**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #2) who was transferred to the hospital, the facility failed to provide the resident and responsible party with the correct transfer and discharge documents and readmit the resident when the resident was ready for discharge from the hospital. The findings include:Based on clinical record reviews, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #2) who was transferred to the hospital, the facility failed to provide the resident and responsible party with the correct transfer and discharge documents and readmit the resident when the resident was ready for discharge from the hospital. The findings include: Resident #2's diagnoses included dementia, anxiety, and a history of alcohol abuse. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily living. The Resident Care Plan dated 6/28/25 identified Resident #2 as a long-term resident at the facility. Interventions aimed at encouraging family participation, to encourage the resident to participate in activities, inform the family of any changes, and social services to provide one (1) to one (1) support as needed. The nurse's note dated 8/31/25 at 8:41 PM identified Resident #2 had eloped from the facility and was found by the police walking along the road, although Resident #2 appeared unharmed, Resident #2 was sent to the hospital to be evaluated and treated and Resident #2's conservator was updated. Review of the clinical record failed to identify a bed hold notice was issued to Resident #2 and/or the conservator. Review of the clinical record failed to identify that a discharge summary was completed for Resident #2. The discharge notice given to Resident #2 identified the notice was dated 9/19/25 and Resident #2 had been discharged on 9/1/25. Interview with the hospital Social Worker (Person #2) on 9/26/25 at 2:58 PM identified she received written documentation from the Resident #2's Conservator (Person #3) regarding the meeting he/she had with the facility on 9/8/25 to discuss a safe discharge plan for Resident #2. Person #2 indicated he/she received a copy of the letter Person #3 received from the facility on 9/10/25 which indicated the facility's refusal to take Resident #2 back. Person #2 identified Resident #2 remained in the hospital under observation because they had not found placement for Resident #2. Interview with an Ombudsman from the Long-Term Care Ombudsman Program (Person #1) on 9/29/25 at 10:30 AM identified she had multiple conversations with the administrator at the facility regarding the discharge process. Person #1 identified she informed the administrator he needed to initiate a consultative process and then follow the involuntary discharge process if the facility still determined they wanted to discharge Resident #2. Person #1 explained she informed the administrator they would have to take Resident #2 back to the facility while the Conservator filed an appeal and wait for the appeal hearing. Person #1 stated training was offered to all nursing homes regarding changes to the discharge process, with the new process a discharge notice needed to be issued to a resident, conservator and filed with Person #1 the same day of discharge, and the facility failed to do this. Person #1 stated discharges cannot be back dated, he/she explained this to the administrator, and sent an email with this information to the administrator on 9/16/25. Person #1 identified as of 9/29/25 Resident #2 remains in the hospital on observation status, and the facility has continued to refuse to take Resident #2 back despite education on the regulations. Interview with Person #3 on 9/29/25 at 1:45 PM identified when Resident #2 initially eloped from the facility he/she was told Resident #2 climbed out of a window but was not given all the information leading up to the event. Person #3 explained he/she was initially concerned about Resident #2 returning to the facility and wanted Resident #2 evaluated at the hospital and after learning the details surrounding the reasons Resident #2 eloped, Person #3 felt it was in the best interest for Resident #2's safety and well-being for him/her to return to the facility and Person #3 met with facility staff the beginning of the week following the elopement. Person #3 explained he/she was unable to recall anyone saying Resident #2 was discharged and would need to apply for a readmission. Person #3 identified he/she had conversations with the facility staff regarding safety measurements and was ready to pay for one (1) to one (1) staff while establishing a safe plan. Person #3 stated he/she received a letter from the facility on 9/10/25 indicating they would not allow Resident #2 to return to the facility, so he/she has filed an appeal on behalf of Resident #2 to allow Resident #2 to return to the facility. Person #3 identified although a bed hold was not issued, Resident #2's bed was still open, and Resident #2's belongings were still at the facility. Person #3 indicated he/she did not sign discharge paperwork. Interview with the administrator on 9/29/25 at 2:00 PM identified the facility received communication in the hospital portal system dated 9/1/25 which indicated Resident #2's conservator did not want Resident #2 to return to the facility, therefore, the facility did not issue a bed hold notice. The administrator identified Person #3 later requested to allow Resident #2 to return to the facility, so Person #3 met with the facility on 9/8/25 and discussed various options to help keep Resident #2 safe. The administrator explained a follow-up meeting was scheduled for 9/10/25 to finalize the return, the facility held a meeting with other staff members, and they determined they would not be able to keep Resident #2 safe. The administrator explained he issued a discharge notice to Resident #2 and Person #3 on 9/19/25 with a discharge date of 9/1/25. The administrator identified he had spoken to Person #1 regarding the discharge and filed the discharge notice with Resident #2, Person #3, and Person #1's office only after learning that he should have filed the discharge notice on 9/1/25. The administrator acknowledged Person #1 sent him the regulations and a slide presentation on 9/16/25 outlining the discharge process and the facility's responsibility regarding discharge. The administrator identified he has not requested a consultative process meeting with the hospital and has continued to refuse to allow Resident #2 to return to the facility while in the appeal process. The administrator indicated he has received notice of a hearing regarding the appeal of discharge filed by the conservator on behalf of the resident. Review of the Resident Rights Policy identified the resident had the right to appeal a transfer or discharge to the state and the facility must safely and orderly transfer or discharge the resident and give the resident proper notice of bed-hold and/or readmission requirements.Review of the Bed Hold Policy identified upon transfer to a hospital the notice will be given to the resident and the facility will send the notice to the hospital with the resident. Documentation will be noted in the medical record that the [NAME] was sent with the resident. A notice will also be sent to the party responsible as soon as possible. The policy further identified the facility will contact the hospital on the day the resident is admitted and ask the hospital if, and when the resident is expected to return to the facility. Documentation from that contact will be maintained in the medical record. If the resident is hospitalized for more than seven (7) days, the facility will repeat the above process and document it. For private pay residents the facility must reserve the bed if payment is available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #26) reviewed for advance directives, the facility failed to ensure the physician's order accurately reflected the resident's chosen code status. The findings include: Resident #26 was admitted to the facility in October of 2024 with diagnoses that included acute respiratory failure with hypoxia, dependence on supplemental oxygen, congestive heart failure and Alzheimer's disease. The physician's order dated [DATE] directed a code status of Do Not Resuscitate, A do-not-resuscitate order, or DNR order, is a medical order written by a health care provider. It instructs providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating. Do Not Intubate, A do not intubate (DNI) order is a medical directive that instructs medical professionals not to insert a breathing tube into a patient's trachea. A DNI order is part of an advanced directive for patients with life-limiting illnesses and is used when a patient or their surrogate believes that resuscitation would not be in their best interest. The order further directed: Nurse may pronounce, and body may be released to the funeral home in the event of cardiac arrest. The admission MDS dated [DATE] identified Resident #26 had moderately impaired cognition, utilized a walker, was taking an anticoagulant (blood thinner), a diuretic, and an opioid (pain medication), and was receiving continuous oxygen. The care plan dated [DATE] identified Resident #26 had a code status of Do Not Resuscitate with an intervention to not perform CPR in the event the resident's heart/breathing stops. Review of the electronic health record (EHR) on [DATE] at 8:19 AM identified an Advance Directive form dated [DATE] that was scanned into the EHR that identified Resident #26 had elected to receive CPR. The form was signed by Resident #26 and RN #4. The advance directive form dated [DATE] and the physician's order dated [DATE] were incongruent and did not reflect the same code status. Interview with the DNS on [DATE] at 7:36 AM identified that in the event a resident stops breathing, the nurse is supposed to check the resident's signed advanced directive form against the physician's orders to verify the resident's code status. She further noted that there books located on the units that contain the signed advance directive forms. A review of the unit 1's advance directive book on [DATE] at 9:14 AM failed to identify a signed Advance Directive form for Resident #26. Interview on [DATE] at 9:14 AM with RN #4 identified Resident #26 had a physician's order that indicated the resident's code status was DNR. She further noted Resident #26's responsible party had filled out an advance directive form after Resident #26 completed an advanced directive form on [DATE]. She further noted that Resident #26's Responsible Party indicated that the resident was not capable of making a decision regarding code status. Interview on [DATE] at 9:29 AM with Resident #26 identified the resident would like CPR administered in the event his/her heart stops and remembers having a conversation with the nurse and signing a form that indicated this decision. Resident #26 further noted he/she could not recall having a discussion with the physician or his/her responsible party regarding code status. Interview on [DATE] at 9:42 AM with the DNS identified she found an additional Advance Directive form dated [DATE] that was signed by the Responsible Party. The Advance Directive had been initialed by the son under the election I do not want CPR. The DNS was not able to confirm the validity of this and identified that the resident was alert and oriented and should be able to make the decision about an advanced directive. Interview on [DATE] at 12:39 PM with the Medical Director identified that if a resident is alert and oriented and able to discuss and make a decision regarding Advanced Directives then the decision of the resident should be followed. If the resident has a power of attorney (POA), then the decision could be changed by that POA if the resident had a sudden cognitive deficit, or loss of the ability to clearly make the decision. The Medical Director identified that in this instance Resident #26's decision and the physician's order should match. He further noted that he had not spoken with the Resident #26's responsible party regarding the resident's code stats. He could not explain why the order and the advanced directive form signed by the resident were incongruent. Interview on [DATE] at 12:52 PM with SW #1 identified Resident #26 was able to decide and sign the advance directive if alert and oriented. The facility process was that nursing explains the Advance Directive to the resident and obtains the signature. SW #1 identified the only way the POA would be able to sign a different code status is if the resident had a significant change in cognition and could no longer make decisions. SW#1 indicated Resident #26 would be able to make the Advance Directive Decision. Although contact was attempted on 11/18 and [DATE], Resident #26's Responsible party could not be reached. The facility policy for Advance Directives identified the facility recognized the right of each resident to make decisions regarding treatment and to execute directives, and if incapacitated, to have these decisions made on their behalf by the appropriate substitute decision maker. Additionally, the policy indicated all signed advance directives would be kept in a code book on wing 2 and uploaded into the electronic chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one sampled resident (Resident #31) reviewed for weight loss, the facility failed to notify the dietician, and physician regarding a significant weight loss. The findings include: Resident #31's diagnoses included congestive heart failure, disorder of kidney and ureter, depression, anxiety, and atrial fibrillation. Physician's orders dated 5/15/24 directed to check weight three times per week and notify physician for weight gain or loss equal to 3 pounds (lbs.). Physician's orders dated 8/26/24 directed Resident #31 be provided a regular diet of regular texture, thin liquids and fluid restriction of 1500 milliliters(ml) per day. Review of the weight and vital summary record identified Resident #31 was weighed on 9/25/24 at 11:20 AM with a noted weight of 238.6 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had intact cognition, and dependent for bed mobility, toileting, hygiene, transfers, and was non-ambulatory. The assessment further identified Resident #31 was independent with eating with set-up assistance and identified the resident had not experienced a weight loss within the past six months. Resident #31's weight record identified a weight of 223.4 on 10/3/24 (a weight loss of 15.2 lbs.), which was a 6.4 % (percent) weight change in less than a month. The weight record further identified a weight of 219.6 on 10/14/24 (a loss of 19 lbs.) indicative of a 7.9% weight loss in less than thirty days (The standard for determining significant weight loss is 5% within thirty days, 7.5% within three months, and 10% within six months). The Resident Care Plan (RCP) dated 10/10/24 identified Resident #31 had a potential nutritional risk related to depression, anxiety, and obesity. Care plan interventions included: provide and serve diet as ordered, monitor intake and record each meal, dietician to evaluate and make diet recommendations as needed weigh at the same time of the day and record. Review of Resident #31's clinical record from 9/25/24 to 11/1/24 failed to identify that the Physician and/or Dietician was notified of the significant weight loss. Interview with MD #1 on 11/19/24 at 8:45 AM identified the dietician is responsible for following up on residents who have experienced a weight loss. He also identified that the facility should notify the dietician and the physician when there is a weight loss for any resident. He further identified that they follow the weight loss policy when addressing resident weight loss and identified that he typically evaluates the root cause of the weight loss to determine whether it is from a lack of eating or an acute illness. Additionally, MD #1 identified that he was not notified of Resident #31's weight loss but should have been notified. Interview with the DNS on 11/19/24 at 9:20 AM identified that Dietician #1 is responsible for assessing residents for weight loss. She identified that she was not sure what the facility's policy for significant weight loss entailed, but identified she would follow what the policy indicated. Further, the DNS identified that she had not conducted any at risk meetings since she started her position. She further identified that Dietician #1, and MD #1 should had been notified of Resident #3's significant weight loss. Interview with LPN #1 on 11/19/24 at 1:00 PM identified that the routine for obtaining weight is the nurse aide obtains the resident's weight and records it on paper, the nurses enter the weight into the electronic health record. LPN #1 identified that she was not sure what the facility's policy was for reporting weight loss. Further, she identified she was not trained on what constituted a significant weight loss and/or when to report the weight loss to the dietician and physician. In addition, she identified that she documents in the nursing notes when there is a significant change in condition which would include weight loss. Attempts to interview Dietician #1 were unsuccessful. The Weight Loss policy identified that the threshold for a significant unplanned weight loss is greater than 5 percent in 1 month and greater than 10 percent in 6 months. It further noted that once the weight loss is verified, nursing should notify the dietician, physician, and family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #13) reviewed for abuse, the facility failed to ensure that an injury of unknow origin was reported to the state survey agency. The findings include: Resident #13's diagnoses included Parkinson's, dementia, and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #13 was severely cognitively impaired, had physical behavioral symptoms directed at others, and required total assistance for bed mobility, transfers, dressing and personal hygiene. The assessment further identified the resident was non-ambulatory and had no functional limitations in range of motion. A nurse's note dated 9/3/24 at 11:30 PM written by RN #2 identified Resident #13 was found with a bruise below the left eye that measured 4 cm by 1 cm and was dark purple in color. The resident was unable to communicate what occurred, neurological checks were initiated, and the on-call APRN, the DNS and Resident #13's Responsible Party were notified. The Reportable Event Report and the skin tear/bruise incident report and investigation forms dated 9/3/24 identified NA#1 reported Resident #13 had a bruise below the left eye. The reports identified they could not identify how the bruise occurred. The forms were missing signatures of the Administrator and/or DNS. A check of the state survey agency's reportable event portal identified that this bruise was not reported to the state survey agency although the reportable event report identified that the facility did not know the origin of the bruise. The care plan dated 9/4/24, identified Resident #13 was at risk for alteration in skin integrity, related to a bruise below the left eye, with interventions that included observing proper technique in positioning and transferring the resident. Interview on 11/18/24 at 8:52 AM with the DNS identified that she had not submitted a reportable event report to the state survey agency regarding Resident #13's bruise because she thought that the cause of the bruise was known (witnessed). In a second interview with the DNS on 11/18/24 at 12:55 PM, she noted that the night shift staff had reported Resident #13 hit his/her head on the wheelchair and noted that this was reported to the on-coming day shift staff. The DNS could not identify who witnessed the accident/incident or why there were not an Accident and Report completed. The DNS was also unable to locate nursing notes or any other documentation regarding the accident. Interview on 11/19/24 at 8:47 AM with the Nursing Supervisor (RN #3) for the 11-7 shift identified that she did not recall any injuries occurring on the 11-7 AM shift. Interview on 11/19/24 at 9:02 AM with RN #2 (Nursing Supervisor 11-7 shift, identified she had no knowledge of an accident or injury involving Resident #13. The DNS further identified she did not have documentation that indicated that the origin of the bruise was known. She further identified that accidents and incidents are usually discussed in morning meeting. She could not explain why she was under the impression that the origin of the bruise was witnessed, and although witnessed, there were no statements or other documentation from staff to validate that the bruise was not an injury of unknown origin. The Abuse/Neglect policy directed that injuries of unknown origin will be investigated as if they could be the result of an abuse. An injury of unknown origin is reportable if the source of the injury was not observed by anyone, the resident is unable to explain what occurred and if the injury is suspicious due to the extent of injury or injury location, number of injuries at one time or the incidence of injuries over time. The investigation and findings will be documented and submitted to the facility's medical staff for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #13), with an injury of unknown origin, the facility failed to ensure that an investigation was conducted to ascertain the origin of the bruise. The findings include: Resident #13's diagnoses included Parkinson's, dementia, and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #13 was severely cognitively impaired, had physical behavioral symptoms directed at others, and required total assistance for bed mobility, transfers, dressing and personal hygiene. The assessment further identified the resident was non-ambulatory and had no functional limitations in range of motion. A nurse's note dated 9/3/24 at 11:30 PM written by RN #2 identified Resident #13 was found with a bruise below the left eye that measured 4 cm by 1 cm and was dark purple in color. The resident was unable to communicate what occurred, neurological checks were initiated, and the on-call APRN, the DNS and Resident #13's Responsible Party were notified. The Reportable Event Report and the skin tear/bruise incident report and investigation forms dated 9/3/24 identified NA#1 reported Resident #13 had a bruise below the left eye. The reports identified they could not identify how the bruise occurred. The forms were missing signatures of the Administrator and/or DNS. Review of the Supervisor's Daily Report sheet (24-hour report) dated 9/3/24 for the 11-7 shift, indicated no Accident or Incidents, no changes in condition and no new skin or wound issues. Resident #13's bruise was not documented on the 24-hour report. A check of the state survey agency's reportable event portal identified that this bruise was not reported to the state survey agency although the reportable event report identified that the facility did not know the origin of the bruise. The care plan dated 9/4/24, identified Resident #13 was at risk for alteration in skin integrity, related to a bruise below the left eye, with interventions that included observing proper technique in positioning and transferring the resident. Interview on 11/18/24 at 8:52 AM with the DNS identified that she had not submitted a reportable event report to the state survey agency regarding Resident #13's bruise because she thought that the cause of the bruise was known (witnessed). In a second interview with the DNS on 11/18/24 at 12:55 PM, she noted that the night shift staff had reported Resident #13 hit his/her head on the wheelchair and noted that this was reported to the on-coming day shift staff. The DNS could not identify who witnessed the accident/incident or why there were not an Accident and Report completed. The DNS was also unable to locate nursing notes or any other documentation regarding the incident/bruise. Interview on 11/19/24 at 8:47 AM with the Nursing Supervisor (RN #3) for the 11-7 shift identified that she did not recall any injuries occurring on the 11-7 AM shift. Interview on 11/19/24 at 9:02 AM with RN #2 (Nursing Supervisor 11-7 shift, identified she had no knowledge of an accident or injury involving Resident #13. The DNS further identified she did not have documentation that indicated that the origin of the bruise was known. She further identified that accidents and incidents are usually discussed in morning meeting. She could not explain why she was under the impression that the origin of the bruise was witnessed, and although witnessed, there were no statements or other documentation from staff to validate that the bruise was not an injury of unknown origin. The Abuse/Neglect policy directed that injuries of unknown origin will be investigated as if they could be the result of an abuse. An injury of unknown origin is reportable if the source of the injury was not observed by anyone, the resident is unable to explain what occurred and if the injury is suspicious due to the extent of injury or injury location, number of injuries at one time or the incidence of injuries over time. The investigation and findings will be documented and submitted to the facility's medical staff for review. It further identified that an investigation of alleged abuse may include statements from witnesses/staff, consultation of family, physician, DPH and Ombudsman. The resident's medical record will be reviewed. A report of the investigation results will contain the information required by the results of investigation form and sent to DPH within 5 days of the allegation. Injuries of unknown origin will be investigated, as if they could be the result of an abuse. An injury of unknown origin is reportable, if the source of the injury was not observed by anyone, the resident is unable to explain what occurred and if the injury is suspicious due to the extent of injury or injury location, number of injuries at one time or the incidence of injuries over time. The investigation and findings will be documented and submitted to the facilities medical staff for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of five sampled residents (Resident #5) reviewed for unnecessary medications, the facility failed develop a care plan for a resident on an anticoagulant. The findings include: Resident #5's diagnoses included long term use of anticoagulants, peripheral vascular disease, acute coronary thrombosis. The physician's order dated 8/19/24 directed to administer 5mg of Eliquis (anticoagulant) every 12 hours by mouth. The annual MDS assessment dated [DATE] identified Resident #5 was cognitively intact, had no behaviors, required maximal assistance with bed mobility, transfers, dressings and personal hygiene, was ambulatory for short distance with maximal assistance and utilized a wheelchair for mobility. The assessment further identified the resident was taking an anticoagulant. The care plan dated 9/30/24 identified Resident #6 was at risk for altered cardiovascular status related to elevated blood pressure and chest pain secondary to angina, and hypertension with interventions that included: assess for chest pain, enforce the need to call for assistance if pain starts and notify physician of abnormalities. Further review of the care plan failed to identify Resident #6 was taking an anticoagulant and/or the possible side effects of taking an anticoagulant and failed to identified interventions to address possible side effects or precautions to take when providing care. The pharmacy consultant's medication regimen review dated 10/4/24 identified a recommendation to monitor Resident #6 for bruising, bleeding, and to monitor for signs/symptoms of thromboembolism (blood clot) related to the resident being on an anticoagulant. Review of the clinical record failed to identify that the pharmacist's recommendation had been addressed. Interview with the DNS on 11/18/24 at 1:10 PM identified that any staff member inclusive of nursing and the social worker can revise/update the care plans. Review of the Care Plan policy directed daily updates to care plans should be added by any member of the IDT (interdisciplinary team) at the time the change is implemented/during the daily clinical meeting. The comprehensive care plan should be reviewed and revised by members of the IDT and the resident, resident's family, surrogate, or representative, as appropriate in conjunction with completion of the Quarterly Assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #17) reviewed for controlled substance reconciliation, the facility failed to ensure medications were administered accurately according to physician's orders and for one sampled resident (Resident #26) reviewed for oxygen use, the facility failed to ensure the physician's order for oxygen use and documentation of resident status including lung sounds were followed. The findings include: 1. Resident #17's diagnoses included anxiety disorder, major depressive disorder and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #17 was cognitively intact, no behaviors, required supervision or touch assistance with personal hygiene and ambulated with minimal assistance using a walker. The assessment further identified Resident #17 was taking antianxiety medication. The care plan dated 6/20/24 identified Resident #17 uses anti-anxiety medication related to anxiety disorder with interventions that included to administer anti-anxiety medications as ordered by physician, monitor side effects and effectiveness every shift, monitor, document and report as needed any adverse reaction to anti-anxiety therapy medication such as drowsiness, lack of energy, slow reflexes, loss of balance and lightheadedness. The physician's order for the months of August 7, 2024, thru November 2024 directed lorazepam 1 milligram (mg) by mouth every 12 hours for anxiety or agitation. The physician's order dated 9/11/24 directed lorazepam 0.5mg by mouth one time a day for anxiety disorder. Observation of Resident #17's Controlled Substance Disposition Record for Lorazepam 1mg for the month of October 2024 and November 2024 with LPN #2 on 11/18/24 at 6:39 AM identified the following: On 10/24/24 identified Lorazepam 1mg was given/taken for scheduled 2:00 PM dosage instead of the Lorazepam 0.5 mg ordered by the physician. On 10/27/24 identified Lorazepam 1mg was not given/taken for scheduled 9:00 PM dosage. On 11/2/24 identified Lorazepam 1mg was not given/taken for scheduled 8:00 AM dosage. On 11/9/24 identified Lorazepam 1mg was not given/taken for scheduled 9:00 AM dosage. Interview with the Charge Nurse (LPN #2) on 11/18/24 at 6:39 AM identified she does not work on the unit during the day shift, as the resident's Lorazepam medications were scheduled to be administered on the day and evening shifts. Review of Resident #17's August 2024 thru November 2024 Controlled Substance Disposition Record for Lorazepam 1mg tablets identified the following: On 9/21/24 identified Lorazepam 1mg was given/taken for the scheduled 2:00 PM dosage instead of the Lorazepam 0.5mg ordered by the physician. On 10/10/24 identified Lorazepam 0.5 mg was given/taken for the scheduled 9:00 AM dosage instead of the Lorazepam 1mg ordered by the physician. On 10/13/24 identified Lorazepam 1mg was not given/taken for scheduled 8:00 PM dosage. On 10/19/24 identified Lorazepam 1mg was not given/taken for scheduled 9:00 PM dosage. On 10/20/24 identified Lorazepam 1mg was not given/taken for scheduled 8:00 AM dosage. Review of Resident #17's Medication Administration Record (MAR) for the months of August 2024, thru November 2024 of Lorazepam 1 mg administration identified the following: The MAR on 10/10/24 identified Lorazepam 1mg was administered at 9:00 AM by LPN #3. The MAR on 10/13/24 identified Lorazepam 1mg was administered at 9:00 PM by LPN #3. The MAR on 10/19/24 identified Lorazepam 1mg was administered at 9:00 PM by LPN #3. The MAR on 10/20/24 identified Lorazepam 1mg was administered at 9:00 PM by LPN #3. The MAR on 10/24/24 identified Lorazepam 1mg was administered at 8:00 AM by LPN #3. The MAR on 10/27/24 identified Lorazepam 1mg was administered at 9:00 PM by LPN #3. The MAR on 11/2/24 identified Lorazepam 1mg was administered at 9:00 AM by LPN #3. The MAR on 11/9/24 identified Lorazepam 1mg was administered at 9:00 AM by LPN #3. Review of Resident #17's August 2024 thru November 2024 Controlled Substance Disposition Record for Lorazepam 0.5mg tablets identified the following: On 9/21/24 identified Lorazepam 0.5mg was not given/taken for scheduled 2:00 PM dosage. On 10/20/24 identified Lorazepam 0.5mg was not given/taken for scheduled 2:00 PM dosage. On 10/24/24 identified Lorazepam 0.5mg was not given/taken for scheduled 2:00 PM dosage. On 11/2/24 at 7:00 AM Lorazepam 0.5mg one tablet was given/taken instead of the Lorazepam 1mg ordered by the physician for 8:00 AM schedule dosage. Review of Resident #17's Medication Administration Record (MAR) for the months of September 2024, thru November 2024 of Lorazepam 0.5mg administration identified the following: The MAR on 9/21/24 identified Lorazepam 0.5mg was administered at 2:00 PM The MAR on 10/20/24 identified Lorazepam 0.5mg was administered at 2:00 PM The MAR on 10/24/24 identified Lorazepam 0.5mg was administered at 2:00 PM Review of Resident #17's clinical record failed to identify any reason as to why the schedule Lorazepam 0.5mg daily dosage at 2:00 PM and Lorazepam 1mg every 12 hours at 9:00 AM and 9:00 PM was not administered to the resident. Interview with the DNS on 11/18/24 at 7:35 AM identified that the facility does not store emergency supply of controlled substances, however, the facility will begin to have emergency-controlled substance on-hand as the secured lock box was recently installed in the medication storage room. Interview and review of the MAR for September 2024 thru November 2024 with the Charge Nurse (LPN #3) on 11/18/24 at 2:37 PM identified when asked what his process was for administering controlled drugs and he responded that he would remove the medication from the blister pack, then sign the resident's control substance disposition record with the date, time, amount taken, signature and amount left. He further identified if the control substance disposition record was not signed then the medication was not administered to the resident. LPN #3 identified the initials on the MAR was his and he had worked the unit on the days of the missed dose and incorrect dose administration for Resident #17. He further identified his initial on the MAR indicates that the medication was administer to the resident. LPN #3 further identified he was a new nurse and a new to the long-term care facility and was told not to administer medications in the dining room and not to wake some of the residents. He identified on 11/2/24, that he had administered the incorrect dose of Lorazepam by giving 0.5mg instead of 1mg and had told someone, however, was unable to recall who he told, nor did he document in the progress note. LPN #3 indicated he was not familiar with the computerized MAR to document when he did not administer the medication, nor did he write a note, nor did he report the issue to the supervisor or DNS. He indicated that he is aware that if the resident refused or did not take the medication, he was to document refusal and to notify the supervisor, however in these cases he failed to do such. LPN #3 further added that he did administer Resident #17's schedule medication maybe late, but the controlled drugs were not administered. Interview with the Supervising Pharmacist Consultant (Pharmacist #3) on 11/18/24 at 2:00 PM identified when Resident #17 missed his/her scheduled Lorazepam dosage or receive less than the amount prescribed it would cause an adverse reaction of increase withdrawal with symptoms such as having a headache due to the resident not getting the medication. Pharmacist #3 identified if Resident #17 received an increase dose of Lorazepam it could cause increase sedation. Interview with the DNS on 11/18/24 at 4:00 PM identified that LPN #3 did not receive any medication competency on orientation nor does the facility has an orientation checklist. The DNS indicated that orientation training was scheduled based on the nurse's experience and their verbalization of needing additional training in which she was not aware by LPN#3 he needed/required additional orientation. Interview with LPN #3 on 11/19/24 at 11:57 AM identified he was only on orientation for a day and half, a nurse observed him administering medications for only half of a shift and he did not receive any medication competency training on orientation. LPN #3 indicated he did not make the facility aware he needed any assistance with the computer because he thought that he did not have an issue until recently. Interview with the MD #1 on 11/19/24 at 9:03 AM identified he was not informed/notified that Resident #17 was not receiving his/her schedule Lorazepam as prescribed until today. MD #1 expects when medications are prescribed that they are administered as such and if the nurse is unable to that the medical provider is notified, and a note is written. MD #1 further identifies he review nursing notes at least monthly and cannot recall seeing a note regarding Resident #17 refusal or not getting his/her medication, nor did the resident express that he/she was not getting the medication. MD #1 identified that if Resident #17 received an increase dose of Lorazepam (1mg) it could cause over sedation; received decrease Lorazepam dose (0.5mg) will cause increase anxiety and if the medication was not administered could cause increase in agitation and anxiety. Review of the Administration of Controlled Medications policy identified administer medications only as prescribed in the resident's care plan and medical orders, which includes administering the correct drug, dose, route, and time. Review of the Controlled Medications policy identified that controlled substance would only be administered according to a physician's order, and each administration must be documented on the Medication Administration Record (MAR). The policy further identified that for schedule II medications, additional documentation is required in a controlled substance log known as a count sheet, which includes: the resident's name, name of the medication, dose administered, time and date of administration, amount remaining in the stock and signatures of the staff involved in the administration and documentation. 2. Resident #26 was admitted to the facility in October of 2024 with diagnoses that included acute respiratory failure with hypoxia, dependence on supplemental oxygen, congestive heart failure and Alzheimer's disease. The admission MDS assessment dated [DATE] identified Resident #26 had moderately impaired cognition, utilized a walker, was taking an anticoagulant (blood thinner), a diuretic, and an opioid (pain medication), and was receiving continuous oxygen. The care plan dated 11/6/24 identified Resident #26 had impaired cognitive function related to dementia with interventions to administer medications as ordered and monitor for side effects and effectiveness. The monthly physician's orders for November 2024 directed to apply Oxygen at 2 Liters per minute via nasal cannula continuous every shift related to acute respiratory failure with hypoxia, change and date oxygen tubing and humidifier as applicable, and to change the storage bag every week on Sunday 11-7 shift. Additionally, the physician's orders directed to write a progress note every shift regarding pain, behaviors, mental status, respirations, lung sounds, bilateral lower extremity edema, wounds, mental status, vital signs, and fluid restriction. A physician's order dated 11/16/24 identified Resident #26 was taking antibiotics for pneumonia. Nursing progress note dated 11/5/24 at 1:58 PM identified a stat chest Xray was ordered, and the resident was encouraged to do incentive spirometer. The nursing note dated 11/15/24 at 10:03 PM identified the results of the chest Xray were shared with the on call APRN who ordered antibiotics and added an extra 20 mg of Lasix in the afternoon for 3 days, and as needed nebulizer treatments. The note further indicated Resident #26 was short of breath during ambulation, but vital signs were stable and pulse oximetry was within normal limits. Review of the nursing notes for 11/15, 11/16, 11/17, and 11/18/24 failed to identify documentation of lung assessments. Review of the MAR for the month of November 2024 identified vital signs, including blood pressure, temperature, pulse, respirations, oxygen saturation for each shift were documented as ordered, but failed to include documentation of lung sounds. Observation on 11/17/24 at 7:45 AM identified Resident #26 was seated in a recliner with nasal cannula in place. The oxygen tubing was connected to the oxygen condenser which was approximately 6 feet away from the resident. The oxygen condenser was set at 3 liters. Review of the MAR for the month of November 2024 identified oxygen was checked for accuracy on 11/18/24 at 8:22 AM by RN #4. Observation on 11/18/24 at 9:31 AM identified Resident #26 had a nasal cannula in place attached to the oxygen condenser that was set to 3 liters. There was a piece of tape with the date 11/18/24 written on it, which Resident #26 did not notice. The resident was seated in the recliner approximately 6 to 8 feet from the oxygen condenser unit. There was a tray table in front of the resident and a walker to the side of the resident. Interview on 11/18/24 at 9:39 AM with RN #4 identified that she had marked off that the oxygen was checked for accuracy that morning. Additionally, she identified that she may have checked quickly and did not notice the 3 liters. She adjusted the flow to 2 liters. RN #4 identified that she checked lung sounds if the resident complained of breathing difficulty or if she noticed breathing difficulties. Interview on 11/18/24 at 12:47 PM with the Medical Director identified he expected orders to be carried out as they are written. The Medical Director identified that oxygen should be applied at the dose ordered and can adversely affect a resident with ongoing respiratory issues when not set at the appropriate level. The Medical Director indicated that lung sounds should be part of any respiratory assessment or ongoing monitoring and should be documented in the chart. The facility oxygen policy identified the policy of the facility was to provide supplemental oxygen in accordance with a physician's order and indicated the tubing would be changed weekly on 11-7 shift for prolonged use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #20) reviewed for range of motion and splint usage, the facility failed to ensure the splint was applied according to physician's orders. The finding include: Resident #20's diagnoses included dementia, delusional disorders and dysthymic disorders. The quarterly MDS assessment dated [DATE] identified Resident #20 had severely impaired cognition, was dependent for toileting hygiene, dressing, personal hygiene, transfers, was non-ambulatory and had functional limitations in range of motion to bilateral upper and lower extremities. The care plan dated 10/31/24 identified Resident #20 was at risk for contractures to the left upper extremity (LUE) with interventions that included monitor skin integrity of LUE with each splint application and removal for the presence of any redness, skin breakdown and resting hand splint on left arm to be on at all times except for ADL's (activity of daily living) and patient care. The physician's order dated 11/19/24 with an origination date of 6/24/24 directed left resting hand splint on for PM and AM hours, off for ADL's and patient care, monitor for skin integrity with each application and removal every shift for splint application and removal. Observation on 11/17/24 at 7:45 AM identified Resident #20 lying supine on his/her bed without the application of a resting hand splint to the left extremity. Observation on 11/17/24 at 12:45 PM identified Resident #20 seated in his/her wheelchair in the dining room being fed by a nurse aide. The resident did not have the splint on the left extremity. Observation on 11/18/24 at 8:28 AM identified Resident #20 seated in his/her wheelchair in the dining rooms in his/her wheelchair being fed breakfast by the DNS without the application of a resting hand splint to the left extremity. Review of the Treatment Administration Record (TAR) with the Charge Nurse (LPN #1) on 11/18/24 at 2:18 PM identified the physician's order which directed splint: (left resting hand splint on for PM and AM hours, off for ADL's and patient care, monitor for skin integrity with each application and removal) every shift for splint application and removal was signed off for 11/18/24 by LPN #1 as having been completed. LPN #1 identified she had completed the treatment as it involved checking the resident's skin integrity and did not included application of a splint on the day shift. Observation on 11/18/24 at 2:18 PM with the LPN #1 identified Resident #20 was in the recreational activity room seated in his/her wheelchair without the application of a resting hand splint to the left extremity. LPN #1 then found Resident #20's splint in the top drawer of his/her nightstand. Interview with the LPN #1 on 11/18/24 at 2:18 PM identified she was the regular day shift nurse for that unit since October 2024 and thought the resident wore the splint at night and it was removed during the day where she would check the resident's skin integrity. LPN #1 read the order over and she clarified the order with the occupational therapist who identified that the splint to left hand was to be worn at all times except for patient care and ADL's. LPN #1 identified that the nurse would apply the splint, and the nurse aides could remove the splint for care. She identified that she had checked Resident #20's skin integrity earlier, when the nurse aide supposedly had removed the splint. Interview with the NA #3 on 11/18/24 at 2:24 PM identified that he did not remove a splint off Resident #20's left hand, nor did he apply a splint to the left extremity that morning. NA #3 further identified he recently started working at the facility about 3 months ago and did not receive any training on splint application for Resident #20. Review of Resident #20's resident care card as of 11/19/24 identified resting hand splint on left arm on at all times except for ADL's and patient care. Interview with the Occupational Therapist (OT #1) on 11/18/24 at 2:25 PM identified Resident #20 should have the splint to the left hand applied in the AM, PM and at mealtimes, and only removed for care and skin checks. OT #1 identified that Resident #20 requires the splint due to his/her contracture of the metacarpal phalangeal joint (MCP) of the left hand and if not worn will increase the risk of more contractures. OT #1 further identified she had last seen the resident last week (11/12/24) with the splint to the left hand and did not identify any increased contractures to the left hand. OT #1 identified that training was provided to the staff on the initiation of the splint on June 25, 2024, added to the care plan and the resident care card as the nurse aide can apply the splint as they were trained. Review of the Splinting policy and procedure under the therapy section identified that splints, either custom made or prefabricated are used to provide contracture management or reduction. The policy and procedure further identified once the wearing schedule is established; the physician's clarification order should specify the type of splint where it is to be applied, and the wearing schedule and the treating therapist is to provide instruction to the nursing staff regarding the wearing schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one of three residents (Resident #31) reviewed for nutrition, the facility failed to ensure that the dietician and/or physician assessed the resident for significant weight loss timely. The findings include: Resident #31 's diagnoses included congestive heart failure, disorder of kidney and ureter, depression, anxiety, atrial fibrillation. Physician's orders dated 5/15/24 directed to check weight three times per week and notify physician for weight gain or loss equal to 3 pounds(lbs.). Physician's orders dated 8/26/24 directed for Resident #31 to have regular diet of regular texture, thin liquid and fluid restriction of 1500 Milliliters(ml) per day. Review of the weight and vital summary identified Resident #31 was weighed on 9/25/24 at 11:20 AM with a weight of 238.6 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had intact cognition and dependent assistance with bed mobility, toileting, hygiene, transfer, and non-ambulatory. The assessment further identified Resident #31 was independent with eating with set-up assistance and did not identify a weight loss within the past six months. Further weight record reviewed identified Resident #31 was weighed on 10/3/24 at 2:31 PM with a weight of 223.4 lbs. (weight loss of 6.4 percent from 9/25/24), on 10/14/24 at 12:34 PM with a weight of 219.6 lbs. (weight loss of 7.9 percent from 9/25/24), and on 11/1/24 at 7:32 AM with a weight of 220 lbs. (weight loss of 7.8 percent from 9/25/24). The Resident Care Plan (RCP) dated 10/10/24 identified Resident #31 had the potential for nutritional risk related to depression, anxiety, and obesity. Care plan interventions included: provide and serve diet as ordered, monitor intake and record each meal, dietician to evaluate and make diet recommendations as needed weight at the same time of the day and record. Review of dietician #1 notes from 9/25/24 through 11/1/24 failed to identify Resident #31 was assessed for weight loss. Reviewed of physician progress notes from 9/25/24 through 11/1/24 failed to identify Resident #31 was assessed for weight loss. Review of nurse's notes from 9/25/24 through 11/1/24 failed to identify that the nursing staff identified that Resident #31 had a significant weight loss from his/her previous weight. Interview with MD #1 on 11/19/24 at 8:45 AM identified that the dietician would be responsible to follow through of any resident's weight loss. He also identified that the facility would notify the dietician and the physician when there is a weight loss for any resident. He identified that the facility would follow it policy in addressing of a resident weight loss. He identified that he would typically evaluate the root cause of the resident weight loss whether it was lack of eating or an acute illness. He further identified that he was not notified when Resident #31 had a weight loss of more than 5 percent, but he would expect the facility would notify the physician when it identified the weight loss. Interview with DNS on 11/19/24 at 9:20 AM identified that Dietician #1 would be responsible for assessing resident for weight loss. She identified that she was not sure what the facility policy for significant weight loss, but she would follow what indicated in the policy for identifying a significant weight loss. She also identified that she had not conducted any at risk meeting at the facility since she started her position at the facility. She further identified that Dietician #1 and MD #1 should had assessed Resident #31 for a significant weight loss in one month. Interview with LPN #1 on 11/19/24 at 1:00 PM identified that NA would obtain the resident weight and the nurse would record the weight in the electronic record. She identified that she was not sure what is the facility policy of reporting weight loss. She identified that she was not trained on what a significant weight loss and when to report the weight loss to the dietician and physician. She further identified that she would document in the nurse notes when there is a significant change of condition with the resident such as a weight loss for a resident. Attempts to interview Dietician #1 were unsuccessful. The Weight Loss policy identified that all weight loss would be medically appropriate and safe in accordance with each individual resident to prevent malnutrition, unintentional weight loss and other weight loss complication. The threshold for a significant unplanned weight loss would be greater than 5 percent in 1 month and greater than 10 percent in 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 1 of 5 sampled residents (Resident #5) reviewed for unnecessary medications, the facility failed to ensure medication reviews were provided to the provider and action taken. The findings included: Resident #5's diagnoses included long term use of anticoagulants, bipolar II disorder, and anxiety disorder. The annual MDS assessment dated [DATE] identified Resident #6 was cognitively intact, had no behaviors, required maximal assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident could ambulate a short distance with maximal assistance and utilized a wheelchair for mobility. The care plan dated 9/30/24 identified Resident #6 was at risk for altered cardiovascular status related to elevated blood pressure and chest pain secondary to angina, hypertension with interventions that included assess for chest pain, enforce the need to call for assistance if pain starts. Vital signs, notify MD of significant abnormalities. Physician's order dated 8/19/24 directed to administer 5mg of Eliquis every 12 hours by mouth. The Pharmacy Consultant #1's medication regimen review dated 10/4/24 identified recommendations to monitor for bruising, bleeding, and to monitor for signs/symptoms of thromboembolism (blood clot) due to the resident being on an anticoagulant. A review of Resident #5's clinical record failed to identify that the Pharmacy Consultants recommendations had been incorporated into the resident's plan of care, or a rationale as to why the monitoring was not necessary. Review of the MAR (medication administration record) and TAR (treatment administration record) TAR for the month of October 2024 failed to identify that the recommendations from Pharmacy Consultant #1 was added to the MAR or TAR. Interview on 11/17/24 at 1:11PM with the DNS identified she had not been receiving pharmacy recommendations since she started in August 2024, and she could not locate previous pharmacy recommendations that had been made. The facility started with a new pharmacy in November 2024 and had recently had a discussion with the provider regarding the recommendations. Interview on 11/18/24 at 11:36 AM with Pharmacy Consultant #1 identified she completed the monthly medication regimen reviews until the new pharmacy started on 11/2/24. The charts were reviewed monthly, and recommendations were entered into a report and sent to the DON or nurse supervisor that was covering the facility, the Social Worker is always copied on the medication recommendations due to the fact she is a constant in the building and could receive them due to the nursing (DNS) turnover. Interview on 11/19/24 at 8:31 AM with MD#1 identified he did recall receiving the pharmacy recommendation for Resident #5 from 10/4/24. The medication regimen review process would include the pharmacy consultant sending to the facility the medication reviews once completed, and the facility would disseminate to the provider. Review of the Pharmacy Recommendations policy dated 9/9/24 identified each recommendation made by the pharmacy team will be documented in the resident's medical record and communicated to the attending physician and nursing team. Upon receiving the recommendation, the attending physician or medical director will review it in the context of the resident clinical condition and make the final decision whether to implement the suggestion. If the physician agrees with the recommendation, they will adjust the resident's medication orders as appropriate. If the physician disagrees with the recommendation, they will document the rational for not following the advice. Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 1 of 5 sampled residents (Resident #5) reviewed for unnecessary medications, the facility failed to ensure medication reviews were provided to the provider and action taken. The findings included: Resident #5's diagnoses included long term use of anticoagulants, bipolar II disorder, and anxiety disorder. The annual MDS assessment dated [DATE] identified Resident #6 was cognitively intact, had no behaviors, required maximal assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident could ambulate a short distance with maximal assistance and utilized a wheelchair for mobility. The care plan dated 9/30/24 identified Resident #6 was at risk for altered cardiovascular status related to elevated blood pressure and chest pain secondary to angina, hypertension with interventions that included assess for chest pain, enforce the need to call for assistance if pain starts. Vital signs, notify MD of significant abnormalities. Physician's order dated 8/19/24 directed to administer 5mg of Eliquis every 12 hours by mouth. The Pharmacy Consultant #1's medication regimen review dated 10/4/24 identified recommendations to monitor for bruising, bleeding, and to monitor for signs/symptoms of thromboembolism (blood clot) due to the resident being on an anticoagulant. A review of Resident #5's clinical record failed to identify that the Pharmacy Consultants recommendations had been incorporated into the resident's plan of care, or a rationale as to why the monitoring was not necessary. Review of the MAR (medication administration record) and TAR (treatment administration record) TAR for the month of October 2024 failed to identify that the recommendations from Pharmacy Consultant #1 was added to the MAR or TAR. Interview on 11/17/24 at 1:11PM with the DNS identified she had not been receiving pharmacy recommendations since she started in August 2024, and she could not locate previous pharmacy recommendations that had been made. The facility started with a new pharmacy in November 2024 and had recently had a discussion with the provider regarding the recommendations. Interview on 11/18/24 at 11:36 AM with Pharmacy Consultant #1 identified she completed the monthly medication regimen reviews until the new pharmacy started on 11/2/24. The charts were reviewed monthly, and recommendations were entered into a report and sent to the DON or nurse supervisor that was covering the facility, the Social Worker is always copied on the medication recommendations due to the fact she is a constant in the building and could receive them due to the nursing (DNS) turnover. Interview on 11/19/24 at 8:31 AM with MD#1 identified he did recall receiving the pharmacy recommendation for Resident #5 from 10/4/24. The medication regimen review process would include the pharmacy consultant sending to the facility the medication reviews once completed, and the facility would disseminate to the provider. Review of the Pharmacy Recommendations policy dated 9/9/24 identified each recommendation made by the pharmacy team will be documented in the resident's medical record and communicated to the attending physician and nursing team. Upon receiving the recommendation, the attending physician or medical director will review it in the context of the resident clinical condition and make the final decision whether to implement the suggestion. If the physician agrees with the recommendation, they will adjust the resident's medication orders as appropriate. If the physician disagrees with the recommendation, they will document the rational for not following the advice.

**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/procedures and interviews for one sampled resident (Resident #6) reviewed for medication administration, the facility failed to ensure Metoprolol Succinate ER (extended release) was not crushed. The findings include: Resident #6's diagnoses included unspecified atrial fibrillation, dysphagia and long-term use of anticoagulants. The care plan dated 7/1/24 identified Resident #1 was at risk for hypertension and atrial fibrillation related to congestive heart failure with interventions that included give cardiac medication as ordered. The quarterly MDS assessment dated [DATE] identified Resident #6 was cognitively intact, required extensive assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident required supervision for eating and had a mechanically altered therapeutic diet. The physician's order dated 11/12/24 directed to administer Metoprolol Succinate ER oral tablet (extended release 24 hour) 50mg twice a day for hypertension (high blood pressure) with directions to not crush or chew. Observation of LPN #1 during medication administration on 11/18/24 at 9:45 AM identified she crushed the Metoprolol Succinate ER in preparation to administer the medication to Resident #6. Interview with LPN #1 on 11/18/24 at 9:50 AM identified she had been crushing the Metoprolol Succinate ER for Resident #6 on a daily basis and realized after re-reading the blister pack that the medication is an extended-release medication that should not be crushed or chewed. Interview with MD#1 on 11/19/24 at 8:31 AM identified Metoprolol Succinate ER should not be crushed, and he would expect his orders to be followed. He further noted that crushing the medication could be dangerous because all the medication is administered all at once instead of over a period of time. According to the literature, crushing Metoprolol Succinate ER increases the risk of side effects inclusive of headache, feeling tired, dizzy or weak, stomach pain and cold hands or feet. The most serious side effect is that it could cause the heart rate to be too low and could worsen lung conditions. Review of the medication pass policy directed to remember the five rights of medication: the right resident, the right drug, the right dose, the right route, and the right time and to know the diagnosis and indication for every medication. A change in the form of medication requires a physician's order. Refusal or hold of high-risk medication to include cardiac medication warrants immediate notification to the provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records, review of facility documentation, facility policy, and interviews for one of five residents (Resident #33) reviewed for immunizations, the facility failed to ensure that the COVID-19 vaccination was offered and/or assessed to resident. The finding include: Resident #33's was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies. The admission MDS assessment dated [DATE] identified Resident #33 had severe cognitive impairment. Review of Resident #33's immunization consents and records, along with the new admission consent documentation with Infection Preventionist (RN #1) on 11/18/24 at 1:30PM failed to identify that the COVID-19 booster vaccine was offered to the resident. Interview with the Infection Preventionist (RN#1) on 11/18/24 at 11:30 AM identified that she just started her position as Infection Preventionist at the facility and she was not sure who would be responsible of offering the resident vaccine when it due. She identified that she could not find the consent for Resident #33 COVID-19 booster vaccine. She further identified that going forward it would be her responsibility to ensure all residents would be offered up to date vaccination. Review of COVID Vaccination identified that the facility would vaccinate its residents against certain preventable disease such as COVID-19 disease. Each resident would be offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident had already been immunized.

Based on review of resident council minutes, and interviews, the facility failed to ensure resident concerns/grievances were addressed. The findings include: Review of the resident council meeting minutes for August, September, and October 2024 identified that expressed concerns were not addressed. The minutes did not contain any references to how the concerns were addressed by facility administration, and the minutes also did not contain any recording of old business. Interview with the Resident Council group on 11/18/24 identified that concerns brought up during the resident council meetings were not formally addressed with the resident council group. They noted there was no follow up at the next meeting that addressed concerns from the previous meeting. The group further noted that the only way they knew concerns were followed up on is if they saw changes made in the facility. Additionally, they identified there were ongoing issues regarding food, and laundry that have been repeatedly brought up in resident council with no decisions, resolutions and/or rationales brought back to the group. Interview on 11/18/24 at 3:30 PM with the Recreation Director identified she never documents the resolutions to the concerns expressed by the resident council group. She noted that the concerns are discussed during the morning meeting, but there is nothing in writing or verbal that is brought back to the resident council group to indicate that the concern was addressed. The Recreation Director could not identify what the resolutions were to the concerns identified in the resident council minutes. Interview on 11/19/24 at 2:40 PM with the President/Owner identified that concerns expressed by the resident council group are discussed during morning meeting, however, he could not provide documentation of what issues had been addressed or the resolution to the concerns. The policy regarding resident council directed that the Recreational Director facilitates the meetings and acts as the liaison between the council and facility leadership. The facilitator is responsible for taking minutes, managing time and dates and ensuring proper communication is done with the facility administration. The policy further noted the facility will act promptly to any issues or concerns discussed by the resident council.

**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/procedures and interviews for one sampled resident (Resident #6) reviewed for medication administration, the facility failed to maintain professional standards and administer medication according to the physician's order and for one sampled resident (Resident #17) reviewed for controlled substance reconciliation, the facility failed to ensure medications that were not administered were documented on the Medication Administration Record (MAR) accurately. The findings include: 1. Resident #6's diagnoses included unspecified atrial fibrillation, dysphagia and long-term use of anticoagulants. The care plan dated 7/1/24 identified Resident #1 was at risk for hypertension and atrial fibrillation related to congestive heart failure with interventions that included give cardiac medication as ordered. The quarterly MDS assessment dated [DATE] identified Resident #6 was cognitively intact, required extensive assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified that the resident required supervision for eating and had a mechanically altered therapeutic diet. The physician's order dated 11/12/24 directed to administer to administer Eliquis (anticoagulant) 5mg twice daily by mouth. Observation of LPN #2 during medication administration on 11/17/24 at 9:44 AM identified the Eliquis was not administered as ordered due to not having the medication in stock. Interview with LPN #2 on 11/17/24 at 9:50 AM identified Eliquis would be re-ordered from the pharmacy. Interview with LPN #2 on 11/18/24 at 6:45 AM identified Eliquis was re-ordered from the pharmacy on a routine and not emergent status. She further identified that the physician was not updated that Resident #6 did not receive the Eliquis on 11/17/24. Interview with Pharmacist #2 on 11/18/24 at 1:32 PM identified that Eliquis was delivered for Resident #6 on 11/17/24 at 8:55 PM and the medication had not been requested prior to 11/17/24. Interview with MD #1 on 11/19/24 at 8:31 AM identified he was not notified that Resident #6 was not administered Eliquis 5mg on 11/17/24, and noted that if he had been notified, he would have requested the facility to order the medication from the pharmacy on an emergent basis. In addition, he noted that if the medication was unable to be obtained on an emergent basis, he may have opted to order a one-time order for another anticoagulant such as Lovenox. Further, MD #1 noted that it is important for the resident to be administered the Eliquis as ordered because not taking the medication increases the resident's risk for developing a blood clot. According to the literature, Eliquis lowers your chance of having a stroke by helping to prevent clots from forming and not taking it as ordered increases the risk of having a stoke. Review of the medication pass policy directed to remember the five rights of medication: the right resident, the right drug, the right dose, the right route, and the right time and to know the diagnosis and indication for every medication. A change in the form of medication requires a physician's order. Refusal or hold of high-risk medication to include cardiac medication warrants immediate notification to the provider. 2. Resident #17's diagnoses included anxiety disorder, major depressive disorder and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #17 was cognitively intact, had no behaviors, required supervision or touch assistance with personal hygiene and was ambulatory with minimal assistance using a walker. The assessment further identified Resident #17 was taking antianxiety medication. The care plan dated 6/20/24 identified Resident #17 used anti-anxiety medication related to anxiety disorder with interventions that included: administer anti-anxiety medications as ordered by physician, monitor side effects and effectiveness every shift, monitor, document and report as needed any adverse reaction to anti-anxiety therapy medication such as drowsiness, lack of energy, slow reflexes, loss of balance and lightheadedness. The physician's orders for the months of August 7, 2024, thru November 2024 directed to administer Lorazepam 1 milligram (mg) by mouth every 12 hours for anxiety or agitation. The physician's order dated 9/11/24 directed Lorazepam 0.5mg by mouth one time a day for anxiety disorder. The physician's order for the month of November 2024 directed Melatonin 5mg by mouth at bedtime for sleep and Carbidopa-Levodopa 25-100 mg give 3 tablets by mouth three times daily for Parkinson's disease. Review of the Medication Administration Record (MAR) identified that the Lorazepam 1mg twice a day doses were scheduled to be administered at 9:00 AM and 9:00 PM. The Lorazepam 0.5mg was scheduled for 2:00 PM and the Carbidopa-Levodopa 25-100 mg give 3 tablets was scheduled for 9:00 AM, 2:00 PM and 9:00 PM and the Melatonin was scheduled to be administered at 9:00 PM. Review of Resident #17's Medication Administration Record (MAR) and the Controlled Substance Disposition Record (CSDR)for the months of September 2024 through November 2024 identified the following discrepancies: 1. On 9/21/24, the MAR reflected Lorazepam 0.5mg was administered at 2:00 PM. The CSDR identified Lorazepam 0.5mg was not signed out/administered for the scheduled 2:00 PM scheduled dose. Further review of the Controlled Substance Disposition Record identified Lorazepam 1mg was administered at 2:00 PM (Lorazepam 0.5mg is what should have been administered). 2. On 10/10/24, the MAR reflected Lorazepam 1mg was administered at 9:00 AM. The CSDR identified Lorazepam 0.5 mg was signed out for the scheduled 9:00 AM dose instead of the ordered dose of Lorazepam 1mg. 3. On 10/13/24, the MAR reflected Lorazepam 1mg was administered at 9:00 PM. The CSDR failed to reflect Lorazepam 1mg was signed out for the scheduled 9:00 PM dose. 4. On 10/19/24, the MAR reflected Lorazepam 1mg was administered at 9:00 PM. The CSDR failed to reflect Lorazepam 1mg was signed out for the scheduled 9:00 PM dose. 5. On 10/20/24, the MAR reflected Lorazepam 1mg was administered at 9:00 PM. The CSDR failed to reflect Lorazepam 1mg was signed out for the scheduled 8:00 AM dose. 6. On 10/20/24, the MAR identified Lorazepam 0.5mg was administered at 2:00 PM, but the Controlled Substance Disposition Record identified Lorazepam 0.5mg was not administered (it was not signed out) for the scheduled 2:00 PM dosage. 7. On 10/24/24, the MAR identified Lorazepam 0.5mg was administered at 2:00 PM, but the Controlled Substance Disposition Record identified reflected the Lorazepam 0.5mg was not signed out for the scheduled 2:00 PM administration. 8. On 10/27/24, the MAR reflected Lorazepam 1mg was administered at 9:00 PM. The CSDR failed to reflect Lorazepam 1mg was signed out for the scheduled 9:00 PM dose. 9. On 11/2/24, the MAR identified Lorazepam 0.5mg was administered at 2:00 PM. The Controlled Substance Disposition Record identified Lorazepam 0.5mg was signed out on 11/2/24 at 7:00 AM instead of the ordered dose of 1mg. further the MAR also reflected Lorazepam 1mg was administered at 9:00 AM, but the CSDR failed to reflect Lorazepam 1mg was signed out for the 9:00 AM dose. 10. On 11/9/24, the MAR identified Lorazepam 1mg was administered at 9:00 AM but failed to reflect that Lorazepam 1mg was administered at 9:00 PM. The CSDR failed to reflect Lorazepam 1mg was signed out for the scheduled 9:00 AM or 9:00 PM doses. Further on 11/9/24, the MAR failed to reflect initials of the administering nurse for the scheduled 9:00 PM dose of Melatonin 5mg and Carbidopa-Levodopa 25-100mg (the initials signify that the medication was given and if the medication was not administered, there should be documentation of the reason why the medication was not administered. Interview on 11/18/24 at 10:26 AM with the Nursing Supervisor (RN#4) who worked the 3:00 PM to 11:00 PM shift on 11/9/24 identified she did not sign off the 9:00 PM medications in the MAR when she administered them to the resident. RN #4 did not provide a reason for not initialing the MAR to indicate that the medications were given. Interview with the Charge Nurse (LPN #3) on 11/18/24 at 2:37 PM (LPN #3 was identified as responsible for the medication administration discrepancies) identified his process for administering controlled medications, is to remove the medication from the blister pack, sign the resident's control substance disposition record with the date, time, amount taken, signature, and amount left. He further noted that once that is done, he initials the MAR to indicate that the medication was administered. LPN #3 noted that he was a new nurse and new to long-term care. He identified, he was instructed to not administer medications in the dining room and to not wake some of the residents. LPN #3 indicated he was not familiar with the computerized MAR to document when he did not administer the medication, and acknowledged he did not write a note, or report the issue to the Nursing Supervisor or the DNS. Interview with LPN #3 on 11/19/24 at 11:57 AM identified that he was on orientation for a day and half, and a nurse observed him administering medications for only half of a shift. LPN #3 further identified he did not receive medication competency training on orientation. Interview with MD #1 on 11/19/24 at 9:03 AM identified he was not notified that Resident #17 was not receiving his/her scheduled Lorazepam as prescribed until today. MD #1 noted that he expects to be notified when a medication is not administered as ordered. MD #1 further noted that if Resident #17 received an increase dose of Lorazepam (1mg) it could cause over sedation and a decreased Lorazepam dose (0.5mg) dose could cause increased anxiety and if the medication was not administered it could cause the resident to experience an increase in agitation and anxiety. Review of the medication pass policy identified that medications are administered safely and timely per the physician's orders. The policy further identified that administration of medications must be documented at the time of the medication pass, and document medications withheld, refused, or given at a time other than schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, review of facility policy and interviews, the facility failed to ensure that controlled medications were periodically reconciled to ensure against diversion of medication. The findings include: Interview with the DNS on [DATE] at 1:05 PM identified she had stored the returned/unused controlled substances in the DNS's office in a drawer which has not been reconciled, as the previous DNS left without them reconciling the controlled drugs together. The DNS identified she started working at the facility in August of 2024 and had not destroyed or reconciled any of the controlled drugs. The DNS identified on her a desk a folder with Controlled Substance Disposition Records which comes in a duplicate form, a yellow sheet kept by the DNS and the white sheet used on the unit. She identified there is a folder filled with both yellow and white copy of the Controlled Drug Disposition Records that has not been reconciled, by matching the yellow copy with the white copy together. Observation of the locked storage drawer located in the DNS's office for returned unused controlled substances with the DNS on [DATE] at 1:05 PM identified the storage drawer contained an over-flowing contents of blister packets, controlled substance patches, and bottles containing liquid controlled substances which did not allow for easy opening of the drawer along with the white copy of the Controlled Substance Disposition Records. Review of the white copy of the Controlled Substance Disposition Records located in the drawer identified the following controlled substance categories of medications: • One white copy of patch Analgesic Opioid medication sheet • Two white copies of tablet form of Sedative -hypnotic medication sheets • One white copy of capsule form of Anticonvulsant medication sheet • Fourteen white copies of tablet form of Antianxiety medication sheets • Twenty-eight white copies of tablet form of Analgesic Opioid medication sheets • Ten white copies of liquid form of Analgesic Opioid medication sheets • Nine white copies of liquid form Antianxiety medication sheets Review of the controlled destruction records with the DNS on [DATE] at 1:05 PM identified the following: • On [DATE] the facility destroyed a total of 12 controlled drugs. • On [DATE] the facility destroyed a total of 13 controlled drugs. Interview with the DNS on [DATE] at 1:05 PM identified that audits of the controlled substance on the unit should be completed monthly, however since employed at the facility she has yet to complete any or locate any that were completed by the previous DNS. The DNS further identified she had not located the yellow copy of the returned/unused controlled substance disposition record as she was waiting to reconcile with another nurse and the Administrator since the previous DNS left without them reconciling the medications. The DNS identified the returned/unused controlled substances should be destroyed and reconcile at least monthly, but she has not done so due to her workload. Review of the Controlled Medications policy and procedure identified all controlled substance transactions orders, receipt, administration, and disposal must be thoroughly documented. Also, monitoring and disposal of controlled substances that unused, expired, or discontinued controlled medications must be securely disposed of in accordance with the Drug Enforcement Agency's secure and responsible drug disposal act and any applicable state laws. The policy and procedure further identified prevention of drug diversion that the facility would implement safeguards to prevent the diversion of controlled substances which includes regular audits of controlled substances to ensure proper inventory management, monitoring of narcotic administration practices, including verification of signatures and any discrepancies, random or schedule checks of medication storage areas by supervisory staff.

Based on observations, review of facility policy and interviews for 1 of 2 medication storage rooms (Wing 2), the facility failed to ensure the medication storage room was secured. The findings included: Observation on 11/17/24 at 7:10 AM identified on Wing 2 a door labelled Medication Room opened greater than 12 inches containing: • Upper cabinets without any securement device containing over the counter medications, overflow prescription medications, mask and treatment supplies. • On the counters identified a sharp container that was filled with used needles and syringes. • Lower cabinets without any securement device with labels on the doors indicating its content such as cups, spoons, straws, gloves, sharp containers, and another cabinet contained oxygen supplies and treatment supplies. • Lower cabinet drawers without any securement device with labels on the drawers indicating its content such as batteries and syringes. • Two refrigerators on the counter, with only one functioning, the functioning refrigerator was without any securement device, contained a locked box, tuberculin vial, unopened insulin vial, Tylenol suppository and Bisacodyl suppository. Observation on 11/17/24 at 7:20 AM identified Resident #32 who resides on Wing 2 ambulating in the hallway while the Charge Nurse was in the hallway with the medication cart administering medication to the residents. Observation and interview on 11/17/24 at 7:26 AM with the Nursing Supervisor (RN #5) identified the medication storage room was left opened and unsecured. She identified that the medication storage room should be kept closed and then proceeded to close the door. Interview with the night shift Nursing Supervisor (RN #6) on 11/17/24 at 7:28 AM identified that he last went into the medication room at 6:15 AM to place a list of over-the-counter medications on the cabinet and left the door opened. He identified that he could not recall closing the medication storage room door as he was seated at the nursing station. Interview with the DNS on 11/18/24 at 7:35 AM identified the medication room should be kept close at all times and both nurses have a key to the medication storage room which is kept with them at all times. The DNS identified the medication room should be kept close even if seated at the nursing station in case of an emergency and the nurse needed to attend to the situation. Review of the Medication Storage policy identified all medication storage areas must be locked when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, review of facility policies/procedures and interviews for two sampled residents (Resident#1, and Resident #24) reviewed for food, the facility failed to post accurate menus and failed to post and or announce changes to the daily menu. The findings include: Resident #1's diagnoses included chronic obstructive pulmonary disease, unspecified, age-related osteoporosis without current pathological fracture, and hyperlipidemia. The care plan dated 9/3/24 identified Resident #1 was at risk for weight loss related to esophageal stricture with interventions that included no added salt diet, regular texture. The annual MDS assessment dated [DATE] identified Resident #1 was cognitively intact, had no behaviors, was independent with bed mobility, transfers, and required supervision with dressings and set up clean up assist with personal hygiene. The assessment further identified that the resident ambulated and utilized a walker and a wheelchair. Resident #24's diagnosis included type 2 diabetes, gastroesophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease. The care plan dated 7/22/24 identified Resident #24 had the potential nutritional problem related to diabetes, asthma, and dementia with interventions that included provide, serve diet as ordered. Registered dietician to evaluate and make diet change recommendations as needed. The quarterly MDS assessment dated [DATE] identified Resident #24 was cognitively intact, had no behaviors, utilized supervision for bed mobility, transfers, and required supervision with dressing and hygiene. The assessment further identified that the resident ambulated and utilized a walker. Observation of lunch service on 11/17/24 at 12:30 PM identified lunch being served was pulled pork, noodles, carrots and teriyaki chicken and roll. Menu posted on the wall said Sunday lunch should include garlic cheddar chicken, broccoli, pasta, and roll. No measured serving utensils were being utilized for service on the unit, and food was being served from a rolling steam table. No announcement of menu changes were made or written on the menu posted. Interview on 11/17/24 at 8:00 AM with Resident #1 identified the menu was not being followed and that food was being run out of before arrival to Resident #1's room, and that mashed potatoes were being served frequently. Interview on 11/17/24 at 8:10 AM with Resident #24 identified the menu was not being followed and that food was run out of before getting to Resident #24's room. Interview on 11/17/24 at 12:40 PM with Head Cook, indicted the use of current slotted spoons, and tongs was how the staff was taught to plate the foods at meals times. No scoops, or portion size utensils (measuring cups) identified as being used during any food service. This is how the staff was taught, not sure about scoops or portion control amounts to delineate calories. These are the utensils that are used and we provide large portions sizes. The facility does not use chafing lids to cover the chafing dishes on the steam table. Tin foil is used to cover the chafing dishes and was torn open on the top when the lunch service began. No cover placed on the dishes as Buddy moved the steam table to a different area on the unit or new unit. Interview on 11/18/24 at 9:04 AM with [NAME] President/owner identified, that the chicken teriyaki was substituted for the garlic chicken yesterday, as it was probably more popular than the garlic chicken. Utilizing scoops or cups was never stressed with the cooks, so they use the utensils available, and provide large servings. Half a cup or 4 ounces are small servings, the cooks give larger servings. Buddy has worked as a cook for many years and provides large servings. When there is a change to the menu it is announced overhead for the residents. The current menu is on week 3. Interview on 11/18/24 at 12:29 PM with [NAME] President/owner identified the week 2 menu posted on unit 1 and unit 2., and week 3 menu will be posted. Not sure why the wrong menu is posted. Interview on 11/18/24 at 12:59 PM with [NAME] President/owner indicated the head cook orders all the food and to his knowledge the facility has not ever run out of food. The residents are offered 2 different entree's/selections and sandwiches are also available for substitution, if the entree's isn't wanted. Interview on 11/19/24 at 8:12 AM with Person #2, the [NAME] President/owner, indicated food is ordered according to resident census and experience, experience knowing how much food is needed to accommodate the resident population/nutritional needs. Meadow Meat is the company used to order meat. For example, for 30 resident's we would order 5 pounds of meat. If chicken was on the menu 5 times during the week, then we would order the meat accordingly. For a census of 38, it would be more than 5lbs of meat. New cooks order more than what's needed usually. When they become more familiar with the facility and residents, the order becomes more accurate. Trial and error. The menu's provided yesterday, were one of the cycles of menus. It was the last menu signed off on by the Dietician. The facility has 3 menu cycles. The first menu provided to surveyors on Sunday 11/17/24, are the menu's being utilized currently at the facility. Interview on 11/19/24 at 9:42 AM with the cook, indicated the ingredients for the chicken cordon bleu were not available today, so Chicken Ala King will be served instead. [NAME] #2 was hired 2 weeks ago and has had to change the entrée selection (s) at lunch time, due to not having all the needed ingredients. He/she was unsure as to how many times this had occurred in the last 2 weeks. Interview on 11/18/24 at 1:11 PM with the Dietician for the facility, indicated she works 3 hours per week and is onsite at the facility every other week. Staff contact the dietician via email with any consults or new doctor's orders/changes. The Maryland Diet Manual for long term care residents is used to determine dietary requirements. An in-service was provided to the 2 new cooks by the dietician at the facility, to ensure/review the Maryland Diet Manual along with therapeutic diets, and what a therapeutic diet should include. The vice president is the Food Service director and handles any issues like menu changes or appropriate serving utensils. If the proper utensils for serving were not used, then the meal may not meet the requirement of a 1800-2200 calorie diet. Which can cause other issues, like weight loss. If a menu item is changed or swapped out for another entree, that would be something the food service director or the cook would handle. The last menu(s) that the dietician signed off on were in June of this year. Review of the Kitchen Food ordering and Supply policy dated 8/4/24 directed, in part, to always have an approved menu (by registered dietician) in place, to post menus in an area visible to residents, staff and visitors. Enough food will be ordered as needed to always ensure continued meal service. Substitutions or changes to the daily menu will be posted or announced before meal service. Any permanent changes to the menu will be approved by the registered dietician before its implementation.

Based on lack of facility documentation and interviews for the facility reviewed for quality and performance improvement, the facility failed to have written policies and procedures for feedback, data collections systems, and monitoring including adverse event monitoring. The findings included: Interview on 11/19/24 at 2:55 PM with one the [NAME] President and the DNS identified the facility had an anonymous suggestion box and a customer survey and identified the facility did not have written policies and procedures for feedback, data collections system and monitoring. He identified that the facility is a small facility, and residents and families address concerns in person. The VP identified that if a staff member identified a concern, or an error, the facility would address this in real time. There is not a system of tracking unless a pattern is noticed. The DNS identified that if a problem was identified, the facility would bring the problem to the QAA committee to address. The DNS identified the QAA committee met quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records, review of facility documentation, facility policy, and interviews for two of five residents (Resident #33 and Resident #35) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was offered and/or assessed to resident. The findings include: 1. Resident #33's was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies. The admission MDS assessment dated [DATE] identified Resident #33 had severe cognitive impairment. The assessment further identified that Resident #33 pneumococcal vaccination was not up to date. Review of Resident #33's immunization consents and records, along with the new admission consent documentation with Infection Preventionist (RN #1) on 11/18/24 at 1:30PM failed to identify that the pneumococcal vaccine was offered to the resident. 2. Resident #35's was admitted to the facility on [DATE] with diagnosis that included major depression, dementia, and anxiety. The admission MDS assessment dated [DATE] identified Resident #35 had severe cognitive impairment. The assessment further identified that Resident #35 pneumococcal vaccination was not up to date. Review of Resident #35's immunization consents and records, along with the new admission consent documentation with Infection Preventionist (RN #1) on 11/18/24 at 1:30PM failed to identify that the pneumococcal vaccine was offered to the resident. Interview with the Infection Preventionist (RN#1) on 11/18/24 at 11:30 AM identified that she just started her position as Infection Preventionist at the facility and she was not sure who would be responsible of offering the resident vaccine when it due. She identified that she could not find the consent for Resident #33 and Resident #35 pneumococcal vaccine. She further identified that going forward it would be her responsibility to ensure all residents would be offered up to date vaccination. Review of Pneumococcal Vaccine identified that all residents would be offered pneumococcal vaccines to aid in preventing pneumonia infections. The policy also identified that all residents would be assessed for eligibility to receive the pneumococcal vaccine series when indicated within 30 days of admission to the facility unless medically contraindicated or the resident had completed the current recommendation of the vaccine series.

Based on review of facility documentation, review of facility, and interviews for infection surveillance, the facility failed to review the infection control program policies and procedures at least annually, the facility failed to ensure monthly environmental rounds was conducted in accordance with the facility practice, and failed to follow the policy and procedures measures developed by the facility to prevent growth of legionella and other water borne pathogens in the building water system. The findings include: 1. Review of the facility Infection Control Program Policies and Procedure manual for the past three years (2022, 2023, and 2024) on 11/18/24 at 10:30 AM failed to identify that the policies and procedures manual was reviewed. Interview with Infection Preventionist (RN #1) on 11/18/24 at 10:40 AM identified that she unable to locate the documentation that the policy and procedures manual was reviewed for the year 2022, 2023, and 2024). She identified that she just started working as IP nurse at the facility on 11/13/24. She further identified that it would be responsibility of the IP nurse to ensure that the infection control policies and procedures were reviewed and signed off annually. Review of the Infection Prevention Program policy identified that infection control policies would be reviewed annually and signed off by the Medical Board. 2. Review of the facility documentation of the monthly environmental round from May 2024 through November 2024 identified that the last monthly environmental was done on June 2024. Interview with IP nurse (RN #1) on 11/18/24 at 11:10 AM identified that she was not sure what is the facility policy for the environmental rounds; however, she identified that based on the facility documentation for environmental rounds that the facility practice was conducting a monthly environmental rounds. She identified that she just started working as IP nurse at the facility on 11/13/24 and the last documentation for environmental rounds that was given to her was on June 2024. Interview with DNS on 11/19/24 at 10:30 AM identified that she recently started her position of DNS 4 months ago and the previous IP left approximately 3 months ago. She identified that the IP nurse would be responsible for conducting the monthly environmental rounds. She was aware that environmental rounds was not being done because there was no IP nurse at that time. She further identified that the facility recently hired an IP nurse who would be responsible for conducting the monthly environmental rounds. Although requested, a policy for environmental rounds was not provided. 3. The Facility Water Management Plan Policy identified that the facility would maintain a log that included the hot water heaters would be drained of sediment and recorded in a log twice a year, the pressure vessels to be drained of sediment and recorded as being done in a log twice a year, ice maker machine to be clean quarterly and sanitized yearly and log would be maintain, and shower head, hoses, eye wash station and aerators to be removed, cleaned, and soaked in chlorine bleach solution on a monthly basis and recorded that it being completed. Interview with the Director of Maintenance on 11/19/24 at 1:30 PM identified that he had no information or documentation of the facility water management plan. He could not identify if the facility had the water tested for the legionella. He further identified that the administrator was responsible for keeping the water management documentation. Interview with the administrator on 11/19/24 at 2:00 PM identified that the previous maintenance director took all the documents related to the water management plan and he could not find any maintenance that were completed related to the facility water management plan. He also could not identify when the facility undergoes water testing for legionella. Review of the Facility Water Management plan and policy identified that sampling, management plan and sampling result would be retained. The Water Management plan policy also identified that the facility was committed to the prevention, detection and control of water-borne contaminants and program log would be utilized and kept within the water management plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, reviews of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #1) who had a behavior of wandering and was at risk for elopement, the facility failed to ensure the courtyard gate was secured to prevent the resident from exiting the courtyard and wandering to the front of the facility. The findings include: Resident #1's diagnoses included dementia with behavioral disturbance, cognitive communication deficit, and anxiety disorder. The readmission Wandering Risk Scale assessment dated [DATE] identified Resident #1 scored a 12 and was considered to be a high risk of wandering. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, independent with transferring and ambulating, and a wander/elopement alarm was utilized daily. The Resident Care Plan dated 4/22/24 identified Resident #1 was at risk for wandering and elopement due to impaired safety awareness. Interventions included to distract the resident from wandering by offering pleasant diversions, provide structured activities, identify pattern of wandering, and intervene as appropriate. A physician's order dated 5/8/24 directed to check function and placement of the wander guard every shift and replace every ninety days to ensure the battery was in working order. The Facility Reported Incident report dated 5/21/24 identified Resident #1 exited the facility through the courtyard fence, was found by staff wandering in front of the facility, was brought back inside the facility, and placed on close monitoring with staff. The investigation identified Resident #1 exited the facility through the courtyard door, which was utilized by alert, oriented, and mobile independent residents. On 5/21/24 residents accessed the courtyard including Resident #1. The report indicated although Resident #1 had a wander guard on his/her left ankle when he/she exited the courtyard door, the courtyard door was not connected to the wander guard system. The investigation concluded that the door to the courtyard was left propped open and Resident #1 walked through the door, crossed through the courtyard, exited through the gate that leads to the outside of the courtyard, as the gate was not secured, and walked around the building to the front of the facility. Interview with the Director of Nursing (DON) on 6/10/24 at 11:00 AM identified a resident notified the Nursing Supervisor on 5/21/24 at 3:30 PM that Resident #1 made it out through the gate of the courtyard. The DON indicated a search was initiated and she was the one who found Resident #1 outside the facility two (2) minutes after Resident #1 was reported outside. The DON identified the patio door was typically secured and locked from the inside of the facility with a keypad lock and the nursing staff were responsible for ensuring the patio door was secured. The DON indicated the patio door was able to be opened by staff or by alert and orientated residents that were provided the code and able to use the courtyard and it was determined Resident #1 exited the facility on 5/21/24 through the patio door, which was left propped open by residents that used the courtyard space on 5/21/24. The DON identified the investigation determined the gate to the outside of the courtyard was able to be pushed open even if the gate was closed and latched which was how Resident #1 was able to go through the gate and walk around the building to the front of the facility. Interview with the Director of Maintenance on 6/10/24 at 11:22 PM identified that maintenance was responsible for ensuring the gate was closed/latched and locked. The Director of Maintenance identified he left the facility prior to 3:30 PM on 5/21/24, which was the time Resident #1 was seen outside. Review of the facility Elopement policy directed every effort was made to protect residents and maintain them in a safe environment and preventative measures would be taken prevent an incident from happening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review and interviews for two of three residents (Resident #1 and #2) reviewed for accidents, the facility failed to ensure orders for side rails and a comprehensive care plan were developed timely to include use of bed rails. The findings include: a. Resident #1 was admitted with diagnoses that included dementia, peripheral vascular disease (PVD) and depression. Physician order dated active 11/1/2023, directed assist of two for bed mobility and ADLs. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognitive status, was dependent for personal hygiene, moderate assist for rolling left to right and was not ambulatory. The Resident Care Plan (RCP) dated 11/30/2023 identified Resident #1 was at risk for falls. Interventions directed to anticipate needs and be sure the call light was in reach. A facility incident report dated 11/5/2023 identified Resident #1 was observed leaning to the right side of bed with his/her head against the side rail and was holding the side rail with her/his left hand. A discoloration was noted to the right forehead. A nursing progress note dated 11/5/2023 at 10:12PM identified that a blue discoloration was noted to Resident #1's forehead after resident was observed leaning to the right side of the bed with her forehead against the bedside rail and holding the rail with their right hand. The note further indicated both side rails were padded after the incident. Review of the clinical record failed to identify a physician order or care plan that directed use of side rails on Resident #1's bed. b. Resident #2 was admitted with diagnoses that included dementia, chronic kidney disease (CKD) and abnormalities of gait and mobility. A quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognitive status and was moderate assist for personal hygiene, independent for rolling left to right, set up assistance for transfer and ambulation with a walker. The RCP dated 9/21/2023 identified Resident #2 had impaired cognition and was at risk of falls. Interventions directed to keep a consistent routine, anticipate needs and to encourage use of the call light. Observations of Resident #1 and Resident #2 on 12/7/2023 at 10: 00 AM identified that each Resident was lying in bed with ¼ side rails up on both sides of their beds. Interview and review of Resident #1 and Resident #2 's medical records with the DON on 12/7/2023 at 1:00 PM identified although Resident #1 and Resident #2 both had ¼ side rails on their beds, the RCP lacked interventions to address side rail use. Further, the DON was unable to explain why physician orders were not in place to direct side rail use. Additional review of Resident #1's RCP failed to identify padded side rails were included after the incident on 11/5/2023. The DON indicated orders should be in place and the care plans should include side rails were used, including padded side rails as per the nursing note on 11/5/2023, and she did not know why it was not done. The facility Care Plan Policy dated 9/1/2023 directed in part, services provided are consistent with each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review and interviews for three of three residents (Resident #1, #2, and #3) reviewed for side rail use, the facility failed to ensure an assessment was completed timely to assess the risk for entrapment, resident risk/benefits of use, and to obtain informed consent for the use of a bed rail, and failed to maintain a maintenance log of routine maintenance. The findings include: a. Resident #1 was admitted with diagnoses that included dementia, peripheral vascular disease (PVD) and depression. Physician order dated active 11/1/2023, directed assist of two for bed mobility and ADLs. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognitive status, was dependent for personal hygiene, moderate assist for rolling left to right and was not ambulatory. The Resident Care Plan (RCP) dated 11/30/2023 identified Resident #1 was at risk for falls. Interventions directed to turn and position every two (2) hours with an assist of two (2) staff, padding to both side rails, and supervise as needed. b. Resident #2 was admitted with diagnoses that included dementia, chronic kidney disease (CKD) and abnormalities of gait and mobility. A quarterly MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognitive status and was moderate assist for personal hygiene, independent for rolling left to right, set up assistance for transfer and ambulation with a walker. The RCP dated 9/21/2023 identified Resident #2 had impaired cognition and was at risk of falls. Interventions directed to keep a consistent routine, anticipate needs and to encourage use of the call light. c. Resident #3 was admitted with diagnoses that included abnormal posture, anxiety, and unsteadiness. A quarterly MDS assessment dated [DATE] identified Resident #3 had moderately impaired cognitive status and required extensive assistance of two (2) staff for bed mobility, was dependent for transfer and required extensive assistance of staff for personal hygiene. The RCP dated 9/7/2023 identified Resident #3 was at risk for falls and had impaired cognition. The RCP directed to break tasks into one step at a time, use of two (2) side rails up to aid in bed mobility, and supervise as needed. Observations of Resident #1, #2 and #3 on 12/7/2023 at 10:00 AM identified each resident was in bed with ¼ side rails up on both sides of the bed. Reviews of Residents #1, #2 and #3's clinical records failed to identify assessments were completed to indicate side rail usage was required, assessed for potential restraints, potential for entrapment, and consents were obtained for side rail use. Interview and clinical record reviews with the DON on 12/7/2023 at 12:00 PM identified each medical record lacked an assessment to identify entrapment risk, potential restraints, or resident need for side rail usage. Further, the clinical records lacked signed informed consents for bed rail uses that would have identified any potential risks of bedrail use. The DON indicated she was unaware assessments should be completed and consents obtained. Interview with Director of Maintenance on 12/7/2023 at 1:15 PM identified that although he performs monthly bed rail assessments and any maintenance performed, he does not document them. Although requested the facility was unable to provide a bed rail policy, restraint policy or a bed rail maintenance log for routine maintenance and assessments of resident's bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident #22) reviewed for abuse, the facility failed to report an allegation of rough care to the State Agency. The findings include: Resident #22's diagnoses included delirium due to known physiological condition, and major depressive disorder. The Resident Care Plan (RCP) dated 5/27/22 identified Resident #22 was at risk for psychosocial well being secondary to history of mental illness. Interventions included to monitor/record occurrence of target behavior symptoms, inappropriate responses to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #22 was moderately cognitively impaired and required extensive assistance for bed mobility, total dependence for transferring and total dependence for toileting. APRN #1's progress note dated 7/13/22 at 6:00 PM identified Resident #22 reported a male Nurse Aide (NA #1) was rough during care and said he/she did not want that NA anymore, Nursing Supervisor made aware and will follow up. A Grievance Log entry dated 7/13/22 identified Resident #22 reported the male NA (NA #1) that was working on the 11:00 PM to 7:00 AM shift was rough with care. When inquired further Resident #22 stated it happens every night however the Social Worker (SW) indicated NA #1's first night of employment was 7/12/22. Interview with SW on 8/22/22 at 9:55 AM identified Resident #22 had a history of delusions and had delusions that night per the RN Supervisor (RN #3) who was on duty. Additionally, the SW identified that Resident #22's allegation could not be substantiated but failed to provide evidence that the allegation was reported to the State Agency. Interview with NA #1 on 8/23/2022 at 11:18 AM identified he was on duty the 11:00 PM to 7:00 AM shift on 7/13/22 and was not aware that Resident #22 complained that he was rough with care. Interview and review of the clinical record with the DNS on 8/23/22 at 12:30 PM failed to identify Resident #22's allegation of rough care was reported to the State Agency. Additionally, the DNS identified she had spoken to the Nursing Supervisor within 2 hours of the allegation and confirmed no roughness had occurred. She also stated the second NA on duty that night also supported no roughness had been observed. The DNS indicated Resident #22 was reported as delusional that night, and the DNS attempted to reach NA #1 however he never returned the call or text. The DNS stated since the allegation was not substantiated there was not a reason to report the allegation to the Stage Agency. A review of the facility abuse policy identified in part that witnessed or alleged abusive action to a resident will be reported within 2 hours by telephone to the Department of Public Health by the Administrator, DNS or designee, and follow up written report will be filed within 72 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident #22) reviewed for abuse, the facility failed to thoroughly investigate an allegation of rough care. The findings include: Resident #22's diagnoses included delirium due to a known physiological condition and major depressive disorder. A Resident Care Plan (RCP) dated 5/27/22 identified Resident #22 was at risk for psychosocial well being secondary to a history of mental illness. Interventions included to monitor/record occurrence of target behavior symptoms, inappropriate responses to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was moderately cognitively impaired and required extensive assistance for bed mobility, total dependence for transferring and total dependence for toileting. APRN #1's progress notes dated 7/13/22 at 6:00 PM identified Resident #22 reported a male Nurse Aide (NA #1) was rough during care and said he/she does not want NA #1 anymore. The Nursing Supervisor was made aware and will follow up. A Grievance Log entry dated 7/13/22 identified that Resident #22 reported a male NA (NA #1) that was working on the 11:00 PM to 7:00 AM shift was rough with care. Resident #22 stated it happens every night however the Social Worker (SW) indicated that 7/12/22 was NA #1's first night of employment. Interview with the SW on 8/22/22 at 9:55 AM identified Resident #22 had a history of delusions and had delusions that night per the Nursing Supervisor (RN #3) who was on duty. Additionally, the SW identified that the allegation of rough care could not be substantiated. Interview with NA #1 on 8/23/22 at 11:18 AM identified he was on duty on the 11:00 PM to 7:00 AM shift on 7/13/22 and was not aware of the allegation of rough care made against him, nor had there been any contact by the facility to discuss care that night. Interview and review of the clinical record with the DNS on 8/23/22 at 12:30 PM, failed to reflect a thorough investigation had been completed regarding Resident #22's allegation of rough care. The DNS stated she spoke with the Nursing Supervisor within 2 hours of the incident and confirmed no roughness had occurred. The DNS also stated the second NA on duty that night also supported no roughness was observed. The DNS indicated Resident #22 was reported as delusional that night, and the DNS stated she attempted to reach NA #1 however he never returned the call or text. Subsequent to surveyor inquiry the DNS provided a statement dated 8/22/22 written at 12:09 PM from RN Supervisor #3, indicating there were no areas of concerns pertaining to the 11:00 PM to 7:00 AM shift on 7/13/22 and NA #1 was not rough with Resident #22. RN #3 also indicated Resident #22 was verbally delusional on 7/13/22, however the only documentation regarding the allegation of rough care the Grievance Log and the recently provided email. Although attempted an interview with RN #3 was not obtained. A review of the facility policy on abuse identified in part that an investigation of the witnessed or alleged abusive action will be initiated within 2 hours of its discovery. A Reportable Event form will be started by the RN Supervisor or designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #21) reviewed for assessments, the facility failed to ensure an RN assessment was completed in a timely manner. The findings include: Resident #21's diagnoses included paranoid schizophrenia, type 2 diabetes, other personality and behavioral disorders due to known physiological condition, autistic disorder, and mild intellectual disabilities. The Resident Care Plan (RCP) dated 3/15/22 identified a potential for alteration in skin integrity and a history of chronic callous right left plantar. Interventions included nursing would assess right and left plantar daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was cognitively intact and required supervision with activities of daily living (ADLs). Nurse's notes from LPN #3 and dated 7/14/22 identified Resident #21 complained of foot pain and LPN #3 indicated assessing the foot and identified calluses. An APRN progress note dated 7/27/2022 at 9:58 AM identified corns and callus to the right plantar, continue skin prep daily-nursing to notify provider if any changes-Podiatry Consult. The clinical record failed to identify Resident #21's foot had been assessed by an RN when LPN #3 was made aware Resident #21 had foot pain and indicated calluses, until being assessed by the APRN on 7/27/22 (13 days after LPN #3 identified Resident #21 had pain and calluses). Interview and clinical record review with LPN #3 on 8/23/22 at 10:52 AM identified LPN #3 examined Resident #21's foot and as a result referred the concerns to the APRN who assessed the foot 7/27/22 (13 days later). LPN #3 further stated Resident #21's foot pain was referred to the RN Supervisor however could not remember the name of the RN Supervisor nor the date and time of the referral. There was no clinical documentation of an RN assessment noted until 7/27/22 when APRN assessed the area. Interview and review of the clinical record with the DNS on 8/23/22 at 12:20 PM failed to provide documentation to reflect that an RN assessed Resident 21's foot during the 13 day interval from 7/13/22 thru 7/27/22. Additionally, the DNS indicated she would have expected the foot pain to have been assessed by the RN Supervisor and documentation noted. Review of facility diabetic residents, observation and routine care policy directed in part, that feet on all diabetics are to be checked daily and any unusual findings reported to immediate supervisor and noted on nurses notes- then appropriate action taken as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of one resident (Resident #12) reviewed for Dental services, the facility failed to ensure that dental services were offered. The findings include: Resident # 12 was admitted on [DATE] with diagnosis which included chronic ulcer (non-pressure) of right foot. Diabetes with foot ulcer, coronary artery disease, vascular dementia with behavioral disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was cognitively intact and required supervision for bed mobility transfer, eating, and toileting and physical assistance of one person for bathing. A physician's order dated 6/1/2021 directed to obtain a dental consult as indicated The resident care plan (RCP) dated 8/11/2022 identified that Resident #12 has a dental health problem related to lack of lower denture. The intervention in part included to coordinate arrangements for dental care and transportation as needed and to monitor, document, report as needed any symptoms of oral dental problems needing attention. The care plan further indicated that Resident #12 has a deficit in self-care performance related to memory loss secondary to dementia. Interventions in part included to aid with personal hygiene and oral care to maximize independence. Interview with Resident #12 on 8/18/2022 at 10:10 AM indicated that his/her upper partial plate had some broken teeth for about 7 months and some lower teeth have some discomfort off and on the lower left and right sides. Observation on 8/18/2022 at 10:10 AM revealed left side upper front tooth/appliance partially chipped off. On 8/22/22 01:30 PM an interview and record review with RN#2 failed to provide documentation of dental visits or consults for Resident #12 but indicated that he does see the consulting services and they come in about every 2 months. Interview, clinical record review, and facility documentation review with the DNS on 8/22/2022 at 1:00 PM indicated that on admission the social worker (out on leave), provides the Resident information to the consultant company providing dental services. Though requested, the DNS was unable to provide documentation of a dental consult, for Resident #12 since admission on [DATE](1 year, 2 months, and 4 days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy review and interviews for one of one resident (Resident #4) reviewed for communication, the facility failed to ensure that Audiology recommendations were addressed timely. The findings include: Resident # 4's diagnosis included dementia with behavioral disturbance, unspecified hearing loss, macular degeneration, pseudobulbar infarct, and mood disorders. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a short and long term memory problem, required total assistance of 1 for bed mobility, dressing, toilet use and personal hygiene. The MDS further identified Resident #4 required extensive assistance of 1 for transfers and his/her ability to hear was moderately difficult, speaker had to increase volume an speak distinctly. Additionally, the MDS identified Resident #4 utilized a hearing aide. The Resident Care Plan (RCP) dated October 2021 identified Resident #4 had a communication problem related to a hearing deficit and speech impediment. Interventions included to anticipate and meet needs, be aware of position of resident when in group settings to promote proper communication with others, allow adequate time to respond repeat what was said as necessary and do not rush. Additional interventions included face Resident #4 when speaking to him/her and make eye contact while being sure TV/radio is turned off to reduce environmental noise, use brief consistent words and cues, observe for problems of decline in cognitive status, mood, decline in hearing impairment (ear discharge, wax accumulation), changes in ability to communicate, and refer to Audiology for hearing consult as ordered. An Audiology consult dated 11/30/21 indicated that wax in both ears needed removal and requested facility to call the physician for wax removal orders. A nurse's note dated 5/2/22 at 7:33 PM indicated that Resident #4 returned to the facility after cataract surgery. A nursing progress note dated 5/31/22 at 12:38 PM indicated that Resident #4's responsible party was updated regarding an audiology appointment being canceled due to current covid outbreak. A Social Service progress note dated 6/23/22 at 3:57 PM indicated that the Resident #4 returned from an Audiology appointment with clean and fixed hearing aids and a follow-up appointment to clean Resident #4's ears was scheduled by the Audiologist for June 28, 2022. A physician's order dated 6/23/22 directed Debrox solution 6.5%, instill 5 drops in both ears two times daily for accumulating wax for 5 days. On 8/23/22 at 10:45 AM an interview and review of the clinical record with the DNS revealed that the Audiologist recommendation to notify Resident #4's physician for was removal orders from 11/30/21 and not been brought to Resident #4's physician's attention. The nursing notes were reviewed with the DNS at that time and a 6 month delay in treating Resident #4's ear wax had occurred between the initial consult from the Audiologist on 11/30/2021 to 6/23/22. The DNS further indicated that the consultation orders were missed and that she recently noted in April 2022 the Nurse Supervisors were being verbally updated by the consultants, but written consultations were not being addressed as the consultants were directly uploading them into the resident's electronic chart. The DNS indicated that she was now emailed the consultation results and she then hands them to the Nursing Supervisors for completion.

Based on clinical record review, facility documentation review, facility policy review during review of the Infection control program, the facility failed to ensure that the licensed staff providing IV therapy had completed annual competencies annual education The findings include: In an interview and review of facility documentation on 8/23/22 at 11:00 AM with the DNS and LPN#2, they were unable to provide any yearly IV education or competencies for licensed staff.Aditionally, the facility was not able to provide any IV education for licensed staff prior to the start of the new pharmacy in October 2021. The DNS could not explain why the competecies and/or education was not completed. The facility IV policy dated April 2010 indicated that it is the policy of the facility to educate staff on IV therapy on an annual basis. The IV infusion therapy policy and procedure manual dated 2011, section 2.3 scope of practice 4 and competency assessment indicated in part that initial competency is assessed and documented before the skill is performed without supervision and documentation of completed continuing education and competency assessment should be available in the facility or employee files.

Based on observations, facility documentation and interviews during the medication storage and labeling review for one of one medication storage rooms, the facility failed to ensure medications were stored safely in the medication refrigerator. The findings include: Observation of the facility medication storage area on 8/19/22 at 6:00 AM with RN #1 identified the refrigerator temperature log lacked documentation as of twice daily checks for August 2022 on 10 occasions. There were 22 unopened Insulin vials and 2 unopened vials of Influenza vaccine stored in the refrigerator. Interview with RN #1 on 8/19/ 22 at 6:20 AM identified that although she knew it should be checked she twice daily, stated that it is completed on the other shifts. She identified that the current temperature in the medication refrigerator was 40 degrees Fahrenheit. A review of the August 2022 refrigerator log with the DNS on 8/19/22 at 9:00 AM identified that there were 5 dates that were missing initials to identify that the refrigerator temperature monitoring had been completed for both the AM and the PM checks. She stated that it would have been the Charge Nurse working at 8:00 AM and 8:00 PM who would check the refrigerator temperature and record it on the medication refrigerator temperature log sheet, and she was not sure the reason it was not done. Interview with LPN #1 on 8/12/22 at 1:15 PM identified that the Charge Nurse would be responsible to check the refrigerator temperature for the temperature checks each shift. LPN #1 further identified the Charge Nurse. The facility policy, Medication Storage dated 1/2021 in part, directed to ensure that medications requiring refrigeration or temperatures between 36 degrees and 46 degrees are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify temperatures have remained with accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for 2 of 8 residents (Resident # 10 and Resident #27) reviewed for vaccination compliance, the facility failed to ensure that residents were offered disease preventing vaccinations. The findings include: 1. Resident # 10 was admitted on [DATE] with diagnoses which included unspecified dementia anemia, chronic kidney disease, Hypertension, and hypercholesterolemia. Review of clinical record with LPN# 2 and the DNS on 8/23/2022 at 1:30 PM failed to provide evidence that the pneumovax vaccine had been offered, was historic or had been refused. LPN# 2 further indicated that she had only been employed at the facility for a few months and had not had a chance yet to review the vaccination status of the residents to see who needed consent and physician orders. 2. Resident # 27 was admitted [DATE] with diagnosis which included dementia with behavioral disturbance, chronic obstructive pyelonephritis, chronic kidney disease and secondary hypertension. Review of clinical record with LPN# 2 and the DNS on 8/23/2022 at 1:30 PM failed to provide evidence that the pneumovax vaccine had been offered, was historic or had been refused. LPN# 2 further indicated that she had only been employed at the facility for a few months and had not had a chance yet to review the vaccination status of the residents to see who needed consent and physician orders. Review of the facility Policy dated 12/14/2021 titled Pneumococcal Immunization- Residents indicated that it is the facility ' s policy to immunize it Residents against preventable diseases, such as Pneumococcal disease. It further indicated that upon admission the Infection Preventionist (IP) will review the Resident ' s vaccine history and if there is no history of Pneumococcal vaccination or only one vaccine given the Medical Director will be notified for further instruction for vaccinating. The Resident or responsible party will then receive education regarding the benefits and potential side effects of the vaccine before offering the vaccine. If the Resident or responsible party refuses the vaccine, they will continue to be offered the vaccine twice yearly. The facility policy indicated that at the minimum the medical record will contain documentation that education was provided, a consent form was completed, and the vaccination data documented into the Resident ' s medical record. If the Resident did not receive the Pneumococcal vaccine due to medical contraindications or refusal, the data would be entered into the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation and interviews for 1 of 2 sampled residents (Resident #1) who was reviewed for allegation of mistreatment, the facility failed to complete a thorough investigation of the alleged violation. The findings include: Resident #1's diagnoses included adjustment disorder with depressed mood. The 30-day Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was able to make decisions regarding tasks of daily life, and was independent with locomotion on unit. The Reportable Event Form dated 7/14/19 identified that Resident #1 reported being scratched on the arm by another resident. The report identified Resident #1 sustained two (2) scratches to the right upper extremity measuring 8 centimeters (cm) by 0.5 cm and 9.5 cm by 0.5 cm. The nurse's note dated 7/15/19 at 11:13 AM identified that Resident #1 reported that another resident had scratched his/her right upper extremity. The note indicated Resident #1 reported that a resident across the hallway had come up to him/her on the evening of 7/14/19 in the hallway and scratched his/her right upper arm. Resident #1 sustained two (2) scratches to the right upper extremity measuring 8 centimeters (cm) by 0.5 cm and 9.5 cm by 0.5 cm and the resident denied pain. The social service progress note dated 7/15/19 at 12:00 PM identified Resident #1 reported to staff that another resident scratched him/her last evening, 7/14/19. Review of the clinical record from 7/15/19 through 8/1/19 failed to reflect documentation Resident #1 was seen by a Social Worker after 7/15/19 in follow-up. Review of the Reportable Event Form and investigation identified one (1) statement dated 7/15/19 at 7:30 AM by a nursing aide to whom Resident #1 reported the incident was obtained. Interview and review of the clinical record with the Director of Nursing (DON) on 10/30/19 at 12:47 PM identified that there were no statements from Resident #1, the other resident, and/or if there were any witnesses as to what happened on the evening of 7/14/19. The DON stated Resident #1 was a good historian, alert and he trusted the resident's statement. The DON indicated that in this case Resident #1 told him exactly what had happened, so he did not investigate this allegation any further. Resident Abuse Policy indicated that a thorough investigation will be conducted and will begin within 24 hours and completed within 5 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #1) who were reviewed for an allegation of mistreatment, the facility failed to document in the clinical record the psychosocial support that was provided to the resident by social services after the incident and for one of three sampled residents (Resident #288) who were reviewed for the provision of personal hygiene, the facility failed to document on the nurse aide documentation form that daily personal hygiene was provided or refused by the resident. The findings include: 1. Resident #1's diagnoses included adjustment disorder with depressed mood. The 30-day Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was able to make decisions regarding tasks of daily life, and was independent with locomotion on unit. The Reportable Event Form dated 7/14/19 identified that Resident #1 reported being scratched on the arm by another resident. The report identified Resident #1 sustained two (2) scratches to the right upper extremity measuring 8 centimeters (cm) by 0.5 cm and 9.5 cm by 0.5 cm. The social service progress note dated 7/15/19 at 12:00 PM identified Resident #1 reported to staff that another resident scratched him/her last evening, 7/14/19. Review of the clinical record from 7/15/19 through 8/1/19 failed to reflect documentation Resident #1 was seen by a Social Worker after 7/15/19 in follow-up. Interview and review of the clinical record with Social Worker #1 on 10/30/19 at 12:30 PM identified that she met with Resident #1 on 7/15/19 after she was made aware of the allegation between Resident #1 and the other resident. Social Worker #1 indicated that she usually stops to talk to Resident #1 and she should have documented in her progress notes that she met with Resident #1 after 7/15/19. The Abuse policy directs that upon receiving information concerning a report of abuse, the Director of Nursing (DON) will request that a representative of the social service department monitor the resident's emotions concerning the incident as well as the residents reaction to his/her involvement in the investigation. 2. Resident #288's diagnoses included Alzheimer's disease, depression, anxiety, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #288 had severe cognitive impairment, exhibited behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging) that occurred one (1) to three (3) days, had difficulty focusing attention and disorganized thinking, and required extensive assistance with personal hygiene. The Resident Care Plan dated 12/28/18 identified Resident #288 had an activities of daily living self-care performance deficit related to weakness. Interventions directed extensive one (1) person assistance with personal hygiene. Review of the nurse aide documentation form from 1/1/19 through 1/28/19 failed to reflect documentation personal hygiene (including combing hair, brushing teeth, washing/drying face and hands) was provided or refused on 20 of 56 shifts. Interview and clinical record review with the Director of Nursing (DON) on 10/31/19 at 12:10 PM identified that personal hygiene and/or the refusal of care were to be documented on nurse aide documentation form. The DON stated there have been concerns with documentation in the record especially with the agency staff due to the staff not being able to access and log into the electronic program. Although requested, a policy was not provided.

**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 Resident (Resident #7) reviewed for infection control, the facility failed to properly implement personal protective equipment use per standards of practice. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, type 2 diabetes mellitus, and urinary tract infection (UTI). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderately impaired cognition, was always incontinent of bladder and frequently incontinent of bowel, required extensive assistance of one for toileting, and required supervision and setup help for eating. The care plan dated 10/23/19 identified alteration in urinary elimination related to UTI. Interventions directed to encourage fluid intake, labs as ordered, and medicate as ordered and monitor effectiveness. A physician's order dated 10/24/2019 directed to administer Macrobid 100mg capsule two times a day for 7 days. The nurse's note dated 10/24/19 at 9:00 PM identified that a urine culture and sensitivity came back positive for extended spectrum beta-lactamases (ESBL). Physician updated and started Resident #7 on Macrobid and discontinued Keflex. Supervisor notified, on contact precautions and the daughter updated. Resident #7's care card identified bladder incontinent, on contact precautions, and 15 minute safety checks. Observation on 10/28/19 at 12:45 pm, identified lunch was to be delivered to Resident #7's room by Nurse Aide (NA) #1. Resident #7 was alone in this room. NA #1 was outside Resident #7's room that had a stop sign barrier on it. Also located outside of room, was a contact precautions sign, a sign that listed the contact precautions that were to be used upon entering: gloves, gown, and mask (if necessary), and the contact precaution container that contained gowns, masks and gloves. NA #1 removed the Stop Sign barrier from the doorway, asked Resident #7 what he/she would like to eat, and subsequently brought the food in to Resident #7 without the benefit of wearing the appropriate Personal Protective Equipment (PPE). NA #1 placed the tray on the over-bed table, moved the over-bed table closer to the resident, moved Resident #7's walker out of the way, assisted the resident by moving his/her legs off of the bed, and took the resident's hand in his/hers to help him/her sit up in bed. NA #1 exited the room, walked up the hall past two bedrooms, approximately 15 feet, and utilized hand sanitizer. Interview with NA #1 at that time identified that NA #1 was aware that Resident #7 was on contact precautions, could identify that contact precautions meant to wear PPE when coming in contact with Resident's urine, and that he/she subsequently utilized hand sanitizer immediately after exiting the room. NA #1 could not firmly identify that Resident #7 was continent at the time he/she sat Resident #7 up in bed, or that Resident #7 hands had not come in contact with urine prior to him/her touching Resident #7's hand, but stated that it was his/her understanding that he/she was to wear gloves when doing peri care only. NA #1 was not sure what the policy identified to do. Interview with Director of Nurses (DNS) on 10/28/19 at 1:05PM identified that NA #1 was to wear contact precaution supplies when coming in direct contact with Resident at the time of delivering lunch trays and that NA #1 thought she would just be delivering the lunch tray and then exiting. DNS further identited that he/she could not confirm if Resident #7 was saturated in urine and/or that Resident #7's hand had not come in contact with urine prior to NA #1 helping resident sit up in bed. DNS also identified that NA #1 needed to prepare better and wear gloves when entering the room. Subsequent to surveyor observation on 10/28/19, the care plan was updated on 10/29/19 to include contact precautions for urine. Interventions directed to maintain contact precautions. Interview with Licensed Practical Nurse (LPN) #1 on 10/31/19 at 10:30 AM identified that a physician's order is not needed to place a Resident on contact precautions if suspected infection is possible. It is a nurses discretion to do so. Review of facility policy for contact precautions directed to wear clean gloves when entering the resident's room or unit if a multi-bed room, and to wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident.

Based on review of facility documentation, interviews, and review of facility policies and procedures, the facility failed to ensure the residents, the resident's legal representative and the public were notified of the facility's use of a twenty-four (24) hour video surveillance of the common areas. The findings include: Observations on 10/29/19 at 2:45 PM identified although there were cameras for video surveillance located in the dining room, recreation room, and hallway, the facility failed to post a notice related to the surveillance cameras at the front door entrance, the nurse's stations and/or the hallways. An interview with the Administrator on 6/27/18 at 2:25 PM identified that the twenty-four (24) hour surveillance cameras have been in use in the facility for a while and that the admission packet did not include any information regarding the cameras. The Administrator indicated the facility did not have a posting related to the surveillance cameras at the front door entrance and/or throughout the facility. The Administrator stated the video cameras were located in the dining room, recreation room, hallways, storage room and outside in the parking lot and not in any of the residents' rooms. Upon surveyor inquiry, signs were posted at the entrance to the facility, at the nurse's station and in the hallway regarding the use of video surveillance.