**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' clinical records were updated regarding advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one of three sampled residents (Resident 59), by failing to maintain a current copy of the resident's advance directives in Resident 59's active clinical record. This failure had the potential to cause conflict with Resident 59's wishes regarding health care services received. Findings: During a review of Resident 59's admission Record, the document indicated Resident 59 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses that included senile degeneration of the brain (a process of gradual decline of brain cells that is associated with memory loss and difficulty thinking clearly), aphasia (a condition that makes it hard for a person to speak, understand, read or write language), and personal history of transient ischemic attack (a stroke that last only a few minutes). During a review of Resident 59's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/7/2024, the MDS indicated, Resident 59's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (including decreased ability to remember things, make decisions, concentrate, or learn), and the resident was dependent on assistance of two or more helpers for eating, personal and toileting hygiene, and showering and dressing. During a concurrent interview and record review on 10/21/2024 at 2:15 PM with the Director of Social Services (SSD), Resident 59's clinical record was reviewed. The SSD stated, Resident 59's Advance Directive acknowledgement form indicated Resident 59 had an advance directive, but it was not found in Resident 59's clinical record. The SSD further stated, Resident 59's advance directive was not in their chart, and she would check the resident's medical record. During an interview on 10/22/2024 at 3:39 PM with the SSD, the SSD stated she had located Resident 59's advance directive in the overflow chart of the medical record. The SSD stated, a copy of Resident 59's advance directive should have been kept in the resident's active chart, to provide guidance to the facility staff about Resident 59's wishes. During an interview on 10/24/2024 at 1:30 PM with the Director of Nursing (DON), the DON stated a copy of Resident 59's advance directive should have been kept in the resident's active chart, to ensure Resident 59's wishes would be carried out, and to provide guidance to the facility staff about Resident 59's wishes. A review of the facility's policies and procedures (P&P) titled, Advance Directives, reviewed 10/16/2024, the P&P indicated, if the resident or resident's representative had executed an advanced directive, a copy of the document was to be obtained and maintained in the same section of the resident medical record and was readily retrievable by any facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the activation of the correct setting of a Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) for one of one sampled residents (Resident 59) requiring a LALM, when Resident 59 was investigated for pressure injury (PI - localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care. This failure had the potential to place Resident 59 at risk for discomfort and development of avoidable pressure ulcers/injuries. Findings: During a review of Resident 59's admission Record, the document indicated Resident 59 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses that included senile degeneration of the brain (a process of gradual decline of brain cells that is associated with memory loss and difficulty thinking clearly), aphasia (a condition that makes it hard for a person to speak, understand, read or write language), and personal history of transient ischemic attack (a stroke that last only a few minutes). During a review of Resident 59's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/7/2024, the MDS indicated, Resident 59's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (including decreased ability to remember things, make decisions, concentrate, or learn), and the resident was dependent on assistance of two or more helpers for eating, personal and toileting hygiene, and showering and dressing. During a review of Resident 59's care plan, dated 7/21/2024, the care plan indicated, Resident 59 was at risk for the development and worsening of unavoidable pressure injuries related to impaired mobilities. The care plan interventions indicated to use a low air loss mattress (LALM) as a pressure relieving device for Resident 59. During a review of Resident 59's Order Summary Review, the document indicated, a physician order to apply an LAL mattress for pressure injury management and prevention. The order indicated to the Charge Nurse, to check proper placement and function of the LAL mattress for Resident 59. During a concurrent observation and interview on 10/23/2024 at 9:23 AM with Treatment Nurse 1 (TN 1) in Resident 59's room, Resident 59's pressure reduction mattress was observed to be set between 150 to 180 pounds (lbs. - unit of measurement for weight). TN 1 stated, the LALM for Resident 59 was supposed to be set at the resident's weight of around 106 lbs. TN 1 stated, the use of the LALM is an intervention to promote wound healing and prevent further pressure injuries from developing. TN 1 stated, if the LALM is not set at the correct setting, then it wouldn't be effective and there was a potential for the resident to develop further pressure injuries. During an interview on 10/24/2024 at 1:30 PM with the Director of Nursing (DON), the DON stated, it was important to follow the physician's order for the correct setting of the LALM for each resident. The DON stated, if the LALM was not set at the correct setting, then it wouldn't be effective and there was a potential the resident may develop further skin injuries. During a review of the manual for the air mattress with pump, the manual indicated, the LAL mattress was designed for wound care therapy treatment and prevention. The manual further indicated to turn the pressure adjustment knob to set a comfortable pressure level by using the weight as a guide.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a locked compartment, when the Station Two Nursing Station Medication Cabinet did not have a lock, which permitted any staff or resident access. This failure had the potential for residents to take medications, which could cause harmful adverse side effects for the residents. Findings: During a concurrent observation and interview on 10/21/2024 at 4:00 p.m. with the Director of Staff Development (DSD), in the facility's medication storage area, observed Nursing Station Two right-side drug cabinet. The cabinet did not have a lock as the left-side cabinet had. The right-side cabinet contained the following: 1. Two Iron Supplement (given to one with a low level of iron in the blood) Liquid 16 fluid ounce (fl. oz., a unit of measure for liquids) bottles. 2. Two Bismuth subsalicylate (commonly known as Pepto Bismol, given for treating diarrhea and upset stomach) 16 fl. oz. bottles. 3. One Liquid Multi-Vitamin 16 fl. oz. bottle. 4. Three Liquid Acetaminophen (also known as Tylenol, given for pain relief but taken in excess can yield liver damage) 16 fl. oz. bottles. 5. Two Liquid Vitamin C Supplement 16 fl. oz. bottles. 6. Two Constulose (also known as Lactulose, a medication to treat constipation and reduce ammonia [a waste product] levels in the blood) 10 grams in 15 milliliters (gm/mL, a unit of measure for liquids) bottles. 7. One Milk of Magnesia (medication to treat constipation and upset stomach) 16 fl. oz. bottle. The DSD stated, the medication storage should not be left unlocked, because residents should be kept safe from taking the medication. During an interview on 10/22/2024 at 1:41 p.m. with the Director of Nurses (DON), the DON stated she was unaware that the Station Two medication cabinet lock was broken. The DON further stated, it was important for medications to be kept in a locked cabinet, so residents do not gain access to them. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, last reviewed 10/16/2024, the P&P indicated, drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls. The P&P further indicated, only persons authorized to prepare and administer medications had access to locked medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dignity and respect for two out of two sampled residents (Resident 18 and 49) when: 1. Restorative Nursing Assistant 1 (RNA 1, a staff who is trained in activities to help residents with limited mobility and abilities) was observed standing over Resident 49 while assisting Resident 49 with eating. 2. Certified Nursing Assistant 3 (CNA 3, a staff who is trained in providing basic, hands-on patient care) was observed standing over Resident 18 while assisting Resident 18 with eating. These failures had the potential to negatively affect Resident 49's and Resident 18's self-esteem and self-worth during mealtimes in the facility. Findings: 1. During a review of Resident 49's admission record indicated the facility admitted the resident on 2/28/2024, including a readmission on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 49's Minimum Data (MDS - a federally mandated resident assessment tool), dated 10/06/2024, the document indicated, Resident 49 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 49 required supervision (helper provides verbal cues, and/or touching assistance as resident completes activity; assistance may be provided throughout the activity or intermittently [irregular intervals, not continuously]). During a review of Resident 49's Care Plan for Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), initiated 2/28/2024, the document indicated a goal for the resident that included, the resident will be well groomed and dressed appropriately daily. The care plan further indicated, Resident 49 required limited assistance with eating, and included an intervention to encourage participation with activities. During a concurrent observation and interview on 10/22/2024 at 7:31 a.m., observed Resident 49 sitting in a wheelchair with a breakfast tray on a bedside table with Restorative Nursing Assistant 1 (RNA 1) standing over the resident while feeding her. There was no chair located in the hallway, and there were approximately six other residents also in the hallway eating breakfast. RNA 1 stated, she knew she should have been sitting while assisting Resident 49 with eating but was unable to because a chair in the hallway would block the hallway. RNA 1 further stated, she needed to watch the other residents in the hallway while they were eating. During an interview on 10/22/2024 at 7:39 a.m. with RNA 1, RNA 1 stated she could have used help, but the residents' trays came, and she was unable to leave to go to Nurse Station One to seek assistance. During an interview on 10/22/2024 at 7:45 a.m. with Treatment Nurse 1 (TN 1), TN 1 stated staff should be seated while assisting a resident with eating. During a review of the facility's policies and procedures (P&P) titled, Assistance with Meals, reviewed on 10/16/2024, the P&P indicated, residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example, not standing over residents while assisting them with meals. 2. During a review of Resident 18's admission Record indicated the facility admitted Resident 18 on 5/12/2019, including a readmission on [DATE], with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), urinary tract infection (UTI - an infection in the bladder/urinary tract), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 18's History and Physical (H&P), dated 8/26/2024, the H&P indicated, Resident 18 did not have the mental capacity to understand and make decisions. During a review of Resident 18's MDS dated 8/27/2024, the MDS indicated, Resident 18 had moderately impaired cognition (decreased mental abilities, including remembering things, making decisions, concentrating, or learning) and required moderate to maximal assistance with toileting and personal hygiene, dressing, and showering. The MDS further indicated, Resident 18 required supervision or touching assistance with eating. During a review of Resident 18's Care Plan for Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), initiated 6/24/2024, the document indicated a goal that Resident 18 will be well groomed and dressed appropriately daily. The care plan further indicated Resident 18 required limited assistance with meals as needed. During a concurrent observation and interview on 10/22/2024 at 12:55 p.m. with Certified Nursing Assistant 3 (CNA 3) in Resident 18's room, Resident 18 was observed to be seated in High Fowler's position (a patient positioning where resident is seated up-right on their back with their upper body at 60 -90-degree angle to their lower body) in the bed. CNA 3 was observed to be standing while feeding lunch to Resident 18, and Resident 18 was observed to be extending her neck to look up at CNA 3 during the feeding. CNA 3 stated, she should be seated during the feeding of residents, but she did not seat herself because she was trying to feed Resident 18 fast. During an interview on 10/22/2024 at 12:56 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, CNAs should feed the residents while in a sitting position. During an interview on 10/22/2024 at 2:11 p.m. with the Director of Nurses (DON), the DON stated, staff should be seated at eye level when assisting residents with eating. The DON further stated, this was important to ensure residents were chewing well, not experiencing aspiration (inhaling food into the lungs), and to ensure residents did not feel rushed while eating. During a review of the facility's policies and procedures (P&P) titled, Assistance with Meals, reviewed on 10/16/2024, the P&P indicated, residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example, not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within accessible reach of the resident from for two of two sampled residents (Resident 23 and Resident 59) in the facility. This failure had the potential for residents in the facility to be unable to summon facility staff for help, as needed, which could have resulted in resident discomfort and/or harm due to the residents' inability to reliably call facility staff for help. Findings: 1. During a review of Resident 23's admission Record, the document indicated the facility admitted Resident 23 on 5/24/2022, including a readmission on [DATE], with diagnoses that included spinal stenosis (a narrowing of one or more spaces within your spinal canal), displaced fracture of left femur (fracture requiring realignment [putting back into its normal position] of the bone), and aphasia (a condition that makes it hard for a person to speak, understand, read, or write language). During a review of Resident 23's History and Physical (H&P), dated 9/2/2024, the H&P indicated, Resident 23 did not have the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/22/2023, the document indicated, Resident 23's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (including decreased ability to remember things, make decisions, concentrate, or learn). The MDS further indicated, Resident 23 required moderate assistance on bed mobility, dressing, toilet hygiene, shower and dressing and supervision on personal and oral hygiene. During a concurrent observation and interview on 10/21/2023 at 9:28 AM with Restorative Nursing Assistant 2 (RNA 2) in Resident 23's room, the call light button of Resident 23 was observed looped over the upper side of the wall light. RNA 2 stated, the call light for Resident 23 should not have been placed over the wall light, and it should have been clipped to the pillow instead, to facilitate ease in the use of the call light for Resident 23. RNA 2 further stated, the call light being out of reach for Resident 23 had the potential for the resident to be unable to ask for help when needed and Resident 23 could fall. 2. During a review of Resident 59's admission Record, the document indicated the facility admitted Resident 59 to the facility on 2/28/2023, including a readmission of the resident on 10/13/2023, with diagnoses that included senile degeneration of the brain (a process of gradual decline of brain cells that is associated with memory loss and difficulty thinking clearly), aphasia (a condition that makes it hard for a person to speak, understand, read or write language), and personal history of transient ischemic attack (a stroke that last only a few minutes). During a review of Resident 59's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/7/2024, the document indicated, the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (including decreased ability to remember things, make decisions, concentrate, or learn), and Resident 59 was dependent on assistance of two or more helpers for eating, personal and toileting hygiene, and showering and dressing. During a concurrent observation and interview on 10/21/2023 at 9:40 AM with Restorative Nurse Assistant 2 (RNA 2) in Resident 59's room, the adaptive call light button of Resident 59 was noticed to be located behind the resident's head of the bed, in the upper-right side railing. RNA 2 stated, the call light of Resident 59 should not have been curled on the upper-right side railing of the resident's bed, and it should have been clipped to the resident's pillow instead, to facilitate ease in the use of the call light for Resident 59. RNA 2 further stated, the call light being out of reach for Resident 59 had the potential for the resident to be unable to ask for help when needed and Resident 59 could fall. During an interview on 10/24/2023 at 1:30 PM with the Director of Nursing (DON), the DON stated the call light should always be within reach for the resident when making rounds, untangled when needed, and clipped to the pillow to make sure it was available for the resident. The DON stated, if the resident needed something, the resident could not get help without the call light within reach. The DON further stated, the resident could also fall if the resident tried to reach the call light out of their reach. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, last reviewed on 10/16/2024, the P&P indicated, residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions prior to administering an as needed (prn) opioid medication on multiple days for two of two sampled residents (Resident 36 and Resident 61). These failures had the potential to result in Resident 36 and Resident 61 receiving unnecessary pain medications. Findings: 1. During a review of Resident 36's Face Sheet (admission record), the document indicated Resident 36 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included pelvic fracture. During a review of Resident 36's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/26/2024, the MDS indicated Resident 36 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 36 required moderate assistance (helper does less than half the effort) with eating, dressing, and personal hygiene. During a review of Resident 36's Physician's Orders, printed on 10/23/2024, the document indicated an order for tramadol (pain medication) 50 milligrams (mg, a unit of measure), give one tablet by mouth every 12 hours as needed for moderate pain (4 - 6 level pain on a pain scale [0 - 10] with zero being no pain and 10 being the most excruciating pain), dated 8/21/2024. The physician's orders did not indicate an order for non-pharmacological interventions prior to giving pain medication. During a review of Resident 36's Pain Care Plan, initiated 1/12/2024, the document indicated Resident 36 suffered a pelvic fracture. The care plan indicated a goal that Resident 36 will remain comfortable daily for three months. The care plan indicated an intervention to medicate with pain medication as ordered. The care plan did not indicate non-pharmacological interventions. A review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed on 10/16/2024, the P&P indicated the resident should be assessed for pain and non-pharmacological interventions should be attempted prior to giving pain medications. 2. During a review of Resident 61's Face Sheet, the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included unspecified fall and dementia (a progressive state of decline in mental abilities). During a review of Resident 61' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated Resident 61 was moderately impaired in cognition with skills required for daily decision making. The MDS further indicated Resident 61 required supervision with personal hygiene and dressing. During a review of Resident 61's Physician's Orders, printed on 10/23/2024, the document indicated an order for tramadol 50 mg, give one tablet by mouth every eight hours as needed for moderate to severe pain (4-10/10), dated 8/30/2024. The physician's orders did not indicate an order for non-pharmacological interventions prior to giving pain medication. During a review of Resident 61's Pain Care Plan, initiated 6/16/2024, the document indicated a goal that the resident will not have an interruption in normal activities due to pain through the review date. The care plan indicated an intervention to anticipate Resident 61's need for pain relief and respond immediately to any complaint of pain. The care plan did not indicate non-pharmacological interventions. During a concurrent interview and record review on 10/23/2024 with the Director of Nurses (DON), reviewed Resident 36's and Resident 61's October 2024 Medication Administration Record (MAR), physician's orders and care plans. The DON verified that there were not any non-pharmacological interventions prior to giving pain medication for the residents. The DON stated, there should always be a non-pharmacological intervention attempted prior to giving pain medication. The DON stated it was important to do this to decrease the chance of giving an unnecessary medication. A review of the facility's policy and procedure (P&P) titled, Pain Management, last reviewed on 10/16/2024, the P&P indicated the resident should be assessed for pain and non-pharmacological interventions should be attempted prior to giving pain medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of eight sampled residents were free from medication error by failing to ensure the Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR - a report detailing the drugs administered to a patient by the licensed nurses) for two (Resident 36 & Resident 61) of four residents sampled during the medication storage observation. These failures had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug) in the facility. Findings: 1. During a review of Resident 36's Face Sheet (admission record), the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included pelvic fracture. During a review of Resident 36's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/26/2024, the document indicated Resident 36 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS further indicated Resident 36 required moderate assistance (helper does less than half the effort) with eating, dressing, and personal hygiene. During a review of Resident 36's Physician's Orders, the document indicated an order for tramadol (pain medication) 50 milligrams (mg, a unit of measure), give one tablet by mouth every 12 hours as needed for moderate pain (4 - 6 level pain on a pain scale [0 - 10] with zero being no pain and 10 being the most excruciating pain), dated 8/21/2024. During a review of Resident 36's Pain Care Plan, initiated 1/12/2024, the document indicated Resident 36 suffered a pelvic fracture. The care plan indicated a goal that Resident 36 would remain comfortable daily for three months. The care plan indicated an intervention to medicate with pain medication as ordered. A review of Resident 36's Controlled Drug Record indicated the medication Tramadol was removed from the bubble pack on 10/7/2024, 10/15/2024, and 10/20/2024, but there was no corresponding entry in Resident 36's October 2024 MAR. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, last reviewed 10/16/2024, the P&P indicated controlled substances were reconciled not only upon receipt, disposition, and at the end of each shift, but also upon administration. During a review of the facility's P&P titled, Administering Medications, last reviewed 10/16/2024, the P&P indicated the individual administering the medication records the administration in the resident's medical record, with the date and time the medication was administered. 2. During a review of Resident 61's Face Sheet, the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included unspecified fall and dementia (a progressive state of decline in mental abilities). During a review of Resident 61' s (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the document indicated Resident 61 was moderately impaired in cognition with skills required for daily decision making. The MDS further indicated Resident 61 required supervision with personal hygiene and dressing. During a review of Resident 61's Physician's Orders, the document indicated an order for tramadol 50 mg, give one tablet by mouth every eight hours as needed for moderate to severe pain (4-10/10), dated 8/30/2024. During a review of Resident 61's Pain Care Plan, initiated 6/16/2024, the document indicated a goal that the resident would not have an interruption in normal activities due to pain through the review date. The care plan indicated an intervention to anticipate Resident 61's need for pain relief and respond immediately to any complaint of pain. During a review of Resident 61's Controlled Drug Record, the document indicated the medication Ultram (also known as Tramadol, a pain medication) was removed from the bubble pack on 10/9/2024 and 10/15/2024, but there was no corresponding entry in Resident 61's October 2024 MAR. During a concurrent observation, interview, and record review on 10/21/2024 at 3:46 p.m. with Licensed Vocational Nurse 2 (LVN 2), the Skilled Nursing Facility Medication Cart 2 was observed. Resident 36's and Resident 61's October 2024 MARs were also reviewed with LVN 2. LVN 2 verified that there were no entries for Resident 36 and Resident 61's October 2024 MARs for the dates signed by the licensed nurse on Resident 36 and Resident 61's Controlled Drug Records. LVN 2 stated, the process when giving a controlled medication was to remove the medication from the medication cart, sign the controlled drug record, give the medication, and then sign the MAR for the respective resident. LVN 2 stated, the licensed nurse who administered the medication on the other dates and times should have signed both the MAR and the controlled drug record. LVN 2 further stated, this was important to have an accurate accounting for controlled medications in the facility. During a concurrent interview and record review on 10/22/2024 at 1:41 p.m. with the Director of Nurses (DON), reviewed Resident 36 and Resident 61's October 2024 MARs and controlled drug sheets. The DON verified that there was a discrepancy between the records for these residents. The DON stated, the process was that when a controlled drug was removed from the bubble pack, the licensed nurse was to sign the controlled drug record, give the medication to the resident, and then sign the MAR for the respective resident. The DON stated it was important to do this to decrease the chance of a medication error. The DON stated, these residents would be at risk of receiving a medication twice, since a second nurse may not have seen that it was given, since it was not signed on the MAR. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, last reviewed 10/16/2024, the P&P indicated controlled substances were reconciled not only upon receipt, disposition, and at the end of each shift, but also upon administration. During a review of the facility's P&P titled, Administering Medications, last reviewed 10/16/2024, the P&P indicated the individual administering the medication records the administration in the resident's medical record, with the date and time the medication was administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the implementation of the Medication Regimen Review (MRR - a pharmacist's thorough evaluation of a resident's medication routine and recommendations) for two of three residents (Resident 49 and Resident 63). This failure could have resulted in preventable medication side effects, including up to bleeding, blood clotting, or seizures for Resident 49 and Resident 63. Findings: 1. During a review of Resident 49's admission Record, dated 11/24/2024, the document indicated Resident 49 was admitted on [DATE] with diagnoses that included hydrocephalus (an abnormal buildup of cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord] deep within the brain), presence of cerebrospinal drainage device (shunt - a passage, such as a tube that is made to allow blood or other fluid to move from one part of the body to another), dysphagia (swallowing difficulties), history of falling, and dementia (the loss of remembering and reasoning to the extent that it effects their everyday activities). During a review of Resident 49's History and Physical (H&P), the H&P indicated Resident 49 had a history of a subdermal hematoma (a collection of blood between the covering of the brain [dura] and the surface of the brain) and did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/6/2024, the document indicated Resident 49 needed assistance from facility staff for toileting, showering, hygiene, and dressing. During a review of Resident 49's Order Summary Report, printed on 10/24/2024, the document indicated Resident 49's medical doctor ordered valproic acid (medication to help prevent seizures [a sudden, uncontrolled burst of electrical activity in the brain]) 250 milligrams (mg - unit if measurement) three times a day and heparin (a medication that prevents or breaks up blood clots) 5000 unit/ml - inject 1ml every eight hours to prevent deep vein thrombosis (DVT - a blood clot that forms in the deep veins) on 4/15/2024. During a review of Resident 49's Medication Regimen Review (MRR - recommendations the pharmacists make for each resident monthly that is given by staff to resident's doctors to view, deny and or makes changes to prescribed medications), dated 5/3/2024, the MRR indicated there was a recommendation for valproic acid level and partial thromboplastin time (PTT - the time it takes for a patient's blood to form a clot; measured in seconds), but did not indicate the recommendation was sent to the physician. During a concurrent interview and record review on 10/24/2024 at 1:30 p.m. with the Director of Nursing (DON), the DON reviewed Resident 49's MRR, dated 5/3/2024, and stated it was her responsibility to notify the physician of the MRR recommendations every month after the consulting pharmacist made their recommendations. The DON further stated, the orders to draw blood to check the valproic acid and heparin levels were missed and were not done since before the resident moved into the facility. The DON further explained, the heparin levels needed to be checked to ensure the resident was safe from bleeding and blood clots and valproic acid to prevent seizures. The DON further stated, the resident was at risk for bleeding, blood clots, and seizures without the MRR being followed up by the physician. A review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, revised 10/16/24, the P&P indicated, a consultant pharmacist was to review the drug regimen of each facility's residents monthly. The P&P further indicated, it was the facility's responsibility to follow-up on each pharmacist's recommendation by providing it to the appropriate primary physician, and the DON was responsible for ensuring proper follow-through. A review of the facility's P&P titled, Physician's Services, revised 10/16/24, the P&P indicated, the attending physician would determine the relevance of any recommended interventions from other disciplines. 2. During a review of Resident 63's admission Record, dated 10/24/2024, the document indicated Resident 63 was admitted on [DATE] with diagnoses that included nontraumatic (not caused by trauma) subdural hematoma, history of falling, and unspecified dementia. During a review of Resident 63's History and Physical (H&P), the H&P indicated Resident 63 did not have the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/9/2024, the document indicated Resident 63 needed assistance from facility staff for toileting, showering, hygiene, and dressing. During a review of Resident 63's Order Summary Report, printed on 10/24/2024, the document indicated Resident 63's medical doctor ordered heparin 5000 unit/ml - inject 1ml every eight hours to prevent to prevent DVT on 7/2/2024. During a review of Resident 63's MRR, dated 7/5/2024, the MRR indicated a recommendation for PTT blood draw, but the MRR did not indicate the recommendation was sent to the physician. During a concurrent interview and record review on 10/24/2024 at 1:35 p.m. with the Director of Nursing (DON), the DON reviewed Resident 63's MRR, dated 7/5/2024, and stated it was her responsibility to notify the physician of the MRR recommendations every month after the consulting pharmacist made their recommendations. The DON further stated, the order to draw blood to check the heparin level was missed and was not done since before the resident moved into the facility. The DON further explained, the heparin levels needed to be checked to ensure the resident was safe from bleeding and blood clots. The DON further stated the resident was at risk for bleeding without the MRR being followed up by the physician. A review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, revised 10/16/24, the P&P indicated, a consultant pharmacist was to review the drug regimen of each facility's residents monthly. The P&P further indicated, it was the facility's responsibility to follow-up on each pharmacist's recommendation by providing it to the appropriate primary physician, and the DON was responsible for ensuring proper follow-through. A review of the facility's P&P titled, Physician's Services, revised 10/16/24, the P&P indicated, the attending physician would determine the relevance of any recommended interventions from other disciplines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs, by failing to adequately monitor valproic acid and heparin for two of three residents (Resident 49 and Resident 63). This failure could have resulted in medication side effects leading up to bleeding, blood clotting, or seizures for Resident 49 and Resident 63. Findings: 1. During a review of Resident 49's admission Record, dated 11/24/2024, the document indicated Resident 49 was admitted on [DATE] with diagnoses that included hydrocephalus (an abnormal buildup of cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord] deep within the brain), presence of cerebrospinal drainage device (shunt - a passage, such as a tube that is made to allow blood or other fluid to move from one part of the body to another), dysphagia (swallowing difficulties), history of falling, and dementia (the loss of remembering and reasoning to the extent that it effects their everyday activities). During a review of Resident 49's History and Physical (H&P), the H&P indicated Resident 49 had a history of a subdermal hematoma (a collection of blood between the covering of the brain [dura] and the surface of the brain) and did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/6/2024, the document indicated Resident 49 needed assistance from facility staff for toileting, showering, hygiene, and dressing. During a review of Resident 49's Order Summary Report, printed on 10/24/2024, the document indicated Resident 49's medical doctor ordered valproic acid (medication to help prevent seizures [a sudden, uncontrolled burst of electrical activity in the brain]) 250 milligrams (mg - unit if measurement) three times a day and heparin (a medication that prevents or breaks up blood clots) 5000 unit/ml - inject 1ml every eight hours to prevent deep vein thrombosis (DVT - a blood clot that forms in the deep veins) on 4/15/2024. During a review of Resident 49's Medication Regimen Review (MRR - recommendations the pharmacists make for each resident monthly that is given by staff to resident's doctors to view, deny and or makes changes to prescribed medications), dated 5/3/2024, the MRR indicated a recommendation for valproic acid level and partial thromboplastin time (PTT - the time it takes for a patient's blood to form a clot; measured in seconds), but did not indicate the recommendation was sent to the physician. During a concurrent interview and record review on 10/24/2024 at 1:30 p.m. with the Director of Nursing (DON), the DON reviewed Resident 49's MRR, dated 5/3/2024, and stated it was her responsibility to notify the physician of the MRR recommendations every month after the consulting pharmacist made their recommendations. The DON further stated, the orders to draw blood to check the valproic acid and heparin levels were missed and not done since before the resident moved into the facility. The DON further explained the heparin levels needed to be checked to ensure the resident was safe from bleeding and blood clots, and valproic acid to prevent seizures, and without the levels, her licensed nurses wouldn't know if the medication was safe to give to the resident. The DON further stated, the resident was at risk for bleeding, blood clots, and seizures without the MRR being followed up by the physician. During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, revised 10/16/24, the P&P indicated a consultant pharmacist was to review the drug regimen of each facility's residents monthly. The P&P further indicated, it was the facility's responsibility to follow-up on each pharmacist's recommendation by providing it to the appropriate primary physician, and the DON was responsible for ensuring proper follow-through. During a review of the facility's P&P titled, Physician's Services, revised 10/16/24, the P&P indicated the attending physician would determine the relevance of any recommended interventions from other disciplines. During a review of the facility's P&P titled, Anticoagulation, revised 10/16/24, the P&P indicated the physician must assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to the drug through recent labs and monitoring. The P&P also indicated the physician should collaborate with the consultant pharmacist and nursing staff. During a review of the facility's P&P titled, Seizures and Epilepsy - Clinical Protocol, revised 10/16/24, the P&P indicated the physician must assess for evidence through lab work if the antiplatelet medication was subtherapeutic or greater than therapeutic drug level. 2. During a review of Resident 63's admission Record, dated 10/24/2024, the document indicated Resident 63 was admitted on [DATE] with diagnoses that included nontraumatic (not caused by trauma) subdural hematoma, history of falling, and unspecified dementia. During a review of Resident 63's History and Physical (H&P), the H&P indicated Resident 63 did not have the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/9/2024, the document indicated Resident 63 needed assistance from facility staff for toileting, showering, hygiene, and dressing. During a review of Resident 63's Order Summary Report, printed on 10/24/2024, the document indicated Resident 63's medical doctor ordered heparin 5000 unit/ml - inject 1ml every eight hours to prevent to prevent DVT on 7/2/2024. During a review of Resident 63's MRR, dated 7/5/2024, the MRR indicated a recommendation for PTT blood draw, but the MRR did not indicate the recommendation was sent to the physician. During a concurrent interview and record review on 10/24/2024 at 1:35 p.m. with the Director of Nursing (DON), the DON reviewed Resident 63's MRR, dated 7/5/2024, and stated it was her responsibility to notify the physician of the MRR recommendations every month after the consulting pharmacist made their recommendations. The DON further stated, the order to draw blood to check the heparin level was missed and not done since before the resident moved into the facility. The DON further explained the heparin levels needed to be checked to ensure the resident was safe from bleeding and blood clots, and without the levels, her licensed nurses wouldn't know if the medication was safe to give to the residents. The DON further stated the resident was at risk of bleeding without the MRR being followed up by the physician. During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, revised 10/16/24, the P&P indicated a consultant pharmacist was to review the drug regimen of each facility's residents monthly. The P&P further indicated, it was the facility's responsibility to follow-up on each pharmacist's recommendation by providing it to the appropriate primary physician, and the DON was responsible for ensuring proper follow-through. During a review of the facility's P&P titled, Physician's Services, revised 10/16/24, the P&P indicated the attending physician would determine the relevance of any recommended interventions from other disciplines. During a review of the facility's P&P titled, Anticoagulation, revised 10/16/24, the P&P indicated the physician must assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to the drug through recent labs and monitoring. The P&P also indicated the physician should collaborate with the consultant pharmacist and nursing staff. During a review of the facility's P&P titled, Seizures and Epilepsy - Clinical Protocol, revised 10/16/24, the P&P indicated the physician must assess for evidence through lab work if the antiplatelet medication was subtherapeutic or greater than therapeutic drug level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors, when the facility continued to give medications without checking the therapeutic levels for two of three sampled residents (Residents 49 and Resident 63). This failure had the potential to result in bleeding, blood clots, or seizures for Resident 49 and Resident 63. Findings: 1. During a review of Resident 49's admission Record, dated 11/24/2024, the document indicated Resident 49 was admitted on [DATE] with diagnoses that included hydrocephalus (an abnormal buildup of cerebrospinal fluid [CSF- a clear, colorless, watery fluid that flows in and around your brain and spinal cord] deep within the brain), presence of cerebrospinal drainage device (shunt - a passage, such as a tube that is made to allow blood or other fluid to move from one part of the body to another), dysphagia (swallowing difficulties), history of falling, and dementia (the loss of remembering and reasoning to the extent that it effects their everyday activities). During a review of Resident 49's History and Physical (H&P), the H&P indicated Resident 49 had a history of a subdermal hematoma (a collection of blood between the covering of the brain [dura] and the surface of the brain) and did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/6/2024, the documentation indicated Resident 49 needed assistance from facility staff for toileting, showering, hygiene, and dressing. During a review of Resident 49's Order Summary Report, printed on 10/24/2024, the documentation indicated Resident 49's medical doctor ordered valproic acid (medication to help prevent seizures [a sudden, uncontrolled burst of electrical activity in the brain]) 250 milligrams (mg - unit of measurement) three times a day and heparin (a medication that prevents or breaks up blood clots) 5000 unit/ml - inject 1ml every eight hours to prevent deep vein thrombosis (DVT - a blood clot that forms in the deep veins) on 4/15/2024. During a review of Resident 49's Medication Regimen Review (MRR - recommendations the pharmacists make for each resident monthly that is given by staff to resident's doctors to view, deny and or makes changes to prescribed medications), dated 5/3/2024, the MRR indicated a recommendation for valproic acid level and partial thromboplastin time (PTT - the time it takes for a patient's blood to form a clot; measured in seconds), but did not indicate the recommendation was sent to the physician. During a concurrent interview and record review on 10/24/2024 at 1:30 p.m. with the Director of Nursing (DON), the DON reviewed Resident 49's MRR, dated 5/3/2024, and stated it was her responsibility to notify the physician of the MRR recommendations every month after the consulting pharmacist made their recommendations. The DON further stated, the orders to draw blood to check the valproic acid and heparin levels were missed and not done since before the resident moved into the facility. The DON further explained the heparin levels needed to be checked to ensure the resident was safe from bleeding and blood clots, and valproic acid to prevent seizures. The DON further stated, the resident was at risk for bleeding, blood clotting, and seizures without the MRR being followed up by the physician. During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, revised 10/16/24, the P&P indicated a consultant pharmacist was to review the drug regimen of each facility's residents monthly. The P&P further indicated it was the facility's responsibility to follow-up on each pharmacist's recommendation by providing it to the appropriate primary physician, and the DON was responsible for ensuring proper follow-through. During a review of the facility's P&P titled, Physician's Services, revised 10/16/24, the P&P indicated the attending physician would determine the relevance of any recommended interventions from other disciplines. During a review of the facility's P&P titled, Anticoagulation, revised 10/16/24, the P&P indicated the physician must assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to the drug through recent labs and monitoring. The P&P also indicated the physician should collaborate with the consultant pharmacist and nursing staff. During a review of the facility's P&P titled, Seizures and Epilepsy - Clinical Protocol, revised 10/16/24, the P&P indicated the physician must assess for evidence through lab work, if the antiplatelet medication was subtherapeutic or greater than therapeutic drug level. 2. During a review of Resident 63's admission Record, dated 10/24/2024, the documentation indicated Resident 63 was admitted on [DATE] with diagnoses that included, nontraumatic (not caused by trauma) subdural hematoma, history of falling, and unspecified dementia. During a review of Resident 63's History and Physical (H&P), the H&P indicated Resident 63 did not have the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/9/2024, the document indicated Resident 63 needed assistance from facility staff for toileting, showering, hygiene, and dressing. During a review of Resident 63's Order Summary Report, printed on 10/24/2024, the documentation indicated Resident 63's medical doctor ordered heparin 5000 unit/ml - inject 1ml every eight hours to prevent to prevent DVT on 7/2/2024. During a review of Resident 63's MRR, dated 7/5/2024, the MRR indicated a recommendation for PTT blood draw, but the MRR did not indicate the recommendation was sent to the physician. During a concurrent interview and record review on 10/24/2024 at 1:35 p.m. with the Director of Nursing (DON), the DON reviewed Resident 63's MRR, dated 7/5/2024, and stated it was her responsibility to notify the physician of the MRR recommendations every month after the consulting pharmacist made their recommendations. The DON further stated, the order to draw blood to check the heparin level was missed and not done since before the resident moved into the facility. The DON further explained the heparin levels needed to be checked to ensure the resident was safe from bleeding and blood clots, and it was considered a medication error without verifying how much medication the resident needed based on the lab work. The DON further stated the resident was at risk for bleeding without the MRR being followed up by the physician. During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, revised 10/16/24, the P&P indicated a consultant pharmacist was to review the drug regimen of each facility's residents monthly. The P&P further indicated it was the facility's responsibility to follow-up on each pharmacist's recommendation by providing it to the appropriate primary physician, and the DON was responsible for ensuring proper follow-through. During a review of the facility's P&P titled, Physician's Services, revised 10/16/24, the P&P indicated the attending physician would determine the relevance of any recommended interventions from other disciplines. During a review of the facility's P&P titled, Anticoagulation, revised 10/16/24, the P&P indicated the physician must assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to the drug through recent labs and monitoring. The P&P also indicated the physician should collaborate with the consultant pharmacist and nursing staff. During a review of the facility's P&P titled, Seizures and Epilepsy - Clinical Protocol, revised 10/16/24, the P&P indicated the physician must assess for evidence through lab work, if the antiplatelet medication was subtherapeutic or greater than therapeutic drug level.

Based on observation, interview, and record review, the facility failed to ensure the storage of food in accordance with professional standards by not labeling stored food with a use-by date (the indicated date that the food item should be used or consumed by). These failures had the potential for 66 of 67 facility residents who receive food from the facility kitchen to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 10/21/2024 at 8:00 a.m. with the Dietary Supervisor (DS), the refrigerator was observed and the following was noted: one clear zip-lock bag of garlic, one clear plastic container of ham, and one clear plastic container of apple sauce - none of these items were labeled with a use-by date. Further observation included the dry storage room and the following was noted: seven pistachio puddings and pie fillings, six vanilla pudding and pie fillings, five lime gelatine desserts, three cherry gelatine desserts, four strawberry gelatine desserts, three orange gelatine desserts, two raspberry gelatine desserts, five paper bags of scalloped potatoes, five jars of complete Instant mashed potatoes, and six jars of seasoned applesauce - none of these items were labeled with a use-by date. The DS stated, there should have been labels with the use-by dates, and if there were not, that could have affected the residents, and the residents could have gotten sick. During an interview on 10/24/2024 at 1:30 p.m. with Director of Nursing (DON), the DON stated food should have been labeled with a use-by date and should always have a use-by date label. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, reviewed on October 16, 2024, the P&P indicated, Dry food that stored in bins will be removed from original packing, labeled and dated (use by date) . All food stored in the refrigerator will covered, labeled and dated (use by date).

Based on observation, interview, and record review, the facility failed to ensure their trash was stored in the dumpster areas while being maintained in a sanitary manner. Two of two facility garbage dumpsters in use had their lids open. These failures had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview on 10/23/2024 at 12:07 PM with the Dietary Supervisor (DS), there were two facility dumpsters observed outside of the facility that were filled with trash bags. Two dumpsters had the lids open and positioned in close proximity to the wall, making it impossible to close them. The DS stated, the dumpsters should have been closed. The DS further stated, if the dumpsters were not closed, the smell would attract flies and there could be an infection control issue, because the flies could get inside the facility and go into the resident's food. During an interview on 10/23/2024 at 12:15 PM with the Maintenance Supervisor (MS), the MS stated the dumpster lids should have been closed. The MS further stated, if the dumpster lids were not closed, that could attract insects or rodents, and become an infection control problem if the insects or rodents enter the facility. During a review of the facility's policy and procedure (P&P) titled Food-Related Garbage and Refuse Disposal, dated January 2024, the P&P indicated, Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pets . Outside dumpsters provided by garbage pickup services will kept closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the implementation of their policy titled, Enhanced Barrier Precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]]) when: 1. Licensed Vocational Nurse 2 (LVN 2) did not don (to put on) a gown while administering medication via gastrostomy (G-Tube, a tube inserted through the abdomen that delivers directly to the stomach) for one of one sampled resident (Resident 48). 2. Licensed Vocational Nurse 1 ( LVN 1) did not don a gown while administering medication through the rectum (the last part of the large intestine, where the body stores stool before it leaves through the anus [an opening at the end of the digestive system]) for one of one sampled resident (Resident 58), and Certified Nursing Assistant 1 (CNA 1) donned a gown while holding and opening Resident 58's briefs while assisting LVN 1 during the administration of medication via rectum. 3. Three sampled residents (Residents 22, 66, and 120) with other with medical devices (devices that are connected to a resident such as a G-tube or catheter) and wounds were placed on EBP without the posting of signs at the entrances into the residents' rooms and without providing personal protective equipment [PPE - equipment designed to protect the wearer from injury or the spread of illness or infection such as gloves and gowns] outside of the residents' rooms. These failures had the potential to transmit infectious microorganisms to the other residents in the facility. Findings: 1. During a review of Resident 48's admission Record, the document indicated the facility admitted Resident 48 to the facility on 9/26/2020, with diagnoses that included Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration of the tissue to less functional active form] of nerve cells in the brain), dysphasia (difficulty swallowing), and essential hypertension (high blood pressure). During a review of Resident 48's History and Physical (H&P), the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 48's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/5/2024, the documentation indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning), and the resident was dependent on assistance of two or more helpers for eating, personal and toileting hygiene, and showering and dressing. During a review of Resident 48's Physician's Order, dated 6/2/2022, the documentation indicated orders to crush all crushable medication and give them via G-Tube. During an observation on 10/22/2024 at 8:22 AM in Resident 48's room, observed Resident 48's door did not have signage that Resident 48 was on enhanced barrier precautions (EBP). During an observation on 10/22/2024 at 8:22 AM in Resident 48's room with Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed administering medication to Resident 48 via G-Tube at the resident's bedside. LVN 2 was observed wearing gloves and no gown while administering medication. During an interview on 10/22/2024 at 8:35 AM with LVN 2, LVN 2 stated, the gown should be used to prevent spreading an infection between residents, but this practice was not yet implemented in the facility. During an interview on 10/24/2024 at 11:25 AM with the Infection Prevention (IP), the IP stated, the Enhanced Barrier Precautions policy was not yet implemented in the facility. The IP stated, she was not aware that the implementation of enhanced barrier precautions was mandatory. The IP stated, enhanced precautions were not implemented for Resident 48, who had a G -tube. The IP further stated, according to the facility's policies regarding EBP, LVN 2 should have donned a gown prior to administering medication via G-Tube. During an interview on 10/24/2024 at 1:30 PM with the Director of Nursing (DON), the DON stated, Enhanced Barrier Precautions had to be initiated for residents with indwelling medical devices, like an indwelling catheter or G-tube, to prevent the spread of Multidrug Resistant Organisms (MDRO - bacteria or other microorganisms that have developed resistance to multiple types of antimicrobial agents). The DON further stated, all staff were required to use gowns and gloves when they were performing high-contact resident care activities and when providing device care or use, such as with a G-Tube or indwelling catheter. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, reviewed 10/16/2024, the P&P indicated, the facility was to implement enhanced barrier precautions for the prevention of spread of multidrug-resistant organisms. The P&P also indicated to wear gowns and gloves while performing the high contact resident care activity (activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated), including device care or use. During a review of the facility's P&P titled, Administration Medication through an Enteral Tube, reviewed 10/16/2024, the P&P indicated, The purpose of this procedure is to provide guidelines for safe administration of medication through an enteral tube . The following equipment and supplies will be necessary when performing this procedure . 13. Personal protective equipment (gown, gloves, mask as needed). 2. During a review of Resident 58's admission Record, the documentation indicated the facility admitted Resident 58 to the facility on [DATE], with a readmission on [DATE], with diagnoses that included multiple sclerosis (MS - an inherited disease that causes the progressive breakdown [degeneration of the tissue to less functional active form] of nerve cells in the brain), quadriplegia (a form of paralysis that affects all four limbs, plus the torso), and methicillin resistant staphylococcus aureus infection (MRSA - a type of bacteria that's tough to treat because it has become resistant to many common antibiotics). During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired (a slight decline in mental abilities, memory and completing complex tasks) and the resident was dependent on the assistance of two or more helpers for eating, personal and toileting hygiene, showering and dressing. During a review of Resident 58's Physician's Order, dated 9/7/2024, the documentation indicated orders for indwelling catheter (a thin, hollow tube that is inserted into the bladder [organ that stores urine] to drain urine) care every shift for Resident 58. During an observation on 10/24/2024 at 8:10 AM in Resident 58's room with Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1), observed LVN 1 administering medication to Resident 58 via rectum. LVN 1 was wearing gloves and no gown while administering the medication. CNA 1 was in Resident 58's room, positioning the resident on his left side and opening his briefs. CNA 1 was observed wearing gloves and no gown during the procedure. During an interview on 10/24/2024 at 8:11 AM with LVN 1, LVN 1 stated, a gown should be used when administering medication via rectum in residents who have an indwelling catheter, to prevent spreading an infection between residents, but this practice was not yet implemented in the facility. During an interview on 10/24/2024 at 11:25 AM with the Infection Preventionist (IP), the IP stated, the Enhanced Barrier Precautions policy was not yet implemented in the facility. The IP stated, she was not aware that the implementation of enhanced barrier precautions was mandatory. The IP stated, enhanced precautions were not implemented for Resident 58, who had an indwelling catheter. The IP further stated, according to the facility's policies regarding EBP, LVN 1 and CNA 1 should have donned gowns prior to administering medication via rectum. During an interview on 10/24/2024 at 1:30 PM with the Director of Nursing (DON), the DON stated, Enhanced Barrier Precautions had to be initiated for residents with indwelling medical devices, like an indwelling catheter or G-tube, to prevent the spread of Multidrug Resistant Organisms (MDRO - bacteria or other microorganisms that have developed resistance to multiple types of antimicrobial agents). The DON further stated, all staff were required to use gowns and gloves when they were performing high-contact resident care activities and when providing device care or use, such as with a G-Tube or indwelling catheter. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, reviewed 10/16/2024, the P&P indicated, the facility was to implement enhanced barrier precautions for the prevention of spread of multidrug-resistant organisms. The P&P also indicated to wear gowns and gloves while performing the high contact resident care activity (activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated), including device care or use. During a review of the facility's P&P titled, Administration Medication through an Enteral Tube, reviewed 10/16/2024, the P&P indicated, The purpose of this procedure is to provide guidelines for safe administration of medication through an enteral tube . The following equipment and supplies will be necessary when performing this procedure . 13. Personal protective equipment (gown, gloves, mask as needed). 3a. During a review of Resident 22's Face Sheet, the document indicated Resident 22 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes mellitus (high blood sugar). During a review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/1/2024, the document indicated Resident 22 was moderately impaired in cognition with skills required for daily decision making. The MDS further indicated, Resident 22 required supervision (helper sets up or cleans up; resident completes activity) with oral hygiene, and personal hygiene. During a review of Resident 22's Physician's Orders, the documentation indicated the following: 1. Left heel deep tissue injury (DTI - deep red or purples areas of intact skin that hides the extent of the injury beneath the skin), cleanse with normal saline (a saltwater solution), pat dry, wipe with betadine (a type of disinfectant), cover with foam dressing daily and as needed if soiled or dislodged, dated 10/22/2024. 2. Sacrococcyx (area around the tailbone) stage III pressure injury (PI - also known as a pressure ulcer, a wound over an area where the bone is close to the skin's surface that involves damage to the subcutaneous tissue [layer of tissue closest to the muscle]), cleans with normal saline, pat dry, apply medihoney (a wound care ointment that is made from honey from the Leptospermum plant [a type of shrub and small tree]), zinc oxide (a type of barrier cream to prevent rashes caused by one wearing a brief) to peri-wound (around the wound) and cover with foam dressing daily and as needed if soiled or dislodged, dated 10/22/2024. During a general observation of the facility on 10/21/2024 at 10:00 a.m., the following was observed outside of the residents' rooms: Resident 48, Resident 58, Resident 22, Resident 66, and Resident 120 did not have EBP signs posted before the rooms' entrances nor PPE containers located outside the rooms. During an observation and interview with the facility's Infection Preventionist (IP) on 10/21/2024 at 11:50 a.m., the IP stated, no resident was on any kind of contact isolation (when gloves and gown need to be worn to prevent spread of infection to other residents). When asked about EBP, the IP stated isolation gowns and gloves were used only for an active infection. Observed the rooms in the facility with the IP and confirmed there were no EBP signs or PPE containers outside any of the residents' rooms. The IP stated they would look at the Department of Health's EBP recommendations. During a concurrent interview and record review on 10/21/2024 at 2:00 p.m. with the IP, the Centers for Medicare and Medicaid Services (CMS, a federal agency that manages health coverage programs, which includes regulating skilled nursing facilities) Quality Safety & Oversight (QSO, documents to promote health and safety in skilled nursing facility) QSO-24-NH, dated 3/20/2024, was reviewed. The document indicated, residents that have wounds or indwelling medical device (such as G-Tube, nephrostomy tube, etc.) should use EBP. The IP stated, the facility would be following these guidelines for those with wounds or indwelling medical devices. During an observation on 10/22/2024 at 9:31 a.m., observed Resident 22 inside his room. Observed there was no EBP sign or PPE container outside Resident 22's room. During an interview with the IP on 10/23/2024 at 10:52 a.m., the IP stated the EBP signs were not posted yet because the facility was waiting for all the trash bins to be delivered. The IP stated the trash bins were to be placed inside the rooms for staff to dispose gown and gloves before exiting a resident's room. During a review of Resident 22's Care Plan for Impaired Skin Integrity, initiated 10/22/2024, the care plan indicated a goal that Resident 22's stage III sacrococcyx wound will be resolved within 30 days. The care plan further indicated to follow the physician's order in daily wound treatment. During a review of Resident 22's Care Plan for Enhanced Barrier Precautions, initiated 10/24/2024, the document indicated Resident 22 had an unhealed pressure ulcer wound. The care plan indicated a goal that Resident 22 would demonstrate reduced risk of MDRO transmission daily, through compliance with EBP guidelines by resident and staff for 90 days. The care plan further indicated a goal to always use gloves and gown during high-contact care activities (activities that would include dressing change). During a review of the facility's reference to QSO-24-08, effective date, 4/01/2024, the document indicated new guidance of EBP, in which EBP was indicated for residents with wounds and/or indwelling medical devices, even if the resident was not known to be infected with a MDRO. 3b. During a review of Resident 66's Face Sheet, the document indicated Resident 66 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure (a sudden and often reversable condition the kidneys are not working properly). During a review of Resident 66's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/17/2024, the document indicated the resident was cognitively intact with skills required for daily decision making. The MDS further indicated, Resident 22 required partial assistance with dressing and eating. During an observation and interview with Resident 66 on 10/21/2024 at 9:20 a.m., Resident 66 stated, she had a nephrostomy tube and showed the right-side insertion site covered with a dressing. There were no EBP signs or containers with gloves and gowns outside of Resident 66's room. During a general observation of the facility on 10/21/2024 at 10:00 a.m., the following was observed outside of the residents' rooms: Resident 48, Resident 58, Resident 22, Resident 66, and Resident 120 did not have EBP signs posted before the rooms' entrances nor PPE containers located outside the rooms. During an observation and interview with the facility's Infection Preventionist (IP) on 10/21/2024 at 11:50 a.m., the IP stated, no resident was on any kind of contact isolation (when gloves and gown need to be worn to prevent spread of infection to other residents). When asked about EBP, the IP stated isolation gowns and gloves were used only for an active infection. Observed the rooms in the facility with the IP and confirmed there were no EBP signs or PPE containers outside any of the residents' rooms. The IP stated they would look at the Department of Health's EBP recommendations. During a concurrent interview and record review on 10/21/2024 at 2:00 p.m. with the IP, the Centers for Medicare and Medicaid Services (CMS, a federal agency that manages health coverage programs, which includes regulating skilled nursing facilities) Quality Safety & Oversight (QSO, documents to promote health and safety in skilled nursing facility) QSO-24-NH, dated 3/20/2024, was reviewed. The document indicated, residents that have wounds or indwelling medical device (such as G-Tube, nephrostomy tube, etc.) should use EBP. The IP stated, the facility would be following these guidelines for those with wounds or indwelling medical devices. During an interview with the IP on 10/23/2024 at 10:52 a.m., the IP stated the EBP signs were not posted yet because the facility was waiting for all the trash bins to be delivered. The IP stated the trash bins were to be placed inside the rooms for staff to dispose gown and gloves before exiting a resident's room. During a review of Resident 66's Physician's Orders, the document indicated an order to drain the output every shift for Resident 66's right nephrostomy tube (a tube that drains urine from the kidney into a bag outside the body), dated 9/10/2024. During a review of Resident 66's Care Plan for Right Nephrostomy Tube, initiated 9/10/2024, the document indicated a goal that there would be no signs or symptoms of infection for three months. The care plan indicated an intervention to monitor for signs and symptoms of infection. During a review of the facility's reference to QSO-24-08, effective date, 4/01/2024, the document indicated new guidance of EBP, in which EBP was indicated for residents with wounds and/or indwelling medical devices, even if the resident was not known to be infected with a MDRO. 3c. During a review of Resident 120's Face Sheet, the document indicated Resident 120 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing). Resident 120 also had a gastrostomy tube (G-Tube, a plastic tube inserted into the stomach to give food and medications to for those who have trouble swallowing). During a review of Resident 120's admission Assessment, dated 10/16/2024, the document indicated the resident was unable to be oriented to the facility due to confusion. The admission Assessment further indicated, Resident 120 was dependent on staff for personal hygiene. During a review of Resident 120's Physician's Orders, the document indicated an order to cleanse the G-Tube site with normal saline, pat dry, and cover with a dry dressing for every dayshift, dated 10/17/2024. During a review of Resident 120's Care Plan for Enhanced Barrier Precautions, initiated 10/24/2024, the care plan indicated Resident 120 had a G-tube and a goal that the resident would demonstrate reduced risk of MDRO transmission daily, through compliance with EBP guidelines by resident and staff for 90 days. The care plan further indicated an intervention to always use gloves and gown during high-contact care activities. During a general observation of the facility on 10/21/2024 at 10:00 a.m., the following was observed outside of the residents' rooms: Resident 48, Resident 58, Resident 22, Resident 66, and Resident 120 did not have EBP signs posted before the rooms' entrances nor PPE containers located outside the rooms. During an observation of Resident 120's room on 10/21/2024 at 11:15 a.m., observed Resident 120 had a G-tube. Observed there was no EBP sign posted before the room's entrance and no PPE container located outside the room. During an observation and interview with the facility's Infection Preventionist (IP) on 10/21/2024 at 11:50 a.m., the IP stated, no resident was on any kind of contact isolation (when gloves and gown need to be worn to prevent spread of infection to other residents). When asked about EBP, the IP stated isolation gowns and gloves were used only for an active infection. Observed the rooms in the facility with the IP and confirmed there were no EBP signs or PPE containers outside any of the residents' rooms. The IP stated they would look at the Department of Health's EBP recommendations. During a concurrent interview and record review on 10/21/2024 at 2:00 p.m. with the IP, the Centers for Medicare and Medicaid Services (CMS, a federal agency that manages health coverage programs, which includes regulating skilled nursing facilities) Quality Safety & Oversight (QSO, documents to promote health and safety in skilled nursing facility) QSO-24-NH, dated 3/20/2024, was reviewed. The document indicated, residents that have wounds or indwelling medical device (such as G-Tube, nephrostomy tube, etc.) should use EBP. The IP stated, the facility would be following these guidelines for those with wounds or indwelling medical devices. During an interview with the IP on 10/23/2024 at 10:52 a.m., the IP stated the EBP signs were not posted yet because the facility was waiting for all the trash bins to be delivered. The IP stated the trash bins were to be placed inside the rooms for staff to dispose gown and gloves before exiting a resident's room. During a review of the facility's reference to QSO-24-08, effective date, 4/01/2024, the document indicated new guidance of EBP, in which EBP was indicated for residents with wounds and/or indwelling medical devices, even if the resident was not known to be infected with a MDRO.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) to address a diagnosis of heart failure (a condition in which the heart doesn't pump blood as well as it should) for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1 due to the absence of the comprehensive care plan. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2023 and readmitted Resident 1 on 10/28/2023. Resident 1's last re-admission was on 12/20/2023 with diagnoses that included Non-ST-Elevation Myocardial Infarction (NSTEMI- a type of heart attack that usually happens when your heart's need for oxygen can't be met), heart failure, and unstable angina (chest discomfort or pain caused by insufficient blood and oxygen flow to the heart). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 11/4/2023, indicated Resident 1 was sometimes able to be understood by others and sometimes able to understand others. The MDS further indicated that Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 1 required maximum assistance from staff with oral hygiene and personal hygiene and was dependent on staff with toileting hygiene, showering and dressing. The MDS also indicated an active diagnosis of heart failure. During an interview and concurrent record review with MDS Nurse (MDSN) on 5/21/2024 at 11:59 a.m., the MDSN reviewed Resident 1's care plans from 10/28/2023 to 1/5/2024. The MDSN stated that there was no documented evidence a comprehensive person-centered care plan was developed to address Resident 1's diagnosis of heart failure. The MDSN stated that Resident 1 should have had a care plan developed specific to heat failure within 14 days of admission. The MDSN stated that a care plan specific to heart failure is important because a care plan will guide staff what specific interventions to provide to Resident 1 when necessary. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, last revised 10/11/2023, indicated a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (admission, annual or significant change in status), and no more than 21 days after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the history and physical (H&P- is the starting point of the resident health concerns that explain why a resident sought medical attention or why a resident is now receiving medical attention) for one of three sampled residents (Resident 1) was completed by the attending physician upon Resident 1 ' s first admission to the facility on [DATE]. This deficient practice had the potential for inconsistent care coordination due to incomplete records. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2023 and readmitted Resident 1 on 10/28/2023. Resident 1 ' s last re-admission was on 12/20/2023 with diagnoses that included Non-ST-Elevation Myocardial Infarction (NSTEMI- a type of heart attack that usually happens when your heart's need for oxygen can't be met), heart failure (a condition in which the heart doesn ' t pump blood as well as it should), and unstable angina (chest discomfort or pain caused by insufficient blood and oxygen flow to the heart). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 11/4/2023, indicated Resident 1 was sometimes able to be understood by others and sometimes able to understand others. The MDS further indicated that Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 1 required maximum assistance from staff with oral hygiene and personal hygiene and was dependent on staff with toileting hygiene, showering and dressing. The MDS also indicated an active diagnosis of heart failure. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 5/21/2024 at 1:35 p.m., RN 2 reviewed Resident 1 ' s undated H&P document from the resident ' s admission on [DATE] . RN 2 stated that Resident 1 ' s H&P undated) indicated that Resident 1 was admitted from home with no other medical information. RN 2 stated that the undated and incomplete H&P was signed by Resident 1 ' s attending physician with no date documented. RN 2 stated that Resident 1 ' s undated H&P did not have Resident 1 ' s pertinent medical information. RN 2 stated that it is import for all residents to have a completed and dated H&P to ensure that the resident ' s attending physician assessed the resident ' s condition on admission or readmission. A review of the facility ' s policy and procedure titled Physician Services, reviewed date 10/11/2023, indicated the medical care of each resident is supervised by a licensed physician. Supervising the medical care of resident ' s includes (but not limited to): a. participating in the resident ' s assessment and care planning; A review of the facility ' s policy and procedure titled Charting and Documentation last revised 7/2017 indicated that all services provided to the resident, progress towards the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition, shall be documented in the resident ' s medical record.

Based on interview and record review, the facility failed to implement their facility ' s medication administration policy by failing to ensure Licensed Vocational Nurse 1 (LVN 1) signed and documented on the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for one of three sampled residents (Resident 1) when LVN 1 did not administer Plavix (a medication used to prevent stroke and blood clots) on 12/21/2023. This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2023 and readmitted Resident 1 on 10/28/2023. Resident 1 ' s last re-admission was on 12/20/2023 with diagnoses that included Non-ST-Elevation Myocardial Infarction (NSTEMI- a type of heart attack that usually happens when your heart's need for oxygen can't be met), heart failure (a condition in which the heart doesn ' t pump blood as well as it should), and unstable angina (chest discomfort or pain caused by insufficient blood and oxygen flow to the heart). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 11/4/2023, indicated Resident 1 was sometimes able to be understood by others and sometimes able to understand others. The MDS further indicated that Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 1 required maximum assistance from staff with oral hygiene and personal hygiene and was dependent on staff with toileting hygiene, showering and dressing. The MDS also indicated an active diagnosis of heart failure. A review of Resident 1 ' s order summary report indicated an order for Plavix oral tablet 75 milligrams (mg- unit of measurement) give one (1) tablet by mouth one time a day for Coronary Artery Disease (CAD- damage or disease in the heart ' s major blood vessels) with an order date of 12/20/2023. During an interview and concurrent record review with Registered Nurse 2 (RN 2) on 5/21/2024 at 2:20 p.m., reviewed Resident 1 ' s 12/2023 MAR. RN 2 further reviewed Resident 1 ' s MAR for December 2023 and stated that on 12/21/2023, LVN 1 was the assigned licensed nurse to administer Resident 1 ' s prescribed medication for the 7:00 a.m. to 3:330 p.m. shift. RN 2 stated that there was no documented evidence on Resident 1 ' s 12/2023 MAR that indicated Plavix was administered or refused by Resident 1 on 12/21/2023 at 9:00 a.m. RN 2 further stated that if the medication was administered to Resident 1, LVN 1 should have then documented LVN 1 ' s initial under the date and medication. A review of the facility ' s policy and procedure titled Administering Medications, reviewed date 10/11/2023, indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribers ' orders. The individual administering the medication initials the resident ' s MAR on the appropriate line after giving each medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary care and services in accordance with its policy and procedure for one of three sample residents (Resident 1), as evidenced by: 1. Failing to schedule an appointment for follow up care with cardiology (branch of medicine that specializes in diagnosing and treating diseases of the heart and blood vessels) within two weeks (per instructions from the General Acute Care Hospital [GACH]) after being re-admitted to the facility on [DATE] and within one week (per instructions from the GACH) after being re-admitted to the facility on [DATE]. 2. Failing to schedule an appointment for follow up care with pulmonology (branch of medicine dealing with diseases involving the respiratory tract [the organs that are involved in breathing]) within one week (per instructions from the GACH) after being re-admitted to the facility on [DATE]. 3. Failing to ensure monitoring was provided to Resident 1 after a change in condition (COC- when there is a sudden change in a resident's health) on 10/31/2023. These deficient practices have a potential to cause a negative outcome to Resident 1's physical health and well-being. Findings: A review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 10/19/2023 and readmitted Resident 1 on 10/28/2023. Resident 1's last re-admission was on 12/20/2023 with diagnoses that included Non-ST-Elevation Myocardial Infarction (NSTEMI- a type of heart attack that usually happens when your heart's need for oxygen can't be met), heart failure, and unstable angina (chest discomfort or pain caused by insufficient blood and oxygen flow to the heart). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 11/4/2023, indicated Resident 1 was sometimes able to be understood by others and sometimes able to understand others. The MDS further indicated that Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 1 required maximum assistance from staff with oral hygiene and personal hygiene and was dependent on staff with toileting hygiene, showering and dressing. The MDS also indicated an active diagnosis of heart failure. A review of Resident 1's GACH Discharge summary dated [DATE] timed at 10:47 a.m., indicated to arrange for follow up care with cardiology within 2 weeks. A review of Resident 1's GACH Discharge summary dated [DATE] timed at 4:18 p.m., indicated to arrange for follow up care with pulmonology and cardiology within 1 week. 1. During an interview and concurrent record review with the MDS Nurse (MDSN) on 5/21/2024 at 11:41 a.m., the MDSN reviewed Resident 1's GACH discharge summary records dated 10/28/2023. The MDSN stated Resident 1 had discharge instructions from the GACH to follow up with cardiology within 2 weeks. The MDSN continued to review Resident 1's nursing progress notes from 10/28/2023 to 12/12/2024. The MDS stated that she was unable to find documented evidence that a cardiology appointment was made for Resident 1. That MDSN further stated Resident 1's cardiology appointment should have been communicated with the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) to ensure Resident 1's cardiology appointment was made. When asked who is responsible for arranging appointments for the resident, the MDSN stated the Social Services Director (SSD) is in charge of making residents' appointments. During an interview with the SSD, on 5/21/2024 at 12:30 p.m., the SSD stated that nursing department is responsible in making residents' appointment. During an interview and concurrent record review with Registered Nurse 2 (RN 2) on 5/21/2024 at 1:44 p.m., RN 2 reviewed the GACH discharge summary records dated 12/20/2023. RN 2 stated Resident 1 had discharge instructions from the GACH to follow up with cardiology within one week of discharge. RN 2 continued to review Resident 1's nursing progress notes from 12/20/2023 to 1/5/2024. RN 2 stated that RN 2 was unable to find documented evidence that a cardiology appointment was made for Resident 1. RN 2 stated that RN 2 was responsible for making all follow up appointments for the residents in the facility. RN 2 stated that she did not make Resident 1's cardiology appointment because she dropped the ball. When asked what should have been done, RN 2 stated that she should have made the cardiology appointments and double checked to make sure appointments were made timely. RN 2 further stated that she should have documented in the resident's clinical record if she made the appointments. 2. During an interview and concurrent record review with RN 2 on 5/21/2024 at 1:50 p.m., RN 2 reviewed the GACH discharge summary records dated 12/20/2023. RN 2 stated Resident 1 had discharge instructions from the GACH to follow up with pulmonology within one week of discharge. RN 2 continued to review Resident 1's nursing progress notes from 12/20/2023 to 1/5/2024. RN 2 stated that she was unable to find documented evidence that a pulmonology appointment was made for Resident 1 after being discharged from the GACH. RN 2 stated that it is important for Resident 1 to receive follow up care appointments and to follow discharge instructions from the GACH to ensure resident's needs are met and to maintain resident's health and safety while in the facility. A review of the facility's policy and procedure titled admission Assessment and Follow Up: Role of the Nurse, last reviewed 10/11/2023, indicated the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident. The policy further indicated to reconcile the discharge summary from the previous institution, according to established procedures. 3. During an interview and concurrent record review with RN 2 on 5/21/2024 at 12:40 p.m., RN 2 stated that a change in a resident's condition is documented on a COC form. RN 2 further stated that after a change in a resident's condition is noted, the nursing staff must monitor the resident closely, every shift for 72 hours. RN 2 reviewed Resident 1's COC forms and stated that on 10/30/2023 at 6:00 p.m., Resident 1 was noted refusing medication and had delusional (false or unrealistic) beliefs. RN 2 continued to review Resident 1's nursing progress notes from 10/31/2023 to 11/3/2023. RN 2 stated that there was no documented evidence found that Resident 1 was monitored specifically to the change in condition noted on 10/30/2023. RN 2 stated that close monitoring after a change in condition is important so that licensed nurses will know if there is any worsening of symptoms. If there is any worsening of symptoms noted, licensed nurses can then notify the physician immediately and the proper intervention can be provided timely. A review of the facility's policy and procedure titled Change in a Resident's Condition or Status, last reviewed 10/11/2023, indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report within two (2) hours to the State Survey Agency (SSA) one incident of injury of unknown origin (injuries resulting without knowing how it happened) that occurred on 3/6/2024 for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 1/23/2024 and readmitted the resident on 3/8/2024 with diagnoses that included age-related osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by a disease rather than an injury), and unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/30/2024, indicated the resident sometimes made self-understood and sometimes had the ability to understand others. The MDS also indicated Resident 1 needed some help from staff for self-care, needs substantial/maximum assistance (helper does more than half the effort) for lying to sitting on side of bed, sit to lying, rolling to left and right, and totally dependent (helper does all of the effort) for sit to stand and bed to chair transfer. A review of Resident 1's Change on Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) form, dated 2/19/2024 at 4 p.m., indicated Resident 1 had pain in left leg/hip/knee with possible unwitnessed fall. A review of Resident 1's physician's order, dated 2/19/2024 at 5:38 p.m., indicated an order for a stat (immediately) X-radiation (x-ray- the process of taking images of the inside of the body) of Resident 1's bilateral (pertaining to, involving, or affecting two or both sides) hip, pelvis, and left knee. A review of Resident 1's Radiology Report, dated 2/19/2024 at 10:05 p.m., indicated Resident 1 had no evidence of fracture or dislocation on Resident 1's bilateral hip, pelvis, and left knee. A review of Resident 1's COC form, dated 3/6/2024 at 12 p.m., indicated Resident 1 complained of pain on the left lower extremity (leg) and hip. The COC further indicated that Resident 1 was unable to bear (supporting the weight of your body) weight on left lower extremity. A review of Resident 1's physician's order, dated 3/6/2024 at 1:43 p.m., indicated an order for x-ray of Resident 1's left hip, left femur (thigh bone), left knee, left tibia (the inner and usually larger of the two bones of the leg located between the knee and the ankle) and left fibula (outer of the two bones of the lower leg), and left foot was ordered. A review of Resident 1's Radiology Report, dated 3/6/2024 at 2:48 p.m., indicated Resident 1 had an acute (new) intertrochanteric fracture (a broken bone in the hip) of the left femur without significant displacement (when the pieces of bone have moved so much that a gap formed around the fracture when your bone broke). During an interview on 3/13/2024 at 1:07 p.m., with Registered Nurse 1 (RN 1), RN 1 stated that on 3/6/2024, the Physical Therapist (PT) reported to RN 1 that Resident 1 had immobility (state of not being able to move around) on the left extremities. RN 1 stated Resident 1 was not able to stand during physical therapy (a medical treatment used to restore functional movements, such as standing). During an interview on 3/14/2024 at 1:30 p.m., with the Director of Nursing (DON), the DON stated that Resident 1's acute intertrochanteric fracture that was identified on 3/6/2024 was considered an injury of unknown origin. The DON stated that Resident 1's injury of unknown origin was not reported to the SSA within two hours. During an interview on 3/14/2024 at 1:51 p.m., with the Administrator (ADM), the ADM stated Resident 1's acute intertrochanteric fracture that was identified on 3/6/2024 is an injury of unknown origin. The ADM stated that the facility staff needed to report Resident 1's injury of unknown origin to the ombudsman (assist residents in long-term care facilities with issues related to day-to-day care), SSA, and local law enforcement within two (2) hours. The ADM stated Resident 1's acute intertrochanteric fracture that was identified on 3/6/2024 was reported within 18 hours. The ADM stated it was an honest mistake and the facility should report immediately. A review of the facility's policy and procedure titled, Abuse Investigation and Reporting, revised 7/2017, indicated that the facility shall ensure that an alleged violation of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources . will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure licensed nurses administered the prescribed dose of Clozaril (an Antipsychotic medication [medications that are used for some types of mental distress or disorder] to treat schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves]) 200 milligrams (mg-unit of measure) to one of nine sampled residents (Resident 1) from 11/23/2023 to 1/29/2024. Resident 1 was administered a total of 31 incorrect (higher than prescribed) doses of Clozaril. The deficient practice of failing to administer medications in accordance with physician's orders placed Resident 1 at risk for serious health complications as a result of being administered a higher dose of Clozaril than prescribed. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A review of Resident 1' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/28 /23 indicated Resident 1 had moderately impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 required supervision with eating and oral hygiene. A review of Resident 1 ' s Physician ' s Orders indicated the following: 1. Clozaril 225 mg by mouth twice a day for schizophrenia manifested by constant talking, ordered 1/19/2020 and discontinued 11/22/2023. 2. Clozaril 200 mg by mouth twice a day for schizophrenia manifested by constant talking, with order date of 11/22/2023. A review of Resident 1 ' s Clozaril medication bubble pack (a small package enclosing the medication in transparent dome-shaped plastic on a flat cardboard backing that also includes a count of the medications remaining and the total amount of medications administered) indicated the following: 1. Clozapine 200 mg tablet, with a label: morning, with 18 tablets intact of a package of 31 tablets, delivery date 1/05/2024. 2. Clozapine 25 mg tablet, with a label: morning, with 16 tablets intact of a package of 31 tablets, delivery date 1/05/2024. 3. Clozapine 200 mg tablet, with a label: evening, with 17 tablets intact of a package of 31 tablets, delivery date 1/05/2024. 4. Clozapine 25 mg tablet, with a label: morning, with 18 tablets intact of a package of 31 tablets, delivery date 1/05/2024. A review of Resident 1 ' s Care Plan for Antipsychotic Medication, last reviewed 12/23/2023, indicated a goal that Resident 1 will interact peacefully in social situations for 90 days. The care plan indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 1/29/2024, at 1:00 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed Resident 1 ' s Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 11/2023, 12/2023, and 1/2024. LVN 1 stated that on the following dates, LVN 1 administered 225mgs of Clozapine to Resident 1 instead of the prescribed dose of 200 mgs of Clozapine: 1. 11/24/2023 9 a.m. dose 2. 11/25/2023 9 a.m. dose 3. 11/30/2023 9 a.m. dose 4. 12/09/2023 9 a.m. dose 5. 12/15/2023 9 a.m. dose 6. 12/21/2023 9 a.m. dose 7. 12/22/2023 9 a.m. dose 8. 12/23/2023 9 a.m. dose 9. 12/28/2023 9 a.m. dose 10. 12/29/2023 9 a.m. dose 11. 1/03/2024 9 a.m. dose 12. 1/04/2024 9 a.m. dose 13. 1/06/2024 9 a.m. dose 14. 1/11/2024 9 a.m. dose 15. 1/13/2024 9 a.m. dose 16. 1/15/2024 9 a.m. dose 17. 1/18/2024 9 a.m. dose 18. 1/19/2024 9 a.m. dose 19. 1/19/2024 5 p.m. dose 20. 1/20/2024 9 a.m. dose 21. 1/21/2024 9 a.m. dose 22. 1/22/2024 9 a.m. dose LVN 1 stated she should have followed Resident 1 ' s physician order of Clozaril 200mg, but mistakenly administered Clozaril 225mg to Resident 1. LVN 1 stated it was important to follow the physician ' s order so that Resident 1 would not receive a higher than intended dose of the medication. LVN 1 stated Resident 1 could have been at risk for sedation (the state of being relaxed or sleepy because of a drug) and constipation (a problem with passing stool) due to receiving a higher than prescribed dose of Clozaril. During a concurrent interview and record review with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2024 at 1:11 p.m., LVN 2 reviewed Resident 1 ' s MAR for 11/2023, 12/2023, and 1/2024. LVN 2 stated that on the following dates, LVN 2 administered 225 mgs of Clozapine to Resident 1 instead of the prescribed dose of 200 mgs of Clozapine: 1. 11/26/2023 9 a.m. dose 2. 11/27/2023 9 a.m. dose 3. 11/28/2023 9 a.m. dose 4. 12/03/2023 9 a.m. dose 5. 12/04/2023 9 a.m. dose 6. 12/05/2023 9 a.m. dose 7. 12/10/2023 9 a.m. dose 8. 12/30/2023 9 a.m. dose 9. 12/31/2023 9 a.m. dose LVN 2 stated she should have followed Resident 1 ' s physician order of Clozaril 200 mg, but mistakenly administered Clozaril 225 mg to Resident 1. LVN 2 stated it was important to follow the physician ' s order so that Resident 1 would not receive a higher than intended dose of the medication. LVN 2 stated that Resident 1 could have been at risk for becoming lethargic (lack of energy) or be at risk for falls. During a concurrent interview and record review with the Director of Nursing (DON) on 2/14/2024 at 3:15 p.m., the DON read the facility ' s policy and procedure titled, Specific Medication Administration Procedures General Procedures to Follow For All Medications last reviewed on 10/11/2023. The policy and procedure indicated the licensed nurse is to read the medication label three times before pouring (giving). The DON stated it was implied in the policy that the licensed nurse will check the medication label with the physician ' s order to ensure the right medication dose is given to the resident.

Based on observation, interview, and record review, the facility failed to ensure it followed its policy and procedure for the implementation of the physical restraint (the use of a manual hold or device to restrict freedom of movement of all or part of a resident's body) of a soft belt (a foam-padded pelvic restraint with ties secured around the back of wheelchair designed to help prevent forward sliding in wheelchairs) for one of one sampled resident investigated for restraints (Resident 38) by failing to: 1. Ensure informed consent (the process in which a health care provider educates a resident about the risks, benefits, and alternatives of a given procedure or intervention and ensures that a decision is made voluntarily) was obtained by the physician for Resident 38's soft belt restraint. 2. Ensure a pre-restraint assessment was completed prior to placing the soft belt on the resident on 9/8/2023. 3. Ensure the physician's order for the soft belt included the specific reason for the restraint, how the restraint will benefit the resident's medical symptom, and the period of time for the use of the restraint. 4. Ensure facility staff documented and monitored Resident 38 every 30 minutes anytime the resident was restrained as per facility policy and procedure. These deficient practices resulted in the absence of continued assessment and monitoring of a restraint and had the potential to result in an increased risk for complications of restraint use such as decline in functioning, injury, entrapment (event in which a resident is caught, trapped, or entangled in a space where they are being restrained), or death caused by physical restraints. Findings: 1. A review of Resident 38's admission Record indicated the facility admitted the resident on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning; thinking, remembering, and reasoning; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. A review of Resident 38's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/5/2023 indicated Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. A review of Resident 38's physician orders dated 9/8/2023 indicated the following orders: a. Apply soft belt while up on the wheelchair, every day and evening shift. b. Assess skin integrity: release soft belt every two hours, every day and evening shift. During a review of Resident 38's Risk for Fall Care Plan initiated 9/8/2023, indicated to apply the soft belt for trunk (body) control and to let Resident 38's wife sign the informed consent. During a concurrent observation and interview on 10/31/2023 at 8:56 a.m., observed Resident 38 sitting in a wheelchair in the activities room with a soft belt restraint applied around the resident's waist and secured to the back of the wheelchair frame. Resident 38 did not respond to questions. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with Registered Nurse 1 (RN 1), Resident 38's Verification of Informed Consent for Chemical Restraints (a form of medical restraint in which a drug is used to restrict the freedom or movement of a resident) or Physical Restraints Form dated 9/8/2023 was reviewed. RN 1 stated the process for applying a restraint is to obtain a physician's order for the use of restraint, obtain a signed informed consent from the resident's responsible party, complete a restraint assessment form, and monitor the safety and use of the restraint. RN 1 stated Resident 38's Verification of Informed Consent for Chemical Restraints/Physical Restraints Form dated 9/8/2023 was not complete because it did not have a physician signature and it did not have Resident 38's responsible party's signature. RN 1 stated she called Resident 38's physician on 9/8/2023 to obtain the informed consent for the use of the soft belt restraint, but the physician did not complete or sign the informed consent form for Resident 38. RN 1 stated the importance of getting a signed consent is to have documented evidence that the physician informed the resident's responsible party of the reason for the restraint, the probable duration, the risks, and the right to accept or refuse the restraint. During a concurrent interview and record review on 10/31/2023 at 4:08 p.m. with the Director of Nursing (DON), the DON reviewed Resident 38's Verification of Informed Consent for Chemical Restraints/Physical Restraints form dated 9/8/2023. The DON stated the facility policy is that an informed consent for restraint must be signed by the physician and the resident's responsible party. The DON stated that since Resident 38's Verification of Informed Consent for Chemical Restraints/Physical Restraints form dated 9/8/2023 was not signed by Resident 38's physician or responsible party, the form was not completed and the facility policy of obtaining an informed consent was not followed. A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated restraints shall only be used for the safety and wellbeing of residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. 2. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with RN 1, Resident 38's medical records were reviewed to find documented evidence that a Pre-Restraint Assessment Form was completed from 9/8/2023 to 10/31/2023, no documented evidence was found. RN 1 stated the facility uses a restraint assessment form to document the need for the restraint and assessment for the safety of use. RN 1 stated there was no documented evidence a restraint assessment was completed prior to administering the soft belt to Resident 38 starting on 9/8/2023. During a concurrent interview and record review on 10/31/2023 at 4:08 p.m. with the DON, Resident 38's medical records were reviewed to find documented evidence that a Pre-Restraint Assessment Form was completed from 9/8/2023 to 10/31/2023, no documented evidence was found. A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated that prior to placing the resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. 3. A review of Resident 38's physician orders dated 9/8/2023 indicated the following orders: a. Apply soft belt while up on the wheelchair, every day and evening shift. b. Assess skin integrity: release soft belt every two hours, every day and evening shift. During a concurrent interview and record review on 10/31/2023 at 4:08 p.m. with the DON, the DON reviewed Resident 38's physician order for a soft belt restraint dated 9/8/2023. The DON stated that Resident 38's physician order for the soft belt restraint was not complete because the facility policy indicates that restraint orders must include the specific reason for the restraint, the period of time for the use of the restraint, and how the restraint would benefit the resident's medical symptom. The DON stated the Resident 38's physician order for soft belt restraint only indicated to apply the soft belt restraint and did not include the reason, benefit to the resident, and duration of use. The DON stated the order should have included that it was used for poor trunk control to prevent toppling from the wheelchair, to prevent injury, and the duration of use. The DON stated the importance of following the facility policy for the use of restraints is to ensure applied restraints are used appropriately and to prevent any negative outcome like injury. A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated restraints shall only be used for the safety and wellbeing of residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include: a. the specific reason for the restraint (as it relates to the resident's medical symptom). b. how the restraint will be used to benefit the resident's medical symptom, c. the type of restraint, and period of time for the use of the restraint. 4. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with RN 1, Resident 38's medical records from 9/8/2023 to 10/31/2023 were reviewed to find documented evidence that Resident 38 was monitored every 30 minutes while the resident was restrained by the soft belt restraint. The review of Resident 38's medical records included progress notes, restraint assessment forms, Medication Administration Record (MAR- used to document medications taken by a resident), Treatment Administration Record (TAR- used to document the various healthcare treatment provided to a resident) and Restraint assessment forms. RN 1 stated that according to Resident 38's MAR for 10/2023, Resident 38 was restrained daily with the use of a soft belt restraint. RN 1 stated that there was no documented evidence found from 9/8/2023 to 10/31/2023 to indicate that facility staff monitored Resident 38 every 30 minutes anytime the resident was restrained with a soft belt restraint. RN 1 stated the facility's restraint policy indicates that facility staff is to document monitoring of a restrained resident every 30 minutes. RN 1 stated due to the safety risk posed by the restraint, Resident 38 should be monitored every 30 minutes while restrained for resident safety. RN 1 stated there was no documented evidence the resident was monitored for safety while the restraint was in use. A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated the following safety guidelines shall be implemented and documented while a resident is in restraints: - a resident in restraints will be observed at least every thirty minutes by nursing personal and an account of the resident's condition shall be recorded in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of 17 sampled residents (Resident 9 and Resident 38) by failing to: 1. Ensure a care plan for oxygen therapy (a treatment that provides extra oxygen to help people with lung diseases or breathing problems) was developed for Resident 9. 2. Ensure a care plan for Resident 9's pacemaker (a small electrical device that's implanted in the chest or abdomen to help your heartbeat at a normal rate and rhythm) was developed. 3. Ensure a care plan for the use of a soft belt restraint (a foam-padded pelvic restraint with ties secured around the back of wheelchair designed to help prevent forward sliding in wheelchairs) was developed for Resident 38. These deficient practices had the potential to result in a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 9's admission Record indicated the facility originally admitted the resident on 4/7/2023 and readmitted the resident on 7/14/2023 with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs) and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/20/2023, indicated the resident had severely impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experiences, and the senses) skills for daily decision making and was totally dependent on staff for locomotion (movement or the ability to move from one place to another) on and off the unit and toilet use. On 10/30/2023 at 10:20 a.m., during a concurrent observation and interview, observed Resident 9 asleep in bed receiving oxygen via nasal cannula (a device that delivers extra oxygen through a tube and into your nose). Licensed Vocational Nurse 1 (LVN 1) stated that Resident 9 was receiving oxygen at four [4] liters per minute (LPM - flow rate of oxygen; unit of measure). On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review with the Director of Staff Development (DSD), Resident 9's care plans from 7/14/2023 to 11/1/2023 were reviewed. The DSD stated that Resident 9 had no care plans addressing the resident's use of oxygen therapy. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that a resident receiving oxygen therapy should have a care plan in place so that staff is aware of what needs to be monitored, or so that staff knows what to look for in the event the resident has a change in condition (a sudden and clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains). RN 1 stated if there was no care plan for staff to follow, Resident 9 could potentially experience complications such as shortness of breath or oxygen toxicity (lung damage that occurs when someone breathes in too much extra oxygen). 2. A review of Resident 9's physician's orders dated 9/3/2023, indicated the following orders: a. Pacemaker monitoring: Avoid activities and equipment which interfere with pacemaker activity: large magnets, magnetic resonance imaging (MRI - a painless medical imaging procedure that uses radio waves and a magnetic field to create detailed images of the inside of the body) scanner, electric razor, microwave, diathermy (a therapeutic treatment that uses electric currents to generate heat in layers of your skin below the surface), transcutaneous electrical nerve stimulator (TENS - a small, battery-operated device that sends electrical pulses through the skin to relieve pain) machine, and radio frequency ablation (a minimally invasive technique that uses radio waves to create heat and destroy tissue) every shift. b. Pacemaker monitoring: Monitor and report to the medical doctor (MD) heart rate less than 60 or greater than 100 beats per minute (BPM) due to pacemaker in place. Monitor every shift. c. Pacemaker monitoring: Observe pacemaker site for infection such as pain, redness, swelling, drainage, warmth, and discoloration (change in your skin that differs from your natural skin tone). Notify MD and monitor every shift. On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review with the DSD, Resident 9's care plans from 7/14/2023 to 11/1/2023 were reviewed. The DSD stated that Resident 9 had no care plan addressing the presence of his pacemaker. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated it was important to have a care plan for Resident 9's pacemaker so that staff is aware of what needed to be monitored, or so that staff knew what to do in case there were any complications related to Resident 9's pacemaker. 3. A review of Resident 38's admission Record indicated the facility admitted the resident on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning ; thinking, remembering, and reasoning ; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. A review of Resident 38's MDS dated [DATE], indicated Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. A review of Resident 38's physician orders dated 9/8/2023, indicated the following orders: a. Apply soft belt while up on the wheelchair, every day and evening shift. b. Assess skin integrity: release soft belt every two hours, every day and evening shift. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with RN 1, Resident 38's care plans from 9/8/2023 to 10/31/2023 were reviewed. RN 1 stated there was no documented evidence that a soft belt restraint care plan was developed for Resident 38. RN 1 stated the importance of a restraint care plan is to guide the residents care and communicate the resident's issues and specific interventions to the healthcare team. RN 1 stated that without a care plan, there is nothing to guide the resident's care. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 10/11/2023, indicated it was the facility's policy that 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 comprehensive, person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; incorporate risk factors associated with identified problems; reflect treatment goals, timetables and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; aid in preventing or reducing decline in the resident's functional status and/or functional levels; and reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure a resident receiving oxygen had a physician's order for oxygen therapy (a treatment that provides extra oxygen to help people with lung diseases or breathing problems) for one of one sampled resident (Resident 9) investigated for oxygen therapy. This deficient practice had the potential to result in Resident 9 experiencing adverse effects due to inadequate or higher than necessary rates of oxygen administration leading to a negative impact to the resident's overall health. Findings: A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 4/7/2023 and readmitted Resident 9 on 7/14/2023 with diagnoses that included pneumonia (an infection that inflames the air sacs in one or both lungs) and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/20/2023, indicated Resident 9 had severely impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experiences, and the senses) skills for daily decision making and was totally dependent on staff for locomotion (movement or the ability to move from one place to another) on and off the unit and toilet use. On 10/30/2023 at 10:20 a.m., during a concurrent observation and interview, observed Resident 9 asleep in bed receiving oxygen via nasal cannula (a device that delivers extra oxygen through a tube and into your nose). Licensed Vocational Nurse 1 (LVN 1) stated that Resident 9 was receiving oxygen at four [4] liters per minute (LPM - flow rate of oxygen; unit of measure). On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review, reviewed Resident 9's physician's orders from 7/14/2023 to 11/1/2023 with the Director of Staff Development (DSD). The DSD stated there was no physician's order for Resident 9 to receive oxygen therapy. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated there should have been a physician's order if a resident is receiving oxygen therapy. RN 1 stated it was important to have an order for oxygen therapy so that staff knew how many liters per minute the resident should be receiving. RN 1 stated that if the resident was receiving oxygen without a physician's order, it is possible for the resident to suffer complications such as shortness of breath or oxygen toxicity (lung damage that occurs when someone breathes in too much extra oxygen) if licensed nurses did not have a specific order to follow. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/11/2023, indicated that the purpose of this procedure is to provide guidelines for safe oxygen administration. The policy further indicated to verify that there is a physician's order for oxygen therapy, and to review the physician's orders or facility protocol for oxygen administration.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 38) was free from unnecessary psychotropic medication (medications capable of affecting the mind, emotions, and behavior) by failing to limit the duration of an as needed (PRN) order for Ativan (a controlled substance [medication with a high potential for abuse] used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) to 14 days. This deficient practice had the potential to result in adverse reaction or impairment in the resident's mental or physical condition. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning ; thinking, remembering, and reasoning ; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. A review of Resident 38's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/5/2023 indicated the Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. A review of Resident 38's physician orders dated 1/26/2023, indicated an order for Ativan 0.5 milligram (mg - a unit of measurement), give one tablet by mouth every eight hours as needed for anxiety manifested by restlessness leading to exhaustion. During a concurrent interview and record review on 11/1/2023 at 9:45 a.m., with the Infection Preventionist (IP), Resident 38's physician orders for Ativan 0.5 mg dated 1/26/2023 was reviewed. The IP stated Resident 38 had an order for Ativan PRN with no duration or stop date. The IP stated psychotropic medications such as Ativan should have a stop date and limited to 14 days. The IP stated psychotropic medication are ordered for 14 days because the resident should be assessed to see if the behavior manifestations justify continuing the order for Ativan as it has a high risk of side effects. A review of the facility policy and procedure titled, Psychotropic Medication Use, last reviewed 10/11/2023, indicated psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. The policy further indicated that PRN orders for psychotropic medication are limited to 14 days.

Based on interview and record review, the facility failed to ensure a resident received his Isosorbide (a medication used for high blood pressure that works by dilating [widens] blood vessels) medication for 12 days as ordered by the physician for one (Resident 112) of six sampled residents observed during medication administration. This deficient practice had the potential to place Resident 112 at increased risk of experiencing adverse effects, such as uncontrolled blood pressure, from not receiving his blood pressure medication. Findings: A review of Resident 112's admission Record indicated the facility admitted Resident 112 on 10/19/2023 with diagnoses that included hypertension (HTN - high blood pressure) and atrial fibrillation (a type of arrhythmia, or abnormal heart rhythm, that causes the heart to beat irregularly). A review of Resident 112's physician orders dated 10/19/2023, indicated an order to administer Isosorbide 240 milligrams (mg- unit of measure) by mouth (PO) daily for HTN. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Resident 112's bubble pack (a card that packages medication per dose within a transparent plastic bubble) medications with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated that she was unable to find the bubble pack for Resident 112's Isosorbide medication. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Registered Nurse 1 (RN 1) call the facility's contracted pharmacy and spoke with Certified Pharmacy Technician 1 (CPhT 1). CPhT 1 stated that Resident 112's Isosorbide medication was never processed or delivered to the facility. On 11/1/2023 at 2:36 p.m., during a concurrent interview and record review, reviewed Resident 112's Medication Administration Record (MAR- a report detailing the drugs administered to a resident by a healthcare professional) for 10/2023 and 11/2023 with LVN 2. LVN 2 stated that she along with the other licensed nurses had been signing that they had administered Resident 112's Isosorbide medication from 10/20/2023 to 11/1/2023, totaling 12 occurrences. When asked why LVN 2 never followed up with the pharmacy Resident 112's missing Isosorbide medication, LVN 2 stated she had mistaken Resident 112's Isosorbide medication for one of the resident's kidney medications. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that if a resident's medication was not available, the licensed nurse should check the physician's order and follow up with the pharmacy so that the pharmacy can send the resident's needed medication. RN 1 stated Resident 112 could have possibly suffered from adverse effects such as a stroke (happens when there is a loss of blood flow to part of the brain) or uncontrolled blood pressure since the resident was not receiving his ordered blood pressure medication. A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. A review of the facility's policy and procedure titled, Pharmacy Services Overview, last reviewed on 10/11/2023, indicated that the facility shall accurately and safely provide and obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist (a person who is professionally qualified to prepare and dispense medicinal drugs).

Based on interview and record review, the facility failed to maintain complete and accurate medical records for two of six sampled residents (Resident 112 and Resident 14) by: 1. Failing to ensure licensed nurses did not sign on the Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) when a resident's Isosorbide (used for the management of angina [chest pain]) medication was not available during medication administration observation. 2. Failing to ensure a licensed nurse did not sign on the MAR when a resident's Apixaban (medication that helps to prevent blood clots) was not available during medication administration observation. These deficient practices resulted in Resident 112 and Resident 14's medical records being inaccurate and not in accordance with professional standards of practice; and had the potential to result in confusion regarding Resident 112 and Resident 14's condition and what care and services were provided to Resident 112 and Resident 14. Findings: 1. A review of Resident 112's admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including hypertension (HTN - high blood pressure) and atrial fibrillation (a type of arrhythmia, or abnormal heart rhythm, that causes the heart to beat irregularly). A review of Resident 112's Physician Orders indicated an order dated 10/19/2023 for Isosorbide 240 milligrams (mg- unit of measure) by mouth (PO) daily for HTN. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, Licensed Vocational Nurse 2 (LVN 2) stated that she gave Resident 112 his Isosorbide 240 mg yesterday (10/31/2023) at approximately 9:00 a.m. When LVN 2 was asked to show Resident 112's bubble pack (a card that packages medication per dose within a transparent plastic bubble) for Isosorbide, LVN 2 stated she could not find the bubble pack for Resident 112's Isosorbide. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Registered Nurse 1 (RN 1) call the facility's contracted pharmacy and spoke with Certified Pharmacy Technician 1 (CPhT 1). CPhT 1 stated that Resident 112's Isosorbide medication was never processed or delivered to the facility. On 11/1/2023 at 2:36 p.m., during a concurrent interview and record review, reviewed Resident 112's MAR for 10/2023 with LVN 2. LVN 2 stated that she along with the other licensed nurses had been signing that they had administered Resident 112's Isosorbide medication from 10/20/2023 to 10/31/2023, totaling 12 occurrences. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 2 (RN 2) stated that if nurses signed their initials on the MAR, it meant that the medication was administered. RN 2 stated that nurses should not be signing the MAR if a medication was not given. RN 2 stated that, in this particular case, since nurses were signing that they had been administering Resident 112's Isosorbide medication from 10/20/2023 to 10/31/2023, Resident 112 could have suffered from adverse consequences from not receiving the medication, such as uncontrolled blood pressure or a stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed on 10/11/2023, indicated that administration of medication must be documented immediately after (never before) it is given. 2. A review of Resident 14's admission Record indicated the facility originally admitted Resident 14 on 7/18/2022 and readmitted Resident 14 on 8/22/2022 with diagnoses including right heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), muscle atrophy (the decrease in size and wasting of muscle tissue), atrial fibrillation, nonrheumatic mitral (valve) insufficiency (when the mitral valve does not close properly, allowing blood to flow backwards into the heart), difficulty in walking, and stenosis of coronary artery stent (blockage or narrowing in portion of the coronary artery treated with a stent [device implanted that keeps the artery from being clogged]). A review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/1/2023, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance from staff for transfers, walking in the room and in the corridor, locomotion (movement or the ability to move from one place to another) on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 14's Physician's Order, dated 8/23/2022, indicated to give one tablet of Apixaban 2.5 mg by mouth one time a day for atrial fibrillation. On 10/31/2023 at 9:03 a.m., during a medication administration observation, observed LVN 2 administering due medications to Resident 14. Observed an empty bubble pack for Resident 14's Apixaban medication. LVN 2 stated she ran out of the apixaban and would follow up with the pharmacy for it. On 10/31/2023 at 9:27 a.m., during a concurrent observation and interview with LVN 2, observing LVN 2 administer Resident 14's due medications. Observed LVN 2 sign her initials on the MAR for Resident 14 under 10/31 for apixaban. When asked why LVN 2 signed Resident 14's apixaban as given for 10/31/2023, LVN 2 stated she did not want to leave a space blank on Resident 14's MAR. LVN 2 stated that if Resident 14's apixaban medication is delivered later in the day, then she will give the medication to the resident. LVN 2 stated that if Resident 14's apixaban medication is not delivered, then she would circle her initials indicating that the medication was not given to the resident. On 11/2/2023 at 1:51 p.m., during an interview, RN 2 stated that if nurses signed their initials on a resident's MAR, it meant that the medication was administered. RN 2 stated that nurses should not be signing the MAR if a medication was not given. RN 2 stated if a medication is not available, then nurses should make a note entry, otherwise licensed nurses can get confused as to what has actually been administered to a resident. A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed on 10/11/2023, indicated that administration of medication must be documented immediately after (never before) it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to: 1. Ensure that a resident who was at high risk for falls had their bed in a low position for one (Resident 44) of five sampled residents investigated for accidents. 2. Ensure the information for a resident's pacemaker (a small electrical device that's implanted in the chest or abdomen to help your heartbeat at a normal rate and rhythm) was readily available in the resident's medical record for one (Resident 9) of five sampled residents investigated for accidents. 3. Ensure that a licensed nurse did not leave a resident's blood pressure medication at the bedside for one (Resident 13) of five sampled residents investigated for accidents. 4. Ensure one of five sampled residents (Resident 56) investigated for Accidents did not have an opened bottle of 0.9 percent (%-unit of measure) Sodium Chloride Irrigation solution (Normal Saline [NS], a sterile solution composed of sodium chloride [salt] in water used for cleansing wounds) left unlabeled and on the resident's nightstand. 5. Ensure licensed nurse did not leave a resident's amlodipine (medication to treat high blood pressure) and hydrochlorothiazide (medication to treat high blood pressure) for one of six sampled residents (Resident 46) observed for Medication Administration in the resident's room unattended. These deficient practices had the potential to place Resident 44 at increased risk of sustaining a fall with injuries, place Resident 9 at increased risk of suffering complications in the event of a pacemaker malfunction, and Resident 13 at risk of experiencing adverse effects from not receiving his blood pressure medications; placed Resident 56 at increased risk of ingesting substances not intended for them resulting in adverse effects such as an upset stomach; and placed Resident 46 at increased risk for hypotension (low blood pressure) and dizziness or headaches for taking medications not intended for them. Findings: 1. A review of Resident 44's admission Record indicated the facility originally admitted Resident 44 on 12/9/2019 and readmitted Resident 44 on 6/24/2022 with diagnoses including multiple sclerosis (a disorder that affects the brain, spinal cord, and optic nerves), muscle wasting and atrophy (when muscles waste away and look smaller than normal), quadriplegia (a form of paralysis that affects all four limbs, plus the torso), epilepsy (a chronic, noncommunicable brain disorder that causes recurrent, unprovoked seizures), and age-related osteoporosis (a chronic bone disease that occurs when bone mineral density and bone mass decrease, or when the quality or structure of bone changes). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/12/2023, indicated Resident 44 had severe impairment in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for locomotion (movement or the ability to move from one place to another) off the unit and toilet use. A review of Resident 44's Fall Risk Assessment (tool used to check how likely it is a resident will fall) dated 8/12/2023 indicated that Resident 44 is identified as a high risk for fall. A review of Resident 44's care plan titled Risk for Fall Injury dated 6/27/2022 indicated Resident 44 is at high risk for fall and injury related to cognitive impairment, poor safety awareness, weakness, visual impairment, and medical diagnoses. The goal was to minimize risk for falls, minimize injury and minimize recurrence of falls. The interventions included are to implement fall precautions, provide a safe environment and to provide adequate assistance and frequent safety reminder. On 10/30/2023 at 10:36 a.m., during an observation, observed Resident 44 awake in bed watching television; Resident 44's bed was noted in the high position (the mattress of the bed high and further distance from the floor). On 10/30/2023 at 10:41 a.m., during a concurrent observation and interview, Registered Nurse 1 (RN 1) Resident 44's bed position was observed. RN 1 stated that Resident 44's bed was in the high position. RN 1 stated that Resident 44 was identified as a high risk for falls, and the resident's bed should be kept in a low position (the mattress is closer to the floor to prevent injuries in the event of a fall). On 11/1/2023 at 9:42 a.m., during a concurrent interview and record review, reviewed Resident 44's Fall Risk Assessment (tool used to check how likely it is a patient will fall), dated 8/12/2023, with RN 1. RN 1 stated that the resident's score of 13 indicated she was at high risk for falls. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that if the bed is kept in a high position for a resident who is at high risk for falls, the resident can potentially fall off the bed and sustain major injuries such as fractured (broken) bones or head trauma (head injury). A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, last reviewed on 10/11/2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Environmental factors that contribute to the risk of falls include .incorrect bed height or width. Resident conditions that may contribute to the risk of falls include delirium and other cognitive impairment, lower extremity weakness, and functional impairments. 2. A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 4/7/2023 and readmitted Resident 9 on 7/14/2023 with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs) and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days). A review of Resident 9's MDS dated [DATE], indicated Resident 9 had severely impaired cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit and toilet use. A review of Resident 9's Physician's Orders dated 9/3/2023 indicated the following orders: - Pacemaker monitoring: Avoid activities and equipment which interfere with pacemaker activity: large magnets, magnetic resonance imaging (MRI - a painless medical imaging procedure that uses radio waves and a magnetic field to create d detailed images of the inside of the body) scanner, electric razor, microwave, diathermy (a therapeutic treatment that uses electric currents to generate heat in layers of your skin below the surface), transcutaneous electrical nerve stimulator (TENS - a small, battery-operated device that sends electrical pulses through the skin to relieve pain) machine, and radio frequency ablation (a minimally invasive technique that uses radio waves to create heat and destroy tissue) every shift. - Pacemaker monitoring: Monitor and report to the physician heart rate less than 60 or greater than 100 beats per minute (BPM) due to pacemaker in place. Monitor every shift. - Pacemaker monitoring: Observe pacemaker site for infection such as pain, redness, swelling, drainage, warmth, and discoloration. Notify the physician and monitor every shift. On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review with the Director of Staff Development (DSD), Resident 9's medical records that included progress notes, physician orders, care plans, and consultations from 4/7/2023 to 11/1/2023 were reviewed. DSD stated that she could not find any information regarding Resident 9's pacemaker in the resident's medical records. The DSD stated a residents pacemaker information should be readily available in the resident's medical record. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that, for a resident with a pacemaker, there should be information in the resident's medical record about the cardiologist, the model, serial number, and date of when the pacemaker was implanted. RN 1 stated that information should be readily available in the resident's medical record in case the resident's pacemaker malfunctioned. RN 1 stated if the facility did not have Resident 9's pacemaker information readily available. RN 1 stated that the facility would not be able to communicate information related to Resident 9's pacemaker to the emergency medical technician (EMT - a medical professional who provides emergency care to people outside of or on the way to the hospital) or general acute care hospital (GACH) if Resident 9 needed to be transferred out. A review of the facility's policy and procedure titled, Pacemaker, Care of a Resident with, last reviewed on 10/11/2023, indicated that for each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist b. Type of pacemaker c. Type of leads (thin, insulated wires that transmit electrical impulses from the pacemaker to the heart muscle to assist blood flow) d. Manufacturer and model e. Serial number f. Date of implant; and g. Paced rate 3. A review of Resident 13's admission Record indicated the facility admitted Resident 13 on 1/3/2020 with diagnoses including hypertension (a condition in which the pressure in your blood vessels is too high). A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had intact cognition and required supervision with bed mobility, transfers, locomotion on and off the unit, and toilet use. A review of Resident 13's Physician's Order, dated 8/3/2021, indicated to give Atenolol (a medication used to mainly treat angina [condition marked by severe pain in the chest] and high blood pressure) 25 milligrams (mg- unit of measure) one tablet by mouth two times a day for hypertension. Hold for systolic blood pressure (SBP - indicates how much pressure your blood is exerting against your artery walls when the heart beats) less than 110 millimeters of mercury (mmHg-unit of measure) or pulse rate less than 60 beats per minute (BPM). A review of Resident 13's Medication Self-Administration Assessment Form, dated 10/11/2023, indicated Resident 13 cannot safely self-administer medications. On 10/31/2023 at 9:03 a.m., during a medication administration observation, observed Licensed Vocational Nurse 2 (LVN 2) hand Resident 13's Atenolol medication to the resident in a medication cup and proceeded to close the resident's privacy curtain before walking back to the medication cart. Observed LVN 2 fail to monitor Resident 13 to ensure the resident took the medication. On 10/31/2023 at 9:27 a.m., during an interview, LVN 2 stated that she did not observe Resident 13 take his Atenolol medication before walking away from the resident. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that licensed nurses should not be leaving residents alone with their medication. RN 1 stated licensed nurses should observe residents to ensure they actually take their medication. RN 1 stated if licensed nurses does not observe the resident take the provided medication, it is possible that the resident may not take the medication resulting in adverse health effects such as high blood pressure. A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that medications are administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the facility's policy and procedure titled, Administering Oral Medications, last reviewed on 10/11/2023, indicated that the purpose of the procedure is to provide guidelines for the safe administration of oral medications. Remain with the resident until all medications have been taken. 4. A review of Resident 56's admission Record indicated the facility admitted Resident 56 on 2/2/2023 and readmitted Resident 56 on 10/13/2023 with diagnoses that included heart disease (a group of disorders that affect the heart's ability to deliver oxygen to the body), Alzheimer's disease (a type of dementia [a group of symptoms that affects memory, thinking, and behavior]), and contractures of muscle (shortening of length of muscle). A review of Resident 56's MDS dated [DATE], indicated Resident 56 rarely/never had the ability to understand others and rarely/never had the ability to make herself understood. During an observation on 10/30/2023 at 10:42 a.m., observed Resident 56 lying in bed awake; Resident 56 did not respond to questions. Observed an opened bottle of unlabeled NS irrigation solution on Resident 56's nightstand. During a concurrent observation and interview on 10/30/2023 at 10:48 a.m. with Certified Nursing Assistant 1 (CNA 1), the opened bottled of unlabeled NS irrigation solution on Resident 56's nightstand was observed. CNA 1 stated she cares for Resident 56 often and uses the NS daily with a piece of gauze (thin translucent fabric) given to her by Treatment Nurse 1 (TN 1) to clean the resident's contracted left hand. CNA 1 stated she opened the bottle of NS last week and left it on Resident 56's nightstand. During an interview on 11/1/2023 at 9:12 a.m. with TN 1, TN 1 stated he did not leave a bottle of NS on Resident 56's nightstand. TN 1 stated NS is stocked in the clean utility room that Certified Nursing Assistants (CNAs) have access to. TN 1 stated NS is only used for cleansing wounds and not for cleaning a resident's hand. TN 1 stated water and soap is used to clean hands, not NS. TN 1 stated NS should not be applied by CNAs to a resident and should never be left in a resident's room because it looks like water and any resident could ingest it. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated the bottle of NS should not have been left on Resident 56's nightstand. RN 1 stated that if NS is ingested by a resident, it could lead to a stomach upset. A review of the facility policy and procedure titled, Hazardous Areas, Devices, and Equipment, last reviewed 10/11/2023 indicated all hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate hazards to the extent possible. A hazard is identified as anything in the environment that has the potential to cause injury or illness. During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 10/11/2023 indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 5. A review of Resident 46's admission Record indicated the facility admitted Resident 46 on 8/12/2021 and readmitted Resident 46 on 3/21/2022 with diagnoses that included parkinsonism (a brain condition that causes slowed movements, stiffness, and tremors), hypertension, and schizoaffective disorder (a mental health disorder with symptoms of hallucinations [a false perception of objects or events involving your senses] or delusions [false belief or judgment about external reality]). A review of Resident 46's MDS dated [DATE], indicated Resident 46 usually had the ability to understand others and usually had the ability to make himself understood. A review of Resident 46's Physician Orders indicated the following orders: a. Amlodipine Besylate tablet 10 mg, give one tablet by mouth one time a day related to essential hypertension, dated 3/22/2022. b. Hydrochlorothiazide tablet 25 mg, give one tablet by mouths one time a day for hypertension, dated 3/21/2022. During a concurrent observation and interview on 11/1/2023 at 8:08 a.m. with Licensed Vocational Nurse 3 (LVN 3), observed LVN 3 take Resident 46's blood pressure then walked back to the medication cart in the hallway. Resident 46 motioned to the surveyor and stated he had something. Observe Resident 46 open a tissue and observed two pills inside the tissue. LVN 3 entered the room and asked Resident 46 where he got the medications from. Resident 46 stated he got the medications off the floor last night. LVN 3 identified the medications as Amlodipine and Hydrochlorothiazide. LVN 3 stated she did not know when or from whom Resident 46 got the medications. LVN 3 stated the medication nurse should always ensure the resident takes the provided medications before leaving the room. During a concurrent interview and record review on 11/1/2023 at 11:22 a.m. with the Infection Preventionist (IP), the IP reviewed Resident 46's Medication Self Administration Assessment Form, dated 9/29/2023 and stated the resident was assessed and it was determined Resident 46 could not safely self-administer medications due to the resident not being able to demonstrate reading medication instructions aloud, verbalize times at which medications are to be taken, verbalize understanding of the purpose of medications and potential side effects, demonstrate opening medication packages, or storing medications properly. The IP stated Resident 46 should not have medications left in his room. The IP stated it was unsafe for Resident 46 to have medications left in his room because those medications have parameters that need to be followed and if taken at the wrong time, he could overdose with the potential to cause an adverse side effect like low blood pressure. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated whoever gave the Amlodipine medication and Hydrochlorothiazide medication to Resident 46 did not follow the facility policy and procedure to ensure the medication was taken before leaving the resident's room; or the licensed nurse may have left the medications at Resident 46's bedside for the resident to self-administer. RN 1 stated leaving medications at Resident 46's bedside was a safety issue and placed the resident at risk for self-administering the medication at the wrong time resulting in his blood pressure dropping and causing dizziness with falls and injury. A review of the facility policy and procedure titled, Administering Medications, last reviewed 10/11/2023 indicated medications are administered in a safe and timely manner and as prescribed. A review of the facility procedure titled, Administering Oral Medications, last reviewed 10/11/2023 indicated the purpose of the procedure was to provide guidelines for the safe administration of oral medications. Remain with the resident until all medications have been taken. During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 10/11/2023 indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on interview and record review, the facility failed to: 1. Ensure licensed nurses followed up with the pharmacy when a resident's Isosorbide (a medication used to prevent angina [chest pain] in residents with a certain heart condition) medication had not been delivered for one (Resident 112) out of six sampled residents observed during medication administration. 2. Ensure licensed nurse staff documented either at the start of the shift, or the end of the shift on Medication Cart 2 Floor Narcotic (a type of medication that is used to relieve pain but has a high potential for abuse) Release form (a form that is signed by both the oncoming shift licensed nurse and the outgoing shift licensed nurse after they have both verified by counting that all controlled medications [medications that can cause physical and mental dependence such as narcotics]) for 12 of 127 shifts. 3. Ensure licensed nurses documented the administration of Ativan (a medication used to treat anxiety [a persistent feeling of worry, nervousness, or unease]) for one of five sampled resident's (Resident 38) for 15 of 16 occurrence in the residents Medication Administration record (MAR- a report detailing the drugs administered to a resident by a healthcare professional) for 10/2023 These deficient practices had the potential to place the residents at increased risk of experiencing adverse health effects form not receiving their due prescribed medications; had the potential to result in inaccurate reconciliation of controlled medication and placed the facility at risk for the inability to readily identify loss and drug diversion (the illegal distribution of prescription drugs for unintended purposes) of controlled medications; and had the potential to result in confusion in the care and services provided to the residents. Findings: 1. A review of Resident 112's admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including hypertension (HTN - high blood pressure) and atrial fibrillation (an irregular heartbeat and often very rapid heartbeat rhythm). A review of Resident 112's Physician Orders indicated an order dated 10/19/2023 for Isosorbide 240 milligrams (mg- unit of measure) by mouth (PO) daily for HTN. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Registered Nurse 1 (RN 1) call the facility's contracted pharmacy and spoke with Certified Pharmacy Technician 1 (CPhT 1). CPhT 1 stated that Resident 112's Isosorbide medication was never processed or delivered to the facility. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that if a resident's medication was not available, the licensed nurse should check the physician's order and follow up with the pharmacy so that the pharmacy can send the resident's needed medication. RN 1 stated Resident 112 could have possibly suffered from adverse effects such as a stroke (happens when there is a loss of blood flow to part of the brain) or uncontrolled blood pressure since the resident was not receiving his ordered blood pressure medication. A review of the facility's policy and procedure titled, Pharmacy Services Overview, last reviewed on 10/11/2023, indicated that the facility shall accurately and safely provide and obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. 2. During a concurrent interview and record review on 11/1/2023 at 7:48 a.m. with Licensed Vocational Nurse 3 (LVN 3), Nursing Station 2 Medication Cart Floor Narcotic Release form for 9/2023 and 10/2023 were reviewed. LVN 3 stated that there were missing documentation entries on the Floor Narcotic Release form for Nursing Station 2 Medication Cart. LVN 3 stated the following missing entries: a) On 9/20/2023 at 7:00 a.m., missing the on-coming nurse's signature and if the narcotic count is short or over. b) On 9/21/2023 at 7:00 a.m., missing the on-coming nurse's signature and if the narcotic count is short or over. c) On 9/21/2023 at 3:00 p.m., missing the outgoing nurse's signature. d) On 10/1/2023 at 11:00 p.m., missing the outgoing nurse's signature. e) On 10/5/2023 at 11:00 p.m., missing the outgoing nurse's signature. f) On 10/6/2023 at 11:00 p.m., missing the outgoing nurse's signature. g) On 10/15/2023 at 3:00 p.m., missing the on-coming nurse's signature and if the narcotic count is short or over. h) On 10/15/2023 at 11:00 p.m., missing the outgoing nurse's signature. i) On 10/16/2023 at 3:00 p.m., missing the on-coming nurse's signature and if the narcotic count is short or over. j) On 10/16/2023 at 11:00 p.m., missing the outgoing nurse's signature. k) On 10/18/2023 at 7:00 a.m., missing the on-coming nurse's signature. l) On 10/18/2023 at 3:00 p.m., missing the outgoing nurse's signature. LVN 3 stated a narcotic count is completed each shift with the oncoming and outgoing nurse to document proof that all controlled medications are account for. LVN 3 stated that if the narcotic count is correct and validated by two nurses, it ensures that there are no missing narcotic medications prior to the start of the next nurse's shift. LVN 3 stated narcotics go missing and are stolen more often than other medications and it is important to account for them. LVN 3 stated if it was not documented as completed on the Floor Narcotic Release form, then it was not done. During an interview on 11/1/2023 at 11:18 a.m. with the Infection Preventionist (IP), the IP stated the Narcotic Count Release form is used to document the outgoing nurse's release of responsibility over the medication cart and narcotics to the oncoming nurse. The IP stated if there was a discrepancy then the oncoming nurse should refuse to accept the cart until the discrepancy is resolved. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated the importance of the Narcotic Release form is to ensure both nurse's count the controlled medications together. RN 1 stated that if a narcotic medication count is not completed, it could potentially lead to missing controlled medications and not being able to identify when they went missing or who was responsible for the missing controlled medications. RN 1 stated the facility policy was not followed because the oncoming and outgoing nurse must document the count of the controlled medications. A review of the facility policy titled, Controlled Substances last reviewed 10/11/2023, indicated only licensed nursing and pharmacy personnel shall have access to Schedule II controlled drugs (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) maintained on premises. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. 3. A review of Resident 38's admission Record indicated the facility admitted the resident on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning ; thinking, remembering, and reasoning ; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. A review of Resident 38's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/5/2023 indicated Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. A review of Resident 38's Physician Orders indicated an order for Ativan tablet 0.5 mg, give one tablet by mouth every eight hours as needed for anxiety manifested by restlessness leading to exhaustion, dated 1/26/2023. During a concurrent interview and record review on 11/1/2023 at 9:45 a.m., with the IP, the IP reviewed Resident 38's Ativan 0.5 mg Medication Count Sheet (a record detailing the number of medication doses removed from a bubble pack [packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover]), and Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) for 10/2023; the IP noted the following: a. On 10/1/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. b. On 10/4/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. c. On 10/6/2023 at 10:00 a.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. d. On 10/6/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. e. On 10/7/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. f. On 10/8/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. g. On 10/12/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. h. On 10/13/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. i. On 10/18/2023 at 5:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. j. On 10/19/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. k. On 10/20/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. l. On 10/24/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. m. On 10/29/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. n. On 10/30/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. o. On 10/31/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. The IP stated the medication nurse must document administration of Ativan in Resident 38's MAR on the date and time of administration. During a concurrent interview and record review on 11/1/2023 at 2:45 p.m. with LVN 3, LVN 3 reviewed Resident 38's Ativan Medication Count Sheet and MAR for 10/2023. LVN 3 stated that she administered a dose of Ativan 0.5 mg to Resident 38 on 10/6/2023 at 10:00 a.m. but forgot to document the medication as administered on Resident 38's MAR for 10/6/2023. LVN 3 stated it was busy on 10/6/2023 and it slipped her mind to document in Resident 38's MAR that she administered a dose of Ativan to the resident. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated the importance of documenting in the MAR is to communicate to the team that a resident received a medication on a specific date and time. RN 1 stated if the medication was not documented in the MAR, then it is considered not given. RN 1 stated if the medication was documented as removed from the bubble pack and not documented as administered, then the medication could have been stolen. During a concurrent interview and record review on 11/2/2023 at 3 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 reviewed Resident 38's Ativan Medication Count Sheet and MAR for 10/2023. LVN 4 stated that she administered a dose of Ativan to Resident 38 on 12 occasions (10/1/2023 at 9:00 p.m., 10/4/2023 at 9:00 p.m., 10/7/2023 at 9:00 p.m., 10/8/2023 at 9:00 p.m., 10/12/2023 at 9:00 p.m., 10/13/2023 at 9:00 p.m., 10/19/2023 at 9:00 p.m., 10/20/2023 at 9:00 p.m., 10/24/2023 at 9:00 p.m., 10/29/2023 at 9:00 p.m., 10/30/2023 at 9:00 p.m., and 10/31/2023 at 9:00 p.m.) in 10/2023 and did document in Resident 38's MAR as administered. LVN 4 stated she knows she is supposed to document in the MAR, but she ran out of time and only signed Resident 38's Medication Count Sheet for Ativan. A review of the facility policy and procedure titled, Administering Medications, last reviewed 10/11/2023 indicated medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication. A review of the facility procedure titled, Documentation of Medication Administration, last reviewed 10/11/2023, indicated that the facility shall maintain a medication administration record to document all medications administered. A nurse shall document all medications administered to each resident on the residents MAR. Administration of medications must be documented immediately after it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure medication bubble packs (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) were not stored in an unlocked drawer in Nursing Station 2 for two of two sampled residents (Resident 26 and Resident 34) investigated for Medication Storage and Labeling. 2. Label one open vial (small container) of glucometer test strips (an absorbent strip that soaks up blood to be read by the glucometer [medical device used for determining the approximate concentration of sugar in the blood]) found in one of two medication carts (Nursing Station 2 Medication Cart) investigated during the facility task Medication Storage and Labeling. These deficient practices had the potential to result in residents or unauthorized personnel accessing Resident 26 and Resident 34's medications and had the potential to compromise the accuracy of glucometer tests strips readings resulting in inaccurate blood glucose (sugar) readings and mismanagement of diabetes mellitus (a chronic condition that affects the way the body processes blood glucose) in residents. Findings: 1. A review of Resident 26's admission Record indicated the facility admitted Resident 26 on [DATE] and readmitted Resident 26 on [DATE] with diagnoses that included hypertensive heart and kidney disease (damage to the heart and kidneys due to chronic elevated blood pressure [the force of the blood pushing on the blood vessel walls is too high]), with heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), schizoaffective disorder (a mental health condition with symptoms of schizophrenia [delusions - false belief or judgment about external reality; hallucinations - sensing things such as visions, sounds, or smells that seem real but are not; disorganized thinking] bipolar type (extreme mood swings), and hyperlipidemia (high levels of fat in the blood). A review of Resident 26's Minimum Data Set (MDS - an assessment and care screening tool) dated [DATE] indicated Resident 26 usually had the ability to make himself understood and usually had the ability to understand others. A review of Resident 26's physician orders indicated orders for the following: a. Isosorbide Dinitrate (a medication to treat heart failure) oral tablet 10 milligrams (mg - a unit of measurement), give one tablet by mouth two times a day for coronary artery disease (a condition where the arteries [blood vessels] of the heart cannot deliver enough oxygen-rich blood to the heart), dated [DATE]. b. Hydralazine (a medication to treat high blood pressure) oral tablet 25 mg, give one tablet by mouth three times a day for hypertension (HTN - high blood pressure), dated [DATE]. c. Seroquel (a medication that treats mental health conditions) oral tablet give 200 mg by mouth at bedtime for schizophrenia manifested by agitation and irritability, picking fights with other residents, dated [DATE]. d. Atorvastatin Calcium (a medication to treat high cholesterol) oral tablet 20 mg, give one tablet by mouth at bedtime for hyperlipidemia (an abnormally high concentration of fats in the blood), dated [DATE]. A review of Resident 34's admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things that once brought joy) and schizophrenia. A review of Resident 34's MDS dated [DATE] indicated Resident 34 had the ability to make herself understood and had the ability to understand others. A review of Resident 34's physician orders dated [DATE], indicated an order for Risperidone (a medication to treat mental health conditions) oral tablet 0.5 mg, give one tablet by mouth at bedtime for schizophrenia manifested by hallucinations talking to unseen people. During a concurrent observation and interview on [DATE] at 3:45 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the following medication bubble packs were in an unlocked desk drawer in Nursing Station 2: a. Isosorbide Dinitrate 10 mg, with one tablet remaining for Resident 26. b. Hydralazine 25 mg with one tablet remaining for Resident 26. c. Seroquel 200 mg with four tablets remaining for Resident 26. d. Atorvastatin Calcium 20 mg with three tablets remaining for Resident 26 e. Risperidone 0.5 mg with two tablets remaining for Resident 34. LVN 3 stated she did not know why or for how long the five (5) medication bubble packs were kept in the unlocked drawer at the nursing station. LVN 3 stated somebody must have removed the bubble packs from the medication cart and forgot they put them in the desk drawer. LVN 3 stated the bubble packs should not have been in an unlocked drawer and should have been kept in a secured and locked area like a medication cart. LVN 3 stated medication should always be kept in a secure area to ensure medications do not go missing and that other staff and residents do not have access to them. During an interview on [DATE] at 9:40 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that the facility's policy and procedure for medication storage was not followed because medications were left in an unlocked drawer when they should be stored in a secure and locked compartment. A review of the facility's policy and procedure titled, Storage of Medications, last reviewed [DATE] indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments. 2. During a concurrent observation and interview on [DATE] at 7:48 a.m. with LVN 3, Nursing Station 2 Medication Cart was observed. Observed one open glucometer test strip bottle with no labeled open date (when an item or medication is opened for the first time and the nursing staff document the date it was opened). LVN 3 stated test strips are labeled with the date opened because they expire one month after opening the vial. LVN 3 stated if expired test strips are used to measure a resident's blood sugar, it could result to an inaccurate reading. LVN 3 stated if the residents blood sugar is not measured accurately, then residents could be administered too much or too little insulin (a medication to treat high blood sugar) resulting in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and possible hospitalization. During a concurrent interview and record review on [DATE] at 9:40 a.m. with RN 1, RN 1 reviewed the facility's Glucose Test Strips User Instruction Manual. RN 1 stated diabetic resident's blood sugar readings are needed to determine the amount of insulin to administer. RN 1 stated the facility follows the manufacture guidelines and all glucometer test strips vial should be labeled with the open date. RN 1 stated the test strips expire three months after opening and should not be used once expired because it could lead to an inaccurate reading of a resident's blood sugar. RN 1 stated if an expired strip gives an inaccurate reading, it could result in resident's diabetes not being properly managed and possibly resulting in life threating issues like a diabetic coma (a life-threatening emergency causing loss of consciousness) or progression of their disease. A review of the facility's Glucose Platinum Test Strip User Instruction [NAME], dated 1/2021, indicated test strips are intended for the quantitative measurement of glucose in fresh capillary whole blood samples drawn from the fingertip as an aid to monitor the effectiveness of diabetes control. When you first open the vial, write the date on the vial label. Use the test strips within three months from first opening the vial.

Based on observation, interview, and record review, the kitchen staff failed to ensure the proper storage, preparation, and distribution of food in accordance with professional standards for food service safety for 60 of 61 residents who receive food from the kitchen by: 1. Failing to ensure food items such as ham, cups of wild berry frozen desserts, lemons, apples, cheese, yogurt, and milk were labeled and dated with the received and/or open date (when staff write on the item the date it was received or the date it was first opened). 2. Failing to ensure the Meat Freezer temperature was maintained below 0 degrees Fahrenheit (?, a unit of measurement) for 16 of 31 logged temperature checks for 10/2023. 3. Failing to ensure the low temperature dishwashing machine (a device that applies water and a chemical sanitizing solution [destroys or prevents the growth of disease-causing microorganisms] to the surfaces of dishes and equipment) chlorine (a sanitizing solution) solution concentration (the amount of chemical dissolved in water) measured a minimum of 50 parts per million (ppm- a unit of measurement). 4. Failing to ensure there was an air gap (a fitting mounted about two inches (in - unit of measure) above the drain that prevents contaminated water from re-entering between the ice machine's drain hose (flexible tubing used to remove excess water from the ice maker and melted ice from the ice storage bin) and the floor drain (a plumbing fixture installed in the floor to remove standing water) to prevent backflow (reversal of normal direction of water) and contamination (the presence of harmful bacteria) of the machine's ice. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). Findings: 1. On 10/30/2023 at 7:52 a.m., during a concurrent observation and interview with the Dietary Supervisor (DS), the kitchen of the facility was observed. The DS stated the facility labels and dates all food items to ensure older items are used first and no expired foods are served to the residents. The DS stated the facility procedure for labeling is every food item is labeled with the date received and the date opened. The DS stated any food removed from its original packaging is also labeled with the item contents and date. Observed inside the facility kitchen alongside the DS were the following: a. Located in the Meat Freezer, one unopened frozen ham not labeled with the received date. The DS stated she did not know when the ham was received because it was not labeled with a received date. b. Located in the Vegetable and Dessert's Freezer, one opened box containing 37 Magic Cup Wild Berry frozen desserts with no labeled received or opened date. The DS stated she did not know when the desserts were received or opened because it was not labeled. c. Located in the Walk-In Refrigerator, a plastic bin containing 12 lemons and six apples with no labeled received date. The DS stated all fruits and vegetables must be labeled with the date received. d. Located in the Walk-In Fridge, the following items were on an unlabeled tray: i. One unlabeled bowl possibly containing cheese. ii. Three unlabeled white Styrofoam cups possibly containing yogurt. iii. Eight unlabeled clear plastic cups possibly containing milk. The DS stated the items on the tray were leftovers from breakfast and should have been labeled with the item contents and dated, but they were not. During an interview on 10/31/2023 at 2:11 p.m., with the DS, the DS stated all foods should be labeled to ensure the First-In, First-Out method (a food rotation system used to ensure the item stored longest will be the next item used) of food is utilized. The DS stated the facility policy and procedures were not followed for refrigerator and freezer food storage. A review of the facility policy and procedure titled, Procedure for Freezer Storage, last reviewed 10/11/2023 indicated all frozen food should be labeled and dated. A review of the facility policy and procedure titled, Procedure for Refrigerated Storage last reviewed 10/11/2023 indicated food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice. Leftovers will be covered, labeled, and dated. Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh product is used. A review of the facility policy and procedure titled, Leftover Foods last reviewed 10/11/2023 indicated leftover foods will be stored and served in a safe manner. Leftover foods are labeled and dated. 2. On 10/30/2023 at 7:52 a.m., during a concurrent interview and record review with DS, the facility's freezer temperature log for the Meat Freezer, dated 10/2023 was reviewed. The DS stated the Meat Freezer temperature log is completed by kitchen staff twice a day and should indicate a temperature of below 0 ?. The DS stated the temperature log indicated the freezer was above 0 ? on the following dates: a. On the 10/3/2023 p.m. shift, the temperature was one (1) ?. b. On the 10/5/2023 p.m. shift, the temperature was three (3) ?. c. On the 10/6/2023 p.m. shift, the temperature was six (6) ?. d. On the 10/7/2023 a.m. shift, the temperature was six (6) ?. e. On the 10/7/2023 p.m. shift, the temperature was seven (7) ?. f. On the 10/9/2023 p.m. shift, the temperature was four (4) ?. g. On the 10/11/2023 p.m. shift, the temperature was seven (7) ?. h. On the 10/14/2023 p.m. shift, the temperature was seven (7) ?. i. On the 10/15/2023 p.m. shift, the temperature was six (6) ?. j. On the 10/16/2023 p.m. shift, the temperature was two (2) ?. k. On the 10/17/2023 p.m. shift, the temperature was six (6) ?. l. On the 10/21/2023 p.m. shift, the temperature was seven (7) ?. m. On the 10/22/2023 p.m. shift, the temperature was five (5) ?. n. On the 10/27/2023 p.m. shift, the temperature was five (5) ?. o. On the 10/28/2023 p.m. shift, the temperature was eight (8) ?. p. On the 10/29/2023 p.m. shift, the temperature was three (3) ?. The DS stated the Meat Freezer should always be below 0 ? to keep the stored foods frozen. During an interview on 10/31/2023 at 2:11 p.m., with the DS, the DS stated she is responsible for monitoring the Meat Freezer temperature log but didn't see the out of normal range temperatures in the log. The DS stated the facility's procedure as well as the instructions on the temperature log indicates that if the temperature is not within an acceptable range, facility staff is to note a comment or correction and report to the supervisor immediately. The DS stated she was not informed when the temperatures were outside of normal range. The DS stated if the freezer temperature is too high it can lead to the meat thawing (going from a frozen state to an unfrozen state). The DS stated thawed meat should never be refrozen due to food safety issues and possible bacteria growth. A review of the facility policy and procedure titled, Procedure for Freezer Storage last reviewed 10/11/2023 indicated the freezer should be maintained at a temperature of 0? or lower. 3. On 10/30/2023 at 7:52 a.m., during a concurrent observation and interview with DS, Dietary Services Aide 2 (DSA 2), and [NAME] 1, the kitchens low temperature dish washing machine was observed. The DS stated the facility uses a low temperature dish washing machine with chemicals to ensure sanitization of resident dishware and utensils, kitchen pots, pans, and other kitchen equipment. DSA 2 stated the dishes to the left of the machine, including a large metal can opener, had just been washed in the machine and were clean. Observed the DS use a Chem [NAME] Chlorine Test Strip (a strip of paper used to indicate the strength of chemicals in a solution, with the correct measurement being 50 to 100 ppm. indicating the dishes were sanitized) on the surface of the clean dishes and the remaining water in the dishwashing machine. The DS stated the strip measured 10 ppm. and indicated the low temperature dishwasher was not sanitizing. The DS ran the dishwashing machine again and rechecked the sanitization solution level. Observed the test strip read 10 ppm. The DS stated there was something wrong with the low temperature dish washing machine because it was not sanitizing. The DS stated she would call the company that services it. During an interview on 10/31/2023 at 2:11 p.m., with the DS, the DS stated the facility uses the manufacture guidelines for the low temperature dishwashing machine and all facility equipment should be working. The DS stated if kitchen equipment and dishes are not properly sanitized it could lead to bacteria growth and it is a food safety concern for residents who may become ill. A review of the facility's policy and procedure titled Dish Washers Operation Manuel, undated, indicated to close the doors to start the machine, the machine will automatically start and run through its cycle. Watch to ensure that the chemicals are delivered and stop during the cycle. Follow the directions on the litmus paper (a type of paper that changes color according to the chlorine solution concentration level) and test the water on the surface of the bottom of the dishware, the concentration should be 50 ppm. 4. During a concurrent observation and interview with the DS on 10/31/2023 at 2:30 p.m., observed the facility's ice machine located inside the Station 2 Storage Room. Observe the machine drain hose placed inside the floor drain with no air gap. The DS stated the Maintenance Director (MD) was responsible for the ice machine and she did not know what an air gap was. During a concurrent observation and interview on 10/31/2023 at 2:50 p.m. with the MD, the MD observed the facility ice machine located inside Station 2 Storage Room. The MD stated there was no air gap between the ice machine drain hose and the floor drain. The MD stated the hose was placed in the floor drain. The MD stated there should always be a three-inch gap above the floor drain and where the drain hose ends to prevent backflow of contaminated water from the drain into the ice machine if the drain becomes backed up. The MD stated the facility did not have a policy regarding air gaps, but it was a standard of practice based on the Health and Safety Code (laws covering subject areas of health and safety in California). A review of the facility's policy regarding air gap included California Health and Safety Code 114193.1, dated 7/1/2007, indicated an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement infection control practices by: 1. Failing to ensure a resident's oxygen tubing (connects to an oxygen source to deliver oxygen to a resident) was labeled with the date it was last changed and was kept off the floor for one (Resident 110) of five sampled residents investigated for infection control. 2. Failing to ensure that, the wound treatment nurse (Licensed Vocational Nurse 1 [LVN 1]), who was observed wearing two sets of gloves on at the same time, performed hand hygiene (washing of hands) when removing one set of gloves during a wound care dressing (sterile [free from germs] pad applied to a wound to promote healing and protect the wound from infection) change observation for two (Residents 47 and Resident 16) of five sampled residents investigated for infection control. 3. Failing to ensure that during a medication administration observation, Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before and after administering medications to two (Residents 13 and Resident 112) of five sampled residents investigated for infection control. These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: a. A review of Resident 110's admission Record indicated the facility originally admitted the resident on 10/19/2023 and readmitted the resident on 10/28/2023 with diagnoses including hypertension (high blood pressure) and diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated). A review of Resident 110's physician's order, dated 10/28/2023, indicated an order for oxygen at two (2) liters per minute (LPM) via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) as needed for shortness of breath. On 10/30/2023 at 9:48 a.m., during a concurrent observation and interview with LVN 1, observed Resident 110 asleep in bed. Observed Resident 110 receiving oxygen at 2.5 LPM via nasal cannula. Also observed was Resident 110's oxygen tubing was not labeled with the date it was last changed, and the oxygen tubing was observed to be on the floor. LVN 1 stated that Resident 110's oxygen tubing was on the floor and had no date on it to indicate when the oxygen tubing was last changed. LVN 1 stated the oxygen tubing should be labeled with the date it was last change and stated that excess tubing should be kept off the floor and inside a plastic bag to prevent contamination of the tubing. On 11/2/2023 at 11:36 a.m., during an interview, the Infection Preventionist (IP) stated it was important to keep oxygen tubing off the floor because the floor is contaminated with bacteria and can cause infection to a resident. The IP stated it was important to label the tubing with the date of when it was last changed to ensure the licensed nurses are aware of when the tubing is due to be changed so that the resident always has a clean oxygen tube. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that oxygen tubing should be labeled with the date of when it was last changed. RN 1 stated the purpose of labeling the tubing is so that staff know when it was last changed and so that it can be changed weekly. RN 1 stated it was also important to keep oxygen tubing off the floor to ensure that it does not become contaminated with the dirt from the floor. RN 1 stated that if the tubing becomes contaminated, then the resident can possibly get an infection from the oxygen tubing. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/11/2023, indicated that after completing the oxygen setup or adjustment, the following information should be recorded - the date and time that the procedure was performed. b. A review of Resident 47's admission Record indicated the facility originally admitted Resident 47 on 2/8/2021 and readmitted Resident 47 on 9/10/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD - refers to group of diseases that cause airflow blockage and breathing-related problems) with lower respiratory infection, atrial fibrillation (an irregular heartbeat and rapid heart rhythm), elevated white blood cell count (a lab test that indicates a resident has an on-going infection). A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/9/2023, indicated Resident 47 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance from staff for walking in the room and in the corridor, locomotion (movement or ability to move from one place to another) on and off the unit, dressing, and toilet use. A review of Resident 47's Physician's Order, dated 9/10/2023, indicated that for Resident 47's neck mid tracheostomy (a surgically created hole [stoma] in the windpipe that provides an alternative airway for breathing) stoma site, cleanse with normal saline (NS - a mixture of sodium chloride [salt] and water), pat dry, then cover with dry dressing daily and as needed. On 10/30/2023 at 9:58 a.m., during an observation, observed LVN 1 performing a dressing change to Resident 47's tracheostomy site. Observed LVN 1 put on two pairs of gloves before removing the dirty dressing and cleaning Resident 47's tracheostomy site. Observed LVN 1 then remove the first layer of gloves and put on a new pair of gloves without performing hand hygiene between glove changes. On 10/31/2023 at 2:11 p.m., during an interview, LVN 1 stated that he wears two pairs of gloves when he does dressing changes. LVN 1 stated he keeps on his first pair of gloves on and only changes the second pair of gloves. LVN 1 stated he only performs hand hygiene before putting on both sets of gloves and after taking off both gloves. LVN 1 stated he should be performing hand hygiene in between changing gloves for infection control. On 11/2/2023 at 11:36 a.m., during an interview, the Infection Preventionist (IP) stated she expected her licensed nurses, during dressing changes, to perform hand hygiene before and after the procedure, between going from dirty to clean, and between changing gloves. The IP stated it was important to perform hand hygiene between changing gloves to ensure that the nurse is not introducing contaminants from the dirty dressing to the clean dressing. The IP stated doing so can potentially lead to the resident contracting an infection. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that, during dressing changes, nurses should be performing hand hygiene before and after the procedure and between changing gloves. RN 1 stated it was important to perform hand hygiene between changing gloves in order to kill the bacteria on your hands and prevent cross contamination between glove changes. RN 1 stated the resident's wound can become infected if the nurse does not perform hand hygiene. A review of the facility's policy and procedure titled, Dressings, Dry/Clean, last reviewed on 10/11/2023, indicated the following steps for wound care dressing changes: 1. Wash and dry hands thoroughly. 2. Put on clean gloves. Loosen tape and remove soiled dressing. 3. Pull glove over dressing and discard into plastic or biohazard bag (used to dispose of waste material that is potentially infectious or could be a threat to a person's health). 4. Wash and dry your hands thoroughly. 5. Put on clean gloves 6. Cleanse the wound with ordered cleanser. 7. Use dry gauze to pat the wound dry. 8. Apply the ordered dressing and secure with tape or bordered dressing per order. 9. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. c. A review of Resident 16's admission Record indicated the facility originally admitted Resident 16 on 2/22/2023 and readmitted Resident 16 on 4/5/2023 with diagnoses that included pressure-induced deep tissue damage (damage of underlying soft tissue from pressure) to the left heel. A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had severely impaired cognition and required extensive assistance from staff for dressing and toilet use. A review of Resident 16's Physician's Order, dated 9/28/2023, indicated that for Resident 16's left heel stage four [4] pressure injury (The most severe type of pressure injury [wound that is the result of prolong pressure over a bony area]. The skin is severely damaged, and the surrounding tissue begins to die [tissue necrosis]), cleanse with NS, pat dry, apply collagen (a protein responsible for healthy joints and skin elasticity) powder, and cover with a foam dressing (used to create a moist environment conducive to wound healing) every day shift one time a day. On 10/30/2023 at 10:24 a.m., during an observation, observed LVN 1 performing a dressing change for Resident 16's left heel wound. Observed LVN 1 put on two pairs of gloves before removing the dirty dressing and cleaning the site. Observed LVN 1 remove the first layer of gloves and put on a new pair of gloves without performing hand hygiene between glove changes. On 10/31/2023 at 2:11 p.m., during an interview, LVN 1 stated that he wears two pairs of gloves when he does dressing changes. LVN 1 stated he keeps on his first pair of gloves and only changes the second pair of gloves. LVN 1 stated he only performs hand hygiene before putting on both sets of gloves and after taking off both gloves. LVN 1 stated he should be performing hand hygiene in between changing gloves for infection control. On 11/2/2023 at 11:36 a.m., during an interview, the IP stated she expected her licensed nurses, during dressing changes, to perform hand hygiene before and after the procedure, between going from dirty to clean, and between changing gloves. The IP stated it was important to perform hand hygiene between changing gloves to ensure that the nurse is not introducing contaminants from the dirty dressing to the clean dressing. The IP stated doing so can potentially lead to the resident contracting an infection. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that, during dressing changes, nurses should be performing hand hygiene before and after the procedure and between changing gloves. RN 1 stated it was important to perform hand hygiene between changing gloves in order to kill the bacteria on your hands and prevent cross contamination between glove changes. RN 1 stated the resident's wound can become infected if the nurse does not perform hand hygiene. A review of the facility's policy and procedure titled, Dressings, Dry/Clean, last reviewed on 10/11/2023, indicated the following steps: 1. Wash and dry your hands thoroughly. 2. Put on clean gloves. Loosen tape and remove soiled dressing. 3. Pull glove over dressing and discard into plastic or biohazard bag. 4. Wash and dry your hands thoroughly. 5. Put on clean gloves 6. Cleanse the wound with ordered cleanser. 7. Use dry gauze to pat the wound dry. 8. Apply the ordered dressing and secure with tape or bordered dressing per order. 9. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. d. A review of Resident 13's admission Record indicated the facility admitted Resident 13 on 1/3/2020 with diagnoses that included hypertension. A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had intact cognition and required supervision from staff with bed mobility, transfers, locomotion on and off the unit, and toilet use. A review of Resident 112's admission Record indicated the facility admitted Resident 112 on 10/19/2023 with diagnoses including hypertension and atrial fibrillation. On 10/31/2023 at 9:03 a.m., observed LVN 2 performing medication administration for Resident 13 and Resident 112. LVN 2 was observed not performing hand hygiene before or after administering medications to Resident 13 and Resident 112. On 10/31/2023 at 9:27 a.m., during an interview, LVN 2 stated that she did not perform hand hygiene before, after, and between giving medications to Resident 13 and Resident 112. On 11/2/2023 at 11:36 a.m., during an interview, the IP stated that, during medication administration, nurses should perform hand hygiene before preparing the medications, before going into the residents' room, and before and after administering medications to each resident. The IP stated hand hygiene is important to keep from spreading germs among residents. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that, during medication administration, nurses should perform hand hygiene before and after each resident interaction so that they do not spread bacteria among the residents. A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that staff should follow established facility infection control procedures (e.g. handwashing, aseptic technique [practices and procedures that helps protect patients from dangerous germs], gloves, isolation precautions used to help stop the spread of germs from one person to another] etc.) for the administration of medications, as applicable. A review of the facility's policy and procedure titled, Standard Precautions (minimum infection prevention and control practices that must be used at all times for all residents in all situations), last reviewed on 10/11/2023, indicated that hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water before and after contact with the resident and after contact with items in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA, the Department) two incidents of injuries of unknown origin (injuries resulting without knowing how it happened), which occurred on 3/5/2023 and 7/22/2023 for one of three sampled residents (Resident 1). These deficient practices resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: 1. A review of Resident 1 ' s admission Record, dated 10/27/2023, indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses hemiplegia (a condition that causes inability to move half of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (area of dead tissue in the brain caused by blocked and/or narrowed arteries that carry blood and oxygen to the brain) affecting the right dominant side, and unspecified dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage caused by problems with supply of blood to the brain). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 4/29/2023, indicated Resident 1 had ability to usually understand others and usually be understood. A record review of Resident 1 ' s Change of Condition/Interact Assessment Form (COC- a documentation to show when there is a physical or mental change in the resident that requires further action by the facility), dated 3/25/2023, timed at 10:00 a.m. indicated Resident 1 had an abrasion (an injury caused by something rubbing or scraping against the skin) to the mid back and right lateral (to the side of or away from the body) lower ribs with skin redness and discoloration (change of skin color from how it usually appears). A record review of Resident 1 ' s Physician ' s Orders, dated 3/25/2023, timed at 7:19 p.m. indicated a STAT (immediate) X-radiation (x-ray-creation of pictures of the inside of the body), of thoracic (chest area of the body between neck and abdomen) and lumbar (lower back area) spine (backbone); right rib for complain of pain in lower back and right rib cage area. A record review of Resident 1 ' s x-ray report dated 3/25/2023, indicated that Resident 1 had acute (of abrupt onset) fractures (broken bone) of the right lateral eighth, ninth, and tenth ribs. During an interview and concurrent record review on 10/30/2023 at 5:55 p.m. with the Director of Nursing (DON), Resident 1 ' s COC dated 3/25/2023 was reviewed. The DON stated that Resident 1 was discovered to have multiple rib fractures but nobody from the facility knew how the resident got those injuries. The DON stated that Resident 1 was not a reliable source of how the incident happened due to his dementia and that he could not remember what happened. The DON verified that Resident 1 ' s x-ray report dated 3/25/2023 indicating multiple fractures to the resident ' s ribs were new significant injuries. The DON stated that due to its unknown origin, the fractured ribs were injuries of unknown origin. When asked if the DON reported this incident with injuries of unknown origin to the SSA, DON stated no. 2. A record review of Resident 1 ' s COC/Interact Assessment Form, dated 7/22/2023, timed at 11:00 a.m. indicated Resident 1 complained of back pain and claims that he had a fall. A record review of Resident 1 ' s Physician ' s Orders, dated 7/22/2023, timed at 12:55 p.m. indicated to transfer Resident 1 to the General Acute Care Hospital (GACH) for further evaluation due to complain of back pain. A record review of Resident 1 ' s GACH records, dated 7/23/2023, indicated a computed tomography (CT - diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body. It shows detailed images of any part of the body, including the bones, muscles, fat, organs and blood vessels.) of the bones indicated a displaced (pieces of the bone moved so much that a gap formed around the bone where it broke) right scapular (shoulder blade bone) tip fracture, minimally displaced (when the bone cracks part or all the way through but maintains alignment) right lateral fourth to seventh and tenth rib fractures, nondisplaced posterior (back or behind) right sixth and eight rib fractures. During an interview and concurrent record review on 10/30/2023 at 6:55 p.m. with the DON, Resident 1 ' s COC dated 7/22/2023 was reviewed. The DON stated that Resident 1 was transferred to the GACH for further evaluation and was found to have fractures to the right shoulder blade and right ribs. The DON stated she did not know how this injury happened and that it was an injury of unknown origin. The DON stated that she did not report this incident to the SSA. When asked who is responsible to report injuries of unknown origin, the DON stated she would report them. When asked if these injuries of unknown origin should have been reported to the SSA, the DON stated yes. During an interview on 11/1/2023 at 5:55 p.m. with the Administrator (ADM), the ADM stated that it is the facility ' s policy to report any injury of unknown origin with significant injuries to the State agency as mandated reporters. The ADM stated he was not informed by the DON regarding the incidents at the time of the injuries and was not aware that the incidents were not reported to the SSA. A review of the facility ' s policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022, indicates that injury of unknown source must be reported immediately (immediately defined as two [2] hours of an allegation involving abuse or resulting in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury) to the state agency.

Based on interview and record review, the facility failed to ensure effective pain management was done by failing to: 1. Administer pain medication as prescribed for one of three sampled residents (Resident 1). 2. Document pain medication administration after new onset of pain for one of three sampled residents (Resident 1). 3. Ensure a pain risk reassessment was completed after a new onset of pain for one of three sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 not maintaining the highest possible level of comfort and had the potential to result in lack of detection of unrelieved pain. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/2/2021 with diagnoses that included Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), schizoaffective disorder (a mental health problem where you experience psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality as well as mood symptoms]) and other lack of coordination. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/12/2023, indicated Resident 1 has clear speech, rarely/never makes self-understood, and rarely/never understands others. The MDS indicated Resident 1 required limited assistance with bed mobility, transfer, and eating and required extensive assistance with dressing, toilet use, and personal hygiene. A review of Resident 1's Change of Condition (COC- sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains)/Interact Assessment Form dated 3/13/2023 at 1:00 a.m., indicated symptoms identified: Left Hand swelling and discoloration. Pain (location): Left hand. A review of Resident 1's physician orders indicated Tylenol (medication that can treat minor aches and pains) tablet 325 milligrams (mg- a unit of measurement) give two tablets by mouth every six hours as needed for mild pain 1-3/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered on 12/2/2021. a. During a concurrent interview and record review on 3/28/2023 at 2:42 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 1's Medication Administration Record (MAR) for the month of March 2023. RN 1 stated Resident 1's MAR did not indicate that Resident 1 was administered pain medication on 3/13/2023 at around 1:00 a.m. when pain to the left hand was noted. During an interview on 3/28/2023 at 4:18 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that on 3/13/2023 at around 1:00 a.m. Resident 1's assigned Certified Nursing Assistant (CNA) reported to RN 2, swelling of Resident 1's left hand. RN 2 stated that she went to assess Resident 1's left hand and noted left hand swelling and discoloration. RN 2 stated when she touched Resident 1's left hand, Resident 1 yelled which indicated pain. RN 2 stated that she asked Resident 1 if she was in pain, however, Resident 1 was unable to verbalize her pain level. RN 2 stated she knew Resident 1 had an order for Tylenol and administered one tablet because Resident 1 yelled when Resident 1's left hand was touched. RN 2 continued to state that she did not recall documenting that she administered Tylenol to Resident 1. RN 2 stated she forgot to document she had administered the Tylenol. During a concurrent interview and record review on 3/29/2023 at 10:58 a.m., with the Director of Nurses (DON), the DON stated that Resident 1 should have been administered pain medication based on pain scale and physician's order. The DON stated that RN 2 should have checked the order first prior to administering the medication. The DON stated RN 2 should have also documented what medication she administered and documented Resident 1's pain reassessment. A review of the facility-provided policy and procedure titled Administering Medications, revised date 4/2019, indicated medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber ' s orders .The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .As required or indicated for a medication, the individual administering the medication records in the resident ' s medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. b. During a concurrent interview and record review on 3/28/2023 at 3:05 p.m., with RN 1, RN 1 stated pain risk assessments are done upon admission, quarterly (every three months), and as needed if resident complains of any new onset of pain. RN 1 reviewed Resident 1's pain risk assessment and stated that a quarterly pain risk assessment was done on 3/12/2023, which indicated low risk. RN 1 stated a pain risk assessment was not done after Resident 1's new onset of pain on 3/13/2023. RN 1 continued to state that because Resident 1 complained of a new onset of pain on 3/13/2023, Resident 1 should have been reassessed. RN 1 stated the purpose of the pain risk assessment is to ensure pain management. RN 1 stated that with Resident 1's new onset of pain, her pain risk assessment would have been high risk. During an interview on 3/29/2023 at 10:53 a.m., with the DON, the DON stated a pain risk assessment should be done when there is new onset of pain. The DON stated RN 2 should have initiated a pain risk assessment on 3/13/2023. A review of the facility-provided policy and procedure titled Pain- Clinical Protocol, revised 3/2018, indicated the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. A review of the facility-provided policy and procedure titled Charting and Documentation, revised 7/2017, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' clinical records were updated to show documentation that Advance Directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were obtained and made readily available in the residents' charts and annually reviewed for two of six sampled residents (Resident 11 and 61). This deficient practice had the potential to result in confusion in the care and services for Resident 11 and 61 and placed both residents at risk of receiving unwanted treatment and not receiving appropriate care based on their wishes. Findings: a. A review of Resident 11's admission Record indicated the facility admitted the resident on 3/30/2007 with diagnoses that included muscle wasting and atrophy (the thinning of muscle mass) and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 11's History and Physical, dated 4/21/2021, indicated the resident had the capacity to understand and make decisions. A review of Resident 11's Minimum Data Set (MDS- an assessment and care screening tool), dated 3/26/2022, indicated Resident 11 had the ability to make self-understood and had the ability to understand others. During an interview on 10/12/2022 at 11:57 a.m., the Social Services Director (SSD) stated the facility AD procedure was to ask the resident or resident representative (RP) on admission if the resident had an AD, the resident or RP would sign the Advance Directive Acknowledgment form to confirm they had an AD or were provided education regarding obtaining one. The SSD stated if the resident had an AD, they would be asked to bring it to the facility and the SSD would follow up to ensure it was received and placed in the resident's chart. During an interview on 10/12/2022 at 2:48 p.m., and concurrent record review of Resident 11's medical chart, the SSD stated the Advance Directive Acknowledgment form, signed on 7/17/2011 by Resident 11, indicated the resident executed an AD. The SSD stated Resident 11's AD was not readily available in the chart. The SSD stated the AD should be in the chart and available to staff to be informed of Resident 11's wishes. During an interview on 10/12/2022 at 3:02 p.m., the SSD stated she was unable to find Resident 11's AD in the facility. The SSD stated Resident 11 was a long-term resident and she would contact Resident 11's family to request they send the AD with any changes that had been made. The SSD stated there was no documented evidence that Resident 11's AD was received after the AD Acknowledgment form was completed or that the facility followed up and tried to obtain a copy. The SSD stated she only completes the AD form and follows up when a resident is admitted . The SSD stated she does not follow up or review the residents' AD annually. The SSD stated she did not know she should review residents' ADs annually. b. A review of Resident 61's admission Record indicated the facility admitted the resident on 6/4/2020 and readmitted on [DATE] with diagnoses that included muscle wasting and atrophy and spinal stenosis (a narrowing of the spinal canal in the lower back that may cause pain or numbness in the legs). A review of Resident 61's History and Physical, dated 10/20/2021, indicated Resident 61 did not have the capacity to understand and make decisions. A review of Resident 61's MDS, dated [DATE], indicated Resident 61 usually had the ability to make self-understood and usually had the ability to understand others. During an interview on 10/12/2022 at 11:57 a.m., the SSD stated the facility AD procedure was to ask the resident or resident representative (RP) on admission if the resident had an AD, the resident or RP would sign the Advance Directive Acknowledgment form to confirm they had an AD or were provided education regarding obtaining one. The SSD stated if the resident had an AD, they would be asked to bring it to the facility and the SSD would follow up to ensure it was received and placed in the resident's chart. The SSD reviewed Resident 61's chart and stated the AD Acknowledgment form, signed on 1/15/2022 by Resident 61's RP, indicated the resident had executed an AD. The SSD stated the AD was not readily available in Resident 61's chart. During an interview on 10/12/2022 at 12:30 p.m., the SSD stated there was no documented evidence that Resident 61's AD was received after the AD Acknowledgment form was completed or that the facility followed up and tried to obtain a copy. The SSD stated she called Resident 61's RP and the RP stated the AD was provided to the facility. The SSD stated the importance of the AD is to know and be able to follow the wishes of the resident. The SSD stated she only completes the AD form and follows up when a resident is admitted . The SSD stated she does not follow up or review the residents' AD annually. The SSD stated she did not know she should review residents' ADs annually. During an interview on 10/13/2022 at 2:30 p.m., the Director of Nursing (DON) stated if a resident indicated they had an AD, then it should be in the resident's chart and available so anyone in the facility would know the wishes of the resident. The DON stated the AD acknowledgment form should not indicate that a resident has an AD if it is not readily available in the resident's chart. The DON stated if a resident or RP indicated there was an AD, there should have been documentation that there were attempts made to get it. The DON stated if a resident had certain wishes in an AD, then it was a legal responsibility for the facility to know those wishes. During an interview on 10/13/2022 at 4:30 p.m., the DON stated it was the responsibility of the SSD to follow up to ensure the AD was received and reviewed annually. The DON reviewed the facility policy and stated the SSD should document the AD follow up communication and annual review and if it was not documented, then it was not done. A review of the facility's Policy and Procedure titled, Advance Directives, last reviewed on 10/13/2021, indicated the Advance Directive will be respected in accordance with state law and facility policy. Prior to or upon admission of a resident to the facility, the SSD or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive. Prior to or upon admission of a resident, the SSD or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directive. Information about whether or not the resident has an advance directive shall be displayed prominently in the medical chart. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN - a written notification to the resident or responsible party of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services with benefit days remaining) in a timely manner for two of three sampled residents (Resident 38 and Resident 55). This deficient practice had the potential to result in Residents 38 and 55 or their responsible parties not being able to exercise their rights to decide their care. Findings: a. A review of Resident 38's admission Record indicated the facility admitted the resident on 6/24/2022 with diagnoses that included multiple sclerosis (a long-lasting disease that can affect the brain, spinal cord, and the optic nerves in the eyes), muscle wasting and atrophy (a weakening, shrinking and loss of muscle caused by disease or lack of use), and neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/11/2022, indicated the resident had the ability to make self-understood and the ability to understand others. A review of Resident 38's SNF Beneficiary Protection Notification Review Form indicated the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The document indicated that the last covered day of Medicare Part A service was 5/4/2022 and that the SNF ABN was not provided to the resident. During an interview, on 10/12/2022 at 3:58 p.m., the Business Office Manager (BOM) stated Resident 38 had benefit days remaining and was still residing in the facility but had been discharged from Medicare Part A services. The BOM stated Resident 38 received the Notice of Medicare Non-Coverage (NOMNC - notice provided to the beneficiary of his or her right to an expedited review of service termination of Medicare Part A services for coverage reasons) but he does not know who completes the SNF ABN. During a concurrent interview and record review on 10/13/2022 at 9:05 a.m., the Director of Nursing (DON) stated that SNF ABN is provided to residents with Medicare coverage and with remaining days but the services the facility provided does not meet the needs of the resident. The DON reviewed Resident 38's SNF Beneficiary Protection Notification Review Form and stated Resident 38's last covered day of Medicare Part A service was 5/12/2022. The DON stated the SNF ABN was not provided to Resident 38 but should have been provided to the resident per policy. b. A review of Resident 55's admission Record indicated the facility admitted the resident on 8/27/2020 with diagnoses that included muscle wasting and atrophy (a weakening, shrinking and loss of muscle caused by disease or lack of use), thrombocytopenia (a condition in which you have a low blood platelet [tiny blood cells that help the body form clots to stop bleeding] count), and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 55's MDS, dated [DATE], indicated the resident had the ability to make self-understood and the ability to understand others. A review of Resident 55's SNF Beneficiary Protection Notification Review Form indicated the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The document indicated that the last covered day of Medicare Part A service was 5/12/2022 and that the SNF ABN was not provided to the resident because the resident did not exhaust the benefit days and had no denial of services. During a concurrent interview and record review, on 10/13/2022 at 8:52 a.m., the BOM stated he had been working in the facility for six months and had never given a SNF ABN before. The BOM stated the SNF ABN should be given at least two days before the last covered day of the resident. The BOM verified that Resident 55's last covered day was 5/12/2022 with benefit days remaining. During a concurrent interview and record review on 10/13/2022 at 9:05 a.m., the DON stated that SNF ABN is provided to residents with Medicare coverage and with remaining days but the services the facility provided does not meet the needs of the resident. The DON reviewed the SNF Beneficiary Protection Notification Review Form and verified that Resident 55's last covered day of Medicare Part A service was 5/12/2022. The DON stated that the SNF ABN should have been provided to the resident per policy. During an interview on 10/13/2022 at 9:54 a.m., the BOM stated the SNF ABN form allows residents to make informed decisions regarding their care and it would outline the estimated costs and financial liability when Medicare coverage part A end and the resident continues to stay at the facility. The BOM confirmed that he is responsible for making sure that SNF ABN and the Notice of Medicare Non-Coverage (NOMNC) are provided to the residents or responsible parties. The BOM stated that he would go over the notices with self-responsible residents or he would reach out to the responsible party by phone or mail. A review of the facility provided untitled policy and procedure on Medicare beneficiary coverage, reviewed on 10/13/2021, indicated that the facility will complete the Medicare Denial Status Change Form upon admission and/or a minimum of two days prior to the last Medicare Part A covered day. The policy also indicated that the facility would provide the SNF ABN to the beneficiary / responsible party when there are skilled benefit days remaining and determined that the beneficiary no longer meets requirements for skilled level of care and resident continue to say in the facility.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 31 and Resident 5) were free from any physical or chemical restraint, imposed for purposes of convenience and not required to treat the resident's medical symptoms, by failing to follow the facility policy and procedure for the implementation of restraint usage: 1. For Resident 31, when two large wedge bolsters were placed under Resident 31's mattress. 2. For Resident 5, when two pillows were placed underneath the Resident 5's bed mattress on the left side, while the resident was lying in bed. These deficient practices had the potential to cause a loss of dignity and created safety risks with the potential to cause physical harm to Residents 31 and 5. Findings: a. A review of Resident 31's admission Record indicated the facility admitted the resident on 8/11/2022 with diagnoses that included fracture of the left femur, muscle wasting and atrophy (the thinning of muscle mass), encephalopathy (a disturbance of normal brain function that may cause changes in cognitive function and level of consciousness), and repeated falls. A review of Resident 31's History and Physical, dated 8/13/2022, indicated Resident 31 did not have the capacity to understand and make decisions. A review of Resident 31's Minimum Data Set (MDS- an assessment and care screening tool), dated 8/18/2022, indicated Resident 31 rarely had the ability to make self-understood and rarely had the ability to understand others. The MDS indicated Resident 31 was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 31's Fall Risk Assessment form (a tool used to determine a resident's risk for falling), dated 8/11/2022, indicated the resident was a high risk for falls. A review of Resident 31's Care Plan (CP) titled, Risk for Falls, initiated 8/11/2022, indicated Resident 31 was at risk for falls related to poor safety awareness, dementia, attempts to get out of bed unassisted, and dangles his leg outside of bed. A review of Resident 31's CP titled, Resident has periods of confusion, disorientation with risk for further decline in cognition and decision making related to dementia, initiated 8/12/2022, indicated Resident 31 would be monitored and needs anticipated. A review of Resident 31's CP titled, Side Rails Management, initiated 8/11/2022, indicated Resident 31 had both ¼ side rails up while in bed for repositioning, improve posture and function, activities of daily living care, and comfort. The CP indicated a goal to minimize the risk for complication related to the use of side rails. The CP further indicated the resident would be monitored for safety and risk for entrapment from siderails. During an observation on 10/11/2022 at 9 a.m., Resident 31 lay in bed with the head of the bed raised approximately 30 degrees (a unit of measurement), legs outstretched at an elevated angle of approximately 15 degrees, and with the bilateral side rails up. Large bolster wedges, measuring approximately 3 feet (ft, a unit of measurement) by 3 ft, were placed below the resident's mattress that unevenly elevated the mattress off the bed frame at the Resident's feet. Resident 31 was not interviewable. During an observation and interview on 10/11/2022 at 3 p.m., Certified Nursing Assistant 3 (CNA 3) assessed Resident 31 and stated there were large bolster wedges under the resident's mattress on both sides. CNA 3 stated they were used to elevate the resident's feet. CNA 3 stated the bolsters were usually used on top of the mattress because the resident tried to get up and they keep him in bed. During an observation and interview on 10/11/2022 at 3:15 p.m., Licensed Vocational Nurse 2 (LVN 2) assessed Resident 31 and stated the bolsters were placed under the mattress. LVN 2 stated she cared for Resident 31 all day but had not seen the bolsters. LVN 2 stated she did not know why the bolsters were under the mattress or who put them there. LVN 2 stated the bolsters should not be placed under the mattress and were not being properly used for positioning of the resident. During an observation and interview on 10/11/2022 at 3:30 p.m., Registered Nurse 1 (RN 1) stated Resident 31 had a history of confusion. RN 1 assessed Resident 31 and stated the bolsters were elevating the resident's legs and appeared to be used as a restraint to keep him in the bed. RN 1 stated there was no order or consent for that type of restraint because it was a safety risk. RN 1 stated the wedges were very large and it was a safety risk because the resident was a fall risk. RN 1 was observed removing the bolsters. During an interview on 10/13/2022 at 3:24 p.m., and concurrent record review of Resident 31's medical chart and Interdisciplinary Team Notes dated 8/31/2022, the Director of Nursing (DON) stated the resident only had a physician's restraint order for hand mittens and side rails. The DON stated Resident 31 had poor safety awareness, attempted to get out of bed, sits at bedside, and gets aggressive when redirected. The DON stated the wedge was used improperly under the mattress as a restraint and it was not removable by the resident. The DON stated there was no order for a wedge restraint because the wedge was improperly used. During an interview on 10/14/22 at 9 a.m., and concurrent record review of Resident 31's medical chart, the Director of Rehabilitation Services (DRS) stated the resident was discharged from physical therapy and occupational therapy on 9/16/2022. The DRS stated Resident 31 was a fall risk. The DRS stated she never recommended any support devices for the resident. The DRS stated the resident was able move his legs off the bed but required assistance with bed mobility. The DRS stated on 10/13/2022 she was made aware that the bolster wedges were used for Resident 31, and they should never be used under the mattress because of safety concerns. The DRS stated she would never manually modify a mattress because it would create an uneven bed surface and place the resident at risk. The DRS stated the bed was not made to have an object placed under the mattress and it could move and create undesired elevation or resident position. The DRS stated she did not know who put the wedges under the mattress or the logic behind the use of wedges. The DRS stated she was concerned that the wedge was improperly used as a restraint because it elevated a resident's legs that did have good trunk control and made it difficult for the resident to get up. The DRS stated the importance of not using the wedge under the mattress was because it did not provide proper pressure distribution, created an uneven bed surface, and was a safety concern with the side rails up and a risk for fall. A review of the facility's policy and procedure titled, Use of Restraints, last reviewed 10/13/2022, indicated restraints shall only be used for the safety and wellbeing of the resident only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. Physical restraints are defined as any manual method or physical or chemical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. A review of the Policy and Procedure titled, Safety and Supervision of Residents, last reviewed 10/13/2022, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. A review of the Policy and Procedure titled, Bed Safety, last reviewed 10/13/2022, indicated the facility shall strive to provide a safe sleeping environment for the resident. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: inspection by maintenance staff of all beds and related equipment as part of a regular bed safety program to identify risk and problems including potential entrapment risks; identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc). The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptom, and only after being reviewed by authorized individuals. A review of the Policy and Procedure titled, Hazardous Areas, Devices and Equipment, last reviewed 10/13/2022, indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Example of environmental hazards include devices and equipment that are improperly used and furniture that is unstable or positioned at an improper height for residents. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. A review of the Policy and Procedure titled, Falls and Fall Risk, managing, last reviewed 10/13/2022, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Environmental factors that contribute to risk for falls include incorrect bed height or width. Resident conditions that may contribute to the risk of falls include delirium or other cognitive impairment, lower extremity weakness, poor grip strength, functional impairments, visual deficits, incontinence. A review of the Policy and Procedure titled, Quality of Life - Dignity, last reviewed 10/13/2022, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture is one that supports and encourages humanization and individuation of residents and honors resident choices, preferences, values and beliefs. b. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 3/24/2022 with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and atrial fibrillation (abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart). A review of Resident 5's History and Physical dated 3/26/2022 indicated the resident did not have the capacity to understand and make decisions. During an observation on 10/11/2022 at 9:02 a.m., Resident 5 was lying in bed awake with two pillows placed under the resident's mattress both placed on the left side located close to the foot of the bed. During an observation on 10/11/2022 at 12:32 p.m., Resident 5 was still lying-in bed, awake, with two pillows placed under the resident's mattress both placed on the left side located close to the foot of the bed. During a concurrent observation and interview at Resident 5's bedside on 10/11/2022 at 3:28 p.m., at Resident 5's bedside, CNA 6 confirmed two pillows with pillowcase tucked in under Resident 5's mattress left side by Resident 5's lower extremities while Resident 5 is lying in bed. CNA 6 stated this was to prevent Resident 5 from rising and getting out of bed. CNA 6 stated Resident 5 is confused and tends to get up unassisted and risk of falling. CNA 6 stated she started her shift at 3 p.m. and the two pillow were already there and she decided to leave it there. During an interview on 10/13/2022 at 2:45 p.m., RN 1 stated Resident 5 should not have pillows tucked underneath the mattress. RN 1 stated pillows are meant to use as lumbar support or for resident's comfort. RN 1 stated when pillows are tucked underneath the mattress it prevents the resident from rising and is considered a restraint. RN 1 stated before using a restraint a consent is obtained from the responsible party and needs to have a physician order and should be care planned. RN 1 stated the pillows should not be under Resident 5's mattress or any residents. During an interview on 10/14/2022 at 12:32 p.m., the DON stated for restraints it has to be least restrictive, not impair or endanger the resident, try verbal cueing, such as resident attempting to pull out their gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) use of binder if did not work, then go higher, risk for injury on the site such as bleeding, risk for infections, depriving of nutrients, such as use of hand mittens. DON stated the pillows should be in direct contact with the body. DON stated the pillows are used for pressure relieving device, maintaining posture and alignment, and off-loading. DON stated it is not to be placed underneath the mattress between the bed frames. DON stated if it hinders the resident from rising or getting out of bed then it is a restraint. DON stated the pillows are not to be used in that manner. DON stated their facility uses a wedge that is demonstrated to the facility by a knowledgeable staff and demonstrate on how to use the device. A review of the policy and procedure titled, Use of Restraints, last reviewed and approved on 10/13/2022, indicated restraints shall only be used for the safety and wellbeing of the resident only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. Physical restraints are defined as any manual method or physical or chemical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.

Based on interview and record review, the facility failed to follow-up on one of four sampled residents (Resident 22) who had a positive Level I (means the resident needs to have an in-depth evaluation by a state-designated authority) Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care). This deficient practice had the potential to result in resident's medical and nursing care needs not being met. Findings: A review of Resident 22's admission Record indicated the facility admitted Resident 22 on 4/14/2022 with diagnoses including cerebral (brain) palsy (weakness or problems with using the muscles), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), and schizoaffective disorder (a mental health disorder a condition where symptoms of both psychotic and mood disorders are present together during one episode [or within a two-week period of each other]). A review of Resident 22's Minimum Data Set (MDS, an assessment and care screening tool) dated 7/22/2022 indicated the resident had the ability to understand others and had the ability to express ideas and wants. The MDS indicated the resident required supervision in bed mobility, transfer, locomotion on and off unit, and eating with setup help from staff. The MDS indicated resident with active diagnoses including cerebral palsy, seizure disorder or epilepsy, and schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). During a concurrent interview and record review of Resident 22's clinical record on 10/13/2022 at 9:12 a.m., the Minimum Data Set Coordinator (MDSC) confirmed there is no Level II evaluation (the in-depth evaluation and determination by a state-designated authority after a positive Level I PASARR is identified) on the clinical record. MDSC confirmed Resident 22's positive Level I PASARR screen and should have an evaluation done by the PASARR representative (state-designated authority). MDSC confirmed Resident 22's PASRR dated 4/18/2022 indicated Level 1- Positive. MDSC stated Medical Records keeps the Level II record if there is a letter. During an interview on 10/13/2022 at 9:16 a.m., the Medical Records Director (MRD) provided letter from the State Representative dated 6/3/2022 indicated unable to complete level II evaluation due to the individual was isolated as a health or safety precaution and that the case is now closed and to reopen, they have to submit a new Level I screening. During an interview on 10/14/2022 at 12:15 p.m., the Director of Nursing (DON) stated the PASARR is completed upon admission and readmission. The DON stated the admitting nurse usually fills out the PASARR gathered from the diagnosis upon admission. The DON stated the PASARR form has to be accurately coded because it presents the current condition of the residents and determine if a resident would need a Level II screening for evaluation and determination by State PASARR representative. The DON confirmed the PASARR letter is a courtesy that the case was closed due the individual was isolated as a health or safety precaution the letter reads. The DON stated this should have been followed up because the Level II evaluation was not done. The DON stated this is usually followed up by social services. The DON stated she will submit a new Level I Screening to reopen the case for Resident 22. A review of the facility's policy and procedure titled admission Criteria, reviewed and approved on 10/13/2021, indicated the facility admits only residents who's medical and nursing care needs can be met. The policy indicated the facility conducts a Level I PASARR screen for all potential admissions to determine if the individual meets the criteria for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) and if the individual meets the criteria, he or she is referred to the state PASARR representative for the Level II screening process. The admitting nurse notifies the social services department when a resident is identified as having a possible MD, ID, or RD. The social worker is responsible for making referrals to the appropriate state-designated authority.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a baseline care plan (a documented plan that includes the necessary healthcare information to properly care for a resident immediately upon admission) within 48 hours of admission for three of four sampled residents (Resident's 30, 40, and 265). This deficient practice had the potential for delayed provision of necessary care and services. Findings: a. A review of Resident 30's admission Record indicated that the facility admitted the resident initially on 11/9/2018, with a readmission date of 8/27/2022, with diagnoses including muscle wasting and atrophy, gout (a common form of inflammatory arthritis that is very painful), and urinary tract infection (infection of the urinary system). A review of Resident 30's History & Physical (H&P), dated 9/28/2022, indicated that the resident does not have the capacity to understand and make decisions. A review of Resident 30's Minimum Data Set (MDS- an assessment and care screening tool), dated 6/30/2022, indicated that the resident can make self-understood and can understand others. The resident has moderately impaired cognition. The resident required total dependence on bed mobility, transfer, locomotion off unit, dressing, toilet use, and personal hygiene. The resident required extensive assistance on eating. The resident uses a manual wheelchair and orthotics/prosthetics (use of artificial or mechanical aids, such as braces, to prevent or assist movement of weak or injured joints or muscles). The resident has a suprapubic catheter (drains urine from your bladder). A review of Resident 30's Fall Risk Assessment, dated 8/27/2022, indicated the resident was high risk for falls. During an interview and record review on 10/12/2022, at 11:59 a.m., with RN 1, RN 1 stated that she cannot find the baseline care plan for fall risk on the resident's records. RN 1 stated that it is important to have a care plan for fall to prevent accidents in the future. A review of the facility's recent policy and procedure titled Care Plans- Baseline, dated 10/13/2021, indicated that to assure that the resident's immediate care needs are met and maintained, baseline care plan will be developed within forty-eight (48) hours of the resident's admission. A review of the facility's recent policy and procedure titled Falls and Fall Risk, Managing, dated 10/13/2021, indicated that the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. b. A review of Resident 40's admission Record indicated that the facility admitted the resident on 5/11/2022, with diagnoses including malignant neoplasm (cancerous tumors) of rectosigmoid junction (end of the sigmoid colon), muscle wasting (a loss of muscle mass) and atrophy (decrease in size), and varicose (enlarged veins) of left lower extremity with ulcer (break in the skin). A review of Resident 40's History and Physical (H&P), dated 5/12/2022, indicated that the resident has the capacity to understand and make decisions. A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/18/2022, indicated that the resident has the capacity to make self-understood and can understand others. The resident has intact cognition (gaining of knowledge and understanding). The MDS indicated that the resident was taking an anticoagulant (a substance that hinders the clotting of blood). A review of Resident 40's Order Summary Report indicated an order date for Eliquis Tablet 2.5mg (apixaban-medicine used to reduce the risk of stroke and blood clots) on 5/11/2022. Give one tablet by mouth two times a day for atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and monitor every shift for anticoagulant medication use. During an interview and record review on 10/12/2022, at 11:43 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that there was no baseline care plan for at risk for bleeding secondary to the use of apixaban for Resident 40. RN 1 stated that it is important to have a baseline care plan for at risk for bleeding for patient safety and to individualize care and treatment to Resident 40. A review of the facility's recent policy and procedure titled Care Plans- Baseline, dated 10/13/2021, indicated that to assure that the resident's immediate care needs are met and maintained, baseline care plan will be developed within forty-eight (48) hours of the resident's admission. c. A review of the Resident 265's admission Record indicated the facility admitted the resident on 9/21/2022 with diagnoses that included toxic encephalopathy (a disturbance of normal brain function that may cause changes in cognitive function and level of consciousness) and difficulty walking. A review of Resident 265's History and Physical (H&P), dated 10/10/2022, indicated Resident 265 did not have the capacity to understand and make decisions. The H&P further indicated Resident 265 had a history of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 265's MDS dated [DATE], indicated the resident rarely had the ability to make self-understood and rarely had the ability to understand others. A review of Resident 265's Physician's Orders indicated an order for the following: -Clonazepam (antianxiety-medication used to manage feelings of excessive uneasiness and apprehension) tablet 0.5 milligrams (mg, a unit of measurement), give 1 tablet by mouth at bedtime for anxiety manifested by restlessness leads to exhaustion, dated 9/21/2022. -Enoxaparin Sodium Solution (anticoagulant-medication that hinders the clotting of blood) prefilled syringe 40 mg per 0.4 milliliters (ml, a unit of measurement), inject 0.4 ml subcutaneously (under the skin) one time a day for deep vein thrombosis (DVT, a blood clot in a vein) prophylaxis (prevention), dated 9/21/2022. -Mirtazapine (antidepressant-medication used to manage depression [persistent feeling of sadness and loss of interest]) tablet 15 mg, give 1 tablet by mouth at bedtime for depression manifested by poor oral intake, dated 9/20/2022. During an interview on 10/12/2022 at 11:30 a.m., and concurrent record review of Resident 265's Medication Administration Record, Licensed Vocational Nurse 1 (LVN 1) stated Resident 265 was administered and monitored for the use of the medications clonazepam, enoxaparin, and mirtazapine since admission on [DATE]. During an interview on 10/12/2022 at 11:41 a.m., and concurrent record review of Resident 265's Physician Orders and care plans (CPs), Registered Nurse 1 (RN 1) stated she admitted Resident 265 on 9/21/2022. RN 1 stated the resident was on an anticoagulant because she did not ambulate (walk) and was in a wheelchair which increased the risk for blood clot formation. RN 1 stated the resident had depression with loss of appetite and anxiety. RN 1 stated the CP's for psychotropic medications (capable of affecting the mind, emotions, and behavior) were completed on 10/4/2022 and there was no documented evidence of a CP for Enoxaparin. RN 1 stated there was no documented evidence that a baseline care plan was initiated within 48 hours of admission for the three medications. During an interview on 10/13/2022 at 1:05 p.m., and concurrent record review of Resident 265's CP's, the Director of Nursing (DON) stated the psychotropic medication CPs were initiated 13 days after admission and there was no documented evidence of a CP for the anticoagulant. The DON reviewed the facility policy and procedure and stated there should be a baseline CP to ensure the immediate needs of the resident are met and it is to be completed within 24 hours of admission. The DON stated the policy and procedure was not followed. A review of the policy and procedure titled, Care Plans - Baseline, last reviewed 10/13/2021, indicated a baseline plan of care to meet and maintain the resident's immediate needs shall be developed for each resident within 48 hours of admission. The interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: Initial goals based on admission orders and Physician Orders. The baseline CP will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. A review of the policy and procedure titled, Anticoagulation - Clinical Protocol, last reviewed 10/13/2021, indicated as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated and assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications.

Based on interview and record review, the facility failed to follow-up with the registered dietician's recommendations for one of one sampled resident (Resident 26) investigated addressing nutrition care area. This deficient practice had the potential to place Resident 26 at risk for a delay in necessary care. Findings: A review if Resident 26's admission Record indicated the facility admitted the resident on 7/28/2020 with a readmission date of 7/6/2021 with diagnoses that included end stage renal disease (chronic irreversible kidney failure), anemia (blood has a lower than normal number of red blood cells), and dependence on renal dialysis (process of removing waste products and excess fluid from the body). A review of Resident 26's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/31/2022 indicated the resident usually makes self-understood and usually has the ability to understand others. A review of Resident 26's Registered Dietician Note dated 9/29/2022 indicated the dietician spoke with the dialysis dietician. The dietician recommended to change Pro-Stat (liquid protein) to 30 milliliters (ml-unit of measure) three time a day (TID) to provide 45 grams (g-unit of measure) of protein. The notes also indicated the resident was on calcium acetate (used to control high blood levels of phosphorus in people with kidney disease who are on dialysis), with calcium level at 10.4 currently (normal range 8.4 to 10.2 milligrams per decilitre (mg/dL-unit of measure). The recommendation included to change to Renvela (medication that can lower the amount of phosphorus in the blood of patients receiving kidney dialysis) 1.6 g TID. During a concurrent interview and record review on 10/13/2022 at 11:06 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 26's progress notes and physician orders. RN 1 verified the registered dietician's recommendations were not followed through and the physician's orders did not reflect the recommendations. During an interview on 10/14/2022 at 10:19 a.m., with the Registered Dietician (RD), the RD stated Pro-Stat was recommended to increase Resident 26's protein because his albumin (simple form of protein) level was low and recommended to change calcium acetate to Renvela because his calcium level was high. The RD stated she does weekly recommendations. The RD stated the recommendation form is emailed to the Director of Nursing (DON) and dietary supervisor, and the nursing staff is able to see it too. During a concurrent interview and record review on 10/14/2022 at 10:26 a.m., with RN 1, reviewed the RD Recommendation form dated 9/29/22. RN 1 stated these recommendations were missed and not followed through. RN 1 verified there is no documentation indicating the physician was notified of the RD recommendations. A review of Resident 26's lab values dated 9/13/2022, indicated the following: - Albumin level 3.3 g/dL (normal range 4.0 g/dL or higher). - Calcium 10.4 mg/dL (normal range 8.4 to 10.2 mg/dL) A review of Resident 26's Care Plan titled, Dialysis Care Plan, initiated on 7/13/2021, indicated an intervention to coordinate resident's care with the dialysis center staff. A review of Resident 26's Care Plan titled, Altered Nutritional Needs, dated 7/2022, indicated a goal that labs will improve and an intervention to confer with dialysis RD as needed (PRN). During an interview on 10/14/2022 at 3:55 p.m., with the Director of Nursing (DON), the DON stated when the RD has recommendations, they are to call the physician and notify them of the recommendations. The DON stated it should be done in a timely manner and promptly. The DON stated if they don't answer, they are to leave a message and follow-up. The DON stated the RD recommendations were not followed up with the physician promptly. The DON stated it is important to follow-up with the physician for continuity of care that is given to the resident. A review of the facility policy and procedure titled, Nutrition (Impaired)/Unplanned Weight Loss, last reviewed and updated on 10/13/2021, indicated, The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition .When medical conditions or medication -related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident/patient's responses, goals, wishes, prognosis, and complications.

Based on interview and record review, the physician and the licensed staff failed to ensure an accurate documentation of death in the facility for one of three sampled residents (Resident 66) investigated addressing closed records. This deficient practice has the potential to result in an inaccurate information placed on the death certificate of Resident 66. Findings: A review of Resident 66's admission Record indicated that the facility admitted the resident on 11/16/2021 with diagnoses including muscle wasting (a loss of muscle mass) and atrophy (decrease in size), urinary tract infection (UTI- an infection in any part of the urinary system), chronic obstructive pulmonary disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), history of falling, hyperlipidemia (high cholesterol), anxiety disorder and oppositional defiant disorder ( a condition in which a person displays a pattern of uncooperative behavior, defiant and angry behavior). A review of Resident 66's Physician's Orders for Life Sustaining Treatment (POLST- a form written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness), dated 11/18/2021, indicated that the resident is on Do Not Resuscitate (DNR- instructs health care providers not to do cardiopulmonary resuscitation if a patient's breathing stops or if the patient's heart stops beating), Comfort-Focused Treatment. A review of Resident 66's Nurses Progress Notes, dated 9/8/2022 at 10:09 p.m., indicated that at 9:19 p.m., Charge Nurse 1 (CN 1) performed rounds and resident was noted not breathing. CN 1 notified Charge Nurse 2 (CN 2) and assessed the resident, no pulse noted upon palpation. Notified Medical Doctor via phone. CN 1 spoke to resident representative and informed them about the resident's passing, and they provided funeral information to CN 1. During an interview on 10/13/2022, at 12:17 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated that he took the vital signs (taking the body temperature, blood pressure, heart rate, and breathing rate), resident did not have the pulse, then he called the charge nurse to double check. He called the doctor and the family. They did postmortem care (the care given once death has occurred through transfer to a funeral provider). LVN 5 stated that he forgot to document some of the necessary information regarding the death of the resident in the progress notes. During an interview and record review on 10/13/2022, at 3:01 p.m., Registered Nurse 1 (RN 1) stated that she did not find the documentation of the resident's date and time of death, and the name and title of the individual pronouncing resident dead on the chart. She also did not find the Attending Physician's notes indicating the cause of death and filing of a death certificate with the appropriate agency within twenty-four hours of the resident's death. RN 1 stated that it is very important to record all these information so that an accurate information will be furnished in the death certificate of the resident. A review of the facility's recent policy and procedure titled Death of a Resident, Documenting, dated 10/13/2021, indicated that all information pertaining to a resident's death (i.e., date, time of death, the name and title of the individual pronouncing the resident dead, etc.) must be recorded on the nurses' notes. The Attending Physician must record the cause of death in the progress notes and must complete and file a death certificate with the appropriate agency within twenty-four (24) hours of the resident's death or as may be prescribed by state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 40's admission Record indicated that the facility admitted the resident on 5/11/2022, with diagnoses including malignant neoplasm (cancerous tumors) of rectosigmoid junction (end of the sigmoid colon), muscle wasting (a loss of muscle mass) and atrophy (decrease in size), and varicose (enlarged veins) of left lower extremity with ulcer (break in the skin). A review of Resident 40's History and Physical (H&P), dated 5/12/2022, indicated that the resident has the capacity to understand and make decisions. A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/18/2022, indicated that the resident has the capacity to make self-understood and can understand others. The resident has intact cognition (gaining of knowledge and understanding). The MDS indicated that the resident was taking anticoagulant (a substance that hinders the clotting of blood). A review of Resident 40's Order Summary Report indicated an order date for Eliquis Tablet 2.5mg (apixaban-medicine used to reduce the risk of stroke and blood clots) on 5/11/2022. Give one tablet by mouth two times a day for atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) and monitor every shift for anticoagulant medication use. During an interview and record review on 10/12/2022, at 11:43 a.m., with RN 1, RN 1 stated that there was no comprehensive care plan for at risk for bleeding secondary to the use of apixaban for Resident 40. RN 1 stated that it is important to have a care plan for at risk for bleeding for patient safety and to individualize care and treatment to Resident 40. A review of the facility's recent policy and procedure titled Care Planning- Interdisciplinary Team (IDT- is a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it), dated 10/13/2021, indicated that a comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). A review of the facility's recent policy and procedure titled Care Plans, Comprehensive Person-Centered, dated 10/13/2021, indicated that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. c. A review of Resident 30's admission Record indicated that the facility admitted the resident initially on 11/9/2018, with a readmission date of 8/27/2022, with diagnoses including muscle wasting and atrophy, gout (a common form of inflammatory arthritis that is very painful), and urinary tract infection (infection of the urinary system). A review of Resident 30's History & Physical (H&P), dated 9/28/2022, indicated that the resident does not have the capacity to understand and make decisions. A review of Resident 30's MDS, dated [DATE], indicated that the resident can make self-understood and can understand others. The resident has moderately impaired cognition. The resident required total dependence on bed mobility, transfer, locomotion off unit, dressing, toilet use, and personal hygiene. The resident required extensive assistance on eating. The resident uses a manual wheelchair and orthotics/prosthetics (use of artificial or mechanical aids, such as braces, to prevent or assist movement of weak or injured joints or muscles). The resident has a suprapubic catheter (drains urine from your bladder). A review of Resident 30's Fall Risk Assessment, dated 8/27/2022, indicated the resident was high risk for falls. During an interview and record review on 10/12/2022, at 11:59 a.m., with RN 1, RN 1 stated that she cannot find the comprehensive care plan for fall risk on the resident's chart. RN 1 stated that it is important to have a care plan for fall to prevent accidents in the future. A review of the facility's recent policy and procedure titled Care Planning- Interdisciplinary Team, dated 10/13/2021, indicated that a comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). A review of the facility's recent policy and procedure titled Care Plans, Comprehensive Person-Centered, dated 10/13/2021, indicated that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. e. A review of Resident 63's admission Record indicated the facility admitted the resident on 6/15/2016, and was most recently readmitted the resident on 12/4/2021, with diagnoses that included paranoid schizophrenia (mental disorder that affects a person's ability to think, feel, and behave), muscle weakness, and lack of coordination. A review of Resident 63's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/9/2022, indicated Resident 63 has the ability to make self-understood and the ability to understand others. The MDS indicated the resident requires one-person extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 63's Fall Risk Assessment, dated 9/9/2022, indicated Resident 63 is a high fall risk. A review of Resident 63's Fall Risk care plan, last revised on 9/22/2022, indicated an intervention to apply anti-skid floor strip on bedside, bathroom, and bed-to-bathroom. During an observation, on 10/13/2022 at 2:47 p.m., observed Resident 63's room with no anti-skid floor strip at bedside nor on the bathroom floor. During a concurrent observation, interview, and record review, on 10/13/2022 at 3:24 p.m., Licensed Vocational Nurse 3 (LVN 3) verified there were no anti-skid floor strips being used for Resident 63. LVN 3 reviewed Resident 63's care plan for fall risk and confirmed one of the fall prevention interventions was applying anti-skid floor strip on bedside, bathroom, and bed-to-bathroom. However, LVN 3 stated anti-skid flooring would be a tripping hazard and is inappropriate for Resident 63 since the resident is able to get up from bed and walk to the bathroom with staff assisting her. LVN 3 stated the intervention should not have been included in the care plan and confirmed Resident 63's care plan for fall risk was not individualized. During a concurrent interview and record review, on 10/13/2022 at 4:02 p.m., the Minimum Data Set Coordinator (MDSC) stated the initial care plan is developed by the registered nurse supervisors (RN supervisor) and whoever is conducting the admissions for newly admitted residents. The MDSC stated she reviews and completes the care plans that are triggered and checks to make sure the care plan is comprehensive and done correctly. The MDSC reviewed Resident 63's fall risk care plan and stated it was completed by the RN supervisor. The MDSC confirmed the intervention regarding anti-slip floor strips should not have been included in Resident 63's care plan when initiated. The MDSC verified it was missed during the quarterly review and should have been removed from the care plan upon review. The MDSC also confirmed Resident 63's care plan for fall risk was not resident-centered and individualized as it included an intervention for anti-skid floor strip which is not recommended for the resident and was not being implemented. The MDSC further stated the importance of a resident-centered care plan to ensure the care planned interventions are developed and implemented according to the needs of the resident and are effectively benefitting the resident. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed and updated on 10/13/2021, indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy and procedure further indicated the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Based on interview and record review, the facility failed to develop and implement a person-centered care plan (written guide that organizes information about the resident's care) for four of 23 sampled residents (Resident 53, 40, 30, 5, and 63). This deficient practice had the potential for residents to not receive the proper and necessary care. Findings: a. A review of Resident 53's admission Record indicated the facility admitted the resident on 12/02/2021 with diagnoses that included peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 53's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/11/2022 indicated the resident rarely/never makes self-understood and rarely/never has the ability to understand others. The MDS also indicated Resident 53 had wandering behavior that occurred daily during the look back period (time frame for observation). During a concurrent interview and record review on 10/13/2022 at 10:29 a.m., with Registered Nurse 1 (RN 1), RN 1 verified Resident 53's quarterly MDS dated [DATE] indicated Resident 53 had wandering behavior that occurred daily. RN 1 stated Resident 53 has a history of wandering and would pace back and forth. RN 1 verified Resident 53 does not have a care plan for wandering behavior. During a concurrent interview and record review on 10/13/2022 at 2:43 p.m., with the Social Service Director/Activities Director (SSD/AD), reviewed Resident 53's quarterly MDS dated [DATE]. The SSD/AD stated she coded wandering behavior occurred daily because during that time Resident 53 had a behavior of pacing back and forth. The SSD/AD stated Resident 53 would sometimes try to go into other resident's room but would be stopped by staff. The SSD/AD stated Resident 53 would wander in the hallway and would be redirected if she went towards the door. The SSD/AD stated a care plan would be required for this type of behavior. During a concurrent interview and record review on 10/13/2022 at 3:09 p.m., with RN 1, reviewed Resident 53's medical chart.RN 1 verified Resident 53 does not have a care plan for wandering behavior. RN 1 stated the purpose of a care plan is to address a concern or problem and have interventions and a guide for what should be done. RN 1 also stated the purpose is to know if the interventions are being implemented. During a concurrent interview and record review on 10/14/2022 at 9:53 a.m., with the Director of Nursing (DON), reviewed Resident 53's medical chart. The DON verified Resident 53's MDS dated [DATE] indicated behavior occurred daily. The DON stated Resident 53 can be hyper and was impulsive when admitted to the facility. The DON stated Resident 53 has a history of elopement at home and had a prior episode at the facility of trying to go to the door by the front desk but did not go out. The DON verified Resident 53 does not have a care plan for wandering behavior. The DON stated the purpose of a care plan is that it is used as a guideline and part of the plan of care of the resident. The DON the care plan includes goals and interventions and is reviewed quarterly and can be resolved. The DON stated care plans are to be followed through and are reviewed to see if interventions need to be improved, changed, or discontinued. The DON stated the MDS should have triggered a care plan to be created for wandering behavior. The DON stated based on Resident 53's history a care plan should have been created. A review of the facility's policy and procedure titled, Wandering and Elopements, last reviewed and updated on 10/13/2021, indicated, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed and updated on 10/13/2021, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will: include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problems areas; incorporate risk factors associated with identified problems; build on the resident's strengths; reflect treatment goals, timetables and objectives in measurable outcomes; reflect currently recognized standards of practice for problems areas and conditions. Areas of concerns that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. d. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 3/24/2022 with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and atrial fibrillation (abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart). A review of Resident 5's History and Physical dated 3/26/2022 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 5's Fall Risk assessment dated [DATE] indicated the resident was at high risk for falls. During a concurrent interview and record review of Resident 5's clinical record on 10/13/2022 at 1:59 p.m., Registered Nurse 1 (RN 1) confirmed there was no comprehensive fall care plan developed. RN 1 stated interventions would include low bed, fall risk wrist band, and sticker at the door. RN 1 stated if the resident has a landing mat there should be an order and indicated in the resident's fall risk care plan. RN 1 stated the purpose of developing a care plan is to address the resident's problem and have a goal and interventions. RN 1 stated the care plan serves as a guide for the facility staff and interventions are implemented. RN 1 stated the care plan is developed by the admission nurse or the MDS Nurse. During an interview on 10/14/2022 at 12:38 p.m., the Director of Nursing (DON) stated care plans are developed upon admission, if there are any resident changes in condition, and revised quarterly and as needed. The DON stated care plans are developed and implemented for each resident and include identified problem areas such as risk for falls or actual falls. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, reviewed and approved on 10/13/2021, indicated that a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** f. A review of Resident 40's admission Record indicated that the facility admitted the resident on 5/11/2022, with diagnoses including malignant neoplasm (cancerous tumors) of rectosigmoid junction (end of the sigmoid colon), muscle wasting (a loss of muscle mass) and atrophy (decrease in size), and varicose (enlarged veins) of left lower extremity with ulcer (break in the skin). A review of Resident 40's History and Physical (H&P), dated 5/12/2022, indicated that the resident has the capacity to understand and make decisions. A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/18/2022, indicated that the resident has the capacity to make self-understood and can understand others. The resident has intact cognition (gaining of knowledge and understanding). The resident required extensive assistance with bed mobility, dressing, eating, and personal hygiene. The resident was totally dependent on transfer, locomotion off unit, and toilet use. The resident was always incontinent of urine and stool (feces). The resident came to the facility with one stage II pressure injury (partial-thickness loss of skin) and one unstageable pressure injury (the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black). A review of Resident 40's admission Assessment, dated 5/11/2022, indicated that the resident had a sacral deep tissue injury (DTI-purple or maroon localized area of discolored intact skin or blood-filled blister) healing, left lower leg ulcer, right heel DTI. A review of Resident 40's Braden Scale (assessment tool for predicting pressure ulcer sore risk), dated 5/11/2022 and 10/13/2022 indicated the resident was at high risk for pressure ulcer. 1. A review of Resident 40's Situation, Background, Assessment and Recommendation (SBAR-tool to aid in facilitating and strengthening communication between nurses and prescribers), dated 10/11/2022, indicated that the resident had a reopened stage III at the sacrococcygeal. A review of Resident 40's latest Order Summary Report, dated 10/13/2022, indicated a physician's order for: - Left buttock (the fleshy part of the human body that you sit on) stage 3. Cleanse with normal saline (an aqueous solution of electrolytes), pat dry, apply Santyl (ointment medicine that removes dead tissue from wounds so they can start to heal) and mixed with collagen powder (protein supplement to aid with wound healing and cover with dry dressings as needed every shift if soiled or as needed and every day shift for 30 days. - Right buttock stage 2. Cleanse with normal saline, pat dry, apply collagen powder and cover with dry dressing as needed for 30 days every shift if soiled or dislodged and every day shift for 30 days. - Sacrococcygeal stage 2, Cleanse with normal saline, pat dry, apply collagen powder and cover with dry dressing every day shift for 30 days and as needed for 30 days every shift if soiled or dislodged. During a wound treatment observation and interview on 10/12/2022, at 10:25 a.m., with RN 1, observed RN 1 picked up a collagen dressing on a packet that fell on the floor and placed them back to the table where clean dressings were placed. RN 1 stated that she should have not picked up the contaminated dressing on the floor and placed them back on the table where the clean dressings were because it contaminated the rest of the dressing materials. During an interview on 10/13/2022, at 11:41 a.m., with TN 2, TN 2 stated that the collagen dressing that fell on the floor should have been discarded instead of picking them up and returning them on the clean table where the other dressing materials were due to infection issues. A review of the facility's recent policy and procedure titled Wound Care, dated 10/13/2021, indicated to verify that there is a physician's order for this procedure. Be certain all clean items are on clean field. 2. During an observation and interview on 10/12/2022, at 8:24 a.m., with Registered Nurse 1 (RN 1), observed Resident 40's bed was set to 170 pounds (lbs - is a unit of weight). RN 1 verified that the setting was set at 170 lbs. RN 1 stated that Resident 40's latest weight was 157 lbs, and the bed should have been set according to the weight of the resident. The low air loss mattress should be set according to the resident's weight as overinflating the mattress will be bad for the resident's skin. During an interview on 10/13/2022, at 11:41 a.m., with Treatment Nurse 2 (TN 2), TN 2 stated that the low air loss bed should be set to the current weight of the resident. TN 2 stated that if the low air loss bed is overinflated it will be inappropriate for the resident to use as it will cause more harm than good to the resident's skin. A review of the Low Air Loss Mattress Instruction Manual, undated, indicated to adjust pressure using knob by patient's weight. Turn the pressure adjust to set a comfortable pressure level by using the weight scale as a guide. 3. During an observation and interview on 10/12/2022, at 10:59 a.m., with RN 1, observed Resident 40 to have an incontinence brief on. There were layers of sheets underneath the low air loss mattress. RN 1 stated that they should have not placed incontinence brief on Resident 40 because she has pressure ulcers on her coccyx (the small bone at the end of the spine) and buttocks, it will make the pressure ulcer worse. It traps the moisture in which causes diaper rash. They should just apply one incontinence pad to the low air loss mattress to maximize its purpose. During an interview on 10/13/2022, at 2:10 p.m., with Resident 40, Resident 40 stated that she did not request for the incontinence brief to be placed on her. She just thought it was needed for her since she was incontinent of urine and stool. A review of the facility's recent policy and procedure titled Support Surface Guidelines, dated 10/13/2021, indicated that redistributing support surfaces are to promote comfort for all bed- or chair bound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. Based on observation, interview, and record review, the facility failed to ensure care consistent with professional standards of practice to prevent pressure ulcers (PU, a wound that occurs as a result of prolonged pressure on a specific area of the body) for six of nine sampled residents (Residents 7, 31, 40, 41, 54, and 61) investigated under the care area of pressure ulcer/injury by: 1.Failing to follow the Physician's Order to place Resident 31 on a low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat PUs). 2. Failing to ensure the low air loss mattress was properly set per resident's weight for five of six sampled residents (Resident 7, 40, 41, 54, and 61). 3. Failing to keep Resident 40's wound dressing materials clean and failing to keep moisture away from the sacrococcygeal (the base of the spine by the tailbone) pressure ulcers by applying an incontinence brief. These deficient practices placed the residents at risk for skin breakdown and the development and worsening of PUs. Findings: a. A review of Resident 31's admission Record indicated the facility admitted the resident on 8/11/2022 with diagnoses that included fracture of the left femur (a break in the thigh bone), muscle wasting and atrophy (the thinning of muscle mass), encephalopathy (a disturbance of normal brain function that may cause changes in cognitive function and level of consciousness), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and mild protein-calorie malnutrition (reduced nutritional status). A review of Resident 31's History and Physical, dated 8/13/2022, indicated Resident 31 did not have the capacity to understand and make decisions. A review of Resident 31's Minimum Data Set (MDS- an assessment and care screening tool) dated 8/18/2022 indicated Resident 31 rarely had the ability to make self-understood and rarely had the ability to understand others. The MDS indicated the resident was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS further indicated the resident was at risk for developing PUs and used a pressure reducing device for the bed. A review of Resident 31's Braden Scale (a tool used to predict PU risk) dated 8/11/2022, indicated the resident was at high risk for PU development. A review of the Care Plan (CP) titled, Risk for skin breakdown, initiated 8/11/2022, indicated Resident 31 was at risk for skin breakdown related to severe protein-calorie malnutrition, debility, and failure to thrive. The CP indicated Resident 31 would use a LALM to prevent skin breakdown. A review of Resident 31's Physician Order, dated 8/11/2021, indicated a treatment order for a LALM. During an observation on 10/11/2022 at 9 a.m., Resident 31 lay on top of a standard mattress. Resident 31 was non-interviewable. During an observation and interview on 10/12/2022 at 1:02 p.m., Licensed Vocation Nurse 1 (LVN 1) stated she was the nurse caring for Resident 31. LVN 1 assessed Resident 31's mattress and stated it was a standard mattress, not a LALM. LVN 1 stated Resident 31 had been on the standard mattress since she had been caring for him. LVN 1 stated she was not aware there was a physician's order for a LALM. LVN 1 reviewed Resident 31's physician orders and stated there was an order for a LALM and it was not there. During an interview on 10/12/2022 at 1:10 p.m., and concurrent record review of Resident 31's CPs and physician's orders, the Registered Nurse 1 (RN 1) stated the resident did have a need for a LALM and it should be there. RN 1 stated the importance of the LALM was to prevent PUs because the resident did not ambulate and was bedbound. During an interview on 10/13/2022 02:49 p.m., the Director of Nursing (DON) stated Resident 31 was at risk for developing PUs because of low mobility and incontinence. The DON stated if there was an order for a LALM, then it should be there. A review of the policy and procedures titled, Prevention of Pressure Injuries, last reviewed 10/13/2022, indicated the purpose of the procedure was to provide information regarding identification of pressure injury (pressure ulcer) risk factors and interventions for specific risk factors. Select the appropriate support surfaces based on the resident's risk factors. Monitor regularly for comfort and signs of pressure related injury. Review the interventions and strategies for effectiveness on an ongoing basis. A review of the policy and procedures titled, Support Surface Guidelines, last reviewed 10/13/2022, indicated the purpose of the procedure was to provide for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown. Redistributing support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Any individual at risk for developing PUs should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. b. A review of the admission Record indicated the facility admitted Resident 61on 6/4/2020 and readmitted on [DATE] with diagnoses that included muscle wasting and atrophy (the thinning of muscle mass) and spinal stenosis (a narrowing of the spinal canal in the lower back that may cause pain or numbness in the legs). A review of the History and Physical, dated 10/20/2021, indicated Resident 61 did not have the capacity to understand and make decisions. A review of the MDS dated [DATE] indicated Resident 61 usually had the ability to make self-understood and usually had the ability to understand others. The MDS indicated the resident required extensive assistance for bed mobility, and personal hygiene and was totally dependent on staff for transfer, dressing, and toilet use. The MDS further indicated the resident was at risk for developing PUs. A review of Resident 61's Braden Scale (a tool used to predict PU risk) dated 9/8/2022, indicated the resident was at moderate risk for PU development. A review of the CP titled, Decubitus (PU) Risk, initiated 10/3/2021, indicated Resident 61 was at risk for recurrent PU formation with contributing factors of incontinence of bowel and bladder, dependence on staff for bed mobility, and diabetes mellitus type II (DM, a disease that involves inappropriately elevated blood glucose levels in the body). The CP further indicated to provide pressure relief device in the bed or chair. A review of the CP titled, Resident is incontinent of bowel and bladder, initiated 10/3/2021, indicated Resident 61 was at risk for skin impairment and PUs and was placed on a LALM. A review of Resident 61's Physician Order, dated 10/3/2021, indicated a treatment order for a LALM. During an observation and interview on 10/11/2022 at 09:10 a.m., Resident 61 lay on top of a LALM mattress placed secured to the bed frame. Resident 61 grimaced and stated she had been uncomfortable since the prior day on her left side (resident pointed to left hip and back area). Observed the DynaRest Airfloat 100 (brand of LALM) air mattress setting with the pressure adjust knob set to indicate a weight of 320 pounds. During an interview on 10/11/2022 at 9:15 a.m., Certified Nursing Assistant 1 (CNA 1) stood at Resident 61's bedside and stated the resident first told her she was uncomfortable from the mattress the day prior. CNA 1 stated she reported the resident's discomfort to the nurse the day prior and the pressure setting was slightly adjusted down to the number 320. CNA 1 reviewed the LALM settings and stated she thought the setting indicated the air pressure of the mattress with a higher number making the bed firmer, but the treatment nurse was in charge of adjusting the settings. CNA 1 stated Resident 61 was on a LALM because she was at risk for PU development and was noncompliant with turning every two hours. During an observation and interview on 10/11/2022 at 9:15 a.m., Treatment Nurse 1 (TN 1) assessed Resident 61 and the resident's LALM settings. TN 1 stated the LALM settings should be set based on the resident's weight. TN 1 reviewed Resident 61's Monthly Record of Vital Signs and Weights form and stated the resident's weight for October of 2022 was 111 pounds (lbs-unit of measure). TN 1 reviewed Resident 61's LALM setting and stated it was set to a resident weight of 320 lbs. TN 1 stated the resident did not weigh 320 lbs and the setting made the bed too firm. TN 1 stated it was important to use the correct weight setting because it determined the firmness of the mattress. Observed TN 1 adjust the setting to coincide with Resident 61's weight of 111 lbs. During an observation and interview on 10/12/22 at 8:25 a.m., observed Resident 61 lying on the LALM set for a weight of 111 lbs. Resident 61 stated she was comfortable. During an interview on 10/13/2022 at 3:08 p.m., the Director of Nursing (DON) reviewed the manufacture instructions for the DynaRest Airfloat 100 Air Mattress and stated the facility follows the manufacturer's instructions. The DON stated the instructions indicated to set the pressure adjust knob to the resident's weight. The DON stated when Resident 61 first stated to CNA 1 that she was uncomfortable, the LALM settings should have been checked and set to resident's correct weight. The DON stated the resident's weight determines the proper setting and proper function of the mattress. The DON stated the LALM is in place because the resident is bedbound and if the LALM is set too firm, based on the incorrect weight, it will create a hard surface that will induce PU formation. A review of the undated Dynarex Manufacture Instructions manual titled, DynaRest Airfloat 100 Air Mattress with Pump, indicated to refer to the instructions before use and under proper medical supervision. Improper operation of the system may cause possible injury to the user. The Pressure Adjust Knob is turned to set a comfortable pressure level by using the weight scale as a guide. A review of the Policy and Procedure titled, Prevention of Pressure Injuries, last reviewed 10/13/2022, indicated the purpose of the procedure was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Select the appropriate support surfaces based on the resident's risk factors. Monitor regularly for comfort and signs of pressure related injury. Review the interventions and strategies for effectiveness on an ongoing basis. A review of the policy and procedures titled, Support Surface Guidelines, last reviewed 10/13/2022, indicated the purpose of the procedure was to provide for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown. Redistributing support surfaces are to promote comfort for all bed - or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Any individual at risk for developing PUs should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. e. A review of Resident 41's admission Record indicated the facility admitted the resident on 5/28/2010 with diagnoses that included muscle wasting and atrophy, Parkinson's disease (progressive brain disorder that causes a gradual loss of muscle control), and traumatic brain injury (damage to the brain induced by direct physical trauma). A review of Resident 41's Minimum Data Set (MDS - an assessment and care screening tool), dated 8/18/2022, indicated Resident 41 has the ability to sometimes make self-understood and the ability to sometimes understand others. The MDS further indicated the resident requires limited assistance from staff with bed mobility and transfers and is at risk for developing pressure ulcers. A review of Resident 41's Physician's Order, ordered on 7/5/2022, indicated an order for low air loss mattress for pressure injury prevention. A review of Resident 41's Monthly Record of Vital Signs and Weights indicated a current weight of 147 pounds (lbs) taken on 10/6/2022. During an observation on 10/11/2022 at 10:45 a.m., observed Resident 41 laying in bed with the low air loss mattress set at the maximum setting of 350 lbs. During a concurrent observation, interview, and record review, on 10/11/2022 at 11:05 a.m., Restorative Nursing Assistant 1 (RNA 1) observed and verified the LAL mattress was set at 350 lbs. RNA 1 stated she does not adjust the settings for LAL mattress and only the licensed nurses are able to change it. RNA 1 further stated the RNAs weigh all residents once a month at the beginning of each month and confirmed Resident 41's current weight is 147 lbs upon reviewing the weight log. During an interview, on 10/11/2022 at 11:11 a.m., Licensed Vocational Nurse 1 (LVN 1) stated the settings for the LAL mattress should be based on the resident's weight and should not have been set to the maximum setting of 350 lbs for Resident 41. LVN 1 explained that if the LAL mattress is at the maximum setting, the resident will not be comfortable and also places the resident at increased risk of developing a pressure ulcer since the surface will be firmer. LVN 1 stated the treatment nurse is responsible for adjusting the low air loss mattress to the correct setting but the licensed nurses also check the settings as well at least once a shift. LVN 1 stated she did not get a chance to check it yet and confirmed it was missed. During a concurrent interview and record review, on 10/13/2022 at 11:01 a.m., Licensed Vocational Nurse 3 (LVN 3) stated the order for LAL mattress was placed for Resident 41 on 7/5/2022 to prevent skin breakdown and pressure ulcers. LVN 3 stated he adjusts the setting for the LAL mattress according to the patient's comfort and what he sees and feels. LVN 3 stated if he observes the resident is sinking in the mattress or if he feels the mattress is underinflated, he would have to inflate it more. During an interview, on 10/14/2022 at 9:43 a.m., the Director of Nursing (DON) stated the facility follows the manufacturer's guidelines for setting the LAL mattress based on the resident's weight. The DON confirmed the maximum setting of 350 lbs was inappropriate for Resident 41 who weighs only 147 lbs and stated the setting should have been in the range of the resident's weight. The DON further stated it would defeat the purpose of relieving pressure if the LAL mattress is on the firmest setting as it can potentially lead to skin breakdown. A review of the undated manufacturer's instructions for Dynarex Dynarest Airfloat 100 Air Mattress with Pump indicated to turn the pressure adjust knob that is adjustable by patient's weight to set a comfortable pressure level by using the weight scale as a guide. c. A review of Resident 54's admission Record indicated the facility admitted the resident on 9/22/2022 with a readmission date of 10/4/2022 with diagnoses that included muscle wasting and atrophy (wasting or thinning of muscle mass), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), and chronic atrial fibrillation (irregular rapid heart rate). A review of Resident 54's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/29/2022 indicated the resident usually makes self-understood and usually has the ability to understand others. The MDS also indicated the resident needs extensive assistance with bed mobility. A review of Resident 54's physician's order indicated an order for low air loss mattress (LALM) for wound healing, ordered on 10/5/2022. During a concurrent observation and interview on 10/11/2022 at 9:58 a.m., with Treatment Nurse 1 (TN 1), observed Resident 54's LALM set to 320 pounds. TN 1 stated settings for the LALM is based on the resident's weight. TN 1 verified Resident 54's weight is 145 pounds and stated the LALM was not set to the resident's weight and should be. TN 1 stated the LALM can't be too hard or too soft because resident's using LALM are at risk for developing pressure sores. A review of Resident 54's admission Assessment indicated the resident had a stage two (2) pressure ulcer (partial-thickness skin loss into but no deeper than the dermis [middle layer of skin]) to the sacrococcyx (tailbone) area measuring 5 centimeter (cm - a unit of measure) in length by 2 cm in width. A review of Resident 54's Braden Scale (a tool used to predict pressure ulcer risk) dated 10/4/2022 indicated the resident was at moderate risk for pressure ulcer. A review of Resident 54's Care Plan titled, Pressure Ulcer Care Plan, dated 10/7/2022, indicated a goal that resident's risk for further development of pressure ulcer will be minimized with interventions. The care plan indicated an intervention for LALM. During an interview on 10/14/2022 at 8:43 a.m., with the Director of Nursing (DON), the DON stated a LALM is used for preventative measures or management of pressure ulcers. The DON stated need to know the resident's weight in order to adjust the firmness on the mattress and maintain a range according to the resident's weight. The DON stated the purpose for a LALM is to maintain proper body alignment, preventative measures, and management for someone who has pressure ulcers. The DON stated there can be a potential risk for developing pressure ulcers or not healing of already developed pressure ulcers. A review of the undated Dynarex Manufacture Instructions manual titled, DynaRest Airfloat 100 Air Mattress with Pump, indicated to refer to the instructions before use and under proper medical supervision. Improper operation of the system may cause possible injury to the user. The Pressure Adjust Knob is turned to set a comfortable pressure level by using the weight scale as a guide. A review of the facility's policy and procedure titled, Support Surface Guidelines, last reviewed 10/13/2022, indicated the purpose of the procedure was to provide for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown. Redistributing support surfaces are to promote comfort for all bed - or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. d. A review of Resident 7's admission Record indicated the facility admitted the resident on 3/24/2021 with diagnoses that included muscle wasting and atrophy (wasting or thinning of muscle mass), decreased white blood cell count (responsible for protecting your body from infection), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/2/2022 indicated the resident rarely/never makes self-understood and rarely/never has the ability to understand others. During a concurrent observation and interview on 10/11/2022 at 10:21 a.m., with Registered Nurse 1 (RN 1), observed Resident 7's LALM set to 320 pounds. RN 1 stated the purpose of the mattress settings is so the mattress wouldn't be too firm or too soft and flat. RN 1 stated the purpose of the LALM is to prevent pressure ulcers. RN 1 stated there can be discomfort if the mattress is too firm and it won't be helping the resident at all if the mattress is too soft. During a concurrent interview and record review on 10/13/2022 at 10:58 a.m., with RN 1, reviewed Resident 7's physician's orders. RN 1 verified Resident 7 did not have a physician order for the use of the LALM. RN 1 stated there should be an order because any treatment should have an order. RN 1 stated Resident 7 is dependent on turning and repositioning. A review of Resident 7's Braden Scale dated 7/2/2022 indicated the resident is at high risk for skin breakdown. A review of Resident 7's Care Plan titled, Skin Breakdown, last reviewed on 9/22/2022, indicated a goal that resident will be free from skin breakdown daily for 90 days. During an interview on 10/14/2022 at 8:43 a.m., with the Director of Nursing (DON), the DON stated a LALM is used for preventative measures or management of pressure ulcers. The DON stated need to know the resident's weight in order to adjust the firmness on the mattress and maintain a range according to the resident's weight. The DON stated the purpose for a LALM is to maintain proper body alignment, preventative measures, and management for someone who has pressure ulcers. The DON stated there can be a potential risk for developing pressure ulcers or not healing of already developed pressure ulcers. A review of the undated Dynarex Manufacture Instructions manual titled, DynaRest Airfloat 100 Air Mattress with Pump, indicated to refer to the instructions before use and under proper medical supervision. Improper operation of the system may cause possible injury to the user. The Pressure Adjust Knob is turned to set a comfortable pressure level by using the weight scale as a guide. A review of the facility's policy and procedure titled, Support Surface Guidelines, last reviewed 10/13/2022, indicated the purpose of the procedure was to provide for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown. Redistributing support surfaces are to promote comfort for all bed - or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's safety for three of six sampled residents (Residents 31, 63, and 53) investigated under the accidents care area by failing to: 1. Ensure two large bolster wedges were not placed under the mattress on bilateral sides of the bed for Resident 31. This deficient practice placed Resident 31 at risk for physical harm due to increased risk of fall and entrapment. 2. Ensure Resident 63's bedside commode (portable toilet used to assist residents with limited mobility) was in safe, operating condition as evidenced by missing rubber leg tips in the front right and rear left legs, resulting in two of four legs not in contact with the floor. This deficient practice had the potential for Resident 63 to result in accidental falls and sustain avoidable injuries. 3. Complete an elopement risk assessment for one of one sampled residents (Resident 53) with wandering behavior. This deficient practice had the potential for Resident 53 to not receive the proper and necessary care and adequate supervision. Findings: a. A review of Resident 31's admission Record indicated the facility admitted the resident on 8/11/2022 with diagnoses that included fracture (broken bone) of the left femur (thigh bone), muscle wasting and atrophy (the thinning of muscle mass), encephalopathy (a disturbance of normal brain function that may cause changes in cognitive function and level of consciousness), and repeated falls. A review of Resident 31's History and Physical dated 8/13/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 31's Minimum Data Set (MDS- an assessment and care screening tool) dated 8/18/2022 indicated Resident 31 rarely had the ability to make self-understood and rarely had the ability to understand others. The MDS indicated the resident was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. A review Resident 31's Fall Risk Assessment form (a tool used to determine a resident's risk for falling), dated 8/11/2022, indicated the resident was a high risk for falls. A review of the Care Plan (CP) titled, Risk for Falls, initiated 8/11/2022, indicated Resident 31 was at risk for falls related to poor safety awareness, dementia (decline in mental ability severe enough to interfere with daily functioning/life), attempts to get out of bed unassisted, and thee resident dangled his legs outside of the bed. A review of the CP titled, Resident has periods of confusion, disorientation with risk for further decline in cognition and decision making related to dementia, initiated 8/12/2022, indicated Resident 31 would be monitored and needs anticipated. A review of the CP titled, Sensory/Perceptual alterations: visual related to cataracts and decreased visual acuity, initiated 8/24/2022, indicated Resident 31 would have an environment maintained that was free from hazards at all times. During an observation on 10/11/2022 at 9 a.m., Resident 31 lay in bed with the head of the bed raised approximately 30 degrees (a unit of measurement), legs outstretched at an elevated angle of approximately 15 degrees, and with the bilateral side rails up. Large bolster wedges, measuring approximately 3 feet (ft, a unit of measurement) by 3 ft, were placed below the resident's mattress that unevenly elevated the mattress off the bed frame at the Resident's feet. Resident 31 was non-interviewable. During an observation and interview on 10/11/2022 at 3 p.m., Certified Nursing Assistant 3 (CNA 3) assessed Resident 31 and stated there were large bolster wedges under the resident's mattress on both sides. CNA 3 stated they were used to elevate the resident's feet. CNA 3 stated the bolsters were usually used on top of the mattress because the resident tried to get up and they kept him in bed. During an observation and interview on 10/11/2022 at 3:15 p.m., Licensed Vocational Nurse 2 (LVN 2) assessed Resident 31 and stated the bolsters were placed under the mattress. LVN 2 stated she cared for Resident 31 all day but had not seen the bolsters. LVN 2 stated she did not know why the bolsters were under the mattress or who put them there. LVN 2 stated the bolsters should not be placed under the mattress and were not being properly used for positioning of the resident. During an observation and interview on 10/11/2022 at 3:30 p.m., Registered Nurse 1 (RN 1) stated Resident 31 had a history of confusion. RN 1 assessed Resident 31 and stated the bolsters were elevating the resident's legs and appeared to be used as a restraint to keep him in the bed. RN 1 stated there was no order or consent for that type of restraint because it was a safety risk. RN 1 stated the wedges were very large and it was a safety risk because the resident was a fall risk. Observed RN 1 remove the bolsters. During an interview on 10/14/22 at 9 a.m., and concurrent record review of Resident 31's medical chart, the Director of Rehabilitation Services (DRS) stated the resident was discharged from physical therapy and occupational therapy on 9/16/2022. The DRS stated Resident 31 was a fall risk. The DRS stated she never recommended any support devices for the resident. The DRS stated the resident was able move his legs off the bed but required assistance with bed mobility. The DRS stated on 10/13/2022 she was made aware that the bolster wedges were used for Resident 31 and they should never be used under the mattress because of safety concerns. The DRS stated she would never manually modify a mattress because it would create an uneven bed surface and place the resident at risk. The DRS stated the bed was not made to have an object placed under the mattress and it could move and create undesired elevation or resident position. The DRS stated she did not know who put the wedges under the mattress or the logic behind the use of wedges. The DRS stated she was concerned that the wedge was improperly used as a restraint because it elevated a resident's legs that did have good trunk control and made it difficult for the resident to get up. The DRS stated the importance of not using the wedge under the mattress was because it did not provide proper pressure distribution, created an uneven bed surface, and was a safety concern with the side rails up and a risk for fall. A review of the policy and procedures titled, Safety and Supervision of Residents, last reviewed 10/13/2022, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. A review of the Policy and Procedure titled, Bed Safety, last reviewed 10/13/2022, indicated the facility shall strive to provide a safe sleeping environment for the resident. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: inspection by maintenance staff of all beds and related equipment as part of a regular bed safety program to identify risk and problems including potential entrapment risks; identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc). A review of the Policy and Procedure titled, Hazardous Areas, Devices and Equipment, last reviewed 10/13/2022, indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A review of the Policy and Procedure titled, Falls and Fall Risk, Managing, last reviewed 10/13/2022, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Environmental factors that contribute to risk for falls include incorrect bed height or width. b. A review of Resident 63's admission Record indicated the facility admitted Resident 63 on 6/15/2016, and recently readmitted the resident on 12/4/2021, with diagnoses that included paranoid schizophrenia (mental disorder that affects a person's ability to think, feel, and behave), muscle weakness, and lack of coordination. A review of Resident 63's Minimum Data Set (MDS - an assessment and care screening tool), dated 9/9/2022, indicated Resident 63 has the ability to make self-understood and the ability to understand others. The MDS indicated the resident requires one-person extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 63's Fall Risk Assessment, dated 9/9/2022, indicated Resident 63 is a high fall risk. A review of Resident 63's Fall Risk care plan, last revised on 9/22/2022, indicated an intervention to keep environment hazard free. During an observation, on 10/13/2022 at 2:47 p.m., observed bedside commode in Resident 63's bathroom missing rubber leg tips in the front right and rear left legs. Observed two of the four legs not in contact with the floor. The bedside commode noted to be unstable and unbalanced, rocking back and forth with minimal touch due to the uneven legs. During a concurrent observation and interview, on 10/13/2022 at 3:45 p.m., Licensed Vocational Nurse 3 (LVN 3) observed and confirmed Resident 63's bedside commode is not stable upon touching it and observing the bedside commode rocks back and forth. LVN 3 stated the legs are uneven and verified that the rubber leg tips on the front right and rear left leg are missing which is allowing the bedside commode to move around easily on the bathroom floor. LVN stated the process is for staff to report to maintenance supervisor if there are defective equipment that needs to be repaired or replaced. LVN 3 stated Certified Nursing Assistants (CNAs) usually would report to charge nurse who would then report to maintenance. LVN 3 further stated the potential outcome of continuing to use bedside commode with missing rubber leg tips is a fall with possible injury. During a concurrent observation and interview, on 10/14/2022 at 11: 35 a.m., the Director of Nursing (DON) observed and confirmed the bedside commode in Resident 63's bathroom is not stable and stated it is not safe for the resident to sit on upon touching the bedside commode and watching it move easily with minimal touch. The DON verified the rubber leg tips are missing on the front right and rear left legs of the bedside commode. The DON stated the bedside commode should not have been in the resident's bathroom and should not have been used at all. The DON further stated Resident 63 is a fall risk and explained that the resident can accidentally trip or fall since the bedside commode is not steady, leading to potential injury. A review of the facility's policy and procedure titled, Hazardous Areas, Devices and Equipment, last reviewed and updated on 10/13/2021, indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The policy and procedure defined hazard as anything in the environment that has the potential to cause injury or illness that includes equipment and devices that are malfunctioning, improperly used, or poorly maintained. The policy and procedure further indicated interventions will address the specific hazards identified and may be facility-specific interventions that may include staff training or repairing equipment. c. A review of Resident 53's admission Record indicated the facility admitted the resident on 12/02/2021 with diagnoses that included peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 53's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/11/2022 indicated the resident rarely/never makes self-understood and rarely/never has the ability to understand others. The MDS also indicated Resident 53 had wandering behavior that occurred daily during the look back period (time frame for observation). During a concurrent interview and record review on 10/13/2022 at 10:29 a.m., with Registered Nurse 1 (RN 1), RN 1 verified Resident 53's quarterly MDS dated [DATE] indicated Resident 53 had wandering behavior that occurred daily. RN 1 stated Resident 53 has a history of wandering and would pace back and forth. During a concurrent interview and record review on 10/13/2022 at 2:43 p.m., with the Social Service Director/Activities Director (SSD/AD), reviewed Resident 53's quarterly MDS dated [DATE]. The SSD/AD stated she coded wandering behavior occurred daily because during that time Resident 53 had a behavior of pacing back and forth. The SSD/AD stated Resident 53 would sometimes try to go into other resident's room but would be stopped by staff. The SSD/AD stated Resident 53 would wander in the hallway and would be redirected if she went towards the door. During a concurrent interview and record review on 10/13/2022 at 3:09 p.m., with RN 1, reviewed Resident 53's medical chart. RN 1 verified Resident 53 does not have an elopement risk assessment. RN 1 stated the purpose of an assessment is to see what the resident's baseline is and evaluate the degree of risk and if they are high risk. RN 1 stated the assessment is done upon admission and then quarterly. During a concurrent interview and record review on 10/14/2022 at 9:53 a.m., with the Director of Nursing (DON), reviewed Resident 53's medical chart. The DON verified Resident 53's MDS dated [DATE] indicated behavior occurred daily. The DON stated Resident 53 can be hyper and was impulsive when admitted to the facility. The DON stated Resident 53 has a history of elopement at home and had a prior episode at the facility of trying to go to the door by the front desk but did not go out. The DON verified Resident 53 does not have an elopement risk assessment completed. The DON stated there should have been an assessment completed since Resident 53 presented to the facility with a history of elopement and could present with that behavior in the facility. The DON stated the importance of an assessment is to assess if a resident is at high risk. The DON stated if an assessment is done and the assessment is reviewed and the resident does not present with behaviors, it can be resolved. The DON stated based on Resident 53's history an elopement risk assessment should have been completed. A review of the facility's policy and procedure titled, Wandering and Elopements, last reviewed and updated on 10/13/2021, indicated, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy and procedure titled, Safety and Supervision of Residents, last reviewed and updated on 10/13/2022, indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

f. A review of Resident 17's admission Record indicated the facility admitted the resident on 2/8/2021 and readmitted the resident on 7/1/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and hypertensive heart disease (a heart problem that occurs from high blood pressure). A review of the Resident 17's History and Physical, dated 4/21/2021, indicated Resident 17 had the capacity to understand and make decisions. A review of Resident 17's Minimum Data Set (MDS- an assessment and care screening tool) dated 7/8/2022 indicated Resident 17 had the ability to make self-understood and had the ability to understand others. The MDS further indicated Resident 17 required extensive assistance with mobility, dressing, toilet use, and personal hygiene. A review of Resident 17's Care Plan (CP) titled, Potential for exacerbation of elevated blood pressure and its acute and chronic complications secondary to hypertension, initiated 7/1/2022, indicated Resident 17 received metoprolol tartrate a medication to treat HTN [high blood pressure]) daily for HTN, to be administered as ordered and taken with food. A review of Resident 17's Physician's Orders, dated 7/1/2022, indicated orders for the following: - metoprolol tartrate ablet 25 milligrams (mg, a unit of measurement), give 1 tablet by mouth one time a day for HTN, hold for systolic blood pressure (SBP - measures the pressure the blood is exerting against the artery walls when the heart beats) less than 110, or heart rate greater than 60, give with food. During a Medication Pass Observation on 10/13/2022 at 8:58 a.m. with Licensed Vocational Nurse 1 (LVN 1) at Nursing Station 1 Medication Cart, LVN 1 administered a metoprolol tablet to Resident 17 without food. During an interview on 10/13/2022 at 10:27 a.m. with Resident 17, the resident stated she last ate food at 7:30 a.m., Resident 17 stated she did not eat prior to, or during her medication administration. During an interview on 10/13/2022 at 11:07 a.m., LVN 1 stated she did not administer any medications to Resident 17 that were required to be given with food and she did not ask the resident when was the last time she ate food. LVN 1 stated she removed Resident 17's breakfast tray at 7:30 a.m. LVN 1 reviewed Resident 17's Medication Administration Record (MAR) and stated she gave the resident a metoprolol tablet one and half hours after the resident last ate, but it should have been given with food. LVN 1 stated she did not have any food to give Resident 17, but she should have asked the kitchen for a sandwich. During an interview on 10/13/2022 at 3:40 p.m., the Director of Nursing (DON) stated if the physician's order for metoprolol indicated it should be given with food, then the medication should have been administered with food. The DON stated if LVN 1 had difficulty obtaining food at that time, she should have clarified the order time with the physician to be given at mealtime. The DON stated per the facility policy, the medication should be administered as ordered. The DON Stated the importance of administering metoprolol with food was that it affects the absorption of the medication and how well it works for HTN. A review of the facility policy and procedures titled, Administering Medications, last reviewed 10/13/2021, indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication and preventing potential medication or food interaction. c. A review of Resident 9's admission Record indicated the facility admitted the resident on 4/8/2022, and recently readmitted the resident on 7/27/2022, with diagnoses of cervical radiculopathy (pinched nerve that results from the compression of a nerve in the neck), spinal stenosis (narrowing of the bony openings within the spine) of cervical (neck area of the spine) region, and low back pain. A review of Resident 9's Minimum Data Set (MDS - an assessment and care screening tool), dated 7/16/2022, indicated Resident 9 has the ability to make self-understood and has the ability to understand others. A review of Resident 9's physician's order indicated the following: Percocet tablet 5-325 mg, give one tablet by mouth every four hours as needed for severe pain 7-10/10 (from a numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) not to exceed 3 grams/24 hours, ordered on 8/25/2022. During a concurrent interview and record review, on 10/13/2022 at 11:51 a.m., Licensed Vocational Nurse 3 (LVN 3) reviewed Resident 9's Medication Count Sheet and the MAR and verified the following doses of Percocet were documented on the Medication Count Sheet but were not documented on the MAR. - One dose of Percocet 5-325 administered on 10/2/2022. - One dose of Percocet 5-325 administered on 10/3/2022. - One dose of Percocet 5-325 administered on 10/4/2022. - Two doses of Percocet 5-325 administered on 10/5/2022. - Two doses of Percocet 5-325 administered on 10/6/2022. - Two doses of Percocet 5-325 administered on 10/7/2022. - Three doses of Percocet 5-325 administered on 10/8/2022. - Two doses of Percocet 5-325 administered on 10/9/2022. - Two doses of Percocet 5-325 administered on 10/10/2022. - One dose of Percocet 5-325 administered on 10/11/2022. - Four doses of Percocet 5-325 administered on 10/12/2022. LVN 3 stated the process is to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions are ineffective, he would check the physician orders to see what pain medications can be given. LVN 3 stated he would then remove the medication from the bubble pack, document on the Medication Count Sheet, administer the pain medication, and document on the MAR upon giving the medication. LVN 3 stated the licensed nurse administering the PRN Percocet should have been documented immediately on the MAR after the medication was given. LVN 3 further stated the Medication Count Sheet should match the MAR and confirmed the multiple doses from 10/2/2022 to 10/12/2022 documented on the medication count sheet were not reflected on the MAR. LVN 3 stated license nurses should document on the MAR to accurately reflect that the medication was administered. During an interview, on 10/14/2022 at 10:47 a.m., the Director of Nursing (DON) verified the missing entries on the MAR for the PRN Percocet administered from 10/2/2022 to 10/12/2022. The DON stated that whatever is on the Medication Count Sheet should reflect on the MAR and both records should match. The DON explained licensed nurses should be documenting on the MAR as soon as they administer the Percocet to keep track of when medication, which was ordered PRN, was last given and for oncoming nurses to know when the medication can be administered again if needed or requested by the resident. The DON further stated it is important for licensed nurses to document on the MAR to accurately reflect and provide proof that the medication was actually given and to prevent medication errors from occurring. A review of the facility's policy and procedure titled, Administering Medications, last reviewed and updated on 10/13/2021, indicated the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. The policy and procedure further indicated the individual administering the medication records in the resident's medical record the date and time the medication was administered, dosage, route, any complaints or symptoms for which the drug was administered, any results achieved and when these results were observed, and the signature and title of the person administering the drug. d. A review of Resident 9's admission Record indicated the facility admitted the resident on 4/8/2022, and recently readmitted the resident on 7/27/2022, with diagnoses of cervical radiculopathy (pinched nerve that results from the compression of a nerve in the neck), spinal stenosis (narrowing of the bony openings within the spine) of cervical (neck area of the spine) region, and low back pain. A review of Resident 9's Minimum Data Set (MDS - an assessment and care screening tool), dated 7/16/2022, indicated Resident 9 has the ability to make self-understood and has the ability to understand others. A review of Resident 9's physician's order indicated the following: Tylenol Extra Strength (acetaminophen) tablet 500 mg. Give six tablets by mouth every six hours as needed (PRN) for moderate pain 4-6/10 (from a numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) not to exceed three grams/24 hours, ordered on 7/26/2022. During a concurrent interview and record review, on 10/13/2022 at 11:31 a.m., LVN 3 reviewed Resident 9's physician's orders and verified the PRN acetaminophen was ordered to be given as six tablets by mouth every six hours as needed for moderate pain. LVN 3 stated he was not aware of the order until now and confirmed the ordered dose of 3 grams is excessive and equals the total amount that can be given within 24 hours. LVN 3 explained that if there is an order for a medication with a dosage that seems to be excessive, the licensed nurse would need to contact the attending physician and clarify the order to make sure the order is correct. LVN 3 stated the order should have been discontinued and removed from the order summary if incorrect upon clarifying with the physician. During a concurrent interview and record review, on 10/14/2022 at 2:12 p.m., the DON stated the order summary is audited every month at the end of the month by medical records or designee. The DON explained medical records would inform the charge nurse or registered nurse supervisor to call the physician if an order requires clarification. The DON verified the ordered dose for PRN acetaminophen was excessive and stated it was missed during the monthly audits since the order was placed on 7/26/2022. The DON stated she has never seen an ordered dose of six tablets for PRN acetaminophen and explained the licensed nurses review the orders as well and contact the doctor to clarify any questionable orders they see. The DON stated the licensed nurse should have clarified the dosage for PRN Acetaminophen with the physician and ask to have it discontinued once it was identified. The DON further stated there is potential for Resident 9 to develop liver toxicity if given the excessive dose of six tablets of acetaminophen A review of the facility's policy and procedure titled, Administering Medications, last reviewed and updated on 10/13/2021, indicated, if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns. Based on interview and record review, the facility failed to: 1. Ensure the Medication Count Sheet (MCS- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for one of two sampled residents (Resident 30 and 53) investigated during the facility task Medication Storage and Labeling. 2. Ensure licensed nurse staff completed documentation indicating reconciliation of controlled medications (medications that are considered to have a strong potential for abuse) was done for 19 of 120 shifts. These deficient practices resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. 3. Ensure administered doses of Percocet (prescription pain medication used to treat moderate to severe pain) as needed (PRN) were documented on the MAR as evidenced by the MCS not matching and accurately reflected on the MAR for one of one sampled residents (Residents 9). This deficient practice had the potential to result in confusion on the delivery of care and services rendered. 4. Clarify an order with the physician regarding an order for acetaminophen 500 milligrams (mg- unit of measure) six tablets by mouth every six hours as needed for moderate pain for one of one sampled resident (Resident 9). This deficient practice had the potential for Resident 9 to receive the maximum amount of acetaminophen within a 24-hour period in one dose that can result in severe liver damage if given. 5. Timely replace an opened and used Ativan (medication used to treat a mental condition, characterized by excessive worry or fear) emergency kit (e-kit - (back-up supplies of medications used to deal with life-threatening medical situations) for one of one Medication Storage Room (Nursing Station 1). This deficient practice had the potential to cause delay when immediate needs of the residents arise. 6. Failing to ensure the licensed vocational nurse (LVN) followed the metoprolol tartrate (a medication to treat high blood pressure) order by failing to administer the medication with food for Resident 17. This deficient practice had the potential to result in ineffective absorption of medication resulting in ineffective management of hypertension (HTN, high blood pressure). Findings: a. A review of Resident 30's admission Record indicated the facility admitted the resident on 11/09/2018 with a readmission date of 8/27/2022 with diagnoses that included post-cholecystectomy syndrome (persistence of right upper quadrant abdominal pain with a variety of gastrointestinal symptoms), muscle wasting and atrophy (wasting or thinning of muscle mass), and gout (type of inflammatory arthritis that causes pain and swelling in the joint). A review of Resident 30's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/14/2022 indicated the resident has the ability to make self-understood and has the ability to understand others. A review of Resident 30's physician's orders indicated an order for tramadol (a controlled strong pain medication) 50mg (milligram- unit of measure) give one tablet by mouth every 12 hours as needed for moderate to severe pain, ordered on 8/26/2022. During an inspection of the Station 1 Medication Cart on 10/11/2022 at 2:36 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 30's Medication Count Sheet (MCS) and Medication Administration Record (MAR). LVN 2 verified the following: - One dose of tramadol 50 mg documented on the MCS for 10/04/2022 was not documented on the MAR. LVN 2 stated the entry should have been documented on the MAR. LVN 2 stated the procedure during medication administration is as soon as you take out the medication out of the bubble pack (a package that contains multiple sealed compartments with medication/s), you are supposed to sign the MCS, give the medication to the resident, and then sign the MAR. LVN 2 stated the procedure is to pour, pass, sign. LVN 2 stated after giving the medication to the resident, the licensed nurse is supposed to sign the MAR. During a concurrent interview and record review on 10/11/2022 at 3:35 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 30's MCS and MAR for the month of September. RN 1 verified the following: - One dose of tramadol 50 mg documented on the MCS for 9/2/2022 was not documented on the MAR. - One dose of tramadol 50 mg documented on the MCS for 9/13/2022 was not documented on the MAR. - One dose of tramadol 50 mg documented on the MCS for 9/14/2022 was not documented on the MAR. - One dose of tramadol 50 mg documented on the MCS for 9/26/2022 was not documented on the MAR. - One dose of tramadol 50 mg documented on the MCS for 9/27/2022 was not documented on the MAR. - One dose of tramadol 50 mg documented on the MCS for 9/28/2022 was not documented on the MAR. RN 1 stated the licensed nurse should give medications according to the order, take the medication out of the bubble pack and sign the MCS, give the medication to the resident, and then sign the MAR to indicate it was given. During a concurrent interview and record review on 10/14/2022 at 8:36 a.m., with the Director of Nursing (DON), reviewed Resident 30's tramadol MCS and MAR for the month of September and October. The DON verified the missing entries not documented on the MAR. The DON stated when taking controlled medication out of the bubble pack, the licensed nurse should document the date and time it was taken out on the MCS and then give the medication to the resident and sign the MAR. The DON stated the licensed nurse should do the pour, pass, sign procedure when giving medications. The DON stated the importance of documenting on the MAR is that it is proof that the medication was given. The DON stated it is important to document PRN medication to know what the outcome was after giving the medication and if it was effective. A review of the facility policy and procedure titled, Administering Medications, last reviewed and updated on 10/13/2021, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; any results achieved and when those results were observed; the signature and title of the person administering the drug. b. During an inspection of the Station 1 Medication Cart on 10/11/2022 at 2:36 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed the Floor Narcotic Release form (form signed by the on-coming nurse [incoming] and retiring [outgoing] nurse attesting all controlled medications are accounted for. LVN 2 verified there were missing entries on the log. The Floor Narcotic Release form indicated the following: - On 9/10/2022 at 11 p.m., missing signature for the on-coming nurse and missing entry indicating if count is correct. - On 9/11/2022 at 7 a.m., missing signature for the retiring nurse. - On 9/12/2022 at 3 p.m., missing signature for the retiring nurse. - On 9/16/2022 at 11 p.m., missing signature for the on-coming nurse. - On 9/17/2022 at 11 p.m., missing signature for the retiring nurse and missing entry indicating if count is correct. - On 9/18/2022 at 7 a.m., missing signature for the on-coming nurse and missing entry indicating if count is correct. - On 9/18/2022 at 3 p.m., missing signature for the retiring nurse. - On 9/20/2022 at 3 p.m., missing entry indicating if count is correct. - On 9/23/2022 at 7 a.m., missing signature for the retiring nurse. - On 9/24/2022 at 11 p.m., missing signature for the retiring nurse. - On 9/29/2022 at 7 a.m., missing entry indicating if count is correct. - On 9/30/2022 at 7 a.m., missing signature for the retiring nurse. - On 10/4/2022 at 7 a.m., missing entry indicating if count is correct. - On 10/4/2022 at 11 p.m., missing signature for the on-coming nurse and missing entry indicating if count is correct. - On 10/5/2022 at 7 a.m., missing signature for the retiring nurse and missing entry indicating if count is correct. - On 10/5/2022 at 11 p.m., missing signature for the on-coming nurse. - On 10/6/2022 at 7 a.m., missing signature for the retiring nurse. - On 10/8/2022 at 7 a.m., missing signature for the retiring nurse. LVN 2 stated when doing shift change, the incoming and outgoing nurse will count the controlled medications, and both will sign the Floor Narcotic Release form indicating the count was verified and correct. LVN 2 stated if it is not counted, the incoming nurse should not accept the cart because it contains controlled medications. During a concurrent interview and record review on 10/14/2022 at 8:36 a.m., with the Director of Nursing (DON), reviewed the Floor Narcotic Release form. The DON verified the missing signatures and documentation. The DON stated it should be signed by the incoming and outgoing nurse to account if the controlled medications were counted and verify nothing is missing and there are no discrepancies. The DON started the controlled medication count should be exact to make sure nothing is missing. A review of the facility policy and procedure titled, Policy and Procedure on Control of Narcotic Drugs, last reviewed and updated on 10/13/2021, indicated, It shall be the policy of this facility to keep an accounting of controlled/narcotic drugs kept in the facility thereby ensuring that drugs are inventoried under proper conditions with regard to security and state/federal regulations .The individual narcotic check sheet shall include the following information: Name and/or signature of outgoing and oncoming licensed nurse, notes on any identified discrepancy on narcotic count .At the beginning of each shift, narcotic drugs/medications are counted by the oncoming nurse and outgoing nurse, with results documented on the prescribed form. e. A review of Resident 37's admission Record indicated the facility admitted Resident 37 on 8/1/2022 with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and chronic atrial fibrillation (long standing abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart). A review of Resident 37's Physician Order indicated an order for lorazepam (Ativan - medication used to treat anxiety [a mental condition, characterized by excessive worry or fear]) 2 milligrams (mg)/1 milliliter (ml - unit of measure) via intramuscular (through the muscle) one time for anxiety manifested by severe agitation by constant yelling and hitting caregiver, order date 7/14/2022. A review of Pharmacy 1 (PHR 1) Ativan e-kit form for Station 1 indicated the facility used Ativan 2 mg/ml for Resident 37 on 7/14/2022. During a concurrent observation and interview on 10/12/2022 at 4:46 p.m., Licensed Vocational Nurse 6 (LVN 6) confirmed the opened Ativan e-kit opened with filled date 4/24/2022 and expiration date 1/2023. During a concurrent observation and interview on 10/12/2022 at 5:01 p.m., Registered Nurse 1 (RN 1) confirmed Resident 37's Ativan was used on 7/14/2022. RN 1 stated they fill out the form that came with the e-kit and fax it to pharmacy right away so they can get a replacement. During an interview on 10/14/2022 at 11:58 a.m., the Director of Nursing (DON) stated once opened, the e-kit is sealed off, and the licensed nurse calls the pharmacy right away. The DON stated they expect all opened e-kits to be replaced same day or the earliest possible the next day. A review of the facility policy and procedure titled Emergency Kit (e-kit) Use, reviewed and approved on 10/13/2021, indicated it is the facility's policy that e-kits are kept at the facility to meet the immediate needs of the residents. The supply is kept in a portable, sealed container. The procedures indicated that the pharmacy is to be notified as soon as possible that the e-kit has been opened so that it can be replaced within 72 hours.

Based on observation, interview, and record review, the facility failed to discard a discontinued bubble pack (a package that contains multiple sealed compartments with medication/s) of clonazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) for one of two sampled residents (Resident 53) investigated during the facility task Medication Storage and Labeling. This deficient practice had the potential to place the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications (drugs that are considered to have strong potential for abuse). Findings: A review of Resident 53's admission Record indicated the facility admitted the resident on 12/02/2021 with diagnoses that included peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anxiety disorder, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 53's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/11/2022 indicated the resident rarely/never makes self-understood and rarely/never has the ability to understand others. A review of Resident 53's physician's orders indicated an order for Klonopin (brand name for clonazepam) 0.5 milligrams (mg-unit of measure) by mouth every 12 hours as needed (PRN), and discontinued on 9/15/2022. During a medication cart inspection of Medication Cart for Station 1 on 10/11/2022 at 3:10 p.m., with Licensed Vocational Nurse 2 (LVN 2) and Registered Nurse 1 (RN 1), observed Resident 53's clonazepam bubble pack stored in the medication cart. RN 1 verified Resident 53 does not have an active order for the use of clonazepam and verified the medication was discontinued on 9/19/2022 as written on Resident 53's Medication Administration Record (MAR) for the month of September. RN 1 verified there are entries made on the Medication Count Sheet (MCS-accountability record of medications that are considered to have a strong potential for abuse) form but not documented on the MAR. A review of Resident 53's MCS indicated clonazepam doses were removed from the bubble pack on: 1. 9/23/2022 (no time indicated) 2. 9/24/2022 at 9 p.m. 3. 9/25/2022 at 9 p.m. 4. 9/26/2022 at 9 a.m. 5. 10/5/2022 at 6 p.m. During an interview on 10/11/2022 at 3:16 p.m., with LVN 2, LVN 2 stated when a controlled medication is discontinued, the medication bubble pack and the MCS should be given to the Director of Nursing (DON) immediately. LVN 2 stated the medication is then counted with the DON and signed on the MCS as witnessed. LVN 2 stated if the medication was discontinued when the DON is not at the facility, the bubble pack is to be stored in the narcotic drawer of the medication cart until the DON is back at the facility. LVN 2 stated the bubble pack would be placed in the side of the drawer and not back with the other controlled medications so it stands out and no one gives a dose to the resident. During an interview on 10/11/2022 at 3:35 p.m., with RN 1, RN 1 stated since the medication was given after it was discontinued, they are to check for any adverse effect and let the physician know it was given. RN 1 stated medications given to residents have to have an active order. RN 1 stated without an order, the medication should not be given. RN 1 stated the licensed nurse should give medications according to the order, take the medication out of the bubble pack and sign the MCS, give the medication to the resident, and then sign the MAR to indicate it was given. During a concurrent interview and record review on 10/13/2022 at 4:46 p.m., with Licensed Vocational Nurse 6 (LVN 6), reviewed Resident 53's clonazepam MCS and MAR for the month of September. LVN 6 verified she took out medication from the bubble pack as indicated by the MCS. LVN 6 stated since the order was discontinued on 9/19/2022, the bubble pack shouldn't have been in the medication cart. LVN 6 stated she should have called the physician for an order. LVN 6 stated the medication was wasted. LVN 6 verified there is no documentation indicating the medication was wasted. LVN 6 stated she should have documented on the MCS that it was wasted. LVN 6 stated controlled medications should be taken out of the medication cart once it's discontinued to prevent errors and to not give to the resident. During a concurrent interview and record review on 10/14/2022 at 12:36 p.m., with LVN 2, reviewed Resident 53's clonazepam MCS and MAR for the month of September. LVN 2 verified she took out medication from the bubble pack as indicated by the MCS. LVN 2 stated she crushed the medication and gave to Resident 53 with apple sauce but Resident 53 spit some of it out. LVN 2 stated she did not know the medication was discontinued. LVN 2 stated if the medication was discontinued it shouldn't have been in the medication cart. LVN 2 stated only active medications should be in the medication cart because it can be given in error. Reviewed Resident 53's MAR for the month of September and LVN 2 stated she doesn't remember seeing the words discontinued on 9/19/2022 documented on the MAR for the medication. LVN 2 stated since she didn't see that written on the MAR she should have documented the administration of the medication on the MAR. During a concurrent interview and record review on 10/14/2022 at 3:31 p.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 53's clonazepam MCS and MAR for the month of September. LVN 4 verified she took out medication from the bubble pack as indicated by the MCS. LVN 4 stated she gave the medication to Resident 53. LVN 4 stated Resident 53 has been taking the medication because she gets agitated. Reviewed Resident 53's MAR for the month of September and LVN 4 stated she doesn't remember seeing the words discontinued on 9/19/2022 documented on the MAR for the medication. LVN 4 stated whoever got the order to discontinue the medication should have taken it out of the medication cart and given it to the DON. LVN 4 stated it is important to take out the discontinued controlled medications because it can be given by mistake. During a concurrent interview and record review on 10/14/2022 at 3:44 p.m., with the Director of Nursing (DON), reviewed Resident 53's clonazepam MCS and MAR for the month of September. The DON verified entries made on the MCS were missing on the MAR. The DON was asked what the procedure is for discontinued controlled medications and stated the medication bubble pack and the MCS are given to her and she places them in a double locked cabinet and waits for the pharmacist to come to the facility. The DON also stated she and the pharmacist will witness it's destruction and document the medication count and that it was witnessed by her and the pharmacist. The DON stated when a controlled medication is discontinued, the medication bubble pack and the MCS should be given to her immediately. The DON stated if she is not at the facility, the medication bubble pack should be kept locked in the medication cart until she comes back to the facility. The DON stated the MCS indicated improper documentation. The DON stated if the medication was wasted, the licensed nurse is to document on the MCS that it was wasted and witnessed by them and another licensed nurse, preferably a registered nurse or herself. The DON stated a medication should not be given if it was discontinued. The DON stated the importance of taking out the discontinued controlled medications is that staff can use it for something else and could commit a mistake if given to the resident. The DON stated licensed nurse should pull out the controlled medication bubble pack when it is discontinued to avoid errors. The DON stated Resident 53's discontinued clonazepam bubble pack should not have been stored in the medication cart. A review of the facility's policy and procedure titled, Discarding and Destroying Medications, last reviewed and updated on 10/13/2021, indicated, All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of .Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. A review of the facility's policy and procedure titled, Drug Disposition, last reviewed and updated on 10/13/2021, indicated, If a physician discontinues a non-controlled or controlled drug, the drug container is to be flagged with a 'Discontinued Drug,' a 'Not in Current Use' sticker or handwritten of a similar meaning .Discontinued or outdated controlled drugs are to be delivered to the Director of Nursing for storage in an appropriately locked and secured storage area separate from other discontinued drugs until disposed properly according to policy .Controlled drugs to be disposed and witnessed per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 35's admission Record indicated the facility admitted the resident on 4/18/2022 and readmitted on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and muscle wasting and atrophy (the thinning of muscle mass). A review of Resident 35's History and Physical, dated 9/16/2022, indicated Resident 35 did not have the capacity to understand and make decisions and the resident had advanced Alzheimer dementia (a type of dementia that destroys brain cells and severely impairs mental and physical abilities). A review of Resident 35's MDS dated [DATE], indicated Resident 35 had the ability to make self-understood and had the ability to understand others. The MDS indicated the resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of the Care Plan (CP) titled, Resident has alteration in nutritional status, initiated 8/11/2022, indicated Resident 35 would have her meal tray set up, be assisted with verbal cues if needed, and be up in the chair in dining at mealtime. d. A review of Resident 27's admission Record indicated the facility admitted the resident on 10/22/2021 with diagnoses including dementia and muscle wasting and atrophy. A review of Resident 27's History and Physical, dated 10/25/2021, indicated Resident 27 did not have the capacity to understand and make decisions. A review of Resident 27's MDS dated [DATE], indicated Resident 27 rarely had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated the resident required extensive assistance for bed mobility, dressing, eating, and personal hygiene. A review of the Care Plan (CP) titled, Cognitive Loss, initiated 10/24/2021, indicated Resident 27 would be assisted with meals as needed. During a Dining Room Observation on 10/11/22 at 12:10 p.m., Resident 27 and Resident 35 sat at separate tables in Station 1 Dining Room and were assisted with eating by Certified Nursing Assistant 1 (CNA 1). Observed Resident 35 pick up food from the plate with her left hand, the resident ate the food from her hand, and licked her hand. Observed CNA 1 assist Resident 27 with eating, CNA 1 set down Resident 27's spoon and walked over to Resident 35. CNA 1 removed the remaining food from Resident 35's left hand and CNA 1 returned to Resident 27 and assisted Resident 27 with the meal. CNA 1 did not perform hand hygiene between resident care. During an interview on 10/11/22 at 12:30 p.m., CNA 1 stated she removed food from the hand of Resident 35 and then returned to feeding Resident 27 without washing her hands between resident care. CNA 1 stated she did not wash her hands because she did not see hand sanitizer in the room. CNA 1 stated knew she should have washed her hands, but she didn't. CNA 1 stated the importance of washing hands between resident care was due to infection control issues and it was especially important because it was flu (a highly contagious viral illness that infect the nose, throat, and lungs) season and viruses could be transmitted between residents. During an interview on 10/13/22 at 2:43 p.m., the Director of Nursing (DON) reviewed the facility policy and procedure and stated handwashing is done before and after assisting residents with meals. The DON stated proper hand hygiene was important because of infection control. The DON stated CNA 1 should have washed with soap and water when her hands were soiled and did not follow the facility procedure. A review of the facility Policy and Procedure titled, Assistance with Meals, last reviewed 10/13/2022, indicated residents shall receive assistance with meals in a manner that meets the individual needs of the resident. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. A review of the facility Policy and Procedure titled, Handwashing/Hand Hygiene, last reviewed 10/13/2022, indicated the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Wash hands with soap when visibly soiled. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap and water for the following situations: before and after direct contact with residents, after contact with objects in the immediate vicinity of a resident, and before and after assisting a resident meals. b. A review of Resident 29's admission Record indicated the facility admitted the resident on 9/26/2020 with diagnoses that included Huntington's disease (condition causes a progressive breakdown of nerve cells in the brain), gastrostomy (surgical opening through the skin of the abdomen to the stomach) status, and dysphagia (swallowing disorder). A review of Resident 29's Minimum Data Set (MDS, an assessment and care screening tool), dated 8/6/2022, indicated Resident 29 had severely impaired cognitive skills (thought process) for daily decision-making. The MDS further indicated the resident is totally dependent on staff of bed mobility, transfer, dressing, toilet use, and personal hygiene. During an observation on 10/14/2022 at 10:03 a.m., observed LVN 4 providing g-tube care for Resident 29. Upon checking the gastric residual (the amount aspirated from the stomach following administration of enteral feed), LVN 4 doffed her gloves, left the room, and went to her medication cart without performing hand hygiene. Observed LVN 4 don new gloves and reenter Resident 29's room without performing hand hygiene. During an interview on 10/14/2022 at 10:08 a.m., LVN 4 confirmed she did not perform hand hygiene after providing g-tube care for Resident 29. LVN 4 stated hand hygiene should be performed before and after providing care for residents. LVN 4 stated she should have performed hand hygiene with alcohol-based hand sanitizer (ABHS) after she doffed her gloves and prior to donning (putting on) new gloves to prevent spread of infection. During an interview on 10/14/2022 at 11:27 a.m., the Director of Nursing (DON) verified LVN 4 should have sanitized her hand with ABHS or wash her hands with soap and water for at least twenty seconds after doffing her gloves upon providing g-tube care for Resident 29. The DON stated hand hygiene should be performed before and after providing patient care and anytime there is contact with invasive devices or contaminated objects. The DON further stated the potential outcome of not performing hand hygiene is transmission of infection among staff and residents within the facility. A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, last reviewed and updated on 10/13/2021, indicated to use an alcohol-based hand rub containing at least 62 percent alcohol or, alternatively, soap and water for the following situations: - before and after direct contact with residents - before and after handling an invasive device - after contact with a resident's intact skin - after contact with objects such as medical equipment in the immediate vicinity of the resident - after removing gloves The policy and procedure further indicated the use of gloves does not replace hand washing or hand hygiene and the integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to: 1. Ensure five of five surveyors were screened for COVID-19 (Coronavirus disease-2019 (COVID-19 - a highly contagious viral infection that can trigger respiratory tract infection) upon entering the facility. 2. Ensure Licensed Vocational Nurse 4 (LVN 4) performed hand hygiene after providing gastrostomy tube (g-tube, a surgically placed device that passes through the abdominal wall into the stomach) care and doffing (removing) contaminated gloves for Resident 29. 3. Ensure that Certified Nursing Assistant 1 (CNA 1) perform appropriate hand hygiene between direct resident contact while assisting with the feeding of Resident 27 and Resident 35. 4. Ensure CNA 6 wore an N95 (a filtering face piece) with the flexible band resting on the nose bridge and the elastic bands placed on the head and neck that fit snugly on the face while he was dressing Resident 56. These deficient practices had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection. Findings: a. During an observation on 10/11/2022 at 7:35 a.m., with LVN 2, LVN 2 met five surveyors upon entering the facility. Notified LVN 2 that the five surveyors were at the facility to conduct the recertification survey. LVN 2 proceeded to escort the five surveyors to the work area. During an interview on 10/11/2022 at 7:45 a.m., with LVN 2, LVN 2 stated they were still doing screening for visitors and stated all visitors get screened. Notified LVN 2 that the five surveyors were all visitors. During an interview on 10/11/2022 at 8:22 a.m., with LVN 2, LVN 2 stated the surveyors should have been screened upon entering the facility. LVN 2 stated the purpose of screening is to make sure no one comes into the facility with a virus. During an interview on 10/11/2022 at 8:41 a.m., with Activities Assistant 1 (AA 1), AA 1 stated he will check temperatures and ask screening questions regarding any COVID-19 symptoms, recent exposure to COVID-19, and any recent travel. AA 1 stated all visitors and staff should be screened before entering facility. During an interview on 10/11/2022 at 8:53 a.m., with the Social Service Director/Activities Director (SSD/AD), the SSD/AD stated LVN 2 should have followed the protocol and screened the surveyors upon entering the facility. During an interview on 10/13/2022 at 5:05 p.m., with the Infection Preventionist (IP), the IP stated all visitors should be screened before entering the facility. The IP stated visitors are high risk, and it is important to screen them to protect the residents and the staff. The IP stated visitors are screened for temperature and signs and symptoms of COVID-19 and any recent exposure to COVID-19. A review of the facility policy and procedure titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan, last reviewed and updated on 10/13/2021, indicated under section for visitation that family members and visitors must perform COVID-19 antigen rapid testing (diagnostic test that detects the surface of a virus) upon arrival to the facility and will be screened upon entry to facility and after leaving facility grounds in order to adhere to COVID-19 regulations and facility policy. e. A review of Resident 56's admission Record indicated the facility admitted Resident 56 on 6/4/2019 with diagnoses including chronic atrial fibrillation (long standing abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart) and anxiety disorder (a mental condition, characterized by excessive worry or fear). A review of Resident 56's History and Physical dated 1/8/2022 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 56's MDS dated [DATE] indicated the resident has the ability to usually understand others and usually made self-understood. The MDS indicated the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) in dressing with one-person physical assistance. During an observation on 10/11/2022 at 9:09 a.m., CNA 5 assisted Resident 56 with dressing by putting on his sweater. Observed CNA 5 wearing an N95 (filtering face piece) with top strap only and missing the lower strap and the metal nose bridge situated under his nose. CNA 5 stated he removed the lower strap because it is hard to breath. CNA 5 stated the metal nose bridge should be placed on his nose bridge to make sure the N95 is sealed. CNA 5 stated he will go replace his N95 with a new one. During an interview on 10/14/2022 at 11:54 a.m., the DON stated the new guidance followed by the facility staff is that they may use surgical mask. The DON stated fit testing (assessment to check the seal between the filtering face piece and the wearer's face for signs of leakage) is done for all staff. The DON stated the facility staff should maintain the seal, ensure the snug fit, and ensure the metal bridge of the N95 is placed on the nose bridge. The DON stated when wearing N95, all facility staff should be wearing it properly to prevent the spread of infections and to protect the residents. A review of the facility's policy and procedure titled Personal Protective Equipment - Contingency and Crisis Use of N95 Respirators (COVID-19 Outbreak), reviewed and approved on 10/13/2021, indicated when putting on an N95 respirator mask the ties have to be secured at the middle of head and neck, fit flexible band to nose bridge and fit mask snug to face and below chin.