**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide the resident the right to make choices about aspects of his life in the facility that are significant to the resident related to left leg prosthetics for one (#55) of one resident out of 59 sample residents. Specifically, the facility failed to honor Resident #55's requests to be fitted and provided with a left leg prosthetic which he had prior to being admitted to the facility. Findings include: I. Resident #55 A. Resident status Resident #55, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included bipolar disorder (mental illness that causes shifts in a person's behaviors), current episode of depression and acquired absence of left leg above the knee. The 11/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required set up assistance with chair to chair transfer and toileting. B. Observations On 1/13/25 at 2:30 p.m. Resident #55 was observed in his room sitting in his wheelchair and had a left above the knee amputation (AKA) and did not have a prosthetic leg to fit his AKA. C. Resident interview Resident #55 was interviewed on 1/13/25 at 2:33 p.m Resident #55 said that he had asked for a new left leg prosthetic since he arrived at the facility and had not yet received assistance to get the prosthetic. Resident #55 said he was not allowed to bring his prosthetic to the facility due to having bed bugs at his previous home. He believed his prosthetic was thrown away. Resident #55 said he was not given many options and choices regarding his health care and not having the prosthetic leg made him feel bad because he had to depend on other people for things he could do on his own. Resident #55 said he spoke with therapy and the director of nursing (DON) in October 2024 about getting a new prosthetic leg and was still waiting for an answer. D. Record review Record review of the physician's progress note dated 7/5/24 revealed that the resident was able to ambulate (walk) when using a prosthetic leg. The interdisciplinary team (IDT) progress note dated 10/22/24 revealed the resident requested to be fitted with a new prosthetic leg and a physician's order was written to follow up with a prosthetics provider. -However, review of Resident #55's electronic medical record (EMR) did not reveal any documentation regarding follow up on the referral. E. Staff interviews The social services director (SSD) was interviewed on 1/16/25 at 12:12 p.m. The SSD said Resident #55's medical provider was responsible for following up on getting the resident his prosthetic device. The SSD said there should have been documentation in the resident's chart on the status of the prosthetic. She said she was not aware of the status of the referral. The nursing home administrator (NHA) was interviewed on 1/16/25 at 2:00 p.m. The NHA said the therapy department was responsible for assessing Resident #55 for a prosthetic leg and making a referral for the device if needed. The NHA said the resident did not have a referral for a prosthetic fitting but he recently made a referral and the resident had an appointment coming up on 2/5/25, through his physician's office. The director of rehabilitation (DOR) and the physical therapy assistant (PTA) were interviewed on 1/16/25 at 2:19 p.m. The PTA said the facility's process, once a resident was referred for therapy services, was to evaluate the resident's level of functioning and determine their assistive needs. The PTA said Resident #55 was assessed and the therapist did not recommend a new prosthetic leg because the resident did not express a desire to transfer or walk. The PTA said that the only reason that the therapy department would provide a resident with a prosthetic leg was if the resident wanted it for walking or transferring. The PTA said per the physical therapy (PT) initial evaluation note dated 6/23/24, the resident declined to work with PT with a front wheel walker and said that he preferred to use a wheelchair to get around. The PTA said on evaluation, Resident #55 was independent with bed mobility and supervision with transfers from bed to wheelchair. The PTA said Resident #55 was also able to propel himself 150 feet independently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for one (#99) of one resident out of 59 sample residents. Specifically, the facility failed to ensure the MDS assessments for Resident #99 accurately documented that the resident had a preadmission assessment screening and resident review (PASRR) Level II qualifying diagnosis. Findings include: I. Professional reference According to the American Association of Post-Acute Care Nursing (AAPACN) The Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Process (October 2024), retrieved on 1/29/25 from https://www.aapacn.org/resources/rai-manual/, The RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. The MDS assessment is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which formed the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. II. Facility policy and procedure The MDS Accuracy policy, revised February 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:26 p.m. It read in pertinent part: It is the policy of this facility to code accurately on the MDS assessment. III. Resident #99 A. Resident status Resident #99, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included bipolar disorder. The 9/27/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of The assessment documented that the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. B. Record review The Preadmission Screening and Resident Review (PASRR) Level II Notice of Determination (NOD) for Mental Illness (MI) dated 9/20/24 revealed that information gathered during the PASRR Level II evaluation determined that Resident #99 had a PASRR condition and was determined appropriate for nursing facility level of care. Specialized services required/recommended included: psychiatry case consultation and additional one-to-one engagement support. -However, the 9/27/24 MDS assessment failed to document the resident's PASRR Level II diagnosis. IV. Staff interviews The social services director (SSD) and social services assistant (SSA) #2 were interviewed together on 1/16/25 at 11:53 a.m. The SSD said it was the social services department's responsibility to review the PASRRs and provide Level II determination information to the MDS coordinators (MDSC) so that the residents' MDS would be coded correctly. MDSC #1 and MDSC #2 were interviewed together on 1/16/25 MDSC #1 and MDSC #2 said they reviewed the residents' records, including admission records, skilled nursing notes and social services assessments to complete the MDS assessment. They said PASRR information was provided to the MDSCs by social services. They said when the information was not up-to-date due to a missing PASRR screening the MDSCs relied on social services to provide updated information. MDSC #2 said she would correct the MDS assessment as soon as updates were provided. MDSC #2 said she was not aware that Resident #99 had received a PASRR Level II determination and would review the documentation and make updates to the MDS assessment as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#47) of two residents reviewed for PASRR out of 59 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #47. Findings include: I. Resident status Resident #47, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included Down's syndrome and major depressive disorder. The 12/24/24 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 assessment revealed the resident had been identified as having a level II PASRR. II. Resident interview Resident #47 was interviewed on 1/15/25 at 1:27 p.m. Resident #47 said she had been interested in leaving the facility to go shopping, becoming involved in community activities and making friends with people her age in the community. However, she said the facility's social services department had not set up any community activities or services for her. III. Record review The PASRR level II, provided by the facility on 1/15/25, included an evaluation which revealed the resident had been evaluated for IDD (intellectual and developmental disability) due to a qualifying diagnosis of Down's syndrome. Specialized services were recommended to include supported community connections (community integration activities). Review of Resident #47's at-risk care plan, initiated 1/13/25 (during survey), revealed the resident had a level II PASRR due to Down's syndrome. The recommendations included case management, psychiatric case consultation, individual therapy, transportation to behavioral management and pastoral care. Interventions, dated 1/13/25 (during the survey), included anticipating and meeting the needs of the resident. -The care plan failed to reveal community integration activities for the resident. -A review of Resident #47's progress notes from 12/18/24 to 1/14/25 failed to reveal any progress notes related to PASRR. -There was no documentation from social services notes regarding Resident #47's PASRR level II or the recommendations. -There were no documentation in Resident #47's electronic medical record (EMR) to indicate the facility had communicated with the State Mental Health Agency regarding a delay or the facility's inability to follow the recommendations. IV. Staff interviews The social services director (SSD) was interviewed on 1/16/25 at 11:53 a.m. The SSD said it was the social services department's responsibility to set up PASRR recommended specialized services for residents with level II PASRRs. She said if recommendations could not be met, the social services department was responsible for documenting the efforts to meet the recommendations and the outcomes in the progress notes and the resident's care plan. The SSD said the PASRR level II recommendations for Resident #47 included case management, transportation and community integration activities. The SSD said she had sent out a few referrals for services but had not been able to secure services for the resident. She said the documentation of the referrals she sent should be in the progress notes and care plan. The social services consultant (SSC) was interviewed on 1/16/25 at 5:51 p.m. The SSC said the social services department had not sent out any referrals for community services for Resident #47 since December 2024 and the SSD had not followed up with the resident regarding services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality two (#69 and #23) of two residents of 59 sample residents. Specifically, the facility failed to: -Follow manufacturer's directions when administering Trulicity (insulin) for Resident #69; and, -Have accurate medication orders for Resident's #69 and #23 Trulicity injections. Findings include: A. Professional reference According to the [NAME] Lilly Manufacturer's Trulicity Injection, Instructions for Use, last revised November 2024, retrieved on 1/25/25 from https://uspl.lilly.com/trulicity/trulicity.html#ug Administration of Trulicity injection pen should be held flat on the skin, press and hold the green injection button. You will hear a loud click. Continue holding the clear base firmly against your skin until you hear a second click. This happens when the needle starts retracting in about five to 10 seconds. Every dose of Trulicity comes in the easy-to-use pen, so you can continue to have the same experience with once-weekly Trulicity, regardless of the dose you've been prescribed. B. Observations On 1/14/25 at 4:08 p.m. LPN #3 was giving a Trulicity injection to Resident #69 3 milligram (mg) /0.5 milliliter (ml), single-use pen. While administering the medication injection LPN #3 pinched the upper left forearm and injected the medication. LPN #3 failed administer the medication per the manufacturer's directions (see above) by holding the pen flat to the skin and wait until two clicks were heard. -The dose given was verified as correct with the pharmacy consultant )PC); however, the order on the medication administration record was verified by LPN #3 to be inaccurate and not matching the dosage administered. C. Record Review Review of Resident #23's January 2025 medication administration record (MAR) documented a medication order for Trulicity, inject 0.75 milligrams (mg) /0.5 milliliters (ml). The administration instructions read administer 0.5 ml, ordered on 1/3/22. -The physician's order for Trulicity did not indicate the specific mg dose to be administered to the resident. Review of Resident #69's January 2025 MAR documented a physician's order for Trulicity to inject 1.5 mg/0.5 ml. The administration instructions read to administer 3 mg, ordered on 7/14/23. -However, the dosage on the Trulicity pen administered by LPN #3 (see observation above) was 3 mg/0.5 ml, which was verified to be the correct physician ordered dose for the resident (see pharmacy consultant interview below). -The physician's order on Resident #69's January 2025 MAR did not match the correct dose of the medication that was to be administered to the resident. D. Staff interviews The pharmacy consultant (PC) was interviewed on 1/14/25 at 5:00 p.m. The PC said she consulted with Resident #69's physician to verify the resident's Trulicity injection order and received confirmation that the dose administered to the resident was correct, however the order in the resident's MAR was not correctly written. The PC said she would conduct an audit on the orders for all residents on Trulicity and similar medications to ensure the orders are clearly and accurately written. The director of nursing (DON) was interviewed on 1/15/25 at 9:10 a.m. The DON said they completed a review of all residents on diabetic medications for accuracy of orders and found all residents on Trulicity had contradictory orders and administration directions. The DON said the nursing staff consulted with each prescribing physician to ensure accurate orders were entered into each resident's MAR. The DON said all of the orders had been corrected. The DON said the audit revealed that each resident had been administered the correct single-dose injection pens. The DON said the nurse who initially entered the orders was no longer working for the facility. She said the facility was planning to educate all of the current nursing staff on how to enter accurate medication orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the January 2025 (CPO), diagnoses included multiple sclerosis (MS). The 10/1/24 MDS assessment revealed the resident had minimal cognitive impairment with a BIMS score of 13 out of 15. The resident required partial assistance with oral hygiene and total assistance with repositioning. B. Failed to provide oral care 1. Resident interview and observation Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she had not had her teeth brushed for some time. She said she needed to tell the staff to brush her teeth because they did not help her. The resident had foul smelling breath and a white substance visible on her upper teeth. Resident #34 was interviewed a second time on 1/15/25 at 10:08 a.m. Resident #34 said she had not had her teeth brushed. She continued to have foul smelling breath and the white substance was still visible on her upper teeth. On 1/15/25 at 10:24 a.m. CNA #3 brushed Resident #34's teeth. The resident did not participate in the teeth brushing task. After her teeth were brushed, Resident #34 said she felt so much better. 2. Record review Resident #34's care plan, revised 12/30/24, identified the resident had a self-care performance deficit related to MS, muscle spasms and glaucoma. Pertinent interventions included providing the resident with partial to moderate assistance with teeth brushing. Review of the CNA task documentation for Resident #34's oral care revealed the resident was set up to brush her teeth on 1/13/25, 1/14/25 and 1/15/25. -There was no other documentation to indicate the CNAs had provided assistance with Resident #34's oral care. 3. Staff interviews CNA #1 was interviewed on 1/15/25 at 10:19 a.m. CNA #1 observed Resident #34's mouth and teeth. CNA #1 said the resident had foul smelling breath and she had a white substance on her teeth which indicated her teeth had not been brushed. Registered nurse (RN) #2, who was the unit manager for the Golden Gate unit, was interviewed on 1/15/25 at 12:35 p.m. RN #2 said Resident #34 required full staff assistance with brushing her teeth. She said residents' teeth should be brushed in the morning and the evening. She said she would talk with the staff in regards to the importance of brushing residents' teeth. The director of nursing (DON) was interviewed on 1/15/25 at 6:00 p.m. The DON said residents' teeth should be brushed twice a day, once in the morning and again before bed. C. Failed to provide repositioning 1. Resident interview Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she was assisted by staff to get out of bed in the morning, sometimes as early as 6:00 a.m. The resident said she stayed up in her wheelchair until the staff laid her back down in the afternoon. She said a mechanical lift was used for her transfers and the staff did not reposition her during the time she was up in her wheelchair. Resident #34 said she had been a registered nurse and she knew she needed to be repositioned more frequently. She said her bottom got sore from not being repositioned but she said she did not have any open areas on her bottom. Resident #34 was interviewed a second time on 1/15/25 at 10:08 a.m. Resident #34 said staff got her out of bed at approximately 7:00 a.m. that morning (1/15/25). 2. Resident observations On 1/15/25 at 7:55 a.m. Resident #34 was sitting up in her wheelchair in the common area. During a continuous observation on 1/15/25, beginning at 8:44 a.m. and ending at 12:35 p.m., the following was observed: At 8:44 a.m. Resident #34 was sitting in the common area in her wheelchair. The reclining wheelchair was slightly tilted backward. At 9:01 a.m. the resident was visiting with her husband. The resident was assisted to another common area for visiting in private. At 10:00 a.m. Resident #34 was assisted back to the common area after her visit with her husband. At 10:05 a.m. CNA #1 assisted Resident #34 to her room so he could administer an injection. CNA #1 did not offer to reposition the resident. At 10:24 a.m. CNA #3 assisted Resident #34 with brushing her teeth. CNA #3 did not offer to reposition the resident. At 10:36 a.m. Resident #34 was assisted to an activity. At 11:00 a.m. CNA #4 assisted the resident from the activity and transported her to the dining room in her wheelchair. CNA #4 did not offer to reposition the resident. At 12:18 p.m. Resident #34 was assisted away from the dining room and transported back to her room. The resident asked to lay down and the unidentified CNA told the resident that CNA #3 would be back later. At 12:42 p.m. Resident #34 was laid down in bed with the use of the mechanical hoyer lift. -Resident #34 was in her wheelchair for three hours and 58 minutes during the continuous observation without being provided or offered repositioning assistance from the staff. 3. Record review Resident #34's care plan, revised 12/30/24, identified the resident had a potential for pressure ulcer development related to MS and weakness. The resident had a history of pressure injuries. Pertinent interventions included repositioning the resident throughout the night as the resident would tolerate. -The care plan did not include how often to offer the resident assistance with repositioning while she was in her wheelchair. 4. Staff interview Registered nurse (RN) #2 was interviewed on 1/15/25 at 12:35 p.m. RN #2 said the resident required full staff assistance with a mechanical lift for transfers. She said the resident was unable to reposition herself. She said Resident #34 was at risk for pressure injuries and the resident should be repositioned at least every two hours. RN #2 said staff had been trained to offer the every two hour repositioning to the resident. -However, observations revealed staff did not offer to reposition Resident #34 for almost four hours when she was sitting up in her wheelchair (see observations above).Based on observations record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three ( #35, #34 and #25) of 10 residents out of 59 sample residents. Specifically, the facility failed to: -Ensure Resident #35 was provided with assistance for oral care and proper nail care; -Ensure Resident #34 was provided with assistance for oral care and repositioning; and, -Ensure Resident #25 was provided with assistance for repositioning. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised September 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:28 p.m. It read in pertinent part, Residents who are unable to carry out ADLs will receive necessary services or support from staff regarding specific needs including eating, grooming, personal hygiene, communication, oral hygiene, transfers and ambulation. II. Resident #35 A. Resident status Resident #35, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included degeneration of the brain, vascular dementia and need for assistance with personal care. The 10/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to participate in the brief interview for mental status (BIMS). The resident was assessed to have difficulty focusing attention and had disorganized thinking with an altered level of consciousness. The assessment indicated the resident was dependent on staff to complete most ADLs and needed maximal assistance to complete oral hygiene. B. Resident observation and interview On 1/13/25 at 10:28 a.m. Resident #35 was in bed. Resident #35's teeth had a heavy build-up of whitish matter on the surface of his teeth and in between each visible tooth on the top and bottom jaw. His nails were long, jagged and dirty. Because his fingers were contracted, the tips of his nails were resting directly on his palms. Resident #35 was interviewed on 1/13/25 at 10:29 a.m. Resident #35 said he felt terrible and shook his head yes when asked if he was thirsty and wanted his teeth brushed. Resident #35 tried to extend his finger to move his nails from resting on his palm but he was unable to move his fingers far enough to relieve the pressure on his palms. On 1/14/25 at 8:05 a.m. Resident #35's nails were still long and dirty and his teeth were still covered with a thick layer of white buildup. C. Resident representative interview Resident#35's representative was interviewed on 1/15/25 at 11:30 a.m. The representative said facility staff had been avoiding providing consistent care and had not been brushing the Resident #35's teeth lately. The representative said that hospice care aides came in a couple of times a week and used an oral swab to remove the food buildup on his teeth and other than the oral care she provided, the resident's teeth were not being cleaned. The representative said the nursing staff was not cutting or cleaning the resident's nails so she brought in nail clippers and cut his nails for him. D. Record review Resident #35's comprehensive care plan, revised 3/7/24, documented a care focus that the resident had a self-care performance deficit related to peripheral neuropathy and mild cognitive impairment. Interventions documented Resident #35 required substantial to maximal assistance from staff to complete oral care and personal hygiene. -There was no care focus for nail care, cleaning nails or maintaining trimmed nails to protect skin integrity. Resident #35's bedside Kardex (care plan instruction for the certified nurse aides (CNA) documented a skincare focus with interventions that included encouraging the resident to avoid scratching and keeping the resident's hands and body parts from excessive moisture and keeping the resident's fingernails short. E. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 1/14/25 at 1:10 p.m. CNA #8 said Resident #35 was dependent on staff for the completion of all ADLs. CNA #35 observed Resident #35's teeth and acknowledged they needed to be cleaned. CNA #8 said the nurse would cut the resident's nails. Licensed practical nurse (LPN) #5 was interviewed on 1/14/25 at 1:55 p.m. LPN #5 said Resident #35 required total assistance with brushing her teeth and the CNAs would trim the resident's nails on both days. LPN #5 said it was the hospice CNAs responsibility to assist the resident with grooming tasks when they came to the facility to work with the resident. LPN #5 said he would follow up with the resident's care needs and ask the facility CNAs to provide the needed care.IV. Resident #25 A. Resident status Resident #25, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included history of urinary tract infections, pressure ulcer of the right buttock (stage 4), multiple sclerosis, Parkinson's disease and quadriplegia. The 1/10/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required maximum staff assistance with transfers, toileting and showering. B. Resident observation and interview On 1/13/25 at 10:30 a.m. Resident #25 was in her room sitting in her wheelchair and leaning to her left side. On 1/13/25 at 2:00 p.m. Resident #25 was in her room sitting in her wheelchair and leaning to her left side. Resident #25 was interviewed on 1/13/25 at 2:30 p.m. Resident #25 said she was left in her wheelchair all day even though she asked staff to put her back to bed after breakfast. Resident #25 said staff had not repositioned her since getting into her wheelchair at 6:00 a.m. this morning (1/13/25). On 1/13/25 at 3:34 p.m. Resident #25 was in her room still sitting in her wheelchair, in the same position, leaning to the left side. CNA #2 and RN #2 entered the resident's room with a mechanical lift to put Resident #25 to bed. Resident #25 was interviewed on 1/15/25 at 8:30 a.m. Resident #25 said CNA #2 got her up at 6:00 a.m. this morning (1/15/25). Resident #25 said she requested to stay in bed until 9:00 a.m. but she was told by CNA #2 that she had to get out of bed. Resident #25 said she was uncomfortable in her wheelchair because it was too small but staff did not give her any other option. On 1/15/25 during a continuous observation, beginning at 8:30 a.m. and ending at 12:30 p.m., the following was observed: At 8:30 a.m. Resident #25 was in her room sitting in her wheelchair and leaning to the left side. At 9:57 a.m., director of rehabiliation (DOR) entered Resident #25's room and asked Resident #25 if she wore her pressure-relieving boots all the time. At 11:35 a.m., a CNA #1 entered Resident #25's room and escorted the resident to the dining room for lunch. CNA #1 did not assist or offer to reposition the resident before taking the resident to the dining room. At 12:15 p.m. a CNA #1 assisted Resident #25 back to her room. CNA #1 did not reposition the resident. The resident was left sitting up in her wheelchair in her room. At 12:21 p.m., Resident #25 put her call bell on requesting to go to bed. CNA #1 entered the resident's room and told Resident #25 she had to wait for CNA #2 to return from break. Resident #25 was interviewed on 1/15/25 at 12:30 p.m. Resident #25 said she asked to go back to bed and was told that she had to wait until CNA #2 returned because CNA #2 went to lunch. At 12:50 p.m. CNA #1 and CNA #2 entered Resident #25's room and transferred her to bed. -Resident #25 sat up in her wheelchair in the same position without repositioning for four hours and 20 minutes. D. Record Review Review of the comprehensive care plan, revised on 11/4/24, revealed Resident #25 had a pressure ulcer on her buttock. The care focus goal was for the resident's pressure ulcer to show signs of healing. Interventions included frequent repositioning with staff assistance. The bedside Kardex, dated 1/14/25, revealed staff should offer and encourage Resident #25 to accept turning and repositioning assistance, as necessary. Review of the resident's electronic medical record (EMR) ADL task response history revealed Resident #25 did not refuse any offers for repositioning from staff. E. Staff interviews RN #2 was interviewed on 1/15/25 at 12:35 p.m. RN #2 said offloading, turning and repositioning for residents who were unable to perform the task on their own should be provided by staff every two hours. The DON and the assistant director of nursing (ADON) were interviewed together on 1/16/25 at 5:46 p.m. The DON said physically dependent residents needed to be repositioned every two hours or more frequently if the resident had a pressure wound. The DON said the CNAs were trained on the importance of repositioning dependent residents to relieve pressure points. -Documentation of the last resident positioning training for staff was requested but was not provided by the facility as of the conclusion of the survey on 1/16/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure proper treatment and assistive device to maintain hearing abilities for one (#138) of three residents reviewed for hearing and vision services out of 59 sample residents. Specifically, the facility failed to provide a hearing exam for Resident #138 when requested Findings include: I. Facility policy and procedure The Hearing policy, revised April 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: obtaining history from medical records, the family, and the resident regarding hearing and vision abilities, MDS (minimum data set) and care area assessments, ongoing monitoring of sensory problems, care plan development and implementation and evaluation. II. Resident # 138 A. Resident status Resident #138, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses include anxiety disorder, hypothyroidism and dysphagia (difficulty swallowing). The 12/13/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment indicated the resident did not have any hearing concerns. B. Resident interview Resident #138 was interviewed on 1/13/25 at 11:12 a.m. Resident #138 said he needed to see an audiologist (hearing doctor) because his hearing was worsening and he wanted to get hearing aides. Resident #138 said he told staff about his concerns but the facility was not helping him to see the audiologist. Resident #138 was interviewed again on 1/16/25 at 8:42 a.m. Resident #138 said he had not had any hearing appointments since he had been admitted to the facility on [DATE]. Resident #138 said he just wanted his hearing tested and that he had spoken to the staff about trying to make an appointment. C. Record Review A progress note, dated 12/7/24, documented Resident #138 had poor hearing and he did not have hearing aids. -Review of Resident #138's electronic medical record (EMR) did not reveal documentation that the resident had seen the audiologist. -Review of Resident #138's EMR did not revealed documentation indicating the facility provided the resident education regarding the consent form to receive hearing services (see interview below). D. Staff interview Social services assistant (SSA) #2 was interviewed on 1/16/25 at 2:51 p.m. SSA #2 said Resident #138 told her he wanted to see the audiologist but when he refused to sign the consent to get hearing services, she did not proceed. SSA #2 said because the resident would not sign the consent for treatment the audiologist would not have agreed to see the resident. She said she was not sure if the resident understood the nature of the consent but thought it was probably explained to him. SSA #2 said she had not asked the audiologist if the resident could give verbal consent with a witness since he did not want to sign the consent document. SSA #2 said she would follow up with Resident #138 about the consent form and hearing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#72 and #80) of eight out of 59 sample residents. Specifically, the facility failed to -Develop and implement effective dementia management focused interventions to prevent Resident #72 from wandering into other resident's rooms; -Develop person centered interventions to communicate with Resident #72 and #80; and, -Reassess the effectiveness of care-plan intervention and adjust intervention approaches based on behaviors for Resident #72 and #80. Findings include: I. Resident #72 A. Resident status Resident #72, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with agitation and mood disorder. The 11/7/24 minimum data set (MDS) revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. The assessment indicated the resident had behaviors of physical and verbal aggression directed at others and wandering. The behaviors interfered with the care of others, the activities and socialization of others, the privacy of others, and put others at risk for physical harm. The assessment documented the resident required set up and supervision with all activities of daily living (ADLs). The MDS assessment indicated it was very important to the resident to listen to music and have the opportunity to go outside. B. Record review The comprehensive behavior care plan, revised on 1/15/25 (during survey), revealed the resident had impaired cognitive functioning related to dementia. Interventions included communicating with the resident clearly, identifying oneself, providing distractions and using simple, direct sentences during communication and engaging the resident in simple and structured activities. The comprehensive elopement care plan, revised on 1/15/25 (during survey), revealed the resident wandered without purpose and could fluctuate between being easy to redirect to being difficult to redirect. Interventions included offering structured activities, food, and conversation to distract the wandering behavior and documenting wandering behavior and attempted diversional interventions. The comprehensive discharge care plan, revised on 1/6/25, revealed due to increased wandering/elopement attempts, the family wanted the resident to be placed in a secure unit (facility that offered locked doors to prevent elopement). Review of the comprehensive care plan failed to include a target focus for communication deficits related to the resident who was not primarily English speaking. The January 2025 CPO revealed the following physician orders: Behavior monitoring for aggression towards others and delusions with non-pharmological interventions of approach/speak to in calm manner, provide back rub, change position, offer fluids, offer food, redirect, assess for pain and offer a quiet environment, ordered on 11/1/24; Behavior monitoring for low mood and tearfulness with non-pharmological interventions of providing one on one interaction, offer activity, adjust room temperature, provide back rub, change position, offer fluids, offer food, redirect, remove resident from environment and offer toileting, ordered on 11/26/24; and, Behavior monitoring for exit seeking behavior every shift with no indicated non-pharmological interventions, ordered on 12/27/24. Behavior monitoring dated 11/1/24 to 1/16/25 revealed: Behaviors of low mood and tearfulness were observed on 11/26/24, 11/27/24, 11/28/24, 11/29/24 and 11/30/24. No behaviors of low mood or tearfulness were observed in December 2024 (12/1/24 to 12/31/24) or January 2025 (1/1/25 to 1/15/25). Behaviors of aggression towards others were observed on 11/3/24, 11/9/24, 11/21/24, 11/28/24, and 11/29/24. Behaviors of aggression towards others were observed on 12/2/24, 12/15/24, 12/21/24, 12/22/24 and 12/23/24. Behaviors of aggression towards others were observed on 1/1/25, 1/4/25, and 1/15/25. Behaviors of exit seeking were observed on 12/27/24, 12/28/24, 12/29/24, 12/30/24 and 12/31/24. Behaviors of exit seeking were observed on 1/1/25, 1/2/25, 1/3/25, 1/4/25 and 1/5/25. Progress notes reviewed from 11/1/24 to 1/15/25 revealed: Daily skilled note, dated 11/2/24, revealed the resident was taking other residents' property, went into other resident's rooms, collected dishes and piled them, collected items and wrapped them in napkins and plastic bags and only spoke Korean. Nursing note, dated 11/4/24, revealed the resident had been moved to a new room. She had smeared feces all over the floor and bed. She was filling the trashcan and tub with water. The staff moved Resident #72 to a private room. Nursing note, dated 11/21/24, revealed the resident had taken clothing belonging to another resident and when the staff tried to retrieve the clothing, the resident grabbed and punched the staff member. Nurse management was able to calm the resident by using a translation line to communicate and contacting the family. Nursing note, dated 12/3/24, revealed the resident was agitated while staff attempted to change her. The resident was hitting and kicking the staff. Nursing note, dated 12/15/24, revealed the resident was wandering into another resident's room and attempting to drink lotion from a bottle. The staff took the bottle of lotion and the resident began hitting the staff. Redirections were unsuccessful. Nursing note, dated 1/4/25, revealed the resident was following a nurse into another resident's room during colostomy care. Nursing note, dated 1/15/25, revealed the resident was following the nurse, touching things on the medication cart, interfering in other resident's care and hitting the nurse. C. Additional resident interview Resident #47, who was cognitively intact through facility assessment was interviewed on 1/15/25 at 1:27 p.m. She said she was new to the facility and would like to make friends. She said she was fearful to leave her room because the staff were not able to prevent Resident #72 from entering her room and touching or taking her belongings. She said she had heard Resident #72 had hit the staff and this concerned her. Resident 47 said she felt she had to remain in her room to protect her belongings. II. Resident #80 A. Resident status Resident #80, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included unspecified dementia, hallucinations and mood disorder. The 11/13/24 MDS revealed the resident had severe cognitive impairments and was unable to answer assessment questions with a BIMS score of zero out of 15. The MDS assessment indicated the resident did not have any behaviors. The resident required set up and supervision with all ADLs. B. Resident observations Resident #80 was observed on 1/14/25 at 4:40 p.m. The resident was sitting in the hallway between her room and the dining room on the second floor yelling at another resident sitting near her. Resident #80 yelled in Korean and the other resident did not understand. The staff removed the other resident from the hallway. -However, the staff did not provide any person centered interventions to address Resident #80's behaviors. During a continuous observation on 1/15/25 starting at 4:45 p.m. and ending at 5:25 p.m., At 4:45 p.m. Resident #80 was sitting in her wheelchair in the hallway between her room and the dining room on the second floor. She was yelling in Korean. There were several staff nearby that were watching the resident. The staff were shaking their heads but no one approached the resident. At 5:00 p.m., a nurse attempted to coax the resident to go to the nurse's station with the nurse in order to contact the resident's family. The resident did not appear to understand and grabbed the arm railing and continued yelling. At 5:10 p.m., the nurse convinced the resident to go to the nurse's station. The resident continued to yell. -The staff did not attempt to use a translation app, call a translator on a portable phone or any other methods to communicate in a language that the resident would understand. At approximately 5:20 p.m, the nurses were able to reach the grandson, but the call was disconnected. The nurse then called the language line and the resident continued to yell at the translator. The translator told the nurse the resident was repeating, if you are going to kill me, go ahead and kill me. The resident also expressed to the translator that she believed someone was going to get her but could not explain. At this time, there were two nurses, another unidentified staff member, and social services assistant (SSA) #1 surrounding the resident at the nurse's station. The resident continued to persist with the delusion that someone was coming for her and kept asking the staff to leave her alone. SSA #1 offered the resident food and fluids but the resident only made fun of SSA #1 to the translator. C. Record review The January 2025 CPO revealed the following physician orders: -Behavior monitoring for exit seeking behavior every shift with no indicated non-pharmological interventions-,ordered on 11/2/24. -Psychosocial charting on 11/27/24 to 12/12/24, ordered on 11/27/24. Behavior monitoring was from 11/1/24 to 1/15/25. There were no behaviors documented during this timeframe. The comprehensive language care plan, revised on 7/23/24, revealed the resident had communication difficulty related to a language barrier. The resident knew some basic English but spoke Korean. The resident preferred the family to assist with translation. The resident required the use of a language line interpreter due to language barrier. Interventions included anticipating and meeting the residents needs and providing a translator as necessary. The comprehensive psychosocial care plan, revised 2/22/24, revealed the resident had a diagnosis of dementia and major depressive disorder. The resident had a history of hallucinations and delusions with changes in perception with hearing, seeing, or smelling things that were not present. Interventions included anticipating and meeting the residents needs, providing positive interaction, approaching the resident in a calm manner, reassuring the resident she was safe and providing a program of activities that were of interest and accommodated the resident's needs. Progress notes reviewed from 11/1/24 to 1/15/25 revealed: Nursing note, dated 12/8/24, revealed the resident had been screaming at staff in Korean. A call was placed to the family to speak with the resident. The family said the resident was having delusions and believed people at the facility were accusing her of things she did not do. III. Staff interviews Certified nursing aide (CNA) #7 was interviewed on 1/15/25 at 2:38 p.m. CNA #7 said Resident #72 went into other resident's rooms almost daily and the staff put stop signs on the doors but Resident #72 just removed the sign. CNA #7 said when the staff tried to redirect her or remove her from a room, she became aggressive towards the staff. CNA #7 said she did not know what person centered interventions were implemented to help Resident #72's behaviors other than offer food, fluids and trying to redirect. She said she did not know where the information was for the language line. She said, she tried to use gestures when communicating with Resident #72. CNA #7 said Resident #80 yelled out in Korean frequently and the staff did not understand what the resident was yelling out. She said the staff tried to call the family to translate but the family was not always available. She said she did not know the specific person centered behavior interventions for the resident. CNA #11 was interviewed on 1/15/25 at 2:45 p.m. CNA #11 said Resident #80 yelled out in Korean all the time and the staff just left her alone until she stopped yelling. CNA #11 said Resident #72 wandered the unit daily and went into other resident's rooms, which upset them. CNA #11 said the staff tried to redirect her or distract her with food or fluids. Licensed practical nurse (LPN) #1 was interviewed on 1/15/24 at 2:49 p.m. LPN #1 said Resident #80 yelled out in Korean all the time and the staff just left her alone until she stopped yelling. LPN #1 said she did not know what the tracking for psychosocial charting was except to document if the resident became aggressive or displayed behaviors out of the ordinary. The social services director (SSD) and SSA #1 were interviewed together on 1/16/25 at 2:20 p.m. The SSD said the facility provided dementia care training to the staff through the electronic training modules. The SSD said there had not been a dementia care in-service or additional training with the staff on the second floor. The SSD said she had not provided any in-person dementia care training with staff in over a year. The SSD said the psychotropic drug meeting was conducted monthly with the director of nursing (DON), assistant director of nursing (ADON), the nursing home administrator (NHA), the psychologist and the psychiatrist who provide services to the facility, the social services department and the pharmacist. The SSD said behaviors, medications and non-pharmological interventions were discussed. The SSD said resident was having challenging behaviors, the resident was discussed at the psychotropic meeting. The SSD and SSA #1 said they would also reach out to the psychiatrist and psychologist between meetings to discuss challenging behaviors. The SSD said these conversations were not documented. The SSD and SSA#1 said the documented behaviors for Resident #80 were confusing and not clear. The SSD and SSA #1 said they did not know why Resident #72 had not been discussed in the psychotropic drug meeting for her aggressive and disruptive behaviors. SSA #1 said she was aware Resident #47 was declining to leave her room for meals and activities due to being fearful Resident #72 would enter her room and touch her belongings if she was not there. The NHA, the corporate consultant (CC) and the DON were interviewed together on 1/16/25 at 3:49 p.m. The NHA said the facility utilized online training modules for dementia care training but the facility did not follow up with staff on their comprehension of the training material. The NHA said for residents with aggressive behaviors, the facility would increase activities, medication review, behavior health services and psychiatry intervention. The NHA said the facility had been trying to work with Resident #80's family on medication interventions but the family declined and the resident frequently refused medications. The NHA said the facility has tried using velcro stop signs on resident doors to deter Resident #72 from attempting to enter others rooms but this had not been successful. The CC said the facility had not attempted to utilize a phone translation application with Resident #72 or Resident #80. He said the facility did not believe the residents would understand how to use the application. He said using an application would help the staff with day to day interactions to understand what the residents were saying in Korean or to convey some words to the residents in Korean which might deescalate agitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included unspecified protein-calorie malnutrition and type 2 diabetes. The 11/5/24 MDS assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The 4/9/24 MDS assessment revealed the resident had no natural teeth or tooth fragments (edentulous). B. Resident interview and observation Resident #23 was interviewed on 1/14/25 at 10:06 a.m. Resident #23 was wearing an upper set of dentures, but she was not wearing a lower denture. Resident #23 said her bottom denture was missing. She said she ate in bed and she snacked on cheetos. She said without her bottom denture she had difficulty eating. She said she was told by a social worker that, because she had received dentures within the past two years, she could not get a replacement for her bottom denture due to cost. C. Record review The nutrition assessment dated [DATE] documented Resident #23 used to have a full set of dentures, however, she now only had the upper dentures. The resident denied having difficulty with eating. The care plan, updated 6/4/24, identified that Resident #23 had the potential for oral health problems related to being edentulous (no teeth). Pertinent interventions included assisting the resident with dental appointments. -Review of Resident #23's electronic medical record (EMR) did not reveal any documentation to indicate the resident had been referred to the dentist for follow up regarding her missing lower denture. D. Staff interviews The social services director (SSD) was interviewed on 1/16/25 at 8:00 a.m. The SSD said she was not aware Resident #23 was missing her lower dentures because another social worker maintained the ancillary appointments for residents. She said she would look into the situation. The nursing home administrator (NHA) was interviewed on 1/16/25 at approximately 5:00 p.m. The NHA said if the facility was made aware that a resident had lost their dentures, the facility would pay for new dentures when there was no other funding available to the resident. SSA #1 was interviewed on 1/16/25 at 6:30 p.m. SSA #1 confirmed Resident #23 did not have lower dentures. She said she was told the resident's dentures were lost and found several times. However, she said the facility had been unable to locate Resident #23's lower dentures since November 2024. SSA #1 said the resident was currently on the list to see the dentist. SSA #1 was interviewed a second time on 1/16/25 at 6:52 p.m. SSA #1 said Resident #23 had just been placed on the dentist list earlier today (1/16/25). She said there was no documentation regarding the resident's missing dentures in the resident's EMR. Based on observations, record review and interviews, the facility failed to assist residents to obtain routine or emergency dental services, as needed, for two (#60 and #23) of two residents out of 59 sample residents. Specifically, the facility failed to: -Follow up on a social services referral for denture replacements for Resident #60; and, -Place a timely referral for dental services for Resident #23. Findings include: I. Facility policy and procedure The Dental Policy, revised October 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part, It is the policy of this facility, in accordance with residents' needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, taking impressions for dentures and fitting dentures. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Promptly means within 3 (three) business days or less from the time the loss or damage to dentures or need for emergent services is identified unless the facility can provide documentation of extenuating circumstances that resulted in the delay. II. Resident #60 A. Resident status Resident #60 age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, anxiety and depression. The 12/27/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively intact with a brief interview for mental health status (BIMS) score of 10 out of 15. The MDS assessment did not document any dental concerns or problems. B. Resident interviews Resident #60 was interviewed on 1/15/25 at 10:30 a.m. Resident #60 said she had been waiting for her new dentures for the past seven months. She said the facility was supposed to be assisting her through the process and she had not heard anything since her admission to the facility regarding the status of her dentures. Resident #60 said not having dentures was problematic and bothered her because she was having a hard time chewing. Resident #60 was interviewed a second time on 1/16/25 at 12:10 p.m. Resident #60 said she required both upper and lower dentures and could only eat soft foods at this time. Resident #60 said she needed to eat slowly in order to chew her food due to needing dentures. She said she wanted dentures. C. Record review The comprehensive care plan, initiated on 2/27/24, documented a care focus for activities of daily living (ADL) self-care performance deficit. The goal was the resident would safely perform ADLs with appropriate assistance. Interventions included oral hygiene and indicated the resident was waiting for dentures (initiated on 3/11/24). The nutrition note dated 3/4/24 documented Resident #60 told the nurse that her appetite had been good and she had been eating her meals. The resident reported she had no teeth but she was supposed to be getting dentures soon. -However, the note did not document who was helping the resident obtain her dentures or when they would be arriving. The social services note dated 3/4/24 documented the resident wore dentures but did not have dentures at that time. The note documented that the social worker sent a referral for new dentures and the new dentures would be coming in about two months (May 2024). The social services note dated 6/3/24 documented Resident #60 used dentures. -However, Resident #60 did not have dentures during the interviews on 1/15/25 and 1/16/25 (see resident interviews above). -Review of Resident #60's progress notes revealed there was no documentation to indicate the facility had followed up when the resident's dentures did not arrive at the facility. D. Staff interviews Social services assistant (SSA) #2 was interviewed on 1/16/25 at 12:29 p.m. SSA#2 said she was not aware of any dental concerns for Resident #60 and she did not know the resident was still waiting for dentures. SSA#2 said she would have to check into the status of the resident's dentures. SSA #2 said, from what she remembered, the social services department initially thought Resident #60 had been fitted for dentures but realized that was not the case, so a denture referral was placed for the resident in March 2024. SSA #2 said she would follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide accessible dining equipment and utensils for residents who need them for one (#172) of one resident reviewed for adaptive equipment out of 59 sample residents. Specifically, the facility failed to provide adaptive drinking equipment for Resident #172. Findings include: I. Facility policy and procedure The Adaptive Equipment policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:22 p.m. It read in pertinent part It is the policy of the facility to evaluate and provide adaptive equipment for residents who have been identified at risk for contractures, skin breakdown, assisting with eating. On admission the resident will be assessed for needs for adaptive devices. Residents needing adaptive equipment will be screened by therapy or nursing and equipment will be supplied for respective residents Residents will be reassessed quarterly for continued needs of the adaptive equipment. II. Resident #172 A. Resident status Resident #172, age less than 65, was admitted to the facility on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dysphagia following cerebral infarction (swallowing difficulties following a stroke), cerebral vascular disease affecting left dominant side, hemiplegia and hemiparesis following other cerebral vascular disease (decreased or no movement on one side of the body following a stroke) and need for assistance with personal care. The 12/20/24 minimum data assessment (MDS) assessment documented the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was dependent on facility staff for most activities of daily living (ADL) and eating. B. Observations On 1/13/25 at 3:57 p.m., Resident #172 was drinking a can of Sunkist soda. Resident #172 was not provided with a straw or a spill-proof cup that is designed to be used with a straw. The resident had visible spills on the front of her shirt. On 1/13/25 at 4:20 p.m., Resident #172 was observed in the small dining room on the second floor Resident #172 was served milk and hot coffee in a styrofoam cup without a lid or a straw. Throughout the entire observation of the dinner meal, Resident #172 was served multiple beverages in styrofoam cups and not in an adaptive cup. On 1/14/25 at 1:18 p.m., Resident #172 was observed in the common area on floor two with a styrofoam cup without handles and a straw or lid. The resident had visible spills on her blue shirt. C. Record review The nutrition care plan, initiated on 1/10/24, revealed Resident #172 had a nutritional problem related to diagnosis of dysphagia, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis, muscle wasting and atrophy. Pertinent interventions included providing adaptive equipment, an adaptive cup. A dietary meal ticket from 1/16/25 revealed Resident #172 required a spill-proof cup that is designed to be used with a straw with all meals. III. Staff interviews The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 1/16/25 at 5:34 p.m. The DON said updates to care plans related to adaptive equipment would be completed by the dietitian and/or the therapy department. The DON said the nursing staff did not update the care plan for adaptive equipment. The DON and the ADON said they were unsure how the dietary department and the therapy department communicated the changes. The dietary consultant (DC) was interviewed on 1/16/25 at 4:48 p.m. The DC said Resident #172's dietary meal ticket documented the resident should receive a spill-proof cup that is designed to be used with a straw for all beverages with every meal. The DC said Resident #172 did not receive a spill-proof cup that is designed to be used with a straw, which was part of the comprehensive plan of care. The DC said she would provide education to the kitchen staff to ensure Resident #172 received the appropriate adaptive equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure specialized rehabilitative services to maintain highest practicable level of functioning for one (#158) of two residents reviewed for specialized rehabilitative services out of 59 sample residents. Specifically, the facility failed to ensure services for Residents #158 were provided to maintain the residents highest practicable levels of functioning. Findings include: I. Resident #158 A. Resident status Resident #158, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included stroke, polyneuropathy and adult failure to thrive. The 11/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance for bed mobility, repositioning, bathing, dressing, transferring and toilet use. Staff provided only set up assistance for meals. The MDS assessment indicated the resident had no deficits with swallowing or eating and was not receiving speech therapy services. B. Resident observation and interview Resident #158 was interviewed 1/14/25 at 4:30 p.m. Resident #158 said the facility sometimes helped him eat his meals in his room and other times the staff just left his tray on the bedside table for him to feed himself. He was unable to say how long this had been occurring. On 1/15/25 at 6:10 p.m. Resident #158 was in his room. A staff member brought in his meal tray and left it on his bedside table. The staff member did not remain in the resident's room to assist the resident with eating. II. Record review The January 2025 CPO revealed the following physician orders: ST (speech therapist) to evaluate and treat related to pocketing food in the mouth and intermittent cough when swallowing, ordered on 12/15/24. Regular diet, mechanical soft texture, thin liquids consistency, ordered on 12/21/24. Supplement shakes two times a day for weight maintenance, ordered on 1/6/25. Resident #158's nutrition care plan, revised 12/20/24, revealed the resident had nutritional deficits related to a history of throat cancer. Interventions included to provide and serve diet as ordered. -The care plan failed to identify the degree of eating assistance or monitoring the resident required. -Review of Resident #158's comprehensive care plan revealed there was no speech therapy care plan focus related to pocketing food or intermittent coughing when swallowing for the resident. A review of Resident #158's electronic medical record (EMR) from 12/15/24 to 1/16/25 revealed the following progress notes: A nursing note, dated 12/15/24, revealed Resident #158 was noted to have a generalized decline as evidenced by being more lethargic and sleepier. The staff encouraged fluids and assisted the resident with the meal. The resident was observed by nursing to be pocketing food and fell asleep while he was eating. The nurse had to remain with the resident to provide cueing to ensure he swallowed his food. The nurse notified the physician and an order for speech therapy was obtained. A registered dietitian (RD) nutrition note, dated 12/20/24, revealed Resident #158 had triggered for an 8 pound (lb) weight loss since 11/22/24. The note indicated the potential cause of the weight change may have been related to increased confusion, lethargy, difficulty swallowing and decreased intake. A RD nutrition note, dated 1/6/25, revealed the RD had changed Resident #158's diet order on 12/21/24 to mechanical soft texture. -Despite the documentation in the progress notes that Resident #158 was having difficulty with swallowing and had been noted to have an 8 lb weight loss, there was no documentation in the resident's EMR to indicate that a speech therapy evaluation had been completed (see physician's order above). III. Staff interviews The director of rehabilitation (DOR) and the speech therapist (ST) were interviewed together on 1/15/25 at 2:09 p.m. The DOT said Resident #158 had been receiving physical and occupational therapy for balance, transfers and general functional mobility with upper extremities. The DOT said the resident had not received speech therapy. The DOT said orders for therapy services were communicated in the morning management meetings, during the Risk Management meeting or the nurses reached out to the therapy department directly. The DOT said he was unable to explain why the 12/15/24 physician's order for a speech therapy evaluation for Resident #158 had not been completed by the therapy department. The ST said she would complete an evaluation with the resident by the end of the day (1/15/25). Certified nurse aide (CNA) #7 was interviewed on 1/15/25 at 2:38 p.m. CNA #7 said the staff did not provide Resident #158 with eating assistance. CNA #7 said the resident ate in his room and the staff checked on him because he ate slowly but the staff did not assist him with eating. The director of nursing (DON) was interviewed on 1/16/25 at 3:49 p.m. The DON said the nursing department communicated new physician's orders for therapy in the morning management meetings, where the therapy department was in attendance. The DON said the therapy department also reviewed the daily physician order reports. The DON acknowledged the facility did not have an explanation for why the 12/15/24 speech therapy evaluation order for Resident #158 was missed.

Based on observations and interviews, the facility failed to ensure reasonable accommodation of needs for residents on one of two floors. Specifically, the facility failed to ensure residents on the second floor received functional utensils for meals to achieve their highest practicable level of well-being. Findings include: I. Observations During a continuous observation of the second floor dining room on 1/14/25, beginning at 4:20 p.m. and ending at 5:45 p.m, the following was observed:. At 4:20 p.m. residents waited in the dining room for dinner service. At 5:00 p.m. the food was brought up to the dining room kitchenette from the first floor kitchen At 5:06 p.m. staff began to serve food onto paper plates for the residents. Residents were provided plastic utensils and styrofoam cups. The meal was chicken fried steak, brown gravy, mashed potatoes, baby carrots and tapioca pudding. Four residents at the first table in the dining room were served dinner. One resident at the table tried to use her plastic knife and fork to cut the chicken fried steak but she was unable to. The resident gave up and instead ate her pudding. A staff member came over to the table and attempted to assist another resident at the table cut up her chicken fried steak with a plastic knife but was unable to. The staff member had to get a regular knife from the kitchenette in order to cut the meat. The staff member had to use the regular knife to cut three other resident's chicken fried steak. Several other staff members attempted to cut the chicken fried steak for three additional residents but were unable to complete the task with the plastic knives. The staff members requested the regular knife that had been used earlier but none of the staff members were able to locate the regular knife and had to use the plastic utensils. At 5:10 p.m. two residents sitting in the corner of the dining room were served their meals, however, no staff members went to the table to offer assistance to the residents with cutting up their chicken fried steak. At 5:33 p.m. a staff member approached the two residents and offered assistance with cutting up their chicken fried steak. The residents told the staff member the chicken fried steak had been too difficult to cut and declined assistance. The residents told the staff member the food was now cold from waiting and both residents declined alternative options. II. Resident interviews Resident #24 was interviewed on 1/15/25 at 1:53 p.m. Resident #24 said she ate her meals in her room and said she was able to cut the chicken fried steak in the center but it was very difficult to cut the meat from the previous night's dinner with the plastic utensils. Resident #22 was interviewed on 1/15/25 at 2:14 p.m. Resident #22 said the chicken fried steak was too hard to cut with the plastic utensils the night before (1/14/25) and by the time the staff came to help her cut up the meat, she was no longer hungry. The resident said the residents on the second floor had been having this problem with the plastic utensils for a while. III. Staff interviews The dietary consultant (DC) was interviewed on 1/13/25 at 11:37 a.m. She said the facility was using disposable silverware on the second floor due to the elevator being temporarily out of service. The DC said it would be unsafe to have the staff carry all the dishes up and down the stairs. The DC was interviewed again on 1/16/25 at 3:09 p.m. The DC said when the facility was aware the elevator was going to be out of service, the management team discussed different concepts of how to bring the food up to the second floor. The DC did not know if the facility discussed with the resident council members the plan to use disposable silverware and dishes. The DC said the facility management team discussed all the areas in which the use of disposable dishes could be problematic, such as temperature and slowing down the delivery of food to the residents. She said the management team did not discuss if the residents would have difficulty using disposable utensils to eat with.

Based on record review, observations and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to ensure resident complaints expressed during the resident council meetings were documented on a grievance and resolved to the residents satisfaction. Findings include: I. Facility policy and procedure The Residents Rights, Subject: Grievances policy and procedure, revised January 2025, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:28 p.m. It revealed in pertinent part, The facility will establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their facility stay; and the facility will make prompt efforts to resolve grievances the residents may have. The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking the grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested; and coordinating with state and federal agencies as necessary. Resident and/or resident representatives have the right to file grievances orally or in writing, the right to file grievances anonymously, and obtain a written decision regarding his or her grievance as requested. Copies of the Grievance Resolution Forms are available from the Grievance Official and at each nursing station. The Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. Upon receipt of a grievance and/or complaint, the grievance officer will respond to the individual expressing the concern within (three) working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. The grievance official or designee completes the Grievance Resolution Form, takes appropriate corrective action in accordance with State Law if the alleged violation of resident's rights is confirmed by facility or an outside entity having jurisdiction, such as State Survey Agency, Quality Improvement Organization, or local law enforcement agency within its area of responsibility. The Grievance Official or designee will contact all parties of the outcome. II. Resident interviews Thirteen residents (#5, #23, #25, #29, #39, #55, #69, #98, #118, #158, #163, #174 and #698) were interviewed during the survey process. All 13 residents were determined to be alert, oriented and cognitively intact based on facility assessments. All residents said the food at the facility did not taste good. Resident #39 was interviewed on 1/14/25 at 1:49 p.m. Resident #39 said she had ordered items to be delivered from two different retailers. She said she had proof of the delivery to the front desk at the facility, however, she did not receive the packages and were reported as missing to the management at the facility. Resident #39 said she was reimbursed for the missing packages, but had not received a resolution to her concern of her packages being delivered to the facility but not receiving them. Resident #118 was interviewed on 1/13/25 at 1:38 p.m. Resident #118 said she did not like the food, the taste was bad and the coffee was always cold. Resident #55 was interviewed on 1/14/25 at 10:05 a.m. Resident #55 said the food at the facility was not appetizing. Resident #163 was interviewed on 1/13/25 at 2:28 p.m. Resident #163 said the food was not flavorful and had no taste. Resident #5 was interviewed on 1/13/25 at 4:39 p.m. Resident #5 said she hated the food. She said the food did not have enough flavor, the meat was tough and the food was often not hot enough. Resident #23 was interviewed on 1/14/25 at 10:04 a.m. Resident #23 said the food was terrible and was either too salty or did not have any salt in it. She said a spoonful of gravy was so salty that it pulled all the moisture out of her mouth. Resident #69 was interviewed on 1/14/25 at 9:00 a.m. Resident #69 said food at the facility was not good and was always cold. Resident #158 was interviewed on 1/13/25 at 10:31 a.m. Resident #158 said the food was not always hot enough. Resident #25 was interviewed on 1/13/25 at 3:52 p.m. Resident #25 said the food did not taste good, was not hot enough and did not have enough flavor. Resident #29 was interviewed on 1/13/25 at 1:49 p.m. Resident #29 said the food was not warm when it was served. Resident #98 was interviewed on 1/13/25 at 2:28 p.m. Resident #98 said the portions of food at the facility were too small. Resident #174 was interviewed on 1/15/25 at 9:47 a.m. Resident #174 said he requested condiments and a slice of cheese with his breakfast. He said he was tired of being served the same meal of eggs every morning and wanted to make himself a sandwich. He said he was not served the condiments and the cheese as he requested. Resident #698 was interviewed on 1/13/25 at 1:49 p.m. Resident #698 said there was a lack of food choices at the facility. He said he preferred sausage links but was brought sausage patties. He said the facility often did not serve what he wanted, but only what was on the menu. B. Record review The 10/22/24 food committee meeting notes documented the following food complaints. -The fruit served in fruit bowls was hard, residents did not receive what they ordered, bacon was too hard, soups had too much pepper, the dining rooms needed more staff for the weekend service and snacks would run out before some residents could get them. -No grievance forms were completed to resolve the resident's concerns. The 11/18/24 food committee meeting notes documented the following food complaints. -The bacon was too hard, the food service assistance in the dining rooms on the weekends had not improved, the residents did not like the tortellini, snacks were not being provided in enough quantity, omelets, waffles and rice were served too often. -No grievance forms were completed to resolve the resident's concerns. The 12/16/24 food committee meeting notes documented the following food complaints. -Condiments were not being offered or delivered on room trays as requested. The tortellini would remain on the menu and residents were instructed to order from the always available menu when it was on the menu. -No grievance forms were completed to resolve the resident's concerns. V. Staff interviews Social services assistant (SSA) #2, the social services director (SSD) and the social services consultant (SSC) were interviewed on 1/16/25 at 2:59 p.m. SSA #2 said grievance forms were posted throughout the facility and were able to be filled out by a resident, resident representative or a staff member. She said the grievance form was placed in a box located in the front lobby of the facility. She said the grievances were retrieved every morning, read in the morning staff meeting and then handed over to the appropriate department head. She said grievances should be resolved and the resident provided a resolution within three days of receiving the form. SSA #2 said she was the grievance official and also ran the resident council meetings and took the minutes. The SSD said the facility staff were educated on the facility grievance process during the regularly scheduled monthly all staff meeting. SSA #2 said she did not always fill out a grievance form when a resident expressed a concern. She said she did not have a way to track those concerns she did not document nor their resolve. SSA #2 said she was aware Resident #39's concern of not receiving her packages, which were also documented in the resident council meeting on 1/15/25. She said multiple residents had brought up the concern during the resident council meetings. She said another resident was taking the packages and placing them in her room. She said the other resident had since been discharged from the facility. SSA #2 said she did not complete a formal grievance for Resident #39's concern. SSA #2 and the SSD said they were unaware of any food related grievances filed by the residents at the facility. -However, the resident council minutes documented multiple resident complaints regarding the food at the facility. SSA #2 said she would begin to run resident council meetings differently by asking residents more probing questions and completing grievances for their concerns. She confirmed she did not complete grievances for resident concerns from the resident council meeting. The registered dietitian (RD) and the dietary consultant (DC) were interviewed on 1/16/25 at 3:09 p.m. The RD said she was aware of resident complaints regarding not having enough snacks, but had not been informed of resident complaints regarding not receiving condiments until today (1/16/25). The DC said the dietary department will be implementing a condiment tray for the aides to have when delivering meal trays to the residents. The RD said the dietary manager (DM) received all complaints from residents. -The DM was unavailable for an interview during the entire survey process. The NHA interviewed on 1/16/25 at 5:46 p.m. The NHA said he was unaware of the missing packages delivered to the facility from the front desk area. The NHA said he reimbursed a lot of residents for a variety of things and did not always keep track. He said last week the facility approved the purchase of two electronic devices for residents, but he did not record the occurrence. The NHA said he implemented a new process two to three weeks ago for packages delivered to the facility for residents. He said previously, the packages were left at the front desk, which was not always manned by a staff member, but the new process required the packages be locked up and verified by a staff member before handing them over to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to maintain a clean and sanitary homelike environment for residents. Specifically, the facility failed to ensure residents were provided clean washcloths and hand towels. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised November 2024, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:22 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The characteristics of the homelike environment are a clean, sanitary, orderly environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. II. Observations On 1/13/25 at 1:41 p.m. room [ROOM NUMBER] had no hand towels or washcloths.Both of the towel holder bars were broken. On 1/13/25 at 3:35 p.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/13/25 at 4:38 p.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/13/25 at 4:02 p.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/14/25 at 10:02 a.m. room [ROOM NUMBER] had no hand towels or washcloths. On 1/15/25 beginning at 2:06 p.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -Room # 1001 had no hand towels or washcloths; -room [ROOM NUMBER] had one wash cloth and no hand towels; -room [ROOM NUMBER] had no hand or washcloths and the towel holder bar was broken; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washclothes. The towel holder bar for the resident on side B of the room was broken; -Room # 2007 had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had one dirty washcloth for the resident on side A of the room and no hand towels or wash cloth for the resident on side B; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had one dirty wash cloth for the resident on side A of the room and no hand towels or wash cloth for the resident on side B; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. On 1/16/25 at 9:30 a.m. a tour with the director of nursing (DON) and the assistant director of nursing (ADON) was completed. The Golden Gate unit had a linen closet which had 18 towels for approximately 65 residents residing on the unit. The second floor laundry room had no hand towels in any of the three blue linen carts. III. Resident group interview Six alert and oriented residents (#128, #44, #124, #70, #60, and #167), selected by the facility and deemed to be interviewable through facility assessment, were interviewed on 1/15/25 at 10:00 a.m. The residents said the facility did not have enough towels or wash cloths and they frequently could not get a clean hand towel on the days they requested one. The residents said shower days were the most problematic and the facility often ran out of clean towels, especially on days when 10 or more residents on their units took showers. IV. Additional resident interviews Resident #5 was interviewed on 1/13/25 at 4:38 p.m. Resident #5 said he did not have linen hand towels in his room. He said he had to use paper towels to dry his hands. Resident #23 was interviewed on 1/14/25 at 10:05 a.m. Resident #23 said she had no hand towels in her room. She said she had to beg the staff for towels. She said she had been told the facility was short on towels. She said she had used paper towels on her face many times. Resident #24 was interviewed on 1/13/25 at 1:41 p.m. Resident #24 said she did not get linen hand towels in her room. She said she preferred using linen hand towels versus paper towels. V. Staff interviews The DON was interviewed on 1/16/25 at 9:30 a.m. The DON said the nursing staff were responsible for passing out hand towels and wash cloths to the residents. She said hand towels and wash cloths should be passed out on each shift and replaced as needed. She said she was not aware the hand towels were not being passed out. She said she would correct the issue immediately. The housekeeping supervisor (HKS) was interviewed on 1/16/25 at approximately 11:00 a.m. The HKS said the hand towels were in the laundry room, and the certified nurse aides (CNA) were to bring the hand towels to the linen closets as needed. -However, observations revealed there were no hand towels in the second floor laundry room (see observation above). The maintenance director (MTD) was interviewed on 1/16/25 at 2:10 p.m. The MTD said he was not aware that resident rooms had broken and non-functional towel holder bars. He said he had a handwritten checklist of repairs to be made and showed that towel holder bar repairs were not on the list. The MTD said the nursing staff should have reported the broken towel holder bars so they could have been repaired and made functional to hold residents' towels and washcloths. VI. Facility follow up On 1/16/25 at 2:06 p.m. the DON provided an audit of all the residents' rooms which was conducted on 1/16/25, during the survey. The audit revealed 22 resident rooms had broken towel holder bars. She said all of the broken towel holder bars were getting replaced as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#23, #34 and #21) of four residents reviewed for activities out of 59 sample residents received an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being. Specifically the facility failed to: -Ensure Resident #23 and Resident #34 were offered more mind stimulating activities; and, -Ensure Resident #21 was provided with a personalized activity program. Findings include: I. Facility policy and procedure The Quality of Life policy, updated December 2024, was received from the nursing home administrator (NHA) on 1/16/25 at 9:26 p.m. The policy read in pertinent part, It is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental and psychosocial well-being of the resident. The Activities policy and procedure, revised December 2024, was provided by the NHA on 1/16/25 at 9:37 p.m. It read in pertinent part, The facility will ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. Activities may be facility sponsored, group or independent. Activities procedures: Residents who wish to meet with or participate in social or religious activities, or other community activities, at or away from the facility are encouraged to do so as they are able. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations. II. Activity calendar The Golden Gate unit's January 2025 activity calendar for the week of 1/12/25 through 1/18/25 revealed there were four to six activities scheduled per day. The activity calendar had mind stimulating activities scheduled on four of seven days for the week (1/12/25, 1/13/25, 1/16/25 and 1/18/25). There were no mind stimulating activities scheduled on the remaining days of the week (1/14/25, 1/15/25 and 1/17/25). The January 2025 Summit Park unit calendar had similar activities scheduled, however, the residents from the Golden Gate unit could not attend those activities, as the elevator had not been working for the past several months. III. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified protein- calorie malnutrition, diabetes type II. The 11/5/24 minimum data set (MDS) assessment dated revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The 4/9/24 MDS assessment revealed it was very important to Resident #23 to do activities she liked. B. Resident interview Resident #23, who resided on the Golden Gate unit, was interviewed on 1/14/25 at 9:50 a.m. Resident #23 said she enjoyed going to the activities. She said a lot of the activities were geared towards residents who were cognitively impaired. She said she liked trivia and word games. She said she was told by someone in activities that they could not have word games or trivia because everyone needed to be able to participate. She said because of this, many of the activities provided ended up being coloring pictures. Resident #23 was interviewed a second time on 1/16/25 at 4:30 p.m. Resident #23 said the board game activities the facility had were only scheduled three to four times a month. She said it made her sad that she was not able to attend more thought provoking activities. C. Record review The 11/1/24 psychiatric follow up note documented Resident #23 enjoyed watching television (TV), playing bingo, trivia and games. She preferred to participate in activities in a group setting. The note further documented that staff should attempt to tailor the activities to the resident's interests and ability level. The 11/4/24 activity assessment documented Resident #23 was spending more time in her room instead of attending group activities. Resident #23's activity care plan, updated 11/5/24, identified Resident #23 enjoyed watching TV in her room, reading, word puzzles, coloring and listening to music. Pertinent interventions included assisting the resident to the activities, inviting the resident to intergenerational programs, inviting the resident to exercise groups and inviting the resident to creative arts and crafts and music programs. -The care plan did not address the resident's desire to attend thought provoking activities. IV. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included multiple sclerosis (MS). The 10/1/24 MDS assessment revealed the resident had minimal cognitive impairment with a BIMS score of 13 out of 15. The resident required total assistance with mobility. The 7/1/24 MDS assessment revealed it was very important to the resident to do activities she liked. B. Resident observations On 1/15/25 at 10:29 a.m. Resident #34 was asked if she wanted to go to the activity of coloring. On 1/15/25 at 10:45 a.m., the resident had a coloring sheet she was coloring, there was an activity assistant at the table, with two other residents, however, there was no talking. C. Resident interview Resident #34 was interviewed on 1/13/25 at 1:42 p.m. Resident #34 said she attended the activities on a regular basis, however, she said she wished there were more trivia type games. She said she liked the cognitively challenging activities. Resident #34 was interviewed a second time on 1/16/25 at 4:20 p.m. Resident #34 said she did have books in her room, however, she said she had nothing new to read. She said she had not received a book from the activity department for quite some time. She said she continued to enjoy reading. Resident #34 again said she liked the cognitively challenging activities. D. Record review Resident #34's activity care plan, updated 12/26/24, identified the resident enjoyed watching TV in her room, reading, word puzzles, coloring and listening to music. Pertinent interventions included assisting the resident to the activities, inviting the resident to intergenerational programs, inviting the resident to exercise groups, inviting the resident to creative arts and crafts, and music programs, offering the resident the daily chronicle and magazines, inviting the resident to resident council and community meetings and inviting the resident to religious programs. -The care plan did not address the resident's desire to attend cognitively challenging activities. The 9/27/24 activity note documented Resident #34's activity interests included bingo, trivia and crafts. V. Staff interview The activity director (AD) was interviewed on 1/16/25 at 4:00 p.m. The AD said Resident #23 and Resident #34 attended all the activities and never complained about the activities. She said the activity calendar did have trivia type games on the schedule. The AD said Resident #23 could attend the activity planning meetings and voice her requests. The AD said Resident #34 had visits from her family and she liked to read. She said the activity department provided her books.VI. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included hypertension (high blood pressure), cognitive communication deficit, heart failure and depression. The 10/31/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. She required maximum assistance with all activities of daily living (ADL). B. Resident interviews and observations Resident #21 was interviewed on 1/13/25 at 11:08 a.m. Resident #21 said she participated in activities approximately one time a month but had not been able to participate with the larger group activities downstairs due to the elevator being disabled. She said she would like to get out of bed more, however, she said she was dependent on staff assistance. She said she had not received assistance from the facility staff for watching movies on her cell phone. On 1/15/25 at 9:43 a.m. activity assistant (AA) #2 was inviting residents to join her in the common area for coffee and reminiscing, which was the 10:00 a.m. scheduled group activity. AA#2 went room to room asking residents on the 2200 hall if they would like to attend the activity. AA#2 approached Resident #21's room, but did not enter. Resident #21 was not invited to participate in the group activity. C. Record review The activities care plan, initiated 1/24/24 and revised 12/26/24, documented Resident #21 enjoyed word searches, reading, watching television, playing bingo and visiting with friends. It indicated the resident structured her own day with self-directed independent activities and attendance of group activity programs of her interest. The interventions included providing an activity calendar to ensure the resident's knowledge of upcoming activities and encouraging participation in expressed individual and/or group activities. The 12/26/24 activity progress note documented Resident #21's religious preference was Catholic and she would have the opportunity to attend in-house services when scheduled. Resident #21 enjoyed reading, playing bingo, knitting/crocheting, arts/crafts, watching television and word searches. Resident #21 attended group activities of her choice. The 11/12/24 and 11/14/24 certified nurse aide (CNA) documentation revealed the resident would only get out of bed to attend the group activity of bingo, however, Resident #21 was unable to attend the group activity because the elevator was not working. -Resident #21 was unable to attend group activities downstairs in the facility due to the elevator being out of service as of 11/7/24. D. Staff interviews The activities director (AD) and the activities consultant (AC) were interviewed together on 1/16/25 at 2:00 p.m. The AD said an initial activity assessment/evaluation was completed for residents upon admission. She said the interventions were determined based on the resident's likes and interests. The AD said all residents received the facility monthly activities calendar. She said currently, there were two different activities calendars issued due to the need to separate the activities based on the elevator being unusable. The AD said all residents received both calendars but the calendar for their specific floor was posted.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Follow the weekly menu to ensure adequate nutrition was provided to the residents. Findings include: I. Facility policy and procedure The Food and Nutrition Services, Menus policy, dated August 2019, was provided by the nursing home administrator (NHA) on 1/16/25 at 9:28 p.m. It revealed in pertinent part, This facility's menus and extensions shall be prepared in advance. Menus procedures: If any meal served varies from the planned menu, the change and the reason for the change are noted in the kitchen and /or in the record book used solely for recording such changes; these changes are to be reviewed and approved by the dietitian. Menu spreadsheets are utilized to ensure all menu items are served at the correct portion sizes. II. Failure to follow the correct portion sizes to ensure adequate nutrition was provided to the residents. A. Observations and record review During a continuous observation during the lunch meal on 1/15/25, beginning at 11:15 a.m. and ending at 12:08 p.m., the following was observed: An unidentified dietary aide placed one gray #8 scoop of tortellini on each resident's meal trays who received a regular diet. -The menu extensions documented residents who received a regular diet should have received two gray #8 scoops of tortellini. III. Failure to follow the weekly menu to ensure adequate nutrition was provided to the residents A. Observations and record review Review of the menu and the menu extensions for the 1/14/25 dinner meal revealed that 2% (percent) milk was to be served with dinner. During a continuous observation on 1/14/25 of the dinner service, beginning at 4:17 p.m. and ending at 5:43 p.m., in the main and second floor dining rooms, the following was observed: -The dietary aides in the main and second floor dining rooms did not offer or serve residents milk as a beverage during the observation period. They offered coffee and juice instead. The dietary aides did not offer a dairy substitute to the residents. IV. Staff interviews The dietary consultant (DC) and the registered dietitian (RD) were interviewed together on 1/15/25 at 3:36 p.m. The DC said during the lunch meal on 11/15/25 the wrong amount of tortellini was served. She said two scoops, using the gray #8 scoops of tortellini should have been served. The DC and the RD were interviewed again on 1/16/25 at 3:09 p.m. The DC said the calorie count was inclusive of all items noted on the menu for the day. The DC said the milk should be offered, however, if the resident refused the milk, an alternative to the milk should be offered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Failed to ensure Resident #98's nebulizer was cleaned and stored appropriately A. Professional reference According to the American Lung Association, How to Clean your Nebulizer, last updated 3/27/23, retrieved on 1/22/25 from https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/resource-library/how-to-clean-a-nebulizer#:~:text=Cleaning%20your%20nebulizer%20is%20important,top%20piece%2C%20and%20medicine%20cup. Many people with chronic lung diseases such as COPD or asthma use a nebulizer to take their medication in the form of a mist that is inhaled into the lungs. Cleaning your nebulizer is important to prevent the spread of germs and keep you from getting sick. It will also keep your device working properly. It is recommended to wash the parts of your nebulizer after each use, including the mouthpiece or mask, top piece, and medicine cup. To start, take the nebulizer apart by removing the tubing and setting it aside. (The tubing should never be placed underwater.) Remove the mouthpiece or mask, and medicine cup from the top piece, and wash the medicine cup, top piece, and mouthpiece or mask, in warm soapy water, and rinse. Shake off the excess water and let the pieces air-dry in a cool, dry place until the next use. Your nebulizer will also need a thorough cleaning once a week. Soak the mouthpiece or mask, top piece, and medicine cup in a white vinegar and water solution for 30 minutes, or as recommended by your device manufacturer. After 30 minutes, rinse and air-dry in a cool, dry place. Clean the surface of the compressor and the outside of the tubing with a soapy cloth or disinfectant wipe. (The compressor and the tubing should never be submerged in water.) and, remember, most compressors have an air filter that will need to be replaced every six months, or as recommended by your manufacturer. B. Resident interviews and observations On 1/13/25 at 1:56 p.m., Resident #98's nebulizer was lying on her nightstand on top of her personal care items. The table was cluttered with papers and used drinking cups. The nebulizer was not clean of the moisture built up from the last use. The nebulizer was not stored on a protective sheet or in any type of protective covering. Resident #98 was interviewed on 1/13/25 at 4:54 p.m. She said the nebulizer needed to be cleaned after each use. She said the staff did not clean it, so she cleaned it herself. On 1/14/25 at 9:30 a.m. and 1/15/25 at 9:30 a.m., the nebulizer was observed, it was still lying on the nightstand with dried water stains. It did not have a protective covering. C. Staff interviews CNA #8 was interviewed on 1/16/25 at 10:30 a.m. CNA #8 said Resident #98 used her nebulizer as needed. CNA #8 said when she requested the nebulizer the nurse would go into her room and give her the medication in the nebulizer. CNA #8 said the nebulizer was then cleaned after each use by nursing staff and it was placed next to her bed on her table. RN #3 was interviewed on 1/16/25 at 11:30 a.m. RN #8 said nursing staff were responsible for taking the nebulizer apart for each cleaning and it dried on the medication cart. RN #8 said once dry it was put back together and placed next to her bed on her table until the next use. The DON and the ADON were interviewed on 1/16/25 at 2:00 p.m. The DON said the nebulizer should be washed after each use and placed in a bag after it was washed and air-dried. The DON said the nurses have access to bags at every nurse's station. The DON did not say why they were not following the procedure for Resident # 98. II. Failure to ensure pull cords were clean A. Observations On 1/15/25 between 3:10 p.m. and 3:50 p.m., resident shower rooms and resident in-room bathrooms were observed. -The first shower room on the first floor was observed; the call light string near the toilet was soiled with a brown substance -The second shower room on the first floor was observed; the call light string near the toilet was soiled with a brown substance. -The shower room on the second floor's call light string was brown. -Nine resident's bathrooms (#1007, #1008, #1210, #2007, #2001, #2204, #2109, #2112, and #2311) were observed. All of them had brown call light strings by their toilets. B. Staff interviews The DON and the ADON were interviewed together on 1/16/25 at 2:20 p.m. The ADON said the housekeeping staff was responsible for cleaning the call light strings. The housekeeping supervisor (HKS) and housekeeper (HK) #3 were interviewed together on 1/16/25 at 4:54 p.m. The HKS said the material that the pull cords were made out of were difficult to clean. The HKS said he would work to create a plan to replace all of the call light strings with a plastic material that would be able to be cleaned. III. Failure to ensure resident's rooms were cleaned appropriately A. Professional reference According to the CDC Prevention Guidelines for Environmental Infection Control in Health Care Facilities (2003), last reviewed 1/8/24, retrieved on 1/21/25 from https://www.cdc.gov/infection-control/hcp/environmental-control/environmental-services.html, High-touch housekeeping surfaces in patient-care areas (doorknobs, bedrails, light switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact (since the transferral of microorganisms from environmental surfaces to patients is largely via hand contact with the surface). Infection-control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff. Cleaning solutions should be replaced frequently. B. Facility policy and procedure The Housekeeping policy, revised September 2024, was provided by the HKS on 1/16/25 at 9:26 p.m. It read in pertinent part, The facility requires effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites, including thorough scrubbing for all environmental surfaces in resident care areas taking dwell times for disinfectants into consideration; frequently changing mop heads, cloths and cleaning solutions; cleaning horizontal surfaces in care areas daily or more often if soiled; disinfectants and detergents must be EPA-approved. C. Observations On 1/16/25 from 10:12 a.m. to 10:50 a.m., a continuous housekeeping observation of room [ROOM NUMBER] was conducted. HK #1 started the cleaning by spraying the sink, bathroom floor and toilet. HK #1 began wiping down the bathroom surfaces and then began wiping the resident's table surfaces with the same towel she used to wipe surfaces in the bathroom. HK #1 also used the same wet towel for both resident spaces in the shared room. The call light string in the bathroom had a brown substance on it. HK #1 did not attempt to clean or replace the soiled call light string. -HK #1 failed to clean high touched areas including the light switches, door knobs, sink handles and call lights. D. Staff interviews The HKS was interviewed on 1/16/25 at 4:54 p.m He said the housekeepers should clean either side of the room using different cleaning towels for different surfaces. Based on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure staff wore the proper personal protective equipment (EBP) for Resident #25, who was on enhanced barrier precautions (EBP); -Ensure pull cords were free from debris; -Ensure the resident's rooms were cleaned appropriately; and -Ensure Resident #98's nebulizer was cleaned and stored appropriately. Findings include: I. Failure to follow enhanced barrier precautions A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), retrieved on 1/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions 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, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing. B. Observations On 1/13/25 at 3:15 p.m. there was a sign on Resident #25's door indicating he was on EBP. There was personal protective equipment (PPE) including gloves, gowns, eye protection and masks stocked on the back of Resident #25 door. On 1/13/25 at 3:34 p.m. Resident #25 was in her room when certified nurse aide (CNA) #2 and registered nurse (RN) #2 entered the resident's room with a Hoyer lift (mechanical lift) to assist Resident #25 to bed. Neither staff applied personal protective gowns prior to providing personal care assistance to the resident. On 1/15/25 at 12:50 p.m., two unidentified staff members entered Resident #25's room with gloves on but no gown or mask to transfer the resident to bed. CNA #2 grabbed a blue protective gown. RN #2 told CNA #2 that she did not need to use the blue protective gown. CNA #2 proceeded to empty Resident #25's nephrostomy tube without applying the required PPE. C. Resident interview Resident #25 was interviewed on 1/15/25 at 8:30 a.m. Resident #25 said the staff never used gowns, masks or eye protection when emptying her nephrostomy tube. Resident #25 said the staff did wear gloves. D. Staff interviews CNA #2 was interviewed on 1/15/25 at 12:55 p.m. CNA #2 said she just needed to wear gloves to empty Resident #25's nephrostomy tube because she did not want to get urine on her hands. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 1/16/25 at 2:41 p.m. The ADON said when a resident was placed on EBP, the staff were expected to put on a mask, gown,and wear face shield/goggles when splashing was likely to occur during care where they came into contact with bodily fluids and open areas of the body. The ADON said the staff received education following EBP in October 2024. The DON said they also provided the staff a more recent in-service in December 2024 on infection control measures.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the dining room tables were stable and in good condition. Findings included: I. Facility policy and procedure The Safe and Homelike Environment policy, revised November 2023, was provided by the nursing home administrator (NHA) on 1/16/25 at 7:00 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. A. Observations and resident interviews On 1/15/25 at 12:45 p.m., there were five dining room tables that were found to be unbalanced. When a resident leaned on the table the table top dipped causing the surface to move up and down in an unsteady manner. On 1/16/25 at 4:15 p.m., the evening meal was observed. There were multiple tables that were unbalanced that residents were eating their meals. Resident #189 was interviewed on 1/16/25 at 4:15 p.m. Resident #189 said the tables wobbled so he had to fold up a paper towel and place it under the leg of the table to stabilize it so his food did not spill when he ate his meal. Resident #189 said the paper towels he stuck under the leg helped but they had to keep replacing it when the table was moved around. Resident #60 was interviewed on 1/16/25 at 4:16 p.m. Resident #60 said the tables were unbalanced and it made it difficult to eat and drink. On 1/16/25 at 4:20 p.m., the dining area was observed and there were pieces of paper towels placed under the table leg to keep the tables balanced. Some tables did not have paper under the legs and were unbalanced. B. Staff interviews The maintenance director (MTD) was interviewed on 1/16/25 at 11:11 a.m. The MTD said the maintenance team was dependent on the nursing staff to report any repair needs. The MTD said the facility had an electronic report database but were not putting it to use. The MTD said all of the maintenance needs observed by staff or requests reported by residents were provided to the maintenance department verbally or by passing along a written note. The MTD said he utilized a legal pad to document his repair to do list. The MTD said there was no backup for this system and no historical data was available to show past repairs. He said once as the repairs were completed he tossed out his to do list. The MTD was interviewed again on 1/16/25 at 4:30. The MTD said he checked the tables in the dining area a few times weekly and did not find any problem with the steadiness of the tables. He said he was not aware of the unbalanced tables. The MTD said he would look at the tables, and he and the maintenance staff would fix any broken tables.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (#7) of three residents out of seven sample residents. Specifically, the facility failed to follow a clean technique when providing wound and incontinence care for Resident #7. Findings include: A. Professional reference According to the Center for Disease Control and Prevention (CDC) When and How to Wear Gloves (1/8/21), retrieved on 12/15/23 from https://www.cdc.gov/handhygiene/providers/index.html, Wear gloves, according to standard precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. According to [NAME] Medicine's How to Wash Your Hands Properly (3/13/2020), retrieved on 12/15/23 from https://www.yalemedicine.org/news/how-to-wash-your-hands, Good handwashing-with the help of soap and the friction of rubbing hands together-is a strategy that can minimize germs, or pathogens that cause disease. Use clean, running water to wet your hands. The water can be cold or warm-cold water actually does work and warm water is more likely to irritate skin. Rub your hands with soap (and rub your hands together to lather the soap). Lather both the front and back of your hands, in between all of your fingers, under the fingernails, thumbs, and up to the wrist. Wash your hands for at least 20 seconds. Dry your hands completely. You can dry them under a warm air dryer, or use a paper towel. Once your hands are clean, avoid touching surfaces such as the sink and faucet. A good strategy is to use the same paper towel you used to dry your hands. B. Facility policy The Incontinence Care policy, revised 7/2018, was provided by the infection preventionist (IP) on 12/5/23. The policy read: Wash peri-area using front to back strokes, rinse, pat dry. Assist the resident with donning a clean disposable incontinence brief or clean clothing as preferred by the resident. Remove gloves and wash hands. C. Observations On 12/4/23 at 3:36 p.m. a certified nurse aide (CNA) #1, provided incontinence care to Resident #7. The resident was positioned on her right side with her back towards CNA #1. CNA #1 donned clean gloves, removed the resident's brief and used wipes to clean the resident's bottom. Right after, she did not change or remove her gloves. She pulled off the dressing that was still half attached to the resident's bottom and waited for the nurse to come in. -CNA #1 did not change her gloves and sanitize her hands after wiping the resident's bottom and removing the soiled dressing. Registered nurse (RN) #1 walked into the room and washed his hands at the resident's sink. -RN #1 proceeded to use his clean hands instead of a paper towel to touch the dirty sink faucet and turn the water off. RN #1 changed the dressing on Resident #7's bottom and then washed his hands again before leaving the resident's room. -After washing his hands, RN #1 again used his clean hands instead of a paper towel to touch the dirty sink faucet and turn the water off. After RN #1 completed the dressing change, CNA #1 used the same gloves she had been wearing to apply a clean brief to Resident #7 and reposition the resident in bed. D. Staff interviews RN #1 was interviewed on 12/4/23 at 4:05 p.m. He said after hand washing, the sink should be turned off with a paper towel to prevent the cross contamination of clean hands. He said he forgot to do it, however, he said he was aware that the sink should not be touched with bare hands after washing his hands. CNA #1 was interviewed on 12/4/23 at 4:15 p.m. She said gloves should be changed only after incontinence care is complete. She said there was no need to change gloves in the middle of the care before repositioning the resident. The infection preventionist (IP) was interviewed on 12/4/23 at 5:03 p.m. She said nurses and CNAs were to follow proper clean technique during hand washing. She said the sink should be turned off by using a tissue or hand towel to prevent cross contamination. She said she would provide education to the nurses and CNAs. The IP said the dressing should not be removed by CNAs, especially with the same gloves that incontinence care was provided. Regarding changing gloves after moving from work on a soiled body site to a clean body site on the same patient, she said the facility policy read that gloves should be changed after incontinence care in general.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one resident (#110) out of 58 sample residents were kept free from abuse. Specifically, the facility failed to prevent resident to resident altercation between Resident #110 and #143. Findings include: I. Facility policy and procedure The Abuse: Prevention of and Prohibition Against policy and procedure, revised October 2022, received from the nursing home administrator (NHA) on 7/24/23 at 9:44 a.m. revealed in pertinent part, each resident has the right to be free from abuse. Wilful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. If the allegation of abuse involves another resident the facility will: Separate the resident so they do not interact with each other until circumstances of the reported incident can be determined. Continue to assess, monitor and intervene as necessary to maximize resident health and safety. II. Altercation on 7/12/23 On 7/12/23 at approximately 5:10 p.m. Resident #143 and Resident #110 had an altercation of alleged money owed from Resident #143 to Resident #110. Resident #143 became upset and lifted his cane in a way that was perceived that Resident #110 was going to be hit with it. Resident #110 grabbed the cane and the two residents began trying to take control of the cane and staff intervened. Altercation was witnessed by Resident #142 and he said the two residents involved had a verbal altercation over money. Resident #143 attempted to hit Resident #110 with cane and both parties were struggling over the cane. A staff members written statement documented she heard screaming for help and looked up then witnessed Resident #143 with his cane against Resident #110's neck. Resident #143 statement dated 7/13/23 documented he owed Resident #110 20 dollars and Resident #110 was mean to him when he asked for the money back and they both tried to hit each other with the cane then the staff stepped in. Resident #110's statement dated 7/13/23 documented that him and Resident #143 had an argument over 20 dollars. Resident #143 attempted to hit him with his cane but he grabbed the cane and they both struggled with the cane until staff separated us. He reported a skin tear to the top of my right hand the next morning. III. Resident #110 A. Resident status Resident #110, age [AGE], admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnoses included malignant neoplasm of stomach (stomach cancer), chronic kidney disease (decreased kidney function) and type two diabetes. The 5/12/23 MDS assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 13 out of 15. B. Resident interviews Resident #110 was interviewed on 7/24/23 at 4:36 p.m. He said he had an issue with a resident about two weeks ago. The resident hit him with his cane and he had to defend himself by hitting him back. He said the resident was still in the facility. The facility told him they could not do anything about the resident until they found a new place for that resident to go. A scab was observed on his right hand Resident #110 stated it was from the fight with the resident. Resident #110 was interviewed on 7/27/23 at 2:52 p.m. He said Resident #143 owed him money and had not paid. Resident #143 started to walk away then turned and hit my head. Resident #143's cane touched my neck, then he punched Resident #143 in the face and hit his glasses and scrapped the back of his right hand. Resident #110 said he tried to stand up but Resident #143 threw his weight on him. Resident #110 reported he told the police he hit Resident #143 four to five times in the face. C. Record review A progress note on 7/13/23 at 6:47 a.m. documented Resident #110 came to the nurse and showed them a skin tear to the right back of his hand. Resident #110 refused to tell the nurse how it was obtained. IV. Resident #143 A. Resident status Resident #143, younger than 65, admitted on [DATE]. According to the July 2023 CPO diagnoses included paranoid schizophrenia (paranoia, false beliefs mental disorder), type two diabetes, sleep disorder and insomnia (unable to sleep). The 4/19/23 MDS assessment revealed the residents cognitive status intact with a BIMS score of 15 out of 15. No behaviors were documented. B. Resident interview Resident #143 was interviewed on 7/27/23 at 5:43 p.m. He said he got hit in the eye a couple weeks ago because he owed someone some money. C. Record review An interdisciplinary team note on 7/14/23 at 10:06 a.m. documented altercation was reported to the police. Police came to the facility and stated they would not investigate further due to no physical injury to either party. Reported occurrence for further investigation by facility. Residents were both at baseline cognition and physical mobility, residents not fearful and denying pain/distress. V. Staff interviews The NHA and nursing home administrator assistant (NHAA) were interviewed on 7/27/23 at 6:38 p.m. Resident #143 had mental health visits increased and was seen on 7/10/23 and was discussed in the psychological pharmacology meeting. The NHA said the altercation between Resident #110 and #143 on 7/12/23 occurred over money owed from Resident #143 to Resident #110. The NHA said verbal words were exchanged between both parties and Resident #143 lifted cane towards Resident #110 and both parties fought over the cane until staff separated the resident from each other. Resident #142 witnessed the altercation and his statement matched both parties involved statements. The NHA said from the statements collected from witnesses the cane was back and forth between Resident #143 and Resident #110 by being pushed and pulled. The resident interviews were conducted on 7/13/23 the day after the altercation. The NHA said Resident #143 would not give up his cane even if staff assessed his need for it he would just go into the community to get another one. Resident #143 was independent with ambulation and the facility could not control what he did in the community, he did what he wanted. Resident #143 was working with behavioral health and the nurse practitioner was working on adjusting his medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to obtain Level II evaluations for residents with major mental illness diagnoses in order to determine the need for specialized services for one (#47) of five residents reviewed for compliance with the Preadmission Screen Annual Resident Review (PASARR) program out of 58 sample residents. Specifically, the facility failed to provide PASSAR IIs for Residents #47, who was diagnosed with major mental illness. Findings include: I. Facility policy and procedure The Resident Assessment-Coordination with PASSAR Program Policy, revised April 2022, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:40 p.m. It revealed, in pertinent part, the following: The facility coordinates assessments with pre-admission screening and resident review programs under Medicaid to ensure the individuals with a mental disorder, intellectual disability, or a related condition, receive care and services in the most integrated setting appropriate to their needs. Policy, explanation and compliance guidelines: all applicants to this facility will be screened for serious mental disorders, or intellectual disabilities and related conditions in accordance with the state's Medicaid rule for screening. PASARR Level II (is) a comprehensive evaluation by the appropriate state designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. The facility will only admit individuals with a mental disorder, or intellectual disability, who the state mental health or intellectual disability authority has determined (are) appropriate for admission. The social service director shall be responsible for keeping track of each resident's PASSAR screening status, and referring to the appropriate authority. Recommendations, such as specialized services, from a PASARR level II determination, and/or PASARR evaluation report will be incorporated into the resident's assessment, care, planning, and transition of care. Any level II resident who experiences a significant change in status, will be referred promptly to the state, mental health or intellectual disability authority for additional resident review. II. Resident #47 A. Resident status Resident #47, under the age of 60, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, bipolar, depression, anxiety, Parkinson's and epilepsy. According to the 5/25/23 minimum data set (MDS) assessment, the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. Active diagnoses included manic disorder (bipolar), anxiety and depression. The resident did not experience delirium or psychosis and did not exhibit depression or behaviors of concern including rejection of care and wandering during the assessment period. The assessment documented the resident was not evaluated by Level II PASARR. B. Record review The 5/18/23 PASAR Level I screen, completed by the social services manager (SSM), revealed the resident did not require a level II PASAR. The PASAR I revealed the resident had no known or suspected mental illness or seizure disorder, therefore no further action was required. The July 2023 computerized physician orders showed an order dated 6/1/23 for behavioral health services and treatment from providers for anxiety and depression. The July 2023 computerized physician orders showed an order dated 6/6/23 for 7.5 mirtazapine (used for depression) gave one tab thru g-tube. A review of the progress notes, assessments and other correspondence failed to reveal a Level II evaluation was completed. C. Staff interviews The social services director (SSD) was interviewed on 7/27/23 at 2:49 p.m. The SSD said she was responsible for the initial PASSAR I. The SSD said the social service team and nursing team met if there was a further behavioral concern. The SSD said residents that had major mental illness such as bipolar, which Resident #47 was diagnosed with, required a PASSAR II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure one (#90) of one resident reviewed for activities of daily living (ADLs) of 58 sample residents was provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #90, who spoke a language other than English. Findings include: I. Resident status Resident #90, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the resident's diagnoses included dementia and chronic heart and kidney disease. According to the 5/24/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. He required extensive assistance of one person for transfers and dressing. He required limited assistance of one person for bed mobility, walking in their room, locomotion and personal hygiene. There was no documentation of language or interpreter needs. II. Resident interview Resident #90 was interviewed on 7/24/23 at 4:10 p.m. Resident #90 said he spoke a few words in English and understood very little. He said staff did not use tools to communicate with him. Resident #90 said his family could translate but they were not always available. Resident #90 said that he would like staff to communicate with him better. III. Observations On 7/25/23 at 1:58 p.m. The resident was observed trying to communicate with an unknown staff person. The staff asked several different things until they said ice and Resident #90 responded yes. Continuous observations on 7/26/23 from 10:37 a.m. until 12:00 p.m. revealed Resident #90 sat in the common area and no one communicated with him. IV. Record review The communication care plan, initiated on 5/24/23, documented Resident #90's primary language was Russian. His preference was to have his family translate for him. He knew minimal English. Interventions included the following: Anticipate and meet needs. Assist with word finding as needed/appropriate. Be conscious of the resident's position when in groups, activities, and dining rooms to promote proper communication with others. Discuss with resident/family concerns or feelings regarding communication difficulty. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Provide a translator as necessary to communicate with the resident. V. Staff interviews The social worker (SW) on the second floor was interviewed on 7/27/23 at 9:45 a.m. The SW said they provided communication cards and a communication hotline for residents that did not speak English. The SW said Resident #90 did not speak much English. His family could interpret for him. The SW said staff should use the communication hotline to interpret for him. Certified nurse aide (CNA) #6 was interviewed on 7/27/23 at 1:04 p.m. CNA #6 said Resident #90 spoke Russian and did not speak or understand much English. CNA #6 said they tried to communicate with him in English and he sometimes understood the staff. CNA #6 was not sure where staff would find out about the communication needs of the resident. The director of nursing (DON) was interviewed on 7/27/23 at 6:35 p.m. The DON said staff should use the communication line for residents that did not speak English. The DON said the nurses would communicate with the CNAs to let them know the communication needs of the residents. The DON said Resident #90 spoke minimal English and not enough to make a full conversation. The DON said that staff knew Resident #90 spoke Russian. The DON said she was able to communicate with Resident #90.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide care and services necessary to maintain the highest practicable physical wellbeing of one (#84) of three residents out of 58 sample residents. Specifically, the facility failed to initiate neuro checks after a fall causing injury to the resident's face. The facility further failed to investigate the circumstances involved in a fall upon review of conflicting medical record documentation for Resident #84, who according to nursing notes was lowered to the floor and suffered a facial contusion on 7/8/23. The findings included: I. Professional reference A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level, according to the World Health Organization website, https://www.who.int, 4/26/21 (accessed 8/9/23). II. Facility policy and procedure The Fall Management Treatment Policy, last reviewed May 2023, was provided by the nursing home administrator (NHA) on 7/27/23 at 2:36 p.m. It revealed, in pertinent part, the following: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs. Procedure: all incidents involving trauma to the head and any unwitnessed falls will result in a comprehensive neurological assessment for a minimum of 72 hours; a comprehensive neurological assessment will be done as follows every 15 minutes for one hour. Every 30 minutes for two hours. Every four hours for eight hours every eight hours for eight hours every 12 hours for 24 hours check and document vital signs. Check and document pupil size and reaction. Check level of consciousness: oriented to person, place or thing. Lethargic, restless, drowsy. Speech check for seizures, headache, vomiting, or other abnormality. -The policy did not include a definition for falls. III. Resident status Resident #84, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included type II diabetes, major depressive disorder, heart failure and epilepsy. According to the 4/19/23 minimum data set (MDS) assessment, the resident was severely cognitively impaired and was unable to complete a brief interview for mental status. He required assistance of one person for personal hygiene. He required set up assistance with bed mobility, locomotion, dressing, toileting, eating and transferring. He uses a walker to assist with walking. IV. Record review According to the nursing note on 7/8/23 at 10:02 a.m., the resident stated to the certified nurse aide (CNA) he was having chest pain and felt dizzy. The CNA assisted him to the floor. He did not fall, but the CNA assisted him on the floor. He did not hit his head or anything. The resident was lethargic, and when he was on the floor he complained of chest pain and was dizzy but was not able to describe his pain when he was on the floor. -There was no further documentation in the medical record of the incident or a follow-up investigation. According to the nursing note on 7/8/23 at 9:43 p.m. the resident returned to the facility from the emergency room (ER) on a stretcher via ambulance service. Per the ER visit summary, reasons for ER visitation included left facial contusion. No fracture or other injury was noted. Instructions include: ok to use ice to the left side face for 30 minutes four times daily. The resident denies pain. Assisted with scheduled pain and other meds. Assist with activities of daily living (ADLs) as needed. Encouraged to call for assistance. Hospital documentation dated 7/8/23 documented Resident #84 was seen in the ER for a fall and had a left facial contusion (bruise). Interventions included extra pain medication as needed and an ice pack to the left side of the resident's face four times a day. A CT (computerized tomography, set of X-ray images) scan indicated the resident did not have a fracture or other injuries. According to the July 2023 computerized physician orders (CPO), Resident #84 has reported no pain for the month of July except for 7/8/23 when he reported his pain level was at four (moderate pain). The regional nursing consultant said on 7/27/23 at 4:30 p.m. Resident #84 had not had a fall on 7/8/23 therefore he did not need neurological assessments. -However, Resident #84 was lowered to the floor according to nursing notes (above) which was by definition a fall. V. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 7/27/23 at 1:10 p.m. LPN #4 said that nursing staff documented all falls in progress notes and in fall assessments. LPN #4 said if a CNA or other staff witnessed the fall or found a resident that had fallen they would tell a nurse and that nurse did the fall assessments. LPN #4 said it was important to document falls correctly in order for the resident to get the proper treatment or tests. LPN #4 said if there was a head injury or face injury staff did neurological assessments. The director of nursing (DON) was interviewed on 7/27/23 at 6:19 p.m. The DON said documenting falls correctly was important in order to assess injury and if the resident needed neuro checks. The DON said it was important to do neuro checks if a resident hit their head to ensure they did not have internal head injuries. The DON said they did neuro checks for all unwitnessed falls and any fall that had an injury to the head including the face. The DON said if they saw an injury to a resident's face or head they should initiate neurological checks. The DON said they relied on the information they got at the time. The DON said she did not know what the EMT told the emergency room but the facility sent him because of chest pain. The DON acknowledged that if an injury appeared that the initial documentation may have been inaccurate. VI. Facility follow-up communication A follow up email from the NHA on 7/28/23 at 4:51 p.m. documented the emergency medical technicians (EMTs) wrongfully reported a fall to the ER and the resident was sent for chest pain. The NHA said there were no fractures, the CT was negative and there was no visible injury. -However, nursing notes documented the resident was lowered to the floor in an assisted fall and hospital notes documented the resident had a facial contusion. The documentation did not support the NHA's assertion that the resident did not fall and was not injured. Therefore, fall identification, further investigation and further resident assessment was needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#76) of two residents reviewed with a feeding tube out of 58 sample residents. Specifically, the facility failed to ensure Resident #76 received his tube feeding as ordered by the physician. Findings include: I. Facility policy and procedure The Gastronomy Tube (G-tube, feeding tube inserted in abdomen) Care and Management policy, dated January 2022, was provided by the nursing home administrator (NHA) on 7/27/23 at 8:26 a.m. It read in pertinent part, It is the policy of this facility to provide proper care and maintenance of gastronomy tubes. Before every feeding verify the tube position. If feeding is continuous check the position every shift, and as needed using aspiration of gastric contents, air auscultation (air sounds), x-ray examination, or external graduation marks. II. Resident status Resident #76, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included protein-calorie malnutrition, anemia, congestive heart failure, diabetes mellitus type two, one sided paralysis and muscle weakness and chronic kidney disease. The 4/26/23 minimum data set (MDS) assessment revealed a brief interview for mental (BIMS) was not completed. The MDS indicated the resident was rarely or never understood, had a memory problem and had severely impaired cognitive skills. He was totally dependent on staff for transfers, locomotion in his room, dressing, eating, toilet use and hygiene. He needed extensive assistance from two people with bed mobility. The resident received greater than 51% of his nutrition and hydration via a feeding tube. III. Observations On 7/25/23 at 3:38 p.m. Resident #76 was observed in bed and the 2:00 p.m. tube feeding had not been initiated. At 4:04 p.m. Resident #76 was observed in bed and the 2:00 p.m. tube feeding had not been initiated. At 4:22 p.m. licensed practical nurse (LPN) #8 raised Resident #76 ' s bed to flush the G-tube (feeding tube) and hung the feeding bag and water. The water was dated 7/25/23 at 4:15 p.m. G-tube flush canister filled with water (tap). LPN #8 then checked the G-tube placement. She connected a syringe to the G-tube connector, pushed in air and then sucked the air out. Thirty milliliters (ml) of water was then added to the syringe and LPN #8 flushed the G-tube. The G-tube feeding was turned on at a rate of 40 ml per hour. On 7/26/23 at 8:30 a.m., Resident #76 was no longer receiving feeding from the G-tube. There was approximately 500 ml of formula left in the bottle. Resident #76 received approximately 500 ml of formula. -However, the resident was supposed to get a total of 720 ml over 18 hours. -The tube feeding was supposed to run longer than 8:00 a.m. due to the tube feeding being connected later than ordered (see director of nursing interview). IV. Record review A. Care plan The nutritional risk care plan, initiated 3/4/23 and revised 3/10/23, documented Resident #76 was at nutritional risk related to NPO (nothing by mouth) with tube feeding for nutrition and hydration need with diagnoses of dysphagia (difficulty swallowing), chronic kidney disease, prostate cancer, respiratory failure, hypernatremia (increased serum sodium), coronary heart failure, paralysis, muscle weakness, depression and anxiety. Pertinent care plan interventions included to provide the tube feeding as ordered, flush as ordered (refer to the registered dietitian notes for the breakdown), observe tolerance of feeding and recommend adjustments to enteral nutrition (tube feeding)/flush PRN (as needed); initiated 3/10/23. The tube feeding care plan, initiated 5/20/23, documented the resident required tube feeding related to dysphagia and swallowing problems. Pertinent interventions included to elevate the HOB (head of bed) during feed administration at least 30 degrees and check placement of feeding tube prior to administration; initiated 5/20/23. B. Tube feeding orders The July CPO documented the following physician orders for Resident #76: -Every shift Nepro 1.8 (1.8 calories/ml of liquid formula for kidney failure) 40 ml/hr for 18 hours continuous to be started at 2:00 p.m. and stopped at 8:00 (the next day). C. Nutritional assessments and progress notes/medication administration The 7/19/23 nutrition assessment documented Resident #76 ' s tube feeding order as: -Nepro @ 40 ml/hour for 18 hours, stop time 8:00 a.m. and start time 2:00 p.m. to provide 1274 kcal, 58 grams protein, and 523 ml of water a day. Progress notes/Med Administration Random dates in July 2023 showed the Nepro was not hung at 2:00 p.m. as ordered -7/5/23 5:18 p.m. -7/6/23 6:37 p.m. -7/8/23 5:00 p.m. -7/9/23 4:04 p.m. 7/10/23 4:56 p.m. -7/12/23 6:05 p.m. 7/20/23 5:18 p.m. V. Staff interviews The registered dietitian (RD) was interviewed on 7/26/23 at 2:02 p.m. She said she reviewed Resident #76 ' s weight and his weights were stable. She said that she did not know the resident receiving less than the prescribed amount of tube feeding to meet his estimated nutrition and hydration needs. She said the flush and free water were automatic as it was a kangaroo pump (a pump that provided automatic flushing). The director of nursing (DON) was interviewed on 7/26/23 at 2:02 p.m. The DON said she spoke to the LPN that was observed setting up Resident #76 ' s tube feeding and the LPN said she usually hung the feeding bag timely at 2:00 p.m. but on 7/25/23 the LPN was behind. The DON said the way the tube feeding order was placed into the resident's electronic medical record was for the shift, versus at 2:00 p.m. as the order read. She said because of how the order was entered, the order did not show as late because it was for the shift. She said she would fix the order and the way it was placed into the resident ' s electronic medical record and said the order was for 18 hours. She said if the tube feeding was hung late, the nurse should post a note that indicated the tube feeding was hung late to communicate with staff on the next shift and adjust the time the tube feeding was removed. VI. Facility follow-up Resident #76 ' s tube feeding order was changed on 7/27/23 to the following: -One time a day tube feeding of Nepro 1.8 (calories/ml liquid formula for kidney failure) 40 ml/hour for 18 hours continuous to be turned off at 8:00 a.m. and on at 2:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure respiratory care was provided in keeping with physician's orders for two (#62 and #41) of five residents reviewed out of 58 sample residents. Specifically, the facility failed to ensure Residents #62 and #41 were provided oxygen therapy as ordered by their physicians. Findings include: I. Resident #62 A. Resident status Resident #62, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to July 2023 computerized physicians orders (CPO), the diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, chronic respiratory failure, type 2 diabetes mellitus, muscle wasting and atrophy and muscle contracture of the left hand. The 5/19/23 minimum data set (MDS) assessment revealed that Resident #62 had moderate cognitive impairment with a brief interview for a mental status score of 12 out of 15. He required extensive assistance from one person with ADLs such as bed mobility, toileting, dressing, personal hygiene, and transfers. No rejection of care or other behavioral symptoms were documented. The resident received oxygen (02) therapy. B. Record review The care plan, last updated 6/28/23, identified Resident #62 had an ADL performance deficit due to weakness, impaired mobility, pain, hemiplegia, and vision issues. The care plan identified that Resident #62 had chronic respiratory illness and oxygen should be administered via nasal cannula as prescribed. The July 2023 CPO did not include a physician's order for oxygen. C. Resident observation and interview Resident #62 was observed on 7/24/23 at 1:30 p.m. seated on his bed. Resident #62 had an oxygen concentrator set to three liters per minute (LPM) via nasal cannula. -On 7/25/23 at 9:30 a.m. the resident was observed in his room on three LPM of oxygen via nasal cannula. -On 7/26/23 at 3:40 p.m. Resident #62 was observed with his oxygen set at three LPM in his room. Resident #62 was interviewed on 7/27/23 at 9:30 a.m. Resident #62 said he had been using oxygen throughout the day. Resident #62 said he did not know the number of liters he was on. D. Staff interviews CNA #3 was interviewed on 7/27/23 at 9:45 a.m. CNA #3 said Resident #62 has been using oxygen continuously and it was set at three LPM. The CNA checked and confirmed that Resident #62 was on three LPM of oxygen. Licensed practical nurse (LPN) #7 was interviewed on 7/27/23 at 10:00 a.m. The LPN said Resident #62 had an order for the use of oxygen only at night. LPN #7 said there should be an order for oxygen therapy, however, could not locate the order on the resident's medication administration record (MAR). II. Resident #41 A. Resident status Resident #41, age over 65 years, was admitted on [DATE]. According to July 2023 CPO, the diagnoses included acute and chronic respiratory failure with hypoxia (lack of oxygen in the tissues), chronic pain, anxiety disorder, supraventricular tachycardia, unspecified mood disorder, age-related osteoporosis, and depression. The 5/18/23 MDS assessment revealed Resident #41 had severe cognitive impairment with a brief interview for a mental status score of seven out of 15. She required extensive assistance of two people with bed mobility, transfers, toileting, dressing, and personal hygiene. No rejection of care or other behavioral symptoms were documented. The resident received oxygen therapy. B. Record review The care plan initiated on 5/11/23 identified the resident had impaired respiratory status related to hypoxia. Interventions included oxygen as ordered by the physician. Provide oxygen every shift. Monitor for increased anxiety associated with shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, and headaches. The July 2023 CPO included an order dated 5/11/23 for oxygen at three liters per minute (LPM) continuously via nasal cannula every shift due to diagnosis of hypoxia. C. Observations On 7/24/23 at 10:15 a.m. Resident #41 was lying in her bed with her oxygen cannula in her nostrils. The oxygen concentrator in her room was set on two LPM. On 7/25/23 at 3:05 p.m., the resident was observed in bed with her oxygen concentrator set at two LPM. On 7/26/23 at 11:00 a.m. Resident #41 was up in her wheelchair with a portable oxygen concentrator hanging at the back of her wheelchair. The portable oxygen tank was set at two LPM. D. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 7/27/23 at 9:06 a.m. The LPN said oxygen was medication and needed a physician's order. The LPN said the resident was supposed to be on three LPM continuously instead of the two LPM. LPN #6 said it was important to follow the physician's order to avoid any negative outcomes. She said she adjusted Resident #41's LPM to three to match the physician's order. She said a negative outcome could be the resident receiving less oxygen which could cause respiratory distress for Resident #41. The DON was interviewed on 7/27/23 at 1:04 p.m. She said oxygen was medication and required an order. She said Resident #41's oxygen should have been set to what the physician's order indicated. The DON said a negative outcome for not following the physician's order could have put the residents in medical emergencies such as respiratory distress. The DON said she would ensure all oxygen orders were reviewed and the nursing unit followed the appropriate order for the use of oxygen therapy.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards. Specifically, the facility failed to lock medication carts when left unattended by licensed personnel. Findings include: I. Facility policy The Medication Access and Storage policy, revised May 2023, provided by the nursing home administrator (NHA) on 7/27/23 at 7:20 p.m. included, It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications II. Observations On 7/23/23 at 3:14 p.m. the medication cart to the 300 hall was observed unlocked and unattended by licensed personnel. The cart belonged to certified nurse aide with medication authority (CNA/MA) #2. She walked by the medication cart two times and failed to lock the cart. She returned to her medication cart at 3:18 p.m. and locked it at 3:20 p.m. when she went to walk away from the cart III. Interview The director of nursing (DON) was interviewed on 7/27/23 at 2:34 p.m. She said it was standard practice for all nursing staff who were assigned to a medication cart to be in possession of the medication cart keys at all times. She said any nursing staff that need to leave their medication carts unattended needed to ensure they had the keys and the cart and computer screen were locked. She said she would have in person conversations with all nursing staff to ensure they were aware of the facility ' s medication storage policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure one (#109) out of 58 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to provide fluids to Resident #109 according to the prescribed fluid order per speech therapy recommendation, physician orders and the resident's care plan. Findings include: I. Facility policy and procedure The Therapeutic Diets policy and procedure,revised October 2021, was received from the nursing home administrator (NHA) on 7/27/23 at 1:40 p.m. revealed in pertinent part, therapeutic diets shall be prescribed as necessary for each resident. A tray identification system was established to ensure that each resident receives his/her diet as ordered. II. Resident #109 A. Resident status Resident #109, age [AGE], admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses include dementia (loss of cognitive thinking), bipolar disorder (mood swing) and protein-calorie malnutrition (decrease nutrition). The 4/19/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of four out of 15. She set up assistance with eating. She required a mechanically altered diet. III. Observations On 7/24/23 at 11:03 a.m. the resident was laying in bed with a bedside table in front of her. The bedside table had one glass of lemonade and one cup of coffee which were regular thin liquid consistency. -The resident was supposed to be provided nectar thick liquids according to the physician order (see below). On 7/25/23 at 12:38 p.m. the resident was in her room eating lunch independently after staff set up. Resident #109 had a glass of regular water on her tray. After Resident #109 took a drink and she started coughing. On 7/26/23 at 9:00 a.m. certified nurse aide (CNA) #1 was observed removing Resident #109's breakfast tray containing a glass of milk at regular consistency. IV. Record review The July 2023 CPO documented Resident #109 diet order as regular, mechanical soft texture and nectar thick liquids for dysphagia ordered on 9/27/21. The comprehensive care plan dated 4/19/23 documented Resident #109 had a potential nutritional risk related to dementia, dysphagia (swallowing difficulty) with risk for silent aspiration and need for altered diet texture and consistency. V. Staff interviews CNA #1 was interviewed on 7/26/23 at 9:00 a.m. She said the milk was regular consistency. She sad Resident #109 was ordered nectar thickened liquids and reviewed the resident's meal ticket which indicated resident on nectar thick liquids. CNA #1 said drinks were provided to residents eating in their rooms prior to when the meal trays arrive on the floor to be distributed. CNA #1 said CNAs on the floor would give a report to a new CNA about residents requiring special things like thickened liquids. Speech therapist (ST) #1 was interviewed on 7/27/23 at 10:17 a.m. She said if a resident had thicken liquids ordered it was important the order was followed to prevent the resident from aspirating fluids which could cause pneumonia. ST #1 said when a resident's diet changed the registered dietitian (RD) and the nursing department were informed at time of change. ST #2 was interviewed on 7/27/23 at 10:23 a.m. She said when a resident diet changed the staff were verbally educated on the changes. The RD and the medical records department got a document with the residents name and diet change in order for meal tickets and physician orders to be changed. There was no formal education given to staff where staff would sign a document indicating that they were educated on a resident's specific diet. The director of nursing (DON) was interviewed on 7/27/23 at 1:46 p.m. She said diet changes were communicated with the kitchen, nurses and CNAs. Staff providing drinks for residents should be looking at meal tickets for special needs like thickened liquids. The DON said the drinks being passed on the floor by CNAs for residents eating in their rooms still needed to be provided the correct diet order. VI. Facility follow-up The NHA provided additional documentation after the survey on 7/28/23 at 3:53 p.m. which showed they had a nurse practitioner evaluate Resident #109 after the facility became aware of thin liquids being provided during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VI. Resident #5 A. Resident status Resident #5, younger than 65, admitted on [DATE]. According to the [DATE] CPO, the diagnoses included joint replacement, chronic obstructive pulmonary disease (abnormal oxygen exchange, COPD), type two diabetes (abnormal glucose), epilepsy (electrical imbalance in the brain), traumatic brain injury, borderline personality disorder and hypertension (high blood pressure). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. B. Record review The MOST form dated [DATE] was signed by the resident however was missing the physician signature. C. Staff interviews LPN #1 was interviewed on [DATE] at 12:04 p.m. She said Resident #5 was admitted to the facility on [DATE] and there was no signature on the MOST form from the physician. LPN #1 said signatures were required to validate MOST forms. VII. Resident #124 A. Resident status Resident #124, age [AGE], admitted on [DATE]. According to the [DATE] CPO, the diagnoses include type two diabetes, COPD and malignant neoplasm of the colon (cancer). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. B. Record review The [DATE] CPO documented resident code status of do not resuscitate (DNR). The MOST document documented the code status as full code with no changes as of the last facility review on [DATE]. C. Staff interviews LPN #1 was interviewed on [DATE] at 11:57 a.m. She said the MOST for documentation must match the order in the resident's electronic medication record (EMR) to ensure the facility was the resident's wishes. LPN #1 said the CPO order for Resident #124 indicated resident was a DNR and the MOST indicated full code. VIII. Resident #104 A. Resident status Resident #104, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included type II diabetes and dementia. According to the [DATE] MDS assessment, the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. B. Record review According to the CPO Resident #104 code status was CPR and full code. According to record review done on [DATE] at 2:20 p.m. there was not a MOST form for Resident #104. The resident's MOST forms were located in a binder at the nursing station. C. Staff interview LPN #2 was interviewed on [DATE] at 12:25 p.m. LPN #2 said when there was a medical emergency they reviewed the MOST forms. LPN #2 said all MOST forms would be located in the book at the nursing station. LPN #2 said Resident #104 did not have a MOST form in the book. LPN #3, who was the unit manager, was interviewed on [DATE] at 12:35 p.m. LPN #3 said nursing staff were responsible for getting the MOST forms filled out and signed and put in the MOST form book. LPN #3 said they look in the book in case of an emergency to know coding status. LPN#3 said they would look in the computer if they were not located in the book. LPN #3 said that Resident #104 did not have a MOST form in the building. LPN #3 started a new MOST form and asked the resident to fill it out. LPN #3 put the new most form signed [DATE] into the book. Based on record review and interviews, the facility failed to ensure each residents had the right to formulate an advanced directive for six (#5, #11, #76, #104, #124 and #133) of six residents reviewed out of 58 sample residents. Specifically, the facility failed to: -Ensure the medical orders for scope of treatment forms (MOST), used as an advance directive by the facility, were accurate, matched the physician's orders and were signed and dated by the resident and physician for Residents #5, #11, #76, #124 and #133; and, -Ensure resident #104 had the right to formulate an advanced directive. Findings include: I. Facility policy and procedure The Code Status Listing policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:40 p.m. It read in pertinent part, It is the policy of this facility to assure that advanced directives are honored as written. All residents will be informed of their opportunity to file advanced directives upon admission and at least annually. A completed list of residents with code status will be kept in a covered paper binder at each nurse's station. Social services will be responsible to keep the code status list current and updated whenever a change occurs. ID (interdisciplinary) team will discuss advanced directives with residents/responsible party during annual care plan conference and update as necessary. II. Resident #133 A. Resident status Resident #133, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included fracture of T-11-T12 vertebra (middle back), fracture of sacrum (lower back), fracture of left pubis (pelvic bone) and multiple fractures of ribs. The [DATE] quarterly 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. B. Record review According to the [DATE] CPO, the resident had orders for Full Code. According to the resident's MOST form in the resident's record, the resident was a No CPR: Do Not Attempt Resuscitation. This form was signed by the resident and dated [DATE]. The form was signed on [DATE] by the physician. According to the [DATE] at 10:14 p.m. the nurse practitioner/physician assistant progress note revealed in pertinent part, MOST FORM: full code. The care plan, initiated [DATE], indicated the resident planned to remain at the facility for long term care. -The care plan did not specify the resident's advance directives or wishes according to the MOST form. III. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included Parkinson's disease (a disorder that affects movement), dementia, and diabetes mellitus type 2. The [DATE] 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. B. Record review According to the [DATE] CPO, the resident had orders for Full Code. According to the resident's MOST form in the resident's record, the resident was a Yes CPR (Cardiopulmonary Resuscitation): Attempt Resuscitation. This form was signed by the legal decision maker (POA) but not dated. The form was signed by the physician but not dated. The care plan, initiated [DATE], indicated the resident planned to remain at the facility for long term care. -The care plan did not specify the resident's advance directives or wishes according to the MOST form. IV. Staff interviews Licensed practical nurse (LPN) #3, who was the unit manager, was interviewed on [DATE] at 12:02 p.m. She said the resident's MOST forms were initiated at admission with the resident and then the physician signed and when needed the medical power of attorney (MPOA) signed. LPN #3 said the resident or MPOA had to sign first then the physician was able. LPN #3 said the resident and physician were supposed to sign and date it; she said it was important to do so because that was the day the MOST initiated and then it became valid. LPN #3 said the physician code orders in the chart should match the MOST form and said Resident #133's MOST/physician orders were conflicting. LPN #3 said the MOST form was what the facility used for advanced directive. LPN #3 said if any emergency occurred the staff reviewed the to MOST form binder first that contained the resident's MOST forms. LPN #3 said Resident #11's MOST form was not dated by the physician or the resident and said they should have dated it. LPN #3 said she would make the corrections immediately and would do a full audit since now brought to her attention. The director of nursing (DON) was interviewed on [DATE] at 1:04 p.m. She said the MOST forms were the advanced directive used at the facility. She said they were to be completed at a resident's admission by the admitting nurse. The DON said the MOST forms should be completed as soon as possible after admission including obtaining the physician signature. The DON said she wanted physician code orders to match the MOST form to make sure delivering appropriate care and to avoid mistakes with the resident's wishes. The DON said since brought to the facility's attention during the survey, she completed a facility audit and the facility was changing the process. The DON said now the social services director (SSD) would be a part of clinical meetings to talk about the resident's MOST forms. V. Resident #76 A. Resident status Resident #76, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included protein-calorie malnutrition, anemia, congestive heart failure, diabetes mellitus type two, one sided paralysis and muscle weakness and chronic kidney disease. The [DATE] MDS assessment revealed a BIMS was not completed. The resident was rarely or never understood, had a memory problem and had severely impaired cognitive skills. He was totally dependent on staff for transfers, locomotion in his room, dressing, eating, toilet use and hygiene. He needed extensive assistance from two people with bed mobility. B. Record review The MOST form was signed on [DATE] by an authorized agent. The form was signed for a Do Not Resuscitate. However, the physician signed the form prior to the authorized agent on [DATE]. The MOST form documented a No CPR (Do not attempt resuscitation). However, under medical interventions documented with a written statement, ok intubation/airway. C. Staff interview LPN #1 was interviewed on [DATE] at 12:49 p.m. The LPN reviewed the MOST form and said she did not know what the write in statement of intubation ok meant. She said she had not seen that on the MOST form prior. She said that because the resident wanted no CPR that they would not intubate. She said the facility did not intubate, he would have to go to the hospital and 911 did not get called for a resident who had a do not resuscitate order. Registered nurse consultant #2 was interviewed on [DATE] at 12:52 p.m. She said the MOST form did not make sense with the statement ok to intubate as the facility did not do that. She said the power of attorney needed to be educated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, and staff interviews the facility failed to provide a comfortable and homelike environment for the residents of the facility for three out of four units. Specifically, the facility failed to ensure: -Residents were provided with hand towels and washcloths; and, -Resident's dressers and electrical power cords were properly maintained. Findings include: I. Lack of washcloths and hand towels in resident rooms A. Observations 7/24/23 at 10:36 a.m. the following rooms had no hand towels and washcloths: -room [ROOM NUMBER], #911 and #1206. 7/25/23 at 8:56 a.m. -room [ROOM NUMBER] had one washcloth in a shared room, otherwise no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no hand towels and washcloths. 7/26/23 at 10:24 a.m. -room [ROOM NUMBER] had no towels -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no hand towels and washcloths. -room [ROOM NUMBER] had one used washcloth in a shared room. -room [ROOM NUMBER]B had no towels. -room [ROOM NUMBER]B had only one used washcloth in a shared room. -room [ROOM NUMBER] had no towels. There were no towel bars, just hinges. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. The towel holder was broken. -room [ROOM NUMBER] no towels. The towel holder was broken. 7/27/23 at 10:49 a.m. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. One towel holder with no name. -room [ROOM NUMBER] only had one wash rag in a shared room. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels and washcloths in a shared room. -room [ROOM NUMBER] had no towels in a shared room. -room [ROOM NUMBER] had no towels. -room [ROOM NUMBER] had no towels. B. Resident interview Resident #100 was interviewed on 7/26/23 at 10:29 a.m. Resident #100 said staff were not consistently providing washcloths and towels. The resident said she used a paper towel to wash her face. She said when the staff removed the used towels and washcloths the staff did not replace them. An unidentified resident was interviewed on 7/26/23 at 10:40 a.m. She said she kept her towels by her bedside because her roommate used them when they were kept by the sink due to the fact the towel racks were not labeled. II. Lack of dressers and electrical power cords properly maintained 7/26/23 at 10:25 a.m. -room [ROOM NUMBER]B a dresser had broken drawers and they were falling out facing the entrance with the resident's clothes in the broken drawer. 7/24/23 at 2:15 p.m., 7/26/23 at 10:14 a.m. and 7/27/23 at 4:00 p.m. the following rooms had multiple electrical power cords bundled up on the floor: -room [ROOM NUMBER]A had many electrical power cords on the floor by the resident's bed. -room [ROOM NUMBER] had electrical power cords bundled up in front of the resident bed. -room [ROOM NUMBER] had a power strip cord, television cord and other accessories cord on the left side of the bed. III. Staff interviews Maintenance assistant (MA) #1 was interviewed on 7/27/23 at 12:03 p.m. The MA said the rooms did not have enough power outlets to accommodate the resident's equipment hence the use of the power strip. The MA said the resident's dresser would be adjusted to be able to slide in properly. The housekeeping supervisor (HKS) was interviewed on 7/27/23 at 6:15 p.m. The HKS said the housekeeping department ensured towels and linens were frequently sent to the floor throughout the day. He said the housekeeping department locked the towels in closets on every unit and it was up to the certified nurse aides (CNAs) to ensure each resident room was supplied with hand towels and washcloths. He said the housekeeping department brought linens to the floor approximately every two hours. CNA #4 was interviewed on 7/27/23 at 6:25 p.m. The CNA said most of the rooms had no towels. CNA #4 said linens were locked in closets in each unit's bathrooms. He said the CNAs on the night shift were responsible for supplying residents' rooms with towels and washcloths. The director of nursing (DON) was interviewed on 7/27/23 at 1:20 p.m. The DON said housekeeping and nursing staff were responsible for ensuring each resident had adequate towels and washcloths. The DON said the housekeepers wash, dry and store linens in the bathroom closet. The DON said it was important for each resident to have clean hand towels and washcloths each day for the resident's dignity and to prevent cross-contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to consistently provide activities of daily living (ADL) support for five (#14, #41, #35, #62 and #79) of 16 dependent residents reviewed for ADLs out of 58 sample residents. Specifically, the facility failed to provide: -Dependent Residents #14, #41, #62 and #79 with consistent assistance with grooming (fingernail care); and, -Resident #35 with consistent assistance with incontinence care, toilet use and repositioning. Findings include: I. Grooming - nail care A. Facility policy and procedure The Resident Nail Care policy and procedure, reviewed/revised in January 2022, was provided by the nursing home administrator (NHA) on 7/27/23 at 4:20 p.m. It read in pertinent part, Assessment of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, including trimming and filing, will be provided on a regular schedule such as weekly on (Wednesday from 3:00 p.m. to 11:00 p.m.). The resident's plan of care will identify the frequency of nail care to be provided.'' B. Resident #14 1. Resident status Resident #14, over age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, low vision in right eye category 1, blindness in left eye category 5, primary open-angle glaucoma, vascular dementia, and pain. The 6/9/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He required extensive assistance from one person for transfers, dressing, and toilet use. He was dependent and required physical help with bathing activities with one person's support. No rejection of care or other behavioral symptoms were documented. 2. Resident observation and interview Resident #14 was observed on 7/24/23 at 11:30 a.m. seated in a wheelchair. Resident #14's fingernails were half an inch long, jagged, and untrimmed with yellow/brown matter underneath. Resident #14 was interviewed on 7/25/23 at 2:08 p.m. Resident #14 said he would like his fingernails cut and trimmed but no one had offered to assist. Resident #14 said he received his scheduled showers but the staff did not assist him with fingernail care. Resident #14 said no staff clipped his fingernails. Resident #14 said he preferred his fingernails short but they were too long (with yellow/brown matter under the nails which were about half an inch long). 3. Record review The comprehensive care plan related to ADLs revised on 3/16/23 revealed the resident had an ADL self-care performance deficit and required assistance for ADL care in bathing, grooming, personal hygiene, dressing, transfer, bed mobility, and toileting related to falls. Goals: The resident will safely perform ADL care needs with the help of staff through the target review date of 9/7/23. Interventions related to bathing, grooming, and personal hygiene revealed to provide the resident with the assistance of one staff for bathing, toileting, dressing, oral care, and grooming, revised 3/16/23. Staff were to check nail length, trim, and clean on bath days and as necessary. -A review of the resident's progress notes in the last 30 days failed to reveal the resident refused any opportunity for fingernail care. C. Resident #41 1. Resident status Resident #41, age [AGE] years, was admitted on [DATE]. According to the July 2023 CPO, the diagnoses included chronic pain, anxiety disorder, supraventricular tachycardia, unspecified mood disorder, age-related osteoporosis, and depression. The 5/18/23 (MDS) assessment revealed Resident #41 had severe cognitive impairment with a brief interview for a mental status score of seven out of 15. She required extensive assistance of two people with bed mobility, transfers, toileting, dressing, and personal hygiene. No rejection of care or other behavioral symptoms were documented. 2. Resident observation and interview Resident #41 was observed on 7/24/23 at 12:30 p.m. lying on her bed. Resident #41's fingernails were a little over half an inch long, jagged, and untrimmed. Her fingernails were dirty with yellow/brown matter under her nails. On 7/25/23 at approximately 10:20 a.m. the resident was in bed, Her fingernails were still long, dirty, and jagged. The resident said she has not been offered assistance from staff with fingernail care. Resident #41 was interviewed on 7/24/23 at 12:30 p.m. She said her fingernails had never been that long and she would prefer them cut and trimmed. The resident said the staff had not offered to cut or trim her nails. 3. Record review The care plan, initiated 5/11/23, revealed Resident #41 had an ADL deficit and required total assistance of two staff for ADL care in bathing, transfer, toileting; and one person extensive assistance with grooming, personal hygiene, dressing, eating, and bed mobility. The care plan documented the resident preferred to bathe two times a week on Mondays and Thursdays. Resident #41's [NAME] (certified nurse aide care plan) had no information for fingernail care for the staff to document when the service was provided. D. Resident #62 1. Resident status Resident #62, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 CPO, the diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, chronic respiratory failure, type 2 diabetes mellitus, muscle wasting and atrophy, and muscle contracture of the left hand. The 5/19/23 MDS assessment revealed that Resident #62 had moderate cognitive impairment with a brief interview for a mental status score of 12 out of 15. He required extensive assistance from one person with ADLs such as bed mobility, toileting, dressing, personal hygiene, and transfers. No rejection of care or other behavioral symptoms were documented. 2. Resident observation and interview Resident #62 was observed on 7/24/23 at 1:30 p.m. seated on his bed. Resident #62's fingernails were over half an inch long, jagged, untrimmed and dirty with black matter under his nails. Resident #62 was interviewed on 7/24/23 at 1:30 p.m. He said his fingernails were long and he would prefer them cut and trimmed. The resident said the staff had not offered to cut or trim his nails. 3. Record review The care plan, last updated 6/28/23, identified Resident #62 had an ADL performance deficit due to weakness, impaired mobility, pain, hemiplegia, and vision issues. The care plan identified that Resident #62 was diabetic but failed to include interventions for fingernail care. Resident #62's [NAME] for care staff to follow documented he preferred showers two times per week, Wednesday and Saturday, on the evening shift. The resident's task records for bathing did not include information as to when fingernail care was provided. The July 2023 medication administration and treatment record (MAR and TAR) did not include directions for diabetic fingernail care. E. Resident #79 1. Resident status Resident #79, under age [AGE], was admitted on [DATE]. According to July 2023 CPO, the diagnoses included multiple sclerosis, chronic pain, depressive disorder, and polyneuropathy (simultaneous malfunction of many peripheral nerves). The 5/9/23 MDS assessment revealed that Resident #79 was cognitively intact with a brief interview for mental status score of 14 out of 15. She required limited assistance from one person with ADLs such as bed mobility, toileting, dressing, personal hygiene, and transfers. No rejection of care or other behavioral symptoms were documented. 2. Resident observation and interview Resident #79 was observed on 7/25/23 at 2:30 p.m. lying on her bed. Resident #79 was dressed. Her fingernails were approximately half an inch long, jagged, and untrimmed with dark substances under her nails. Resident #79 was interviewed on 7/25/23 at 2:30 p.m. Resident #79 said her fingernails were pretty long and she preferred them short and trimmed. Resident #79 said she received showers on Tuesday and Friday evenings. Resident #79 said she did not receive consistent fingernail care during shower days. The resident said she had multiple sclerosis and right-side paralysis so it was difficult for her to be able to cut and trim her own fingernails. 3. Record review The care plan, initiated 5/17/23, revealed Resident #79 had an ADL performance deficit and required total staff assistance with personal hygiene, and bathing. She preferred to bathe two times per week on Tuesdays and Fridays. -The care plan revealed that the resident often refused showers but failed to include interventions for staff to follow in the event of a refusal. The 5/20/23 progress notes documented a refusal of showers for four days but did not indicate any intervention for the refusal of the resident's showers. There was no evidence of refusals after May 2023. F. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 7/27/23 at 9:00 a.m. LPN #6 said the certified nurse aides (CNAs) and floor nurses were responsible to provide fingernail care for all residents. LPN #6 said showers consisted of washing the hair, soaping the body, and nail cutting and trimming. LPN #6 said nurses were responsible for cutting and trimming fingernails for residents who were diabetics. LPN #6 said it was important for residents to have regular fingernail care for good hygiene and to prevent infectious diseases. CNA #3 was interviewed on 7/27/23 at 9:32 a.m. She confirmed Residents #14, #41, #62, and #79 had long fingernails. CNA #3 said fingernail care should be completed on the resident's shower days and as necessary. CNA #3 said dirty and long fingernails could cause skin issues such as skin tears. She said there was no scheduled time for fingernail care that she was aware of. CNA #3 said fingernail care was important for good hygiene and to prevent skin breakdown. The director of nursing (DON) was interviewed on 7/27/23 at 1:04 p.m. The DON said fingernail care was to be completed on the resident's shower days and as needed. The DON said CNAs and floor nurses were to ensure nail care was provided regularly to promote dignity and good hygiene to prevent skin breakdown. The DON said the facility would develop a routine to monitor fingernail care during rounds. II. Incontinence care - toilet use assistance - repositioning A. Resident #35 status Resident #35, age [AGE], admitted on [DATE]. According to the July 2023 computerized physician orders, diagnoses include atrial fibrillation (abnormal heart function), type two diabetes (abnormal glucose), chronic kidney disease (decrease kidney function), venous insufficiency (decreased circulation) and hypertension (high blood pressure). The 4/12/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required two person physical assistance for bed mobility, transferring and toileting. She needed one person physical assistance with dressing, eating, and personal hygiene. Resident #35 was always incontinent of bladder and frequently incontinent of bowel. B. Resident interview Resident #35 was interviewed on 7/24/23 at 10:35 a.m. She said she got a new incontinence brief applied in the morning and again at night before bed. Resident #35 said her incontinence brief at night was very wet. She reported she struggled to get staff to help her throughout the day. C. Observations During a continuous observation on 7/25/23 from 12:00 p.m. to 5:00 p.m., Resident #35 was in the dining room at 12:00 p.m. sitting in her wheelchair. At 12:35 p.m. Resident #35 was escorted to her room by staff and left in a wheelchair after lunch with no offer to toilet or change positions. At 1:26 p.m. she was escorted to activities without being asked if she needed restroom assistance or to change position. She remained in the activity until 3:30 p.m. when she was escorted back to her room. At 4:30 p.m. Resident #35 was heard calling out requesting to go to the dining room for dinner. Staff came and took her directly to the dining room without offering toilet assistance or repositioning. Resident #35 was observed in the same position from 12:00 p.m. to 5:00 p.m. and had not been offered toileting assistance. D. Record review The 5/23/23 comprehensive care plan documented Resident #35 had bowel and bladder incontinence related to activity intolerance, disease process, and physical limitations. The care plan interventions listed were to establish voiding patterns and check as required for incontinence. The bedside [NAME] for certified nurse aides (CNAs) reviewed on 7/27/23 documented Resident #35 required extensive two person assistance with transfers and to encouraged Resident #35 to sit on a toilet to evacuate her bowels. The point of care record, reviewed on 7/27/23 at 3:30 p.m., documented Resident #35 required total assist for transfers 32 times out of 43 transfer occurrences from 6/28/23 to 7/27/23. E. Staff interviews CNA #2 was interviewed on 7/27/23 at 2:19 p.m. She said residents should be checked every two hours for incontinence, or when resident requests and if residents showed signs of discomfort like grimacing or hollering. She acknowledged Resident #35 was incontinent and would not let staff know, along with her being a two person assist with transfers. CNA #2 said Resident #35 required assistance with shifting her weight or changing positions. CNA #2 said residents should have their position changed every two hours to prevent skin breakdown. The director of nursing (DON) was interviewed on 7/27/23 at 1:46 p.m. She said residents should be offered toileting or incontinence care upon rising in the morning, before and after meals, at bedtime and upon resident request. She acknowledged Resident #35 was not on a bowel and bladder plan but had a bowel and bladder assessment indicating she was a candidate for a plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Accident hazards regarding medical equipment plugged into nonmedical grade power strips A. Resident #76 1. Resident status Resident #76, over age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 CPO, diagnoses included unspecified protein-calorie malnutrition, vascular dementia, type 2 diabetes mellitus, cardiomyopathy, chronic systolic congestive heart failure, and anxiety disorder. The 4/26/23 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). He required total assistance from two persons for transfers, dressing, toileting, and bed mobility. He was dependent and required one person assistance with hygiene. He had no rejection of care and other behavioral symptoms were documented. 2. Observations The resident's environment in his room was observed on 7/25/23 at 10:49 a.m. The resident's tube feeding pump and oxygen concentrator were plugged into a nonmedical grade power strip. On 7/26/23 at 2:14 p.m. Resident #76's tube feeding pump and oxygen concentrator were still plugged into a nonmedical power strip. 3. Record review The comprehensive care plan focus initiated on 3/4/23 revealed Resident #76 had increased nutritional risk and chronic respiratory illness, Interventions included providing tube feeding as ordered and applying oxygen via nasal cannula. Resident #76 care plan failed to include the use of oxygen therapy and interventions in the event of respiratory issues. -The 6/29/23 clinical physician orders revealed an order for the resident to be on continuous oxygen via nasal cannula two liters per minute (LPM). -The resident's medical equipment was at risk of being damaged by being plugged into a nonmedical power strip. This could cause a potential medical emergency such as hypoxemia (low oxygen in the blood) for a resident who required continuous oxygenation and tube feeding. B. Additional resident room observations On 7/27/23 at 10:05 a.m. a further observation of three halls revealed there were multiple rooms with medical equipment plugged into nonmedical power strips. The following rooms were observed to have medical equipment plugged into nonmedical power strips: -room [ROOM NUMBER] had an oxygen concentrator plugged into a nonmedical grade power strip and lots of electrical power cords on the floor -room [ROOM NUMBER] had a bed plugged into a nonmedical grade surge protector. -room [ROOM NUMBER] had an oxygen concentrator plugged into a nonmedical-grade power strip. -Rooms #1104 and #1205 had oxygen and tube-feeding pumps plugged into nonmedical power strips. -Rooms #2305 and #2307 had oxygen concentrators plugged into nonmedical grade surge protectors. C. Staff interviews Maintenance assistant (MA) #1 was interviewed on 7/27/23 at 12:03 p.m. The MA said he was aware that medical equipment needed a medical-grade power strip or should be plugged directly into the power outlet. The MA said the facility ordered the power strips from online merchants and acknowledged that they were not medical grade. The MA said the potential negative outcome was a resident could suffer a medical emergency if they did not receive the needed medical support. He said medical equipment could be damaged due to the facility's failure to use medical-grade surge protectors. The MA said there were not enough wall power outlets to accommodate all the needed equipment for some residents including Resident #76. The MA said he will ensure all medical equipment was plugged into medical-grade power strips. The DON was interviewed on 7/27/23 at 1:04 p.m. The DON said medical equipment needed to be plugged directly into the wall power outlet or medical-grade surge protectors to prevent damage to the equipment and a potential medical emergency. The DON acknowledged that there were not enough wall outlets to accommodate all the needed medical equipment of some residents hence the use of the power strips. Based on observations, record review and interviews the facility failed to ensure two (#5 and #76) of six residents reviewed for accidents out of 58 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure safety precautions were in place to prevent Resident #5 from falling; and, -Ensure medical equipment was plugged into a medical grade power strip for Resident #76 and additional residents. Findings include: I. Resident #5 A. Resident status Resident #5, younger than 65, admitted on [DATE]. According to the July 2023 computerzied physician orders (CPO), the diagnoses included joint replacement, chronic obstructive pulmonary disease (abnormal oxygen exchange COPD), type two diabetes (abnormal glucose), epilepsy (electrical imbalance in the brain), traumatic brain injury, borderline personality disorder and hypertension (high blood pressure). The 5/14/23 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. She required two person physical assistance with transfers; one person physical assistance with bed mobility and dressing; and set up assistance for eating, toileting and personal hygiene. B. Resident interview Resident #5 was interviewed on 7/24/23 at 2:52 p.m. She said she had fallen in the facility after slipping on water in her room, after reporting a leaking sink and staff placed a basin under the sink to catch the water but it overflowed onto the floor. Resident #5 reported she went to the hospital and the fall had aggravated her back injuries and felt this fall has set her back from rehabilitating her knee replacement. Resident #5 said, They came to my room once and said they fixed it but it still continued to leak. Resident #5 had moved to a different room after transitioning to long term care at the facility. C. Record review A nurse progress note dated 6/14/23 at 6:35 a.m. documented they heard Resident #5 screaming from her room and observed the resident lying on the floor in front of her bed between the sink and her bed. The resident was lying in a puddle of water on the floor and a basin full of water was underneath the sink. Resident #5 was yelling, I threw out my back, I threw out my lumbar, it's not my fault. I told y'all to fix that sink three times and nobody did anything. A nursing note on 6/15/23 at 10:33 a.m. for an interdisciplinary team meeting documented Resident #5 had a fall in her room between her bed and the sink. The resident was educated to ask for assistance with transfers when her floor was wet. The 5/10/23 comprehensive care plan identified Resident #5 as a fall risk related to decreased mobility, psychotropic drug use and diuretic use. Interventions included call light within reach, bed in lowest position, educate on safety reminders and ensure appropriate footwear when ambulating or when wheeling in a wheelchair. All interventions were initiated on 5/10/23 and revised on 5/23/23. The 5/10/23 comprehensive care plan also documented an actual fall with no injury, with a goal that the resident would resume usual activities without further incident. Interventions included: complete an environmental assessment of the resident bed, continue interventions on the at risk plan initiated 5/10/23; and education to ask for assistance during transfers when her floor was wet; physical therapy evaluation for transfers, balance and strength initiated on 6/14/23. A fall risk evaluation completed on 6/14/23 at 6:42 a.m. documented Resident #5 was a medium fall risk with a score of seven. A second fall risk evaluation was completed on 6/14/23 at 10:08 p.m. documented Resident #5 was a medium fall risk with a score of eight. The NHA provided documentation on 7/26/23 at 12:45 p.m. showing a work order for sink repair for Resident #5's room was placed on 6/2/23 and repairs were completed on 6/3/23. -However, Resident #5 was found on the floor in a puddle of water 11 days later on 6/14/23 (see above). Neurological assessments post fall were requested on 7/27/23 at 3:57 p.m. but were not provided by facility staff. There were no hospital records to review in the electronic medical record. -There was no documentation the resident's sink was repaired after her 6/14/23 fall involving a wet floor. D. Staff interviews The director of nursing (DON) and licensed practical nurse (LPN) #5 were interviewed on 5/27/23 at 5:04 p.m. The DON said they were still looking for the neurological assessments for Resident #5. LPN #5 said she remembered the resident refused to have her neuros completed after staff went in two times because she did not want to be disturbed every 15 minutes. -Progress notes failed to document refusal of neurological assessments upon return from the hospital. The DON was interviewed a second time on 7/27/23 at 6:16 p.m. She said the pipe was replaced in Resident #5's room despite it was not leaking but Resident #5 complained so it was completed per resident request. The DON acknowledged she did not know how the basin got under the sink or how the water was found on the floor where the resident fell. The DON said she asked the nurse who found the resident and she said there was no basin under the sink. -Resident interview and documentation in the medical record (above) did not support the DON's statement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 for two out of three units at the facility. Specifically, the facility failed to: -Ensure residents' personal toiletry items were labeled appropriately; and, -Ensure residents were provided with an opportunity to participate in hand hygiene before and after meals. Findings include: I. Failure to ensure resident toiletry items were marked in shared rooms. A. Observations 7/25/23 at 10:25 a.m. The following shared rooms had unlabeled hygiene containers with toiletries items such as tubes of toothpaste, toothbrushes and hairbrushes: -room [ROOM NUMBER] had no label on hygiene containers with toothpaste, toothbrushes, and hairbrushes. -room [ROOM NUMBER] had unmarked hygiene containers with unmarked toothbrushes and tubes of toothpaste. -room [ROOM NUMBER] had unmarked hygiene containers with unmarked toothbrushes and tubes of toothpaste. -room [ROOM NUMBER] had unmarked hygiene containers with unmarked toothbrushes and tubes of toothpaste. -room [ROOM NUMBER] had an unlabeled urine container in a shared bathroom. -room [ROOM NUMBER] had unmarked hygiene containers with unmarked toothbrushes and tubes of toothpaste. -room [ROOM NUMBER] had unmarked hygiene containers with unmarked toothbrushes and tubes of toothpaste. -room [ROOM NUMBER] had unmarked hygiene containers with unmarked toothbrushes and tubes of toothpaste. On 7/26/23 at 10:49 a.m. the above rooms still have toiletry items unlabeled in shared bathrooms. -At 11:08 a.m., room [ROOM NUMBER] a shared room, had no markings on the towel bar to distinguish which towel belonged to which resident. -At 11:16 a.m. room [ROOM NUMBER] had an unmarked toothbrush on the sink; no towels, washcloths, and towel racks were unmarked in a shared room. -At 11:20 a.m. rooms #905, #908, and #909 had unmarked towel racks in shared rooms. Toiletry containers with tubes of toothpaste, hairbrushes and toothbrushes were unmarked. II. Failed to ensure residents were provided with an opportunity to participate in hand hygiene before and after meals. A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 7/27/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by the CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy The Infection Control Policy and Procedure, revised October 2022, was provided by the facility on 7/28/23 a day after the survey exit. It read in pertinent part, It is the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. The policy procedure included, washing hands with soap and water for the following situations: a. When hands are visibly soiled. b. before and after direct contact with residents. c. after contact with objects in the immediate vicinity of residents. d. before and after assisting a resident with meals. C. Observations On 7/23/23 at approximately 5:00 p.m., approximately six residents in hall 900 were not provided the opportunity to perform hand hygiene during meal time. The meal trays were passed out, without the staff offering hand hygiene. There were no hand sanitizing wipes provided on the residents' room trays. On 7/25/23 at approximately 4:55 p.m. an unidentified resident self-propelled himself to the first floor dining room by wheeling himself with both hands in a manual wheelchair. The resident was served a tuna sandwich, a banana and chicken noodle soup. The staff did not offer to open the bottle of hand sanitizer and just placed it on the resident's table and left. The resident ate the sandwich and afterward peeled the banana and held the middle of the banana to eat. The resident left the dining room after finishing his meal and wheeled himself out of the dining area without any form of hand hygiene. The staff did not encourage him to perform hand hygiene. On 7/27/23 at 4:49 p.m. dinner was being served at the second-floor dining room. There was no hand sanitizer in the dining area nor did the staff did not offer Sani wipes to the residents. The residents had fish and rolls on their plates. Two residents had hamburgers. The residents ate their rolls and hamburgers with their hands without being offered hand sanitizer, Sani-wipes or to wash their hands. D. Staff interview The director of nursing (DON) was interviewed on 7/27/23 at 2:00 p.m. The DON said the nursing staff were trained to ensure hygiene containers and toiletry items were marked to prevent cross-contamination. The DON said all staff received periodic training and education to perform frequent hand hygiene and provide opportunities for all residents to perform adequate hand hygiene before and after meals. The DON said the facility provided hand sanitizers at entrances and corners of each dining room for staff and residents to perform hand hygiene before and after meals. She said the residents were provided Sani wipes for a second opportunity to perform hand hygiene in the dining room and for room trays before and after meals. Registered nurse (RN) #1, who was the infection preventionist, was interviewed on 7/27/23 at 4:30 p.m. She said facility staff were educated on infection control and proper hand hygiene. RN #1 said all staff attended infection control education. She said hand sanitizer solutions were at the entrance and corners of every dining room for staff and residents to perform hand hygiene. She said each hallway had hand sanitizer dispensers for the staff to perform hand hygiene when they come out of a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the pharmacy consultant failed to ensure medications were ordered correctly for one (#2) of three residents reviewed out of 12 sample residents. Specifically, the pharmacy failed to pay attention to alerts for dose warnings for Resident #2 and make recommendations to the resident's physician and to the facility. Cross-reference F760 significant medicon error Findings include: I. Facility policy and procedure The Drug Regimen Review policy, dated October 2022, was provided by the director of nursing (DON) on 2/2/23. It read in pertinent part: It is the policy of the facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The consultant pharmacist may need to conduct the medication regimen review more frequently depending on the resident condition, review of short stay residents and risk of adverse consequences. The licensed pharmacist will report in writing any irregularities to the attending physician, the facility's medical director and the director of nursing to be acted upon. -The pharmacy consultant will complete the drug regimen review by reviewing the comprehensive assessment information of the resident, identifying irregularities, syndromes potentially related to medication therapy, adverse medication consequences, as well as potential for adverse drug reactions and medication errors. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included acute encephalopathy (a disease of the brain that alters brain function), hypertension (high blood pressure), and overactive bladder. The 1/17/23 minimum data set (MDS) assessment revealed the resident did not have an impaired cognitive status with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was assessed as not requiring assistance for activities of daily living and personal hygiene. B. Record review (Pharmacy name) nursing recommendations dated 8/31/22, provided to the facility by the consulting pharmacy, documented an order had a recommended physicians order for Resident #2 to receive Vitamin D3 50,000 units by mouth, once a month, on the 15th of every month. The February 2023 CPO documented a physician order which read, Cholecalciferol (Vitamin D3) 50,000 units, give one (1) tablet orally (by mouth), one time a day every one (1) month(s) starting on the 15 th for 28 day(s) for Vitamin D deficiency. Vitamin D supplement, with an order date of 9/7/22. The September 2022, October 2022, and November 2022 medication administration records (MAR) documented Vitamin D3 was given to the resident every day from 9/15/22 through 11/30/22 with the exception of four dates in November 2022. This was not what the physician ordered and was in excess of the physician's order to give the resident 50,000 units of Vitamin D3 once a month on the 15th of the month. Pharmacist monthly medication review notes dated 9/30/22, 10/31/22 and 11/27/22 documented a review was completed and there were no significant medication issues. -The pharmacy did not identify or report that the medication administration system identified the resident was redieving an excessive Vitamin D3 dose. A physician review note dated 10/20/22 documented that the resident's physician reviewed the resident medication orders and no changes were made to the orders including the Vitamin D order; it was left as it was entered into the resident's MAR. -The medical record failed to show evidence that any further drug regimen review or medication order entry audit was performed by the facility to identify the incorrect order entry for Vitamin D3. III. Interview The pharmacy consultant (PC) was interviewed on 2/2/23 at 8:16 a.m. The PC said that safe daily intake of Vitamin D when treating for deficiency with a high dose therapy is 50,000 units once a week. The PC said she did not see the alert warning pop up that the Resident #2's Vitamin D3 dosage was outside the recommended dosage. She acknowledged this type of alert was common even for 50,000 units once a week which was a standard dosage for vitamin D deficiency treatment, so it would have been normal for her to not pay much attention to the alert.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent a significant medication error for one (#2) of three residents reviewed out of 12 sample residents. Specifically, the facility failed to ensure a physician's order for vitamin D were entered correctly into the medication administration record (MAR) for Resident #2. Findings include: I. Facility policy and procedure The Medication Orders policy, revised February 2014, was provided by the director of nursing (DON) on 2/2/23. It read in pertinent part: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. When recording orders from medication, specify the type, route, dosage, frequency and strength of the medication ordered. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included acute encephalopathy (a disease of the brain that alters brain function), hypertension (high blood pressure), and overactive bladder. The 1/17/23 minimum data set (MDS) assessment revealed the resident had intact cognitive status with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was assessed to be independent with activities of daily living and personal hygiene. B. Resident interview Resident #2 was interviewed on 2/1/23 at 3:04 p.m. The resident said she told the unidentified evening . agency nurse, she had too many pills and she did not take Vitamin D every day. She said she took the pill but she felt like she was forced to take all of the medications. Resident #2 told her daughter about the extra Vitamin D pill and that she had dizzy spells and nausea after taking the extra Vitamin D pill. The resident said her daughter told her it was too much Vitamin D. Resident #2 said her daughter was not a nurse but she used to work for a medical facility. Resident #2 reported her symptoms to the nurse on duty on 10/15/22 and she was prescribed Meclizine tablets, as needed for the dizziness. No other changes were made to the resident's medical treatment plan or her MAR. C. Record review (Pharmacy name) nursing recommendations dated 8/31/22, provided to the facility by the consulting pharmacy, documented an order had a recommended physicians order for Resident #2 to receive Vitamin D3 50,000 units by mouth, once a month, on the 15th of every month. The February 2023 CPO documented a physician order which read, Cholecalciferol (Vitamin D3) 50,000 units, give one (1) tablet orally (by mouth), one time a day every one (1) month(s) starting on the 15th for 28 day(s) for Vitamin D deficiency. Vitamin D supplement, with an order date of 9/7/22. The September 2022, October 2022, and November 2022 medication administration records (MAR) documented Vitamin D3 was given to the resident every day from 9/15/22 through 11/30/22 with the exception of four dates in November 2022. This was not what the physician ordered and was in excess of the physician's order to give the resident 50,000 units of Vitamin D3 once a month on the 15th of the month. Order note dated 9/7/22 read: The system has identified this order as being outside of the recommended dose for this drug: Cholecalciferol Tablet 50000 unit, give one (1) tablet orally one time a day every one (1) month(s) starting on the 15th for 28 day(s) for Vitamin D deficiency. Vitamin D supplement. Pharmacist monthly medication review notes dated 9/30/22, 10/31/22 and 11/27/22 documented a review was completed and there were no significant medication issues. -The pharmacy did not identify or report that the medication administration system identified the resident was redieving an excessive Vitamin D3 dose. Cross-reference to F755 failure pharmacy review identified and provided alerts on prescribed medications errors and concerns. A physician review note dated 10/20/22 documented that the resident's physician reviewed the resident medication orders and no changes were made to the orders including the Vitamin D order; it was left as it was entered into the resident's MAR. -The medical record failed to show evidence that any further drug regimen review or medication order entry audit was performed by the facility to identify the incorrect order entry for Vitamin D3. III. Staff interview The pharmacy consultant (PC) was interviewed on 2/2/23 at 8:16 a.m. The PC said that safe daily intake of Vitamin D3 when treating for deficiency with a high dose therapy is 50,000 units once a week. The pharmacy consultant said she did not have an age specific related dose recommendation. The PC said the signs and symptoms of Vitamin D3 toxicity were nausea, vomiting, constipation and loss of appetite. The PC said she did not see the alert warning pop up that the Resident #2's Vitamin D3 dosage was outside the recommended dosage. She acknowledged this type of alert was common for 50,000 units once a week which was a standard dosage for vitamin D deficiency treatment, so it would have been normal for her to not pay much attention to the alert. Registered nurse (RN) #1 was interviewed on 2/2/23 at 10:01 a.m. RN #1 said was asked what the process was when an alert opens up during medication pass for drug interactions or high doses. The medication nurse was expected to call the doctor to confirm medicion orders if a high dose alert message popped up in the resident's medication record to make sure it was ok to give the medication as written on the resident's MAR. The nurse was to document this communication in the resident's chart after speaking with the resident's physician. The director of nursing (DON) was interviewed on 2/2/23 at 12:30 p.m. The DON said she found the medication error while she was looking at other concerns for the resident. The DON said the nurses were to call the prescribing provider if they receive medication dosage alerts or warnings when performing the medication pass. IV. Facility follow-up Upon survey exit on 2/2/23 the DON provided the facility investigation packet for the medication error. The investigative documents revealed the facility notified the pharmacy consultant and the doctor of the medication error on 12/6/22. Disciplinary action was taken against the nurse who entered the medication order incorrectly. Several nurses were provided general education related to medication administration and physician's orders. The DON also provided a copy of the facility's progress with a medication error performance improvement project (PIP). The DON said the PIP was implemented 12/1/22 as soon as Resident #2's Vitamin D3 medication error was discovered. The DON said they had been working on the PIP for the past two months and they would continue with the project until it was determined to be resolved. The December 2022 PIP read in pertinent part: Resident medications will be administered without incident. Trends: Resident Vitamin D order incorrectly entered. Residents complained of over-the-counter medications not being administered as ordered. Nurses not double checking their work and the audit system not being utilized. New action plan: 1. 100% audit conducted of all vitamin D 50,000 units scheduled. 2. Residents' medication was reviewed by the provider on 11/27/22. 3. All residents interviewed about medication pass concerns. 4. Medication list with pictures, time and purpose given to Resident #2. 5. Provide education to nursing staff on medication administration. 6. The provider will review medications monthly. 7. The pharmacist will complete a monthly medication review. Provider/don/designee will complete medication review suggestions and input in PCC. 8. Staff educated on two persons care with Resident #2 (DON or designee). 9. DON or designee will check in on residents regularly to ensure residents' needs are met with medications and care. 10.Startup will be re-initiated to ensure orders entered correctly. 11. DON or designee will comprise a report and present in QA until deemed unnecessary. The January 2023 medication errors PIP included updates to the action plan which included: Medication errors 2 (two): New action plan: 1. Provide nursing staff education regarding medication administration, rights of medication pass. 2. Random rounds to ensure enteral feeding is hung correctly, type of supplement and rate of supplement. 3. Continue providing care in pairs with Resident #2. 4. DON will continue meeting with residents regularly to ensure needs are met with a medication pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that before a resident was allowed to self-administer medications, an assessment was conducted to determine if the resident was safe to do so for 1 (Resident #103) of 5 residents observed during medication administration. Findings included: Review of a facility policy titled, Medication Administration, dated 09/2018, revealed, Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. Review of an admission Record revealed the facility admitted Resident #103 on 10/01/2021 with diagnoses including multiple sclerosis (MS - a disease that affects the central nervous system which impedes the ability of the brain to send signals to the rest of the body), rhabdomyolysis (a serious condition caused by muscle breakdown and muscle death), and major depressive disorder. The significant change Minimum Data Set (MDS), dated [DATE], revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Per the MDS, the resident exhibited verbal behavioral symptoms directed toward others and rejected evaluation or care on one to three days during the assessment period. During an observation and interview on 06/13/2022 at 1:14 PM, the resident's bedroom door had a handwritten note stating the resident was not to be awakened until after 10:00 AM. Upon entrance into the resident's room, it was observed the resident's room was very dirty, with trash all over the floor and opened food containers. Next to the resident's bed, there were numerous pills on the floor, which included pink oblong pills, white round pills, and white oblong pills. The resident stated one was a Benadryl, one was Tylenol, and one was another allergy medication. The resident stated all the medications belonged to him/her and that the medications were inside a drinking cup with pens and a hairbrush and that he/she had knocked over the cup and spilled the medications on the floor, where they stayed. The resident stated the medications were in a cabinet drawer next to their bed; however, the resident refused to show the surveyor the contents of the drawer. The resident stated he/she did not allow housekeeping to come in the room to clean due to having post-traumatic stress disorder (PTSD). A review of Resident #103's care plan, updated on 05/03/2022, indicated Resident #103 had multiple sclerosis affecting his/her vision, depressive behaviors, muscle spasms, and pain. Interventions included providing the resident's medications as ordered, as well as monitoring and documenting side effects and effectiveness. The care plan also indicated Resident #103 used psychotropic medications related to behavior management and had episodes of yelling at staff and declining care. The care plan did not address the resident's ability to self-administer medications. A review of the June 2022 Medication Summary indicated the resident had a physician's order for dimethyl fumarate delayed release 240 milligram (mg) tablet, twice a day for MS, with a start date of 04/08/2022. The order indicated, Personal [pharmacy] bottle, Pls [please] check in bottom drawer. The summary did not include physician's orders for Benadryl, Tylenol, or a generic allergy medication. A review of the June 2022 physician's orders revealed no order for Benadryl, Tylenol, or a generic allergy medication. A review of the resident's medical record revealed no assessment for self-administration of medications. In an interview on 06/14/2022 at 10:53 AM, Social Worker (SW) #1 stated she had been in the resident's room that day and that there was a lot of trash and things of that nature on the resident's floor. SW #1 indicated she had asked the resident to allow her to move some of it and the resident declined. SW #1 stated that the resident told staff to vacate the room and does not want staff in the room. During an interview and observation on 06/14/2022 at 11:01 AM, SW #1 entered the resident's room to discuss a concern with the resident. The medications that were on the floor the previous day were still on the floor. SW #1 acknowledged there were medications on the floor. In an interview on 06/14/2022 at 11:07 AM, Registered Nurse (RN) #1 stated the resident was not allowed to self-administer medications but that the resident ordered his/her own medication and refused to give it to the facility. The facility staff had documented this, and the Director of Nursing (DON) was aware. RN #1 stated the resident had Tylenol in the room and, whenever the resident took it, he/she was supposed to let the nurse know so it could be documented. RN #1 stated he was only aware of the Tylenol the resident had in the room. RN #1 stated the resident had not been assessed for self-administration of medication. When asked how staff knew the resident was capable and safe to self-administer, he stated, We only have the requirement of [the resident] notifying us when [he/she] takes the Tylenol. RN #1 stated he was unaware of the medications on the resident's floor due to the amount of clutter in the resident's room. During an interview and observation on 06/14/2022 at 11:22 AM, Licensed Practical Nurse (LPN) Unit Manager #3 entered the resident's room and told the resident that she was notified there were medications on the resident's floor. The resident replied, So? The staff stated the medications could not be on the floor, then exited the resident's room. LPN #3 stated the medications on the resident's floor were not provided to the resident by the facility. LPN #3 stated the resident ordered medication online and that the medications on the floor were not in the resident's physician's orders. LPN #3 stated the resident was not allowed to self-administer medications and was unsure whether the resident had been assessed for self-administration. LPN #3 was unsure of how staff were aware that the resident was capable and safe to self-administer. In an interview on 06/14/2022 at 12:14 PM, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) stated the resident ordered medication online. The ADON stated the resident would not allow the facility to complete a self-administration assessment to see if the resident could safely self-administer medications, and that the resident ordered the medications online and would not provide the medication to the facility. The ADON stated they had provided the resident with education and talked to the resident about ordering medication online. The DON stated the resident's physician was aware the resident self-administered medication. The DON stated the resident ordered one medication, dimethyl fumarate, from the resident's pharmacy. The DON stated the facility could not go through the resident's medications or take any of the resident's possessions and that the resident denied having medications in the room. The ADON stated the resident was not capable of safely administering medications; however, the resident would not allow staff to assess the resident to safely administer medications. The DON stated the resident dropped medication on the floor and refused to allow staff to pick them up or remove them. The ADON was unaware of which medications were in the resident's room, due to the resident refusing to allow staff to look in room. The DON stated the facility did not have the right to take the resident's medications, could not go through the resident's packages, and just notified the doctor. The DON agreed that allowing the resident to have medications that the resident had not been assessed to safely administer could compromise the resident's safety. The ADON stated the resident was an adult and can make [his/her] own decisions, so has that right to keep the medications. In a phone interview on 06/14/2022 at 3:42 PM, the Medical Doctor (MD) stated that Nurse Practitioner (NP) #1 would be able to answer questions regarding Resident #103. In an interview on 06/15/2022 at 10:30 AM, LPN #1 stated the resident was not allowed to self-administer medications and she did not know if the resident had been assessed to self-administer. LPN #1 stated she did not think the resident could safely administer medications. In an interview on 06/15/2022 at 5:17 PM, LPN #2 stated the resident was not allowed to self-administer medications and had not been assessed to self-administer medications. On 06/15/2022, NP #1 was in the facility and was with a resident. The surveyor asked for the NP to speak with the surveyor when time allowed. The NP left the facility without speaking with the surveyor. In an interview on 06/16/2022 at 12:26 PM, the DON stated that NP #1 declined to speak to the surveyors. In an interview on 06/16/2022 at 12:59 PM, the Administrator (ADM) stated the resident should have a self-administration assessment. The ADM stated the facility should ask permission to see what medications the resident ordered and contact the doctor to see if it was appropriate for the resident to take or not. The ADM stated that the facility was ultimately responsible if the facility knew the resident was ordering his/her own medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to protect the rights of 2 of 2 sampled residents (Resident #102 and Resident #81) to formulate an advance directive. The facility failed to ensure information about whether the resident had executed an advance directive was in the residents' medical record as required by facility policy. Findings included: A review of the facility's policy titled, Advanced Directives, revised [DATE], indicated, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so .7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1. A review of Resident #102's admission Record revealed the facility admitted the resident on [DATE] with diagnoses of multiple sclerosis, adult failure to thrive, and chronic obstructive pulmonary disease. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. A review Resident #102's electronic health record (EHR) on [DATE] at 12:54 PM revealed no documentation regarding whether the resident had formulated advance directives. A record review on [DATE] at 4:44 PM revealed the Medical Orders for Scope of Treatment (MOST) binder, located at the nurse's station, did not contain any information regarding Resident #102's advance directives. During an interview on [DATE] at 1:57 PM with the Administrator, Resident #102's advance directive information was requested. During an interview on [DATE] at 4:45 PM with the Director of Nursing (DON), the DON brought in a MOST form for Resident #102 that was signed and dated by the resident and physician that day, [DATE]. The DON stated she did not know why it was signed on [DATE] and not when the resident was admitted . According to the MOST form, Resident #102 requested resuscitation not be attempted if cardiopulmonary arrest should occur. During an interview on [DATE] at 12:06 PM, the DON stated advance directives should be initiated by the nurse on admission. The social worker and nursing department should work together to get it completed. The DON stated residents' advance directives should be accessible in the residents' medical record and were kept in a book on the unit where the resident resided. The DON stated a copy should also be downloaded in the EHR. The DON stated if the facility did not obtain advance directives timely, the facility could not honor the resident's wishes. According to the DON, if the facility did not have a signed form, the facility presumed the resident was a full code (cardiopulmonary resuscitation [CPR] would be provided). During an interview on [DATE] at 12:55 PM, the Administrator stated that the social worker was responsible for completing residents' advance directives and they should be completed right away, within a few days of admission. The Administrator stated advance directives should also be accessible in the resident's medical record. During an interview on [DATE] at 9:20 AM, Social Worker (SW) #1 stated upon admission, nursing staff and the social worker should ensure advance directives were obtained. SW #1 stated nursing staff went over the MOST form with the resident, the doctor signed the form, and the SW reviewed them quarterly to see if there were any changes. SW #1 stated if there was not a MOST form in the binder, then a new one should be initiated. 2. A review of Resident #81's admission Record revealed the facility admitted the resident on [DATE] with diagnoses of end stage renal disease, kidney transplant failure, and type I diabetes mellitus. A review of a significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. A review of Resident #81's electronic health record (EHR) on [DATE] at 2:19 PM revealed no documented evidence regarding the resident's advance directives. A record review on [DATE] at 4:47 PM revealed the Medical Orders for Scope of Treatment (MOST) binder, located at the nurse's station, contained a Colorado MOST form that was not signed by the resident/resident representative or the resident's physician. According to the MOST form, cardiopulmonary resuscitation (CPR) was requested. During an interview on [DATE] at 4:45 PM, the Director of Nursing (DON) brought in a MOST form for Resident #102 that was signed and dated by the resident and physician that day, [DATE]. The DON stated she did not know why it was not signed until [DATE]. During an interview on [DATE] at 12:55 PM, the Administrator stated that the social worker was responsible for ensuring residents' advance directives were completed and they should be completed right away, within a few days of admission. During an interview on [DATE] at 9:20 AM, Social Worker (SW) #1 stated the MOST form should have a doctor's signature to be in compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure staff promoted dignity and provided privacy during medication administration for 1 of 5 residents (Resident #82) observed during medication administration. Specifically, staff failed to announce entry into the room or knock on the door prior to entry into the room and failed to pull the privacy curtain and close the door while providing medications to Resident #82 through a PEG (percutaneous endoscopic gastrostomy) tube. Findings included: A review of the facility's policy, Quality of Life - Dignity, revised February 2020, revealed 5. Staff are expected to knock and request permission before entering resident's room .10. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of the admission Record revealed the facility admitted Resident #82 with diagnoses that included hemiplegia and hemiparesis affecting the right dominant side, dysphagia, an encounter for attention to gastrostomy (PEG), and tracheostomy. A review of the significant change Minimum Data Set (MDS, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the resident had a feeding (PEG) tube. A review of Resident #82's care plan, revised on 03/18/2022, indicated Resident #82 had a communication problem related to neurological symptoms, stroke, aphasia, and was non-verbal. Interventions included the resident needed yes or no questions that the resident could respond to by nodding. The care plan further indicated that staff may need to repeat for understanding since the resident was non-verbal. During an observation and interview on 06/15/2022 at 8:27 AM, Registered Nurse (RN) #1 was completing the morning administration of medication to residents. RN #1 entered Resident #82's room without knocking or announcing entry. Resident #82 was lying in bed with the head of the bed elevated approximately 30 degrees. RN #1 stopped the PEG tube machine to administer medications. RN #1 did not close the resident's door or pull the curtain for privacy. After administering most of the resident's medication, RN #1 left the room to replace a medication that had been spilled. Upon return to the room, RN #1 again did not knock before entering the resident's room or pull the curtain closed for privacy. After the observation, RN #1 stated that he was supposed to knock on the door before entering but he did not either time because he was holding medication and the door was already open. On 06/16/2022 at 12:14 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed together. The DON stated the facility policy on dignity and privacy when a resident was receiving care in their room was that the curtain should be pulled, and the door should be closed. During an interview on 06/16/2022 at 12:57 PM, the Administrator (ADM) stated that anyone that entered a resident room had to knock before entering because it was the resident's home. The ADM stated that if the resident was having a treatment done, the privacy curtain should be drawn, the door should be closed, and the blinds closed.

Based on interview, record review, and review of facility policy, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 (Resident #86) of 2 residents reviewed for PASARR. Specifically, the facility failed to complete a Level 1 PASARR for Resident #86, who was admitted to the facility with a diagnosis of schizophrenia and seizure disorder. Findings included: A review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR), reviewed 08/11/2020, revealed, All individuals who are admitted to a Medicaid certified nursing facility must have a level 1 PASSR completed to screen for possible mental illness (MI), intellectual disability (ID), (mental retardation (MR) in federal regulation)/developmental disability (DD), or related conditions regardless of the resident's method of payment. A review of Resident #86's admission Record revealed the facility admitted the resident on 08/17/2021. Resident #86 had diagnoses that included schizophrenia and seizure disorder. According to the admission Record, both diagnoses were present upon admission to the facility. A review of Resident #86's electronic health record (EHR) revealed no documented evidence a Level 1 PASARR was completed for the resident. A review of a letter to the facility, dated 08/30/2021, from the Utilization Review and Utilization Management contractor for Long Term Care Medicaid in the state of Colorado, revealed the company required more information from the facility to complete the Level 1 PASRR review for Resident #86's. The letter indicated in order to process the review, the facility needed to provide a document to indicate the age of the resident when the specific diagnosis of seizures manifested or was first diagnosed. The letter indicated if the additional information was not received within five days, the case would be technically denied due to not receiving documentation. In an interview on 06/15/2022 at 2:24 PM, Social Worker (SW) #1, after looking in the computer, through a paper file, and a PASARR binder, confirmed she did not see a PASSAR for Resident #86. A follow-up interview on 06/15/2022 at 4:57 PM with SW #1 revealed a PASARR request for Resident #86 was submitted in August 2021 for a seizure diagnosis. SW #1 stated that additional information was requested to complete the PASARR, but the information was not resubmitted within the 5-day timeframe; subsequently, a PASARR for the resident was never completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident's care plan was updated to address self-administration of medication and refusal of housekeeping services for 1 (Resident #103) of 34 sampled residents whose care plans were reviewed. Cross Reference F554, Resident self-administering medications where clinically appropriate. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive, person-centered care plan would, b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. The policy indicated the care plan would also, g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident's strengths; j. Reflect the resident's expressed wishes regarding care and treatment goals. Per the policy, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change and 15. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies. Review of an admission Record revealed the facility admitted Resident #103 on 10/01/2021 with diagnoses including multiple sclerosis (MS), rhabdomyolysis, and major depressive disorder. The significant change Minimum Data Set (MDS), dated [DATE], revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Per the MDS, the resident exhibited verbal behavioral symptoms directed toward others and rejected evaluation or care on one to three days during the assessment period. During an observation and interview on 06/13/2022 at 1:14 PM, Resident #103's bedroom door had a handwritten note stating the resident was not to be awakened until after 10:00 AM. Upon entrance into the resident's room, it was observed that the room was very dirty, with trash all over the floor and opened food containers. Next to the resident's bed, there were numerous pills on the floor, which included pink oblong pills, white round pills, and white oblong pills. The resident stated one was a Benadryl, one was Tylenol, and one was another allergy medication. The resident stated all the medications belonged to him/her and that he/she had them inside a drinking cup with pens and a hairbrush and had knocked over the cup and spilled the medications on the floor, where they stayed. The resident stated the medications were in a cabinet drawer next to the bed; however, the resident refused to show the surveyor the contents of the drawer. The resident stated he/she did not allow housekeeping to come in the room to clean due to having post-traumatic stress disorder (PTSD). A review of Resident #103's care plan, updated on 05/03/2022, indicated Resident #103 had multiple sclerosis affecting their vision, depressive behaviors, muscle spasms, and pain and to provide the resident's medications as ordered as well as to monitor and document side effects and effectiveness. The care plan also indicated Resident #103 used psychotropic medications related to behavior management and had episodes of yelling at staff and declining care. The care plan did not address the resident's ability to self-administer medications or the refusal to allow housekeeping to clean the room. A review of the June 2022 physician's orders revealed no order for Benadryl, Tylenol, or a generic allergy medication. In an interview on 06/14/2022 at 10:53 AM, Social Worker (SW) #1 stated she had been in the resident's room that day and that there was a lot of trash and things of that nature on the resident's floor. SW #1 had asked the resident to allow her to move some of it, and the resident declined. SW #1 stated the resident would tell staff to vacate the room and did not want the staff in the room. SW #1 stated it was nursing and social services' responsibility to update the resident's care plan, and the resident's refusal of services should be care planned. In an observation with SW #1 on 06/14/2022 at 11:01 AM, Resident #103's room was in the same condition as the previous day. SW #1 acknowledged the room was dirty and there were unknown medications on the resident's floor. In an interview on 06/14/2022 at 11:07 AM, Registered Nurse (RN) #1 stated the resident was not allowed to self-administer medications but ordered his/her own medication and refused to give it to the facility. The facility staff had documented this, and the Director of Nursing (DON) was aware. RN #1 stated the resident had Tylenol in his/her room and, whenever the resident took it, the resident was supposed to let the nurse know so it could be documented. RN #1 stated he was only aware of the Tylenol the resident had. RN #1 stated the resident had not been assessed for self-administration of medication. When asked how staff knew that the resident was capable and safe to self-administer, he stated, We only have the requirement of [Resident #103] notifying us when [he/she] takes the Tylenol. RN #1 stated he was unaware of the medications on the resident's floor due to the amount of clutter in the resident's room. During an interview and observation on 06/14/2022 at 11:22 AM, Licensed Practical Nurse (LPN) Unit Manager #3 entered the resident's room and told the resident that she was notified there were medications on the resident's floor. The resident replied, So? The staff stated the medications could not be on the floor, then exited the resident's room. LPN #3 stated the medications on the resident's floor were not provided to the resident by the facility. LPN #3 stated the resident ordered medication online, and the medications on the floor were not on the resident's physician's orders. LPN #3 stated the resident was not allowed to self-administer medications and was unsure if the resident had been assessed for self-administration. LPN #3 was not sure how staff were aware that the resident was capable and safe to self-administer. LPN #3 stated that housekeeping could only, do what they can. In an interview on 06/14/2022 at 12:14 PM, the Assistant Director of Nursing (ADON) and DON stated the resident ordered medication online. The ADON stated the resident would not allow the facility to complete a self-administration assessment to see if the resident could safely self-administer medications and that the resident ordered the medications online and would not provide the medication to the facility. The ADON stated they had provided the resident with education and talked to the resident about ordering medication online. The DON stated the resident's physician was aware the resident self-administered medication. The DON stated that the resident ordered one medication, dimethyl fumarate, from a pharmacy. The DON stated the facility could not go through the resident's medications or take any of the resident's possessions, and the resident denied having medications in their room. The ADON stated the resident was not capable of safely administering medications; however, the resident would not allow staff to assess the resident. The DON stated the resident dropped medication on the floor and refused to allow staff to pick them up or remove them. The ADON stated they were unaware of which medications were in the resident's room due to the resident refusing to allow staff to look in the room. The DON stated the facility did not have the right to take the resident's medications and could not go through the resident's packages, just notified the doctor. The DON acknowledged that allowing the resident to have medications that the resident had not been assessed to safely administer could compromise the resident's safety. The ADON stated the resident was, an adult and can make [his/her] own decisions, so [he/she] has that right to keep the medications. Both the DON and ADON stated the self-administration of medication and refusal of housekeeping services should be care planned. In an interview on 06/16/2022 at 12:59 PM, the Administrator (ADM) stated the resident's refusal of housekeeping services should be care planned, as well as the self-administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policy review, the facility failed to provide appropriate treatment and services to prevent complications from an indwelling urinary catheter for 1 (Resident #160) of 2 sampled residents with indwelling catheters. Specifically, the facility failed to ensure there were physician's orders and a care plan that addressed the use, care, and monitoring of an indwelling urinary catheter for Resident #160. Findings included: A review of the facility policy titled, Catheter Care, Urinary, revised September 2014, revealed, The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. The policy also indicated, Complications: 1. Observe the resident for complications associated with urinary catheters. a. If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor. b. Check the urine for unusual appearance. c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed. d. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. Further review of the policy revealed, Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. A review of an admission Record revealed the facility admitted Resident #160 on 05/21/2022 and readmitted the resident on 06/06/2022, with diagnoses including neuromuscular dysfunction of bladder, type 2 diabetes mellitus, and local infection of the skin and subcutaneous tissue. Review of a Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status. The MDS indicated the resident had an indwelling catheter. Review of the care plan revealed undated special instructions indicating the resident had a urinary catheter in place that was draining well. The care plan did not address the care or monitoring required for the catheter. In an interview on 06/13/2022 at 9:42 AM, the resident stated the urinary catheter was in place because of large bed sores, which were present upon admission to the facility. Review of a Medication Review Summary, dated 06/16/2022, revealed there was no current physician's order for an indwelling urinary catheter, nor for staff to monitor and care for the catheter. Observation on 06/16/2022 at 8:18 AM revealed a urinary catheter hanging at the resident's bedside with very little urine visible in the drainage bag. The urine was clear and yellow. The resident was interviewed at this time and stated the staff had been emptying the catheter bag as needed. During an interview on 06/16/2022 at 10:17 AM, Licensed Practical Nurse (LPN) #1 stated if there was no order for the urinary catheter, then there would not be any documentation of any care provided for the catheter. LPN #1 stated she would have to get a physician's order. LPN #1 confirmed that staff had been emptying the catheter bag. During an interview on 06/16/2022 at 1:14 PM, the Director of Nursing (DON) stated that when a resident was admitted with a urinary catheter, an order should be present on admission with the diagnosis that necessitated the catheter, as well as the care and treatment needed for the catheter. The DON stated the nurse should have caught the lack of an order for the catheter upon admission. During an interview on 06/16/2022 at 2:53 PM, the Administrator stated he would expect anyone who was admitted with a catheter to have a plan in place to discontinue the catheter as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 2 of 4 residents (Resident #86 and Resident #82) reviewed for tube feeding. Specifically, the facility failed to provide the correct tube feeding formula according to physician orders for Resident #86 and failed to appropriately check tube placement prior to administering medications for Resident #82. Findings included: 1. A review of the facility policy titled, Enteral Tube Feeding via Continuous Pump, revised November 2018, revealed, General Guidelines: .3. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID and room number; b. Type of formula .Initiate Feeding: .5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. A review of Resident #86's admission Record revealed the resident had diagnoses that included metabolic encephalopathy, dysphagia, Parkinson's disease, type 2 diabetes mellitus, and gastro-esophageal reflux. A review of Resident #86's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a feeding tube and had sustained a weight loss due to a physician-prescribed weight-loss regimen. A review of Resident #86's care plan, revised 04/30/2022, indicated Resident #86 was at increased nutritional risk related to taking nothing by mouth (NPO), having a feeding tube, protein calorie malnutrition, being overweight, and potential for weight fluctuation. The goal was for Resident #86 to tolerate enteral (tube feeding) nutrition with minimal signs and symptoms of gastrointestinal distress and maintain a current weight, or to have a gradual weight loss closer toward normal body mass index. Interventions included providing tube feeding as ordered. A review of Resident #86's Order Summary Report revealed an order dated 04/26/2022 for continuous tube feeding of Formula Vital 1.2 at 56 cc (cubic centimeters)/hour (Nutritional Information: 1344 cc, 1612 calories). A review of the nutrition Progress Notes, dated 05/26/2022, revealed RD #2 visually verified the tube feeding was running as ordered. The progress note did not document any change of tube feeding formula. A review of Resident #86's Medication Administration Record revealed staff documented on 06/14/2022 and 06/15/2022 that the resident received Vital 1.2 formula. Observation on 06/14/2022 at 3:14 PM revealed Resident #86 lying in bed with Vital 1.5 (not 1.2 as ordered) formula hanging and infusing at 56 milliliters (ml) per hour. The bottle was labeled as being hung on 06/13/2022 at 2:00 PM. Observation on 06/15/2022 at 4:00 PM revealed Resident #86 lying in bed with Vital 1.5 formula hanging and infusing at 56 cc/hr. The bottle was labeled as being hung on 06/14/2022 at 2:00 PM. In an interview on 06/15/2022 at 4:05 PM, Registered Nurse (RN) #1 stated the facility ran out of Vital 1.2 tube feeding formula and two to three weeks ago the RN contacted Registered Dietitian (RD) #2, who stated Resident #86's feeding could be changed to Vital 1.5. RN #1 stated the physician's order should have been modified to reflect the change. The RN stated RD #2 would normally make the change or ask the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) to make the change. An interview on 06/16/2022 at 11:48 AM with RD #1 revealed RD #2 was not able to be reached by phone. RD #1 stated that if the facility ran out of a tube feeding formula, she would expect nursing staff to notify the RD. The RD would check to see what substitute formulas were available. The RD would then recalculate calorie needs and water flushes to avoid over or under feeding the resident. RD #1 stated the RD would make the recommendation to change the order and the DON or the ADON would change the physician's order. RD #1 stated she would expect nursing to verify that they were using the correct product and monitor for any intolerance with the new product. A review of Progress Notes dated 06/15/2022 at 7:00 PM revealed there was a medication error. Vital 1.5 was hung instead of Vital 1.2 by error. In an interview on 06/16/2022 at 1:14 PM, the DON stated if they ran out of a tube feeding formula, the nurse should go to the RD and get a recommendation for something comparable. The DON or ADON would call the physician for a new order. The DON stated the correct formula was available and RN #1 admitted he had hung the incorrect formula; subsequently, she asked RN #1 to write up a medication error. In an interview on 06/16/2022 at 2:53 PM, the facility Administrator stated the correct formula was available, and RN #1 could have picked up the wrong bag. The Administrator stated nursing staff should verify the formula before administering it to a resident. 2. A review of a facility policy titled, Enteral Tube Feeding via Continuous Pump, revised November 2018, indicated the steps in the enteral feed process included: 8. Verify placement of tube. 9. If anything suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 10. When correct tube placement has been verified, flushing tubing with at least 30 mL [milliliters] warm water. Review of an admission Record revealed Resident #82 had diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) affecting the right dominant side, encounter for attention to gastrostomy (percutaneous endoscopic gastrostomy/PEG - an opening through the abdomen into the stomach to allow tube feedings), and tracheostomy (a surgical opening through the neck into the trachea). The significant change Minimum Data Set (MDS), dated [DATE], revealed the resident scored 0 on a Brief Interview for Mental Status (BIMS), which indicated the resident was severely cognitively impaired. A review of the care plan, revised 03/28/2022, indicated the resident was at increased nutritional risk related to hemiplegia, dysphagia, PEG, and tracheostomy. Interventions included to check placement and check residuals (volume of residual stomach contents) as ordered. A review of the June 2022 Medication Review Summary indicated staff were to verify PEG-tube placement and measure residual stomach contents on every shift, with a start date of 03/23/2022. During an observation and interview on 06/15/2022 at 8:27 AM, the surveyor observed Registered Nurse (RN) #1 as the morning medication administration was completed. Before administering Resident #82's crushed medications via PEG tube, RN #1 did not check placement via auscultation or check for residual stomach contents. RN #1 did not lift the resident's gown to monitor the resident's stomach for distention. RN #1 had crushed each medication individually and added approximately 5-10 milliliters (mL) of water to each medication. RN #1 flushed the resident's tube with 30mL of water before administering each medication individually. After the observation, RN #1 stated to check placement for the PEG tube, he looked at the abdomen for distention and also stated, I see with my eyes. RN #1 stated that he only checked for residual if the resident's abdomen was distended. A review of the June 2022 Medication Administration Record (MAR) revealed RN #1 documented on 06/15/2022, on day shift, that he checked placement and there was no measurable volume of residual stomach contents. During an interview on 06/16/2022 at 12:14 PM, the Director of Nursing (DON) stated staff should check placement by listening to the swoosh with the air and to check for residual before administering medication via PEG tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident #26's admission Record revealed diagnoses that included dementia with behavior disturbance, cognitive communication deficit, major depressive disorder, anxiety disorder, hoarding disorder, and obsessive-compulsive disorder. A review of Resident #26's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #26 scored a 12 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The MDS revealed that Resident #26 experienced hallucinations and delusions and exhibited physical and verbal behaviors during the assessment period. Resident #26 received antipsychotics and antidepressants seven of seven days of the look-back period according to the MDS. Review of Resident #26's care plan, revised 03/18/2022, revealed Resident #26 received psychotropic medications related to dementia with behaviors, obsessive compulsive disorder, worried, and stressed. Goals included for Resident #26 to be free of drug-related complications and to reduce the use of psychotropic medications through the next review date. Interventions included for staff to administer medications as ordered, consult with the pharmacy and physician to consider a dosage reduction when clinically appropriate, and discuss with the physician and family the need for ongoing use of the medications. A review of Resident #26's Order Summary Report for June 2022 revealed an order for 2 milligrams (mg) per milliliter (ml) of Ativan solution (lorazepam; benzodiazepine; sedative/hypnotic) with a start date of 05/18/2022. The order directed staff to inject 2 mg/ml intramuscularly every 12 hours PRN (pro re nata; as needed) for agitation. A review of a Note to Attending Physician/Prescriber, dated 05/29/2022, revealed the Consultant Pharmacist made a recommendation that PRN psychotropic orders could not exceed 14 days without a rationale in the resident's medical record and indicating a duration for the PRN order. One of the options the pharmacist recommended considering was to discontinue the PRN lorazepam. The recommendation to discontinue the lorazepam was checked on the form and was signed by the physician assistant (but not dated). A review of Resident #26's Medication Administration Record for June 2022 indicated Resident #26 had received the Ativan (lorazepam) on 06/02/2022, 06/04/2022, 06/05/2022, and 06/10/2022 for a total of four doses. In an interview on 06/15/2022 at 2:30 PM, the Pharmacist was interviewed. The Pharmacist stated she expected her recommendation to be transcribed to the current MAR as soon as a physician signed the recommendation. In an interview on 06/17/2022 at 8:42 AM, the Director of Nursing (DON) stated she was in the process of changing the process for physician recommendations. The DON stated the recommendations currently went through medical records. The DON stated the recommendations were given to the medical records person, who obtained physician signatures and then distributed to the unit managers, who then transcribed the orders into the medical record. The DON stated she was not sure what happened with the recommendations from 05/29/2022, but there was obviously a problem with the recommendations from that day being implemented. In an interview on 06/17/2022 at 9:13 AM, Licensed Practical Nurse (LPN) #4 (the unit manager) stated she never received the recommendation from 05/29/2022. LPN #4 stated she would have discontinued the medication immediately if she had seen the recommendation. LPN #4 stated the medical records person was responsible for putting them in her box so she could then transcribe it to the orders. Based on record review and interviews, the facility failed to ensure residents did not receive psychotropic medications at an excessive dose by failing to implement pharmacy recommendations for decreases in dosage and discontinuation of a psychotropic medication, which had been agreed to and signed for by the physician, for 3 (Resident #32, #26 & #126) of 7 sampled residents reviewed for unnecessary medications. Findings included: A review of the facility's policy titled, Medication Monitoring Medication Management, dated 2007, revealed Policy: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug in excessive dose .Based on a comprehensive assessment of a resident, the facility must insure: .Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in effort to discontinue these drugs. PRN [as needed] orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order .Identifying Opportunities for Gradual Dose Reductions: There are various opportunities during the care process to evaluate the effects of medications on a resident's physical, mental, and psychosocial well-being, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modified. Examples of these opportunities include: During the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medications; When evaluating the resident's progress, the attending physician or prescribing practitioner reviews the total plan of care, orders, the resident's response to medication(s), and determines whether to continue, modify, or stop a medication. 1. A review of Resident #32's admission Record revealed the facility admitted Resident #32 with multiple diagnoses including cancer, hypertension, and depression. A review of Resident #32's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #32's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. The MDS indicated the resident received an antidepressant medication for seven of seven days of the look-back period. A review of the care plan, dated 03/22/2022, revealed Resident #32 received antidepressant medication related to depression. Interventions included to administer antidepressant medications as ordered by the physician. A review of Resident #32's Order Summary Report for May 2022 and June 2022 indicated an order for one tablet of paroxetine (an antidepressant) 10 milligrams (mg) by mouth at bedtime with a start date of 07/07/2021 and an end date of 05/05/2022. On 05/05/2022 the order was changed to one tablet of paroxetine 10 mg by mouth at bedtime every day except for Sunday. A review of a Note to Attending Physician/Prescriber revealed on 04/29/2022, the Pharmacy Consultant recommended to decrease paroxetine from 10 mg daily to 5 mg daily. It was determined that a dose reduction was recommended due to staff noting the resident was doing well with few or no depressive symptoms. On 05/08/2022, the physician responded to the recommendation indicating the recommendation of paroxetine 5 mg every day was accepted. Review of Resident #32's Medication Administration Record [MAR] for May 2022 and June 2022 revealed that paroxetine was not decreased from 10 mg to 5 mg as recommended by the pharmacist and accepted by the physician. The MARs indicated Resident #32 received 10 mg dosing of paroxetine instead of 5 mg for the months of May 2022 and June 2022. The Nurse Practitioner (NP) was unavailable for an interview during the survey. In an interview on 06/15/2022 at 2:30 PM, the Pharmacist was interviewed. The Pharmacist stated she expected her recommendation to be transcribed to the current MAR as soon as a physician signed the recommendation. The Pharmacist indicated she was not aware that Resident #32's recommendation was not transcribed to the May 2022 or June 2022 MARs. In an interview on 06/15/2022 at 2:40 PM, Licensed Practical Nurse (LPN) #4 (the unit manager) stated she had not seen the pharmacy recommendation signed by the physician on 05/08/2022 indicating a decrease of the paroxetine medication from 10 mg to 5 mg. LPN #4 indicated the pharmacy recommendations were usually emailed to medical records staff who printed them and had the physician sign the form. Per LPN #4, the recommendations were then given to the unit managers to transcribe to the MAR. In an interview on 06/15/2022 at 2:52 PM, Medical Records (MR) #1 stated after Resident #32's recommendation was signed by the physician, she did not recall giving the signed pharmacy recommendation to the unit manager. In an interview on 06/15/2022 at 2:54 PM, the Director of Nursing (DON) was interviewed. The DON stated that unit managers were responsible for the implementation of the pharmacy recommendations. She indicated MR #1 was responsible for getting the signature from the physician before giving it to the unit manager. The DON indicated starting immediately she was going to assign a nurse who would make sure the pharmacy recommendations were signed then transcribed to the MAR. In an interview on 06/16/2022 at 10:25 AM, the Administrator stated that his expectation was for the pharmacy recommendation for Resident #32 to have been transcribed to the MAR as soon as the physician signed the pharmacist recommendation. 2. A review of the admission Record revealed the facility admitted Resident #126 with diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, bipolar disorder, anxiety disorder, major depressive disorder, and polyneuropathy. A review of Resident #126's admission Minimum Data Set (MDS), dated [DATE], revealed Resident #126 had a Brief Interview for Mental Status (BIMS) score 13, which indicated intact cognition. The MDS indicated Resident #126 received an antianxiety and antidepressant for six of seven days of the look-back period. A review of Resident #126's care plan, dated 05/11/2022, revealed the resident used psychotropic medications related to depression and anxiety. Interventions directed staff to administer psychotropic medications as ordered by the physician and consult with pharmacy and the medical doctor to consider a dosage reduction when clinically appropriate at least quarterly. A review of Resident #126's June 2022 Medication Administration Record revealed the resident was receiving three 7.5 milligram (mg) capsules (total of 22.5 mg) of temazepam (benzodiazepine; sedative/hypnotic) by mouth at bedtime for insomnia. A review of a Note to Attending Physician/Prescriber, dated 05/29/2022, revealed the Consultant Pharmacist made a recommendation to decrease the temazepam to the recommended dose of 7.5 mg every night. The Consultant Pharmacist indicated the order for 22.5 mg of temazepam every night exceeded the manufacturer's recommended dosage for geriatric patients. The resident also received 0.5 mg of lorazepam (benzodiazepine; sedative/hypnotic) every six hours routinely, which was duplicate benzodiazepine use. On 06/03/2022 the physician agreed to the recommendation to decrease the temazepam to 7.5 mg every night and signed the form. A review of Resident #126's June 2022 Medication Administration Record revealed the resident continued receiving three 7.5 mg capsules of temazepam by mouth at bedtime after the physician agreed to decrease the dose on 06/03/2022. In an interview on 06/15/2022 at 2:30 PM, the Pharmacist was interviewed. The Pharmacist stated she expected her recommendation to be transcribed to the current MAR as soon as a physician signed the recommendation. During an interview on 06/16/2022 at 1:09 PM, the Director of Nursing (DON) indicated that the order for the decrease in temazepam did not get transcribed after the physician signed the recommendation. The DON further indicated that it was her expectation that the order would be transcribed after the doctor signed off on it. During an interview on 06/17/2022 at 8:28 AM, Licensed Practical Nurse (LPN) #5 (the unit manager) indicated that he had not seen the pharmacist recommendation for Resident #126 dated 05/29/2022. LPN #5 indicated that medical records staff was responsible for getting the pharmacy recommendation to the unit managers so that the orders could be transcribed. LPN #5 indicated that when he received a pharmacist recommendation signed by the doctor, the order was transcribed immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors related to insulin administration for 1 (Resident #82) of 5 residents reviewed for medication administration. Findings included: A review of a facility policy titled, Medication Administration General Guidelines, dated September 2018, revealed, Medication Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .14. Medications are administered within 60 minutes of scheduled time .16. Medications supplied for one resident are never administered to another resident .Documentation: .2. If a dose of regularly scheduled medication is withheld, refused, or give at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed) the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN [as needed] documentation. A review of Resident #82's admission Record revealed the resident had diagnoses that included type 2 diabetes, hemiplegia and hemiparesis affecting the right dominant side, a feeding tube, and a tracheostomy. The significant change Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated Resident #82 was severely cognitively impaired. According to the MDS, the resident received insulin injections the last seven days. A review of Resident #82's care plan, revised on 02/23/2022, revealed the resident was as risk for altered endocrine status related to diabetes mellitus and had an intervention to administer diabetes medication as ordered by the doctor and to monitor/document side effects and effectiveness. A review of Resident #82's June 2022 Order Summary Report revealed an order with a start date of 12/20/2021 to inject 10 units of Lantus SoloStar Solution (insulin) Pen-injector (100 units per milliliter [ml]) two times a day. On 06/15/2022 at 8:27 AM, Registered Nurse (RN) #1 was observed completing the morning administration of medication to residents. An interview with RN #1 revealed Resident #82 had an order for Lantus insulin that was due during the observation of the medication administration. However, the medication had been ordered yesterday and was not in the facility; subsequently RN #1 stated the RN would not be administering the medication. A review of Resident #82's June 2022 Medication Administration Record [MAR] indicated that RN #1 administered Lantus insulin to the resident on the morning of 06/15/2021, and the resident's blood glucose level was 169. During an interview on 06/15/2022 at 12:09 PM, RN #1 stated the RN checked Resident #82's blood glucose level at 11:30 AM and it was 182. RN #1 stated they administered Lantus insulin to Resident #82 from Resident #104's Lantus until the RN received Resident #82's medication pen from the pharmacy. RN #1 stated the RN used the medication because it was an emergency, and the facility would not be able to reimburse or give it [insulin] back to Resident #104. Further interview revealed RN #1 did not notify the resident's doctor of the late insulin dose or that another resident's medication was used. A review of the medication label for Resident #104's insulin revealed the vial contained Lantus 100 unit/ml. A review of Resident #82's Progress Notes revealed the last documented note was dated 06/11/2022. There was no documentation regarding the resident's insulin for 06/15/2022. During an interview on 06/16/2022 at 12:06 PM, the Director of Nursing (DON) stated if an insulin pen was not in the facility and the medication was due, the nurse should check the emergency medication kit (E-Kit), notify the physician, and call the pharmacy to see if there was an alternative medication that could be provided to the resident. The DON stated the nurse had to call the physician to notify them of the issue. The DON stated that staff were not allowed to use another resident's insulin. During an interview on 06/16/2022 at 12:55 PM, the Administrator stated that if an insulin pen was not in the facility and the medication was due, the nurse should call the doctor and tell them the medication was not available. The Administrator stated staff were not allowed to use another resident's insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure that food was protected from contamination during delivery to resident rooms. Specifically, the facility failed to ensure food items were covered while being transported in the hall to resident rooms. The deficient practice affected 3 (500 Hall, 300 Hall, and 200 Hall) of 4 units observed. Findings included: A review of the facility policy, titled Meal Distribution, dated 09/2017, indicated, All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. A review of the FDA [Food and Drug Administration] Food Code 2017 subpart 3-305.14 Food Preparation, indicated, During preparation, unpackaged food shall be protected from environmental sources of contamination. During an observation of the lunch meal service on 06/13/2022 at 12:14 PM, the surveyor observed the 500 Hall lunch trays on a baker's cart covered with a plastic bag. The cart was outside of room [ROOM NUMBER]. A certified nurse aide (CNA) removed a tray and carried it in the hall to room [ROOM NUMBER] with pears on the tray uncovered. The CNA then removed another tray and carried it to the main lobby area of the unit and set it at an unoccupied table. The applesauce on the tray was uncovered. At 12:17 PM, Resident #156 came into area and sat down to eat. Resident #156 ate 100% of the applesauce. During an observation of the lunch meal service on 06/14/2022 at 12:03 PM, the surveyor observed CNA #1 roll the covered tray cart down the 300 Hall to outside room [ROOM NUMBER]'s door. CNA #1 carried a food tray to room [ROOM NUMBER] with pasta salad uncovered on the tray. The CNA then delivered individual trays to Rooms 311, 310, 306, 304, 301, and 302 with the pasta salad uncovered on each tray. During an observation of the lunch meal service on 06/14/2022 at 12:50 PM, the surveyor observed the plastic cover on the 200 Hall meal cart had been lifted to the top of the cart, revealing the trays on the cart. CNA #2 rolled the uncovered cart down the hall, delivering trays to resident rooms. The pasta salad was uncovered on each tray. During an interview on 06/14/2022 at 1:03 PM, CNA #2 stated the trays were covered in the kitchen so that people would not touch the food. CNA #2 stated the carts should only be opened when they are removing the trays for delivering to resident rooms. During an observation of the lunch meal service on 06/15/2022 at 12:00 PM, the surveyor observed CNA #3 remove the plastic cover and rolled the uncovered cart to the 500 Hall. Peaches with whipped topping were observed to be uncovered on all trays. CNA #3 proceeded to deliver trays to the rooms on 500 Hall. During an interview on 06/15/2022 at 12:05 PM, CNA #3 stated this was her first time delivering trays and had received no training. CNA #3 stated the plastic cover was to keep germs off but did not have an answer as to what happened when she removed the plastic cover to push the cart down the hall. During an observation of the lunch meal service on 06/15/2022 at 12:07 PM, the surveyor observed CNA #4 park the covered food cart by room [ROOM NUMBER]. CNA #4 removed a tray from the cart and carried it to a room at the other end of the hall. During an interview on 06/15/2022 at 12:09 PM, CNA #4 stated the plastic cover was meant to keep everything clean. CNA #4 stated when she removed the tray from the covered cart, the dome still covered it. CNA #4 stated the dessert should have been covered by the kitchen. During an interview on 06/15/2022 at 12:10 PM, CNA #1 stated the plastic cover was to make sure nobody touched or sneezed on it. CNA #1 stated when she removed the tray out and carried it down the hallway, it should be covered. During an interview on 06/15/2022 at 2:17 PM, the Dietary Manager (DM) stated that the nursing staff were responsible for serving trays. The DM stated that the trays going down the hallway uncovered was not supposed to happen and it should be a part of training. During an interview on 06/15/2022 at 3:11 PM, Registered Dietitian (RD) #1 stated the dietitians were not very involved in the kitchen. RD #1 stated that both the hot and cold items on the tray should be covered. During an interview on 06/15/2022 at 3:16 PM, the Administrator (ADM) stated his expectation would be that the entire tray would be covered. During an interview on 06/16/2022 at 1:14 PM, the DON stated staff members should be moving the cart with them and not removing trays until they were outside the door of the resident's room and side dishes should be covered.