Based on interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan was revised to accurately reflect the information in the comprehensive assessment, which affected 1 (Resident #61) of 4 residents reviewed for advance directives. Specifically, the facility failed to revise Resident #61's care plan to reflect the resident's code status listed in the comprehensive assessment. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, revealed, 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 policy revealed, 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission). The policy indicated, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #61's admission Record indicated the facility admitted the resident on 03/29/2025. According to the admission Record, the resident had a medical history that included a primary diagnosis of acute pyelonephritis (kidney infection). Resident #61's Physician Orders for Live-Sustaining Treatment (POLST), dated 04/01/2025 and signed by the resident, indicated that if the resident had no pulse and was not breathing, the resident's choice was Do Not Attempt Resuscitation/DNR (Allow Natural Death). An admission MDS, with an Assessment Reference Date (ARD) of 04/04/2025, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Per the MDS, the resident's POLST form identified that if the resident had no pulse and was not breathing, the resident's choice was not to be resuscitated. The MDS was signed as completed on 04/07/2025. Resident #61's Care Plan Report included a focus area, initiated 03/29/2025, that indicated the resident had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. In contrast to the resident's POLST form, a care plan intervention identified that the resident's code status was Attempt Resuscitation - Full Code (initiated 03/29/2025). On 05/08/2025 at 8:55 AM, MDS Coordinator #6 stated all staff had the duty to update a resident's care plan based on a change in condition. He stated a resident's care plan should match their POLST. He noted that resident code statuses were reviewed during clinical meetings. MDS Coordinator #6 stated Resident #61's care plan was not updated with their current code status. On 05/08/2025 at 9:27 AM, the Director of Nursing (DON) stated a resident's care plan should reflect a resident's current POLST. On 05/08/2025 at 9:44 AM, the Administrator stated a resident's care plan should reflect their POLST.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to obtain orders for the use of a non-invasive mechanical ventilator (specifically, continuous positive airway pressure; CPAP) timely, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care . Findings included: A facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, revised 03/2015, directed staff under a Preparation section to 2. Review the physician's order to determine the oxygen concentration and flow and the PEEP [positive end-expiratory pressure] pressure (CPAP, IPAP [inspiratory positive airway pressure] and EPAP [expiratory positive airway pressure]) for the machine. An admission Record indicated the facility admitted Resident #184 on 04/19/2025. According to the admission Record, the resident had a medical history that included a diagnosis of chronic diastolic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS did not indicate the resident used a non-invasive mechanical ventilator. Resident #184's Care Plan Report did not include information on the use of a non-invasive mechanical ventilator. Resident #184's Cardiology Follow-Up Visit progress note from a hospital visit, dated 03/24/2025, indicated Resident #184 should continue the use of CPAP, and a CPAP company was being contacted. Per the hospital records, Resident #184 was discharged from the hospital on [DATE]. Resident #184's medication administration records (MARs) and treatment administration records (TARs), for the timeframe from 04/19/2025 (admission) to 05/07/2025, revealed no evidence of an order for the use of a CPAP machine prior to 05/07/2025. An observation on 05/05/2025 at 10:51 AM revealed a CPAP machine on Resident #184's nightstand with tubing attached, with a mask on the bed above a pillow. An observation on 05/07/2025 at 2:07 PM revealed Resident #184's CPAP machine, with tubing and mask attached, had water in the humidifier chamber. During an interview at the time of the observation, Resident #184 stated they had used the CPAP machine for the last 20 years. The resident stated they had not used the CPAP machine in the prior three to four days, but was not sure why. Resident #184's Order Summary Report, for active orders as of 05/07/2025, included the following orders, each with an order date of 05/07/2025: -CPAP/APAP (automatic positive airway pressure): setting from 6.0 to 20.0 centimeter of water (cmH20) pressure. Apply at bedtime and remove in the morning upon awakening. -CPAP: replace mask, tubing, accessories, and device upon degradation as needed (PRN). -CPAP: cleanse the reservoir with solution of saline, rinse, and air dry PRN. -CPAP: Empty the reservoir and refill at night with distilled or sterile water at bedtime. -CPAP: Wash mask in warm soapy water, rinse and air dry every day shift. -CPAP: Wash tubing and headgear in warm soapy water, rinse and air dry every day shift on Sunday. During an interview on 05/07/2025 at 4:17 PM, Licensed Vocational Nurse (LVN) #2 stated that if a resident had a CPAP machine, she entered the resident's room when they were ready to go to bed and put distilled water in the humidifier chamber and assisted the resident with putting on their mask as needed. She stated that, other than that, she did not do anything else with CPAP machines. She stated Resident #184 wanted to put on their own CPAP mask, and she had not gone in to determine if the resident had been wearing it lately. She stated she was not aware there were no orders for the use of Resident #184's CPAP machine. During an interview on 05/08/2025 at 9:32 AM, the Director of Nursing (DON) stated orders for the use of a CPAP machine were required, noting the orders should include settings and the care of the equipment. She stated Resident #184's CPAP machine was their own machine. She stated that when she found out about the CPAP machine, she had staff contact the physician and they obtained orders for its use. She stated the resident had no orders for the CPAP machine when they were admitted from the hospital. She stated the resident was not having any distress from not using the CPAP machine. During an interview on 05/08/2025 at 9:52 AM, the Administrator stated staff should confirm any orders for respiratory equipment with the attending physician. He stated communication between nursing staff, admissions staff, family members, and medical staff was needed.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment (specifically, continuous positive airway pressure; CPAP equipment) was stored appropriately, which affected 1 (Resident #184) of 3 residents reviewed for respiratory care . Findings included: An admission Record indicated the facility admitted Resident #184 on 04/19/2025. According to the admission Record, the resident had a medical history that included a diagnosis of chronic diastolic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #184's Care Plan Report did not include information on the use of a non-invasive mechanical ventilator. Resident #184's Order Summary Report, for active orders as of 05/07/2025, included the following orders, each with an order date of 05/07/2025: -CPAP/APAP (automatic positive airway pressure): setting from 6.0 to 20.0 centimeter of water (cmH20) pressure. Apply at bedtime and remove in the morning upon awakening. -CPAP: replace mask, tubing, accessories, and device upon degradation as needed (PRN). -CPAP: cleanse the reservoir with solution of saline, rinse, and air dry PRN. -CPAP: Empty the reservoir and refill at night with distilled or sterile water at bedtime. -CPAP: Wash mask in warm soapy water, rinse and air dry every day shift. -CPAP: Wash tubing and headgear in warm soapy water, rinse and air dry every day shift on Sunday. An observation on 05/05/2025 at 10:51 AM revealed a CPAP machine on Resident #184's nightstand with tubing attached, with an associated mask on the resident's bed above a pillow. An observation on 05/06/2025 at 8:59 AM revealed a CPAP machine on Resident #184's nightstand with the tubing draped over the head of the bed and the mask hanging down behind the bed. Resident #184 was sitting on the side of the bed, and a certified nurse assistant (CNA) was assisting the resident to get ready for the day. An observation on 05/07/2025 at 2:07 PM revealed the CPAP machine on Resident #184's nightstand with the tubing attached and the mask on the floor at the head of the bed. The humidifier chamber was full of water. During an interview at the time of the observation, Resident #184 stated they had used the CPAP machine for the last 20 years. During an observation and interview on 05/07/2025 at 2:26 PM, Licensed Vocational Nurse (LVN) #1 entered Resident #184's room and verified the CPAP mask was hanging off the bed frame under the head of the bed and that there was no bag to store it in. LVN #1 stated the mask should be stored in a bag when not in use. During an interview on 05/07/2025 at 4:17 PM, Licensed Vocational Nurse (LVN) #2 stated that, if a resident had a CPAP machine, she entered the resident's room when they were ready to go to bed and put distilled water in the humidifier chamber and assisted the resident with putting on their mask as needed. She stated that, other than that, she did not do anything else with CPAP machines. During an interview on 05/08/2025 at 9:52 AM, the Administrator stated staff should follow the appropriate protocol to clean and store CPAP equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform abdominal assessment and verify Resident 1 ' s appointment prior to sending to Interventional Radiology (IR) clinic. As a result , Resident 1 was left outside of the clinic in a cold weather close to an hour and not needed to be seen at the clinic. Findings: A review of Resident 1 ' s admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Hydronephrosis with renal and ureteral calculous obstruction( excess fluid in the kidney due to a backup of urine) and Osteomyelitis of the lumbar region (inflammation of the lower back). A review of the hospital record titled, service encounter dated 12/18/24 Hospitalist, History and Physical indicated, in October 2024, Resident 1 had a rising white blood count and had an interloop (to loop together) collection that underwent an IR drainage after which the catheter was removed on November 22, 2024. During an interview on 12/23/24 at 10:26 A.M., with family member ( FM) 1, FM 1 stated Resident 1 had an appointment on 12/11/24 for a drain site check at the IR hospital and did not need to be seen at the clinic anymore. FM 1 stated, Resident 1 was left out in the cold weather close to an hour and that FM 1 had to pay for Resident 1 ' s transport to the clinic. An interview on 12/23/24 at 12 noon with Licensed nurse (LN)1 was conducted. LN 1 stated she knew Resident 1 did not have a drain site anymore but was sent to IR at the hospital without verifying the appointment. An interview on 12/23/24 at 2 P.M., with the Unit clerk (UC) was conducted. The UC stated, the admission LN placed the standing orders that came with the resident from the hospital. The UC stated after the LN verified the orders, schedule the appointment, the UC would arrange the transportation and inform the resident ' s family regarding the appointment including the payment. An interview on 12/24/24 at 2:46 P.M., with LN 2 was conducted. LN 2 stated, when a resident got admitted to the facility, the licensed nurse follows the physician orders including appointments from the hospital after verifying with the resident's physician. LN 2 stated the UC was responsible to follow up resident's appointment, scheduling of appointment, and transportation arrangements. An interview on 12/30/24 at 12:31 P.M., with the Director of Nursing (DON) was conducted. The DON stated the admission nurse review and carry over the appointment and the hospital orders. The DON stated FM 1 was upset because she had to pay the transportation for Resident 1 that did not happen because there was no appointment. An interview on 1/13/25 at 8:12 A.M., with LN 3 was conducted. LN 3 stated her role included, admissions and medication administration to residents, initial admission assessments and verification of orders, and scheduling of appointments. Resident 1 had an appointment to follow up with IR for a drain site check on 12/11/24 at 2 P.M. LN 3 stated she handed a copy of the order to the UC to follow up with the clinic and to arrange transportation. LN 3 stated she did not verify with the IR clinic regarding Resident 1 ' s appointment. An interview on 1/17/25 at 3:59 P.M, with the certified nursing assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was dependent with his activities of daily living that included feeding , dressing, and toileting. CNA 1 stated he was not sure if Resident 1 had a device of any sort. A record review of Resident 1 ' s minimum date set ( MDS- a federally mandated assessment tool) dated 12/1/24 indicated, Resident 1 ' s brief interview for mental status (BIMS) was 10 which meant Resident 1 had moderate cognition impairment. A review of Resident 1 ' s MDS section GG dated, 12/1/24 indicated, Resident 1 was dependent with his activities of daily living and no attempt was made for Resident 1 to do sit to stand , chair to chair transfer due to medical condition and safety concerns. A review of the weekly summary report dated, 12/07/24 indicated, Resident 1 drain removal site to left lower quadrant with 100% scab, dry and was not being treated. A review of the care plan initiated on 12/7/24 indicated, Resident 1 was admitted with actual impairment to skin integrity with a drain removal site to left lower quadrant (LLQ) of abdomen 0.5 cm x 0.7 cm , 100% scab, dry- arrived back to facility resolved on 12/7/24. A review of the Physicians orders, dated 12/7/24, did not indicate an order for monitoring of the drain site. A review of the facility's undated policy titled, Resident Assessments indicated, assessments are completed by the staff members who have the skills and qualification to assess relevant care areas and who are knowlegeable about the resident's health .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide supervision for one of two residents (Resident 1) when Resident 2's wandering (moving from place to place) behavior was not identified which resulted to an altercation with Resident 1. This failure had the potential for Resident 1's safety and wellbeing. Findings: Review of Resident 1's admission Record indicated, Resident 1 was admitted on [DATE] to the facility with diagnoses that included Chronic Pain Syndrome, and dependent on wheelchair use. A review of Resident 2's admission Record indicated, Resident 2 was admitted on [DATE] to the facility with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory), and Dementia (a group of thinking and social symptoms that interferes with daily functioning). An interview on 5/28/24 at 10:30 A.M., with Resident 1 was conducted. Resident 1 stated Resident 1 was sitting on her wheelchair in her room when Resident 2 came from behind. Resident 1 stated she told Resident 2 to get out of the room and Resident 2 suddenly hit Resident 1 at the back of her head and felt pain and told staff. Resident 1 stated staff immediately separated her from Resident 2 and notified the licensed nurses. A record review of Resident 1's Minimum Data Set (MDS-assessment tool) indicated a BIMS (brief interview for mental status) score of 14 which indicated Resident 1's cognition was intact. BIMS score of 0-7 indicated severe cognitive impairment, 8-12 indicated moderate cognitive impairment, and a score of 13-15 indicated cognition was intact. A record review of Resident 2's MDS dated [DATE] indicated Resident 2's BIMS score was 8, which indicated Resident 2's cognition was severely impairment. The same MDS assessment section E for behaviors, indicated, Resident 2 had wandering episodes and behaviors such as resistance to care. An interview on 5/28/24 at 10:50 A.M., with licensed nurse (LN) 1 was conducted. LN 1 stated resident 2 was ambulatory (able to walk about) and wandered into other resident rooms. LN 1 stated they tried to closely monitor Resident 2 but sometimes it's not feasible. An interview on 5/28/24 at 11:40 A.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated it was the first incident between Resident 1 and Resident 2, although Resident 2 had behavioral encounters with other residents in the facility. A phone interview on 5/28/24 at 1:30 P.M., with the Director of Nursing (DON) was conducted. The DON stated Resident 2 has had behaviors of grabbing cookies from other residents and a behavior care plan was initiated instead. The DON stated the facility did not have a wandering assessment for Resident 2 since Resident 2 was not exhibiting exit seeking behaviors on admission. Review of Resident 2's care plan dated, 5/16/24 indicated, behavioral symptoms/problem, pinched another resident's arm, revised 5/20/24. Review of facility's policy titled, admission Assessment; Role of the Nurse dated September 2012 .#3 conduct supplemental assessments including .f. behavioral assessments. Review of the Centers for Medicare & Medicaid Service of the rights of a nursing home resident included the basic human rights, the right to be free from verbal, sexual, physical and mental abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medication per the physician ' s order for 2 of 2 sampled residents (1,2). As a result, residents may have had increased pain and anxiety Findings: 1a Per the facility ' s admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (weakness on one side of the body). Per the facility ' s Medication Administration Record, dated April 2022, gabapentin (a medication for nerve pain) was ordered to be given at bedtime. Gabapentin was not marked as administered on 4/9/22, 4/11, or 4/12. Per the facility ' s Progress Notes, on 4/13/22 LN 1 noted that gabapentin was not delivered from the pharmacy. 1b Per the facility ' s Medication Administration Record, dated April 2022, levothyroxine (a medication for low thyroid hormone) was ordered to be given every morning. Levothyroxine was not marked as administered on 4/14/22. On review of the facility ' s Progress notes, dated 4/10/22 through 4/16/22 there was not a note to explain why levothyroxine was not administered on 4/14/22. 1c Per the facility ' s Medication Administration Record, dated April 2022, baclofen (a medication for abnormal muscle stiffness) was ordered to be given three times per day. Baclofen was not marked as administered one time on 4/13/22 and one time on 4/14. Per the facility ' s Progress Notes, on 4/13/22 LN 1 noted that baclofen was not delivered from the pharmacy. Per the facility ' s Progress notes, on 4/15/22 LN 1 noted that Resident 1 missed two doses of baclofen on 4/14/22 because the medication was not delivered from the pharmacy. 2 -Per the facility ' s admission Record, Resident 2 was admitted to the facility on [DATE]. Per the facility ' s Medication Administration Record, dated April 2022, lorazepam (a medication for anxiety) was not marked as administered on 4/24/22. Per the facility ' s Progress Notes, on 4/24/22, LN 2 noted that lorazepam was not available to administer. On 4/27/22 at 10:47 A.M., an interview was conducted with the administrator. The administrator stated, in the beginning of April 2022, the facility ' s pharmacy made a change to their system which caused a delay in medication deliveries. The administrator further stated, the pharmacy did not notify the facility that the change to their system would occur and cause medication delays. The facility ' s policy, titled Medication Ordering and Receiving from Pharmacy, revised June 2018, did not indicate how timely the pharmacy had to deliver ordered medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to include a surgical history of mastectomy (surgical breast removal) on the baseline care plan for one of two sampled residents (1). As a result, staff took Resident 1's blood pressure on the affected side, which had the risk of causing lymphedema (swelling). Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include dementia (a physical and mental decline), and history of breast cancer. Per the facility's Admission/readmission Evaluation for Resident 1, dated 10/20/22, .Dx (Diagnoses) of .Mastectomy of left breast . The admission note did not indicate if there were any restrictions on taking Resident 1's blood pressure on either arm. Per the facility's Weights and Vitals Summary dated 12/7/22, the facility took Resident 1's blood pressure 216 times between 10/20/22 and 12/7/22. Of the listed blood pressure results, 55 were obtained from Resident 1's left arm. On 12/7/22 at 3:30 P.M., an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated, on 11/9/22, a sign was posted on Resident 1's wall which directed staff not to take her blood pressure on the left arm. LN 2 further state, prior to 11/9/22, that sign was not posted, and there were not any restrictions on which arm they could use to take Resident 1's blood pressure. On 12/9/22 at 3:55 P.M., a telephone interview was conducted with LN 3. LN 3 stated, at the time of admission, she was aware of Resident 1's history of a mastectomy to the left breast. LN 3 further stated, due to Resident 1's history of mastectomy, her blood pressure should not have been taken on the left arm. LN 3 stated, she did not enter Resident 1's mastectomy or left arm blood pressure restriction into an order or care plan. On 12/13/22 at 4:10 P.M., a telephone interview was conducted with the Administrator. The Administrator stated, even though there was not an order or care plan which directed staff not to take Resident 1's blood pressure on her left arm, the staff should have used their critical thinking skills to know that they should not have taken her blood pressure on the left arm because of her history of mastectomy. Per the facility's policy, titled Baseline Care Plan, revised 2/19/18, .The facility develops a baseline care plan within 48 hours of a resident's admission .Each resident's baseline care plan includes the instructions needed to provide effective and person-centered care for the immediate needs of the resident .The baseline care plan includes the minimum healthcare information necessary to properly care for a resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a care plan for one of one resident (173) on dialysis (a process of cleaning blood) with fluid restriction. As a result Resident 173 had the potential for fluid overload. Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis per the facility's admission Record. On 3/16/22, a review of Resident 173's records was conducted. The physician order, dated 3/3/22, indicated fluid restriction of 1,600 milliliters (ml)/day. There was no documented care plan for Resident 173's dependence on dialysis and the ordered fluid restriction. On 3/16/22 at 2:52 P.M., a concurrent interview and record review of Resident 173's records with LN 6 was conducted. LN 6 stated there should be a care plan for dialysis and fluid restriction for Resident 173. Per the facility's policy and procedure titled Care Plans- Comprehensive and revised 10/17, Policy Statement: An individualized comprehensive care plan that includes .to meet the resident's medical, nursing, .needs is developed for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the staff followed a physician's orders for one of one resident (Resident 173) on dialysis (a process of cleaning blood) when: 1. The staff did not follow the fluid restriction order 2. The staff took blood pressure measurement on the resident's vascular access arm As a result, 1. Resident 173 was given more fluids than what was ordered 2. There was a potential for vascular access complication Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis per the facility's admission Record. 1. On 3/16/22, a review of Resident 173's records was conducted. The physician order dated 3/3/22 indicated fluid restriction of 1600 milliliters (ml)/day- dietary 960 ml/day, nursing 640 ml/day and to document amount of fluid consumed. On 3/16/22 at 10:16 A.M., an interview with Resident 173's family member (FM) was conducted. The FM stated the facility staff did not inform her there was an order for fluid restriction. She stated she brought Resident 173 coffee and tea and had Resident 173 drink a bottle of Ensure (supplement) the other day for a snack. The FM stated the staff knew Resident 173's family brought him food and drinks from home but was not told how much Resident 173 can drink. On 3/16/22 at 2:52 P.M., a concurrent interview and review of Resident 173's records with LN 6 was conducted. LN 6 stated Resident 173 had a physician's order for fluid restriction of 1600 ml/day. She stated any food or drink the family brought in for Resident 173 should have been documented and the family educated regarding Resident 173's fluid intake and diet. Resident 173 was given the following total fluid amounts on these dates: 3/4/22: 1440 ml (from fluid intake) plus 240 ml (from nurse fluids), 80 ml more than the physician ordered maximum fluid per day. 3/6/22: 1160 ml plus 720 ml, 280 ml more than the physician ordered maximum fluid per day. 3/7/22: 1760 ml plus 240 ml, 400 ml more than the physician ordered maximum fluid per day. 3/8/22: 1440 ml plus 240 ml, 80 ml more than the physician ordered maximum fluid per day. 3/10/22: 1440 ml plus 800 ml, 640 ml more than the physician ordered maximum fluid per day. 3/11/22: 1080 ml plus 800 ml, 280 ml more than the physician ordered maximum fluid per day. 3/14/22: 1700 ml plus 240 ml, 340 ml more than the physician ordered maximum fluid per day. 3/16/22: 1440 ml plus 840 ml, 680 ml more than the physician ordered maximum fluid per day. On 3/17/22 at 9:41 A.M., an interview with LN 7 was conducted. LN 7 stated residents on fluid restriction should have their fluid intake measured and recorded. He stated if the family of Resident 173 brought extra food or drink, it needed to be reported to the LNs and measured. LN 7 stated the family needed to be educated on Resident 173's fluid restriction. Per the facility's policy and procedure titled Intake and Output revised on 7/19, .Fluid intake and output shall be recorded for each patient as follows: 3. Residents with an order for fluid restriction . 2. On 3/16/22, a review of Resident 173's records was conducted. A physician order, dated 2/27/22, indicated not to take blood pressure (BP) on the dialysis access site. The vitals sign flow sheet indicated BP was taken by the staff on the left arm access site on the following dates: 3/6/22 9:10 A.M. 3/8/22 6:03 P.M. 3/9/22 5:47 P.M. 3/10/22 3:53 A.M. 3/15/22 10:16 A.M. On 3/17/22 at 9:41 A.M., an interview with LN 7 was conducted. LN 7 stated the dialysis access could clot if BP was taken on Resident 173's dialysis access site. Per the policy and procedure titled Dialysis Management, dated 11/17, .Procedure .5) The physician provides orders for dialysis treatments .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a pressure relieving mattress was set up according to the physician's order for one of five sampled residents (320) with pressure ulcers (areas of damaged skin caused by staying in one position for too long). This failure had the potential to cause Resident 320's pressure ulcer to deteriorate. Findings: Resident 320 was admitted to the facility on [DATE], with a diagnoses of stage 2 Pressure ulcer of sacral region and aftercare following surgery of the digestive system, per the facility's admission Record. A review of the Braden Scale for Predicting Pressure Sore Risk , dated 3/10/22, indicated Resident 320 was at risk, slightly limited mobility, makes frequent though slight changes in body independently. During an observation on 3/14/22, at 8:40 A.M., in Residents 320's room, Resident 320 was in bed, on a low air loss mattress (LAL, alternating pressure low air loss mattress; reduces pressure to aid in the prevention and treatment of pressure ulcers). The LAL mattress was set at 450 pounds. A review of Resident 320's March monthly weight indicated Resident 320's weight was at 226.6 pounds. A review of Resident 320's physician's order, dated March 10, 2022, indicated for LAL set mode alternating and setting based on comfort and/or weight of resident. During an observation on 3/15/22, at 9:40 A.M., Resident 320's mattress was set up at 250 pounds. During a concurrent observation and interview with Resident 320 on 3/16/22, at 11:06 A.M., the LAL mattress was noted to be set up at 250 pounds. Resident 320 stated he was more comfortable with this LAL mattress setting. An interview with LN 12 on 3/17/22 at 10:55 A.M., was conducted. LN 12 stated LAL mattress was being monitored by LN's, based on the resident's weight and comfort. LN 12 stated in monitoring resident's LAL, the priority was resident's weight and then comfort. LN 12 agreed that the LAL mattress should had been set up at 250 pounds on 3/14/22, basing on Resident 320's weight of 226.6 pounds, not at 450 pounds. LN 12 added that it was important to follow physician's orders in setting up the LAL mattress to prevent worsening of pressure ulcers. An interview with the DON on 3/17/22 at 1:24 P.M., was conducted. The DON stated Resident 320's LAL mattress should had been set up according to resident's weight and it was important to prevent worsening of pressure ulcers and promote healing. Per the facility's policy, dated 7/1/2020, titled Prevention of Pressure Ulcers/Injuries .The purpose of this procedure is to provide .Support surfaces and pressure redistribution .select appropriate support surfaces based on the resident's body weight .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise fall specific preventative measures for one of one resident (Resident 61), after a fall. As a result, Resident 61 suffered another fall six days later after the initial fall. Findings: Resident 61 was admitted to the facility on [DATE] with diagnoses which included abnormalities of gait and mobility and dementia (impaired memory) per the facility's admission Record. On 3/15/22 at 9:31 A.M., Resident 61 was observed in bed, leaning towards the right side. Resident 61 was grasping the right siderail of the bed with both hands and attempting to pull himself up. His right leg was off to the right side of the bed. He was wearing a brief, which appeared to be wet. On 3/17/22 at 9:28 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 61 had an incontinent of bladder (having no or insufficient voluntary control over urination). CNA 1 stated Resident 61 was a fall risk. CNA 1 further stated she heard Resident 61 fell before but did not know why or when he fell. On 3/17/22 at 1:36 P.M., an interview was conducted with LN 7. LN 7 stated Resident 61 has dementia, confused, and had tried to get out of bed. LN 7 stated Resident 61 had history of falls prior to this admission and had fallen at least once since being admitted . LN 7 stated when a resident fell, the care plan should have been updated with new interventions by either the medication nurse or the charge nurse. LN 7 stated the interventions should have reflected the cause of the fall. A review of the facility's Monthly Falls Tracking Form indicated Resident 61 fell on 2/15/22, 2/21/22, and 3/1/22. A review of Resident 61's records was conducted. Resident 61's fall care plan initiated on 2/14/22 had indicated the resident was a high risk for fall. The intervention included in this care plan was to, review information on past falls and attempt to determine cause of falls. Record possible root causes . and to anticipate and meet the resident's needs. Resident 61's eINTERACT SBAR Summary Providers (a form to communicate to physicians) progress note, dated 2/15/22, indicated Resident 61 was found on the floor. Resident 61 had claimed he stood up to go to the bathroom and fell. Interventions added on 2/17/22 to Resident 61's fall care plan after his fall were not related to the cause of the fall. Resident 61's eINTERACT SBAR Summary Providers progress note, dated 2/21/22, stated resident was observed on the floor of resident's restroom. Resident was attempting to use restroom and was unable to tell nurse how he got the floor. On 3/17/22 at 2:03 P.M. an interview was conducted with the DON. The DON stated when a resident falls, interventions added to the care plan should have been based on the cause of the fall. Per the facility's policy titled, Fall and Fall Risk, Managing, dated 7/1/20, Policy: Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try and prevent the resident from falling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the staff provided the services required for the care of one of one resident (Resident 173) on dialysis (a process of cleaning blood) when: 1. The staff did not remove the dressing on the dialysis vascular access per the dialysis center recommendation 2. The staff did not accurately identify the dialysis access' bruit (sound of blood flow) and thrill (vibrations of blood flow) As a result, there was a potential a dialysis access complication would not be identified. Findings: Resident 173 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis per the facility's admission Record. 1. On 3/16/22, at 10:16 A.M., an observation of Resident 173's left arm was conducted. A gauze dressing was noted on Resident 173's left upper arm. On 3/16/22, at 2:37 P.M., a concurrent interview and record review with LN 6 was conducted. LN 6 stated Resident 173 has a dialysis access on the left upper arm and his dialysis schedule was every Tuesday, Thursday and Saturday. LN 6 stated the dialysis access dressing should be removed three to four hours after dialysis per the dialysis center's recommendation. On 3/16/22 at 3:16 P.M., a joint observation of Resident 173's dialysis access was conducted with LN 6. LN 6 noted there was still a dressing on the access on the left upper arm. LN 6 stated Resident 173 had dialysis treatment yesterday. LN 6 stated when residents come back to the facility after dialysis, the staff had to check the dialysis access. On 3/17/22, at 9:41 A.M., a concurrent interview and record review with LN 7 was conducted. The document titled Dialysis Communication Record dated 3/15/22 indicated to remove dressing on the left upper arm three to four hours after dialysis. 2. On 3/16/22, at 3:16 P.M., a joint observation of Resident 173's dialysis access was conducted with LN 6. LN 6 noted there was a dialysis access on Resident 173's left upper arm. LN 6 stated when residents come back to the facility after dialysis, the staff had to check if the access was still functioning by listening to the thrill and feeling for the bruit. On 3/17/22, at 9:41 A.M., an interview with LN 7 was conducted. LN 7 stated when residents came back to the facility from a dialysis treatment, the staff had to check the communication record from the dialysis facility to check for any changes in orders, instructions and to check if the access was working or not. LN 7 stated the correct way was to listen for the bruit via stethoscope and feel for the thrill. Per the facility's policy and procedure titled, Dialysis Management, dated 11/17, .1) The facility has an agreement with contracted Dialysis Unit(s) which operate in accordance with current standards of practice including communication and collaboration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the staff followed the physician's order for one of three sampled residents (20) for pain medication. This failure had the potential for Resident 20's pain to be unrelieved. Findings: Resident 20 was admitted to the facility on [DATE], with a diagnoses of cellulitis (bacterial skin infection) of bilateral lower limbs and chronic pain syndrome (pain that lasts for over 3 months that can interfere with daily activities), per the facility's admission Record. During a clinical record review conducted for Resident 20, per the physician's order dated 2/20/22, Norco (medication for pain) tablet 5-325 mg (Hydrocodone-Acetaminophen), give 1 tablet by mouth every 4 hours as needed for moderate (5-7 pain scale), to severe pain (8-10 pain scale) and dated 7/25/21, Hydromorphone HCL tablet 2 mg (medication for pain) give 1 tablet by mouth every 4 hours as needed for break through pain A concurrent observation and interview with Resident 20 on 3/14/22 at 9:15 A.M., in her room, was conducted. Resident 20 was observed to be in a wheelchair, alert, oriented and comfortable. Resident 20 stated that she was pain free and knows that she can have her pain medications as needed but was not aware what pain medication she was getting. An interview with CNA 12 on 3/15/22, at 3:55 P.M., was conducted. CNA 12 stated that Resident 20 was alert, gentle and had chronic pain in her legs. CNA 12 added that if Resident 20 was in pain, she normally asked for pain medications. On 3/17/22 at 10:30 A.M., Resident 20's MAR was reviewed with LN 11 for the following dates: 2/21/22, Hydromorphone HCL tablet 2 mg was given for a pain of 8 at 10:18 P.M., last dose of Norco 5-325 mg was at 9:15 A.M. 2/22/22, Hydromorphone HCL tablet 2 mg was given for a pain of 8 at 8:55 P.M., last dose of Norco 5-325 mg was at 8:34 A.M. 2/24/22, Hydromorphone HCL tablet 2 mg was given for a pain of 8 at 9:12 A.M., last dose of Norco 5-325 mg was at 4:32 A.M. 2/27/22, Hydromorphone HCL tablet 2 mg was given for a pain of 7 at 8:10 P. M., no Norco 5-325 mg dose was given 2/27/22 2/28/22, Hydromorphone HCL tablet 2 mg was given for a pain of 7 at 4:05 P.M., last dose of Norco 5-325 mg was at 9:22 A.M. 3/2/22, Hydromorphone HCL tablet 2 mg was given for a pain of 8 at 10:33 P.M., last dose of Norco 5-325 mg was at 8:46 A.M. 3/3/22, Hydromorphone HCL tablet 2 mg was given for a pain of 7 at 8:35 A.M. and at 3:42 P.M. for a pain of 8, no Norco 5-325 mg dose was given on this date. 3/8/22, Hydromorphone HCL tablet 2 mg was given for a pain of 8 at 8:00 P.M., last dose of Norco 5-325 mg was at 4:00 P.M. 3/14/22, Hydromorphone HCL tablet 2 mg was given for a pain of 7 at 6:57 P.M., no Norco 5-325 mg dose was given 3/14/22 The MAR indicated on these dates Hydromorphone HCL tablet 2 mg was given not for break through pain, as the physician had ordered, but was given for pain scale of 7-8, which was the ordered indication for Norco 5-325 mg. LN 11 stated that administering Hydromorphone HCL tablet 2 mg, first, before Norco 5-325 mg was not following physician's orders. An interview with LN 12 on 3/17/22 at 10:45 A.M., was conducted. LN 12 stated Norco should have been given first for pain relief, then reassessed the resident in 30-45 minutes post administration. If it was not effective then administer Hydromorphone HCL tablet 2 mg for break through pain per physician's orders. An interview with the DON on 3/17/22 at 1:40 P.M., was conducted. The DON stated it was important to follow physician's orders for pain management. Per the facility's Policy, titled Pain Assessment and Management, dated June 2016, indicated, .6. Implement the medication regimen as ordered .

Based on observation, interview and record review, the facility failed to decrease the transmission of COVID-19 to residents when: 1. the facility's staff vaccination policy was not in accordance with federal regulation 2. an unvaccinated staff member did not wear the required protective facial covering. These failures had the potential to contribute to the transmission and spread of COVID-19 to residents, staff, and visitors in the facility. Findings: 1. An interview with the facility's ICP was conducted on 3/16/22 at 2:06 P.M. The ICP stated the facility's staff vaccination policy was reviewed and updated as needed according to state and federal guidelines, adhering to the stricter regulation. On 3/16/22, at 3:50 P.M., a concurrent interview and record review of the facility's policy titled, Health Care Worker Vaccine Requirement, revised on 3/1/22, was conducted with the ICP. Per the facility's policy under Exemption .2 .unvaccinated exempt worker must meet the following requirements when entering of working in the facility .b. Wear a surgical mask or higher-level respirator at all times while in the facility. The ICP stated information in the policy was obtained from websites listed on the reference page. Review of the reference page showed web links to the California Department of Public Health and the Centers for Disease Control and Prevention. The ICP stated she and the other staff members involved with the policy also referred to CMS's Quality Safety & Oversight (QSO) memoranda and guidance when updating the policy. The ICP had QSO 22-07, dated 12/28/21, on her clipboard, which addressed the COVID-19 Health Care Staff Vaccination. When asked if the QSO she had was the most current, the ICP stated as far as she was aware, it was. The ICP was asked to verify if the QSO she had was current. On 3/16/22, at 4:12 P.M., the ICP returned and stated there was an updated QSO 22-07 memoranda released in January 2022. The ICP referred to section 483.80(i)(iii), which indicated .staff who are not yet fully vaccinated, or who have a pending or been granted an exemption .adhere to additional precautions that are intended to mitigate the spread of COVID-19 .requiring staff who have not completed their primary vaccination series to use a NIOSH-approved N95 or equivalent .regardless whether they are providing direct care to or otherwise interacting with patients. The ICP stated the facility's policy for staff vaccination was not in accordance with the current federal regulation. 2. On 3/16/22, at 2:06 P.M., an interview was conducted with the ICP. The ICP stated unvaccinated staff are required to wear a N95 respirator in resident care areas. The ICP provided a list of unvaccinated staff members with approved exemptions. On 3/16/22, at 3:32 P.M., the SSD was observed in the dining room speaking with a state surveyor. The SSD was wearing a black mask, secured looped around the ears. The SSD was identified on the list of unvaccinated staff members. On 3/16/22, at 3:38 P.M., an interview was conducted with the SSD. The SSD stated she was unvaccinated and was granted a religious exemption. She stated the facility provided her with a N95 mask that she was fit tested for but preferred to wear her own personal mask from home. She stated she was not fit tested with the mask she was currently wearing and should be wearing the mask she was fit tested for. She further stated no one in the facility has talked to her about wearing her own personal mask. On 3/16/22, at 3:55 P.M., an interview was conducted with the ICP. The ICP stated all unvaccinated staff members were fit tested for a N95 mask and were instructed to only wear the mask they were fit tested for. On 3/17/22, at 2:07 P.M. an interview was conducted with the DON. The DON stated unvaccinated staff member should be wearing a N95 in patient care areas and in the hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/18/19 at 9:58 A.M., an interview was conducted with Confidential Resident (CR) 5. CR 5 stated staff would barge into his bathroom without knocking on the door or announcing themselves. CR 5 stated he would feel embarrassed especially if he were naked or sitting on the toilet. CR 5 stated this occurred over and over and stated it was an invasion of his privacy. On 9/18/19 at 3:24 P.M., an interview was conducted with CR 5. CR 5 stated he had just been in his bathroom on the toilet and CNA 21 barged in without knocking. On 9/18/19 at 3:32 P.M., an observation of CNA 21 was conducted in hall A. CNA 21 entered rooms [ROOM NUMBERS], the CNA did not knock or request to enter. On 9/18/19 at 3:37 P.M., an observation of CNA 22 was conducted in Hall B. CNA 22 entered rooms [ROOM NUMBERS], the CNA did not knock or request to enter. On 9/18/19 at 3:44 P.M., an interview was conducted with CNA 22. CNA 22 stated the proper procedure before entering a resident room would be to knock or request to enter. CNA 22 stated he did not do either upon entering rooms [ROOM NUMBERS]. On 9/18/18 at 4:03 P.M., an interview was conducted with CNA 21. CNA 21 stated she should have knocked or announced herself prior to entering rooms, 9 and 11 and she did not do either prior to entering the rooms. On 9/19/19 at 9:15 A.M., an interview was conducted with LN 23. LN 23 stated staff should always knock or announce themselves prior to entering resident rooms. LN 23 stated the facility was the residents home and their dignity should be respected. On 9/19/19 at 11:10 A.M., an interview was conducted with the DSD. The DSD stated the staff should knock or announce themselves prior to entering a resident room or bathroom. The DSD stated the residents dignity must be preserved. The DSD stated in order to avoid embarrassment to the resident, staff should always knock first. On 9/20/19 at 1:59 A.M., an interview was conducted with the DON. The DON stated it was her expectation that the staff knock or announce themselves prior to entering a resident room or bathroom. The DON stated the resident's rooms were their private areas, and resident dignity would not be respected if staff did not knock or announce themselves prior to entering the room. Per the facility's policy, titled Dignity, dated 6/16/16, Procedure .1. Residents should be treated with dignity and respect at all times. 2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . 6. Residents' private space .shall be respected at all times .10. Staff shall keep the resident informed . 3. Resident 34 was admitted to the facility on [DATE], per the facility's Transfer/Discharge report. On 9/17/19 at 3:39 P.M., a joint observation and interview was conducted with Resident 34. Resident 34 was in bed and was observed crying. Resident 34 stated she had asked for pain medicine at 2:55 P.M., greater than 30 minutes prior. Resident 34 stated she had knee and back pain at a level 9 (scale of 1-10 with 10 being the worst). Resident 34 stated she felt neglected because her pain would be unbearable at times and would frequently not be managed timely. The interview had concluded at 3:45 P.M., and the resident had not yet received her pain medication. On 9/17/19 at 3:47 P.M., an interview was conducted with LN 29. LN 29 stated she had not brought Resident 34's pain medication to her because the surveyor had been in the room with the resident. LN 29 also stated it was not appropriate for a resident to wait almost one hour to receive pain medication. LN 29 stated a residents pain should be managed as soon as possible. On 9/18/19 at 12:14 P.M., an interview was conducted with LN 30. LN 30 stated an acceptable amount of time for a resident to wait to be medicated for pain would be no longer than 10 minutes. LN 30 stated it was important for the residents to be kept comfortable and pain free so they could heal and perform well in therapy. On 9/20/19 at 1:59 P.M., an interview was conducted with the DON. The DON stated the nurses should address a resident's pain immediately. The DON stated a resident that waits to receive pain medication for almost 60 minutes was not acceptable. Per the facility's policy, titled Pain Assessment and Management, dated June 2016 .1. The Pain management program is based on a facility-wide commitment to resident comfort . Based on observation, interview, and record review, the facility failed to treat residents in a dignified manner when: 1. Staff did not answer call bells in a timely manner for 2 of 19 sampled residents (20, 21), 2. Staff did not knock prior to entering a residents' room and bathroom for one of 19 sampled residents (Confidential Resident 5), and; 3. A resident (34) waited 55 minutes before receiving pain medication. These failures resulted in Resident 20 having accidents, Resident 21 feeling unimportant, Confidential Resident 5 feeling embarassed and Resident 34 feeling neglected because her pain was not managed in a timely manner Findings: 1A. Resident 20 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs), per the facility's admission Record. Per the MDS (an assessment tool), dated 9/3/19, Resident 20 had a BIMS (a cognitive test) of 13 out of 15 (a score of 13-15 indicates a resident is cognitively intact), which indicated the resident was mentally intact. On 9/17/19 at 9:48 A.M., an interview was conducted with Resident 20. Resident 20 stated he needed staff assistance and used a portable lift (a machine used to lift and transfer a person from one area to another) to transport him to/from the bed and to/from the wheelchair because he had a spinal cord injury from the neck down. Resident 20 stated an incident occurred when he first was admitted to the facility in July 2019 where he rang the call bell for assistance to have his adult briefs changed. Resident 20 stated a staff member answered the call bell, asked him what he needed, left the room without stating when they would return, and did not assist him. Resident 20 stated after 45 minutes, he rang the call bell again; another staff answered the call bell and said they needed to get the portable lift, did not state when they would be back, and left the room. Resident 20 stated while he was waiting for assistance, he defecated on himself. Resident 20 stated, After I sh*tted and peed on myself, (the DSD) came in and said he would go get someone but he didn't come back to say if someone was coming. I didn't know what was going on. Resident 20 stated he stayed in a wet and dirty brief for at least 90 minutes. Resident 20 further stated it had been about two hours from when he initially rang the call bell to when staff assisted him. Resident 20 stated another incident occurred about two to three weeks ago when he rang his call bell for assistance. Resident 20 stated he was sitting in his wheelchair and he was getting tired of sitting and wanted to be transferred to his bed. Resident 20 stated a male nurse answered the call bell and stated he did not have time to assist the resident back to bed since the nurse had an hour's worth of charting to do and the next shift would assist him. Resident 20 stated, It was ten minutes to 2 p.m. when I rang the call bell .I got into bed around 4 p.m. that day. On 9/18/19 at 3:05 P.M., an interview was conducted with CNA 1. CNA 1 stated call bells should be answered within two minutes. CNA 1 further stated to fulfill a resident's request to be changed should be done within 15 minutes. CNA 1 stated it was a dignity issue if the resident had a bladder or bowel accident while waiting for the call bell to be answered in a timely manner. CNA 1 further stated it was everyone's responsibility to answer call bells. CNA 1 stated it was not acceptable to wait 20 minutes or more to answer call bells or fulfill a resident's request. On 9/18/19 at 3:40 P.M., an interview was conducted with LN 1. LN 1 stated calls bells should be answered within five minutes. LN 1 stated it was not acceptable to wait 30 minutes or more to answer call bells or to fulfill a resident's request to be changed. LN 1 stated residents needed to be changed immediately to prevent skin breakdown, sores, and infection. On 9/19/19 at 3:08 P.M., an interview was conducted with the DSD. The DSD stated he had checked on Resident 20 that day. The DSD stated it was possible Resident 20 was sitting in his urine and feces but was not sure for how long since they needed to find at least two staff members to transfer him by the use of the portable lift. The DSD stated it would be terrible and humiliating to sit in one's own urine and feces. The DSD stated call bells should be answered within 20 minutes. The DSD further stated the male nurse should not have told Resident 20 to wait until the next shift to be put back to bed; it shouldn't have happened. On 9/20/19 at 1:58 P.M., a joint interview was conducted with the ADM and the DON. The ADM stated he expected staff to answer call bells within 10 minutes. The DON stated 30 minutes was too long to fulfill a resident's request to use the bathroom or to have their incontinence brief changed because it could cause skin issues. The DON further stated, It's too long [to wait] if you had an accident. The DON stated it was a dignity issue to sit in one's own urine and feces. 1B. Resident 21 was admitted to the facility on [DATE] with diagnosis including bilateral amblyopia (decreased eyesight due to abnormal visual development) and right below the knee amputation, per the facility's admission Record. On 9/17/19 at 7:40 A.M., Resident 21 was observed awake and alert sitting on the bed. Resident 21's right leg was amputated below the knee. Resident 21 had an urinary catheter connected to a drainage bag, hanging on the bedside rail. On 9/17/19 at 7:45 A.M., Resident 21 was interviewed. Resident 21 stated, When I first came here, I used to use my call bell to ask for help. They would take a long time to answer my call bell. Sometimes it would take them over an hour to answer my call [bell] and other times they wouldn't come at all. Resident 21 further stated, I started to take myself to the toilet .I get on my wheelchair because I only have one leg. I go slowly because I'm legally blind and I have to carry my bag [urinary catheter]. Resident 21 stated, Since I've been here, no one has cleaned me. I clean myself. I feel like they don't really care about me. I think the call bell is useless. On 9/18/19 at 4 P.M., Resident 21's care plan for falls, created 7/24/19, was reviewed. Resident 21's care plan indicated, .anticipate and meet the resident's needs .the resident needs prompt response to all reports for assistance . On 9/18/19 at 3:05 P.M., an interview was conducted with CNA 1. CNA 1 stated call bells should be answered within two minutes. CNA 1 further stated to fulfill a resident's request to be changed should be done within 15 minutes. CNA 1 stated it was a dignity issue if the resident had a bladder or bowel accident while waiting for the call bell to be answered in a timely manner. CNA 1 further stated it was everyone's responsibility to answer call bells. CNA 1 stated it was not acceptable to wait 20 minutes or more to answer call bells or fulfill a resident's request. On 9/18/19 at 3:40 P.M., an interview was conducted with LN 1. LN 1 stated calls bells should be answered within five minutes. LN 1 stated it was not acceptable to wait 30 minutes or more to answer call bells or to fulfill a resident's request to be changed. LN 1 stated residents needed to be changed immediately to prevent skin breakdown, sores, and infection. On 9/19/19 at 3:08 P.M., an interview was conducted with the DSD. The DSD stated it would be terrible and humiliating to sit in one's own urine and feces. The DSD stated call bells should be answered within 20 minutes. On 9/20/19 at 1:58 P.M., a joint interview was conducted with the ADM and the DON. The ADM stated he expected staff to answer call bells within 10 minutes. The DON stated 30 minutes was too long to fulfill a resident's request to use the bathroom or to have their incontinence brief changed because it could cause skin issues. The DON further stated, It's too long [to wait] if you had an accident. The DON stated it was a dignity issue to sit in one's own urine and feces.

Based on observation, interview, and record review, the facility failed to ensure nursing staff followed the dietary cards during a meal observation for two of seven randomly observed residents (47, 49). This failure had the potential to cause aspiration (breathing foreign objects into the airways, such as food or liquids) for the residents. Findings: On 9/17/19 at 11:53 A.M., a lunch observation of residents in the dining room was conducted. At 11:58 A.M., the CCC set up the tray for Resident 47, including putting a straw into the orange juice. At 11:59 A.M., the CCC set up the tray for Resident 49, including putting three straws into a vegetable juice, a milk container, and a shake. On 9/17/19 at 12 P.M., a record review of the residents' dietary cards was conducted. Resident 47's and Resident 49's dietary cards were next to their meals and indicated no straws. On 9/17/19 at 12:06 P.M., an interview and record review was conducted with the CCC. The CCC stated she had set up the trays for both Resident 47 and Resident 49. The CCC further stated she had read both of the cards and had done it correctly. The CCC picked up the dietary cards, read them, and stated, Oh, no straws .I didn't notice it before. The CCC stated staff were supposed to follow the instructions on the dietary cards. On 9/18/19 at 4:05 P.M., an interview was conducted with the RD. The RD stated if a resident's dietary card indicated no straws then the SLP assessed straws could cause unsafe swallowing issues. The RD stated it was a nursing staff's responsibility to check the trays before distribution and to follow the dietary card. The RD further stated if the dietary card said no straws, then straws should not have been given to Residents 47 and 49. On 9/19/19 at 8:52 A.M., an interview and record review was conducted with the SLP. The SLP stated she did not recommend straws for elderly people, including Resident 47 and Resident 49, since the swallow reflex slowed down as a person aged, which could cause a risk for aspiration. The SLP reviewed the residents' records and stated both residents had a diagnosis of dysphagia (difficulty swallowing). The SLP stated nursing staff were supposed to follow the directions on the dietary card. Per the facility's undated policy, titled Nursing Department Responsibilities at Mealtime, Procedure .4. The assigned licensed nurse will check all trays for accuracy of tray vs. card prior to the tray being served to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's code status was formulated for 1 of 19 sampled residents (30). This failure had the potential to administer the incorrect care or treatment to Resident 30 during an emergency. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a decreased amount of oxygen in the blood), per the facility's admission Record. On [DATE] at 4:55 P.M., a record review of Resident 30's medical record was conducted. The POLST (a document indicating life sustaining treatment and end-of-life care) was not filled out to indicate if the resident wished to receive CPR (a lifesaving technique used during an emergency) or not and it was not signed by the resident or the physician. The code status field in Resident 30's electronic medical record was blank. There was no physician's order to indicate Resident 30's code status. On [DATE] at 10:18 A.M., an interview was conducted with the ICN. The ICN stated the code status for a resident was documented on the resident's electronic medical record and it was confirmed with the POLST. The ICN further stated once the POLST was signed, then a physician's order of their code status was made. The ICN stated the code status should be obtained during the admission process. The ICN stated it was a problem if there was no code status and it had been over a month since the resident's admission. On [DATE] at 10:46 A.M., an interview was conducted with LN 2. LN 2 stated if a resident was coding (when a resident was found to not have a pulse or a breath), she would look at the POLST or the resident's profile on the electronic medical record to find out their code status. LN 2 stated the code status was supposed to be obtained during the admission process. LN 2 stated it was unacceptable to not have a code status for a resident. On [DATE] at 11:04 A.M., an interview and record review was conducted with the DON. The DON stated if the POLST was blank, it meant the resident was full code (someone who needed CPR during an emergency situation). The DON stated nursing staff were expected to fill out the code status on the resident's profile on the electronic medical record, including documenting full code when the POLST was blank. The DON stated there should also be a physician's order for the current code status. The DON stated all three documents should agree. The DON stated she expected the nursing staff to obtain the code status within three days of admission. The DON stated Resident 30 had been in the facility since [DATE] and the code status should have already been done. The DON reviewed Resident 30's records and stated there was no code status in the resident's profile on the electronic medical record and there was no physician's order. The DON looked through Resident 30's medical records and stated Resident 30 had an advanced directive but was unable to locate it. On [DATE] at 11:18 A.M., a concurrent interview and record review was conducted with the DON and the SSD. The SSD reviewed Resident 30's medical records. The SSD stated there was a care conference on [DATE] but they did not discuss the code status. The DON stated the code status should have been discussed during the care conference on [DATE] and updated in Resident 30's chart on the same day. On [DATE] at 12:08 P.M., a concurrent interview and record review was conducted withe the DON. The DON reviewed Resident 30's advanced directive, pointed to a section where it indicated the code status of the resident, and stated, It says here she is supposed to be DNR [do not give CPR, allow the resident to die naturally]. The DON further stated Resident 30's advanced directive was not in her medical chart; it was in the SSD's office when it should have been in Resident 30's medical chart. Per the facility's policy, titled Advanced Directives, dated [DATE], Procedure .4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .8. The Physician together with the resident .will discuss advance directives so that appropriate orders can be documented in the resident's medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a nurse followed a physician's order when a Lidocaine (a medication that relieves pain and numbness) patch was not removed for one of four residents (219) observed during medication pass. This failure had the potential for the resident to be over medicated. Findings: Resident 219 was admitted to the facility on [DATE] per the facility's Transfer/Discharge report. On 9/19/19 at 8:07 A.M., a concurrent observation and interview of Resident 219 was conducted with LN 24 during a medication administration. When LN 24 attempted to place a Lidocaine patch on Resident 219's neck, the patch from the prior day was observed to still be on the resident's neck. LN 24 stated the patch should not have been there. LN 24 stated, per the schedule, the patch should have been removed 12 hours after application on the evening of 9/18/19 at 9 P.M. LN 24 removed the patch and applied the new patch. On 9/19/19, a review of Resident 219's medical record was conducted. Per a physicians order, dated 9/10/19, a Lidocaine 5% patch was to be applied to the neck in the morning and removed per schedule. On 9/20/19 at 9:06 A.M., an interview was conducted with the DON. The DON stated her expectation was that physician orders were followed as written, as that would be the treatment prescribed for the resident. The DON stated if the patch had not been removed at 9 P.M. on 9/18/19, the night nurse had not followed the physician's order. The facility did not provide a policy specific to following physician's orders

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respond to the pharmacist's monthly MRR for one of five residents reviewed for unnecessary medications (10). This deficient practice had the potential to cause adverse consequences related to medication therapy. Findings: Resident 10 was admitted on [DATE] with diagnoses which included, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), per the admission Record. On 9/17/19 at 9:35 A.M., Resident 10 was observed in bed with eyes closed. Resident 10 had stitches on the right side of her forehead. The right side of her face was black and blue. On 9/19/19, Resident 10's record was reviewed. A review of documents titled, Consultant Pharmacist's MRR were conducted. The MRR dated 2/4/19 indicated, Resident has been on the same dose of Risperdal (a medication to treat schizophrenia) 0.25mg q am (every morning) and 0.5mg q hs (every bedtime) since 8/18 .GDR is due if medically warranted. Review of Resident 10's MRR dated 8/1/19 indicated, Resident has been on the same dose of Risperdal 0.25 mg in the mornings and 0.5 mg nightly since 8/18. GDR is due if medically warranted. On 9/19/19 at 9:45 A.M., a joint interview and record review was conducted with the Pharm. The Pharm stated, I recommended a GDR of (Resident 10's) Risperdal twice, once in February and again in August of 2019. I made this recommendation because residents with dementia are more likely to have side effects like nervous system toxicity and gait instability when taking antipsychotic drugs. On 9/19/19, a review of Resident 10's Order Summary Report for September 2019 indicated: Lexapro (a medication for depression) Tablet give 7.5mg by mouth one time a day which was ordered on 7/18/19, Risperidone (a medication to treat schizophrenia) tablet 0.25 mg give 1 tablet by mouth one time a day which was ordered on 8/2/18, Risperidone tablet 0.25 mg give 2 tablets by mouth at bedtime which was ordered on 8/2/18, and; Aricept (a medication to treat Alzheimer's disease) tablet 10 mg give 1 tablet by mouth at bedtime which was ordered on 4/17/16. Review of Resident 10's Physicians Orders dated 9/12/19 indicated, Discontinue Lexapro, Risperidone, Aricept per family's request. Review of Resident 10's progress note dated 9/13/19 indicated Resident 10 had a fall on 9/12/19. On 9/20/19 at 10:50 A.M., the DON and CCC were interviewed. The DON stated, The facility has one week to respond to the pharmacists' recommendation. The CCC said she was responsible for contacting the physician, documenting his response, and carrying out his orders. On 9/20/19 at 11:10 A.M., a concurrent interview and record review was conducted with the CCC. The CCC was unable to find evidence that the MRRs, dated 2/4/19 and 8/1/19, were reported to the physician. The CCC said she did not have documentation that the pharmacist's MRR recommendations were sent to the physician. Per the facility's policy titled, Consultant Pharmacist Reports, dated June 2018, .D. Resident specific irregularities and/or clinical significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, and/or prescriber as appropriate .E. Recommendations are acted upon and documented by the facility staff and or the prescriber.

The facility failed to ensure a licensed nurse dated a multi-dose vial of Aplisol (a solution used to test for tuberculosis- a lung disease) when opening it. As a result, staff would not know when the Aplisol would be expired. Findings: On 9/19/19 at 9:22 A.M., a concurrent observation and interview was conducted with LN 25 in the medication storage room B. An opened 1-milliliter (ml) vial of Aplisol Lot # 328705 was observed in the medication room refrigerator. The vial did not have an open date written on it. LN 25 stated the vial had been opened and not dated. LN 25 stated the vial should have been dated because the solution would expire 28 days after it had been opened. RN 25 then placed the vial back into the refrigerator. On 9/19/19 at 9:50 A.M., an interview was conducted with LN 26. LN 26 stated all multidose vials of medications needed to be dated when opened so nursing staff would know when to discard them. On 9/19/19 at 11:04 A.M., an interview was conducted with the DSD. The DSD stated when opening a multidose vial, the nurse needed to date it so nursing staff would know when the medication expired. The DSD stated multidose vials were only good for 28 days after its opened and could no longer be effective if used past that date. The DSD stated the vial should have been discarded. On 9/20/19 at 9:24 A.M., an interview was conducted with the DON. The DON stated a multidose vial needed to be dated when opened so staff would know when to discard it. The DON stated if the solution was used after 28-30 days, it could lose it's potency and no longer be effective. The DON stated LN 26 should not have placed the vial back in the refrigerator, it should have been discarded. The facility did not provide a policy specific to expired medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received specialized rehabilitative services as determined by the occupational therapy's comprehensive plan of care for 1 of 19 sampled residents (21). As a result, Resident 21 did not meet his goal of walking with a prosthetic leg. Findings: Resident 21 was admitted on [DATE] with diagnoses which included right leg below the knee amputation, per the facility's admission Record. On 9/17/19 at 7:40 A.M., Resident 21 was observed awake, alert and sitting up in bed. Resident 21 had a right below the knee amputation. On 9/18/19 at 3:05 P.M., Resident 21 was interviewed. Resident 21 said, I had my right leg amputated last year. I came to this facility for rehab. I requested a prescription for a prosthetic leg three months ago and have not heard anything about it. On 9/19/19 at 10:05 A.M., the DOR was interviewed. The DOR said, The resident started rehab on 5/2/19. He completed physical therapy and occupational therapy. His goals were to improve strength, balance, transfers and ADLs. He did not tolerate walking with a walker. He was weak and tired easily. The prosthetic was never brought up. On 9/19/19 at 3:30 P.M., the SSD said she had not heard anything about Resident 21 wanting a prosthetic leg. On 9/19/19 at 3:35 P.M., the Case Manager was interviewed. The Case Manager said, I'm responsible for ordering the DMEs like prosthetics but had not heard anything about (Resident 21's name) wanting a prosthetic. Record review of the Occupational Therapy Evaluation & Plan of Treatment, dated 5/2/19, indicated, Patient Goals: To be able to walk (with prosthetic) and to return to PLOF (Prior Level of Function). Potential for Achieving Goals: Patient demonstrates good rehab potential as evidenced by motivation to return to PLOF. Record review of physicians orders, dated 5/27/19, indicated, R (right) lower extremity Prosthesis (RBKA [right below the knee amputation]). On 9/19/19 at 4:50 P.M., CCC said, I remember receiving the order during a time when we were transitioning to a new clerk. The order was given to her to process, it must have been missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/17/19 ay 12:57 P.M., a dining observation was conducted in the restorative dining room. CNA 27 touched her hair, picked a residents hat up off the floor and placed it back on the resident's head. CNA 27 did not sanitize her hands. CNA 27 removed the paper from a resident's straw, touched the bottom half of the straw and placed it in the resident's drink then proceeded to feed the resident. On 9/17/19 at 12:57 P.M., a observation of CNA 28 was conducted in the dining room. CNA 28 carried a folding chair into the dinning room, opened it and sat down, she did not sanitize her hands. CNA 28 proceeded to remove the paper from a resident's straw, touched the bottom half of the straw and placed it in the resident's drink. On 9/17/19 at 2:42 P.M., an interview was conducted with CNA 27. CNA 27 stated she should have washed her hands after touching her hair, picking the hat up off the floor and putting it back on the residents head because of the possibility of spreading infection, and she did not. CNA 27 also stated she handled the straw incorrectly. On 9/17/19 at 2:54 P.M., an interview was conducted with CNA 28. CNA 28 stated she should have disinfected her hands after carrying the chair into the dining room because of the possibility of contamination, and she did not. CNA 28 also stated she handled the straw incorrectly. On 9/18/19 at 4:35 P.M. an interview was conducted with the RD. The RD stated her expectation regarding hand hygiene when assisting resident's in the dining room would be to wash their hands after touching a resident and/or touching their own face or hair, to prevent contamination. The RD stated when opening a straw, it was to be held at the top, the paper pulled off the bottom of the straw, placed in the drink and then the top paper removed. The RD stated the straw itself should never be touched. The RD stated this procedure would keep the straw from becoming contaminated. On 9/19/19 at 11:04 A.M., an interview was conducted with the DSD. The DSD stated, to prevent contamination, the staff should be disinfecting their hands in between serving resident trays, if they touched their hair or face or touched a resident. The DSD stated if the staff were to touch anything in the environment such as a chair or pick anything up off the floor, they should disinfect their hands prior to assisting a resident with their meal. On 9/20/19 at 9:06 A.M., an interview was conducted with the DON. The DON stated the staff should have sanitized their hands prior to assisting the residents in the dining room. The DON stated it was not appropriate for staff to touch their hair or face, touch a resident or pick something up off the floor and not sanitize their hands. The DON stated staff not sanitizing or washing their hands or handling a drinking straw inappropriately could contribute to the possibility of contamination and the spread of infection. Per the facility's policy titled, Handwashing/Hand Hygiene, dated December 2007 .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to .residents . Based on observation, interview, and record review, the facility failed to ensure visitors followed the proper procedures when visiting a resident on contact precautions (a set of procedures to minimize the transmission of infectious organisms by direct or indirect physical contact with an infected resident) for 1 of 1 residents on transmission based precautions (29). In addition, the facility failed to ensure staff performed hand hygiene when assisting residents in the dining room. These failures had the potential to spread infection to other residents. Findings: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included zoster (a virus that causes chickenpox or shingles, which is spread by touching someone who actively has the virus) without complications, per the facility's admission Record. On 9/17/19 at 9:12 A.M., during a tour of the facility, there was a sign posted outside of Resident 29's door indicating to see the nurse before entering the room along with PPE (protective gowns, gloves, and masks to protect the wearer from infection) on the door. On 9/18/19 at 12:04 P.M., an observation was conducted of Resident 29's visitor. Resident 29's visitor removed the PPE, put them in the trash, and walked out of the room without washing her hands. On 9/18/19 at 2:24 P.M., an observation was conducted of Resident 29's family member. Resident 29's family member was sitting inside Resident 29's room with only a face mask; he did not have on an isolation gown or gloves. Resident 29's family member touched and adjusted Resident 29's pillows with his bare hands. At 2:31 P.M., Resident 29's family member walked out of the room with the face mask on and without conducting hand hygiene. Resident 29's family member stated the facility did not tell him that he needed to wear an isolation gown and gloves before entering the room nor what the process was for contact precautions. On 9/18/19 at 3:21 P.M., an interview was conducted with CNA 1. CNA 1 stated the process for someone on contact precautions was to put on an isolation gown, gloves, and face mask before entering the room, conduct care, discard the PPE into the trash can inside the room, and conduct hand hygiene before leaving the room. CNA 1 stated it was not acceptable to have on only a face mask and it was not acceptable not to conduct hand hygiene before leaving the room. CNA 1 further stated it was not acceptable to walk out of the room with any part of the PPE on, including the face mask. On 9/19/19 at 11:44 A.M., a record review was conducted of Resident 29's medical records. On 9/16/19, there was a nursing order for contact isolation for shingles (an infectious virus that spreads from an infected person to another person by touch). On 9/19/19 at 2:53 P.M., an interview was conducted with the DSD. The DSD stated an isolation gown, gloves, and face mask were required before going into Resident 29's room. The DSD stated shingles were airborne precautions (an infectious disease transmitted to others through the air). On 9/19/19 at 3 P.M., a joint interview was conducted with the DSD and the ICN. The ICN stated Resident 29 was on contact precautions, which required everyone to put on an isolation gown and gloves before entering the room; a face mask was not required. The ICN stated before leaving the room, all of the PPE should be removed, discarded in the trash can inside the room, and hand hygiene performed before leaving the room. The DSD stated it was the nurses responsibility to educate visitors of the proper procedure for visiting someone who was on contact precautions, and visitors were expected to follow it. The DSD stated it was not appropriate to not put on the appropriate PPE nor was it appropriate to not conduct hand hygiene before leaving the room. On 9/20/19 at 8:55 A.M., an interview was conducted with the DON. The DON stated she expected staff to follow the correct procedure for contact isolation when taking care of Resident 29 to prevent the spread of infection. The DON stated she expected staff to put on an isolation gown and gloves before entering the room, conduct care, remove the PPE, discard the PPE in the trash can inside the resident's room, conduct hand hygiene, and then exit the resident's room. The DON stated it was not appropriate for Resident 29's guest to leave the room without conducting hand hygiene. The DON stated Resident 29's family member should not have been walking around the facility with a face mask on after leaving Resident 29's room. The DON stated it was the nursing staff's responsibility to educate all visitors on the correct procedure for contact isolation. Per the facility's policy, titled Contact Precautions, dated February 2018, Guidelines .3. PPE should be donned upon entering the room and properly discarding before exiting the resident room .6. Remove and dispose of contaminated PPE and perform hand hygiene prior . Per the facility's policy, titled Visitation, Infection Control During, revised December 2007, 2. Family members and visitors .will be trained regarding the appropriate use of infection control barriers such as personal protective equipment.