**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** documentation, review of facility policy/procedures and interviews for two of two sampled residents (Residents #9 and #336) reviewed for choices, the facility failed to ensure the resident's choices were accommodated when the resident requested to go to bed, and staff did not assist the resident for four hours and failed to ensure menu choices were provided at mealtime. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, difficulty walking, abnormal posture, pain, and peripheral neuropathy. The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition, required partial to moderate assistance with personal hygiene, required total dependent with transfers (chair to bed/bed to chair), bed mobility, toileting, dressing, and utilized a wheelchair for mobility. The care plan dated 1/27/25 identified Resident #9 had an ADL (activities of daily living) function compromise and required substantial and maximal assist with transfers. Interventions directed extensive assist of 2 with bed transfers, extensive assist of 1 with dressing, personal hygiene, bed mobility, and toileting. The physician orders dated 3/1/25 - 3/12/25 directed to transfer with extensive assist of 2. The nurse's note dated 3/1/25 - 3/12/25 failed to reflect documentation for 3/4/25 on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. Review of the nurse aide's late loss ADL report dated 3/1/20 - 3/12/25 failed to reflect documentation for 3/4/25 on the 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. Review of the nurse aide's point of care ADL category report dated 3/1/25 - 3/12/25 failed to reflect documentation for 3/4/25 on the 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift. Review of the concern/complaint form dated 3/5/25 identified Resident #9's representative had concerns regarding Resident #9 being put to bed late and no one answering his/her call light. The investigation identified NA #7 was coached because she did not put Resident #9 to bed in a timely manner. NA #7 was in-service on putting residents to bed and answering call lights in a timely manner. A discussion with the 3:00 PM - 11:00 PM shift nursing staff regarding putting residents to bed in a timely manner. The resident representative was satisfied with the resolution. An e-mail statement by the resident representative dated 3/5/25 at 2:26 PM identified Resident #9 told him/her that he/she had the worst night. Apparently, nobody put Resident #9 to bed until midnight and fully clothed. The night nurse had finally answered Resident #9 call light and explained that there was nobody to help him/her for another half an hour. Resident #9 indicated he/she did not get much sleep. Resident #9 indicated he/she hates going to bed at night because he/she never knows who's going to be assigned to him/her and what type of care they will provide. The resident representative indicated it all goes back to the shortage of staffing and resident not getting care. The resident representative indicated it is a travesty. During the Resident Council meeting on 3/10/25 at 12:30 PM Resident #9 identified the night (3/4/25) the president gave his speech he/she was put back to bed at midnight. Interview with the DNS on 3/10/25 at 1:15 PM identified was aware of the issue. The DNS indicated she was notified via an e-mail on 3/5/25 at 2:26 PM from the resident representative. The DNS indicated a concern/complaint form was initiated and an investigation was conducted. The DNS indicated the investigation concluded that the nurse aide that was assigned to Resident #9 failed to provide care to the resident on 3/4/25 on the 3:00 PM - 11:00 PM shift. The DNS identified NA #7 indicated she was not aware that Resident #9 was on her assignment, and she did not provide care to the resident. Interview with Resident #9 on 3/10/25 at 1:40 PM identified the night (3/4/25 on the 3:00 PM - 11:00 PM shift) the president gave his speech was the night the nurse aide did not put him/her to bed. Resident #9 indicated he/she rang the call light, and no one answered. Resident #9 indicated he/she was put to bed at midnight, and he/she was very upset. Resident #9 indicated he/she notified his/her representative of the issue. Resident #9 indicated he/she likes to go to bed after supper around 7:00 PM and no later than 8:00 PM. (Resident #9 was put to bed 4 hours later). Interview with the DNS on 3/18/25 at 9:10 AM identified the expectation of the facility is that all nurse aides read their assignment thoroughly and provide resident care in a timely manner. The DNS indicated NA #7 should have put Resident #9 to bed in a timely manner. The DNS indicated all nursing staff on the 3:00 PM - 11:00 PM shift were in-service. Interview with NA #7 on 3/19/25 at 1:25 PM identified she has been employed by the facility since 9/2024. NA #7 indicated she works on the 3:00 PM - 11:00 PM shift and she is a float. NA #7 indicated she does not remember if Resident #9 was on her assignment. NA #7 indicated if she did not put Resident #9 to bed it was a mistake. NA #7 indicated she did not provide any care to Resident #9. Although attempted, an interview with NA #1, NA #8, NA #10, LPN #6, and RN #10 was not obtained. Review of the facility Activities of Daily Living (ADL) policy identified residents will receive services to optimize their level of independence with activities of daily living and the assistance they need to complete activities of daily living. The resident will receive assistance daily with hygiene, dressing, bathing, feeding, transfer, ambulation, and elimination as necessary. Resident are encouraged to make choices regarding their care including the timing of care and choice of clothing and activities. Review of the facility Resident's [NAME] of Rights identified you have the right to be treated equally with other residents in receiving care and services, and regarding transfer and discharge, regardless of the source of payment for your care. 2. Resident #336's diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, atrial fibrillation, and heart failure. The Nursing admission assessment/observation dated 3/7/25 identified Resident #336 was alert and oriented to person, place and time, had no impairment to upper and lower extremities and utilized a walker for mobility. The care plan dated 3/7/25 identified Resident #336 had potential for ADL function compromise with interventions that included resident was independent with meal set-up. The physician's order dated 3/7/25 directed regular diet with thin liquids. Observation on 3/10/25 at 12:56 PM identified Resident #336 was seated in his/her wheelchair with the overbed table positioned in front of him/her. On top of the overbed table was the lunch tray which contained a plate with a sandwich made with lettuce and bacon on tossed bread, a cup of hot water, a small carton of milk, small container with yellow-orange colored fruit, unopened tea bag, sugar packets, glass with yellow liquid, utensils, and napkins. On the resident's meal ticket, it indicated coffee, milk, no cheese, no onion, ginger ale zero, and BLT (bacon, lettuce and tomato) with mayo. Resident #336 indicated that he/she was unable to eat the sandwich provided as it did not have the tomato nor the mayo which he/she had specifically requested. Resident #336 continued to identify that his/her meal trays have been wrong since being admitted to the facility and has made them aware. She further noted that they conveyed they were going to ensure he/she would receive what she had ordered moving forward. Interview with the Director of Dietary Services and the Dietician on 3/10/25 at 1:07 PM identified that there were no tomatoes on the sandwich as they did not receive any tomatoes on Friday's delivery. The Dietician identified she had spoken to the resident in the morning to discuss the menu as there was no chef salad and he/she then selected a BLT sandwich and coffee as he/she reported not wanting to have tea. She identified that this was communicated on the meal ticket and to the kitchen. The Director of the Dietary services identified that it was the kitchen staff who were responsible for placing the coffee, tea and beverages on the trays and to ensure that resident have the items they select on their meal tray. Interview with [NAME] #1 on 3/14/25 at 9:25 AM identified she had prepared the sandwich for the resident on that day and there were no tomatoes and that she had placed the mayo on the sandwich but moving forward the mayo will be placed on the side. Interview with the Director of Dietary Services on 3/18/25 at 9:15 AM identified he was not aware that there were no tomatoes and if he did, he would have gone to the store or informed the residents they had no tomatoes. He further identified that the BLT was an alternative menu and was not on the regular menu for the day. He identified that everyone on the tray line is responsible for checking and ensuring that the items selected by the residents are on their tray prior to leaving the kitchen. The Director of Dietary Services identified he did not see the mayo on the sandwich but moving forward that the mayonnaise will be placed on the side for the resident to add. He also identified that residents should get the menu items they select on their meal ticket and staff will be in-service as such. Review of the Menus policy identified that menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Review of the Dietary Notice policy identified when resident food/fluid preferences are identified by the staff, a dietary notice should be completed allowing communication to the kitchen of the resident's choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews for one of two sampled residents (Resident #335) reviewed for advanced directives, the facility failed to ensure consents were obtained regarding the resident's wishes regarding advance directives and decisions related to cardiopulmonary code status from the resident/responsible party. The findings include: Resident #335 was admitted to the facility in March/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and cellulitis of the left lower limb. The admission MDS assessment dated [DATE] identified Resident #335 was moderately impaired cognition, required maximal assistance with dressing, toileting hygiene and bed mobility. The physician's order dated [DATE] directed full code (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). The care plan dated [DATE] identified Resident #335 had chosen to be a full code with interventions that included the resident or responsible party will notify social service if choses to change code status. Review of Resident #335's physical chart and the electronic clinical record system both failed to identify a signed Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form signed by the resident/resident representative indicating the code status of Full Code was completed. Interview with the Charge Nurse (RN #5) on [DATE] at 11:20 AM identified that if Resident #335 had a life-threatening emergency where it would be necessary to provide CPR or withhold CPR, she would look in the physical chart under the advance directive tab as this is the most accurate place than the physician's order to determine the resident's code status. RN #5 reviewed the physical chart and noted Resident #335 did not have a completed Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form signed by the resident/resident representative. RN #5 identified the Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form should be completed on admission and based on what the resident/resident representative selected the physician's order would then be written. Subsequent to surveyor's inquiry, an Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form for Resident #335 was completed and signed by the resident on [DATE] indicating a code status of do not resuscitate (DNR) and do not intubate. Interview with the Nursing Supervisor (RN #8) who was the admitting nurse on [DATE] at 9:32 AM identified the advance directive form was not completed at the time of admission. RN #8 identified that Resident #335 was capable of completing the advance directive paperwork but when she went to the resident to sign the form, he/she was asleep. She added that she then utilized the code status written on the hospital discharge paperwork to determine what the code status was until the resident/responsible party signed the form. RN #8 identified the hospital discharge code status is often used when the resident is unable to complete the form, and the facility is unable to reach the responsible party. RN #8 identified on that evening she had received a total of three admissions and had passed on in report that Resident #335 advance directive form was not completed and for the next shift to follow-up. Review of the Advance Directives policy and procedures identified Advance Directive are discussed with the resident and/or primary decision maker by a licensed nurse at the time of admission. The policy further identified that the resident and/or primary decision maker will be asked to sign the appropriate form according to his/her wishes which will be maintained in the clinical record and the physician will then sign the Advance Directive form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility documentation, review of facility policy/procedure and interviews for one of two sampled residents (Resident #62) reviewed for Pre-admission Screening and Record Review (PASRR), the facility failed to ensure that a Level 2 determination was completed when the 30-day approval stay expired. The findings include: Resident #62 was admitted to the facility in January/2025 and had diagnoses that included anxiety disorder, type 2 diabetes mellitus, and squamous cell carcinoma The admission MDS assessment dated [DATE] identified Resident #62 was cognitively intact, independent with personal hygiene, and was dependent on care with toileting hygiene, lower body dressing, and transfers. Review of the PASRR screen level 1 dated [DATE] identified Resident #62 was approved for 30 days. The Psychiatric APRN note dated [DATE] identified Resident #62 has a history of bipolar disorder. Interview with the Social Worker (SW) on [DATE] at 12:20 PM identified she is responsible for submitting the request for PASRR screens to the PASRR agency. She further identified Resident #62 was approved for a 30 day stay which ended on [DATE] but she had not requested for a PASRR screen Level 2 (rescreen) because the approved time expired on [DATE]. The SW identified that she submitted the request for the screen on [DATE], after the request was made by the surveyor for the information. She added that the resident stayed beyond the 30 days (discharged [DATE]) and had a diagnosis of bipolar so a level 2 PASRR request should have been submitted prior to the expiration date. She identified she was the only Social Worker in the building and had expressed to both the DNS and Administrator that she was behind and needed some assistance. Interview with the DNS and the Administrator on [DATE] at 1:18 PM identified the social worker was responsible for submitting request for PASRR. They both identified, they were only aware that she was behind with MDS assessment and needed assistance, which they provided. However, they were unaware that she needed any other assistance or was behind in any other areas of her work. Review of the Pre-admission Screening and Resident Review (PASRR) policy and procedure identifies a level of Care are also required to determine the medical necessity for individuals continued stay at a Skilled Nursing facility. In addition, if a resident is admitted with a short-term level 1 or level of care add them to facility PASRR/Ascend Smart sheet tracker and ensure to place a due date for 10 days prior to expiration date. The policy and procedure further identified that a level of care request for continued approval must be submitted no later than 10 days prior to current approval expiration, and up to 15 days prior to current level of care approval expiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #62) reviewed for unnecessary medication the facility failed to ensure that physician's orders were implemented and completed as prescribed by the physician and one of seven residents (Resident #335) reviewed for accidents the facility failed to ensure that medications were administered as prescribed by the physician. The findings include: 1. Resident #62's diagnoses included anxiety disorder, type 2 diabetes mellitus, and squamous cell carcinoma. The admission MDS assessment dated [DATE] identified Resident #62 was cognitively intact, independent with personal hygiene, and was dependent on care with toileting hygiene, lower body dressing, and transfers. The assessment further identified the resident utilized antipsychotic (used for managing mental health disorders) medication which the assessment noted to be of the high-risk drug classes. Review of physician orders from January/2025 through March 12, 2025, directed to administer Risperidone 1 milligrams (mg) two tablets by mouth twice daily at 9:00 AM and 9:00 PM (used to treat bipolar disorder). Review of the Medication Administration Records (MAR) from January/2025 through March/2025 identified anti-psychotic drug use and to observe closely for significant side effects: sedation, drowsiness, dry mouth, extra pyramidal reactions, postural hypotension, loss of appetite, edema and urinary retention. The physician order dated 2/2/25 directed orthostatic blood pressure (BP) monitoring once weekly on Monday on the day shift for four weeks, lying and standing or lying and sitting, if unable to stand, and to notify the provider for systolic change greater than 20 millimeters of mercury (mm Hg) and/or diastolic change greater than 10 mm Hg and to document BP readings in progress note. The Pharmacy Medication Regimen Review by the Consultant Pharmacist dated 1/20/25 identified a recommendation to consider adding an order for orthostatic blood pressure (BP) monitoring once weekly for four weeks, lying and standing or lying and sitting if unable to stand and notify MD for systolic change greater than 20 millimeters of mercury (mm Hg) and/or diastolic change greater than 10 mm Hg, which APRN #1 signed and agreed on 2/2/25. Review of the MAR from February/2025 through March 12, 2025, identified nurses initial on the date the orthostatic BP was ordered to be completed, which indicated that the order was completed. However, a review of Resident #62's clinical records failed to identify the orthostatic blood pressure that was taken as ordered by the APRN #1. Interview and record review with the Nursing Supervisor (RN #3) on 3/18/25 at 12:15 PM failed to identify the orthostatic BP readings after reviewing resident #62's nursing progress notes, vitals and MAR. RN #3 identified when the order was transcribed, the task option should have been trigger for the nurse to document the reading. She further identified the order did indicate to document the BP readings in the progress note, therefore the charge nurse should have documented the readings in his/her note as the physician's order had indicated. Interview with the Charge Nurse (RN #5) who worked on some of the Mondays when the Orthostatic BP was to be completed on 3/18/25 at 1:50 PM identified when she signs the MAR it indicates that the order was completed, or the medication was administered, or she would write a note if it was not completed. RN #5 was asked where she would document the orthostatic BP and her response was there was no place on the MAR to document the readings and if the order was inputted correctly, they would have been written there. She was then asked if orthostatic BP was taken, and she did not respond. She further identified she could not recall if she had written them in her nurse's note or in the vital section of the electronic record and kept indicating that the order was inputted incorrectly. Interview with APRN #1 on 3/18/25 at 1:20 PM identified that normally she puts in her orders into the electronic health record system and added that she did enter the orders for Resident #62 on 2/2/25. The APRN #1 identified she does not know how to place the drop down for the nurses to input the BP, hence why she added to the order that the BP reading be placed in the progress note. She added that orthostatic blood pressure monitoring was ordered as the resident was on an antipsychotic medication which could cause orthostatic changes to resident's BP. Further, she indicated that there wasn't a need to follow-up whether the orthostatic blood pressure was completed because if there was a concern with the reading the facility would have notified her as stated in the order. Interview with the DNS on 3/18/25 at 2:10 PM identified that 11-7AM shift nurse completes a 24-order check to ensure orders are inputted correctly. The DNS further identified if the charge nurse was responsible for reviewing and completing a physician's order as directed and if he/she signs it means that the order was completed so the BP should have been documented as directed. Review of the Doctor's Order policy identified that the facility would meet all current standards of nursing practice in accepting, transcribing and executing doctor's orders to ensure compliance with current standards of nursing practice a ensure the resident's needs are met. 2. Resident #335's diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and cellulitis of the left lower limb. The admission MDS assessment dated [DATE] identified Resident #335 was moderately impaired cognition, required maximal assistance with dressing, toileting hygiene and bed mobility. The care plan dated 3/10/25 identified Resident #335 had COPD related to recent acute respiratory failure and it may be hard for the resident to breathe at times with interventions that included offer to provide resident with nebulizer treatments, and if increased coughing, respiratory rate, decreased oxygen levels, trouble breathing, increased mucus production could indicate an exacerbation of the resident COPD. The physician's order dated 3/5/25 directed Trelegy Ellipta (Fluticasone-umeclidin-vilanter) 200-62-5-25 micrograms (mcg) to inhale one puff once daily at 9:00 AM (used to treat COPD). Review of the electronic Medication Administration Record (MAR) identified the following: • On 3/6/25 and 3/7/25 the medication was not administered with a note that indicated the resident was a new admission and awaiting pharmacy delivery. • On 3/8/25, 3/9/25, 3/10/25, and 3/11/25 the medication was administered • On 3/12/25 and 3/13/25 the medication was not administered with a note that indicated drug/item unavailable. Review of Resident #335 clinical records failed to identify the provider was updated regarding Trelegy medication was unavailable until 3/13/25. Interview and observation of the Medication Cart on unit with the day shift Nursing Supervisor (RN #3) and the Charge Nurse (LPN #12) on 3/12/25 at 11:30 AM failed to identify the Trelegy medication within the cart. LPN #12 identified that the medication was not there as she was unable to administer the medication in the morning. LPN #12 added she looked in the medication storage room and was unable to locate the medication. RN #3 indicated that she had spoken to the pharmacy regarding the medication to clarify the duplicate order and that the pharmacy would deliver the medication. Interview with the Pharmacist #1 on 3/14/25 at 9:28 AM identified Trelegy was not dispensed to the facility due to a duplicate warning which was clarified on 3/7/25 and due to a billing issue. However, she added that the pharmacy sent an email to the facility (usually to the DON and ADON) on 3/7/25, 3/9/25, 3/10/25, 3/11/25, and 3/12/25 for authorization to bill the facility for the medication, which the pharmacy received no response from the facility. Pharmacist #1 identified if the resident was not receiving the medication he/she could have an exacerbation of symptoms, and it would not be immediate as the medication was a long-acting inhaler. Interview with the DNS on 3/14/25 at 12:50 PM identified she had received the notification from the pharmacy regarding Resident #335 inhaler. She added that the email sent by the pharmacy was also sent to the nursing supervisor's, however, she usually prints the email and gives it to the nursing supervisor to follow-up. The DNS was unable to locate the copy of the pharmacy notification she had provided to the nursing supervisor after searching through a folder in her office where she kept her records. Interview with RN #3 on 3/14/25 at 12:19 PM identified she was unable to recall receiving any information from the pharmacy from the DNS as if she did, she would have followed up as she was looking for the medication. RN #3 added that she had called the pharmacy on 3/12/25 and discovered that the medication was not sent as it was not covered by the resident's insurance, and this would need approval from the DNS. She further added that the resident's family was notified, and they picked up the medication from the local pharmacy and brought it to the facility. RN #3 was asked if the provider was notified throughout the time-period the resident was not getting the medication, which she responded that the charge nurse was responsible for notifying the provider if the medication was unavailable. She further indicated that she then notified the provider on 3/13/25 regarding the resident not receiving the medication. Interview with the Charge Nurse (RN #6) on 3/17/25 at 10:20 AM identified she did not notify the provider as she thought the medication would have been delivered by the pharmacy to administer the medication. However, she added that the provider should have been notified as the medication was not available to administer. Interview with the Nursing Supervisor (RN #7) on 3/17/25 at 11:05 AM identified she had worked on 3/9/25 and had signed the MAR, indicating Trelegy was administered. She further identified she was unable to recall if the medication was there and had not notified the provider regarding the resident not receiving the inhaler but should have if the medication was unavailable. Review of the General Guidelines for Medication Administration policy identified if 3 consecutive doses of vital medication are withheld or not available, the physician is notified and nursing documents the notification and physician's response. The policy further identifies the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy, and interviews for two of four sampled residents (Resident #36 and #286) reviewed for pressure ulcer/injury, the facility failed to ensure weekly skin audits were completed per the physician's order. The findings include: 1. Resident #36's diagnoses included dementia, and pressure ulcers on the right and left buttock. The quarterly MDS assessment dated [DATE] identified Resident #36 had severely impaired cognition, was always incontinent of bowel and bladder and required total assistance with eating, bed mobility, toileting, dressing, and personal hygiene. Additionally, Resident #36 had one stage 4 pressure ulcer. The care plan dated 12/10/24 identified Resident #36 had a coccyx pressure ulcer. Interventions included pressure reducing mattress and cushions and provide incontinent care with barrier cream as needed. Physician's orders dated 12/19/24 directed to perform weekly body audits on shower days Tuesday 3:00 PM to 11:00 PM shift and document under skin observation section in the EMR. Review of the weekly body audits dated 12/17/24 to 3/4/25 did not reflect the body audits were completed on 12/31/24, 1/14, 2/4, 2/11, 2/18, and 2/25/25. There were 6 missing out of 12 weeks. Interview with the DNS on 3/19/25 at 11:58 AM indicated that the charge nurses are responsible for performing the weekly body audits on the resident's shower day and document in the EMR. The DNS indicated that Resident #36 was to have a weekly body audit completed and documented on Tuesdays 3:00 PM to 11:00 PM shift. Interview and clinical record review with the DNS on 3/19/25 at 12:20 PM was unable to provide documentation to reflect that the weekly body audits had been completed during that time frame. Review of the facility Body Audits identified residents will have a body audit performed weekly to ensure that skin is intact and without impairment. Body audits are scheduled to coincide with shower days. Body audits are completed by the licensed nurse assigned to that unit. Body audits are signed as done on the body audit form. Any area of skin that is not intact or is impaired will be followed up per the facility protocol. 2. Resident #286 was admitted to the facility on [DATE] with diagnoses that included zoster without complications, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, benign hyperplasia with lower urinary tract symptoms, and atopic dermatitis. A physician's order dated 12/2/24 directed to complete a body audit weekly, on Tuesday; 7:00 AM-3:00 PM. The admission MDS dated [DATE] identified Resident #286 had moderately impaired cognition, was dependent for personal and toilet hygiene, required substantial/maximal assistance rolling left to right and lying to sitting on the side of the bed, had an indwelling catheter, was frequently incontinent of bowel, and had no pressure ulcers/injuries. The APRN note dated 12/23/34 at 8:00 AM identified Resident #286 was seen for pain management status post shingles treatment and pain management was reviewed. The patient was admitted to the facility for short term rehabilitation following a recent hospitalization for fever and abdominal shingles. The review of systems identified a left buttock blister with treatment recommendations directing to cleanse the wound, apply Calcium Alginate, secure dry/clean dressing, and change daily and as needed. The care plan dated 12/30/25 identified Resident #286 had fragile skin. Interventions included handling skin with extra care, inspecting skin tears, and providing dressing and skin tear treatments as ordered. Review of the December 2024 through February 2025 weekly body audits documentation failed to identify weekly body audits were completed during the week of: 12/31/24, 1/4/25, 2/4/25, and 2/11/25. Review of the nurse's notes on 12/31/24, 1/4/25, 2/4/25, and 2/11/25 failed to identify that a body audit was completed or that Resident #286 had refused a shower or body audit. Interview and clinical record review with the RN Supervisor (RN #3) on 3/19/25 at 12:13 PM identified Resident #286 does not ambulate and is incontinent of bowel, which places him/her at risk for skin issues and has current skin conditions with treatments in place. RN #3 indicated that she was not aware that Resident #286's weekly body audits were not completed on 12/31/24, 1/4/25, 2/4/25, and 2/11/25, and she was not notified of any refusals. RN #3 identified that weekly body audits are to be completed by the charge nurse on the resident's first shower day, and she would expect to be notified if the skin audit was not completed, for any reason. Interview and clinical record review with the DNS on 3/19/25 at 12:02 PM identified that she was not aware that Resident #286 did not have documented body audits completed on 12/31/24, 1/4/25, 2/4/25, and 2/11/25. The DNS indicated that she would expect weekly skin audits to be completed on the resident's shower day, by the floor nurse, per the facility policy. Interview and clinical record review with the charge nurse (RN#5) on 3/19/25 at 12:41 PM identified that she could not recall if she was the nurse assigned to Resident #286 on 12/31/24, 1/4/25, 2/4/25, or 2/11/25, but the expectation is that body audits are completed weekly on the resident's shower day and documentation would be completed on the body audit form. RN #5 indicated that she could not recall if Resident #286 had refused any body audits, but if he/she had refused a shower or bed bath she would have documented the refusal in the chart, notified the RN Supervisor, educated the resident, and reapproached at a later time. Although attempted, an interview with the wound nurse was not obtained. The facility's Body Audit policy directs that residents will have a body audit performed weekly to ensure the skin is intact and without impairment. Body audits are scheduled to coincide with shower days by the licensed nurse assigned to that unit and body audits are signed as done on the Body/Oral Check form. r

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of facility policy/procedures and interviews for one sampled resident (Resident #24) reviewed for pressure ulcer/injury, the facility failed to ensure the bilateral hand rolls/rolled wash cloths were in place as ordered. The findings include: Resident #24's diagnoses included multiple sclerosis, deformity of the wrist, deformity of the hand and right sided weakness. The quarterly MDS assessment dated [DATE] identified Resident #24 was severely cognitively impaired, was dependent with bed mobility, transfers, bathing and personal hygiene. The care plan dated 2/1/25 identified Resident #24 was at risk for skin breakdown/redness related to bilateral hand deformities (contractures), with interventions that included the application of bilateral hand rolls or rolled wash cloths at all times. The nursing assistant (NA) care card identified left and right-hand rolls (can utilize wash cloths) to be worn at all times. Physician's orders for March 2024 directed that bilateral hand rolls and or rolled wash cloths be placed in the resident's hands, to be worn at all times. Remove for skin checks and hygiene, and check every shift, per facility policy. Observation on 3/10/25 at 10:43 AM identified Resident #24's air mattress was set at 200, and the resident had no hand rolls or rolled washcloths in place. Observation on 3/12/25 at 11:28 AM identified, Resident #24 did not have hand rolls nor rolled washcloths in place. Bilateral heel lift boots were on. Left foot observed with thick scaley like areas covering the top and side of the left foot and slightly on the lower ankle area of the left foot. Scaley skin appeared brown to dark brown in color. Observation on 3/14/25 at 9:54 AM of Resident #24 identified, there were no hand rolls or wash cloths placed for the resident as ordered by the physician. Interview on 3/14/25 at 9:58 AM with LPN #4, indicated, NA #3, had just been getting supplies ready to provide care for Resident #24, that's why the heel lift boots were off and possibly why the hand rolls were not in place. The hand rolls/splints should be worn at all times, except when providing skin care or changing them when they are soiled. The heel lift boots would be put on after care is provided as ordered by the physician. Interview on 3/14/25 at 10:03 AM with RN #3 (7-3 supervisor), indicated the supervisor was not sure why the hand rolls or splints for the resident's hands were not in place. RN #3 was unable to find or locate any hand rolls or splints for the resident in the resident's room, closet or dressers. Subsequent to surveyor inquiry, a soft pillowcase was placed by RN #3 to Resident #24's left hand. RN #3 was unable to place a rolled washcloth or rolled soft pillowcase to Resident #24's right hand, due to right hand and finger deformity and stiffness. RN #3 explained, due to the contracture, it could cause pain to the resident. RN #3 spoke to one of the Occupational Therapists, OT #1 to update him/her regarding the inability to place a rolled wash cloth to the right hand. Occupational therapy to evaluate due to inability to place the hand roll to the right hand. Interview on 3/14/25 at 10:08 AM with NA #3, indicated there were hand rolls in each hand, that were removed by NA #3 as they were soiled. NA #3 along with RN #3 attempted to place a rolled washcloth and or soft rolled pillowcase in the right hand and were unsuccessful at placing it, due to right hand contractures. NA #3 then indicated bilateral clean hand rolls would have been placed once care was provided/completed. Interview on 3/14/25 at 11:55 AM with OT #1, indicated OT had been working with Resident #24 and is very familiar with the resident. OT #1 also indicated the resident had been followed by all 3 OT's ongoing, due to bilateral hand contractures and wheelchair positioning needs. Initially, splints were utilized then carrots (carrot shaped splints) due to the ongoing bilateral hand contractures. Resident #24 occasionally resists the placement of the washcloths subsequently; the staff may have found it difficult to place the washcloths at times. This has been an ongoing issue with the staff, education has been provided to staff on how to place the washcloths. Wash cloths are utilized now, as the splints and carrots are no longer appropriate due to the worsening of the hand contractures. OT #1 placed wash cloths to both hands prior to the interview. OT #1 also indicated that he/she informed the resident prior to placing the washcloths and had no issues placing the washcloths today. Review of the Splint/Orthotics/Prosthetics policy identified the nursing staff will apply/remove the designated splint/orthotic/prosthetic device during the scheduled wear times. Also, the nursing staff should notify the rehabilitation department of any ill-fitting and or misplaced splint/device. Including, if the resident refused to wear any device, to notify the rehab department, physician and responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility policy review, and interviews for one sampled residents (Resident #51) for enteral feeding, the facility failed to ensure enteral feeding were properly labeled with date and time and discarded when appropriate in accordance to the facility policy. The findings include: Resident #51's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant hand, dysphagia, and gastrostomy. The significant change MDS assessment dated [DATE] identified Resident #51 with intact cognition, required extensive assistance with eating and had an enteral feeding tube. The physician's orders dated 2/13/25 directed to administer Jevity 1.5 calories via enteral feeding at 30 centimeters (cc) per hours in which the enteral feeding will be stop every day at 6:00 AM and resume at 10:00 AM every day. The care plan dated 2/20/25 identified Resident #51 had an enteral feeding tube to supplement food intake. Care plan interventions directed to check the placement of the enteral feeding, kept the head of bed at least 45 degree to prevent aspirations, and to provide the enteral feeding and fluid per physician orders. Observation on 3/17/25 at 9:00 AM identified Resident #51 lying in bed, with Jevity 1.5 calories with approximately 700 milliliters (ml) left in the plastic container hung in the pole with no label and tubing was hung in the pole with no cap (means tubing was exposed and not covered with cap) and not connected to the resident. Observation on 3/17/25 at 11:15 AM identified Resident #51 was sitting in the wheel chair, with Jevity 1.5 calories (same bottle) was connected to Resident #51 and the Jevity 1.5 calories bottle had a date label on 3/16/25 and with time at 8:00 PM. Interview with LPN #4 on 3/17/25 at 11:30 AM identified that she stopped and disconnected Resident #51's enteral feeding at 6:00 AM and re-started the enteral feeding at 10:00 AM per physician's order. She identified that the enteral feeding must be labeled with date, time, rate and the tubing should be re-capped when not in use to ensure the safe administration of the enteral feeding. She identified that she noted that the enteral feeding was not labeled this morning. She further identified that she labeled the enteral feeding bottle dated for 3/16/25 at 8:00 PM because she knew that it was changed the previous shift. She further identified that she should discarded the undated enteral feeding bottle and replaced with the new one when she noticed that it was not labeled. Subsequent to surveyor inquiry, LPN #4 discarded the old container of Jevity and replace with a new container. Interview with the DNS on 3/17/25 at 11:45 AM identified that the facility policy for enteral feeding was to properly label the enteral feeding with date, time, and rate for each administration. She further identified that the enteral feeding can be re-connected to the resident as long as enteral tubing was capped when not in use; otherwise, the enteral feeding should be replace when the enteral feeding was not properly label and/or when the enteral feeding cap was missing. The Enteral Feeding policy identified to check the physician's order for formula, rate, and water flushes. The policy also identified to label the formula and administration set with date, time, resident's name and discard the supplies and equipment when appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy, and interviews for one of three sampled residents (Resident #68) reviewed for pain management, the facility failed to ensure pain medication was administered in accordance with the physician's order. The findings include: Resident #68 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, malignant neoplasm of pancreas, and Myelodysplastic syndrome. The nurse's note dated [DATE] at 7:20 PM identified that Resident #68 was readmitted to the facility at 2:00 PM. Resident was alert and oriented to person, place, and time. The care plan dated [DATE] identified Resident #68 required an opioid medication to help with pain management. Interventions included providing opioid medication to manage pain and evaluate its efficacy. A physician's order dated [DATE] directed to administer Tramadol 50mg, 1 tablet by mouth, every 12 hours as needed (PRN) for pain, for 10 days. Interview with Resident #68 on [DATE] at 8:29 AM identified that he/she had an order for Tramadol to take as needed for pain, and that he/she requests it every night usually around 9:00 PM or just before going to bed. Resident #68 indicated that he/she had requested Tramadol before bed on [DATE], and a male staff member told him/her that the nurse would return with the medication, but nobody returned. Resident #68 further indicated that he/she had difficulty falling asleep and was finally given Tylenol around 3:30 AM, because he/she was done requesting the Tramadol. Resident #68 identified that he/she had 7/10 pain in the head, mouth, and ribs, which was not relieved by the Tylenol. Resident #68 indicated that the nurse did not assess his/her pain. Resident #68 further indicated that around 6:00 AM somebody communicated to him/her that the Tramadol order needed to be renewed and that was why the medication had not been available. Interview and clinical record review with RN #5 on [DATE] at 9:01 AM identified that during morning report LPN #3 identified that on [DATE], Resident #68 had requested Tramadol, but the PRN order had been completed and the order needed to be renewed, and he administered Tylenol for pain. RN #5 indicated that LPN #3 told her that he added a request to renew the Tramadol order to the APRN notification book, at the desk, and asked RN #5 to follow up on the order. Review of the clinical record identified that the Tramadol 50mg, 1 tablet by mouth, every 12 hours as needed (PRN) for pain, for 10 days order was active and had an end date of [DATE]. RN #5 identified that since the Tramadol order remained active, she would assess Resident #68's pain and offer him/her Tylenol or Tramadol, if needed. Subsequent to surveyor inquiry Tramadol 50mg was administered on [DATE] at 9:50 AM. Interview with LPN #3 on [DATE] at 9:16 AM identified that Resident #68 has chronic pain that he/she had asked for Tramadol by name but could not recall the exact time of the request because he was working on both units. LPN #3 indicated that while he did not assess his/her pain using a pain rating scale, he/she appeared to be a 2/10 based on non-verbal indicators, so he had repositioned Resident #68 and gave him/her water. LPN #3 further indicated that he saw that the PRN order for Tramadol had expired and could not be given without a provider's order. LPN #3 identified that he returned to Resident #68's room, but he/she had fallen asleep, and when he returned to check on Resident #68, he/she had identified that he/she was in more pain. LPN #3 indicated that he informed Resident #68 that the PRN Tramadol order had expired and needed to be renewed, and he administered Tylenol for pain. LPN #3 identified that he did not contact a medical provider overnight to renew the order, but he notified the RN supervisor, wrote a notification of the expired Tramadol in the APRN book, and reported off to the on-coming nurse to ensure the order got renewed. Interview with the Nursing Supervisor (RN #2) on [DATE] at 9:48 AM identified that LPN #3 notified her that Resident 68's Tramadol order had expired, and that LPN #3 had medicated Resident #68 with Tylenol. RN #2 indicated that LPN #3 had put the renewal request in the APRN book, which she felt was appropriate because usually Tylenol is offered first for pain, and she was not notified that Resident #68 had unrelieved pain after the Tylenol. Interview with APRN #1 on [DATE] at 10:43 AM identified that Resident #68 has chronic pain, and she would have expected a pain assessment to have been completed when Resident #68 requested the Tramadol, and if he/she reported 7/10 pain, she would have expected the on-call physician to have been notified to reinstate the Tramadol order, if it had expired. Interview and clinical record review with the DNS on [DATE] at 12:26 PM failed to identify that the Tramadol order had expired. The DNS indicated that, had the Tramadol been expired, she would have expected Resident #68's pain to be assessed and if he/she reported 7/10 pain the doctor should have been contacted to renew the order so the Tramadol could have been given that night. The facility's Pain Management policy directs general treatment principles to include: ask about pain regularly, believe the resident's and family's reports of pain and what relieves it, choose appropriate pain control options, deliver interventions in a timely, logical, and coordinated fashion, and empower patients and their families.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy, and interviews for one of five sampled residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure target behavior monitoring was completed, per the physician's order. The findings include: Resident #65 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety disorder, dementia in other diseases classified elsewhere, with other behavioral disturbances, and repeated falls. A physician's order dated 11/28/23 directed to administer Quetiapine (an antipsychotic medication) 50mg by mouth, at bedtime. A physician's order dated 9/13/24 directed to monitor target behaviors: hallucinations/aggression, every day, evening, and night shift. The annual MDS dated [DATE] identified Resident #65 had severely impaired cognition, had no changes in behavior status, care rejection, or wandering compared to the prior assessment, was receiving an antipsychotic on a routine basis, and a gradual dose reduction (GDR) had been documented by a physician as clinically contraindicated. The care plan dated 12/18/24 identified Resident #65 was prescribed an antipsychotic medication. Interventions included observing resident's interactions with others for appropriateness and observing the resident's mood and behavior. January 2025 through March 2025 Medication Administration Records (MAR) failed to identify documentation for target behavior monitoring. January 2025 through March 2025 Treatment Administration Records (TAR) failed to identify documentation for target behavior monitoring. Nurse's notes dated January 2025 through March 2025 failed to identify documentation for target behavior monitoring, every day, evening, and night shift. The Psychiatric APRN note dated 11/28/25 identified upon regular follow-up that staff denied behavioral disturbances, for Resident #65, since medication management and current medications. Resident was eating and sleeping well, with no signs and symptoms of delusions and hallucinations; will continue to monitor closely. Interview and clinical record review with the RN Supervisor, also working as the floor nurse (RN #3) on 3/19/25 at 10:12 AM identified that while there was an order to monitor Resident #65's target behaviors, the field to document the behaviors was not showing up on the TAR, due to the way the order was entered. RN #3 indicated that she did not see documentation for behavior monitoring in Resident #65's clinical record, but she would expect to see documentation for target behavior monitoring, per the physician's order, and any new behaviors exhibited by the resident would be documented under the progress notes and a notification would be made to the psychiatric provider. RN #3 identified target behavior monitoring was the responsibility of the floor nurse, and while she was not aware that there had not been target behavior monitoring documentation, she would have been expected to have been notified if the nurse was having an issue documenting his or her observations. RN #3 further indicated that she would modify the order to ensure target behavior monitoring documentation could be completed in the TAR. Interview with the Psychiatric APRN (APRN #3) on 3/19/25 at10:59 AM identified that Resident #65 takes an antipsychotic medication for agitation, delusions, and hallucinations, and that he/she has been stable at baseline for these behaviors, for some time. APRN #3 indicated that when she comes in to speak with Resident #65, she will also speak to the nurse aides and nurses on the floor to assess if any increased behaviors have been reported, but she would also expect target behavior monitoring to be completed per the physician's order, to ensure the resident's on-going treatment remains effective. Interview and clinical record review with the DNS on 3/19/25 at 11:37 AM identified that she would expect target behavior monitoring to be completed every shift, by the floor nurse, per the physician's order. The DNS indicated that the original physician's order for target behavior monitoring was placed on 9/13/24, but she did not see documentation of the behavior monitoring in accordance with the order. The DNS further indicated that any of the licensed nurses could have modified the order to create a documentation field for target behavior monitoring, or they could have documented in the progress notes. The Medication Management policy directs that when a resident receives a new medication the dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. When a resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved and/or non-pharmacological interventions have been effective in reducing the symptoms, the resident is evaluated for the appropriateness of a taper or GDR. For antipsychotics, if a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility should attempt a GDR in two separate quarters within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. GDR is considered clinically contraindicated if target symptoms returned or worsened after the most recent attempt at a GDR and the physician documents the clinical rationale for why any additional attempted dose reductions would likely impair the resident's function or the continued use is in accordance with relevant current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records, review of facility policy, and interviews for two of three sampled residents (Resident #15 and #68) reviewed for pain management, the facility failed to ensure accurate administration documentation of pain medication. The findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included lower back pain, pain in the left upper arm, and dementia. The care plan dated 2/7/25 identified Resident #15 had activities of daily living (ADL) function compromised related to dementia, weakness, and advanced age. Interventions included referring to Resident #15's 24-hour positioning plan and to encourage him/her to do as much as possible before offering assistance. The quarterly MDS dated [DATE] identified Resident #15 had moderately impaired cognition, had pain with occasional frequency with a numeric rating scale of 3/10, and was not on a scheduled pain medication regimen. A physician's order dated 1/20/25 directed to administer Acetaminophen 325mg, administer 2 tablets by mouth, every 6 hours, as needed (PRN) for pain/fever. A physician's order dated 3/4/25 directed to administer Acetaminophen 325mg, administer 2 tablets by mouth, twice daily at 9:00 AM and 5:00 PM. The 24-Hour Shift Report dated 3/1/25 identified that Resident #15 was given PRN APAP (Acetaminophen) with positive effects, on the 7:00 AM-3:00 PM shift. The 24-Hour Shift Report dated 3/13/25 identified that Resident #15 was given Tylenol (Acetaminophen) at 12:30 AM, crushed with applesauce and tolerated well. The 24-Hour Shift Report dated 3/17/25 identified that Resident #15 was given PRN Tylenol 650mg. The March 2025 Medication Administration Record (MAR) failed to identify documentation that PRN Acetaminophen was administered on 3/1/25, 3/13/25, and 3/17/25. Interview and clinical record review with LPN #8 on 3/17/25 at 11:20 AM identified that the nurse aide had notified her that Resident #15 had requested Tylenol for arm pain, but she was unable to administer Tylenol because he/she had just received her scheduled Tylenol dose, and that, during morning report, LPN #10 had told her that she had given Resident #15 a PRN dose not too long ago around 5:00 AM or 6:00 AM. Review of the MAR failed to identify that the PRN dose was administered. LPN #8 indicated that she would expect medication administration times to be documented in the MAR to ensure resident safety and appropriate administration times. LPN #8 further indicated that she would follow up with Resident #15 to assess his/her pain. Interview with LPN #10 on 3/18/25 at 9:29 AM identified that she had worked at the facility on 3/17/25 from 11:00 PM-7:00 AM, and that she had medicated Resident #15 with Tylenol around 6:00 AM and thought that she had signed the medication as given in the MAR. LPN #10 indicated that she was aware that the expectation was to sign a medication as given right away but she must have forgotten. LPN #10 further indicated that she usually always signs out PRN medications on the MAR and also documents on the 24-hour report. Interview and clinical record review with the DNS on 3/19/25 at 11:37 AM failed to identify documentation in Resident #15's MAR that corresponded with the documentation on the 24-Hour Report that Acetaminophen was given on 3/1, 3/13, and 3/17/25. The DNS indicated that she would expect that any order completed, and medication given to a resident would be signed off in the MAR and only documenting in the 24-hour report was not the expectation; documentation needed to be completed in the resident's clinical record. The facility's General Guidelines for Medication Administration policy directs the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. When PRN medications are administered, the following documentation is provided: date and time of the administration, dose, complaints or symptoms for which the medication was given, results achieved from giving the dose, and the time the results were noted. 2. Resident #68 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, malignant neoplasm of pancreas, and Myelodysplastic syndrome. The nurse's note dated 3/6/25 at 7:20 PM identified that Resident #68 was readmitted to the facility at 2:00 PM. Resident was alert and oriented to person, place, and time. A physician's order dated 3/6/25 directed to administer Tramadol 50mg, 1 tablet by mouth, every 12 hours as needed (PRN) for pain, for 10 days. The care plan dated 3/7/25 identified Resident #68 required an opioid medication to help with pain management. Interventions included providing opioid medication to manage pain and evaluate its efficacy. Interview with Resident #68 on 3/12/25 at 8:29 AM identified that he/she has an order for Tramadol to take as needed for pain, and that he/she requests it every night around 9:00 PM or just before going to bed. Resident #68 indicated that he/she was told that Tramadol was unavailable last night because the order needed to be renewed and that he/she had been in pain throughout the night. The Control Substance Disposition Record (accountability record) identified that one Tramadol 50mg tablet was dispensed on the following dates in March of 2025: 3/6 at 9:00 PM, 3/7 at 9:00 PM, 3/8 at 9:00 PM, 3/9 at 9:00 PM, 3/10 at 9:00 PM, 3/12 at 9:15 AM and 9:45 PM, 3/13 10:00 PM, 3/14 at 9:00 PM, 3/15 at 9:00 PM, 3/16 at 9:30 PM, and 3/17 at 11:15 PM. The March 2025 Medication Administration Record (MAR) failed to identify that Tramadol was administered to Resident #68 on 3/6, 3/7, 3/10, 3/15, and 3/17/25. The Progress Notes dated 3/6/25 through 3/17/25 failed to identify documentation that Tramadol was administered to Resident #68 on 3/6, 3/7, 3/10, 3/15, and 3/17/25. Interview and clinical record review with RN #5 on 3/19/25 at 11:14 AM identified that it was her initials on Resident #68's Control Substance Disposition Record for the removal of Tramadol on 3/6, 3/7, and 3/17/25 but failed to document that the medication was administered on the MAR. RN #5 indicated that she was aware of the importance to document on both the disposition record and MAR, and she also tries to write a progress note identifying the reason the medication was given. RN #5 further indicated that sometimes she works double shifts or works on multiple units, and may get pulled away to assist another resident before she has the time to circle back and sign the medication off in the MAR. Interview and clinical record review on 3/17/25 at 12:26 PM with the DNS failed to identify that the Tramadol that was signed off on the Control Substance Disposition Record on 3/6, 3/7, 3/10, 3/15, and 3/17/25 was also signed off as administered in Resident #68's MAR. The DNS identified that it was her expectation that when a controlled substance is removed and signed off on the Control Substance Disposition Record it must also be signed off, as administered, in the resident's MAR. The DNS indicated that the nurse administering the medication would be responsible for both signoffs, and re-education would be provided to licensed nursing staff. The facility's Controlled Substances policy directs the provider pharmacy shall identify medications as controlled medications either as a part of the label, or by sending a controlled medication countdown sheet with the medication, or both. Accurate inventory of all controlled medications is maintained at all times. When a controlled substance is administered, the licensed nursing personnel administering the medication immediately enters the following information on the accountability record and the MAR: date and time of administration (MAR and Accountability Record), amount administered (Accountability Record), remaining quantity (Accountability Record), signature of the nursing personnel administering the dose (Accountability Record), and the initials of the nurse administering the dose, completed after the medication has been administered (MAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Resident #33 and Resident #336) observed with medications at the bedside, the facility failed to ensure that medications were administered according to acceptable standards of practice and the facility failed to ensure that medication was not left at the resident's bedside for a resident who is without an order or assessment for self-administration. The findings include: 1. Resident #33's diagnoses included chronic diastolic congestive heart failure, hypoxemia, and acute cough. The quarterly MDS assessment dated [DATE] identified Resident #33 had severe cognitive impairment, required moderate assistance with toileting hygiene, and supervision or touch assistance with dressing and personal hygiene. The assessment further identified the resident uses a walker with supervision for ambulation. The care plan dated 3/13/25 identified Resident #33 had a memory/recall problem related to low BIMS (brief Interview for Mental Status) score with interventions that included ensure resident's areas are free of hazards and encourage assistive devices available and in good condition. The physician's order dated 2/13/25 directed medications may not be self-administered. The physician's order dated 3/6/25 directed Guaifenesin liquid 100 milligram/5mililiter (mg/ml) to give 10 ml by mouth four times daily at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. Observation on 3/10/25 at 10:53 AM identified Resident #33 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was a medicine cup containing approximately 15ml of a reddish liquid and other personal items in which resident indicated the nurse left the medicine cup for him/her to take. Observation on 3/10/25 at 11:12 AM with the Charge Nurse (RN #5) identified Resident #33 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was a medicine cup containing 15ml of a reddish liquid and other personal items. RN #5 identified the liquid in the medication cup as the resident's cough medicine. RN #5 then removed the medicine cup and brought it to the medication cart to discard. Interview with RN #5 on 3/10/25 at 11:12 AM identified she brought the resident's medication in the room when the resident had to use the bathroom and was to return to check if the resident had taken the medication, but she did not return. RN #5 identified Resident #33 did not have a medication self-administration order and she should not have left the medication for the resident to take without being present. RN #5 signed off in the Medication Administration Record indicating that she had administered the medication to Resident #33 but should have only signed when the resident had taken the medication. She added that she then changed the MAR subsequent to the surveyor's inquiry. Interview with the Nursing Supervisor (RN #3) on 3/12/25 at 11:37 AM identified the nurse should stay with the resident when administering medication for safety and to ensure they took the medication. Interview with the DNS on 3/14/25 at 12:50 PM identified the nurse should watch the resident take the medication and staff was provided education. Review of the General Guidelines for Medication Administration policy identified the resident is always observed after administration to ensure that the dose was completely ingested. The policy further identifies that residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medication. 2. Resident #336's diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, atrial fibrillation, and heart failure. The Nursing admission assessment/observation dated 3/7/25 identified Resident #336 was alert and oriented to person, place and time, had no impairment to upper and lower extremities and utilized a walker for mobility. The care plan dated 3/11/25 identified Resident #336 had altered respiratory status related to pneumonia complicated by COPD with interventions that included to administer mediation/antibiotic as ordered and to observe alterations in respiratory status and report abnormalities to MD. The physician's order dated 3/7/25 directed Albuterol Sulfate HFA aerosol inhaler 90 microgram (mcg)/actuation to inhale 2 puffs into lungs every four hours as needed (PRN) for COPD. The physician's order dated 3/7/25 directed medications may not be self-administered. Observation on 3/10/25 at 10:13 AM identified Resident #336 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was an opened medication box containing albuterol sulfate HFA aerosol inhaler 90 microgram (mcg)/actuation, television remote, water pitcher, and other personal items. Resident #336 identified the nurse left the medication. Review of the Medication Administration Record from 3/7/25 to 3/11/25 failed to identify that the medication was administered. Observation on 3/10/25 at 11:51 AM with the Charge Nurse (RN #6) identified Resident #336 was out bed and seated in the wheelchair with the overbed table positioned directly in front of the resident, and on top of the overbed table was an opened medication box containing albuterol sulfate HFA aerosol inhaler 90 microgram (mcg)/actuation, water pitcher, and other personal items as resident identified that he/she had taken the medication. Interview with RN #6 on 3/10/25 at 11:52 AM identified the resident did have a PRN physician's order for the medication but the medication should not have been left in the resident's room. She also identified that the medication was dispensed from the facility's pharmacy. RN #6 further identified that Resident #336 did not have an order for medication self-administration, and she had not administered this medication to the resident. Interview with the Nursing Supervisor (RN #3) on 3/12/24 at 11:37 AM identified that if a resident wanted to administer their medication a self-administration assessment would need to be completed, and the medication would be stored in the medication cart. Review of the General Guidelines for Medication Administration policy identified the resident is always observed after administration to ensure that the dose was completely ingested. The policy further identifies that residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medication. Review of the Medication, Self-Administration and Discharge Program policy identified that an individual may self-administer medications only after the interdisciplinary team has determined that this practice is safe.

**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, the facility failed to ensure the second-floor windows contained mechanisms to prevent them from fully opening, presenting a safety hazard to residents residing on the unit (dementia unit). The findings include: Observation on 3/10/25 at 10:05 AM identified in room [ROOM NUMBER](a resident room), the window was fully opened, and did not contain a screen. The degree to which the window was opened presented a safety hazard to residents who were able to access the window. Interview with NA #2 on 3/10/25 at 10:10 AM indicated that she was providing care to a resident in that room with NA#1 and NA #1 opened the window because it was very hot in the room. Interview with NA #1 on 3/10/25 at 10:15 AM identified she had opened the window in room [ROOM NUMBER] because while providing care to the resident she had gotten hot. NA #1 indicated that she was aware that windows are only supposed to open a little but that for at least a month the window could be opened fully. NA #1 indicated that she opens the windows because it is hot on the second floor, and she needs the cool air. She further identified that some residents ask for their windows to be opened and indicated that she had not put it in the maintenance book for repair nor had she informed anyone. Interview with the Director of Maintenance (DOM) on 3/10/25 at 10:27 AM indicated that it was maintenance's responsibility to make sure the windows have a safety device on them to prevent the windows from opening more than 6 inches. The DOM indicated that he does not make rounds to check that the windows have the safety device he relies on the nursing staff to report it in the maintenance book. The DOM measured the open window in room [ROOM NUMBER] and it measured 17 inches high by 33 inches wide and the windowsill from the floor to the base of the window was 30.5 inches. The DOM indicated that he was not aware that this window did not have the safety device, and no one had put it in the maintenance book. The DOM indicated that the window never should be able to open that much especially on the second floor. The DOM indicated that he would have it fixed right away. The DOM indicated that most windows do not have screens, and he does not think they need them. Tour with the Director of Maintenance on 3/10/25 at 10:50 AM on the secured dementia unit on the second floor identified 8 (room [ROOM NUMBER], 253, 257, 258, 259, 260, 263, and 269) out of 17 rooms had windows that did not have the safety device to prevent the windows from fully opening. The DOM measurements of the open windows were from 17 to 22 inches high by 33 inches wide. Below the windows on the outside of the buildings contained grass or a concrete walkway. The DOM indicated that the windows had air conditioners in them that had been removed. Interview with the Administrator, DOM, DNS, and the [NAME] President of Clinical Services on 3/10/25 indicated that the second floor contained 23 residents. The Administrator identified the windows were not to open more than a maximum of 6 inches and the maintenance director was responsible for periodically checking the windows to make sure there was a safety device on them. The Administrator indicated that there was no documentation of the periodical checks. The VP of Clinical Services indicated that maintenance will immediately go around and repair the 8 windows that were identified on the second floor and then audit all the rest of the windows in the facility on first and second floor. The VP of Clinical Services indicated that nursing will immediately start education with staff regarding the windows must have a safety device to prevent windows from opening more than 6 inches and if a safety device was missing to remove the residents from the room for safety and call maintenance immediately to repair it. The VP of Clinical Services indicated that if maintenance was not in the facility residents would be removed and someone would stay in that room until maintenance came in and repaired the window. The VP of Clinical Services indicated that since the beginning of October when the air conditioners were removed there have not been any residents that have attempted to exit the windows that she was aware of. The VP of Clinical Services identified that she was aware that all residents on the second floor were at risk of an accident or incident occurring. Interview with LPN #1 on 3/10/25 at 12:10 PM indicated there were 23 residents on the secured unit and there were 7 residents that ambulate independently on the secure dementia unit and there were 3 residents that ambulate independently with supervision but do get up unassisted at times. Interview with the Director of Maintenance on 3/10/25 at 1:30 PM identified when the air conditioners were removed by his maintenance guys in the first 2 weeks of October, they did not install the safety devices to the windows. The DOM indicated that he should have informed them to do that and then checked the windows after removal to make sure there was a safety device installed but he was his fault he did not do that. Interview with the Administrator on 3/10/25 at 1:40 PM identified that all windows in resident areas cannot open more than a maximum of 6 inches. The Administrator indicated that he was not aware of the issue regarding the windows being able to open fully on the second floor. The Administrator identified there was not a system in place for routine checking and monitoring of the windows for the safety devices in the facility unless it was reported by nursing to maintenance. Interview with VP of Clinical Services on 3/10/25 at 1:50 PM identified that the 8 windows that were identified as not secured was repaired and the education has started. Review of the Window Opening Policy identified windows within the residents' accessible areas shall not be allowed to open more than 6 inches at any time. This limitation is in place to ensure safety, prevent unauthorized access, and maintain proper building conditions. When air conditioning units are removal from windows, appropriate stopping devices (window stoppers or locks) must be installed security and prevent the window from being inadvertently opened beyond the safe limit. Prior to the winter season, it is required that when air conditioning units are removed, the stopper or screw used to secure the window should be replaced if it has been removed during the unit's installation or removal. The stopper or screw must be inspected for wear or damage, and if needed, replaced to ensure propre window security. A training and awareness program will be provided to educate all relevant personnel on the importance of this procedure and the proper installation of the stopper or screw to maintain window security during colder months. This will be monitored and checked monthly and as needed by maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy, and interviews, the facility failed to complete license nurses and nurse aides education and competencies related to intravenous therapy (IV) therapy and the facility failed to ensure licensed nurses had intravenous therapy (IV) certificate. The findings included: 1. Review of the State Agency documentation identified the facility has a licensed bed capacity of 217 and an IV therapy program. Review of the census daily report dated 3/10/25 identified the facility census was 83 residents in the facility. A request was made on 3/17/25 for documentation of the annual licensed nurses and nurse aides IV competencies for 2023. The facility failed to provide any documentation regarding the completion of 2023 annual competencies. Review of the nursing IV competencies provided for 2024 identified only 15 of 29 licensed nurses received competency training in intravenous therapy (IV), and 17 of 43 nurse aides received competency training in intravenous therapy (IV). Although requested, RN #1 (Infection Preventionist) and LPN #9 failed to provide documentation that IV therapy education/training/in-service and competencies was provided to the license nurse and nurse aides in 2023 and 2024. Interview with RN #1 on 3/17/25 at 11:34 AM identified she has been employed by the facility since 3/2024 as the Infection Preventionist (IP), staff development, and the wound nurse. RN #1 indicated she could not locate IV competencies completed in 2023. RN #1 indicated she was unable to find any more documentation related to IV competencies for 2024. RN #1 indicated she was responsible for the education, in-service and competencies of the IV therapy to the nursing staff for the year 2024. Interview with the DNS on 3/18/25 at 8:00 AM identified she was not aware that all the licensed nurses and nurse aides did not have yearly education, in-service, and competencies of IV therapy for the year 2024. The DNS indicated it was the responsibility of RN #1 to provide the nursing staff with education, in-service and competency of IV therapy. Although requested, a facility policy was not provided. Review of the facility assessment dated [DATE] identified staff competencies that are necessary to provide the level and types of care needed for the resident population. Establishing a peripheral venous route, central line dressing changes, and intermittent infusion via peripherally inserted catheter. Annual competencies/training, and in-service. Clinical departments are encouraged to utilize continuing education. 2. Review of the licensed nurses IV certificate log failed to reflect documentation (IV certificate) for 11 of 29 licensed nurses had IV certificates. Review of the State Agency documentation identified the facility has a licensed bed capacity of 217 and an IV therapy program. Review of the census daily report dated 3/10/25 identified the facility census was 83 residents in the facility. A request was made on 3/17/25 for documentation of IV certificate for licensed nurses. The facility failed to provide 11 of 29 IV certificates. Interview and facility documentation review with RN #1 on 3/17/25 at 11:34 AM identified she was not aware of the issue. RN #1 indicated she was not aware that 11 of 29 licensed nurses do not have an IV certificate. RN #1 indicated she will contact the pharmacy IV department and schedule an IV education and certificate class. Interview with the DNS on 3/18/25 at 8:10 AM identified she was not aware of the issue and that RN #1 was responsible to oversee the staff development position and review the licensed nurse's IV certificates. The DNS indicated the facility will address the issue. Although requested, a facility policy was not provided. Review of the facility assessment dated [DATE] identified staff competencies that are necessary to provide the level and types of care needed for the resident population. Establishing a peripheral venous route, central line dressing changes, and intermittent infusion via peripherally inserted catheter. Annual competencies/training, and in-service. Clinical departments are encouraged to utilize continuing education.

Based on observations, review of facility documentation, review of facility policy, and interviews for four of four medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include: Based on observations, review of facility documentation, facility policy, and interviews for 4 of 4 medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include: Observations on 3/18/25 between 1:44 PM - 2:00 PM of the medication carts with LPN #9 (IP from another facility) identified the February 2025 and March 2025 narcotic drug change of shift audit sheet (the narcotic count that the on-coming and off-going nurses complete to ensure the narcotic medications are counted) were missing signatures on multiple dates on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift on the following units: The [NAME] 1 unit was missing 21 signatures for the month of February 2025, and 9 signatures for the month of March 1, 2025 - March 18, 2025. The Aspen unit was missing 10 signatures for the month of March 1, 2025 - March 18, 2025. The [NAME] 2 unit was missing 21 signatures for the month of February 2025, and 11 signatures for the month of March 1, 2025 - March 18, 2025. The Redwood unit was missing 6 signatures for the month of March 1, 2025 - March 18, 2025. Interview with LPN #2 on 3/18/25 at 1:50 PM identified she is an agency nurse. LPN #2 indicated would you like for me to sign the narcotic drug change of shift audit sheet now. Interview with RN #3 on 3/18/25 at 1:53 PM identified all nurses are responsible to sign the narcotic drug change of shift audit sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with LPN #4 on 3/18/25 at 1:55 PM identified it was the responsibility of all the nurses to sign the narcotic count sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with LPN #1 on 3/18/25 at 2:00 PM identified all nurses are responsible to sign the narcotic count sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with the DNS on 3/19/25 at 8:30 AM identified she was aware of the issue, and she has been educating the licenses nurses regarding signing the narcotic count sheet at the beginning of the shift and at the end of each shift when the controlled substance count is completed. The DNS indicated the expectation of the facility is that the on-coming and out-going nurse count the controlled substances during each shift change and sign the narcotic count sheet after completing the count. The DNS indicated that the facility would continue to educate the licensed nurses. Review of the pharmacy storage of controlled substance form identified the medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for 5 of 5 sampled residents (Resident #14, 16, 24, 56, and 73) reviewed for immunizations, the facility failed to offer and provide influenza vaccine as required and for 4 of 5 residents (Resident #12, 26, 37, and 61) reviewed for immunizations, the facility failed to offer and provide pneumococcal vaccine as required. The findings include: Interview and review of facility immunization documentation with RN #1 (Infection Preventionist) on 3/17/2023 at 12:37 PM identified the following: a) Resident #14 was admitted to the facility on [DATE] with diagnosis that included diabetes mellitus, hypertension, and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #14 had severe cognitive impairment. The assessment further identified that Resident #14 influenza vaccination was not up to date. Review of Resident #14 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. b) Resident #16 was admitted to the facility on [DATE] with diagnosis that included vascular dementia, psychotic disturbance, and mood disturbance. The quarterly MDS assessment dated [DATE] identified Resident #16 had severe cognitive impairment. The assessment further identified that Resident #16 influenza vaccination was not up to date. Review of Resident #16 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. c) Resident #24 was admitted to the facility on [DATE] with diagnosis that included multiple sclerosis, hypertension, and hydrocephalus. The quarterly MDS assessment dated [DATE] identified Resident #24 had severe cognitive impairment. The assessment further identified that Resident #24 influenza vaccination was not up to date. Review of Resident #24 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. d) Resident #56 was admitted to the facility on [DATE] with diagnosis that included schizophrenia, and pulmonary fibrosis. The quarterly MDS assessment dated [DATE] identified Resident #56 had moderate cognitive impairment. The assessment further identified that Resident #56 influenza vaccination was not up to date. Review of Resident #56 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. e) Resident #73 was admitted to the facility on [DATE] with diagnosis that included dementia with psychotic disturbance, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #73 had intact cognition. The assessment further identified that Resident #73 influenza vaccination was not up to date. Review of Resident #73 clinical record on 3/17/25 at 12:37 PM failed to identified that the influenza vaccine was offered and/or administered to the resident. f) Resident #12 was admitted to the facility on [DATE] with diagnosis that included atherosclerotic heart disease, and hyperlipidemia. The annual MDS assessment dated [DATE] identified Resident #12 had moderate cognitive impairment. The assessment further identified that Resident #12 pneumococcal vaccination was not up to date. Review of Resident #12 clinical record on 3/17/25 at 12:37 PM failed to identified that the pneumococcal vaccine was offered and/or administered to the resident. g) Resident #26 was admitted to the facility on [DATE] with diagnosis that included hemiplegia and hemiparesis, and cerebrovascular disease affecting the right dominant side. The annual MDS assessment dated [DATE] identified Resident #26 had intact cognition. The assessment further identified that Resident #26 pneumococcal vaccination was not up to date. Review of Resident #26 clinical record on 3/17/25 at 12:37 PM failed to identified that the pneumococcal vaccine was offered and/or administered to the resident. h) Resident #37 was admitted to the facility on [DATE] with diagnosis that included cerebral palsy, and hydronephrosis. The quarterly MDS assessment dated [DATE] identified Resident #37 had severe cognitive impairment. The assessment further identified that Resident #37 pneumococcal vaccination was not up to date. i) Resident #61 was admitted to the facility on [DATE] with diagnosis that included subarachnoid hemorrhage, and diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #61 had severe cognitive impairment. The assessment further identified that Resident #61 pneumococcal vaccination was not up to date. Review of Resident #61 clinical record on 3/17/25 at 12:37 PM failed to identified that the pneumococcal vaccine was offered and/or administered to the resident. Interview with RN #1 on 3/17/25 at 1:00 PM identified that she did not receive some of the influenza vaccine consent forms from the resident representatives, so the facility was unable to administer the influenza vaccine. RN #1 was unable to verify if the facility had followed up with the resident representatives. RN #1 indicated the facility had obtained some consents for the influenza and pneumococcal vaccination on 3/13/25. RN #1 indicated she was unable to find any previous pneumococcal vaccination records from 2023 and 2024. RN #1 indicated she did not administer any pneumococcal vaccine in 2024 and 2025. Interview with RN #1 on 3/19/25 at 9:50 AM identified influenza and pneumococcal vaccine were offered on 3/14/25 but the pharmacy did not deliver the vaccines. RN #1 indicated she will reach out to the pharmacy regarding the delay of the influenza and pneumococcal vaccines. Interview with RN #1 on 3/19/25 at 11:10 AM identified that the pharmacy received the vaccines but some where the profile for payment purpose and insurance coverage was not communicated. RN #1 indicated the communication from the pharmacy to the facility to explain why there was a delay and/or a reason why there was not a delivery done. RN #1 indicated that she asked the pharmacy to escalate to quality insurance and she was told that it would take approximately 48 hours for a response. Interview with the DNS on 3/19/25 at 11:30 AM identified she was not aware of the issue. The DNS indicated RN #1 is responsible to oversee that all resident in the facility receives their influenza and pneumococcal vaccines in a timely manner. Review of the facility immunization of residents policy identified all eligible residents will be offered the influenza and pneumococcal vaccines unless medically contraindicated. The resident or the resident's legal representative will be provided a copy of the current vaccine information statement prior to administration. The resident or resident's legal representative has the right to refuse the vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #2, 12, 19, 59, and 61) reviewed for immunizations, the facility failed to offer and provide Covid-19 immunizations as required. The findings include: Interview and review of facility immunization documentation with RN #1 (Infection Preventionist) on 3/17/2023 at 12:37 PM identified the following: 1) Resident #2 was admitted to the facility on [DATE] with diagnosis that included fracture of shaft of left femur, difficulty walking, and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #2 had intact cognition. The assessment further identified that Resident #2 Covid-19 Booster vaccination was not up to date. Review of Resident #2 clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. Review of the Covid-19 immunization record identified Resident #2 had a consent for the vaccine. 2) Resident #12 was admitted to the facility on [DATE] with diagnosis that included atherosclerotic heart disease, and hydrocephalus. The annual MDS assessment dated [DATE] identified Resident #12 had intact cognition. The assessment further identified that Resident #12 Covid-19 Booster vaccination was not up to date. Review of Resident #12's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/18/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. 3) Resident #19 was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder, and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #19 had intact cognition. The assessment further identified that Resident #19 Covid-19 Booster vaccination was not up to date. Review of Resident #19's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/18/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. 4) Resident #59 was admitted to the facility on [DATE] with diagnosis that included malignant neoplasm of right female breast, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #59 had severe cognitive impairment. The assessment further identified that Resident #59 Covid-19 Booster vaccination was not up to date. Review of Resident #59's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/19/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. 5) Resident #61 was admitted to the facility on [DATE] with diagnosis that included subarachnoid hemorrhage, and diabetes mellitus. The quarterly MDS assessment dated [DATE] identified Resident #61 had severe cognitive impairment. The assessment further identified that Resident #61 Covid-19 Booster vaccination was not up to date. Review of Resident #69's immunization record identified the Covid-19 vaccine additional dose/booster was last administered on 12/19/23. Review of the clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. Review of the Covid-19 vaccine documentation form identified Resident #2, 12, 19, 59, and 61 had a sign consent dated 3/13/25 by the residents and/or the resident representative. Interview with RN #1 on 3/17/25 at 1:00 PM identified that she did not receive some of the Covid-19 vaccine consent forms from the resident representatives, so the facility was unable to administer the Covid-19 booster vaccine. RN #1 was unable to verify if the facility had followed up with the resident representatives. RN #1 indicated the facility had obtained some consents for the Covid-19 vaccination on 3/13/25. RN #1 indicated she did not administer any Covid-19 Booster vaccine in 2024 and 2025. Interview with RN #1 on 3/19/25 at 9:50 AM identified Covid-19 vaccine were offered on 3/14/25 but the pharmacy did not deliver the vaccines. RN #1 indicated she will reach out to the pharmacy regarding the delay of the influenza, pneumococcal, and Covid-19 Booster vaccines. Interview with RN #1 on 3/19/25 at 11:10 AM identified that the pharmacy received the vaccines but some where the profile for payment purpose and insurance coverage was not communicated. RN #1 indicated the communication from the pharmacy to the facility to explain why there was a delay and/or why there was no delivery was not done. RN #1 indicated that she asked the pharmacy to escalate to quality insurance and she was told that it would take approximately 48 hours for a response. Interview with the DNS on 3/19/25 at 11:30 AM identified she was not aware of the issue. The DNS indicated RN #1 is responsible to oversee that all resident in the facility receives their Covid-19 Booster vaccines in a timely manner. Review of the facility resident Covid-19 vaccine documentation form identified the vaccine will be offered to all eligible residents as recommended by the Center for Disease Control (CDC), and the resident or legal guardian is provided with education regarding the pros and cons of the vaccine. The resident or resident's legal representative has the right to refuse the vaccine.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wound care, the facility failed to ensure wound treatment recommendations were implemented. The findings include: Resident #1 had diagnoses that included metastatic malignant neoplasm of breast, fungating mass (tumor has broken through the skin) of right breast, secondary malignant neoplasm of bone, severe protein-calorie malnutrition, and adult failure to thrive. The nursing admission body audit dated 11/14/24 at 4:37 P.M. completed by RN #3 (wound nurse) identified Resident #1 has alterations in skin integrity with a cancerous wound to h/her right breast that is erythematous (red)with sanguineous drainage (clear fluid mixed with blood). A physician's order dated 11/14/24 directed to cleanse the right breast cancer wound with Dakins 0.125 % (an antimicrobial cleanser) , pat dry, apply Xeroform 4x4 gauze (a non adhesive dressing), cover with dry gauze, and abdominal pad secure with large stockinette like tube top change daily while awake on the 11:00 P.M.- 7:00 A.M. shift. The care plan dated 11/15/2024 identified Resident #1 has impaired skin integrity with interventions that directed to provide treatment as ordered, weekly skin assessment per facility protocol, monitor for healing process and notify MD and responsible party if no improvement, and change treatment as indicated. Review of APRN #2's (wound APRN) note dated 11/19/24 at 9:48 A.M. identified Resident #1 was seen today for evaluation and management of wounds. APRN #2 identified Resident #1 has a full thickness wound to h/her right breast from carcinoma that measures 14.0 centimeters (cm) in length by 12.0 cm in width, with a depth of 0.2 cm, and a moderate amount of sanguineous drainage. APRN #2 identified on 11/19/24 for Resident #1's right breast the wound treatment recommendation directed to cleanse with 0.125 % Dakins, apply xeroform, calcium alginate with silver to base of the wound (absorbs excess moisture), secure with an abdominal pad, change daily and as needed. Review of the physician's orders dated 11/19/24 to 11/24/24 failed to reflect that APRN #2's wound treatment recommendation for Resident #1's right breast were implemented. Review of Resident #1's Treatment Administration Record (TAR) from 11/19/24 to 11/24/24 identified the wound treatments for Resident #1's right breast cancer directed to cleanse the right breast cancer wound with Dakins 0.125 %, pat dry, apply Xeroform 4x4 gauze, cover with dry gauze, and abdominal pad secure with large stockinette like tube top change daily while awake not before 5:00 A.M. and did not include APRN #2's wound treatment recommendations dated 11/19/24 that directed to apply calcium alginate with silver to base of wound. An interview with APRN #2 (wound APRN) on 12/19/24 at 3:25 P.M. identified on 11/19/24 she was consulted to evaluate Resident #1's wounds. APRN #2 identified Resident #1's right breast carcinoma wound had a moderate amount of sanguineous drainage. APRN #2 identified based on the amount of drainage from Resident #1's right breast she changed the wound treatment and added calcium alginate with silver to be applied to the base of the wound. APRN #2 identified on 11/19/24 her wound treatment recommendation for Resident #1's right breast wound directed to cleanse the right breast with 0.125 % Dakin's solution, apply xeroform, apply calcium alginate with silver to base of the wound, secure with an abdominal pad, change daily and as needed. APRN #2 identified on 11/19/24 Resident #1's wound treatment recommendations for the right breast should of been implemented. Interview with the DNS on 12/19/24 at 3:45 P.M. identified on 11/19/24 RN #3 (wound nurse) was on vacation and on the charge nurses of each unit conducted wound rounds with APRN #2. The DNS identified the charge nurses are responsible for implementing APRN #2's wound treatment recommendations. The DNS was unable to provide documentation to reflect that on 11/19/24 APRN #2's wound treatment recommendations for Resident #1's right breast was implemented. The DNS identified her expectation is the charge nurses implement APRN #2's wound treatment recommendations. The DNS further identified on 11/19/24 APRN #2's wound treatment recommendation for Resident #1's right breast should have been implemented. Review of facility undated wound treatment and wound care policy identified that there are scheduled wound observation rounds (same day each week) with observation of resident's skin (head to toe) and documentation of meetings will be kept to include recommendations as appropriate, new treatments, and progress of wounds.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wound treatments, the facility failed to ensure the clinical record was complete and accurate to reflect wound treatments were administered. The findings include: Resident #1 had diagnoses that included metastatic malignant neoplasm of breast, fungating mass of right breast ( the mass has broken through the skin), pressure-induced deep tissue damage of sacral region, pressure-induced deep tissue damage to right and left buttock, secondary malignant neoplasm of bone, severe protein-calorie malnutrition, and adult failure to thrive. The nursing admission body audit dated 11/14/24 at 4:37 P.M. completed by RN #3 (wound nurse) identified Resident #1 has alterations in skin integrity with a cancerous wound to h/her right breast that is erythematous (red) with sanguineous drainage (drainage mixed with blood). RN #3 identified Resident #1 has ulcers to lower right lateral leg, right medial leg, and lower left medial leg and pressure ulcers 'injury' to h/her right buttock and left buttock. a. A physician's order dated 11/14/24 directed to cleanse bilateral lower leg wounds with normal saline, pat dry, apply calcium alginate with silver gauze (absorbs wound drainage), cover with dry gauze, followed by rolled gauze daily change while awake before 5:00 A.M. Review of Resident #1's Treatment Administration Record dated identified Resident #1's wound treatments to h/her bilateral lower leg wounds were not administered per the physician's order on 11/15/24 during the 11 P.M. - 7 A.M., on 11/19/24 during the 11 P.M.- 7 A.M. shift, and on 11/20/24. Further review of Resident #1's TAR identified on 11/16/24 at 7:34 A.M. LPN #4 noted he did not administer Resident #1's wound treatment to h/her bilateral lower leg wounds because Resident #1 was sleeping, on 11/20/24 at 7:58 A.M. RN #1 noted she did not administer Resident #1's wound treatment to h/her bilateral lower leg wounds because Resident #1 refused, and on 11/21/24 at 8:14 A.M. RN #1 noted she did not administer Resident #1's wound treatment to h/her bilateral leg wounds because Resident #1 refused. Interview with RN #1 on 12/19/24 at 8:45 A.M. identified on 11/19/24 and 11/20/24 during the 11 P.M. - 7 A.M. shifts Resident #1 refused the wound treatments to h/her bilateral leg wounds. RN #1 indicated she notified RN #2 (7 A.M. -3 P.M. shift) when she came in to relieve her at 7 A.M. on 11/20/24 and 11/21/24. Interview with RN #2 (7 AM -3 PM shift) on 12/19/24 at 12:35 P.M. identified on 11/16/24 the 11:00 P.M. - 7:00 A.M. nurse LPN #4 reported to her that he did not administer Resident #1's wound treatment to h/her bilateral leg wounds because Resident #1 was sleeping. RN #2 indicated on 11/16/24 she administered Resident #1's wound treatment to h/her bilateral lower leg wounds per the physician's order. RN #2 identified on 11/20/24 and 11/21/24 RN #1 reported that she did not administer Resident #1's wound treatments to h/her bilateral leg wounds because Resident #1 refused. RN #2 indicated on 11/20/24 and 11/21/24 she administered Resident #1's wound treatments to h/her bilateral leg wounds. RN #2 identified on 11/16/24, 11/20/24, and 11/21/24 she forgot to document that she did administer Resident #1's wound treatments to h/her bilateral leg wounds. RN #2 identified she is expected to write a nurse note whenever she administers wound treatments. Although attempted an interview with LPN #4 was not obtained. b. A physician's order dated 11/14/24 directed to cleanse the right breast cancer wound with Dakins 0.125 %, pat dry, apply Xeroform 4x4 gauze, cover with dry gauze, and abdominal pad secure with large stockinette like tube top change dressing daily and as needed, cleanse the bilateral buttocks with normal saline, pat dry, apply calcium alginate, cover with dry clean dressing daily and as needed, and cleanse the on 11:00 P.M. - 7:00 A.M. change dressing while awake not before 5:00 A.M. The care plan dated 11/15/2024 identified Resident #1 has impaired skin integrity with interventions that directed to provide treatment as ordered, weekly skin assessment per facility protocol, monitor for healing process and notify MD and responsible party if no improvement, and change treatment as indicated. Review of Resident #1's Treatment Administration Record dated 11/19/24, 11/22/24, and 11/23/24 identified Resident #1's right breast cancer wound treatments were not administered per the physician's order. On 11/20/24 at 7:58 A.M. RN #1 documented noted Resident #1 refused, on 11/22/24 at 8:14 A.M. RN noted Resident #1 refused, and on 11/24/24 at 8:29 A.M. RN noted not administered due to condition. A nurse's note dated 11/24/24 at 8:00 A.M. written by RN #1 identified Resident #1's breast cancer dressing was found with old blood, supervisor notified. RN #1 identified an assessment was done by the supervisor RN #5 and RN #5 said she will take care of Resident #1's dressing. Interview with RN #1 on 12/19/24 at 8:45 A.M. identified on 11/19/24 and 11/22/24 during the 11 P.M. - 7 A.M. shifts when Resident #1 refused wound treatment to h/her right breast wound she reported it to RN #2 the 7 A.M. - 3 P.M. nurse who relieved her. RN #1 indicated on 11/23/24 during the 11 P. M. to 7 A.M. shift when Resident #1 refused wound care to h/her right breast she notified RN #5 the day shift supervisor. RN #1 indicated RN #5 came down to assess Resident #1 and told her she would take care of Resident #1's dressing. Interview with RN #5 on 12/19/24 at 10:30 A.M. identified she could not recall if on 11/24/24 RN #1 notified her that during the 11 P.M. - 7 A.M. shift on 11/23/24 Resident #1 refused h/her wound treatment to the right breast. RN #5 indicated she could not recall if she had assessed Resident #1, but RN #5 indicated if RN #1 documented that she did it was possible that she did. Interview with RN #2 (7 AM -3 PM shift) on 12/19/24 at 12:35 P.M. identified on 11/20/24, 11/23/24, and 11/24/24 when she came on duty to relieve RN #1 (11 P.M. - 7 A.M. shift) RN #1 reported that Resident #1 refused h/her right breast wound treatments. RN #2 indicated on 11/20/24, 11/23/24, and 11/24/24 she administered Resident #1's right breast wound treatments per the physician's order. RN #2 identified on 11/20/24, 11/23/24, and 11/24/24 she forgot to document that she did Resident #1's right breast wound treatments. RN #2 identified she is expected to write a nurse's note whenever she administers wound treatments. c. A physician's order dated 11/19/24 directed to cleanse right buttock and coccyx with normal saline, pat dry, apply Santyl and calcium alginate cover with a dry clean dressing daily and as needed once per day change dressing while awake not before 5:00 A.M. Review of Resident #1's TAR dated 11/22/24 identified the wound treatment to Resident #1's right buttock and coccyx was not administered. RN #1 noted on 11/23/24 at 8:14 A.M. the wound treatment was not done because Resident #1 refused. Interview with RN #1 on 12/19/24 at 8:45 A.M. identified on 11/22/24 during the 11 P.M. - 7 A.M. shift Resident #1 refused the ordered wound treatment to h/her right buttock and coccyx. RN #1 indicated on 11/23/24 when RN #2 (7 AM - 3 PM) came in to relieve her she reported to RN #2 that Resident #1 refused the wound treatment to h/her right buttock and coccyx. Interview with RN #2 (7 AM - 3 PM shift) on 12/19/24 at 12:35 P.M. identified on 11/24/24 during report RN #1 communicated to RN #2 that Resident #1 refused the wound treatment to h/her right buttock and coccyx during the 11 P.M.- 7 A.M. shift on 11/23/24. RN #2 indicated on 11/24/24 she administered Resident #1's wound treatment to h/her right buttock and coccyx per the physician's order. RN #2 identified on 11/24/24 she forgot to document that she did Resident #1's wound treatment. RN #2 identified she is expected to write a nurse's note whenever she administers wound treatments. An interview with the DNS on 12/19/24 at 1:05 P.M. identified whenever a nurse administers an as needed wound treatment, she expects a nurse's note to be written in the resident's medical record. The DNS identified when RN #2 administered Resident #1's wound treatments because Resident #1 was asleep or when Resident #1 refused RN #2 should have written a nurse's note to identify that RN #2 administered Resident #1's wound treatments. Review of the facility charting and documentation policy dated 2023, in part, identified all services provided to the resident shall be documented in the resident's medical record and the following information is to be documented in the resident medical record treatments or services performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #21, Resident #34 and Resident #70) reviewed for resident to resident altercations, the facility failed to protect a resident (Resident #28) from abuse and failed to protect Resident #21 and Resident #70 from resident to resident altercations. The findings include: 1. Resident #21 was admitted to the facility with diagnoses that included dementia without behaviors, intellectual disorder, and multiple myeloma. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 had severely impaired cognition and required supervision for transfers and locomotion in wheelchair on the unit with one person. The Resident Care Plan dated 5/3/22 identified Resident #21 was verbally abusive towards staff. Interventions included to gently set limits on inappropriate behavior. Resident #70 was admitted to the facility with diagnoses that included major depression, visual disturbances, and cognitive communication deficit. The quarterly MDS dated [DATE] identified Resident #70 had moderately impaired cognition, had no behaviors or hallucinations, and required supervision in the hallway and limited assistance for transfers with 1 person. The Resident Care Plan dated 4/13/22 identified sexually inappropriate behaviors. Interventions included to keep resident seated away from female residents if possible. The APRN progress note dated 4/25/22 indicated Resident #70 was having aggressive behaviors toward staff. Resident #70 was touching a staff member and when asked to stop Resident #70 picked up a wet floor sign and threatened to hit multiple staff with the sign. Interventions included to perform a urinalysis and start Depakote. A physician's order dated 5/2/22 directed to consult psych for depression, administer Celexa (a medication to treat depression) 10 mg at bedtime, and Depakote ER (a medication to treat psychiatric conditions) 5000 mg twice a day. a. An Accident/Incident report dated 5/26/22 at 12:50 PM identified in the hallway Resident #70 mocked another resident (Resident #21). Resident #21 hit Resident #70 in the arm and Resident #70 then hit Resident #21 back about 4 times in the chest and face. This was witnessed by 2 staff. Interventions were to receive psychiatric services, continue to receive Social Services support, and staff in-serviced to remove both residents if an argument is observed, and staff to remain with resident until both parties have calmed down. Due to cognition limitations, Resident #21 may strike out when agitated and to ensure hallway was cleared when Resident #21 was observed out of his/her room. The nurse's note dated 5/26/22 at 2:30 PM identified the DNS was informed that at approximately 12:50 PM Resident #21 had an argument and a fight with Resident #70. Resident #21 was mocked by Resident #70 and hit Resident #70 in the arm. Resident #70 then hit him/her back on the chest and face about 4 times. Staff who witnessed the incident separated both residents right away and stayed with them until seen by the psych APRN. In house psych APRN assessed and cleared both residents. MD and POA updated. Currently Resident #21 was sitting in his/her room in the wheelchair. No visible injuries. When checked by writer Resident #21 stated I don't know what happened and get away now and Resident #70 stated it was no big deal. Will continue to separate both residents from each other. Psychiatric Evaluation dated 5/26/22 identified Resident #21 self-propels in the wheelchair and spends time in his/her room. Resident #21 was not a danger to self/others at the time of evaluation. The Psychiatric Evaluation further indicated Resident #70 had good memory recall. Resident #70 reported that Resident #21 hit him/her first and then he/she hit back. Resident #70 responds to firm limit setting. Resident #70 was not a danger to self/others at time of evaluation. Plan was to keep both residents on separate sides of the same unit. Both residents tend to spend a good amount of time in their rooms. The RCP dated 5/26/22 identified Resident #21 was involved in a resident-to-resident altercation. Interventions included Resident #21 may strike out when agitated so clear the hallway when observed out of his/her room. Additionally, Social Worker to provide support. The APRN progress note dated 6/8/22 noted Resident #21 was recently in an altercation with another resident and was being followed by psych. Resident #21 will continue to be followed by psych for the dementia. Interview with the DNS on 7/14/22 at 2:05 PM indicted the incident between Resident #21 and Resident #70 occurred on 5/26/22 at 12:50 PM per the Accident/Incident Report, she was notified the same day by NA #4 but she did not recall the time or who informed her. The DNS noted she went to the supervisor and informed RN #2 and they both went to the unit. The DNS noted both residents were in their rooms when she arrived on the unit. The DNS noted the Administrator, or she had called the police. The DNS noted the 5/26/22 intervention was to tell staff when they see Resident #21 and #70 going near each other to separate them. The DNS noted both residents were cleared by psych and their rooms were at opposite ends of the same unit so she did not feel that she had to make any room changes. The DNS thought it was a one-time event and they were cleared by psych and so the interdisciplinary team thought it would not happen again. b. An Accident/Incident report dated 6/9/22 at 3:40 PM identified Resident #21 was witnessed in a physical altercation with another resident (Resident #70). Witness statement indicated he witnessed Resident #70 hit the abdomen of Resident #21 and Resident #21 fought back hitting Resident #70 in the arm. This occurred near the exit of the unit, and he quickly removed Resident #21 to prevent further fight and injury. Interventions included to place Resident #21 on 1:1 until cleared by psych services, SW for support, and in-service staff that Resident #21 and Resident #70 do not go near each other to avoid incident from reoccurring. To create a harmonious unit Resident #70 agreed to have a room change. The nurse's note dated 6/9/22 at 5:11 PM identified he witnessed Resident #70 and Resident #21 both on Aspen Unit fighting each other near the exit and quickly removed Resident #21 to prevent further fighting and injury. Supervisor from 3:00 PM to 11:00 PM shift aware. The nurse's note dated 6/9/22 at 10:51 PM identified Resident #21 was alert and verbally responsive, no distress noted. 1:1 monitoring by staff, safety maintained. The Psychiatric Evaluation dated 6/10/22 at 2:04 PM identified Resident #21 was evaluated via Telehealth by facility request to assess resident to resident conflict. Resident #21 denied any fight. It was unclear who initiated the contact. Resident #21 was not a danger to self/others at time of evaluation. The plan was to provide for physical separation by putting the 2 residents on separate facility units. The Social Worker note dated 6/10/22 at 4:27 PM indicated Resident #70 was relocated temporarily to [NAME] Unit to get some space from another resident that has verbal altercations with him. Interview with DNS on 7/14/22 at 2:50 PM indicated the incident occurred on 6/9/22 at 3:40 PM with the same 2 residents. The DNS noted it occurred in the Aspen Unit hallway by the lounge area at the end by the exit area. The DNS noted then Resident #70 told Resident #21 that he/she was on the wrong end of the unit. The DNS noted Resident #70 hit Resident #21 first and then Resident #21 hit Resident #70 back witnessed by RN #4. The DNS indicated she spoke with RN #4, and he told her he was busy passing medications and did not realize both residents were together. The DNS noted RN #4 immediate separated the residents, psych recommended a room change for Resident #70 the next day and Resident #70 was transferred to another unit. Review of facility Residents [NAME] of Rights identified the resident has the right to be free from verbal, physical, sexual, or mental abuse, corporal punishment, and involuntary seclusion. 2. Resident #28 was admitted to the facility with diagnoses that included unspecified sequelae of nontraumatic subarachnoid hemorrhage, wrist contracture unspecified hand, hypertension, multiple sclerosis, and normal pressure hydrocephalus. The annual MDS assessment dated [DATE] indicated Resident #28 was severely cognitively impaired and was totally dependent for all activities of daily living (ADL). The Resident Care Plan (RCP) dated 5/17/22 identified Resident #28 required total assist with ADL's with interventions to provide bath and showers per schedule, skin checks, nail care, lotion, shampoo per facility protocol as well as total assist with grooming, oral hygiene, shaving, combing hair, washing face/hands as needed. Additionally, the RCP identified Resident #28 utilized splints/appliances with interventions for left hand splint and right-hand roll to be worn at all times. Resident #34 was admitted to the facility with the diagnosis that included Diabetes Mellitus, unspecified convulsion, bipolar disorder, intermittent explosive disorder, psychotic disorder with delusions due to known physiological condition, anxiety, unspecified sequelae of unspecified cerebrovascular disease and personal history of benign neoplasm of the brain. The significant change MDS assessment dated [DATE] identified Resident #34 was severely cognitively impaired and required extensive assistance with ADL's. The RCP dated 5/17/22 identified Resident #34 had behavioral symptoms of socially inappropriate/disruptive behavioral symptoms such as poor impulse control, intrusiveness, physical aggression and poor insight into behaviors. Interventions included to provide opportunities in the gym to burn off energy, investigate potential day programs, positive reinforcement, set boundaries with resident, encourage resident to attend activities, emotional support as needed, psych evaluation and follow up as needed, separate resident as needed from peers if behaviors are noted and cannot be de-escalated and avoid over-stimulation. a. A nurse's note dated 6/15/22 at 4:05 PM indicated at approximately 2:20 PM the charge nurse informed her that Resident #28 needed to be checked as blood was noted all over his/her gown and bed. Additionally, the nurse's note indicated the assessment noted Resident #28's right index finger nail came off, nail bed continued bleeding and the resident had facial grimacing. The note further indicated the finger nail was found on the bed underneath the resident's right arm, pressure was applied to the area to stop the bleeding, medicated Resident #28 with Tylenol for pain, Bacitracin applied to nail bed and covered with a dry clean dressing. The note indicated the MD was notified and assessed the resident, the DNS and Social Services were made aware and Resident #28 was transferred to another room. A nurse's note dated 6/15/22 at 3:39 PM indicated at approximately 2:20 PM Resident #34 was found wearing gloves with blood on them while holding his/her roommates (Resident #28) right hand. The nurse's note further identified there was blood over Resident #28's gown and bed due to the right index fingernail coming off and found in the bed. Resident #34 stated through a Spanish speaking interpreter that he/she was washing his/her hands and saw Resident #28 digging into his/her fingernail with blood, so Resident #34 stated he/she cleaned Resident #28's finger with alcohol. The note further indicated the MD was notified and assessed the resident, Resident #28 was separated from him/her immediately and POA was updated via phone. A Social Worker (SW) note dated 6/15/22 at 4:27 PM indicated Resident #34 approached his/her roommate (Resident #28) and finagled the roommates nail and removed it. Additionally, the note indicated Resident #34 thought he/she was trying to help but does not know the level of his/her impulsiveness and understanding of what he/she was doing. The note further indicated Resident #34 had a history of being intrusive and had had psychiatry intervention. The note further indicated that Resident #34's caregiver was made aware of the act, understood the goal was to get the resident into inpatient psych directly admitted , if not sent to psych ED, the resident was on frequent checks and the caregiver was aware of the plan. A SW note dated 6/15/22 at 4:36 PM indicated Resident #28's roommate (Resident #34) became intrusive towards him/her and to prevent further intrusive acts, Resident #28 would be relocated and continue to be monitored. A SW addendum note dated 6/15/22 at 4:43 PM indicated the psych APRN, Psychiatrist, and MD made aware, the DNS informed the Administrator and the incident would be reported. Additionally, the note indicated the goal was to have psych intervene and get Resident #34 appropriately placed for further psychiatric/medical evaluation regarding his/her history and current impulsive behaviors. A SW note dated 6/17/22 at 4:56 PM indicated a meeting was held with Resident #34's caregivers in person along with the SW, nursing and Administrator. The note further indicated it was explained to the caregivers that due to the resident's current behavior referrals were being sent to psych units by the SW. Additionally, the note indicated Resident #34 was on 1:1 close monitoring by facility staff, psych did a medication review and that caregivers were aware the SW would contact them when a psych bed was available. A physician's order dated 6/21/22 directed for 1:1 monitoring from 7:00 AM to 9:00 PM, document all behaviors. A physician's order dated 6/22/22 directed to provide every 15-minute checks from 7:00 AM to 9:00 PM, document all behaviors. An interview with SW #1 on 7/6/22 at 12:34 PM indicated that after the incident between Resident #28 and Resident #34, a meeting was held with Resident #34's responsible parties, due to diagnosis and current behaviors, it was agreed that referrals would be sent to a psych facility and they are waiting for an open bed, keep close watch on the resident, providing 1:1 observation and every 15 minute checks. Additionally, SW #1 indicated there have been no recurrence of behaviors and Resident #34 was being placed by the nurse's station. An interview with RN #2 on 7/6/22 at 12:42 PM indicated that she was called by the charge nurse and informed Resident #28 had blood on his/her hospital gown. RN #2 entered the room to assess the finger. Additionally, RN #2 indicated that upon entering the room, Resident #34 was in the bathroom washing his/her hands and that Resident #34 had been wearing gloves with blood stains on them. RN #2 further indicated that when questioned, Resident #34 stated that he/she noticed Resident #28's nail was loose and bleeding as he/she was trying to clean it with alcohol, but no alcohol was found in the area. RN #2 indicated the two residents were separated immediately and Resident #28 had a room change. RN #2 also indicated Resident #34 also had a room change to a private room. RN #2 indicated that Resident #34 was immediately placed on 1:1 observation which was upgraded to every 15-minute checks. An interview with NA #2 on 7/6/22 at 1:00 PM indicated that on 6/15/22 she was called in to the resident's room by a member of the housekeeping staff. Upon entering NA #2 indicated she saw Resident #34 with bloody gloves on, sitting next to Resident #28's bed and Resident #28 had blood all over. Additionally, NA #2 indicated she called the charge nurse, separated the resident and tended to Resident #28. NA #2 indicated that Resident #34 had impulsive behaviors in the past but had no knowledge of any prior incidents of aggressive behaviors. An interview with Housekeeper #1 on 7/6/22 at 1:15 PM indicated, via interpreter, while she was finishing up on the unit, she walked into the resident's room and found Resident #34 on Resident #28's bedside. Additionally, Housekeeper #1 indicated she asked Resident #34 what he/she was doing and was told he/she was helping Resident #28 because he/she was hurt. Housekeeper #1 then told Resident #34 he/she should not being doing that and moved Resident #34 away from Resident #28 and called the Nurse Aide who then came in and called the nurse. Housekeeper #1 indicated that once the nursing staff took over, she had no further involvement in the incident. An interview with SW #2 on 7/7/22 at 10:42 AM indicated that she was informed of the incident between Resident #28 and Resident #34 by the DNS at which time they both immediately moved Resident #28, informed psych, informed the family and attempted to get Resident #34 in a psych inpatient facility. Additionally, SW #2 indicated that Resident #34 had previous history of behavioral issues but that he/she would not try to hurt anyone as he/she enjoyed playing the role of caregiver. SW #2 further indicated that Resident #34 was being closely monitored and the facility was working on getting the resident at least in to a day program but was having difficulties due to his/her medical issues and limitations and that the team care plans Resident #34 for these behavior issues. An interview with APRN #1 on 7/7/22 at 11:00 AM indicated Resident #34 was on medications for his/her behaviors, could be impulsive and does not understand the consequences of his/her actions, the resident wants to be helpful but lacks the insight into his/her limitations. The APRN indicated Resident #34 was on antipsychotic medication and had recently undergone some medication changes and gradual dose reductions. Additionally, the APRN indicated that she and the staff had been working with Resident #34 on non-pharmacological approaches, room change with decreased stimulation, 1:1 monitoring and then downgraded to every 15-minute checks. The APRN indicated Resident #34 was not a candidate for psychotherapy due to his/her limitations and was being seen to manage behaviors. APRN #1 indicated that she had no prior knowledge of Resident #34 being intentionally aggressive towards other residents unless provoked and it was her opinion that the other residents in the facility were safe. An interview with the DNS on 7/7/22 at 11:27 AM indicated that on 6/15/22 she was called by the supervisor and informed of the incident that occurred. The DNS indicated she quickly went to the unit to assess the situation and found the staff working with Resident #28 and that Resident #34 was removed from the area while staff were getting Resident #28 stabilized. Additionally, the DNS indicated immediately following the incident Resident #34 was placed on 1:1 monitoring and was sent to the ED the following day due to increased agitation with the 1:1 monitoring, upon return the resident was again placed on 1:1 monitoring. The DNS indicated that to ensure 1:1 is being carried she looks at documentation, speaks to the supervisor to ensure rounds are being made as well as doing rounds herself to monitor. Additionally, the DNS indicated that Resident #34 had been moved to another unit where there was less crowding and the resident remains on every 15-minute checks, medications were reviewed, and changes were made with no further behavior issues. A review of facility documentation every 15-minute monitoring dated 6/16/22 through 7/6/22 indicated that every 15-minute checks were being completed per order. A review of the facility policy title Abuse Prohibition, Prevention, Reporting and Investigation indicated the purpose was to protect residents from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, misappropriate of property, neglect, exploitation or mistreatment and to ensure that all allegations are investigated thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation and interviews for one of three residents (Resident #25) reviewed for pressure ulcers, the facility failed to ensure the specialty air mattress was maintained on the appropriate setting according to the residents weight and as per the physicians orders. The findings included: Resident #25's diagnoses included chronic kidney disease, metabolic encephalopathy, anemia and dementia. The quarterly MDS assessment dated [DATE] identified Resident #25 was severely cognitively impaired, required extensive assistance with bed mobility, dressing and personal hygiene. The MDS assessment further identified Resident #25 was at risk for developing pressure ulcers and indicated Resident #25 had a pressure ulcer at the time of the assessment. The Resident Care Plan dated 5/9/22 identified Resident #25 with alternation in skin integrity and a community acquired pressure ulcer related to decreased mobility. Interventions included a low air loss mattress, check function and settings every shift and assist with turning and positioning every 2 hours. The monthly physician's order dated 5/24/22 directed an alternating pressure mattress set at 100, check for setting and functioning every shift. A wound evaluation dated 6/30/22 identified Resident #25 had a Stage III pressure ulcer on the left upper back that measured 0.5 cm by 0.4 cm by 0.1 cm with a light serous exudate. The wound evaluation further identified the wound was improving. Observation on 7/11/22 at 6:45 AM, 7:23 AM and 10:30 AM identified Resident #25 lying in bed, positioned on his/her back on an air mattress. Further observation identified the alternating pressure air mattress control unit was attached to the foot of the bed. The mattress weight control setting was noted to be set at 280 pounds. Review of Resident #25's weight identified a weight of 70 pounds. Observation and interview with NA #3 on 7/11/22 at 10:32 AM identified she checked Resident #25 for incontinence, repositioned Resident #25 and assisted him/her with breakfast. NA #3 only checked if the control setting lights were on but was unaware what settings the specialty mattress required. Review of Resident #25's care card directed alternating pressure mattress to be set at 100 and check for setting and functioning every shift. Observation and interview with RN #4 on 7/11/22 at 10:35 AM identified air mattress settings were monitored for functionality every shift by the Charge Nurse. RN #4 further identified he checked the mattress about 20 minutes prior to interview but was not aware that the mattress control setting was based on the resident's weight and he did not compare it to the physician order. Further observation identified that the air mattress settings could be adjusted for weight of 80 or 120 pounds and not for 100 as ordered. Subsequent to surveyor inquiry, a physician's order was obtained on 7/11/22 which directed an alternating pressure mattress to be set at 80 and nursing staff to check for setting and functioning every shift. Interview with MD #2 (wound care specialist) on 7/14/22 at 1:30 PM identified that he recommended alternating pressure air mattress with settings based on the resident's weight to promote existing pressure ulcer healing and to prevent possible further skin injury. MD #2 further identified that the resident has severe kyphosis and it would not help if the mattress was not set up correctly. Air mattress operation manual identified the air mattress was intended to reduce the incidence of pressure ulcers while optimizing patient comfort. Directed to check to see if a suitable pressure was selected by sliding one hand between the air mattress and the foam base to feel the patient's buttock. The manual further identified that users can adjust the air mattress to desired firmness according to the patient's weight and comfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to ensure the accuracy of an admission dietary assessment to calculate fluid needs and obtain an admission weight timely. The findings include: Resident #85 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, Type II diabetes, chronic kidney disease and recovering pneumonia secondary to Covid. A Hospital Intra-agency Referral Report dated 6/28/22 noted Resident #85's recorded weight as 100.6 kg (221 pounds/lbs). Labs dated 6/28/22 with a sodium (NA) of 138 (135-146 is normal range), Albumin 3.0 (3.6-5.1 is normal range), white blood cell count 11.4 (3.8-10.8 is normal range). A History and Physical dated 6/29/22 identified no complaints, somnolent but arousable, negative for abnormal findings and clinically stable. A Nutritional assessment dated [DATE] identified Resident #85's weight as 100.6 lbs (Resident #85 was 100.6 kg and not 100.6 lbs per hospital discharge documentation) using hospital weight, underweight with a BMI of 15.4, appetite as poor, multiple co-morbidities, decreased albumin. Identified as having nutritional risk. Fluid needs estimated between 1143-1372 ml/day. Recommendations included sugar free milkshakes with meals to help meet estimated nutritional needs, diet as ordered, encourage po intake, provide feeding assistance as needed and adjust plan of care/interventions as needed. A Resident Care Plan dated 6/29/22 identified Resident #85 was at nutritional risk due to compromised oral intake, Body Mass Index (BMI) of 15.4, underweight, multiple co-morbidities, therapeutic diet and decreased albumin. Interventions included to provide assistance with eating as needed, monitor intake, weights, labs, medications and skin status, offer preferences, sugar free milkshakes for breakfast and dinner and weekly weights for four weeks. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 had moderate cognitive impairment and required extensive assist with bed mobility, eating and personal care. admission weight dated 7/2/22 (taken 4 days after admission) identified Resident #85 weighed 204.8 lbs (16.2 lbs less than the hospital identified discharge weight). Nurse's notes dated 6/28/22 through 7/3/22 noted Resident #85 remained under observation for Covid-19 pneumonia, no distress, with occasional cough, receiving assist of one with feeding, needing cuing, not following commands/instructions due to dementia. Head of the bed up and contact precautions maintained. Nurse's notes dated 7/4/22 at 2:08 PM identified Resident #85 had 2 episodes of emesis (vomit) around lunchtime. When assessed, noted resting comfortably in bed, stating feeling okay when asked, abdomen slightly distended, soft, with positive bowel sounds in all quadrants. Last bowel movement was that morning, medium size per vitals report. MD notified, order for PRN (as needed) Zofran 4 mg in place, administered, awaiting effect. Power of Attorney (POA) updated via phone. Nurse's notes dated 7/4/22 at 9:00 PM noted Resident #85 had no signs of pain/discomfort noted. Breathing non labored. Occasional cough persists. Breath sounds diminished. Oxygen saturation was recorded at 94% on room air, afebrile. Continues with poor PO (oral) intake. Coughing when drinking thin liquids; pocketing food in his/her mouth and coughing when trying to swallow. Liquids downgraded to nectar thick and was given by spoon; resident still coughing. No emesis this shift. MD was notified and new orders received for diagnostic testing of the kidney, ureter and bladder (KUB), complete blood count (CBC), comprehensive metabolic profile (CMP) in AM. POA was notified of the new orders and the resident's condition. Weight record dated 7/5/22 at 2:05 PM noted a recorded weight of 148.8 lbs (a 56 lb/27.3% weight loss in 3 days). A reweight was obtained 7/5/22 at 2:23 PM that also identified a weight of 148.8 lbs. A Dietician's progress note dated 7/7/22 noted suspected error on 148 lb weight on 7/5/22, patient was around 200 lbs in hospital. Was 205 lbs on 7/2/22, do not suspect significant weight change at this time. The Dietician's note failed to recommend further verification to ensure Resident #85 did not have a true significant weight loss since the re-weight showed the same weight loss. There was not a subsequent Dietician assessment to follow up on Resident #85's significant weight loss. Social service progress notes dated 7/8/22 identified a care plan meeting took place where the Dietician was not present and nutritional status was not discussed. Oral intake dated 6/28/22 through 7/11/22 noted 15 out of 34 documented meals Resident #85 consumed 0% on 12 occasions, 1-25% (quarter of the meal) on 15 occasions and 25-50% (up to half) on 6 occasions. Fluid intake was documented between 60 ml and 660 ml daily, below estimated fluid needs except for 7/1/22 where Resident #85 consumed 1200 ml fluids. Weight record dated 7/12/22 noted a recorded weight of 177.2 lbs (a 27.6 lb/13.4% weight loss in 10 days) a re-weight obtained the same day identified Resident #85's weight was 177.2 lbs. Nurse's notes dated 7/12/22 at 11:55 PM identified Resident #85 was seen MD today for leukocytosis, sleepy, not taking anything by mouth this shift. Spitting out fluids and food. Continued with occasional moist cough. New order was received for 1/2 NS at 60 ml/hr for 2 Liters, Ceftriaxone 1 gram IM x 1, UA (urinalysis), culture and sensitivity (C&S), chest X-ray (CXR). POA notified of the new orders and fluids were started at 8:45 PM without any complications. Ceftriaxone was also admin per charge nurse. Later during the shift resident vomited light large amount of brown emesis. Breath sounds congested with no respiratory distress. ABD soft, distended with positive bowel sounds but hypoactive (slow). No signs of pain noted. Temperature was 97.6, Pulse 85, Respirations 20, oxygen saturation 95% RA (room air), fasting sugar 140. MD notified; new order received to transfer resident to the hospital. POA notified of the transfer. Resident left the facility at 10:45 PM with emergency medical staff (EMS) to the Emergency Department (ED). An interview and clinical record review on 7/13/22 at 1:15 PM and 7/14/22 at 3:06 PM with Dietician #1 identified all new admissions receive a nutritional assessment within three to five days of being admitted . Residents identified at high risk, such coming in not eating, poor oral intake, not liking the food, would be followed more closely (almost daily). Resident #85 was considered high risk due to a poor appetite upon entering into the facility and comorbidities. Dietician #1 was also responsible for reviewing weights and recommending supplements/fortifying foods when true weight loss was identified through her review or communicated in morning report. According to Dietician #1 weights were supposed to be obtained on admission but that they were not always timely (Resident #85's weight was obtained 4 days after admission). Additionally, Dietician #1 used the hospital weight for the initial assessment for Resident #85 and in doing so, mistakenly recorded Resident #85's weight as 100.6 lbs rather than 100.6 kg (221 lbs). Based on the adjusted weight, Resident #85's fluid needs would be 2027.5-2433 ml/day instead of 1143-1372 ml/day. Dietician #1 stated an alternate Dietician from another facility (Dietician #2) covered her caseload while she was on vacation from 6/30/22 through 7/11/22. Dietician #1 indicated had she been involved with Resident #85's care from the beginning, she would have followed the resident more closely knowing Resident #85 was at high risk by reviewing intake and fluids from the beginning, continue to add fortifying supplements, extra protein, fluids and further explore preferences to boost nutritive status. An interview on 7/13/22 at 2:49 PM and 7/14/22 at 12:20 PM with the DNS identified weights were to be obtained on admission and weekly for the first four weeks. The weights were to be recorded by the NA's and the nurse was responsible for monitoring for discrepancies and then report to the Nursing Supervisor, APRN/ physician and Dietician. Nurses were expected to report abnormal labs to the APRN/MD immediately. Interview on 7/14/22 at 9:10 AM with APRN #2 identified she was not notified of significant weight discrepancies for Resident #85 and that poor intake and significant weight discrepancies, if determined to be significant weight loss would likely have contributed to Resident #85's hospitalization adding the Dietician as well as the entire Interdisciplinary Team should have been involved from the beginning. An interview on 7/14/22 at 11:41 AM and with Dietician #2 identified he was covering the facility while the regular Dietician was on vacation following Resident #85's admission. Dietician #2 indicated he noted the weight discrepancy when reviewing weights and did not feel it reflected a true discrepancy as Resident #85's weight was 200+ in the hospital. Dietician #2 did not speak with nursing, review intake, labs or assess Resident #85 at the time the discrepancy was identified. Dietician #2 indicated noting the weight discrepancy was his only involvement with Resident #85. Dietician #2 indicated had he been made aware of Resident #85's poor intake and abnormal labs, he would have increased supplements, conducted a three-day weight check, three-day food and fluid intake and check with the APRN who likely would have known. A subsequent interview on 7/15/22 at 11:44 AM with the DNS identified a residents hydration status was implemented with every new admission, poor intake, and when placed on antibiotic therapy. Nurses document the hydration status as part of their nursing assessment. Nurses should have been documenting the hydration status for Resident #85 as part of their assessment. The DNS indicated it was also her expectation that the Dietician monitor nutrition/hydration. The facility policy for Assessment and Management of Resident's weights direct the admission weight be obtained within 24 hours of admission and documented in the clinical record and MDS. Residents with a significant weight change will be re-weighed under the supervision of a licensed nurse. Monthly and weekly weights are evaluated by nursing staff and the Dietician to determine significant changes. The Dietician will review the documentation to determine the identified cause for the significant weight loss and communicated to the charge nurse and physician for review. The Dietician will visit the resident, review food preferences and offer appropriate snacks and make recommendations for addressing weight loss which will be communicated to the charge nurse and physician for review. The physician will evaluate the Dietician's recommendations and authorize appropriate orders. The interdisciplinary team in collaboration with the resident/ responsible party review goals for treatment preferences, weight loss, risk and appropriate interventions. The policy for Hydration Protocol directs the facility to ensure a resident's hydration needs be met unless contraindicated. The Registered Dietician (RD) will determine fluid needs on admission and when there is a resident change that affects fluid intake. New admissions and residents returning from the hospital will have intake and fluids monitored for 72 hours, compare with fluid needs after 3 days and determine if additional evaluation and monitoring is indicated. Residents are to be evaluated for risk of dehydration and placed on I+O. Hydration evaluation will be completed if a resident is not meeting fluid needs. For 3 consecutive days. Observations that include abnormal blood pressure and pulse, dry mucous membranes, dry cracked lips, tenting of skin on forehead, dark/decreased urine, new confusion or change in mental status. The physician and dietician are to be notified for a resident who does not meet fluid needs for 3 consecutive days. The facility failed to ensure the Dietician accurately calculated fluid needs upon Resident #85's admission, complete an admission weight timely, participate with the Interdisciplinary Team to discusss Resident #85's poor fluid/solid intake and provide additional nutritional interventions when Resident #85 experienced a significant weight loss on 7/7/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to ensure laboratory blood work was completed timely as directed by the physician. The findings include: Resident #85 was admitted to the facility from the hospital on 6/28/22 with diagnoses that included vascular dementia, Type II diabetes, chronic kidney disease, and recovering pneumonia secondary to Covid. The Hospital Intra-Agency Referral Report dated 6/28/22 noted Resident #85's lab values dated 6/28/22 identified a Sodium (NA) of 138 (135-146 is the normal range), Albumin 3.0 (3.6-5.1 is the normal range), and white blood cell count 11.4 (3.8-10.8 is the normal range). A Resident Care Plan dated 6/29/22 identified Resident #85 was at nutritional risk due to compromised oral intake, Body Mass Index (BMI) of 15.4, underweight, multiple co-morbidities, therapeutic diet and decreased albumin. Interventions included to provide eating assistance as needed, monitor intake, weights, labs, medications and skin status. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 was moderately cognitively impaired and required extensive assist with bed mobility, eating and personal care. Nurse's notes dated 7/4/22 at 9:00 PM noted Resident #85 had no signs of pain/discomfort. Breathing non labored. Occasional cough persists. Breath sounds diminished. Oxygen saturation was recorded at 94% on room air, afebrile. Continues with poor PO (oral) intake. Coughing when drinking thin liquids; pocketing food in his/her mouth and coughing when trying to swallow. Liquids downgraded to nectar thick and was given by spoon; resident still coughing. No emesis this shift. MD was notified and new orders received for diagnostic testing of the kidney, ureter and bladder (KUB), Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP) in the AM. POA (power of attorney) was notified of the new orders and the resident's condition. Physician's orders dated 7/5/22 directed a CBC and CMP to be collected on 7/5/22. Laboratory values dated 7/8/22 (collected 3 days after physician's order to collect on 7/5/22) noted abnormal results that included Sodium (NA) 147 (135-146 is the normal range), Blood Urea Nitrogen (BUN) 32 (6-22 is the normal range) Creatinine (create) 1.11 (0.7-1.11 is the normal range) Albumin 3.4 (3.6-5.1 is the normal range), white blood cell count (WBC) 13.6 (3.8-10.8 is the normal range), absolute neutrophils 10227 (1500-7800 is the normal range), absolute monocytes 1306 (200-950 is the normal range). Interview with the Medical Director on 7/14/22 at 10:15 AM and 7/14/22 at 12:49 PM identified he had previously ordered the labs to have been drawn on 7/5/22 after nursing staff contacted him to report Resident #85 was coughing and had some swallowing issues. The Medical Director received a text on 7/5/22 from nursing staff that the lab did not obtain the specimen on 7/5/22 due to Resident #85 having a diagnosis of Covid. However, according to the Medical Director, this issue had occurred in the past and nursing staff had an alternate lab used to obtain specimens and expected this would be the case on this occasion, since the order directed to obtain the labs on 7/5/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to notify the physician/Advanced Practice Registered Nurse (APRN) of abnormal lab values in a timely manner. Resident #85 was admitted to the facility from the hospital on 6/28/22 with diagnoses that included vascular dementia, Type II diabetes, chronic kidney disease, and recovering pneumonia secondary to Covid. The Hospital Intra-Agency Referral Report dated 6/28/22 noted Resident #85's lab values dated 6/28/22 identified a Sodium (NA) of 138 (135-146 is the normal range), Albumin 3.0 (3.6-5.1 is the normal range), and white blood cell count 11.4 (3.8-10.8 is the normal range). A Resident Care Plan dated 6/29/22 identified Resident #85 was at nutritional risk due to compromised oral intake, Body Mass Index (BMI) of 15.4, underweight, multiple co-morbidities, therapeutic diet and decreased albumin. Interventions included to provide eating assistance as needed, monitor intake, weights, labs, medications and skin status. Additional interventions included to offer preferences, sugar free milkshakes for breakfast and dinner and weekly weights for four weeks. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 was moderately cognitively impaired and required extensive assist with bed mobility, eating and personal care. Nurse's notes dated 7/4/22 at 9:00 PM noted Resident #85 had no signs of pain/discomfort. Breathing non labored. Occasional cough persists. Breath sounds diminished. Oxygen saturation was recorded at 94% on room air, afebrile. Continues with poor PO (oral) intake. Coughing when drinking thin liquids; pocketing food in his/her mouth and coughing when trying to swallow. Liquids downgraded to nectar thick and was given by spoon; resident still coughing. No emesis this shift. MD was notified and new orders received for diagnostic testing of the kidney, ureter and bladder (KUB), Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP) in the AM. POA (power of attorney) was notified of the new orders and the resident's condition. Physician's orders dated 7/5/22 directed a CBC and CMP to be collected on 7/5/22. Laboratory values dated 7/8/22 (collected 3 days after physician's order to collect on 7/5/22) noted abnormal results that included Sodium (NA) 147 (135-146 is the normal range), Blood Urea Nitrogen (BUN) 32 (6-22 is the normal range) Creatinine (create) 1.11 (0.7-1.11 is the normal range) Albumin 3.4 (3.6-5.1 is the normal range), white blood cell count (WBC) 13.6 (3.8-10.8 is the normal range), absolute neutrophils 10227 (1500-7800 is the normal range), absolute monocytes 1306 (200-950 is the normal range). The lab report noted the result was reported on 7/8/22 at 12:41 PM and faxed to the facility at 1:30 PM. APRN progress notes dated 7/11/22 (3 days after lab results were faxed to the facility) noted Resident #85 continued to eat and drink when fed, coughing. Chest x-ray negative for infection. Grimacing noted with palpation of the super pubic area. Mucous membranes were moist. Noted leukocytosis, super pubic discomfort with a plan in place for a urinalysis by straight catheterization, continue I+O (intake and output), hydration and pulmonary assessments for 3 additional days. MD progress notes dated 7/12/22 (4 days after lab results were faxed to the facility) at 6:29 PM noted a request was made to evaluate Resident #85 due to not being usual self and lethargy. Found to be lethargic, chest clear, abdomen negative. Labs were reviewed with elevated WBC, BUN, NA. Orders in place to start intravenous fluids (IVF) ½ normal saline (NS) at 60 cc/hr for two liters, Ceftriaxone (a medication to treat several different infections) 1 (gram) GM intramuscularly (IM) now and discussed with nursing to follow up. Interview on 7/14/22 at 9:10 AM with APRN #2 identified she was made aware Resident #85 was experiencing poor oral intake and emesis on 7/5/22 when she evaluated Resident #85, and that the Medical Director (MD #1) had previously ordered labs. APRN #2 indicated she was not notified of the of the abnormal lab results until 7/11/22 during her visit (3 days after lab results were faxed to the facility). Interview and most recent hospital record review with the Medical Director on 7/14/22 at 10:15 AM and 7/14/22 at 12:49 PM identified he was notified of the abnormal labs on 7/12/22 (4 days after lab results were faxed to the facility) when he came to evaluate Resident #85 for a report of altered mental status. The Medical Director indicated he reviewed the lab results noting elevations in the WBC, BUN and NA. Suspecting an underlying infection, the Medical Director ordered intravenous fluids (IV), chest x-ray, and initiate IV antibiotic therapy preferring to treat in place as Resident #85 was otherwise clinically stable and the initiation of fluids usually helped. The Medical Director indicated he would expect staff to report labs. An interview on 7/14/22 at 12:20 PM with the DNS identified nurses were expected to report abnormal labs to the APRN/MD immediately. An interview on 7/14/22 at 12:32 PM with RN #2 identified labs with greater abnormal are called in to the facility and then faxed in to the facility from the lab. All others were faxed and the oncoming Nursing Supervisor reviews. RN #2 indicated she was the assigned Nursing Supervisor for the 7:00 AM to 3:00 PM shift on 7/8/22 but did not recall receiving any lab results for Resident #85. Interview on 7/14/22 at 12:45 PM with RN #3 indicated she was the 3:00 PM to 11:00 PM shift Nursing Supervisor who worked on 7/8/22. RN #3 indicated she did not receive any lab reports for Resident #85 and if she had, the physician would be notified, and any abnormal results reported. The facility policy for Notifying the Physician directed the physician must be notified of all changes in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #19) reviewed for transfers, the facility failed have a system in place to assess residents per manufacturer guidelines for the use of the correct size hoyer pads for residents being transferred utilizing a mechanical lift. The findings include: Resident #19 was admitted to the facility with diagnoses that included rheumatoid arthritis and morbid obesity. The quarterly MDS assessment dated [DATE] identified Resident #19 had intact cognition and required total dependence for transfers with 2 person physical assistance. Additionally, Resident #19's height was 62 inches (5 feet 1 inch) and weighted 241 lbs. The Resident Care Plan dated 5/10/22 identified Resident #19 required assistance with activities of daily living. Interventions included to provide assistance of 2 to transfer in and out of bed with a mechanical lift into an electric wheelchair (but failed to identify what size hoyer pad to utilize). Nurse Aide care card dated 7/14/22 identified that Resident #19 transfers via mechanical lift with assist of 2 and used a power wheelchair (but failed to identify what size hoyer pad to utilize). Observation of Resident #19 on 7/13/22 at 12:05 PM was seated on a blue hoyer pad (with blue strip edging) in an electric wheelchair. Interview with NA #4 on 7/13/22 at 12:30 PM indicated she thought the hoyer pad colored edge braids were according to body weight of the resident. NA #4 thought the purple edge was a Large size. NA #4 noted she goes by the 3 loop straps at the top and the bottom of the pad to put the resident in a seated position for transferring. NA #4 indicated she did not know what weight range the different color pads were and did not know where to find a chart to guide her. Interview with Resident #19 on 7/13/22 at 12:35 PM indicated he/she was in the wrong size hoyer pad and the pad he/she was on cut into the back of his/her legs and was painful. Resident #19 noted the facility had gotten him/her a larger hoyer pad and it worked great, but the pad was sent to laundry about a month ago and did not return. Resident #19 indicated over the last couple of months the pad he/she was currently using still cut into his/her legs. Additionally, Resident #19 indicated there were other residents that complained about the staff not using the correct size hoyer pads. Interview with NA #4 on 7/13/22 at 12:45 PM indicated she was assigned to Resident #19 and had transferred him/her out of bed with the hoyer lift. NA #4 indicated she placed Resident #19 on a full sling pad with the blue edging. NA #4 noted if the hoyer pad was too big or too small the straps would not connect to the lift. NA #4 noted there was no direction on the Nurse Aide care card for Resident #19 that would inform her of the correct size hoyer pad to use. NA #4 noted it was based on trial and error and the NAs would see which hoyer pad would fit and which one didn't. NA #4 noted LPN #3 assisted getting Resident #19 out of bed that morning. Interview with LPN #3 on 7/13/22 at 1:06 PM indicated when she went in to assist with getting Resident #19 out of bed, NA #4 had already placed Resident #19 on the hoyer pad and attached it to the mechanical lift. LPN #3 indicated she did not know the reason Resident #19 was on the blue edge hoyer pad or if that was the correct pad to use. LPN #3 noted she just knows the loops attached to the hoyer pad have to be placed on the correct loops so the resident would sit in an upright position. LPN #3 noted there was not a guide or any documentation (either in the physician orders, care plan or NA care card) to inform staff of the correct size pad to use. Observation and interview with Resident #19 on 7/14/22 at 9:36 AM identified Resident #19 was in an electric wheel chair with the blue edge hoyer pad under him/her. Resident #19 noted she had complained to staff about the hoyer pad hurting him/her during the transfers but they still used the same pad. Resident #19 indicated the blue edge hoyer pad hurt under the back of his/her legs. Interview with LPN #4 on 7/14/22 at 9:40 AM indicated the hoyer pads were selected by the NAs based on the resident's weight and then based on the straps if the resident was small, medium, or large. LPN #4 noted there was nothing on the NA care cards or in the physician's orders to assist in knowing what size hoyer pad to use. LPN #4 reviewed the physicians order and noted it only had assist of hoyer via mechanical lift. LPN #4 indicated prior to today there had not been anything at the nurses station telling the staff what size hoyer pads were for what weight ranges. LPN #4 noted that this morning the DNS had a new sheet at the nurses station that indicated all the different hoyer pads the small, medium, large, extra-large, and double extra-large had a weight capacity of 600 pounds, but did not give any weight ranges for each size pad. LPN #4 indicated the NAs and the nurse just eye ball it for positioning and do not know which size pad to use. Interview with NA #5 on 7/14/22 at 9:45 AM indicated the hoyer pads are used according to the resident's weight. NA #5 noted the facility does not utilize the small size pad anymore, and the medium was yellow, the large was green, the extra-large was purple but did not know the weight to use for each pad. NA #5 noted there was nothing at the nurse's station to tell her or other staff what the weight range for each pad was for at least the last year. NA #5 noted there was a new sheet this morning at the nurse's station. NA #5 in reviewing the sheet noted the colors for the sizes must have changed. Interview with the DNS on 7/14/22 at 9:52 AM indicated the NAs have worked with the residents for a long time so they know the size of the pad that best works whether it is a small, medium, large, or extra-large. The DNS indicated there was not a policy for the use of the hoyer pads and sizing. The DNS indicated subsequent to surveyor inquiry regarding the different size hoyer pads, she had put out a sheet that indicated that all size hoyer pads had weight capacity of 600 pounds. The DNS indicated she was going to start education with the staff about the hoyer pads from the sheet she had put at the nurse's stations. The DNS indicated she was going to request the rehab department assist with looking at the system to select the correct hoyer pad. The DNS further indicated there was not any manufactures recommendations for the hoyer pads but would contact the company. Interview with the DNS and Administrator on 7/14/22 at 11:10 AM indicated they had contacted the company that provides the facility with the slings, and they did not have specific weight ranges for the slings just that the slings had a weight capacity of 600 pounds. Interview with the Administrator on 7/14/22 at 12:00 PM indicated they were able to obtain a full body sling instruction manual, but it did not have the resident sling reference guide to indicate the weight ranges for each size sling. Interview with Person #1 (a representative from the hoyer pad supplier) on 7/14/22 at 12:30 PM indicated the hoyer pad colors go by weight and measurements of the residents. Person #1 indicated she could email the manufacturer recommendations. On 7/14/22 at 12:32 PM received email from Person #1 with the manufacturer recommendations for the resident sling reference guide including a height/weight sling chart based on the height and weight of a resident indicating which sling the resident would use for the mechanical lift. Based on the chart provided, Resident #19 was to use the medium hoyer pad not the extra-large hoyer pad (blue). Interview with RN #5 on 7/14/22 at 4:20 PM indicated she had received a copy of the manufacturer recommendations for the hoyer pads. RN #5 indicated the staff were not aware of the sizes to use for residents that utilize the hoyer pads and indicted the facility had done an audit. RN #5 noted they would educate the staff and place the sheet listing the correct size hoyer pad for each resident that utilizes a hoyer lift on the NA resident profiles and will also be posted at the nurses' stations. Although requested, a facility policy for the use of hoyer pads was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview for the only resident in the survey sample reviewed for Pre-admission Screening and Resident Review( PASARR) (Resident # 62), the facility failed to ensure a resident with a Level I pre-screen which later identified with a mental disorder was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. The findings include: Resident # 62 was admitted to the facility on [DATE] with diagnoses that included benign neoplasm of the brain and anxiety. A quarterly Minimum Data Set ( MDS) assessment dated [DATE] indicated Resident # 62 had moderately impaired cognition, no mood symptoms, no behaviors, and noted a diagnosis of bipolar disorder. A Resident Care Plan (RCP) dated 10/2019 identified a problem related to behavioral symptoms including physical aggression. Interventions included: to involve family, maintain routine and schedules, avoid confrontations, and to reproach as needed. A physician's order dated 10/26/19 through 11/26/19 indicated Resident # 62 had a bipolar disorder. A review of the clinical record and interview with the Director of Social Service on 11/26/19 at 10:13 A.M. failed to reflect that Resident # 62 had been referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination after the physician's orders dated 10/26/19 through 11/26/19 indicated the resident had a diagnosis of bipolar disorder. The Director of Social Service on 11/26/19 was unable to provide evidence that a referral to the appropriate state-designated authority had been made for Resident # 62's newly diagnosis of bipolar disorder. A subsequent interview on 11/26/19 at 10:45 A.M. with the Director of Social Service indicated he/she had contacted the appropriate state-designated authority. The facility's contracted state -agency authority indicated Resident # 62 should be referred for a Level II PASARR evaluation and determination. The Director of Social Service indicated the referral was completed at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility documentation for the only resident in the survey sample reviewed for choices (Resident #51), the facility failed to ensure specialized test were conducted in accordance to the physician's orders. The findings include: Resident #51's diagnoses included depression and a history of breast cancer with lumpectomy. The Annual Minimum Data Set (MDS) dated [DATE] identified the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers and personal hygiene. A Nurse Practitioner (NP) note dated 3/7/19 at 11:11 A.M. identified that Resident #51 was concerned that he/she had not had a recent mammogram or ultrasound of his/her breasts. Resident #51 was told by his/her physician in the community that he/she should continue to be monitored. The plan identified a history of breast cancer of the left breast. A physician's order dated 3/7/19 directed to obtain a mammogram and ultrasound of breasts. Resident # 51 is status post left lumpectomy for cancer and has a pacemaker in the left lateral upper breast. A nurse's note dated 3/7/19 at 11:45 A.M. identified that the Advanced Practical Registered Nurse (APRN) had seen Resident #51 for a breast examination and indicated a new order for a mammogram and breast ultrasound was obtained. Additionally, the nurse's note dated 3/7/19 indicated a message was left for the scheduler to schedule the appointment. The quarterly MDS assessment dated [DATE] identified the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers and personal hygiene. A quarterly MDS assessments dated 6/29/19 and 9/29/19 indicated Resident # 51 had no cognitive dysfunction and no behaviors. A RCP dated 10/1/19 identified a problem related to Resident # 51 does not always remember and misinterpret events. Interventions included: to provide him/her with pad and pen to write down date, time, details and to provide the resident with the Director of Nursing Services (DNS) card to have a point of contact for concerns. An interview on 11/24/19 at 12:04 P.M. with Resident # 51 indicated he/she was supposed to have a mammogram but never received an appointment. An interview and review of facility documentation with the Assistant Director of Nursing Services (ADNS) on 11/26/19 at 9:19 A.M. identified when a Nurse Practitioner (NP) writes an order he/she (ADNS) places the order in the computer and then the appointment is made by the scheduler. The ADNS was unable to explain why Resident #51 was not scheduled for the mammogram and ultrasound. An interview with the Scheduler # 1 on 11/26/19 at 10:06 A.M. identified that he/she had never received a message to schedule a mammogram and ultrasound for Resident # 51. Subsequent to surveyor inquiry, the DNS indicated that he/she would schedule a mammogram and a breast ultrasound for Resident # 51 to be done as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, review of facility documentation, and review of facility policies and procedures for one of three residents in the survey sample reviewed for pressure ulcers (Resident # 307), the facility failed to ensure interventions were implemented to ensure offloading and positioning/repositioning were performed to prevent the development of a pressure ulcer. The findings include: Resident #307's diagnoses included functional quadriplegia, osteoarthritis, vascular dementia, and anemia. The annual MDS assessment dated [DATE] identified the resident was moderately cognitively impaired , required extensive assistance of two people for bed mobility , total dependence for transfers, noted at risk for developing pressure ulcer/injuries and no unhealed pressure ulcer/injuries. Additionally, the annual MDS assessment dated [DATE] directed staff to provide a pressure reducing device for the chair and bed but failed to reflect the resident was on a turning and repositioning program. A Pressure Ulcer Risk assessment dated [DATE] identified Resident #307 scored a 12 indicating he/she was a high-risk for pressure ulcer development. A quarterly MDS assessment dated [DATE] identified Resident #307 had severe cognitive impairment, totally dependent on facility staff for bed mobility and transfers, and was at risk for pressure ulcer development /injuries and noted no unhealed pressure ulcer/injuries. The assessment also failed to reflect that Resident # 307 was on a turning and repositioning program. A RCP dated 7/6/19 identified Resident #307 was at risk for pressure ulcers related to impaired mobility. Interventions included : to turn and reposition every two to three hours, observe skin for signs and symptoms of potential skin breakdown, provide a pressure relieving/reducing device as ordered, and to off load heels. A nurse's note dated 9/18/19 at 11:01 A.M. identified Resident #307 had an intact blister to the left heel measuring 2.0 Centimeter (CM) x 2.5 CM. Heel boots were applied. A new order from the APRN directed skin prep twice daily and a wound Medical Doctor (MD) evaluation on 9/19/19. A physician's order dated 9/18/19 directed to apply skin prep twice daily to the left heel blister. If the blister ruptures to apply dry dressing. Review of the facility Pressure Injury Prevention and Management policy 2017 notes in part,directs an environment and program to prevent the development of pressure injuries will be maintained unless clinically unavoidable. The policy also notes a plan of care is developed by the Interdisciplinary Team (IDT) based on the resident's assessed needs and risk factors taking into consideration the resident's goals of treatment. Appropriate interventions will be implemented such as pressure reduction mattress, pressure reduction cushion in wheelchair, offloading of heels, positioning /repositioning. A review of the clinical record, facility documentation, and interview on 11/25/19 at 9:57 A.M. with Registered Nurse (RN # 1) indicated he/she was unable to provide documentation that Resident # 307 was being turned and positioned every two to three hours or that the resident's heels were off loaded prior to the development of the left heel pressure ulcer on 9/18/19. RN #1 identified that even though Resident #307 was a high risk for pressure ulcer development according to the Braden scale dated 6/23/19, he/she did not identify that Resident # 307 was at risk. RN #1 also indicated that in-servicing was conducted for off-loading in May of 2019 and he/she was constantly reminding staff to ensure that all resident's heels were off-loaded. RN #1 identified that Resident #307 moved around in his/her bed, moving his/her legs around and that Resident # 307 may have developed the left heel pressure ulcer due to leg movement that caused the heels to no longer be off-loaded. RN #1 also indicated Resident 307 had never flagged in her/his head and therefore no further preventative measures such as an air mattress were implemented prior to the development of the left heel pressure ulcer. RN #1 identified that the nurse aides were responsible for off-loading the resident's heels and the charge nurses were responsible for ensuring the nurse aides performed the off-loading of Resident #307's heels. RN #1 indicated that although the resident care plan identified heel off-loading, he/she was unable to provide documentation that the nurse aides off-loaded Resident # 307's heels every shift and that the charge nurses' were monitoring to ensure Resident # 307's heels were off-loaded every shift.