**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for medication storage, the facility failed to ensure a narcotic medication was removed from the medication cart timely following the resident's death within the facility. The findings include: Resident #1's diagnoses included cellulitis (bacterial skin infection), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet) and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 11), required setup assistance for eating and bed mobility and supervision assistance with transfers. The Resident Care Plan (RCP) dated [DATE] identified that Resident #1 had a terminal illness and end of life and continued decline is expected. Interventions included pain management and administering medications as ordered. A physician's order dated [DATE] directed to administer Dilaudid (narcotic pain medication) oral liquid, four (4) milliliters (mL) by mouth every three (3) hours as needed for severe pain. The physician's order was noted to have an end date of [DATE]. A nurse's note dated [DATE] at 3:29 AM identified, in part, that Resident #1 was observed to have no breathing and no pulse and was pronounced dead at 3:04 AM. Review of the pharmacy Controlled Substance Disposition Record for the Dilaudid with prescription number R52895700 identified the medication was received by the facility on [DATE] and last administered to Resident #1 on [DATE]. It identified that the Dilaudid was removed from the medication cart and 'Returned to the Office' on [DATE] (20-days after Resident #1's death). Interview with LPN #2 on [DATE] at 9:42 AM identified that within a few days of Resident #1's death, she requested the previous DNS take possession of Resident #1's Dilaudid and indicated there were a lot of narcotics to count in the medication cart. She identified the DNS stated no and that he didn't have time for that, and refused to sign-off on the removal of the Dilaudid. Interview with the previous DNS on [DATE] at 12:59 PM identified he was employed at the facility for two months up until [DATE]. He reported he did not take possession of any narcotics from nursing staff and there were not many narcotics in the medication carts because it was a small facility. He identified he was not concerned with diversion or misappropriation of the narcotics and stated that removing the narcotics from the medication carts were not his top priority, as a lot was going on within the facility. He was unable to explain medication cart audits, how often they were to be done and if he had completed them while employed at the facility. Interview with RN #2 (the ADNS) on [DATE] at 1:49 PM identified that narcotics were not being removed from the medication carts timely following residents being discharged and expiring. She identified that when she was reemployed by the facility in May of 2025, she removed a bunch of narcotics from the medication carts and indicated they should have been removed as soon as possible or within a few days after a resident is no longer in the facility. She reported that Resident #1's Dilaudid was not removed from the medication cart timely. Interview with RN #1 (Regional) on [DATE] at 2:15 PM identified that when a resident is discharged or expires, the charge nurse should notify the DNS and request the DNS co-sign for the removal of the narcotic on the pharmacy disposition sheet. Once it is removed from the medication cart, the DNS is to put the narcotic in the designated double locked cabinet and destruction of narcotics is to be completed monthly. RN #1 identified that the narcotics should be removed from the medication cart within a day or two after a resident is no longer in the facility. RN #1 identified she co-signed the removal of Resident #1's liquid Dilaudid on [DATE] with RN #2, which was not a timely removal. Review of the Disposal/Destruction of Expired or Discontinued Medications policy dated [DATE] directed, in part, that once an order to discontinue a medication is received, facility staff should remove the medication from the resident's medication supply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for three (3) of three (3) residents (Residents #1, 2 and 3) reviewed for skin impairments, the facility failed to review and revise the Resident Care Plans (RCP) to include additional interventions to prevent further deterioration following the identification of new skin impairments. The findings include: 1. Resident #1's diagnoses included cellulitis (bacterial skin infection), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet) and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 11), required setup assistance for eating and bed mobility and supervision assistance with transfers. A nurse's note dated 3/16/25 at 7:51 AM by RN #5 identified Resident #1 had an irregularly shaped open area to the right lateral (outer) foot, the area was painful, and warm to touch. The note identified Resident #1 needed podiatry (foot) services and/or a wound care follow-up and that an order was obtained to cleanse the area and apply a scant (tiny) amount of Santyl (an ointment that's used to remove damaged tissue from skin ulcers and severely burned areas) followed by a dry dressing and gauze wrap to protect the area daily and as needed. Review of the facility census identified Resident #1 was admitted to the hospital from [DATE] through 3/26/25. Review of the hospital documentation dated 3/19/25 identified Resident #1 was noted with diffuse (spread over a wide area) rheumatoid arthritis nodules (firm lumps under the skin that form close to joints), an open foot ulcer and lower extremity cellulitis. The documentation identified the skin impairments as a right upper calf rash, an ulcer to the right medial (closer to the midline) first toe and an ulcer to the right posterior (backside) calf. The Nursing admission assessment dated [DATE] identified Resident #1 was readmitted to the facility with right lower leg cellulitis and a right medial (closer to the midline) foot vascular wound (an open sore that develops due to problems with blood circulation and can be slow to heal). A wound physician note dated 4/2/25 at 4:13 PM identified Resident #1 was evaluated for right lower leg and right foot wounds. The note reported the wounds were full thickness (extending through all layers of the skin and can affect deeper tissues like muscle, bones or tendons) and that only the largest of the two (2) wounds were measured identifying the size as 20 centimeters (cm) by 16 cm by 1.5 cm with 25 to 49 percent (%) granulation tissue (newly formed connective tissue that develops at the wound site in the process of healing), 50 to 74 % slough (a collection of dead tissue and debris that's a pale yellow or brown color and can hinder the healing process) and a moderate amount of serosanguinous drainage (a thin and watery fluid that's pink in color due to small amounts of red blood cells). The Resident Care Plan (RCP) dated 4/22/25 (36-days after the skin impairements were identified and 4-days after the resident passed away at the facility) identified Resident #1 was at risk for skin breakdown due to decreased mobility and incontinence and other risk factors included poor nutrition, pronounced bony prominences (bones close to the surface), poor circulation and altered sensation. The RCP identified that on 3/26/25 Resident #1 was identified with cellulitis of the lower extremities. Interventions included inspecting skin when providing care for signs and symptoms of skin breakdown and consulting with the wound care nurse as ordered/needed. Interview with LPN #1 on 5/21/25 at 12:45 PM identified Resident #1 had rheumatoid arthritis nodules to both lower extremities since admission and they should have been documented in the RCP. 2. Resident #2's diagnoses included subarachnoid hemorrhage (a type of stroke where bleeding occurs in the space between the brain and the tissue covering the brain) and epilepsy (repeated seizures due to abnormal electrical signals produced by damaged brain cells). The RCP dated 3/11/24 identified Resident #2 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required substantial assistance for bed mobility and was dependent on staff for personal hygiene and transfers. The facility wound tracker identified Resident #2 acquired a right lateral foot pressure ulcer on 12/30/24 and a right lateral ankle pressure ulcer on 2/13/25. The facility wound tracker identified that as of 5/14/25 the right lateral foot pressure ulcer and the right lateral ankle pressure ulcer were still open, requiring wound care treatments. A nurse's note dated 5/14/25 at 7:15 PM identified the right lateral ankle and right lateral foot pressure ulcers remained unhealed and that the RCP was updated with new interventions as appropriate. Review of the clinical record failed to identify revisions or additional interventions were added to the RCP since 3/11/24 (one year, two months ago). 3. Resident #3's diagnoses included dementia without behavioral disturbances, type 2 diabetes mellitus, peripheral vascular disease (a circulatory condition when narrowed blood vessels reduce the blood flow to the limbs) and neuropathy (weakness, numbness and pain from nerve damage most often in the hands and feet). The Resident Care Plan (RCP) dated 6/18/24 identified Resident #3 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), was independent with bed mobility and dependent on staff for personal hygiene and transfers. A nurse's note dated 4/26/25 at 1:52 PM identified Resident #3's family member notified nursing of redness between the right great toe and right second toe. The note identified the area was assessed, cleansed, dried and lambs wool was applied to the area followed by gauze, Resident #3 denied pain and the Advanced Practice Registered Nurse (APRN) was notified. The facility wound tracker identified Resident #3 acquired a right second toe diabetic wound on 4/30/25. A nurse's note dated 5/14/25 at 7:39 PM identified the right second toe wound remained unhealed and that the RCP was updated with new interventions as appropriate. Review of the clinical record failed to identify any revisions or additional interventions to the RCP since 6/18/24 (eleven months ago). A nurse's note dated 5/20/25 at 1:13 PM identified, in part, that Resident #3 was receiving doxycycline (antibiotic) for a right second toe infection with no adverse (unwanted) effects. Interview with RN #2 (Infection Control nurse) on 5/21/25 at 1:35 PM identified that upon the discovery of a new skin impairment, the charge nurse is responsible for initiating/revising the RCP. She identified that if any additional interventions need to be added or if she evaluates the resident with the wound physician and new recommendations or interventions are initiated, she would be responsible for revising the RCP. RN #2 reported that the skin RCP's for Residents #1, 2 and 3 should have been revised following the discovery of skin impairments but was unable to explain why interventions had not been added timely to prevent further deterioration of the skin. Interview with RN #1 on 5/21/25 at 2:01 PM identified that RCP's should be an interdisciplinary effort but reported that for any resident change in condition, including a new skin impairment, the charge nurse or whoever assessed the area should initiate/revise the RCP immediately and then RN #2 would be responsible for ensuring the revision was made and further revising the RCP with any updated interventions and changes until the area is healed. RN #1 identified that she was unaware the RCP's of Residents #1, 2 and 3 had not been revised timely and that the RCP should be revised immediately but not to exceed 72-hours. Interview with RN #4 on 5/21/25 at 2:32 PM identified that following a new skin ulcer or skin irregularity, the charge nurse or RN #2 should have updated the RCP immediately to include a new intervention to prevent worsening of the area. She identified that she was unsure why the RCP hadn't been revised for Residents #1, 2 and 3 but reported she would revise the RCP for areas she identified as missing and for Resident #1, she updated the 3/26/25 occurrence when she closed out the MDS following his/her death in the facility. Review of the Wound and Skin Care Protocol policy (undated) directed, in part, that weekly body audits will be completed on bath/shower day by a licensed nurse and all skin areas will have weekly documentation until healed. The interdisciplinary plan of care will address problems, goals and interventions directed towards the prevention and/or treatment of impaired skin integrity/pressure ulcer, consistent with resident/family goals. The care plan including the admission/readmission care plan will address preventative and/or treatment of impaired skin integrity/pressure ulcer. Review of the Care Planning policy dated 10/30/20 directed, in part, that the care plan is developed by the Interdisciplinary Team (IDT) in collaboration with the resident and/or family/responsible party and the resident's physician. The IDT may include, but is not limited to, the Resident Care Coordinator, Charge Nurse, NA, Dietary Manager or Dietician, Social Worker, Rehab Therapist and Activities Director. The care plan will include: a statement of the problem/focus; reasonable and measurable goals; interventions to achieve these goals and the discipline(s) responsible for carrying out the interventions. The care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the residents' status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for three (3) of three (3) residents (Residents #1, 2 and 3) reviewed for skin impairments, the facility failed to complete weekly skin assessments per physician's order. The findings include: 1. Resident #1's diagnoses included cellulitis (bacterial skin infection), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet) and chronic pain syndrome. A physician's order dated 1/23/25 directed that a body audit was to be completed weekly on the shower day. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 11), required setup assistance for eating and bed mobility and supervision assistance with transfers. Review of the Weekly Body Audit dated 2/20/25 identified that a body audit was completed, and no new areas were identified. Review of the clinical record from 2/21/25 through 3/15/25 failed to identify any further Weekly Body Audits for Resident #1. A nurse's note dated 3/16/25 at 7:51 AM by RN #5 identified Resident #1 had an irregularly shaped open area to the right lateral (outer) foot, the area was painful, and warm to touch. The note identified Resident #1 needed podiatry (foot) services and/or a wound care follow-up and that an order was obtained to cleanse the area and apply a scant (tiny) amount of Santyl (an ointment that's used to remove damaged tissue from skin ulcers and severely burned areas) followed by a dry dressing and gauze wrap to protect the area daily and as needed. Review of the facility census identified that Resident #1 was admitted to the hospital from [DATE] through 3/26/25. Review of the hospital documentation dated 3/19/25 identified Resident #1 was noted with diffuse (spread over a wide area) rheumatoid arthritis nodules (firm lumps under the skin that form close to joints), an open foot ulcer and lower extremity cellulitis. It reported Resident #1 had a [NAME] Blood Cell (WBC) count of 15.7 (signaling infection) and Resident #1 was continued on antibiotics and admitted for further evaluation. The documentation identified the skin impairments as a right upper calf rash, an ulcer to the right medial (closer to the midline) first toe and an ulcer to the right posterior (backside) calf. The Nursing admission assessment dated [DATE] identified Resident #1 was readmitted to the facility with right lower leg cellulitis and a right medial (closer to the midline) foot vascular wound (an open sore that develops due to problems with blood circulation and can be slow to heal). A wound physician note dated 4/2/25 at 4:13 PM identified Resident #1 was evaluated for right lower leg and right foot wounds. The note reported the wounds were full thickness (extending through all layers of the skin and can affect deeper tissues like muscle, bones or tendons) and that only the largest of the two (2) wounds were measured identifying the size as 20 centimeters (cm) by 16 cm by 1.5 cm with 25 to 49 percent (%) granulation tissue (newly formed connective tissue that develops at the wound site in the process of healing), 50 to 74 % slough (a collection of dead tissue and debris that's a pale yellow or brown color and can hinder the healing process) and a moderate amount of serosanguinous drainage (a thin and watery fluid that's pink in color due to small amounts of red blood cells). The Resident Care Plan (RCP) dated 4/22/25 (36-days after the skin impairments were identified and 4-days after the resident passed away at the facility) identified Resident #1 was at risk for skin breakdown due to decreased mobility and incontinence and other risk factors included poor nutrition, pronounced bony prominences (bones close to the surface), poor circulation and altered sensation. The RCP identified that on 3/26/25 Resident #1 was identified with cellulitis of the lower extremities. Interventions included inspecting skin when providing care for signs and symptoms of skin breakdown and consulting with the wound care nurse as ordered/needed. 2. Resident #2's diagnoses included subarachnoid hemorrhage (a type of stroke where bleeding occurs in the space between the brain and the tissue covering the brain) and epilepsy (repeated seizures due to abnormal electrical signals produced by damaged brain cells). The RCP dated 3/11/24 identified Resident #2 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), required substantial assistance for bed mobility and was dependent on staff for personal hygiene and transfers. A physician's order dated 1/27/24 directed a body audit be completed on admission and weekly by a licensed nurse on shower day and that it was to be documented on the body audit form. The facility wound tracker identified Resident #2 acquired a right lateral foot pressure ulcer on 12/30/24 and a right lateral ankle pressure ulcer on 2/13/25. Review of the Weekly Body Audit dated 2/2/25 identified that a body audit was completed, and no new areas were identified. Review of the clinical record from 2/3/25 through 5/21/25 failed to identify any further Weekly Body Audits for Resident #2. Review of nurse's notes from 2/6/25 through 5/21/25 failed to identify any documentation on the resident's wounds the week of 3/9/25, the week of 4/13/25, the week of 4/20/25, the week of 4/27/25 or the week of 5/4/25. A nurse's note dated 5/14/25 at 7:15 PM identified the right lateral ankle and right lateral foot pressure ulcers remained unhealed and that the RCP was updated with new interventions as appropriate. The facility wound tracker identified that as of 5/14/25 the right lateral foot pressure ulcer and the right lateral ankle pressure ulcer were still open, requiring wound care treatments. 3. Resident #3's diagnoses included dementia without behavioral disturbances, type 2 diabetes mellitus, peripheral vascular disease (a circulatory condition when narrowed blood vessels reduce the blood flow to the limbs) and neuropathy (weakness, numbness and pain from nerve damage most often in the hands and feet). The Resident Care Plan (RCP) dated 12/17/24 identified Resident #3 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included inspecting the skin when providing care for signs and symptoms of breakdown, offloading heels while in bed and consulting with the wound care nurse as ordered/needed. A physician's order dated 12/31/24 directed a body audit be completed on admission and weekly by a licensed nurse on shower day and that it was to be documented on the body audit form. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), was independent with bed mobility and dependent on staff for personal hygiene and transfers. Review of the clinical record from 3/1/25 through 4/14/25 failed to identify any completed Weekly Body Audits. A physician's order dated 4/15/25 directed that a body audit was to be completed weekly by a licensed nurse on shower day. Review of the clinical record from 4/15/25 through 4/25/25 failed to identify any completed Weekly Body Audits. A nurse's note dated 4/26/25 at 1:52 PM identified Resident #3's family member notified nursing of redness between the right great toe and right second toe. The note identified the area was assessed, cleansed, dried and lambs wool was applied to the area followed by gauze, Resident #3 denied pain and the Advanced Practice Registered Nurse (APRN) was notified. The facility wound tracker identified Resident #3 acquired a right second toe diabetic wound on 4/30/25. Review of nurse's notes from 4/27/25 through 5/14/25 failed to identify weekly skin notes until 5/14/25. A nurse's note dated 5/20/25 at 1:13 PM identified, in part, that Resident #3 was receiving doxycycline (antibiotic) for a right second toe infection with no adverse (unwanted) effects. Interview with RN #1 (Regional) on 5/21/25 at 2:01 PM identified that all residents are to have a skin/body audit weekly and that nursing should follow physician's orders. She was unsure why weekly skin audits were not done consistently for Residents #1, 2 and 3 but indicated they should have been. She reported that around mid-April 2025, the company adopted a new skin process where licensed nurses only chart by exception and if a new skin area is found, nurses should document the area in the clinical record, notify the provider and transcribe any new orders. RN #1 was unsure why the physician's orders for Residents #2 and #3 still directed to document the skin assessment on the body audit form but identified that prior to mid-April, licensed nurses should have been documenting on the Body Audit Form for each resident weekly. Although attempted, an interview with RN #5 was not obtained. Review of the Wound and Skin Care Protocol policy (undated) directed, in part, that weekly body audits will be completed on bath/shower day by a licensed nurse and all skin areas will have weekly documentation until healed. The interdisciplinary plan of care will address problems, goals and interventions directed towards the prevention and/or treatment of impaired skin integrity/pressure ulcer, consistent with resident/family goals. The care plan including the admission/readmission care plan will address preventative and/or treatment of impaired skin integrity/pressure ulcer. Although requested, a policy on following physician's orders was not obtained.?

Based on observations, review of the clinical record, review of facility policy/procedures and interviews for nine (9) of nine (9) residents (Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11) reviewed for Enhanced Barrier Precautions (EBP), the facility failed to ensure trash cans were positioned inside the residents rooms and near the exit for discarding Personal Protective Equipment (PPE) after removal and failed to ensure periodic monitoring of resident rooms with EBP supplies and staff adherence to EBP. The findings include: Review of the facility Multidrug Resistant Organisms (MDRO) and Precautions Log dated 5/14/25 identified that Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11 were on precautions, requiring PPE. Observations and interview with RN #2 (Infection Control nurse) on 5/21/25 at 1:35 PM failed to identify that trash receptacles were placed in the doorways of Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11's room. The closest trash receptacles in each room were located behind closed doors of the bathrooms. RN #2 identified she was responsible for ensuring each room had the proper precaution supplies, spot checking rooms intermittently to ensure proper precaution signage, PPE was available and in place, a trash receptacle was located inside each doorway and that staff were donning and doffing PPE appropriately when entering and exiting identified rooms. She identified she had not done the spot checks. RN #2 reported that the MDRO and Precautions Log was up-to-date and that Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11 required precautions. Additionally, she identified that the facility did not have enough trash receptacles available for all the residents currently on precautions and reported that she was going to the store to purchase more. Interview with NA #4 on 5/21/25 at 1:42 PM identified that since a trash receptacle was not available to discard PPE upon exiting residents' rooms, she either removed the PPE and placed it in the bathroom trash or in the community trash in the hallway. She identified there was a shortage of trash receptacles within the facility. Interview with RN #1 (Regional nurse) on 5/21/25 at 2:01 PM identified that for infection control, trash receptacles should be located inside the doorway of each resident room on precautions for easy disposal of contaminated PPE. She reported she was unaware that trash receptacles were not located inside the doorway of Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11's room. Observation on 5/22/25 at 10:58 AM identified covered trash receptacles were located inside the doorway of Residents #2, 4, 5, 6, 7, 8, 9, 10 and 11's room. Review of Center for Disease Control (CDC) guidance for the Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24 identified that when implementing Contact Precautions or Enhanced Barrier Precautions, a trash can is to be positioned inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. Additionally, it identified that the facility is to incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. Although received, the Enhanced Barrier Precautions policy dated 5/5/24 did not speak to trash receptacle location or periodic monitoring to the adherence of EBP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Tag: F677 Based on clinical record reviews, review of pictures submitted by complainant, facility documentation, facility policy and interviews for one (1) of two (2) sampled residents (Resident #2) who was reviewed for personal and oral hygiene, the facility failed to provide daily personal hygiene including oral care and nail care. The findings include: Resident #2's diagnoses included dementia, pneumonia, and a history of falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was severely cognitively impaired, required extensive assistance with all daily living skills and was always incontinent of bowel and bladder. The Resident Care Plan dated 10/6/20 identified Resident #2 resisted care at times and required assistance with all daily living skills. Interventions directed to educate the resident on the possible outcome of resisting care, encourage resident to participate in care, give clear explanations of all care, if resistive with care, reassure resident, and re approach in five (5) to ten (10) minutes and notify nurse if resident continues to refuse, assist resident daily with washing, dressing, grooming, bathing, and mouth care, and assist with transfer out of bed. Review of the nurse aide treatment sheets for January 2021 failed to identify Resident #2 was receiving personal care as ordered on each shift. There were multiple entries left blank and multiple entries that identified care was not provided in an entire day. The nurse's notes for January. 2021 failed to identify any reason Resident #2 was not receiving personal or oral care. Review of pictures of Resident #2 taken by the complainant upon the Resident's transfer to the Emergency Department on 1/26/21, identified Resident #2 had long, jagged fingernails, with unidentifiable dark markings around the bed and sides of some of the nails. Some of the toenails were longer than others, jagged, and curved. A video provided by the complainant identified a hospital staff member evaluating Resident #2's oral cavity and providing oral care. Prior to the oral care the resident had large amounts of debris in his/her mouth, on the teeth, and around the gum line. After the oral care, the debris was gone and the teeth and gums appeared clean. Interview with the Administrator and the Director of Nursing (DON) on 11/14/24 at 4:15 PM identified there should not have been any missing signatures on the nurse aide care documentation sheets and nurse aides were expected to document every shift. The DON further identified staff were allowed to trim fingernails. The Administrator and DON further identified if staff were not following the treatment plan and providing care as directed, they were not following the facility policy. Review of the facility policy Nail Care identified the facility was responsible to keep the residents' nails clean and to prevent injury to keep them short and smooth. The policy further identified residents are provided nail care weekly and as needed and toenails may be trimmed by a podiatrist or nursing staff. Diabetic toenails were to be trimmed by a podiatrist only. (Resident #2 did not have a diagnosis of Diabetes).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Residents #257, 258, and 260) reviewed for advance directives, the facility failed to review and obtain, upon the residents' admission, the advance directives and code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops). The findings include: 1. Resident #257 was admitted to the facility on [DATE] with diagnoses that included alcoholic cirrhosis of the liver with ascites, muscle weakness, and difficulty walking. Review of the clinical record identified that Resident #257 was responsible for self and the admission MDS had not yet been completed. The baseline care plan dated [DATE] identified Resident #257 needed assistance with activities of daily living (ADLs). Interventions included advance directives per the physician's order. A Medical Interventions Consent form dated [DATE] and signed only by the physician, was blank and did not identify Resident #260's choice(s) for the administration of life support systems in the event of a medical emergency. The form included the following options for the residents to choose from. a. Cardiopulmonary Resuscitation (CPR). b. Do not resuscitate/Do not intubate (DNR/DNI). c. Artificial means of nutrition. d. Intravenous (IV) fluids. d. Hospitalization. e. Other specific requests. The physician's orders dated [DATE] through [DATE] failed to identify an order for Resident #257's code status (code status directs the medical team to administer or withhold life support systems in the event of a cardiac or respiratory arrest). A Medical Interventions Consent form, signed by the resident, and dated [DATE] identified Resident #257's choices regarding the administration of life support systems were CPR, artificial means of nutrition, IV fluids, and hospitalization. An undated physician's order directed Resident #257's code status as a full code (full code directs the medical team to take all possible measures to save the residents' life in the event of a medical emergency). Interview and review of the clinical record with RN #1 on [DATE] at 1:18 PM identified that an order was written on [DATE] directing Resident #257 to be a full code and the Medical Interventions Consent form was completed and signed by Resident #257 on [DATE] (5 days after admission). RN #1 further identified that Resident #257 was responsible for self and that she would expect that the Medical Interventions Consent form and a physician's order to be completed on admission. Interview and review of the clinical record with the DNS on [DATE] at 1:51 PM identified that there should not have been a delay in completing Resident #257's Medical Interventions Consent form and obtaining a physician's code status order. The DNS further identified that it is the responsibility of the nursing supervisor on the floor to review the Medical Interventions Consent form with the resident and then obtain the appropriate order, at the time of admission or within 24 hours. 2. Resident #258 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis, chronic obstructive pulmonary disease, and a non-ST elevation myocardial infarction. Review of the clinical record identified that Resident #258 was responsible for self and the admission MDS had not yet been completed. The baseline care plan dated [DATE] identified Resident #258 required assistance with activities of daily living (ADLs). Interventions included Advance Directives per the physician's order. A Medical Interventions Consent form in the record was blank and did not identify Resident #258's choice(s) for the administration of life support systems in the event of a medical emergency. The form included the following options for the residents to choose from. a. Cardiopulmonary Resuscitation (CPR). b. Do not resuscitate/Do not intubate (DNR/DNI). c. Artificial means of nutrition. d. Intravenous (IV) fluids. d. Hospitalization. e. Other specific requests. The physician's orders dated [DATE] through [DATE] failed to identify an order for Resident #258's code status. A Medical Interventions Consent form signed and dated [DATE] identified Resident #258's choices regarding the administration of life support systems were CPR, artificial means of nutrition, IV fluids, and hospitalization. A Physician's order dated [DATE] directed Resident #258 as a full code. Interview and review of the clinical record with RN #1 on [DATE] at 1:18 PM identified that an order was written on [DATE] directing Resident #258 to be a full code and the Medical Interventions Consent form was completed and signed by Resident #258 on [DATE] (5 days after admission). RN #1 further identified that Resident #258 was responsible for self and that she would expect that the Medical Interventions Consent form and a physician's order to be completed and in the clinical record on admission. Interview and clinical record review with the DNS on [DATE] at 1:51 PM identified that there should not have been a delay in completing Resident #258's Medical Interventions Consent form and obtaining a physician's code status order. The DNS further identified that it is the responsibility of the nursing supervisor on the floor to review the Medical Interventions Consent form with the resident and then obtain the appropriate order, at the time of admission or within 24 hours. 3. Resident #260 was admitted to the facility on [DATE] with diagnoses that included syncope, neoplasm of the brain, and first- and second-degree atrioventricular blocks. Review of the clinical record identified that Resident #260 was responsible for self and the admission MDS had not yet been completed. The baseline care plan dated [DATE] identified Resident #260 needed assistance with activities of daily living (ADLs). Interventions included Advance Directives per the physician's order. A Medical Interventions Consent form in the record was blank and did not identify Resident #260's choice(s) for the administration of life support systems in the event of a medical emergency. The form included the following options for the residents to choose from. a. Cardiopulmonary Resuscitation (CPR). b. Do not resuscitate/Do not intubate (DNR/DNI). c. Artificial means of nutrition. d. Intravenous (IV) fluids. d. Hospitalization. e. Other specific requests. The physician's orders dated [DATE] through [DATE] failed to identify an order for Resident #260's code status. A signed Medical Interventions Consent form dated [DATE] identified Resident #260's choice regarding the administration of life support systems was DNR/DNI. A physician's order dated [DATE] directed Resident #260's code status as a DNR/DNI, RN may pronounce death. Interview with RN #1 on [DATE] at 1:18 PM identified that she had received a telephone order from the APRN directing Resident #260's code status to be a DNR/DNI, and she had Resident #260 complete and sign the Medical Interventions Consent form, earlier that day (4 days after admission). RN #1 further identified that Resident #260 was responsible for self and that she would expect that the Medical Interventions Consent form and a physician's order to be completed and in the clinical record on admission and if the resident can't sign for him/herself then they remain a full code (CPR) until specified otherwise by the responsible party. Interview and review of the clinical record with the DNS on [DATE] at 1:51 PM identified that there should not have been a delay in completing Resident #260's Medical Interventions Consent form and obtaining a physician's code status order. The DNS further identified that it is the responsibility of the nursing supervisor on the floor to review the Medical Interventions Consent form with the resident and then obtain the appropriate order, at the time of admission or within 24 hours. The DNS indicated that she would conduct re-education pertaining to completing the Medical Interventions Consent form and obtaining a code status order in a timely manner, and audits of advance directive documentation would also be completed. The facility's Advance Directives policy directs that upon admission to the facility, the advance directives will be reviewed with the resident and/or the resident's substitute decision maker by the licensed nursing staff or the attending physician, if a decision is made regarding advance directives, the advance directive consent form will be signed and dated by the resident or substitute decision maker, the physician, and the person who explained the advance directives. The policy further directs that the advance directive consent form will be kept in the resident's medical record and a physician's order will be obtained regarding advance directives. If no decision is made related to advance directives the resident will remain a full code until a decision is made by the resident or substitute decision maker.

**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 4 residents (Resident #26) reviewed for accidents, the facility failed to ensure that a physician ordered medication was administered by a licensed nurse, was not left at the bedside, and was not expired and for 2 of 3 residents (Resident #31 and Resident 308) reviewed for medication administration observation, the facility failed to utilize resident identifiers to ensure the resident received the correct medication prior to administering the medication. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, heart attack, and stroke. Review of the clinical record identified that Resident #26 had a conservator of person upon admission to the facility on [DATE]. A physician's order dated [DATE] identified Resident #26 required monitoring every shift for behaviors that included refusing care. A physician's order dated [DATE] directed to administer saline nasal spray, one spray to each nostril 3 times daily for dry nose and chronic nose bleeds. The care plan dated [DATE] identified Resident #26 had a history of being resistive to care and treatments. Interventions included to discuss implications of not complying with the therapeutic regime. The quarterly MDS dated [DATE] identified Resident #26 had moderately impaired cognition, was dependent on staff with dressing, bathing, and toileting. The MDS also identified that Resident #26 had exhibited behaviors that included rejection of care 4 - 6 days but less than daily. Review of the clinical record admission through [DATE] failed to identify any evaluations, care plans or education provided related to Resident #26 self-administering medications. Observation on [DATE] at 9:05AM identified a 1.5 fluid ounce bottle of Deep Sea Premium Saline Nasal Moisturizing Spray on the resident's bedside table. The nasal spray had Resident #26's last name handwritten along the top portion of the bottle with the date [DATE]. Interview with Resident #26 at that time identified the nasal spray was provided by the facility and left with the resident at his/her bedside. Resident #26 identified that he/she used the nasal spray three times a day for dry nose to help prevent nose bleeds. Observation and interview with Resident #26 on [DATE] at 1:45 PM identified the nurse assigned to him/her removed the saline bottle his/her room. Interview with LPN #1 on [DATE] at 1:50 PM identified she was the nurse assigned to Resident #26 and had removed the saline nasal spray and discarded it. LPN #1 identified she was not sure why the nasal spray was in Resident #26's room as it was usually kept locked in the medication cart. LPN #1 identified she discarded the nasal spray because it was expired based on the date of [DATE] written on the bottle. LPN #1 identified that she threw the expired nasal spray away, opened a new bottle for Resident #26 and that the new bottle was locked in the medication cart. LPN #1 identified that medications at the facility were good for 28 days from the open date, which was written on the bottle. Interview with RN #4 (Corporate Clinical Nurse) on [DATE] at 1:55 PM identified that she was unsure why the nasal spray was at Resident #26's bedside if Resident #26 had not been evaluated for self-administration of medication and that the medication must be in a locked location if the resident was self-administering the medication. RN #4 further identified that multi dose medications for residents were labeled with an open date and the use by date was 28 days from that date. Subsequent to surveyor inquiry, RN #4 completed an evaluation for self-administration of medication for Resident #26 on [DATE] at 2:14 PM and identified Resident #26 was able to self-administer medications. The evaluation identified that Resident #26 was unable to identify any side effects of the medication. Interview with the DNS on [DATE] at 9:40 AM identified that dates written on the medication bottles varied depending on the medication. The DNS also identified that any medication provided by the facility for residents to self-administer should not be left at the bedside of the resident due to safety concerns as any medication left out in the open could be accessed by another resident. The DNS further identified that any resident who self-administered medications should have an evaluation to ensure that the resident was clinically appropriate and capable to manage medications at the bedside and to self-administer medication, and that would include providing education to the resident, having the resident provide a return demonstration of self-administering the medication, and that information would be documented in the clinical record. The DNS identified that Resident #26 had cognitive issues, a history of refusing care, medications, and noncompliance with his/her plan of care. The DNS identified she did not feel Resident #26 would be clinically appropriate to self-administer or keep medications within his/her room and she was not aware RN #4 had completed any evaluations for Resident #26. The facility policy on self-administration of medication directed that medications at the resident's bedside, including prescription and over the counter medications, should be kept in a manner that should prevent access by other residents. The policy further directed to ensure safe and appropriate self-administration, the facility would ensure the resident was able understand possible medication side effects, notify the facility staff of side effects, correctly administer the medication, and store the medication in a locked compartment. The policy also directed that residents should be regularly observed to determine the resident's cognitive and functional skills allowed for safe and appropriate continuation of self-administration, and that any issues related to observations of the resident missing medication doses, refusing medications should be reported to the DNS or supervisor immediately. The facility policy on storage and expiration dating directed that medications should be labeled when a medication had a shortened expiration date once opened, and that facility staff may record the calculated expiration date, based on the date opened, on the medication container. The policy also directed that all expired/outdated or deteriorated medications should be destroyed within pharmacy guidelines. The policy also directed that the facility should not provide/administer bedside medications without a physician/prescriber order and approval from the interdisciplinary care team and facility administration. The policy further identified that bedside medications should be stored within a locked compartment within the resident's room. 2a. Resident #308 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of liver, muscle weakness, and difficulty in walking. A physician's order dated [DATE] directed to check the identification band prior to medication administration. Observation on [DATE] at 8:04 AM during medication administration identified LPN #1 carried prepared medications to Resident #308's bedside and administered the medications. LPN #1 did not verify the identification band prior to administering the medication. Interview with LPN #1 on [DATE] at 8:05 AM identified she did not use a resident identifier when she administered the medications because she remembered Resident #308 from the day prior. 2b. Resident #31 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, congestive heart failure and acute kidney failure A physician's order dated [DATE] directed to check the identification band prior to medication administration. Observation on [DATE] at 8:50 AM during medication administration identified LPN #2 indicated she does not usually pass medications on this unit. LPN #2 was observed to prepare medications for Resident #31. Upon arrival to Resident #31's bedside, LPN #2 indicated she knew the resident and proceeded to administer the medications. Resident #31 was not wearing an identification band. Interview with LPN #2 on [DATE] at 9:25 AM indicated she would have used resident identifiers to identify Resident #31 if she did not know the resident. LPN #2 indicated she would use the name plate outside of the resident room or the electronic medical record photo for identifiers for residents she does not know. Interview with the DNS on [DATE] at 12:24 PM identified it is facility policy that resident identifiers are used prior to medication administration. Review of the Medication Administration policy directs the policy purpose is to ensure safe, accurate, and effective administration of medications to residents promoting optimal health outcomes while minimizing medication errors. The policy further directs to confirm the residents identity using at least two identifiers (e.g., name and date of birth ) before administering medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the December 2022 admission assessment revealed resident ID # 158 was admitted with a indwelling catheter. The December 18, 2022 Minimum Data Set admission Assessment revealed the resident requires extensive assistance for toilet use and personal hygiene and indicated the resident had a catheter, urinary ostomy, or no urine output for the entire 7 days. The Resident Care Card revealed that the resident had a 'foley' catheter (type of indwelling catheter). A 12/17/2022 nursing note documented very poor output from foley and the foley was flushed with some output. Review of the nursing discharge summary revealed the resident required extensive assistance with toilet use and had an indwelling urinary catheter. Further record review failed to reveal evidence of a physician's order for a catheter. Interview with the RN #3 on 8/12/24 at approximately 2:15 PM revealed there should be a diagnosis for urinary catheters and an order for the catheter. S/he indicated resident ID #148 had a foley catheter and there should have been a physician's order for the catheter. 3. The inter-agency referral report dated 8/1/24 identified Resident #259 had a past medical history of mental health issues. The report further identified Resident #259's discharge medication and orders included, 1mg Alprazolam (commonly known as Xanax), take 1 tablet by mouth, twice daily, for anxiety. Resident #259 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, anxiety, and major depressive disorder. The nursing admission assessment dated [DATE] identified Resident #259 was able to recall the following: current season, that he/she was in a nursing home, and location or room. The nursing admission assessment further identified that Resident #259 had taken the following medications more than 3 times per week: benzodiazepines, cathartics, narcotics, psychotropics, and sedative/hypnotics. A physician's order dated 8/1/24 directed to administer 1mg of Alprazolam by mouth, twice daily, for anxiety. The nurse's note dated 8/1/24 at 6:21 PM identified Resident #259's orders were reviewed and confirmed by the APRN. The baseline care plan dated 8/8/24 identified Resident #259 was at risk for changes in mood state due to diagnoses of depression and chronic illness. Interventions included to be aware of and report any changes in mood state when a new medication is added. The August 2024 MAR identified Resident #259 missed 4 doses of 1mg of Alprazolam (a benzodiazepine) on the following dates and times. 8/3/24 at 9:00 AM. 8/5/24 at 5:00 PM. 8/6/24 at 9:00 AM. 8/6/24 at 5:00 PM. The nurse's note dated 8/6/24 at 11:15 AM identified that Resident #259 complained of nausea and the nausea was entered into APRN book for evaluation. Further, Resident #259 reported 1 episode of emesis. New orders were received to administer 4mg of Zofran every 6 hours, as needed (prn) for nausea and vomiting. The pharmacy was called and the pharmacy technician identified he will STAT the medication. The nurse's note dated 8/7/24 at 12:42 PM identified prn Zofran and scheduled 1mg Alprazolam were administered with positive effect, no further episodes of anxiety or emesis reported on this shift. Interview with Resident #259 on 8/11/24 at 8:05 AM identified that he/she is supposed to take Xanax and that the facility nurses didn't understand that if a dose was missed, he/she would get sick and throw up. Resident #259 further indicated that a dose was missed shortly after being admitted to the facility; subsequently, he/she reported being sick for 2 days. Interview and review of the clinical record with LPN #1 on 8/12/24 at 7:16 AM identified that she was unable to medicate Resident #259 with 1mg Alprazolam during the morning medication pass on 8/6/24 because the medication was unavailable. LPN #1 indicated that she notified the pharmacy that the medication was unavailable, around 11:15 AM that morning and was told that there was something wrong with the prescription, but they would send the medication. LPN #1 further indicated that Resident #259 had received some of his/her prior doses utilizing the emergency box supply. Interview with Pharmacy Consultant #1 on 8/12/24 at 10:22 AM identified that the pharmacy did not receive an order for the Alprazolam or a signed prescription until 8/6/24, and the medication was delivered to the facility on 8/6/24, during the evening delivery. Interview and review of the clinical record with the RN Supervisor (RN #2) on 8/12/24 at 10:35 AM identified that she entered the order for Resident #259's Alprazolam on 8/3/24, but she was unsure why the pharmacy would not have received the order. RN #2 was also unsure about why the pharmacy did not receive the signed prescription. Interview and review of the clinical record with the DNS on 8/13/24 at 10:30 AM identified that it is her expectation that medications are administered, per the physician's order. The DNS further identified that the physician was out on 8/5/24 and 8/6/24 and that there was an issue with some of the prescriptions for controlled substances being signed. The DNS indicated that while the issue was promptly fixed and was a rare occurrence, a resident should not have missed multiple doses of a medication. Although attempted, an interview with MD #1 was not obtained. The facility's Medication Administration policy directs all medications shall be administered safely and accurately in accordance with the physician orders, facility protocols, and applicable state and federal regulations. Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #38 and 46) reviewed for accidents, the facility failed to ensure neurological assessments and post fall assessments were completed per policy, and for 1 resident (Resident #259) reviewed for behaviors, the facility failed to administer an anxiolytic medication according to the physician's order, and for 1 of 1 residents (Resident #158) reviewed for indwelling catheters, the facility failed to obtain a physician's order for the catheter. The findings include: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, left femur fracture, hypotension, and muscle weakness. The admission MDS dated [DATE] identified Resident #38 had severely impaired cognition, was dependent for chair/bed-to-chair transfers, and had sustained a fracture related to a fall, in the last 6 months. The care plan dated 8/1/24 identified Resident #38 was at risk for falls due to multiple risk factors. Interventions included maintaining commonly used articles within easy reach, provision of a clutter free environment, and analyzing previous falls to determine whether a pattern or trend could be addressed. a. The nurse's note dated 8/2/24 at 5:40 PM identified that Resident #38 was found on the floor in the hallway, outside of the Serenity room, lying next to his/her wheelchair. The note further identified that Resident #38 had poor safety awareness, multiple falls, was assisted by staff up to the wheelchair, and reported discomfort in the left hip area without external rotation or deformity observed. A reportable event form dated 8/2/24 failed to neurological checks was completed, following the unwitnessed fall. The nurse's notes dated 8/2/24 through 8/4/24 failed to identify neurological checks had been completed. b. The nurse's note dated 8/6/24 at 11:09 AM identified Resident #38 had an unwitnessed fall, no changes to mental status observed, and no changes in neurological, respiratory, or GI system status observed. A reportable event form dated 8/6/24 failed to identify neurological checks were completed following the unwitnessed fall. The nurse's notes dated 8/6/24 through 8/8/24 failed to identify neurological checks were completed. Interview and review of the clinical record with the DNS on 8/12/24 at 2:09 PM failed to identify that neurological checks had completed following the unwitnessed falls on 8/2/24 and 8/6/24. The DNS indicated that it is the responsibility of the charge nurse to complete and document neurological checks for 72 hours after an unwitnessed fall, if the resident is unable to accurately communicate if he/she hit their head, per the facility policy. The facility's Falls: Minimizing Risk of Injury policy directs that each time a resident experience a fall, an Accident and Incident (A&I) report will be completed and an interdisciplinary fall assessment to identify the potential causes of the fall. Statements will be obtained from staff members at the time of the fall. A status post A&I assessment and neurological checks will be completed if any resident that experiences an unwitnessed fall and is unable to accurately verbalize if he or she hit their head due to cognitive status or experienced any type of injury. The post A&I assessment and neurological monitoring will be documented for 72 hours. 2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included chronic myeloproliferative disease, chronic obstructive pulmonary disease (COPD) and difficulty walking. The care plan dated 2/13/24 identified Resident #46 was at risk to fall due to multiple risk factors including an unstable health condition. Interventions included to keep the call bell within reach and ensure the environment was free of clutter. The admission MDS dated [DATE] identified Resident #46 had moderately impaired cognition, was always incontinent of bowel and bladder and required maximal assistance from staff with transfers and dressing and was dependent on staff assistance for toileting. The MDS also identified Resident #46 required a wheelchair and had a history of falls within the 30 days prior to admission to the facility. A reportable event form for Resident #46 identified an unwitnessed fall on 2/26/24 at 4:15 AM. The report identified Resident #46 rolled out of bed, which was in the lowest position, and onto the floor, and that Resident #46 reported looking for his/her spouse. Interventions included initiation of neurological checks and mats on Resident #46's floor while in bed. A reportable event form for Resident #46 identified an unwitnessed fall on 3/8/24 at 9:00 PM. The report identified Resident #46 was confused and attempted to retrieve his/her shoes and slipped on the floor. Review of the clinical record failed to identify any neurological assessment documentation following Resident #46's fall on 3/8/24. Further review of the record also identified post accident and incident (A&I) assessment monitoring, which was to be done every shift for 72 hours post fall (beginning 3/8/24 3:00 PM - 11:00 PM and ending 3/11/24 7:00 AM - 3:00 PM), was completed on the following shifts: 3/9/24: 7:00 AM - 3:00 PM and 11:00 PM - 7:00 AM. 3/10/24: 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM. A reportable event form for Resident #46 identified an unwitnessed fall on 4/8/24 at 9:30 AM while in the bathroom. The report further identified Resident #46 was confused and unable to describe how the fall occurred. Review of the clinical record identified neurological assessments and post A&I assessments following Resident #46's fall on 4/8/24 were incomplete. A reportable event form for Resident #46 identified an unwitnessed fall on 4/9/24 at 5:15 PM. The report identified Resident #46 reported sliding out of his/her wheelchair while in his/her room which resulted with a skin tear to the left lower leg. Review of the clinical record identified incomplete neurological assessments and post A&I assessment monitoring following Resident #46's fall on 4/9/24. The post A&I assessment monitoring flowsheet with no identifying information related to a resident name or incident date, was included with Resident #46's clinical record and completed on 4/9/24 during the 11:00 PM - 7:00 AM shift and on 4/10/24 during the 7:00 AM - 3:00 PM shift. The clinical record failed to identify any additional documentation related to neurological or post A & I assessments for Resident #46's falls on 4/8/24 and 4/9/24. A reportable event form for Resident #46 identified an unwitnessed fall on 5/1/24 at 1:30 PM. The report identified Resident #46 was seated in his/her wheelchair and was participating in activities with other residents in the Serenity room, a lounge located on the unit. The report identified Resident #46 was then observed on the floor and was unable to articulate how the fall occurred. The clinical record failed to identify any documentation related to neurological or post A & I assessments following the 5/1/24 fall. A reportable event form for Resident #46 identified an unwitnessed fall on 7/1/24 at 2:30 PM. The report identified Resident #46 fell out of the wheelchair while in his/her room and was found on the floor in the fetal position with a bump to the right side of the forehead. The report further identified Resident #46 was unable to articulate how the fall occurred and was sent to the hospital for evaluation and returned on 7/2/24 at approximately 10:00 AM. Review of the clinical record identified neurological assessments and post A&I assessments were incomplete. Review of the clinical record identified post A&I assessments were completed following the 7/1/24 fall once daily on the 7:00 AM - 3:00 PM shift from 7/1/24 - 7/3/24 (should be done every shift for 72 hours post fall). Further, the clinical record failed to identify any additional documentation related to neurological assessments following the 7/1/24 fall. A reportable event form for Resident #46 identified an unwitnessed fall on 7/5/24 at 9:15 AM. The report identified Resident #46 was found on the floor of the Serenity room next to his/her wheelchair and reported he/she did not know what happened. Review of the clinical record identified the neurological assessment flowsheet, which did not include any information related to a resident name or date of incident, located within the 7/5/24 reportable event form for Resident #46 was completed on 7/5/24 9:15 AM, 6:15 PM, and 10:15 PM. On 7/6/24 at 2:15 AM documented resident was sleeping, no neurological assessment. On 7/6/24 during the 11:00 PM - 7:00 AM shift documented resident was sleeping, no neurological assessment and on 7/7/24 during the 11:00 PM - 7:00 AM shift. The clinical record failed to identify any additional documentation related to neurological assessments following the 7/5/24 fall. A reportable event form for Resident #46 identified an unwitnessed fall on 7/28/24 at 3:30 PM. The report identified Resident #46 was found on the floor of the Serenity room alone and reported he/she slid out of his/her wheelchair. Review of the clinical record identified one post A&I assessment completed following the 7/28/24 fall during the 3:00 PM - 11:00 PM shift. The clinical record failed to identify any additional post A&I assessments, or any neurological assessments initiated or completed related to this fall. A reportable event form for Resident #46 identified an unwitnessed fall on 8/5/24 at 1:45 PM. The report identified Resident #46 found on the floor of the Serenity room alone and was unable to identify what happened. The clinical record failed to identify any neurological assessments initiated or completed related to this fall. Interview with the DNS on 8/13/24 at 9:45 AM identified that she was aware of Resident #46's frequent falls. The DNS identified she had only been employed by the facility for approximately 8 weeks and was working to improve fall interventions for all residents. The DNS identified that for any resident who fell, the resident should have a physical assessment by a RN, including vital signs and neurological checks, and that the provider should be notified. The DNS also identified that neurological assessments should be done per facility policy for 72 hours for any unwitnessed falls and that assessments should also be done every shift for 72 hours after any accident or incident. The DNS identified that she was working with staff regarding education to improve investigations regarding falls, that appropriate interventions were added to the resident's care plan, and that assessments were documented in the clinical record per the facility policy. Review of the post A&I assessment flowsheet directed that the assessment was to be completed each shift for 72 hours following an accident or incident and to notify the physician if the assessment revealed new or worsened symptoms, and included assessment areas for skin bruising, range of motion, pain, blood pressure, pulse and respirations. The facility policy on falls identified each time resident experienced a fall, post A&I assessments would be completed and documented on for 72 hours after the fall, and that neurological checks would also be completed for 72 hours after a fall for any resident that experienced an unwitnessed fall and was unable to accurately verbalize a head strike due to cognitive status or experienced any type of head injury. The facility policy on neurological assessments directed that neurological checks were used to assess a resident's neurological status following a head injury or any other situation that might alter the resident neurological status, including a fall when a resident was unable to cognitively verbalize a head injury. The policy further directed that the neurological flow sheet would be instituted by the nurse and would be completed every 15 minutes for the first hour, every hour for 4 hours, every 4 hours for the next 24 hours, and every shift for 48 hours after that. The policy directed that the flowsheet documentation should include the date and time of the assessment, the level of consciousness, the pupillary response, the strength and sensation of the extremities, and vital signs.

**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 6 residents (Resident #46) reviewed for accidents, the facility failed to provide the necessary supervision, according to the plan of care, to prevent falls. The findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included chronic myeloproliferative disease, chronic obstructive pulmonary disease (COPD) and difficulty walking. The care plan dated 2/13/24 identified Resident #46 was at risk to fall due to multiple risk factors including an unstable health condition. Interventions included to keep the call bell within reach and ensure the environment was free of clutter. The admission MDS dated [DATE] identified Resident #46 had moderately impaired cognition, was always incontinent of bowel and bladder and required maximal assistance from staff with transfers and dressing and was dependent on staff assistance for toileting. The MDS also identified Resident #46 required a wheelchair and had a history of falls within the 30 days prior to admission to the facility. A reportable event form for Resident #46 identified an unwitnessed fall on 2/26/24 at 4:15 AM. The report identified Resident #46 rolled out of bed, which was in the lowest position, and onto the floor, and that Resident #46 reported looking for his/her spouse. Interventions included initiation of neurological checks and mats on Resident #46's floor while in bed. A reportable event form for Resident #46 identified an unwitnessed fall on 3/8/24 at 9:00 PM. The report identified Resident #46 was confused and attempted to retrieve his/her shoes and slipped on the floor. The care plan, updated on 3/21/24 (13 days post fall), included an intervention to keep Resident #46's shoes within reach. A reportable event form for Resident #46 identified an unwitnessed fall on 4/8/24 at 9:30 AM while in the bathroom. The report further identified Resident #46 was confused and unable to describe how the fall occurred. Review of the clinical record identified no new interventions were implemented following this fall. A reportable event form for Resident #46 identified an unwitnessed fall on 4/9/24 at 5:15 PM. The report identified Resident #46 reported sliding out of his/her wheelchair while in his/her room which resulted with a skin tear to the left lower leg. Review of the clinical record identified no new interventions were implemented following this fall. A reportable event form for Resident #46 identified an unwitnessed fall on 5/1/24 at 1:30 PM. The report identified Resident #46 was seated in his/her wheelchair and was participating in activities with other residents in the Serenity room, a lounge located on the unit. The report identified Resident #46 was then observed on the floor and was unable to articulate how the fall occurred. Review of the care plan following the fall identified a new intervention to reinforce the need for Resident #46 to call for assistance. A reportable event form for Resident #46 identified an unwitnessed fall on 5/15/24 at 5:30 PM. The report identified Resident #46 was found lying on his/her left side on the floor of the Serenity room, and that Resident #46 reported he/she slid down the wheelchair and rolled over. Review of the clinical record identified no new interventions were implemented following this fall. A reportable event form for Resident #46 identified an unwitnessed fall on 7/1/24 at 2:30 PM. The report identified Resident #46 fell out of his/her wheelchair while in her room and was found on the floor in the fetal position with a bump to the right side of the forehead. The report further identified Resident #46 was unable to articulate how the fall occurred and was sent to the hospital for evaluation and returned on 7/2/24 at approximately 10:00 AM. A CT scan of the head was negative. Review of the clinical record identified no new interventions were implemented following this fall. A reportable event form for Resident #46 identified an unwitnessed fall on 7/5/24 at 9:15 AM. The report identified Resident #46 was found on the floor of the Serenity room next to his/her wheelchair and reported he/she did not know what happened. Interventions implemented following this fall included not leaving Resident #46 in the Serenity room unattended due to poor safety awareness. A reportable event form for Resident #46 identified an unwitnessed fall on 7/28/24 at 3:30 PM. The report identified Resident #46 was found on the floor of the Serenity room, alone, and reported he/she slid out of his/her wheelchair. Interventions implemented on 7/31/24, 3 days post fall, included evaluating for fatigue and restlessness in the afternoon and assist Resident #46 back to bed by 2:00 PM after personal care. A reportable event form for Resident #46 identified an unwitnessed fall on 8/5/24 at 1:45 PM. The report identified Resident #46 found on the floor of the Serenity room, alone, and was unable to identify what happened. Review of the clinical record failed to identify any new interventions implemented following this fall. Review of the Resident Care Card on 8/11/24 for Resident #46 identified that the care card included a note dated 7/31/24 which identified Do not leave unattended in Serenity room. Observation on 8/11/24 at 8:37 AM of the Serenity room identified the room was located across the hallway from the nursing station, however, the location of the entrance door to the Serenity room did not allow direct visualization of the room from any viewpoint in the nurse's station. Observations identified staff would be required to stand directly at the threshold of the entrance door to visualize the entire room. Observation and interview with Resident #46 on 8/11/24 at 10:15 AM identified Resident #46 was unable to identify any information related to care or falls at the facility. Observation identified Resident #46 was seated in his/her wheelchair and was observed rocking back and forth slightly. During this observation, no staff were present in or near Resident #46's room, which was not visible unless directly positioned across from the room entrance. Multiple observations of Resident #46 were completed during the survey from 8/11/24 - 8/13/24 across all 3 shifts between the hours of 6:00 AM and 3:45 PM. During the observations, Resident #46 was not observed at any time in the Serenity room alone. Interview with the DNS on 8/13/24 at 9:45 AM identified that she was aware of Resident #46's frequent falls. The DNS identified she had only been employed by the facility for approximately 8 weeks and was working to improve fall interventions for all residents. The DNS identified that she was working with staff regarding education to improve investigations regarding falls, and that appropriate interventions were added to the resident's care plan. The DNS also identified that nursing staff at the facility had been instructed multiple times that Resident #46 was not to be left in the Serenity room without a staff member present. The facility policy on falls directed that the purpose of the policy included minimizing the resident's risk of injury when a fall occurred and to develop an interdisciplinary care plan with fall/injury prevention strategies. The policy further directed residents who experience a fall would be evaluated following the occurrence to identify the position causes of the fall and that an individualized care plan would be developed and updated as needed to identify interventions to prevent falls and minimize injuries. The policy also directed that each time a resident experienced a fall, the care plan would be revised with any interim interventions to minimize risk of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #38) reviewed for nutrition, the facility failed to ensure daily weights were completed per the physician's order. The findings include: Resident #38 was admitted to the facility on [DATE] with diagnoses that included acute chronic systolic (congestive) heart failure, Alzheimer's Disease, and anorexia. The admission MDS dated [DATE] identified Resident #38 had severely impaired cognition, had a mechanically altered and therapeutic diet and had no/unknown weight loss or gain in the last 1 or 6 months. The care plan dated 8/1/24 identified Resident #38 was at risk for cardiac issue (heart attack, chest pain, stroke) related to cardiovascular disease: congestive heart failure (CHF). Interventions included obtaining weights as ordered/per policy. The care plan further identified that Resident #38 had the potential for a nutritional decline related to multiple medical problems, need for a therapeutic diet, need or altered consistency diet, recent hospitalization, and recent surgery. Interventions included encouragement to eat meals independently and to assist as needed, provide diet as ordered, and monitor weights as ordered. A physician's order dated 7/25/24 directed to weigh once daily, in the AM. Call the physician for gain of 3 pounds or more in 24 hours or 5 pounds in one week, for CHF. Although the physician ordered daily weights on 7/25/24, review of the weight and vitals summary dated 7/25/24 through 8/12/24 identified weights were not obtained on 7/25, 7/26, 7/27, 7/28, 7/30, 7/31, 8/2, 8/3, 8/5, 8/6, 8/7, 8/8, 8/9, and 8/10 (14 of 19 weights were not obtained). Further, on 8/4/24 Resident #38 weighed 121.6 lbs., and on 8/12/24, Resident #38 weighed 113.1 lbs., an 8.5 lbs. loss which represents a 7.07% loss. Interview with LPN #1 on 8/12/24 at 11:41 AM identified that she was not aware that Resident #38 had an order for daily weights and it was not being completed because the 11:00 PM - 7:00 AM nurse aide would usually complete the weight, and the night shift charge nurse would enter the weight into the computer. LPN #1 further identified that Resident #38's weight loss was not communicated to her in report, but she had completed a reweight to confirm accuracy, and would notify the physician and resident representative of the weight loss. Interview with the RN Supervisor (RN #2) on 8/12/24 at 12:06 PM identified that she would expect Resident #38 to be weighed daily, per the physician's order. RN #2 further identified that weights are typically completed on the 11:00 PM - 7:00 AM shift, but when all the residents get their monthly weights, all shifts help with the task. Interview with LPN #3 on 8/13/24 at 7:08 AM identified that she was aware of the order for daily weights but on the nights that she was working, and the weights were missed, Resident #38 was most likely sleeping, and she didn't want to wake the resident up. LPN #3 further identified that she did not notify anyone that weights were missed. Interview and review of the clinical record with the DNS on 8/13/24 at 10:30 AM failed to identify that Resident #38's weights were completed daily. The DNS indicated that it is her expectation that weights are completed per the physician's order. The facility's Weight Monitoring policy directs that residents will be weighed weekly for 4 weeks, on admission and readmission, and then monthly, unless otherwise indicated by the physician's order and/or recommended by the Registered Dietitian.

Based on observation, review of facility documentation, facility policy and interviews the facility failed to ensure a record of receipt and disposition of controlled drugs brought into the facility from an outside pharmacy in pill bottles, in sufficient detail to enable an accurate reconciliation. The findings include: Interview with the DNS on 8/12/24 at 9:25 AM identified discontinued controlled drugs are stored in a locked file cabinet in her office until destroyed. The DNS further identified the office door acts as the second lock for the controlled drugs being stored there. Observation on 8/12/24 at 10:50 AM identified the DNS's office door was wide open with no staff in the office. Subsequent to surveyor request, the DNS was paged to the office and arrived in approximately 5 minutes. During this time, no staff were in the office, which was open. Upon entry into the office, the DNS was asked to open the file cabinet where the discontinued controlled drugs were stored. The DNS walked over to a bag in the office, approximately 2 feet from the file cabinet, and obtained a lanyard that was hanging out of the bag and visible to anyone in the office. Attached to the lanyard was the key to the file cabinet containing the controlled drugs, which had only 1 lock. Upon opening the drawer of the file cabinet, a large number of controlled drugs, including blister packs, pill bottles and liquids were observed. The DNS and Regional Clinical Nurse (RCN) identified that there were 2 controlled drugs in the drawer, which were contained in pill bottles and had been brought into the facility from an outside pharmacy, that did not have reconciliation forms. Observation of the pill bottles and count of the number of pills identified the following. Tramadol 50 mg: 3 tablets remaining, and Clonazepam 1mg: 43 tablets remaining. After a search for the absent reconciliation forms for the Tramadol and Clonazepam, the facility provided a facility Resident Medication Sheet with the resident's name and Clonazepam 1 gm written on the top (the pill bottle label indicated the medication was Clonazepam 1mg, not 1gm). All other areas of the form were blank. The form did not identify sufficient detail to allow reconciliation specifying the name and correct strength of the medication, or the quantity and date received. Further, there was a yellow Post-it stuck to the front of the form. The Post-it contained the following information. Gave one, a first initial and last name, 8:15 PM, count 44. Additionally, the form identified gave one, an unreadable signature, 8:55 PM, count 43. The Post-it did not identify sufficient detail to allow reconciliation specifying the name and strength of the medication, the quantity and date received, or the resident's name. Subsequent to surveyor inquiry, the facility contacted the nursing supervisor, RN #7 (who no longer worked for the facility) who admitted the 2 residents who brought the controlled drugs Tramadol and Clonazepam into the facility from an outside pharmacy. The facility provided an email from RN #7 dated 8/20/24 in which RN #7 indicated that the resident who brought the Tramadol was admitted on 4/4 with Tramadol 3 tabs which were stored behind 2 locked doors. Further, RN #7 wrote in the email the resident who brought in the Clonazepam was admitted on 4/6 with 45 Clonazepam which were also stored behind 2 locked doors. Observation and review of facility documentation identified there had been no reconciliation forms for the Tramadol and Clonazepam since April of 2024. The Inventory Control of Controlled Substances policy directs the facility should ensure the incoming and outgoing nurses count all Schedule II controlled substances and other medications with the risk of abuse or diversion at the change of each shift or at least once daily, and document the results on a controlled substance count verification/shift count sheet.

Deficiency Text Not Available

Based on observation, review of facility policy, and interviews for 2 of 3 residents (Resident #308 and resident 307) reviewed for medication administration observation, the facility failed to ensure licensed staff performed hand hygiene during medication administration and failed to ensure nurse aides performed hand hygiene prior to providing resident care and after removing gloves. The findings include: 1. During a medication administration observation on 8/11/24 at 7:47 AM, LPN #1 failed to perform hand hygiene during the entirety of the observation to include: before preparing medications for Resident #308, after going into the medication room to retrieve additional medications, before administering medications to Resident #308, after administering medications to Resident #308, before preparing medications for Resident #307, before administering medications to Resident #307 and after administering medications to Resident #307. An interview with LPN #1 on 8/11/24 at 8:45 AM identified she did not wash her hands during medication administration because she forgot to do so. 2. During an observation on 8/11/24 at 9:25 AM, NA #1 was observed walking in and out of 4 resident rooms (rooms: 214, 213, 212, 211) collecting dirty dishes, and clearing uneaten food into a bin on a cart in the hallway. NA #1 did not perform hand hygiene between resident rooms. Further, without the benefit of hand hygiene, NA #1 entered Resident #6's room, removed and discarded her dirty gloves in a trash can near the room entryway, did not perform hand hygiene, and proceeded directly to Resident #6's bedside. NA #1 then assisted Resident #6 with upper body positioning and adjusted the bed linens. 3. During an observation on 8/11/24 at 9:41 AM, NA #1 was observed walking in and out of 5 resident rooms (rooms: 209, 208, 207, 206, 205) collecting dirty dishes, and clearing uneaten food into a bin on a cart in the hallway, without performing hand hygiene between resident rooms. NA #1 then entered Resident #13's room, with the same dirty gloves on, opened the bathroom door, looked inside the bathroom, then walked over to the residents tray table, moved the tray table and wiped a spill off the tray table. NA #1 then returned to the dirty dish cart wearing the same dirty gloves. An interview with NA #1 on 8/11/24 at 9:45 AM identified she changes her gloves after removal of all dirty dishes, not in between rooms. NA #1 indicated she should have removed her gloves and performed hand hygiene before touching surfaces in Resident #13's room but did not know if she should have performed hand hygiene after removing her gloves and assisting Resident #6. Subsequent to surveyor inquiry, NA #1 continued down the hallway, pushing the dirty dish cart with unchanged dirty gloves on and proceeded into the lounge to continue clearing dirty dishes. An interview with the Director of Nursing (DNS) on 8/12/24 at 12:24 PM identified hand hygiene should be performed before and after entering resident rooms and before and after administering medications. The DNS further indicated staff are expected to perform hand hygiene after removing gloves. The Handwashing policy directs to perform hand hygiene before preparing or handling medications, before and after resident contact, and after removing gloves.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to store controlled drugs in a separately locked permanently affixed compartment and failed to limit access to the stored controlled drugs. The findings include: Interview with the DNS on 8/12/24 at 9:25 AM identified discontinued controlled drugs are stored in a locked file cabinet in her office until destroyed. The DNS further identified the office door acts as the second lock for the controlled drugs being stored there. Observation on 8/12/24 at 10:50 AM identified the DNS's office door was wide open with no staff in the office. Subsequent to surveyor request, the DNS was paged to the office and arrived in approximately 5 minutes. During this time, no staff were in the office, which was open. Upon entry into the office, the DNS was asked to open the file cabinet where the discontinued controlled drugs were stored. The DNS walked over to a bag in the office, approximately 2 feet from the file cabinet, and obtained a lanyard that was hanging out of the bag and visible to anyone in the office. Attached to the lanyard was the key to the file cabinet containing the controlled drugs, which had only 1 lock. Upon opening the drawer of the file cabinet, a large number of controlled drugs, including blister packs, pill bottles and liquids were observed. Interview with the DNS and RCN on 8/12/24 at 10:50 AM identified the office door should not have been left open. The DNS stated she did not think about the door over the last 2 days with everything going on and identified she was trained to keep the door closed and locked to act as a second lock for the controlled drug storage. The DNS further indicated she should have carried the key on her person rather than leaving the key in the office near the file cabinet. The following controlled drugs were stored in the cabinet in the DNS office. Oxycodone 5mg: 23 tablets. Tramadol 25mg: 7 half- tablets. Tramadol 50mg: 13 tablets. Lorazepam 0.5mg: 26 tablets. Tramadol 25mg: 24 half- tablets. Tramadol 50 mg: 85 tablets. Oxycodone 10mg: 30 tablets. Oxycodone 5mg: 23 tablets. Tramadol 50mg: 5 tablets. Oxycodone 10mg: 30 tablets. Tramadol 25mg: 24 half- tablets. Tramadol 50mg: 25 tablets. Oxycodone 5mg: 29 tablets. Diazepam 5mg: 10 tablets. Morphine Sulfate 100mg/5ml: 30ml. Lorazepam 2mg/1ml: 30ml. Morphine Sulfate 20mg/5ml: 20ml. Morphine Sulfate 100mg/5ml: 30ml. Tramadol 50mg: 6 tablets. Hydrocodone-acetaminophen 5-325mg: 24 tablets. Morphine Sulfate 100mg/5ml: 30ml. Morphine Sulfate 100mg/5ml: 26ml. Interview on 8/12/24 at 11:46 AM with the DNS identified she is in the process of being trained on narcotic destruction. The DNS identified when she was hired 8 weeks prior, the same file cabinet was full of controlled drugs. At that time, the DNS and RCN destroyed the controlled drugs. The DNS stated she has not destroyed controlled drugs since. Subsequent to surveyor inquiry, the facility permanently affixed the file cabinet, used for storing discontinued controlled drugs, to the wall, and added a second lock. The Storage and Expiration Dating of Medications and Biologicals policy directs that the facility should store all drugs and biologicals in locked compartments, including the storage of Scheduled II - V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #30) reviewed for falls, the facility failed to ensure that the resident was assessed by a registered nurse following the fall. The findings include: Resident #30's diagnoses included Parkinson's disease, diabetes mellitus and dementia with behavioral disturbances. An annual MDS assessment dated [DATE] identified Resident #30 was severely cognitively impaired, required extensive assistance of one staff member for transfers, required extensive assistance of two staff for bed mobility and was independent for locomotion on unit utilizing a wheelchair. The care plan dated 12/13/21 identified Resident #30 was a fall risk due to poor safety awareness, unsteady gait and cognitive deficits with interventions that included, ensure the environment is safe, offer toileting assistance before meals and to encourage resident to lock wheelchair before getting up. Further review of the care plan identified an intervention dated 2/8/22 that identified, have PT/OT evaluation to fix lock on wheelchair. A nursing note dated 3/3/22 at 3:53 PM identified Resident #30 was found on the floor, no injuries noted and vital signs stable. An interdisciplinary fall assessment was completed on 3/3/22 following Resident #30's fall. The assessment was completed by an LPN. Review of the clinical record failed to reflect documentation to support that a post fall assessment was performed by a registered nurse following Resident #30's fall. Interview on 3/23/22 at 7:00 AM with the Director of Nurses (DNS) identified that Resident #30's medical record lacked documentation to reflect that the resident was assessed by a registered nurse following his/her fall on 3/3/22. The DNS further identified that an assessment by the registered nurse after a fall is done in order to assess for any possible injuries. The facility's Fall policy identified that a resident who experiences a fall should be evaluated following the fall to minimize the risk of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of four sampled residents (Resident #18) reviewed for accidental hazards, the facility failed to monitor the ingestion of dietary supplements and failed to identify that the resident had non-prescription dietary supplements on his/her person. The findings include: Resident #18 was admitted to the facility in November of 2021 with diagnoses that included dementia without behavioral disturbances, hallucinations, encephalopathy, alcohol abuse and cognitive communication deficit. The quarterly MDS assessment dated [DATE] identified Resident #18 had moderately impaired cognition and was independent with eating. The care plan dated 3/14/22 identified the resident had impaired memory, recall and decision-making skills related to encephalopathy, hallucinations, and delusions. Care plan interventions included, offer medications as ordered, orient resident to room, staff and call light system and allow time for resident to respond when speaking. Observation on 3/23/22 at 10:20 AM identified four brown capsules located on top of a notepad on Resident #18's bedside table, two of the capsules appeared to be the same and the other two capsules appeared to be the same (size/color). Interview with Resident #18 on 3/23/22 at 10:25 AM identified the tablets were echinacea goldenseal complex and reishi mushroom. Resident #18 identified he/she brought them on admission, and he/she takes two tablets twice a day to maintain a healthy immune system. Observation on 3/23/22 at 10:30 AM of Resident #18 in his/her room identified he/she walked over to his/her dresser and retrieved one bottle labeled Echinacea Goldenseal Complex (no dosage identified) 100 capsules and one bottle labeled Reishi Mushroom [ROOM NUMBER],200mg, 100 capsules. Both bottles were approximately half-filled. A review of the clinical record on 3/23/22 failed to identify documentation that a self-administration evaluation had been completed or a physician's order in place that directed the use of the identified supplements. The Inventory of Personal Belongings form completed on admission did not identify that the resident was admitted with supplements. Interview with the DNS on 3/23/22 at 12:00 PM identified Resident #18 was not able to self-administer medications under any circumstance, and therefore, the facility did not perform/assess the resident for this task. The DNS identified the resident should not have any medications at bedside and was unaware of any medication currently at resident's bedside. The DNS identified the resident may have received medications from family or through the mail. Observation with the DNS on 3/23/22 at 12:15 PM identified one bottle of Echinacea Goldenseal Complex and one bottle of Reishi Mushroom in Resident #18's drawer. The DNS removed both medications from the drawer and notified APRN #1 to obtain orders for further administration. A physician's order dated 3/23/22 directed to administer Reishi Mushroom [ROOM NUMBER],200mg total, twice a day and Echinacea Goldenseal 1 capsule, twice a day. Review of the Storage and Expiration Dating of Medications policy identified the facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with Applicable Law.

Based on observations, review of facility documentation, review of facility policy/procedure and interviews, the facility failed to ensure that the glucometer was cleaned according to the manufacturer's directions following resident us. The findings include: Observation on 3/23/22 at 11:17 AM identified LPN #2 utilized a glucometer to perform a blood glucose test on Resident #189 during which LPN #2's gloves became soiled with blood. After performing the test, LPN #2 returned to the medication cart removed her gloves and proceeded to place the glucometer in the top drawer of the medication cart without the benefit of washing her hands. Once the glucometer was placed in the drawer, LPN #2 proceeded to administer medications to Resident #189. Interview with LPN #2 on 3/23/22 at 11:17 AM identified that she only cleans the glucometer prior to using it. Review of LPN #2's in-service records identified LPN #2 received education on the cleaning of the glucometer on 10/16/21. A review of the manufacturer's recommendation in regard to the cleaning of the glucometer identified that the glucometer should be cleaned and disinfected after use on each resident. Interview on 3/23/22 at 1:47 PM with the Infection Control Nurse identified that nurses are taught and are expected to clean the glucometer after use with each resident with the manufacturer's recommended cleaning agent. A review of the facility's blood glucose monitoring policy identified that the glucometer should be cleaned and disinfected after each resident use with any one of the environmental approved disinfectants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation and interviews for one sampled resident (Resident #8) who required the use of hearing aids, the facility failed to safeguard the hearing aids, refer the resident to an audiologist in a timely manner and obtain replacement hearing aids. The findings include: Resident #8's diagnoses included hypertension, gastroesophageal reflux disease, arthritis, depression, hyperlipidemia and visual deficits. A significant change MDS assessment dated [DATE] identified Resident #30 had moderately impaired cognition, had adequate hearing with the use of a hearing aide, had clear speech and was able to understand and be understood. The assessment further identified that the resident required extensive assistance with bed mobility, transfers, and dressing, and required supervision with eating and with ambulation. Observation on 3/31/22 at 10:30 AM during the initial resident pooling process identified Resident #8 requested the surveyor to come closer and to speak into his/her ear. Resident #8 identified that his/her hearing aids had been missing since last August and the facility was aware but had not assisted him/her to replace the hearing aids. A review of the August/2021 MAR (medication administration record) identified that Resident #8's hearing aids were removed and placed in the MAR for safe keeping on the evening of August 6, 2021, at bedtime. A nurse's note dated 8/7/2021 at 2:22 PM identified that Resident #8 was unable to locate his/her hearing aids in the morning and noted that the hearing aids were not in the medication cart. The note further noted that she and the nurse aide searched the unit and were unable to locate the hearing aids; in addition, the resident's POA (power of attorney) was called and updated. A care plan dated 8/17/21 identified Resident #8 had hearing impairments, utilized hearing aids in both ears, and noted the hearing aids were missing. Care plan interventions included, gain Resident #8's attention before attempting to communicate, offer audiology consult as needed, be patient with Resident #8 and offer reassurance as needed, and when talking to Resident #8 face resident directly and speak slowly and clearly. Review of facility documentation identifying residents scheduled to be seen by the audiologist identified that Resident #8 was placed on the list in February of 2022 by LPN #1 and is scheduled to be seen in April of 2022. Review of facility documentation and review of the clinical record lacked documentation that the resident was placed on the list to be seen by the audiologist or was seen by the audiologist prior to February of 2022; although, his/her hearing aids were identified as being lost since 8/7/21. A review of the facility's hearing aid(s) policy identified that licensed staff was responsible to ensure a resident's hearing aid(s) are in place and functioning daily. The policy further noted that the resident or the nurse aide may place or remove the aid(s) and if the hearing aid(s) go missing then the missing items policy will be initiated. Interview on 3/22/22 at 2:27 PM with LPN #1(MDS Coordinator) identified that the process for missing items depends on whether it is the family or the facility that is responsible. He identified that he was informed that Resident #8's hearing aids were missing a few months ago and noted that he was responsible for booking appointment for audiology consults. LPN #1 further noted that he booked an audiology consult for Resident #8 in February and identified that he had not done it earlier because of COVID relates issues. Interview on 3/22/22 2:36 PM with Social Worker #1 identified that she was out on leave during the time Resident #8's hearing aids went missing. She identified that she was updated in January of 2022. She further identified that she would have done a room search, checked in with the family and updated the Administrator; additionally, the resident would have been placed on the list to see the audiologist. Interview on 3/22/22 at 2:50 PM with the DNS identified that the MDS Coordinator (LPN #1) was responsible for scheduling audiology appointments and there had been no restrictions on consultants entering the building between 8/2021 to the present. Interview on 3/23/22 at 11:08 AM with audiology out-patient service representative identified that the last visit to facility was back in August 2020 and noted that the facility had to book appointments and then onsite visits are made. She further identified that there had been no request for audiologist services by the facility during the time period of January 2021 to December 2021. Interview on 3/23/22 at 12:15 PM with LPN #2 identified that she discovered Resident #8's hearing aids were missing on the morning of 08/07/21, reported it to the nursing supervisor and told LPN #1 the next week. Resident #8's hearing aids were normally removed by the NA and given to the charge nurse at bedtime. LPN #2 identified that Resident #8 had them in the day before because she saw them. The facility's hearing aid policy failed to address the process for replacing missing hearing aids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #25) reviewed for dignity, the facility failed to provide a cover for a personal medical device to ensure dignity and/or for one of two sampled residents ( Resident #14) reviewed for assistance with ADL, the facility failed to ensure privacy during incontinent care in effort to maintain the resident's dignity . The findings included: 1. Resident #25's diagnoses included flaccid neuropathic bladder and hemiplegia following a cerebral infarction affecting the left dominant side. The Resident Care Plan (RCP) dated 7/22/19 identified I have an indwelling catheter. Interventions directed to change catheter and bag as needed. The 14 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 was without cognitive impairment and required extensive assistance with bed mobility and transfers. A physician's order dated 7/31/19 directed to change the Foley catheter monthly and as needed with a 14 French/30 Cubic Centimeter (CC) balloon. Observation on 9/9/19 at 11:30 A.M. identified Resident #25 up in his/her wheelchair with a Foley catheter bag hanging from the bottom of the wheelchair, visibly containing yellow urine. The Foley catheter bag was dated 9/2/19 at 1:30 P.M. Observation at 12:48 PM identified the dietary staff serving lunch outside of Resident #25's room and that the Foley bag was still visible to public view. Observation and interview with RN #1 on 9/11/19 at 1:19 P.M. identified Resident #25's Foley catheter should be covered for privacy and that all the residents in the facility are supposed to have Foley catheters bags supplied by the facility with privacy screens attached to the bag. RN #1 identified that Resident #25 must have had his/her catheter bag changed at the hospital and that is why he/she did not have the bag covered. Subsequent to surveyor inquiry, Resident #25's Foley catheter bag was changed to ensure privacy. Review of the facility catheter drainage system policy, directs that the drainage bag is covered be to maintain resident privacy. 2.Resident #14's diagnoses included dementia and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was severely cognitively impaired and required the extensive assistance for bed mobility and personal hygiene and was totally dependent on staff for transfers, dressing and toilet use. The Resident Care Plan (RCP) dated 7/22/19 identified I require assistance with all of my ADL and am at risk for alterations in ski integrity. Interventions directed to provide extensive assistance with daily grooming, dressing and all ADL, provide a pressure reducing mattress in bed, off load heels and ensure gentle handling during care procedures. Intermittent observations on 9/10/19 at 9:48 AM identified Resident #14 remained on his/her back the entire time with his/her heels resting on the APM that was set to static at 250 pounds. Subsequent to surveyor inquiry, the DNS on 9/10/19 at 1:15 P.M. directed staff to provide Resident #14 with incontinence care and to reposition the resident in bed. Observation with NA #1 and Resident #14 on 9/10/19 at 1:19 PM identified NA #1 removed the resident's incontinent product and began to provide incontinent care. Resident #14's roommate was in the room with his/her resident representative. NA #1 failed to pull the privacy curtain prior to initiating incontinent care. The resident representative was noted to look at Resident #14 who was exposed from the waist down. NA #1 was stopped by the surveyor and asked to close the privacy curtain, which he/she then did. When Resident #14 was turned onto his/her side, with the extensive assistance of NA #1, who had to pull on the draw sheet to move the resident, the resident was noted to have bright red, reddened skin that was blanched. Interview and review of facility policy with the RN #2 on 9/11/19 at 10:50 A.M. identified that it is the facility policy to provide residents with privacy during incontinent care. Review of the incontinent care policy identified that privacy should be assured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, review of facility documentation, review of facility policy, and interviews for two sampled residents (Resident #7 and Resident #40) reviewed for Activities of Daily Living (ADL's), the facility failed to ensure nail care for a dependent resident was provided. The findings include: 1. Resident #7's diagnoses included diabetes, dementia and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was severely cognitively impaired and required extensive assistance with personal hygiene. The Resident Care Plan (RCP) dated 6/27/19 identified I need assistance with personal care due to cognitive impairment. Interventions directed to provide moderate assistance for bathing, dressing and toileting hygiene. The social service note dated 9/10/19 at 9:30 AM identified that Resident #7 was receiving increased physical supports for persona ADL. Review of the NA flow sheets dated 9/8/19, 9/9/19 and 9/10/19 identified that Resident #7 required extensive assistance to being totally dependent on staff for personal hygiene. Observations on 9/9/19 at 11:50 AM and 9/10/19 at 11:40 A identified Resident #7 with dark brown/black debris under all 10 fingernails. An interview and observation with the DNS on 9/10/19 at 2:00 P.M. identified Resident #7 with dark brown/black debris under all 10 fingernails. The DNS identified that she would find a staff member to cut and clean Resident #7's nails. Review of facility AM care/ADL Policy identified that individualized assistance in preparation for daily activities should be provided including fingernail care and trimming nails if needed. 2. Resident #40's was admitted on [DATE] and had a diagnoses that included diabetes mellitus. The 14 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was without cognitive and required extensive assistance with bed mobility and personal hygiene. The Resident Care Plan (RCP) dated 9/10/19 identified I require assistance with all of my ADL. Interventions directed to assist with bathing, grooming and dressing. The NA flowsheet dated 9/8/19 through 9/12/19 identified that Resident #40 required limited assistance to being totally dependent with personal hygiene. An interview and observation with the DNS on 9/12/19 at 10:00 A.M. identified Resident #40 was a diabetic, had long toenails and that the toenails needed to be cut. The DNS identified that the standard of practice directed to have the podiatrist cut Resident #40's toenails due to diabetes mellitus. The DNS identified that the NA should have notified the nursing staff of the need to have Resident #40's toenails cut. The DNS identified that she would add Resident #40 to the list for the next podiatrist visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #15) reviewed for range of motion, the facility failed to ensure placement of a splinting device for a dependent resident with a loss in range of motion in accordance to the plan of care. The findings include: Resident #15's diagnoses included dementia and right hand contracture. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was severely cognitively impaired, and was totally dependent on staff for transfers, dressing and personal hygiene. The Resident Care Plan (RCP) dated 7/22/19 identified a right hand contracture. Interventions directed to apply splints as ordered. Review of the undated NA care card identified a special need/routine for a right hand splint to be on at all times, may remove for care. A physician's order dated 7/14/19 directed to apply a right hand splint at all times, may remove every morning and as needed for care. Observations on 9/9/19 at 12:31 PM and 1:43 PM, and again on 9/10/19 at 12:30 and 2:00 P.M. identified Resident #15 with a right hand contracture without the benefit of a splint. Review of the Treatment Administration Record (TAR) dated September, 2019 identified a physician's order to ensure Resident #15 had a right hand splint on at all times, remove for morning care and as needed. The right hand splint was signed off on the TAR that the splint had been in place from 9/2/19 through 9/10/19 on the 11-7 A.M. shift and on 9/5/19 on the 7-3 PM shift. The right hand splint was not identified in place on all 3 shifts on 9/1/19, on 9/2/19 through 9/4/19 and on 9/7/19 to 9/10/19 on the 7-3 PM shift and from 9/2/19 through 9/10/19 on the 3 to 11 PM shift (19 out of 29 opportunities). Interview and observation with the DNS on 9/10/19 at 2:12 P.M. identified two signs in Resident #15's room instructing staff to keep the splint to the right hand on all the times, may remove for care and then replace, and an additional sign instructing how to apply the Leeder Grip splint. Observation of the bed side chair identified a hand splint laying on the seat of the chair. The DNS identified Resident #15's splint should be on at all times except during care. Additionally, review of the TAR failed to identify that the facility staff had signed off on the placement of the right hand splint for 19 out of 29 shifts. The DNS identified that the TAR should have been signed by the nursing staff to indicate placement of the right hand splint. Subsequent to surveyor inquiry, Resident #15's splint was put in place. The DNS identified that it is the responsibility of the NA to ensure placement of the splint and that the charge nurse should oversee and ultimately ensure the splint placement. Interview with NA #1 on 9/11/19 at 7:40 AM identified that he/she could not find the splint for Resident #15 and that is why Resident #15 did not have his/her splint applied. Re-interview with the DNS on 09/11/19 at 7:45 AM identified that Resident #15's splint was in the laundry and was returned late in the day on 9/10/19. The DNS further indicated that he/she had placed the night splint for Resident #15's left hand from the bed side chair on Resident #15's right hand by mistake on 9/10/19, because the resident did not have any splinting device. Additionally, the DNS identified that a resident who requires hand splinting should not be left without some alternative splinting method for two days. Subsequent to surveyor inquiry, Occupational therapy conducted a screening for Resident #15 and found no decline in Resident #15's contracture. Review of facility splint and orthotic device policy identified that a physician's order with the wearing schedule is obtained and then transcribed onto the TAR, and that the splint will be applied by the nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of two sampled resident (Resident #14) reviewed for Activities of Daily living (ADL's), the facility failed to ensure that physician's orders were followed in accordance to the plan of care for a pressure relieving mattress and/or for repositioning the resident in accordance to facility practice and/or for one of two sampled resident reviewed for accidents and /or for one of two sampled residents (Resident #191) reviewed for an allegation of mistreatment, the facility failed to ensure a complete RN assessment following a fall, and/or failed to a perform a quarterly fall assessment and/or failed to conduct weekly skin checks and/or failed to initiate/complete neurological checks following an unwitnessed fall/head injury, and/or failed to complete thorough monitoring of a resident following a fall and/or injury, and/or failed to update a care plan following a fall. The findings included: 1. a Resident #14's diagnoses included dementia and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was severely cognitively impaired and required the extensive assistance for bed mobility and personal hygiene and was totally dependent on staff for transfers, dressing and toilet use. The Resident Care Plan (RCP) dated 7/22/19 identified I require assistance with all of my ADL and am at risk for alterations in ski integrity. Interventions directed to provide extensive assistance with daily grooming, dressing and all ADL, provide a pressure reducing mattress in bed, off load heels and ensure gentle handling during care procedures. A physician's order dated 8/8/19 directed to transfer Resident #14 with mechanical lift and two staff. Intermittent observations on 9/10/19 at 9:48 AM identified Resident #14 on his/her back in bed, the alternating pressure mattress (APM) was set to static, 250 pounds and the resident's heel were both resting on the bed without the benefit of off-loading. A pillow was noted to be on the seat of Resident #14's wheelchair approximately 4 feet from the end of the bed. Continued intermittent observations at 10:07 AM, 10:30 AM, 10:50 AM, 11:30 AM 11:52 AM 12:30 PM, 12:50 PM and 1:15 PM identified that although the head of the residents bed went from flat to a 45 degree incline at times, Resident #14 remained on his/her back the entire time with his/her heels resting on the APM that was set to static at 250 pounds. Review of the NA flow sheets identified that on 9/4/19, 9/5/19, 9/6/19, 9/9/19 and 9/10/19 (documentation was lacking for 9/7/19 and 9/8/19) Resident #14 was totally dependent on staff for bed mobility on the 7 to 3 shift. Interview and review of facility policy with the DNS on 9/10/19 at 1:45 PM identified that Resident #14's mattress should not have been set to static and should have been set to alternating because the mattress was an APM. The DNS identified that all compromised residents received an APM. Additionally, the DNS indicated that according to the facility policy, all APM's require a physician's order for the APM and to have the charge nurse check placement and function each shift, but Resident #14 did not have a physician's order and/or a directive on the treatment [NAME] for an APM and/or to check placement and function. The DNS identified that the company who provides the APMs sets up for the resident with the new mattress according to the resident's weight and then provide the setting to the facility. The DNS identified that Resident #14 has had the APM beginning on 4/16/19. Subsequent to surveyor inquiry, the DNS on 9/10/19 at 1:15 P.M. directed staff to reposition Resident # 14 in bed. Interview with RN #1 on 09/11/19 at 01:18 PM identified she was unaware of Resident # 14's alternating pressure mattress therefore the mattress was not observed during weekly rounds. Review of the manufacture's recommendations identified that it was recommended to reposition resident periodically while using the mattress and that the weight button should be set according to the resident's weight and that the weight setting should be adjusted if the mattress was too soft or firm to suit the resident's needs. Caregivers should always perform a hand check by placing their hands underneath the resident's pelvis area to ensure sufficient air support to avoid the resident from bottoming out. b. Intermittent observations on 9/10/19 at 9:48 AM identified Resident #14 on his/her back in bed, the alternating pressure mattress (APM) was set to static, 250 pounds and the resident's heels were both resting on the bed without the benefit of off-loading. A pillow was noted to be on the seat of Resident #14's wheelchair approximately 4 feet from the end of the bed. Continued intermittent observations at 10:07 AM, 10:30 AM, 10:50 AM, 11:30 AM 11:52 AM 12:30 PM, 12:50 PM and 1:15 PM identified that although the head of the residents bed went from flat to a 45 degree incline, Resident #14 remained on his/her back the entire time with his/her heels resting on the APM that was set to static at 250 pounds. Observation with NA #1 and Resident #14 on 9/10/19 at 1:19 PM. NA #1 was identified to return Resident #14 onto his/her back without the benefit of a pillow behind his/her back and/or offloading of the resident's heels. Resident #14's pillow that had been identified on the wheelchair since 9:48 A.M. remained in the same position. The undated NA care card identified turning and repositioning as per protocol, alternating air mattress and off load heels as per protocol. The DNS on 9/10/19 during an interview at 1:45 P.M. identified that Resident #14 should have been turned and repositioned every two hours (not 3.5 hours after the initial observation at 9:48 AM) and that he/she should have had his/her heels off loaded, off of the mattress, according to the facility standards of practice and the care plan. Re-interview with NA #1 on 9/11/19 at 7:40 AM identified that it had been false information that the resident was not turned and repositioned on 9/10/19 because he had changed the resident's position from lying flat to the head of the bed being positioned to a 45 degree angle. NA #1 identified that Resident #14 independently moves around in bed so he did not reposition Resident #14 of his/her back. Although Resident #14's pillow was observed on his/her wheelchair, NA #1 identified that Resident #14 throws his/her pillows off the bed and that was why his/her heels were not off loaded. Review of facility wound prevention/intervention Policy identified that residents should have turning and repositioning every two hour and as needed per the individualized resident care plan and to use pillows to elevate heels while in bed or other pressure reducing devices for feet in the bed or chair. 1a.Resident #191's diagnoses included Alzheimer's disease, anxiety delirium and anxiety. The Resident Care Plan (RCP) dated 6/11/19 identified I am at risk for falls, have had a fall with/without injury. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #191 was severely cognitively impaired and required extensive assistance with ADL. Interventions directed to place a fall mat to the right side of the bed, bed in low position, encourage to ask and wait for staff assistance. The nurse's note dated 6/11/19 at 2:29 PM identified that Resident #191 was sitting on the fall mat next to the bed. The Reportable Event form dated 6/11/19 identified Resident #191 had an unwitnessed fall and was found sitting on the floor mat at the side of the bed. Resident #191 was alert and disoriented. The untimed physician's order dated 6/11/19 directed Ativan 0.25 mg every 8 hours for anxiety and/or restlessness. The care plan was updated to include getting Resident #191 out of bed for all meals and encourage him/her to be in a common area when out of bed. Interview and review of facility documentation on 9/12/19 at 4:15 PM with the DNS identified that since Resident #191 landed on the fall mat and there was no suspicion of a head injury, neurological checks were not conducted. Additionally, the DNS identified that although Resident #191 had been assessed to be severely cognitively impaired on the MDS and alert and disoriented on the Reportable Event form, he/she was capable of indicating whether he/she had hit his/her head. The nurse's note dated 6/11/19 at 10:37 PM identified that during the 5:00 PM medication pass, Resident #191 was next to her for supervision and was witnessed attempting to stand up and slid out of the chair landing on the foot rest. The APRN was notified. Review of the untimed APRN orders dated 6/11/19 directed to monitor Resident #191 for changes in mental status, bruising and, vital signs for 72 hours. The care plan was updated to include monitoring for changes in mental status and bruising for 72 hours, and walk every two hours with a gait belt and assist of two staff until cleared by physical therapy. Interview and review of facility documentation with the DNS on 9/12/19 at 4:15 PM failed to identify that the facility had thoroughly monitored Resident #191 per the new APRN orders for mental status changes and/or bruising on 6/12/19 and 6/13/19. 2. The nurse's note dated 6/15/19 at 11:36 AM identified Resident #191 was found sitting on the floor in front of the bed by the door and that the resident was in bed prior to being found. The nurse's note dated 6/15/19 at 3:36 PM identified that at 7:45 AM Resident #191 was witnessed asleep in bed and that at 7:50 AM Resident #191 was heard moaning and found on the floor. The Reportable Event dated 6/15/19 at 7:50 AM identified Resident #191 had an unwitnessed fall, was alert and confused, unable to ambulate and required total care with ADL. The care plan was updated to include encourage Resident #191 to remain in common areas and place on every 30 minutes checks. Interview and review of facility documentation with the DNS on 9/12/19 at 4:15 PM identified that the facility policy was to conduct neurological checks for unwitnessed falls, but failed to provide documentation that neurological checks were initiated but should have been. Additionally, the DNS identified that the facility failed to conduct a thorough investigation surrounding the fall and had not collected any statements from potential witnesses. 3. Review of the concern form dated 6/16/19 identified that Resident #191 was witnessed being pushed back down into his/her wheelchair as he/she attempted to get up. The Reportable Event form dated 6/17/19 identified Resident #191 was alert, confused and disoriented and that a visitor had reported witnessing Resident #191 being pushed down from standing up out of his/her wheelchair by placing both hands on the resident's shoulders. The untimed physician's order sheet dated 6/17/19 identified to monitor bilateral upper arms for bruising for 72 hour as a nursing measure. The DNS nurse's note dated 6/18/19 at 3:02 PM identified that a concern form was received by a visitor. Interview with RN #5 on 9/12/19 at 12:00 PM identified that he/she had witnessed Resident #191 being supervised by LPN #2 due to safety concerns, and that LPN #2 had been attempting to keep Resident #191 from falling because if Resident #191 had stood up, he/she would have fallen forward over the foot rests on the wheelchair. Interview and review of facility documentation with the DNS on 9/12/19 at 4:15 PM failed to identify that subsequent nurse's notes dated 6/17/19 at 6:32 PM, 6/18/19 at 6:37 AM, and on 6/18/19 at 2:07 PM identified that Resident #191 had been monitored for bilateral upper arm bruising until Resident #191 fell on 6/18/19 at 3:00 PM. 4. The nurse's note dated 6/18/19 at 3:30 PM identified that Resident #191 had attempted to stand up without assistance and fell forward. The Reportable Event dated 6/18/19 identified a witnessed fall and that Resident #191 had attempted to stand up from the wheelchair, the NA had attempted to assist Resident #191 but that both the resident and the NA fell to the floor. Resident #191 was noted with a lump and bruising to the forehead above the left eye. The care plan was updated to include the assistance of one for transfers and the need to use a wheelchair for locomotion. Interview and review of facility documentation with the DNS on 9/12/19 AT 4:15 P.M. identified that the Resident Representative had concerns regarding bruising on Resident #191's arms and face, but that the nursing admission assessment clearly documented the bruising on re-admission from the hospital and that the bruising on his/her face occurred when Resident #191 fell on 6/18/19. Review of the nurse's note dated 6/27/19 at 4:09 PM identified that Resident #191 had walked into the glass in the lobby as the resident was being escorted away from the door. The care plan was updated to include the provision of safe redirection when agitated and not making safe choices. The Reportable Event dated 6/27/19 identified that Resident #191 was alert and had been witnessed by two staff to attempt to walk through the wrong door and walked into the glass. Resident #191 sustained a bruise to his/her nose. The investigative statement date 6/27/19 identified the staff had been attempting to take Resident #191 for a walk outdoor, but Resident #191 was agitated and walked the wrong way, into the glass. The nurse's note dated 6/29/19 at 6:45 AM identified that bruising persisted to Resident #191's head and face. Interview and review of facility documentation with the DNS on 9/12/19 at 4:00 PM identified that the resident had sustained a bruise to his/her nose bridge due to bumping his/her glasses on the glass when he/she walked into the glass, but that neurological checks were not required due to Resident #191's causing the injury due to the glasses, and that it was not a true head injury. 5. The nurse's note 7/25/19 at 6:30 PM identified that Resident #191 fell at 6:30 PM and was found lying on the floor beside his/her wheelchair Additionally, the fall was witnessed and that when Resident #191 was seen to stand up from the wheelchair, he/she took a few step and then fell. The care plan was updated to check on the resident every 30 minutes. The Reportable Event dated 7/25/19 identified that Resident #191 was alert and oriented, required assistance staff for ADL's, had stood up from his/her wheelchair, took a few steps and fell. The Reportable event investigation identified that a change to the care plan would include scheduled ambulation and toileting. Interview and review of facility documentation with the DNS on 9/12/19 at 4:15 PM identified that scheduled ambulation and toileting was an inappropriate intervention due to being a standard of practice, and that this intervention was not placed on the care plan. Additional review of facility documentation identified that Resident #191 had previously been on and continued to be on every 30 minute checks. The DNS failed to identify a new care plan intervention following the fall on 7/25/19. Additionally, the DNS failed to identify that Resident #191 had a Range of Motion assessment prior to moving the resident off of the floor. 6. The nurse's note dated 8/7/19 at 6:34 PM identified Resident #191 was noted with a bruise to the right hand/thumb during a body audit. The APRN was notified. The untimed APRN's order dated 8/8/19 directed to monitor the bruise to the right hand/thumb every shift for increased pain and swelling for 14 days or until resolved. The care plan was updated to include the encouragement of safe hand placement during wheelchair ambulation. Interview and review of facility documentation with the DNS on 9/12/19 at 4:15 PM failed to identify consistent monitoring of the right hand/thumb for increased pain and swelling for 72 hours and/or per the APRN orders, for 14 days. 7. Review of the nurse's note dated 8/19/19 at 1:38 AM identified that Resident #191 suffered a witnessed fall at 5:00 PM. The Resident attempted to stand up from his/her wheelchair but fell forward to the floor. Resident #191 sustained a small bump to the right forehead. The care plan was updated to identify the provision of every 15 minute safety checks for 30 days and 1:1 supervision for 8 hours. Review of the neurological vital sign sheet identified that pupillary response was not applicable on 8/19/19 from 5:30 AM through 7:15 AM. Review of the nurse's note dated 8/25/19 at 4:50 PM identified that the resident was restless and agitated in the wheelchair by the nurse's station. Resident #191 fell attempting to get up from the wheelchair without assistance. The care plan was updated to include a geriatric psychiatric examination. Review of the Reportable Event dated 8/25/19 at 12:55 PM identified Resident #191 was confused and unable to articulate needs, and was dependent on staff for ADL. Interview and review of facility documentation with the DNS on 9/12/19 at 4:15 PM failed to identify that Resident #191 had a Range of Motion assessment prior to moving the resident off of the floor. 7.The nurse's note dated 8/26/19 at 1:05 PM identified the resident was exhibiting signs of agitation, reaching out at people, unable to stay in one position for any amount of time, insisted on standing and walking and was not accepting of assistance. The physician was in the building, ordered Seroquel (Antipsychotic) and to place a call for a psychiatric hospital bed. The social service's note dated 8/26/19 at 4:28 PM identified no available bed at the psychiatric hospital. Review of the DNS nurse's note dated 8/26/19 at 6:20 PM identified a witnessed fall during which Resident #191 was able to take approximately 10 steps prior to falling. The charge nurse attempted to assist Resident #191 but was unable to get to him/her quickly enough. Resident #191 had a healing bruise noted to the forehead, a new bruise noted to the right elbow, abrasions noted to right fingers and did not hit his/her head. The physician's order dated 8/26/19 at 7:00 PM directed to send Resident #191 to the hospital. The Reportable Event dated 8/26/19 at 6:20 PM identified that Resident #191 was confused, agitated and combative and had a witnessed fall, at which time he/she stood up from the wheelchair and attempted to walk in the hall and Resident #191 was sent to the Emergency Department. Review of the social service's note dated 8/27/19 at 3:28 PM identified that Resident #191 was being transported on 8/27/19 to a second hospital for a geriatric psychiatric evaluation. Interview and review of facility documentation with the DNS on 9/12/19 at 4:15 PM identified that, according to facility body audit policy all resident are required to have weekly body audits to determine skin condition. The facility failed to perform weekly body audits on 7/10/19, 7/17/19, 7/31/19 and 8/21/19 (which would have included the APRN order dated 8/8/19 for skin checks to the right thumb). The DNS identified that according to the fall policy, documentation of fall risk assessments are to be conducted and documented on a quarterly basis, but the clinical record identified a fall risk assessment had been conducted twice in the last nine months, on December 5, 2018 and June 12, 2019. Further, the fall policy identified that the care plan should have be revised with an interim intervention follow every fall to minimize the risk of injury, but had not been updated on 7/25/19 following Resident #191's fall. Additionally, the DNS identified that according to the neurological check policy, neurological checks should be completed per the policy which included every 15 minutes for the first hour and with unwitnessed falls where the resident is unable to accurately verbalize if his/her head was hit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and interviews during medication storage, the facility failed to ensure safe storage of medications in the Unit Two medication cart and/or failed to ensure that Mantoux PPD was discarded after 28 days in accordance to facility policy and /or for one three sampled resident observed during medication administration (Resident # 38) the facility failed to ensure the resident's medication was not left at the resident's bedside. The findings included: 1. Observation on 9/11/19 at 10:29 AM identified the Unit Two medication cart outside of the nurse's station unlocked. Resident #20 was seated at the cart requesting an item that had been stored in the medications cart from the surveyor. LPN#3 was in the area, and, subsequent to surveyor inquiry, LPN #3 retrieved Resident #20's item without the use of a key, locking the cart behind himself after retrieving the resident's item. LPN #3 identified that LPN #2 should have locked the cart when she left the area, and that he locked the cart because he was the last one to access the cart. Observation of LPN #2 on 9/11/19 at 10:32 AM noted she had been behind a closed door at the back of the nursing station. Interview with LPN #2 on 9/11/19 at 10:29 AM identified that he/she had just left the cart to go into the back room and forgot to lock the medication cart. Review of the medication storage policy identified that the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/car or locked medication room that is inaccessible by resident and visitors. 2. Resident # 91 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, type 2 diabetes mellitus and anxiety. The physician's order dated 9/4/19 directed 2 step Mantoux PPD: 0.1 ml.ID on admission (unless +HX, then do chest X ray). Observations and review of medication storage and labeling on 9/10/19 at 9:00 A.M. with LPN #1 identified one opened vial of tuberculin purified protein (10 test multi-dose vial) dated 7/31/19 in the medication refrigerator. Interview with DNS on 9/10/19 at 9:40AM identified medications that have past the expiration date should be discarded at the date of expiration. The DNS indicated that nurses are responsible for discarding expired medications and she was unsure of the reason why the expired medication was not discarded. Review of the Medication administration record with LPN#1 and RN#3 on 9/10/19 at 11:00AM indicated that six residents who still reside in the facility received tuberculin test doses between 8/31/19 and 9/10/19. Review Resident #91's Medication Administration Record indicated Mantoux PPD was administered to the resident on 9/7/19 Interview with LPN#2 on 9/11/19 at 11:10AM indicated that after she administered a number of doses of tuberculin test doses on 9/4/19 she then discarded the vial that was used. However, LPN #2 was unable to confirm that a dose administered on 9/7/19 was not taken from the vial that was expired. Review of the Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles Policy notes if a multi-dose has been opened or accessed (e.g. needle punctured) the vial should be dated and discarded within 28 days unless the manufacture specifies a different date for the opened vial. Review of the General dose Preparation and Medication Administration policy directed, Prior to administration of medication facility staff should check the expiration date on the medication. 3. Resident # 38 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, personality disorder, and alcohol dependence with withdrawal, hypertension, peripheral vascular disease, and atrial fibrillation. The admission care plan dated 8/19/19 identified Resident #38 required supervision to ensure s/he swallows her medications. Interventions directed to observe Resident #38 swallowing medications when medications are administered. The admission MDS assessment dated [DATE] identified Resident #38 was without impaired cognition and required extensive assistance with bed mobility, transfer, dressing and limited assistance with walking and hygiene. A physician's order dated 9/5/19 directed to discontinue PRN Gabapentin and administer 300 MG gabapentin three times a day. Observation on 9/09/19 at 12:09 PM identified a capsule in a plastic medication cup was in Resident #38's bedside stand open top drawer. Interview with Resident #38 on 9/9/19 at 12:09 PM identified that she/he did not know the name of the capsule and indicated the nurse gave it to him/her on this morning when Resident#38 was on his/her way to therapy and Resident #38 placed it in the bed-side drawer so she/he could take it when she/he return from therapy, but she/he forgot to take it. Interview with LPN #1 on 9/09/19 at 12:17 PM identified she/he was not previously aware the capsule was in the resident's bed-side drawer and identified the capsule appeared to be a gabapentin capsule. LPN #1 identified she/he gave the 9:00 AM dose of gabapentin and observed Resident #38 swallow the medication. LPN #1 indicated there is no way of knowing how long the medication was in the drawer and or when that capsule was given to the resident. LPN #1further indicated the medication was not from this morning as the resident reported; the resident did not provide the surveyor with accurate information. Surveyor observed LPN #1 remove the capsule from the bedside drawer and LPN #1 indicated she/he would discard it. Interview with DNS on 9/09/19 at 1:16 PM: identified there should not be any medications left at the bedside of Resident #38 and indicated Resident #38 is frequently noncompliant with taking his/her medications. The RCP directs to remain at the bedside until he/she swallows the medications. The DNS also indicated she/he would attempt asking the nurses who have administered the medication who left it at the bedside, but it would be unlikely the nurse who left the medication for her/him would be identified. The DNS further identified Resident #38 pockets his/her medications and the nurse who administered the medication may not be aware Resident #38 did not take the medication.