**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up and promptly report the results of an x-ray for one of three sampled residents (Resident 1) who were sampled due to falls in the facility when Resident 1 fell on her knee and her physician ordered an x-ray and the facility did not recognize they had not received the x-ray results for two days. This resulted in Resident 1 experiencing unnecessary severe left knee pain and a delay in treatment for two days due to a broken bone. This delay in treatment had the potential for Resident 1 to experience ongoing severe pain and negatively impact her physical, emotional, and psychosocial well-being. Findings: Review of a facility policy titled,Change in a Resident's Condition or Status dated July 2024, indicated 1. The nurse will notify in a reasonable timely manner the resident's attending physician or physician on call when there has been a(an): e. need to transfer the resident to a hospital/treatment center. Review of admission records for Resident 1 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a condition that changes how the brain works and can cause confusion, memory loss, and loss of consciousness), fracture of right ankle and fibula (a long bone in the lower leg positioned on the outer side of the calf), effusion right knee (an abnormal accumulation of fluid in a body cavity or body tissues), asthma, acute respiratory failure, dementia (loss of memory and ability to make sound decisions), dysphagia (difficulty swallowing), difficulty walking, muscle weakness, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness). Review of Resident 1's BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) admission assessment dated [DATE], showed a score of 8 out of 15, which indicated Resident 1 had a moderate cognitive impairment. During an interview on 3/6/25 at 12:16 PM, with Resident 1 in her room, Resident 1 stated that she had pain from her knee down related to her fall. Review of Resident 1's Progress Note dated 3/1/25 at 8:45 PM, written by Licensed Nurse (LN) C, indicated that Resident 1 had a fall in her room and had pain in her left knee with redness and swelling. Review of Resident 1's, Post Fall Evaluation dated 3/2/25 at 4:18 AM, completed by LN C, indicated that Resident 1's left lower leg had bruising, swelling, redness, pain. Review of Resident 1's, Pain Evaluation dated 3/2/25 at 4:18 PM, completed by LN C, indicated that Resident 1 described her pain as aching. Review of Resident 1's Progress Note dated 3/2/25 at 9:56 AM, written by LN D, indicated that an order for left knee x-ray (images taken of the bones) was requested from the physician. Review of Resident 1's, Physician's Orders dated 3/2/25 at 10:44 AM, indicated that an x-ray to Resident 1's left knee/shin was ordered by the Medical Doctor (MD). Review of Resident 1's x-ray results that were done on 3/2/25, no time, indicated, Left Tibia/Fibula [the shin bone and the calf bone] X-Ray results were, Acute avulsion of the tibial tuberosity [a break in the bony bump at the top of the tibia where the knee is connected] the front of the tibia just below the kneecap) with effusion [swelling]. Review of Resident 1's Progress Note dated 3/4/25 at 5:53 PM, written by LN E, indicated, Resident vocal complaint of continuous pain 8-10 [10 being the worst pain imaginable], in LLE [left lower extremity]. Bruising, and swelling noted. Orders to send to the hospital. During a concurrent interview and record review of Resident 1's x-ray report dated 3/2/25, with the Director of Nursing (DON) on 3/6/25 at 2:44 PM, in the DON's office, the DON confirmed that a physician's order for an x-ray of Resident 1's left knee was obtained on 3/2/25 at 10:45 AM. The DON confirmed that an x-ray of Resident 1's knee was completed on 3/2/25 and the x-ray had indicated that Resident 1 had a broken tibia. DON confirmed that the facility had not received the x-ray report for Resident 1 on 3/2/25, and had not followed up on getting those results. DON confirmed Resident 1's physician was not notified of the x-ray results until 3/4/25, when the facility recognized they never received the x-ray report from 3/2/25. The DON indicated her expectation would be if the facility does not receive x-ray results within 24 hours, they should call and ask the imaging company about the x-ray results in order to prevent a delay in getting treatment for a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the rights for one of three sampled residents (Resident 1) when Resident 1 did not receive a written notice of a proposed room change. This failure resulted in Resident 1 experiencing distress, frustration and the feeling of not having control over anything in her life. Findings: A review of the facility's policy titled Room Change/Roommate Assignment revised March 2021, indicated Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., [example] residents and their representatives) is given a notice of change prior to the transfer. A review of Resident 1's admission Record (undated), indicated she was admitted [DATE] with diagnoses that included a fracture of the right leg, history of falling, and pain. A review of Resident 1's admission Minimum Data Set (MDS, a clinical assessment) dated 11/13/24, indicated a Brief Interview for Mental Status (BIMS, an assessment of mental capacity) was conducted and Resident 1 scored a 15 out of 15 indicating her cognition was intact. Resident 1 was her own responsible party (RP, makes her own decisions about health care). During an interview on 1/17/25 at 10:50 am, Resident 1 stated They moved me from my room. I did not want to move. I was crying when I came over here because I did not have my door decorations. There were more drawers and a bigger closet (in the previous room). I am just a line item; it is a business. I did not want to move. They said I did not have a choice (and) it was happening. We have no control over anything in our lives. Resident 1 indicated that she did not receive a written notice indicating the move or the reason why. During an interview on 1/17/25 at 11:30 am, Social Service Director (SSD) indicated that the move for Resident 1 was decided by the admission Department and the Social Service Department because they needed the room for new residents. During an observation and interview on 1/17/25 at 11:51 am, Resident 1 was observed laying in her bed and Resident 1's Personal Therapist (PT) was sitting in a chair next to her bed. There were boxes, papers, clothes and many other items heaped on the floor next to her bed. PT indicated she was present when the facility asked her to move to a new room. PT stated She (Resident 1) was first asked if she wanted to move, and she said no. Then she was told she had to move, and she threw a fit. She did not want to move. She did not agree to move. She has such a short time left (in the facility) and so much stuff to move, now it is in disarray. A review of Resident 1's nursing progress notes dated 1/14/25 at 10:19 am, indicated SSD noted Spoke with resident and requested her to move rooms to 17 A, (Resident 1's name) was not happy about the move but did agree to move rooms. During an interview on 1/17/25 at 12:26 pm, SSD indicated she spoke with Resident 1 about the room change. SSD stated, I did have to work with her, but she did finally agree to try. SSD indicated they needed to do the room change because they needed a room to admit males into and there was no other choice for that situation. During an interview on 1/17/25 at 12:32 pm, Certified Nursing Assistant (CNA) A indicated that the Staffing Coordinator (SC) and herself went into Resident 1's room to talk with her about the move. CNA A indicated that Resident 1 was upset (about having to move) and throwing things and that someone had already come in and asked her about the move. CNA A did not know who that was. CNA A indicated that she then asked for SSD to speak to Resident 1 about the move because Resident 1 was upset. During an interview on 1/17/25 at 12:40 pm, the SSD and Director of Nursing (DON) indicated that they did not give a written notice to Resident 1 about the move and did not know they had to. SSD and DON reviewed the Federal Regulations and confirmed that a written notice was required and that they should have done this, and they did not.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #65 and Resident #72) of 19 sampled residents. Findings included: During an interview on 11/20/2024 at 10:16 AM, the Director of Nursing (DON) indicated the facility did not have a policy on MDS accuracy. 1. An admission Record revealed the facility admitted Resident #72 on 10/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. An admission MDS, with an Assessment Reference Date (ARD) of 10/19/2024, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed that the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. A letter from the California Department of Health Care Services, dated 09/26/2024, revealed a Level II evaluation was conducted on 09/26/2024 and specialized services were recommended. During an interview on 11/21/2024 at 8:43 AM, the MDS Coordinator stated she reviewed the electronic and paper chart, observed the resident, and interviewed the resident and staff to complete an accurate MDS. The MDS Coordinator indicated that to complete the admission MDS she reviewed the hospital documentation and the resident's history and physical. During an interview on 11/21/2024 at 9:35 AM, the DON stated she expected for the MDS to be accurate. The DON stated it was important for information to be true and accurate because the MDS needed to reflect the actual state of the resident. During an interview on 11/21/2024 at 9:54 AM, the MDS Coordinator stated Resident #72's PASRR Level II was missed and should have been coded on the resident's admission MDS. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated he expected the MDS to be completed accurately and in a timely manner. The Administrator stated it was important to capture the correct information so the MDS would be accurate. 2. An admission Record indicated the facility admitted Resident #65 on 07/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, chronic peptic ulcer, and hypertension. An admission MDS, with an Assessment Reference Date (ARD) of 07/09/2024, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Per the MDS, Resident #65 did not use tobacco at the time of the assessment. Resident #65's care plan included a focus area initiated 09/19/2024 that indicated the resident was a smoker. Interventions directed staff to educate the resident regarding the facility's smoking policy, designated smoking areas, and the storage of smoking materials. Resident #65's Progress Notes dated 07/02/2024 indicated the resident was a current smoker and was interested in the facility smoking schedule. During an interview on 11/20/2024 at 8:50 AM, Resident #65 stated they had been a smoker since before admission to the facility. During an interview on 11/21/2024 at 8:43 AM, the MDS Coordinator stated she reviewed the resident's chart and interviewed staff and the resident when completing their MDS. The MDS Coordinator further stated she thought when she interviewed Resident #65 upon admission that they were not smoking, but the resident was in fact smoking with the activities department. During an interview on 11/21/2024 at 9:35 AM, the DON stated she expected the MDS to be completed to accurately reflect the resident's status to ensure facility staff provided the appropriate care for each resident. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated he expected the MDS to be completed accurately and in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident who received a psychiatric diagnosis, prior to readmission, for 1 (Resident #16) of 3 residents reviewed for PASRR. Findings included: An undated facility policy titled, PASRR Completion Policy revealed, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An admission Record revealed the facility originally admitted Resident #16 on 01/10/2024 and re-admitted the resident on 08/01/2024. According to the admission Record, the resident had a medical history that included diagnosis of dementia with behavioral disturbance. A Medicare 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active psychiatric diagnoses of anxiety and psychotic disorder. Per the MDS, the resident received antipsychotic and antianxiety medication during the assessment timeframe. Resident #16's care plan included a focus area revised on 01/29/2024, that indicated the resident had the potential to be physically aggressive towards staff. Interventions directed staff to analyze the time of day, place, circumstances, triggers, and what de-escalates the behavior (initiated 01/29/2024); to assess and address for contributing sensory deficits (initiated 01/29/2024); and when the resident becomes agitated, intervene before agitation escalates (initiated 01/29/2024). The care plan included a focus area initiated on 06/07/2024, that indicated the resident used psychotropic medications related to psychosis, as evidenced by verbal and physical aggression, sexual outbursts, and the inability to redirect. Interventions directed staff to administer psychotropic medications as ordered by the physician, and to monitor for side effects and effectiveness (initiated 06/07/2024). Resident #16's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 12/28/2023, prior to Resident #16's first admission to the facility, indicated the resident did not have a serious diagnosed mental disorder. The Level I Screening indicated a Level II Mental Health Evaluation was not required. Resident #16's Census List, dated 11/19/2024, revealed Resident #16 was transferred to the hospital on [DATE] and discharged from the facility after seven days, on 07/19/2024. The Census List further revealed Resident #16 was re-admitted to the facility on [DATE]. An IDT [Interdisciplinary Team] Review note dated 07/11/2024 revealed Resident #16 was sent to a facility for psychiatric care for two to four weeks because of aggressive behaviors and would return to the facility when completed. A General Note dated 08/02/2024 revealed Resident #16 arrived back at the facility and was adjusting well. A hospital Discharge Summary dated 08/01/2024, revealed Resident #16 had a new diagnosis of unspecified psychosis, in addition to an existing diagnosis of dementia with behavioral disturbance. Resident #16's medical record revealed no other PASRR had been completed since re-admission to the facility on [DATE], and no evidence that indicated a referral was made to the appropriate state-designated authority after receiving a new psychiatric diagnosis. During an interview on 11/20/2024 at 10:16 AM, the Director of Nursing (DON) stated a new PASRR should have been completed when Resident #16 was readmitted to the facility in August 2024. During a subsequent interview on 11/20/2024 at 11:15 AM, the DON stated she was going to have the Social Services Director (SSD) submit a new Level I Screening, as it should have been done when the resident returned from a psychiatric stay with a diagnosed mental illness of psychosis. During an interview on 11/21/2024 at 8:23 AM, the SSD stated the Level I Screening was to be completed at the hospital prior to a resident's admission to the facility, and the Business Office Manager (BOM) would make sure the paperwork was present prior to admission. During an interview on 11/21/2024 at 8:27 AM, the BOM stated the hospital completed the PASRR prior to a resident coming to a skilled nursing facility. The BOM stated that the accuracy of the PASRR was assessed by the DON, and if the resident had an issue with mental illness after admission, the facility would initiate an additional PASRR. She also stated if the resident triggered a positive Level I PASRR and required a Level II assessment, both should be completed at the hospital prior to admission. During an interview on 11/21/2024 at 8:32 AM, the DON stated all admissions were reviewed for medications and diagnoses that would trigger a positive Level I PASRR prior to admission. She stated the Admissions Director would bring the PASRR to her to review if it did not match the diagnoses available in the resident's medical history. The DON stated that if the PASRR was incorrect, the facility would notify the hospital's PASRR department so they could educate their team on what was incorrect. The DON stated there was a lack of training regarding Resident #16's PASRR. The DON stated the facility Resident #16 was sent to for psychiatric inpatient care did not participate in the PASRR program and did not complete a Level I assessment prior to discharge. She stated it was the responsibility of the facility to complete the Level I PASRR when the resident returned. The DON stated they should have completed another assessment for Resident #16, and the facility would start the assessment process. The DON stated her expectation going forward was for the PASRR to be reviewed by the Admissions Director, who is a nurse, prior to admission. The DON stated if there was a question or concern regarding a medication or diagnosis, she could get clarification. She stated she reviewed admissions as well and corrected or initiated a new PASRR if needed and notified the hospital of errors. The DON stated the PASRR system needed work and more training so the facility could have a good and functioning PASRR program. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated the PASRRs should come from the hospital, and if a Level II was needed, it should happen at the hospital prior to admission. He stated the PASRRs needed to be accurate with proper psychiatric diagnoses and he would defer to the DON on the importance of the PASRR process.

Based on interview, record review, facility document review, and facility policy review, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for 1 (Resident #24) of 3 residents reviewed for PASRR. Specifically, Resident #24 had a diagnosis of schizophrenia that was not captured on their Level I PASRR. Findings included: An undated facility policy titled, PASRR Completion Policy, indicated, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An admission Record indicated the facility admitted Resident #24's on 06/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia with an onset date of 06/03/2024 and major depressive disorder with an onset date of 06/03/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #24 was not considered by the state Level II PASARR process to have a serious mental illness. Resident #24's care plan included a focus area initiated on 06/03/2024 that indicated the resident used psychotropic medications related to schizophrenia as evidenced by auditory hallucinations. Interventions directed staff to monitor for any adverse reactions of psychotropic medications and to monitor and record the occurrence of target behavior symptoms. Resident #24's Order Summary Report contained an order dated 08/24/2024, for Aripiprazole (antipsychotic) oral tablet 30 milligrams (mg) with instructions to give 30 mg by mouth one time a day as evidenced by auditory hallucinations related to schizophrenia. Resident #24's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/03/2024, indicated the resident had a serious diagnosed mental disorder of depression. The screening revealed schizophrenia was not listed as a diagnosed mental disorder. A letter from the State of California Health and Human Services Agency Department of Health Care Services dated 06/03/2024 indicated the state was unable to complete a Level II evaluation because Resident #24 had no serious mental illness. During an interview on 11/21/2024 at 8:24 AM, the Social Services Director (SSD) stated the Level I PASRR was completed at the hospital prior to admission. During an interview on 11/21/2024 at 8:25 AM, the Business Office Manager (BOM) stated the hospital completed the Level I PASRR and the Director of Nursing (DON) was responsible for ensuring the accuracy of these screenings. The BOM further stated the facility accepted the hospital-completed Level I PASRR for admission. During an interview on 11/21/2024 at 8:32 AM, the DON stated the BOM had access to the PASRR screening system, and she reviewed them prior to a resident's admission for accuracy. The DON further stated Resident #24's schizophrenia diagnosis was not listed on their Level I PASRR and that it needed to be redone and resubmitted to include that diagnosis. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated that Level I PASRRs were completed at the hospital prior to admission, and they needed to accurately reflect a resident's mental health diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of six residents who were sampled for quality of care (Resident 1), received care that was in accordance with professional standards and consistent with Resident 1's preferences and goals and at the level of assistance he needed. Resident 1 was admitted for Comfort Care (end of life care) on the afternoon of 9/14/24, and requested not to be put into a brief (adult diaper). During the night shift on 9/14/24, Certified Nursing Assistant (CNA) D had left Resident 1 in a soiled night gown, soiled brief, wet sheets, and the television (TV) in his room blaring and had not assisted Resident 1 in eating his supper. Resident 1 was found on 9/15/24 around 6:45 am, by his Family Member (FM) A and CNA C, in a soiled and soaking wet brief and hospital gown with dried brown rings on his bed sheets and the TV blaring. These failures resulted in Resident 1 having a horrible experience and lack of sleep and he left the facility that morning and returned to the hospital. These failures had the potential for residents to experience an undignified existence, discomfort, skin breakdown, nutritional declines, loss of sleep and inability to attain or maintain their highest practicable level of physical and emotional well-being. Findings: Resident 1 was admitted to the facility on [DATE] around 4 pm, from the hospital with conditions ranging from thrombocytopenia (low platelets, inability of the blood to clot), an infected pacemaker (an implanted device that regulates the heart beat), and was terminally ill (dying). Resident 1 was admitted to receive comfort care (support of a resident ' s emotional and physical needs while at the end of life, focusing on comfort rather than treatment). Resident 1 requested to return to the hospital on 9/15/24, after about a 12 hour stay at the facility. A review of the, National Institutes of Health Information, Providing Care and Comfort at the End of Life, (undated), indicated, physical comfort (e.g. soft lighting, soft sounds) are a critical part of comfort care. A review of the facility ' s policy titled, Resident Rights dated 12/2021 indicated that various rights are guaranteed to all residents by federal and state law including, to be treated with respect, kindness, and dignity and to be free from .neglect. Resident 1's Progress Notes were reviewed. On 9/14/24, Licensed Vocational Nurse (LVN) B documented that Resident 1 was admitted around 4 pm, for end of life comfort care related to multiple comorbidities [many illnesses]. Further review of that record indicated under continence (ability to hold/control stool and urine) that Resident 1 had mixed continence of bladder (occasions where a loss of control may happen). Resident 1's Progress Notes were further reviewed. On 9/15/24 at 9:15 am, LVN B documented, Family had concerns about resident care and thought comfort care was questionable, resident alert and able to express himself, family arrived early this am and was told by resident that he had not received any care all night, and roommate yelled out most of the night, TV on and loud volume all night. Review of the record titled, admission Assessment for Resident 1 dated 9/14/24 indicated Resident 1 was aware of person, place, and time and was continent (full control) of his bowel and bladder and had an indwelling urinary catheter (sometimes called a Foley catheter, a tube inserted into the urethra to drain the bladder). Review of a statement written and signed by CNA C, dated 9/15/24, was provided by the Administrator (ADMIN) and indicated, I was checking rooms at 0645 when I noticed that room [ROOM NUMBER]A resident's [FM A] was upset at the current state of her father. Upon entering the room, I noticed 25A was soaked as well as dried ooze over his entire bed and gown. There wasn't much water. 25A told me that no CNA came in all night and he has been sitting in his filth for more than 8 hours. The [FM A] was extremely upset, I changed the bedsheets, gave the client more water, took off the diaper and left it off, and let the nurse know exactly what had happened. Review of a document signed by CNA D was provided by the facility ADMIN titled, Employee Warning/Discipline/Coaching Memo dated 9/16/24. The record indicated that Resident 1 was left heavily soiled, that CNA D ' s last interaction with the resident was at 3 am, while his shift was not over until 7 am. The record indicated that corrective action was taken regarding performing two-hour rounding (checking) on rooms, making sure walking rounds (where the on-coming and off-going CNAs inspect the residents together), at change of shift and coaching in incontinence care. In an interview on 9/18/24 at 4:46 pm, FM A stated that Resident 1 was placed in a diaper after telling the night nurse he was not incontinent and didn ' t want to wear a diaper. FM A stated that when she came into the facility early in the morning of 9/15/24, Resident 1 was in a messy diaper and the bed was saturated. FM A stated that Resident 1 was not incontinent. FM A further stated that Resident 1 appeared frightened when she arrived early morning on 9/15/24. His TV was so loud that I had to put my mouth to his ear and yell. He was telling me that he complained at night for them to turn the TV down, but it was just as loud at 7 am as it was the night before. He was a mess in a room with a blasting television; he had asked the night staff to turn it down and they responded to him that his roommate liked it that way. I asked [Resident 1], Do you want me to get you out of here? He said, Ok, get me out of here. FM A stated, Based on what I saw, there was a total lack of compassion. In an interview on 9/19/24 at 4:45 pm, Resident 1 was interviewed by telephone in his home. Resident 1 stated that being at home and being cared for by his daughters, was precisely the situation he had tried to avoid by being admitted to the facility and that his daughters were now caring for him as he was actively dying. The hospital sent me to the facility so I could get ready to pass on. I didn't want my daughters to take care of me, so I went to [the facility]. All I wanted was to be comfortable and rest, but it was a horrible experience. The television was on all night long and the person next to me was screaming. I told the CNA taking care of me that I was uncomfortable, that the TV was too loud, and he told me my roommate liked it that way and did nothing about it. I asked if they had any earplugs, but he never brought them. Resident 1 also stated that he was placed in a diaper after stating to staff that he was not incontinent and had requested a bedpan, I had never had to be in a diaper before. I just figured this is what they do. I'm [AGE] years old and dying, I assumed that at least they'd give me a bedpan if I asked for one. Resident 1 stated that during that night shift he was unable to eat or drink and received no assistance, I didn't get to eat my meal. I was slumped down in the bed and couldn't even see or reach the food. The aide just plopped it down on the table and it stayed there all night, there was no way I could get to it. It was a terrible night. I asked for water and never got it. I felt like I was just 'somebody in a home,' here today and gone tomorrow. In an interview on 9/23/24 at 11:50 am, LVN A stated, Our protocol for admitted residents is to monitor their bowel and bladder habits from the moment they get here to determine continent versus incontinent and their needs. Nutrition is the same, it is the facility's responsibility to observe how a resident is eating their food from the first meal they get. It's obvious when you go into a room that the patient hasn't touched their food, it's questionable why they aren't eating. We should be taking note of that from their first meal here. LVN A stated that a resident's request should never be ignored. In an interview on 9/23/24 at 12:00 pm, Assistant Director of Nursing (ADON) A stated that she was aware of the situation with Resident 1 and heard about him asking for earplugs and and a request for a bed pan, instead of diapers. ADON A stated, They should have given him a bedpan, it's a basic nursing intervention for his dignity. Regarding ear plugs, ADON A stated, We have ear plugs and offer them to residents when requested. I know earplugs are available. In a concurrent record review of Resident 1 ' s hospital discharge summary that was provided to the facility on 9/14/24, ADON A confirmed Resident 1 was continent of bowel and that he could not walk to the restroom, not ambulatory. In an interview on 9/15/24 at 12:15 pm, LVN B stated that she was aware of Resident 1 ' s concerns. The CNA who was assigned that morning saw that he was very soiled, laying in head to toe urine. He had a wound on his right side that had covered the sheet in dried pus. I know this happened that night [9/14/24]. Also, when urine sits for more than a few hours on a sheet, it makes a brown recognizable 'ring.' I could tell the urine had been there all night. The night shift CNA was CNA D. LVN B confirmed that Resident 1 was alert and oriented and could make his needs clearly known. LVN B indicated that CNAs work according to a scheduled routine rounding every two hours, concluded by rounds on the night shift about 4:30 am, preparing for the next shift. LVN B stated that CNA D, could not have done those rounds or he would have noticed the sheets. Regarding the room noise, LVN B stated, We usually have a rule, 10 pm, the television needs to be turned down. This patient hadn't been with us that long and his roommate tends to yell out at night, which was another problem. I was not aware he requested a bedpan. He came to us incontinent per his records, it was for him, not for the convenience of staff. He appeared able to feed himself, he was able to hold a cup. He wasn't with us long enough to do a full assessment or lengthy evaluation. In an interview on 9/23/24 at 12:45 pm, CNA C confirmed that he came in to find Resident 1, filthy and saturated with urine. CNA C stated that Resident 1's bed had not been changed, and that bed pans were always available to residents if they wanted one, we have three types of them. CNA C further stated, When we came in that morning, the room lights were all on, the TV was loud in the room, to the point where the resident across the hall closed their door. I ended up finding the remote and turning it down. [Resident 1] had a wound on his right side that had pus all over the sheet and the bed was saturated. CNA C confirmed that the night shift CNA was CNA D. CNA C stated, The family was unhappy and there was nothing I could do to console them, and I didn't blame them. In an interview on 9/23/24 at 12:55 pm, Director of Staff Development (DSD, nurse who trains CNAs) E stated, I spoke to [CNA C] after the situation. He came on shift and stated that he had been doing room rounds and went in to see [Resident 1] whose [FM A] was upset. [CNA C] had to change the bed, it was heavily soiled. I had to contact CNA D to educate him about room rounds, thorough documentation, and taking residents to the restroom or changing them every two hours. DSD E stated, regarding Resident 1's supper meal tray, When a resident first arrives, we have to assist at the bedside to assess if they're eating their meals. If he hadn't eaten his food, it would have been determined immediately and we should have intervened by either offering an alternative or determining why he wasn't eating. Regarding ear plugs, DSD E stated, We are pretty quick to respond, we have headphones and earplugs for residents. In an interview on 9/26/23 at 5 pm, with LVN F, she confirmed that she assumed the care of Resident 1 on 9/14/24 at 10 pm. LVN F indicated that she had taken over for another nurse who had completed the nursing assessments and did the initial rounds. LVN F stated, It was a busy night, 3 admits lots of comfort care residents, and only 2 aides; [CNA B] and a CNA from a registry [temporary staffing agency]. LVN F indicated that CNA B was in Resident 1's room a lot because the roommate needed a lot of care and there was a lot going on, but could not confirm that she witnessed CNA B actually giving care to Resident 1. LVN F stated, I went in to listen to [Resident 1's] lungs and give him pain medication if he needed it. His daughter gave me information about him being hard of hearing, requiring feeding assistance with meals because he couldn't eat on his own. LVN F was not able to confirm whether or not Resident 1 had eaten supper. LVN F confirmed that Resident 1 had an indwelling urinary catheter, and I don't recall what he was wearing, usually if they have a foley it's their own clothes and chux [pad for the bed]. He was alert and oriented and able to use a bedpan, but I don't know if [Resident 1] had a bedpan, because I didn't see what supplies were taken into the room that night. LVN F indicated that there were two TVs in Resident 1's room, she did not recall the TV being loud but stated that resident's roommate was very loud and yelling out when care was provided to him. LVN F indicated that she was unaware of Resident 1's request for earplugs or for a bedpan and that Resident 1 never complained to her about anything. LVN F indicated that she had not seen what Resident 1's bedsheets looked like. LVN F indicated that she left the facility at 7 am the next morning, on 9/15/24, and no staff had approached her about problems with Resident 1's care. In an interview on 9/26/24 at 6 pm, CNA D stated, I was surprised about it. I told the [ADMIN] the night I was on duty that I was in that room a lot when I came into work, I had to remove all the trays and went to him [Resident 1] he refused feeding and asked me to leave the tray. Asked if he wanted something else, grilled cheese, he said to leave the tray there, would have given to him. Asked him several times during night he said leave it there. He called me at midnight BM [bowel movement] and I cleaned him, nothing else happened, I checked him, he called me by name and I said thank you. I attended to him every two hours. I was so busy that night. Second bed TV on but wasn't too loud, he [Resident 1] didn't complain. By the time I got my last rounds at 5 am, got to him, discovered he had a little BM, made me change his brief again, turn him on his strong side, not leaking, no complaint. No pus. First thing I would have done is to report to nurse. He was friendly to me. Of course I supplied fresh water. Saw him drinking, no issues, if he had complained about anything I would have done it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP-care customized to an individual resident's needs) for one of three sampled residents (Resident 5) when Resident 5's: 1. Care plans were not developed for two areas of skin breakdown. 2. Comprehensive care plans were not implemented when Resident 5 displayed behaviors which indicated pain. These failures resulted in unmet care needs and a decline Resident 5's health status. Findings: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered revised December 2016, indicated 8. The comprehensive care plan will: a. includes measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. g. Incorporate identified problem areas; h. incorporate risk factors associated with identified problems; M. Aid in preventing or reducing decline in the resident ' s functional status 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s conditions change. 15. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in resident's condition. A review of the facility's policy titled, 1. Change in Resident's Condition or Status revised 2016, was provided by the Medical Records Director and reviewed. The policy directed, change of condition is a major decline or improvement in the resident ' s status that; Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; Impacts more than one area of the resident ' s health status; Requires interdisciplinary review and/or revision to the care plan . 1. A review of Resident 5's medical record indicated that he was admitted on [DATE] with diagnoses that included a stroke, diabetes, pain, right sided paralysis, dysphagia (difficulty swallowing), aphasia (trouble speaking), contractures (drawn up muscles) of the right hand, right knee, left hand, and left foot. Resident 5's annual Minimum Data Assessment (MDS, a standardized assessment tool), dated 6/11/22, showed that he had moderately impaired decision-making skills and required 2 people to help with bed mobility, transfers, dressing and toileting. His son was his responsible party. A review of Resident 5's Pressure Ulcer at Risk care plan showed that on 8/4/22, the Treatment Nurse (TN) added the intervention, DTI (Deep Tissue Injury, Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to Lateral Right Malleolus(ankle) (over boney prominence). Site measures 2cm (centimeters) x 2cm. Dark purple tissue. UTD [undetermined] depth at this time. There were no other problems, goals, or interventions added to Resident 5's care plan for the management of Resident 5's right ankle pressure injury. On 8/5/22 at 10:30 am, (a day after the wound was identified) the TN created an SBAR (Situation, Background, Observation/Evaluation Assessment and Response, a change in condition nursing assessment) and documented, Re-occurring DTI to the lateral Right Malleolus [ankle bone] 2cm [about the size of a peanut] x 2 cm. It started as some discoloration, and he had previously had foam dressing placed 3x (times) a week as a preventative but now it is an actual DTI and is likely to turn into a pressure injury over the ankle bone. Skin is already so thin I am very concerned that this will deteriorate quickly. At initial observation some discoloration was noted on wed [Wednesday] 8/3/22. Site still had skin fully intact .[Resident 5] fights staff and continues to put pressure on the area There were no interventions, added to Resident 5's care plan, for fighting with staff, possible refusal of care and TN's concern that the wound might deteriorate quickly. On 8/6/22 at 9:21 pm, Licensed Nurse (LN) 6 created an SBAR (Situation, Background, Observation/Evaluation Assessment and Response, a change in condition nursing assessment) for a newly discovered pressure injury, sore to Resident 5's right buttock that measured 2cm x 3cm. No care plan was developed to manage the newly discovered pressure injury. During an interview on 12/28/22 at 1:45 pm, the TN confirmed no care plans were developed for these wounds that had measurable objectives, risk factors and specific interventions to aid in the healing of these wounds and prevent them from getting worse. 2. The facility's policy titled, Wound Care dated October 2010, was provided by the DON and reviewed. The policy directed, Review the resident ' s care plan to assess for any special needs of the resident. A review of Resident 5's At risk for Pain care plan revised 6/18/22, indicated a goal of, will not experience a decline in function related to pain with interventions to include Administer pain medication as ordered and evaluate need to provide medications prior to treatment or therapy. A review of Resident 5's Behavior care plan revised on 6/18/22, revealed a focus area indicating he sometimes had behaviors which included yelling during care, yells ow, ow, shouting, screaming when he does not want to get out of bed or take a shower during the course of care or when he is joking around with staff. Interventions included to make sure he was not in pain or uncomfortable. On 8/9/22 at 3:47 pm, LN 4 entered a Late Entry progress note for 8/8/22 at 3:40 pm, despite multiple attempts and education and coaxing to comply resident refused wound Tx, resident refused wound care to right foot, refused repositioning, oral care and incontinence care resident was yelling out, grabbing staff, squeezing nurse and CNA wrists, and kicking, resident was approached multiple times this shift . Resident 5 was not evaluated for pain, as indicated in the above care plans. On 8/9/22 at 3:53 pm, LN 4 documented, resident refused wound care as ordered despite multiple attempts. Resident was not evaluated for pain as indicated in care plans above. On 8/9/22 at 4:01 pm, LN 4 documented a late entry note for 8/7/22 at 3:54 pm, Resident was noncompliant with wound care as ordered today, resident was approached multiple times, education and encouragement offered, resident allowed Tx to buttocks/coccyx, offloading boots in place per order, but resident refused wound care to right foot, dressing intact to wound, did not appear soiled. Resident would not allow repositioning, resident would yell hold up a fist indicating he would hit staff if attempted, grabbing at staff, flailing with attempts and kicking, staff would leave, and re-approach and this behavior continued. Resident was not evaluated for pain as indicated in care plans above. A review of Resident 5's Medication Administration Record (MAR) for August 2022, revealed he had not been given any pain medication prior to wound treatments. During an interview and record review on 12/5/22 at 4:00 pm, of Resident 5's MAR, the DON confirmed that pain medication was not given prior to wound treatments. During an interview on 12/5/22 pm at 4:30 pm, the TN confirmed that care plans were not developed for 2 newly discovered pressure injuries and that Resident 5's care plans for behavior and pain were not implemented, and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services which promoted healing and the prevention of infection and evaluate the basis for the refusal of care, for one of three sampled residents (Resident 5), when a Deep Tissue Injury (DTI-Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface), was discovered on his right outer ankle on [DATE], and a treatment order was not obtained until [DATE]; and he was not evaluated for alternative treatment options when he refused treatments for 3 consecutive days and his physician and responsible party were not notified; and he was not evaluated for pain related to his DTI; and no care plan was developed. (Refer to F636 and F697) This resulted in Resident 5's DTI quadrupling (4 times larger) in size and worsened to an infected Stage 4 pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough [infection] and/or eschar [dead tissue] may be visible on some parts of the wound bed), which required an emergent hospital admission for treatment. Findings: The facility's policy titled, Requesting, Refusing and/or Discontinuing Care or Treatment revised 2017, was provided by the Medical Records Director and reviewed. The policy directed, Treatment is defined as services provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. 6. If a resident requests, discontinues or refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with the resident to: determine why the resident is requesting, refusing or discontinuing care or treatment; try to address the resident's concerns and discuss alternative options .9. The interdisciplinary team will assess the resident's needs and offer the resident alternative treatments .12. Documentation pertaining to a resident's request, discontinuation or refusal of treatment shall include at least the following: The date and time the care or treatment was attempted; the type of care or treatment; the resident's response and stated reason (s) for request, discontinuation or refusal; the name of the person attempting to administer the care or treatment; that the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/or treatment; the resident's condition and any adverse effects due to the request; the date and time the practitioner was notified as well as the practitioner's response. 13. The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. The facility's policy titled, Prevention of Pressure Injuries dated [DATE], was provided by the DON and reviewed. The policy directed, Review the interventions and strategies for effectiveness on an ongoing basis. The facility's policy titled, Wound Care dated [DATE], was provided by the DON and reviewed. The policy directed, Review the resident's care plan to assess for any special needs of the resident. A review of the facility's policy titled, 1. Change in Resident's Condition or Status revised 2016, was provided by the Medical Records Director and reviewed. The policy directed, The nurse will notify the resident's Attending Physician or physician on call when there has been a need to alter the resident's medical treatment significantly, refusal of treatment or medications two (2) or more consecutive times, change of condition is a major decline or improvement in the resident's status that; Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; Impacts more than one area of the resident's health status; Requires interdisciplinary review and/or revision to the care plan .3. Prior to notifying the Physician .the nurse will make detailed observations and gather relevant and pertinent information for the provider .4. A nurse will notify the resident's representative .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of Resident 5's medical record indicated that he was admitted on [DATE] with diagnoses that included a stroke, diabetes, pain, right sided paralysis, dysphagia (difficulty swallowing), aphasia (trouble speaking), contractures (drawn up muscles) of the right hand, right knee, left hand, and left foot. Resident 5's annual Minimum Data Assessment (MDS, a standardized assessment tool), dated 6 /11/22, showed that he had moderately impaired decision-making skills and required 2 people to help him with bed mobility, transfers, dressing and toileting. His son was his responsible party. A review of Resident 5's Pressure Ulcer at Risk care plan showed that on [DATE], the Treatment Nurse (TN) added the intervention, DTI to Lateral Right Malleolus (over boney prominence). Site measures 2cm (centimeters) x 2cm. Dark purple tissue. UTD [undetermined] depth at this time. There were no other problems, goals, or interventions added for the management of Resident 5's right ankle pressure injury. Resident 5's Progress Notes were reviewed. There was no documentation by the TN regarding her discovery of Resident 5's right ankle pressure ulcer on [DATE], or that his physician was notified for a treatment order. On [DATE] at 9:03 am, the Interdisciplinary Team (IDT-facility managers who discuss resident care and services) documented that Resident 5 had been exposed to Covid (a serious respiratory virus), however, had not included any discussion regarding his newly discovered pressure injury. On [DATE] at 10:30 am, (a day after the wound was identified) the TN created an SBAR (Situation, Background, Observation/Evaluation Assessment and Response, a change in condition nursing assessment) and documented, Re-occurring DTI to the lateral Right Malleolus [ankle bone] 2cm [about the size of a peanut] x 2 cm. It started as some discoloration, and he had previously had foam dressing placed 3x (times) a week as a preventative but now it is an actual DTI and is likely to turn into a pressure injury over the ankle bone. Skin is already so thin I am very concerned that this will deteriorate quickly. At initial observation some discoloration was noted on wed [Wednesday] [DATE]. Site still had skin fully intact .[Resident 5] fights staff and continues to put pressure on the area .The tissue appears to be more broken down but I am not able to determine how deep this injury goes. Resident 5's physician (PMD), responsible party (RP), and the wound physician (WP-a physician who specializes in wound care) were notified. On [DATE] at 9:21 pm, Licensed Nurse (LN) 6 created another SBAR for a newly discovered pressure injury, sore to Resident 5's right buttock that measured 2cm x 3cm, and documented, recommending treatment nurse evaluate and treat. LN 6 had not documented that he notified the PMD for treatment orders, or that the RP was notified, and no care plan was developed. There was no documentation regarding Resident 5's right ankle pressure injury or that the treatment was done. On [DATE], there was no documentation regarding the condition of Resident 5's right ankle pressure injury or that the treatment had been done. On [DATE], there was no documentation regarding the condition of Resident 5's right ankle injury or that the treatment had been done. On [DATE] at 7:36 am, LN 5 documented that Resident 5 was sent to the hospital by ambulance at 6:30 am, as recommended by the WP for evaluation and treatment of his right ankle pressure injury and that the WP had notified the PMD and RP. On [DATE] at 3:47 pm, after Resident 5 was already at the hospital, Registered Nurse (RN) 4 entered a Late Entry progress note for [DATE] at 3:40 pm, despite multiple attempts and education and coaxing to comply resident refused wound Tx, resident refused wound care to right foot, refused repositioning, oral care and incontinence care resident was yelling out, grabbing staff, squeezing nurse and CNA wrists, and kicking, resident was approached multiple times this shift . There was no documentation that his PMD or RP were notified. On [DATE] at 3:53 pm, RN 4 documented, resident refused wound care as ordered despite multiple attempts. Resident 5's PMD and RP were not notified. At this point, Resident 5 had been at the hospital for over 9 hours. On [DATE] at 4:01 pm, RN 4 documented a late entry note for [DATE] at 3:54 pm, Resident was noncompliant with wound care as ordered today, resident was approached multiple times, education and encouragement offered, resident allowed Tx to buttocks/coccyx, offloading boots in place per order, but resident refused wound care to right foot, dressing intact to wound, did not appear soiled. Resident would not allow repositioning, resident would yell hold up a fist indicating he would hit staff if attempted, grabbing at staff, flailing with attempts and kicking, staff would leave, and re-approach and this behavior continued. There was no documentation that Resident 5's PMD or RP had been notified. On [DATE] at 10:47 am, LN 3 created a late entry SBAR for [DATE] at 10:30 am, DTI right malleolus measurement 9 cm x 7.5 cm x 2.5 cm [about the size of an orange], dressing removed Wound MD eval area darkened area right malleolus with open area at base of malleolus 2.5cm depth scant amount of drainage clear in color resident refused treatment for 2 days prior to MD wound assessment. MD recommended acute transfer for eval and treat . A review of Resident 5's Physician's Orders reflected that an order was obtained on [DATE], for DTI to Lateral Right Malleolus. Cleanse site w/WC [with wound cleanser]. Apply Iodosorb Gel [antimicrobial wound gel] to WB [wound bed], cover with Adaptic [a non-adhering dressing], then place a square of Calcium Alginate [a moisture absorbing dressing] over the Adaptic and cover entire site with foam dressing every day and PRN [as needed] until healed/resolved. Please make sure site is always off-loaded. Every day shift for Wound Care, monitor for any s/sx [signs or symptoms] of infection and notify MD of any abnormalities noticed. A review of Resident 5's Treatment Administration Record (TAR) for [DATE], showed that no treatment was done on [DATE], and no reason was recorded. On 8/7 and [DATE], RN 4 recorded that Resident 5 refused the treatments and had a pain level of 5 (out of a possible 10 with 10 being the worst) on [DATE]. There was no documentation that alterative options were evaluated or that his PMD and RP were notified, and the care plan was not updated. On [DATE], Resident 5's PMD documented a History and Physical note which indicated that a DTI to the right ankle was present and that a WD consult was needed. There was no documentation regarding a wound observation or assessment and nothing to indicate that alternative treatment options were necessary due to Resident 5's refusals. On [DATE], 5 days after the pressure injury had been discovered and after 3 days of refused treatments, the WD evaluated Resident 5. According to the WD's Progress Note, dated [DATE], a right outer ankle Stage 4 pressure injury was present that measured 9 cm x 7.5 cm x 2 cm deep. The tissue in the wound bed was 60% [percent] necrotic [dead] and had an odor. The WD documented, Assessment of wounds .extensive damage .worked up for osteo [bone infection] at acute, possible amputation .Reportedly, pt [patient] has been non-adherent to offloading and dressing change schedule. A review of Resident 5's hospital History and Physical dated [DATE], was conducted. According to the hospital record, Resident 5's white blood cell count (WBC) was 13.5 (normal is 4,000 to 11,000) which indicated that he had an infection in the bloodstream, and he was treated with intravenous (IV) Vancomycin and Rocephin (strong antibiotics). On [DATE], Resident 5 was taken to surgery with the intention of cleaning out the dead tissue from the wound and applying a Wound Vac (a machine that helps pull fluid from a wound and promotes healing), however, he had a heart attack while in surgery and died. On [DATE] at 4:40 pm, an interview and concurrent Treatment and Medication record reviews was conducted with the TN. The TN confirmed that the wound was discovered on [DATE] by a night shift nurse and she received a text message about it and the night nurse expected her to do the SBAR, charting and assessment and notify the physician. She confirmed that the nurse did not call the physician or get a treatment at that time and the nurse should have. The TN confirmed that Resident 5's right ankle treatment was not done on [DATE] and refused on 8/7 and [DATE]. The TN indicated that an ankle wound can be very painful and could have contributed to Resident 5's treatment refusals. TN indicated that Resident 5 should have been assessed and medicated for pain prior to attempting to do the treatments. The TN added that she was out on leave over the time period when Resident 5 had refused his treatments and there had not been a dedicated treatment nurse to take her place. The TN confirmed that there was no documentation that Resident 5's PMD or RP had been notified of his refusals and that there had been no evaluations conducted to determine if there were alternative options, and there should have been because facility staff were aware that Resident 5 had a history of refusing cares. The TN confirmed that no care plan had been created which described the care and services that were to be furnished in order to heal Resident 5's right ankle pressure injury. During an interview on [DATE] at 3:45 pm, the Director of Nursing (DON) confirmed that the TN first noticed a reddened area on Resident 5's right ankle on [DATE], then the night shift nurse discovered a DTI on [DATE], but no action was taken until the morning of [DATE]. The DON indicated that her expectation was for an SBAR progress note to be entered, a care plan developed, and for the PMD and RP to be notified upon the initial discovery of any pressure injury, and that was not done for Resident 5. The DON confirmed that there were 3 consecutive days of missed treatments and no documentation of physician or family notification or discussions about alternative treatment options. The DON confirmed that Resident 5 was not assessed for pain or offered pain medication prior to attempting dressing changes. The DON spoke with RN 4 about Resident 5's pain. RN 4 indicated that she could not remember if Resident 5 was in pain or not, however, RN 4 had recorded on Resident 5's TAR on [DATE], that he had a pain level of 5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to asses for pain and administer pain medications as ordered by the physician and in accordance with the resident's plan of care, for one of three sampled residents (Resident 5), when nursing did not assess pain during a wound treatment and administer available pain medications when he complained of pain. This failure resulted in unrelieved pain for Resident 5 and a decline in his health status. Findings: A review of the facility's policy titled, Pain-Clinical Protocol dated June 2013, indicated, 2. The nursing staff will assess each individual for pain . whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. 3.a. The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. 4. The nursing staff will identify any situations or interventions where an increase in the resident ' s pain may be anticipated; for example, wound care, ambulation, or repositioning. A review of Resident 5's medical record revealed he was admitted to the facility on [DATE] with diagnoses of stroke, diabetes, pain, right sided paralysis, dysphagia (difficulty swallowing), aphasia (trouble speaking), and contractures (drawn up) of the right hand, right knee, left hand and left foot. Resident 5's annual Minimum Data Assessment (MDS, a comprehensive standardized assessment), dated 6/11/22, revealed his ability to make decisions was moderately impaired. He required extensive assistance with 2 staff for bed mobility, transfers, dressing and toileting. A review of Resident 5's At risk for Pain care plan revised 6/18/22, indicated that the goal was, will not experience a decline in function related to pain and interventions included, Administer pain medication as ordered and evaluate need to provide medications prior to treatment or therapy. A review of Resident 5's Behavior care plan revised on 6/18/22, revealed a focus (problem) area which indicated that he sometimes had behaviors which included yelling during care, yells ow, ow, shouting, and screaming when he does not want to get out of bed or take a shower during the course of care, or when he is joking around with staff. Interventions included to make sure he was not in pain or uncomfortable. A review of Resident 5's Physician's Orders revealed that on 5/16/2021, Tylenol 650 mg (milligrams) by mouth every 12 hours as needed for pain (rated from a 1 to 3 on a scale of 1-10) was ordered. On 6/3/2021, for Ibuprofen 600 mg by mouth every 6 hours as needed for pain was ordered. A review of Resident 5's Progress Notes dated 8/5/2022 at 10:30 am, by the Treatment Nurse (TN), revealed a change of condition observed on 8/3/22 with some discoloration on the lateral right malleolus (outside right ankle), then on 8/5/22 the wound had progressed to a Re-occurring DTI (Deep Tissue Injury, an injury caused from pressure to the area), 2 cm [centimeters] X2 cm, about the size of a peanut. A review of Resident 5's August 2022 Medication Administration Record (MAR), revealed that on 8/3/22, Licensed Nurse (LN) 4 documented that Resident 5 rated his pain at a 2 (mild pain), and no pain medication was given. On 8/7/22, LN 4 documented that Resident 5 rated his pain at a 5 (moderate pain), and no pain medication was given. A review of Resident 5's Progress Notes dated 8/9/22 at 4:01 pm, by LN 4 revealed a late entry for 8/7/22 that indicated, Resident was noncompliant with wound care as ordered today. There was no documented pain assessment or record that pain medication was offered. A review of Resident 5's Progress Note dated 8/9/22 at 3:47 pm, by LN 4 revealed a late entry for 8/8/22, that indicated, despite multiple attempts and education and coaxing to comply resident refused Tx (treatment), resident refused wound care to right foot, refused repositioning, oral care and incontinence care, resident was yelling out, grabbing staff, squeezing nurse and CNA [certified nursing assistant] wrists, and kicking . resident was compliant with all medications this shift. There was no mention that pain was assessed for this behavior, as described as an intervention in Resident 5 ' s care plans above. There was no record that pain medication was given. During an interview on 12/5/22 at 1:20 pm, the Director of Staff Development (DSD) indicated that Resident 5 was non-verbal, and they used the nonverbal pain scale to assess his pain. If Resident 5 was in pain, he would let you know by his actions like slapping your hand away, grimacing or pushing you away. During an interview and record review on 12/5/22 at 4:00 pm, of Resident 5's MAR, the Director of Nursing (DON) confirmed that Resident 5 had complained of pain on 8/3 and 8/7/22, and that pain medication was available but not given. The DON confirmed that when Resident 5 refused wound treatments, the facility policy was not followed by not offering pain medication, nor were Resident 5's care plans. During an interview and record review on 12/5/22 at 4:30 pm, of Resident 5's MAR, the TN confirmed that an ankle wound would be very painful and since Resident 5 complained of pain, he should have been medicated for pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that water temperatures for resident bathroom sinks were in a safe range to avoid burns when the water temperature exceeded 120F (degrees Fahrenheit). This failure placed residents at risk for burns caused by scalding hot water. Findings: During a review of the facility ' s policy titled, Safety and Supervision of Residents dated 7/2021, the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. During a review of the facility ' s policy titled, Water Temperatures, Safety of dated 12/2009, the policy indicated, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120F degrees Fahrenheit, or the maximum allowable temperature per state regulation. During an observation on 12/5/22 at 11:48 am, in the facility ' s lobby bathroom, the sink water temperature was 129.4F after a few seconds of running. During an observation and interview on 12/5/22 at 2:10 pm, resident room handwashing sink water temperatures were tested. room [ROOM NUMBER], 4, 7, and 8 had hot water that was 129.4F. Resident 1 and Resident 2 indicated the water was too hot for them, but they were able to put the cool water on to cool it down (separate knobs for hot and cold water). They denied receiving a burn because of it. During an observation and interview on 12/5/22 at 2:20 pm, in rooms [ROOM NUMBERS], the handwashing sinks hot water was 122.3F, and Resident 3 indicated that the water was too hot for him and one time he remembered it hurting his finger. During an observation and interview on 12/5/22 at 2:30 pm, of resident bathroom sinks; rooms [ROOM NUMBERS]'s hot water was 124.6F and rooms [ROOM NUMBERS]'s hot water was 129.4F. Resident 4 indicated that the water was too hot sometimes, but she did not use it that long. During an observation and interview on 12/5/22 at 2:50 pm, with the Director of Nursing (DON) in the lobby bathroom, the DON confirmed the hot water to the bathroom handwashing sink was 129F degrees and that it should not be that hot. During an interview on 12/5/22 at 3:11 pm, with the Treatment Nurse (TN), she confirmed that the hot water in bathroom sinks throughout the facility did get too hot. During an interview and observation on 12/5/22 at 3:17 pm, with the Interim Maintenance Director (IMD), the IMD indicated that he had just started filling in at this facility 3 days a week beginning in December 2022. The IMD had not done any water temperature checks and did not know when they were last checked. The IMD was unable to find any temperature logs that had been done for this year. He added that the regular Maintenance Director had been off for the past 90 days and he was not sure if anyone had done maintenance checks on hot water temperatures or other equipment since September 2022. During an observation and interview on 12/5/22 at 3:25 pm, in rooms [ROOM NUMBERS] with IMD, he confirmed that the hot water was over 120F degrees. During an interview on 12/5/22 at 3:40 pm, with the Administrator, he indicated that the boilers (hot water tanks) were serviced on 9/6/22, but was unable to provide hot water temperature logs for the past 90 days. During an interview on 12/7/22 at 2:10 pm, with the IMD, he indicated that the hot water temperatures in the rooms were still as high as 122F in some rooms. He confirmed that their policy indicated that hot water should have been no more than 120F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained while changing a dressing on a Stage 4 (Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI) pressure ulcer for one of two sampled residents (Resident 6). This had the potential to contaminate Resident 6's wound with harmful and unwanted bacteria and place him at a high risk for wound infection and cause a delay in the wound healing process, which could negatively impact Resident 6's physical and emotional well-being. Findings: During a review of the facility ' s policy titled, Wound Care dated October 2010, the policy indicated The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. A review of Resident 6 ' s Medical Record indicated Resident 6 was admitted to the facility on [DATE] with the diagnoses of dementia, high blood pressure, heart attack, history of falling, and muscle weakness. During his stay on 9/13/22, he aquired a right heel pressure ulcer. Resident 6 ' s quarterly Minimum Data Set (MDS, clinical assessment) dated 11/6/2022, indicated he required extensive assistance, with the help of 2 staff, for transfers and toileting and required extensive assistance, with the help of 1 staff, for bed mobility and dressing. Resident 6 ' s Brief Interview for Mental Status (BIM ' s, a brief evaluation of attention, level of orientation, ability to recall information) score was a 3 out of 15 which indicated he was severely cognitively impaired and not able to make his own decisions. During an observation on 12/5/22 at 2:15 pm, the Treatment Nurse (TN) was observed doing a dressing change on Resident 6 ' s Stage 4 pressure wound on his right heel. The TN did hand hygiene and put on clean gloves, she entered the room with the wound dressing equipment on a clean tray. She removed the old, soiled dressing and set it on Resident 6's bed instead of placing the dirty dressings in an appropriate receptacle, such as a plastic bag to contain the infectious bacteria. The wound had light brown colored drainage inside of the wound bed. With the same, now soiled gloves, TN proceeded to clean the wound with wound cleanser and wiping the wound bed with gauze. TN then placed her contaminated gloved finger inside the wound to physically removed dead tissue and drainage. She wiped the wound with her contaminated gloved finger repeatedly until all of the drainage was removed. She then applied the clean dressings without washing her hands or changing her contaminated gloves. The TN then gathered up the soiled dressings (unbagged) with her gloved hands and while she was leaving the room, she pulled the privacy curtain open with her dirty gloves. TN returned to the treatment cart and discarded the dirty soiled dressings into the open trash can on the cart. During an interview on 12/5/22 at 2:18 pm, the TN confirmed she had not changed her gloves and performed hand hygiene after she removed the soiled dressings and before she cleaned and redressed Resident 6's wound, and she should have. TN confirmed that she put her soiled gloved finger inside the wound to remove drainage after she cleaned it and she should not have. The TN indicated she rushed during the treatment because she had been pulled to the floor do another person ' s job as well as her own. She stated she does not have time to get everything done. TN confirmed that this practice contaminated Resident 6's wound and placed him at risk for an infection in his wound. During an interview on 12/5/22 at 5:00 pm, the Director of Nursing (DON) confirmed that to prevent infections and cross contamination during a dressing change, gloves should be changed, and hands washed between removing a soiled dressing and redressing a wound and that dirty dressings should be bagged up at the bedside before being carried out of a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications were administered per physician's orders when one of two sampled residents (Resident 1) was given 7 medications in error. This failure had the potential for Resident 1 to experience adverse medication reactions and have a decline in health status. Findings A review of the facility's policy titled, Administering Medications dated December 2012, indicated, Medications must be administered in accordance with the orders , The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. A review of Resident 1's admission Record revealed Resident 1 was admitted on [DATE] with diagnoses of Alzheimer's, stroke, high blood pressure, muscle weakness, and contractures. A review of Resident 1's Physician's Orders dated 10/4/22, revealed her medication list included, Bisacodyl suppository as needed for constipation, Fleet Enema as needed for constipation, Oral Anesthetic Paste as needed for mouth discomfort, and a Tylenol tablet by mouth every 6 hours as needed for pain. Resident 1 had no known medication allergies. A review of Resident 1's Progress Notes dated 9/26/22 at 4:09 pm, reflected that the Director of Staff Development (DSD) documented, On 9/22/22 resident was administered another residents medications crushed in applesauce including Norco (an opioid pain medication that can slow or stop breathing) 5/325mg (milligram) tablet, cyclobenzaprine (medication for muscle spasms that can cause drowsiness, dizziness, fatigue or nausea) 5mg tablet, Metformin (used for diabetics to control blood sugar, side effects include a a buildup of lactic acid which can cause death, hypothermia, low blood pressure and slowed heart beats) 500 mg tablet, Labetalol (medication for high blood pressure that can cause drowsiness, insomnia and fatigue) 100 mg tablet, Zoloft (an antidepressant) 75 mg tablet, Atorvastatin (used to lower blood cholesterol, side effects include joint pain, diarrhea, heart burn and nausea) 80 mg tablet, Melatonin (used for sleep) 9mg During an interview and concurrent record review on 12/22/22 at 11:24 am, Resident 1's progress notes were reviewed with the Director of Nursing (DON). The DON confirmed that Licensed Nurse (LN) A confessed she administered Resident 1 medication that was meant for another resident but did not tell anyone until 4 days later, when she was confronted by the DON. The DON indicated that LN A stated she only looked at the picture and assumed it was the same person. She did not verify the name of resident by an arm band or by asking another staff member. LN A indicated to the DON that after she gave Resident 1 some of the medication that was crushed up in applesauce, she realized it was the wrong resident because of identifying articles in the resident's room. The DON confirmed that LN A was a traveling nurse and did not know the residents very well and she should have used two methods of identification before administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accepted professional standards were followed when one of two residents (Resident 1) was given seven medications in error and the physician and resident's representative (RP), were not notified timely, and the resident was not monitored for adverse reactions. These failures had the potential for Resident 1 to experience adverse reactions and have a decline in health status. Findings A review of the facility's policy titled, Adverse Consequences and Medication Errors dated April 2014, indicated, 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professional(s) providing services. 9. Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur .f. Medication error. 13. The Attending Physician is notified promptly of any significant error or adverse consequence. a. The physician's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. A review of Resident 1's admission Record revealed Resident 1 was admitted on [DATE] with diagnoses of Alzheimer's, stroke, high blood pressure, muscle weakness, and contractures. Resident 1 did not have the capacity to make health care decisions. A review of Resident 1's Physician's Orders dated 10/4/22, revealed her complete medication list included, Bisacodyl suppository as needed for constipation, Fleet Enema as needed for constipation, Oral Anesthetic Paste as needed for mouth discomfort, and a Tylenol tablet by mouth every 6 hours as needed for pain. Resident 1 had no known medication allergies. A review of Resident 1's progress notes dated 9/26/22 at 4:09 pm, by the Director of Staff Development (DSD), the DSD documented, On 9/22/22 resident was administered another residents medications crushed in applesauce including Norco (an opioid pain medication that can slow or stop breathing) 5/325mg (milligram) tablet, cyclobenzaprine (medication for muscle spasms that can cause drowsiness, dizziness, fatigue or nausea) 5mg tablet, Metformin (Used for diabetics to control blood sugar, side effects include a a buildup of lactic acid which can cause death, hypothermia, low blood pressure and slowed heart beats.) 500 mg tablet, Labetalol (medication for high blood pressure that can cause drowsy, insomnia and fatigue) 100 mg tablet, Zoloft (an antidepressant) 75 mg tablet, Atorvastatin (used to lower blood cholesterol, side effects include joint pain, diarrhea, heart burn and nausea) 80 mg tablet, Melatonin (used for sleep) 9mg During an interview and record review on 12/22/22 at 11:24 am, Resident 1's progress notes were reviewed with the Director of Nursing (DON). The DON confirmed that Licensed Nurse (LN) A confessed she administered Resident 1 medication that was meant for another resident but did not tell anyone until 4 days later when she was confronted by the DON. LN A confirmed to the DON that she did not tell anyone, call the doctor or notify the resident's responsible party. She indicated to the DON that she did not know what to do but that she did keep an eye on the resident and there were no changes in her condition after the medication error. The DON confirmed that LN A did no documentation of the event and there was no documentation of monitoring Resident 1 for unwanted side effects of the medications. The DON indicated LN A was a registry nurse and her contract was terminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their fall protocol, including updating the care plan and implementing interventions in the care plan, was completed to prevent falls, for one of four sampled residents, with a history of falls (Resident 4). This had the potential to result in a fall with serious injury. Findings: A review of Resident 4's record indicated she was admitted on [DATE] with diagnoses that included dementia, diabetes, and muscle weakness. Resident 4 had a falls care plan started upon admission. It had been updated to include non-slip socks while in bed, and non-slip socks and shoes when out of bed. Resident 4 had an unwitnessed fall on 9/1/21 and 11/30/21. Nursing progress notes, dated 9/1/21 at 10:26 am, indicated the resident had ambulated (walked) to the restroom without assistance and fell, landing on the right side of her body in front of the bathroom door. An assessment was done and she moved all extremities without pain. On 9/1/21 at 10:34 am, a post fall evaluation note was completed. A review of this note indicated see progress note with no other summary or details of how the fall occurred. No Interdisciplinary Team (IDT) note could be found in the record. Nursing notes dated 11/29/21 included a post fall evaluation was completed at 6:09 pm, which indicated the resident was found on the floor in her room at 12 pm, lying on her left side on the floor mat beside bed 7 A. The Resident in 7 C (one of Resident 4's roommates) said she saw Resident 4 climb out of her bed, walk to the door and fall on the mat near Bed 7 A. A head to toe assessment was done and there was no injury and no complaints. There was an IDT note, dated 11/30/21 which included new interventions to try to prevent further falls. On 1/27/22 at 8:45 am Resident 4 was observed in bed barefoot, without non-slip socks, on her feet. Certified Nursing Assistant (CNA) 1 confirmed Resident 4 had no socks on her feet. She said sometimes they put non-slip socks on her. She then picked up the resident's shoes, which had been placed on the seat of her wheelchair, and said, there are no socks here. During a concurrent interview and record review on 1/27/22 at 9 am, the above observation was discussed above with the Director of Nurses (DON). Resident 4's care plan was reviewed and she confirmed, that according to the care plan, Resident 4 should have non-slip socks on in bed, because she has gotten up and walked by herself. DON confirmed the care plan had been updated after the 11/29/21 fall, but not after the 9/1/21 fall. There was also no IDT note after the 9/1/21 fall. She confirmed the post fall evaluation, dated 9/1/21, indicated to see progress note under the summary section of the incident, with no other details about the fall. DON said the IDT note was the documentation that included the discussion about the cause of the fall and new interventions, if possible, to prevent future falls, as per their facility protocol, but this was not done after Resident 4 fell on 9/1/21. The facility Falls - Clinical Protocol, revised 9/2012, was reviewed. It indicated, based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on interview, and record review the facility failed to ensure resident's symptoms and distress were addressed on timely manner when existing nursing treatment and or medication did not improve the symptoms in one out of 17 sampled residents (Resident 52). This failure could contribute to unsafe care and/or resident's comfort level. Findings: During Resident 52's medical record review titled Medication Administration Record (or MAR, a legal drug chart where nurse documented medications administration and monitoring), with date range of 1/1/22 to 1/31/22, the MAR indicated a medication order for Benadryl (or diphenhydramine, a medication used to treat allergy symptoms such as itching) as follow: Benadryl Allergy Tablet 25 mg (mg is a measure of unit), [diphenhydramine HCL]: Give 25 mg by mouth every 6 hours as needed for itching- Order Date- 6/25/21. Further review of the MAR indicated Benadryl medication was administered up to 3 times per day for itching. During review of Resident 52's nursing Care Plan (Care Plan was a nursing record of how to identify and address resident's needs and potential risks related to medication and other health issues), initiated on 1/3/22, the Care Plan indicated The resident has potential/actual impairment to skin integrity . shearing, bruising and scratches. The Care Plan on the Intervention section, indicated identify/document potential causative factors and eliminate/resolve where possible; Date initiated: 1/3/22. Review of a nursing communication document with Medical Doctor 1 (MD 1), dated 1/24/22, regarding Resident 52, the note indicated Resident is picking on RUA (Right Upper Arm); Now has open areas, start to weep clear secretions. Review of the Resident 52's medical record under Nursing Note, written by Registered Nurse 1 (RN 1) on 1/26/22 at 09:07 AM, the note indicated It was noticed to have sleeves on both shoulders having spots of wetness, looking at BUE ( means both sides of the upper body extremities), arms were seen with self-inflicted scratch/picking areas that were leaking copious amounts of clear, yellow serous fluids (serous a type of body fluid). The RN 1 note under assessment indicated . Benadryl ineffective. RN 1 note under recommendation indicated request for hydroxyzine (a medication for itching) scheduled med ( means medication) and wound referral .PRN creams also advised. In an interview with RN 1 on 1/26/22 at 1:20 PM, RN 1 stated Resident 52 has had an ongoing issue with scratching the skin with subsequent shearing and leaking yellow fluid from the scratch spots. RN 1 stated the current treatment plan had not helped alleviate the uncomfortable itching. RN 1 stated the medication prescribed was not helping as the resident's skin swelling (or edema) had worsen due to kidney not working very well. RN 1 acknowledged that the root cause of itching should be first addressed in addition to topical treatment by medical provider that so far had been ineffective. Review of the Resident 52's medical record in the paper chart under Physician Progress Notes section, indicated the MD-1's most recent progress notes were documented on 12/31/21 and 11/19/21. Further review of these two progress notes indicated, MD-1 had signed and dated the exact same progress note with no new information from one visit to another on 11/19/21 and 12/31/21. In a telephone interview with MD-1 on 12/27/22 at 9 AM, MD-1 stated that he did not remember Resident 52's medical condition as he did not have access to electronic medical chart. MD-1, however, could recall that he signed an informed consent for Resident 52 on 12/31/21. MD-1 stated that Resident 52's skin condition should be referred to a skin specialist. MD-1 was not aware of nursing communication regarding Resident 52's itching, scratching and severe edema with leaking yellow serous fluid on the skin. In an interview with Director of Nursing (DON) on 1/27/22 at 9:45 AM, in her office, the DON stated that she expected the medical doctors or providers provide timely guidance to the nursing staff on how to deliver the best care. DON stated, it was expected that the medical providers address the resident's suffering or change of condition by providing guidance such as nursing care, lab work or medications when needed. DON stated, she was not aware of nursing staff needed to get a hold of MD 1 to address wounds, itching and skin issue when Benadryl was not helping to alleviate the symptoms. Review of facility's policy titled Medication Therapy, last revised on 4/2007, the policy indicated 4. Periodically, and when circumstances are present ., the staff and practitioner will review the medication regimen for continued indication, proper dosage and duration, and possible adverse consequences; 5. The Physician will identify situations where medications should be tapered, discontinued, or changed . Review of facility's policy titled Medical Director, last revised 7/2016, the policy indicated 3 b. Acting as a consultant to the director of nursing services in matters relating to resident care services; 3 c. Helping assure that the resident receive adequate services appropriate to meet their needs; 3rd. Helping assure that the resident care plan accurately reflects the medical regimen.

Based on interview, and record review the facility failed to ensure high risk anticoagulant medication (or blood thinner medication that may cause bleeding) was monitored on daily basis by nursing staff for possible adverse effects of the medication in one out of 17 sampled residents (Resident 28). This failure could result in unsafe medication use in the facility. Findings: During a review of Resident 28's medical record titled Medication Administration Record (or MAR, a legal drug chart where nurse documented medications administration and monitoring), the MAR indicated a doctor's medication order for rivaroxaban (or Xarelto, a blood thinner or anticoagulant medication) as follow: Rivaroxaban Tablet 20 mg (mg is a measure of unit); Give 20 mg by mouth in the evening for prevention of DVT/PE (DVT stands for Deep Vein Thrombosis which was blood clot in the leg's arteries and PE stands for Pulmonary Embolism which was blood clot in the lung; both conditions could cause resident harm); order date: 8/14/2021 Review of the Resident 28's nursing Care Plan (Care Plan correctly identified resident's needs and potential risks related to medication and other health issues) with initiation date of 5/18/2019, the Care Plan document for anticoagulant (blood thinner) medication called Xarelto, indicated a goal of Resident will be free from discomfort or adverse reactions related to anticoagulant use though the review date . Target date: 03/01/2022. Further review of the Care Plan document under Interventions indicated, Administer ANTICOAGULANT medication as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (means every work shift) . The Care Plan document further indicated BBW (or Black Box Warning- the highest level of warning issued by drug manufacturer and/or United States Food and Drug Administration on use of high-risk medications) Monitor for side effects of anticoagulants: S/S (means Signs and Symptoms) of abnormal bleeding, black stools, red or dark urine, coffee ground emesis, red spots on skin, unusual bruising, bleeding from eye, gums, nose . Review of the Resident 28's MAR, where the nursing staff were guided to monitors resident's response to medication or adverse effects, the MAR did not show daily nursing monitoring for side effects such as bleeding or bruising from use of a high-risk blood thinner based on the plan of care. In an interview with the Director of Nursing (DON) in her office, on 1/27/22 at 9:45 AM, the DON stated for anticoagulation safety, the facility did lab monitoring and monitored for side effects such as bleeding, like gum bleed, or bruises on the MAR for nurse documentation. The DON acknowledged there was no specific monitoring line in the MAR to document the serious side effects of Xarelto, although the plan of care indicated the need for every shift monitoring. Review of the facility's policy titled Anticoagulation- Clinical Protocol, last revised on 09/2012, the policy under Assessment and Recognition, indicated Assess for any sign or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. The policy under the Treatment/Management, indicated The staff and physician will identify and address potential complications in individuals receiving anticoagulation. Review of the facility's policy titled Medication Regimen Reviews, last revised on 5/2019, the policy indicated the MRR involves a thorough review of the residents' medical record to prevent, identify . medication . and other irregularities, for example: . inadequate monitoring for adverse consequences.

Based on observation, interview, and record review, the facility failed to ensure house supply medications in the Central Supply Storage room (a storage room in the facility for non-prescription medications) were stored at a safe controlled room temperature in one out of three medication storage areas and a census of 54 residents. This failure could potentially cause medication to become ineffective if stored outside the manufacturer's recommended temperature guidelines. Findings: During an observation and tour of the facility's Central Supply Storage (a room that stored medical supplies and non-prescription or Over the Counter [OTC] medications) on 1/24/22 at 9:05 AM accompanied by LVN 1, the small storage room stored shelves of OTC medications, medical supplies, and multiple computer wiring's that served the facility's computer needs. The small storage room's temperature was warm upon entrance to the room. LVN 1 confirmed the warm temperature while standing in the unvented storage room. Further observation with LVN 1, it was confirmed the facility did not monitor room temperature for the Central Supply Storage room and there was no temperature monitoring device was installed in the room. During the tour of the Central Supply Storage room on 1/24/22 at 9:05 AM, the following medications were a random example of medication or supplies where the labeling indicated the need for controlled room temperature for storage: *Assure Platinum Blood Glucose Test Strips (a test strip used to measure accurate blood sugar): The label on the box indicated store between 39-86-degree Fahrenheit (Fahrenheit was a scale of temperature) *Omeprazole Delayed Release Tablet: Acid Reducer (med used for heartburn); The label on the box indicated Store at 20-25 degree Celsius (66-77-degree Fahrenheit) and protect from moisture. Celsius was another scale of temperature) *Probiotic (Saccharomyces boulardii), Dietary supplement: The label on the bottle stated, store at controlled room temperature. During an interview with the Director of Nursing (DON) on 1/25/22 at 3:11 PM, the DON was not aware of temperature issues in the Central Supply Storage room. DON stated she never thought that was an issue and appreciated a different eye to see the problem. The DON stated that the facility had enough storage areas to correct the storage environment by moving the medications to a well vented area with room temperature monitoring. Review of the facility's policy titled Storage of Medications, last revised in April 2019, the policy indicated Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. .

Based on observation and interview, the facility failed to ensure food was prepared in a clean sanitary manner. This had the potential to cause food borne illnesses to the residents. Findings: During an observation on 1/25/22 at 10:15 am, the trash can in the food prep area had a lid, without foot controls, so staff had to use their hands to open and close the lid. The facility cook (FC) opened the trash can lid with her hand, threw away trash, closed the trash can lid with her hand, then picked up spices and continued in her meal prep, without hand hygiene. During an interview on 1/25/22 at 10:20 am, this was discussed with the Dietary Services Manager (DSM)who agreed they needed a trash can with a lid that could be opened with foot controls. He said he would talk to the Administrator about getting a new one. During an observation on 1/25/22 at 2:40 pm, the gas line-valve next to the stove/oven was covered with dust and what appeared to be spider webs (see pictures). This was immediately showed to the DSM who confirmed the observation and said he would make sure it was cleaned right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, and sanitary environment and to help prevent the transmission of infections with the census of 54 when: 1. Two out of two medication carts (a mobile cart used to store the medication and supplies for quick access for administration to residents) had unclean pill cutter (a small device that splits individual pills) shared among residents. 2. Licensed Nurse 4 (LVN 4) did not follow infection control practices when entered resident's rooms without following facility's policy on Transmission Based Disease (or same as TBP or Transmission Based Precaution used to help stop the spread of germs from one person to another by using protective measures such as putting gloves, sanitizing hand and putting on the gown and mask) before entering the rooms on three resident's rooms (Resident 41, Resident 23, Resident 36) with census of 54. 3. The shared glucometer (a device that measured blood sugar by using resident's blood droplet) was not sanitized based on standards of care and the manufacturer recommendations in one of 54 residents (Resident 23). 4. Hand sanitizers were not located in a convenient location for quick and safe access by staff caring for residents. 5. Personal Protective Equipment (PPE)d, used to protect transmission of infection was not fully available and accessible in the facility's hallway prior to entrance to resident rooms. These failures had the potential for all residents in the facility to contract infectious diseases. Findings: 1. During an observation on 1/14/22 at 10:15 AM with Licensed Vocational Nurse (LVN) 3, in facility's Zone 3 hallway, the pill cutting device inside the medication cart was noted to have white color powder debris inside from prior use. LVN 3 confirmed that it was dirty and needs to be cleaned. During an observation on 1/24/22 at 2:15 PM with Licensed Vocational Nurse (LVN) 2, in facility's Zone 2 hallway, the pill cutting device inside the medication cart was noted to have white color powder debris inside from prior use. LVN 2 confirmed that it looks like it needed to be cleaned. During an interview with the Director of Nursing, (DON), on 1/27/22 at 9:30 AM, the DON stated the pill cutters should be cleaned after each use to prevent cross contamination. Review of the facility's policy titled General Infection Control Practices, last revised on 1/2012, the policy on page 29 under 7 b, indicated If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. 2 a. During a medication pass observation with LVN 4, on 1/26/22 at 6:45 AM, LVN 4 entered Resident 41's room without putting on gloves before entering the room. LVN 4 was observed touching surfaces, curtains, and Resident 41 with bare hands. Resident 41 was in a room that required Transmission Based Precautions (TBP) which included to use of gown, gloves, and eye protection in addition to hand sanitizing when entering and exiting the room. 2 b. During a medication administration observation with LVN 4, on 1/26/22 at 6:51 AM, LVN 4 did not put on gloves before entering Resident 23's room. LVN 4 touched curtains, bedrails surfaces and the resident with bare hands. 2 c. During a medication administration observation with LVN 4, on 1/26/22 at 7:00 AM, LVN 4 did not put on gloves before entering Resident 36's room. LVN 4 put on gloves prior to insulin shot (a medication used to treat diabetes or blood sugar disease) administration without hand sanitization while inside resident's room and after touching surfaces and bedrails. During an interview with LVN 4, on 1/26/22 at 3:30 PM, LVN 4 acknowledged that she should have been putting gloves on and using hand sanitizer before and after entering the residents' rooms. During an interview with the Director of Nursing (DON), on 1/27/22 at 9:30 AM, the DON stated that the nursing staff should have followed the facility's policy on hand hygiene and glove use prior to entering TBP rooms. During an interview with Infection Control Nurse (IP), on 1/26/22 at 2:10 PM, IP stated that the residents in Zone 1, 2 and 3 were in Transmission-Based Precautions (a form of isolation), and that signs were posted outside all the rooms to remind staff and visitors of the requirements. IP confirmed that TBP would include hand sanitizing, putting on gown, gloves, and eye protection in addition to mask before entering residents' rooms. IP stated that spot audits (random checks on following the procedure) were performed regularly, however, there was no formal process to document the audits. 3. During a medication pass observation with LVN 2 on 1/25/22 at 11:09 AM, LVN 2 used a shared device called glucometer (device used to measure blood sugar) to measure Resident 15's blood sugar. LVN 2 entered the Resident 15's room and measured the blood sugar by poking the fingertip with a needle and then administered the insulin (a medication to help lower blood sugar) as ordered by the doctor. LVN 2, after exiting the resident's room, wiped the glucometer surface with sanitizing wipe labeled Bleach Germicidal Wipes for less than 30 seconds. LVN 2 subsequently placed the glucometer in the drawer on top of a clean tissue. In an interview with the LVN 2 on 1/25/22 at 11:13 AM, LVN 2 stated that she was instructed to leave the glucometer on a surface to dry out after wiping. During an interview with the Director of Nursing (DON), on 1/27/22 at 9:30 AM, the DON stated the policy on shared devises was to sanitize the device appropriately in-between residents' use. The DON stated the nursing staff should have followed the facility's policy on glucometer cleaning and sanitization in-between resident use. The DON stated facility's IP nurse should have given feedback and monitored the compliance. Review of the facility's policy titled Blood Sampling, Capillary (Finger Sticks), last revised on 9/14, the policy indicated 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. Review of the glucometer manufacturer information sheet for ASSURE ®PLATINUM BLOOD GLUCOSE MONITORING SYSTEM( the name of glucometer brand), last accessed on 2/1/22, the information sheet indicated The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood, and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens. Review of the facility's sanitization wipe instructions for this product Clorox, Healthcare Bleach Germicidal Wipes, last accessed on 2/1/22, the manufacturer's product instruction indicated the following steps for effective sanitization: *Remove gross soil if present . *Wipe the surface until completely wet. *Wait for the contact time (3 minutes for all pathogens listed on the product label). *Discard the wipe. 4. On 1/24/22 12:56 PM During rounding on the above residents observed isolation carts for rooms 1-7, 33 & 34. Closest hand sanitizer is inside the resident rooms behind privacy curtains making it impossible to sanitize appropriately before and after donning/doffing. 01/24/22 04:40 PM Interview with the Assistant Facility Administrator (AFA) regarding availability of hand sanitizer on isolation carts. There is sanitizer in each room and also along the hallways near the nurses station. When asked about the process of donning and doffing PPE the AFA did not know sanitizing was part of the process. The AFA stated he would get sanitizer placed on the isolation carts and install more dispensers on the hallway walls. 5. During observations on 1/24/22 at 9:35 am, there were no gloves in the isolation carts in front of rooms [ROOM NUMBERS], and only one gown left in the isolation cart for room [ROOM NUMBER]. During an interview on 1/24/22 at 10 am, the Director of Nurses (DON) confirmed the above and said they had personal protective equipment (PPE) in the carts earlier but staff have been going through them a lot, to go into the rooms and answer call lights. During observations on 1/24/22 at 9:35 am, there was no hand sanitizer in the hallway outside rooms [ROOM NUMBER] and none on the isolation carts in front of these rooms. The hand sanitizer for these three rooms was located inside the room on the wall for the bed closest to the hall. However, it was so far inside the room, that one had to enter the room a few feet, and push the resident privacy curtain aside, before having access to the hand sanitizer. During an interview on 1/24/22 at 10 am, the lack of access to hand sanitizer was discussed with DON who confirmed the above observations and said she thought there was some in the hallway outside the rooms at one time. During an observation on 1/25/22 at 8 am, there was no hand sanitizer seen on isolation carts in front of rooms 30, 31 and 32. This was immediately discussed with the Infection Preventionist (IP) Nurse. In room [ROOM NUMBER], the resident's bed prevented access to the hand sanitizer on the wall, in room [ROOM NUMBER] a decoration on the wall prevented access to hand sanitizer, and in room [ROOM NUMBER], the privacy curtain would have to be opened, to have access to the hand sanitizer. The IP confirmed these observations and said the Administrator was bringing sanitizer containers to place on the walls in the hallway outside the room.

Based on observation, and interview, the facility failed to have an air gap (a gap in the sink's drain line that prevents the possibility of back flow of water) in it's four kitchen sink drain lines. This failure had the potential that sewage could back up into sinks used for cleaning dishes and fresh produce causing food contamination. Findings: During an initial kitchen tour, and concurrent interview, on 6/10/19 at 9:05 am with the Dietary Services Supervisor (DSS) no air gap was observed in four of the kitchen sink drain lines. A three compartment sink was observed available for manual dishwashing of dishes (if the main dishwasher failed). These three sinks ran to a combined central line behind them to combine with a fourth sink drain from a fourth sink that was used for washing produce. DSS confirmed that the sinks were used for rinsing fresh produce and cleaning dishes if the dishwasher failed. When DSS was asked about the sink air gaps he stated that the facility Environmental Services Supervisor (ESS) would show an air gap that was in the four sinks central line outside of the building. During an observation and concurrent interview on 06/12/19 at 9:50 am, with ESS, she directed the surveyor to an outside common drainage line that ran from the kitchen sinks. The line ran out of the building and turned 90 degrees downward to the ground. At the 90 degree turn was a straight pipe that went up approximately four inches that contained a screwed down cap. No complete air gap was observed and all lines ran out in a continuous single drain. ESS acknowledged that the facility kitchen sinks did not contain an air gap to prevent back up of sewage to the kitchen sinks.