**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents were provided an environment as free of accident hazards as possible for one (#32) of two residents reviewed for accidents and hazards out of 40 sample residents. Specifically, the facility failed to: -Ensure a thorough investigation was conducted after a skin tear was acquired during a staff-assisted transfer for Resident #32; and, -Identify the root cause of Resident #32's skin tear. Findings include: I. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, interstitial pulmonary disease (lung disorder), heart failure, atrial fibrillation, morbid obesity and unsteadiness on her feet. The 6/19/24 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. She required substantial assistance for toileting. She was dependent on staff for showering, dressing and transfers. She required supervision for oral hygiene and personal hygiene. B. Resident interview and observation Resident #32 and the resident's representative were interviewed together on 7/29/24 at 2:28 p.m. Resident #32 said the certified nurse aide (CNA) went too fast during her toileting care on 7/27/24 during the day shift. She said the CNA brought the walker to her while she was seated on the toilet. Resident #32 said she used the walker to transfer from the toilet to her wheelchair. She said the CNA went too fast when she placed the walker in front of her and caused a skin tear on her left shin. Resident #32 said the day shift nurse put a bandaid on the skin tear. She said the skin tear bled through the bandaid. She said she did not have proper skin care until the night shift nurse arrived. She said it was important to her to have good skin care because she had edema in both of her lower extremities. Resident #32 said her doctor told her that her skin was very fragile and she needed to be careful because it was easy to tear her skin. During the interview, Resident #32's left lower leg was observed with a white bandage which was loosely wrapped around the resident's left shin. She had swelling in both of her lower extremities and her legs were dry. C. Skin tear observation On 7/31/24 at 12:07 p.m., wound care of the skin tear was observed. Resident #32 had an L-shaped skin tear on her left lower extremity that was approximately four and a half centimeters (cm) by one cm. The skin tear was on the upper left side of her left shin. D. Record review Resident #32's skin breakdown care plan, revised 6/14/24, revealed the resident had the potential for skin breakdown related to impaired mobility secondary to weakness and debility. Interventions included applying moisturizer to the skin and performing a Braden Scale assessment (a tool used to predict the risk of developing pressure injuries) every week and as needed. Resident #32's edema care plan, revised 7/31/24 (during the survey), revealed the resident was at risk for skin injury due to edema of bilateral lower extremities. Interventions included administering medications per physician's orders, elevating the resident's legs as tolerated, monitoring weight and monitoring for signs and symptoms of fluid overload as needed. Resident #32's skin tear care plan, revised 7/30/24 (during the survey), revealed the resident had a skin tear to the left lower extremity related to assistive device use. Interventions included encouraging good nutrition and hydration, identifying potential causative factors if skin tears occurred, using caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp and hard surface, placing tennis balls on the resident's walker, treating the skin tear per facility protocol and notifying the physician. The 7/27/24 nurse progress note revealed Resident #32 sustained a skin tear during the day shift on her left lower extremity. The wound was oozing and bleeding. The note documented the wound was cleaned with normal saline, covered with an ABD (abdominal) pad and wrapped with Kerlix (gauze) until the wound nurse was able to put new orders in. The wound nurse was messaged. The 7/28/24 nurse progress note revealed an as needed wound care was provided at the resident's request for a saturated dressing. -A review of the resident's electronic medical record (EMR) revealed there was no documentation by the day shift nurse on 7/27/24 that described how the skin tear occurred, skin assessment, pain assessment, who was notified and what orders were obtained for treatment of the skin tear. -There were no new care plan interventions added to prevent further skin tears for the resident until 7/30/24 (during the survey). The August 2024 CPO revealed the following physician's order: Wound care, cleanse the open area to left lower extremity with normal saline or wound cleanser, pat dry, apply xeroform (a moist wound dressing) to open area, cover with ABD pad, wrap with kerlix daily and as needed, ordered 7/28/24. II. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 8/1/24 at 10:40 a.m. CNA #5 said she knew if a resident required assistance with toileting based on the shift change report, information on the vital signs sheet and on the white board in the resident's room. She knew if a resident needed one or two-person assistance based on the white board and she asked the resident. She said she knew if assistive devices were required with toileting based on the white board and vital signs sheet. CNA #5 said if she noticed a skin injury during toileting care, she finished the care then told the nurse about the skin tear. She said skin injuries included bed sores, weeping of skin, bruises and skin tears. She said she was familiar with Resident #32. CNA #5 said the resident required two-person assistance with toileting. CNA #5 said one person helped the resident stand while the other staff member provided toileting care. She said she saw the bandage on Resident #32's shin but the resident did not tell her what happened. CNA #5 said she was not told what happened to her shin. After the interview, the vital signs sheet was reviewed with CNA #5. The vitals signs sheet document revealed Resident #32 required an extensive two-person assist. Licensed practical nurse (LPN) #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said the CNAs knew if a resident required assistance with toileting based on the report from the hospital when they were admitted . She said the hospital report usually had a physical therapy (PT) and occupational therapy (OT) evaluation. She said the PT/OT evaluation said if assistance was needed and how much assistance. LPN #1 said if there was not an evaluation, she did two-person assistance until the facility's therapists completed an evaluation. LPN #1 said the CNAs asked the nurses if a resident required assistance with personal care. LPN #1 said skin tears happened because accidents happen. She said if a skin injury happened, she called the doctor to obtain an order, referred to the skin protocol and started the risk management module. LPN #1 said the risk management module for a skin tear included a section that described what happened, who was contacted and if physician's orders were obtained. Registered nurse (RN) #1 was interviewed on 7/31/24 at 3:18 p.m. RN #1 said if she noticed a new skin injury, she told the wound nurse. RN #1 said she worked the night after the skin tear occurred for Resident #32. She said she went to the resident's room and saw the skin tear weeping. She said she used her nurse's judgment to clean the wound. She said did not notice a bandaid on the skin tear. RN #1 said Resident #32 told her the skin tear happened when the day shift CNA helped her transfer from the toilet to the wheelchair. RN #1 said the resident told her the day shift nurse placed a band aid on the wound. RN #1 said she did not notify the physician, obtain wound care orders or complete a head to toe assessment. RN #1 said the skin tear happened during the day shift so the day shift nurse was responsible for notifying the physician and obtaining wound care orders. RN #1 said she documented what she did as a progress note in the resident's chart. -However, Resident #32 told RN #1 how she obtained the skin tear and there were no additional measures put in place to prevent the skin tear from occurring again The nursing home administrator (NHA) was interviewed on 7/30/24 at 1:43 p.m. The NHA said the nurse who worked the day shift did not complete an incident report on the day of the incident. The NHA said the nurse was coming in to complete the incident report when he returned from vacation. The NHA said an investigation regarding the skin tear was underway (during the survey) to determine what happened with the resident. The NHA said a request was made to nursing services for what immediate interventions were put in place to prevent the skin tear from occurring again. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 7/31/24 at 9:44 a.m. The DON reviewed the incident report for Resident #32's skin tear. The DON said the incident revealed the root cause was the walker hit the resident's shin and caused a skin tear. The DON said the intervention was to complete wound care and individual staff education. The DON said the intervention put in place was for wound care but an immediate intervention to prevent the skin tear from occurring again was not completed. The resident's care plan was reviewed with the DON. The DON said the care plan was updated for wound care but the care plan was not updated to include interventions to prevent the skin tear from occurring again. The DON was interviewed again on 7/31/24 at 3:47 p.m. The DON said when the staff noticed a new skin injury,the nurse needed to notify the physician and the resident's representative The DON said the staff needed to notify the DON for risk management to be completed and obtain wound care orders from the physician. The DON said the nurse should add interventions, monitor for signs and symptoms of infection and complete a head to toe assessment, including the actual injury site. The DON said the nurse told the wound nurse about the wound so the wound nurse could determine if she needed to follow the resident's wound. The DON said the nurse documented the skin injury when the risk management module was triggered. The DON said the risk management module was not part of the resident's EMR. She said the risk management module had a section where the nurse was supposed to describe what occurred. She said this section was transferred to the resident's EMR as a progress note. The DON said the 7/27/24 skin tear was not investigated until 7/30/24 (during the survey). The DON said the investigation did not start because the nurse was on vacation and the DON wanted the nurse to complete the investigation report. The DON said she did not identify the skin tear as an accident. The DON was interviewed again on 8/1/24 at 11:01 a.m. The DON said the CNAs knew a resident required assistance with toileting, assistive devices and the type of assistance based on the [NAME] (an abbreviated care plan for staff), tasks and the white board in the resident's room. The DON said if a CNA noticed a skin injury they told the nurse. She said Resident #32 required one-person assistance. The DON said the CNAs might have said the resident required two-person assistance because the CNAs preferred the additional assistance. The DON said Resident #32's skin tear happened because the skids on her walker's legs tore the resident's skin on her shin. The DON said she did not interview the nurse or the CNA because the nurse was on vacation and the CNA was not scheduled to work until 8/2/24. The DON said she did not interview any other staff or other residents. The DON said the ADON interviewed the resident. III. Facility follow up The DON provided the following information on 8/2/24. Resident #32 obtained a skin tear on 7/27/24 during a transfer. The CNA moved the walker in front of the resident and hit her left lower extremity, causing the skin tear. The CNA immediately reported the incident to the nurse on duty who assessed the injury and notified the provider. The provider gave verbal orders to cleanse and place a bandage, which the nurse did. The skin tear was passed on in the report so the night shift nurse contacted the wound nurse who collaborated with the provider for the new order due to increased drainage. The day shift nurse performed the original assessment and treatment. The nurse progress note revealed on 7/27/24, the CNA reported a small skin tear on the resident's leg during a transfer. The provider and family were notified. A physician's order was obtained to cleanse and cover the skin tear with a bandage. Treatment was performed and the wound care nurse was notified. The resident denied pain. On 8/2/24, on the spot training and education for safe transfers with a walker was completed with the staff involved in the incident on 7/27/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goal for one (#32) of two residents out of 40 sample residents. Specifically, the facility failed to, for Resident #32: -Ensure a pain assessment was completed that identified the type of pain, the effects of pain on the resident, the aggravating factors and the relieving factors; -Ensure person centered non-pharmacological interventions for pain management were offered and monitored for effectiveness; and, -Ensure the administration of pain medications was documented consistently. Findings include: I. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, interstitial pulmonary disease (inflammation and scarring that made it hard for lungs to get oxygen), heart failure, atrial fibrillation (irregular and often rapid heart rhythm), morbid obesity and unsteadiness on her feet. The 6/19/24 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. She required substantial assistance for toileting. She was dependent on staff for showering, dressing and transfers. She required supervision for oral hygiene and personal hygiene. The assessment revealed the resident did not have a pain management regimen. The resident took pain management as needed and received non-medication interventions for pain. The MDS assessment documented the resident had pain frequently, which occasionally affected her sleep and her day-to-day activities. The resident reported her pain as moderate. B. Resident interview Resident #32 was interviewed on 7/29/24 at 2:28 p.m. Resident #32 said she sometimes had pain in different locations on her body. Resident #32 said she did not like to take pain medications. She said the facility did not offer non-pharmacological interventions when she experienced pain. She said if the lighting in her room was lowered, it would help her pain. C. Record review Resident #32's pain care plan, revised 8/1/24 (during the survey), revealed the resident had acute and chronic pain related to joint pain, peripheral vascular disease (blood circulation is reduced to a body part), interstitial lung disease and diabetes. She did not want to take pain medications and preferred non-pharmacological interventions. Interventions included acknowledging the presence of pain and discomfort, administering pain medications and monitoring for effectiveness, implementing non-pharmacological interventions, monitoring for pain every shift and notifying the physician as needed. Resident #32's opioid medication care plan, revised 6/17/24, revealed the resident took opioid medication for pain relief. The intervention was to monitor for side effects of dependence, nausea, vomiting, constipation, itching, respiratory depression and addiction. Resident #32's comfort care plan, revised 6/25/24, revealed the resident was at the facility for comfort care with minimal therapy. She received pain medications as ordered to keep her comfortable. Interventions included administering pain medication as ordered, notifying the physician if pain continued, providing a calm dimly lit environment, providing incontinence care and repositioning throughout the shift. -The care plan did not identify the location of her pain. The 6/13/24 admission pain assessment revealed the resident reported her pain was a 5 on a scale of 1 to 10. Her pain level, based on a verbal scale, was moderate. Her acceptable pain level was a 3 out of 10. She said she had pain in her knees, left arm and shoulders. The assessment documented the pain started years ago and the pain was constant and sharp. Voltaren gel and Advil helped her pain and movement made her pain worse. The 6/17/24 comprehensive pain assessment revealed the resident's pain, based on a verbal scale, was moderate. She had pain in her abdomen. -The type of pain, effects of pain on the resident's life, aggravating factors, relieving factors and associated symptoms portions of the assessment were not documented. The 7/27/24 comprehensive pain assessment revealed the resident's pain, based on a verbal scale, was moderate. She had pain in her abdomen. -The type of pain, effects of pain on the resident's life, aggravating factors, relieving factors and associated symptoms were marked as unable to determine. The August 2024 CPO revealed the following physician's orders: Voltaren gel 1%. Apply two grams transdermally every six hours as needed for chronic joint pain, ordered 6/13/24. Oxycodone five milligrams (mg). Take one tablet by mouth every four hours as needed for a pain level of 6 to 10 on a scale of 1 to 10, ordered 6/14/24. Tramadol 50 mg. Take one tablet by mouth every six hours as needed for a pain level of 1 to 5 on a scale of 1 to 10, ordered 6/14/24. Evaluate pain every shift and document, ordered 6/13/24. -A review of the resident's August 2024 CPO did not reveal a physician's order for non-pharmacological pain interventions and non-pharmacological interventions were not monitored for effectiveness. On 6/28/24, 6/29/24, 6/30/24, 7/3/24, 7/4/24, 7/5/24, 7/6/24 7/7/24, 7/8/24, nurse progress note revealed the resident had pain. She had a pain level of 2 out of 10 on a scale of 1-10. The location of the pain was generalized. The action taken was repositioning, immobilization of the affected area and pain medication. -A review of the resident's electronic medical record (EMR) did not reveal documentation indicating if the non-pharmacological pain interventions were effective. The 7/10/24 nurse progress note revealed the resident had pain. She reported her pain as a 7 out of 10. The location of the pain was generalized. The action taken was repositioning, immobilization of the affected area and pain medication. -A review of the resident's EMR did not reveal documentation indicating if the non-pharmacological pain interventions were effective. On 7/11/24, 7/12/24, 7/14/24, 7/15/24, 7/16/24, 7/18/24, 7/21/24 the nurse progress notes revealed the resident had pain. She had a pain level of 2 out of 10. The location of the pain was generalized. The action taken was repositioning, immobilization of the affected area and pain medication. -A review of the resident's EMR revealed repositioning and immobilization were not determined as a personalized pain management intervention. -A review of the resident's EMR did not reveal the facility followed up to see if the repositioning and immobilization interventions were effective. -A review of the resident's July 2024 medication administration record (MAR) revealed pain medication was not administered. The narcotic log book was reviewed on 7/31/24. Oxycodone and tramadol were not administered in July 2024. -However, the nursing progress notes indicated pain medication was administered (see above). II. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 8/1/24 at 10:40 a.m. CNA #5 said if a resident reported they were in pain, she would ask them what their pain was based on a scale of 1 to 10. CNA #5 said she told the nurse and then the nurse told her what the nurse planned to do. CNA #5 said she told the resident what the nurse's plan was to alleviate the pain. CNA #5 said she provided non-pharmacological interventions if the resident could not have pain medication. CNA #5 said the nurse told her what pain relieving interventions to provide for the resident. CNA #5 said Resident #32's pain plan was not documented. CNA #5 was familiar with Resident #32. She said the resident did not have pain at the moment. CNA #5 said the resident sometimes refused pain medication and the family representative, who was frequently present, helped encourage the resident to take the pain medication. Licensed practical nurse (LPN) #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said she completed pain assessments for residents at admission, during shift change and during medication pass. LPN #1 said she asked the resident where the pain was located, what the level of pain was, if it was acute or chronic pain and what helped the resident's pain improve. Registered nurse (RN) #1 was interviewed on 8/1/24 at 10:32 a.m. RN #1 said a pain assessment was completed every morning during medication pass and as needed throughout the day. She said the residents who had chronic pain told her when they had pain. RN #1 said a pain assessment was completed at admission. She said the pain assessment included what an acceptable pain level was for the resident, where the pain was located and what medication and non-medication interventions relieved the pain. RN #1 said if the resident reported they only wanted pain medications, she documented that in the assessment. RN #1 said she encouraged the residents to use non-pharmacological interventions, such as ice and elevation. RN #1 said typical interventions included ice, elevating, resting and limiting movement. She said she knew if pain medication or non-pharmacological interventions were effective because she followed up with the resident an hour after the medication was administered or an intervention was offered. She said she documented the effectiveness in the progress note. RN #1 said Resident #32 had generalized pain. RN #1 said Resident #32 had pain in her neck, chest and back. RN #1 said the resident used to have little to no pain. She said since the resident received a skin tear on 7/27/24, she had pain more frequently. RN #1 said Advil and tramadol helped the resident when she had pain. She said a calm, quiet and dark environment helped her. The director of nursing (DON) was interviewed on 8/1/24 at 11:01 a.m. The DON said a pain assessment was completed at admission, every seven days and quarterly. The DON said the pain assessment covered the resident's pain level and if the pain was managed. She said non-pharmacological interventions were not personalized to the resident. The DON said the pain assessments were documented in a progress notes. The DON said if the assessment sections were marked as unable to determine, it meant the resident was unable to answer because they were confused. -However, Resident #32 was cognitively intact and was able to answer questions regarding her pain The DON was not aware Resident #32's assessments were marked as unable to determine because the resident was able to answer the questions. The DON said she did not know why the pain assessments revealed the resident had pain in her abdomen. The DON said she was not aware the nurse progress notes documented the resident was administered pain medication but the MAR showed no pain medication was administered. The DON said Resident #32's care plan should have included monitoring if the resident's non-pharmacological interventions were effective and indication that the resident would refuse pain medication. IV. Facility follow up The DON provided the following information on 8/2/24 at approximately 1:54 p.m. (after the survey): Resident #32 had a comprehensive pain evaluation every seven days per protocol. The DON said the pain evaluation addressed the location of pain, if the pain was tolerable and if the pain impacted her day-to-day activities. The 8/1/24 nurse progress note revealed the resident said her pain level was a four. The resident said once pain medication was administered, the pain level decreased. The resident had tramadol available as needed. Non-pharmacological interventions were discussed. The resident said she usually dealt with it or took Advil. The resident was asked if repositioning, distraction, music, or cold helped the pain. The resident said the cold made it worse for her and repositioning did not help. -However, the facility did not update the resident's EMR to identify Advil was an effective intervention for the resident. -The facility did not update the pain assessment to demonstrate the resident was able to answer questions in the pain assessment, specifically the quality of pain, effects of pain on the resident's life, aggravating factors, relieving factors and associated symptoms. -The facility did not update the resident's EMR to monitor if non-pharmacological interventions were offered and if the interventions were effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#98) of six residents reviewed for unnecessary medications out of 40 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #98's hours of sleep were documented for psychotropic medication use; and, -Ensure person-centered interventions to address Resident #98's repetitive statements were identified and attempted prior to ordering an antipsychotic medication for the resident. Findings include: I. Resident #98 A. Resident status Resident #98, age [AGE], was admitted on [DATE], discharged on 6/1/24 and readmitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included dementia, transient ischemic attack (stroke), cerebral infarction, psychotic disturbance, mood disturbance, insomnia and anxiety. The 5/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. He required supervision for oral hygiene and toileting. He required partial assistance for transfers. B. Resident observations During a continuous observation on 7/29/24, beginning at 10:54 a.m. and ending at 11:27 a.m., the following was observed: At 10:54 a.m. Resident #98 was in his room. He said can you help me, help me, help me please. At the nurse's station, directly across from the resident's room, an unidentified nurse said it was time to give him medicine. At 10:55 a.m. the unidentified nurse went into the resident's room with medicine. At 11:00 a.m. the resident left his room in his wheelchair with the unidentified nurse. The nurse assisted him to the activity room. At 11:02 a.m. Resident #98 tried to go into Resident #99's room, which was next to Resident 98's room. Resident #98 said he needed help. Resident #99 asked him what he needed help with. An unidentified staff member assisted Resident #98 back to the activity room. -There were no activities being conducted in the activity room and the unidentified staff member did not attempt to interact with the resident to determine what the resident needed or provide him with a meaningful activity to distract the resident from his repetitive statements. At 11:19 a.m. the unidentified staff member assisted Resident #98 to his room. The unidentified staff member provided toileting assistance and assisted Resident #98 to his bed. The unidentified staff member left his room. At 11:20 a.m. Resident #98 said help me. There was a certified nurse aide (CNA) who walked past his room and two staff members at the nurse's station. The nurse's station was directly across from Resident #98's room. The resident continued to say help me fifteen times. -The CNA and the two other staff members did not attempt to interact with the resident to determine what the resident needed or provide him with a meaningful activity to distract the resident from his repetitive statements. At 11:22 a.m. Resident #98 said hello. At 11:22 a.m. an unidentified nurse went into the resident's room and asked the resident if he wanted to watch a sports competition (Olympics). At 11:23 a.m. the nurse left the room. From 11:23 a.m. to 11:27 a.m. the resident said help, I need help, and help me and help me, please help me multiple times until an unidentified CNA went into the resident's room. On 7/30/24, Resident #98 was observed throughout the day. The resident was in his bed asleep. On 7/31/24, the following observations of Resident #98 were made: From 12:33 p.m. to 12:35 p.m. the resident was in his bed. He said please help and help me seven times. There were two nurses at the nurse's station across from the resident's room. -Neither nurse provided assistance to the resident. From 3:28 p.m. to 3:30 p.m. the resident was in his bed. He said help and hello, help me. Registered nurse (RN) #1 went into the resident's room and asked him if he wanted to take a nap. C. Record review Resident #98's antipsychotic medication care plan, revised 7/28/24, revealed the resident was on an antipsychotic medication related to repetitive statements causing agitation, pacing and delusions disturbing to the patient. The resident would yell out after needs were met. Interventions included administering medications per physician orders, considering a gradual dose reduction when necessary, monitoring as needed for fall risk, monitoring and reporting to the physicians for adverse side effects, offering non-pharmacological interventions and pharmacy to review the drug regimen monthly. -The care plan failed to document what type of delusions the resident exhibited which were disturbing to the resident. -The resident's antipsychotic medication care plan did not include effective non-pharmacological interventions when the resident asked for help. -Further review of the resident's comprehensive care plan revealed there was no care plan to monitor for hours of sleep related to the use of Melatonin for insomnia. The July 2024 CPO revealed the following physician's orders: Melatonin one milligram (mg). Take one tablet as needed for insomnia, ordered on 7/19/24. -There was no physician's order to monitor the hours of sleep. Seroquel 25 mg. Take one tablet by mouth every morning and at bedtime for delirium for seven days, ordered on 7/9/24 and discontinued on 7/11/24. Seroquel 25 mg. Take one tablet by mouth every morning and at bedtime for delirium until 7/16/24 for delusions that are disturbing to the resident, ordered on 7/11/24 and discontinued on 7/16/24. Seroquel 25 mg. Take one tablet by mouth every morning and at bedtime for medical illness with psychotic features for seven days for delusions that are disturbing to the resident and pacing to the point of exhaustion, ordered on 7/19/24 and discontinued on 7/24/24. Seroquel 25 mg. Take one tablet by mouth stat (immediately) for delusions and pacing to the point of exhaustion, ordered on 7/19/24 and discontinued on7/19/24. Seroquel 25 mg. Take one tablet by mouth one time a day for repetitive statements causing agitation for one day, ordered on 7/23/24 and discontinued on 7/24/24. Seroquel 25 mg. Take one tablet by mouth three times a day for medical illness with psychotic features due to delusions that are disturbing to the resident and pacing to the point of exhaustion, ordered on 7/24/24. Antipsychotic medication monitoring. Monitor every shift for signs and symptoms of sedation, drowsiness, dry mouth, constipation, blurred vision, weight gain, edema, sweating and loss of appetite, ordered on 7/9/24 and discontinued on 7/18/24. The 7/21/24 nurse progress note revealed melatonin was given and was ineffective. On 7/24/24, 7/25/24, 7/26/24, 7/27/24, 7/28/24 the nurse progress notes revealed the resident called out help me several times after needs were met. It revealed redirection was sometimes effective. -The progress note failed to document if any other interventions were attempted with Resident #98 when redirection was not effective. On 7/29/24 and 7/30/24 the resident called out help me and hello several times after needs were met. It revealed redirection was sometimes effective. -The progress note failed to document if any other interventions were attempted with Resident #98 when redirection was not effective. The 7/27/24 nurse progress note revealed the resident was up at night moving around in his room due to incontinence care that required a bed linen change. The 7/28/24 nurse progress note revealed melatonin was given and was effective. -There were no hours of sleep documented. The 7/31/24 provider progress note revealed the resident had dementia with psychosis. He remained an elopement risk. He required constant supervision and redirection. He was at risk for self harm and wandering into another resident's room. The 8/1/24 provider discharge summary revealed the resident had a challenge during his stay. He continued to have a decline in overall cognitive function. At times, he was redirectable and other times he was not. A few days prior to discharge, nursing noticed increased agitation. The resident continued to yell out for help and had increased restlessness and agitation at night. -A review of the resident's electronic medical record (EMR) did not reveal documentation indicating the resident's hours of sleep were monitored. II. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/1/24 at 8:54 a.m. LPN #2 said she knew a resident had behaviors requiring monitoring based on the diagnosis of dementia, if the psychiatrist saw the resident, at shift change report and monitoring based on protocol. LPN #2 said she was told at shift change if the resident had an active behavior or if the resident was on a psychotropic medication. She said she documented if the resident had behaviors in the resident's EMR. LPN #2 said she knew what interventions to use by asking the resident's physician. She said she tried redirection and guiding as an intervention. She said she would ask the resident what they wanted. LPN #2 said she would ask the family for effective interventions but she said the family did not know what interventions worked most of the time. She said she would notify the MDS coordinator so the care plan was updated. LPN #2 said she was not familiar with Resident #98. LPN #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said she knew a resident had behaviors requiring monitoring based on her assessment, if the behaviors were in the resident's chart, and the resident's hospital summary. LPN #1 said a dementia diagnosis did not mean a resident had behaviors. She said behaviors were based on how staff approached and interacted with residents. LPN #1 said she knew what interventions to use based on the care plan, on the report form, the CNA task list and the nurses shared at shift change what interventions worked for them. LPN #1 said she tried to put new interventions on the care plan but it was hard to do with the other charting responsibilities. She said it was important to have interventions to keep the resident safe and comfortable. LPN #1 said it was important to give a high quality of life so the resident could improve and go home. LPN #1 said Resident #98 constantly said help but it was not a behavior. She said he did not show distress, discomfort or agitation. She said she held his hand and he continued to say help. She said she added a care plan for the resident saying help repeatedly and his needs were met. LPN #1 said there were no interventions to stop him from saying help. She said everyone was responsible for identifying interventions for Resident #98. The director of nursing (DON) was interviewed on 8/1/24 at 11:01 a.m. The DON said certain diagnoses triggered specific behaviors that needed to be monitored. The DON said the staff knew what interventions to use to stop a behavior based on the psychiatrist visits and what the staff saw during their shift. She said a personalized care plan was important. The DON said the interventions used were based on a list of interventions. The DON said the interventions were not personalized for the residents. The DON said sleep should be monitored anytime a resident was on a hypnotic or on an antipsychotic medication. She said the sleep was documented in the medication and treatment administration records. The DON said she was not aware Resident #98's hours of sleep were not monitored. The DON said Resident #98 often said help me. She said sometimes he said what he needed. The DON said if a resident said help consistently, a personalized intervention should be on the resident's care plan to help address the behavior. The DON said it was important to have interventions to monitor behaviors and sleep so the resident had the best care. She said the resident should have personalized care to stay safe and receive good care. The DON said personalized interventions were important because there were different ways to identify the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to meet all of the requirements for the provision of hospice for one (#19) of one resident reviewed for hospice services out of 40 sample residents. Specifically, the facility failed to ensure a hospice care plan was initiated for Resident #19 to determine who was responsible for resident care. Findings include: I. Facility policy and procedure The Care Plan policy, revised 2/8/21, was received by the director of nursing (DON) on 8/1/24 at 10:54 a.m. The policy read in pertinent part, It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident. The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the patient's strengths, limitations, and goals. The care plan will be specific and appropriate to the individual needs of each resident. The interdisciplinary care plan will be developed through collaborative efforts of the IDT (interdisciplinary team) and other health care professionals. The care plan will be patient centered emphasizing the resident's and/or family's goals. The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate. It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs. (Facility name) will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The care plan will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated. II. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included metabolic encephalopathy and unspecified dementia. The 5/24/24 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 was dependent on staff for assistance with lower body dressing, putting on/taking off footwear, sitting to lying, and sitting to standing, chair/bed to chair transfers, toileting transfers and tub/shower transfers. B. Record review Review of the July 2024 CPO revealed Resident #19 was admitted to hospice services for metabolic encephalopathy, ordered 8/29/24. -Review of Resident #19's comprehensive care plan revealed there was not a care plan for hospice care. The care plan did not indicate which cares the facility would provide versus what cares the hospice services would provide. C. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 8/1/24 at 8:40 a.m. CNA #2 said she knew Resident #19 was receiving hospice care. She said when a resident was receiving hospice care a care plan should be implemented. CNA #2 said she provided basic care for Resident #19 such as repositioning, turning the resident, getting him out of bed and basic hygiene. She said the hospice staff came in on Tuesdays and Fridays. She said if she had any questions or concerns regarding Resident #19 she would call hospice. Registered nurse (RN) #2 was interviewed on 8/1/24 at 8:56 a.m. RN #2 said anytime a resident was receiving hospice care a care plan should be implemented. She said when a resident was admitted to hospice services she would initiate the care plan along with the minimum data set coordinator (MDSC). She said she could add to and update the care plan when she saw any changes. She said she did not know what Resident #19's goals were for care and treatment at the end of life. She said she was not aware that a care plan was not initiated for Resident #19. RN #2 said she was responsible for providing direct patient care, checking on the resident as needed and providing medications and treatments. She said any staff member could communicate with the hospice staff. She said the hospice CNA came in twice a week to shower Resident #19. She said she did not know how often the hospice nurse came in to check on Resident #19. She said the hospice staff came to the facility on a routine basis. She said if she had any concerns regarding Resident #19 she would call the hospice nurse. The director of nursing (DON) was interviewed on 8/1/24 at 9:14 a.m. The DON said when a resident was receiving hospice care a care plan should be implemented. She said the resident should have a hospice initiated care plan and a facility initiated care plan. She said she knew Resident #19 was receiving hospice services. She said she did not know a care plan for the resident's hospice services was not implemented. She said the MDSC and nursing staff were responsible for implementing the care plans. The MDSC was interviewed on 8/1/24 at 9:24 a.m. The MDSC said she was responsible for implementing the comprehensive care plans She said she would look at the physician's orders and go off them to determine what needed to be updated on the residents' care plans. She said the care plans should be updated daily and as needed. She said a team that consisted of the DON, the nursing home administrator (NHA), the case manager (CM), the unit manager (UM) and the MDSC met every morning. She said if there was a change of condition the CM and the UM would notify the team. The MDSC said she was not aware that a care plan for hospice was not initiated for Resident #19. She said she did not know how the care plan was missed. She said a change of condition in the MDS assessment was updated but a care plan was never initiated. She said she would make sure that a care plan would be implemented.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three of three out of eight sampled staff. Specifically, the facility failed to ensure: -CNA #3, CNA #4 and CNA #5 completed the annual dementia and abuse training. Findings include: I. Facility policy and procedure The Abuse and Dementia Training policy and procedure was requested from the director of nursing (DON) on 8/1/24 at 12:00 p.m. The policy and procedure was not provided. II. Record review A review of the 5/30/24 dementia training sign in sheet failed to reveal documentation that CNA #3, CNA #4 or CNA #5 had attended the dementia training. A review of the dementia and abuse training documentation on 7/31/24 revealed the following: -The training records revealed CNA #5 had not received dementia and abuse training since 5/25/23. -The training records revealed CNA #4 had not received dementia and abuse training since 6/8/23. -The training records revealed CNA #3 had not received dementia and abuse training since 7/13/23. III. Staff interview The DON was interviewed on 8/1/24 at 8:44 a.m. The DON said abuse training was conducted by the nursing home administrator (NHA) because he was the abuse coordinator. She said he had conducted a recent training on abuse but she was unable to find the documentation or the agenda for the training. She spoke with the NHA and he did not have the documentation. She said a dementia training was completed on 5/30/24 but it did not contain the signatures of CNA #3, CNA #4 or CNA #5. She did not know why those staff members did not complete the training. She said the facility did not have a training policy or procedure for dementia or abuse.

Based on observations, record review and interviews, the facility failed to keep medical records in a secure and confidential manner. Specifically, the facility failed to ensure nursing staff logged off their workstation when leaving the work area to protect the confidentiality of resident information. Findings include: I. Facility policy and procedure A request for a protected health information policy was requested on 8/1/24, but was not received. II. Observations On 7/30/24 observations were made on the second and third floor units. The second and third floors each had a nurses station in the middle of the unit with five to seven computer monitors. The second and third floor units had three hallways with resident rooms. Each hallway had a computer at a workstation in the middle of the hallway. The second and third floor units had three medication carts with a computer. Residents, visitors and families frequently walked down the hallways and by the nurses station, which enabled the computers to be visible to anybody walking by. At 2:42 p.m. an unidentified nurse left her computer screen, with a resident's electronic medical record (EMR) open, at the third floor nurses station. At 2:47 p.m. an unidentified certified nurse aide (CNA) left her computer screen, with a resident's EMR open, in the hallway at the third floor nurses station. At 3:00 p.m. a computer screen was left unattended, with a resident's EMR open, on a second floor medication cart. At 3:00 p.m. a computer screen was left unattended, with a resident's EMR open, on the second floor hallway desk workstation. An unidentified resident was sitting in a wheelchair next to an unidentified CNA. The unidentified resident was looking at the computer monitor. On 7/31/24 the following observations were made on the third floor unit: At 9:18 a.m. licensed practical nurse (LPN) #1 left her computer screen open, with a resident's EMR visible, at the nurses station. At 11:15 a.m. LPN #1 left her computer screen open, with a resident's EMR visible, at the nurses station. Two family members walked by the nurses station and Resident #99 came out of her room to the nurses station. At 12:41 p.m. LPN #1 left her computer screen open, with a resident's EMR visible, at the nurses station. On 7/31/24 observations were made on the third floor unit with the nursing home administrator (NHA) and the director of nursing (DON). At 2:46 p.m. a computer screen was left open, with a resident's EMR visible, in the hallway. The DON locked the computer screen. At 2:47 p.m. a computer screen was left open, with a resident's EMR visible, at the third floor nurses station. The DON locked the computer screen. III. Staff interviews CNA #5 was interviewed on 8/1/24 at 10:40 a.m. CNA #5 said residents' EMRs should not be left open on the computers where they were easily accessible to non-staff members. She said she needed to log off her workstation when she left the work area. LPN #2 was interviewed on 8/1/24 at 8:54 a.m. LPN #2 said the residents' EMRs with personal health information should not be left open and easily accessible to non-staff members. She said the nurses needed to log off their workstations when leaving the work area. LPN #1 was interviewed on 8/1/24 at 9:26 a.m. LPN #1 said the resident's EMRs with personal health information should not be left open and easily accessible to non-staff members. She said the nurses needed to log off their workstations when leaving the work area. The NHA was interviewed on 7/31/24 at 2:44 p.m. The NHA said the staff needed to log off their workstation when they left their workstation. He said the residents should not sit right next to nurses or CNAs who had resident medical record information visible on the computer monitor. The NHA said it was important to not leave the monitors unattended to keep resident medical information private.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #75 Resident #75, age [AGE], was re-admitted to facility on 12/19/21. According to the December 2021 computerized physician orders (CPO) diagnoses included pleural effusion, kyphosis, parkinson's disease, chest pain, and right upper quadrant pain. The minimum data set (MDS) assessment dated [DATE] showed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. The resident required limited assistance with mobility, locomotion and transfers. The MDS coded the resident as having experienced pain the past 5 days. The pain did not affect day to day activity. B. Pain management plan The December 2021 CPO included an order for the resident's pain to be evaluated every shift starting on 12/19/21 using a pain scale of 0-10, and to document on the medication administration record (MAR). Resident was initially admitted to facility 12/5/21. The resident's December 2021 CPO and recent physician telephone orders revealed current orders for pain control include: -Tylenol 325 mg (Acetaminophen) give two tablets by mouth every six hours as needed for pain level one through five out of ten; and -Norco tablet 10-325 mg (HYDROcodone-Acetaminophen) give one tablet by mouth every six hours as needed for pain level five through ten out of ten C. Pain assessment The most recent pain assessment was completed 12/20/21, 12/22/21, 12/23/21 and 12/27/21 and failed to completely and accurately assess the resident's pain level. The pain assessment documented that the resident had generalized pain and the remainder of the assessments were not filled out. D. Failure to follow pain medication parameters The facility failed to follow pain medication parameters when administering pain medication to resident. Resident #75 had specific pain medication orders depending on stated level of pain. Pain level one through five out of ten had physician order that resident should be given Tylenol 325 mg (Acetaminophen) give two tablets by mouth every six hours as needed. Pain level five through ten out of ten indicated that resident should be given Norco tablet 10-325 mg (HYDROcodone-Acetaminophen) give one tablet by mouth every six hours as needed for pain. On 12/20 21, resident was given Norco 10-325 mg one tablet for documented pain level of three out of ten at 5:05 p.m. On 12/22/21, resident was given Tylenol 325 mg two tablets for documented pain level of six out of ten at 6:45 p.m. On 12/23/21, resident was given Norco 10-325 mg one tablet for documented pain level of four out of ten at 7:35 a.m. On 12/27/21, resident was given Norco 10-325 mg one tablet for documented pain level of three out of ten at 4:00 a.m. The medical record failed to show documentation of non-pharmaceutical interventions (NPI) in resident #75's chart prior to administration of pain medication. E. Interview The assistant director of nursing (ADON) was interviewed on 1/6/21 at 12:07 p.m. The ADON reviewed the computerized medical record and confirmed the three comprehensive pain assessments (see above) were incomplete. She said the comprehensive pain assessments were incomplete and should have been completed after each admission. In addition the ADON said there was a book located in (ADON) office with schedule of weekly pain assessments. No weekly pain assessments documented for resident #75. Based on observations, record review and interviews, the facility failed to ensure pain management program was in a manner consistent with professional standards of practice for two (Resident #55 and Resident #75) of three out 40 total sample residents. Specifically, the facility failed to: -Follow pain medication parameter order, and ensure all pain medications have a pain level parameter ordered for Resident #55 and #75; -Complete comprehensive pain evaluation every week as ordered for Resident #55 and #75; and, -Follow thecare plan for Resident #55 and #75 and attempt non pharmacological interventions prior to providing as needed pain medication. Findings include: I. Facility policy and procedure The policy titled Analgesia policy & Procedure, issued 2/1/18 and revised on 2/8/21, read in pertinent parts, Upon admission, all patients will be evaluated for pain. Pain level will also be evaluated every shift. Once a patient expresses the perception of pain or makes a request for pain medication, patient will be provided with a dose of analgesic pain medication or non-pharmacological intervention will be initiated. II. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO), the diagnoses included motor vehicle accident with fracture of upper end of left tibia, displaced bimalleolar fracture (ankle fracture) of left lower leg, multiple fractures of pelvis, fracture of fifth metacarpal bone (pinky fracture) of right hand, non-displaced fracture of proximal phalanx of right little finger, chronic obstructive pulmonary disease, neuropathy, major depressive disorder, delusional disorder, and cognitive communication deficit. The 12/15/21 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for a mental status score of seven out of 15. She required extensive assistance from two people with bed mobility, transfers, toileting, dressing, locomotion on and off the unit. She required supervision with set up help only for eating and limited assist from one person only for personal hygiene. Resident #55 received scheduled pain medication regimens, and almost constantly experienced pain or hurting during the last five days with an intensity of 10 out of 10. III. Observations and resident interview On 1/5/22 at 9:42 a.m., Resident #55 sat in bed sleeping. At 9:56 a.m., activity assistant brought a cup of coffee to the resident. Resident #55 woke up and started drinking coffee. Noted Resident #55 had a cast on her right hand. Resident #55 was able to hold and drink coffee without difficulty observed. On 1/5/22 at 10:02 a.m., Resident #55 stated her hand did not hurt, but it just looked terrible. Resident #55 stated she was in after a motor accident, she had been here for about two months. IV. Record review A. Pain management regime The CPO included an order for the resident's pain to be evaluated every shift starting on 12/9/21 using a pain scale of 0-10, and to document on the medication administration record (MAR). An order to complete comprehensive pain evaluation every week in the morning every Tuesday for routine screening was started on 12/9/21. The December 2021 CPO revealed current orders for pain control include: - Lidocaine Patch 4%, ordered 12/9/21 and changed on 12/14/21. Apply to affected area topically in the morning for chronic pain for 23 days. - Acetaminophen tablet 325 mg, ordered 12/14/21 to discontinue on 1/6/22. Give one tablet by mouth every four hours as needed for pain 1-4 out of 10. - Acetaminophen tablet 325 mg, ordered 12/14/21 to discontinue on 1/6/22. Give two tablets by mouth every four hours as needed for pain 5-10 out of 10. - Tramadol hydrochloride (HCL) tablet 50mg, ordered on 12/10/21 and discontinued on 12/14/21. Give one tablet by mouth every six hours as needed for pain. No parameters for pain level ordered. - Tramadol HCL tablet 100mg, ordered on 12/14/21 to discontinue on 1/6/22. Give 100mg by mouth every six hours as needed for pain for 28 days. No parameters for pain level ordered. - Tylenol Extra Strength Tablet 500mg (Acetaminophen), ordered 12/9/21 and discontinued on 12/14/21. Give two tablet by mouth every six hours as needed for pain 1-5 out of 10. A review of an undated and untitled document indicated staff must always use TWO non-pharm(acological)-interventions when administering PRN (as needed) medications. The sample interventions listed included resting, repositioning, elevation, ice, warm blanket, redirection, drink, food, toileting, distraction, music, television, and one on one. Resident #55 care plan for pain initiated 12/14/21, last revised on 1/3/22, the interventions include to Implement non-pharmacological interventions when able such as: positioning/support, exercise/stretching, ice packs/moist hot pack application, relaxation. B. Medication administration record (MAR) review Based on the review of December 2021 MAR, acetaminophen 325mg one tablet as needed was administered on 12/24/21 at 8:14 p.m. for a pain level of 10, when the ordered indicated pain parameter was for pain level of 1-4 out of 10. A review of December 2021 MAR on acetaminophen 325mg two tablets as needed order revealed, the pain levels documented were below parameters of 5-10 out of10 for four out of six administrations. On 12/21/21 at 12:33 p.m., pain level documented was four. On 12/23/21 at 11:12 a.m., pain level documented was four. On 12/24/21 at 2:58 p.m., pain level documented was three. On 12/26/21 at 3:57 p.m., pain level documented was two. A review of December 2021 MAR on Tylenol Extra Strength tablet 500mg as needed order revealed, the pain levels documented were above parameters of 1-5 out of 10 for seven out of eight administrations. On 12/9/21 at 5:05 p.m., pain level documented was 10. On 12/10/21 at 7:15 a.m., pain level documented was eight. On 12/11/21 at 3:13 a.m., pain level documented was 10. On 12/11/21 at 9:37 p.m., pain level documented was eight. On 12/12/21 at 7:55 p.m., pain level documented was 10. On 12/13/21 at 3:47 p.m., pain level documented was eight. On 12/14/21 at 1:47 p.m., pain level documented was eight. A review of December 2021 MAR on Tramadol HCL 100mg administration showed Resident #55 received this as needed pain medication daily from 12/14/21 to 12/31/21 for pain levels ranging from five to 10; however, the NPI (non-pharmacological intervention) section on the MAR was left blank without documentation. There was no parameter ordered for Tramadol HCL to indicate what pain level was needed to administer this as needed pain medication. C. Pain assessment documentation The CPO included an order starting on 12/9/21 to complete comprehensive pain evaluation every week in the morning every Tuesday for routine screening. First comprehensive pain evaluation documentation was on 12/21/21, which indicated pain frequency was daily with a severity of eight out of 10. Resident's self-reported acceptable pain level was two out of 10. Second comprehensive pain evaluation documented was on 1/4/22, which indicated Resident #55 continued to experience pain daily with a severity of eight out of 10 scale. Resident's self-reported acceptable pain level remained at two out of 10. There was no weekly documentation on Tuesday 12/14/22 and Tuesday 12/28/22 as ordered. D. Licensed nurse progress notes The daily skilled nursing notes documented from 12/9/21 to 1/5/22, failed to show non-pharmacological intervention (NPI) were used prior to the administration of a PRN medication except on 12/25/21 and 1/3/22. The January notes were as follows: Daily skilled nursing note documented on 1/5/22 at 6:03 p.m. indicated Resident #55 had a pain rating of 10 out of 10 at bilateral lower extremities (BLE), and the action taken documented was PRN Tylenol was administered. No NPI was included as an intervention. Daily skilled nursing note documented on 1/4/22 at 16:26 p.m. indicated Resident #55 had a pain rating of two out of 10 at BLE, and the action taken documented PRN tramadol was administered. No NPI was included as an intervention. Daily skilled nursing note documented note on 1/2/22 at 23:58 p.m. indicated Resident #55 had a pain rating of 10 out of 10 at BLE, and the action taken documented PRN tramadol was administered. No NPI was included as an intervention. Daily skilled nursing note documented on 1/1/22 at 21:15 p.m. indicated Resident #55 had a pain rating of nine out of 10 at BLE, and the action taken documented tramadol was administered. No NPI was included as an intervention. V. Staff interviews Licensed practical nurse (LPN) # 3 was interviewed on 1/6/22 at 10:59 a.m. LPN #3 reviewed the computerized medical record and confirmed the Tylenol was administered outside of the parameters. LPN #3 stated according to the order, theTylenol one 325 mg tablet pain parameter was 1-4 out of10, that meant Tylenol would be given if reported pain level was between 1-4. If pain level was 5-10 the Tylenol 325 mg two tablets would be administered according to physician order. LPN #3 was interviewed a second time on 1/6/22 at 11:01 a.m., LPN #3 stated she would ask the resident which PRN (as needed) pain medication they wanted if there were multiple PRN pain medications ordered. LPN #3 stated she agreed that it would be difficult for residents to choose which PRN medication to take if they were cognitively impaired, and there should be a pain parameter for the Tramadol order. LPN #3 stated they need to try non pharmacological interventions (NPI) first prior to giving PRN pain medication, and they would document the interventions under the action taken tab in the daily skilled notes. LPN # 3 opened 1/5/21 daily skilled note to show the action taken tab, but there were no NPI documented. LPN # 3 stated everyone charted a little differently; however, she confirmed she could not find NPI documentation in 1/5/21 daily skilled note. The assistant director of nursing (ADON) was interviewed on 1/6/22 at 12:07 p.m. The ADON said comprehensive pain evaluation should be completed weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure one (Resident #55) out of one reviewed for dementia care out of 40 total sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to implement person-centered and non- pharmacological interventions to address the Resident #55 dementia care needs. Findings include: I. Policy and procedure The Dementia care policy, dated 2/10/2020, read in pertinent part, all staff will be educated on appropriate dementia care and dealing with difficult behaviors through Relias training on hire and, at least annually and as determined to be necessary by the nursing supervisor. Behaviors related to any/all types of dementia will be monitored and documented for the purpose of tracking and trending those behaviors for the purpose of including but not limited to: development of person centered, individualized dementia care plan programming for each resident. Identification of triggers of specific behaviors to assist staff members to avoid those triggers. Identification of unmet needs which the resident is unable to verbalize or communicate. Indemnification of times of day to include need for rest periods for residents. II. Resident #55 A. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO), the diagnoses included motor vehicle accident with fracture of upper end of left tibia (left lower leg fracture), major depressive disorder (mental disorder with persistently depressed mood), delusional disorder (a mental disorder when one cannot tell what is real from what is imagined), and cognitive communication deficit. The 12/15/21 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for a mental status score of 7 out of 15. She required extensive assistance from two people with bed mobility, transfers, toileting, dressing, locomotion on and off the unit. She required supervision with set up help only for eating and limited assist from one person only for personal hygiene. The resident mood interview (PHQ-9) showed the resident was mildly depressed with a severity score of seven out of 27. Resident did not exhibit any behaviors or change in behavior or other symptoms. The MDS indicated it is very important for her to have books, newspapers, and magazines to read, listen to music she likes, be around animals such as pets, keep up with news, do things with groups of people, participate in her favorite activities and participate in religious services. B. Resident Observations and interviews On 1/5/22 at 10:05 a.m., Resident #55 was sitting in the bed watching television (TV). Resident #55 frowned and pointed to the TV, stated look at what those girls were wearing. -At 11:41 a.m., Resident #55 was sitting in the wheelchair by her bedside table next to the door. The resident did not have any meaningful activity, such as books and magazine. -At 3:45 p.m., Resident #55 was sitting in the wheelchair by the bedside table next to the door looking at her phone. She stated she liked watching TV and listening to shows. -At 4:50 p.m., Resident #55 still sat in the wheelchair by the bedside table. Licensed practical nurse (LPN) #7 went in to adjust the nasal cannula that was below her chin. Resident #55 started crying as LPN #7 was assisting her. LPN # 7 closed the door at 4:52 p.m. and left the resident alone in the room with the door closed. -At 4:54 p.m. CNA #3 entered the room and closed the door after entering. 1/6/22 -At 8:44 a.m. Resident #55 was sleeping in bed. Resident's room did not have crafts, crochet, or puzzle materials on the bedside table. -At 2:30 p.m., activity director (AD) checked Resident #55's room to look for supplies. He did not find crochet supplies but found magazines, puzzles and coloring material inside the drawers and cabinet which were out of reach for the resident. Resident #55 stated she liked crocheting and drawing, stated she used to crochet blankets. C. Record review The resident's December 2021 CPO revealed current pertinent orders include: -Trazodone Hydrochloride (HCL) tablet 50mg by mouth at bedtime for insomnia for 23 days, started on 12/14/2021. Targeted behavior: inability to fall asleep or stay asleep. -Zoloft 100mg, give one tablet by mouth in the morning for depression, started on 12/9/21. Targeted behavior: crying, sad affect, self-isolating. -Risperidone, give 0.75mg tablet by mouth at bedtime for dementia with behaviors, started on 12/10/21. Targeted behavior: irritability. -Risperidone, give 0.25mg tablet by mouth in the morning for dementia with behaviors, started on 12/10/21. Treatment Administration Records review revealed the following behavior episodes: Trazodone: zero episode documented. Zoloft: one episode documented on 12/26/21 during the day shift. Risperidone: one episode documented on 12/ 26/21 during both day and night shift. Review of daily skilled nursing notes revealed: On 1/5/22 at 7:03 p.m., Resident #55 was calm and cooperative during day. Patient did have an episode of crying in the evening. On 1/2/22 at 11:58 p.m., Resident #55 had crying episodes twice, she was wet and needed to be changed, patient was crying out for help Anxiousness and confusion continued until patient fell asleep. On 12/30/21 at 2:29 p.m., Resident #55 was anxious at times, redirection and distraction with effect. On 12/29/21 at 10:27 a.m., Resident #55 was anxious at times, redirection and distraction with effect. On 12/26/21 at 3:13 p.m., Resident #55 had been mild agitated and anxious, yelling out her daughter Maria's name. Patient was easily re-oriented. On 12/25/21 at 11:34 p.m., Resident #55 had been mild agitated and anxious, yelling out her daughter Maria's name. Patient was easily re-oriented. Review of the care plan showed Resident #55 would cry out for help and be weepy at times as related to dementia. One of the interventions was to provide a calm, therapeutic environment and structured routine. The care plan initiated on 12/11/21, revised on 12/14/21, identified Resident #55's leisure needs and interest in participating in: arts/crafts, games/puzzles, computers, phone correspondence, TV/movies, reading, listening to music, creative activities, pet visits, visits with family, keeping up w/ the news, being outdoors, intellectual & spiritual activities as her condition allows. Resident #55 enjoys crochet and puzzles and was provided w/ supplies for both. She was Catholic and will be provided with spiritual activities as current conditions allow and assisted as needed to engage in individual spiritual practice. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 1/5/22 at 4:57 p.m. CNA #3 said Resident #55 crying episode. CNA #3 said Resident #55 missed her family and wanted them to call her family.She said Resident #55 talked about her son, she talked about family members from the past. CNA # 3 said the resident cried sometimes as she got confused more at night. Licensed practical nurse (LPN) #7 was interviewed on 1/5/22 at 5:12 p.m. LPN #7 said she never observed crying episodes during her shift, this was the first time she cried and maybe it was something on the television that upset her. LPN #7 stated the resident was on Zoloft, trazodone and she did not have any as needed medication. LPN #3 was interviewed on 1/6/22 at 10:09 a.m. LPN # 3 said Resident #55 was alert and oriented during the day but more confused at night, she had more behaviors at night. CNA #6 was interviewed on 1/6/22 at 11:18 a.m. CNA #6 said Resident #55 became more confused during later of the day. Resident #55 would yell out sometimes but she was never aggressive. Case manager (CM) #1, director of nursing (DON) and nursing administrator (NHA) were interviewed on 1/6/22 at 2:02 p.m CM #1 said Resident #55 had severe cognitive impairment based on her brief interview for mental status (BIMs) score of seven out of 15. CM #1 said Resident #55 was not showing any behaviors based on documentation and social service notes. CM #1 said during the interdisciplinary team meeting (IDT) and discharge planning meeting, there were no report of behavioral episodes. The DON stated Risperidone kept Resident #55 calm, and she did not have behavior because it was controlled by the use of the medication. NHA stated Resident #55 had crying episodes but she was easily redirected. Redirection was the non-pharmacological interventions they would do for Resident #55. NHA stated they did not do gradual dose reduction (GDR) for psychotropic medication as residents here were short term stay and not long term. The activity's director (AD) was interviewed on 1/6/21 at 2:23 p.m. The AD said the resident did have cognitive impairments and that he visited with her most days. He said she did attend a few group activities. He said the resident should have supplies in her room for her to do independent type activities. He said the supplies got misplaced when CNAs cleaned her room. The AD said Resident #55 seemed confused but she did not yell. She never had disruptive behaviors when he visited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were evaluated by a physician within 14 days for use and duration for one (#11) of five residents reviewed for unnecessary medication use out of 40 sample residents. Specifically, the facility failed to: -Re-evaluate the use of a PRN psychotropic medication by a physician within 14 days; and, -Try non-pharmacological interventions and document the outcome prior to the administration of a PRN anti-anxiety medication. I. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included disorder of the brain, ataxia, and depression. -The resident did not have a diagnosis of anxiety. The 11/5/21 minimum data set (MDS) assessment revealed the resident had mild impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She had no behaviors or rejections of care. She was not identified utilizing an anti-anxiety medication. II. Record review The care plan, initiated on 10/28/21 and revised on 12/3/21, identified potential for development of negative side effects related to the use of an anti-anxiety medication. Interventions included: -Non pharmacological interventions: One on one with patient, change position, give food/fluids, offer toileting, redirect and refer to nursing notes. -Administer medications per physician orders. The January 2022 CPO identified an order start date on 12/2/21 for Lorazepam 0.5 milligrams (MG); Give one tablet by mouth every six hours as needed for anxiety/restlessness. - The order did not identify the duration of the order. The December 2021 electronic medication administration record (eMAR) documented Resident #11 received PRN Lorazepam (from 12/3/21 to 12/31/21) 27 times. The eMAR did not identify if non-pharmacological interventions were attempted prior to the administration of Lorazepam. The December 2021 eMAR Lorazepam anti-anxiety monitoring for the target behavior of terminal agitation documented one episode. The January 2022 eMAR (from 1/1/22 to 1/4/22) documented the resident receiving one dose of PRN Lorazepam. The eMAR did not identify if non-pharmacological interventions were attempted prior to the administration of Lorazepam. The January 2022 eMAR Lorazepam anti-anxiety monitoring for the target behavior of terminal agitation had no documented behaviors. III. Interviews Certified nurse aide (CNA) #2 was interviewed on 1/4/22 at 9:42 a.m. She said she had not seen Resident #11 display any behaviors. She said she had not received any education on behaviors specific to Resident #11. Registered nurse (RN) #1 was interviewed on 1/4/22 at 10:02 a.m. She said she was not aware of Resident #11 having behaviors. Licensed practical nurse (LPN) #4 was interviewed on 1/4/22 at 10:15 a.m. She said the eMAR indicated she had anti-anxiety monitoring every shift. She said she had not seen the resident display any behaviors. She said she had not administered the PRN medication. She said she had not received training for resident specific individualized non-pharmacological interventions for Resident #11. Case managers (CM) #1 and #2 were interviewed on 1/4/22 at 10:40 a.m. They said Resident #11 did not have behaviors and the Lorazepam was ordered through nursing. They said nursing was responsible for all medications. They said they had not provided education to staff on the resident's behaviors. They said the behavior education was nursing's responsibility. The director of nursing (DON) was interviewed on 1/4/22 at 4:30 p.m. she said she was not aware the PRN order needed an identified duration for use. She said she would provide education going forward to providers to identify the need for use of a PRN psychoactive medication for longer than 14 days and include an end date. She said the resident utilized the medication for agitation and would clarify the orders. She said staff needed to ensure they attempted non-pharmacological intervention prior to administration and needed to make sure they documented what they did.

Based on record review and interviews, the facility failed to ensure residents have the right to receive visitors of their choosing at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Specifically, the facility failed to allow visitation except in cases of Hospice care and compassion care visits for all residents. I. Facility policy Visitation policy was requested, the updated, untitled policy, revised 11/12/21, was provided by the nursing home administrator (NHA) on 1/4/22 at 10:00 a.m. The policy included: Visitation is now allowed for all residents at all times, in accordance with adherence to the core principles of COVID-19 infection prevention and control to mitigate the risk of infection spread. Indoor visitation: -Must be allowed at all times and for all residents as permitted under the regulations. Facilities can no longer limit the frequency and length of visitation for residents, the number of visitors, or require advance schedule of visits. -Residents on transmission-based precautions (TBP) or quarantine, while not recommended, can still receive visitors in the resident's room. The resident should wear a well-fitting face mask (if tolerated). Visitors should be made aware of the risks of visitation, core principles of infection prevention. A facility is not required to, but may offer masks and other PPE as appropriate. Indoor Visitation During Outbreak Investigation: -Visitors must still be allowed into the facility, but they must be made aware of the potential risk of visiting and adhere to core principles of infection prevention. Visitor Testing and Vaccination: -Facilities may offer testing to visitors, if feasible, but it is not required. Facilities should educate and encourage vaccination. -Facilities may ask visitors about their vaccination status, but visitors are not required to be tested or vaccinated, or show proof if such, as a condition of visitation. If a visitor declines to disclose their vaccination status, they wear a face covering/mask at all times. Compassionate care visits are allowed at all times. II. Interviews Resident #15 was interviewed on 1/3/22 at 2:52 p.m. She said she would like to see her family. She said her family had not visited because she had been told the facility was on lockdown over the weekend. She said she did not know she could have visitors. Resident #139 was interviewed on 1/3/22 at 2:54 p.m. He said he was upset about the visitor policy. He said on the previous Wednesday or Thursday, his wife drove to the facility for a visit. She was not allowed to enter and was refused by staff to visit with him. He said what is the point of getting vaccinated if she cannot visit. Resident #14's daughter was interviewed on 1/5/22 at 1:25 p.m. She said she was concerned about the visitation protocol. She said she didn't understand the visitation rules. Medical records (MR) #1 was interviewed on 1/4/22 at 10:06 a.m. She said only visitation for compassion visits were allowed. She said the facility had a specific list of residents who were allowed to have visitors. Visitors had to be approved by upper management and only for compassionate care visits. She said all visitors had to pass a rapid test before they were allowed to have the visit. She said the testing was to make sure the visitors were safe to be in the building. Licensed practical nurse (LPN) #5 was interviewed on 1/4/22 at 10:10 a.m. She said any resident was allowed to have a visitor. She said the only requirement was to be screened into the facility at the reception desk at the entrance to the facility. Registered nurse (RN) #2 was interviewed on 1/4/22 at 10:15 a.m. She said anyone can have a visitor, but they have to be tested before entry. She said the visitor would get screened at the entrance. The receptionist (RCT) was interviewed on 1/4/22 at 10:28 a.m. She said no visitors were allowed unless they were identified as compassion care visits. She said she had a list at the desk that identified who were allowed into the building.She said the facility had COVID-19 outbreaks in the past and wanted to prevent another one. She said the nursing home administrator (NHA) determined who was on the compassion care visitor list. She said anyone who wished to visit the residents who were on the compassion care visitation list and were required to complete a rapid test prior to entry. Residents allowed to have visitors were only allowed to have one visitor at a time. If someone showed up who was not on the approved visitor list, she had to call the NHA for approval. The NHA was interviewed on 1/4/22 at 11:30 a.m. He said the facility allowed visitors for all residents. He said the facility offered testing to all visitors. He said the facility did not refuse visitation for any resident. He said the facility encouraged one visitor at a time. He said the facility did ask visitors to wear a face mask and offered a free rapid test. He said the facility was trying to prevent an outbreak from occurring. He said if families had any questions, the families were encouraged to call the NHA and he would explain the facilities recommendations. The facility did not limit the number of visitors. He said he was not aware visitors were not being allowed in, was not aware rapid tests were expected before entrance, and was not aware residents were not able to have visitors. He said he would provide education for MR #1 and the RCT on the updated guidelines and the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to administer oxygen in a manner consistent with professional standards of practice for three (#32, #49 and #55) out of five sample residents out of 40 total sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #49, and #55 and #32. Findings include: I. Facility policy On 1/4/22, The director of nursing (DON) provided a copy of the oxygen policy dated 12/20/18. The policy read in pertinent parts, a patient receiving oxygen therapy, the patient's record must reflect ongoing evaluation of the patient's respiratory status, response to oxygen therapy and include, at a minimum, the attending practitioner's orders and indication for use. In addition, the record should include the type of oxygen delivery system; when to administer and/or when to discontinue; equipment settings for the prescribed flow rates; monitoring of SP02 (oxygen saturation) levels and/or vital signs as ordered; and monitoring for complications. II. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. III. Failure to follow physician's orders 1. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO) diagnoses included fracture of right clavicle, multiple fracture of ribs, right side, wedge compression fracture of T5-T6 vertebra, stable burst fracture of third thoracic vertebra, stable burst fracture of fourth thoracic vertebra, stable burst fracture of T5-T6 vertebra, acute respiratory failure with hypoxia, pleural effusion, atelectasis, pulmonary hypertension. The minimum data set (MDS) assessment dated [DATE] showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance with mobility, dressing and transfers. The resident required supervision with eating. The MDS coded the resident as using oxygen. B. Record review The January 2022 CPO documented a physician order for oxygen to be on at (1-5) liters per minute (lpm) (continuously), delivered through NC (nasal cannula) may titrate to greater than or equal to 88% every shift and prn (as needed) for SOB (shortness of breath)/decreased O2 (oxygen) saturation. Okay for therapy to titrate. The oxygen order had a start date of 11/23/21. The care plan, last updated 12/30/21, identified the resident used oxygen related to acute respiratory failure with hypoxia; pleural effusion; atelectasis; pulmonary hypertension as ordered and prn (as needed). According to the computerized medical record, the resident's oxygen level was between 90% and 99% oxygen saturation between 11/23/21 and 1/4/22. C. Observations On 1/5/22 at 10:13 a.m., the resident was lying in bed. The resident had oxygen on per NC at 3 lpm. On 1/5/22 at 12:01 p.m., the resident was sitting in her wheelchair. The resident had oxygen on via NC at 3 lpm. On 1/6/22 at 8:45 a.m., the resident was sitting in her recliner. The resident had oxygen on via NC at 3 lpm. On 1/6/22 at 2:45 p.m., the resident was sitting in her recliner. The resident had oxygen on via NC at 3 lpm. The LPN #3 was observed to check her pulse oximeter and it was found to be at 97% oxygen saturation level. D. Interview Licensed Practical Nurse (LPN) #3 was interviewed on 1/6/22 at 2:45 p.m., LPN #3 said that oxygen orders were entered into the resident's chart as batch orders and demonstrated on her computer how to find generic batch orders. LPN #3 said that if the resident's oxygen level was below 88% oxygen saturation, she would titrate her oxygen up by one liter per minute until the resident's oxygen level was above 88% oxygen saturation, checking it with the pulse oximeter as she was increasing her oxygen. LPN #3 said she would not decrease the resident's oxygen unless told to do so by the physician. LPN #3 said that nurses and therapy are allowed to increase and/or decrease oxygen flow and are to chart any changes to liter flow in the resident's chart. She said that therapy was to notify the nurse if they made a change in the resident's oxygen liter flow. LPN #3 said that oxygen is a medication. 2. Resident #49 A. Resident status Resident #49, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO) diagnoses included acute osteomyelitis right ankle and foot, type 2 diabetes, acute respiratory failure with hypoxia, unspecified asthma, chronic obstructive pulmonary disease, pneumonia due to coronavirus disease 2019, heart failure, pleural effusion. The minimum data set (MDS) assessment dated [DATE] showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance with mobility, dressing, transfers and eating. The MDS coded the resident as using oxygen. B. Record review The January 2022 CPO documented a physician order for oxygen to be on at (1-5) liters per minute (lpm) (continuously), delivered through NC (nasal cannula) may titrate to greater than or equal to 88% every shift and prn (as needed) for SOB (shortness of breath)/decreased O2 (oxygen) saturation. Okay for therapy to titrate. The oxygen order had a start date of 12/8/21. The care plan, last updated 12/20/21, identified the resident used oxygen related to asthma, COPD (chronic obstructive pulmonary disease), oxygen delivery, respiratory infection as ordered and prn (as needed). According to the resident's chart, the resident's oxygen level was between 90% and 99% oxygen saturation between 12/8/21 and 1/5/22. C. Observations On 1/5/22 at 10:30 a.m., the resident was sitting on the edge of bed. The resident did not have oxygen on. On 1/5/22 at 10:32 a.m., the resident put NC on. The oxygen was set at 3 lpm. On 1/6/22 at 3:10 p.m., the resident had oxygen on via NC at 3 lpm. On 1/6/22 at 3:15 p.m., the resident had oxygen on via NC at 3 lpm. The LPN #6 was observed to check her pulse oximeter and it was found to be at 94% oxygen saturation level. D. Interview LPN #6 was interviewed on 1/6/22 at 3:11 p.m. LPN #6 said the oxygen orders were generic batch orders that were entered and the goal was to titrate residents off of oxygen. LPN #6 said the physician order read, if the resident was at 88% oxygen saturation the resident would be put on oxygen and monitored with the pulse oximeter and hopefully that would enable the resident's oxygen level above 95% going up one liter per minute at a time. LPN #6 said the nurse or the therapist was able to titrate the oxygen and if needed contact the physician. LPN #6 said the resident was not on oxygen at this time. LPN #6 then entered the resident's room and stated that the resident must have just put her oxygen on. LPN #6 said that oxygen is a medication. The assistant director of nursing (ADON) was interviewed on 1/6/22 at 3:53 p.m. The ADON said that oxygen orders were entered as batch orders and not individualized. She said the facility would receive report from the hospital and the resident had discharge orders. The ADON said that if the resident's oxygen level was below 88% saturation, then the nurse was to titrate up 0.5 liters per minute at a time allowing ample opportunity for oxygen to work and then continue to titrate if needed. Licensed nurses and the physical therapists were allowed to titrate oxygen at their discretion. ADON states that oxygen should be titrated down if high. Standard titration orders were followed each shift. The ADON said that oxygen was a medication. 3. Resident # 55 A. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician orders (CPO), the diagnoses included motor vehicle accident with fracture of upper end of left tibia, chronic obstructive pulmonary disease (disease that causes airflow blockage and breathing related problem). The 12/15/21 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for a mental status score of seven out of 15. She required extensive assistance from two people with bed mobility, transfers, toileting, dressing, locomotion on and off the unit. She required oxygen, and did not have episodes of shortness of breath or trouble breathing with exertion, or when sitting at rest, or when lying flat. II. Observations and resident interview On 1/5/21 at 9:42 a.m., Resident #55's room oxygen was set at two liters per minute (lpm). At 9:59 a.m., Resident #55 removed the nasal cannula and placed it below her nose to drink coffee. At 10:00 a.m., certified nursing assistant (CNA) #3 came in to the room and assisted Resident #55 to place the nasal cannula back to her nose. On 1/5/21 at 3:45 p.m., Resident #55 had the nasal cannula on. The resident said she wore it every day. 1/6/21 -At 8:44 a.m., Resident #55's oxygen was set at 3.5 LPM. -At 11:15 a.m., the resident was lying in bed. The oxygen was set at 3.5 LPM. Licensed practical nurse (LPN) #3 also observed the liter flow at 3.5 LPM. The LPN checked the resident's oxygen saturation level and it was at 93%. III. Record review The December 2021 CPO included the following relevant physician orders: Oxygen to be on at (2) liters per minute (continuously), delivered through NC (nasal cannula) may titrate to greater than or equal to 88% every shift and prn (as needed). Okay for therapy to titrate, every shift for SOB (shortness of breath), order started on 12/9/21. Oxygen to be on at (2) liters per minute (continuously), delivered through NC (nasal cannula) may titrate to greater than or equal to 88% every shift and prn (as needed). Okay for therapy to titrate, as needed for SOB/decreased O2 saturation, order started on 12/9/21. The daily skilled nursing notes documented from 12/9/21 to 1/4/21, failed to show oxygen flow rate was set at 2 liters as ordered. The notes were as follows: On 1/4/22 at 4:26 p.m., Resident #55 needed oxygen and the flow rate in liters per minute (LPM) was 4.5 liters nasal cannula (NC). On 1/3/22 at 4:26 p.m., Resident #55 needed oxygen and the LPM was 4.5 liters NC. On 1/2/22 at 11:58 p.m., Resident #55 needed oxygen and the LPM was 4.5 liters NC. On 1/1/22 at 9:15 p.m., Resident #55 needed oxygen and the LPM was 4.5 liters NC. On 12/31/21 at 9:06 p.m., Resident #55 needed oxygen and the LPM was 4.5 liters NC. On 12/30/21 at 2:29 p.m., Resident #55 needed oxygen and the LPM was 3 liters NC. On 12/29/21 at 10:27 a.m., Resident #55 needed oxygen and the LPM was 3 liters NC. On 12/28/21 at 11:35 a.m., Resident #55 needed oxygen and the LPM was 3 liters NC. On 12/27/21 at 10:45 a.m., Resident #55 needed oxygen and the LPM was 4 liters NC. On 12/26/21 at 5:13 p.m., Resident #55 needed oxygen and the LPM was 4 liters NC. On 12/25/21 at 10:34 p.m., Resident #55 needed oxygen and the LPM was 4 liters NC. On 12/24/21 at 10:46 p.m., Resident #55 needed oxygen and the LPM was 4 liters NC. On 12/23/21 at 11:52 a.m., Resident #55 needed oxygen and the LPM was 4 liters NC. On 12/22/21 at 2:58 p.m., Resident #55 needed oxygen and the LPM was 3.5 liters NC. On 12/21/21 at 9:32 a.m., Resident #55 needed oxygen and the LPM was documented as RA (room air). On 12/20/21 at 9:48 a.m., Resident #55 needed oxygen and the LPM was documented as RA (room air). On 12/19/21 at 10:29 p.m., Resident #55 needed oxygen and the LPM was documented as RA (room air). On 12/18/21 at 10:55 p.m., Resident #55 needed oxygen and the LPM was documented as RA (room air). On 12/17/21 at 10:05 p.m., Resident #55 needed oxygen and the LPM was documented as RA (room air). On 12/16/21 at 10:14 a.m., Resident #55 needed oxygen and the LPM was not documented. On 12/15/21 at 10:10 a.m., Resident #55 needed oxygen and the LPM was not documented. On 12/14/21 at 12:49 p.m., Resident #55 needed oxygen and the LPM was not documented. On 12/13/21 at 12:33 p.m., Resident #55 needed oxygen and the LPM was not documented. On 12/12/21 at 10:01 p.m., Resident #55 needed oxygen and the LPM was not documented. On 12/11/21 at 9:36 p.m., Resident #55 needed oxygen and the LPM was not documented. On 12/10/21 at 9:00 p.m., Resident #55 needed oxygen and the LPM was not documented. A review of Resident #55 oxygen saturation summary indicated resident's oxygen level documented twice daily were all above 90% between 12/10/ 21 to 1/6/22. IV.Staff Interviews Licensed practical nurse (LPN) #3 was interviewed on 1/6/21 at 11:13 a.m. LPN #3 stated Resident #55 oxygen saturation was 97% this morning. At 11:15 a.m., LPN #3 reviewed the oxygen setting in Resident #55's room and confirmed it was set at 3.5 liters. LPN #3 stated according to the physician order it should be set at 2 liters. LPN #3 adjusted the oxygen level down to two liters. At 11:22 a.m., LPN #3 rechecked Resident #55 oxygen level and stated it was at 93%. The LPN said she had not titrated the resident up and had not been informed that a physical therapist (PT) had titrated the resident to 3.5 LPM. She said if a PT would titrate the oxygen then she would be informed so she could do proper monitoring.

Based on observations, interviews, and record review the facility failed to ensure menus were followed to meet the nutritional needs of residents. Specifically the facility failed to follow the menu, menu items were omitted without substitutions being made of the same nutritional value, and did not follow extensions for the pureed and mechanical soft diets. Findings include: I. Menu items were omitted for residents during the survey. Evening meal 1/5/22 -Regular diet: The menu called for eight ounces of 2% milk to be served. Observations at 4:00 p.m., in the kitchen revealed residents were not served or offered milk or a milk substitute. Observations at 4:45 p.m., on the 200 and 300 hall revealed residents were not served or offered milk or a milk substitute when served meal room trays. Noon meal 1/6/22 -Regular diet: The menu called for eight ounces of 2% milk to be served. Observations at 11:00 a.m., in the kitchen revealed the residents were not served or offered milk or a milk substitute. II. Food extensions for pureed and mechanical soft diet Evening meal 1/5/22 -Puree diet: The menu called for a chocolate chip cookie to be pureed and served. -Mechanical soft diet: The menu called for a soft, moist chocolate chip cookie to be served. Observations at 4:00 p.m., in the kitchen revealed residents were served chocolate pudding cups on a pureed diet and mechanical soft diet in place of the chocolate chip cookie on the menu. Noon meal 1/6/22 -Puree diet: The menu called for four ounces of rice pureed to be served or four ounces of buttered noodles pureed for the alternate meal. Observations at 11:00 a.m., in the kitchen revealed the residents were served mashed potatoes on a pureed diet in place of the rice or buttered noodles on the menu. III. Interviews The dietary aide (DA) #1 was interviewed on 1/6/22 at 11:00 a.m. She said the residents were provided a meal ticket every Monday, Wednesday and Friday to choose their meals for the upcoming days. She said each resident filled out their own meal ticket unless they needed help from nursing. She said milk was on the meal ticket as a beverage option for residents to choose from, but it was not served as part of the meal. She said most of the residents did not choose milk for a beverage and preferred juice, soda or water. The dietary manager (DM) was interviewed on 1/6/22 at 11:10 a.m. He said milk was offered as a beverage on the meal ticket. He said it was listed on the menu as part of the meal, however, not every resident chose milk to drink. He said the pureed dessert offered for the evening meal on 1/5/22 was chocolate pudding. He said the menu called for the chocolate chip cookie to be pureed, however, he did not have success in the past pureeing a cookie so he served pudding instead. He said the menu for noon meal on 1/6/22 called for rice or buttered noodles to be pureed, however, he did not have success in the past pureeing rice and chose to serve mashed potatoes instead of what was on the menu. He said he did not have a recipe for pureed extensions and would use the liquid from the meal to add flavor to the puree. He said the puree should have a smoothie consistency. The registered dietitian (RD) was interviewed on 1/6/22 at 1:03 p.m. She said a corporate RD approved the menus and that the milk was part of the calorie count. She said that everything on the menu needed to be served. She said if a resident did not want milk then an alternative needed to be served to replace the calorie count. She said there were recipes for all regular food, however, she was not aware of recipes for the pureed foods. She said the corporate office was rolling out a new dietary program that would provide recipes for all food and would include posters on how to prepare the food extensions. She said the dietary cook should follow the menu and prepare what was listed for each meal. She said substituting mashed potatoes for the menu items could be repetitive and may not have the same nutritional value. She said having recipes for pureed and mechanical soft foods would help the dietary cooks prepare what was on the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Hand hygeine offered to residents A. Observations Second floor At 12:18pm, CNA #5 started passing lunch trays. CNA #5 delivered a tray to room [ROOM NUMBER] and placed the tray on the bedside table. She adjusted the table placement for the resident. CNA #5 did not assist the resident with hand hygiene prior to the resident started eating. CNA #5 came out of the room to deliver another tray to room [ROOM NUMBER]. CNA #5 did not perform hand hygiene after leaving room [ROOM NUMBER] nor prior to taking another lunch tray from the cart and entered room [ROOM NUMBER]. She failed to offer hand hygeine to the resident. On 1/5/22 at 12:28 p.m., meal trays were passed to residents without offering resident's hand hygiene and without staff sanitizing hands between residents. Observations were as follows: An unidentified certified nurse aide (CNA) was observed to deliver a meal tray to the resident in room [ROOM NUMBER]. The resident was not offered hand hygiene. The CNA failed to sanitize her hands prior to entering the room or after exiting the room. The CNA then entered room [ROOM NUMBER] The resident was not offered hand hygiene. The CNA did not sanitize her hands prior to entering the room or after exiting the room. The CNA then entered room [ROOM NUMBER] to deliver the meal tray. The meal tray was left next to the resident who was sleeping. The Unidentified CNA) did not sanitize her when she left the room. A meal tray delivered to room [ROOM NUMBER]. The CNA did not offer hand hygiene to the resident. She also failed to sanitize her hands prior to entering the room or after exiting the room. B. Interview The assistant director of inures, and the director of inures were interviewed on 1/5/22 at 2:21 p.m. The ADON said staff had been trained on assisting residents to wash their hands prior to eating their meal. She said hand sanitizer or hand wipes could be used. She said that it was constant reminders to staff to encourage hand hygeine. III. Cleaning equipment A. Facility policy The policy and procedure titled Medical devices/ equipment - disinfection, dated 3/27/2020, revised on 2/8/21, read in pertinent part, The Centers will follow CDC (Centers for disease control and prevention) guidelines for disinfection of medical devices/ equipment . All non - dedicated, non-disposable medical equipment used for patient care is cleaned and disinfected with EPA (environmental protection agency) approved product/CDC guidelines & recommendations. B. Observations On 1/5/22 at 11:50 a.m., CNA #3 wheeled a resident into room [ROOM NUMBER]. She then brought a weighing chair into room [ROOM NUMBER]. She did not perform hand hygiene or disinfected the portable scale prior to weighing the resident. CNA # 4 was assisting CNA #3 with documentation of weight and vital signs. After CNA #3 took resident's vitals and oxygen level, she handed the thermometer, blood pressure cuff and pulse oximeter to CNA #4. CNA #4 placed the equipment into the bag that she wore across her body. Both CNAs did not disinfect the equipment after use prior to storage. On 1/5/22 at 11:59 a.m., CNA # 5 came in and took the portable scale to weigh another resident in room [ROOM NUMBER]. CNA #5 did not disinfect the weighing chair after taking the chair into room #W221. At 12:06 p.m., CNA #5 and CNA #2 transferred resident from the wheel chair to the weighing chair. The portable scale was not disinfected after use. On 1/6/22 at 3:15 p.m., LPN #6 was handed a pulse oximeter by CNA #7. CNA #7 was observed to take the personal pulse oximeter out of his personal backpack. LPN #6 then proceeded to check the pulse oximeter for Resident #49. She failed to clean it prior to placing it on her finger. When finished, LPN #6 handed it directly back to CNA #7. and CNA #7 was observed placing the pulse oximeter back into a personal backpack without it being sanitized. C. Interview The assistant director of inures, and the director of inures were interviewed on 1/5/22 at 2:21 p.m. The ADON said all equipment needed to be disinfected prior to being used on another residnet. She said it also needed to be disinfected prior to being stored. The staff were provided with disinfecting wipes which were available thoughout the facility. She said she would provide more education on the importance of cleaning the equipment. Based on observations, record review and interviews, the facility failed to follow infection prevention and control procedures during resident care. Specifically, the facility failed to: -Perform hand hygiene before entering or after leaving resident's rooms and in between tasks; -Perform hand hygiene for residents before meals; and, -Disinfect equipment in between resident use; Findings include: I. Facility policy and procedure The policy and procedure titled Infection prevention, control & immunizations, dated 5/15/2020, revised on 2/8/21, read in pertinent part, 2. Staff will use standard precautions (hand hygiene and appropriate PPE (personal protective equipment). 3. Staff will follow appropriate hand hygiene practice 6. Staff will wash hands and perform hand hygiene even when gloves are used in the following situations: Before and after patient contact, after contact with blood, body fluid, or visibly contaminated or other objects or surfaces in patient's environment, after performing procedures and removing PPE and catheter care (PICC (peripherally inserted central catheter) line, CVC (central venous catheters) / dressing care). II. Lack of handwashing A. Facility policy and procedure The policy and procedure titled Infection prevention, control & immunizations, dated 5/15/2020, revised on 2/8/21, was received by the director of nurses on 1/5/22, read in pertinent part, 2. Staff will use standard precautions (hand hygiene and appropriate PPE (personal protective equipment). 3. Staff will follow appropriate hand hygiene practice 6. Staff will wash hands and perform hand hygiene even when gloves are used in the following situations: Before and after patient contact, after contact with blood, body fluid, or visibly contaminated or other objects or surfaces in patient's environment, after performing procedures and removing PPE and catheter care (PICC (peripherally inserted central catheter) line, CVC (central venous catheters) / dressing care). B. Professional reference The Centers for Disease Control (CDC) Hand Hygiene Guidance updated 1/30/2020, retrieved on 1/13/22 from: https://www.cdc.gov/handhygiene/providers/guideline.html, revealed in part, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal The Centers for Disease Control (CDC) Hand Hygiene updated 5/17/2020, retrieved on 12/19/21 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 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. 1. Observations During the observation on 1/5/22 at 10:00 a.m., certified nursing aide (CNA) #3 entered room [ROOM NUMBER] adjusted Resident #55's nasal cannula. CNA #3 came out of the room without hand hygiene, adjusted her face mask and sat down at the charting station. CNA #3 went through the purse then put it back on the charting station, and started typing on the computer. At 10:10 a.m., noted CNA #3 mask fell below her nose, she adjusted the mask back to the correct position. At 10:11 a.m., CNA #3 went to room [ROOM NUMBER] and did not sanitize or wash her hands prior to entering the room. At 11:08 a.m., CNA # 3 assisted the resident out of room [ROOM NUMBER] and returned to the room for cleaning. She put on a pair of gloves and started cleaning the bed. There was no hand hygiene after assisting the resident out of the room and prior to putting on the gloves. CNA #3 came out of room [ROOM NUMBER] and went to the linen closet to take clean linen with gloves on. At 11:10 a.m., CNA #3 went to room [ROOM NUMBER] while holding clean linen in her gloved hand. She talked to an unidentified nurse then returned to room [ROOM NUMBER]. CNA #3 then started placing a clean sheet over the bed and removed the soiled sheet out of the room and, placed the soiled bed sheet into the linen bin outside of the room by the trash bin. She returned to the room to continue adjusting the clean bed sheet. CNA #3 did not perform hand hygiene or change gloves in between changing sheets or after placing used sheet into the linen bin. -At 11:14 a.m., CNA #3 removed gloves in the room and came out to the charting station. She took the clip board for review then went back into room [ROOM NUMBER] without hand hygiene. CNA#3 took a pair of gloves out from the scrub pocket and donned gloves, she then put a blue blanket over the bed and continue cleaning the room. -At 11:19 a.m., CNA #3 removed gloves in the room and came out with a trash bag in her hand. She discarded the trash bag into the trash bin outside of the room. CNA #3 did not perform hand hygiene after leaving room [ROOM NUMBER] or after discarding the trash bag. -At 11:37 a.m., CNA # 3 returned to the station with a key in her hand. She placed the key in the bag and entered room [ROOM NUMBER] without hand hygiene prior to entering. CNA # 3 left the room at 11:48 a.m. and did not perform hand hygiene after leaving the room. C. Interview The assistant director of inures, and the director of inures were interviewed on 1/5/22 at 2:21 p.m. The ADON said staff were to perform hand hygiene prior to entering a room, after leaving a room, and between tasks. The ADON said hand hygiene training had been provided to all staff. She said she would continue to provide education.

Based on observations and interviews, the facility failed to follow the infection control measures to prevent the potential cross contamination of SARS-CoV-2 COVID-19, during testing procedures on visitors and staff. Specifically, the front desk staff failed to wear proper personal protective equipment (PPE), a protective gown, gloves and N95 mask, consistently when collecting SARS-CoV-2 COVID-19 specimens from visitors and staff. Findings include: I. Professional reference According to the CDC guidance, Guidance for SARS-CoV-2 Point-of-Care and Rapid Testing, updated 12/13/21, available from: https://www.cdc.gov/coronavirus/2019-ncov/lab/point-of-care-testing.html#print, accessed on 1/11/22. It read in pertinent part: Rapid point-of-care tests provide results within minutes (depending on the test) and are used to diagnose current or detect past SARS-CoV-2 infections in various settings, such as: Long-term care facilities and nursing homes. Specimen Collection & Handling of Point-of-Care and Rapid Tests -Proper specimen collection and handling are critical for all COVID-19 testing. For personnel collecting specimens or working within six feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which could include an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a lab coat or gown. II. Facility policy The Center COVID-19 vaccination, exemption and testing policy issued on 9/23/21, provided by the director of nursing (DON) on 1/5/22 at 2:15 p.m., read in pertinent part: All employees, direct contractors and support staff will be required to daily screening upon entering the facility and prior to start of shift. Employees, direct contractors, and support staff who are granted exemptions, but are still working in the facility, will be required to submit to rapid testing prior to every shift and COVID 19 PCR testing 2x (twice) per week. The exemption and testing policy did not provide protocol on how to protect patients and staff during specimen collection and handling of point of care and rapid tests. III. Observations and interviews The receptionist (RCT) was observed on 1/5/22 at 10:47 a.m. She collected a SARS-CoV-2 rapid test specimen from two visitors entering the building. The RCT wore a surgical mask. She handed the visitors each a swab and placed the collected specimen swabs into the testing card after the visitors self-swabbed. Both visitors stood in the front entrance next to the front desk while they swabbed their nose. The visitors were approximately one to two feet away from the RCT when they self-swabbed The RCT did not wear gloves, a face shield or gown during the rapid testing process. The two visitors wore a surgical mask and sat in the lobby while they waited for the rapid test results. The RCT placed the collected specimens on her desk and set a timer for ten minutes while the tests were processed. During the specimen processing, other visitors and staff entered the building and were screened while the collected specimens sat in the front desk. The tested visitors sat in the lobby while their specimens were processed. Once the tests were processed the RCT discarded the tests in the lobby trash can. The testing was not done in a secured room away from other visitors, staff or residents. During the observation three visitors were provided a rapid test in the lobby area. Proper personal protective equipment (PPE) was not worn by the RCT during the testing process. The RCT was interviewed on 1/5/22 at 11:15 a.m. She said the front desk staff assisted with COVID-19 rapid testing. She said she wore a surgical mask when she assisted with the screening process and testing process. She said all visitors regardless of vaccination status were encouraged to take a rapid test before entering the resident's room. She said all unvaccinated staff are required to take a rapid test prior to working. All staff and visitors are provided a wristband after screening to verify they have completed the screening process before entering the building. She said she would separate visitors in the lobby area if they were not together and try to have them wait 6 feet apart while their rapid test was processed. She said she always wore a surgical mask, but did not always wear a face shield. She said she did not wear gloves or a gown during the testing process. The director of nursing (DON) was interviewed on 1/5/22 at 2:21 p.m. The DON said they did not have any positive COVID-19 cases in the building and did not know the current rapid testing process was out of compliance. She said the visitors and staff tested themselves. She said the RCT did handle the specimen after the visitor or staff member swabbed themselves and agreed the RCT should wear proper PPE during the testing process. She said they would change their current rapid testing process and remove it from the lobby front desk area. She said they would move testing to an office at the front lobby area to provide an enclosed self-testing area for staff and visitors. She said all staff should be wearing N95 masks and face shields when assisting in the rapid testing and specimen collection process.