**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #66) reviewed for respiratory care, the facility failed to notify the physician/APRN that a prescribed respiratory treatment was unavailable, and for 1 of 2 resident's (Resident #177) reviewed for notification of change, the facility failed to notify the resident representative when there was a change in the residents condition and new orders were obtained for a chest x ray and antibiotics. The findings include: 1. Resident #66 was discharged from an acute care facility on 12/21/23 and the W-10 discharge plan dated 12/21/23 identified a new medication: 12.9gm Atrovent HFA (a bronchodilator) inhaled, three times daily for 5 days. Resident #66 was admitted to the facility on [DATE] with diagnoses that included respiratory syncytial virus (RSV) pneumonia, acute respiratory failure with hypoxia, and asthma. The admission MDS dated [DATE] identified Resident #66 had intact cognition, experienced dyspnea when lying flat, and required continuous oxygen therapy. The care plan dated 12/29/23 identified Resident #66 was at risk for respiratory insufficiency status post a hospital admission related to RSV pneumonia, and a history which included the use of asthma inhalers. Interventions included the administration of medications and oxygen as ordered by the physician. A physician's order dated 12/21/23 directed to administer 17mcg/act of Atrovent HFA, 1 puff inhaled orally, three times daily, for 5 days. The MAR dated 12/21/23 through 12/26/23 failed to identify 17mcg/act of Atrovent HFA was administered three times daily for 5 days as ordered. The medication administration notes, regarding the 17mcg/act of Atrovent HFA, dated 12/21/23 through 12/26/23 identified the following: 12/21/23 at 8:22 PM awaiting from pharmacy. 12/22/23 at 10:12 AM awaiting from pharmacy. 12/22/23 at 1:41 PM not available. 12/22/23 at 8:22 PM not available. 12/23/23 at 8:15 AM awaiting from pharmacy. 12/23/23 at 1:23 PM awaiting from pharmacy. 12/23/23 at 9:09 PM awaiting from pharmacy. 12/24/23 at 9:52 AM awaiting from pharmacy. 12/24/23 at 2:25 PM awaiting from pharmacy. 12/24/23 at 9:08 PM not available. 12/25/23 at 10:09 AM awaiting from pharmacy. 12/25/23 at 1:43 PM NA. 12/25/23 at 9:02 PM not available. 12/26/23 at 8:46 AM NA. 12/26/23 at 1:24 PM NA. Interview with Resident #66 on 1/8/24 at 8:50 AM identified that he/she had been hospitalized with RSV pneumonia, in December of 2023, and after discharge from the hospital he/she was ordered 2 inhalers, Albuterol and Atrovent. Resident #66 indicated that the Atrovent was unavailable for the first week of his/her admission to the skilled nursing facility. Resident #66 further identified that he/she was initially having a hard time breathing and having the second inhaler would have been beneficial. Interview and review of the clinical record with LPN #1 on 1/10/24 at 9:28 AM identified that Resident #66's Atrovent was not administered because she was told that it was on back order. LPN #1 identified she was notified that the medication would be delivered as soon as it was in stock, but the medication was not available during the 5-day timeframe that the medication was ordered. LPN #1 further indicated that she did not notify the physician/APRN that the medication was unavailable nor was she informed during report that the APRN was notified. Interview with the RN Supervisor (RN #3) on 1/10/24 at 9:30 AM identified that he was unaware when the APRN had been notified that the Atrovent was unavailable from the pharmacy. RN #3 further identified that RN #1 had been in contact with the pharmacy and would be better able to provide more information. Interview with RN #1 on 1/10/24 at 11:09 AM failed to identify documentation that the physician/APRN had been notified that the Atrovent was on back order. RN #1 identified that LPN #2 had notified her (RN #1 was unable to recall the notification date and time) that the Atrovent was unavailable. RN #1 indicated she called the pharmacy and was notified that the medication had already been signed for and was in the building. The following day LPN #2 reapproached RN #1 and notified her that the Atrovent still had not arrived at the facility. RN #1 called the pharmacy again, and at that time was notified that the medication was on back order. RN #1 was unable to identify if the physician/APRN had been notified that Resident #66 had not been receiving the scheduled Atrovent. RN #1 indicated that she did not notify the physician/APRN. RN #1 indicated she had notified someone that the medication was unavailable but could not recall who that individual was. Interview and review of the clinical record with APRN #1 on 1/10/24 at 11:19 AM failed to identify that Atrovent was administered from 12/21/23 through 12/26/23, per the physician's order. APRN #1 indicated that she was not made aware that Resident #66 did not receive the scheduled medication until this interview. APRN #1 further indicated that while Resident #66 did well during his/her recovery, she would have wanted to have been notified that the medication was not available so she could have ordered a DuoNeb or the facility could have requested the family to bring in the medication from home, until the order was filled. Interview with the Pharmacist #1, from the vendor pharmacy on 1/11/24 at 9:38 AM identified that the Atrovent order for Resident #66 was received on 12/21/23, a fax indicating that the medication was out of stock was sent to the facility on [DATE], and the Atrovent was delivered to the facility on [DATE] at 2:00 AM. Pharmacist #1 was unable to access documentation indicating that a pharmacy representative spoke to any of the facility staff members regarding the Atrovent order, but he further indicated that it is not customary to document on every telephone encounter. Pharmacist #1 indicated that there is no specific policy for communicating to a facility that a medication is unavailable, but it is usual procedure to make the notification, via fax or telephone, within a business day of the order being processed when medication is out of stock. Interview and review pf the clinical record with the DNS on 1/12/24 at 6:53 AM failed to identify that Resident #66 received Atrovent from 12/21/23 through 12/26/23, per the physician/APRN order. The DNS indicated that it should have been brought to her attention that the Atrovent was on back order. The DNS further indicated that it is the responsibility of the nursing supervisors to notify the physician/APRN that the medication was unavailable so she could have put a hold on the order, discontinue the order, modify the order, or request a family member to bring in the medication from home, if possible. Although attempted, an interview with LPN #2 was not obtained. Review of the facility's change in a resident's medical condition/status policy directs that a resident's physician and representative, if appropriate, be notified of changes in the resident's condition and/or status. The policy further identified that nursing services shall be responsible for notifying the physician when the resident refuses treatment or medications and when deemed necessary or appropriate, in the best interest of the resident. 2. Resident #177 was admitted to the facility in November 2022 with diagnoses that included atrial fibrillation, and chronic kidney disease stage 3. The admission MDS dated [DATE] identified Resident #177 had intact cognition and required extensive assistance with personal hygiene. The APRN progress note dated 12/23/22 at 7:14 PM identified Resident #177 presented with a fever of 100.4 F today. Resident #177 complained of cough with no shortness of breath. New orders for chest x-ray, stat blood work, and Levaquin (antibiotic) ordered for pneumonia. A physician's order dated 12/23/22 directed to obtained stat blood work, a chest x-ray and directed to administer Levaquin 750mg tablet (antibiotic) by mouth every 48 hours prophylactic for fever until 12/29/22. The care plan dated 12/23/22 identified Resident #177 had a fever and pneumonia. Interventions included administering antibiotics as ordered. The nurse's note dated 12/23/22 through 12/26/22 failed to reflect documentation the resident representative had been notified of the new orders for chest x-ray, stat blood work, and antibiotic. Review of the APRN progress notes dated 12/23/22 through 12/26/22 failed to reflect documentation the resident representative had been notified of the new orders for chest x-ray, stat blood work, and antibiotic. Interview and review of the clinical record with the DNS on 1/10/24 at 12:30 PM failed to provide documentation that the resident representative had been notified of the new orders for chest x-ray, stat blood work, and antibiotic. The DNS identified she was not aware of the issue. The DNS indicated it is the responsibility of the nurse who receives the orders to notify the resident or the resident representative of the new orders before the medication is administered. Interview with RN #3 on 1/10/24 at 12:35 PM identified he was not aware of the issue. RN #3 indicated the nurses are responsible to notify the resident and the resident representative as soon as a new medication is ordered or a change of condition in the resident. Interview with Person #1 on 1/10/24 at 3:28 PM identified he/she was not notified when Resident #177 had a chest x-ray done and started on antibiotic therapy. Interview and review of the clinical record with LPN #2 on 1/12/24 at 8:30 AM failed to provide documentation the resident representative had been notified of the new orders for chest x-ray, stat blood work, and antibiotic. LPN #2 indicated she failed to notify the resident representative. An interview with the DNS on 1/12/24 at 9:00 AM identified the facility 24-Hour report dated 12/23/22 through 12/26/22 failed to reflect documentation resident representative was notified of the new orders for chest x-ray, Stat blood work, and antibiotic. Interview with Person #5 on 1/12/24 at 11:31 AM identified he/she was not notified when Resident #177 had a chest x-ray done and started antibiotic therapy. Review of the facility change in a resident's medical condition/status policy identified the facility is to notify the resident's attending physician and representative, if appropriate of changes in the resident's condition and/or status. Deemed necessary or appropriate in the best interest of the resident any other changes deemed necessary.

**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 2 residents (Resident #177) reviewed for discharge, the facility failed to ensure medication sent home with the resident upon discharge, was prescribed to the resident. The findings include: Resident #177 was admitted to the facility in November 2022 with diagnoses that included atrial fibrillation, and chronic kidney disease stage 3. The admission MDS dated [DATE] identified Resident #177 had intact cognition and required extensive assistance with personal hygiene. The nurse's note dated 1/25/23 at 3:16 PM identified Resident #177 was discharged home at 2:43 PM. The nurse's note dated 1/25/23 at 3:35 PM identified Resident #177 ready for discharge today per social service now that the oxygen has been delivered. The family wants Resident #177 to be discharged today. Discharge process expedited to meet the family wishes. The private aide is in attendance and is the caretaker and oversees medication administration in the home setting. All medications and discharge instructions reviewed with the private aide who voiced understanding. Appears only medication not familiar with is the Pantoprazole. Education as to administration and related diagnosis with voiced understanding. Review of a reportable event form dated 1/25/23 identified Resident #177 was discharged today and inadvertently had been given two blister packs of medications that did not belong to him/her (Famotidine 20mg). The Administrator received a phone call today from Resident #177's representative indicating Resident #177 was discharged home with another resident medications. The physician was notified, and nursing staff were educated on discharging residents with medications. Review of the physician's orders dated 1/1/23 through 1/25/23 identified a list of Resident #177 current active medications did not include Famotidine 20mg. Review of the in-service form dated 1/25/23 and 1/26/23 identified all residents are discharged home with the right medications. Supervisors are to clarify medications being sent home with residents, so they are matched to physician's order. Review of the W-10 Inter-Agency Patient Referral Report and MD Certification dated 1/25/23 identified Resident #177 was discharged to home with medications and visiting nurse agency. The W-10 Inter-Agency Patient Referral Report and MD Certification included a list of the resident's current active medications and did not include Famotidine 20mg which did not belong to Resident #177. Interview with the DNS on 1/10/24 at 12:06 PM identified that at the time, she was not aware that Resident #177 had been discharged home with another resident's blister pack medication (Famotidine 20mg). The DNS indicated this is not the expectation of the facility. The DNS indicated the nurse that is discharging the resident is responsible to review/compare the medication blister packs to the physician's order upon discharge with the resident or the resident representative. The DNS indicated she does not remember who notified her of the issue. The DNS indicated the nurses were educated regarding the medication discharge process as soon as she was made aware of the issue. Interview and review of the clinical record with RN #3 on 1/10/24 at 12:13 PM identified he was not aware that Resident #177 had been discharged home with another resident's Famotidine until the resident representative called the unit and notified the facility. RN #3 indicated he was the supervisor that reviewed the discharge medications and discharge documents with Resident #177 and the private aide. RN #3 indicated he did not have the medications present when he reviewed the physician's order with Resident #177 and the private aide. RN #3 indicated the nurse gives the medication blister packs to the resident and/or the resident representative upon discharge. Review of the facility discharge coordinator process policy identified the nurse manager is responsible to oversee the completion of W-10 and medication instructions sheet. Request that the nurse manager, charge nurse review the resident's discharge medications and perform any necessary teaching and documentation in the medical record regarding this issue.

**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 resident (Resident #11) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on scheduled shower days. The findings include: Resident #11 was admitted to the facility in December 2023 with diagnoses that included obesity, lumbar spinal stenosis, and hydronephrosis with renal and ureteral calculous obstruction. The admission MDS dated [DATE] identified Resident #11 had intact cognition and required partial/moderate assistance with shower/bath. Review of the first-floor East wing shower schedule identified Resident #11 shower days are scheduled for Mondays on the 3:00 PM - 11:00 PM shift and on Thursdays on the 3:00 PM - 11:00 PM shift. The care plan dated 12/24/23 identified Resident #11 had altered mobility and self-care performance deficit related to weakness status post hospitalization for hydronephrosis with obstructing calculus. Interventions included to assist only as needed and allow sufficient time and privacy. Review of the December 2023 MAR and TAR failed to reflect documentation that Resident #11 received a shower on his/her scheduled day Thursday 12/21/23, and 12/28/23 during the 3:00 PM - 11:00 PM shift or Monday 12/25/23 during the 3:00 PM - 11:00 PM shift. Review of the nurse aide flowsheet dated 12/18/23 - 12/31/23 failed to reflect documentation that Resident #11 had been provided a shower on his/her scheduled day Thursday 12/21/23, and 12/28/23 during the 3:00 PM - 11:00 PM shift or Monday 12/25/23 during the 3:00 PM - 11:00 PM shift. Review of the nurse's note dated 12/18/23 through 12/31/23 failed to reflect documentation that Resident #11 had been provided a shower on his/her scheduled day Thursday 12/21/23, and 12/28/23 during the 3:00 PM - 11:00 PM shift or Monday 12/25/23 during the 3:00 PM - 11:00 PM shift. Review of the nurse aide care card dated 12/18/23 identified shower days were scheduled Monday and Thursday during the 3:00 PM - 11:00 PM shift. Interview with Resident #11 on 1/8/24 at 9:25 AM identified he/she only had 2 showers since being admitted to the facility. Resident #11 indicated his/her shower days are on Mondays and Thursdays on the 3:00 PM - 11:00 PM shift. Resident #11 indicated he/she would like a shower like he/she is supposed to have. Interview and review of the clinical record with the DNS on 1/10/24 at 11:58 AM identified she was not aware that Resident #11 had not received any showers in the month of December 2023. The DNS indicated the nurse aides should have provided Resident #11 with a shower on his/her schedule shower days. The DNS indicated the assigned nurse aide should have reported to the charge nurse if the resident had refused the shower or if the shower was not given. The DNS indicated the assigned nurse aide should have documented if the shower was given or not. Interview with RN #3 on 1/10/24 at 12:21 PM identified he was not aware that Resident #11 had not received showers in the month of December 2023. RN #3 indicated the nurse aides should have provided Resident #11 with a shower on his/her schedule shower days. RN #3 indicated the assigned nurse aide should have reported to the charge nurse if the resident had refused the shower or if the shower was not given. Interview with NA #6 on 1/11/24 at 9:40 AM identified she has been employed by the facility for approximately one month. NA #6, who was assigned to Resident #11 on 12/25/23 on the 3:00 PM - 11:00 PM shift indicated she does not remember anything she did on her shift. Interview with RN #5 on 1/11/24 at 9:49 AM identified she has been employed by the facility for 4 years. RN #5 indicated she worked 12/28/23 on the 3:00 PM - 11:00 PM shift. RN #5 indicated she was not aware that Resident #11 did not receive his/her shower on Thursday 12/28/23 on the 3:00 PM - 11:00 PM shift. RN #5 indicated the nurse aide should have provided Resident #11 with a shower on his/her schedule shower day. RN #5 indicated the nurse aide should have notified her that Resident #11 did not receive his/her schedule shower. Although attempted, an interview with NA #7 and LPN #4 was not obtained. Review of the facility shower policy identified it is the policy of the facility to promote a resident's proper hygiene and to ensure a clean, fresh appearance daily. At least twice weekly, bathing is assisted or supervised by nursing staff assigned to the resident. Bathing may be offered in the form of showering or tub baths as preferred by the resident. Bathing schedules have been arranged primarily on the day or evening shifts. Assigned nursing staff to document shower administration on the NA flowsheets.

**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 5 residents (Resident #52) reviewed for accidents, the facility failed to conduct neurological vital signs, according to facility policy, after the resident had an unwitnessed fall. The findings include: Resident #52 was admitted to the facility on [DATE] with diagnoses that included dementia and anxiety. A physician's order dated 4/18/23 directed staff supervision for transfers and ambulation without a device. The quarterly MDS dated [DATE] identified Resident #52 had severely impaired cognition, had 1 fall since admission and required supervision with transfers, ambulation in room, and ambulation in hallway. A quarterly fall risk assessment dated [DATE] identified Resident #52 was at moderate risk for falls. The care plan dated 5/17/23 identified Resident #52 was at risk for falls. Interventions included Resident #52 ambulates with supervision and no devices and was observed on the floor 4/28/23. Additionally, consider frequent checks when this resident is in his/her room for safety and reassurance. A reportable event form dated 6/18/23 at 3:50 PM identified Resident #52 had an unwitnessed fall in the west side hallway and was noted to be the supine position on the floor. The reportable event form identified Resident #52 ambulated independently before the fall. The clinical record identified Resident #52 was sent to the hospital in the morning on 6/19/23. A nursing note dated 6/19/23 at 12:15 PM identified Resident #52 had returned from hospital via ambulance with a diagnosis of right distal radius fracture. Resident #52 denies pain but was given pain medication at the hospital. APRN in to see resident and ordered Tylenol 1000mg every 8 hours for pain. Review of the neurological assessment form identified staff did not monitor neurological vital signs after Resident #52 returned from the hospital on 6/19/23 at 12:15 PM. Additionally, neurological vital signs were not completed during the 11:00 PM - 7:00 AM and 7:00 AM - 3:00 PM shifts on 6/20/23, or at all on 6/21/23. The nurse's note dated 6/19/23 at 5:41 AM, as a late entry for 6/18/23 at 3:50 PM, identified that Resident #52 was observed by this writer on his/her back, on the floor in the west side hallway at approximately 3:50 PM. Supervisor, physician, and family were notified. Resident #52 had increased confusion and anxiety. Ativan is ongoing with minimal effect. Resident #52 had signs and symptoms of pain and was given Tylenol with good effect. Ice pack applied to right wrist. X-ray completed with conclusion: wrist fracture. Frequent safety precautions were maintained. Poor safety awareness persists. Interview with RN #2 (day supervisor) on 1/9/24 at 8:05 AM indicated it was the responsibility of the charge nurse to complete the neurological assessments after an unwitnessed fall. Interview and review of the clinical record with the DNS on 1/10/24 at 7:45 AM indicated the RN supervisor was responsible to start the neurological assessments and then the charge nurses were responsible to complete the neurological assessments through 3 days for an unwitnessed fall per the facility policy. The DNS indicated there was not an order to discontinue the neurological assessments after the resident fell on 6/18/23. The DNS indicated her expectation is that neurological assessment should have been done. Review of the facility neurological assessment policy identified when a resident sustains head trauma or injury, including unwitnessed falls, the neurological assessments will be implemented immediately. Every 15 minutes for 1 hour. Every 30 minutes for 1 hour. Every hour for 2 hours. Every shift for 3 days. The charge nurse or nurse manager will initiate the Episodic Vital Signs and/or Neurological Assessment Flow Sheet at the time of the trauma or injury. Notify the supervisor and the physician of any neurological changes.

**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 resident (Resident #4) reviewed for limited range of motion, the facility failed to follow the physician order in the treatment of a hand contracture. The findings include: Resident #4 was admitted to the facility with diagnoses that included dementia and stroke with left sided deficit. The quarterly MDS dated [DATE] identified Resident #4 had severely impaired cognition and required total assistance with care. Additionally, Resident #4 had no behaviors or rejection of care, had limited range of motion to upper and lower extremities on one side and had a contracture of the left hand. A physician's order dated 10/30/23 directed Resident #4 was to have a rolled washcloth in the left hand at all times. The care plan dated 11/9/23 identified left hand contracture. Interventions included placing a left hand splint or washcloth per physician order. Additionally, check skin for integrity when donning and doffing splint. The nurse's aide care card for Resident #4 identified to place a washcloth hand roll to the left hand. Observation on 1/8/24 at 7:22 AM and 10:00 AM identified Resident #4 was in the wheelchair, dressed, and the left hand was noted to be contracted without the benefit of a splint or washcloth in the left hand. Observation on 1/9/24 at 8:25 AM identified Resident #4 was dressed sitting in the wheelchair in the main dining room being fed breakfast by NA #1 without the benefit of the washcloth roll in the left hand. Interview with NA #1 on 1/9/24 at 8:26 AM indicated she was feeding Resident #4 but did not provide morning care. NA #1 indicated there was nothing in Resident #4's left hand like a washcloth. Interview with NA #2 on 1/9/24 at 8:27 AM indicated she did not look at Resident #4's care card for providing care today. NA #2 indicated that she had cared for Resident #4 in the past and knew Resident #4 couldn't do anything for him/herself. NA #2 indicated she did not put a washcloth in Resident #4's hand and was not aware she needed to do that. Observation and interview with RN #2 on 1/9/24 at 8:30 AM identified Resident #4 was washed and dressed in an adaptive wheelchair in the dining room being fed breakfast. RN #2 indicated that Resident #4 did not have a washcloth in his/her left hand. After clinical record review, RN #2 indicated Resident #4 had a physician's order for a washcloth to the left hand at all times and the nurse's aides were responsible to place the washcloth in Resident #4's hand every morning during morning care. RN #2 indicated that the nurses were to sign off on the physician's order in the electronic medical record on the treatment record every shift. RN #2 indicated she did not know why Resident #4 did not have the washcloth in his/her left hand but should have per the physician's order. RN #2 indicated that the expectation was that NA #2 would have placed the washcloth during morning care prior to bringing Resident #4 to the dining room for breakfast. Review of the clinical record, RN #2 indicated that the order was put in wrong. RN #2 indicated that the order was put in as a physician's order but when transcribed it did not specify every shift so that the nurses would have to sign off checking to make sure the washcloth was in the left hand. RN #2 indicated she would fix the physician's order so the nurses will see the order and must sign off every shift. Interview with OT #1 (Director of Rehabilitation), on 1/9/24 at 8:45 AM indicated Resident #4 had a stroke and has a contracture of the left hand. OT #1 indicated therapy was involved for splinting with Resident #4. OT #1 indicated she had put in the original order as a recommendation on 4/21/23 for the washcloth rolled in the left hand for hygiene and prevention of skin breakdown then the physician signs off making it an order. After surveyor inquiry, RN #2 on 1/9/24 at 10:10 AM indicated the washcloth was placed in Resident #4's left hand and she inspected Resident #4's left hand and there were no open areas. Interview with the DNS on 1/10/23 at 9:32 AM identified the charge nurse was responsible to make sure the handroll was in Resident #4's left hand and the expectation was that the nurse's would follow the physician's order. Review of the Physician Orders policy identified it was the policy to ensure proper identification of physician's orders. All physicians' orders must be dated and timed. Physicians may write their orders or give verbal or telephone orders to a licensed nurse. These orders will be signed by the physician the next time he/she is in the facility. Review of the Splinting Policy identified splints, either custom made or prefabricated, are used to provide proper body support, prevent unwanted motion, contracture management or reduction, pain management, and to facilitate motor activity. Therapists evaluate the resident to determine the type of splint. Once the wearing schedule is established, the physician's clarification order should specify the type of splint, where it is to be applied, and wearing schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #14 and 52) reviewed for accidents, the facility failed to follow the physician's orders related to transfers and ambulation. The findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included dementia, atrial fibrillation, and peripheral vascular disease. The hospital interagency referral form (W-10) dated 3/10/23 identified that Resident #14 required the assistance of 2 - 3 staff for transfers, and skin was intact but fragile. The W-10 did not reflect the resident had any purpura or bruises on the skin. A physician's order dated 3/13/23 directed to transfer the resident with the assistance of 2 without a device. The care plan dated 3/14/23 identified the resident required complete care. Interventions included to apply skin protectors due to the propensity for skin tears. Additionally, to assist the resident to transfer via a mechanical device to and from the wheelchair and bed daily as tolerated. A reportable event form dated 3/15/23 at 7:21 PM Resident #14 had a skin tear to the left lower extremity that measured 7.0 cm by 2.0 cm by 0.5 cm. A pressure dressing and ice pack were applied, and Resident #14 was transferred to the emergency room. Prior to skin tear, Resident #14 required the assistance of 2 for transfers. A nurses note dated 3/15/23 at 9:40 PM indicated at 7:21 PM a skin tear was noted to left lower extremity that measured 7.0 cm by 2.0 cm by 1 inch deep. Pressure dressing applied and ice pack to stop bleeding. Resident representative and physician were notified. Resident #14 was transferred to the hospital at 10:30 PM for evaluation. A statement, written by NA #8, on 3/15/23 indicated she was assigned to Resident #14, and she had transferred the resident with the assistance of 2 from the wheelchair to the bed and Resident #14 informed NA #8 that his/her left leg was burning. NA #8 noticed the resident's derma saver (a padded geri sleeve) was filled with blood. NA #8 removed the derma saver and noticed a skin tear. NA #8 indicated she reported the skin tear to the nurse. The statement failed to identify the name of the other staff member who assisted with the transfer. A statement, written by RN #4, on 3/15/23 identified on 3/15/23 at 7:25 PM she was asked to come to Resident #14's room to assess the residents left leg derma saver that was filled with red blood. When the derma saver was removed, a laceration to the left lower leg with bleeding was present. The area was cleansed with normal saline, a pressure dressing was applied, the area was wrapped with gauze bandage and ice was applied to area with a stockinette to keep ice pack in place. The physician, DNS, and the resident's representative were notified. Resident #14's representative requested that a nurse's aide accompany the resident to the emergency room. Statements by NA #9 and NA #10, dated 3/15/23, who were working on the resident's unit, identified they were busy in other resident rooms and/or not assigned to Resident #14 and were not aware of the skin tear. A statement, written by LPN #5, dated 3/15/23, who was working the 3:00 PM - 11:00 PM shift identified the supervisor informed him that she was going to be sending a nurse's aide to the hospital with Resident #14. A statement, written by NA #4, dated 3/15/23 identified Resident #14 was not her resident, but she did accompany Resident #14 to the hospital. A nurse note dated 3/16/23 at 6:17 AM identified Resident #14 had returned from the hospital with 12 sutures to the left lower leg. A physician's order dated 3/16/23 directed to transfer the resident via a mechanical lift and the assistance of 2 staff. The care plan dated 3/17/23 identified the resident was at risk for skin irritation and injury due to fragile skin with recurrent skin tears. Interventions included to consider applying a calf-board to wheelchair leg pedals when resident is out of bed to decrease for potential injury related to legs dropping between the pedals. The APRN progress note dated 3/17/23 at 8:02 AM identified the resident was seen for a skin tear on purpura. Resident #14 sustained a skin tear below the left lateral knee during transfer from wheelchair to bed. Resident #14 was sent to the emergency room for suturing and returned with 12 sutures. The admission MDS dated [DATE] identified Resident #14 had severely impaired cognition and required total assistance with eating, toileting, bathing, dressing, and transfers. Interview with the DNS on 1/10/24 at 10:55 AM indicated that Resident #14 was a difficult assist of 2 for transfers on 3/15/23 when the skin tear occurred. After review of the reportable event and clinical record, the DNS indicated NA #8 transferred Resident #14, but based on the statements, the DNS was not able to identify the other staff member who assisted NA #8 with the transfer. The DNS indicated she asked the nurse's aides to reenact what had happened to cause the skin tear but she does not recall who she asked for the reenactment, and she did not write it down. The DNS indicated she believed it might be NA #4 that assisted with the transfer but was not sure. The DNS indicated the nursing staff statements all stated they were not aware of the skin tear and had not assisted NA #8 with the transfer. The DNS indicated that the statement written by NA #4 only stated that she went with the resident to the emergency room it did not state she assisted NA #8 with the transfer. The DNS indicated she had spoken with NA #8 at that time and NA #8 indicated she had not seen any blood on Resident #14's leg prior to the transfer. The DNS indicated Resident #14 had fragile skin. After review of the reportable event summary the DNS noted she had only listed NA #8 as the witness and not a second nurse's aide. Interview with NA #4 on 1/10/24 at 11:52 AM indicated she did not help transfer Resident #14 on 3/15/23 or any other time during that shift. NA #4 indicated she did not touch Resident #14 at all that night. NA #4 indicated she only accompanied Resident #14 to the hospital with EMS. NA #4 indicated the only transfer she witnessed was the EMS transferring Resident #14 onto the stretcher and she was present. Interview and review of the clinical record with the DNS, she was unable to indicate who was the second staff member that assisted with Resident #14's transfer on 3/15/23. Although attempted, an interview with NA #8, who transferred the resident on 3/15/23, was not obtained. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses that included dementia and anxiety. A physician's order dated 2/2/23 directed the resident to have supervision for transfers and ambulation without a device. A physician's order dated 3/25/23 directed to administer Trazadone 25 mg once a day. A physician's order dated 3/31/23 directed to give Lorazepam 0.25 mg twice a day. A physician's order dated 4/18/23 directed the resident to have supervision for transfers and ambulation without a device. a. Reportable event form dated 4/28/23 at 7:10 AM identified Resident #52 had an unwitnessed fall in his/her bathroom. Resident #52 was noted lying on his/her left side on floor stating he/she hit his/her head. RN noted swelling on posterior scalp, ice was applied. Actions taken ice applied, neurological assessment, and follow fall protocol. A fall risk assessment dated [DATE] identified Resident #52 was at moderate risk for falls. The care plan dated 4/28/23 identified a fall. Interventions included to encourage the resident to request assistance with activities. A nurses note dated 4/28/23 at 3:31 PM identified Resident #52 had an unwitnessed fall in the bathroom at 7:10 AM and was noted to be lying on his/her left side with bilateral lower extremities outward. Resident #52 had bare feet at the time of the fall. On assessment this writer noted swelling to posterior scalp. No bleeding noted. Physician and family notified. A physician's order dated 5/1/23 directed Resident #52 to have supervision for transfers and ambulation without a device. The quarterly MDS dated [DATE] identified Resident #52 had severely impaired cognition and required extensive assistance with dressing, personal hygiene, bed mobility and toilet use. Resident #52 required supervision with transfers, ambulation in room, and ambulation in hallway. Additionally, Resident #52 has had 1 fall since admission. A quarterly fall risk assessment dated [DATE] identified Resident #52 was at moderate risk for falls. b. A reportable event form dated 5/24/23 at 7:10 PM identified Resident #52 had an unwitnessed fall in the hallway and was found sitting on his/her buttocks. No injuries noted. Action taken was frequent safety checks. Fall risk assessment dated [DATE] identified Resident #52 was at high risk for falls. The nurse's note dated 5/24/23 at 10:51 PM identified Resident #52 was noted sitting on buttocks in the hallway at 7:10 PM. No injuries noted. Supervisor, physician, and family notified. The care plan dated 5/26/23 identified a fall on 5/24/23. Interventions included considering frequent room checks when the resident is in his/her room for safety and reassurance. Activities of daily living flowsheet dated 6/1/23 - 6/17/23 identified the nurse's aides coded Resident #52 as independent with transfers during the 7:00 AM - 3:00 PM shift 11 out of 17 days and 4 were blank and coded the resident independent during the 3:00 PM - 11:00 PM shift 15 out of 17 days with 1 blank. Independence is defined as no help or staff oversight at any time. Activities of daily living flowsheet dated 6/1/23 - 6/17/23 identified the nurse's aides coded Resident #52 as independent with ambulation in hallway during the 7:00 AM-3:00 PM shift 10 out of 17 days with 5 blank and for 3:00 PM-11:00 PM nurse's aides documented 13 out of 17 with 4 blanks shift. Independent defined as no help or staff oversight at any time. Even though, a physician's order for Resident #52 directed supervision (defined as oversight, encouragement, and cueing) for transfers and ambulation. The individual resident care card identified that Resident #52 was independent with ambulation. A physician's order dated 6/1/23 directed Resident #52 required supervision for transfers and ambulation without a device. c. A reportable event form dated 6/18/23 at 3:50 PM identified Resident #52 had an unwitnessed fall in west side hallway. Resident #52 was noted to be supine position on the floor. Before event Resident #52 ambulates independently. Resident #52 had complaints of pain to the right wrist with swelling. The physician ordered an x-ray of the right wrist. Post fall Risk assessment dated [DATE] identified Resident #52 score was a 9 and was at high risk for falls. The care plan dated 6/18/23 identified a fall on 6/18/23. Interventions included applying ice to affected area, pain assessment, and x-ray right wrist. Observe the right upper extremity for pulse, swelling, numbness, tingling, movement, circulation frequently and follow up with orthopedics as required. The nurse's note dated 6/19/23 at 5:41 AM as a late entry for 6/18/23 at 3:50 PM, identified that the resident was observed by this writer on his/her back, on the floor on west side hallway at approximately 3:50 PM. Supervisor, physician, and family were notified. Resident #52 had increased confusion and anxiety. Ativan is ongoing with minimal effect. Resident #52 had signs and symptoms of pain, Tylenol administered with good effect. Ice pack applied to right wrist. Xray completed with conclusion: wrist fracture. Frequent safety precautions were maintained. Poor safety awareness persists. emergency room report dated 6/19/23 identified an acute nondisplaced comminuted right distal radius impaction fracture and severe soft tissue swelling about the wrist. An individually customized short arm volar splint was applied to immobilize the joint. d. a reportable event summary, written by the DNS on 6/23/23, indicated Resident #52 was independent with ambulation and was observed on the floor in west hallway. Resident #52 had an unwitnessed fall with a fracture to the right wrist. Resident #52 was still ambulating independently and was compliant with wearing the splint. Resident #52 was spending more time in the common areas. A physician's order dated 1/1/24 directed Resident #52 was supervision for transfers and ambulation without a device. e. a reportable event form dated 1/6/24 at 10:30 AM identified Resident #52 had an unwitnessed fall. Resident #52 was found sitting on the floor between the doorway. Fall investigation noted Resident #52's shoes had no tread on them. A nursing note dated 1/7/23 at 1:52 PM identified Resident #52's left ankle appeared to be slightly swollen. Observation on 1/9/24 at 8:00 AM identified Resident #52 was standing in his/her room in-between the 2 beds touching items on his/her nightstand. Observation of 1 nurse aide near nurse's station sitting with a resident feeding him/her and 3 nurse's aides and charge nurse in dining room serving breakfast and assisting with feeding other residents. Interview with RN #2 (day supervisor) on 1/9/24 at 8:05 AM indicated Resident #52 was 1 out 5 residents that can ambulate independently on the unit. RN #2 indicated she needed to go check the physician's order. After clinical record review, RN #2 indicated Resident #52 had a physician's order for supervision with transfers and ambulation without assistive devices. RN #2 indicated supervision with transfers and ambulation means a staff person needs to be with the resident during all transfers and ambulation and should be within arm's length away from Resident #52. RN #2 indicated the last fall assessment prior to the 6/18/23 fall indicated it was completed on 5/4/23 and indicated Resident #52 was at moderate risk for falls due to being on anti-psychotropic medications and dementia. RN #2 indicated that since Resident #52 was at risk for falls nursing tries to make sure resident has the proper footwear and that staff were supervising him/her. Interview with OT #1 (Director of Rehab) on 1/9/23 at 8:19 AM indicated she put in the physician's order for Resident #52 at admission and on 4/18/23 which directed for Resident #52 was to be supervision with transfers and ambulation. OT #1 indicated supervision was resident must be in eyesight and hearing. OT #1 indicated that nursing staff should follow the definition in section gg in the MDS. OT #1 identified the definition of section gg code #4 was supervision or touching assistance and the helper provides verbal cueing and/or touching/steading and/or contact guard assistance as a resident completes activities. Interview with OT #1 on 1/9/23 at 8:40 AM identified Resident #52 was only screened on admission and not picked up for therapy because Resident #52 was at his/her baseline for supervision for transfers and ambulation. Interview and review of the clinical record with the DNS on 1/10/24 at 7:45 AM identified with an unwitnessed fall, the nurse or supervisor will call or text her that there was a fall and who was notified such as physician and family. The DNS indicated after a fall, witnessed or unwitnessed, the resident is assessed by the nursing supervisor or the RN on the unit, and if the APRN is in house will go see the resident after. The DNS indicated the RN must document in the clinical record and do the reportable event form. The DNS indicated the nurses will get statements from everyone working that day for unwitnessed falls. Review of the nurse's aide flow sheets for Resident #52 identified Resident #52 had ambulated and transferred independently during that shift. The DNS indicated the occasional documented number 2 or 3 were documented in error. The DNS indicated the resident was independent when he/she was admitted to the facility and was still independent with ambulation and transfers. Review of the physician's orders, the DNS indicated the physician order directe supervision for transfers and ambulation. After reviewing the reportable event dated 6/18/23, the DNS indicated when Resident #52 had fallen on 6/18/23 that Resident #52 was independent with ambulation. The DNS indicated that every resident had to be watched to some degree on the second floor because they all have some form of dementia. The DNS indicated Resident #52 could walk in her room and in the hall independently. After review of the clinical record, the DNS indicated supervision with transfers and ambulation means that someone can see Resident #5, but the staff can't see Resident #52 in his/her room when he/she gets up and transfers. The DNS indicated that Resident #52 was independent by getting up and going to the bathroom. The DNS indicated that transfers and ambulation with supervision and independently are different. After clinical record review, the DNS indicated that OT put in the order for supervision for transfer and ambulation. The DNS indicated the resident can't use the call bell. The DNS indicated that the resident was independent and does not know why therapy wrote it that way. The DNS indicated her expectation was that nursing would follow the physician's orders. After reviewing the clinical record, the DNS indicated for the 6/18/23 unwitnessed fall that the intervention was consider frequent room checks for safety and room clutter free. The DNS indicated she believes that Resident #52 was independent even though the rehab department and physicians order stated supervision for transfers and ambulation. Review of the facility Fall Prevention Protocol identified all residents will have a fall risk assessment performed upon admission, readmission, quarterly, post-fall or a significant change of condition assessment to monitor fall risk and implement appropriate risk reduction measures. All falls will be assessed and documented according to policy. Resident intervention will be determined by the interdisciplinary care team. If a resident was identified at high risk for falling as determined by nursing the resident will have a special care plan interventions to address their fall risk areas. This must include constant visual supervision with toileting. Other interventions may include the following nonskid footwear, room closer to nurses' station, bed alarm, chair alarm, curved lip mattress, toileting schedule, increased safety monitoring every 15 minutes, bed side mats, Hi-low bed, mattress on floor, and medication review. If a resident is at moderate risk for falling the resident will have a special care plan interventions to address their risk areas. This may include nonskid footwear, room closer to nurses' station, bed alarm, chair alarm, curved lip mattress, toileting schedule, medication review, exercise program, and transfer training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #66) reviewed for respiratory care, the facility failed to provide necessary respiratory medications for a newly admitted resident for 5 days. The findings include: Resident #66 was discharged from an acute care facility on 12/21/23 and the W-10 discharge plan dated 12/21/23 identified a new medication, 12.9gm Atrovent HFA (a bronchodilator) to be inhaled, three times daily for 5 days. Resident #66 was admitted to the facility on [DATE] with diagnoses that included respiratory syncytial virus (RSV) pneumonia, acute respiratory failure with hypoxia, and asthma. The admission MDS dated [DATE] identified Resident #66 had intact cognition, experienced dyspnea when lying flat, and required continuous oxygen therapy. The care plan dated 12/29/23 identified Resident #66 was at risk for respiratory insufficiency status post a hospital admission related to RSV pneumonia, and he/she had a history which included the use of asthma inhalers. Interventions included the administration of medications and oxygen as ordered by the physician. A physician's order dated 12/21/23 directed to administer 17mcg/act of Atrovent HFA, 1 puff inhaled orally, three times daily, for 5 days. The MAR dated 12/21/23 through 12/26/23 failed to identify 17mcg/act of Atrovent HFA was administered three times daily for 5 days. The medication administration notes related to the 17mcg/act of Atrovent HFA dated 12/21/23 through 12/26/23 identified the following: 12/21/23 at 8:22 PM awaiting from pharmacy. 12/22/23 at 10:12 AM awaiting from pharmacy. 12/22/23 at 1:41 PM not available. 12/22/23 at 8:22 PM not available. 12/23/23 at 8:15 AM awaiting from pharmacy. 12/23/23 at 1:23 PM awaiting from pharmacy. 12/23/23 at 9:09 PM awaiting from pharmacy. 12/24/23 at 9:52 AM awaiting from pharmacy. 12/24/23 at 2:25 PM awaiting from pharmacy. 12/24/23 at 9:08 PM not available. 12/25/23 at 10:09 AM awaiting from pharmacy. 12/25/23 at 1:43 PM NA. 12/25/23 at 9:02 PM not available. 12/26/23 at 8:46 AM NA. 12/26/23 at 1:24 PM NA. Interview with Resident #66 on 1/8/24 at 8:50 AM identified that he/she had been hospitalized with RSV pneumonia, in December of 2023, and after discharge from the hospital he/she was ordered 2 inhalers, Albuterol and Atrovent. Resident #66 indicated that the Atrovent was unavailable for the first week of his/her admission to the skilled nursing facility. Resident #66 further identified that he/she was initially having a hard time breathing and having the second inhaler would have been beneficial. Interview and review of the clinical record with LPN #1 on 1/10/24 at 9:28 AM identified that Resident #66's Atrovent was not administered because it was on back order. LPN #1 was told that the medication would be delivered as soon as it was in stock, but the medication was not available during the 5-day timeframe that it was ordered. Interview and review of the clinical record with RN #1 on 1/10/24 at 11:09 AM identified that Resident #66's Atrovent was on back order. RN #1 identified that LPN #2 had notified her (RN #1 was unable to recall the notification date) that the Atrovent was unavailable. RN #1 called the pharmacy and was notified that the medication had already been signed for and was in the building. The following day LPN #2 reapproached RN #1 and notified her that the Atrovent still had not arrived at the facility and RN #1 called the pharmacy again, and at that time was notified that the medication was on back order. Interview with the Pharmacist #1, from the vendor pharmacy, on 1/11/24 at 9:38 AM identified that the Atrovent order for Resident #66 was received on 12/21/23, a fax indicating that the medication was out of stock was sent to the facility on [DATE], and the Atrovent was delivered to the facility on [DATE] at 2:00 AM. Pharmacist #1 was unable to access documentation indicating that a pharmacy representative spoke to any of the facility staff members regarding the Atrovent order, but he further indicated that it is not customary to document on every telephone encounter. Pharmacist #1indicated that there is no specific policy for communicating to a facility that a medication is unavailable, but it is usual procedure to make the notification, via fax or telephone, within a business day of the order being processed when medication is out of stock. Interview and review of the clinical record with the DNS on 1/12/24 at 6:53 AM failed to identify that Resident #66 received Atrovent from 12/21/23 through 12/26/23, per the physician/APRN order. The DNS indicated that it should have been brought to her attention that the Atrovent was on back order. The DNS further indicated that it is the responsibility of any of the nursing supervisors to notify the physician/APRN that the medication was unavailable so she could have put a hold on the order, discontinued the order, modified the order, or requested a family member to bring in the medication from home, if possible. Although attempted, an interview with LPN #2 was not obtained. Review of the facility's drug order and receipt policy directs that all medications are promptly ordered from the vendor pharmacy for timely administration according to the physician's orders. Review of the facility's medication administration protocols, the policy directs that the all medications are administered in strict accordance with the facility's pharmacy policies and procedures, including: any prescribed treatment as ordered by the physician will be performed, or delegated to another licensed nursing staff member, at the appropriate time and all medications will be administered at appropriate time intervals, to all residents as order by their physician.

Based on observation, review of facility policy and interview the facility failed to follow infection control guidelines related to glucometer (blood sugar measuring device) sanitizing. The findings included: Observation on 9/19/21 at 5:45 AM, LPN #1 was noted to remove a pouch from the medication cart, open the pouch and remove a glucometer LPN #1 sanitized the device with the approved sanitizing wipe, immediately placed it back into the pouch. LPN #1 was then observed to proceed into 3 resident rooms, briefly walking in and out again while carrying the pouch. LPN #1 returned to the medication cart, then entered Resident #13's room. LPN #1 left Resident #13's bedside with the pouch in hand (closed) and proceed directly to the medication cart and placed the pouch into the bottom drawer without the benefit of sanitizing the device after its use. Interview with LPN #1 on 9/19/21 at 6:05AM (with supervisor RN #2) present, identified that the pouch contained alcohol wipes and lancets, but not approved sanitizing wipes. LPN #1 indicated that he had sanitized the device before he utilized it and indicated that he was trained to clean the device by wiping the device and letting it air dry for 2 minutes. LPN #1 further indicated that he did not clean the device after its use because he had sanitized it before he used the device. Interview with the nursing supervisor, RN #2, on 9/9/21 at 6:14 AM identified LPN #1 should not bring the pouch into a resident's room, and the indicated the glucometer device requires sanitizing before it is put back into the pouch and into the medication cart. Interview and review of Glucometer Policy and Procedure with the Infection Preventionist (IP/RN #1) on 9/19/21 at 8:13 AM identified the glucometer should be wiped with a Super Sani-Cloth, and air dried for 2 minutes. Review of the multi blood glucose monitoring system user instruction manual with IP/RN #1 identified specific disinfectants that included utilization of Super Sani-Cloth germicidal wipes to sanitize the device. It further identified to please read the Germicidal wipe instructions before using. Review of Super Sani-Cloth germicidal utilization directions with IP/RN#1 identified to disinfect, thoroughly wet surface and to allow the treated surface to remain wet for a full two minutes and then let air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, and interviews for 1 resident (Resident #18) reviewed for positioning, the facility failed to address positioning needs that were in accordance with the resident's comprehensive assessment. The findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbances, abnormalities of gait and mobility, muscle weakness, abnormal posture, and lack of coordination. The quarterly MDS dated [DATE] identified Resident #18 had severely impaired cognition, bilateral functional range of motion limitation, required a wheelchair for mobility, and was totally dependent for bed mobility and transfers. The care plan dated 5/15/19 identified Resident #18 had abnormal posture and generalized muscle weakness. Interventions included to utilize a customized wheelchair with head rest and leg rests to achieve and maintain optimum posture. Observation on 7/1/19 at 1:38 PM identified Resident #18 in a customized wheelchair leaning forward with arched back and his/her head resting on the left edge of head/neck support bracket and flexed forward and to the left. Additionally, the top ridge of the head rest was level with the middle of Resident #18's head. Observation on 7/2/19 at 12:31 PM identified Resident #18 in a customized wheelchair, however, the head rest of the chair was in a different position as compared to observation on 7/1/18, did not make contact with Resident#18's head, and Resident#18's head was flexed and tilted to the left. Interview with LPN #2 on 7/2/19 at 1:50 PM identified the head/neck support bracket on Resident #18's wheelchair obviously had moved and was not keeping the resident's head/neck in proper alignment. LPN #2 identified the rehabilitation department should have been contacted by nursing staff to screen and adjust the bracket so the bracket maintains the resident's head in proper head and neck alignment. LPN #2 indicated she had not yet noticed the mal-adjusted head rest and did not routinely work on this nursing unit. LPN #2 identified the facility expectation is the rehabilitation department is contacted to facilitate screening and evaluation of the head rest for adjustment. Interview with RN #1 on 7/2/19 at 1:57 PM identified the head/neck support bracket was not in contact with Resident #18's head, it was too low, and Resident #18 was poorly aligned with the head/neck forward and turned to the left side. RN #1 identified there is no written policy relating to this but the facility expectation is the nurse aide would tell licensed staff if they note in-effective equipment, and licensed staff are to notify the rehabilitation department when they observed poor adjustment/alignment. RN #1 further identified all nursing staff are in-serviced regarding wheelchair maintenance, proper body alignment, and communicating needs to the rehabilitation department; in-servicing is provided to nursing staff both by the facility and by the companies providing the customized wheel chair. Interview and observation with PT #1 on 7/2/19 2:20 PM identified the head/neck support bracket of Resident #18's wheelchair needs to be adjusted to maintain proper alignment of the resident's head and neck, and identified Resident #18's head and neck was poorly aligned with forward flexion and leaning to the left. PT #1 identified the support bracket is in need of adjustment. Review of an OT summary dated 5/15/19 with PT #1 identified Resident #18 had a diagnosis of abnormal posture and this customized wheelchair was obtained to assist in maintaining head and body in a properly aligned upright position. PT #1 further identified when head/neck alignment brackets do not promote optimum head/neck alignment nursing staff is trained to recognize that adjustments need to be made and to notify the rehabilitation department when they are identified. PT #1 indicated that there is no written policy. PT #1 indicated the rehabilitation department promptly responds to calls to evaluate these situations and intervene. Interview and review of the clinical record with Director of Rehabilitation on 7/3/19 at 10:09 AM identified the head rest of Resident #18's wheel chair was in need of adjustment to properly position/align the head and neck. Review of the rehabilitation screen form dated 7/2/19 identified adjustment to the head rest was performed. Although requested, a policy was not provided.

**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 resident (Resident #55) reviewed for urinary catheter, the facility failed to ensure care and services were provided for a resident with an indwelling catheter. The findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included pneumonia and urinary retention. The quarterly MDS dated [DATE] identified Resident #55 had moderately impaired cognition, and required total assistance with personal care. The care plan dated 3/21/19 identified Resident #55 utilized a Foley catheter size 16 with changes every 30 days by nursing staff and as needed, and that the catheter may be flushed with 20 cc normal saline as needed. A nurse's note dated 3/20/19 identified that a Foley catheter was placed on 3/15/19. A nurse's note dated 5/1/19 identified the Foley catheter was due to be changed on that day. Interview and review of the clinical record on 7/2/19 at 12:44 PM with RN #1 identified Resident #55 was readmitted on [DATE] with the Foley catheter and was placed on hospice services. Although the hospice admission care plan and physician order recommendations directed the catheter to be changed every 30 days and flushed as needed, the clinical record failed to reflect that recommendation, and/or that it had been done. Interview with RN #1 and the DNS on 7/3/19 at 9:49 AM identified there was a transcription error, and as a consequence, Resident #55 may not have had the catheter changed in April or May of 2019. Subsequent to surveyor inquiry a physician's order was obtained for a Foley catheter change. The urinary catheterization policy directed that a physician's order was required for any catheterization.

**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 resident (Resident #50) reviewed for nutrition/hydration, the facility failed to provide and/or document supplements as ordered by the physician and/or consistently monitor intake and output. The findings include: Resident #50 was admitted to the facility on [DATE] with diagnoses that included stroke, dysphagia and dementia. A physician's order dated 6/29/18 directed to provide a regular dysphagia pureed diet with thin consistency, fortified custard, and magic cup with breakfast, lunch and dinner. A physician's order dated 7/9/18 directed when feeding Resident #50, put magic cup on the tip of the spoon with every bite of food. A physician's order dated 10/15/18 directed to provide Glucerna (supplement) 240 cc twice daily. The annual MDS dated [DATE] identified Resident #50 had both short and long term memory problems, required extensive assistance with eating and required total care with bed mobility, transfers, toilet use and bathing. Additionally, Resident #50 was on a mechanically altered diet, had no significant weight loss and was not dehydrated. Review of an APRN note dated 6/27/19 identified that he/she was asked to see Resident #50 for a monthly medication review, continued weight loss, poor appetite. The note indicated Resident #50 had adult failure to thrive with continued weight loss, most likely related to advance dementia. Bloodwork to be obtained. Review of the laboratory results dated [DATE] identified the BUN was high at 31mg/dL (normal range 7 mg/dL - 25 mg/dL). A nurse's note dated 6/29/19 identified bloodwork results reported to MD #1. New order for vital signs every shift for 72 hours, IV hydration (D 5 ½ normal saline at 75cc/hour for a total of 500cc), and encourage oral fluids. A physician's order dated 6/29/19 directed to administer D 5 ½ NS via intravenous 500 cc at 75 cc/hour for 1 bag. The care plan dated 6/29/19 identified Resident #50 was at risk for dehydration and adverse medication reaction due to dementia with behavioral disturbances, decreased awareness for thirst and dependence on other to provide fluids. Interventions included to consider frequent fluid offerings, intake and output if clinically warranted, and observe for symptoms of dry mucous membranes, indications for thirst, oliguria, intervene with fluids and update the physician with findings. Additionally, the care plan identified Resident #50 was at high risk for altered nutrition due to advanced dementia, swallowing problem, and slow weight loss, and requires supplementation to meet nutritional needs. Interventions included to follow prescribed diet with magic cup and provide Glucerna 8 ounces twice daily, supplement with custard, and magic cup at meals. Observation and interview on 7/1/19 at 10:25 AM with Person #1 identified a sign above Resident #50's bed which read (when feeding the resident, PLEASE put magic cup on the tip of the spoon with every bit of food, thank you). Person #1 identified that the resident had been losing weight and that the facility did not consistently provide Resident #50 with his/her supplements. Interview with RN #1 on 7/1/19 at 10:25 AM identified that she was aware of the discussion, at a recent care plan meeting, that Resident #50 had not been receiving all the ordered supplements, and that sometimes the kitchen did not supply the magic cup. Observation on 7/2/19 at 12:58 PM identified NA #1 had fed Resident #50 approximately 75% of his/her meal, which included a regular ice cream cup that had not been opened. NA #1 identified that despite the sign above the resident bed, she had not obtained the magic cup. NA #1 identified that she was aware of Resident #50's weight loss, but the resident was doing well eating lunch without using the magic cup supplement and felt Resident #50 did not need the supplement this day. Interview with RN #1 on 7/2/19 at 2:21 PM identified that Resident #50 should have received his/her supplement per the physician's orders. Interview and review of facility documentation with RN #2 on 7/3/19 at 10:24 AM identified although staff monitored and documented the intravenous fluid intake, the facility policy was to also document the resident's by mouth intake of fluids and urinary output. RN #2 was unable to identify that the facility had monitored Resident #50's oral intake and/or urinary output. Interview and review of facility policy with the DNS on 7/3/19 at 10:36 AM identified that the staff should have also monitored the resident's oral intake and output. Interview and review of facility documentation on 7/3/19 at 11:32 AM with RN #1 identified that although she was sure Resident #50 had been receiving the supplemental Glucerna twice daily, the facility had failed to transcribe the order to the MAR and the record lacked documentation how much of the supplement Resident #50 was receiving and/or if the supplement was given. Review of the hydration policy identified that residents at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to maintain proper hydration and health. Risk factors for dehydration include dementia. Clinical signs of possible insufficient fluid intake include an elevated BUN. Residents with a diagnoses of dehydration will have an individualized treatment, and will be re-evaluated through the assessment/reassessment and care planning process. The intake and output policy identified it is the policy to accurately determine a residents fluid intake and output over a fixed time for those resident's whose medical conditions require strict monitoring. If a resident shows symptoms of dehydration notify the physician, family and dietician and continue intake and output. Although Resident #50 was at risk for dehydration, had poor oral intake, required extensive assistance with eating, had an elevated BUN, and was receiving IV hydration, the facility failed to monitor the resident's oral fluid intake and urinary output. Additionally, the facility failed to ensure the resident consistently received the ordered supplements.

**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 2 residents (Resident #38 and 55) reviewed for incontinence and/or urinary catheter, the facility failed ensure infection control practices were followed. The findings include: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, gastro-esophageal reflux disease without esophagitis (GERD). The quarterly MDS dated [DATE] identified Resident #38 had intact cognition and required extensive 2 person assistance with personal care. The care plan dated 6/13/19 identified Resident #38 was at risk for small bowel obstruction and or gastric upset due to a diagnosis of GERD, diverticulosis and history of adenocarcinoma and rectal bleeding. Interventions included to observe for decreasing hemoglobin and hematocrit, check stools for blood, monitor for other signs of anemia and update the physician of the findings. Observation on 7/1/19 at 10:03AM identified a urinary/stool collection device was tucked in the hand rail in Resident #38's bathroom. The collection device was not labeled and/or secured in a storage device. Interview with RN #2 on 7/3/19 at 9:03 AM identified Resident #38 was to use the collection device for monitoring for rectal bleeding. RN #2 further indicted that while the collection system was not labeled and/or secured in a storage device, Resident #38 was the only one who used the device. Interview with the DNS on 7/3/19 at 10:00 AM identified the collection device should have been labeled and stored in a bag when not in use. Review of the policy for handling contaminated materials directed all disposable items to be labeled, and secured in a plastic bag. 2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included pneumonia and urinary retention. The quarterly MDS dated [DATE] identified Resident #55 had moderately impaired cognition, and required total assistance with personal care. The care plan dated 3/21/19 identified Resident #55 utilized a Foley catheter size 16 with changes every thirty days by nursing staff and as needed, and that the Foley may be flushed with 20 cc normal saline as needed. A nurse's note dated 3/20/19 identified that a Foley catheter was placed on 3/15/19. A nurse's note dated 5/1/19 identified the Foley catheter was due to be changed on that day. Observation on 7/1/19 at 11:07 AM and 7/2/19 at 12:44 PM identified Resident #55's catheter drainage bag was hanging on the bed rail making direct contact with the floor. Interview, observation and review of the clinical record with RN #1 on 7/2/19 at 12:44 PM identified although Resident #55 was in a private room and often prefers to stay there, the drainage bag should have been covered, and that she forgot to obtain another storage device when changing the bag. Staff education dated for 2019 included information that directed when a leg bag not in use, the drainage bag was to be placed in a plastic bag inside a waste basket.