substantial/ maximal assistance (a helper to do maximal effort to lift, hold trunk or limbs and provides more than half the effort) for sit to stand, walk 10 feet. MDS indicated Resident 13 required partial/moderate assistance (a helper to does less than half the effort. Helper lift or holds trunk or limbs and provides more than half the effort) for oral hygiene, toileting, sit to lying, lying to sitting on side of bed, and toilet transfer. During a review of a facility form titled, Behavioral Medication Management, dated 11/28/2023, it indicated Resident 13 was recommended to start Abilify 2.5 MG for psychosis and all nursing staff should monitor all behaviors every shift. During a review of Resident 13's Order Summary Report, dated 2/1/2024, the Order Summary Report, indicated Resident 13 should be monitored for episodes of responding to internal stimuli (things that seem real but are not), stating looking for her babies, for use of Abilify. During a concurrent record review of Resident 13's care plan and interview on 2/2/2024 at 3:02 PM with MDS 2, MDS 2 stated Resident 13 did not and should have a care plan for the use of Abilify and indwelling catheter. During an interview on 2/2/2024 at 3:15 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, Resident 13 has been getting Abilify because she was sad and not eating. During a concurrent observation and interview on 2/1/2024 at 9 AM with Resident 13, in Resident 13's room, Resident 13 had an indwelling catheter in place. Resident 13 stated she needed the catheter because she was unable to urinate on her own and was going to have surgery for her back soon. Resident 13 stated she had the catheter since she was admitted to the facility. 3. During a review of Resident 291's admission Record, it indicated Resident 291 was admitted on [DATE] for orthopedic (relating to the branch of medicine dealing with the correction of?deformities?of bones or muscles) after care and zoster (viral infection). During a review of Resident 291's MDS, dated [DATE], the MDS, indicated Resident 291 was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident 291 did not have any delusions (misconceptions about reality) or hallucinations (experiencing things/stimuli that are not real).??The MDS indicated Resident 291 required helper to do less than 50 percent assistance to bathe, toilet, get dressed, and get transferred from chair/bed-to-chair. During a review of Resident 291's Telephone/Verbal Orders, dated 1/5/2024, the Telephone/Verbal Orders, indicated Resident 291 should take Melatonin 5 MG at night for sleep. During a concurrent record review of Resident 291's care plan and interview on 2/2/2024 at 3:44 PM with MDS 2, MDS 2 stated Resident 291 did not and should have a care plan for the use of Melatonin. During an interview on 2/2/2024 at 6:35 PM with the Director of Nursing (DON), the DON stated, the facility does its best to complete the Resident Care Plans and does not have an answer to why some Care Plans were not complete. The DON stated she is not in control of what the doctors prescribe, or why it is not included in the Care Plan. During a review of the facility's policy and procedure titled, Care Plans- Comprehensive Person-Centered, dated December 2016, indicated, a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a review of the facility's policy and procedure titled, Care Planning, dated September 2013, it indicated, a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one of 19 sampled Residents (Resident 28) when Resident 28/ Responsible Party's (RP) request to have the resident's suprapubic catheter (medical device that drains urine from bladder) dressing change after breakfast to provide more time for resident activities was not reflected on the care plan. This deficient practice had the potential for inconsistency of care being rendered for Resident 28, which could affect resident's well being. Findings: A review of Resident 28's admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hypertension (high blood pressure), urinary retention and difficulty in walking. A review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/13/2023, indicated Resident 28 had moderately impaired cognitive (thought process and ability to reason or make decisions) skills for daily decision making. Resident 28 was assessed as needing extensive assistance (resident Involved in activity, staff provide weight-bearing support) with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. Resident 28 required limited assistance (Resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating. A review of Resident 28's Order Summary, dated 2/1/2024, indicated an order on 11/1/2023 to cleanse suprapubic catheter with normal saline solution (NSS) and apply dry dressing daily for wound healing. A review of Resident 28's Care Plan on suprapubic catheter, initiated on 10/26/2023, indicated approaches (interventions) as follows: Monitor suprapubic catheter and change catheter or bag when needed. Monitor for pain/discomfort and intolerance and report to Medical Doctor (MD, physician). Monitor urine for sediment, cloudy, odor, blood, and amount. Report any of the above or fever promptly to MD. Monitor lab. Turn every 2 hours and monitor skin for redness. Good peri care. Notify MD if no urine output within 2-4 hrs or less than 250 milliliters (ML, unit of measurement)/ 8 hours. Observe abdomen for distention to rule out urinary retention. During an interview on 2/1/2024 at 12:30 PM with RP, RP stated that she had requested to have Resident 28's suprapubic catheter dressing change early so Resident 28 can be out of bed, be seated on the wheelchair, and move around the facility. During an interview on 2/2/2024 at 3:22 PM with Certified Nursing Assistant 5 (CNA5), CNA5 stated that she was aware that Resident 28's RP had requested for Resident 28's treatment to be done before getting out of bed. CNA 5 stated that Resident 28's normal activity is to be in wheelchair and move around the facility on his own pace. During a concurrent record review of Resident 28's Care Plan and interview with Licensed Vocational Nurse 3 (LVN 3) on 2/2/2023 at 6:15 PM, LVN 3 stated that RP wants Resident 28's treatment of suprapubic catheter to be done between 9 AM to 9:30 AM. LVN 3 stated she was aware of this request since the RP had requested this to staff. LVN 3 stated that this request was not indicated on Resident 28's suprapubic care plan. LVN 3 stated that RP's request should have been in care plan to ensure that the staff taking care of Resident 28 will have the knowledge about the type of care to provide to Resident 28. LVN 3 stated that Resident's representative request should have been documented in the care plan because care plan involves the Resident and Resident's family or representatives. A review if facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, revised in September 2013, policy indicated the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. A review of facility's P&P titled Care Plans, Comprehensive Person Centered, revised in December 2016, policy indicated the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), difficulty in walking, and muscle weakness. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/26/2024, indicated Resident 4 had severely impaired cognitive (thought process and ability to reason or make decisions) skills for daily decision making. Resident 4 was assessed as partial dependent/ moderate assistance (helper does less than half the effort) with eating, oral hygiene, upper body dressing, and personal hygiene. Resident 4 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. A review of Resident 4's Order Summary Report, dated 2/1/2024, indicated an order, dated 1/23/2024 as follows: a. Cleanse the sacrum with normal saline solution (NSS), pat dry and apply zinc oxide (used to treat or prevents skin irritation), every day for wound healing for 3 weeks, b. Cleanse left hip and right hip with NSS, pat dry and paint betadine (used to clean skin) on deep tissue injuries (DTI, injuries of the skin and/or underlying tissue over a bony prominence as a result of pressure or pressure in combination with shear), every day for wound healing for 3 weeks, and c. LAL mattress for skin maintenance and resident comfort for wound healing. During a concurrent observation of wound treatment for Resident 4 and interview with Licensed Vocational Nurse (LVN) 1, on 2/1/2024, at 8:24 AM, LVN 1 stated that Resident 4 has an order to use LAL mattress, LVN 1 stated that she does not know how to set and change settings of LAL mattress and that she had been asking the facility's maintenance staff to adjust LAL settings when needed. LVN 1 stated that LAL mattress is set according to resident's weight. LVN 1 verified that Resident 4's LAL mattress control unit indicated that it was set at 300 pounds (LBS, unit of measurement). LVN 1 stated that Resident 4's weight has never been at 300 LBS. LVN 1 stated that Resident 4's latest weight on 1/30/2024 was 82 LBS. LVN 1 stated that LAL mattress should be set according to resident's weight to provide the right pressure that is necessary for wound healing and prevention of pressure ulcer. During an interview on 2/1/24 at 10:55 AM with Certified Nurse Assistant (CNA5), CNA 5 stated that Resident 4 is on LAL mattress because of skin problems. CNA 5 stated that she remembered being assigned to Resident 4 on 1/22/2024 and that Resident 4's back was red, but with no open skin. During a concurrent record review of Resident 4's medical records and interview with LVN 1 on 2/1/2024 at 11:22 AM, LVN 1 stated that Resident 4 has a moisture-associated skin damage (MASD) in the sacrum, and right hip and left hip deep tissue injury. LVN 1 stated that Resident 4's skin admission assessment was done on 1/22/2024. LVN 1 stated that facility's practice and per policy, the skin assessment should have been done upon admission, on 1/19/2024. LVN 1 stated this will ensure timely physician (MD) notification and prevent delay in wound treatment. LVN 1 stated that wound care MD was consulted on 1/22/2024 and initial wound assessment by wound care MD was done on the same day. LVN 1 stated that wound care MD's notes indicated a recommendation to implement pressure relieving measures and offloading as tolerated. During an interview with MDS Nurse 2 (MDS) 2 on 2/2/2024 at 8:40 AM, MDS 2 stated that Resident 4 was admitted on [DATE] and nurses' notes did not indicate any wound or skin problems upon admission. MDS 2 stated that skin assessment was not done until 1/22/2024. MDS 2 stated Resident 4 was assessed on 1/22/2024 as having sacral MASD, right hip and left hip DTI. MDS 2 stated that it was important to conduct a skin assessment upon admission. MDSN 2 added, skin conditions such as wounds and pressure ulcers should be reported to MD so a treatment order can be obtained as needed. MDS 2 stated, LAL mattress should be set according to resident's weight, and licensed nurses, especially treatment nurses should be checking the LAL mattress periodically to make sure that the settings were correct, and the LAL was functioning right. A review of facility's policy and procedure titled, Prevention of Pressure Injuries, revised in April 2020, indicated risk assessment to assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. A review of Med Aire Plus 10' Alternating Pressure and Low Air loss Bariatric mattress replacement system user manual, product features control unit indicated that digital control unit includes intuitive controls for adjusting the air pressure based on the patient's weight and comfort levels. 2. A review of Resident 27's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 27's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), stage 2 pressure ulcer (progressed to affect both the top and bottom layers of the skin but has not yet affected the fatty tissue beneath) of the sacral region (triangular-shaped bone at the base of the spine just superior to the coccyx [tailbone]) and functional quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function) A review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/14/2023, indicated Resident 27 was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident 27 was dependent (helper does all the effort. Resident does none of the effort to complete the activity or holds trunk or, the assistance of two [2] or more helpers is required to complete the activity) in eating, shower/bathe self, lower body dressing, putting on/ taking off footwear, toilet transfer and chair /bed-to-chair transfer. A review of Resident 27's Physician's Order, dated 12/5/2023, indicated to keep low air loss mattress setting at Resident weight (12/1/2023 at 124 pounds [LBS., unit of measure]) every shift. During multiple observation in Resident 27's room, on 1/30/2024 at 8:10 AM, 2/1/2024 at 1:55 PM and 2/2/2024 at 8:49 AM, Resident 27 was observed in bed with the LAL set on maximum 600 millimeter of mercury (mmHg, unit of pressure) 25 minutes cycle time. During a concurrent observation in Resident 27's room and interview with the Director of the Staff Development (DSD) on 2/2/2024 at 8:50 PM, DSD stated, Resident 27 LAL was set on 500 LBS. The LAL setting was incorrect. Resident 27 's weight is 124 LBS. It should be in the correct setting because Resident 27 will move frequently because he is uncomfortable because of the incorrect setting, and it will not be therapeutic for the resident. A review of the manufacturer's manual Med Aire Plus 10, Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System User Manual, dated 2009, indicated weight settings range from less than <250-1,000 LBS. and can be used to adjust the pressure of the inflated cells based on the Resident's weight and comfort level. Pressure Range Selection (+/-) users can adjust the pressure level of the air mattress, using the plus (+) and minus (-) buttons, to a desired firmness based on personal comfort of weight setting. Based on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for three (3) of seven (7) sampled residents (Residents 289, 27, and 4) for pressure injury care area, in accordance with the facility's policy and procedure by failing to ensure: 1. The low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct setting for Resident 289. The facility also failed to ensure Resident 289's pressure ulcer was assessed with measurements and documented on 1/27/2024. 2. The LAL was on the correct setting for Resident 27. 3. Resident 4's pressure injuries/skin was not assessed upon admission on [DATE] and Resident 4's LAL mattress was not set according to weight. This deficient practice had the potential to place Residents 289 27, and 4 at risk for skin integrity complications and pressure injury. Findings: 1. A review of Resident 289's admission Record indicated Resident 289 was admitted to the facility on [DATE] with diagnoses of methicillin resistant staphylococcus aureus infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA - infections caused by specific bacteria that are resistant to commonly used antibiotics), acute respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily function), pneumonia (lung inflammation caused by bacterial or viral infection), and adult failure to thrive (describes a state of decline and may be caused by chronic diseases and functional impairments, manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity). A review of the Resident 289's Admit Screener dated 1/27/2024, indicated Resident 289 had a stage two pressure ulcer (partial thickness of loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough or bruising) located at the sacrum (bone located at the base of the spine) with no measurements of the pressure ulcer documented. A review of Resident 289's weight dated 1/28/2024, indicated Resident's weight was 145 pounds (LBS). A review of Resident 289's Skin/Wound Note dated 1/30/2024, indicated head to toe assessment done. New order for stage 2 wound to coccyx (small bone at the bottom of the spine). Cleanse with normal saline and apply Medihoney (a wound and burn gel used to support the removal of necrotic [characterized by, or producing death of a usually localized area of living tissue] tissue and aids in wound healing) with dry dressing daily for 21 days. During an observation on 1/30/2024 at 8:34 AM in Resident 289's room, Resident 289 was lying in bed and the LAL mattress setting was at 250 LBS. During a concurrent interview and record review of Resident 289's pressure ulcer picture taken on 1/30/2024 at 3:59 PM with the Director of Nursing (DON), the DON verified Resident 289's photo was taken, but the measurement was not done for Resident 289 pressure ulcer. The DON stated the treatment nurse needed to measure the wound for its length, depth, and width to know the size and appearance of the wound. The DON stated knowing the measurement of the wound was needed to know the treatment of the wound. The DON stated it was crucial to measure the wound to track whether the pressure ulcer was deteriorating or healing. A review of Resident 289's Care Plan dated 2/1/2024, indicated air low loss to be applied for risk for impaired skin integrity with intervention to monitor setting for LAL mattress in accordance with resident's weight. During an observation on 2/1/2024 at 8:03 AM in Resident 289's room, Resident 289 was lying in bed and his LAL mattress setting was at 250 LBS. A review of Resident 289's Braden Scale (tool used for Predicting Pressure Ulcer Risk), dated 2/2/2024, indicated Resident 289 was at high risk for pressure ulcers. It indicated Resident 289's activity was bedfast (confined to bed). Resident 289's had very limited mobility (makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently). It also indicated Resident 289 had a problem with friction and shear (requires moderate to maximum assistance in moving). During an observation on 2/2/2024 at 8:35 AM in Resident 289's room, Resident 289 was lying in bed and his LAL mattress setting was at 200 LBS. During a concurrent observation, record review, and interview on 2/2/2024 at 11:36 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 289's setting at 200 LBS is incorrect. LVN 1 verified that Resident 289's weight in accordance to the clinical record indicated 145 LBS as of 1/28/2024. LVN 1 stated Resident 289's LAL mattress setting should be set at 150 LBS. LVN 1 stated Resident 289's setting at 200 LBS would not help with the distribution of pressure and would not assist with the healing of the wound. LVN 1 stated all licensed nurses were responsible for checking the LAL mattress settings for residents. During a concurrent interview and record review of Resident 289's pressure ulcer picture (taken on 1/30/2024) on 2/2/2024 at 3:02 PM with LVN 1, LVN 1 stated a picture of Resident 289's wound was taken, but no measurements were documented. LVN 1 stated the stage two pressure ulcer needed to be measured. LVN 1 stated she returned to work on 1/31/2024 and did not measure the wound. A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, revised 4/2020, indicated for support surfaces and pressure redistribution select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Consult with current clinical practice guidelines for prevention measures associated with specific devices. A review of the manufacturer's guide titled, Med Air Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System, not dated, indicated the digital control unit includes controls for adjusting the air pressure based on the patient's weight. A review of the facility's policy and procedure titled, Wound Care, revised 10/2010, indicated all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound should be recorded in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label an intravenous (IV-administered into a vein) medication with the resident's name, medication name, dosage, route, and time administered and an IV tubing (plastic tubing that connects the set-up to a bag of fluid to the IV) was not labeled with date initiated, time, and initials (licensed nurse who started the IV) for one of two sampled resident (Resident 289) for antibiotic care area. This deficient practice had the potential for Resident 289 to receive an incorrect IV medication as ordered by the physician and infection control risks from using an unlabeled IV tubing. Findings: A review of Resident 289's admission Record indicated Resident 289 was admitted to the facility on [DATE] with diagnoses of methicillin resistant staphylococcus aureus infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA - infections caused by specific bacteria that are resistant to commonly used antibiotics), urinary tract infection (UTI - an infection of the bladder and urinary system), and type 2 diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin [a hormone released from the pancreas that controls the amount of glucose in the blood], causing blood sugar [glucose] levels to be abnormally high). A review of Resident 289's Nurses Notes dated 1/26/2026, indicated Resident 289's mental status was alert and oriented x 3 (alert and oriented to person, place, and time), able to communicate verbally, speech clear, and was able to understand and be understood when spoken. A review of Resident 289's Physician's Order dated 1/26/2024, indicated vancomycin hydrocholoride (HCl, an antibiotic used to treat severe bacterial infections) in sodium chloride (NaCl, also known as salt, an ionic compound representing a 1:1 ratio of sodium and chloride) Intravenous Solution 1.25 milligrams (MG-unit of measurement)/250 milliliter (ML - unit of fluid volume) - Use 1.25 gram (G-unit of measurement) intravenously every 12 hours for MRSA sputum culture (a test that check for bacteria or another type of organism that may be causing an infection in the lungs or the airways leading to the lungs) for seven days administer over two hours. During an observation on 1/31/2024 at 9:05 AM in Resident 289's room, an empty bag of Sodium Chloride 0.9 % 250 ML bag hung on an IV pole and the IV tubing was disconnected from Resident 289. The IV bag was not labeled, and the tubing was not label ed with date initiated, time, and the licensed nurse's initials. During a concurrent observation and interview on 1/31/2024 at 9:12 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated the IV bag was not labelled and should be labeled with the name of the medication and the date. LVN 1 stated the IV bag should contain Resident's 289's name, room number, flow rate, date, name of the medication, and time of administration. LVN 1 stated the IV bag should had been disposed after the infusion (a method of putting fluids, including drugs, into the bloodstream) was completed. LVN 1 stated the tubing on the IV bag was also not labeled with the date, time, and initialed and should have been changed with a new IV tubing set. During an observation on 2/1/2024 at 8:03 AM in Resident 289's room, an empty IV bag labeled RN to reconstitute (the process of adding a solvent or diluent to a medication in powdered form to dissolve it and form a solution) two (2) vials of Vancomycin 1 GM with 10 ML normal saline (NS, 0.9 % saline, there is 0.9 G of salt [NaCl] per 100 ML of solution, or 9 G per liter) and mix 12.5 ML (1.25 GM) in 250 ML NS and infuse intravenous piggyback (IVP, a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time) over 120 mins every 12 hours for MRSA sputum culture for 7 days hung on the IV pole disconnected from the resident. The tubing connected to the IV bag was not labeled with the date, time, and the licensed nurse's initials. During a concurrent observation and interview on 2/2/2024 at 8:38 AM with Registered Nurse (RN 1), RN 1 stated the Vancomycin IV bag (hanging on Resident 289's IV pole) did not have the date when it was administered. RN 1 stated the medication label should include today's date and initialed by the Director of Nursing (DON) since she administered the medication. RN 1 stated the IV bag needed to be labeled with resident's name, medication, dose, route, and time to ensure the correct medication was given to the correct resident with the correct dose and time. RN 1 stated a wrong medication could be administered to the resident since there was no label. RN 1 also stated the medication should be disposed once the infusion was completed to avoid residents or visitors from seeing what medication Resident 289 was on. RN 1 stated the tubing was not labeled with date opened/ used. RN 1 stated the unlabeled tubing could be an old tubing or be reused since the tubing was not labeled. RN 1 stated tubing used that was over a day old could lead to bacterial growth in the tubing which could infect the resident if used. During an interview on 2/2/2024 at 10:09 AM with the DON, the DON stated the IV medication given to Resident 289 should have been labelled with the medication name, dosage, and rate. The DON stated once the infusion was completed the IV bag and tubing should be discarded to avoid family members or roommate to look at Resident 289's medication. A review of the facility's policy and procedure titled, Administering Medications, revised 4/2019, indicated the individual administer the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the facility's policy and procedure titled, Administration Set/Tubing Changes, revised 2/2022, indicated to label tubing with date, time, and initials. The label may include the date and time that tubing was initiated and when tubing should be discontinued or changed. Any tubing that is found not labeled must be changed and then labeled accordingly. A review of the facility's policy and procedure titled, Administering an Intermittent Infusion, updated 7/2023, indicated label contend tubing with date, time and nurses initials for when it was hung.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 15) for pain care area, receive the treatment and care to address the resident's pain during rehabilitation exercise (aim to return full function following injury through re-building muscle strength, endurance, power and improving overall flexibility and mobility), in accordance with the facility's policy and procedure. This deficient practice had the potential to result in a delay of necessary care and treatment and unmanaged pain that could negatively affect the resident's quality of life. Findings: A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 15's diagnoses included liver cirrhosis (is permanent scarring that damages your liver and interferes with its functioning), cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right and left lower limbs, and muscle weakness. A review of Resident 15' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/21/2023, indicated Resident 15 had intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 15 needed substantial/maximal assistance (helper does more than the effort helper lifts or holds trunk or limbs and provides more than half the effort) toileting hygiene, shower/bathe self, lower body dressing, and putting on and taking off footwear. The MDS also indicated, Resident 15 needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides [NAME] than half the effort) toilet transfer, chair/bed-to-chair transfer and walk 10 feet (ft, unit of measurement). A review of Resident 15's Physician's order dated, 1. On 1/11/2024 and discontinued the same date, Advil Oral Tablet (Ibuprofen [is a nonsteroidal anti-inflammatory drug {NSAID} that works by reducing hormones that cause inflammation and pain in the body]) Give 200 MG (milligrams, unit of measurement) by mouth every eight (8) hours as needed for mild pain, pain scale 1-3 (score of 10 as the most painful). 2. On 1/31/2024, Physical Therapy (PT) and Occupational Therapy (OT) treatment continuation order daily (QD) 5x/week for 4 weeks for therapeutic exercise (therex), therapeutic activities (theract), neuromuscular re-education gait/self-care training and patient caregiver education. During interview with Resident 15, on 01/31/2024 at 9:50 AM, Resident 15 stated, I have pain on my left knee and left hip when I move. Tylenol does not work so I refuse it. Ibuprofen is the only medication that works for me. Hospital discharge instruction said No Ibuprofen because it is not good for the liver. Tylenol is the only option, but it does not work. The staff informed the medical doctor (MD, primary doctor in the facility), they asked the MD if I could have that, and he agreed that I can take it before exercise . During interview with Resident 15, on 2/1/2024 at 12:18 PM, Resident 15 stated, I only have pain when I walk or move during rehabilitation exercises. I have not taken any pain medications since I came back from the hospital. So, it is painful when I do therapy. During concurrent interview with Registered Nurse 1 (RN 1) and record review of Resident 15's Medication Administration Record (MAR), on 2/1/2024 at 12:26 PM, RN 1 checked Resident 15's MAR and there was no pain medication ordered. There was no pro re nata (PRN, as needed) and regular routine pain medications for Resident 15. During interview with Occupational Therapist Assistant (OT 1), on 2/1/2024 at 1:16 PM, OT 1 stated, there was no pain medication for Resident 15 before or during they do the rehabilitation therapy. A review of facility's policy and procedure (P&P) titled, Administering Pain Medications, dated 10/2022, P&P indicated, the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain management is a multidisciplinary care process that includes developing and implementing approaches to pain management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call system (the means of the initial communication between staff and residents) was functional on two out of two (2) sampled residents (Resident 10 and 292). This deficient practice had a potential in a delay in meeting the residents' needs for assistance and can lead to frustration, falls and accidents. Findings: 1. A review of Resident 10's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses included subdural hematoma (a serious condition where blood collects between the skull and the surface of the brain), history of falling and hypertension (high blood pressure). A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/4/2023, indicated Resident 10 has severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 10 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides more than half the effort) in toilet hygiene, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear and tub/shower transfer. During an interview with Resident 10 on 1/30/2024 at 7:59AM, Resident 10 stated she was not feeling well. Resident 10 stated she was not able to call for help and no staff was coming inside her room. Resident 10 feels upset because she was waiting for 20 minutes and there was no staff coming inside her room. During an observation inside Resident 10's room on 1/30/2024 at 8:00 AM, CNA 4 came in with blood pressure (BP, is the pressure of blood pushing against the walls of your arteries [carry blood from your heart to other parts of your body]) machine to get Resident 10's vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate). There was no call light (an alerting device for nurses or other nursing personnel to assist a resident when in need)cord on the call light adapter that was plugged in on the wall mount located on Resident 10's head of the bed. During a concurrent observation inside Resident 10's room and interview with Certified Nursing Assistant (CNA) 4 on 1/30/2024 at 8:01 AM, CNA 4 stated, the call light fell on the side of the bed. CNA 4 looked around Resident 10's bed but there was no call light cord or call light button found. CNA 4 stated, we will find the call light. CNA 4 looked under Resident 10's bed but she cannot find it. During an observation inside Resident 10's room at 1/30/2024 at 11:21 AM, Resident 10 was sleeping. The call light was observed laying on the floor and was not within the Resident 10's reach. During an interview with Infection Preventionist Nurse (IPN) on 2/2/2024 at 4:55 PM, IPN stated, The call light is important because it is how residents communicate with the staff. The IPN stated, call light should always be within the resident's reach. A review of facility's policy and procedure (P&P) titled, Answering the Call Light, dated 10/2010, P&P indicated, be sure that the call light is plugged in at all times. Answer the Resident's call as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with facility's policy and procedures (P&P) titled, Psychotropic Medication (drugs that affect the person's mental state) Use, and Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) - Clinical Protocol, to ensure three of five sampled residents (Residents 10, 13 and 291) for unnecessary medication care area. Residents prescribed with psychotropic medications included clear, clinical indications for use or continued use to treat a specific condition. The deficient practices had the potential for adverse effect (unwanted, unintended result) on resident's psychosocial wellbeing, risk for falls, constipation, confusion, excessive sedation, and increased agitation, and receiving more medication than needed for three out of five sampled residents (Resident 10, 13, 291). Cross reference with F758. Findings: 1. During a review of Resident 10's admission Record (a document containing medical and demographic information), the admission Record indicated the resident was originally admitted to the facility 6/24/2023 and readmitted on [DATE]. Resident 10's diagnoses included dementia (progressive loss of memory) without behavioral disturbance, unspecified psychosis (a mental disorder characterized by a disconnection from reality), dizziness, repeated falls, and depression (a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities) A review of Resident 10's History and Physical (H&P) dated 10/13/2023 indicated, This resident has the capacity to understand and make decision. A review of Resident 10's Minimum Data Summary (MDS), dated [DATE] indicated under behavior section no potential indicators of psychosis, no hallucinations (perceptual experiences in the absence of real external sensory stimuli) and no delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident 10's MDS indicated there was no physical, verbal, or other behavioral symptoms exhibited or directed toward others. A review of Resident 10's current Order Summary Report dated 2/2024, included an order for: a. Seroquel (medication used to treat mental illness) Oral Tablet 25 milligram ([MG] - unit of measure of weight), order date 9/27/2023 and renewed on 10/3/2023 with instructions to administer one tablet (25 MG) by mouth two times a day for psychosis manifested by yelling out at staff. b. Seroquel Oral Tablet 50 MG, order date 10/3/2023, was added, with instructions to give one tablet (50 MG) by mouth at bedtime for psychosis manifested by yelling at staff. Resident 10's total daily dose increased from 50 mg to 100 mg daily on 10/3/2023. A review of Resident 10's Multidisciplinary Care Conference, dated 1/9/2024, indicated per Resident 10's physician that the resident is able to make her own decisions and Psych (Psychiatrist) has evaluated the resident and stated she is stable. A review of Resident 10's Psychiatric Progress Note dated, 12/22/2023 indicated, Still asking to go home - otherwise stable. During an interview on 2/2/2024 at 5:06 PM with a Registered Nurse (RN) 2, RN 2 stated, Resident 10 was on Seroquel for sleep, because the resident calls the nurses frequently, irritated and cannot sleep (physician's order for Seroquel was indicated for Resident 10's behavior of yelling at staff). 2. A review of Resident 13's admission Record, dated 2/2/2024, indicated the resident was originally admitted to the facility 6/24/2023 and readmitted on [DATE]. Resident 10's diagnoses included major depressive disorder, insomnia (difficulty falling or staying asleep), history of falling, fecal impaction, and difficulty walking. A review of Resident 13's H&P, dated 11/7/2023 indicated, resident has capacity to make decisions. A review of Resident 13's MDS, dated [DATE] indicated under behavior section the resident did not have potential indicators of psychosis, no hallucinations, and no delusions. A review of current Order Summary dated 2/2024, indicated on 2/2024, Resident 13 was prescribed, Abilify (Aripiprazole, antipsychotic medication that helps treat several kinds of mental health conditions) Oral Tablet 5 MG, with instructions to give half tablet (2.5 MG) by mouth one time a day for Psychosis as manifested by (m/b) responding to internal stimuli stating she is looking for her babies. During an interview on 2/2/2024, at 3:01 PM with Resident 13, Resident 13 stated that she has never heard voices, never hallucinated, or had delusions, and have never been diagnosed with a psychiatric problem. During an interview on 2/2/2024 at 3:19 PM, with a Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 13 receives Abilify because she is sad, not eating, and getting anxious for everything (the prescribed indication for use of Abilify for Resident 13's behavior of psychosis m/b responding to internal stimuli stating she is looking for her babies). 3. A review of Resident 291's admission Record, dated 2/2/2024, indicated the resident was admitted to the facility 1/5/2024. Resident 291's diagnoses included major depressive disorder, history of falling, right femur fracture (a break in the thighbone), difficulty walking, zoster (Shingles is a viral infection that causes a painful rash), and unspecified psychosis. A review of Resident 291's facility's H&P, under physician progress notes dated 1/15/2024 indicated, Resident 291 does not have capacity to understand and make decisions. A review of current Order Summary dated 1/2024, indicated, on 1/17/2024 Resident 291 was prescribed Seroquel 25 mg, with instructions to give one-half (12.5 MG) tablet by mouth at bedtime for psychosis m/b delusional thoughts, thinking her daughter is her mother. A review of Resident 291's Initial Psychiatric Evaluation dated, 1/11/2024 indicated, family medical and psychiatric history, Unknown .Unable to assess. During an interview on 2/2/2024, at 3:28 PM with Resident 291's Responsible Party (RP) 1, RP 1 stated, Resident 291 does not have delusions, the resident speaks Armenian and Farsi. RP 1 stated the facility has one therapist that speaks Resident 291's language. RP 1 stated that Resident 291 is very healthy with a good memory and no history of dementia or Alzheimer's (type of dementia that affects memory, thinking and behavior). During a concurrent interview and record review on 2/2/2024, at 5:17 PM, with RN 2, Resident 291' MARs between 1/6/2024 to 2/2/2024 was reviewed which indicated, Resident 291 was administered both Melatonin (a sleep supplement) and Seroquel each night at bedtime for sleep. RN 2 stated, Resident 291 is Armenian, and she could not understand the resident and thought Resident 291 was getting both medications to help the resident sleep (the prescribed indication for use of Seroquel for Resident 291's behavior of psychosis m/b delusional thoughts, thinking her daughter is her mother). RN 2 stated Resident 291 is more confused and sleeps more (potential side effects of Seroquel). During a concurrent interview and record review on 2/2/2024, at 6:01 PM with the Director of Nursing (DON), Resident 291's Order Summary dated 1/2024, MARs dated from 1/6/2024 to 2/2/2024, progress notes were reviewed dated from 12/1/2023 to 2/2/2024. The DON stated we must reassess each resident on psychotropic medications to determine if the medications are appropriate for the residents. A review of the facility's P&P titled, Dementia - Clinical Protocol, dated 11/2018, indicated, as needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications . The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. A review of the facility's P&P titled, Psychotropic Medication Use, dated 7/2022, indicated, residents will not receive medications that are not clinically indicated to treat a specific condition . Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 13's admission record, indicated Resident 13 was admitted on [DATE] with diagnosis of Extended Spectrum?Beta-Lactamase (ESBL) (bacteria in the urine), and urine retention (inability to urinate) with an indwelling catheter (tube that drains urine from the bladder into a bag) in place. During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 has the ability to understand and make decisions. During a review of Resident 13's Orders Report, dated 11/6/2023, the Orders report, indicated indwelling catheter to be changed monthly on the 23rd of every month for diagnosis of urinary retention. During a review of Resident 13's Treatment Administration Record (TAR), dated 1/23/2024, the TAR, indicated the licensed nurses did not change out the indwelling catheter because Resident 13 refused treatment. During a concurrent observation and interview on 2/1/2024 at 9:00 AM, with Resident 13, in Resident 13's room, Resident 13 stated she had the indwelling catheter when she was admitted to the facility on [DATE]. During an interview on 2/1/2024 at 9:35 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 13 did not want her indwelling catheter changed because the process was uncomfortable. LVN 1 stated she did not document the reason for Resident 13 refusing treatment LVN 1 stated she should have documented the refusal and reporting, but she did not. During an interview on 2/2/2024 at 8:51 AM with MDS 2 coordinator, MDS 2 coordinator stated, Resident 13 did not have a baseline care plan to address the care for indwelling catheter. During an interview on 2/2/2024 at 6:35 PM with the DON, the DON stated licensed nurses are supposed to document when a resident refuses treatment, report to the physician, and document the reasons for refusal on the electronic health record. During a review of the facility's policy and procedure titled, Catheter Care, Urinary, dated 8/2022, Catheter Care, Urinary, indicated, notify the supervisor if the resident refuses the procedure, and document the reason why the resident refused the procedure and the intervention taken. Based on observations, interviews and record reviews, the facility failed to provide services and treatment to prevent urinary tract infection (UTI, clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract, including the urethra, bladder, ureters, and/or kidney) for two of four sampled residents (Resident 290 and 13) who have indwelling catheter (tube that drains urine from the bladder into a bag) by failing to: 1. Monitor and document signs and symptoms of UTI for Resident 290 on 1/30/2024. 2. Change Resident 13's indwelling catheter on 1/23/2024 as ordered by the physician. Theses deficient practices resulted in Resident 290 developing cloudy urine, worsening gross hematuria (blood in urine that can be seen with naked eye) and possible UTI. In addition, it may result to Resident 13 developing UTI. Findings: 1. A review of Resident 290's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included gross hematuria, benign prostatic hyperplasia (BPH; enlargement of the prostate [male reproductive gland] that is not cancerous), retention of urine and acute kidney failure. During a review of Resident 290's Multidisciplinary Care Conference, dated 1/11/2024, the Multidisciplinary Care Conference indicated, Resident 290 has an indwelling catheter. During a review of Resident 290's Minimum Data Set (MDS; a standardized assessment and care screening tool) dated 1/12/2024, indicated Resident 290 had moderate cognitive (ability to understand and make decisions) impairment. During a review of Resident 290's Lab Results Report: Urinalysis, dated 2/2/24, the Lab Results Report indicated, Resident 290 had blood in his urine, was turbid and had a high white blood cell count. During an observation on 1/30/2024 at 9:26 AM in Resident 290's room, reddish and turbid urine with sediment was observed in Resident 290's indwelling catheter tubing. During a concurrent observation and interview on 2/1/2024 at 11:47 AM with Certified Nurse Assistance (CNA) 4 in Resident 290's room, Resident 290's urine in indwelling catheter bag was observed. CNA 4 stated, the urine looks dark brown to reddish color with lumps of little white stuff. CNA 4 stated, cloudy, and red urine can signify infection and it needs to be reported to the charge nurse immediately. During a concurrent observation and interview on 2/1/2024 at 12:17 PM with Registered Nurse (RN) 1 in Resident 290's room, Resident 290's urine in the indwelling catheter bag was observed. RN 1 stated the urine looks amber and cloudy with pus. RN 1 stated this could signify infection and dehydration and it is important to notify the doctor immediately. During a concurrent interview and record review on 2/1/2024 at 12:52 PM with Minimum Data Set Nurse (MDS) 2 at MDS 2's office, Resident 290's Care Plans dated 1/2024 to 2/2024 was reviewed. The Care Plans indicated, an indwelling catheter care plan was not found for Resident 290. MDS 2 stated, Resident 290 does not have a care plan for his foley catheter. MDS 2 stated, Resident 290 should have a foley care plan that specifically indicates monitoring for signs and symptoms of UTI such as: sediment in urine, hematuria, and pain. During an interview on 2/2/2024 at 10:09 AM with the director of nursing (DON) in the DON's office, the DON stated, oncoming nurses should assess the indwelling catheter. DON stated that the charge nurse should inform the medical doctor (MD) as soon as possible if there is blood or puss in the urine. During a review of the facility's policy and procedure titled, Catheter Care, Urinary dated 9/2014, indicated, Observe the resident for complications associated with urinary catheters. Observe for signs and symptoms of UTI. Report findings to the physician or supervisor immediately. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status dated 12/2016, indicated, the nurse will notify the resident's Attending Physician on call when there has been a significant change in the resident's physical condition. During a review of the facility's policy and procedure titled, Urinary Tract Infection/Bacteriuria dated 4/2018, indicated, The staff and practitioner will identify individuals with possible signs and symptoms of a UTI. Nurses should observe, document and report signs and symptoms in detail and avoid premature diagnostic conclusions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 243's admission Record indicated the resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 243's diagnoses included congestive heart failure (a long-term condition in which the heart cannot pump blood well enough to meet your body needs), pleural effusion (water on the lung, happens when fluid builds up in the space between your lungs and chest cavity), and hypertension (high blood pressure) A review of Resident 243' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/1/2024, indicated Resident 246 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 243 needed partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides [NAME] than half the effort) in toileting hygiene, shower/bathe self, upper body dressing, chair/bed-to-chair transfer and walk 10 feet (ft, unit of measurement). A review of Resident 243's Physician's order, dated 1/26/2024, indicated oxygen at 2 liters per minute (LPM) via nasal cannula as needed for shortness of breath. During an observation in Resident 243's room on 1/30/2024 at 7:55 AM, Resident 243's nasal cannula was observed on the resident's cheek and not on the resident's nostrils. During concurrent observation and interview with the Infection Prevention Nurse (IPN), on 2/2/2024 at 6:56 PM, IPN stated, Resident 243's nasal cannula was not properly placed on her nostrils. Resident 243 was not getting the full concentration of oxygen. The licensed nurse should check the resident when passing medications and when the Certified Nursing Assistant (CNA) was doing Activities of Daily Living (ADLs, activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Place appropriate oxygen device on the resident. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. Based on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for two (2) of 2 sampled residents (Resident 289 and 243) for oxygen care area in accordance with the facility's policy and procedure when: 1. Resident 289 did not receive three (3) liters of oxygen continuously per physician's order. 2. Resident 243's nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was not properly placed on the resident's nostrils (two openings in the nose through which air moves when you breathe). These deficient practices had the potential to cause complications associated with oxygen therapy to Residents 289 and 243. Findings: 1. A review of Resident 289's admission Record indicated Resident 289 was admitted to the facility on [DATE] with diagnoses of methicillin resistant staphylococcus aureus infection Methicillin Resistant Staphylococcus Aureus Infection (MRSA - infections caused by specific bacteria that are resistant to commonly used antibiotics), acute respiratory failure with hypoxia (lack of oxygen in the tissues to sustain bodily function), pneumonia (lung inflammation caused by bacterial or viral infection), and adult failure to thrive (describes a state of decline and may be caused by chronic diseases and functional impairments, manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 289's Nurses Notes, dated 1/26/2026, indicated Resident 289 had a physician order for oxygen therapy (nasal cannula) at 2 to three (3) liters/minute (LPM - flow of oxygen) to maintain an oxygen saturation (SpO2, measures how much oxygen is carried by the hemoglobin [Hgb- a protein in red blood cells that carries oxygen to the body's organs and tissues and transports carbon dioxide from your organs and tissues back to the lungs] in your blood or how well a person is breathing) at 92% or greater. The Nurses Notes also indicated Resident 289's mental status was alert and oriented times three (alert and oriented to person, place, and time), able to communicate verbally, speech clear, and was able to understand and be understood when spoken. A review of Resident 289's Medication Administration Record for the Month of January and February 2024 indicated Resident 289 to receive oxygen at three LPM via nasal cannula continuously for shortness of breath. During a concurrent observation and interview on 1/30/2024 at 8:34 AM in Resident 289's room, Resident 289 was lying in bed receiving oxygen at four (4) LPM via nasal cannula. Resident 289 stated he was supposed to receive three liters of oxygen. During a concurrent record review of Resident 289's physician order and interview with RN 1 on 1/30/2024 at 8:41 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 289 was receiving 4 LPM of oxygen via nasal cannula. RN 1 stated the physician ordered oxygen therapy on 1/27/2024 for oxygen administration at 2 to three (3) LPM. RN 1 stated Resident 289 was not receiving the correct oxygen administration of 4 LPM. RN 1 stated if Resident 289 received extra oxygen than prescribed, he could go into shock if he received too much oxygen. During an interview on 2/2/2024 at 10:09 AM with the Director of Nursing (DON), the DON stated the physician ordered the oxygen to be administered to the resident based on the physician's assessment of Resident 289. The DON stated the licensed nurses should administer the correct amount of oxygen prescribed to the resident and should not give more than what is ordered by the physician. A review of the facility's policy and procedure titled, Oxygen Administration, revised 10/2010, indicated to adjust the oxygen delivery device to the proper flow of oxygen being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were administered in accordance with physician orders for two of six residents reviewed during medication administration pass. The facility failed to ensure: 1a. Resident 19's Metformin (a medication that treats type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) was not administered over two hours after the scheduled administration time of 7:30 AM, with instructions to administer daily with breakfast. 1b. Resident 19's blood pressure (BP) was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's combination BP medication, Lisinopril 20 milligram (MG, unit of measure of weight) with Hydrochlorothiazide (HCTZ) 12.5 MG 2. Resident 239's ClearLax (also known as MiraLAX [polyethylene glycol 3350 powder, for solution] used to treat occasional constipation) was prepared in accordance with the physician's order and the resident was accessed as a parameter to determine whether to hold or administer the medication. This deficient practice increased the risk that Residents 19 and 239 could have received too much or too little medication due to lack of assessment and inaccurate dosing and failing to administer in accordance with physician orders. These failures increased the potential for Resident 19 and Resident 239 to experience adverse reactions related to uncontrolled blood pressure, blood glucose, or bowel management. Findings: 1a. A review of Resident 19's admission Record (a document containing medical and demographic information), the admission Record indicated the resident was admitted to the facility 5/26/2022. Resident 19's diagnoses included Type 2 Diabetes Mellitus (a group of disease that result in too much sugar in the blood) and Hypertension (HTN, high blood pressure). A review of Resident 19's History and Physical (H&P). dated 6/1/2023 indicated, This resident has the capacity to understand and make decision. A review of Resident 19's current Order Summary Report, dated 1/31/2024, included the following active orders: a. Metformin 500 MG, with instructions to give two tablets by mouth in the morning for Diabetes Mellitus. Take two (1000 MG) tablets by mouth every morning with Breakfast, with an order date of 10/22/2022. b. Metformin 500 MG, with instructions to give one tablets by mouth in the evening for Diabetes Mellitus. Take one (500 MG) tablet by mouth every evening, with an order date of 10/22/2022. b. Lisinopril/HCTZ 20 MG/12.5 MG, with instructions to five one tablet by mouth one time a day for HTN and to hold the medication if systolic blood pressure (SBP, blood pressure when the heart is contracting) is less than 110 mm Hg (millimeters of mercury, target blood pressure is below 120 mm Hg for SBP ), with an order date of 6/2/2023. A review of the facility's Schedule of Mealtimes. indicated: Breakfast 7:00 AM Lunch 12:00 PM Dinner 5:00 PM During a concurrent observation and interview on 2/2/2024 between 9:21 AM to 9:38 AM with Registered Nurse (RN) 1, RN 1 was observed preparing the following medications for Resident 19: a. Metformin 500 mg, two tablets (1000 mg), prescription label indicated to give with breakfast. b. Vitamin B-12 (vitamin supplement) 1000 mcg, one tablet exp c. Lisinopril-HCTZ (treat high blood pressure) 20/12.5, one tablet, RN 1 stated that she will hold Resident 19's blood pressure medication because SBP is less than 110 mm Hg. RN 1 was not observed measuring Resident 19's blood pressure. d. Daily Vitamin - MVI with Multimineral Supplement, one tablet e. Omeprazole (treat indigestion and heartburn), 40 mg, one capsule During interview on 2/2/2024 at 9:33 AM, RN 1 stated she prepared and will administer a total of four morning medication for Resident 19. RN 1 stated the medication did not include the resident's BP medication, Lisinopril/HCTZ 20 MG/ 12.5 MG, which was held and not administered. During observation on 2/2/2024 at 9:35 AM, RN 1 entered Resident 19's room and administered the four medications. No food was observed available or offered to Resident 19 when the resident was administered the Metformin 1000 MG dose. During an interview on 2/2/2024 at 9:40 AM with RN 1, RN 1 stated Resident 19 ate some time ago around 8:00 AM (on 2/2/2024). During a concurrent record review of Resident 19's physician order for Metformin and interview on 2/2/2024, at 11:41 AM, with RN 1, RN 1 stated the Metformin is scheduled to be administered to Resident 19 at 7:30 AM. RN 1 stated Resident 19 should have been given her Metformin with food. RN 1 stated, Metformin could drop the blood sugar and we do not want the resident to bottom out. Giving it with meal gives a safety net for the resident's blood sugar level control. RN 1 stated there was no documentation of Resident 19 having her blood sugar checked in the last 90 days. RN 1 stated there was no physician order to check Resident 19 blood sugar. RN 1 stated, she does not have an idea what Resident 19's blood sugar level was. During a concurrent record review of Resident 19's physician order for Metformin, laboratory test, and Care Plan for Diabetes and interview on 2/2/2024 at 5:31 PM with the Director of Nursing (DON), the DON stated Resident 19's Metformin should have been given at 7:30 AM with breakfast. The DON stated Metformin should have been administered with food to prevent side effects that include low blood sugar, nausea, and stomach upset. The DON stated Resident's 19 blood sugar and A1C test (a simple blood test that measures average blood sugar levels over the past 3 months) was last taken on 9/18/2023 and the results indicated the resident's blood sugar was 100 milligrams (mg) per deciliter (dL) which was slightly higher than normal and the resident's A1C level was 5.6 (%) percentage (normal A1C level is below 5.7%). The DON stated Resident 19 A1C of 5.6 % was considered normal based on the criteria. The DON reviewed Resident 19's care plan that indicated to check blood sugar as ordered. The DON confirmed there was no physician order to monitor or check Resident 19's blood sugar levels while on the diabetic medication Metformin. The DON stated the care plan should coincide with the physician orders. The DON added, there was no physician order to check or monitor Resident 19's blood sugar level while on Metformin (total daily dose of 1500 MG of Metformin). According to the Centers for Disease Control and Prevention (CDC) dated 2/2023, indicated, fasting blood sugar level of 99 mg/dL or lower is normal, 100 to 125 mg/dL indicates prediabetes, and 126 mg/dL or higher indicates diabetes. According to DailyMed, The National Library of Medicine (NLM, DailyMed searchable database provides the most recent labeling submitted to the Food and Drug Administration [FDA]), updated 2/2017, Metformin hydrochloride should be given in divided doses with meals .Response to all diabetic therapies should be monitored by periodic measurements of fasting blood glucose and glycosylated hemoglobin (A1C) levels, with a goal of decreasing these levels toward the normal range. During initial dose titration, fasting glucose can be used to determine the therapeutic response. Thereafter, both glucose and glycosylated hemoglobin (A1C) should be monitored. Measurements of glycosylated hemoglobin may be especially useful for evaluating long-term control. A review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame. 1b. During an interview on 2/2/2024 at 9:40 AM with RN 1, RN 1 stated that she had not taken Resident 19's BP. RN 1 stated, she relied on the BP taken by a Certified Nurse Assistant (CNA) that was documented in the computer system dated 2/2/2024 and timed at 8:04 AM, which was over an hour and a half before RN 1 began to prepare Resident 19's morning medications scheduled for 9 AM administration time. During a concurrent interview and record review on 2/2/2024 at 11:52 AM with RN 1, RN 1 stated that Resident 19's BP medication Lisinopril/HCTZ was held (not administered to the resident) yesterday (2/1/2024) and today (2/2/2024) because the resident's BP was below the ordered parameter to administer to the resident. RN 1 stated Resident BP should have ben taken within an hour of administering the BP medication. RN 1 stated if over an hour since taking the BP, the BP should be retaken because the BP measurement may no longer be accurate. RN 1 stated, A lot could happen to the resident after an hour. The resident could be in pain which may cause the BP to go up. I do not know if the CNA used the correct size BP cuff for the resident. This could cause the BP measurement not to be accurate. A review of the facility's P&P titled, Medication and Treatment Orders, dated 7/2016, indicated, Orders for medication and treatments will be consistent with principles of safe and effective order writing .Orders for medications must include .any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). 2. A review of Resident 239's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 239's diagnoses included Type 2 diabetes mellitus, hypertension, fracture (a partial or complete break in the bone) of one rib, left side, and protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients]). A review of Resident 239's History and Physical (H&P), dated 1/25/2024 indicated, This resident has the capacity to understand and make decision. A review of Resident 239's Order Summary Report, dated 1/31/2024, included an order for Polyethylene glycol powder 1450, order date 1/23/2024, instructions indicated to give 17 gram (G, unit of measure in weight) by mouth one time a day for constipation hold if loose stools. The ordered strength of Polyethylene glycol powder 1450 was different from the observed prepared strength of 3350 and label on the bottle of ClearLax- Polyethylene glycol 3350 for Resident 239. During a concurrent observation and interview on 2/2/2024 between 9:59 AM to 10:14 AM with RN 1, RN 1 was observed preparimg the morning medication for Resident 239 that included a bottle labeled to contain ClearLax. RN 1 took off the cap from the ClearLax bottle and poured powder into the cap to the first line in the middle of the cap below the fill line marked with arrows pointing up to indicate the 17 gram line. RN 1 showed the cap and pointed to the middle line in the cap and stated that was the line she used to prepare the ClearLax medication for the resident. RN 1 was shown the correct fill line inside the dosing cap and prepared the medication again and entered the Resident 239's room to administer the prepared medications. RN 1 was not observed asking Resident 239 about her bowel movements (BM) or if she had experienced any diarrhea. Resident 239 refused the ClearLax and stated, I am doing pretty well. During an interview on 2/2/2024, at 11:58 AM with RN 1, RN 1 stated for Resident 239's ClearLax, I know I should have used a full cap and don't know why I used a half cap. I did not measure it correctly. RN 1 stated if the Resident was constipated a low dose of ClearLax would not help move the resident's bowels and if given too much the resident could cause loose stools or dehydration (means the amount of water in the body has dropped below the level needed for normal body function). RN 1 stated that she did not assess the resident for loose stools. RN 1 stated, she should have asked the resident about her bowel movement and when was the last BM. RN 1 stated that Resident 239 was independent for toileting but should call for assistance before she goes to the bathroom. During an interview on 2/2/2024, at 12:08 PM with Resident 239, Resident 239 stated, I am having okay bowel movements and did not need the MiraLAX or docusate (used to treat occasional constipation). Resident 239 stated she just had a BM a few minutes and been having soft BMs for a few weeks. Resident 239 stated the nurses have not asked her about her bowel movements. According to DailyMed, updated 1/2024, manufacturer labeling for ClearLax-polyethylene glycol 3350 powder, for solution indicated, the bottle top is a measuring cap marked to contain 17 grams of powder when filled to the indicated line (white section in cap) . fill to top of white section in cap which is marked to indicate the correct dose (17 g) . stir and dissolve in any 4 to 8 ounces of beverage (cold, hot or room temperature) then drink

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of five sampled residents (Residents 10, 13, 291), for unnecessary medication care area, were free from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to: 1. Identify specific, measurable target behaviors related to the use of Seroquel (antipsychotic [medications used to treat mental illness]) for Resident 10 2. Identify specific, measurable target behaviors related to the use of Abilify (antipsychotic) and Seroquel for Resident 13. 3. Identify specific, measurable target behaviors related to the use of Seroquel and Melatonin (medication to promote sleep) for Resident 291 This deficient practice had the potential to place Residents 10, 13, and 291 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status. Cross reference to F656 and F658 Findings: 1. During a review of Resident 10's admission Record (a document containing medical and demographic information), the admission Record indicated the resident was originally admitted to the facility 6/24/2023 and readmitted on [DATE]. Resident 10's diagnoses included dementia (progressive loss of memory) without behavioral disturbance, unspecified psychosis (a mental disorder characterized by a disconnection from reality), dizziness, repeated falls, and depression (a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities) A review of Resident 10's Order Summary Report, included the following orders: a. Seroquel Oral Tablet 25 milligram (MG, unit of measure of weight), order date 9/27/2023 and renewed on 10/3/2023 with instructions to administer one tablet (25 MG) by mouth two times a day for psychosis manifested by (mb) yelling out at staff. b. Seroquel Oral Tablet 50 MG, order date 10/3/2023, was added, with instructions to give one tablet (50 MG) by mouth at bedtime for psychosis manifested by yelling at staff. Resident 10's total daily dose increased from 50 mg to 100 mg daily on 10/3/2023. A review of Resident 10's History and Physical (H&P), dated 10/13/2023, indicated Resident 10 has the capacity to understand and make decision. A review of Resident 10's Medication Administration Record (MAR, a written record of all medications given to a resident) between 12/1/2023 through 2/2/2024 indicated the resident had zero documented episodes of yelling at staff for 62 out of 64 days. A review of Resident 10's Weekly Nursing Progress Notes indicated on 12/20/2023, 1/6/2024, 1/21/2024, and 1/29/2024, licensed nurses documented under Mood/Behavior that Resident 10's, Mood is pleasant, no unwanted behaviors witnessed. Resident does not wander at night. Resident sleeps through the night. A review of Resident 10's Psychiatric Progress Note dated, 12/22/2023, indicated, Still asking to go home - otherwise stable. A review of Resident 10's Minimum Data Summary (MDS, a comprehensive standardized assessment and screening tool), dated, 1/4/2024, indicated Resident 10 did not have potential indicators of psychosis, no hallucinations (perceptual experiences in the absence of real external sensory stimuli) , and no delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident 10's MDS indicated there were no physical, verbal, or other behavioral symptoms exhibited or directed toward others. Resident 10 required maximal assistance ( a helper to do maximal effort to lift, hold trunk or limbs and provides more than half the effort) for daily activities such as eating, bathing, toileting, and getting dressed.? A review of the facility's Multidisciplinary (Interdisciplinary, IDT, care team consists of healthcare professionals that include but are not limited to physicians, licensed nurses, clinical support staff, pharmacists, respiratory therapists, and rehabilitation staff) Care Conference, dated 1/9/2024, indicated per Resident 10's physician, Resident 10 is able to make her own decisions. It also indicated that Psychiatrist (Psych) had evaluated Resident 10 as stable. A review of the facility's consultant pharmacist Monthly Regimen Review (MRR), dated 1/16/2024, indicated that Resident 10 has been on Seroquel oral tablet 25 mg by mouth twice a day and 50 mg by mouth nightly at bedtime for Psychosis since 10/3/2023. A Check mark was placed next to the comment, A dose reduction is not clinically indicated. Physician checked the box Disagree and documented, Benefits outweigh the risk, signed and dated the form on 1/22/2024. Physician failed to indicate the benefit or the risk to Resident 10. During an interview with Resident 10, on 2/2/2024 at 3:13 PM, in the resident's room, Resident 10 stated she does not know what medications she gets. During an interview on 2/2/2024 at 5:06 PM with a Registered Nurse (RN) 2, RN 2 stated that Resident 10 was on Seroquel for sleep, because the resident calls the nurses frequently, irritated and cannot sleep. RN 2 stated when Resident 10 ask for a sleeping pill, RN 2 stated the resident is given Seroquel. RN 2 stated that Seroquel is a psychosis medication for agitation and refusing care. RN 2 stated, Residents sometimes have the right to refuse care, not all the time. RN 2 stated for Resident 10, I do not see yelling. I do not hear any reports that she yelled. RN 2 stated Resident 10 has not tried to hurt staff or herself. During a concurrent record review of Resident 10's Order Summary, progress notes, and MAR and interview on 2/2/2024, at 6:42 PM, with the Director of Nursing (DON), the DON stated, Resident 10 was on Seroquel for yelling at staff. The DON stated, I don't know the last time she stuck out at a staff. The DON stated, she did not find documentation that Resident 10 has a history of psychosis. The DON stated the facility should have identified specific, measurable target behaviors related to Resident 10's use of Seroquel. A review of the facility's policy and procedure (P&P) titled, Dementia - Clinical Protocol, dated 11/2018, indicated, The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. a. Medications will be targeted to specific symptoms and will be used in the lowest possible doses for the shortest possible time unless a clinical rationale for higher doses or longer-term use is documented. 2. A review of Resident 13's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included major depressive disorder, insomnia (difficulty falling or staying asleep), history of falling, rheumatoid arthritis (inflammation or swelling of one or more joints), other muscle spasm (occur when your muscles involuntarily and forcibly contracts uncontrollably and cannot relax), and difficulty walking. A review of Resident 13's Minimum Data Summary (MDS), dated [DATE], indicated Resident 13 did not have any potential indicators of psychosis, no hallucinations and no delusions. Resident 10's MDS indicated there was no physical, verbal, or other behavioral symptoms exhibited or directed toward others. A review of Order Summary indicated Resident 13 was prescribed: a. Seroquel (Quetiapine Fumarate) oral tablet 25 MG, instructions to give1 tablet by mouth every 12 hours as needed for Psychosis m/b verbal outburst, order date 11/7/2023, order was documented discontinued, with an unclear discontinuation date. b. Abilify (Aripiprazole) oral tablet 5 MG, with instructions to give 0.5 tablet by mouth one time a day for Psychosis m/b responding to Internal stimuli stating she is looking for her babies, new order dated 12/1/2023. A review of Resident 13's H&P, dated 11/7/2023 indicated, Patient is on Pain management with Percocet (a narcotic [a controlled medication with a high potential for abuse] combination drug containing acetaminophen (an over-the-counter medication) and oxycodone (narcotic), prescribed as a pain reliever . It also indicated the Resident has the capacity to make decisions. A review of Resident 13's MAR between 12/1/2023 through 2/2/2024 indicated the resident had zero documented episodes of yelling at staff for 63 out of 64 days. Resident 13's MAR and Pain assessment for the month of 12/2023, indicated the resident had one behavioral episode of psychosis during the day of 12/20/2023. A review of Resident 13's Care Plan did not indicate the use of Abilify. A review of Resident 13's Weekly Nursing Progress Notes, dated 12/30/2023, 1/6/2024, 1/13/2024, 1/20/2024, and 1/28/2024, indicated a licensed nurse's documentation under Mood/Behavior that Resident 13's, Mood is pleasant, no unwanted behaviors witnessed. Resident does not wander at night. Resident sleeps intermittently at night. A review of Resident 13's Psychiatric Progress Note dated, 1/10/2024, indicated, recent behavioral problems, none . No new behavioral issues reported . Assessment: Psychiatric condition is generally stable . Plan: Monitor and continue current regimen. Under Antipsychotic medications, Abilify was not marked, and no dosage or instructions was included on the Psychiatric Progress note for Resident 13. A review of Resident 13's Psychiatric Progress Note dated, 12/22/2023, indicated, Stable. No recent behavioral issues reported. Abilify was not marked, and no dosage or instructions was included on the Psychiatric Progress note for Resident 13. During an interview on 2/2/2024, at 3:01 PM with Resident 13, Resident 13 stated that she has never heard voices, never hallucinated, or had delusions. Resident 13 stated, There is a lot of noises at night. When I first came here, I was confused. I do not feel ill at all. I feel tired. I am in a lot of pain from rheumatoid arthritis . I have never been to a psychologist or a psychiatrist. A woman comes to the facility once a month and talks to you for about 1 or 2 minutes and leaves. I am pretty sharp and talk to people all day long, and never accused of having psychiatric problems in my entire life. Resident 13 stated her background with work in education, her college credentials, and her over 50 years of marriage. Resident 13 stated that she do not remember signing an informed consent for Ability. Resident 13 stated, I heard the name before, but was not told what the medication was for. Never received anything in writing to explain the medication (Abilify). During an interview on 2/2/2024 at 3:19 PM, with a Licensed Vocational Nurse 2 (LVN 2) , LVN 2 stated that Resident 13 receives Abilify because she is sad, not eating, and getting anxious for everything. LVN 2 stated that Resident 13 is clear when she talks and seem all there. LVN 2 stated Resident 13 was more confused three or four months ago. LVN 2 stated Resident 2 was in a lot of pain with her back and did not want to be touched, moved, or sit up at certain times. LVN 2 stated her hashmark for resisting care was when the resident did not want to be touched. LVN 2 stated Resident 13 could have been experiencing pain. During a concurrent record review of Resident 13's physician orders, MAR, and progress notes and interview on 2/2/2024, at 6:25 PM, the DON stated, Resident 13's severe pain could have caused confusion. The DON stated Resident 13 has constant pain and could not move the resident's blanket without the resident screaming in pain. The DON stated a gradual dose reduction (GDR) should have been considered for the use of antipsychotics. The DON stated, she did not find documentation that Resident 13 has a history of psychosis. The DON stated the facility should have identified specific, measurable target behaviors related to Resident 13's use of Abilify and Seroquel. A review of the facility's P&P titled, Dementia - Clinical Protocol, dated 11/2018, indicated, The staff and physician will determine any relationship between the resident's level of pain and cognitive loss. 3. A review of Resident 291's admission Record, dated 2/2/2024, indicated the resident was admitted to the facility 1/5/2024. Resident 291's diagnoses included major depressive disorder, history of falling, and unspecified psychosis. A review of Resident 291's facility's H&P, under physician progress notes dated 1/15/2024 indicated, Resident 291 does not have capacity to understand and make decisions. A review of Order Summary indicated Resident 291 was prescribed: a. Seroquel 25 mg, with instructions to give one-half (12.5 MG) tablet by mouth at bedtime for Psychosis m/b delusional thoughts, order date 1/6/2024, changed on 1/17/2024 to; b. Seroquel 25 mg, with instructions to give one-half (12.5 MG) tablet by mouth at bedtime for Psychosis m/b delusional thoughts, thinking her daughter is her mother, order date 1/17/2024. c. Melatonin oral tablet 5 MG, with instructions to give one tablet by mouth at bedtime for sleep for 31 days, order date 1/6/2024. A review of Resident 291's MAR between 1/8/2024 through 1/31/2024 indicated the resident had zero documented episodes of delusional thoughts. A review of Resident 291's Care Plan titled, The resident uses psychotropic medications Quetiapine (Seroquel) r/t Psychosis, initiated 1/17/2024, indicated: a. Monitor/record occurrence of, for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/other, etc.) and document per facility protocol. b. Monitor/document/report PRN (as needed) any adverse reactions of Psychotropic medications: unsteady gait, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, social isolation, diarrhea, fatigue, insomnia, loss of appetite, muscle cramps, behavior symptoms not usual to the person. During an interview on 2/2/2024, at 3:28 PM with Resident 291's Responsible Party (RP) 1, RP 1 stated, Resident 291 does not have delusions, has a good memory and no history of dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) or Alzheimer's (type of dementia that affects memory, thinking and behavior). RP 1 stated Resident 291 understands and speaks a foreign language. During an interview on 2/2/2024, at 3:32 PM, with Resident 291's Certified Nurse Assistant (CNA) 3, CNA 3 stated that she does not speak the resident's language. CNA 3 stated Resident 291 looked uncomfortable and was constipated. During a concurrent record review of Resident 291's MARs and interview on 2/2/2024, at 5:17 PM, with RN 2, RN2 stated Resident 291's MARs between 1/6/2024 to 2/2/2024 indicated Resident 291 was administered both Melatonin and Seroquel each night at bedtime for the scheduled 9 PM for sleep. RN 2 stated, Resident 291 does not understand English and thought Resident 291 was getting both medications to help with sleep. RN 2 stated Resident 291 is more confused and sleep more. RN 2 reviewed Resident 291's MAR and stated the licensed nurses was not monitoring the resident's hours of sleep to determine if the medications were effective or causing the resident side effects. RN 2 stated there was no documentation in Resident 291's chart that the facility was monitoring for hours of sleep, and they should have. During a concurrent record review of Resident 291's Order Summary, MARs, and progress notes and interview on 2/2/2024, at 6:01 PM with the DON, the DON stated, Not up to me if the resident gets both Melatonin and Seroquel nightly at bedtime. Most likely using Seroquel for agitation. I am not here at night - depending on her sleeping pattern. The DON stated, Do not have documentation of the facility monitoring the resident for hours of sleep. The medication is given to calm her. The DON stated Resident 291 is getting Seroquel based on the manifested behavior of thinking the resident's daughter is her mother. A review of the facility's P&P titled, Psychotropic Medication Use, dated 7/2022, indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition . Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. Residents receiving psychotropic medications are monitored for adverse consequences, including .altered mental status, difficulty urinating, falls, excessive sedation and constipation, shortness of breath, orthostatic hypotension, agitation, inability to perform ADLs or interact with others, diminished ability to think or concentrate. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether other causes for symptoms (including symptoms that mimic a psychiatric disorder) have been ruled out .a particular medication is clinically indicated to manage the symptoms or condition; and the actual or intended benefit of the medication is understood by the resident/representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage of controlled refrigerated medication (a prescription medicine that is subject to strict legal controls) and disposal of expired supplies for one of one medication storage rooms when: 1. A bottle of liquid lorazepam (medication used to treat anxiety) was not stored inside a locked box inside the refrigerator. 2. One (1) unopened foley catheter insertion tray (a soft, thin tube used to pass urine from the body) with expiration date of [DATE] was stored in medication room [ROOM NUMBER] (MR 1). 3, 15 unopened needles (a small tube used for injecting or withdrawing liquids) with expiration date of [DATE] was stored in MR 1. 4. Two (2) unopened intravenous tubing's (Y-set, three-way connector sets made of connecting plastic tubes used for delivering intravenous drugs into the body from multiple fluid sources) for a resident who has been discharged was stored in MR 1. This deficient practice had the potential for liquid lorazepam to be accessed by non-licensed personnel that can lead to medication error, and to cause residents to be exposed to adverse side effects of using expired supplies such as signs of an allergic reaction, like rash, itching, severe dizziness and trouble breathing if it was used. Findings: During a concurrent observation in the MR1 observation and interview with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 10:36 AM, LVN 3 verified the following were in MR 1: a. 1 unopened foley catheter insertion with expiration date of [DATE] b. 15 unopened needles with expiration date of [DATE] c. 2 unopened intravenous tubing's for a resident who has been discharged . During a concurrent observation of MR 1 and interview with LVN 3 on [DATE] at 10:40 AM, medication refrigerator was observed with 3 shelves was observed. The top shelf has unlocked grey metal box, LVN 3 did not know what the gray metal box for. LVN 3 removed the box from the medication refrigerator since it was empty and stated did not know what was used for. The third shelf of the medication refrigerator was observed with liquid lorazepam. LVN 3 stated that liquid lorazepam was a controlled medication and needed to be refrigerated. LVN 3 stated that expired foley catheter insertion tray and needles can cause harm and infection to residents and these items should not be store in the medication room because they were already expired. During a concurrent MR 1 observation and interview with Director of Nursing (DON) on [DATE] at 11:16 AM, DON stated that using expired supplies might not be beneficial and could cause harm to the residents. The DON stated that she did not know what is the grey metal box that was inside the medication refrigerator is used for. The DON stated that the grey metal box has a key lock, and she does not know where the key was. The DON stated that it should be removed from the medication refrigerator. The DON stated that storing expired supplies increase the risk to be mistakenly used and can cause possible harm to the residents. The DON stated that expired needles might not be sharp enough anymore when used and can cause nerve damage and infection. During a concurrent record review of facility's policy and procedure for controlled substance storage and interview with LVN 3 on [DATE] at 11:30 AM, LVN 3 stated that there should be a locked box inside the medication refrigerator for refrigerated narcotic medications. A review of the facility's policy and procedure (P&P) titled, Medication Storage in the facility, revised on [DATE], indicated controlled substance storage policy that medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedure indicated controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with their policy and procedure by: 1. Facility failed to label food in the kitchen with item name, date opened and expiration date, and failed to discard expired food. 2. Facility failed to ensure kitchen equipment were clean and in good condition. 3. Failed to ensure there was no blanket and personal belongings stored in the kitchen storage. 4. Failed to ensure Dietary Staff performs hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) in between tasks. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: 1. During a concurrent observation in the kitchen and interview with the Dietary Supervisor (DTS), on 1/30/2024 at 8:47 AM, there were three (3) ice cream cups with preparation date of 1/22/2024 and used by date of 1/27/2024 inside Freezer 2. DTS stated, the ice cream in a cup is for usage for 7 days only from when it was prepared. During a concurrent observation of Freezer 1 in the kitchen and interview with the DTS, on 1/30/2024 at 9:14 AM, a bag of frozen mixed vegetables has no label of date opened nor expiration date .DTS checked the bag of frozen mixed vegetables and stated there was no label of date opened or expiration date. During a concurrent observation of Freezer 1 in the kitchen and interview with the DTS, on 2/1/2024 at 8:48 AM, there were 3 boxes of frozen eggrolls that was not labeled with expiration date. DTS checked the 3 boxes of frozen eggrolls and did not find expiration dates and stated, there were no expiration dates on the 3 boxes so I will just throw them away. 2. During a concurrent observation in the kitchen and interview with the DTS, on 1/30/2024 at 8:40 AM, DTS stated, this tray with deformed corner with chipping paint, it needs to go to trash. During a concurrent observation in the kitchen and interview with the DTS, on 1/30/2024 at 8:57 AM, DTS stated, the cooking pan under the sink still had stains and the dietary staff did not wash it well. During a concurrent observation in the kitchen and interview with the DTS, on 1/30/2024 at 8:59 AM, DTS stated, it was not okay to have food stains on the trays. The dietary staff did not scrub it well. We need to replace it. During a concurrent observation in the kitchen and interview with the DTS, on 1/30/2024 at 9:01 AM, DTS stated, the disposable drinking cups on the window was used by the dietary staff to measure water while cooking. The DTS also stated, the disposable drinking cups should not be placed by the window, and it should be placed in the dry storage area to avoid contamination. During a concurrent observation in the kitchen and interview with the DTS, on 1/30/2024 at 9:03AM, There were food debris noted on the blender and the mixer. DTS stated, They should be cleaned. They need to be cleaned after each use to prevent cross contamination. During a concurrent observation in the Freezer 1 and interview with the DTS, on 1/30/2024 at 9:15 AM, DTS stated, the box should not have ice on top of the dough sheet box. It might cause contamination on the food item. During a concurrent observation in the kitchen and interview with the Dietary Staff (DS)1, on 1/30/2024 at 9:22 AM, DS 1 stated, microwave knob has food crumbs and was not clean. It is important to keep it clean, fresh, and contaminated free because the residents can get sick. During a concurrent observation in the Utility Room and interview with the DTS, on 2/1/2024 at 8:56 AM, DTS stated, the ice machine cover is broken. It is not okay, because it was supposed to be attached on the metal lid. But we do not know what is inside and it might cause cross contamination and it might get the resident sick. During a concurrent observation in the Utility Room and interview with the Maintenance Supervisor (MTS) on 2/1/2024 at 8:58 AM, MTS checked the ice machine and saw the insulator was not attached to the metal lid. MTS stated the ice machine lid was broken and the facility need to change it. MTS stated, he was not able to provide a copy of the ice machine maintenance check every three months in accordance with their Handling Ice policy and procedure. 3. During a concurrent observation in the kitchen and interview with the DTS, on 1/30/2024 at 8:56 PM DTS stated, the rolled blanket (left by the maintenance personnel) under sink, it should not be there because it does not belong there. It was left there because they fixed something, but it should not be there because of infection control. During a concurrent observation in the dry storage room and interview with the DTS and Dietary [NAME] (DC), on 1/30/2024 at 9:03AM, an apron was hanged on the dry storage rack. DC stated, I just hanged it there because I stepped out. DTS stated, the apron should not be hanged on the dry storage rack. 4. During a concurrent observation in the kitchen and interview with the Dietary Staff (DS) 2, on 2/1/2024 at 8:14 AM, DS 2 did not wash his hands before getting a big stainless spoon to mix the white beans that was boiling on the stove. Then, DS2 grabbed a pitcher by the handle and poured some water on the white beans then continued working on sorting the food delivery. DS 2 stated, I am sorry I just poured water on the beans. I forgot to wash in between tasks. Every time I do something I need to wash my hands because it is cross contamination. A review of the facility's policy and procedure titled, Food Storage, revised on 7/25/2019, P&P indicated, food items will be stored, thawed, and prepared in accordance with good sanitary practice. The P&P also indicated all items will be correctly labeled and dated. In addition, the P&P indicated, wash hands before handling food. A review of the undated facility's policy and procedure titled, General Food Preparation and Handling, P&P indicated the kitchen surfaces and equipment will be cleaned and sanitized as appropriate. A review of the undated facility's policy and procedure titled, Handling Ice, P&P indicated, maintenance checks should be made every three months .Check for possible leakage or dripping into the machine.

Based on observation, interview, and record review, the facility failed to clean the dryer lint trap for three (3) of 3 dryers located in the laundry room as indicated in the policy. This deficient practice had the potential to cause fire in the facility. Findings: During a concurrent observation in the laundry room and interview with Laundry Staff 1 (LS 1) and Licensed Vocational Nurse 3 (LVN 3) on 2/2/2024 at 5:35 PM, 3 dryers were observed in the laundry room. Lint f ound in the lint traps in all three dryers. LS 1 stated, Lint is removed from the lint traps twice a day, and it's been logged. LVN 3 verified that lint was found in the lint traps for all three dryers. LVN 3 stated leaving the lint in the lint traps can cause fires and was unsanitary. During a concurrent interview with LS 1 and record review on 2/2/2024 at 5:45 PM, the Lint logs, from January 2023 to present for dryers 1, 2, and 3 indicated two columns for time and two columns for initial, LS 1 stated that their practice is to clean dryer 1, 2, 3 twice a day, and LS 1 added I think our policy only stated to remove lint once a day. LS 1 stated that it's been their practice to remove lint at 10 AM and 2 PM, as indicated on their lint log records. During a concurrent interview with LVN 3 and record review on 2/2/2024 at 7 PM, LVN 3 stated that their policy indicated to clean lint filters after each use of dryer or at least daily. LVN 3 stated that their policy is not clear about to the frequency of lint removal, it is somehow confusing if lint should be removed after each use or daily. A review of facility's P&P titled, laundry and Linen, revised on 8/16/2002, indicated maintenance of the laundry room and laundry equipment to clean lint filters after each use of washer or dryer or at least daily. The maintenance supervisor vacuums areas under and around machines at least monthly to remove all collected lint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the resident's responsible party, for one of three sampled residents (Resident 1), of a change in the resident's condition when resident was noted to have herpes zoster (an infection of a nerve and the skin around it). This deficient practice had violated the Resident 1 Responsible Party's right to be informed of the resident's condition. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection that affects one or both lung) dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), and depression (constant feeling of sadness). A review of Resident 1's History and Physical (H&P) dated 6/01/2022, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 2/11/2022, indicated Resident 1 thought process is moderately impaired. Resident 1 required extensive one-person assistance during bed mobility, toilet use, dressing, locomutation on the unit, and personal hygiene. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication) Communication Form (SBAR) dated 3/8/2023 entered by 9:46 PM by licensed vocational nurse (LVN) 1, indicated resident complained of discomfort along lower back region. The SBAR indicated the certified nurse assistant (CNA [was not specified]) reported resident had blisters along lower back to left buttock and noted little raised red blisters along lumbosacral (lower back near the buttocks) dotting downward to left buttock. The SBAR also indicated resident was noted to have similar red raised bister in left inner groin. and blisters noted dry with no active bleeding. During an interview on 5/02/2023 at 1:00 PM, LVN 2 stated any change of resident's condition should be documented and resident's Physician and responsible party should be notified and documented in COC/ SBAR. LVN 2 stated, Resident 1 has a new diagnosis of herpes zoster, and it is considered a COC and resident's responsible party should have been notified. During an interview and record review of Resident 1 Face sheet, on 5/02/2023 at 2 PM, the Director of Nursing (DON) stated there is a diagnosis of herpes zoster entered on 3/09/2021. The DON stated it meant Resident 1 had diagnose of herpes zoster. The DON stated Resident 1's responsible party was involved with care and wanted facility to notify her with any change of condition, but facility was not able to notify Resident 1's responsible party regarding resident's COC from 5/8/2023 to 5/9/2023. During an interview and record review of Resident 1's SBAR dated 3/08/2021, on 5/02/2023 at 2:10 PM, the DON stated there was a Change of condition skin color or condition entered by LVN 1 for Resident 1 on 3/8/2023. The DON stated Herpes zoster is a significant COC and Resident 1's responsible party should have been notified regarding the COC. The DON stated she was not able to find any documented evidence in Resident 1's medical records that Resident 1's responsible party was notified. The DON stated facility's policy for Change in a Resident's Condition or Status was not followed. During an interview on 5/19/2023 at 2:46 PM, Resident 1's Responsible Party stated, the facility did not notify her about diagnosis of herpes zoster. A review of the facility's policy titled Change in a Resident's Condition or Status revised in February 2021 indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, Mental, or psychosocial status.'. The Policy also indicated except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to develop a care plan to address bilateral lower extremities edema (swelling caused by too much fluid trapped in the body's tissues) for one of two sampled residents (Resident 34) in accordance with the facility policy and procedure. This deficient practice had the potential to not be able to implement interventions to prevent worsening of Resident 34's condition, which could lead to increased pain, swelling, stiffness, difficulty walking, stretched or itchy skin, scarring, and decreased blood circulation on right and left foot. Findings: A review of Resident 34's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident originally on 12/31/2022 with diagnoses of chronic kidney disease (a gradual loss of kidney function), rectal prolapse (intestinal segment protruding outward), and mitral valve insufficiency (the valve between the left heart chambers doesn't close completely). A review of Resident 53's Minimum Data Set (MDS, an assessment and care screening tool), dated 12/11/2022, indicated Resident 34 had Brief Interview for Mental Status (BIMS, a brief cognitive screening measure that focuses on orientation and short-term word recall) score of eight (8) (a score of 8-12 indicated moderately impaired cognitive skills [ability to think, understand, and reason]). The MDS also indicated supervision for bed mobility, walking, eating, toilet use and limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs of other non-weight-bearing assistance) for dressing and personal hygiene care. During observation in hallway and interview on 2/1/23 at 11:47 AM, Resident 34's bilateral lower extremities were swollen + two (2) (grade +2 indicated a three ([3] - four [4] millimeter of depression, rebounding in 15 seconds or less; scale to determine the severity of the edema on a scale from + one [1] to +4). During interview with Resident 34's family member in resident room on 2/1/23 at 2:21 PM, Resident 34's family member stated Resident 34's BLE edema condition is chronic. A review of Resident 34's Physician Order, dated 1/11/2023, indicated to give Lasix (used to reduce extra fluid in the body) 20 milligrams (mg, a unit of mass) one time a day for fluid retention for 3 days for BLE edema that started on 1/12/23 to 1/14/23 per medication administration record. During an interview and record review of Resident 34's physician orders and care plan (CP) with the Director of Nursing (DON) on 2/1/23 at 4:26 PM, the DON stated Resident 34 was admitted with BLE edema. The DON stated there was no care plan which addressed Resident 34's BLE edema and use of Lasix. A review of the facility policy and procedure titled, Care Plan, Comprehensive Person-Centered, revised March 2022, indicated the comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was accurately assessed and monitored for the resident's access site (a central line catheter [a catheter used for exchanging blood to and from a hemodialysis machine and a resident]) for one of two (2) sampled residents (Resident 42). This deficient practice had the potential for unnoticed or missed excessive bleeding and infection on the resident's access sites. Findings: A review of Resident 42's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), muscle weakness, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and psychosis (mental disorder characterized by a disconnection from reality). A review of Resident 42's History and Physical (H&P) report completed on 1/22/2023, indicated diagnosis of renal failure. H&P indicated Resident 42 does not have the capacity to understand and make decisions. A review of the care plan initiated on 1/29/23, indicated Resident 42 was on dialysis and to anticipate weight fluctuations. Staff interventions were to provide and serve diet as ordered, and dialysis three times a week (Tuesday-Thursday-Saturday). The assessment and monitoring of dialysis access site was not included in the care plan. During a concurrent record review of Resident 42's Dialysis Communication Record and interview on 2/3/23 10:26 a.m., with Licensed Vocational Nurse 1 (LVN1) verified the Resident 42's Dialysis Communication Record was not filled out completely when the resident returned from dialysis on 1/26/23 and 2/2/23. The post dialysis assessment, which included the vital signs, post dialysis weight, catheter access site, site location, change in condition, presence of nausea/vomiting, behavioral problem, licensed nurse printed name and signature were not completed on 1/26/23 and 2/2/23. LVN 1 stated the Dialysis Communication Record for Resident 42 should have been completed by the Charge Nurse upon Resident's return from dialysis to know the status of the resident. During a concurrent record review of the Dialysis Communication Record and interview on 2/3/23 10:44 a.m., theDirector of Nursing ( DON) stated Resident 42 had a right upper chest central dialysis access site. The DON was unable to provide Resident 42 's documented evidence for post dialysis monitoring on 1/26/23 and 2/2/23. The DON stated, The importance of post dialysis monitoring was to make sure that resident's blood pressure did not lower too much. Charge nurses need to check vital signs and dialysis access needs to be observed and documented. A review of the facility's form titled, Communication Record for Dialysis Residents, indicated the facility nursing staff shall complete the top pre-dialysis section I before going to the dialysis center. The dialysis center staff will complete the middle part/section II treatment section. Upon completion of the treatment the facility nursing staff shall complete section III. Post dialysis section upon return to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to carry out the physician's orders and administer the medications ordered for two of 12 sampled residents (Resident 42 and 289) as indicated in the facility policy and procedure by failing to. 1. Administer Memantine (used to slow the progression of moderate-to-severe Alzheimer's disease [chronic mental ability decline]) extended release (XR) seven (7) milligrams (mg, unit of measurement) by mouth once a day times 7 days on 1/30/23 for dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) as ordered for Resident 42. 2. Administer Aricept (a medication used to treat dementia) five (5) mg one (1) tablet orally at hour of sleep for dementia as ordered for Resident 289. These deficient practices resulted to Residents 42 and 289 missing their medications as ordered, which could potentially contribute to the worsening of dementia and affecting the residents' quality of life and functional capacity. Findings: 1. A review of Resident 42's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), muscle weakness, dementia, and psychosis (a mental disorder characterized by a disconnection from reality). A review of Resident 42's History and Physical report completed on 1/22/2023, indicated diagnosis of renal failure and the resident does not have the capacity to understand and make decisions. A review of Resident 42's physician order, dated 1/30/2023, indicated to give Memantine XR 7 mg by mouth once a day times 7 days, fourteen (14) mg by mouth once a day times 7 days, twenty-one (21) mg by mouth once a day times 7 days, then twenty-eight (28) mg by mouth once a day for dementia. During a concurrent record review of Resident 42's physician's order and Medication Administration Record (MAR) for the month of January 2023 and interview on 2/2/23 at 8:20 a.m., Licensed Vocational Nurse 2 (LVN 2) stated written orders were to be reviewed and noted by the licensed nurse. LVN 2 stated written orders were to be transcribed in the electronic charting and automatically ordered to the pharmacy if medication was not a narcotic (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) or antibiotics (medicines that fight bacterial infections). LVN 2 stated did not know why the written order of Memantine XR (7 mg by mouth once a day times 7 days, 14 mg by mouth once a day times 7 days, 21 mg by mouth once a day times 7 days, then 28 mg by mouth once a day for dementia), dated 1/30/2023 was not signed and carried out by a licensed nurse. LVN 2 verified that Resident 42's order for Memantine XR was not in the MAR and Resident 42 did not receive the medication for 3 days, from 1/31/23 to 2/2/23. 2. A review of Resident 289's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing), difficulty walking, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) A review of Resident 289's History and Physical report completed on 1/24/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 289's physician's order, dated 1/30/2023, indicated an order of Aricept 5 mg 1 tablet orally at hour of sleep for dementia. A review of Resident 289's MAR for the month of January 2023, did not indicate the order of Aricept 5 mg 1 tablet orally at hour of sleep for dementia as written. A review of Resident 289's Care Plan titled, Impaired Cognitive Function/Dementia and Impaired Thought Process Related to Dementia, dated 2/1/23, included a staff intervention to administer medications as ordered. During a concurrent record review of Resident 42 and 289's January 2023 MAR and physician's order and interview on 2/2/23 at 8:59 a.m., the Director of Nursing (DON) stated that the licensed nursing staff did not carry out Resident 42's Memantine XR and Resident 289's Aricept physician's order. A review of the facility's policy titled, Medication Orders, revised 11/2014, indicated the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. A review of the facility's policy titled, Medication and Treatment Orders, revised 07/2016, indicated Orders for medications and treatments will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that there was a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of one sampled resident (Resident 18) in accordance with the facility's hospice agreement . 1. There was no progress notes documentation of the hospice licensed nurse's visit on 1/31/23. 2. A care plan which included the interventions addressing hospice care was not developed. This deficient practice had the potential for Resident 18 not to receive the hospice care and services necessary to promote comfort and quality of life. Findings: A review of Resident 18's admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included acute systolic heart failure (the heart isn't pumping as well as it should be), type 2 diabetes (high blood sugar), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) and dementia (memory loss). A review of Resident 18's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 1/7/23, indicated Resident 18 was totally dependent of two-person assist with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS also indicated Resident 18 received hospice care while a resident in the facility. A review of Resident 18's Plan of Care (POC) Summary, dated 1/06/2023, indicated to admit to active hospice care with diagnosis of heart failure. Resident 18 did not have any other care plan addressing hospice interventions. A review of Resident 18's hospice flow sheet binder, dated 1/31/23, showed a Hospice Registered Nurse (RN) signature. There were no progress notes completed for the Hospice RN visit on 1/31/23. During a concurrent interview and record review of Resident 18's hospice binder on 2/3/23 at 11:15 a.m., the Director of Nursing (DON) stated there was no progress notes documentation of the Hospice RN visit on 1/31/23. During a concurrent interview and record review of Resident 18's hospice binder and progress notes on 2/3/23 at 11:27 a.m., Licensed Vocational Nurse 1 (LVN 1) stated the hospice staff communicates with the facility staff and would document resident visit under the progress notes. LVN 1 stated that there was a hospice nurse who visited Resident 18 on 1/31/23. Resident 18's nurse's progress notes did not indicate documentation of hospice nurse visit. LVN1 validated there was no progress note regarding hospice communication on 1/31/23. The facility's hospice agreement, dated 7/31/2017, indicated the hospice and the facility will establish a method to ensure that the needs of patients are addressed and met 24 hours a day. This communication will be documented in the patient's medical record by both parties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices for one of five sampled residents (Resident 39) as indicated on the facility's policy and procedure by failing to properly disinfect a cloth gait belt (safety device worn around the waist that can be used help safely transfer a person from one surface to another) after a physical therapy treatment session with Resident 39. This deficient practice had the potential to spread infections among residents and staff. Findings: A review of Resident 39's admission records indicated the resident admitted to the facility on [DATE] with diagnoses including but not limited to heart failure (condition in which the heart has difficulty pumping enough blood to keep up with demands of body), muscle weakness, and difficulty in walking. A review of Resident 39's Minimum Data Set (MDS, an assessment and care screening tool), dated 1/19/23, indicated the resident was cognitively intact (sufficient judgement, planning, organization to manage average demands in one's environment), required limited assistance (requires minimal amount of assistance from another person to perform task) with transfers, walking in the room and hallway, dressing, and toileting. A review of Resident 39's Physician's Orders, indicated an order dated 1/13/23, indicated for physical therapy evaluation and treatment clarification order for skilled physical therapy services once a day, five times a week for four weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education (rehabilitation techniques to restore muscle function and movement), gait (walking) training, and resident/caregiver education. During an observation and interview on 1/31/23 at 10:45 a.m. in the hallway, Resident 39 walked with Physical Therapy Assistant (PTA 1) using a front-wheeled walker and had a cloth gait belt around the waist area. When PTA 1 completed walking with Resident 39, PTA 1 removed the cloth gait belt from the resident's waist. PTA 1 took the gait belt and FWW into the hallway. PTA 1 stated she used the cloth gait belt everyday with multiple residents in one day. PTA 1 stated the cloth gait belt was disinfected after each resident use with disinfecting wipes in the rehabilitation gym. PTA 1 proceeded to go to the rehabilitation gym and used disinfecting wipes from a container with blue colored cap. PTA 1 read the manufacturer's use label and stated, household cleaning on hard, non-porous surfaces. PTA 1 stated the cloth gait belt was not a hard, non-porous surface and should not be used on the cloth gait belt. PTA 1 stated they did not know how to properly disinfect a cloth gait belt. PTA 1 stated it was important to properly disinfect the gait belt because staff used the gait belt between multiple residents in a day and it could spread germs between residents. During an interview on 1/31/23 at 1:15 p.m., PTA 1 stated all staff should be using a plastic or vinyl gait belt because the disinfecting wipes could be used on the hard, non-porous surface of this type of gait belt. PTA 1 stated the only way for the cloth gait belt to be disinfected was to wash and launder the gait belt after each use. During an interview on 1/31/23 at 1:30 p.m., the Infection Prevention Nurse (IP) stated cloth gait belts should only be used with the same resident and individually issued. IP stated if a gait belt was used between multiple residents, then it should be of plastic or vinyl material which could be properly disinfected with disinfecting wipes. IP stated it was important to properly disinfect any shared items between residents, including gait belts, because it was part of infection control and it prevented transferring bacteria from one resident to another. A review of the facility's policy revised September 2022, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, indicated, resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote dignity and respect when Certified Nursing Assistant 2 (CNA 2) failed to be at eye level when assisting two of four sampled residents (Resident 290 and Resident 18) with lunch as indicated on the facility policy and procedure. This deficient practice had the potential to cause a decline in the resident's individuality, self-esteem, and self-worth. Findings: 1. A review of Resident 290's Face Sheet (a document that gives a patient's information at a quick glance) indicated, the facility admitted Resident 290 on 1/12/23 with diagnoses including acute kidney failure (a condition in which the kidneys [organs in the abdomen that remove waste and extra water from the blood] suddenly can't filter waste from the blood), gastrointestinal hemorrhage (bleeding that occurs in digestive tract, the blood often appears in stool or vomit), and acute respiratory failure (an acute or chronic impairment of gas exchange between the lungs and blood causing hypoxia [an absence of enough oxygen in the tissues to sustain bodily functions]). A review of Resident 290's History and Physical, dated 1/14/23, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 290's Minimum Data Set (MDS, an assessment and screen tool), dated 1/19/23, indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 290 required total dependence (full staff performance every time during entire seven [7] day period) with bed mobility and transfer. The MDS indicated Resident 290 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with eating. A review of Resident 290's Nutritional Risk care plan, initiated on 1/15/23, indicated staff interventions were to assist resident with meals as needed and to ensure resident in in the proper position for eating. During a dining observation in Resident 290's room, on 1/31/23 at 12:35 PM, CNA 2 was observed standing over Resident 290 while assisting the resident in eating lunch. Resident 290's bed was below CNA 2's waist and CNA 2 was not at eye level with the resident. During an interview with CNA 2 on 1/31/23 at 12:49 PM, CNA 2 stated sometimes staff must offer food to assist Resident 290 with eating. CNA 2 proceeded to walk away and entered another resident's room. 2. A review of Resident 18's Face Sheet indicated the facility admitted Resident 18 on 9/6/22 with diagnoses including sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of unspecified part of limb, and hypertension (high blood pressure). A review of Resident 18's History and Physical, dated 9/14/22, indicated the resident had the capacity to understand and make decisions. A review of Resident 18's MDS dated [DATE], indicated the resident had severe cognition. The MDS indicated Resident 18 required total with bed mobility, transfer, and eating. A review of Resident 18's Activities of Daily living (ADL) Self-care care plan initiated on 9/6/22 indicated staff intervention was to ensure resident with 1:1 feeder for all meals as needed. During a dining observation in Resident 18's room, on 1/31/23 at 12:52 PM, CNA 2 was observed standing over Resident 18 while assisting the resident in eating lunch. Resident 18's bed was below CNA 2's waist and CNA 2 was not at eye level with the resident. During an interview with CNA 2 on 1/31/23 at 1:05 PM, CNA 2 stated Resident 18 needs assistance with meals and again, proceeded to walk away. During an interview with CNA 2 on 1/31/23 at 1:09 PM, CNA 2 stated she had a chair at Resident 290 and Resident 18's bedside. CNA 2 stated she knows to sit down and to be at eye level when feeding residents, but she prefers to stand. During an interview with the Director of Staff Development (DSD) on 2/1/23 at 2:03 PM, the DSD stated staff must always be at eye level when feeding a resident. The DSD stated staff must explain to the resident what's on their plate and ask the resident what they want to taste first. A review of the facility's policy and procedure titled, Assistance with Meals, dated 3/2022, indicated residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatments and services to minimize the decline in mobility and joint range of motion (ROM, full movement potential of a joint) for three of three sampled residents (Residents 13, 15 and 25) who had limited range of motion and/or functional mobility when the facility failed to ensure: 1. Resident 13 received Restorative Nursing Aide (RNA) program (nursing aide program to help residents maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) for the right hand and application of a right palm protector (device to keep fingers open) seven times a week as ordered by the physician. In addition, ensure Resident 13 received RNA program for sit to stand exercises five times a week as ordered by the physician. 2. Resident 15 received RNA treatments for ambulation (walking) with a front-wheeled walker (FWW, type of mobility aid with wide base of support) five times a week as ordered by the physician. 3. Resident 25 received RNA treatments for ambulation with a FWW five times a week as ordered by the physician. These deficient practices had the potential to cause further decline in the residents' range of motion, functional mobility, and ability to participate in activities of daily living (basic activities such as eating, dressing, toileting). CROSS REFERENCE TO F725 Findings: 1. A review of Resident 13's admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to heart failure (condition in which the heart has difficulty pumping enough blood to keep up with demands of body) and respiratory failure (any condition that affects breathing function and result in lungs not functioning properly). A review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 12/13/22 indicated the resident required extensive assistance (requires significant amount of assistance from another person to perform task) with bed mobility, transfers (moving from one surface to another), and dressing. The MDS indicated the resident could eat with set up assistance only. A review of Resident 13's physician's history and physical dated 12/8/22 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 13's physician's orders indicated an order dated 7/27/22 for RNA to provide transfers sit to stand as tolerated by resident once a day five times a week. The physician's order also indicated an order dated 12/9/22 for RNA to do passive range of motion (PROM, movement at a given joint with full assistance from another person) on the right hand and right-hand palm and apply palm protector (device to keep fingers open) seven days a week and remove while sleeping. A review of Resident 13's care plan dated 7/27/22 indicated the resident was at risk for decreased independence with functional mobility. The care plan indicated the resident will maintain or prevent decline in functional mobility with transfers sit to stand and to provide RNA for sit to stand as tolerated by resident daily five times a week. A review of Resident 13's joint mobility screening dated 12/2/22 indicated the resident had moderate range of motion loss in the right wrist and right shoulder and full range of motion in the right elbow, and left wrist, elbow, and shoulder. The joint mobility screening also indicated Resident 13 had moderate range of motion loss in the right ankle and minimal range of motion loss in the right knee and right hip. The joint mobility screening indicated full range of motion in the left ankle, knee, and hip. A review of Resident 13's November 2022 RNA flowsheet documentation for RNA treatment of transfers sit to stand exercises daily five times a week as tolerated did not indicate RNA 1's initials on the following days: 11/4/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/11/22, 11/14/22, 11/15/22, 11/16/22, 11/17/22, 11/18/22, 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/25/22, 11/29/22, and 11/30/22 for a total of 18 missed RNA treatments. A review of Resident 13's November 2022 RNA flowsheet documentation for RNA treatment for passive range of motion on right hand and RNA assistance with palm protector in right hand seven times a week as tolerated did not indicate RNA 1's initials on the following days: 11/4/22, 11/5/22, 11/6/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/11/22, 11/12/22, 11/13/22, 11/14/22, 11/15/22, 11/16/22, 11/17/22, 11/18/22, 11/19/22, 11/20/22, 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/25/22, 11/26/22, 11/27/22, 11/29/22, 11/30/22 for a total of 26 missed RNA treatments. A review of Resident 13's December 2022 RNA flowsheet documentation for RNA treatment of transfers sit to stand exercises daily five times a week as tolerated did not indicate RNA 1's initials on the following days: 12/1/22, 12/8/22, 12/20/22, 12/26/22, 12/28/22, and 12/31/22 for a total of five missed RNA treatments. A review of Resident 13's December 2022 RNA flowsheet documentation for RNA treatment for passive range of motion on right hand and RNA assistance with palm protector in right hand seven times a week as tolerated did not indicate RNA 1's initials on the following days: 12/1/22, 12/3/22, 12/4/22, 12/8/22, 12/10/22, 12/11/22, 12/17/22, 12/18/22, 12/20/22, 12/24/22, 12/25/22, 12/26/22, 12/28/22, and 12/31/22 for a total of 14 missed RNA treatments A review of Resident 13's January 2023 RNA flowsheet documentation for RNA treatment of transfers sit to stand exercises daily five times a week did not indicate RNA 1's initials on the following days: 1/2/23, 1/3/23, 1/4/23, 1/7/23, 1/8/23, 1/16/23, 1/19/23, 1/30/23, 1/31/23 for a total of nine missed RNA treatments. A review of Resident 13's January 2023 RNA flowsheet documentation for RNA treatment for passive range of motion on right hand and RNA assistance with palm protector in right hand seven times a week as tolerated did not indicate RNA 1's initials on the following days: 1/1/23, 1/2/23, 1/3/23, 1/4/23, 1/7/23, 1/8/23, 1/14/23, 1/15/23, 1/16/23, 1/19/23, 1/21/23, 1/22/23, 1/23/23, 1/27/23, 1/28/23, 1/29/23, 1/30/23, 1/31/23 for a total of 18 missed RNA treatments. During an observation on 1/31/23 at 12:30 p.m., Resident 13 was sitting up in a wheelchair in the resident's room and eating lunch independently. Resident 13 was using the left hand to scoop and bring the food from the plate to the mouth. The right hand was in a fist and right elbow was bent and resting on the wheelchair arm rest. During the observation, Resident 13 did not have a palm protector noted in her right hand. During an interview on 2/1/23 at 9:02 a.m., Restorative Nursing Aide (RNA 1) stated she was the only RNA staff that worked in the facility and that there was no back up or other RNA staff member. RNA 1 stated she worked only Monday through Friday. RNA 1 stated there was no RNA scheduled to provide RNA treatments to any residents on the weekends. RNA 1 stated that if she went on vacation, called in sick, or was reassigned to work as a Certified Nursing Assistant (CNA) for the day, no residents would receive any RNA treatments for that day. During an interview and record review on 2/1/23 at 3:08 p.m., RNA 1 reviewed Resident 13's RNA treatment flowsheets for the following months and stated that Resident 13 did not receive RNA treatments for sit to stand exercises daily five times a week as ordered by the physician: -January 2023 - nine missed days of sit to stand RNA treatments. -December 2022 - five missed days of sit to stand RNA treatments. -November 2022 - 18 missed days of sit to stand RNA treatments. During the same interview and record review on 2/1/23 at 3:08 p.m., RNA 1 stated she was on vacation during the month of November 2022 and there was no RNA staff to cover for her. RNA 1 stated it was important for residents to receive their RNA treatments as ordered so that the residents do not lose their range of motion and help to maintain their ability to move. RNA 1 reviewed Resident 13's RNA treatment flowsheets for the following months and stated that Resident 13 did not receive RNA treatment for PROM to the right hand and palm protector to the right hand daily seven times a week as ordered by the physician: -January 2023 - 18 missed days of PROM to the right hand and palm protector to the right-hand RNA treatments. -December 2022 - 14 missed days of PROM to the right hand and palm protector to the right-hand RNA treatments. -November 2022 - 26 missed days of PROM to the right hand and palm protector to the right-hand RNA treatments. During an interview and record review at 2/2/23 at 9:04 a.m., the Director of Staffing Development (DSD) reviewed Resident 13's medical records and confirmed Resident 13 had an order for RNA to provide transfers sit to stand as tolerated once a day five times a week. It also indicated an order for RNA to do passive range of motion on right hand and right-hand palm and apply palm protector seven days a week and remove while sleeping. The DSD reviewed Resident 13's RNA treatment flowsheets for November 2022, December 2022, and January 2023 and confirmed RNA treatments were not provided as ordered by the physician. The DSD stated the facility only had one RNA staff and there was no back up RNA. The DSD also stated that RNA 1 only worked five days a week and the facility did not have a plan for residents who had RNA orders for seven days a week of RNA. The DSD confirmed that when RNA 1 was on vacation, sick, or pulled for a CNA assignment, there was no other staff to perform RNA treatments for residents on those days. During an interview and record review on 2/2/23 at 11:17 a.m., the Director of Nursing (DON) reviewed Resident 13's medical records and confirmed Resident 13 did not receive RNA treatments as ordered in the months of November 2022, December 2022, and January 2023. The DON stated the facility reassigned RNA 1 sometimes for CNA duties and there was no other staff to complete RNA 1's assignments on those days that RNA 1 was working as CNA. The DON stated it was important for residents to receive RNA treatments because it helped residents with movement, strength, and mobility. The DON stated that RNA treatments were an important aspect of the care the facility provide to its residents. The DON stated residents needed to be seen by an RNA as ordered by the physician. 2. A review of Resident 15's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to fracture of right femur (broken thigh bone), difficulty in walking, and Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). A review of Resident 15's Minimum Data Set, dated [DATE], indicated the resident was cognitively intact, required extensive assistance (requires significant amount of assistance from another person to perform task) with bed mobility, transfers, and dressing. It indicated the resident could eat with set up assistance only. The MDS indicated the resident required limited assistance to walk in the room and hallways. The MDS indicated the resident did not have any functional limitations in ROM on both sides of the upper extremity and lower extremity. A review of Resident 15's physician's history and physical dated 4/5/22 indicated the resident had the capacity to understand and make decisions. A review of Resident 15's physician's orders indicated an order dated 7/11/22, for RNA to provide ambulation with FWW at distances tolerated by the resident daily five times a week. A review of Resident 15's care plan dated 7/11/22, indicated the resident was at risk for decreased independence with ambulation. The care plan indicated Resident 15 will maintain or prevent decline in function with ambulation and to provide RNA for ambulation with FWW at distances tolerated by the resident daily five times a week. A review of Resident 15's joint mobility screening dated 1/24/23 indicated the resident had full range of motion in both wrists and elbows and had minimal range of motion loss in both shoulders. A joint mobility screen dated 1/30/23 indicated the resident had full range of motion to both hips, knees, and ankles and to continue with the RNA program. A review of Resident 15's January 2023 RNA flowsheet documentation for RNA treatment of ambulation with FWW at distances tolerated by the resident daily five times a week did not indicate RNA 1's initials on the following days: 1/2/23, 1/3/23, 1/4/23, 1/6/23, 1/9/23, 1/16/23, 1/23/23, 1/27/23, 1/30/23 for a total of nine missed RNA treatments. A review of Resident 15's December 2022 RNA flowsheet documentation for RNA treatment of ambulation with FWW at distances tolerated by the resident daily five times a week did not indicate RNA 1's initials on the following days: 12/1/22, 12/8/22, 12/20/22, 12/27/22, 12/28/22 for a total of five missed RNA treatments. A review of Resident 15's November 2022 RNA flowsheet documentation for RNA treatment of ambulation with FWW at distances tolerated by the resident daily five times a week did not indicate RNA 1's initials on the following days: 11/4/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/11/22, 11/14/22, 11/15/22, 11/16/22, 11/17/22, 11/18/22, 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/15/22, 11/29/22, 11/30/22 for a total of 18 missed RNA treatments. During an observation and interview on 1/31/23 at 9:42 a.m., Resident 15 was sitting in a wheelchair (WC) and able to use both hands to maneuver the WC short distances inside the room. During an interview on 2/1/23 at 9:02 a.m., RNA 1 stated she was the only RNA staff that worked in the facility and that there was no back up or other RNA staff member. RNA 1 stated she worked only Monday through Friday. RNA 1 stated there was no RNA scheduled to provide RNA treatments to any residents on the weekends. RNA 1 stated that if she went on vacation, called in sick, or was reassigned to work as a CNA for the day, no residents would receive any RNA treatments for that day. During an interview and record review on 2/1/23 at 3:08 p.m., RNA 1 stated she was on vacation during the month of November 2022 and there was no RNA staff to cover for her. RNA 1 stated it was important for residents to receive their RNA treatments as ordered so that the residents do not lose their range of motion and help to maintain their ability to move. RNA 1 reviewed Resident 15's RNA treatment flowsheets for the following months and stated that Resident 15 did not receive RNA treatments for ambulation with FWW for distances tolerated by the resident daily five times a week as ordered by the physician: -January 2023 - nine missed days of RNA treatment for ambulation. -December 2022 - five missed days of RNA treatment for ambulation. -November 2022 - 18 missed days of RNA treatment for ambulation. During an interview and record review at 2/2/23 at 8:56 a.m., the DSD reviewed Resident 15's medical records and confirmed Resident 15 had an order for RNA to provide ambulation with FWW for distances tolerated by resident once a day five times a week. The DSD reviewed Resident 15's RNA treatment flowsheets for November 2022 December 2022, and January 2023 and confirmed RNA treatments were not provided as ordered by the physician. The DSD stated the facility only had one RNA staff and there was no back up RNA. The DSD confirmed that when RNA 1 was on vacation, sick, or pulled for a CNA assignment, there was no other staff to perform RNA treatments for residents on those days. The DSD stated it was important for Resident 15 to walk with the RNA to maintain the resident's strength and prevent a decline in range of motion and walking. During an interview and record review on 2/2/23 at 11:17 a.m., the DON reviewed Resident 15's medical records and confirmed Resident 15 did not receive RNA treatments as ordered in the months of November 2022, December 2022, and January 2023. The DON stated the facility reassign RNA 1 sometimes for CNA duties and there was no other staff to complete the RNA 1's assignments on those days. DON stated it was important for residents to receive RNA treatments because it helped residents with movement, strength, and mobility and that RNA treatments were an important aspect of the care the facility provided to its residents. DON stated residents definitely need to be seen by an RNA as ordered. 3. A review of Resident 25's admission records indicated the resident originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to chronic pain and difficulty in walking. A review of Resident 25's MDS dated [DATE] indicated the resident was cognitively intact, required limited assistance of one person to walk in corridor, extensive assistance with dressing, transfers, and toileting, and was able to eat with setup help only. The MDS indicated the resident did not have any functional limitations in range of motion with both upper extremities (shoulder, elbow, wrist, hand) or lower extremities (hip, knee, ankle, foot). A review of Resident 25's physician's history and physical assessment dated [DATE], indicated the resident had the capacity to understand and make decisions. A review of Resident 25's physician order summary report indicated a physician's order dated 12/27/22, for RNA to provide ambulation with FWW at distances tolerated by resident once a day five times a week. A review of Resident 25's care plan dated 12/27/22 indicated, resident needs ambulation RNA program and was at risk for decline in function. The care plan indicated the resident will maintain and prevent a decline in functional ambulation. A review of Resident 25's joint mobility screen dated 11/21/22 indicated the resident had full range of motion in both wrists, elbows, and left shoulder. The joint mobility screen indicated the resident had minimal range of motion loss in the right shoulder. It also indicated the resident had full range of motion in both hips, knees, and ankles. During an observation on 1/31/23 at 11:13 a.m., RNA 1 walked Resident 25 down the hallway with a front-wheeled walker. Resident 25 was wearing a blue plastic gait belt (safety device worn around the waist that can be used help safely transfer a person from one surface to another) around the waist and RNA 1 provided verbal cues for Resident 25 to lift the right leg up higher to minimize dragging the right foot while walking. During an interview on 2/1/23 at 11:39 a.m., Resident 25 was sitting up in a WC in the resident's room. Resident 25 stated he walked with RNA 1 about two times a week on average, sometimes more and sometimes less. Resident 25 stated he was walking about the same distance. During an interview and record review on 2/1/23 at 1:34 p.m., the Medical Records (MR 1) Coordinator 1 reviewed Resident 25's medical records and stated there were no available documentation related to provision of RNA treatments or services. During an interview on 2/1/23 at 3:08 p.m., RNA 1 stated Resident 25 was receiving RNA for ambulation and stated that RNA 1 did not document anywhere in the resident's medical records that the RNA treatment was completed. RNA 1 stated that it was important to maintain documentation for all RNA treatments completed, because if there was no documentation, then it meant that the treatment was not completed. During an interview and record review on 2/2/23 at 11:06 a.m., the DON confirmed there was no documentation for RNA from 12/27/22 from when the RNA order was written to 2/1/23 when the documentation for RNA was completed. The DON stated the facility would not know if the resident completed their RNA treatments if it was not documented and that if staff did not document it, then there was no way to prove it happened. A review of the facility's policies and procedures titled, Restorative Nursing Services, revised 7/2017, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate and sufficient nursing staff to ensure Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments and services were completed for three of three sampled residents (Residents 13, 15, and 25) as indicated on the physician's order. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function. CROSS REFERENCE TO F688 Findings: 1. A review of Resident 13's admission records indicated the resident initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to heart failure (condition in which the heart has difficulty pumping enough blood to keep up with demands of body) and respiratory failure (any condition that affects breathing function and result in lungs not functioning properly). A review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/13/22, indicated the resident required extensive assistance (requires significant amount of assistance from another person to perform task) with bed mobility, transfers (moving from one surface to another), and dressing. It also indicated the Resident 13 could eat with set up assistance only. A review of Resident 13's Physician's History and Physical, dated 12/8/22, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 13's Physician's Order, indicated an order dated 7/27/22, indicated RNA to provide transfers sit to stand as tolerated by resident once a day five (5) times a week. It also indicated a physician's order, dated 12/9/22, for RNA to do passive range of motion (PROM, movement at a given joint with full assistance from another person) on right hand and right hand palm and apply palm protector seven days a week. Remove while sleeping. A review of Resident 13's Care Plan, dated 7/27/22, indicated the resident was at risk for decreased independence with functional mobility. The care plan objective indicated the resident will maintain or prevent decline in functional mobility with transfers sit to stand. The care plan approach indicated to provide RNA for sit to stand as tolerated by resident daily five times a week. A review of Resident 13's Joint Mobility Screening, dated 12/2/22, indicated the resident had moderate range of motion (ROM) loss in the right wrist and right shoulder and full range of motion in the right elbow, and left wrist, elbow, and shoulder. It also indicated Resident 13 had moderate range of motion loss in the right ankle and minimal ROM loss in the right knee and right hip. It indicated full ROM in the left ankle, knee, and hip. A review of Resident 13's November 2022 RNA flowsheet documentation for RNA treatment of transfers sit to stand exercises daily five (5) times a week as tolerated did not indicate RNA 1's initials on the following days: 11/4/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/11/22, 11/14/22, 11/15/22, 11/16/22, 11/17/22, 11/18/22, 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/25/22, 11/29/22, and 11/30/22. There was a total of 18 missed RNA treatments. A review of Resident 13's November 2022 RNA flowsheet documentation for RNA treatment for passive range of motion on right hand and RNA assistance with palm protector in right hand seven (7) times a week as tolerated did not indicate RNA 1's initials on the following days: 11/4/22, 11/5/22, 11/6/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/11/22, 11/12/22, 11/13/22, 11/14/22, 11/15/22, 11/16/22, 11/17/22, 11/18/22, 11/19/22, 11/20/22, 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/25/22, 11/26/22, 11/27/22, 11/29/22, 11/30/22. There was a total of 26 missed RNA treatments. A review of Resident 13's December 2022 RNA flowsheet documentation for RNA treatment of transfers sit to stand exercises daily 5 times a week as tolerated did not indicate RNA 1's initials on the following days: 12/1/22, 12/8/22, 12/20/22, 12/26/22, 12/28/22, and 12/31/22. There was a total of 5 missed RNA treatments. A review of Resident 13's December 2022 RNA flowsheet documentation for RNA treatment for passive range of motion on right hand and RNA assistance with palm protector in right hand 7 times a week as tolerated did not indicate RNA 1's initials on the following days: 12/1/22, 12/3/22, 12/4/22, 12/8/22, 12/10/22, 12/11/22, 12/17/22, 12/18/22, 12/20/22, 12/24/22, 12/25/22, 12/26/22, 12/28/22, and 12/31/22. There was a total of 14 missed RNA treatments. A review of Resident 13's January 2023 RNA flowsheet documentation for RNA treatment of transfers sit to stand exercises daily five times a week did not indicate RNA 1's initials on the following days: 1/2/23, 1/3/23, 1/4/23, 1/7/23, 1/8/23, 1/16/23, 1/19/23, 1/30/23, 1/31/23. There was a total of nine (9) missed RNA treatments. A review of Resident 13's January 2023 RNA flowsheet documentation for RNA treatment for passive range of motion on right hand and RNA assistance with palm protector in right hand seven times a week as tolerated did not indicate RNA 1's initials on the following days: 1/1/23, 1/2/23, 1/3/23, 1/4/23, 1/7/23, 1/8/23, 1/14/23, 1/15/23, 1/16/23, 1/19/23, 1/21/23, 1/22/23, 1/23/23, 1/27/23, 1/28/23, 1/29/23, 1/30/23, 1/31/23. There was a total of 18 missed RNA treatments. During an observation in Resident 13's room on 1/31/23 at 12:30 p.m., Resident 13 was sitting up in a wheelchair and eating lunch independently. Resident 13 was using the left hand to scoop and bring the food from the plate to the mouth. Resident 13's right hand was in a fist and right elbow was bent and resting on the wheelchair arm rest. During the observation, there was no palm protector noted in Resident 13's right hand. During a concurrent interview of RNA 1 and record review of Resident 13's November 2022 to January 2023 RNA treatment flowsheets on 2/1/23 at 3:08 p.m., RNA 1 confirmed Resident 13 did not receive the following RNA treatments as ordered by the physician: a. Sit to stand exercises daily 5 times a week 1. November 2022 - 18 missed days of RNA treatment 2. December 2022 - 5 missed days of RNA treatment 3. January 2023 - 9 missed days of RNA treatment b. PROM to the right hand and palm protector to the right hand daily 7 times a week 1. November 2022 - 26 missed days of RNA treatment 2. December 2022 - 14 missed days of RNA treatment 3. January 2023 - 18 missed days of RNA treatment During the same interview and record review on 2/1/23 at 3:08 p.m., RNA 1 stated she was on vacation during the month of November 2022 and there was no RNA staff to cover for her. RNA 1 stated it was important for residents to receive their RNA treatments as ordered so that the residents do not lose their range of motion and help to maintain their ability to move. During an interview and record review at 2/2/23 at 9:04 a.m., the Director of Staffing Development (DSD) reviewed Resident 13's medical records and confirmed Resident 13 had an order for RNA to provide transfers sit to stand as tolerated by resident once a day five times a week. It also indicated an order for RNA to do passive range of motion on right hand and right hand palm and apply palm protector seven days a week. Remove while sleeping. DSD reviewed Resident 13's RNA treatment flowsheets for November 2022 December 2022, and January 2023 and confirmed RNA treatments were not provided as ordered by the physician. DSD stated the facility only had one (1) RNA staff and there was no back up RNA. DSD also stated that the RNA only worked 5 days a week and the facility did not have a plan for residents who had RNA orders for 7 days a week of RNA. DSD confirmed that when RNA 1 was on vacation, sick, or pulled for a Certified Nurse Assistant (CNA) assignment, there was no other staff to perform RNA treatments for residents on those days. DSD stated there was not sufficient nurse staffing for Resident 13 to receive their RNA treatment as ordered, because a lot of RNA treatments were missed. During a concurrent interview with the Director of Nursing (DON) and record review on 2/2/23 at 11:17 a.m., the DON confirmed Resident 13 did not receive RNA treatments as ordered in the months of November 2022 December 2022, and January 2023. The DON stated the facility did reassign RNA 1 at times for CNA duties and there was no other staff to complete the RNA assignments on those days. The DON stated residents definitely needed to be seen by an RNA as ordered. The DON stated it was important for residents to receive RNA treatments because it helped residents with movement, strength, and mobility and that RNA treatments were an important aspect of the care the facility provided to its residents. 2. A review of Resident 15's admission records indicated the resident admitted to the facility on [DATE] with diagnoses including but not limited to fracture of right femur (broken thigh bone), difficulty in walking, and Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). A review of Resident 15's MDS, dated [DATE], indicated the resident was cognitively intact, required extensive assistance (requires significant amount of assistance from another person to perform task) with bed mobility, transfers, and dressing. The MDS indicated Resident 15 could eat with set up assistance only. It indicated Resident 15 required limited assistance to walk in the room and hallways. The MDS indicated the Resident 15 did not have any functional limitations in ROM on both sides of the upper extremity and lower extremity. A review of Resident 15's Physician's History and Physical, dated 4/5/22, indicated the resident had the capacity to understand and make decisions. A review of Resident 15's Physician's Orders, dated 7/11/22, indicated an order for RNA to provide ambulation with FWW at distances tolerated by the resident daily 5 times a week. A review of Resident 15's Care Plan, dated 7/11/22, indicated the resident was at risk for decreased independence with ambulation. The care plan objective indicated the resident will maintain or prevent decline in function with ambulation. The care plan approach indicated to provide RNA for ambulation with FWW at distances tolerated by the resident daily five times a week. A review of Resident 15's Joint Mobility Screening, dated 1/24/23, indicated the resident had full ROM in both wrists and elbows and had minimal ROM loss in both shoulders. A joint mobility screen, dated 1/30/23, indicated Resident 15 had full ROM both on hips, knees, and ankles and to continue with the RNA program. A review of Resident 15's November 2022 RNA flowsheet documentation for RNA treatment of ambulation with FWW at distances tolerated by the resident daily five times a week did not indicate RNA 1's initials on the following days: 11/4/22, 11/7/22, 11/8/22, 11/9/22, 11/10/22, 11/11/22, 11/14/22, 11/15/22, 11/16/22, 11/17/22, 11/18/22, 11/21/22, 11/22/22, 11/23/22, 11/24/22, 11/15/22, 11/29/22, and 11/30/22. There was a total of 18 missed RNA treatments. A review of Resident 15's December 2022 RNA flowsheet documentation for RNA treatment of ambulation with FWW at distances tolerated by the resident daily five times a week did not indicate RNA 1's initials on the following days: 12/1/22, 12/8/22, 12/20/22, 12/27/22, and 12/28/22. There was a total of five missed RNA treatments. A review of Resident 15's January 2023 RNA flowsheet documentation for RNA treatment of ambulation with FWW at distances tolerated by the resident daily five times a week did not indicate RNA 1's initials on the following days: 1/2/23, 1/3/23, 1/4/23, 1/6/23, 1/9/23, 1/16/23, 1/23/23, 1/27/23, and 1/30/23. There was a total of nine missed RNA treatments. During an observation and interview on 1/31/23 at 9:42 a.m., Resident 15 was sitting in a wheelchair (WC) and able the to use both hands to maneuver the WC short distances inside the room. Resident 15 stated she walked with staff and participated in activities and exercises at the facility. During an interview on 2/1/23 at 9:02 a.m., RNA 1 stated she was the only RNA staff that worked in the facility and that there was no back up or other RNA staff member. RNA 1 stated that if she went on vacation, called in sick, or was reassigned to work as a CNA for the day, then no residents received any RNA treatments that day. During a concurrent interview of RNA 1 and record review of Resident 15's November 2022 to January 2023 RNA treatment flowsheets on 2/1/23 at 3:08 p.m., RNA 1 confirmed that Resident 15 did not receive RNA treatment for ambulation with FWW for distances tolerated by the resident daily 5 times a week as ordered by a physician: 1. November 2022 - 18 missed days of RNA treatment 2. December 2022 - 5 missed days of RNA treatment 3. January 2023 - 9 missed days of RNA treatment During an interview and record review at 2/2/23 at 8:56 a.m., the DSD reviewed Resident 15's medical records and confirmed Resident 15 had an order for RNA to provide ambulation with FWW for distances tolerated by resident once a day 5 times a week. DSD reviewed Resident 15's RNA treatment flowsheets for November 2022 December 2022, and January 2023 and confirmed RNA treatments were not provided as ordered by the physician. DSD stated the facility only had one RNA staff and there was no back up RNA. DSD confirmed that when RNA 1 was on vacation, sick, or pulled for a CNA assignment, there was no other staff to perform RNA treatments for residents on those days. DSD stated it was important for Resident 15 to walk with the RNA, because it helped to maintain the resident's strength and prevent a decline in range of motion and walking. DSD stated there was not sufficient nurse staffing for Resident 15 to receive their RNA treatment as ordered, because a lot of RNA treatments were missed. During an interview and record review on 2/2/23 at 11:17 a.m., the DON reviewed Resident 15's medical records and confirmed Resident 15 did not receive RNA treatments as ordered in the months of November 2022 December 2022, and January 2023. The DON stated the facility did reassign RNA 1 at times for CNA duties and there was no other staff to complete the RNA assignments on those days. The DON stated it was important for residents to receive RNA treatments because it helped residents with movement, strength, and mobility and that RNA treatments were an important aspect of the care the facility provided to its residents. DON stated residents definitely need to be seen by an RNA as ordered. 3. A review of Resident 25's admission records indicated the resident originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to chronic pain and difficulty in walking. A review of Resident 25's MDS, dated [DATE], indicated the resident was cognitively intact, required limited assistance of one person to walk in corridor, extensive assistance with dressing, transfers, and toileting, and was able to eat with setup help only. It also indicated the resident did not have any functional limitations in range of motion with both upper extremities (shoulder, elbow, wrist, hand) or lower extremities (hip, knee, ankle, foot). A review of Resident 25's 15's Physician's History and Physical, assessment dated [DATE], indicated the resident had the capacity to understand and make decisions. A review of Resident 25's Physician's Orders, dated 12/27/22, indicated for RNA to provide ambulation with FWW at distances tolerated by resident once a day five times a week. A review of Resident 25's Care Plan, dated 12/27/22 indicated, Resident needs ambulation RNA program and was at risk for decline in function. The care plan objective indicated the resident will maintain and prevent a decline in functional ambulation. A review of Resident 25's Joint Mobility Screen, dated 11/21/22, indicated the resident had full ROM in both wrists, elbows, and left shoulder. It indicated Resident 25 had minimal ROM loss in the right shoulder. It also indicated Resident 25 had full ROM in both hips, knees, and ankles. During an observation on 1/31/23 at 11:13 a.m., RNA 1 walked Resident 25 down the hallway with a FWW. Resident 25 was wearing a blue plastic gait belt (safety device worn around the waist that can be used help safely transfer a person from one surface to another) around the waist and RNA 1 provided verbal cues for Resident 25 to lift the right leg up higher to minimize dragging the right foot while walking. During an interview on 2/1/23 at 11:39 a.m., Resident 25 was sitting up in a WC in the resident's room. Resident 25 stated he walked with RNA 1 about two times a week on average, sometimes more and sometimes less. Resident 25 stated he was walking about the same distance. During an interview and record review on 2/1/23 at 1:34 p.m., Medical Records (MR) reviewed Resident 25's medical records and stated there were no documentation from 12/27/22 from when the RNA order was written to 2/1/23 related to provision of RNA treatments or services. During an interview on 2/1/23 at 3:08 p.m., RNA 1 stated Resident 25 was receiving RNA for ambulation and confirmed that RNA 1 did not document anywhere in the resident's medical records that the RNA treatment was completed. RNA 1 stated that it was important to maintain documentation for all RNA treatments completed, because if there was no documentation, then it meant that the treatment was not completed. RNA 1 stated she was unsure the days Resident 25 received RNA treatment for ambulation and which days were missed. During an interview and record review on 2/2/23 at 11:06 a.m., the DON confirmed there was no documentation for RNA from when the RNA order was written on 12/27/22 to 2/1/23 when the documentation for RNA was completed. The DON stated the facility would not know if the resident completed their RNA treatments if it was not documented and that if staff did not document it, then there was no way to prove it happened. A review of the facility's Nursing Staffing Assignment and Sign-In Sheet for the month of November 2022 indicated a total of 25 days without an RNA assigned: -Thursday, 11/3/22 -Friday, 11/4/22 -Saturday, 11/5/22 -Monday, 11/7/22 -Tuesday, 11/8/22 -Wednesday, 11/9/22 -Thursday, 11/10/22 -Friday, 11/11/22 -Saturday, 11/12/22 -Sunday, 11/13/22 -Monday, 11/14/22 -Tuesday, 11/15/22 -Wednesday, 11/16/22 -Thursday, 11/17/22 -Friday, 11/18/22 -Sunday, 11/20/22 -Monday, 11/21/22 -Tuesday, 11/22/22 -Wednesday, 11/23/22 -Thursday, 11/24/22 -Friday, 11/25/22 -Saturday, 11/26/22 -Sunday, 11/27/22 -Tuesday, 11/29/22 -Wednesday, 11/30/22 A review of the facility's Nursing Staffing Assignment and Sign-In Sheet for the month of December 2022 indicated a total of 16 days without an RNA assigned. -Thursday, 12/1/22 -Saturday, 12/3/22 -Sunday, 12/4/22 -Thursday, 12/8/22 -Saturday, 12/10/22 -Sunday, 12/11/22 -Tuesday, 12/13/22 -Friday, 12/16/22 -Saturday, 12/17/22 -Sunday, 12/18/22 -Tuesday, 12/20/22 -Friday, 12/23/22 -Saturday, 12/24/22 -Sunday, 12/25/22 -Wednesday, 12/28/22 -Saturday, 12/31/22 A review of the facility's Nursing Staffing Assignment and Sign-In Sheet for the month of January 2023 indicated a total of 16 days without an RNA assigned. -Sunday, 1/1/23 -Friday, 1/6/23 -Saturday, 1/7/23 -Sunday, 1/8/23 -Saturday, 1/14/23 -Sunday, 1/15/23 -Tuesday, 1/17/23 -Friday, 1/20/23 -Saturday, 1/21/23 -Sunday, 1/22/23 -Monday, 1/23/23 -Tuesday, 1/24/23 -Friday, 1/27/23 -Saturday, 1/28/23 -Sunday, 1/29/23 -Tuesday, 1/31/23 During an interview on 2/1/23 at 9:02 a.m., RNA 1 stated she was the only RNA staff that worked in the facility and that there was no back up or other RNA staff member. RNA 1 stated she worked only Monday through Friday and that there was never RNA scheduled on the weekends. RNA 1 stated if she worked on the weekends, it would be as a Certified Nursing Assistant (CNA) and never an RNA. RNA 1 stated that if she went on vacation, called in sick, or was reassigned to work as a CNA for the day, then no residents received any RNA treatments that day. During an interview on 2/1/23 at 3:08 p.m., RNA 1 stated she was on vacation during November and there was no staff to replace her during that time. RNA 1 stated it was important for residents to receive their RNA treatments as ordered so that the residents do not lose their range of motion and it helped to maintain their ability to move. A review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, indicated Facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment .staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care .

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food safety by failing to discard expired food in the refrigerator and storage room. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, other serious medical complications, and hospitalizations in 36 out of 38 medically compromised residents living in the facility. Findings: During a concurrent observation of refrigerator and interview with the dietary supervisor (DS), on 1/31/2023 at 8:46 AM, DS verified one package of unopened white chocolate with an expiration of 1/16/2023 was on the top of the shelf. DS stated expired food should be discarded. During a concurrent observation of storage room and interview with the DS on 1/31/2023 at 9:14 AM, DS verified three (3) bottles of unopened white chocolate dessert sauces with an expiration date of 10/30/2022 were on the top of the shelf. DS stated expired food should be discarded. A review of the facility's policy and procedure (P&P), revised November 2022 and titled, Food Receiving and Storage, indicated food shall be received and stored in a manner that complies with safe food handling practices. The P&P indicated: a. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). b. Dry food and goods are handled and stored in maintains the integrity of the packaging until they are ready to use. A review of the 2017 U.S. Food and Drug Administration Food Code indicated, ready-to-eat, Time/Temperature control for safety food should be marked by date or day or preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed, sold, or discarded. It further stated Time/Temperature control for safety refrigerated food must be consumed, sold, or discarded by the expiration date.