**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy, and interviews for 1 resident, (Resident #63) reviewed for dignity, the facility failed to ensure Residents #63 was treated in a dignified manner while services were provided. The findings include. Resident #63's diagnoses include spinal stenosis, anxiety and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was cognitively intact with no impairment, independent with eating, dependent with toileting, and maximal assist for bathing, transfers, and personal hygiene. Review of the Resident Council minutes from 10/2024 identified that residents had concerns regarding distractions, such as ear buds and cell phones, used by nursing staff. Interview with Resident #63 on 12/19/24 at 11:08 AM identified LPN #6 was performing the medication pass during the evening on 12/18/24 and was on her cell phone arguing with someone. LPN #6 had her ear buds in and was swearing at the person she was on the phone with while in Resident #63's room. Resident #63 indicated that it was inappropriate and that the residents should not be exposed to that kind of behavior from staff while providing care to residents. The Director of Nursing Service (DNS) was immediately notified by the surveyor of Resident #63's statements on 12/19/24. Review of the investigation performed by the facility identified LPN #6 was talking on her phone, using inappropriate language and had her earbuds in place which was witnessed by all the staff members working on the unit on 12/18/24. Also identified was that education was provided to LPN #6 regarding customer service, cell phone usage while working to include using ear buds, and appropriate conduct while working. Interview with the Administrator on 12/20/24 at 2:30 PM identified that LPN #6 was an agency nurse, and the agency was called and informed that LPN #6 was no longer welcome to work at the facility. An interview with LPN #6 on 12/23/24 at 10:03 AM identified she was on her cell phone with her earbuds in arguing with someone, using inappropriate language, while on the facility unit such as the medication room, hallway and nurse's unit. LPN #6 further identified that it was not appropriate for her to be on her phone while working and she should not have been using foul language on the unit. Review of the Cell Phones and Other Personal Electronic Devices policy identified that while in the workplace during work hours, workers are expected to focus on work first and foremost. Further identified was not to be engaging in personal conversations. Employees may use devices while they are not working. Devices may be used in the following designated areas during non-working times: lunchrooms, grounds, and offices. Employees are expected to be considerate of others, keep phone volume low or on vibrate, and modulate their conversation voice volume.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interview for the only sampled resident (Resident #3) reviewed for trauma informed care, the facility failed to develop a comprehensive care plan for a resident with post-traumatic stress disorder (PTSD). The findings include: Resident #3 was admitted to the facility in November of 2017 and had diagnoses that included cerebral palsy, PTSD, and major depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), had PTSD as an active diagnosis, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/29/2024 identified Resident #3 had a history of accusatory behaviors related to a diagnosis of bipolar disorder, and traumatic history, and Resident #3 was uncomfortable with male care givers but was comfortable receiving medications from a male nurses. Interventions included no male nurse or caregiver for personal care and provide Resident #3 with support as needed. The RCP identified Resident #3 preferred not to have apple juice as it reminded him/her of a past trauma. Interventions included please do not give Resident #3 apple juice per his/her request and Resident #3 may have apples/apple sauce. The RCP further identified Resident #3 had potential for behavior problems of swearing, yelling out, banging wheelchair into closet and walls, and sobbing. Interventions included to decrease visual or auditory stressors, listen and be supportive, and monitor for triggering events and avoid them in the future. The RCP failed to identify Resident #3 had a diagnosis of PTSD related to childhood trauma, with interventions to include triggers that cause flashbacks or emotional responses of the past trauma. An interview and clinical record review with Social Worker #2 on 12/23/2024 at 12:15 PM identified the RCP did not contain a focus related to Resident #3's diagnosis of PTSD. Social Worker #2 stated she was aware of Resident #3's history of childhood trauma and triggers which caused flashbacks or emotional responses for Resident #3, but did not realize there was a diagnosis of PTSD until checking the clinical record subsequent to surveyor inquiry. Social Worker #2 indicated Resident #3 should have a RCP focus related to PTSD and that the Social Work department was responsible for entering these focuses into the RCP. Social Worker #2 could not identify why the focus was not entered into the RCP and stated Resident #3 was admitted prior to her starting employment. Review of the Comprehensive Care Plans policy identified comprehensive care plans are developed by the interdisciplinary team and include objectives to accommodate psychosocial needs, and care plans are evaluated and revised as needed but at least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy, and interviews for one sampled resident (Resident #20) reviewed for weight loss, the facility failed to follow a dietician recommendation for a resident with known weight loss. The findings include: Resident #20 was admitted to the facility in May of 2022 with diagnoses which included dementia, diabetes, and abnormal weight loss. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility and substantial/maximal assistance with bed/chair transfers. The Resident Care Plan (RCP) dated 11/6/2024 identified Resident #20 had potential for impaired nutrition related to dementia and was at risk for weight loss. Interventions included to allow Resident #20 adequate time to consume meals, assist with meals as needed, and monitor weight as needed. Review of the Weights and Vitals Summary report identified the following documented weights: 125.2 lbs. on 5/30/2024, 124.8 lbs. on 6/28/2024, 124.4 lbs. on 6/29/2024, 125.1 lbs. on 7/25/2024, 125 lbs. on 8/21/2024, 120.5 lbs. on 9/18/2024, 118.6 lbs. on 10/10/2024, 113.2 lbs. on 11/28/2024, 111.5 lbs. on 12/2/2024, and 111.5 lbs. on 12/5/2024. The report further identified a 9.44% severe weight loss from 8/21/2024 through 11/28/2024, and a 10.66% severe weight loss from 6/28/2024 through 12/2/2024. A late entry Nursing progress note dated 12/2/2024 at 7:43 PM identified the Advanced Practice Registered Nurse (APRN) was aware of Resident #14's weight loss and no new orders were given. A progress note by the Dietician dated 12/4/2024 at 11:09 AM identified Resident #20's weight was 111.5 pounds (lbs.) which reflected a 13.3 lbs. (10.7%) weight loss from 6/28/2024 through 12/2/2024. The progress note further identified Resident #20 would continue diet, supplements and weekly weights. Review of the clinical record failed to identify that weekly weights were ordered and completed as recommended by the dietician. Interview with the Dietician on 12/20/2024 at 2:53 PM identified she was unaware Resident #20 was not on weekly weights and still had a current order in place for monthly weights. The Dietician stated she sometimes enters orders into the electronic medical record (EMR) and other times she writes her recommendations on a Dietary Recommendation form which she then hands directly to the Nursing Supervisor. The Dietician stated she wrote a request for weekly weights on a Dietary Recommendation form on 12/4/2024 and gave the form to the Nursing Supervisor. She could not identify why the order was not changed. A progress note by the Dietician dated 12/21/2024 at 10:43 AM identified a new nutritional supplement order but failed to further address the need for weekly weights. Review of the Order Summary Report dated 12/23/2024 identified a provider order dated 10/9/2024 which directed to obtain a weight and vital signs monthly on Thursday every 4 weeks. The Order Summary Report failed to identify a new order for weekly weights. Interview and clinical record review with Registered Nurse (RN) #1 on 12/23/2024 at 9:43 AM identified she is responsible for entering the dietician's written recommendations into the EMR as soon as the form is handed to her and then discards the form. RN #1 was unable to recall receiving a recommendation for weekly weights and confirmed that this order was not in place in the EMR. Interview with APRN #2 on 12/23/2024 at 11:25 AM indicated she did not know if she was notified of a weight loss for Resident #20 and further indicated the care for Resident #20 was managed by MD #1. She identified that she addressed only urgent acute needs when MD #1 was unavailable. Attempts to interview MD #1 were unsuccessful. Although requested, facility policies for dietician assessments and dietician recommendations were not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #75) reviewed for bladder and bowel incontinence, the facility failed to follow the toileting plan and provide incontinence care as directed in the plan of care. The findings include: Resident #75 was admitted to the facility in November of 2023 with diagnoses which included Diffuse Traumatic Brain Injury, Aphasia, Dysphagia, Gastrostomy Tube status, Seizures, and Quadriplegia. The annual Minimum Data Set assessment dated [DATE] identified Resident #75 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0) and required total assistance with eating, bathing, dressing, toileting and mobility. Resident #75 was always incontinent of bladder and bowel. The Resident Care Plan (RCP) dated 11/26/24 identified Resident #75 was incontinent of bowel and/or bladder with a history of urinary retention. Interventions included a maintenance toileting plan which instructed to toilet or provide use of bed pan before and after meals, at hour of sleep and as needed if able, that Resident #75 could raise hand to let staff know s/he needed to go to the bathroom and would shake leg for urgent bathroom use, observe nonverbal clues of needing to use the bathroom, provide incontinent care per incontinent episode and as needed, check every 2 hours for toileting needs. The Resident Care Card (RCC) (readily accessible document used by Nurse Aides (NA) to quickly reference key patient information) identified toileting: bladder continent/incontinent, bowel continent, assist of 2 staff to bathroom. The RCC failed to identify the toileting plan or to check for incontinence every 2 hours as identified in the RCP. Observation on 12/20/24 at 12:20 PM, identified NA #3 provided morning care for Resident #75 from 9:30 AM to 10:00 AM. Observation on 12/20/24 from 10:30 AM to 12 PM identified Resident #75 in the dining room and then assisted back to his/her room without the benefit of toileting or being checked for incontinence. Observation from 12 PM to 12:35 PM identified Resident #75 was in his/her room sitting in his/her wheelchair and no toileting or incontinence checks occurred. Person #1 arrived at 12:35 PM and checked Resident #75 for incontinence and identified that Resident #75's brief was saturated with urine. Person #1 asked Licensed Practical Nurse (LPN) #3 if an NA could change Resident #75, and Resident #75 was subsequently changed. Interview on 12/20/24 at 12:35 PM with NA #3 identified she usually tried to change Resident #75 twice before lunch but was unable to do this today because she was pulled to do other tasks on the unit. Interview and record review with LPN #3 identified Resident #75 should have been checked, changed and toileted before lunch. LPN #3 did not know why Resident #75 was not checked for incontinence and toileted before lunch and indicated NA #3 should have toileted Resident #75 prior to starting other tasks. Observation on 12/23/24 at 9:15 AM identified Resident #75 was receiving morning care. Observation on 12/23/24 from 9:30 AM to 11:04 AM identified Resident #75 was sitting in his/her wheelchair at the nurse's station. Observation on 12/23/24 from 11:04 AM to 11:28 AM identified Resident #75 was sitting in his/her wheelchair in the lounge with visitors. Resident #75 was then assisted back to his/her room by his/her visitors. Observation on 12/23/24 At 12:10 PM identified NA #7 assisted Resident #75 into the dining room without the benefit of providing incontinent care or toileting. Interview on 12/23/24 at 12:10 PM with NA #7 (temporary agency NA) identified that she was unaware that Resident #75 was to be checked for incontinence and toileted prior to lunch because no one at the facility communicated this information to her and she was unaware that the RCC was available for reference in Resident #75 ' s closet. Interview on 12/23/24 at 12:12 PM with LPN #8 (temporary agency LPN) identified that she was unaware that Resident #75 should have been toileted and checked for incontinence before lunch. Interview on 12/23/24 at 12:20 PM with Director of Nursing (DNS) identified agency NA's and nurses should utilize and follow the RCP and RCC to identify how to care for the residents. Additionally, she did not know why the nurse and NA did not know what the RCP or RCC instructed for toileting or incontinence care. Review of the Incontinence Care policy directed, in part, residents who are incontinent of bowel or bladder or who need assistance in hygiene after toileting will receive incontinence care. Although requested, a facility policy for toileting was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy and interviews for the only sampled resident (Resident # 75) reviewed for activities, the facility failed to ensure aspiration precautions were maintained during pleasure eating. The findings include: Resident #75 was admitted to the facility in November of 2023 with diagnoses which included Diffuse Traumatic Brain Injury (TBI), Aphasia, Dysphagia, Gastrostomy Tube status, Seizures, and Quadriplegia. A physician's order dated 2/9/24 directed to provide pureed food including a magic cup and honey thick liquids, by teaspoon only, and with strict aspiration precautions for oral pleasure. The annual Minimum Data Set assessment dated [DATE] identified Resident #75 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0) and required total assistance with eating, bathing, dressing, toileting and mobility. Resident #75 had a feeding tube. The Resident Care Plan dated 11/26/24 identified Resident #75 was at elevated risk for aspiration in the setting of TBI, Dysphagia and Gastrostomy tube status. Interventions included to always maintain at least 30 degrees head elevation, pleasure food: pureed consistency 3 to 4 ounces once per day, recline 10-15 degrees head elevation in wheelchair for feeding positioning, only feed if alert and awake, may have honey thick liquids by teaspoon only with strict aspiration precautions for pleasure. Observation on 12/19/24 at 12:01 PM, identified NA #4 feeding Resident #75 yogurt in the dining room with Resident #75's chair reclined to 30 degrees. LPN #5 repositioned Resident #75's wheelchair to recline 10-15 degrees and educated NA #4 that Resident #75 was on strict aspiration precautions. Interview and record review with LPN #5 on 12/19/24 at 12:05 PM identified Resident #75 as an aspiration risk with associated interventions to prevent aspiration. LPN #5 did not know why NA #4 was feeding Resident #75 in a reclined position. Review of the Aspiration Precautions policy directed, in part, aspiration precautions will be utilized to reduce the risk of aspiration of food or liquid into a resident's lungs. A resident with significant risk of aspiration which is not completely controlled by current diet modifications will require aspiration precautions by the interdisciplinary team. Resident's needing aspiration precautions will be individualized. Any signs or symptoms of aspiration such as increased temperature, abnormal lung sounds, increased coughing will be further assessed and the physician notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #3) reviewed for trauma informed care, the facility failed to provide trauma-informed care to minimize triggers and/or re-traumatization for a resident with post-traumatic stress disorder (PTSD). The findings include: Resident #3 was admitted to the facility in November of 2017 with diagnoses which included cerebral palsy, PTSD, and bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), had PTSD as an active diagnosis, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/29/2024 identified Resident #3 was uncomfortable with male care givers and preferred to not have male Nurse Aides (NA) but was comfortable receiving medications from male nurses. Interventions included no male NA ' s and Resident #3 requested female nursing staff for treatments or procedures requiring exposure. The RCP identified Resident #3 preferred not to have apple juice as it reminded him/her of a past trauma. Interventions included to not give Resident #3 apple juice per his/her request and Resident #3 may have apples/apple sauce. The RCP further identified Resident #3 had potential for behavior problems of swearing, yelling out, banging his/her wheelchair into the closet and walls, and sobbing. Interventions included to monitor for triggering events and avoid them in the future. A Clinical Social Worker progress note dated 11/5/2024 at 5:21 PM identified Resident #3 expressed he/she was having difficulty with agency and per diem staff because they didn't understand him/her and that emotional support was provided. A Clinical Social Worker progress note dated 12/17/2024 at 4:20 PM identified Resident #3 expressed sadness related to recent feeding struggles, expressed how these struggles related to past childhood traumas and that emotional support was provided. Interview with Resident #3 on 12/18/2024 at 11:23 AM identified he/she was given apple juice or spicy food at times, which triggered memories of past trauma. Resident #3 stated he/she would like staff to be more aware of his/her triggers to avoid memories of childhood trauma. Review of the Resident Care Card (RCC) on 12/19/2024 at 12:09 PM (located on the inside Resident #3's closet door) identified Resident #3 was to have no male NA ' s and no apple juice. A progress note by APRN #1 dated 12/19/2024 at 5:13 PM identified Resident #3's history of childhood trauma continued with dissociative episodes and flashbacks to childhood trauma events and there were no new orders. Interview with APRN #1 on 12/20/2024 at 11:50 AM identified she was familiar with Resident #3 having PTSD, and her main trigger of apple juice but was not aware of a trigger for Resident #3 related to hot sauce or spicy foods. APRN #1 was not able to identify any recommendations given to staff to help manage or prevent trauma triggers for Resident #3. Interview with Social Worker #2 on 12/23/2024 at 12:15 PM identified Resident #3 had a diagnosis of PTSD and had childhood trauma triggers related to apple juice, hot sauce, men, and new/different beds. Social Worker #2 stated the most recent incident of Resident #3 being triggered was when a staff member brought a bottle of hot sauce into the dining room for use on their own food, and Resident #3 saw the bottle of hot sauce and subsequently expressed distress. Social Worker #2 indicated there are periodic generalized in-services related to PTSD provided to staff. She further identified the in-services are an opportunity for improvement because they are not resident-centered, and indicated she was unsure of how to educate staff specifically on Resident #3's triggers. Social Worker #2 stated regular facility staff were aware of Resident #3's history of trauma but utilizing agency nursing staff complicated the continuity of communication because they do not consistently follow the RCP or RCC. Observation on 12/20/2024 at 12:35 PM identified Resident #3 was in the dining room finishing his/her lunch meal. Pureed food identified by the diet slip was almost completely consumed. Resident #3 was eating vanilla ice cream. The diet slip accompanying the meal listed the entrée as chicken fricassee, the vegetable as [NAME] blend vegetables, the dessert as lactose free vanilla ice cream w/ toppings, and extra items as 1 right curved utensil, 1 hiwall plate, and 1 [NAME] anti-spill cup. The diet slip failed to identify Resident #3 ' s dietary preferences for no apple juice, no hot sauce, and no spicy foods. Subsequent to surveyor inquiry, a progress note by Social Worker #2 dated 12/23/2024 at 1:37 PM identified a new RCP focus was added to address Resident #3's PTSD diagnosis. Interview with the Dietary Menu Clerk on 12/23/2024 at 1:45 PM identified resident preferences are usually listed on the bottom of dietary slips. She further identified that when nursing staff enter dietary orders in the electronic medical record with preferences, the order will carry over to the system used to print the dietary slips. The Dietary Menu Clerk identified foods that were triggers for Resident #3 and indicated she did not think to add these foods to the diet slip so that they were visible to all staff assisting in the dining room or passing trays. Subsequent to surveyor inquiry, printed diet slips dated 12/23/2024 included instructions at the bottom for: no apple juice; no tomato sauce; no hot sauce/spicy foods. Although requested, a facility policy for trauma informed care was not provided due to absence of a facility policy.

Based on observations, review of facility documentation, facility policy and interviews the facility failed to maintain completed shift change reconciliation records for controlled drugs and failed to periodically reconcile the facility inventory of controlled drugs. The findings include: Review of the Apple Gate South medication cart on 12/18/24 at 9:41AM identified the Count Sheets for Narcotics and Sedatives form (the controlled drug reconciliation form that on-coming and off-going nurses complete to ensure controlled drugs were counted) were missing signatures on the following dates: a. 11/19/24: off-going b. 11/26/24 on-coming and off-going c. 11/27/24 on-coming and off-going d. 12/6/24 on-coming e. 12/7/24 on-coming f. 12/8/24 off-going and on-coming g. 12/11/24 off-going h. 12/16/24 on-coming and off-going i. 12/17/24 off-going j. 12/18/24 on-coming, off-going, on-coming and off-going k. 12/19/24 on-coming, off-going and off-going. Interview with LPN #2 on 12/18/24 at 9:41 AM indicated that upon completion of the Count Sheet for Narcotics and Sedatives, the sheets were placed in the Director of Nursing's (DNS) document bin. Interview and record review with the RN supervisor (RN #1) on 12/19/24 at 11:25 AM identified blanks on the Count Sheets for Narcotics and Sedatives form. RN #1 indicated she was not aware of the blanks and that no one monitors whether the forms are complete or have blanks. The completed Count Sheets for Narcotics and Sedatives forms are placed in the DNS document bin when completed. Interview with the DNS on 12/20/24 at 9:30 AM identified she tried to follow up with nurses to complete the missing signatures on the Count Sheets for Narcotic and Sedatives forms but was unsuccessful. The DNS indicated she completed twice monthly audits of random medication carts but failed to provide documentation of the audits. When asked how diversion of narcotics would be identified, the DNS stated, no comment. Review of the Storage of Controlled Substance policy directed, in part, medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. The Director of Nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerated items, is conducted by 2 licensed personnel and is documented. Controlled substance inventory is regularly reconciled to the Medication Administration Record and documented on a control count sheet or similar form or in accordance with facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents reviewed for facility medication administration, the facility failed to maintain a medication error rate of less than 5% (omission of 3 medications out of 35 opportunities resulting in a medication error rate of 8.57%). The findings include: Resident #16 was admitted to the facility in November of 2024 with diagnoses that included fracture of thoracic vertebrae 9-10, thrombocytopenia, and severe protein calorie malnutrition. The admission Minimum Data Set assessment dated [DATE] identified Resident #16 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and required set up assistance with eating, oral hygiene, personal hygiene, substantial maximum assistance to dependence with dressing, toileting and mobility. The Resident Care Plan dated 11/26/24 identified Resident #16 had potential for impaired nutritional status due to anemia, myelodysplastic syndrome, low body mass index and dysphagia. Interventions included to monitor labs as ordered, monitor weight as needed, monitor percentage consumed of solids and fluids and provide vitamins as ordered. Physician's orders dated 12/17/24 directed to administer Prevagen capsule 10 milligrams (mg), in the morning for memory supplement, Quercetin tablet 50 mg in the morning for supplement, and [NAME] cartilage capsule 500 mg in the morning for supplement. Observation and review of the Medication Administration Record (MAR) with LPN #2 identified on 12/18/24 at 9:41 AM, Prevagen, Quercetin and [NAME] cartilage were not administered as directed. Interview with LPN #2 on 12/19/24 at 10:50 AM identified that Resident #16's family member was providing the Prevagen, Quercetin and [NAME] cartilage from home. LPN #2 indicated she called the family member on 12/18/24 to remind them to bring in the medications, but the medications were still not available. LPN #2 indicated she notified the supervisor of the medication omission, but did not notify the provider. Interview and review of the MAR and progress notes with RN #1 on 12/19/24 at 11:25 AM identified that Resident #16's Prevagen, Quercetin and [NAME] Cartilage had been omitted because they were unavailable. RN #1 further indicated that LPN #2 notified her of the omissions but failed to add a progress note notifying the provider of the omission. RN #1 indicated she would notify the provider and request the Prevagen, Quercetin and [NAME] cartilage be placed on hold until the medications were brought in by the family. A nurse's note dated 12/19/24 at 12:02 PM identified the Advanced Practice Registered Nurse (APRN) was made aware of the unavailable medications and the medications were placed on hold until provided by the family. Review of the Ordering Medications from the Pharmacy policy directed, in part, medication orders are written on a physician order form, telephone order sheet or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's Electronic Health Record (EHR) system and transmitted to the pharmacy. When calling, faxing, sending electronically medication orders for a newly readmitted resident, the pharmacy is also given all allergies and diagnosis to facilitate generation of a patient profile and permit initial medication use assessment.

Based on observations, review of facility documentation, facility policy and interviews, the facility failed to store discontinued controlled drugs in a separately locked permanently affixed compartment, and failed to have a system to limit access to controlled drugs. The findings include: Observation on 12/19/24 at 12:20 PM identified the DNS office door was open without any staff present within the office. Interview with the DNS on 12/20/24 at 9:30 AM identified the discontinued controlled drugs were kept in a cabinet drawer in her office until destroyed. Observation on 12/20/24 at 2:15 PM identified the DNS office door was open without any staff present in the office. Interview on 12/20/24 at 2:20 PM with the DNS identified the keys to both locks of the discontinued controlled drugs cabinet drawer were located in her unlocked desk drawer and that she normally kept the keys stored in that drawer. Observation on 12/20/24 at 2:20 PM with the DNS identified the desk drawer containing the keys to the discontinued controlled drugs cabinet drawer was unlocked. Observation on 12/20/24 at 2:22 PM of the cabinet drawer containing discontinued controlled drugs identified the following controlled drugs to include blister packs, patches and liquids: Oxycodone IR 5 milligram (mg) tabs quantity 57 tabs, Hydromorphone 2 mg tabs quantity 1 tab, Oxycodone- APAP 5-325 mg tab quantity 46 tabs, Tramadol 25 mg tab quantity 1 tab, Tramadol 25 mg tab quantity 12 tabs, Oxycodone IR 5 mg tab (1/2 tab = 2.5 mg) quantity 20(1/2 tabs),Tramadol 50 mg tab quantity 19 tabs, Oxycodone IR 5 mg tab quantity 30 tabs, Oxycodone IR 5 mg tab quantity 17 tabs, Amphetamine salt combo 10 mg tab quantity 9 tabs, Tramadol 50 mg tab quantity 21 tabs, Tramadol 50 mg (½=25 mg) tab quantity 59 (1/2 tabs), Lorazepam 0.5 mg tab quantity 52 tabs, Tramadol 50 mg tab quantity 10 tabs, Tramadol 25 mg tab quantity 27 tabs. Hydromorphone 4 mg tab quantity 25 tabs, Hydromorphone 2 mg tab quantity 29 tabs, Tramadol 25 mg tab quantity 27 tabs, Pregabalin 150 mg cap quantity 60 caps, Oxycodone IR 5 mg tab quantity 30 tabs, Lorazepam 0.5mg tab quantity 2 tabs, Hydromorphone 2 mg tab quantity 22 tabs, Diazepam 2 mg tab quantity 30 tabs, Tramadol 50 mg tab quantity 30 tabs, Diazepam 2 mg tab quantity 11 tabs, Hydromorphone 2 mg tab quantity 30 tabs, Alprazolam 0.25 mg tab quantity 20 tabs, Oxycodone IR 5 mg tab quantity 45 tabs, Oxycodone IR 5 mg tab quantity 27 tabs, Morphine Sulfate ER 15 mg tab quantity 35 tabs, Oxycodone IR 5 mg tab quantity 6 tabs, Hydromorphone 2 mg tab quantity 7 tabs, Tramadol 50 mg tabs quantity 22 tabs, Diazepam 5 mg tab quantity 86 tabs, Alprazolam 0.25 mg tab quantity 7 tabs, Alprazolam 0.25 mg tab quantity 36 tabs, Oxycodone- APAP 5-325 mg tab quantity 19 tabs, Oxycodone IR 5 mg tab quantity 4 tabs, Lorazepam 2 mg tab quantity 90 tabs, Lorazepam 2mg tab quantity 55 tabs, Tramadol 50 mg tab quantity 28 tabs, Clonazepam 0.5 mg quantity 21 tabs, Oxycodone IR 5 mg quantity 5 tabs, Lorazepam 0.5 mg tab quantity 29 tabs, Lorazepam 0.5 mg tab quantity 9 tabs, Oxycodone IR 5 mg tab quantity 15 tabs, Hydromorphone 2 mg tab quantity 59 tabs, Hydromorphone 2 mg tab quantity 16 tabs, Oxycodone IR 5 mg quantity 28 tabs, Tramadol 50 mg tab quantity 38 tabs, Tramadol 25 mg tab quantity 60 tabs, Zolpidem 5 mg tab quantity 1 tab, Alprazolam 0.5 mg tab quantity 17 tabs, Morphine 20 mg /milliliters(ml) quantity 25.25 ml, Lacosamide 10mg /ml quantity 20 ml, Lorazepam 2 mg/ml quantity 24.75 ml, Fentanyl patch 25 microgram /hour quantity 3 patches, Lorazepam 2mg /ml quantity 0 ml, Morphine Sulfate 100mg /5ml (20mg /ml) quantity 7 ml, Lorazepam 2 mg /ml quantity 28 ml, Lorazepam 2 mg /ml quantity 28.50 ml, Morphine 20 mg /ml quantity 30 ml, Hydromorphone 1 mg/ml quantity 6 ml, Morphine 20 mg/ml quantity 19 ml, Lorazepam 2mg /ml quantity 22 ml, Lorazepam 2mg /ml quantity 27 ml, Morphine Sulfate 100mg /5 ml quantity 29.75 ml. All 67 controlled drugs were reconciled by the DNS and RN #1, and the quantities matched the controlled drug disposition records. Subsequent to surveyor inquiry, observation on 12/23/24 at 9:24 AM identified a new file cabinet was permanently affixed to the wall with a double lock. The new file cabinet contained the facility discontinued controlled drugs. Review of the Storage of Controlled Substance policy dated revision 8/2020 directed, in part, medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. The Director of Nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. Schedule 2 through 5 medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double locked compartment separate from other medications or in accordance with state regulations. The access system to controlled medications is not the same as the access system for other medications. If a key system is used, the medications nurse on duty maintains possession of the key to controlled substances storage areas. Back up keys to all medication storage areas, including those for controlled substances, are kept by the Director of Nursing or designee. A controlled substance accountability record is prepared by the pharmacy/facility for all schedule 2, 3, 4 and 5 medications, including those in the emergency supply. At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerated items, is conducted by 2 licensed personnel and is documented. Controlled substance inventory is regularly reconciled to the Medication Administration Record and documented on a control count sheet or similar form or in accordance with facility policy. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed in accordance with facility policy and state regulations. Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of and then stored for 5 years or as required by applicable law or regulation. The consultant pharmacy or designee routinely monitors controlled substance storage, records, and expiration dates during routine medication storage inspections.

Based on observations, staff interviews, and review of facility documentation, the facility failed to ensure open food items were dated and labeled. The findings include: Tour of the Dietary Department on 12/17/24 at 10:05 AM with the Kitchen Manager identified the following: a. The walk-in refrigerator was noted to contain an opened 1-pound bag of cheddar cheese (that was ½ full), an opened 1-gallon container of mayonnaise (that was ¼ full), and an opened bag of 7 croissants with no open date or expiration date identified. b. The walk-in freezer was noted to contain an opened 3-pound bag of French fries (that was ¼ full), an opened bag of 2 fish filets, and an opened 3-pound bag of potato tots (that was ¼ full) with no open date or expiration date identified. c. The dry storage room was noted to contain an opened 3-pound bag of elbow noodles (that was ½ full), an opened 3-pound bag of tri-color macaroni noodles (that was ½ full), an opened 5-pound bag of taco seasoning (that was ¾ full), and an opened 1-pound bag of pearled barley (that was ½ full) with no open date or expiration date identified. Interview with the Kitchen Manager at that time identified the staff member who opened the food items was responsible to label the food item with a date when opened, as well as when the items should have been discarded or expired. He further identified that it was his responsibility to do spot checks weekly in the refrigerator, freezer and dry storage room to ensure open food items were dated and labeled and it was not done. He indicated he was not aware of a policy on labeling and dating open food items. Interview with the Administrator on 12/23/24 at 2:00 PM identified there was no Facility or Corporate Policy on Date Marking or Labeling Open Food items.

Based on facility documentation review, facility policy review and interviews, the facility failed to perform quarterly Quality Assurance meetings and failed to ensure Quality Assurance meetings consisted of the minimum required members to maintain an effective and comprehensive Quality Assurance and Performance Improvement (QAPI) program. The findings include: 1. Review of the attendance record for the Quality Assurance Review meeting provided by the administrator failed to show that a Quality Assurance meeting was completed for September 2024. Interview with the administrator on 12/18/24 at 1:03 PM identified there was no QAPI meeting held since 6/2024. The administrator was unable to provide QAPI meeting minutes (official records of discussions, decisions, and actions taken during QAPI meetings) for the 6/2024 QAPI meeting and produced, only, a sign in sheet. The administrator identified she began working in the facility in 9/2024 as an interim administrator up until 3 weeks prior to the current date when she accepted the role permanently. She identified the previous administrator oriented her to the position and instructed her to hold quarterly QAPI meetings and indicated a QAPI meeting should have been held in 9/2024.The administrator further identified she had not held a QAPI meeting because she was trying to keep the building going subsequent staff turnover. The administrator identified she did not have a future QAPI meeting scheduled as of the current date. 2. The attendance sheet for the quarterly QAPI meetings were reviewed for 3/2023, 6/2023, 9/2023, 12/2023, 3/2024, and 6/2024 and failed to identify that the Infection Preventionist and 2 other staff members were in attendance during the QAPI meetings. On 12/23/24 at 2:44 PM an Interview with the Administrator and the Director of Nursing (DNS) during a review of the QAPI meeting agenda and criteria, the Administrator identified that a QAPI meeting had not been completed since 6/20/24 and indicated that she lost sight of it and thought it had been done in September. The Administrator further identified that she had just began working at the facility in September of 2024 and she was not aware that the Infection Preventionist and 2 other staff members were required to be in attendance. The Facility policy for Quality Assurance Performance Improvement dated 4/2015 indicated the governing body/and/or administration of the nursing home develops a culture that involves leadership seeking input from facility staff, residents, and their families and /or representative. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. The governing body should foster a culture where QAPI is a priority by ensuring that policies are developed to sustain QAPI despite changes in personnel and turnover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 resident (Resident #1) observed on facility tour, 10 of 32 residents (Resident #5, Resident #12, Resident #20, Resident #32, Resident #36, Resident #51, Resident #53, Resident #67, Resident #70, and Resident #244) reviewed for Enhanced Barrier Precautions (EBP) and 1 of 2 residents (Resident #242) reviewed for Transmission Based Precautions (TBP), the facility facility failed to properly store a urinary containment bag and failed to initiate and maintain EBP per the Center of Disease Control (CDC) guidelines for residents with a history of Multiple Drug Resistant Organisms (MDROs) and failed to utilize personal protective equipment (PPE) while assisting a resident requiring EBP and failed to maintain TBP while assisting a resident with a positive COVID-19 diagnosis and failed to maintain a clean and sanitary environment. The findings include: 1. Resident #1's diagnoses included paraplegia, multiple sclerosis, and neuromuscular dysfunction of the bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and was a set up for meals, and personal hygiene, also dependent for toileting, bathing, dressing and transfers. Further, identified was Resident #1 had a urostomy. The Resident Care Plan (RCP) dated 10/22/24 identified a urinary containment bag with interventions which directed to place the urinary containment bag in a basin on the floor and to provide education to Resident #1 on infection control measures. Observation on12/17/24 at 10:32 AM identified of the urinary containment bag on the floor under Resident #1's bed, no basin in place. Observation on 12/18/24 at 10:19 AM identified the urinary containment bag on the floor under Resident #1's bed, no basin in place. Observation on 12/20/24 at 10:41 AM identified the urinary containment bag on the floor under the bed, no basin in place. Interview with Nurse Aid (NA) #2 on 12/20/24 at 10:41 AM identified that she provided care for Resident #1 previously, and she was familiar with his/her care. NA #2 provided the NA Care Card which was in Resident #1 ' s closet. NA #2 stated she was not aware of any specific instructions regarding Resident #1's urinary containment bag but stated it should not be on the floor. Review of the NA Care Card on 12/20/24 at 10:45 AM did not identify care instructions for the urinary containment bag. Interview on 12/20/24 at 10:46 AM with Licensed Practical Nurse (LPN) #1 identified she did not know of specific instructions regarding Resident #1 ' s urinary containment bag. LPN #1 reviewed the NA Care Card and indicated there was nothing specific noted on the NA Care Card regarding the urinary containment bag. LPN #1 reviewed the RCP and identified Resident #1 ' s urinary containment bag with an intervention for the containment bag to be placed in a basin while the resident was in bed. LPN #1 further identified that she was unsure how this intervention would be communicated to staff if it was not on the NA Care Card. LPN #1 identified that the urinary containment bag should not be on the floor. Subsequent to surveyor inquiry, the NA Care Card was updated for Resident #1's urinary containment bag to be placed in a basin. Review of the Urine Drainage Bags Policy identified that urinary drainage bags are to be hung in a privacy bag on the bed. 2. Resident #5, Resident #12, Resident #32, Resident #36, Resident #53, Resident #67, and Resident #244 had a history of Extended Spectrum Beta Lactamases (ESBL). Resident #32 had a history of ESBL and Vancomycin Resistant Enterococci (VRE). Resident #20 and Resident #51 had a history of Methicillin Resistant Staphylococcus Aureus (MRSA). Resident #70 had a history of Clostridium Difficile (C. Diff.). Review of the History vs Active MDRO list compared to the EBP list provided by the Infection Control Nurse identified that residents with active MDRO ' s or a history of MDRO ' s were not on EBP. Interview and review of the MDRO list, EBP list and current CDC guidelines with LPN #4 on 12/19/24 at 12:33 PM identified that residents identified to have a history of an MDRO should be placed on EBP. Center for Disease Control (CDC) guidelines identified April 1, 2024: Implementation of Enhanced Barrier Precautions (EBP) in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms. Multidrug-resistant Organism (MDRO): bacteria or fungi resistant to multiple antimicrobials and colonization identifies a germ is found on or in the body but is not causing infection. Many nursing home residents are unknowingly colonized with an MDRO, especially residents with risk factors like indwelling medical devices or wounds. Residents who have an MDRO can develop serious infections, remain colonized for long time periods, and spread MDROs to others. EBP are indicated for nursing home residents with any of the following: Infection or colonization with an MDRO when Contact Precautions do not otherwise apply, wounds and/or indwelling medical devices. EBP is not limited to outbreaks or specific MDROs. 3. Observation on 12/23/24 at 9:12 AM identified signage outside of Resident #75 ' s room directing EBP and PPE was stocked outside of the room. NA #7 was observed finishing morning care for Resident #75 without the benefit of using PPE. Interview on 12/23/24 at 9:12 AM with NA #7 identified she was aware of the signage outside of Resident #75 ' s room but indicated she was unaware of which resident was on EBP. NA #7 identified she was unaware of the Resident Care Card (readily accessible document used by NA ' s to quickly reference key patient information) which was located inside Resident #75 ' s closet. NA #7 indicated she provided morning care without using PPE. Review of facility policy titled Enhanced Barrier Precautions, directed in part, the facility will implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDRO). Novel or targeted MDROs are organisms that are resistant to all, or most antibiotics tested, are uncommon in a geographical area, or have special genes that allow them to spread their resistance to other germs. Additional epidemiologically important MDROs may include but are not limited to: MRSA, ESBL, VRE. Enhanced barrier precautions require the use of gowns and gloves for certain residents during specific high contact resident care activities in which there is an increased risk for transmission of multi-drug-resistant organisms. High contact resident care activities include bathing/showering, providing hygiene, dressing, transferring, linen changes, toileting, device care and wound care. 4. Observation on 12/20/24 at 12:09 PM identified signage outside of Resident #242 ' s room instructing contact and droplet precautions. NA #10 was observed entering Resident #242 ' s room to answer the call light but wore a surgical mask rather than an N95 mask as instructed by the signage outside the room. N95 masks were available in the PPE cart outside the room. Resident #242 was on contact and droplet precautions due to Covid-19. Interview with NA #10 on 12/20/24 at 12:09 PM identified that the sign posted outside of Resident #242's room identified that Resident #242 was on contact and droplet precautions and NA #10 should have worn an N95 mask rather than a surgical mask. Review of facility policy titled Transmission Based Precautions, directed in part, Transmission based precautions will be employed for known or suspected infections for which there are active symptoms, and the route of transmission is known. The transmission-based categories used in this facility are Droplet precautions and Contact precautions. 5. Observation on 12/17/24 at 11:20 AM, in the 3rd floor shower room, identified 2 commode buckets on the floor in a shower stall. Observation on 12/17/24 at 11:29 AM in room [ROOM NUMBER] identified 2 unlabeled wash basins on the bathroom floor. Observation on 12/17/24 at 11:29 AM in room [ROOM NUMBER] identified 2 unlabeled wash basins on the bathroom floor. 1 of the wash basins contained an unlabeled bed pan. Observation on 12/17/24 at 11:29 AM in room [ROOM NUMBER] identified a wash basin on the bathroom floor and a urine containment bag (leg bag) draped over a railing located above the trash can. The trash can contained soiled wipes with a brown substance laying over the edge of the trash can. Observation on 12/19/24 at 10:47 AM in room [ROOM NUMBER] identified 2 unlabeled wash basins on the bathroom floor. Observation on 12/19/24 at 10:47 AM in room [ROOM NUMBER] identified 2 unlabeled wash basins on the bathroom floor. 1 of the wash basins contained an unlabeled bedpan and the other wash basin was placed on top of a 2nd unlabeled bed pan. Observation on 12/19/24 at 10:47 AM In room [ROOM NUMBER] identified unlabeled wash basins were on the bathroom floor, a urine containment bag (leg bag) was hanging over the railing located above the trash can. The trash can was ¾ full and contained soiled wipes with a brown substance and odor of feces. Observation on 12/19/24 at 11:51 AM of the 3rd floor shower room identified 3 commode buckets on the floor and wet linens draped over a railing. The shower stall floor was noted to be wet and a strong smell of urine was noted inside the shower stall. Observation on 12/20/24 at 10:18 AM of the 3rd floor shower room with LPN #4 and the Director of Nursing (DNS) identified 2 commode buckets and a wet used washcloth on the floor in the shower stall and 3 disposable razors on the countertop. LPN # 4 discarded the razors in a sharps container. Observation on 12/20/24 at 10:18 AM with LPN #4 and the Director of Nursing (DNS) in room [ROOM NUMBER] with LPN #4 and the Director of Nursing (DNS) identified wash basins were on the floor in the bathroom. Observation on 12/20/24 at 10:18 AM with LPN #4 and the Director of Nursing (DNS) in room [ROOM NUMBER] identified wash basins containing a bedpan were on the bathroom floor. Observation on 12/20/24 at 10:18 AM with LPN #4 and the Director of Nursing (DNS) in room [ROOM NUMBER] identified a urine containment bag (leg bag) was draped over the railing in the bathroom. Additionally, a foul odor of urine was identified. LPN #4 discarded the urine containment bag in the trash can. Interview with the DNS on 12/20/24 at 10:18 AM identified that the NA's should label the personal care items and the staff should perform auditing and rounding on the units. Additionally, the DNS stated no comment when the surveyor inquired why this was not done. Review of the facility policy titled General Infection Control Nursing Policies directed, in part, all resident personal items will be appropriately labeled with resident name and stored in the bedside stands or other designated resident storage areas and cleaned and disinfected as indicated. All resident common areas will be maintained in a clean and orderly manner and will be free of obvious hazards such as fall hazards, chemical hazards, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident, (Resident #13) who experienced a significant weight loss, the facility failed to notify the physician of the significant weight loss in a timely manner. The findings include: Resident #13's diagnoses included multiple sclerosis, dysphasia, chronic respiratory failure, and pressure ulcer. The quarterly MDS assessment dated [DATE] identified Resident #13 had intact cognition, required extensive assistance of two persons for bed mobility, was independent with eating once set up and was totally dependent for toileting and bathing. The care plan dated 6/16/22 identified Resident #13was at risk for impaired nutrition due to dysphagia and multiple sclerosis. Care plan interventions included, provide a regular puree diet dysphagia level 1 diet with extra gravy/sauces with meals and nectar thick liquids, allow resident adequate time to consume meals, provide aspiration precautions, feed as needed, magic cup(supplement) with dinner and monitor weights as needed. Review of Resident #13's weight record in the electronic medical record identified the following: On 7/5/22 at 1:22 PM, the resident's weight was noted to be 161.4 lbs. On 8/16/22 at 7:31 and 7:32 PM, the resident's weight was noted to be 145 lbs. The electronic medical record noted that the resident had a 10.16 % weight loss (16.4 lbs.) A dietary note dated 8/24/22 (8 days after the weight loss was noted) identified that fortified food at breakfast was added in response to the noted weight loss. APRN #1's progress note dated 9/8/22 (23 days after the significant weight loss was identified) identified that Resident #13 had notified her of his/her continued weight loss. The note further identified that all supplements were to be continued and to obtain weights every two weeks. The Physician's order dated 9/9/22 directed to obtain weights every other Tuesday and to notify provider of any further weight loss. Interview with the Director of Nursing on 9/12/22 at 11:00 am indicated that Resident #13 had a significant weight loss on 8/16/2022 and that there was no documentation that the physician was notified of the significant weight loss. The DNS further indicated that the dietician was notified, but it was not documented. The DNS further indicated that on 8/24/22 the dietician completed a note (8 days after weight obtained) and that it is the charge nurse's responsibility to notify the physician and responsible party with a significant weight loss. The DNS was unable to indicate why the notifications to the physician and responsible party were not made. Interview with APRN #1 on 9/12/22 at 11:45AM identified that the progress note she wrote on 9/8/22 was a mistake. She identified that the nursing staff had notified her on the Monday after the weight loss was noted (six days later). She further noted that she had not written a progress note or addressed the weight loss on that date because she was waiting to hear from the dietician. Interview on 9/12/22 at 12:15 PM with the Dietician indicated that she became aware of Resident #13's weight loss when she checked the weight warnings in the electronic medical record. During the interview the Dietician did not have her computer with her and asked if she had not documented that information in the resident's electronic medical record. The weight warning indicated the dietician made an entry on 8/24/22 in acknowledgment of the significant weight loss (8 days after weight obtained). The dietician indicated that she becomes aware of significant weight losses when she reviews the weight warnings in the computer and occasionally a note will be left in her mailbox. The Dietician further indicated that she did not have a note in her mailbox regarding Resident #13's significant weight loss nor was she notified by staff or the APRN. Review of the facility's weight policy indicated that if a significant weight loss or gain is identified, the interdisciplinary team, the dietician, the physician, and the family are notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for one sampled resident (Resident #77) with a vision deficit, the facility failed to ensure that the resident's vision deficit was addressed within the plan of care. The findings include: Resident #77's diagnoses included diabetes, general anxiety disorder, depression, and dementia. The admission MDS assessment dated [DATE] identified Resident #77 was cognitively intact, had moderately impaired vision, required limited assistance for bed mobility and transfers, was independent with eating once set up. The assessment further identified that vision triggered as a care plan area and that the team (IDT) would proceed with care planning for the vision deficit. Review of the Nurse Aide care card dated 8/11/22 failed to reflect Resident #13's vision deficit. The care plan dated 8/23/22, indicated resident #77 required assistance with activities of daily living (ADLs) and mobility. Further review of the care plan failed to identify that Resident #13 had a vision deficit and failed to identify interventions to address the vision deficit. Interview on 9/6/22 at 10:45AM with Resident #77 identified that due to his/her poor vision, he/she was unable to read the activity schedule that was provided to him/her. Interview on 9/12/22 at 12:40 PM with the Director of Recreation indicated that her department uses large print on the recreation programs located throughout the facility, in each resident's room and given directly to the resident if that is their preference. The Director of Recreation could not remember if Resident #77 had a vision deficit. Interview on 9/13/22 at 9:12 AM with LPN #2 identified that Resident #13's care plan dated 8/23/22 should have addressed the resident's vision deficit. LPN #2 further indicated that on 9/12/22 (after surveyor inquiry) there was discussion amongst administration and the MDS department about the resident's vision deficit and the focus area and interventions were added to the care plan. Interview on 9/13/22 at 9:30 AM with RN #2 identified that care plan triggered areas should be addressed on the care plan. She offered no explanation as to why the resident's vision deficit had not been addressed. RN #2 further identified that each department writes their own care plans, some are interdisciplinary, but the MDS department does not double check to be sure all areas have been addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for one sampled resident (Resident #77) reviewed for activities of daily living, the facility failed to ensure that Resident #77's was offered and given a weekly shower. Resident #77's diagnoses included diabetes, general anxiety disorder depression and dementia. The admission MDS assessment dated [DATE] indicated that Resident #77 had moderately impaired vision, had intact cognition, required limited assistance of one person for bed mobility and transfers, and required assistance for bathing. The Nurse Aide care card date 8/11/22 indicated Resident #77's shower schedule was every Friday on the 3:00 PM to 11:00 PM shift with the assistance of one person. The care plan dated 8/23/2022, indicated resident #77 required assistance with activities of daily living (ADL's) and mobility with interventions that included, provide assistance of one person for transfers to wheelchair, provide assistance or cueing to maximize current level of function, encourage self-performance, allow sufficient time to complete activities and provide privacy while bathing and dressing. Interview on 9/6/22 at 11:52 AM with Resident #77 identified that he/she has only had one shower since being admitted . Interview on 09/12/22 at 12:50 PM with RN #5 indicated that if the nurse aides are from the agency they may not chart because they do not have access to the computer. RN #5 further noted that there was no documentation entered on Friday during the 3:00 PM -11:00 PM shift for September. Interview on 9/12/22 at 1:00 PM with the ADNS indicated there was no documentation on Friday 8/26/2022 or 8/19/2022 to indicate that a shower was provided to Resident #77. The ADNS further indicated that there is not an alternative way for the agency staff to document but if the computer goes down there is paper documentation that can be utilized. Interview on 9/12/22 at 1:22 PM with NA #2 identified that Resident #77 was scheduled for a shower on Fridays on the 3-11 shift and noted there was no documentation to indicate that a shower was given last Friday. NA #2 further indicated that last week a co-worker on 7-3 gave resident #77 a shower. She noted that the shower may have been given due to the shower not being administered the prior week. Interview on 9/12/22 at 1:30 PM with LPN #3 indicated that she did not have any paper documentation completed by the nurse aides and that would only occur when the computers go down. LPN #3 further indicated that the supervisors provide passwords for the agency nurse aides to use to document the care they provide. Interview on 9/12/22 at 1:45 PM with the ADNS accompanied by the corporate RN indicated that all the nurses were looking at the wrong task on the electronic documentation for the nurse aides and that in August Resident Number #77 was on a different unit with a scheduled shower day on Wednesday. While reviewing the bathing documentation for August 4th, 2022 (date of admission) through August 31st, there was no documentation of a shower given on any shift. Though the Corporate RN indicated that there is documentation that bed baths were given for the month of August the facility could not provide documentation of resident refusal of showers and preference for bed baths. Review of the facility policy for showers indicated that the resident would receive a shower, assisted and or given by the nursing staff as desired and the procedure will be documented.

Based on observations, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure that the temperature logs of the refrigerators, dishwasher and meals were maintained on a consistent basis to ensure the safe storage, preparation, and cleanliness of the dishes to prevent foodborne illness. The findings include: Observations made during the initial inspection of the kitchen on 9/6/22 indicated that food temperature logs were incomplete as well as the temperature logs for the refrigerator and the dishwater. An interview with the Food Services Director on 9/6/22 at 10:06 AM indicated that the responsibility for log completion is that of the cook on duty and noted that the cook was currently in training. The Food Service Director provided no explanation as to why the temperature logs were incomplete. The policy for logging food temperatures identified that food temperatures are to be taken for each food item during each meal service and recorded on a temperature monitoring log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff interviews and a review of the facility documentation for one sampled resident (Resident #34), the facility failed to notify the responsible party when there was a change in medication regimen. The findings include: Resident #34 was admitted to facility on 08/09/19 with diagnoses that included non-Alzheimer's dementia, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and generalized anxiety disorder . The resident care plan dated 8/9/19 identified anxiety as a problem with interventions that included to observe behaviors for periods of anxiety, provide a calm environment, diversional activities, psychiatric evaluations as needed for medication management, administration of anxiolytics and monitor their effectiveness, provide support and reassurance to the resident and the family. Physician's admission orders dated 8/13/19 directed to administer Trazadone 25 milligrams (mg) every twenty four hours as needed for sleep and to administer Clonazepam 0.5 mg once a day by mouth for generalized anxiety. An admission Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, extensive assistance with activities of living and seven days of antianxiety and antidepressant medication administration. An Advanced Practice Registered Nurse (APRN) progress note dated 08/28/19 identified the Trazadone order had been discontinued on 08/23/19 and the Clonazepam order was discontinued on 08/26/19. The note further indicated the resident's anxiety was stable and that he/she was doing well without the medications. An APRN note dated 10/16/19 at 9:57 AM identified Person #1 reported Resident #34's mood had change and presented with worsening mood symptoms and delusions. A nurses note dated 10/17/19 identified Resident #34 was evaluated by MD #2 on 10/16/19. A nurses note dated 10/24/19 identified Person #1 was made aware that Clonazepam was increased to 0.5 mg twice a day and was in agreement with the medication change. Interview with APRN #1 on 11/14/19 at 1:25 PM indicated on 8/28/19 when reviewing the resident's clinical record he/she became aware that Clonazepam and Trazadone had been discontinued. APRN #1 identified he/she made the decision to not re-order Trazadone and Clonazepam as Resident #34 had not been exhibiting symptoms that required the use of the medications. Further interview with APRN #1 indicated when medications were discontinued, it was the expectation of the nursing staff to contact the on call physician. Typically, the medication would be continued until APRN #1 was able to assess Resident #34 to determine the need for the medications. Additionally, APRN #1 identified it was the responsibility of the nursing staff to notify the resident's representative when medications were changed or discontinued. Interview with Person #1, Resident #34's representative, on 11/15/19 at 1:15 PM, identified he/she was unaware of the medication changes that occurred on 08/23/19 and 08/26/19 and was not made aware until Resident #34 exhibited a change in behavior and mood on 10/17/2019. Person #1 further indicated if she/he was aware, he/she would not have allowed the medications to be discontinued until an assessment was conducted. Interview and review of Resident #34's clinical record with the Director of Nursing (DON) on 11/18/19 at 10:01 AM failed to identify that Resident #34's representative was notified when there was a change in the residents medications. The DON indicated the the residents responsible party should have be notified and the notification should have been documented in the clinical record and was not. Review of the facilities Residents' [NAME] of Rights directed in part that the resident or responsible party have the right to participate in planning care, treatment and to be fully informed in advance about changes in care and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and interview for one sampled resident (Resident # 34), the facility failed to follow physician's diet orders prior to a medical procedure. The findings include: Resident #34 was admitted to facility on 08/09/19 with diagnoses that included non-Alzheimer's dementia, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and generalized anxiety disorder. An admission Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, extensive assistance with activities of living and a mechanically altered diet . A resident care plan dated 8/16/19 identified impaired nutritional status due to dysphagia with interventions that included monitor intake at meals, assist and allow the resident adequate time to consume meals, nutritional assessments and education, assess and monitor for the presence of factors interfering with nutritional status, and document consumed fluids and foods. Physician's orders dated 09/27/19 directed Resident #34 would not eat or drink after midnight on 10/10/19 prior to an esophageal motility study to be conducted on 10/10/19. A nurses note dated 10/10/2019 at 2:07 PM identified Resident #34 accidentally ate his/her breakfast, therefore, the test was rescheduled for 10/16/19. The motility study consult communication report from MD #3 dated 10/10/19 identified the esophageal motility study was not performed on 10/10/19 because Resident #34 consumed breakfast. Recommendations indicated the procedure would need to be rescheduled for 10/16/19 and to ensure the resident did not eat or drink after midnight on 10/16/19. Interview with LPN #1 on 11/14/19 at 2:20 PM identified it was his/her responsibility to alert the nurse aides of procedures that required the absence of food or drinks first thing in the morning during report. LPN #1 indicated it was a busy morning on 10/10/19 and he/she failed to notify Resident 34's nurse aide that he/she was not to eat breakfast or consume fluids due to a procedure that required a NPO (nothing by mouth) status.