**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide services for one (#3) of three residents out of seven sample residents according to professional standards of practice. Specifically, the facility failed to: -Ensure Resident #3 was consistently monitored when having a change in condition; -Follow the physician's orders; and, -Call the provider when Resident #3's blood pressure and heart rate dropped. Findings include: I. Facility policy and procedure The Change in Resident Condition policy, dated [DATE], was provided by the regional clinical resource (RCR) on [DATE] at 2:59 p.m. It read in pertinent part, A facility must immediately inform the resident; consult with the resident's provider; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychological status (deterioration in health in life threatening conditions). Immediate notification to the provider would include but not limited to: a fall resulting in significant injury, critical lab values, respiratory arrest, acute changes in respiratory status, acute changes in cardiac status, significant change in wound status, significant changes to vital signs, sudden cognitive changes, or any life threatening episode. Document in the resident's medical record the date and time of change of condition, who (physician/family member/responsible party) was notified regarding the condition change, information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, care provided, document the time emergency personnel arrived and took over the care of the resident, if applicable and update the care plan as needed. The Verbal Orders policy, revised February 2014, was provided by the RCR on [DATE] at 2:59 p.m. It read in pertinent part, Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. A telephone order is a verbal order given over the telephone.The individual receiving the verbal order must write it on the physician's order sheet as a verbal order or a telephone order. The individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed, record the ordering practitioner's last name and his or her credentials (MD, NP and PA) and record the date and time of the order. The Charting and Documentation policy, revised [DATE], was provided by the RCR on [DATE] at 11:36 a.m. It read in pertinent part: 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. The following information is to be documented in the resident medical record including objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the resident and progress toward or changes in the care plan goals and objectives. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Documentation of procedures and treatments will include care-specific details including, the date and time the procedure/treatment was provided, the name and title of the individual(s) who provided the care, the assessment data and/or any unusual findings obtained during the procedure/treatment, how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated and the signature and title of the individual documenting. II. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included acute and chronic respiratory failure with hypoxia (an absence of oxygen in the tissues to sustain bodily functions), dependence on oxygen, dependence on a ventilator (a machine that helps you breathe, encounter for attention to a tracheostomy, cerebral palsy, protein calorie malnutrition, chronic atrial fibrillation (irregular heart beat), type 2 diabetes, epilepsy (seizures) and bradycardia (slow heart rate). The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status score (BIMS) of five out of 15. He was dependent on staff for all of his activities of daily living (ADLs). He received oxygen, suctioning, tracheostomy care and ventilator support. B. Record review On [DATE] at 1:18 a.m., Resident #3's heart rate was 91 beats per minute (bpm) and his blood pressure was 106/52 millimeters of mercury (mmHg). At 1:39 a.m. the resident's heart rate was 36 bpm and his blood pressure was 131/44 mmHg. At 3:49 a.m. the resident's heart rate was 34 bpm and his blood pressure was 126/39 mmHg. -A review of Resident #3's electronic medical record (EMR) did not reveal any additional documentation indicating the resident's heart rate and blood pressure was taken every 30 minutes per the nurse practitioner's (NP) orders. A NP note, dated [DATE] at 12:50 a.m. revealed, the nurse reported that Resident #3 complained of dizziness to the respiratory therapist (RT) and was found to have a heart rate in the 30's. A new order was given for a STAT (immediate) EKG (electrocardiogram), a CBC (complete blood count) in the morning, check the resident's blood pressure and heart rate every 30 minutes until the heart rate was stable above 50 and call back for any changes in condition. -Review of the resident's vital signs from [DATE] after the NP was notified indicated the resident's blood pressure continued to drop. Review of the resident's EMR did not reveal documentation that the NP was notified after the resident's blood pressure continued to decrease. A nursing progress note, dated [DATE] at 6:52 a.m., documented the RT reported Resident #3's heart rate was in the 30s. The resident was assessed and no distress was noted. Manual palpation of the resident's pulse was 33 to 36 BPM. The resident had a history of cardiac arrhythmias (irregular heartbeat) and was on amiodarone (blood pressure medication). The note documented the nurse called the on-call NP who reviewed the resident's chart and gave orders for a STAT CBC and STAT EKG to be done today ([DATE]). Resident #3 remained stable. At 5:37 a.m., the nurse administered the morning medications. The resident was asleep and responsive to tactile stimuli. The nurse returned to the room around 6:10 a.m. to change the resident's tube feeding. The resident was unresponsive and diaphoretic (sweating heavily). The day nurse was present in the room with the night nurse. The resident's blood sugar was checked and his blood sugar was 248. The nurse called the on-call NP and informed her that resident condition had deteriorated. A new order was received to call 911. The RT went to the resident's room and initiated CPR (cardiopulmonary resuscitation). Emergency medical services were called and they arrived around 6:25 a.m. and took over CPR. The resident's mother was called and informed that CPR was being performed and she said to keep her informed. -Review of the resident's EMR did not reveal any further documentation indicating the licensed nursing staff monitored the resident per NP orders. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 10:52 a.m. LPN #1 said the nurses needed to follow the physician's orders as written to ensure care was provided as ordered. She said this ensured that the physician was in charge and the resident was getting care to promote their health. She said when the nurse received a telephone or verbal order they were supposed to read back the order to the provider to ensure they understood and wrote the order correctly. She said then the order was put into the medical record as a verbal order to show it was received over the phone and the provider did not write the order themself. LPN #2 was interviewed on [DATE] at 11:01 a.m. LPN #2 said it was important to follow the physician's orders to ensure the care was completed the way the physician wanted to get the best possible outcome. LPN #2 said when receiving an order over the phone, the nurse should repeat the order back to the provider to ensure they received the correct order. LPN #2 said the order was then put into the medical record as a verbal order to show it was received over the phone. The director of nursing (DON) was interviewed on [DATE] at 11:03 a.m. The DON said the nurse should always follow the physician's orders. She said the nurse should write down the verbal order and repeat it back to the provider for clarification. She said she had received a text message from the nurse, who was an agency nurse, on duty at the time of the incident and she said she was doing frequent vital sign checks. She said frequent checks did not have set parameters. She said when there was a change in Resident #3's blood pressure and heart rate, the NP should have been notified of his decline. The DON said there should have been documentation that the resident was monitored related to his change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for two residents (#32 and #3) out of four residents reviewed for dignity of 26 sample residents. Specifically, the facility failed to provide Resident #32 and Resident #3 with a dignified existence by ensuring call lights were consistently answered in a timely manner. Findings include: I. Resident #32 A. Resident status Resident #32, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physicians order (CPO), diagnoses included chronic respiratory failure and amyotrophic lateral sclerosis (a neurodegenerative disease that affects the nerve cells that control muscles). The 7/11/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependant on staff for all activities of daily living (ADL). B. Resident and resident representative interview Resident #32 and his representative were interviewed together on 10/3/24 at 4:15 p.m. Resident #32 said he had issues with wait times for call light responses at night when he needed help. Resident #32's representative said the resident's call lights were left on for 15 to 20 minutes at a time with no response. Resident #32's representative said the CNAs came into the resident's room and turned off his call light without providing him with assistance, so now they had no way of documenting how long Resident #32 had been waiting. Resident #32 said the issue was inhumane. C. Record review The ADL care plan, dated 1/8/24, revealed Resident #32 had deficits in his ADL performance due increased weakness. Pertinent interventions included encouraging Resident #32 to use his call light to call for assistance. The fall care plan, dated 1/8/24, revealed Resident #32 was at risk for falls due to an inability to self-reposition. Pertinent interventions included ensuring Resident #32's call light was within reach and encouraging the resident to use it for assistance as needed as the resident needed prompt response to all requests for assistance. The myopathy care plan, dated 1/2/24, revealed Resident #32 had an alteration in his musculoskeletal status due to disease progression. Pertinent interventions included anticipating and meeting needs, ensuring Resident #32's call light was within reach and responding promptly to all requests for assistance. On 7/15/24 Resident #32's representative filed a grievance report which revealed neither the resident nor his representative had seen any improvements in call light times over 10 minutes. The resolution revealed staff education was provided on 7/16/24 regarding answering call lights timely, meeting the needs of residents, and waiting for a response before leaving the room. -However, Resident #32 was still experiencing long call wait times (see interview above). On 8/8/24 Resident #32's representative filed another grievance report that revealed on the date of the report the resident had waited 25 minutes for an respiratory therapist (RT). Resident #32 had asked a CNA twice for an RT but did not receive any response. The resolution, dated 8/13/24, revealed a training and inservice was conducted with the nursing staff which enforced answering call lights and following up on them as soon as possible. -However, Resident #32 was still experiencing long call wait times (see interview above). Call light records for Resident #32 from 9/3/24 to 10/4/24 were reviewed and revealed the following: -Activated on 9/3/24 at 9:46 p.m. for 33 minutes; -Activated on 9/4/24 at 5:56 a.m. for 24 minutes; -Activated on 9/5/24 at 4:24 a.m. for 24 minutes; -Activated on 9/5/24 at 8:47 p.m. for 42 minutes; -Activated on 9/7/24 at 7:07 p.m. for 21 minutes; -Activated on 9/7/24 at 7:51 p.m. for 21 minutes; -Activated on 9/10/24 at 4:48 a.m. for 25 minutes; -Activated on 9/10/24 at 9:37 p.m. for 21 minutes; -Activated on 9/11/24 at 5:23 a.m. for 24 minutes; -Activated on 9/12/24 at 7:28 p.m. for 24 minutes; -Activated on 9/12/24 at 8:48 p.m. for 29 minutes; -Activated on 9/12/24 at 9:46 p.m. for 25 minutes; -Activated on 9/13/24 at 5:53 a.m. for 33 minutes; -Activated on 9/15/24 at 4:53 a.m. for 38 minutes; -Activated on 9/16/24 at 5:15 a.m. for 35 minutes; -Activated on 9/18/24 at 3:17 a.m. for 23 minutes; -Activated on 9/19/24 at 3:48 a.m. for 23 minutes; -Activated on 9/22/24 at 6:09 p.m. for 29 minutes; -Activated on 9/23/24 at 3:57 a.m. for 27 minutes; -Activated on 9/24/24 at 5:49 a.m. for 26 minutes; -Activated on 9/25/24 at 3:53 a.m. for 21 minutes; -Activated on 9/26/24 at 3:21 a.m. for 30 minutes; -Activated on 9/26/24 at 4:47 a.m. for 42 minutes; -Activated on 9/26/24 at 11:19 p.m. for 24 minutes; -Activated on 9/27/24 at 4:32 a.m. for 41 minutes; -Activated on 9/30/24 at 4:53 a.m. for 50 minutes; -Activated on 10/1/24 at 1:25 a.m. for 30 minutes; -Activated on 10/1/24 at 3:39 a.m. for 27 minutes; -Activated on 10/1/24 at 11:20 p.m. for 25 minutes; -Activated on 10/2/24 at 4:42 a.m. for 22 minutes; -Activated on 10/2/24 at 7:14 a.m. for 20 minutes; -Activated on 10/2/24 at 8:49 p.m. for 32 minutes; -Activated on 10/3/24 at 12:14 a.m. for 21 minutes; -Activated on 10/3/24 at 2:15 a.m. for 22 minutes; and, -Activated on 10/3/24 at 4:30 a.m. for 43 minutes. II. Resident #3 A. Resident Status Resident #3, age [AGE], was admitted on [DATE]. According to the October 2024 CPO, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hemiplegia (weakness in one side of the body) and hemiparesis (paralysis in one side of the body). The 7/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependant on staff for most ADLs. B. Resident interview Resident #3 was interviewed on 10/2/24 at 10:16 a.m. Resident #3 said the nursing staff had recently changed from 12 hour shifts to eight hour shifts and it seemed like they were not answering call lights as quickly since the change. Resident #3 said it took the nursing staff 15 to 20 minutes at a minimum before her call light was answered. Resident #3 said she sometimes had to put her call light on two or three times before someone responded. Resident #3 said some of the certified nurses aides (CNA) were quicker to respond to the call lights than others and call light response times were longer in the late afternoon. Resident #3 was interviewed a second time on 10/7/24 at 3:03 p.m. Resident #3 said she used her call light whenever she needed ice or water. Resident #3 said she tried not to use her call light excessively, as she realized the CNAs were busy. Resident #3 said since the change in scheduling she sometimes had to wait much longer for her call light to be answered. Resident #3 said waiting 15 to 20 minutes for a response may not have seemed like much, but since she was debilitated made her wonder if they were ever going to come and help her. C. Record review The ADL care plan, revised 10/27/23, revealed Resident #3 had deficits in her ADL performance due hemiplegia and decline due to disease process. Pertinent interventions included encouraging Resident #3 to use her call light to call for assistance. The fall care plan, dated 7/26/22, revealed Resident #3 was at risk for falls due to lack of mobility. Pertinent interventions included ensuring Resident #3's call light was within reach and encouraging the resident to use it for assistance as needed as the resident needed prompt response to all requests for assistance. The oxygen therapy care plan, revised 1/28/23, revealed Resident #3 received oxygen therapy for her COPD. Pertinent interventions included having an agreed-on method for Resident #3 to call for assistance and having a staff member stay with her during episodes of respiratory distress. Call light records for Resident #3 from 9/3/24 to 10/4/24 were reviewed and revealed the following: -Activated on 9/12/24 at 8:18 p.m. for 41 minutes; -Activated on 9/14/24 at 7:32 p.m. for 21 minutes; -Activated on 9/19/24 at 6:50 p.m. for 60 minutes; -Activated on 9/24/24 at 8:03 p.m. for 42 minutes; -Activated on 9/28/24 at 8:17 p.m. for 61 minutes; and, -Activated on 9/30/24 at 8:35 p.m. for 31 minutes. III. Staff interviews CNA #1 was interviewed on 10/7/24 at 3:29 p.m. CNA #1 said she answered the call lights as soon as she saw them. She said the CNAs had phones that beeped whenever the call lights were activated. CNA #1 said when she saw multiple call lights were activated, she went to whichever one she saw first. CNA #1 said the residents used the call lights when they needed to be changed, were ready for their shower, or needed to use the urinal. CNA #1 said Resident #32 used his call light whenever he needed a RT. CNA #1 said the facility's goal was to answer call lights within five to ten minutes of being activated. CNA #1 said the call lights were sometimes on for longer than that goal because the CNAs were already giving showers, helping the nurses change dressings, or helping reposition residents. CNA #1 said Resident #32 sometimes complained about the length of time his call light was activated, to which CNA #1 said she just apologized. CNA #1 said she knew of one instance where it took a longer time to answer Resident #32's call light in which she was helping transfer another resident. CNA #6 was interviewed on 10/8/24 at 9:33 a.m. CNA #6 said she usually had ten to eleven residents depending on the facility census that day. CNA #6 said the facility's call light system did not make a sound but instead they had telephones that rang when the lights were activated. CNA #6 said when there were multiple call lights going off, she checked the phone to see how many minutes the lights had been going off. CNA #6 said Resident #32 used his call light more so she tried to get to his room as fast as possible. CNA #6 said she tried to answer the call lights as quickly as possible but the facility's goal was five to six minutes. CNA #6 said certain residents called over and over for the same things. CNA #6 said longer call light times depended on how the facility was staffed, as when they had less staff things took more time. CNA #6 said most of the residents required the assistance of two staff members, so sometimes when the CNAs were showering residents everyone was occupied so call lights were activated for longer. CNA #6 said the facility also brought in a lot of agency staff which made things more difficult as the agency staff did not have the same routine or know the residents as well. CNA #6 said Resident #3 used her call light to ask for ice or an RT. CNA #6 said Resident #3 was alert and oriented and knew to use her call light whenever she needed help. Licensed practical nurse (LPN) #5 was interviewed on 10/8/24 at 9:44 a.m. LPN #5 said the goal for answering call lights was within five minutes. LPN #5 said they had a pager or phone system to let the nursing staff know when the call lights were activated. LPN #5 said the phone system cycled through with whether or not it was working. LPN #5 said she was not sure if the pagers were working or not, but the CNAs on shift that day had her nurse phone. LPN #5 said if the nurse phone started beeping that meant the call light had been activated for a while. LPN #5 said the pager system worked by having the CNAs receive the page first, then the nurses, then the unit manager. LPN #5 said since there was not presently a unit manager the system ended with the nurse on shift. She said the facility was trying to hire a unit manager. LPN #5 said the administration would call and ask why the call lights were still activated if they had been on for an extended period. LPN #5 said longer call light times could be caused by the RT needing help with a resident or if the CNAs were already in a room. LPN #5 said there were a lot of agency staff who did not answer call lights or keep up with call light response times. LPN #5 said LPN #3 was working on servicing the phones the week prior. LPN #5 said the CNAs knew to look up and down the hallway to check and see which call lights were going off. CNA #2 was interviewed on 10/8/24 at 9:49 a.m. CNA #2 said the unit used to have two phones for the CNAs but they were gone. CNA #2 said someone took them to get them fixed. LPN #3 was interviewed on 10/8/24 at 10:15 a.m. LPN #3 said he had taken over some of the unit manager responsibilities until the facility could hire one. LPN #3 said the call lights notified the nursing staff in a few ways. LPN #3 said once the call light was activated, it pushed alerts out to the notification system. LPN #3 said these notifications were sent out to pagers, which they had been struggling to keep functioning and cell phones. LPN #3 said ideally each CNA would have a pager. LPN #3 said he had gathered all the pagers the week prior to send them out for servicing. LPN #3 said there was a monitor in the administration office that showed how long the call lights had been activated and the managers got alerts once the call light had been activated over three minutes. LPN #3 said the goal for answering call lights was within three minutes. LPN #3 said call light times were typically longer in the hospital back-up unit because the CNAs had to work in pairs while providing care. LPN #3 said the facility had received grievances about call light times periodically. LPN #3 said the response for these grievances involved creating a plan of action that usually involved reeducating the staff before going back to the resident that submitted the grievance and ensuring they were satisfied with the outcome. LPN #3 said there had not been any issues brought to his attention regarding agency staff differing in call light response compared to the facility staff. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 10/8/24 at 11:56 a.m. The DON said the facility's call light system was electronic and notifications were sent to cell phones. The DON said the notifications immediately went to the CNAs, then were sent to the nurses after two to five minutes, then to the unit manager after ten minutes, and to the DON after 20 minutes of being activated. The DON said the administrative team had directed the nursing staff to go into the room once the call light was activated, but leave the call light on if the staff member could not meet the need of the resident and needed to retrieve another staff member such as an RT or nurse. The DON said this may skew the call light times. The DON said the nursing staff also forgot to turn off the call lights after addressing the resident's needs. The DON said call lights could be longer if the RT was having an emergency. The DON said she had called in during the night to see why call lights were not being answered timely. The DON said she encouraged residents to activate their call light again if they felt they had not had their needs addressed. The DON said she had also educated the staff on giving residents time to respond and communicate their needs. The DON said sometimes the staff asked rapid-fire questions and did not give Resident #32 the time he needed to respond. The DON said the facility had moved away from using pagers and transferred to cell phones. The NHA said she had received complaints about not having chargers for the cellphones. The NHA said she addressed this so there would be chargers that could not be unplugged and moved so they would not go missing. The DON said the facility had a lot of staff that were just floating around and not doing anything so they had to address those concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.06%, or two errors out of 33 opportunities for error. Findings include I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure The Medication Administration policy and procedure, dated 2/29/24, was received from the infection preventionist (IP) on 10/7/24 at 1:02 p.m. It revealed in pertinent part, Resident medications are administered in an accurate, safe, timely and sanitary manner. Physician orders are administered in accordance with written orders of the attending physician or physician extender. If a dose is inconsistent with the resident's age and condition or medication order is inconsistent with the resident's current diagnosis or condition, contact the physician for clarification prior to the administration of the medication. Document the interaction with the physician in the nursing progress notes and elsewhere in the medical record, as appropriate. Verify the medication label against the medication administered record (MAR) for accuracy of drug frequency, duration, strength and route. Follow safe preparation practices as follows: Be sure to check the bottle label against the physician's orders. Medication is to be given in compliance with the physician orders and or manufactures recommendations. III. Observations and interviews On 10/3/24 at 5:20 p.m. licensed practical nurse (LPN) #4 was administering medications to Resident #2. LPN #4 dispensed one tablet of Lactaid 9000 units. Resident #2's MAR indicated the resident had a physician's order for Lactaid oral tablet 3000 units via nasogastric tube (NGT) two times a day for abdominal bloating. -LPN #4 dispensed one tablet of Lactaid 9000 units. This was 6000 units more than the physician's order indicated the resident was to receive. When LPN #4 was asked to review the physician's order for Lactaid. After reviewing the order, she said she could cut the tablet in half. LPN #4 proceeded to cut the tablet in half with a pill cutter and placed a half tablet into the medication cup. -The half tablet of Lactaid 9000 units was still 1500 units more than the physician's order indicated the resident was to receive. LPN #4 was asked a second time to review Resident #2's Lactaid order. LPN #4 said she should have cut the tablet into three parts so it would equal the 3000 units of Lactaid indicated by the physician's order. LPN #4 removed the half tablet from the medication cup and disposed of the tablet. At 5:44 p.m. LPN #4 said she needed to check central supply to see if the facility carried the 3000 unit dose of Lactaid the physician ordered for Resident #2. LPN #4 checked the central supply medications and said the only Lactaid in stock was the 9000 units dose. She added Lactaid 3000 units to the order supply list in central supply. -LPN #4 did not administer Resident #2's Lactaid because she did not have the correct dose. LPN #4 said if a medication tablet did not have a score line (mark or indentation down the middle of a medication tablet that allows for accurate cutting of the medication) by the manufacturer it should not be cut. LPN #4 said she should not have attempted to administer the Lactaid tablet she cut with a pill cutter because it did not follow the dose the physician had ordered for Resident #2. LPN #4 said cutting a tablet in half that did not have a score line was not safe because staff could not ensure the medication concentration would equal the dose ordered. On 10/7/24 at 8:20 a.m. LPN #2 was administering medications to Resident #11. Resident #11's MAR revealed the resident had a physician's order for Flonase suspension 50 microgram/actuation (mcg/act) two inhalations in both nostrils every 12 hours for allergy, runny nose and sinusitis. LPN #2 said he was unable to find the medication so he reordered it from the pharmacy. LPN #2 said he documented the medication was on order with the pharmacy in the MAR. -LPN #2 did not administer the medication to Resident #11 as ordered because the medication was not available. IV. Additional staff interviews LPN #3, who was also the unit manager, was interviewed on 10/7/24 at 10:18 a.m. LPN #3 said nurses were not supposed to cut medication tablets in half unless they contained a score line created in the medication by the manufacturer. LPN #3 said cutting a tablet without a score line in half could lead to the wrong dose of the medication being administered to a resident. She said cutting medications in half was the responsibility of the pharmacist. LPN #3 said if a medication was not available it should be ordered and the physician should be contacted to be notified of the missing dose. She said nurses should get an order from the physician to hold a medication until it was available or see if the physician wanted to change the medication to a different dose the facility may have on hand. The director of nursing (DON) was interviewed on 10/7/24 at 10:32 a.m. The DON said nurses were not to cut medication tablets in half unless the medication was scored. The DON said cutting an unscored tablet could lead to the resident getting too much or too little of a medication. The DON said if a medication was not available at the time of an ordered administration, the pharmacy should be contacted to reorder the medication. She said the physician should be contacted to inform them of the missing dose and get an order on how to proceed, whether it be to hold the medication until it was available or change the medication to a different dose on hand.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on one of two units. Specifically the facility failed to ensure safe and appropriate storage of food items in personal resident refrigerators. Findings include: A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/8/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises or discarded The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. B. Facility policy and procedure The Foods Brought by Family/Visitors policy, revised March 2022, was provided by the nursing home administrator (NHA) on 10/8/24 at 10:28 a.m. It revealed in pertinent part, Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date. C. Resident interview Resident #3 was interviewed on 10/2/24 at 10:16 a.m. Resident #3 said her refrigerator had not been checked by a member of the dietary staff in months. Resident #3 was interviewed again on 10/7/24 at 9:58 a.m. Resident #3 said her daughter had come two days prior, defrosted her refrigerator and threw away all of the food items that had expired. -However, multiple items remained in the refrigerator that were expired. C. Observations and record review On 10/2/24 at 10:16 a.m. the following items were found in Resident #3's refrigerator: -An open bag of croutons, with an expiration date of 12/14/23; -A bottle of Caesar salad dressing, with an expiration date of 6/21/23; -A bottle of barbeque sauce, with an expiration date of 1/24/24; -Another bottle of barbeque sauce, with an expiration date of 12/5/23; -A slice of zucchini bread wrapped in plastic wrap that had no date; -Two containers cocktail sauce, with an expiration date of 4/26/23; -A bag of sliced carrots, that had no date or label on it; and, -Two opened containers of chocolate pudding, with no date. -There were 10 to 15 small gnats or fruit flies that were dead at the inside of the refrigerator at the bottom. The paper on the side of the refrigerator was labeled October 2024 with columns for refrigerator and freezer temperatures. The temperatures for 10/1/24 and 10/2/24 had not been filled out. The following items were found in Resident #3's refrigerator 10/07/24 at 9:58 am: -The same open bag of croutons, with an expiration date of 12/14/23; -The same bottle of barbeque sauce, with an expiration date of 1/24/24; and, -An unlabeled and undated tupperware container of asparagus. The paper on the side of the refrigerator was labeled October 2024 with columns for fridge and freezer temperatures. The temperatures for 10/1/24 through 10/7/24 had not been filled out. D. Staff interview The dietary manager (DM) was interviewed on 10/7/24 at 12:19 p.m. The DM said the dietary staff had temperature logs for Resident #3's personal refrigerator. The DM said the dietary staff went through Resident #3's refrigerator to throw expired food items away and to ensure any food brought in by the resident's family was appropriately labeled and dated. The DM was interviewed again on 10/7/24 at 12:40 p.m. She said, while reviewing the contents of Resident #3's refrigerator, the refrigerator had a temperature log for October 2024 that no one had filled out. The DM said the expired croutons and the barbeque sauce needed to be thrown away. She asked Resident #3 if she could throw them away. The DM said there was a cook that was previously employed at the facility that was really consistent with checking through Resident #3's refrigerator. The DM said she had told the dietary staff members to ensure they were checking Resident #3's refrigerator and fill out the respective temperature log whenever they checked the unit refrigerators.

Based on record review and interviews, the facility failed to complete a performance review ofevery nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of five certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5 in order to determine potential training needs. Findings include: I. Facility policy and procedure The In-Service Training, Nurse Aide policy and procedure, revised August 2022, was received from the infection preventionist (IP) on 10/7/24 at 1:02 p.m. It revealed in pertinent part, All nurse aide personnel participate in regular in-service education. The facility completes a performance review of nurse aides at least every 12 months. In-service training is based on the outcome of the annual performance reviews. Supervised practical training means training in a setting in which instruction and oversight are provided by a person who has relevant education and/or experience specific to the subject of the training being provided. Training curriculum includes learning objectives, performance standards and evaluation criteria. Nurse aides are evaluated based on individual performance when appropriate. Competency may also be demonstrated through a written exam or by consistently applying interventions necessary to meet the needs of the residents as identified in the facility assessment. II. Record review Annual performance reviews were requested on 10/3/24 at 10:40 a.m. for CNA #2 (hired on 12/30/22), CNA #3 (hired on 6/6/23), CNA #4 (hired on 1/26/23) and CNA #5 (hired on 4/13/23). -The facility was unable to provide annual performance evaluations or regular in-service education based on the outcome of the reviews for CNA #2, CNA #3, CNA #4 or CNA #5. III. Staff interviews The nursing home administrator (NHA) was interviewed on 10/7/24 at 2:47 p.m. The NHA said annual performance evaluations had not been completed for CNAs. The NHA said the facility was implementing a process, going forward, where human resources would print out a list of CNAs/staff who required annual performance evaluations for each manager to complete. The NHA said each manager would then be responsible for getting them completed and she would review the evaluations prior to them being given to the staff for finalization.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination. Findings include: I. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/8/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B. Facility policy and procedure The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions Policy, revised January 2024, was received from the nursing home administrator (NHA) on 10/7/24 at 2:30 p.m. It revealed in pertinent part, Food is handled properly with frequent handwashing and proper sanitation guidelines per local, state and federal guidelines and codes. C. Observations During a continuous observation of the dinner meal service on 10/3/24, beginning at 4:40 p.m. and ending at 5:42 p.m. the following was observed: At 4:50 p.m. cook (CK) #1 was wearing a pair of gloves and handling meal tickets, plate warmers, a door handle and serving utensils. Using the same gloved hands, CK #1 sliced a chicken breast on the griddle and used his gloved hand to stabilize the chicken while he scooped it up with a spatula before setting it on a plate. CK #1 then took out a bag of bread, opened the plastic bag, and grabbed two slices of bread with the same gloved hands before setting them on the griddle. Using the same gloved hands, CK #1 grabbed a handful of french fries out of the fryer basket and set them on a plate. At 4:55 p.m. CK #2 began preparing a southwest salad. Using gloved hands, CK #2 opened the cold storage doors and took out a container of lettuce. Using the same gloved hands, CK #2 removed the lettuce lid and grabbed handfuls of lettuce to put into a bowl. CK #2 repeated this process with containers of chopped red onion and tortilla strips. At 5:00 p.m. CK #1 washed his hands and donned (put on) a new set of gloves. CK #1 handled several serving utensils before grabbing a handful of fries using his gloved hands and setting them on a plate. After this, CK #1 used a spatula to scoop up a cooked chicken breast and place it on a plate. CK #1 then used the same gloved hands to adjust the chicken breast on the plate before serving it. At 5:07 p.m. CK #2 was wearing a pair of gloves. CK #2 opened the cold storage doors and took out a container of egg salad. CK #2 set the egg salad container on the table and with the same gloved hands that had touched the lettuce she had previously set on a plate At 5:10 p.m. CK #2 was preparing a to-go order salad. CK #2 took out a cardboard to-go container and using the same gloves retrieved the container of lettuce from the cold storage and took out handfuls of lettuce using the same gloved hands. At 5:25 p.m. CK #2 was handling meal tickets and serving utensils before returning to the to-go order salad. CK #2 sliced an avocado and used her same gloved hands to peel the skin off the avocado before placing the avocado slices into the to-go salad container. At 5:29 p.m. CK #1 was handling meal tickets and serving utensils on the service line with gloved hands. Using the same gloved hands, CK #1 picked up the plastic bread bag and used his gloved hand to push the slices of bread down before closing the bag and putting it away. D. Staff interview The dietary manager (DM) was interviewed on 10/7/24 at 12:19 p.m. The DM said the dietary staff typically did not handle much ready-to-eat food but that ready-to-eat food should be handled with gloves and clean utensils. The DM said gloves should be changed any time a staff member started a new task. The DM said gloves needed to be removed when handling meal tickets and new gloves donned afterward. The DM said one of the cooks was new to the role, so she was still trying to instill good hand hygiene habits in him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Failure to ensure staff wore appropriate PPE when administering medications through a feeding tube for a resident on EBP A. Facility policy and procedure The Enhanced Barrier Precautions (EBP) policy and procedure, dated 1/6/23, was received from the IP on 10/7/24 at 1:02 p.m. It read in pertinent part, EBP are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents. EBP employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing high-contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, and tracheostomy/ventilator)and complicated wound care (any skin opening requiring a dressing). EBP remains in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk as they can still serve as a source of transmission even after the infection has resolved. Staff are trained prior to caring for residents on EBP. Signs are posted on the door or wall outside the residents' rooms indicating the type of precautions and PPE required. PPE is available outside of the residents' rooms. The gown and gloves used for each resident during high-contact resident care activities should be removed and discarded after each resident care encounter. Hand hygiene should be performed, and new gown and gloves should be donned before caring for a different resident. B. Observations and staff interview On 10/7/24 at 8:40 a.m. licensed practical nurse (LPN) #1 was administering medications to Resident #27. Resident #27 had a physician's order for medications to be administered via G-tube (gastrostomy tube - a tube inserted through the belly directly into the stomach). LPN #1 prepared all medications as ordered. LPN #1 went to Resident #27's room, knocked on the door and announced herself. There was a sign outside Resident #27's door that indicated the resident was on EBP. LPN #1 entered the resident's room, placed medications on the bed side table, performed hand hygiene with an alcohol based hand rub and applied clean gloves. LPN #1 collected water and a large syringe to administer the medications via the resident's G-tube. LPN #1 administered the medications as ordered. During administration of the medications, the G-tube was connected to a large syringe, bubbles were seen in the syringe and gurgling noises were heard as LPN #1 administered the medications. LPN #1 washed her hands with soap and water prior to exiting Resident #27's room. -LPN #1 failed to apply PPE, including a gown, mask, and face shield prior to the administration of Resident #27's medications via the G-tube. LPN #1 was interviewed immediately upon exiting Resident #27's room at 8:59 a.m. LPN #1 said she did not have to wear all of the PPE for medication administration via G-tube. She said the PPE was only required for Resident #27 when his wound care was being provided. C. Additional staff interviews LPN #3, who was also the unit manager, was interviewed on 10/7/24 at 10:18 a.m. LPN #3 said PPE, such as gowns, masks and gloves were required to be worn when administering medications via a G-tube to a resident on EBP. LPN #3 said the PPE was needed due to the increased risk of splashing from a G-tube. LPN #3 said the PPE was to be worn to help prevent the spread of infection. The DON was interviewed on 10/7/24 at 10:32 a.m. The DON said if medications were being administered to a resident on EBP via a G-tube, PPE, such as a gown, gloves and mask should be worn to prevent infection. The DON said the G-tube was an opening in the body which increased the risk of infection. The IP was interviewed on 10/7/24 at 12:50 p.m. The IP said PPE should be worn during medication administration via G-tube for a resident on EBP. The IP said a mask, gown and gloves were to be worn to help prevent the spread of infection. The IP said staff would be re-educated on EBP procedures. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents' rooms; -Ensure housekeeping staff performed appropriate hand hygiene and changed gloves after cleaning residents' toilets; and, -Ensure staff wore the appropriate personal protective equipment (PPE) when administering medications through a feeding tube for a resident who was on Enhanced Barrier Precautions (EBP). Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 10/9/24 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 10/9/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Cleaning and Disinfecting Resident Rooms policy and procedure, revised August 2013, was provided by the director of nursing (DON) on 10/7/24 at 3:20 p.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident rooms. Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products. Floor mopping solution will be replaced every three resident rooms, or changed no less often than at 60 minute intervals. Resident room cleaning: -Gather supplies as needed; -Prepare disinfectant according to manufacturer's recommendations; -Discard disinfectant/detergent solutions that become soiled or clouded with dirt and grime and prepare fresh solution; -Change mop solution water at least every three (3) rooms, or as necessary; -Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters; and, -Clean personal use items (lights, phones, call bells, bed rails) with disinfectant solution at least twice weekly. C. Observations During a continuous observation on 10/7/24, beginning at 8:22 a.m. and ending at 8:44 a.m., housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER] and room [ROOM NUMBER]. HSK #1 removed a purple rag, a green rag, the toilet brush and a bottle of disinfectant from the cart. She entered room [ROOM NUMBER] and wiped the surfaces of the dresser and the bedside table with the purple rag. -HSK #1 did not use a disinfectant while cleaning the room or disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 entered the bathroom and sprayed the disinfectant on the counter and sink. She immediately wiped the surface off. HSK #1 sprayed the toilet rim and bowl with the disinfectant. She used the toilet brush to clean the inside of the toilet bowl and used the green rag to wipe the rim of the toilet. -HSK #1 failed to allow the disinfectant to remain on surfaces for the appropriate disinfectant dwell time. -HSK #1 failed to disinfect any other parts of the toilet, the bathroom grab bars, the shower, the light switch or the door knobs. HSK #1 placed the soiled rags and the disinfectant bottle in the cart. Without removing her gloves or performing hand hygiene, she removed two mop pads from a bucket on her cleaning cart and the mop handle. She dropped one of the mop pads on the floor by the door and one in the bathroom and proceeded to mop the resident's room and bathroom. -HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water. -HSK #1 did not change her gloves or perform hand hygiene after cleaning the toilet before removing the mop pads from the bucket of plain water. After finishing the mopping in room [ROOM NUMBER], HSK #1 proceeded to room [ROOM NUMBER]. HSK #1 removed two green rags, the toilet brush and a bottle of disinfectant from the cart. She wiped the dresser and bedside table with the dry cloth. -HSK #1 did not use a disinfectant while cleaning the room or disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 entered the bathroom and sprayed the disinfectant on the counter and sink. She immediately wiped the surface off. HSK #1 sprayed the toilet rim and bowl with the disinfectant. She used the toilet brush to clean the inside of the toilet bowl and used the second green rag to wipe the toilet seat, the top of the tank, the tank, behind the seat, the rim and then the base of the toilet. -HSK #1 failed to allow the disinfectant to remain on surfaces for the appropriate disinfectant dwell time. -HSK #1 failed to disinfect the toilet from top to bottom, the grab bars, the shower, the light switch or the door knobs. HSK #1 placed the soiled rags and the disinfectant bottle in the cart. Without removing her gloves or performing hand hygiene, she removed two mop pads from the bucket on her cleaning cart and the mop handle. She dropped one of the mop pads on the floor by the door and one in the bathroom. and proceeded to mop the resident's room and bathroom. -HSK #1 did not change her gloves or perform hand hygiene after cleaning the toilet before removing the mop pads from the bucket of plain water. D. Staff interviews HSK #1 was interviewed on 10/7/24 at 8:45 a.m. HSK #1 said she did not clean the bed because the resident never left the bed. She said she should have sprayed the rag with the disinfectant and immediately wiped it off. HSK #1 said she did not know what high touch surfaces were. She said she usually wore the same gloves through the entire cleaning process and did not know if a cleaner or disinfectant needed to be in the mop water. The housekeeping and laundry manager (HLM) was interviewed on 10/7/24 at 9:38 a.m. The HLM said HSK #1 should have cleaned the residents' rooms from clean to dirty and all surfaces, as well as high touch areas, should have been disinfected. The HLM said the disinfectant had a dwell time of one minute and should not be wiped off immediately. The HLM said surfaces should remain wet for a full minute before wiping in order to kill the pathogens that may be present. The HLM said HSK #1 should not have mopped the floor with plain water. The HLM said a disinfectant should have been mixed with the water in the mop bucket. The HLM said housekeepers should always change gloves and perform hand hygiene after cleaning the toilet. The HLM said based on the observation of HSK #1, hand hygiene was not adhered to, cleaning methods were not followed per the facility's procedures and the surface disinfectant times were not followed. The HLM said she would immediately educate the housekeepers on the proper techniques for room cleaning. The DON was interviewed on 10/7/24 at 10:39 a.m. The DON said every room should be cleaned and disinfected daily and the housekeepers should follow the manufacturer's recommended dwell time for the products to disinfect properly. The DON said gloves should be changed and hand hygiene performed after cleaning the bathroom. The DON said all high touch surfaces need to be cleaned daily, especially with the medically complex residents that resided at the facility. The DON said the residents' rooms should be cleaned from clean to dirty and top to bottom. The infection preventionist (IP) was interviewed on 10/7/24 at 12:45 p.m. The IP said the residents' rooms should be cleaned and disinfected daily, gloves should be changed after each task and a disinfectant needed to be used on all surfaces, including the floor. The IP said the toilet should be cleaned from clean to dirty and the disinfectant dwell times followed for infection control purposes. The IP said she would immediately re-educate the housekeeping staff on the facility's cleaning procedures, hand hygiene and the disinfectant dwell time.

Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include: I. Record review The PBJ staffing report for quarter three (4/1/24 to 6/30/24) showed the following triggered areas: -Excessive low weekend staffing; and, -One star rating. The trigger for low weekend staffing triggered the facility's one star rating. -However, review of the facility's April 2024 to June 2024 staff time cards revealed the facility did not have low weekend staffing. II. Staff interview The nursing home administrator (NHA) was interviewed on 10/7/24 at 2:45 p.m. The NHA said the facility used a third party processor to submit their PBJ report. She said the third party processor did not submit the report timely and it was rejected. The NHA said the one star rating and the low weekend staffing triggers occurred because the report was not submitted timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#240, #242, #245 and #246) of five residents out of 11 sample residents. Specifically, the facility failed to ensure Resident #240, Resident #242, Resident #245 and Resident #246 experienced a dignified living experience by answering the residents' call lights in a timely manner. Resident #240 and Resident #242, who required assistance with toileting, expressed embarrassment, frustration and anger due to long call times and not being provided timely assistance which resulted in them experiencing episodes of urinary incontinence. Findings include: I. Facility policy and procedures The Accommodation of Needs policy, revised March 2021, was provided by the clinical mentor (CM) on 10/18/23 at 11:11 a.m. It read in pertinent part, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. -The policy did not specifically address resident call lights. II. Resident #240 A. Resident status Resident #240, age greater than 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included unsteadiness on feet, need for assistance with personal care and history of falling. The 9/30/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required one-person extensive assistance for bed mobility and personal hygiene. He required one-person limited assistance for dressing and toilet use. Transfers occurred only once or twice during the seven day MDS look back period and required the assistance of one person. B. Resident interview Resident #240 was interviewed on 10/5/23 at 1:15 p.m. Resident #240 said he sometimes had to wait a long time for his call light to be answered. He said he occasionally was incontinent of urine when staff did not come to assist him to the bathroom in time. He said he understood that the staff was very busy, however, he said it was frustrating and extremely embarrassing when he did not make it to the bathroom in time. He said it was embarrassing because he was a grown man and should not be wetting himself. He said he was not supposed to take himself to the bathroom, however, he said he sometimes tried to do it himself so that he would not have a urinary accident. He said he had not spoken to anyone about his concerns with the long call wait times. C. Record review Review of Resident #240's fall care plan, initiated 9/26/23, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #240's call light log report from 9/26/23 to 10/5/23 revealed the following: -9/27/23 at 7:28 a.m: the call light was on for 17 minutes; -9/27/23 at 12:21 p.m: the call light was on for 21 minutes; -9/29/23 at 3:43 p.m: the call light was on for 15 minutes; -9/29/23 at 6:06 p.m: the call light was on for 17 minutes; -9/29/23 at 7:13 p.m: the call light was on for 34 minutes; and, -9/29/23 at 8:04 p.m: the call light was on for 37 minutes. III. Resident #242 A. Resident status Resident #242, age greater than 65, was admitted on [DATE]. According to the October 2023 CPO, diagnoses included history of falling, difficulty with walking, muscle weakness and need for assistance with personal care. The 8/28/23 MDS assessment revealed that the resident was cognitively intact with a BIMS score of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers and toilet use. She required one-person limited assistance for dressing. She required supervision for personal hygiene. B. Resident interview Resident #242 was interviewed on 10/5/23 at 1:02 p.m. Resident #242 said it sometimes took staff a long time to answer her call light. She said she had occasionally had to wait longer than 15 to 20 minutes for staff to answer her light. She said she had experienced a couple incidents of urinary incontinence when staff did not answer her call light in a timely manner. She said she was on a diuretic medication which made it difficult sometimes to hold her urine until staff was able to assist her if it took a long time for them to answer her light. She said it was frustrating and made her embarrassed and angry when she was incontinent of urine because she had to wait too long to use the bathroom. She said she was embarrassed because she was an adult and should be able to urinate in the toilet instead of her pants. She said she had not spoken to anyone regarding her frustrations with the long call wait times. She said she knew the staff worked hard and she did not want to get anyone in trouble. C. Record review Review of Resident #242's fall care plan, initiated 8/24/23, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #242's call light log report from 8/24/23 to 10/5/23 revealed the following: -8/26/23 at 8:55 a.m: the call light was on for 17 minutes; -8/29/23 at 7:43 p.m: the call light was on for 15 minutes; -8/30/23 at 7:59 a.m: the call light was on for 15 minutes; -9/2/23 at 10:25 a.m: the call light was on for 16 minutes; -9/7/23 at 1:14 p.m: the call light was on for 15 minutes; -9/8/23 at 7:04 a.m: the call light was on for 23 minutes; -9/8/23 at 2:52 p.m: the call light was on for 17 minutes; -9/8/23 at 8:25 p.m: the call light was on for 18 minutes; -9/11/23 at 4:56 a.m: the call light was on for 18 minutes; -9/16/23 at 10:31 p.m: the call light was on for 17 minutes; -9/17/23 at 9:15 a.m: the call light was on for 15 minutes; -9/19/23 at 11:40 a.m: the call light was on for 25 minutes; -9/20/23 at 2:05 p.m: the call light was on for 17 minutes; -9/24/23 at 7:23 p.m: the call light was on for 22 minutes; and, -9/28/23 at 4:10 p.m: the call light was on for 30 minutes. IV. Resident #245 A. Resident status Resident #245, age greater than 65, was admitted on [DATE] and discharged to the community on 9/20/23. According to the September 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness and reduced mobility. The 9/19/23 MDS assessment revealed that the resident was cognitively intact with a BIMS score of 15 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person extensive assistance for dressing and personal hygiene. She required one-person limited assistance for toilet use. B. Record review Review of Resident #245's fall care plan, initiated 9/14/23, revealed the resident was at risk for falls, however, there were no pertinent interventions listed on the care plan. Review of Resident #245's call light log report from 9/14/23 to 9/21/23 revealed the following: -9/14/23 at 3:27 p.m: the call light was on for 17 minutes; -9/14/23 at 4:22 p.m: the call light was on for 33 minutes; -9/14/23 at 6:49 p.m: the call light was on for 19 minutes; -9/14/23 at 11:05 p.m: the call light was on for 37 minutes; -9/15/23 at 5:44 a.m: the call light was on for 25 minutes; -9/15/23 at 12:08 p.m: the call light was on for 36 minutes; -9/15/23 at 3:06 p.m: the call light was on for 18 minutes; -9/15/23 at 5:11 p.m: the call light was on for one hour and three minutes; -9/16/23 at 10:13 a.m: the call light was on for 23 minutes; -9/16/23 at 6:46 p.m: the call light was on for 16 minutes; -9/16/23 at 10:51 p.m: the call light was on for 29 minutes; -9/17/23 at 8:03 a.m: the call light was on for 17 minutes; -9/17/23 at 11:17 a.m: the call light was on for 17 minutes; -9/17/23 at 11:44 a.m: the call light was on for 30 minutes; -9/17/23 at 2:25 p.m: the call light was on for 32 minutes; -9/17/23 at 5:02 p.m: the call light was on for 20 minutes; -9/17/23 at 8:59 p.m: the call light was on for 30 minutes; -9/18/23 at 7:17 a.m: the call light was on for 15 minutes; -9/18/23 at 12:41 p.m: the call light was on for 16 minutes; -9/18/23 at 6:35 p.m: the call light was on for 22 minutes; -9/19/23 at 1:31 a.m: the call light was on for 32 minutes; -9/19/23 at 3:07 a.m: the call light was on for 16 minutes; -9/19/23 at 6:15 a.m: the call light was on for 19 minutes; -9/19/23 at 10:54 a.m: the call light was on for 18 minutes; -9/20/23 at 4:38 a.m: the call light was on for 17 minutes; -9/20/23 at 5:54 a.m:the call light was on for 35 minutes; and, -9/20/23 at 6:37 a.m: the call light was on for 38 minutes. V. Resident #246 A. Resident status Resident #246, age greater than 65, was admitted on [DATE] and discharged to the community on 9/21/23. According to the September 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness and reduced mobility. The 8/31/23 MDS assessment revealed that the resident had moderate cognitive impairment with a BIMS score of eight out of 15. She required two-person limited assistance for bed mobility. Transfers occurred only once or twice during the seven day MDS look back period and required the assistance of two people. Toilet use and personal hygiene occurred only once or twice during the seven day MDS look back period and required the assistance of one person. Dressing did not occur during the seven day MDS look back period. B. Record review Review of Resident #246's fall care plan, initiated 9/11/23, revealed the resident was at risk for falls due to impaired balance and required staff assistance for stability. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #246's call light log report from 8/29/23 to 9/21/23 revealed the following: -8/29/23 at 6:14 p.m: the call light was on for 16 minutes; -8/30/23 at 9:34 a.m: the call light was on for 16 minutes; -9/1/23 at 12:05 p.m: the call light was on for 17 minutes; -9/3/23 at 5:39 p.m: the call light was on for 28 minutes; -9/4/23 at 10:05 a.m: the call light was on for 18 minutes; -9/7/23 at 1:33 p.m: the call light was on for 19 minutes; -9/9/23 at 6:34 p.m: the call light was on for 16 minutes; -9/10/23 at 3:30 p.m: the call light was on for 18 minutes; -9/10/23 at 7:43 p.m: the call light was on for 23 minutes; -9/12/23 at 7:26 a.m: the call light was on for 15 minutes; -9/13/23 at 8:20 a.m: the call light was on for 19 minutes; -9/14/23 at 8:55 a.m: the call light was on for 19 minutes; -9/15/23 at 9:10 a.m: the call light was on for 16 minutes; -9/15/23 at 2:00 p.m: the call light was on for 18 minutes; -9/15/23 at 7:19 p.m: the call light was on for 32 minutes; -9/16/23 at 10:43 a.m: the call light was on for 25 minutes; -9/16/23 at 6:43 p.m: the call light was on for 20 minutes; -9/17/23 at 9:28 a.m: the call light was on for 45 minutes; and, -9/20/23 at 11:39 a.m: the call light was on for 29 minutes. VI. Staff interviews Registered nurse (RN) #1 was interviewed on 10/11/23 at 9:55 a.m. RN #1 said certified nurse aides (CNA) answered call lights. He said CNAs had a pager that let them know a resident's call light was on. He said nurses did not have a pager. He said nurses' cell phones were programmed to get a text message on their phone if the call light had not been answered by the CNAs after five minutes. He said call lights should be answered as soon as possible. He said a reasonable expectation to answer a call light was in five to six minutes. RN #2 was interviewed on 10/11/23 at 10:10 a.m. RN #2 said resident call lights should be answered as soon as possible. He said staff should attempt to answer resident call lights within two to three minutes. RN #2 said CNAs had a pager that alerted them to a resident's call light. He said nurses had a pager and a cell phone. He said the pager and the cell phones were set up to receive an alert that a resident's call light was on if it had not been answered after five minutes. CNA #1 was interviewed on 10/11/23 at 10:15 a.m: CNA #1 said CNAs carried pagers that alerted them a resident's call light was on. She said a call light should be answered in less than five minutes if possible. She said if a resident's call light could not be answered quickly, the CNA should let the nurse know so the nurse could assist with getting the resident's call light answered timely. CNA #2 was interviewed on 10/11/23 at 10:25 a.m. CNA #2 said CNAs wore a pager which alerted them when a call light was turned on. She said call lights needed to be answered as soon as possible. She said call lights should be answered in under 15 minutes. The director of nursing (DON) was interviewed on 10/11/23 at 11:15 a.m. The DON said call lights should be answered as soon as possible and all attempts should be made to answer the call lights in less than 10 minutes. She said CNAs and nurses wore pagers which alerted them a resident's call light was on. She said CNA pagers alerted them at the time a resident's call light was turned on and kept alerting them every minute afterward until the call light was answered. The DON said nurses wore a pager which alerted them a resident's call light was on after the call light had been on for three minutes without being answered. She said the nurses received repeat alerts every two minutes after the initial alert until the call light was answered. The DON said the nurses' cell phones were programmed to receive text message alerts that a resident's call light was on. She said the nurses received a text message about the call light when it had been on for six minutes, 10 minutes and 15 minutes. The DON said unit managers did not have pagers, however, she said they received text message alerts on their cell phones if a call light had gone unanswered for 10 minutes. She said they received another alert if a call light had been on for 15 minutes. The DON said she and the assistant director of nursing (ADON) received text message alerts on their cell phones if a call light had gone unanswered for 15 minutes. She said the alert system program for the cell phones did not have the capability to send alerts past 15 minutes. The DON said everyone who received an alert was expected to go and investigate why the resident's call light had not been answered and assist residents with their needs. She said sometimes staff forgot to turn off a resident's call light when it was answered and that was why some of the call light response times were so long. She said with the way the facility's call light alert system was set up a resident's call light should never be unanswered for more than 20 minutes at the most. The DON said she conducted random call light audits, however she said she did not have documentation of the audits. She said she would pull up call lights on the call light log by unit and see if there was a concern for long call wait times on a specific unit. She said if she found an issue she would check in with the staff on that unit to make sure the pagers were all functioning and not turned to the silent mode. The DON said she conducted random visits on night shift and asked unit managers to follow up to ensure the pagers on their units were functioning properly and that batteries were available on a daily basis. VII. Facility follow up On 10/11/23 at 12:00 p.m. the DON provided an email which was sent by her to the NHA and unit managers on 9/14/23 at 2:51 a.m. The email informed the recipients that she had conducted a night shift visit and discovered two pagers that were in disrepair on the 2 North unit. She instructed the unit managers to conduct an audit of all of the pagers on their units on the morning of 9/14/23 and bring any concerns with pagers to the morning meeting. There were no other concerns found with the pagers in the facility. -There was no other documentation provided by the facility regarding call light audits or other random night shift visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one (#52) out of 52 sample residents. Specifically, the facility failed to administer scheduled pain medication, for neuropathy pain, at the correct dosage as ordered by the resident's physician, to Resident #52. Findings include: I. Professional reference According to [NAME] Nursing Drug Handbook 2020, Kizior, R. J. and [NAME], K.J., St. Louis Missouri 2020, revealed the following pharmaceutical information, page (pp). 963-965 read in part: Pregabalin. Use: Management of neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia. Administration: discontinue gradually over at least one week. II. Facility policy The Administering Medications policy revised April 2109, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: Medications are administered in a safe and timely manner, and as prescribed. The Pharmacy Services Overview policy revised April 2109, was provided by the corporate nurse CNC on 7/31/23 at 2:35 p.m. The policy read in pertinent part: The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. -Pharmacy services are available to residents 24 hours a day, seven days a week. -Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. -Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. III. Resident #52 A. resident status Resident #52, age [AGE], was admitted to the facility on [DATE] and was discharged to the hospital on 7/19/23. According to the computerized physician's orders, diagnoses included heart failure, diabetes mellitus with diabetic neuropathy and chronic stage 3 kidney disease. The admission minimum data set assessment (MDS) dated [DATE] documented the resident had intact cognition with a brief interview for mental status score of 15 out of 15. The resident needed staff supervision to complete activities of daily living (ADL). -The resident had frequent pain and received scheduled and as needed pain medications to manage the pain. The resident rated his worst pain as an 8 on a pain scale of 1 to 10. B. Resident representative interview The resident was not available for an interview. The resident's representative was interviewed on 7/31/23 at 10:06 a.m The resident representative said there was a pharmacy error and Resident #52 did not get the correct dosage of pregabalin (Lyrica) for neuropathy and Resident #52 complained of increased pain. The resident was prescribed pregabalin 150 milligrams (mg) twice a day, upon admission to the facility he was receiving the correct dose of medication but the facility ran out of medication and the nursing staff gave him 100 mg capsules instead until the pharmacy delivered the correct dose of medication a couple of days later. C. Record review The July 2023 CPO documented the following orders: - Lyrica (pregabalin) oral capsule 150 mg, give 1 capsule by mouth two times a day for pain; start date 6/30/23. -Lyrica (pregabalin) oral capsule 100 mg, give 100 mg by mouth one time only for neuropathic pain for one day; order date 7/12/23. --Lyrica (pregabalin) oral capsule 100 mg, give 100 mg by mouth one time only for neuropathic pain for one day; order date 7/13/23. Review of the July 2023 medication administration records (MAR) revealed: Lyrica (pregabalin) was not administered on 7/12/23, 7/13/23 for the morning and evening dose and 7/14/23 for the morning dose. The resident received a one time dose of Lyrica 100 mg at 7/12/23 at 11:00 p.m. and 7/13/23 at 2:13 p.m. Physician admission summary dated [DATE] read in pertinent part: Other orders: Pregabalin (Lyrica) 150 mg oral capsule; take one capsule by mouth two times a day for neuropathy. Medication administration note dated 7/12/23 at 11:46 a.m. read: Lyrica 150 mg (was unavailable). Waiting for the pharmacy to deliver. Medication administration note dated 7/12/23 at 10:00 p.m. read: Lyrica oral capsule 150 mg, give one capsule by mouth two times a day for pain. (Medication) unavailable. On-call physician notified. Skilled nursing note dated 7/13/23 at 5:12 a.m. read in pertinent part: Lyrica 150 mg was unavailable. On call physician notified. Obtained an order to give 100 mg by mouth tonight and in the morning. Prescription to be sent to the pharmacy. Lyrica 100 mg provided from emergency medication stock. IV. Staff interview Licensed practical nurse LPN #3 was interviewed on 7/25/23 at 11:02 a.m. LPN #3 said the nurse was to administer medication as ordered. The nurse should check the resident's MAR for the order, correct medication, dosage and time; if the medication was unavailable, the nurse should notify the physician that the medication is unavailable and document the communication and any additional orders. The nurse should also contact the pharmacy to reorder the mediation. Medication should be ordered at least three to seven days prior to the medication running out. Some medication could be obtained from the emergency medication storage with pharmacy approval. The CNC, director of nursing (DON), nursing home administrator (NHA) and corporate consultation (CC) were interviewed on 7/31/23 at 3:55 p.m. The DON said medication should be reordered prior to the medication running out. If medications were unavailable, the nurse should check the emergency medication supply to see if the medication is available in the kit; then contact the pharmacy for an approval code to provide them medication and a prescription refill. When the medication is unavailable, the nurse should contact the prescribing physician for additional orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure biologicals were labeled and stored in accordance with accepted professional standards for one of four medication storage rooms. Specifically, the facility failed to discard expired vaccines from the medication storage room. Findings include: I. Facility policy The Storage of Medications policy, dated [DATE], was received on [DATE] at 2:35 p.m. from the corporate nurse consultant (CNC). The policy read in pertinent part: The nursing staff is responsible for maintaining medication storage and preparation areas. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Observations Medication room two-south unit On [DATE] at 3:03 p.m., the medication room was observed with registered nurse (RN) #1 and the unit manager (UM). After the observation, RN #1 and the UM verified the medication room had the expired biological items including: Sanofi Pasteur fluzone influenza (flu vaccine), 10 pre-filled syringes that expired [DATE], 97 days prior to the observation. III. Interviews RN #1 and the UM were interviewed together immediately after the observation on [DATE] at 3:09 p.m. The UM said the expired vaccines should have been removed from the supply room. The UM said the policy for vaccine storage was to discard or return expired vaccines to the pharmacy. RN#1 disposed of the expired vials immediately. The assistant director of nursing (ADON) was interviewed on [DATE] at 2:15 p.m. The ADON said the expired vaccines should be removed from storage immediately to prevent expired items being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide prompt acceptable resolution to resident/resident representative grievances that were important to the residents. Specifically, the facility failed to resolve grievances for long call wait times in a manner that was satisfactory to the residents in the facility. Findings include: I. Facility policy and procedure The Grievance policy and procedure, reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 4:48 p.m. It read, in pertinent part, to ensure residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form. A resident, family member, staff member or visitor may file a grievance at any time with an appropriate staff member or supervisor. There is no set time frame or minimum amount of time in which it must be filed except for those required under the Elder Justice Law. Upon receipt of a Grievance and Complaint Report or Complaint Concern form, the social services director or designee will begin an exploration into the allegations/concerns. The appropriate department director will be notified of the nature of the complaint and that follow up is necessary. The investigation and report will include, as each may apply: the date and time the incident took place; the circumstances surrounding the incident; where the incident took place; the names of any witnesses and their account of the incident; the resident's account of the incident; the employee's account of the incident; accounts of any other individuals involved; and recommendations for corrective action if not already remedied. The Grievance and Complaint Investigation Report must be filed with the administrator within five working days of the receipt of the grievance of complaint form. II. Resident interviews Resident #41 was interviewed on [DATE] at 1:45 p.m. Resident #41 said she waited several hours for staff to answer her call light. Resident #41 said she used the call light and no staff came. She said it sometimes made her upset and anxious and the staff did not care. Resident #68 was interviewed on [DATE] at 1:45 p.m. Resident #68 said he waited 45 minutes for staff to answer his call light when he used it to request pain medication. Resident #1 was interviewed on [DATE] at 3:05 p.m. Resident #1 said it could take staff 20 to 30 minutes or more to answer the call light. Sometimes the certified nursing aids (CNA) came into the room after the 20 to 30 minute wait and did nothing for her; turned off the call light; left the room and then did not come back for another 20-30 minutes. Resident #1 said she did not like it because there were several times they turned off the light and left when she felt uncomfortable and needed personal care. Resident #233 was interviewed on [DATE] at 4:20 p.m. Resident #233 said she waited in pain for about 45 minutes for staff to come when she needed the bedpan on [DATE]. Resident #233 said there were sometimes after she used her call light that she waited for longer than 20 minutes after activating the call light when she needed to use the bedpan. Resident #233 said sometimes when staff did not answer the call light it made her scared, worried and anxious about having an accident. III. Record review A. Grievance log The grievance log from [DATE] to [DATE] revealed there were 13 grievances for call lights. B. Call light alert and response times report A request was made for call light response time for residents who reported long call light wait times during the survey; and for observations during the survey where call light's where staff failed to respond to the resident's call light effectively. The call light response logs (incident details report) revealed the following: -Resident #4's call light log for [DATE] at 8:37 a.m. revealed the call light was not answered for 30 minutes. -Resident #233's call light log for [DATE] at 5:10 a.m. revealed the call light was not answered for 44 minutes and not answered for 24 minutes during the same morning at 6:09 a.m. -Resident #34's call light log for on [DATE] at 9:22 p.m. revealed the call light was not answered for 18 minutes. -Resident #22's call light log for [DATE] between 8:35 a.m. and 4:47 p.m. revealed the call light was not answered timely five times during that day. The call light activated at 8:35 a.m., was not answered for 48 minutes; the call light activated at 10:11 a.m, was not answered for 45 minutes; the call light activated at 1:46 p.m., was not answered for 26 minutes; the call light activated at 2:17 p.m., was not answered for 55 minutes; and the call light activated at 4:47 p.m., was not answered for 45 minutes. IV. Staff interviews CNA #1 was interviewed on [DATE] at 4:08 p.m. CNA #1 said the CNAs were supposed to answer the call lights within three minutes, but sometimes she was busy with other residents and could not answer right away. CNA #1 said she when a call light was activated she would check on the resident and turn off their call. If the resident needed to be changed or toileted, she would help them immediately. If she could not help the resident immediately then she would let the nurse know. CNA #2 was interviewed on [DATE] at 4:08 p.m. CNA # 2 said she tried to answer the call lights within three minutes, but answering call lights in that time was sometimes difficult when there were a lot of call lights on at the same time. CNA #2 said when that happened she would finish up with the resident she was working with and then answer the next call light as soon as possible. CNA # 2 said if she could not get to the residents she would tell the nurse. CNA #3 was interviewed on [DATE] at 11:56 a.m. CNA #3 said she tried to answer the call light as soon as possible. If she was in the middle of helping a resident she would finish with them before answering the call light. She said if a resident could wait she would go in and turn off the call light and return after finishing with another resident. CNA #3 said if a resident needed personal care or the bathroom she would find another staff member to help right away. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 4:13 p.m. LPN #2 said the resident call light system used pagers which the CNAs had. LPN #2 said the CNAs should answer the call lights within a reasonable time frame, which was considered to be within seven minutes. LPN #2 said there were times when the CNA would be in with a resident and was unable to answer the call lights timely. LPN #2 said when that happened another CNA would help them. LPN #2 said it would depend on a resident's need, if it was something simple then the CNA could help them quickly. LPN #2 said if it was a more significant need, such as personal care was needed for a resident who required a two-person lift, the CNA might turn off the call light and then leave to get help from another staff member. LPN #2 said there were times when the CNA would forget to turn off the call light when they went to get another staff, which would show an increase in the call light response time. The director of nursing (DON) was interviewed on [DATE] at 3:56 p.m. The DON said the call light system used pagers and an escalation system. The CNAs, the unit nurses and nurse managers carried pagers. The assistant director of nursing (ADON) and the DON got the call light alerts on their cell phones. The DON said when a call light was used the CNAs get an alert on their pagers letting them know which room and resident needed attention. The CNAs needed to respond to the call light within three minutes if they did not the unit nurse received an alert page after the three minute mark. If the call light was not answered by six minutes, the nurse manager would then receive an alert pager message; and the ADON would receive an alert after 10 minutes. Then after 15 minutes DON received a notification message a resident's call light was still unanswered. The DON said when she received the notification on her phone she would call the unit/facility to determine what happened. The DON said she reviewed the call light report weekly and would determine why there were long call light times and provide education for staff who were involved in the long call light times. The DON said a CNA was to answer the call light within a reasonable time of 10 minutes or less. The DON said for a CNA to answer a call light timely would depend upon several factors such as time of day; if there was an emergency; if someone had a change in condition; if a resident needed a two person assist; or if the CNAs were busy helping another resident. The DON said another reason for the long call light times could be due to the CNA forgetting to turn off the call light before helping the resident, not turning off the call light off prior to leaving the room to finish up with another resident or getting help from another CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure meaningful activities designed to support residents physical, mental, and psychosocial well-being were provided for three (#1, #4 and #41) of six residents out of 52 sample residents. Specifically, the facility failed to: -Offer the resident population a consistent and regular scheduled activities program that included both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community; -To provide residents #1, #4 and #41 meaningful activities; and, -To offer residents #1, #4 and #41 regularly scheduled activities of choice. Findings include: I. Facility policy and procedure The Activity Documentation policy and procedure, revised on 6/20/23, was provided by the director of nursing (DON) on 7/31/23 at 4:00 p.m. It revealed, in pertinent part, The community will offer at least three group activities per week, one of which must be offered in the evening (after dinner) that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies and culture of the participants and community. Activities include community sponsored group and assistance in individualized/independent activities. Activities will create opportunities for participants to have a meaningful life by supporting their domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). Activities will be designed to meet participants' best ability to function, incorporating their strengths and abilities. The activity department will provide 1:1 (one-to-one) recreation and social visits if the individual was unable to participate in independent leisure, or, upon participant request. II. Activities programming A. Resident interviews Resident #34 was interviewed on 7/24/23 at 9:05 a.m. She stated activities were none existent. She said that staff provided assistance to select television programs. She said that staff had not offered a selection of activities and that she had participated once with an activity but it was not meaningful because it was not interesting to her. She said she had not been invited to participate in other activities. Resident #57 was interviewed on 7/26/23 at 11:42 a.m. Resident #57 said he had been at the facility for about six weeks, since mid June 2023. Resident #57 said he had not met any other residents for his first three weeks at the facility. Resident #57 said the first time he met other residents was when he attended a group therapy session. He then began to eat meals with the other residents. Resident #57 said he suggested to staff they have group activities such as an ice cream social, bingo or games in order for residents to meet each other and socialize. Resident #57 said he was not offered one-to-one or group activities since he had arrived. Resident #57's room did not have an activities calendar posted. Resident #23 was interviewed on 7/27/23 at 9:52 a.m. Resident #23 was unable to speak answers aloud but was able to answer some questions with gestures. Resident #23 shook his head no when asked if he was offered or participated in activities. When Resident #23 was asked how long it had been since he was offered or participated in activities and he held up three fingers indicating he had not been offered activities opportunities in the three months since he arrived in the facility. Resident #23 shook his head yes that he would participate in activities if they were offered. Resident #23's room did not have an activities calendar posted. B. Record review The combined July 2023 therapeutic and activity calendar documented the following activities opportunities: -On 7/5/23 activities offered Bingo at 5:45 p.m.; -On 7/11/23 activities offered a viewing of a docu-series show at 5:45 p.m.; -On 7/18/23 activities offered evening devotional at 5:45 p.m.; -On 7/25/23 activities offered a social with card games at 5:45 p.m -All other offerings listed on the calendar were therapy-oriented groups activities provided by the therapy department. C. The activities director (AD) interview The AD was interviewed on 7/27/23 11:06 a.m. The AD said the activities staff were offering only one group activity a week in the evenings from 5:00 p.m. to 7:00 p.m., due to lack of staff. There were no group activities being offered during the day time hours. The AD was the only staff member in the activities department but when the department was fully staffed there were three to five staff and they were able to provide regular activities programming when they were fully staffed. When fully staffed there would be two group activities every day and one-to-one activities programming would be provided to all residents assessed to need that level of programming on a regular schedule. The one to one activities would be completed by the AD and one other activity staff while the others would provide group programming and offer resident supplies for independent activities. The AD said she was currently the only staff providing one-to-one activities to residents. The AD said over the last couple of months the activity calendar was merged with the therapeutic group exercise calendar since the activities department was only able to provide one group activity weekly. The therapeutic group exercise programming was a part of the therapy department services; the therapy department provided physical therapy and occupational therapy for residents who received skilled nursing services. The group therapy sessions listed on the combined activities therapy calendar was open to all residents if they wanted to attend. The AD said when the activity department was fully staffed a separate calendar would be posted to include two recreational and social group activities per day. A paper copy of the calendar would be posted in each of the residents ' rooms so the resident would be aware of what activity was offered by the AD. At present, they did not post an activity calendar in the residents ' rooms. The AD described independent leisure activities as any activity residents were observed participating in independently such as reading, watching television, talking or visiting with someone. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included ventilator dependence, reduced mobility, dementia, bipolar II disorder and anxiety disorder. The 5/1/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. She required extensive assistance of two people for most activities of daily living (ADLs). The assessment documented the resident's speech was unclear, but the resident was able to make concrete requests and to respond adequately to simple direct communication. The 8/7/22 MDS initial assessment indicated it was very important for Resident #4 to listen to music, have animals/pets around, to participate in her favorite activities and religious services. It was somewhat important for Resident #4 to have books, newspapers and magazines to read and to go outside to get fresh air in good weather. B. Resident observations and interview -On 7/26/23 at 2:34 p.m., Resident #4 was in bed resting, she appeared to be sleeping. -From 3:33 p.m. to 3:39 p.m., two staff provided personal care and repositioning. There was no additional stimulation or interactions between the staff and the resident and the resident was not offered or encouraged to participate in any type of recreational activity. -At 5:02 p.m. Resident #4 was in bed sleeping. Resident #4 did not have any external stimulation or social interactions. -On 7/27/23 at 9:54 a.m., 11:14 a.m. and 1:49 p.m. Resident #4 was observed in her room sleeping with no external stimulation or social interactions. -At 2:48 p.m. staff provided personal care and repositioning. There was no additional stimulation or interactions with others. Resident #4 was interviewed on 7/27/23 at 2:54 p.m. Resident #4 was awake, looking out her window and moving around in bed. Resident #4's television was not on and she did not have any additional stimulation or items for independent activities. Resident #4 was unable to speak aloud but was able to respond to questions by mouthing simple words and by use of gestures. Resident #4 mouthed yes to wanting to participate in activities including listening to music, visiting with animals and observing or working with art. When asked if she wanted to get out of her room to participate in activities she nodded her head yes. She then pointed to the window and smiled, she nodded her head when asked if she enjoyed looking out of the window. Resident #4's room did not have an activities calendar posted. C. Resident representative interview The resident's representative was interviewed on 7/27/23 at 2:10 p.m. The representative said Resident #4 loved music, animals and art. The resident representative said she did not think Resident #4 did any activities right now. She said she would like it if Resident #4 could participate in activities that interested her. She would especially like it if Resident #4 were to be able to get out of her room to participate in activity programming. The resident representative said Resident #4 would not refuse those activities if they were offered to her either for a one-to-one or group activity. D. Record review Activities care plan initiated on 8/5/22 revealed Resident #4's interests were reading books, listening to music (rock n ' roll, country, Conway [NAME], and blues), being around animals, watching movies, westerns, or sports on the television (TV). Resident #4 was a Broncos football fan and enjoyed getting fresh air and having her blinds and windows open. Resident #4 was Christian and practiced by listening to gospel music. The care focus goal initiated on 8/5/22 revealed Resident #4 would participate in independent leisure activities of choice approximately three to five times per week by watching shows of interest on TV, reading or listening to music of interest. Goal initiated on 2/10/23 revealed Resident #4 would accept therapeutic one-to-one visits approximately three to five times per week which included activities of interest such as listening to music, being spoken to or reading books by nodding her head and making eye contact. Activities participation documentation revealed Resident #4 participated in a one-to-one activity in the month of July 2023 on 7/17/23; and participated 15 times in independent leisure activities from 7/3/23 to 7/28/23. -Independent leisure activities were described by the activities director (AD) as any activity residents were observed participating in independently such as reading, watching tv, talking or visiting with someone (see above). -There was no other documentation in record of Resident #4 participating in one-to-one or group activities of choice. IV. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 CPO, the diagnoses included aphasia (difficulty with language), dysphagia (difficulty with swallowing), cervical disc disorder, and muscle wasting and atrophy. The 5/23/23 MDS assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She required extensive assistance of two people for most ADLs. The assessment documented it was very important for Resident #41 to keep up with the news, do her favorite activities, go outside and get fresh air and participate in religious services or practices. It was somewhat important for Resident #41 to have books, newspapers and magazines to read, listen to music and to do things with groups of people. A. Resident interview and observations Resident #41 was interviewed on 7/25/23 at 9:42 a.m. Resident #41 was sitting up in bed and said she had not been offered activities in the two months since she had been at the facility. Resident #41 said she would like to go to activities if they had them. Resident #41 was interviewed again on 7/25/23 at 4:32 p.m. Resident #41 was in her room sitting up in bed, she said she was happy she attended the resident group meeting and felt much better now that she met other residents she could talk to. She said she had not met any other residents prior to the meeting because she never got out of her room to meet residents. Resident #41 said she had not been offered an invitation to activities and was unaware of activities opportunities. The resident said she did not have an activities calendar posted. Resident #41 was interviewed again on 7/26/23 at 2:03 p.m. Resident #41 said things had been going pretty well, but she still had not been offered an opportunity to participate in activities. B. Record review There was no documentation in the resident record showing that Resident #41 had been offered or had participated in activities since during her time in the facility. V. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the July 2023 computerized CPO the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominance (stroke with left side weakness), chronic obstructive pulmonary diseases (lung disease), multiple sclerosis, post polio syndrome, tracheostomy, ventilator dependence, depression and weakness. The 4/19/23 MDS assessment documented the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required two person assistance to extensive assistance with most ADLs. The resident's activity prefrence were not assessed. B. Resident interview Resident #1 was interviewed on 7/24/23 at 1:45 p.m. Resident #1 said she used to play Bingo. The activities staff would bring a computer tablet to her bed so she could play with the other residents from her bed. She said it stopped when one of the activities staff members stopped working at the facility and they no longer brought her the tablet so she could participate. The resident said she loved to play Bingo and missed participating. Resident #1 said she missed letter writing with a family member. An activities staff member used to pick up her outgoing mail every day at 11:00 a.m. since she was unable to leave her room to get the written letter in the mail. The activities staff did so to help the resident participate in a letter writing exchange with a special family member. The resident said this letter writing exchange was a great sense of enjoyment and was very important to her. The activities staff's participation in this social activity was necessary to ensure that her letters got out in the day's mail and arrived to its recipient in a timely fashion so the recipient could respond timely and she could receive letters back in exchange. She looked forward to the recipient's response to her letters. The resident said the staff member who picked up her mail stopped working at the facility three weeks ago and no staff came to pick up her mail in their absence. The resident filed a grievance and they started to pick up her mail; but then that stopped five days later and had not resumed. Resident #1 said she felt terrible because there were times she would work to find staff to take her mail to the receptionist only to find out the letter was not picked up by the postman. Resident #1 said sending and receiving mail was the most important thing to her. She had a family member who was only able to visit once a month so they wrote to each other every day. The resident and her family member set up a system of letter writing so they could expect a letter from one another most every day, but without activity staff's assistance that was not happening. The resident said to most people mail may not be that important but for her, it was important because she was in her bed 24 hours a day, 7 days a week and the correct correspondences made her feel connected. C. Record review The 7/25/23 comprehensive care plan focus for activities program revealed Resident #1 loved to write letters everyday, visit family and playing games like Bingo with groups of people. Interventions included sending mail daily and providing Resident #1 with assistance setting up a tablet in the resident's room to use for virtual group activities of interest. The resident's activity record revealed she had three total one-on-one visits in the past 30 days. One for each of the following activities: social, music and drawing in the past 30 days. -The activity record did not document any resident participation for playing Bingo in the virtual group setting nor did the activities record document that mail assistance was provided to the resident as care planned. D. Staff interview The corporate nurse consultant (CNC) was interviewed on 7/31/23 at 3:57 p.m The CNC looked in the resident's record and confirmed that there was no record of mail being sent out and no record of the resident attending Bingo. VI. Other staff interviews Certified nurse aide (CNA) #3 was interviewed on 7/27/23 at 11:56 a.m. CNA #3 said group activities such as bingo and movies were held upstairs in the activity room. The residents were offered one-on-one activities in their rooms. CNA #3 said there used to be more activity staff but right now there was only one staff available. CNA #1 was interviewed on 7/31/23 1:10 p.m. CNA #1 said she had not seen residents participating in any activities in the last two months. CNA #1 said two months ago residents would offer group activities such as bingo, movies, arts and crafts and also one-to-one activities in their rooms. CNA #1 said she was not sure why there had not been any activities recently. CNA #4 was interviewed on 7/31/23 at 2:37 p.m. CNA #4 said she had been working at the facility for two months and had worked on both long term care and rehabilitation floors. CNA #4 said had not seen one-to-one or group activities being offered to residents since she had started working. The nursing home administrator (NHA) was interviewed on 7/31/23 at 2:23 p.m. The NHA said there was currently one activity staff and he said the activity department was fully staffed. The NHA said there were two staff in the activity department a month ago. The NHA said group activities were located on the calendar but was unsure as to how many group activities were held daily. The NHA said the therapeutic group activities were counted as activities and all residents were offered therapy. The NHA said for social activities the residents were encouraged to self-initiate and could join other residents in the dining hall during meals. The NHA said one-to-one activities were offered to residents up to six times a week depending on what was refused or accepted by the resident. The resident's preferences were included in the resident's file. The NHA said they instituted an ambassador program where each department head was assigned residents to visit each morning. Every resident was visited daily and had the option to share any concerns they had during the visit. The concerns were documented in a spreadsheet and all concerns were addressed at the morning meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (#124) of three residents out of 52 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #124: -Received the medication selpercatinib, a prescribed kinase inhibitors medication (a medication that blocks the action of an abnormal protein that signals cancer cells to multiply) according to manufacturer's directions when give with a protein pump inhibitor (PPI) medication (a class of medications that blocks gastric acid secretions by dissolving chemical bonds within food molecules); and, -Received the medication selpercatinib timely within permeates of also giving the medication before meals and doses 12 hours apart per manufacturer's directions. I. Professional reference According to the manufacture Eil Lilly and Company Prescribers Information highlights, revised September 2022, retrieved from https://uspl.lilly.com/retevmo/retevmo.html#pi on 7/27/23 Retevmo- selpercatinib capsule is indicated for the treatment of adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) with a rearranged during transfection (RET) gene fusion, as detected by an FDA-approved test. Retevmo may be taken with or without food unless co-administered with a proton pump inhibitor (PPI) Dosage modifications for concomitant (given with) use of acid-reducing agents Avoid concomitant use of a PPI, a histamine-2 (H2) receptor antagonist (a medication used to treat gastric intestinal ulcers and for some conditions, in which the stomach produces too much acid), or a locally-acting antacid with Retevmo. If concomitant use cannot be avoided: -Take Retevmo with food when co-administered with a PPI. -Take Retevmo 2 (two) hours before or 10 hours after administration of an H2 receptor antagonist -Take Retevmo 2 (two) hours before or (two) hours after administration of a locally-acting antacid. Concomitant use of RETEVMO with acid-reducing agents decreases selpercatinib plasma concentrations, which may reduce RETEVMO anti-tumor activity. Patient counseling information: -Advise patients that they will require regular blood pressure monitoring and to contact their healthcare provider if they experience symptoms of increased blood pressure or elevated readings; -Advise patients that RETEVMO may increase the risk for bleeding and to contact their healthcare provider if they experience any signs or symptoms of bleeding; -Advise patients to contact their healthcare provider promptly to report any signs and symptoms of tumor lysis syndrome (TLS-caused by massive tumor cells lysis with the release of large amounts of potassium, phosphate and nucleic acid into the the circulatory system) symptom include: nausea, vomiting, diarrhea, muscle cramps or twitches, weakness, numbness or tingling, fatigue, and decreased urination. -Advise patients and caregivers to inform their healthcare provider of all concomitant medications, including prescription medicines, over-the-counter drugs, vitamins, and herbal products. According to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 599 - 609. Nurses play an important role in patient safety, especially in the area of medication administration. The safe administration of medications is also an important topic for current nursing researchers. As a nurse you need to know how to calculate medication doses accurately and understand the different roles that members of the health care team play in prescribing and administering medications. The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. -Preventing medication errors is essential. -Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. Professional standards such as scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors follow the seven rights of medication administration consistently every time you administer medication. -The right medication; the right dose; the right patient; the right route; the right time; the right documentation; and right indication. II. Facility policy The Administering Medications policy revised April 2109, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: 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. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The Medication Regimen Reviews policy revised May 2109, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. -Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. -The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. -The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses or without clinical indication; b. medication regimens that appear inconsistent with the resident's stated preferences; c. duplicative therapies or omissions of ordered medications; d. inadequate monitoring for adverse consequences; e. potentially significant drug-drug or drug-food interactions; f. potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences; g. incorrect medications, administration times or dosage forms; or h. other medication errors, including those related to documentation. -Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. -An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. -If the identified irregularity represents a risk to a person's life, health, or safety, the consultant pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally, and documents the notification. -If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. -The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. III. Resident #124 A. Resident status Resident #124, under the age of 65, admitted on [DATE] and discharged on 7/4/23. According to the July 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm (cancer) of the bronchus/lungs, malignant neoplasm of the brain, respiratory failure, epilepsy and gastroesophageal reflux disease (GERD). The 6/22/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for a mental status score of 14 out of 15. The resident needed limited assistance from staff for mobility and completion of activities of daily living (ADL). B. Record review 1. Physician's orders and medication administration record (MAR) The June and July 2023 CPO and MARs documented the following orders: Selpercatinib (Retevmo) oral capsule 80 mg, give two capsules by mouth every 12 hours, for cancer. Give at 8:00 a.m. and 8:00 p.m. Pantoprazole sodium (protonix -a PPI) oral tablet delayed release 40 mg, give one tablet by mouth one time a day for GERD. Give at 7:00 a.m. -The CPO and MAR gave the same instruction; failing to give specific instructions for giving the two medications concomitant per manufacturer's directions (see professional reference above). -Review of the June and July 2023 CPO and MAR revealed the resident's medication was given late consistently for four of 13 morning doses and five of 14 evening doses (see below). The pantoprazole sodium (PPI medication) was only scheduled for one hour before the selpercatinib medication as directed by the pharmaceutical manufacturer and in most cases the PPI medication was given at the same time as the selpercatinib medication (see below). The MAR administration time revealed both the selpercatinib and the pantoprazole sodium (PPI medication) were given incorrectly and in direct contradiction to selpercatinib manufacturer's instructions. On 6/20/23 Selpercatinib was given at 8:53 p.m., this was almost one hour late. On 6/21/23 Pantoprazole sodium was given at 8:27 a.m., this was almost one hour and 39 minutes late. Selpercatinib was given at 8:27 a.m. Selpercatinib was given at 8:40 p.m. On 6/22/23 Pantoprazole sodium was given at 8:20 a.m., this was over one hour late. Selpercatinib was given at 8:20 a.m. Selpercatinib was given at 1:42 p.m. (this was over six hours early from being 12 hours after the previous dose. On 6/23/23 Pantoprazole sodium was given at 8:10 a.m., this was over an hour late. Selpercatinib was given at 5:36 p.m., this was over nine hours and 30 minutes late. Selpercatinib was given at 7:55 p.m., this was less than three hours after the previous dose was administered. On 6/24/23 Pantoprazole sodium was given at 9:10 a.m., this was over two hours late. Selpercatinib was given at 10:07 a.m., this was over two hours late. Selpercatinib was given at 10:20 p.m., this was over two hours late and within the orders to administer doses 12 hours apart, which throws off the 12 hours between administration times. On 6/25/23 Pantoprazole sodium was given at 9:02 a.m., this was over two hours late. Selpercatinib was given at 9:05 a.m., this was over an hour late. Selpercatinib was given at 10:23 p.m., this was over two hours late. On 6/26/23 Pantoprazole sodium was given at 8:49 a.m., this was one hour and 49 minutes late. Selpercatinib was given at 8:49 a.m. Selpercatinib was given at 8:14 p.m. On 6/27/23 Pantoprazole sodium was given at 7:15 a.m. Selpercatinib was given at 7:14 a.m. Selpercatinib was given at 7:13 p.m. On 6/28/23 Pantoprazole sodium was given at 7:11 a.m. Selpercatinib was given at 711 a.m. Selpercatinib was given at 8:38 p.m. On 6/29/23 Pantoprazole sodium was given at 11:17 a.m., this was over four hours late. Selpercatinib was given at 11:26 a.m., this was over four hours late. Selpercatinib was given at 10:29 p.m., this was over two hours late. On 6/30/23 Pantoprazole sodium was given at 8:48 a.m., this one hour and 48 minutes late. Selpercatinib was given at 8:47 a.m. Selpercatinib was given at 8:41 p.m. On 7/1/23 Pantoprazole sodium was given at 9:02 a.m., this was over two hours late. Selpercatinib was given at 8:59 a.m. Selpercatinib was given at 8:12 p.m. On 7/2/23 Pantoprazole sodium was given at 8:06 a.m., this was over an hour late. Selpercatinib was given at 8:07 a.m. Selpercatinib was given at 9:59 p.m., this was three hours late. On 7/3/23 Pantoprazole sodium was given at 8:58 a.m., this was two hours late. Selpercatinib was given at 8:58 a.m., this was almost one hour late. Selpercatinib was given at 8:05 p.m. 2. Nursing notes Orders note dated 5/2/23 read in pertinent part: The order you have entered Selpercatinib oral capsule 80 mg, has triggered the following drug protocol alerts/warning(s): Drug to drug interaction. Interaction: Severity: Severe. Interaction: Pharmacologic effects and plasma concentrations of selpercatinib may be decreased by proton pump inhibitors (Pantoprazole sodium oral tablet delayed release 40 mg. -This alert appeared again on the progress notes on 5/9/23, 6/20/23 and 6/21/23 when the resident readmitted to the facility. There was no documentation in the residents records that any facility staff took action to address the drug interaction alert note. Physician's note dated 5/5/23 read in pertinent part: Resident with a diagnosis of lung cancer metastasis to the brain; started chemo pill again on 4/28/23 after a one-month hiatus. Was referred to SNF (skilled nursing facility) for physical and occupational therapy (PT/OT) to increase strength, mobility, and ADL independence related to her decreased ability to care for herself at home and reduced activity tolerance over the last several weeks. There is a potential drug interaction with another medication, selpercatinib oral capsule. Continue selpercatinib 160 mg twice a day. Continue pantoprazole 40 mg daily. -The physician's note did not document if the physician looked into the details of the drug interaction or took consideration for the manufacturer's warnings when taking selpercatinib with a PPI medication to take action to make sure the administration orders outlined precautions to lessen the potential drug interactions and outcomes. 3. Comprehensive care plan The resident's comprehensive care plan initiated 6/23/23 did not contain a care for the resident's cancer treatment or for GERD. IV. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 7/25/23 at 11:02 a.m. LPN #3 said medications should be administered to a resident as close to the prescribed administration time as possible, but no earlier or later than one hour before or after the scheduled administration time. The pharmacy conducts an initial review of resident medications and monthly thereafter to identify any irregularities and alert the facility to recommendations for findings. The nurse was responsible to administer the medication correctly as ordered. The pharmacist consultant (PC) was interviewed on 7/27/23 at 4:05 p.m. The PC said according to manufacturer's recommendations selpercatinib had a warning related to an adverse interaction.While manufactures recommendations selpercatinib should be given twice a day with each administration being12 hours apart, it was more importantly that when given with a PPI, the selpercatinib should be given two hours before the PPI or 10 hours after the administration of the PPI mediation. When the manufacturer's recommendations were not followed, the effectiveness of selpercatinib as a cancer treatment was reduced by 70 percent. The CNC, director of nursing (DON), nursing home administrator (NHA) and corporate consultation (CC) were interviewed on 7/31/23 at 3:55 p.m. The DON said she was not familiar with any administration warnings for the resident's selpercatinib medication. The DON said she talked with the resident and the resident's representative specifically about how she was taking the selpercatinib medication and based on the resident selpercatinib to be administered at 8:00 a.m. and 8:00 p.m. so she would received it 12 hours apart. The DON was not aware there were manufacturer's warning instructions when the resident was also taking a PPI. The CNC said the administering nurse should be aware of medication administration standards and if they were unfamiliar with a medication the nurse should look up the medication for administration instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Electrical cords and trip hazards A. Facility policy The Safety Precautions, Electrical policy, revised 2011, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 3:44 p.m. The policy read in pertinent part: Report any and all unsafe electrical hazards to your supervisor immediately. -However, the policy did not document any methods of how and where electrical cords should be plugged in to prevent electrical cords from creating a trip hazard. B. Observation On 7/26/23 and 7/27/23 observations of resident rooms on the second floor unit were conducted. The resident's on the second unit were highly vulnerable individuals requiring the use of complex electrically powered medical equipment for life support. Each resident had several pieces of equipment that required electrical power to remain operational (ventilators, oxygen concentrators, suction machines, nebulizers, tube feeding pumps, pressure relieving mattresses and electrically controlled beds) and their rooms contained other non medical items (televisions, radios, fans) that required electricity to operate. There were not enough electrical outlets for all of the equipment and the electrical outlets were not placed strategically to keep electrical cords out of walkways so that staff and visitors did not trip; trip on a cord and pull it out of the outlet; or trip and fall onto the resident's bed. Some rooms used medical grade surge protectors to extend power cord so they reach outlets and several power cord laid in walkways; cords were not secured in place or affixed to walls to reduce potential trip hazards. The resident's on the unit were dependent on staff for all care and positioning needs, requiring equipment including ventilator and or use of oxygen treatment. Observations revealed there were several rooms where electrical cords laid unsecured in walkways where staff and visitors had to walk in order to provide resident care and have conversations with the resident in the room. Of 27 rooms observed on the second floor units there were 13 rooms were an electrical cord (for medical equipment) laid in the walkway causing a trip hazard for staff and visitors leaving the vulnerable resident at risk for injury due to staff getting injured and not being able to continue needed care; equipment being unplugged improperly; due to being improperly pulled out after a staff tripped over it; and/or a person falling on the resident after tripping over the cord. Based on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public in one of three units. Specifically, the facility failed to: -Control foul odors throughout the two-south unit; -To properly dispose of trash soiled with feces and urine; -To maintain cleanliness in the dirty utility room; and, -To keep electrical cords out of walkways, in resident rooms in order to prevent trip hazards. Findings include: I. Facility policy The facility policy for environment maintenance was requested on 7/31/23 and was not received before survey exit on 7/31/23. II. Observations Foul odors were detected in the hallway near trash collection bags and outside resident's rooms on the two-north unit on: 7/24/23 at 9:15 a.m., 11:30 a.m., and 12:45 p.m.; 7/26/23 at 11:30 a.m., 1:15, p.m. and 4:15 p.m.; 7/27/23 at 1:25 p.m., and 3:55 p.m.; and, 7/31/23 at 10:35 a.m., and 3:00 p.m. On 7/25/23 at 11:37 a.m., the dirty utility room was observed in the presence of the respiratory therapy manager (RTM). The trash collection bins were approximately one half full and there were two clear plastic trash bags full of trash soiled with bodily fluid discarded on the counter of the hand washing sink, in the utility room. The trash bags contained trash generated as a result of providing incontinence care to residents. The trash was smeared feces which was visible through the plastic. There was a 12 inch x 12 inch circle size, moist, brown and mucous spot on the floor in the walkway. III. Staff interviews On 7/25/23, a family member of the resident in room [ROOM NUMBER], said when he visited the resident, the foul odors were always present in the hallway where the trash disposal bags were frequently left in the hallway outside the resident's room and the odor could be smelled in the resident's room. Certified nurse aide (CNA) #6 was interviewed on 7/25/23 at 11:40 a.m. CNA #6 said she was unsure why the trash bags were on the counter top and she placed the bags into the trash collection container. The CNA said sometimes the trash collection bags in the hallways were filled to capacity and piled up in the dirty utility room before the end of shift, staff removed trash from the facility for disposal, as time allowed. The CNA said the floors in the soiled utility room were monitored and cleaned by the housekeeping staff. On 7/26/23 trash collected by the housekeeping department was observed sitting outside the dirty utility room in the hallway adjacent to the two-north nurses desk, next to the emergency equipment cart and vital signs machine. The unit manager (UM) and the assistant nursing home administrator (ANHA) were interviewed on 7/26/23 at 9:12 a.m. They said they were unaware the housekeeping department left the collected trash in the hallway next to the dirty utility room. The UM and ANHA said the housekeeper should have placed the collected trash into the trash collection bags or removed the trash from the facility for disposal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Accurate medical record A. Facility policy The Charting and Documentation policy, revised July 2017, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy documented in pertinent part: 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 following information is to be documented in the resident medical record: Objective observations; Medications administered; Treatments or services performed; Changes in the resident's condition; Events, incidents or accidents involving the resident; and Progress toward or changes in the care plan goals and objectives. B. Resident status Resident #47 was admitted on [DATE] and readmitted [DATE]. According to the July 2023 computerized physician order (CPO), the diagnoses included acute and chronic respiratory failure, diabetes, tracheostomy, hemiplegia (paralysis) and dysphagia (difficulty swallowing) due to non traumatic intracranial hemorrhage (stroke), weakness and reduced mobility. The 6/23/23 minimum data sheet (MDS) assessment documented that the resident was rarely understood and a brief interview for mental status score (BIMS) was not completed. She required two person assistance with bed mobility, transfer, toileting, bathing, dressing, personal hygiene and total dependence on eating. The assessment document that the resident was not receiving physical therapy, occupational therapy or restorative nursing services at the time of the assessment. C. Record review The 7/3/23 care plan revealed that the resident had limited physical mobility. One intervention was to provide gentle range of motion as tolerated with daily care. There was a physical therapy and occupational referral; this was not care planned, or documented as being provided to the resident anywhere in the resident record. The 1/12/23 occupational therapy discharge summary revealed that the nursing staff were trained on how to provide the resident's recommended restorative nursing program as well as what safety precautions were needed, in order to promote mobility, safety and reduce the risk of further medical complications to the resident. The 3/24/23 physical therapy progress note revealed that the resident would benefit from a restorative program for maintaining and improving bilateral lower extremities flexibility by passive range of motion and repositioning to decrease risk of skin breakdown. -There was no documentation in the resident medical record to explain how the resident restorative services benefited the resident, the frequency of services provided and the resident's response to services provided. D. Staff nterviews The director of rehabilitation (PTD) was interviewed on 7/27/23 at 1:32 p.m. The PTD said the resident was evaluated a couple times for mobility needs and recommendations for ongoing restorative services were made. At the last evaluation in March 2023, the resident was totally dependent on staff for care. The rehabilitation therapist recommended the resident be placed on a restorative nursing program (RNP) to maintain flexibility and reduce skin breakdown. The RNP included passive range of motion (ROM) and positioning. The restorative nursing staff would be responsible for documenting services. The director of nursing (DON) and unit manager (UM) were interviewed on 7/27/23 at 1:56 p.m. The DON said she and the UM needed to do some research to see if there was any documentation of services. The DON was interviewed on 7/27/23 at 2:55 p.m. The DON said that there was no documentation that passive ROM was being provided by the restorative staff. The DON said that passive ROM was included with routine care that certified nurse aide (CNA) performed. The DON said that going forward there would be a separation from routine provision of care and provision of restorative nursing program services so that the restorative nursing care was clearly defined and documented accurately in the resident's record. The corporate nurse consultant (CNC) was interviewed on 7/31/23 at 11:23 a.m. The CNC provided an updated care plan that reflected interventions that clearly defined the resident restorative nursing program services for type and frequency of ROM services. The intervention was initiated on 7/27/23. The DON was interviewed on 7/31/23 at 5 p.m. The DON said that there was no documentation of the resident restorative nursing program in the resident's record to explain how often services were provided or how the resident was responding to the service. Based on record review and interviews, the facility failed to keep confidential resident-identifiable personal information and medical treatments for 27 of 27 residents; and to ensure medical records were complete and accurately documented medical status and response to nursing/medical care and treatment in keeping with accepted standards of practice for a sample of two of four residents reviewed. Specifically, the facility failed to: -Keep confidential information specifically protected health information (PHI) out of view of other residents and visitors for 27 of 27 residents on the unit; and, -Ensure Resident #47's medical record contained accurate and complete documentation regarding the resident's restorative management plan; restorative services provided; and the resident's response to services. Findings included: I. Confidentiality of PHI A. Facility policy The Confidentiality of Information and Personal Privacy policy, dated October 2017, was requested and received from the corporate nurse consultant (CNC) on 7/27/23 at 9:45 a.m. The policy documented in pertinent part: The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records; The facility will strive to protect the resident's privacy regarding medical treatment and personal care; Access to resident personal and medical records will be limited to authorized staff and business associates. B. Observations The facility respiratory therapy department hung a white board on the wall in the common area on the two-south hallway. The white board contained PHI information which was clearly visible to any person (visitors or other resident) entering the unit. The white board contained the following PHI: -Resident first and last name; -Resident code status (do not resuscitate/full code); -Resident room number; -Resident ventilator settings; -Resident oxygen settings; -Resident respiratory therapy treatments and treatment schedule; -Resident ventilator settings; and , -Resident tracheostomy details (size and type) and treatment schedule. Respiratory therapist (RT) #3 was observed updating the white board on 7/25/23 and 7/26/23 with resident PHI as listed above. C. Staff interviews The unit manager (UM) was interviewed on 7/26/23 at 9:35 a.m. The UM said the white board was used by the respiratory therapy department to share pertinent medical information about the residents to whom they provided services. The UM said the board contained resident specific PHI that applied to end of life decisions (code status) and life support care provided. The UM said resident specific healthcare information should be protected from the public such as visitors and other resident family members. RT #1 was interviewed on 7/26/23 at 11:18 a.m. RT #1 said the white board was helpful to quickly identify which residents had ventilators, the settings and treatments they received and was referenced during shift reports and as needed during her shift. The RT said the resident information was also available to reference in the resident's electronic health record. The CNC was interviewed on 7/27/23 at 9:45 a.m. The CNC said a board in public view should not include PHI. The CNC said she would review confidentiality of PHI with facility staff. The respiratory therapy manager (RTM) was interviewed on 7/31/23 at 3:01 p.m. The RTM said the white board had been relocated to an office behind the nurses desk to prevent any confusion regarding what information was considered private and protected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain emergency patient care equipment in safe operating condition. Specifically, the facility failed to perform daily quality readiness checks on the emergency response cart and to ensure expired items were removed and replaced. Findings include: I. Facility policy The facility policy for maintaining patient care equipment was requested on [DATE] and a copy of the Crash Cart (a cart containing medicine and equipment for use in emergency resuscitations) Checklist, undated, was received from the corporate nurse consultant (CNC) on [DATE] at 11:30 a.m. The checklist documented, the crash cart should be checked daily and contain the following items: -suction machine, -record keeping paperwork, -vitals machine, -nonrebreather mask, -nasal cannula high flow, -nebulizer mask, -14 French (FR) suction cath kits, -yankauer suctioning wand, -spare suction canister with short and long tubing, -ventilation (AMBU) bag (a device to provide respiratory support to an individual in distress) with mask, -oxygen regulator, -oxygen tank wrench, and an -extension cord. II. Observations On [DATE] at 3:15 p.m. the two-south emergency response cart was observed with the unit manager (UM)). Observations revealed the cart contained several expired and missing items (see crash cart checklist above). Expired items included: -Wolf Medical Supply, 10 cubic centimeters (cc) prefilled normal saline syringes, expired [DATE], 673 days prior to the observation; -Two 100 militer (ml) medline sterile water solutions, expired, [DATE], 777 days prior to the observation; -Three B [NAME] Introcan safety IV (intravenous) start catheters needles, 22 gauge (needle width) by one inch, expired [DATE], 25 days prior to the observation; and, -Two [NAME] IV start catheter needles, expired [DATE], 693 days prior to the observation. -The UM was unable to locate a wrench to open the oxygen canister on the emergency response cart and had to look for one. A spare wrench was located on the nurses desk. -In the event of a true emergency the oxygen wrench would not have been easily accessible to staff responding to an emergency without having to leave the emergency area to locate the wrench if oxygen was needed. -The crash cart did not include a checklist for equipment readiness or documentation of when the cart was last checked for completeness of supply and expression date of the supplies. III. Interviews The UM was interviewed on [DATE] at 3:15 p.m. The UM said the expired items (see observations above) could no longer be used and needed to be replaced. The UM removed the expired items and said they would be replaced. The UM said he did not know if the facility had a checklist or policy and was unaware of when the emergency equipment cart was last checked. The UM and the assistance director of nursing (ADON) were interviewed together on [DATE] at 3:27 p.m. The ADON said the emergency response carts were checked daily as part of a risk management review. The ADON said the daily checks did not include a checklist and the UM on each unit was responsible to monitor the equipment for readiness. The UM said he was unaware of the equipment checklist. IV. Facility follow-up On [DATE] the emergency equipment cart for two-north and two-south were observed with the UM. The equipment carts included a designated binder with an equipment readiness checklist and the equipment carts were properly stocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure two (#7 and #5) of four out of 16 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to: -Ensure timely incontinence and reposition was provided to Resident #7, who had a pressure injury; -Ensure a treatment was in place for a pressure injury to the coccyx for Resident #7; -Ensure treatments were provided as ordered by the physician for Resident #7; and, -Assess, notify the physician and obtain treatment order for newly identified skin concern for Resident #5. Cross reference F880: failure to ensure wound care was provided within accepted infection control standards of practice. Findings include: I. Professional reference The National Pressure Ulcer Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 4/18/23 read in pertinent part: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. The National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. [NAME] Haesler (Ed.). Cambridge Media: [NAME] Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (2/17/2017), accessed on 4/18/23. It read in pertinent part, Steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure injury should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. - The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, periwound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedure The Pressure Injury Management policy and procedure, reviewed October 2019, was provided by the nursing home administrator (NHA) on 4/6/23 at 1:30 p.m. It revealed in pertinent part, The purpose of this policy is to establish protocols for the care of residents who have been admitted to the facility with a pressure injury or who have developed a pressure injury while residing in the facility. If a resident admits to the facility with a pressure injury or is assessed to have a pressure injury: the charge nurse will be responsible to assess the pressure injury to include site/location of the pressure injury, staging of the pressure injury, size in cm (centimeters) (length x width), appearance of the wound bed, depth, undermining, draining/exudates to include the type/amount, color of the wound bed, and surrounding skin color and any pain related to the pressure injury. The charge nurse or designee will be responsible to initiate the evaluation in the resident medical record. The charge nurse or designee will be responsible to notify the physician and the responsible party regarding the development of the pressure injury. A treatment order will be initiated. The charge nurse or designee will be responsible to complete an initial narrative note in the resident's medical record to describe the resident's identified risk factors and a description of how the pressure injury most probably occurred if known. A care plan will be initiated to identify actual skin breakdown to include identified risk factors and individualized interventions to aid in wound healing. Residents will be offered position changes at least every two hours unless otherwise specified per their plan of care. Any resident who has a pressure injury - nursing will be responsible to complete daily documentation on the monitoring of the wound in the progress note section of the medical record. III. Failure to provide repositioning and incontinence timely A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (low blood oxygen), long-term use of anticoagulants, contracture of the right elbow, contracture of the left elbow and tracheostomy (an opening in the windpipe). The 4/3/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He was dependent upon staff for all activities of daily living. It indicated the resident did not have any unhealed pressure injuries. B. Observations On 4/4/23, during a continuous observation starting at 8:55 a.m. and ended at 1:30 p.m. Resident #7 was observed lying on his back, in bed, sleeping. At 9:04 a.m. an unidentified certified nurse aide (CNA) entered the resident's room to check on the resident. She did not provide care and exited the room at 9:15 a.m. The resident remained in the same position. At 9:21 a.m. three unidentified staff members entered the resident's room. Upon exiting, one CNA was observed exiting the room with a bag of soiled incontinence supplies. The resident's bed was lowered and the resident remained positioned on his back, with the head of the bed positioned at a 30-degree angle. -The resident was supposed to be repositioned on his left and right side, not in the supine position (see record review). At 1:30 p.m. facility staff had not re-entered Resident #7's room, in over four hours, to provide incontinence care or repositioning. On 4/5/23, during a continuous observation starting at 8:57 a.m. and ended at 12:00 p.m., Resident #7 was observed lying on his back, in bed, sleeping. At 9:43 a.m. two unidentified staff members entered the resident's room and provided incontinence care. The resident was observed still lying on his back in the supine position. At 11:26 a.m. two unidentified CNAs were observed entering the resident's room and closing the door. At 11:29 a.m. an unidentified nurse entered the resident's room At 11:45 a.m. CNA #1 and CNA #2 said they had repositioned Resident #7 when they provided incontinence care. They said they had cleaned the resident's face, mouth, and performed oral care, however the resident was observed still lying on his back, in the supine position. C. Record review The April 2023 CPO documented the following: -Reposition on the left and right side only to offload pressure of the coccyx, every shift for wound care - ordered 3/10/23. The ADL care plan, initiated and revised on 12/10/22, documented the resident had a self-care performance deficit due to an anoxic (lack of oxygen) brain injury. It indicated the resident was dependent upon staff for bed mobility, personal hygiene, toileting and transfers. The communication care plan, initiated on 12/10/22 and revised on 2/8/23, documented the resident had a communication problem due to an anoxic brain injury and was unable to make his needs known. It indicated the facility staff would anticipate his needs. The bowel and bladder incontinence care plan, initiated and revised on 12/10/22, documented the resident was incontinent of bowel due to an anoxic brain injury. The interventions included checking the resident for incontinence often, assisting with toileting as needed and providing peri care after each incontinence episode. The risk for pressure injuries care plan, initiated on 12/10/22 and revised on 3/13/23, documented the resident had potential for pressure injury development related to immobility and bowel and bladder incontinence. It indicated the resident had actual skin breakdown of moisture associated skin disease (MASD) to the right buttocks. The resident was dependent upon the facility staff for turning and repositioning. The interventions included, in pertinent part, administering treatments as ordered and providing education as to the causes of skin breakdown and frequent repositioning. The resident went to the hospital from [DATE] to 4/3/23 due to a clogged G-tube. The 4/3/23 hospital wound physician notes documented to reposition Resident #7 on the right and the left side only. It indicated not to position the resident in the supine position. The hospital physician noted if a hand cannot be placed underneath the resident's coccyx, then the resident was not turned enough. IV. Failure to provide treatments as ordered by the physician and ensure treatments were in place for an existing wound A. Wound observations On 4/6/23 at 9:20 a.m., during a wound observation with the assistant director of nursing (ADON), Resident #7 was repositioned by two unidentified CNAs flat on his back with his feet offloaded onto a rectangular cushion. Neither heel had a dressing in place. A dressing was observed to the left elbow, however no dressing was observed to the right elbow and foam was present underneath the tracheostomy ties on the left side of the resident's neck. There was no dressing on the right elbow, the left elbow had a foam dressing. Foam was positioned under the tracheostomy ties on the left side of the resident's neck. When the CNAs rolled Resident #7 to his left side, the dressing to the right ischium was not intact. It had migrated down his leg and was completely saturated in serosanguinous (blood, serum) fluid. The dressing was not dated. The disposable pad under the resident also had a large amount of serosanguinous (approximately five to six inches in diameter) drainage. The entire buttock on each side were deep red/purple in areas and macerated with peeling skin caked with a white powdery substance. The left buttock, midway down toward where the buttocks meet, had a superficial round open area approximately one centimeter (cm) in the center of the MASD (moisture associated skin disease). The sacral coccyx area had an opening toward the right buttock. It was liner and covered in yellow slough. The ADON said that he and the wound physician did not see the area that morning when he had evaluated Resident #7's wounds. He said the facility did not have a treatment in place for the open area. The open area was very visible when the resident was rolled over. The ADON said he would contact the physician for a treatment to the open area to the sacral coccyx. The ADON said he thought the wound to the right ischium was a stage 3 but he could not remember. The ischium was observed and had two wounds, close to each other in proximity. There was a large wound over the ischium area with a smaller wound above it. The wound bed was red and shiny with the skin around the edges of the wound peeling and rolling. The ADON measured the wound to the left of the coccyx. It measured 0.5 cm (w) x 1.8 cm (l) x 0.4 cm (d). It was covered in a layer of yellow slough which did not come off when the ADON cleansed the area with gauze and normal saline. The ADON sent the CNA to get barrier cream. He said he would apply the barrier cream to the MASD on the buttocks. He said he did not know what the treatment orders were for the buttocks. The ADON did not leave the room to check the orders to ensure he was following the physician ordered treatment. The ADON dressed the wound to the right ischium, however he did not use medi honey, which was the physician ordered treatment. The ADON put barrier cream over the MASD on the buttocks, even though there was still a dry and crusty substance on them. He placed barrier cream over the coccyx area and the open area on the left buttock because he said he had no other orders. He said he was going to cover the coccyx wound with Tegaderm. He then placed it on top of the coccyx wound which was covered in barrier cream. The ADON said the elbows should both have a foam dressing for protection. He said he was not sure why the right elbow did not have a dressing in place. He said the left elbow was healed. He removed the left elbow dressing and revealed a quarter size deep reddened area. The ADON pushed on it and said the area did not blanch. He said he saw the area that morning, however just before he had said the left elbow was healed. The resident's right and left heel were observed. The ADON confirmed there was no dressing in place and the resident did not have any open areas. He said a foam dressing should have been in place for protection. He said he did not know why the dressing was not in place. The resident's left index finger was observed with a pulse oximeter tube taped to it. The respiratory therapist (RT) said that was not one of the facility's pulse oximeter wires. She said it must be from when the resident was recently in the hospital. The taped wire was removed with difficulty and the pad of the resident's fingertip was deep red and blanchable. The resident's G-tube had a drain sponge (gauze) on it, not taped down, with no visible ointment or cream applied. The area around the tube was raw, red and shiny and about one cm circumference with approximately 0.5 cm pink tissue. The ADON said he thought there should be a treatment for the area but did not know what it was. B. Record review The risk for pressure injuries care plan, initiated on 12/10/22 and revised on 3/13/23, documented the resident had potential for pressure injury development related to immobility and bowel and bladder incontinence. It indicated the resident had actual skin breakdown of moisture associated skin disease (MASD) to the right buttocks, MASD to the right distal buttocks and an abrasion to the neck from the trach tie. The resident was dependent upon the facility staff for turning and repositioning. The interventions included, in pertinent part, administering treatments as ordered, monitoring for the effectiveness of the treatments, providing education as to the causes of skin breakdown, frequent repositioning, informing the family of any new skin breakdown, monitoring the resident's non-verbal cues of pain prior to and during treatments, monitoring and reporting any changes to the resident's skin status, utilizing barrier cream as indicated and following incontinent episodes and conducting weekly skin checks by the licensed nurse. -The comprehensive care plan did not include the actual skin breakdown of the resident's coccyx or ischium. The 3/28/23 hospital wound physician progress note documented Resident #7 was admitted to the hospital due to a clogged/leaking G-tube. The wound physician was consulted for an unstageable pressure injury to the perineum, blanchable erythema (superficial reddening of the skin) and scar tissue to the left elbow and blanchable erythema to the bilateral ankles and dorsal feet. It indicated the perineum had soft eschar covering the wound with it beginning to open to the right side of the wound with nongranular and granular tissue noted. The left elbow, bilateral ankles and dorsal feet had well defined areas and the wound physician placed bordered foam to the heels for preventative measures. The 4/3/23 nursing data collection documented the resident was readmitted to the facility from the hospital due to a clogged G-Tube. It indicated the resident returned with open areas to the coccyx, redness to the bilateral buttocks, bilateral elbows and heels. The April 2023 CPO documented the following physician ordered treatments: -Wound care: peri g-j-tube (GJT): Clean with normal saline (NS) moistened gauze, pat dry and apply skin prep to peri wound. Cover with Mepilex Ag one time per day for wound care - ordered 4/4/23; -Bilateral elbows and heels: Cleanse with NS, pat dry and cover with bordered foam dressing, one time a day for wound care - ordered 4/4/23; -Bilateral buttock: Cleanse with peri wipes or foam cleanser (avoid rubbing, only remove soiled cream for skin). Apply lidocaine/nystatin/zinc oxide cream. Alternate with clear-aid after each incontinence episode, three times a day for wound care - ordered 4/4/23; -Coccyx: Cleanse with NS, apply skin prep to the peri wound, apply Dakins moistened gauze to the open area and cover with ABD Medipore tape, two times per day for wound care - ordered 4/4/23. The 4/3/23 Braden scale for predicting pressure sore risk documented the resident was unresponsive, had very moist skin, was bedfast (confined to a bed) and completely immobile. It revealed the resident scored a 10 out of 18, which indicated the resident was at a high risk for developing pressure injuries. V. Staff interviews CNA #3 interviewed on 4/6/23 at 12:30 p.m. She said that Resident #7 required the assistance of two staff members with repositioning. She said Resident #7 was incontinent of bowel and bladder. She said Resident #7 had pressure injuries and should be repositioned from side to side and sometimes on his back. The director of nursing (DON) and the ADON were interviewed on 4/6/23 at 11:24 a.m. The DON said that residents who were dependent upon staff, should be repositioned every two hours. She said facility staff should check in with dependent residents to determine if they required incontinence care every two to three hours. She confirmed Resident #7 had pressure injuries and was at high risk of skin breakdown. She acknowledged repositioning and timely incontinence care was a tool that assisted in the healing and prevention of the worsening or continued skin breakdown for Resident #7. She said repositioning only occurred if the resident had actually changed positions. The ADON confirmed when the wound observations were conducted, the treatment to the ischium was floating. He said he had forgotten to date when he had conducted wound rounds with the wound physician that morning. He said, according to the wound physician notes, he had identified it as a stage three pressure injury. He said he contacted the wound physician who confirmed he did not see the open area to the coccyx. He said he obtained a treatment order and the wound physician said he would come to the facility to evaluate the wound. He said the wound physician had clustered the wound to the right ischium as a stage 2. The DON said when the wound physician performed weekly wound rounds, he did not perform a head to toe skin assessment. She said the wound physician assessed and treated the wounds he was aware of. She said the nurse should have caught the new open area to the coccyx on the daily skin checks, the CNA during incontinence care and upon the resident's readmission to the facility. The ADON said the resident had barrier cream on the surrounding area and that was why he missed it. He said prior to the resident being recently admitted to the hospital, the resident's coccyx had been healed. The ADON confirmed the resident did not have dressings in place on both heels. He said the resident did not have any open areas but the dressings were preventative. The DON said the admission nurse should have identified the pulse oximeter tubing upon the resident's admission to the facility. She said the nurse must have thought it was from the facility, however it was not. She said it had been removed, the physician was notified and a treatment was put in place. VI. Assess, notify the physician and obtain treatment order for newly identified skin concern A. Resident status Resident #5, age [AGE], was admitted on [DATE] and discharged on 10/30/23 to home. According to the October 2022 CPO, the diagnosis included stage three chronic kidney disease and hypertension. The 10/5/22 nursing data collection documented the resident was cognitively intact and required assistance of one person with transfers, dressing, toileting and personal hygiene. It indicated the resident did not have any skin concerns. B. Record review The activities of daily living (ADL) care plan, initiated on 10/7/23, documented the resident had a self-care performance deficit related to weakness. The interventions included encouraging the resident to participate to the fullest extent possible with each interaction, encouraging the resident to use the call bell for assistance and an evaluation by physical and occupational therapy. -A review of the resident's comprehensive care plan did not indicate the resident was at risk for developing pressure injuries. The 10/5/22 nursing data collection documented the resident had redness to the right buttocks. -However, the CPO did not reveal a treatment in place for the reddened right buttocks. The 10/16/22 nursing progress note documented the resident had developed redness to the buttocks. The nurse provided the resident with Calazinc cream for her buttocks. -It did not indicate the nurse had completed an assessment of the area or notified the physician and obtained a treatment order. The 10/18/22 nursing progress note documented that a skin assessment was completed for the resident by the assistant director of nursing (ADON). During the assessment, the resident's daughter informed the ADON that the resident had a fluid filled blister to the right buttocks. It indicated that the blister was healing and the peri area appeared pink and dry. -It did not indicate the ADON had notified the physician or obtained a treatment order for the blister. The 10/19/22 discharge summary documented the resident was discharged with home health physical and occupational therapy. It did not document that a nurse was ordered for wound care. The 10/20/22 social services progress note documented the resident discharged home with physical and occupational home health therapy. -It did not indicate a nurse was provided for wound care. C. Staff interviews The DON and ADON were interviewed on 4/5/23 at 4:56 p.m. She said the ADON was the nurse that documented Resident #5 had a blister to the buttocks. She said he noted that the surrounding tissue was healthy and dry. The ADON said he had performed the skin assessment for the nurse that was assigned to Resident #5. He said he expected that the nurse would have contacted the physician and obtained a treatment order. He said he was unable to find documentation that the physician had been notified or a treatment had been put into place. He said the facility did not order a home health nurse for wound care. He said that had been an oversight. The DON said when a new skin concern was identified, the physician should be notified immediately and a treatment put into place. She said the nurse should continue to follow up until the area was resolved. She said the area should be assessed to include measurements. She said that assessment should be documented in the resident's medical record. The DON confirmed Resident #5's medical record did not reveal documentation that the blister had been assessed to include measurements, the physician was notified or a treatment was put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure wound care was provided within accepted infection control standards for Resident #7. Cross-reference F686: failure to ensure timely incontinence care and repositioning was provided, a treatment was in place for a pressure injury, treatments were provided as ordered by the physician, and a newly identified skin concern was assessed and the physician was notified with a treatment obtained. Findings include: I. Resident #7 status Resident #7, age less than 65, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (low blood oxygen), long-term use of anticoagulants, contracture of the right elbow, contracture of the left elbow and tracheostomy (an opening in the windpipe). The 4/3/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He was dependent upon staff for all activities of daily living. It indicated the resident did not have any unhealed pressure injuries. A. Observations On 4/6/23 at 9:20 a.m., during a wound observation with the assistant director of nursing (ADON), Resident #7 was repositioned by two unidentified CNAs flat on his back with his feet offloaded onto a rectangular cushion. The ADON brought a bedside table over to the bed and wiped the table one time with a wipe. The tabletop dried in less than one minute. He brought a drape over to the table and waited a full minute before he laid it on the table. He said he wanted to make sure they waited the full two minutes for the surface disinfectant time of the wipe, however the table had been dry for over a minute. He laid the drape on the table and began laying out the wound care supplies. During the wound observation, the ADON used alcohol based hand rub (ABHR), donned clean gloves and cleaned the large wound to the resident's right ischium. The disposable pad underneath Resident #7 was observed with a large amount of drainage. The ADON did not place a new disposable pad prior to cleaning the wound. He cleaned the outside edges and then worked toward the center of the wound. Instead of cleaning the wound from the center and moving to the outside, the ADON used gauze soaked with normal saline to clean the wound from the outside and then moved inside. He obtained a new gauze soaked in saline and cleaned the wound to the coccyx sacral area with the same technique. As the ADON measured the wound, his gloved hands rubbed on the dirty drainage covered area of the disposable pad. The ADON dressed the wound to the right ischium. As he was placing the foam gauze and sealing the edges, his gloved hands were again touching the drainage on the pad underneath the resident. He moved to the bedside table, with the same gloved hands, and began cutting a Tegaderm (dressing) adhesive to place over the top of the dressing to ensure it was secured. As he was placing the Tegaderm over the top of the dressing, his gloved hands touched the drainage on the disposable pad, underneath the resident. B. Record review The April 2023 CPO documented the following physician ordered treatments: -Wound care: peri g-j-tube (GJT): Clean with normal saline (NS) moistened gauze, pat dry and apply skin prep to peri wound. Cover with Mepilex Ag one time per day for wound care - ordered 4/4/23; -Bilateral elbows and heels: Cleanse with NS, pat dry and cover with bordered foam dressing, one time a day for wound care - ordered 4/4/23; -Bilateral buttock: Cleanse with peri wipes or foam cleanser (avoid rubbing, only remove soiled cream for skin). Apply lidocaine/nystatin/zinc oxide cream. Alternate with clear-aid after each incontinence episode, three times a day for wound care - ordered 4/4/23; -Coccyx: Cleanse with NS, apply skin prep to the peri wound, apply Dakins moistened gauze to the open area and cover with ABD Medipore tape, two times per day for wound care - ordered 4/4/23. II. Staff interviews The ADON and director of nursing (DON) were interviewed on 4/6/23 at 11:24 a.m. The ADON said he used a sani-wipe to clean the bedside table prior to placing the drape and supplies. He said the wipes required a two minute surface disinfectant time. He said the area should be wiped down and let sit for two minutes prior to placing supplies. The DON acknowledged the surface should remain wet for the entire two minute surface disinfectant time. The ADON acknowledged there was a significant amount of drainage on the disposable pad underneath Resident #7 during the wound dressing change. He said he should have disposed of the pad and placed a new one prior to cleaning and dressing the wound. The DON said there should always be a clean field underneath when cleaning and dressing a wound. The ADON said he should have changed his gloves when they touched the drainage underneath the resident. The DON said each wound should be cleansed starting from the inside with one swipe. She said a new gauze should be obtained for each swipe and the wound should be cleansed starting from the inside to the outside edges. The ADON acknowledged he started from the outside and worked on the cleansing of the wound. He acknowledged that he used the same piece of gauze for multiple swipes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for three (#5, #4 and #2) of four out of 16 sample residents. Specifically, the facility failed to ensure records were provided timely upon request for Resident #5, Resident #4 and Resident #2 from a government adult protection agency. Findings include: I. Facility policy and procedure The Release of Information, revised November 2009, was provided by the nursing home administrator (NHA) on 4/6/23 at 1:38 p.m. It revealed, in pertinent part, Access to the resident's medical records will be limited to the staff and consultants providing services to the resident. (Note: Representatives of state and federal regulatory agencies have access to resident information without the resident's consent). Closed or thinned medical records are maintained in the medical records department and are available only to authorized personnel. Authorized personnel include, but are not necessarily limited to: nursing personnel; physicians; consultants; support services; administration; government agencies; and/or resident/representative. A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services. The facility may recommend that the resident or representative review the active chart in the presence of a knowledgeable staff person who can discuss the information and answer questions capably. II. Failure to provide medical records as requested by a government agency A. Interviews The supervisor with the government adult protection agency was interviewed on 4/5/23 at 11:58 a.m. He said his staff had entered the facility on three occasions to conduct an investigation and each time when they had requested medical records they were either not provided at all or not provided timely. He said three different members of his staff had the same experience when requesting medical records. He said obtaining the medical records was important in the agency's goal to protect vulnerable adults. He said a request was sent to the NHA on 11/8/22 for Resident #5's medical records. He said they had still not received the requested documents. He said a request was sent via email to the director of nursing (DON) on 11/18/22 for Resident #4's medical records. He said the facility did not respond to the request and they had still not received the records. He said a request was sent to the NHA on 12/20/22 for Resident #2's medical records. He said they did not receive the requested records until 12/28/22. B. Record review The 11/8/22 records request was sent via email from the government adult protection agency to the NHA for the following records for Resident #5: all hospital, clinic, nursing and treatment facility admissions; treatment and physical therapy records; test results; ER (emergency room), outpatient and inpatient records; and pharmacy and prescription information; neuro-psychiatric exam or similar assessment to determine cognition, mental status, competency, or capacity; and current list of diagnosis and medication. -The response from the NHA documented he had received the request for records for Resident #5. The 11/29/22 email communication from the adult protection agency to the NHA indicated they had not received the records or any other communication for their request for Resident #5's records on 11/8/22. The 11/18/22 records request was sent via email from the government adult protection agency to the DON for the following records for Resident #4: all hospital, clinic, nursing and treatment facility admissions; treatment and physical therapy records; test results; ER (emergency room), outpatient and inpatient records; and pharmacy and prescription information; neuro-psychiatric exam or similar assessment to determine cognition, mental status, competency, or capacity; and current list of diagnosis and medication. -The facility was unable to provide documentation to indicate they had responded to the government adult protection agency's request for records. The request was not documented on the facility's request for records log. -According to the government adult protection agency, they never received a response or the records that were requested (see interview above). The 12/20/22 records request was sent via email from the government adult protection agency to the NHA for the following records for Resident #2: all hospital, clinic, nursing and treatment facility admissions; treatment and physical therapy records; test results; ER (emergency room), outpatient and inpatient records; and pharmacy and prescription information; neuro-psychiatric exam or similar assessment to determine cognition, mental status, competency, or capacity; and current list of diagnosis and medication. -According to the facility's request for records log, the request was documented as received and records sent on 12/28/22. However, the email record clearly indicated the request was sent to the facility on [DATE]. III. Staff interviews The health information manager (HIM) was interviewed on 4/6/23 at 12:42 p.m. She said when a request for records was submitted, she would indicate the request on the log and then provide the records according to the request within 24 to 48 hours of the request being made. She said emailed records were sent secured within 24 hours of the request. She said she was aware of the requests made by the government adult protection agency. She said she was only aware of the requests as indicated on the log. She said she had received the requests for Resident #5 and Resident #4 from the NHA. She said she was not aware a request had been made for records regarding Resident #2. The NHA was interviewed on 4/6/23 at 1:15 p.m. He said he was aware of the requests for medical records from the government adult protection agency. He confirmed the records had not been provided timely or at all for Resident #5 and Resident #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to address a resident's concern to their satisfaction for one (#19) of one resident reviewed for grievances out of 20 sampled residents. Specifically, the facility failed to: -Honor Resident #19's right to have a grievance filed on her behalf when she reported a concern regarding certified nurse aide (CNA) #5; -Promptly respond, verbally and in writing, Resident #19's reported concern; -Follow up with Resident #19 and provide resolution to her concern; and -Educate CNA #5 and provide resolution to Resident #19 before CNA #5 continued to work on the same hall where Resident #19 resided. Findings include: I. Facility policy According to the Grievance Policy, revised on 10/10/19 and provided by the nursing home administrator (NHA) on 12/5/19 at 1:30 p.m., it reflected: -The facility ensured residents were given their right to file a grievance of their concerns. -The facility responded promptly and in written form to resident grievances. -Staff members could file grievances on behalf of residents. -The NHA could assign responsibility of investigating grievances. -The social service director or designee began exploration of resident concerns, and notified the appropriate department manager of their concerns and informed the department manager of the need to follow up with the resident. -The facility documented an investigative report with all pertinent information of the resident's concerns, and included all applicable corrective actions. -Grievances were filed with the NHA. -The resident was informed of the investigation findings of their grievance as well as any applicable corrective actions. -A copy of the grievance and investigation report were retained in the facility's records. -Copies of all grievances and reports were to be signed by the facility and the resident. II. admission agreement According to Resident #19's 11/13/19 admission agreement, retrieved from the electronic record on 12/10/19 at 1:30 p.m., it reflected the resident had the right to: -Exercise their rights as a resident of the facility. -Receive assistance from the staff. -A dignified existence and self-determination. -Be treated with respect and dignity in an environment which promoted the maintenance of their quality of life. -Voice grievances regarding their stay at the facility, to include those which involved the behaviors of staff. -Have the facility make prompt efforts to resolve all their grievances. -Resolution of all their grievances. III. Resident #19 A. Resident status Resident #19, under [AGE] years of age, was admitted on [DATE]. The December 2019 computerized physician orders (CPO), revealed diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting her left dominant side. According to the facility this resident was scheduled to be discharged on 11/11/19 and her discharge minimum data set (MDS) assessment was still in process (see the care plan for her self-performance status). According to Resident #19's 12/6/19 patient health questionnaire (PHQ9), retrieved on the facility's electronic system on 12/10/19 at 1:45 p.m., it identified she had mild depression. According to the 12/6/19 brief interview for mental status (BIMS), Resident #19 had no cognitive impairment with a score of 13 out of 15. B. Resident interview Resident #19 was interviewed on 12/4/19 at 1:25 p.m. She said a couple of days ago after 8:00 a.m., CNA #5 yelled at her and said That's not how you get out of bed! She said CNA #5 yelled at her for putting her legs off her bed and onto the floor when she tried to get out of bed to sit on a chair to eat her breakfast; she said she did not offer to transfer her out of bed. She said she felt like CNA #5 treated her like a child, and that CNA #5 was disrespectful toward her. She said I did not know what CNA #5's problem was when she yelled at me, maybe she had a bad day. She said she told one of the nurses that CNA #5 yelled at her; she could not recall the name of the nurse. She said the nurse told her she would look into it. She said she had not received feedback from the facility since she told the nurse CNA #5 yelled at her. She said CNA #5 was not providing care for her on this day. She said CNA #5 needed to learn how to respect her. C. Record review The care plan, initiated and revised on 11/3/19, identified Resident #19 was at risk for falls due to decreased functional mobility. Interventions included to anticipate and meet her needs. The care plan, initiated and revised on 12/4/19, identified she had limited physical mobility related to weakness. Interventions included to provide supportive care, provide assistance with mobility as needed, and document assistance as needed. Review of the December 2019 progress notes for Resident #19, revealed there was no documentation regarding Resident #19's report to nursing staff of CNA #5 being rude; or CNA #5's attempt to provide Resident #19 transfer assistance out of bed (to help prevent her from falling). D. Failure to file a grievance A request was made to the NHA on 12/5/19 at 11:46 a.m. for grievances filed by the facility regarding Resident #19. The NHA was interviewed on 12/5/19 at 1:30 p.m. He said there were no grievances filed for Resident #19. E. Staff interviews CNA #8 was interviewed on 12/5/19 at 12:27 p.m. He said when residents had concerns about the care they received he would notify the nurse and the nurse would handle it from there. CNA #2 was interviewed on 12/5/19 at 1:01 p.m. She said when residents had concerns she would tell the nurse or the director of nursing (DON). She did not identify a grievance process. CNA #1 was interviewed on 12/5/19 at 1:16 p.m. She said when residents had concerns she would tell the nurse. She did not identify a grievance process. The licensed practical nurse (LPN) #1 was interviewed on 12/5/19 at 4:11 p.m. She said when residents expressed concerns about the care they received she would: fill out a complaint form and put the form in the DON's box, inform the supervisor of their concerns, and begin to try and address their concerns as soon as possible. She said the NHA and DON worked to resolve all resident concerns. She said staff were to follow the same grievance procedures on the weekends; the facility had on-call supervisors, the DON, and managers-on-duty available to contact anytime residents expressed concerns. Registered nurse (RN) #5 was interviewed on 12/5/19 at 4:17 p.m. She said when residents expressed concerns staff were to fill out a grievance form and put it in the assistant director of nursing (ADON) or DON's box; staff could contact the ADON or the DON at any time when residents had concerns. F. Administrative interviews The NHA and DON were interviewed on 12/5/19 at 5:12 p.m. The NHA and the DON were informed of what Resident 19 reported during the survey: CNA #5 yelled at her, made her feel like a child and disrespected her when she was trying to transfer from her bed to her chair for breakfast. In response, the NHA said the facility needed to talk to Resident #19 regarding her allegation that CNA #5 yelled at her, treated her like a child, and said she felt disrespected by CNA #5. The DON said It's my fault. She said she was the one who had the information of Resident #19's concern regarding CNA #5. She said a nurse told her that: Resident #19 did not want CNA #5 to take care of her because she did like CNA #5 telling her to keep her feet in the bed. The DON said she considered what the nurse told her to be nothing more than a customer service issue. As a result, she immediately removed CNA #5 from providing care for Resident #19. She said she and the NHA would follow up (today) with Resident #19 regarding what she said during this survey. She said she would provide education to CNA #5. III. Follow up A. Record review The following documentation was generated after the NHA and DON were interviewed on 12/5/19 at 5:12 p.m. According to the 12/5/19 Concern Form for Resident #19, provided by the NHA on 12/9/19 at 1:30 p.m., it reflected: -The facility filed a grievance on 12/5/19 at 5:35 p.m., which identified: Resident #19 stated CNA #5 entered her room, a couple of days ago after 8:00 a.m., and was rude to her when she asked for assistance to get out of bed. When CNA #5 told her to put her feet back in bed Resident #19 felt CNA #5 was in a bad mood, and was rude to her. -The facility removed CNA #5 from her assignment on 12/5/19. The facility asked Resident #19 if CNA #5 could provide care for her and Resident #19 told the facility she would be fine if CNA #5 returned to provide care. -The facility's follow-up action was to educate CNA #5 on customer service and a resident's right to fall. -The facility resolved Resident #19's grievance on 12/9/19. According to the 12/5/19 Resident Interview Summary for Resident #19, provided by the NHA on 12/9/19 at 1:30 p.m., the NHA and DON interviewed Resident #19 and documented that Resident #19 stated: -CNA #5 was rude to her because she would not let her put her feet on the floor. -She was not hurt by CNA #5 and would like her to continue to help her. -She felt CNA #5 was in a bad mood on that day. -She felt that CNA #5 was rude; she never said CNA #5 made her feel like a child or that she was disrespected by CNA #5 and she would still like CNA #5 to care for her. -She denied CNA #5 treated her roughly, CNA #5 was rude to her on one occasion when she wanted Resident #19 to put her feet down, and she was not afraid of CNA #5. According to the 12/9/19 Education form to CNA #5, provided by the NHA on 12/9/19 at 1:30 p.m., it reflected CNA was educated on: -Residents' rights to make care decisions and unsafe choices. -The facility educated residents about safety decisions to prevent falls (such as to use the call light to ask for assistance or position safety) and residents had the right to make unsafe decisions such as refuse to use the call for assistance with transfers or ambulation, and to position themselves however they chose to. -The facility provided education to residents in a respectful and polite manner; not inappropriately or in a bossy manner. -CNA #5 was interviewed on 12/9/19. She documented in her interview that: She answered Resident #19's activated call light, entered her room, saw her grabbing the headboard of the bed, saw her legs tangled on the floor, and begged Resident #19 to put her feet back in the bed to stop her from falling due to she fell twice in the week because she did not call for help. CNA #5 did not document she offered assistance to help Resident #19 transfer in or out of her bed and ask her where she wanted to transfer to; Resident #19 had the right to receive assistance from staff as listed in her admission agreement above. According to the facility staff schedule, provided by the NHA on 12/9/19 at 3:00 p.m., it reflected that the facility allowed CNA #5 work on 12/7/19 in the same hall where Resident #19 resided before they educated her on resident rights and the right to fall per the facility's follow-up action to the 12/5/19 grievance the facility filed for Resident #19. B. DON interview The DON was interviewed on 12/10/19 at 10:50 a.m. She said it was a therapist (not a nurse) who reported to her that Resident #19 did not want CNA #5 to care for her because CNA #5 wanted her to keep her feet in the bed. She said she did not speak to Resident #19 nor to other residents because she thought that what the therapist reported to her was a customer service issue. She said she did not report it to the NHA because she thought that what the therapist reported to her was a customer service issue. She said her response to what the therapist reported to her was she told CNA #5 that due to a personality conflict (with Resident #19) CNA #5 was to switch positions with another CNA (who would be the one to provide care for Resident #19). She said she told the nurse on duty that Resident #19 did not want CNA #5 to tell her what to do. She said she had no documentation of her discussions with CNA #5 or the nurse on duty. She said grievance forms were located outside of her office, and were filled out for resident complaints. She said grievances were handled by department heads and ultimately the NHA was involved in the grievance process. She said, in hindsight (for Resident #19) and other residents, she would interview them when they requested to not have specific CNAs to care for them. C. NHA interview The NHA was interviewed on 12/10/19 at 1:01 p.m. He said he would have wanted to have been informed of Resident #19's concerns with CNA #5 so he could follow-up on her concerns. He said he reviewed all grievances and conducted follow-up to grievances if he felt it was necessary to do so as department managers were able to handle concernss. He said in general he signed off on all grievances, could handle a grievance first-hand if necessary, and was ultimately responsible for all grievances. He said when he reviewed grievances he looked for: severity, appropriate follow-up, resolution for the resident (indicated by the resident's signature), patterns (because he tracked and trended grievances), and if there was a need to continue to look further into the grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the accuracy and timely revision of care plans for two (#17 and #37) of three care plans reviewed out of 20 sample residents. Specifically, the facility failed to ensure: -Resident #17's care plan reflected her current transfer status; and -Resident #37's care plan included his current therapeutic diet. Findings include: I. Facility policies A. The Care Plans - Baseline policy, dated July 2019, was provided by the director of nursing (DON) on 12/10/19 at 11:45 a.m. It revealed in pertinent part, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission .The interdisciplinary team (IDT) will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including .dietary orders .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an IDT person-centered care plan .a summary of the baseline care plan includes dietary instructions, services and treatments administered by the facility, and updated information based on the details of the comprehensive care plan. B. The Care Plans, Comprehensive Person-Centered policy, revised December 2016, was provided by the DON on 12/10/19 at 11:45 a.m. It revealed, in pertinent part, 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 describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .The IDT must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. II. Failure to update current transfer status Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis affecting the left non-dominant side, dysphagia, diabetes, and hypertension. The 11/2/19 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of 14 out of 15. She required total two-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene and limited one-person assistance for eating. C. Record review The care plan initiated on 10/16/19 documented the resident had limited physical mobility related to left sided deficit and right sided weakness. She required extensive to total assistance with all activities of daily living (ADL's) and transfers. The goal was for complications related to immobility be minimized through the review date. Interventions included physical therapy (PT) and occupational therapy (OT) referrals as ordered, as needed (PRN). The care plan was revised on 10/27/19 with a goal of nursing rehabilitation/restorative active range of motion (AROM) for upper body (UB) and lower body (UB). The care plan was initiated and revised on 12/4/19 with a goal to increase Resident #17's level of mobility by performing transfers and walking at least 50 feet (ft) with partial to moderate assistance by the time she was discharged from skilled services. Intervention documented the resident required hoyer lift by two staff for transfers. Aside from the aforementioned revisions, the care plan had not been updated since 10/16/19. Resident #17 discharged acutely to the hospital on [DATE] with a diagnosis of hypoxemia (abnormally low level of oxygen in the blood). The resident returned to the facility on [DATE]. The 11/2/19 MDS documented the resident required total two-person assistance for transfers; however, the intervention on the care plan related to mobility was not updated with the residents current transfer status until 12/4/19 (see below). The PT progress note, dated 11/15/19, was provided by the director of therapy (DOT) on 12/9/19 at 4:28 p.m. It documented the resident fluctuated between minimal two-person assistance and maximum one-person assistance for transfers during therapy and the CNA's continued to use the hoyer lift. The revision to the care plan was not made until 12/4/19 with a goal to increase Resident #17's level of mobility by performing transfers and walking at least 50 feet (ft) with partial to moderate assistance by the time she was discharged from skilled services. Intervention documented the resident required hoyer lift by two staff for transfers. The PT progress note, dated 11/27/19, was provided by the DOT on 12/9/19 at 4:28 p.m. It documented the resident required moderate assistance for transfers during therapy. The resident roster dated 12/4/19 documented the resident required two-person assistance for transfers. D. Interviews CNA #7 was interviewed on 12/9/19 at 11:19 a.m. She said Resident #17 required total two-person assistance for transfers. She said, dependent on how much the resident participated in the transfer, a hoyer (mechanical) lift was required for resident safety. She said the hoyer lift was not used when the resident was transferred to the bathroom, as she was able to hold onto the grab bars and pivot to the toilet. The CNA said there were always two people present during the transfer and resident care. Registered nurse (RN) #4 was interviewed on 12/9/19 at 2:28 p.m. She said when Resident #17 admitted to the facility, she required max assistance and the use of a hoyer lift for transfers. Now the resident required total assistance, but no longer required the use of the hoyer lift. She confirmed that the care plan had not been updated with the current transfer status of the resident. RCNA was interviewed on 12/9/19 at 3:20 p.m. He said depending on the residents willingness, a transfer from the bed to the wheelchair only required two-person assistance without the use of the hoyer lift. He said the resident was typically a hoyer lift for transfers and was used only if the resident did not participate in the activity. He said when the resident transferred to the bathroom, she grabbed the taller bar in the bathroom to help her stand. He said therapy has worked with the resident on standing and walking and gave CNA's the green light to assist the resident to the bathroom without the use of the hoyer lift. The DOT was interviewed on 12/9/19 at 4:28 p.m. He said the resident fluctuated in the level of assistance she required for transfers. He said when the resident required maximum two-person assistance in therapy, the CNA's were educated to use a hoyer lift for transfers. However, when the resident required moderate two-person assistance, the CNA's were educated to transfer the resident in the same manner. He said training was provided to the CNA's and they were instructed to read the board in the resident's room related to the level of assistance the resident required. The DON and clinical nursing consultant (CNC) were interviewed on 12/10/19 at 10:43 a.m. The DON said the facility followed the resident assessment instrument (RAI) manual, with the baseline care plan completed in 48 hours after admission, the comprehensive care plan completed 21 days after admission and seven days for any revisions. She said the current level of assistance a resident required should be reflected on the care plan. E. Follow-up The DOT added a laminated white piece of paper to the bulletin boards adjacent to the small dry erase board for each room on the second floor. This allowed for improved communication with the nursing staff on the level of care a resident required. III. Failure to include current therapeutic diet Resident #37 A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the December 2019 CPO, diagnoses included acute myeloblastic leukemia, bone marrow transplant, and diabetes. The 11/14/19 MDS assessment revealed the resident was cognitively impaired with a BIMS score of 13 out of 15. He required extensive two person assistance for bed mobility, dressing, and toilet use, extensive one person assistance for transfers and personal hygiene, limited one person assistance for walking in the room and one person supervision for eating. The MDS did not indicate the resident was on a therapeutic diet. B. Record review The nutritional and dietary assessment of the baseline care plan dated 11/8/19 was not completed. The CPO dated 11/10/19 revealed the resident was on a regular diet, regular texture, and thin consistency for a neutropenic diet (all foods cooked). The care plan initiated on 11/11/19 documented the resident had nutritional problem or potential nutritional problem for increased nutrient needs related to declined health status secondary to numerous comorbidities (diagnoses) of bone marrow transplant and diabetes. The goals were for the risk of malnutrition be minimized through the review date and to maintain a weight of 125 pounds (lbs) plus/minus 3 percent for ninety days. Interventions included: -Monitor weights as ordered. -Obtain food preferences and offer as able. -Offer food alternates of equal nutritional value. -Provide, serve diet as ordered. Monitor intake and record every meal. -Obtain and monitor lab and diagnostic work as ordered. Report results to physician and follow up as indicated. -Registered dietician to evaluate and make diet change recommendations as needed (PRN). The mini nutritional assessment completed by the registered dietician (RD) on 11/11/19 revealed Resident #37 required a neutropenic diet related to his current medical status. However, the care was not updated with the specifics of a therapeutic neutropenic diet. The care plan had not been updated since 11/11/19 and failed to specify Resident #37 was on a therapeutic neutropenic diet. C. Interviews The DON and clinical nursing consultant (CNC) were interviewed on 12/10/19 at 10:43 a.m. The DON said the facility followed the resident assessment instrument (RAI) manual, with the baseline care plan completed in 48 hours after admission, the comprehensive care plan completed 21 days after admission and seven days for any revisions. She said the current level of assistance a resident required and current diet orders should be reflected on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure services provided met professional standards for medication administration. Specifically, the facility failed to: -Administer Prevacid (proton pump inhibitor) according to physician orders for Resident #27; -Administer Acyclovir (antiviral) according to physician orders for Resident #145; and -Ensure the medications were available and administered according to physician orders for Resident #17. Findings include: I. Facility policy The Medication Administration policy, revised on 11/26/19 was provided by the director of nursing on 12/10/19 at 1:25 p.m. It read, in pertinent part, Resident medications are administered in an accurate, safe, timely, and sanitary manner. -Medications are administered in accordance with written orders of the attending physician or physician extender. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the resident's current diagnosis or condition, contact the physician for clarification prior to the administration of the medication. Document the interaction with the physician in the nursing progress notes and elsewhere in the medical record, as appropriate. -Begin new medications timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. If the resident admits to the facility in the evening, the facility will speak to the physician to authorize to give medications when available from pharmacy. -Each time a medication is administered it must be documented. II. Resident #27 A. Resident status Resident #27, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included bypass graft, presence of cardiac pacemaker, dependence on supplemental oxygen and gastrostomy tube. The 11/20/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive two person assistance with all activities of daily living (ADLs). B. Record review According to the facility's electronic medication administration record (eMAR) system documenting the code number nine (9) meant a medication was not given see progress notes. Resident #27 November 2019 MAR revealed an order dated 11/2/19 for Prevacid 30 milligram (mg) disintegrating tablet via PEG (percutaneous endoscopic gastrostomy) tube one time a day for indigestion. Review of Resident #27's November 2019 medication administration record (MAR) revealed staff did not administer the resident's Prevacid five times. -On 11/4, 11/8, 11/9, 11/12, and 11/25/19 the code number 9 was documented for Prevacid on the MAR. Review of Resident #27's November 2019 progress revealed no documentation of the reason why the medication was not administered. III. Resident #145 A. Resident status Resident #145, age [AGE], was admitted on [DATE]. According to the December 2019 CPO diagnoses included malignant neoplasm of the cerebellum, chronic kidney disease and atrial fibrillation. The 11/29/19 MDS assessment revealed the resident was moderately impaired with a BIMS score of 12 out of 15. She had behavioral symptoms of yelling. She required two-person extensive assistance with bed mobility, dressing, transfers, and toilet use. B. Record review Resident #145's November and December 2019 MAR revealed an order dated 11/23/19 for Acyclovir capsule 200 mg give two caps by mouth two times a day for prophylaxis. Review of Resident #145's November and December 2019 MAR revealed the resident was not given her bedtime Acyclovir on 11/23/19 and 12/8/19. The code number 9 was documented for the Acyclovir bedtime dose on 11/23/19 and 12/8/19. Review of Resident #145's November and December 2019 progress notes revealed no documentation of the reason why the medication was not administered. IV. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the December 2019 CPO, diagnoses included diabetes mellitus, cerebral infarction and atrial fibrillation. The 11/2/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required two person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. B. Record review The November 2019 MAR revealed the following orders: -Melatonin 3 mg by mouth at bedtime for supplement (order date 11/22/19). -Citalopram 10 mg by mouth daily for depression (order date 11/18/19). -Enulose 10 gm (gram)/15 ml (milliliters) give 30 ml via G-tube daily for constipation (order date 11/1/19). -Potassium 20 meq (milliequivalent) by mouth daily for hypokalemia (order date 11/15/19). -Silvadene cream 1% apply to right buttock topically three times daily for unstageable pressure ulcer (order date 11/1/19). Review of the November and December 2019 MAR revealed several medications which were documented as not available from the pharmacy and it was coded number 9 (see below). The order administration note (which is linked to the MAR) dated 11/2/19 at 5:34 a.m., documented the Enulose was not available and at 10:07 a.m., it was ordered from the pharmacy. The order administration note dated 11/2/19 at 11:35 a.m., and at 12:44 p.m., documented the Silvadene cream 1% was not available and it was ordered from the pharmacy. The order administration note dated 11/19/19 at 11:42 a.m., documented the Citalopram 10 mg medication not available physician and pharmacy notified and the pharmacy will send today. The order administration note dated 11/19/19 at 11:43 a.m., documented the Potassium 20 meq was not available the physician was notified and the pharmacy was called the resident took medications via peg tube; however, the order documented she took the medication by mouth (see above). The order administration note dated 11/30/19 at 7:35 p.m., documented Melatonin 3 mg was not available. The order administration note dated 12/1/19 at 10:06 p.m., documented Melatonin 3 mg was out of stock and reordered. V. Staff interviews Registered nurse (RN) #4 was interviewed on 12/9/19 at 10:15 a.m. She said the nurses were responsible for reordering medications. She said typically for new admissions pharmacy would take longer to fill the medications. She said she would contact the pharmacy if medications were not available. The pharmacist was interviewed on 12/9/19 10:54 a.m. He said all prescriptions, new admissions, refills, and over the counter (OTC), were delivered four times a day at 10:00 a.m., 2:00 p.m., 6:00 p.m., and the close of business. He said there was an on-call pharmacist if needed. He said he communicated to the facility that the stickers on the medication cards should be sent three days before the medication ran out so it could be refilled. He said refills were not a priority. He said sometimes the facility called and the medication was sent out with the next run. He said there had been times when the pharmacy ran out of stock of a medication from the manufacturer, but if that happened (which was rare), he would call other pharmacies and/or hospitals to obtain the medication; but it also depended on how urgent the medication was. He said some insurances would not allow prescriptions to be filled prior to the date on the sticker. He said they did everything humanly possible to make sure the orders were received in a timely manner. He said the pharmacy typically did not receive many calls for refills because the facility had run out medications, rather received calls for routine orders. RN #3 was interviewed on 12/9/19 at 1:53 p.m. She said documentation of the code 9 on the MAR indicated other see progress notes. She said if she documented the code 9 then she would document the reason a medication was not given. She said if a medication was not available she would try to obtain it from the Cubex (an automated medication dispensing system). If the medication was not in the Cubex then she would call the pharmacy to see if the medication was ordered. She said she would also call physician to notify him/her that the medication was not available and typically the physician would give orders to give the medication when it arrived from the pharmacy depending on how it was scheduled. She said normally the pharmacy provided all medications, but they usually kept OTC stock. RN #1 was interviewed on 12/10/19 at 10:07 a.m. She said if they run out of medications, she would let the resident know, notify the physician, call and fax orders to the pharmacy and would document in the progress note when the pharmacy planned to send the medication. She said she would also check the e-kit (emergency) for the medication. She said there was a sticker on the medication cards with a reorder date that also needed to be followed. She said the pharmacy delivered medications three times a day. She said the pharmacy delivered stat medications within a two hour window and other refills outside of delivery times if able. She said the process was the same for new admissions, reorders, and OTC medications. She said the DON would be notified if medications were not available. The DON and clinical nurse consultant were interviewed on 12/10/19 at 10:46 a.m. The DON said they had used their current pharmacy for four months and recently started using the Cubex which only had a small number of emergency medications such as acute medications for pain or blood pressure. She said the process for medications that were not available, was the nurse should notify the pharmacy to have it delivered, check the Cubex and the nurse should contact the physician to obtain a hold order for the medication or obtain new orders. She said the pharmacy provided a 10-day supply of medications and they delivered medications three times a day. She said they also provided all OTC medications, but they had other means to obtain medications such as going to Walgreens. She said one of the reasons medications were not available could have been because the nurses did not reorder in time since the residents were short stay residents. VI. Follow-up On 12/10/19 at 12:19 p.m. The DON provided a copy of all medications that were available in the Cubex which included the medication Potassium. She said she started an education with all the nurses for proper procedure for following up with medications that were unavailable which read in pertinent part, If you document 9, See Progress Note on the MAR for a medication that is not available you must: Call the pharmacy to have medication sent, call the physician to inform that patient's dose is late and the action you have taken, put an order in that the medication may be skipped or late, make a detailed progress note regarding the steps taken and the end result of the medication not being available. If medication was given, please strike out previous 9, See Progress Note and enter it as administered. Six staff signed acknowledgement of the education (two licensed practical nurses' and four RNs).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide a therapeutic diet as prescribed by the physician to one (#37) out of two sampled residents for therapeutic diet, out of a total sample of 20 residents. Specifically, the facility failed to consistently provide Resident #37 with a diet that met the physician ordered therapeutic diet of neutropenic (all foods cooked). Findings include: I. Facility policy The Therapeutic Diets policy, revised October 2017, provided by the director of nursing (DON) on 12/10/19 at 11:45 a.m., revealed, in pertinent part, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .A 'therapeutic diet' is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. II. Resident #37 A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included acute myeloblastic leukemia, bone marrow transplant, and diabetes. The 11/14/19 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of 13 out of 15. He required extensive two-person assistance for bed mobility, dressing, and toilet use, extensive one-person assistance for transfers and personal hygiene, limited one-person assistance for walking in the room and one-person supervision for eating. However, the MDS failed to indicate the resident was on a therapeutic diet. B. Resident interview The resident was interviewed on 12/5/19 at 10:17 a.m. He said the facility was lucky if they got a meal right. He was certain the kitchen staff did not understand the foods he was allowed to have on the neutropenic diet, because on numerous occasions there would be things on his tray that he was to avoid such as salad (which is an uncooked food). D. Record review The mini nutritional assessment completed by the registered dietician (RD) on 11/11/19 revealed Resident #37 required a neutropenic diet related to his current medical status and the RD documented she would advise the kitchen. However, interviews with the kitchen staff revealed they had no knowledge of Resident #37's neutropenic diet (see below). The December 2019 CPO revealed the resident was on a regular diet, regular texture, and thin consistency for a therapeutic neutropenic diet (all foods cooked). Reviewed Resident #37's meal ticket for the noon meal on 12/5/19 at 12:51 p.m. The noon meal ticket was not printed. Instead, it was hand written in pencil with the residents name and room number at the top of the ticket and the meal choice was circled. The hand written meal ticket did not indicate that the resident was on a neutropenic therapeutic diet. Reviewed Resident #37's meal ticket for the evening meal on 12/5/19 at 5:45 p.m. The evening meal ticket was not printed. Instead, it was hand written in pencil with the residents name and room number at the top of the ticket. The meal selection had been crossed out and a message of Will supply own dinner was written on the ticket. The hand written ticket did not indicate if the resident was on a therapeutic diet. E. Staff Interviews Cook #3 was interviewed on 12/5/19 at 4:43 p.m. She said if a resident was on a therapeutic diet, it showed at the top of the printed meal ticket. However, if a meal ticket was not printed, a hand written ticket was used. She said the meal tickets were preprinted with a place for the residents name and room number, diet textures (regular, mechanical, and pureed), and showed the meal selection for the day. She said the hand written tickets were not preprinted with therapeutic diets such as NAS, renal, diabetic, gluten, or neutropenic. She said, if a resident was on a therapeutic diet, the certified nurse aides (CNAs) were supposed to add the therapeutic diet to the meal ticket when they took the residents meal order. She was unaware that the resident was on a neutropenic diet. The RD was interviewed on 12/5/19 at 5:21 p.m. The RD said if a resident was on a therapeutic diet, she put the therapeutic diet in the progress notes of the resident's medical chart. However, she said the kitchen staff did not have access to the progress notes. She said the CNA's were aware of the residents diets and were supposed to write the information on the meal ticket. She said the facility was in the process of revamping the handwritten tickets so the therapeutic diets were preprinted. The RD said an in-service for the kitchen staff on specialized diets was given in June 2019. Unfortunately, it did not include information on a neutropenic diet. She said when Resident #37 was admitted to the facility, she provided a verbal in-service to the kitchen staff for this therapeutic diet. Cook #2 was interviewed on 12/9/19 at 8:32 a.m. She said at times, the kitchen received a handwritten ticket because the residents meal order had not been taken the day before. The CNA wrote up the meal ticket and sent it to the kitchen. She said that if she did not know about a particular therapeutic diet, she referred to the folders that hung on the wall near the serving line. Observation of the folders revealed reference sheets for diet textures such as mechanical, pureed, and thickened and therapeutic diets such as finger foods, portion size, gluten/lactose, high/low fiber, renal, diabetic, and fluid restrictions. There was not a folder for a neutropenic diet. The cook said she did not know which foods were allowed and which foods were to be avoided on a neutropenic diet. She was unaware that Resident #37 was on a neutropenic diet. The dietary service manager (DSM) was interviewed on 12/9/19 at 9:16 a.m. He said he was not aware there was a resident in the facility on a therapeutic neutropenic diet. CNA #7 was interviewed on 12/9/19 at 11:19 a.m. She said she did not know what foods were allowed and which foods were to be avoided for therapeutic diets of renal, cardiac, and neutropenic. Registered nurse (RN) #3 was interviewed on 12/9/19 at 11:50 a.m. She said she was not familiar with what foods were allowed and which foods were to be avoided on a neutropenic therapeutic diet. Cook #1 was interviewed on 12/9/19 at 1:49 p.m. He said sometimes the meal tickets were handwritten and if the diet texture was not circled, then it meant the resident was on a regular diet. He said he referred to the reference folders if he did not know about a particular therapeutic diet. He said he did not know which foods were allowed and which foods were to be avoided on a neutropenic diet. Registered nurse (RN) #1 was interviewed on 12/10/19 at 9:36 a.m. She said she had not received any training or in-service related to the various therapeutic diets. She said she was not aware which foods were allowed and which foods were to be avoided on a neutropenic diet. CNA #4 was interviewed on 12/10/19 at 9:51 a.m. He said he had received some training on therapeutic diets and diet textures. However, he said he did not receive training on a neutropenic diet. He said he usually knew what was allowed on a residents diet when he took their order. He said the handwritten tickets did not list the therapeutic diets and it was up to the CNA to indicate the proper therapeutic diet on the meal ticket. He said he was not aware there was a resident in the facility on a neutropenic diet. The DON and clinical nurse consultant (CNC) were interviewed on 12/10/19 at 10:43 a.m. They said the staff were educated on therapeutic diets during orientation and completed a computer based training (CBT) course on therapeutic diets. The DON said normally the therapeutic diets were printed on the meal tickets, but the registered dietician consultant (RDC) noticed some therapeutic diets were not on the meal tickets. The DON said the facility was in the process of switching forms. The DON was not aware there were nurses and CNA's who did not have knowledge about which foods were allowed and which foods were to be avoided for a neutropenic diet. III. Follow-up on 12/9/19 and 12/10/19 Cook #2 said the DSM provided her a handout on neutropenic diets. She had not read it yet. She said the DSM was going to review the information on the therapeutic diet with her. The RD said she coordinated with the DON and would attend next weeks nurses meeting and provide an in-service to the CNA's and nurses on the various therapeutic diets and which foods were allowed and which foods were to be avoided for each diet. The registered dietician consultant (RDC) was interviewed on 12/9/19 at 4:02 p.m. She said the facility would incorporate education on therapeutic diets in the new hire orientation, and would conduct regular in-services and educate the staff as needed. The RDC was interviewed a second time on 12/10/19 at 11:52 a.m. She said the meal tickets were being revised so the therapeutic diet would be in capital letters at the bottom of the meal ticket. She said, for example, a therapeutic diet of neurtopenia would read neurtopenic diet: no fresh fruits and vegetables and a no gluten diet will be listed in the allergy section of the meal ticket. She said it was a work in progress and would be evaluated on a regular basis for effectiveness and understanding by the staff.

Based on observations, record review, and staff interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Ensure expired foods were discarded from two of three nutrition refrigerators; and -Ensure an uncovered pie was discarded from the walk in freezer. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; -Except when packaged food using a reduced oxygen packaging method, Time/Temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41ºF (farenheit) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. II. Facility policy The Food Receiving and Storage policy, revised October 2017, was provided by the director of nursing (DON), on 12/10/19 at 11:45 a.m. It read, in pertinent part, Food shall be received and stored in a manner that complies with safe food handling practices .Food services, or other designated staff, will maintain a clean food storage areas at all times .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing .Food items and snacks kept on the nursing units must be labeled with a use by date. III. Expired foods not disposed of in a timely manner A. Observations Observation of the nutrition refrigerator located on the first floor, north hall on 12/5/19 at 11:28 a.m with the dietary service manager (DSM) revealed the following contents: four expired blueberry yogurts, all with an expiration date of 11/28/19. Observation of the nutrition refrigerator located on the second floor, south hall, (the second floor north hall was not in use) on 12/5/19 at 11:56 a.m., with the DSM revealed the following contents: five expired blueberry yogurts, one with an expiration date of 10/7/19 and four with an expiration date of 11/29/19. B. Staff interviews Dietary aide (DA) #2 was interviewed on 12/5/19 at 12:25 p.m. He said he checked the temperature of the nutrition room refrigerators and stocked them daily with items like soda, juice, pudding, sandwiches, and yogurt. He failed to mention if he checked for expired foods when he stocked the nutrition refrigerators. DA #1 was interviewed on 12/5/19 at 12:30 p.m. She said the night DA was responsible for assuring the nutrition refrigerators were stocked and the temperatures were logged. She said the nutrition refrigerators were stocked daily and any expired foods were discarded. She said dated three days after the date written by the kitchen or the manufacturer date stamped on the item were discarded. She said the kitchen stocked the nutrition refrigerators with various juices and snacks to include items like jello, pudding, and sandwiches. She said she inspected the freezer and stocked it with ice cream. The DSM was interviewed on 12/5/19 at 4:34 p.m. He said it was the responsibility of the kitchen to manage the nutrition refrigerators on both the first and second floor. He said the refrigerators were checked and stocked daily. Observed the refrigerator on the one north hall and on the second floor with the DSM. He said food prepared and dated by the kitchen could only be in the refrigerator for three days from the date indicated on the item. If there was a manufacturer stamped date, that was the date the kitchen followed. The DSM agreed that the expired yogurts should have been removed from the refrigerators according to the date stamped on the item. The registered dietician consultant (RDC) was interviewed on 12/9/19 at 4:02 p.m. She said the date stamped on the yogurts by the manufacturer was the expiration date of the food and it should be discarded on the date shown. IV. Improperly covered food A. Observations On 12/04/19 at 8:16 a.m., the main kitchen was observed and the following was revealed: -A fruit pie in the walk-in freezer dated 11/18/19, was not fully covered with plastic wrap, which left the pie crust and filling exposed to the temperature of the freezer. On 12/09/19 at 11:12 a.m., the fruit pie was observed once more, not fully covered with plastic wrap, which left the pie crust and filling exposed to the temperature of the freezer. B. Staff interviews The RDC, registered dietician (RD), and DSM were interviewed on 12/9/19 at 4:02 p.m. The RDC said contents of the walk-in freezer needed to be fully covered, so the food was not exposed to the temperature of the freezer and risk freezer burn. She said the uncovered pie needed to be disposed of since it had been exposed to the temperature of the walk-in freezer. V. Follow-up The DSM said he would educate the kitchen staff to check the dates of the food in the nutrition refrigerators daily and to rotate the contents, with the older items moved to the front and the newer items moved to the back. This would aid in assuring the expired foods were removed from the refrigerators. The RDC said she would educate the kitchen staff on the proper way to wrap food with plastic wrap to prevent freezer burn.