**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 3 residents (Resident #2 and 3) reviewed for pressure injuries (ulcers), the facility failed to ensure Braden scale assessments and weekly skin checks were documented and completed per facility policy. The findings include:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease and dementia.The Braden scale assessment dated [DATE] identified Resident #2 was at moderate risk for developing pressure injuries.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderate impairment in cognition (Brief Interview for Mental Status (BIMS) score of 10), had one (1) unstageable pressure injury, and was at risk for developing pressure injuries.A physician's order dated 4/4/25 directed weekly skin checks.The Braden scale assessment dated [DATE] identified Resident #2 was at risk for developing pressure injuries.The care plan dated 4/9/25 identified Resident #2 had multiple pressure injuries. Interventions included to assess risk of skin breakdown using the Braden scale assessment per policy and check skin at least weekly on scheduled bath day.Review of the medical record failed to identify a Braden scale assessment was completed weekly during the first month of admission (for two out of four opportunities on 4/12/25 and 4/19/25).3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included stroke, type II diabetes and gastrostomy.The care plan dated 1/7/25 identified Resident #3 had the potential for alteration in skin related to decreased mobility, diabetes and incontinence. Interventions included Braden scale assessment completed on admission and per facility skin protocol.The Braden scale assessment dated [DATE] identified Resident #3 was at risk of developing pressure ulcers/injuries.The re-entry skin check dated 1/31/25 identified Resident #3's skin was intact. The medical record failed to identify a skin check was completed for the week of 2/9/25 to 2/15/25.The Braden scale assessment dated [DATE] and 2/14/25 identified Resident #3 was at risk of developing pressure ulcers/injuries.Review of the medical record failed to identify a Braden scale assessment was completed weekly during the first month of admission (for one out of four opportunities on 2/21/25).The skin check dated 2/16/25 identified Resident #3 had no injuries after a fall.The medical record failed to identify a skin check was completed for the weeks of 2/23/25 to 3/1/25, 3/2/25 to 3/8/25, 3/9/25 to 3/15/25 and 3/16/25 to 3/22/25.The weekly wound evaluation dated 3/24/25 identified Resident #3 had a coccyx pressure injury measuring 1 centimeter (cm) by .5 cm by .1 cm. The weekly wound evaluation failed to identify a full body skin check was conducted.The weekly wound evaluation dated 3/31/25 identified Resident #3 had a coccyx pressure injury measuring 1 cm by .5 cm by .1 cm. The weekly wound evaluation failed to identify if a full body skin check was conducted.The skin check dated 4/4/25 identified Resident #3's skin was intact. The skin check failed to identify the status of Resident #3's coccyx pressure injury, and a weekly wound evaluation was not documented.The weekly wound evaluation dated 4/7/25 identified Resident #3 had a coccyx pressure injury measuring .5 cm by .2 cm by .1 cm.Interview with the DNS on 5/5/25 at 3:00 PM identified Braden scale assessments (risk evaluations) are to be completed per facility policy on admission/readmission, weekly for the first month, quarterly, and with a significant change. If there is a new skin concern identified, then a skin check form should be completed. She identified a weekly wound evaluation should be completed weekly for resident's with an existing wound and a separate skin check form should be completed for the weekly skin check (or documented in the TAR).Review of the skin integrity management policy directed to complete a risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Perform skin inspections (checks) on admission/readmission and weekly. Document on the TAR or in the electronic medical record. Perform wound observations and measurements and complete the skin observation tool upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound.Review of the nursing documentation policy directed that documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs, ideally within the same shift. All entries must be factual, complete, and reflect the resident's current condition and care provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #650) reviewed for a change in condition, the facility failed to ensure the health care representative was notified of new orders for intravenous fluids timely. The findings include: Resident #1 had diagnoses that included congestive heart failure, chronic kidney disease, osteomyelitis of vertebra, dysphagia, diabetes mellitus, and dementia. Review of Resident #650's advance directives dated 11/19/2019 identified Person #3 was the designated health care representative authorized to make any and all health care decisions for Resident #650. The form directed Person #3 was authorized to make decisions including the decision to accept or refuse any treatment, service, or procedure used to diagnose or treat Resident #650's physical or mental conditions and the decision to provide, withhold, or withdraw life support systems. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #650 had severely impaired cognition and required extensive assistance of one (1) to two (2) persons with all ADL's (activities of daily living). The Resident Care Plan (RCP) dated 2/11/2023 identified Resident #650 required tube feeding related to dysphagia. Interventions directed to monitor/document/report as needed any signs/symptoms of aspiration (fever, shortness of breath) and abnormal lab values. Review of the physician progress notes dated 2/22/2023 at 1:58 PM by MD #1 identified MD #1 performed a face-face visit to assess hypernatremia in the setting of chronic congestive heart failure (CHF) and edema of the upper extremities. The note indicated a plan to hydrate gently with IV D5W at 50 cc/hour for two (2) liters. Review of the physician orders dated 2/22/2023 directed to administer Dextrose Intravenous Solution 5% at 50 ml/hr for hyperkalemia. Review of the nursing progress notes failed to identify documentation that Person #3 was notified regarding Resident #650's new order for IV hydration. Review of the Medication Administration Record (MAR) identified Resident #650 had received Dextrose Intravenous Solution 5% on 2/22 through 2/24/2023. Interview with LPN #8 on 3/13/2024 at 12:20 PM identified she did not make calls to notify families; if a call needs to be made, she notifies the supervisor to make the call. LPN #8 indicated she did not notify Person #3 of the orders for IV fluids. Interview with LPN #9 on 3/13/2024 at 2:15 PM identified she was unable to recall if she notified Person #3 and she would have written a nursing note if she had made the notification. LPN #9 identified the facility standard practice was to notify the POA at the time when an order is received. Review of the nursing schedule dated 2/22/2023 identified the DON was the RN Supervisor on 2/22/2023 during the 7:00 AM to 3:00 PM shift. Interview with DON on 3/13/2024 at 2:45 PM identified the facility staff should notify a resident's POA when there is a new medication order. The DON indicated the physician would not notify the POA, but upon placing the new order, the nursing staff or RN Supervisor should update the POA of the situation. The DON was unable to provide documentation that Person #3 was notified, indicated they should have been notified. Additional interview at 2:50 PM identified although the DON was the shift supervisor when the new order was obtained, the DON indicated she did not recall notifying Person #3. Review of the Change in a Resident's Condition or Status and Notification Policy identified the facility shall promptly notify the resident and representative (consistent with his or her authority) of changes in the resident's medical condition and/or status (e.g., changes in level of care). The Nurse Supervisor/Charge Nurse will notify the resident's family or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for 1 of 1 sampled residents (Resident #19) reviewed for dental, the facility failed to report missing dentures to afford the opportunity for Resident #19 to submit a grievance. Resident 19's diagnosis included unspecified sequelae of cerebral infarction, paroxysmal atrial fibrillation and Type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was independent with eating, required supervision or touching assistance for oral hygiene, substantial/ maximal assistance for toileting hygiene, substantial/ maximal assistance for showering, partial/ moderate assistance for lower body dressing, supervision or touching assistance for upper body dressing. On 3/4/24 at 11:00 AM, interview with Resident #19 identified that his/her upper dentures were missing for about a week and could not recall if he/she told anyone. Interview with Licensed Practical Nurse (LPN) #1 on 3/4/24 at 12:07 PM identified that she was unaware that Resident #19's top dentures were missing. Interview with Social Worker (SW) #1 on 3/4/24 at 12:15 PM identified that he was unaware, and it was not reported to him that Resident #19's top dentures were missing. Interview with Nurse Aide (NA) #1 on 3/4/24 at 12:21 PM identified that although she noticed Resident #19's upper dentures were missing, she did not report the missing denture to licensed staff or the SW because she thought someone had already reported it. Although NA #1 was aware of Resident #19's missing upper dentures, she did not report to facility staff in order for a grievance to be initiated to resolve the missing denture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 2 of 5 sampled residents (Resident #2 and Resident #58) reviewed for unnecessary medications, the facility failed to initiate a Resident Care Plan related to a diagnosis with corresponding medication use. The findings include: 1. Resident #2's diagnoses included Atrial Fibrillation (A-fib), dementia, and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired and required assistance with ADL'S, meals, and medications. A physician's order dated 10/2/23 directed to administer Apixaban 2.5 milligram (mg) twice a day for atrial fibrillation (A-fib). Review of the Resident Care Plan (RCP) failed to identify a problem reflecting Resident #2's A-fib or the use of an anticoagulant medication (blood thinner). Interview and review of the clinical record with Registered Nurse (RN) #1 on 3/4/24 at 9:03 AM identified that there was not a RCP for the anticoagulant medication, and she must have missed adding the problem for Resident #2's anticoagulant medication use. Subsequent to surveyor inquiry, RN #1 indicated that the RCP would be revised to include the use of the anticoagulant medication. 2. Resident #58 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, morbid obesity, and Raynaud's syndrome. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was cognitively intact and required moderate assistance for transfers, maximum assistance for toileting, and setup assistance for personal hygiene. A physician's order dated 2/19/24 at 9:28 AM directed Resident #58 be administered Toujeo 50 units subcutaneously daily, and Mounjaro 5 milligrams subcutaneously every 7 days (both medications for diabetes). Review of the Resident Care Plan (RCP) failed to identify a care plan for Resident #58's diabetes or diabetic medication use. Interview and clinical record review with RN #1 on 3/4/24 at 12:22 PM, failed to identify Resident #58's had a RCP for his/her diabetes or for the use of diabetic medications. RN #1 identified that RN supervisors were responsible to initiate a RCP for pertinent diagnosis and medications upon admission but had not done so for Resident #58's diabetes. Additionally, a Resident Care Conference (RCC) had been held on 2/26/24 and although the interdisciplinary team was present, no one had initiated, updated, or identified the missing RCP for diabetes or diabetic medication use. RN #1 indicated that RCC's are used to review and revise the care plan so the missing RCP information should have been identified at that time, and that subsequent to surveyor inquiry a diabetic RCP would be generated. Review of the Care Planning policy directed, in part, that a comprehensive care plan for each resident is developed within 7 days of completion of the resident assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, facility documentation, and interviews for 1 of 4 sampled residents reviewed for accidents (Resident #15), the facility failed to revise the Resident Care Plan regarding discontinuation of anti-embolism stocking and initiation of interventions following a fall. The findings include: Resident #15's diagnoses included dementia, history of falling, and difficulty walking. a. A physician's order dated 4/7/22 through 3/1/23 directed Resident #15 was independent with bed mobility, wheelchair mobility, transfers, and ambulation with rollator within the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, was independent with walking, and required partial/moderate assistance with sit to lying and sit to stand. The Resident Care Plan (RCP) dated 1/17/23 identified Resident #15 was at risk for falls and that Resident #15 had limited physical mobility. Interventions included a dycem to the wheelchair cushion, call bell within reach, encourage resident to wear nonskid socks over his/her stockings, and that the resident was independent with rollator or wheelchair for transfers and ambulation within the facility. A Reportable Event form dated 2/24/23 at 7:10 PM identified Resident #15 had a witnessed fall with severe pain and he/she was sent to the hospital for evaluation. Resident #15 was hospitalized [DATE] through 2/28/23 for a fall with left hip fracture and had surgery completed. Resident #15 was readmitted to the facility on [DATE]. A physician's order dated 3/3/23 through 4/15/23 directed Resident #15 was to wear Thrombo-Embolus Deterrent (Ted) stockings daily for 6 weeks. The RCP dated 3/3/23 identified that Resident #15 was to have [NAME] stockings on in the morning and removed in the evening. Observation on 2/29/24 at 9:17 AM identified that Resident #15 was not wearing [NAME] stockings. Interview and observation with LPN #1 on 3/1/24 at 12:25 PM identified that Resident #15 was wearing regular stockings and did not wear [NAME] stockings anymore. Interview with NA #3 on 3/1/24 at 12:50 PM also identified that Resident #15 wore regular stockings and did not wear [NAME] stockings. An interview and RCP review with the MDS Coordinator (RN #1) on 3/4/24 at 12:07 PM identified that [NAME] stockings remained on the RCP even though there was no current physician's order and Resident #15 no longer utilized them. Subsequent to surveyor's inquiry, the intervention for [NAME] stockings was removed from the RCP. b. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was cognitively intact and required supervision or touch assistance with walking, sit to lying, and sit to standing. A physician's order dated 5/16/23 through 9/1/23 directed Resident #15 was independent with bed mobility, independent with a 4 wheeled walker for transfers, independent with a 4 wheeled walker for ambulation on level surfaces and supervision on uneven surfaces. The Resident Care Plan (RCP) dated 5/24/23 identified Resident #15 was at risk for falls and that Resident #15 had limited physical mobility. Interventions included a dycem to the wheelchair cushion, call bell within reach, encourage resident to wear nonskid socks over his/her stockings, and that the resident was an assist of 1 for bed mobility, and an assist of 1 with a 4 wheeled walker for both transfers and ambulation. A Reportable Event form dated 7/5/23 at 11:40 AM identified Resident #15 had an unwitnessed fall with severe pain after falling out of his/her wheelchair and he/she was sent to the hospital for evaluation. A nurse's note dated 7/7/23 at 10:00 PM identified that Resident #15 was readmitted to the facility. The Summary Report dated 7/7/23 and submitted to the State Agency from the Reportable Event dated 7/5/23 identified that to prevent reoccurrence, Resident #15 would be reminded to lock the wheelchair when stationary. Additionally, the summary from the Reportable Event identified Resident #15 had confirmed thoracic fractures. An interview and RCP review with the MDS Coordinator (RN #1) on 3/4/24 at 12:07 PM identified that the interventions (remind resident to lock the wheelchair when stationary) from the Corrective Action Plan was not added/included in the RCP. She further identified it was the responsibility of the Director of Nursing Services (DNS) to add interventions to the RCP resulting from the Corrective Action Plan, however the MDS Coordinator could also add interventions, as they work together. Subsequent to surveyor's inquiry, the intervention to remind the resident to lock the wheelchair when stationary was added to the RCP. c. A physician's order dated 10/11/23 through 3/5/24 directed that Resident #15 was an assist of 1 for bed mobility, independent with a 4 wheeled walker for transfers, and independent with a 4 wheeled walker for ambulation on the unit with supervision outdoors. The Resident Care Plan (RCP) dated 10/30/23 identified Resident #15 was at risk for falls and that Resident #15 had limited physical mobility. Interventions included a dycem to the wheelchair cushion, call bell within reach, encourage resident to wear nonskid socks over his/her stockings, and that the resident was an assist of 1 for bed mobility, independent with a 4 wheeled walker for transfers, and independent with a 4 wheeled walker for ambulation on the unit with supervision outdoors. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, was independent with walking and sit to lying, and required supervision or touch assistance with sit to stand. A Reportable Event form dated 12/4/23 at 12:00 PM identified Resident #15 had an unwitnessed fall with reported spine pain after and he/she was sent to the hospital for evaluation. The root cause/conclusion from the Reportable Event investigation identified that the resident must wear rubber sole shoes. A nurse's note dated 12/5/23 at 2:21 AM identified Resident #15 had returned to the facility without any acute injuries or fractures to the thoracic/lumbar spine. An interview and RCP review with the MDS Coordinator (RN #1) on 3/4/24 at 12:07 PM identified that the interventions (the resident must wear rubber sole shoes) from the corrective action to prevent recurrence on the Reportable Event dated 12/4/23 were not added/included in the RCP. She further identified it was the responsibility of the Director of Nursing Services (DNS) to add interventions to the RCP resulting from the Corrective Action Plan, however the MDS Coordinator could also add interventions, as they work together. Subsequent to surveyor's inquiry, the intervention that the resident must wear rubber sole shoes was added to the RCP. Review of the Care Planning policy directed, in part, that a comprehensive RCP is developed within 7 days of completion of the resident assessment (MDS). The RCP is created by Interdisciplinary Team. The resident and family, or legal representative, are encouraged to participate in the development of and revisions to the RCP. RCP meetings will be scheduled at times best for the resident and family.

**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 sampled residents reviewed for abuse (Resident #15) the facility failed to complete a nurse's note for the refusal of treatment, and for 1 of 4 sampled residents (Resident #33) reviewed for medication administration, the facility failed to check placement of the gastrostomy tube prior administering medication and feeding. The findings include: 1. Resident #15's diagnoses included dementia, depression, and anxiety disorder. The Resident Care Plan (RCP) dated 10/30/23 identified that Resident #15 had episodes of urinary incontinence, the potential for alteration in skin related to incontinence, and had decreased communication skills related to hearing loss. Interventions included to provide incontinent care as needed, to toilet the resident upon waking/prior to meals, to use simple direct communication, to verify verbal communication by repeating back to resident, and to ensure hearing aids were working properly. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, was highly hearing impaired, required partial/moderate assistance with personal hygiene, and required setup or clean up assistance with toileting hygiene. A Reportable Event form dated 1/8/24 on the 11:00 PM to 7:00 AM shift identified that Resident #15 reported to a family member that he/she had been touched inappropriately overnight and that the facility initiated an investigation. A nurse's note dated 1/8/24 at 1:44 PM identified that a call had been received from Resident #15's family member regarding concerns of Resident #15's overnight care. The Director of Nursing Services (DNS) had a conversation with the resident and notified the Administrator, Medical Director, Psychiatric Advanced Practice Registered Nurse, and Social Work, as well as the Police Department. A physician's progress note dated 1/8/24 at 2:45 PM identified that Resident #15 should be evaluated in the emergency room (ER) for a rape kit and Gynecological assessment. An interview and review of the nurses notes with the DNS on 3/4/24 at 12:42 PM identified that Resident #15's family member had told her that they did not want Resident #15 to go to the ER, however the DNS had not documented the refusal of treatment in a nursing note. Additionally, she had identified she had documented on the Reportable Event form but not in the nurses notes. Subsequent to surveyor inquiry, a late entry nursing note was added 3/4/24 dated for 1/8/24 and was chronologically inserted in-between the 1/8/24 notes identifying refusal of the ER visit. 2. Resident #33's diagnoses included Parkinson's disease, severe protein calorie malnutrition, and a malignant neoplasm of the head and neck. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 was moderately cognitively impaired and required extensive assistance with bed mobility, transfer, eating, and required a feeding tube. The Resident Care Plan dated 2/21/24 identified Resident #33 required a tube feeding related to dysphagia, a swallowing problem, and, at times, refused his/her tube feeding. Interventions included administering tube feeding and water flushes, per physician orders, check for tube placement and gastric contents/residual volume per facility protocol and record, and hold feeding if greater than 500 milliliters (ml) of aspirate (return of gastric content). A physician's order dated 2/28/24 directed Oxycodone 10 milligrams to be given via gastrostomy tube every 4 hours related to chronic pain, may crush tablet and enteral feeding three times a day via bolus tube feeding with [NAME] Farms 1.4 (1) 325 milliliter (ml) carton at 11:00 AM, (1) 325 ml carton at 2:00 PM and (1) 325 ml carton at 5:00 PM four times a day, medications may be administered via gastrostomy tube or by mouth at resident's preference; flush tube with 5 to 10 ml between each medication, Provide 30 ml free water flush before and after each bolus feed. Observation of medication administration with LPN #1 on 3/4/24 at 11:41 AM identified LPN #1 poured the Oxycodone tablet into a medication cup and crushed the medication. LPN #1 then mixed the medication with water. At the bedside, LPN #1 was observed to attach the feeding tube syringe to the gastrostomy tube and instilled the Oxycodone through the gastrostomy tube without the benefit of checking the tube placement prior to administration. LPN #1 indicated that she had checked placement prior to medication and feeding administration but earlier in the morning. LPN #1 was not aware of the facility policy for checking gastrostomy tube placement each time the gastrostomy tube required access. LPN #1 was unable to identify how she would have known if the tube had migrated out of its proper positioning. Review of the medication administration enteral tube policy directed, in part, to check the placement of the gastrostomy tube in accordance with facility policy. (a.) place resident in proper position with head of bed elevated 45 degrees. (b.) insert a small amount of air into the tube with a syringe and listen with a stethoscope for placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, facility policy, and interviews for 1 of 2 sampled residents reviewed for abuse (Resident #15), the facility failed to complete an assessment by a Registered Nurse after an allegation of mistreatment and for 1 sampled resident (Resident #39) reviewed for splints, the facility failed to ensure a hip abduction splint was applied daily as directed by the physician and for 1 of 3 sampled resident reviewed for hospitalization (Resident #55), the facility failed to obtain physician orders for multiple hospital transfers and for the 1 sampled resident (Resident #64) reviewed for death, the facility failed to transcribe Registered Nurse (RN) pronouncement orders before an RN pronouncement was completed. The findings include: 1. Resident #15's diagnoses included dementia, depression, and anxiety disorder. The Resident Care Plan (RCP) dated [DATE] identified that Resident #15 had episodes of urinary incontinence, the potential for alteration in skin related to incontinence, and had decreased communication skills related to hearing loss. Interventions included to provide incontinent care as needed, to toilet the resident upon waking/prior to meals, to use simple direct communication, to verify verbal communication by repeating back to resident, and to ensure hearing aids were working properly. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, was highly hearing impaired, required partial/moderate assistance with personal hygiene, and required setup or clean up assistance with toileting hygiene. A Reportable Event form dated [DATE] on the 11:00 PM to 7:00 AM shift identified Resident #15 reported to a family member that he/she had been touched inappropriately overnight and that the facility initiated an investigation. A nurse's note dated [DATE] at 1:44 PM identified that a call had been received from Resident #15's family member regarding concerns of Resident #15's overnight care. The Director of Nursing Services (DNS) had a conversation with Resident #15 and notified the Administrator, Medical Director, Psychiatric Advanced Practice Registered Nurse, and Social Work, as well as the Police Department. A physician's progress note dated [DATE] at 2:45 PM identified that Resident #15 should be evaluated in the emergency room (ER) for a rape kit and Gynecological assessment. An interview and Reportable Event review with the DNS on [DATE] at 12:42 PM identified that Resident #15's family member had refused for him/her to be seen at the ER. Also, an RN assessment after the allegation had not been completed. An interview with MD #1 on [DATE] at 3:14 PM identified that he could not perform an assessment on the resident due to cognitive concerns and that he advised for the resident to be evaluated in the ER. An additional interview with the DNS on [DATE] at 9:25 AM identified she would have been responsible for completing the RN assessment after the allegation. She was unable to identify the reason she did not complete an assessment. Review of the Abuse policy directed, in part, that upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. 2. Resident #39 was admitted to the facility on [DATE] with a diagnosis of cerebral vascular infarction (CVA), pleural effusion, and lung cancer. A Quarterly Minimum Date Set (MDS) assessment dated [DATE] identified Resident #39 was moderately cognitively impaired and required set up for eating, moderate assistance for toileting, transfers, and dressing. The MDS further identified Resident #39 required supervision assistance for personal hygiene and was physically impaired on one side. A physician order dated [DATE] directed to don (put on) a hip abduction splint when up in the wheelchair, doff (take off) while in bed A Resident Care Plan dated [DATE] identified Resident #39 had reduced positioning when sitting in the wheelchair due to cerebral vascular accident. Interventions included to don a hip abduction splint while in the wheelchair and doff when resident was in bed. The goal was for Resident #39 to be appropriately positioned when sitting in the wheelchair for proper lower extremity positioning utilizing hip abduction splint and elevating leg rests through the next review date. Review of the treatment admission record (TAR) from [DATE] through [DATE] failed to identify the hip abduction splint was included. On [DATE] at 1:00 PM, observation of Resident #39 with LPN #1 noted him/her to be in a wheelchair in the staff dining area, without the benefit of a hip abduction splint in place. On [DATE] at 2:10 PM, an interview and review of the TAR dated 2/2824 with LPN #1 failed to identify the hip abduction splint was included. LPN #1 was unsure of the reason the hip abduction splint was not applied to Resident #39, and could not see any record of it being included on the TAR. Interview on [DATE] at 11:15 AM with the Rehab Director (PT) #1 stated the travel Physical Therapist (who was no longer with the facility) placed the order and put order in the computer system incorrectly and that was the reason the hip abduction splint never was included on the TAR. Resident #39 needed the splint for positioning while in the wheelchair as he/she sat to one side which was called wind swept, the hip abduction splint was to keep Resident #39 legs apart. She stated that Resident #39 should have been added to the splint list and training should have been provided for the Nurses' Aides and the nurses. Review of the facility policy Preferred Therapy Solutions 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. Therapist coordinates with the interdisciplinary team to determine splinting needs and to monitor appropriate use and fit on a regular basis. Subsequent to surveyor inquiry, the Director of Rehab charted a functional area of change dated [DATE] stating the Resident #39 refused to utilize the hip abduction splint and screened Resident #39 on [DATE]. 3. Resident #55 's diagnoses included chronic obstructive pulmonary disease, heart failure, and respiratory failure. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 was moderately cognitively impaired and required set up assistance for eating, moderate assistance for transfers, and was independent for bed mobility. The Resident Care Plan dated [DATE] identified that Resident #55 was at risk for respiratory distress. Interventions included to monitoring for signs and symptoms of respiratory distress, provide medications per physician's orders, monitor vital signs as ordered, elevate the head of the bed to prevent shortness of breath, and encouraging rest periods as needed. Review of the Hospital Transfer Forms in the clinical record identified that Resident #55 was transferred to the hospital two times on [DATE], and once on [DATE] and [DATE]. The physician's order dated [DATE] through [DATE] failed to reflect any active or discontinued orders directing the staff to transfer Resident #55 to the hospital. Interview and clinical record review with the DNS on [DATE] at 12:52 PM identified the clinical record failed to reflect a physician's order to transfer Resident #55 to the hospital for evaluation on three separate dates: [DATE], [DATE], and [DATE]. The DNS indicated that there should always be a physician's order entered when a resident was transferred to the hospital for evaluation, per the facility policy. She stated it was her expectation that in an emergency, the physician's order to send the resident out to the hospital be entered as soon as possible after the emergency, but not to exceed the same day. Review of the Physician's Orders, Medication, and Treatment Orders policy dated 2014, directed, in part, that verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, and the date and time of the order. Review of the Transfer or Discharge, Emergency policy dated 2012, directed, in part, to notify the resident's attending physician. 4. Resident #64's diagnoses included Hodgkin's lymphoma, pneumonitis, chronic obstructive pulmonary disease, and ischemic cardiomyopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 was severely cognitively impaired, required partial/moderate assistance for oral hygiene, dependent of toileting hygiene, dependent for showering and upper/lower body dressing. Nursing notes dated [DATE] at 12:41 AM and written by RN #10 identified she observed Resident #64 not breathing at 11:40 PM on [DATE], no heart rate and no pupillary response. Additionally, the nursing note identified she pronounced Resident #64 dead at 11:50 PM on [DATE] and MD #3 was notified. Although a physician progress note dated [DATE] identified the physician confirmed a Do Not Resuscitate/Do Not Intubate/RN may pronounce with Resident #64's family, a review of the clinical record failed to identify a RN pronouncement physician order was written and in place prior to the RN pronouncement of death. Physician orders dated [DATE] directed RN pronouncement orders (obtained after the RN pronouncement of Resident #64's death had occurred). Interview with RN #10 on [DATE] at 9:53 AM identified she would check the paper chart/physician orders for the code status of a resident because it was more reliable than the electronic health record. RN #10 cannot recall if Resident #64 had an RN pronouncement order at the time of pronouncement. Interview with the Director of Nursing (DNS) on [DATE] at 10:00 AM identified that the RN pronouncement order was placed in the electronic health record on [DATE] (after Resident #64 expired), stated that RN #10 called her about not having an RN pronouncement order in place at Resident #64's time of death and then called MD #3, who then directed an order after RN #10 had made the pronouncement of death. Interview with MD #1 on [DATE] at 10:58 AM identified that he would expect an RN pronouncement order to be placed before the pronouncement of a resident's death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility documentation, observations, and review of the clinical record for 1 of 1 sampled residents (Resident #39) reviewed for splints, the facility failed to ensure that a hip abduction splint was applied daily as directed by the physician. The findings included: Resident #39 was admitted to the facility on [DATE] with a diagnosis of cerebral vascular infarction (CVA), pleural effusion, and lung cancer. A Quarterly Minimum Date Set (MDS) assessment dated [DATE] identified Resident #39 was moderately cognitively impaired and required set up for eating, moderate assistance for toileting, transfers, and dressing. The MDS further identified Resident #39 required supervision assistance for personal hygiene and was physically impaired on one side. A physician order dated 11/7/23 directed to don (put on) a hip abduction splint when up in the wheelchair, doff (take off) while in bed A Resident Care Plan dated 11/7/23 identified Resident #39 had reduced positioning when sitting in the wheelchair due to cerebral vascular accident. Interventions included to don a hip abduction splint while in the wheelchair and doff when resident was in bed. The goal was for Resident #39 to be appropriately positioned when sitting in the wheelchair for proper lower extremity positioning utilizing hip abduction splint and elevating leg rests through the next review date. Review of the treatment admission record (TAR) from 11/7/23 through 2/28/24 failed to identify the hip abduction splint was included. On 2/28/24 at 1:00 PM, observation of Resident #39 with LPN #1 noted him/her to be in a wheelchair in the staff dining area, without the benefit of a hip abduction splint in place. On 2/28/24 at 2:10 PM, an interview and review of the TAR dated 2/2824 with LPN #1 failed to identify the hip abduction splint was included. LPN #1 was unsure of the reason the hip abduction splint was not applied to Resident #39, and could not see any record of it being included on the TAR. Interview on 3/4/24 at 11:15 AM with the Rehab Director (PT) #1 stated the travel Physical Therapist (who was no longer with the facility) placed the order and put order in the computer system incorrectly and that was the reason the hip abduction splint never was included on the TAR. Resident #39 needed the splint for positioning while in the wheelchair as he/she sat to one side which was called wind swept, the hip abduction splint was to keep Resident #39 legs apart. She stated that Resident #39 should have been added to the splint list and training should have been provided for the Nurses Aides and the nurses. Review of the facility policy Preferred Therapy Solutions 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. Therapist coordinates with the interdisciplinary team to determine splinting needs and to monitor appropriate use and fit on a regular basis. Subsequent to surveyor inquiry, the Director of Rehab charted a functional area of change dated 2/28/24 stating the Resident #39 refused to utilize the hip abduction splint and screened Resident #39 on 3/6/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #55) reviewed for oxygen therapy, the facility failed to obtain a physician's order for oxygen administration. The findings include: Resident #55's diagnoses included respiratory failure with hypoxia, pneumonia, and Chronic Obstructive Pulmonary Disease (COPD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 was cognitively intact and required moderate assistance for bed mobility and personal hygiene, and required maximum assistance for transfers. Additionally, the MDS identified Resident #55 utilized oxygen therapy. The Resident Care Plan dated 2/28/24 identified Resident #55 had COPD and required supplemental oxygen. Interventions included oxygen administration as ordered by the physician, oxygen saturation as ordered and per policy, monitoring for signs and symptoms of respiratory distress, and encouraging rest periods as needed. Observations on 2/28/24 at 11:55 AM, on 2/29/24 at 11:55 AM, and on 3/1/24 at 10:10 AM identified Resident #55 utilizing oxygen at 2.0 liters per minute (lpm) via a nasal cannula. Interview, observation, and clinical record review with LPN #6 on 3/1/24 at 10:18 AM identified that Resident #55 was utilizing oxygen via a nasal cannula at 2.0 lpm. LPN #6 was not able to locate any active or discontinued oxygen physician orders, but stated Resident #55 had been on oxygen for at least a few weeks. She reported that Resident #55 went out to the Pulmonary physician recently and maybe the order was never transcribed, but she indicated that there should be an active physician's order for the resident to be utilizing oxygen. Interview with RN #2 on 3/1/24 at 10:29 AM identified that she was not able to locate either an active or discontinued oxygen order for Resident #55. She indicated she also checked with the former Nursing Supervisor, who was also not able to locate an order, but that she would obtain a physician's order and enter it into the clinical record. Subsequent to surveyor interview, a physician's order was obtained on 3/1/24 at 11:15 AM directing oxygen at 2.0 lpm via nasal cannula to maintain an oxygen saturation greater than 91% as needed. The facility policy regarding the Use of Oxygen: Nasal Cannula policy dated 1/1/2019 directed, in part, that oxygen is used only once an order is verified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for 1 of 1 sampled residents (Resident #19) reviewed for dental, the facility failed to report missing dentures to afford the opportunity for Resident #19 to submit a grievance. Resident 19's diagnosis included unspecified sequelae of cerebral infarction, paroxysmal atrial fibrillation and Type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was independent with eating, required supervision or touching assistance for oral hygiene, substantial/ maximal assistance for toileting hygiene, substantial/ maximal assistance for showering, partial/ moderate assistance for lower body dressing, supervision or touching assistance for upper body dressing. On 3/4/24 at 11:00 AM, interview with Resident #19 identified that his/her upper dentures were missing for about a week and could not recall if he/she told anyone. Interview with Licensed Practical Nurse (LPN) #1 on 3/4/24 at 12:07 PM identified that she was unaware that Resident #19's top dentures were missing. Interview with Social Worker (SW) #1 on 3/4/24 at 12:15 PM identified that he was unaware, and it was not reported to him that Resident #19's top dentures were missing. Interview with Nurse Aide (NA) #1 on 3/4/24 at 12:21 PM identified that although she noticed Resident #19's upper dentures were missing, she did not report the missing denture to licensed staff or the SW because she thought someone had already reported it. Although NA #1 was aware of Resident #19's missing upper dentures, she did not report to facility staff in order for a grievance to be initiated to resolve the missing denture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility documentation, and review of the clinical record for 2 of 5 residents (Resident #26 and Resident #39) reviewed for immunizations, the facility failed to ensure that Resident #26 was provided with the Influenza vaccine after receiving consent. Also, the facility failed to ensure that Resident #39 or the resident representative was educated and given the opportunity to consent or decline the Pneumonia vaccination upon admission and subsequent to admission to the facility. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with a diagnosis of heart disease, dementia, and diabetes. Interview and review of the facility immunization tracking with RN #6 (Infection Control Nurse) and RN #7 (the previous Infection Control Nurse) on 3/1/24 at 11:07 AM identified that RN #6 received consent upon admission for Resident #26 to receive the Influenza immunization for the 2023/2024 season. Resident #26 was ill and had Covid-19 on 10/4/23 and that RN #6 never provided the immunization once Resident #26 recovered from Covid 19. Resident #26 was hospitalized for Influenza on 2/23/24 and had since returned to the facility. 2. Resident #39 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (CVA), pleural effusion, and lung cancer. On 3/1/24 at 11:15 AM, interview and review of Resident #39's immunization record with RN #6 failed to provide documentation that Resident #39 was offered to receive/decline or provide proof of a previous Pneumonia vaccination. Interview on 3/1/24 at 11:15 AM with RN #7 indicated when someone was on the short term rehab unit, the facility does not offer pneumonia vaccines and the residents are directed by the Medical Director to go to their primary care physician for the Pneumonia vaccine. Facility Policy for Influenza Vaccines states that the vaccine shall be offered to residents between October 1st and March 31st. The Infection Preventionist will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among residents and staff. Facility Policy for Influenza, Prevention and Control of Seasonal states that the Infection Preventionist will promote and administer seasonal influenza vaccines. Facility Policy for Pneumococcal Vaccine states prior to or upon admission, residents will be assessed for the eligibility to receive the pneumococcal vaccines series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessment of the pneumococcal vaccine status will be conducted with in 5 working days of the resident's admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effect of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. Residents/representative have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of refusal of the pneumococcal vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility documentation, and review of the clinical record for 2 of 5 sampled residents (Resident #11 and Resident #59) reviewed for immunizations, the facility failed to ensure upon admission, the residents or resident representative was educated and given the opportunity to consent or decline the Covid-19 vaccine. The findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnosis of an autoimmune disease, sepsis, and calculus of the kidney. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was moderately cognitively impaired and dependent for toileting and dressing, set up for eating and substantial assist for personal hygiene. 2. Resident #59 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease, sepsis, and congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 moderately cognitively impaired and was dependent for dressing, personal hygiene, toileting, and maximum assist for eating and transfers. Interview and review of the facility immunization tracking with Registered Nurse (RN) #6 (the Infection Preventionist) and RN #7 (the previous facility Infection Preventionist) on 3/1/24 at 11:07 AM failed to identify Resident #11 and Resident #59 was offered the Covid-19 vaccine on and since admission. Additionally, there was not a record of Resident #11 or Resident #39's representative being offered education or an opportunity to receive or decline the Covid-19 vaccination on their behalf. The facility was also unable to provide documentation that Resident #11 or Resident #59 had received the Covid-19 immunization in the past/prior to admission. Additionally, RN #6 stated that she did not offer the Covid-19 vaccination to Resident #11, Resident #59 or their resident representatives on their behalf. The Facility Covid Vaccination of Resident policy states all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident is already vaccinated and that all new residents shall be assessed for current vaccination status upon admission. If the vaccines are refused, the refusal shall be documented in the resident's medical record. Subsequent to surveyor inquiry, the facility began completing immunization records for residents who received the Influenza, Pneumococcal, and Covid-19 vaccination.

Based on review of facility documentation, review of facility policy and interviews 3 of 5 employee files reviewed (Licensed Practical Nurse (LPN) #4, LPN #5 and Registered Nurse (RN) #4), the facility failed to ensure that the required employee training's/inservices were completed. The findings include: 1. LPN #4's date of hire was 12/12/23. Review of the facility time-card documentation for LPN #4 identified that she had worked in the facility between 12/12/23 through 2/2/24. 2. LPN #5's date of hire was 11/15/23. Review of facility time-card documentation for LPN #5 identified that she had worked in the facility between 11/15/23 through 2/24/24. 3. RN #4's date of hire was 9/29/23. Review of facility time-card documentation for RN #4 identified that she had worked in the facility between 10/9/23 through 2/18/24. Review of employee files for LPN #4, LPN #5, and RN #4, failed to identify that new employee orientation training/inservices were completed and in the files. Additionally, the employee files failed to identify that documentation of Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication and Behavioral Health training's were completed and in the files. Interview and record review with the facility Administrator on 3/6/24 at 12:00 PM identified that although the required training's should have been completed upon hire, she was unable to provide documentation that the required training's had been completed for LPN #4, LPN #5 and RN #4. The Administrator further indicated that she did not know the reason the required training's were not completed and that the person responsible for conducting the training had resigned. Facility policy regarding Orientation Program for Newly Hired Employees, Transfers, Volunteers, directed that all newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.

Based on review of facility documentation, employee files, review of facility policy and interviews 1 of 2 Nurse Aide (NA) employee files reviewed (NA #4), the facility failed to ensure that the required employee training/inservices were completed. The findings include: NA #4's date of hire was 9/28/23. Review of the facility time-card documentation for NA #4 identified that she had worked in the facility between 9/28/23 to present. Review of the employee file for NA #4 failed to identify that any inservicing had been provided (Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication and Behavioral Health) and included in the files from the date of hire until present. Interview and record review with the facility Administrator on 3/6/24 at 12:00 PM identified that although the required training/inservices should have been completed upon hire, she was unable to provide documentation that the required inservices had been completed for NA #4. The Administrator further indicated that she did not know the reason the required inservices were not completed and that the person responsible for conducting the training/inservices had resigned. Facility policy regarding Orientation Program for Newly Hired Employees, Transfers, Volunteers, directed that all newly hired personnel/volunteers/transfers must attend a 10-hour orientation program within their first five (5) days of employment.

**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 5 residents (Resident #7 and Resident #43) reviewed for unnecessary medication, the facility failed respond to pharmacy recommendations related to an as needed (PRN) psychotropic medication. The findings include: 1. Resident #7's diagnoses included Alzheimer's disease, anxiety disorder and Type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired, required practical assistance with shower transfer and toileting hygiene and maximal assistance with showering. The Resident Care Plan dated 11/10/23 identified Resident #7 had episodes being resistive to care- refused to shower and refused to change clothes. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness. A physician's order dated 11/13/23 directed to provide Ativan (Lorazepam) 0.5 milligrams (mg), give 1 tablet by mouth every 24 hours as needed for anxiety/agitation prior to showers (administer 45 minutes prior to shower). However, the physician order failed to indicate a stop date. Nursing Notes dated 11/13/23, 11/24/23, 12/14/23 and 1/26/24 identified Resident #7 was administered Ativan (Lorazepam)0.5 mg prior to a shower for anxiety. Interview with Pharmacy consultant on 3/5/23 at 10:24 AM indicated that he had provided recommendations for Resident #7 on 1/8/24 and 2/8/24 that indicated that PRN for psychotropic drugs are limited to 14 days, and further assessment by the prescribing physician was required if a PRN should be extended. Interview with the DNS on 3/5/24 at 12:10 PM indicated that she was unable to locate the signed acknowledged pharmacy recommendation for Resident # 7 from the November 2023 to March 2024 time frame. Interview with the DNS on 3/5/24 at 1:00 PM indicated that once pharmacy consults/recommendation were sent to the facility, consults are placed in the Medical Director's box and reviewed. The DNS indicated she and the Nursing Supervisors were responsible for putting the approved order in the medical records. The DNS was unable to explain the reason this was not done. Interview with the DNS on 3/5/24 at 2:17 PM indicated that she did not see a psychiatrist note from 12/18/23, which directed Ativan 0,5 mg PRN for 14 days. Subsequent to surveyor inquiry Ativan 0.5 mg PRN was discontinued on 3/5/24. 2. Resident #43's diagnoses included dementia, depressive episodes, and history of fractures. a. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was moderately cognitively impaired, was not identified to have behaviors, and required extensive one-person physical assistance with personal hygiene. Additionally, the MDS identified Resident #43 received an antidepressant medication. The Resident Care Plan (RCP) dated 2/17/22 identified Resident #43 had impaired cognitive function and thought processes related to dementia, and a mood problem related to admission. Interventions included to administer medications as ordered, monitor/document side effects and effectiveness, and behavioral health consults, including psychiatry, as needed. A physician's order dated 11/3/21 through 3/5/24 directed to administer Trazodone (medication used for depression) 25 mg every 8 hours PRN for agitation but failed to include a stop date of 14 days. Medication Administration Record dated 12/17/21, 12/26/21, 1/1/22, 1/2/22, 1/9/22, 1/15/22, 1/17/22, and 1/18/22 identified Resident #43 received Trazodone 25 mg for agitation. Although PRN Trazodone was renewed monthly by the physician, the resident had not received subsequent PRN doses. b. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a short/long term memory problem, was identified to have verbal behavioral symptoms occurring 1 to 3 days, and other behavioral symptoms occurring 4 to 6 days. Additionally, the MDS identified Resident #43 required partial/moderate assistance with toileting hygiene and upper/lower body dressing and that the resident received an antidepressant medication. The Resident Care Plan (RCP) dated 11/11/22 identified that Resident #43 used an antidepressant medication related to depression and psychotropic medications related to paranoia. Interventions included to administer medications as ordered, educate about the risks, monitor/document regarding adverse reactions, and to consult with the pharmacy/physician to consider a dosage reduction when clinically appropriate at least quarterly. A physician's order dated 10/14/22 through 2/14/24 directed to administer Ativan (medication used for anxiety) 0.5 mg every 4 hours PRN for anxiety but failed to include a stop date of 14 days. A physician's order dated 2/14/24 through 3/5/24 directed to administer Ativan 0.5 mg every 6 hours (decreased frequency from previous order of every 4 hours) PRN for anxiety or agitation. Do not give if resident is sleepy, lethargic, or sedated. Medication Administration Record dated 6/17/23, 6/21/23, 6/23/23, 6/26/23, 7/9/23, 7/29/23, and 7/30/23 identified Resident #43 received Ativan 0.5 mg for anxiety. Although PRN Ativan was renewed monthly by the physician, the resident had not received subsequent PRN doses. Consultant Pharmacist Recommendations dated 2/8/22 identified that the Centers for Medicare and Medicaid Services guidelines will limit PRN psychotropic orders to 14 days maximum use without a reassessment. Recommendations included for the physician to assess continued need for PRN Trazodone or add a specific stop date to the order. The same recommendation was identified subsequently in the 5/6/22 and 8/12/22 reports. The 8/13/23 report included the same recommendation for PRN Ativan, as well as PRN Trazodone. All Pharmacy reports received failed to identify the physician responded to pharmacy recommendations. Additionally, pharmacy medication review failed to identify an open-ended PRN order for Trazodone and/or Ativan on 3/8/22, 4/7/22, 6/10/22, 7/14/22, 9/7/22, 11/7/22, 12/8/22, 1/4/23, 2/7/23, 3/6/23, 4/14/23, 5/9/23, 7/14/23, 9/20/23, 10/20/23, 11/10/23, 12/9/23, 1/8/24, and 2/9/24 despite the resident being prescribed PRN Tradozone and/or Ativan. An interview with MD #1 on 3/4/24 at 3:16 PM identified that he was aware that psychotropic PRN medications should only be ordered for 14 days and could not identify the reason he did not include the 14 days stop date, but Resident #43 had been on psychotropic PRN medications for a long time. An interview with the Pharmacy Consultant on 3/5/24 at 10:10 AM identified that the duration of PRN psychotropic medications had been addressed in past reports. An interview with the Director of Nursing Services (DNS) on 3/5/24 at 1:00 PM identified that she did not have a reason why the pharmacy reports and recommendations were not responded to by the physician. An additional interview with the Pharmacy Consultant on 3/6/24 at 12:05 PM identified that a pharmacy progress note stating no irregularities was generated when there is no physician recommendation report.

**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 5 residents (Resident # 7 and #43) reviewed for unnecessary medication, the facility failed to order as needed (PRN) psychotropic medications for only 14 days. The findings include: 1. Resident #7's diagnoses included Alzheimer's disease, anxiety disorder and Type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired and required practical assistance with shower transfer and toileting hygiene and maximal assistance with showering. The Resident Care Plan dated 11/10/23 identified Resident #7 had episodes of resistive to care- refused to shower, and refused to change clothes. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness. A physician's order dated 11/13/23 directed to provide Ativan (Lorazepam) 0.5 milligrams (mg), give 1 tablet by mouth every 24 hours as needed for anxiety/agitation prior to showers (administer 45 minutes prior to shower). However, but failed to indicate a stop date. Nursing notes dated 11/13/23, 11/24/23, 12/14/23 and 1/26/24 identified Resident #7 was administered Ativan (Lorazepam) prior to his/her shower for anxiety. Interview with the Pharmacy Consultant on 3/5/23 at 10:24 AM indicated that he had provided recommendations on 1/8/24 and 2/8/24 that indicated that PRN usage for psychotropic drugs were limited to 14 days, and further assessment by the prescribing physician was required if a PRN should be extended. Interview with the DNS on 3/5/24 at 12:10 PM indicated that she was unable to locate the signed acknowledged pharmacy recommendation for Resident #7 from the November 2023 to March 2024 time frame. Interview with the DNS on 3/5/24 at 1:00 PM indicated that once pharmacy consults/recommendations were sent to the facility, the recommendations were placed in the Medical Director's box and reviewed. The DNS indicated she and the Nursing Supervisors were responsible for putting the approved order in the medical records. The DNS was unable to explain the reason this was not done. Interview with the DNS on 3/5/24 at 2:17 PM indicated that she did not see the Psychiatrist note from 12/18/23, which directed Ativan PRN for 14 days. Subsequent to surveyor inquiry, Ativan 0.5 mg PRN was discontinued on 3/5/24. 2. Resident #43's diagnoses included dementia, depressive episodes, and history of fractures. a. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was moderately cognitively impaired, was not identified to have behaviors, and required extensive one-person physical assistance with personal hygiene. Additionally, the MDS identified Resident #43 received an antidepressant medication. The Resident Care Plan (RCP) dated 2/17/22 identified Resident #43 had impaired cognitive function and thought processes related to dementia, and a mood problem related to admission. Interventions included to administer medications as ordered, monitor/document side effects and effectiveness, and behavioral health consults, including psychiatry, as needed. A physician's order dated 11/3/21 through 3/5/24 directed to administer Trazodone (medication used for depression) 25 milligrams (mg) every 8 hours PRN for agitation but failed to include a stop date of 14 days. Medication Administration Record dated 12/17/21, 12/26/21, 1/1/22, 1/2/22, 1/9/22, 1/15/22, 1/17/22, and 1/18/22 identified Resident #43 received Trazodone 25 mg for agitation. Although PRN Trazodone was renewed monthly by the physician, the resident had not received subsequent PRN doses. b. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a short/long term memory problem, was identified to have verbal behavioral symptoms occurring 1 to 3 days, and other behavioral symptoms occurring 4 to 6 days. Additionally, the MDS identified Resident #43 required partial/moderate assistance with toileting hygiene and upper/lower body dressing and that the resident received an antidepressant medication. The Resident Care Plan (RCP) dated 11/11/22 identified that Resident #43 used an antidepressant medication related to depression and psychotropic medications related to paranoia. Interventions included to administer medications as ordered, educate about the risks, monitor/document regarding adverse reactions, and to consult with the pharmacy/physician to consider a dosage reduction when clinically appropriate at least quarterly. A physician's order dated 10/14/22 through 2/14/24 directed to administer Ativan (medication used for anxiety) 0.5 mg every 4 hours PRN for anxiety but failed to include a stop date of 14 days. A physician's order dated 2/14/24 through 3/5/24 directed to administer Ativan 0.5 mg every 6 hours (decreased frequency from previous order of every 4 hours) PRN for anxiety or agitation. Do not give if resident is sleepy, lethargic, or sedated. Medication Administration Record dated 6/17/23, 6/21/23, 6/23/23, 6/26/23, 7/9/23, 7/29/23, and 7/30/23 identified Resident #43 received Ativan 0.5 mg for anxiety. Although PRN Ativan was renewed monthly, the resident had not received subsequent PRN doses. An interview with MD #1 on 3/4/24 at 3:16 PM identified that he was aware that psychotropic PRN medications should only be ordered for 14 days and could not identify the reason he did not include the 14 days stop date, but Resident #43 had been on psychotropic PRN medications for a long time. An interview with the Pharmacy Consultant on 3/5/24 at 10:10 AM identified that the duration of PRN psychotropic medications had been addressed in past reports. Subsequent to surveyor inquiry, both Trazodone and Ativan PRN medications were discontinued on 3/5/24. Review of the Psychotropic Medication PRN Usage policy directed, in part, that medication renewal is required every 14 days. To continue use, a new order for the PRN medication may be written if the prescribing practitioner directly examines and assesses the resident and documents the rationale for continuing use, which should include benefits of use for the resident.

Based on the staff interviews, facility documentation, and review of the facility policies, the facility failed to ensure that Infection Prevention Control Program standards (IPCP) policies and procedures are reviewed annually by the Administrator, Medical Director, and the Director of Nursing and that the facility maintained an updated list of residents with Multidrug Resistant Organism. (MDRO) The findings included: On 3/1/24 at 11:07 AM, review of the Infection Prevention policies/procedure manual with RN #6 (the Infection Preventionist) and RN #7 (the previous Infection Preventionist) failed to identify the policies had been reviewed and signed by the Administrator, Medical Director, and Director of Nursing annually. Additionally, the signature page was blank, with no signatures present and both RNs stated that they were unaware that the policies needed to be signed on an annual bases. The MDRO (Multidrug Resistant Organisms) list was last updated on 4/14/23 with some of those residents having been discharged or no longer in the same rooms as identified on the MDRO list. RN #7 stated on 3/1/24 the Director of Admissions was aware of which residents were on the MDRO list and she was the one who had a current list. Interview on 3/1/24 at 2:17 PM with the Director of Admissions identified she had no knowledge of which residents were on the MDRO list and denied having a current or historical list of residents that had a MDRO. Subsequent to surveyor inquiry, the facility completed an updated MDRO log on 3/4/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents,(Resident #1), reviewed for abuse, the facility failed to ensure the reporting of a suspected crime to local law enforcement following and allegation of staff to resident physical mistreatment. The findings include: Resident #1's diagnoses included atrial fibrillation, type II diabetes and cognitive communication deficit. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required one person assist with bed mobility and transfer, two person assist with toileting, dressing, and was mobile with the use of a wheelchair. The Resident Care Plan dated 11/28/23 identified Resident #1 had impaired cognitive function and required assistance with activities of daily living related to disease process with interventions directed to communicate with the resident and caregivers regarding resident's capabilities and provide two care givers due to fragile skin. A nurse's note dated 12/28/23 at 2:42 PM identified that the resident had a change in mental status and was transferred to the hospital. A hospital admission social worker progress note dated 12/28/23 identified the hospital social worker met with Resident #1 and Person #1 who identified herself as the Health Care Representative were at bedside. Resident #1 was alert and oriented to person, place, time and circumstances. Resident #1 and Person #1 explained Resident #1 did not want to return to the facility. Resident #1 reported a nurse was grabbing and bruising h/her arms from around Thanksgiving time. Person #1 confirmed this information and stated the facility was aware and that the resident no longer had this nurse assigned to him/her. Resident #1 and Person #1 were unable to provide the nurse's name or when the last time this occurred, and that Resident #1 was conflicted whether to report to the facility. Support and reassurance were provided. A facility Reportable Event dated 12/29/23 identified the facility Admissions Director brought to this nurse's attention that resident reported to staff at an outside hospital that a nurse at the facility was rough with him/her while at the facility. The report failed to identify that law enforcement had been notified of the suspected crime. A nurse's note dated 1/19/24 identified that the resident was re-admitted to the facility from the hospital and the previous plan of care would be continued. An interview with the Director of Nursing, DNS on 1/23/24 at 2:40 PM identified she did not contact local law enforcement at any time after learning of the allegation because Resident #1 was not in the facility at the time she learned of the allegation and was not expected to return to the facility given the statement made in the hospital that s/he did not want to return. An interview with the [NAME] President of Clinical Operations for Ark on 1/23/24 at 2:40 PM identified local law enforcement should have been called upon learning of the allegation whether the resident was in the building or not. A review of the facility policy for Abuse directs that should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown origin occur, the Administrator or designee will investigate the alleged incident. The report of the investigation will be sent to local police department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to ensure a complete and thorough investigation was completed following an allegation of staff to resident physical mistreatment. The findings include: Resident #1's diagnoses included atrial fibrillation, type II diabetes and cognitive communication deficit. The hospital Discharge summary dated [DATE] identified abrasions, bruising and excoriation (unspecified location). The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required one person assist with bed mobility and transfer, two person assist with toileting, dressing, and was mobile with the use of a wheelchair. The Resident Care Plan dated 11/28/23 identified Resident #1 had impaired cognitive function and required assistance with activities of daily living related to disease process. Interventions directed to communicate with the resident and caregivers regarding resident's capabilities and provide two care givers due to fragile skin. A physician's order dated 11/28/23 directed two staff for care due to fragile skin. A nurse's note dated 12/28/23 at 2:42 PM identified Resident #1 was lethargic and only able to state h/her name with an oxygen saturation (measures the level of oxygen in the blood) of 90% that dropped to 85% (normal 95%-100%) and a blood pressure of 156/72. The bed was elevated to fowlers (the head of the bed raised to a sitting position while in bed) and 2 liters of oxygen was applied by nasal cannula with pulse oxygenation reading of 93%. The supervisor was made aware, and Resident #1 was transferred to an outside hospital at 9:15 AM. A hospital admission social worker progress note dated 12/28/23 identified the hospital social worker met with Resident #1 and Person #1 who identified herself as the Health Care Representative were at bedside. Resident #1 was alert and oriented to person, place, time and circumstances. Resident #1 and Person #1 explained Resident #1 did not want to return to the facility. Resident #1 reported an nurse was grabbing and bruising h/her arms from around Thanksgiving. Person #1 confirmed this information and stated the facility was aware and that the resident no longer had this nurse assigned to him/her. Resident #1 and Person #1 were unable to provide the nurse's name or when the last time this occurred, and that Resident #1 was conflicted whether to report the not. Support and reassurance were provided. A facility Reportable Event dated 12/29/23 identified the facility Admissions Director brought to this nurse's attention that resident reported to staff at an outside hospital that a nurse at the facility was rough with him/her while at the facility. The Reportable Event Summary dated 1/4/24 identified several alterations in skin integrity including multiple areas of bruising, abrasions, and excoriation throughout her body according to the hospital discharge summary (dated 10/25/23) and multiple areas of bruising noted on admission. The allegation of abuse was unsubstantiated. Factors included in this determination were the resident's ongoing altered mental status (including dementia and anxiety), that all care was provided by two persons, and the documented history of significant alterations in skin integrity. A review of the facility Reported Event investigation did not include documentation that staff interviews were conducted or that statements had been obtained to conclude that mistreatment had not occurred. An interview and clinical record review on the Director of Nursing, DNS on 1/23/24 at 12:31 PM and subsequent interview on 1/23/24 at 2:40 PM identified she was not aware of any allegations of mistreatment until being notified by the facility admissions director that the allegation was made by Resident #1 while in the hospital. The DNS stated that although the hospital documentation noted the alleged incident took place around Thanksgiving, she had no solid time reference to go by so based her investigation on a chart review. The DNS did not speak to staff until after the investigation was completed when Resident #1 was returning to the facility and did not obtain statements from staff during the investigation. An interview with the [NAME] President of Clinical Operations for Ark on 1/23/24 at 2:40 PM identified she directed the DNS to talk with staff following the allegation and that written statements should have been included as part of the investigation. A review of the facility policy for Abuse directs that should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown origin occur, the Administrator or designee will investigate the alleged incident. The person conducting the investigation will, at minimum, include interviews with staff members on all shifts who had contact with resident #1 during the period of the alleged event and interviews with family and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and interviews for two of two residents (Resident# 2, and #31) reviewed for advanced directives, the facility failed to ensure the advance directives were completed timely and were in accordance with resident's wishes. The findings include: a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and vascular dementia without behavioral disturbances. The nursing admission assessment dated [DATE] identified Resident #2 was confused and required extensive assistance with ADLs. The Resident Care Plan (RCP) dated [DATE] identified Resident #2 had an established advanced directive of Do Not Resuscitate/Don Not Intubate (DNR/DNI). Interventions directed to adhere to advance directives per resident wishes, and to review the advanced directives with the resident and family quarterly. Clinical record review identified Resident #2 had a family member listed as the responsible party. Additional review identified Advance Directives form signed by Resident #2's responsible party and dated [DATE] were included in the paper chart. The form identified Resident #2 had a living will and directed the following: NO cardiopulmonary resuscitation (CPR) with mechanical ventilation; YES, DNR (Do not resuscitate; No CPR, no mechanical ventilation, allow death to occur naturally. The form was signed not signed by a facility staff member of the physician. Review of physician's orders dated [DATE] failed to identify and order that directed Resident's #2's code status/advance directives for DNR. An interview with LPN #1 on [DATE] at 1:29 PM indicated that a physician's order was required to be signed by the physician for advance directives/code status. Additionally, LPN #1 indicated the order should be in the Electronic Medical Record (EMR). LPN #1 further indicated that Resident #2 did not have a physician's order for advanced directives in the EMR and with no order in place, Resident #2 would be a full code (received CPR) if Resident #2's heart stopped or ceased breathing. An interview with the ADNS on [DATE] at 1:41 PM identified Resident #2's advanced directive form should have been completed upon admission with physician orders obtained to direct DNR in accordance with the resident's advance directives. Subsequent to surveyor inquiry, Resident #2's advanced directives were completed and signed on [DATE], and the physician's orders were updated to identify Resident #2's code status as DNR. b. Resident #31 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation and dementia with behavioral disturbance. The nursing admission assessment dated [DATE] identified Resident #31 was confused and required assistance with ADLs. The RCP dated [DATE] identified Resident #31 had an established advanced Directive of full code. Interventions directed to adhere to advance directives per resident wishes, and to review advanced directives with the resident and family quarterly. Clinical record review identified Resident #31 had a family member listed as the responsible party. Additional review identified Advance Directives form signed by Resident #31's responsible party and dated [DATE]. The form indicated that Resident #31 had a living will and directed NO cardiopulmonary resuscitation (CPR with mechanical ventilation, and NO DNR (Do Not Resuscitate). Physician's orders dated [DATE] directed for DNR, DNI (Do Not Intubate), and RN may pronounce (death). An interview with RN #1 on [DATE] at 11:41 AM identified the advanced directive form in Resident #31's chart read both no CPR and no to being a DNR. RN #1 indicated that she would always check the EMR and follow the physician's order in the EMR for a resident's code status. Resident #31's order directed DNR, and no CPR would be administered if Resident #31's heart stopped or he/she stopped breathing. An interview with the ADNS on [DATE] at 11:47 AM identified Resident #31's advanced directive form was not clear (conflicting No CPRN, and No DNR). Additionally, the ADNS indicated the admitting nurse should have clarified the resident and family's direction when the form was signed on [DATE]. She indicated that her expectation was that the form would be filled out completely and give clear direction for a resident's code status. The ADNS further indicated that she would follow up to clarify and update the medical record. Subsequent to surveyor inquiry, Resident #31's code status was updated on [DATE] to identify the decision was clarified with the responsible party, and Resident #31 was listed as No CPR, and YES, DNR (Do Not Resuscitate). Review of the facility's Advanced Directive Policy directed in part, that prior to, or upon admission the social services director or designee will inquire of the resident, and/or his/her family members about the existence of any written advance directives. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. The policy further directed the DNS or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility's documentation, review of facility's policy, and interviews for one of three residents (Resident #304) reviewed for a change in condition, the facility failed ensure the physician was notified timely when weekly weights were not obtained in accordance with physician's orders. The findings include: Resident #304 was admitted on [DATE] with diagnoses that included metabolic encephalopathy, sepsis, UTI, Marfan's syndrome, urinary retention, muscle weakness, and dementia without behavioral disturbance. A physician's order by Physician's Assistant (PA) #1 dated 11/3/2021 directed to weigh weekly every Friday for four (4) weeks and once a day starting on the first day and ending on the last day of every month. The weight record dated 11/3/2021 identified Resident #304's weight was 98.6 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #304 had severe cognitive impairment, required extensive assistance with ADLs, weight was 108 pounds (lbs), and was unknown if Resident #304 had a weight loss or gain in the last 30 days or six (6) months. The Resident Care Plan (RCP) dated 11/4/2021 identified a potential for alteration in nutrition. Interventions directed to monitor, record and report weight loss. Nutrition Risk assessment dated 11/ 9/2021 identified Resident #304's [NAME] was 5 feet, Body mass index was 21.1 (indicated he/she was at risk), and weight on 11/5/2021 was 108 lbs. The assessment recommended supplements and directed to monitor weights. Review of the Medication Administration Record (MAR) for November 2021 identified weekly weights for four (4) weeks were due on 11/5 (weight recorded), 11/12, 11/19 and 11/28. Weights were missing on 11/12 and 11/28, and although staff initialed that a weight was obtained on 11/19, review of the clinical record failed to identify a weight was obtained and recorded. Additional facility documentation and clinical record review failed to identify daily weights were obtained in accordance with the physician orders. An interview with the dietician on 12/6/2021 at 10:03 AM identified the physician/practitioner should be notified if staff are unable to obtain weights in accordance with physician orders. An interview with PA #1 on 12/6/21 at 10:15 AM indicated that he was not aware Resident #304 was not weighed on 11/12, 11/19 and 11/28/2021, and that daily weights were not obtained. He indicated his expectation was to be notified if the weights were not obtained. An interview with the DNS on 12/6/21 at 10:42 AM indicated that if a staff member is unable to carry out an MD order, the charge nurse or supervisor should be notified, and the physician/practitioner should be notified. Review of the facility Weight Assessment and Intervention Policy directed in part, that weights will be recorded on admission, the next day and weekly for 2 weeks thereafter. Additionally, the policy directed weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review and interviews and for one of two residents reviewed for pressure ulcer, Resident #46, the facility failed to ensure a comprehensive care plan was develped timely related to risk for pressure ulcers and the presence of a pressure ulcer. The findings include: Resident #46 was admitted in August 2021. Resident #46's diagnoses included dementia, diabetes, difficulty walking and a pressure ulcer to the left heel. A Braden Scale for Predicting Pressure Sore Risk dated 8/19/2021 identified the resident was at risk for pressure sores. The admission MDS dated [DATE] identified Resident #46 had severe cognitive impairment, required extensive assistance of one staff for bed mobility and transfers and identified the resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer (due to coverage of wound bed by slough and/or eschar). The Resident Care Plan (RCP) dated 9/9/2021 identified an alteration in personal care related to a fibula fracture. Interventions directed to provide assistance with ADLs. Although Resident #46 was admitted with a pressure ulcer, review of the RCP failed to identify a care plan was developed for a risk for pressure ulcers, or the presence of a pressure ulcer until a care plan was initiated on 12/2/2021 by RN #4 that identified a Stage 4 pressure ulcer on the left heel. Interventions directed to administer medications and treatments as ordered and to monitor for effectiveness. Interview and record review with the DNS on 12/6/2021 at 12:41 PM identified that the nursing staff should have initiated a care plan for pressure ulcer risk and for the presence of an actual pressure ulcer when Resident #46 was admitted in August 2021. The DNS indicated it was the responsibility of the admitting nurse to create the RCP, and the wound nurse and MDS could create the care plan if the admitting nurse did not create it. Interview with RN #3 (wound nurse) on 12/6/2021 at 12:48 PM identified the MDS nurse was responsible for ensuring a care plan was in place for residents at risk for pressure ulcers and for residents with pressure ulcers. Interview with RN #4 (MDS nurse), on 12/6/2021 at 1:06 PM identified that nurses work together to ensure care plans were completed. RN #4 identified he/she was responsible for reviewing care plans to ensure completeness. Further, although Resident #46 was admitted during August 2021, RN #4 had not initiated a care plan related to pressure ulcer until discussing the wound treatment orders with the wound nurse on 12/2/2021 (over three 3½ months after Resident #46's admission). RN #4 identified that he/she had not created the care plan in error, and that it should have been initiated when he/she completed the MDS. The facility Care Plan Policy directed in part: The Care Planning/Interdisciplinary team, in coordination with the resident, his/her family or representative, develops a comprehensive care plan for each resident. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility documentation review, and interviews for one of two residents (Resident #46) reviewed for pressure ulcers, the facility failed to ensure consistent use of a skin protection device in accordance with physician orders, and the facility failed to ensure the wound physician's recommendations were acted upon in a timely manner. The findings include: Resident #46 had diagnoses that included diabetes, peripheral vascular disease and a stage 4 pressure ulcer to left heel. The Resident Care Plan (RCP) dated 10/6/2021 identified an ADL self-care deficit. Interventions directed to assist with ADLs. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #46 had moderate cognitive impairment, required extensive assistance of one staff for bed mobility and transfers, was at risk for developing pressure ulcers and had one stage four pressure ulcer. A physician's order dated 11/11/2021 directed waffle boot to offload heel at all times. Wound physician consult note dated 11/17/2021 identified a sharp debridement of the left heel was completed and measured 1.8 by 1.6 by 0.3 centimeters (cm). The wound was noted to have light green tinge serosanguinous exudate, 50% granulation, 20% epithelial and 30% slough, and the physician directed to cleanse the wound with Dakin's, apply Santyl/bacitracin, cover with 4 by 4 gauze and secure with Kling. The note further directed to off load the heel. Observation on 11/30/2021 at 10:50 AM in the resident's room identified Resident #46 was sitting in a wheelchair and was not wearing a waffle boot; the resident was wearing tan colored gripper socks on both feet. Observation in the dining room on 12/1/2021 at 9:02 AM identified Resident #46 was sitting in a wheelchair with no waffle boot; Resident #46 was wearing only gripper socks to both feet. Additional observation on 12/1/2021 at 10:01 AM identified Resident #46 was sitting in a wheelchair in the unit corridor and was not wearing a waffle boot. Interview and observation on 12/1/2021 at 10:02 AM with LPN #2 identified Resident #46 was in the corridor in a wheelchair and was not wearing a waffle boot. LPN #2 identified the waffle boot should have been on Resident #46's left foot. Observation identified a purple waffle boot was on a chair in Resident #46's room. LPN #2 indicated that the use of the waffle boot should be noted on the NA care card in the resident's closet. Observation of Resident #46's closet failed to identify a NA care card. LPN #2 indicated that the NA care card should be there, and she did not know why it was not there. Subsequent to surveyor inquiry, LPN #2 applied the waffle boot to Resident #46's left foot. a. Physician's order dated 11/21/2021 directed to discontinue use of a CAM boot per podiatry/surgeon. Wound consultant physician note dated 12/1/2021 indicated the left heel pressure ulcer measured 1.3 by 1.2 by 0.3 cm. the physician directed to clean the wound with Dakins, apply collagen foam, cover with a dry clean dressing daily, and to off-load the heel. Interview and observation with NA #1 on 12/6/2021 at 9:20 AM identified Resident #46 was wearing a Controlled Ankle Movement (CAM) boot (a rigid device that covers the foot, and lower leg below the knee). NA #1 identified he/she had applied the CAM boot on Resident #46's left foot because he/she knew the resident was to have a boot on the left foot and that was the only boot NA #1 found in the room. Review of the NA care card with NA #1 identified the NA care card did not contain any information directing use of any type of boot. Interview and observation with the ADNS on 12/6/2021 at 9:40 AM identified the Resident #46 was wearing a CAM boot. The ADNS located the purple waffle boot in Resident #46's room under several folded blankets. Review of the NA care card with the ADNS failed to identify the NA care card directed use of the waffle boot. Review of physician's orders with the ADNS identified Resident #46 was to wear a waffle boot and identified the CAM boot had been discontinued. The ADNS identified the CAM boot should have been removed from the room when it was discontinued, and the care card should have clearly identified use of the waffle boot. The ADNS identified nursing was responsible for updating the care cards, and Resident #46 should have had the waffle boot applied to his/her foot. A NA care card policy was not provided for review. b. The wound physician consult note dated 11/17/2021 identified sharp debridement of the left heel was completed and measured 1.8 by 1.6 by 0.3 centimeters (cm). The wound was noted to have light green tinge serosanguinous exudate, 50% granulation, 20% epithelial and 30% slough, and the physician directed to cleanse the wound with Dakin's, apply Santyl/bacitracin, cover with 4 by 4 gauze and secure with Kling. The note further directed to off load the heel and to start clindamycin 600 mg orally three times a day for seven days. Nurse's note dated 11/17/2021 at 4:21 PM, written by RN #3, identified Resident #46 was seen by the wound physician with new orders to start Clindamycin and the Supervisor was aware. Review of the clinical record failed to identify the Clindamycin was administered in accordance with the wound physician consult recommendation on 11/17/2021, until orders were entered in the clinical record on 12/1/2021. A physician's order dated 12/1/2021 directed Clindamycin 300 mg by mouth three times a day for ulcer to left heel for seven days. Interview and clinical record review with RN #3 on 12/6/2021 at 11:54 AM identified although the wound consult physician had ordered the Clindamycin oral antibiotic on 11/17/2021, and RN #3 had entered the information in the nursing progress notes, review of the physician orders and November MAR identified the recommendation was not addressed or implemented in November. RN #3 indicated that the reason the recommendation was not addressed was that RN #3 had informed the ADNS and the ADNS was to obtain the order from the attending physician for the Clindamycin. RN #3 further indicated that although she could have called the attending physician or APRN to obtain the orders on 11/17/2021, she did not call the attending physician or APRN because she felt it was better to inform the RN supervisor (ADNS), and the ADNS would obtain the order. RN #3 indicated that the wound consultant physician's recommendation should have been addressed on 11/17/2021. She further indicated that when wound rounds were conducted on 12/1/2021 (two weeks later), it was identified that the Clindamycin had not been implemented, and it a physician's order was obtained at that time. Interview with the ADNS on 12/6/2021 at 1:06 PM identified that she did not recall being asked to obtain an order for the resident. The ADNS identified she would expect the wound RN to follow up on wound physician recommendations, because she was the nurse who had done the wound rounds. Interview with the DNS on 12/7/2021 at 1:14 PM identified although either the supervisor (ADNS) or RN #3 could have obtained the order for the Clindamycin, she would expect the nurse who did the wound rounds to obtain orders from the attending physician to ensure the recommendations were addressed timely. Interview with the DNS identified obtaining physician orders timely was a nursing expectation, and there was no specific policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, interviews, and facility documentation review for one of one resident (Resident #4) reviewed for range of motion, the facility failed to ensure a splint was applied consistently in accordance with physician's orders. The findings include: Resident #4 had diagnoses that included hemiplegia and hemiparesis following cerebrovascular disease affecting his/her right side. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, required total assistance of one staff for personal hygiene, eating, and had functional limitations in range of motion on one side for both upper extremities. The Resident Care Plan (RCP) dated 9/9/2021 identified Resident #4 had a contracture of the right hand. Interventions directed to the use of a supportive right-hand splint, apply in the AM and off in PM. A physician's order with initial order dated 11/30/2021 directed to apply a right upper extremity (RUE) resting hand splint after AM care and to remove the splint prior to PM care. Review of the nurse's notes from 11/1 to 12/2/2021 failed to identify information regarding the use of a right-hand splint. Review of Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for November and December 2021 failed to identify information regarding use of a right-hand splint. Observation on 11/30/2021 at 11:30 AM and 12:16 PM identified Resident #4 was not wearing a right-hand splint. Observation and interview with LPN #1 and NA #5 on 12/2/2021 at 12:53 PM identified Resident #4 was not wearing a right-hand splint. NA #5 indicated that when providing care for Resident #4, in error, she had followed another resident's care card that did not direct use of a splint. Interview and record review with the ADNS on 12/2/2021 at 12:54 PM identified the electronic NA care card for Resident #4 did not identify any information directing the use of a hand splint and indicated that it should have. Additional interview with the ADNS on 12/2/2021 at 2:45 PM identified that the facility could not ensure the splint was used consistently, in accordance with physician orders, because it was not included on the MAR, TAR or the NA care card. The ADNS indicated that although she believed most staff were aware the splint should be used for Resident #4, she was unable to provide documentation that the splint had been applied as ordered and she could not determine that all staff working with Resident #4 had knowledge of the splint orders. No policy was provided regarding use of splinting devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation review, and interviews, for one of twelve bathrooms observed on the secured dementia unit, the facility failed to ensure cleaning products were stored in accordance with accepted practice. The findings include: Intermittent observations on 11/30/2021 from 9:45 AM through 10:53 AM on the secured dementia unit identified residents were ambulating and self-propelling in their wheelchairs independently throughout the unit. Observation of one resident bathroom (room [ROOM NUMBER]) identified the following facility cleaning products were located on the seat of a shower chair: Peroxide Multi Surface Cleaner and Disinfectant. No facility staff/housekeepers were observed within view of the products during the observations, and no residents were observed in the room. Interview and observation with LPN #1 on 11/30/2021 at 11:00 AM identified the cleaning products should not have been left in the bathroom and indicated that housekeeping may have left the items in error. Subsequent to surveyor inquiry, LPN #1 removed the cleaning products from the resident bathroom and indicated they would be put in the locked housekeeper's closet. Interview with the Director of Housekeeping, on 12/2/2021 at 8:51 AM identified cleaning no products should be left unsecured in in a resident's room and the observed items should not have been left in the resident bathroom. He further indicated that the items may have been left by a housekeeper on 11/29/2021 (the day prior to when it was observed by the surveyor). Review of the Safety Data Sheet for Peroxide Multi Surface Cleaner and Disinfectant identified it was reserved for industrial and professional use, with hazard statements: Harmful if swallowed or in contact with skin. Causes severe skin burns and eye damage. May cause an allergic skin reaction. Toxic if inhaled. The Facility Policy for Chemical Storage Housekeeping directed in part, no chemical shall be left in any patient care areas unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for three of six residents (Resident #6, #11 and #304) reviewed for a change in condition, the facility failed to ensure physician recommendations were acted upon timely, and the facility failed to ensure treatments provided were indicated, and the facility failed to ensure weights were obtained in accordance with physician's orders. The findings include: a. Resident #6's diagnoses included Alzheimer's disease, difficulty walking and localized edema. The admission MDS dated [DATE] identified Resident #6 had moderate cognitive impairment, was independent with transfers and ambulation, and had no pressure ulcers or other wounds. The care plan dated 9/10/2021 identified Resident #6 had a potential for alteration in skin integrity related to decreased mobility and edema with blisters. Interventions directed to follow skin protocol and document on any skin alterations weekly. Wound physician consultation progress note dated 11/24/2021 identified a new treatment recommendation for both lower legs. Recommendations directed: on Saturdays, take down the Unna Boots, clean both legs with soap and water, pat dry and replace the Unna Boots by placing 4 by 4 gauze between the toes in open fashion, and to wrap medicated boot rolls from Resident #6's toes to knees. Follow with a dry wrap of Kerlix roll from the toes to knees and to then wrap an ACE bandage roll from the toes to knees. The note further indicated that in addition to the Saturday Unna Boot change, the wound physician would change the dressing on the following Wednesday. Nurse's note dated 11/24/2021 identified wound rounds were completed with the wound MD and Resident #6 had ruptured blisters on both legs. The note further indicated a plan to change the wound treatment to Unna Boots (flexible moist compression bandages) followed by Kerlix, followed by two ACE wraps on each leg, and change on Saturdays and Wednesdays. Review of November 2021 Treatment Administration Record (TAR) failed to identify Resident #6 received the Unna Boot treatments as described. Although the described Unna Boot treatment was included on the TAR in the electronic medical record (EMR), the option for the nurse to initial that the treatment was provided was blocked off as not due to be provided. Although the Unna Boot was due to be changed on Saturday 11/27/2021, additional review of the TAR failed to identify treatments were completed as described by the wound physician on 11/24/2021 through 11/30/2021. Interview with wound MD #1, on 12/1/2021 at 10:30 AM identified the Unna Boot treatment was applied on 11/24/2021 by MD #1 and the wound nurse (RN #3) during wound rounds and should be changed every three days or at least twice a week. MD #1 further indicated that for Resident #6, the recommendation and his/her expectation was that the Unna Boot treatment would be changed during weekly wound rounds on Wednesdays and the facility nurse would change the Unna Boot on the Saturdays (when there were no wound rounds completed). MD #1 identified the Unna Boot should have been changed on Saturday 11/272021, and he/she was not aware it had not been done. MD #1 did not know why the treatment had not been provided as directed and indicated that he/she gave verbal information to the nurse regarding the expected treatment and wrote it in his/her note. Interview and record review with the wound nurse/RN #3 on 12/1/2021 at 11:50 AM identified the treatment was not completed on Saturday 11/27/2021 because he/she had not entered the order correctly into the EMR. She indicated that when she entered the treatment order in the EMR, she should have identified a date the treatment was due to be completed, and the nurse would sign that the treatment was provided. Interview with the DNS on 12/7/21 at 1:14 PM identified the nurse should have ensured the order was entered correctly, and further identified this was a nursing expectation, there is no facility policy for that. 1. A physician's order dated 9/17/2021 and renewed on 11/30/2021 directed thrombo-embolism deterrent (TED) stockings to bilateral lower extremities secondary to edema, on in the morning and off at bedtime every day. Wound physician consultation progress note dated 11/24/2021 identified a new treatment recommendation for both lower legs. Recommendations directed: on Saturdays, take down the Unna Boots, clean both legs with soap and water, pat dry and replace the Unna Boots by placing 4 by 4 gauze between the toes in open fashion, and to wrap medicated boot rolls from Resident #6's toes to knees. Follow with a dry wrap of Kerlix roll from the toes to knees and to then wrap an ACE bandage roll from the toes to knees. The note further indicated that in addition to the Saturday Unna Boot change, the wound physician would change the dressing on the following Wednesday. Nurse's note dated 11/24/2021 identified wound rounds were completed with the wound MD and Resident #6 had ruptured blisters on both legs. The note further indicated a plan to change the wound treatment to Unna Boots (flexible moist compression bandages) followed by Kerlix, followed by two ACE wraps on each leg, and change on Saturdays and Wednesdays. Review of MAR for November 2021 identified nurses had documented application and removal of thrombo-embolism deterrent (TED) stockings to bilateral lower extremities secondary to edema, on in the morning and off at bedtime, daily, to include 11/24 through 11/30/2021. Interview with wound MD #1, on 12/1/2021 at 10:30 AM identified TED stockings were not to be used when an Unna Boot was used. MD #1 indicated that he/she and RN #3 applied the Unna Boots on 11/27/2021, and TED stockings could not be applied over the Unna Boots. Interview and record review with the wound nurse, RN #3, on 12/1/21 at 11:50 AM identified the resident had not been wearing TED stocking while the Unna Boot treatment was being used, and nurses should not have been documenting that the resident was wearing the TED Stockings. RN #3 further indicated that the nurses should have reviewed the order for TED stockings with the physician when leg treatment orders did not match what was on Resident #6's legs. Interview with the DNS on 12/7/2021 at 1:14 PM identified the nurse should have ensured the orders were appropriate and ensured documentation on the MAR was accurate. The DNS further identified this was a nursing expectation, there was no facility policy. b. Resident # 11's diagnoses included Parkinson's Disease, Dementia, hypertension, Gastric Reflux Disease, Congestive Heart Failure, Type 2 Diabetes, Metabolic Encephalopathy, Anemia and Depression. The Quarterly MDS assessment dated [DATE] identified Resident #11 had moderate cognitive impairment and required extensive assist with all aspects of ADL care. The Resident Care Plan (RCP) dated 5/18/2021 identified resident CMO with increased risk for weight loss. Interventions directed to staff to obtain and monitor lab/diagnostic work as ordered and to report results to MD and follow up as indicated. The Physician's Assistant (PA) #1 progress note dated 8/13/2021 at 3:38 PM identified that PA #1 was requested to see Resident #1 due to fatigue, decreased appetite and increased urination. The PA progress note further identified that given Resident #11's history of urinary tract infections (UTI) with similar symptoms, directed to obtain a urine culture (straight catheterize) and obtain lab work (CBC and CMP), and the plan was discussed with nursing staff. Review of the clinical record failed to identify a physician's order for the urine culture, CBC and CMP. Further review failed to identify the urine culture was obtained until 8/18 (five days after the PA visit), and lab results dated 8/19/2021 (six days after the PA visit). In an interview with PA #1 on 12/7/2021 at 11:25 AM identified after he assessed Resident #11 on 8/13/2021 he reviewed the plan of care, including obtaining a urine culture and lab work with the nursing staff. PA #1 indicated that he expected the nursing staff to enter the orders into the electronic medical record (EMR), and that he would have expected the urine sample and lab work to be obtained timely before 8/18 and 8/19/2021. In an interview with LPN #1 on 12/7/2021 at 12:00 PM identified she did not enter the orders into the EMR when PA #1 directed to obtain the urine culture and lab work, and she could not recall why the orders was not entered. In an interview with MD #2 (attending physician) on 12/7/2021 at 12:30 PM identified he would expect the lab work to be obtained within three (3) to four (4) days. Interview with Lab Person #1 on 12/7/2021 at 1:00 PM identified that the lab orders for Resident #11's urine culture and lab work were received by the lab on 8/18/2021 at 4:59 PM. c. Resident #304 was admitted on [DATE] with diagnoses that included metabolic encephalopathy, sepsis, UTI, Marfan's syndrome, urinary retention, muscle weakness, and dementia without behavioral disturbance. A physician's order by Physician's Assistant (PA) #1 dated 11/3/2021 directed to weigh weekly every Friday for four (4) weeks and once a day starting on the first day and ending on the last day of every month. The weight record dated 11/3/2021 identified Resident #304's weight was 98.6 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #304 had severe cognitive impairment, required extensive assistance with ADLs, weight was 108 pounds (lbs), and was unknown if Resident #304 had a weight loss or gain in the last 30 days or six (6) months. The Resident Care Plan (RCP) dated 11/4/2021 identified a potential for alteration in nutrition. Interventions directed to monitor, record and report weight loss. Nutrition Risk assessment dated 11/ 9/2021 identified Resident #304's [NAME] was 5 feet, Body mass index was 21.1 (indicated he/she was at risk), and weight on 11/5/2021 was 108 lbs. The assessment recommended supplements and directed to monitor weights. Review of the Medication Administration Record (MAR) for November 2021 identified weekly weights for four (4) weeks were due on 11/5 (weight recorded), 11/12, 11/19 and 11/28. Weights were missing on 11/12 and 11/28, and although staff initialed that a weight was obtained on 11/19, review of the clinical record failed to identify a weight was obtained and recorded. Additional facility documentation and clinical record review failed to identify daily weights were obtained in accordance with the physician orders. An interview with the DNS on 12/6/2021 at 10:42 AM indicated that if a staff member is unable to carry out an MD order, the charge nurse or supervisor should be notified, and the physician/practitioner should be notified. The DNS further indicated that the weights should have been obtained in accordance with physician's orders. Review of the facility Weight Assessment and Intervention Policy directed in part, that weights will be recorded on admission, the next day and weekly for 2 weeks thereafter. Additionally, the policy directed weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, and interviews for 1 resident (Resident #15) reviewed for positioning, the facility failed to ensure the resident's positioning needs were met during dining. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbances, cerebral infarction, diabetes, and cognitive communication deficit. A physician's progress note dated 9/18/19 identified Resident #15 was on a controlled carbohydrate diet, and the blood sugars are stable. The quarterly MDS dated [DATE] identified Resident #15 had severely impaired cognition, required extensive assistance for transfers and toilet use, and required set up and supervision for meals. The care plan dated 11/14/19 identified Resident #15 required assistance for eating, transfers, and toilet use related to dementia. Additionally, the care plan identified that Resident #15 prefers to eat in the dining room. Review of the monthly physician's orders dated December 2019 directed to provide a regular/ liberalized dysphasia advanced texture diet. Additionally, the orders directed to utilize the hypoglycemic protocol if blood sugar is less than 70. Observation on 12/17/19 at 12:05 PM identified Resident #15 was brought into the dining room in a low custom wheelchair that was slightly tilted back. Resident #15's was not positioned with his/her buttocks all the way to the back of the chair. Resident #15 was placed sideways at the table and parallel to the table. Additionally, because the resident was in a low custom wheelchair, the table was almost at shoulder height. Resident #15 received his/her tray which included a hamburger and tater tots, a piece of chocolate cake and a bowl of vegetable soup. The resident was observed to have to reach up to reach the hamburger and cake, but was not able reach the tater tots behind the hamburger, or the soup. At 12:20 PM a nurse aide placed a cup of coffee on the tray, however, it was out of the residents reach. Resident #15 was observed eating the hamburger and chocolate cake over his/her lap and was observed to have dropped chocolate cake crumbs onto the front of his/her shirt and top of pants. Resident #15 had a paper napkin he/she was using from the tray. Interview on 12/17/19 at 12:46 PM with the DNS indicated she noticed Resident #15 was not able to reach her coffee or the soup and that was why she went over and handed the resident the coffee and turned the plate. The DNS indicated Resident #15 was not at the correct height or position to be able to reach the table. Subsequently, the DNS moved the soup bowl closer where the resident was able to reach it. Observation on 12/18/19 at 12:05 PM identified the charge nurse and MDS coordinator stood and pivoted the resident into a standard chair at the table for lunch, and removed the custom wheelchair. Resident #15 was sitting upright at a 90 degree angle in a standard chair and but was not able to reach the floor with his/her feet and he/she and his/her legs were dangling. Interview on 12/20/19 at 10:00 AM with OT #1 indicated that a resident should be positioned at the dining room table so the resident can reach all utensils, the plate, and all food and drink items, and their feet should touch the floor. Although requested, a facility policy was not provided for fine dining or positioning during dining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interview for 1 of 3 residents (Resident #33) reviewed for nutrition, the facility failed to ensure weekly weights were obtained per facility policy and interventions were implemented and monitored timely after a significant weight loss was identified. The findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses that included seizure disorder, dementia and anxiety. The physician's order dated 8/12/19 directed to provide a regular/liberalized diet, with regular texture. A Nutritional assessment dated [DATE] identified Resident #33 was 65 inches tall, weighed 141.2 lbs., and had a Body Mass Index (BMI) of 23.49 (healthy weight). The assessment identified a normal BMI, good appetite, intake 75% - 100% for most meals. Regular/liberalized diet as ordered appears appropriate at this time. The admission MDS dated [DATE] identified Resident #33 had severely impaired cognition, required extensive assistance with eating, ambulated independently, was 65 inches tall and weighed 142 pounds lbs. The care plan dated 8/30/19 identified Resident #33 required assistance with eating. Interventions included to provide a limited assistance of 1 for eating, cue and feed if necessary. Review of the weight record dated 9/9/19 identified Resident #33 weighed 142.8 lbs. Review of the weight record dated 10/1/19 identified Resident #33 weighed 131 lbs., a loss of 8.26% in less than one month. Review of the weight record dated 10/4/19 identified Resident #33's reweight was 131.2 lbs. A Medical Director Rounds/Customer at Risk Minutes form dated 10/9/19 identified Resident #33 had an 11.2 lb. weight loss from 9/9/19 - 10/1/19 and that a re-weight was obtained. A Diet Order and Communication Form dated 10/10/19 directed to administer house supplement twice per day. A progress note (Weight Warning) dated 10/16/19 indicated a 7.7% weight loss. Additional documentation identified the resident paces, doesn't always eat meals and the interdisciplinary team was aware. Review of the weight record dated 11/2/19 identified Resident #33's weight was 131.2 lbs. Review of the October and November 2019 MAR's failed to reflect supplement intake documentation. Review of the December 2019 MAR directed to administer 120ml house supplement 2 times a day at 10:00 AM and 2:00 PM and to document the percentage taken. Although the diet order and communication form identified that the house supplement was initiated on 10/10/19, the December 2019 MAR failed to reflect that the supplement was given, or that the amount consumed was monitored. Interview and review of the clinical record with the Dietitian on 12/18/19 at 2:00 PM identified that although he/she was only in the building 1 day per week, staff was able to communicate concerns via email or if non urgent, could notify him/her when in the facility. The Dietitian identified that it was the responsibility of the nursing staff to obtain resident weights and also to identify when there was a significant weight change. Additionally, the Dietitian indicated staff should have followed the policy for reweights to verify accuracy and then they should contact him/her for recommendations or speak to the physician or APRN. The Dietitian identified that although he/she was aware of resident's weight loss in September 2019, and that a supplement was initiated by nursing, he/she still should have done an assessment or documented a progress note. Interview with RN #1 on 12/20/19 at 1:00 PM identified that any of the nurses can initiate weekly weights when a significant weight loss is identified. Although RN #1 was not working in the facility at the time of Resident #33's significant weight loss, he/she would have followed the facility policy and obtained a re-weight to verify accuracy, notify dietitian, physician/APRN, and responsible party, and initiate weekly weights. Additionally, if a supplement was ordered, he/she would ensure it was transcribed onto the MAR so the percentage taken could be documented and reviewed. Interview and review of the clinical record with the DNS on 12/23/19 at 8:00 AM identified that weekly weights should be obtained on any resident who has a significant weight loss and any nurse can initiate weekly weights. Although he/she identified not being DNS at the facility at the time of the significant weight loss, it was his/her expectation that the facility policy be followed. Additionally, the supplement which was initiated on 10/10/19 should have been transcribed on the October 2019 MAR to document and monitor the amount taken, identifying that it must have been an oversight. Review of the facility's Weights and Heights policy identified if a patient's weight is less than or greater than five pounds from the previous weight, the patient will be re-weighed and the weight verified by a licensed nurse to determine accuracy. A significant weight change is defined as 5% in one month, 10% in six months. Additionally, the licensed nurse will notify the physician/APRN/PA and dietitian of significant weight change, document in the progress notes and notify the family.

Based on observation, review of facility policy, and interview the facility failed to store controlled drugs in accordance with professional standards. The findings include: Observation of the 2nd floor medication room on 12/18/19 at 1:15 PM identified the door to medication room was locked. Inside the 2nd floor medication room was a locked refrigerator which contained a small metal box containing 2 bottles of Ativan (controlled substance). Interview with the DNS at that time indicated that the small metal box was not permanently affixed in the refrigerator. The DNS indicated that because the refrigerator was locked, she felt that was sufficient. Review of facility medication storage policy dated 10/31/16 identified the facility should ensure controlled substances are only accessible to licensed nursing, pharmacy, and medical personnel designated by the facility, and once receiving controlled substance, they are immediately placed into a secured storage area in accordance with applicable law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and interview for 1 resident (Resident #20), reviewed for infection, the facility failed to ensure abnormal laboratory results were reported to the physician/APRN and addressed timely. The findings include: Resident #20's diagnoses include chronic obstructive pulmonary disease and chronic pain syndrome. A quarterly MDS dated [DATE] identified Resident #20 had intact cognition, required extensive assistance with ADL's, and was always incontinent of urine. The corresponding care plan identified Resident #20 was incontinent of urine with an intervention of monitoring of signs and symptoms of infection. An APRN note dated 12/13/19 identified the APRN was notified on 12/12/19 of Resident #20's increased lethargy. On exam, Resident #20 complained of dysuria and pain over the bladder. A urine sample was sent, and Bactrim (antibiotic) was ordered. A nurse's note dated 12/15/19 identified urinalysis results returned with >100,000 E. coli, the on call medical provider was informed of the results and that the susceptibility was still pending, and Bactrim had been ordered. Review of an APRN note dated 12/16/19 indicated Resident #20 was on Bactrim and the sensitivities were still pending. Review of a lab result report (urine culture) reported to the facility on [DATE] at 9:33 AM, identified >100,000 cfu/ml Escherichia coli was present in the urine and was resistant to Bactrim. Review of an APRN note dated 12/18/19 at 1:50 PM, (2 days after the urine susceptibility list was reported to the facility), identified the bacteria in the urine is resistant to Bactrim. The note further identified that Bactrim was discontinued and Macrobid and Florastor started. Interview with the DNS on 12/20/19 at 11:30 AM indicated when laboratory results are faxed to the facility, the physician is notified of the result if the APRN is not in the building. The DNS further indicated that on 12/16/19 the APRN was in the building in the morning and would have checked for the lab results in the computerized charting system, reviewed the labs and made changes if needed. The DNS was not aware that the laboratory results were not addressed by the APRN on 12/16/19. Although attempted, the APRN was not available to be interviewed. Although a policy was requested, none was provided. Although the facility received a urine culture on 12/16/19 at 9:33 AM that identified >100,000 cfu/ml Escherichia coli was present in the urine and was resistant to Bactrim, the facility failed to promptly notify the physician/APRN of the results, and that bacteria was resistant to the Bactrim, for an additional 2 days.