**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #72) reviewed for missing property, the facility failed to ensure a report of a missing item was thoroughly investigated to conclude loss or theft and Observations of the facility environment, the facility failed to ensure a sanitary environment by ensuring a rusted medicine cabinet without doors was replaced and for 1 of 3 sampled residents (Resident #88) who was reviewed for environment, the facility failed to provide a clean, home like environment related to cleaning of a small appliance which was provided by the facility and based on observations and interviews for 3 of 4 shower rooms, the facility failed to provide a homelike, sanitary, and safe environment for the 3 of 4 showers. The findings included: 1. Resident #72 had diagnoses included morbid obesity, heart failure and absence of a right leg above the knee. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #72 was cognitively intact and required total assist with activities of daily living, independent with eating. The Resident Care Plan (RCP) dated 12/5/23 identified Resident #72 was at risk for limited physical mobility and related to obesity and above the knee amputation and had little to no activity involvement related to h/her preference to remain in bed. Interventions directed to provide supportive care and assistance as needed and note the resident's preferred activities include watching television, talking with family and shopping online. A Grievance/ Concern Form dated 1/24/24 identified Resident #72 reported that h/her apple watch was missing. A room search was conducted with resident consent and an investigation initiated including notifications to social services, dietary, housekeeping, laundry, maintenance, and nursing supervisor. A resolution dated 1/29/24 completed by Social Worker (SW) #1 identified the watch was located with education provided to the resident on safe keeping of valuables. The grievance did not include an investigation detailing the recovery of the watch. The social service notes dated 1/29/24 to present did not identify any conclusion regarding the missing watch. An interview with Resident #72 on 7/1/24 at 12:06 PM identified h/her watch went missing months ago and was reported to the nursing supervisor Registered Nurse ( RN #4) who looked for it. The watch had not yet been recovered. An interview with RN #4 on 7/08/24 at 12:44 PM identified Resident #72 did report a missing Apple watch to him a few months prior but he was unable to recall all the details of the incident. RN #4 believed he had assisted in searching for the item, reported the incident to the the Administrator at the time and asked staff if they were aware of the missing watch. RN #4 identified Resident #72 never reported the watch had been located. An interview with (former) Social Worker #2 on 7/09/24 at 11:57 AM and 7/11/24 at 10:44 AM identified she was employed by the facility until 6/28/24. Social Worker #2 identified a grievance form should be completed for any reported missing item, and social services would meet with the resident and speak to staff to determine the origin of the missing item. A room search would be completed with consent and the resident would remain informed until the origin/outcome could be determined. If the missing item was not located, the matter would be referred to administration to determine next steps which could include reimbursement. Social Worker #2 identified Resident #72 did initially report a missing Apple watch to her but there was mixed information if the resident actually had the watch in the first place and Resident #72 may have thought another item to have been the watch. Social Worker #2 identified she had only initially heard the watch had been recovered and had not learned the additional information that called into question the actual existence of the watch until after the completion of the grievance form. Social Worker #2 could not recall if any additional steps were made to determine the accuracy of the information, interview staff, or return to Resident #72 to acquire any additional information but would have likely documented if she had. An interview with Social Worker #1 on 7/09/24 at 2:15 PM identified she had documented the watch was recovered based on information provided by Social Worker #2 had informed her and had not actually observed that the watch had been recovered. Subsequent to surveyor inquiry, Social Worker #1 met with Resident #72 and determined through an alternate electronic device owned by Resident #72, that the watch was last discovered on 1/29/24. Social Worker #1 was working with Resident #72 for a replacement. A review of the facility policy for missing items directed that a search be conducted for any reported missing items. If the item is not located, the item will be reported to social services who will initiate a lost item grievance. Social Service will communicate the report of lost items to all department heads and follow up with any action taken and the conclusion will be documented on the form . The resident/ responsible party will be notified of the results. 2. Observation of the environment on 7/1/24 at 12:55 PM identified the medicine cabinet in the bathroom did not have doors, the shelving had rust on it, as confirmed by maintenance, and there were 2 light bulb sockets, disconnected, without light bulbs on top of the cabinet. Observation and interview on 7/1/24 at 12:58 PM with Maintenance Worker #2, identified that he was not sure how long the cabinet had been like that and stated he would fix it now. Observation and interview on 7/1/24 at 1:00 PM with the Director of Maintenance identified he did not know how long the medicine cabinet was without doors and had rust. He also stated he was new to his position. The Maintenance Director indicated he believed the light bulb sockets, disconnected were not a hazard. The Director of Maintenance identified that staff communicate repairs needs through rounds and/or by writing them in the maintenance book . He further indicated he was not made aware of the above needed repairs. The Director of Maintenance identified that cabinet and other repair items would be fixed/replaced within 1 hour. Observation on 7/2/24 at 10:00 AM identified the cabinet was not fixed. Observation on 7/08/24 at 11:02 identified the cabinet was replaced. Review of Maintenance Log for June 2024 and July 2024 identified no documentation of a request for repair for the broken medicine cabinet . Although requested a maintenance policy was not provided. Although requested documentation of maintenance rounds was not provided. 3. Resident #88's diagnosis included chronic obstructive pulmonary disease, anxiety, and COVID 19. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #88 was moderately cognitively impaired, requires set up assist for eating, and oral hygiene. Resident #88 was dependent for toileting, bathing, and dressing. Also identified was Resident #88 needed supervision for personal hygiene. The Resident Care Plan dated 6/4/24 identified Resident #88 was at risk for alteration in respiratory status. Interventions directed to maintain a clear airway, and to monitor for sign and symptoms of respiratory distress. A physician's order dated 6/4/24 for ProAir inhaler (90) base directed that Resident #88 take 2 puffs by mouth every 4 hours as needed for shortness of breath. Observation on 7/1/24 at 11:40AM identified that Resident #88 had a fan in her/his room that had a dark substance noted to each fan blade. Interview with Housekeeping/Maintenance Director on 7/2/24 at 1:40AM identified the fan was not looking very clean, and he was unsure of when it was last cleaned or how long it has been in Resident #88 room. The Housekeeping/Maintenance Director was unsure of the cleaning policy of the fan or if one did exist. Interview with RN#1 on 7/2/24/ at 1:45 PM identified the fan was not clean and was dusty. RN #1 identified that if Resident #88 had a respiratory illness this could have caused a exacerbation. RN #1 was unsure of the policy for cleaning the fans and also stated that he performs environmental rounds monthly. RN # 1 further identified the facility provided the fan to Resident #88. Interview with Resident #88 on 7/3/24 at 10:15AM identified that the fan has been in her/his room for at least 6 months and has never been cleaned. Resident #88 identified when the fan was turned on it would blow dust at her/him. Environmental Logs reviewed but did not identify any concerns or issues with the fan from Resident #88 room. The facility does not have a policy for cleaning fans. 4. Observation during the initial facility tour on 7/1/24 at 12:30PM on the second floor [NAME] shower room identified the following: Chipped, cracked paint on the walls and ceiling, A black substance on the floors, and walls, Torn wallpaper, Rusty shower curtain rod, Nonskid black stripping torn and loose on the floor of the shower. Observation during the initial facility tour on 7/1/24 at 12:30PM on the second floor Cathedral shower room identified the following: Chipped, cracked paint on walls and ceiling, A black substance on the floors, and walls, Torn ripped ceiling above the sink above the light. Cracked cover on the light fixture. Observation on 7/2/24 at 10:16AM on the third floor Cathedral shower room identified the following: Chipped paint on the ceiling and walls. Interview with Director of Housekeeping/Maintenance on 7/2/24 at 1:35PM identified environmental rounds are done every other week. He identified that the black substance to be dirt and the shower curtain rod was rusty and needed to be replaced. He also stated the shower rooms are cleaned daily with grout cleaner and Lysol. The Director of Housekeeping/Maintenance identified that the nonskid tape needed to be replaced on the [NAME] floor shower of the second floor. The Environmental Rounds logs were reviewed and failed to identify any concerns for any of the 4 showers in the facility.

Based on observation, facility policy and interviews for 1 of 3 Residents (Resident #45), observed during medication administration, the facility failed to meet professional standards when staff borrowed(Resident # 202 's Lactulose medication to administer to Resident # 45 when the resident's medication was not available. The findings include. Resident #45's diagnosis included Type 2 diabetes mellitus and incontinence. A physician's order dated 9/30/2023 directed to administer Lactulose Oral Solution 10grams/15ml and to provide 15 ml's orally, once daily for constipation and to hold for loose stool or diarrhea. The 6/9/2024 quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive loss. The care plan dated 6/25/2024 indicated Resident #45 was at risk for complications related to constipation. Intervention included: monitoring medications for side effects and to follow facility bowel protocol for bowel management while increasing fiber and fluid intake and to update the physician with any concerns. On 7/8/2024 at 8:02 AM an observation and interview with LPN #1 during medication administration to Resident #45 at which time LPN #1 proceeded to pour the correct dose of Lactulose syrup(laxative) as ordered by the physician for Resident #45 but on observation the bottle of lactulose syrup was prescribed belonged to another resident (Resident #202). LPN #1 indicated Resident #45's supply of Lactulose syrup was depleted and an order was sent to the pharmacy the day before. LPN #1 further indicated his/her usual practice is to utilize other resident's medication when the resident's supply was out. An interview on 7/08/24 at 8:15 AM with the RN Unit Manager indicated the facility practice is not to borrow medications from other residents and to ensure medications are reordered to ensure the medication is available for the resident. After surveyor inquiry, LPN #1 was immediately re-educating LPN #1. The facility policy labeled Medication Administration - General Guidelines, indicated in part if a medication cannot be located the pharmacy should be contacted and medication supplied for one resident is never administered to another Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy, staff interviews for 1 of 1 resident reviewed for specialized treatment (Resident #48), the facility failed to consistently maintain the resident's communication log regarding the resident's status with the specialized treatment center. The findings include: Resident #48's diagnosis of end-stage kidney disease, dementia, and Parkinson's disease. The quarterly MDS assessment dated [DATE] identified Resident #48 was cognitively intact and required set-up assistance with eating, personal hygiene, and transferring to and from the bed. A care plan dated 7/3/2024 indicated the resident was at risk for dehydration, or fluid deficit related to end stage kidney disease and receiving specialized treatment. Interventions included: monitoring intake and output, and monitoring vital signs as ordered/per protocol. The care plan also indicated that Resident #48 required specialized treatment three times per week on Tuesdays, Thursdays, and Saturdays. On 7/8/2024, a review of the resident's specialized treatment communication log identified that certain line items were missing from the communication form. The missing items were the following: For 6/18/2024, the name of the nurse, the condition of the specialized access site, and the time of the resident's last meal were missing. For 6/29/2024 and 6/22/2024, the condition of the specialized access site was missing. For 7/4/2024 and 7/2/2024, the name of the nurse and the condition of the specialized access site were missing. For 7/6/2024, the name of the nurse, the condition of the specialized access site, the resident's last vital signs, and the time of the resident's last meal were missing. On 7/8/2024 at 12:26 PM, an interview and record review with the nurse unit manager (RN#2) identified the expectation was for the specialized treatment center communication log to be completed. Additionally, RN#2 indicated that, at the least, the form should contain the resident's last vital signs, weight, and the status of the specialized access site. RN#2 further indicated the mediation list was not routinely added to the communication log because the facility had provided the specialized treatment center with a medication list for the resident, and only changes to the medications would be communicated in the log. Additionally, RN#2 indicated that the specialized treatment center does not have access to the resident's electronic medical record and that communication is held through the specialized treatment communication log and by telephone. On 7/8/2024 at 12:36 PM, an interview with LPN #1 identified Resident #48 had an external specialized treatment catheter on his/her chest that was being used for specialized treatment and that the resident also had an arteriovenous (AV) fistula that was new and was not yet being used for the specialized treatment. LPN#1 indicated that staff were expected to monitor both specialized access sites daily for signs of bleeding and infection. Additionally, LPN#1 indicated that he believed only the resident's vital signs were required to be put in the specialized treatment communication log. LPN#1 further indicated that the nursing supervisor would be the one communicating with the specialized center if there was a change in the resident's condition. A review of the facility policy for communication and documentation of specialized treatment indicated notes facility staff are to complete the specialized treatment communication record. A review of the facilities Specialized Treatment Provided by a Certified Specialized Treatment Center Facility policy indicated that there should be a communication process between the long-term care facility and the specialized treatment center. The policy identified that communication included vital signs and the provision of meals before, during, and/or after specialized treatment.

Based on observation of Resident Information, review of policy and interviews, the facility failed to inform residents of how to complete a grievance and ensure forms were accessible and available to residents and visitors. The findings include. On 7/8/2024 at 12:57 PM a meeting with 8 residents identified they were unaware of how to complete a grievance or where the forms were located. An interview with Social Worker #1 on 7/9/2024 at 10:00AM indicated the grievance forms were located in the nursing office behind the nursing station on both floors. During an observation and interview with Social Worker #1 on 7/9/2024 at 10:15 AM identified the grievance policy was noted to be posted on a bulletin board to the right when exiting the elevator on the 3rd floor prior to needing to use a code to enter the 3rd units. Further observations and interview with SW#1 identified s/he was unable to locate the grievance forms on the paper wall file in the nursing office behind the nurse's station. SW #1 could not provide any other location for forms but indicated the forms had been provided to the nursing unit in the past and could not explain why the grievance forms were not available. A review of the grievance policy indicated the forms should be easily accessible if the person using wants to remain anonymous. SW #1 indicated the forms are not easily accessible and further indicated the location would be changed to meet the needs of the residents and residents will be informed of the change. Although a copy of the facility grievance policy was requested one was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for 2 of 7 sampled residents for (Resident #13) who were reviewed for range of motion, the facility failed to ensure the comprehensive care plan was revised for a resident with identified with physical limitations of the hands and for (Resident # 98), the facility failed to develop a care plan to address the residents skin integrity to prevent further skin break down and for 1 of 2 residents reviewed for accidents for (Resident # 54), the facility failed to revise the resident's care plan timely post fall. The findings included: 1. Resident #13 was admitted with diagnoses that included mild cognitive impairment, protein calorie malnutrition and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired, had no functional limitations in the upper/ lower extremities, required partial to moderate assist in bed mobility and oral care and total assist in all other activities of daily living (ADL). The Resident Care Plan, RCP dated 12/12/21 identified Resident #13 had an ADL self-care deficit, impaired cognition and potential alteration in discomfort related to compromised functional mobility. Interventions directed to provide total assist with ADL care, communicate needs and capabilities to resident and family and evaluate for pain, alleviating symptoms, and impact on functional mobility. An Interdisciplinary Rehabilitation screen dated 1/19/22 identified Resident 13 had a left-hand deformity but refused range of motion for bilateral upper extremities and asked the therapist to leave. The Physical Therapy evaluation and Plan of Treatment dated 12/3/22 identified Resident #13 was being referred for services for splinting of a right knee for contracture management. However, Resident #13 was not receptive to the device despite education and services were terminated with emphasis on bed positioning with pillows and bilateral foot booties. No other functional limitations were identified at the time of the evaluation. A Resident Round Screen dated 8/30/23 and 3/1/24 identified Resident #13 now had bilateral hand deformities with no subsequent evaluation or plan to address the functional limitation. An advanced Practice Registered Nurse Progress note beginning 3/8/24 through 6/10/24 note bilateral hand contractures with no signs of discomfort. The Resident Care Plan did not include the deformity/contracture with any interventions for management to prevent progression. An interview with the Director of Nursing on 7/11/24 at 9:11 AM identified the development and revision of the care plan was an interdisciplinary effort and s/he would have expected the care plan to be revised once the physical limitation for Resident #13 was identified. 2. Resident #98's diagnoses included stage 3 pressure ulcer of the left heel, paraplegia and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #98 was cognitively intact, at risk for pressure ulcers, had no unhealed pressure ulcers and required extensive assistance of two persons for bed mobility. The care plan dated 3/14/2024 indicated Resident #98 was at an increased risk of pressure ulcer development related to functional mobility/paraplegia incontinence and diabetes mellitus. Interventions included: to provide treatments as ordered, avoid positioning on the affected region, monitor dressing to ensure intactness and integrity, monitor nutrition, laboratory work, teach resident/family importance of positional changes, provide supplements as ordered to promote wound healing. The care plan indicated Resident #98 demonstrated poor body alignment requiring the use of a manual adaptive tilt in space wheelchair with headrest, foam cushion, and elevating footrests. The interventions included to follow the 24-hour positioning plan as outlined by the rehabilitation department to observe for poor toleration while out of bed in the adaptive wheelchair and to notify the rehab department with any issues. The care plan further indicated Resident #98 had a self-care deficit related to activity intolerance due to back pain, spinal abnormality and limited mobility. The intervention included in part to assist Resident #98 to apply a knee, ankle, foot orthotic (KAFO) on the left lower leg with assistance of 2 persons during morning care and to be removed during evening care, apply a tubi-grip and or geri-sleeve to left lower leg daily prior to the application of the leg brace (KAFO) and when lying in bed, and to place a roll between the knees and check skin integrity every 4 hours. The interventions further indicated Resident #98 required the assistance of 2 persons to turn and reposition in bed and a mechanical lift transfer with 2 person assist between surfaces. A nurse practitioner provider progress note dated 3/26/2024 identified on examination a new Deep Tissue Injury (DTI) pressure ulcer on Resident #98's left heel. The progress not further indicated to float the heel, provide skin prep and notification of the wound team of the new pressure ulcer with a resulting physician's order dated 3/26/2024. A nursing skin/wound care note dated 3/26/2024 at 5:38 PM indicated an APRN visit occurred and in addition to a new order for skin prep every shift to the left heel (newly noted DTI left heel) Resident #98 was to wear offloading boots to prevent further injury as left heel is prone to skin breakdown due to leg spasms Resident #98 cannot control. A wound physician progress note dated 4/4/2024 indicated a new stage 2 pressure ulcer (Deep Tissue injury progressed to a stage 2 pressure ulcer) with treatment recommendations to apply betadine to base of the wound secure with an ABD pad and rolled gauze to be changed daily with a resulting physician's order obtained on 4/5/2024. A wound care specialist's handwritten progress note dated 4/9/2024 (no time) recommended offloading boots and further indicated the leg brace (AKFO) could be used with occupational and physical therapy evaluation of the brace support surfaces. A wound physician progress note dated 4/23/2024 at 8:14 PM indicated the wound bed of the left heel stage 2 pressure ulcer was found to have slough and a debriding agent, Santyl, was recommended and to apply calcium alginate to the base of the wound secure with an ABD pad and rolled gauze to be changed daily with a physician's order obtained on 4/24/2024. A wound physician progress note dated 4/30/2024 at 4:00 PM indicated completing a follow up visit with findings the pressure ulcer had now progressed to a stage 3 pressure ulcer with 100% granulation of the wound base. Treatment recommendation included to cleanse with normal saline, apply Calcium Alginate to the wound base and secure with bordered foam and to change the dressing daily. A physician's order dated 5/31/2024 directed the beds air mattress every shift for functioning and to confirm the setting to be at the resident's current weight or comfort level. On 5/31/224 an entry into the care plan was made to indicate Resident #98 had a stage 3 pressure ulcer of the left heel but no additional interventions were added at that time. The quarterly MDS dated [DATE] indicated Resident #98 had a stage 3 pressure ulcer. Resident #98's care plan was updated on 6/24/2024 to add consulting the dietitian for wound healing. An interview and record review with the DNS on 7/9/24 at 12:35 PM indicated no physician's orders for offloading boots and no indication of the use of offloading boots could be found in the care plan. An interview and record review with the wound care nurse RN#1 on 7/09/24 at 1:00 PM identified there was no physician's order to use offloading boots as recommended by the wound physician on 4/9/2024 and may have been overlooked. RN #1 further indicated he/she had seen Resident #98 wearing off-loading booties at times but was unable to indicated how staff would know how and when to apply offloading boots and to evaluate the effectiveness if there was not a physician order to use them. RN #1 further indicated the care plan did not reflect the recommendation for use of offloading boots and should have been revised by the MDS nurse who would have been updated in morning report of any changes. After surveyor inquiry a physician order dated 7/10/2024 was obtained directing to check offloading boot placement every shift and the discontinuation of donning the KAFO on the left lower extremity in the am removing it in the evening. After surveyor inquiry a physician's orders dated 7/10/2024 were obtained directing to use bilateral lower leg foam cushion on bilateral leg rests of the wheelchair for proper leg positioning while out of bed in the adaptive wheelchair, and to discontinue use of the KAFO and tubi-grip/geri-sleeve to left lower extremity and to put the use of the KAFO on hold from 7/10/2024 through 7/17/2024. After surveyor inquiry on 7/10/2024 the care plan interventions were updated to include the use of a bilateral lower leg foam cushion on the leg rests of the w/c for proper positioning while out of bed in the AWC and to wear bilateral off-loading boots while seated in the wheelchair and while in bed. This intervention was also added to the nurse aide care card on 7/10/2024 (93 days after the recommendation for its use). The care plan was further updated on 7/10/2024 indicating Resident #98 refuses booties and offloading devices at times indicating not needing them and indicated the left KAFO is on hold until the stage 3 pressure ulcer is resolved. A review of the facility policy for Care Planning directed a comprehensive care plan will be developed for each resident to guide care givers and assist residents to achieve or maintain their highest practical level of wellbeing. The care plan will be reviewed quarterly and as necessary to reflect changes in the resident status. 3.Resident #54's diagnoses included muscle weakness, acute respiratory failure with hypoxia and vascular dementia. A physician's order dated 3/24/24 directed to have bed on Lower Position and scoop mattress. The significant change MDS assessment dated [DATE] indicated Resident 54 had impaired cognition and requires partial assist with bed mobility and bed to chair transfers and maximal assistance with toilet transfer. The care plan dated 4/26/24 indicated Resident 54 is at risk for falls. Interventions include adjusting height of bed as needed to promote safe transfers out of bed, analyze previous falls to determine whether pattern/ trend can be addressed, anticipate residents needs and follow facility fall protocols. The focus section of the 4/26/24 care plan was revised on 6/24/24, however, it did not show where the interventions were updated. A nurse's note dated 6/24/24 at 7:20 PM identified Resident 54 was found on the floor inside her/his room. The charge nurse responded to yelling coming from the resident's room but Resident 54 was unable to provide account of the events. Interview with DNS 07/11/24 11:00 AM indicated that post fall, staff are expected to see what interventions are in place and add new interventions to prevent injuries. The DNS reports nurses and care plan coordinator are responsible for updating the care after falls. DNS requested for the Care Plan Coordinator to print the most recent/ revised care plan. Interview with DNS at 12:26 PM indicated that the care plan we reviewed together earlier, is the most updated version available. Facility's policy indicates Each time a resident experience a fall, an interdisciplinary fall assessment will be completed . The care plan will be revised with any interim interventions to minimize the risk of injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, and interview for 1 of 2 residents reviewed for pressure ulcers (Resident # 98), the facility failed to ensure staff consistently provided evidence of turning and repositioning the resident prior to the development of a pressure ulcer and the facility failed to ensure physician's orders were obtained for recommendations made by a consulting wound physician contributing to the pressure ulcer's further decline. The findings included. Resident #98's diagnoses included Stage 3 pressure ulcer of the left heel, paraplegia, and diabetes mellitus. A physician's order dated 1/16/2024 directed to provide a pressure redistribution mattress every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #98 was cognitively intact, at risk for pressure ulcers, had no unhealed pressure ulcers and required extensive assistance of two persons for bed mobility. A physician's order dated 3/6/2024 directed to assist Resident #98 out of bed to an Adaptive Wheelchair (AWC) per the 24-hour positioning plan every shift. The Resident Care Plan (RCP) dated 3/14/2024 indicated Resident #98 was at risk for pressure ulcer development related to functional mobility/paraplegia, incontinence, and diabetes mellitus. Interventions included: to provide treatments as ordered, avoid positioning on the affected region, to monitor the dressing's integrity, monitor nutrition, laboratory work, teach resident/family importance of positional changes, and to provide supplements as ordered to promote wound healing. The RCP dated 3/14/2024 indicated Resident #98 demonstrated poor body alignment requiring the use of a manual adaptive tilt in space wheelchair with headrest, foam cushion, and elevating footrests. The interventions included: to follow the 24-hour positioning plan as outlined by the rehabilitation department, to observe for poor toleration while out of bed in the adaptive wheelchair and to notify the therapy department with any issues. The RCP further indicated Resident #98 had a self-care deficit related to activity intolerance due to back pain, spinal abnormality, and limited mobility. The intervention included in part to assist Resident #98 to apply a Knee Ankle Foot Orthotic (KAFO) on the left lower leg with assistance of 2 persons during morning care and to be removed during evening care, apply a Tubi-grip and or Geri-sleeve to the left lower leg daily prior to the application of the leg brace (KAFO) and when lying in bed, and to place a roll between the knees and to check skin integrity every 4 hours. Additionally, directed Resident #98 required the assistance of 2 persons to turn and reposition in bed and a mechanical lift transfer with 2 persons assist between surfaces. a.A progress note dated 3/26/2024 indicated on examination a new Deep Tissue Injury (DTI) pressure ulcer was observed on Resident #98's left heel. The progress notes further indicated to float the heel, provide skin prep, and indicated the wound team was notified of the new pressure ulcer with resulting physician's orders dated 3/26/2024. A nursing skin/wound care note dated 3/26/2024 at 5:38 PM indicated an Advance Practice Registered Nurse (APRN) visit occurred and in addition to a new order for skin prep every shift to the left heel to the (newly noted DTI left heel) Resident #98 was to wear offloading boots to prevent further injury as left heel was prone to skin breakdown due to uncontrollable leg spasms. A wound physician progress note dated 4/4/2024 indicated a new stage 2 pressure ulcer (Deep Tissue injury progressed to a stage 2 pressure ulcer) with treatment recommendations to apply betadine to base of the wound secure with an ABD pad and rolled gauze to be changed daily with a physician's order obtained on 4/5/2024. A wound care specialist's handwritten progress note dated 4/9/2024 (no time) recommended offloading boots and further indicated the leg brace (AKFO) could be used with occupational and physical therapy evaluation of the brace support surfaces. A wound physician progress note dated 4/23/2024 at 8:14 PM indicated the wound bed of the left heel stage 2 pressure ulcer was found to have slough and a debriding agent, Santyl, was recommended, to apply Calcium Alginate to the base of the wound and to secure with an ABD pad and rolled gauze to be changed daily with a physician's order obtained on 4/24/2024. A wound physician progress note dated 4/30/2024 at 4:00 PM indicated completing a follow up visit finding the left heel pressure ulcer had progressed (worsened) to a stage 3 pressure ulcer with 100% granulation of the wound base. Treatment recommendation included cleansing with normal saline, applying Calcium Alginate to the wound base and secure with bordered foam and to change the dressing daily. Physician treatment orders were obtained. The Nurse Aide documentation sheet dated 4/1/2024 through 4/30/2024 had no documentation of the provision of turning and repositioning between 8:00AM and 4:00PM on 4/1/2024, from 12:00AM-6:00 AM on 4/14/2024, 12:00 AM-6:00AM on 4/20/2024, 4:00PM-10:00PM on 4/28/2024, 8:00AM-4:00PM on 4/29/2024 and 4:00PM-11:00PM on 4/30/2024. An interview on 7/18/2024 at 11:47 AM with MD#3 indicated that although turning and repositioning is a fundamental practice in an effort to prevent pressure ulcers and without it could contribute to pressure ulcer formation, he/she could not say with certainty if the dates and time periods of the missing turning and repositioning documentation directly contributed to the formation of the DTI pressure ulcer found on 4/30/2024. On 7/18/2024 at 1:05 PM an interview and record review with the DNS and the Administrator indicated he/she was unable to explain why there was missing documentation on the nurse aide flow sheet for 4/1,14, 20, 28, and 29/2024 prior to the discovery of the Deep Tissue Injury pressure ulcer on 4/30/2024 and missing documentation on the evening shift of 4/30/2024 for the provision of turning and repositioning. The DNS indicated he/she would have expected documentation to have been completed by the end of the shift, indicated the nursing supervisors were responsible for ensuring the nurse aides documentation of care provided for each resident was completed prior to the end of the shift. The DNS further indicated on 5/29/2024 a QAPI (Quality Assurance Performance Improvement) was initiated to start a process for the nursing supervisors to run a report an hour before the shift end to determine what nurse aides have yet to document then speaking to the staff to ensure completion of the task . The DNS also indicated she has found an improvement in consistent documentation of resident care. The facility policy dated as revised on 9/28/2023 labeled Skin Care Management Pressure Injury Treatment indicated in part the pressure injury treatment program should focus on assessing the resident and the status of the pressure ulcers, the current support surfaces, pressure ulcer care, managing bacterial colonization and infection, education, and quality improvement. The policy further indicated a deep tissue injury (DTI or DTPI) result from intense and/or prolonged pressure and shear forces at the bone-muscle level and may rapidly evolve to reveal the true extent of tissue damage. b.A physician's order dated 5/31/2024 directed the check bed air mattress every shift for functioning and to confirm the setting to be at the resident's current weight or comfort level. On 5/31/224 a care plan entry indicated Resident #98 had a stage 3 pressure ulcer of the left heel with no additional interventions. The quarterly MDS assessment dated [DATE] indicated Resident #98 had a stage 3 pressure ulcer. Resident #98's care plan was updated on 6/24/2024 to consult the dietitian for wound healing. An interview and record review with the DNS on 7/9/2024 at 12:35 PM indicated no physician's orders for offloading boots and no indication of the use of offloading boots could be found in the care plan. An interview and record review with the wound care nurse Registered Nurse (RN#1) on 7/9/2024 at 1:00 PM indicated there was no physician's order to use offloading boots as recommended by the wound physician on 4/9/2024 which must have been overlooked. RN #1 further indicated he/she had seen Resident #98 wearing off-loading booties at times but was unable to indicate how staff would know how and when to apply offloading boots and to evaluate the effectiveness if there was not a physician's order to use them. After surveyor inquiry a physician's order dated 7/10/2024 (90 days later) was obtained directing to check offloading boot placement every shift and the discontinuation of donning the KAFO on the left lower extremity in the am removing it in the evening. After surveyor inquiry physician orders dated 7/10/2024 were obtained directing to use bilateral lower leg foam cushion on bilateral leg rests of the wheelchair for proper leg positioning while out of bed in the adaptive wheelchair, and to discontinue use of the KAFO and tubi-grip/geri-sleeve to left lower extremity and to place the use of the KAFO on hold from 7/10/2024 through 7/17/2024. After surveyor inquiry on 7/10/2024 the care plan interventions were updated to include the use of a bilateral lower leg foam cushion(blue) on the leg rests of the w/c for proper positioning while out of bed in the AWC and to wear bilateral off-loading boots while seated in the wheelchair and while in bed. This intervention was also added to the nurse aide care card on 7/10/2024 (93 days after the recommendation for its use). The care plan was further updated on 7/10/2024 indicating Resident #98 refuses booties and offloading devices at times indicating not needing them and indicated the left KAFO to be on hold until the stage 3 pressure ulcer resolves. On 7/10/2024 at 10:40 AM an observation, interview and record review with Nursing Supervisor, RN #5, during observation of Resident #98 sitting in the AWC with lower legs crossed at the feet wearing socks, and legs in between the footrests and a blue foam cushion just below the knees across both footrests identified areas of pressure to both feet. The areas receiving pressure at the time were the right great toe, left upper ankle, top of the left foot and the right shin above ankle. Although RN #5 indicated there was an order for offloading booties and Resident #98 could be non-compliant RN #5 was unable to find a physician's order prior to 7/10/2024 for the use of offloading boots and was unable to find a care plan indicating Resident #98 was noncompliant with care, and was unable to explain or provide documentation as to how licensed nurses monitored for pressure of the feet and heels while out of bed in the AWC. RN #5 further indicated Resident # 98 had been mostly bed bound per his/her choice until around July 4, 2024. On 7/10/2024 at 11:10 AM an interview with Nurse Aide ( NA #6) with RN #5 present indicated he/she has worked in the facility for years and is familiar with his/her regularly assigned residents but had not worked on Resident #98's unit for some time, had received a verbal report of how to care for the residents on his/her assignment from the off going NA he/she was replacing. NA #6 further indicated he/she had provided AM care for Resident #98 along with the off going NA, and Resident #98 told them what care was to be done. NA#6 indicated no NA care cards were on paper, on his/ her person, in the resident rooms or at the nurse's station and s/he can remember what is needed for all the residents on the assignment but was unaware Resident #98 should have had pressure relieving booties on both feet. On 7/10/2024 an observation and interview at 11:15 AM with RN #5 found the electronic tablets in the work room behind the nurse's station the nurse aides use to document care provided at the end of the day but was unable to find information that described the care needed for each resident. RN #5 further indicated the process the nurse aides are to follow is to review the assignment on the tablet at the beginning of the shift and to document on them at the end of the shift and further indicated this did not occur with NA #6 and the process could use some improvement. On 7/10/24 at 11:30 AM interview and record review with the DNS and RN #5 indicated there were no orders for pressure relieving boots although Resident #98 had some available in his/her room, and both had seen Resident #98 wearing them at times no documentation to show the start date, consistent use or evaluation of the effectiveness of the use of the booties or a care plan indicating the need for offloading booties was found. RN #5 was able to find an area in the nurse aide tablet that would bring up items that have been added to the nursing care plan that electronically produce the nurse aide care card and was unable to find electronic communication within the care card of the need for use of offloading boots. An interview with the wound Medical Doctor (MD) #3 on 7/11/2024 at 11:25 AM indicated Resident #98's left heel pressure ulcer could have been prevented but once discovered were managed. MD #3 further indicated many factors could have contributed to the decline of a DTI as the DTI is making a big process occurring below the surface of the skin caused by unrelieved pressure and could not be sure if not using pressure relieving boots consistently as recommended could have by itself caused the decline as many factors play a part in pressure ulcer development. An interview with the Medical Director (MD #2) on 7/15/2024 at 12:34 PM indicated he/she would have expected the wound nurse to have provided the APRN of the facility with the wound physician's recommendations for Resident #98 for review and written orders. MD #2 further indicated not having a physician's order for the offloading boots and monitoring of its use could have contributed to the decline of the pressure ulcer along with multiple factors that could predispose the development of or decline in a pressure ulcer. The facility policy labeled Prevention of Pressure Injuries indicated in part a Risk assessment would be completed on admission, weekly and with any change of condition, use a standardized screening tool to determine risk factors for developing a pressure ulcer. The policy further indicated preventative skin care, use of a pressure relieving mattress may be recommended to aid in the prevention and or healing of a pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 2 of 7 sampled residents (Resident #13 and Resident #97) reviewed for position and mobility, the facility failed to ensure further evaluation and timely treatment were implemented for resident(s) with newly identified limited mobility to maintain, improve or prevent further decline in range of motion and mobility over time and for 1 of 7 residents reviewed for contractures ( Resident # 86) the facility failed to ensure the application of braces and/or splints as per physician's orders.The findings included: 1.Resident #13 was admitted with diagnoses that included mild cognitive impairment, protein calorie malnutrition and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 as moderately cognitively impaired, had no functional limitations in the upper/ lower extremities, required partial to moderate assist in bed mobility, oral care, and total assist in all other Activities of Daily Living (ADL). The Resident Care Plan, (RCP) dated 12/12/21 identified Resident #13 had an ADL self-care deficit, impaired cognition and potential alteration in discomfort related to compromised functional mobility. Interventions directed to provide total assistance with ADL care, communicate needs and capabilities to the resident and family and evaluate for pain, alleviating symptoms, and impact on functional mobility. An Interdisciplinary Rehabilitation screen dated 1/19/22 identified Resident #13 had a left-hand deformity but refused range of motion for bilateral upper extremities and asked the therapist to leave. A review of the clinical record identified that there were no subsequent rehabilitation screens through 12/2/22 for Resident #13 that further identified the status of the left-hand deformity, the functional restriction to the left hand or any plan to address the limitation. The Physical Therapy evaluation and Plan of Treatment dated 12/3/22 identified Resident #13 as being referred for services for splinting of a right knee for contracture management. However, Resident #13 was not receptive to the device despite education and services being terminated with emphasis on bed positioning with pillows and bilateral foot booties. No other functional limitations to the upper extremities/hands were identified at the time of the evaluation. A Resident Round Screen dated 8/30/23 and 3/1/24 identified Resident #13 now had bilateral hand deformities with no subsequent evaluation or plan to address the functional limitation. An Interdisciplinary Rehabilitation screen dated 5/16/24 identified Resident #13 presented with deformities in both hands with the left hand presenting with severe distal interphalangeal or DIP (contracture at the tips of the fingers) and that the right hand would benefit from a splint. There was no documented evaluation following the screen to identify the extent of the functional limitation. An Advanced Practice Registered Nurse Progress note beginning 3/8/24 through 6/10/24 note bilateral hand contractures with no signs of discomfort. An observation on 7/02/24 at 11:12 AM identified bilateral hand contractions with no splint/brace noted. An interview with the Director of Rehabilitation on 7/08/24 at 11:40 AM identified rehabilitation screens were completed on admission and quarterly for every resident to determine any functional changes. Any change would be fully evaluated to determine the extent of limitation and treatment initiated to prevent further progression. The Director of Rehabilitation identified that although Resident #13 had deformities and contractures on both hands, a full evaluation was never conducted for Resident #13 to determine the extent of the limitation(s) and treatment was not initiated to prevent further progression and should have been. After surveyor inquiry, an Occupational Therapy Evaluation and Plan of Treatment dated 7/8/24 identified Resident #13 was being evaluated for left- and right-hand splints for contractures. Functional limitations were noted to the left and right upper extremity bilaterally. Right hand grip strength was less than 5lbs and left and strength was unable to be tested. Functional limitations were not present due to the contract. Recommendations included contracture management and possible splint for both hands. A second interview with the Director of Rehabilitation on 7/8/24 at 1:33 PM identified Resident #13 demonstrated increased tightness during the evaluation indicative of a progression of the contractures. An interview with the Director of Nursing Services (DNS) on 7/10/24 at 11:41 AM identified residents should be screened on admission by rehabilitation staff to determine if an evaluation was indicated. The DNS further identified she would expect the evaluation and treatment to have been initiated at the time an abnormality was identified. An interview with Advanced Practice Registered Nurse (APRN) #1 on 7/11/24 at 9:48 AM identified she began services with the facility beginning December 2023 and Resident #13 was known to her. APRN #1 identified Resident #13 had a functional limitation to one or both hands that was likely unavoidable. However, whether a contracture or deformity, APRN #1 would expect staff to complete screening at regular intervals and further evaluate and implementation of any measures to prevent the progression of the limitation. APRN #1 further identified that not implementing preventative measures at an earlier time could have led to further decline in Resident #13's contracture(s). An interview with the Medical Director on 7/11/24 at 1:26 PM identified she was employed by the facility beginning May 2024 and was not completely familiar with Resident #13 and any limitations. The Medical Director identified that she would expect that once an abnormality was identified, a treatment plan should be discussed interdisciplinary with rehabilitation providing any necessary services to prevent further decline. A review of the Clinical Services Policies and Procedures dated 1/2018 directed that a screening process is used to identify the need for a rehabilitation evaluation and determine a resident's ability to perform in either skilled or restorative nursing. 2. Resident #97 had diagnoses that included cerebral infarction (stroke) with hemiplegia (paralysis) and hemiparesis (weakness) unspecified and breakdown of skeletal muscle due to direct or indirect muscle injury. The MDS assessment dated [DATE] identified Resident #97 as severely cognitively impaired and dependent with all ADL skills. The RCP dated 5/19/23 identified Resident #97 had an ADL self-care deficit related to stroke and impaired cognitive function. Interventions directed to cue and reorient and supervise as needed. a. An Occupational Evaluation and Plan of Treatment dated 5/19/23 identified Resident #97 presented with impairments in balance, dexterity and fine/gross motor coordination, mobility, strength, and attention resulting in limitations/restrictions in self-care which required services to increase functional activity tolerance and maximize independence with ADL's. Impairments limited in the right and left upper extremity with inability to flex or extend at the elbow in the left extremity. The Occupational Treatment notes dated 5/22/23 through 6/28/23 identified Resident liked to keep the left upper in a flexed position and that passive range of motion (completed by therapist) was performed for those areas for improved range of motion. The Occupational Discharge summary dated [DATE] identified Resident #13 allowed the therapist to range muscles of the bilateral upper extremities but fought against upper body dressing. Resident #97 was discharged to the care of nursing without any further recommendations to prevent further loss of limitation to the right upper extremity. The Interdisciplinary Rehabilitation Screens dated 1/29/24, 2/8/24 identified Resident #97 demonstrated increased tone throughout the body with no further evaluation/intervention. A Contracture Splint Rounds dated 5/16/24 identified Resident #97 as being referred for contractures of the left knee, left hip and left elbow. An Interdisciplinary Rehabilitation Screen dated 5/24/24 identified Range of motion was unable to be completed due to increased tone but also noted that range of motion was unable to be performed to the upper extremity (unidentified) due to increased tone with no further evaluation. An interview with the Director of Rehabilitation on 7/08/24 at 11:40 AM identified rehabilitation screens were completed on admission and quarterly for every resident to determine any functional changes. Any change would be fully evaluated to determine the extent of limitation and treatment initiated to prevent further progression. After surveyor inquiry, an Occupational Therapy Evaluation and Plan of Treatment dated 7/9/24 identified Resident #97 presented with contractures of the left upper and left extremity and was trialing splints for the left upper extremity and hand. A second interview and clinical record review with the Director of Rehabilitation on 7/10/24 at 3:27 PM identified Resident #97 should have been discharged from rehabilitation services with a range of motion program to prevent the development of contractures. The Director of Rehabilitation further indicated, once the increased tone was identified, a full evaluation should have been completed to determine the extent with interventions to prevent further progression at the time identified. Resident #97 was referred for splinting on 5/16/24. b. A Physical Therapy Evaluation and Plan of Treatment dated 5/19/23 identified Resident #97 presented with new onset or reduced dynamic balance and decrease in functional mobility. The right and left lower extremities presented within functional limits for strength and range of motion with recommended services to increase activity tolerance and left extremity range of motion/ strength. The Physical Therapy Treatment notes dated 5/22/23 through 6/23/23 identified Resident #97 tended to maintain the left lower extremity and hip in a flexed/abducted position. Therapy included passive range of motion to the left lower extremity and tapping/stroking to the left hip to facilitate muscle relaxation and promote left hip range of motion. The Physical Therapy Discharge summary dated [DATE] identified skilled services included range of motion exercises to maintain joint mobility and prevent contracture. Resident #97 was discharged to the unit with nursing assistance, pressure relieving booties and repositioning every two hours to prevent pressure ulcers with current level of function prognosis identified as good with consistent staff follow through. The summary did not include any further recommendations to maintain or prevent further contractures. An APRN progress note dated 9/14/23 identified a request was made to see Resident #97 to approve a request for a knee splint/brace. Resident #97 was noted to have a left knee contracture and abnormalities of gait and mobility and needed a splint as medically necessary to aid in providing patient with potential to complete ADL's. The case was discussed with nursing and rehabilitation. A review of the clinical record did not include a documented physician's order for the splint/brace or its implementation. Subsequent Interdisciplinary Rehabilitation Screens dated 1/29/24, 2/8/24 identified Resident #97 demonstrated increased tone throughout the body with no further evaluation/intervention. An Interdisciplinary Rehabilitation Screen dated 5/24/24 identified Range of motion was unable to be completed due to increased tone extremity (unidentified) due to increased tone in the lower with no further evaluation. An interview and clinical record review with the Director of Rehabilitation on 7/11/24 at 12:02 PM identified she had never received the referral for a brace/splint for Resident #97 and was unaware s/he had contractures prior to completion of a recent evaluation dated 7/8/24. An interview and facility documentation review with the Director of Nursing Services, DNS on 7/11/24 at 9:27 AM identified any concerns related to changes in a resident's function was discussed at a weekly risk meeting that included the medical provider. The DNS identified that Resident #97 was not documented as having been discussed at any risk meeting dated 6/30/23 through present. The DNS further identified she was unaware that a brace/splint had been recommended and would have expected a physician order to have been transcribed to facilitate the implementation of the brace. An interview with APRN #1 on 7/11/24 at 9:29 AM identified she began services with the facility beginning December 2023 and that Resident #97 was known to her. APRN #1 identified Resident #97's contractures were unavoidable second to h/her stroke. However, APRN #1 would expect staff to complete screening at regular intervals and further evaluate and implement any measures to prevent the progression of the limitation. APRN #1 further identified that not implementing preventative measures at an earlier time could have led to further decline in Resident #97 contracture(s). An interview with APRN #2 on 7/11/24 at 1:45 AM identified she stopped providing services for the facility effective December 2023. APRN #2 identified she would have provided a prescription directly to rehabilitation services when ordering a splint and they would initiate the process of acquisition with an outside vendor for fitting. APRN #2 believed she had written the prescription for the brace but understood it took a while to obtain so did not recall ever actually seeing the brace. An interview with the Medical Director on PM 7/11/24 at 1:26 PM identified she started working at the facility on May 202024 and was not completely familiar with Resident #97 and any limitations. The Medical Director identified that although contractures in a resident with a history of stroke was unavoidable, she would expect that once an abnormality was identified, a treatment plan should be discussed interdisciplinary with rehabilitation providing any necessary services to prevent further decline. A review of the Clinical Services Policies and Procedures dated 1/2018 directed that a screening process is used to identify the need for a rehabilitation evaluation and determine a resident's ability to perform in either skilled or restorative nursing. Although requested, a policy for implementing rehabilitations services for a splint/brace was requested. None was provided. 3. Resident #86's diagnoses included Hemiplegia and Hemiparesis, Cerebral Infarction, and Metabolic Encephalopathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #86 as severely cognitively impaired and required maximum assistance for personal hygiene, and was dependent for toileting, and showering. The Resident Care Plan dated 7/8/24 identified the resident had limited physical mobility and a left knee contracture. Interventions included application of a left elbow splint after AM care and remove before PM care, application of a left knee splint after AM care and remove before PM care, and application of left palm roll splint after AM care and remove before PM care. A physician's order dated 7/10/24, subsequent to surveyor inquiry, directed to wear left elbow splint after AM care and remove before PM care, wear left knee splint after AM care and remove before PM care, to wear left palm roll splint after AM care and remove before PM care, and to wear left knee splint after AM care and remove before PM care. A Social Services note dated 7/2/24 at 6:49 PM identified in an IDT meeting that resident received a left knee brace, left elbow, and hand brace per rehab. The Treatment Administration Record (TAR) for the month of June 2024 indicated that the left elbow splint was applied after AM care and removed prior to PM care. The Treatment Administration Record (TAR) for 7/1/24 - 7/10/24 did not indicate that the left elbow splint, left knee splint and left palm roll splint were applied. Further the TAR identified that the orders for the left knee splint, left palm roll splint, and the left elbow splint were pending confirmation subsequent to surveyor inquiry. Splint application instructions for the elbow splint, hand splint, were taped to the Residents closet door with the aide care plan. An Occupational Therapy Evaluation and Plan of Care dated 5/22/24-7/16/24 identified that Resident #86 had functional limitations due to contractures, further identified that Resident #86 had a resting hand splint, an elbow extension splint, and a knee extension splint. An Occupational Therapy Discharge summary dated [DATE] at 4:11 PM written by OT#1 identified that Resident #86 was being discharged from therapy and staff were trained for donning and duffing left-hand splint, left elbow splint, and left knee splint. Further the documentation identified that a splint/brace program was established and prognosis was good with consistent follow through. Observations on 7/10/24 at 12:00 PM, identified Resident #86 sitting in a custom wheelchair without any splints on her elbow, knee, or hand. Interview with LPN # 1 on 7/10/24 at 12:10 PM identified that he was unaware that Resident #86 was supposed to be wearing splints, further he stated that it was not indicated on the TAR to apply any splints. Interview with OT #1 on 7/10/24 at 12:45 PM identified that Resident #86 was to have a left elbow splint, left wrist splint, and left knee splint to be applied after am care and removed at bedtime. Further she stated that she was applying them until resident was discharged from therapy, then she educated the NAs and included diagrams and instructions. Written instructions with diagrams were found on the closet door. Interview and observation with RN #2 on 7/10/24 at 1:00 PM identified that the splints were not on the resident, and they were in the closet drawer. Further she identified that she did not know what the order was for the application of the splints, she would have to confirm with the MD. Interview with NA#1 on 7/10/24 at 1:43 PM identified that application of the splints is not part of the care she provides. Someone else comes in sometimes and puts them on but not her, further she stated that the nurse tells her in the morning what to do for each resident and was not told to apply the splints. Review of the splinting policy dated 1/18 directed, in part, the treating therapist is to provide instruction to the nursing staff regarding the wearing schedule, application and removal of the splint, precautions, and when to contact the therapist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the tour of the Dietary Department, observations, policy review, and staff interviews, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner and failed to ensure staff applied proper beard guards and failed to consistently labeled and stored food to reflect their age or shelf life. The findings included: Tour of the dietary department on 7/1/24 at 10:40AM, during the initial walk through of the kitchen with the Dietary Manager (DM) identified the following: a. The kitchen was observed to have ceiling tiles with a brown substance noted on them. b. The dishwasher wash station identified that a piece of a cover was broken and discolored in the clean area. c. The dishwasher had black substance noted around the edges. d. The tiles in the kitchen and dishwasher room were observed with a black substance. e. The floor throughout the kitchen was noted to have dirt, debris, and food. f. The second-floor nourishment refrigerator was noted to have a red substance covering the bottom of it on the inside. g. The day cook was not wearing a beard guard. h. The ceiling vent in the main kitchen was noted to have a brown substance around it. i. The baking oven was covered with a brown substance inside and out. j. The cooktop in the kitchen was covered with a brown substance. k. The dry goods storage area was observed to have numerous items that were noted unlabeled or dated, items included were cereal marked with 11/21(unsure of year), elbow pasta opened without a date, 2 bags of egg noodles opened without a date, sprinkles opened, not sealed and without a date. l. The main refrigerator was observed to have a bag of 5 rolls which was not sealed or dated. m. The Ice cream freezer was observed with a large container of frozen strawberries underneath the tubs of ice cream without a lid or date. n. The freezer was observed with numerous items not labeled or dated, a large box containing chicken tenders, shelved items without dates included ribs, Tortillas, chocolate chips, a quiche, (not sealed) 1 Pie crust, 5 waffles, 1 loaf of [NAME] soda bread, broccoli, a large tray of Danish, (not sealed) a box of smoked chicken kielbasa which had frost on it. (not sealed) o. The temperature logs for the freezer and the refrigerator were missing numerous evening readings, from June 2024 freezer Temp Log missing dates that included 6/20/24, 6/21/24, 6/22/24, 6/23/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24, 6/29/24, and 6/30/24. The June 2024 refrigerator Temp Logs reviewed and identified missing dates from the evening that included 6/20/24, 6/21/24, 6/24/24 6/25/24, 6/26/24, 6/27/24, 6/28/24, 6/29/24, and 6/30/24. On 6/22/24, and 6/23/24 there are no temperatures recordings for AM or PM for the freezer and the refrigerator. Interview with the Dietary Manager DM on 7/1/24 at 1:25PM identified that all staff are responsible for labeling and dating of items once opened. Interview with the DM on 7/3/24 at 10:25AM identified that hair covering is to be worn once staff is around food and beard covering is included in this policy. DM was unsure why this policy was not followed. DM identified the policy for monitoring the temperatures for the freezer and the refrigerator are to be done twice a day and that the night cook was not logging the temperatures, he also identified that he did an in-service with the night cook. The DM identified that all open items should be sealed once the items are opened and not left out to air. Interview with the DM on 7/3/24 at 1:45PM identified that the facility hired a company to steam clean the kitchen and that it was not as clean as it should be. The DM identified that there was dust on the ceiling, dirt and grease were by the dishwasher, the tile was dirty, and the wash station had a broken piece which the DM stated he reported a week earlier to maintenance. The DM stated that there is not a maintenance log for documenting items that need to be fixed in the kitchen. Interview with the DM on 7/3/24 at 2:00PM identified that he was handling the entire building and was unable to fix the clean area by the dishwasher. Review of the policy for Hair Restraints dated 1/2017 identified that compliance with the local and federal service code requires that anyone with the kitchen, who will have close contact with preparation or service of food, food storage areas, equipment will keep hair effectively/appropriately restrained to include facial hair. The purpose of hair restraints is to prevent hair from contacting food and food equipment surfaces, and to deter food services employees from touching their hair. Review of the policy for Refrigeration Temperature Recording dated 4/29/20 identified that Temp Logs were to be completed twice a day and that the day cook is responsible to record in the morning upon opening the kitchen and the evening cook is responsible to record the temperatures upon closing the kitchen. Review of the policy for Food storage dated 4/29/20 identified that Dry storage items will be required to have a date including day, month, and year. The facility uses the Date Marking Policy in conjunction with the Food Storage Policy ensuring ready to eat, closed, or opened foods maintain as expiration or use by date system. The temperatures of all refrigerators and freezers within the Dietary Department will be recorded a minimum of two times in the morning and the evening,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident had an elopement risk evaluation when the resident expressed intentions on leaving the facility. The findings include: Resident #1 had diagnoses that included altered mental status, adjustment disorder with anxiety, generalized muscle weakness, and anorexia. A review of Resident #1's admission elopement risk assessment dated [DATE] identified Resident #1 was not at risk for elopement. The care plan dated 2/16/2024 identified Resident #1 was at an increased risk for falls and injury related to adjustment issues to the new environment, anxiety, agitation, deconditioning due to alcohol abuse, sepsis, and pyelonephritis. Interventions directed to anticipate and meet the resident's needs and encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved activity. The APRN note dated 2/26/2024 at 4:31 P.M. by APRN #1 identified Resident #1 asking to go home. Resident #1's wife stated that Resident #1 wants to go home so he/she can drink and smoke. The nurse's note dated 2/27/2024 at 9:11 A.M. by RN #1 identified Resident #1 was expressing his/her desire to be discharged home today. APRN #1 was notified, and she explained to Resident #1 that his/her diabetes is not well controlled, and she was not comfortable discharging him. The APRN note dated 2/27/2024 at 11:43 A.M. by APRN #1 she identified Resident #1 was referred to her by nursing due Resident #1 wanted to go home. APRN #1 identified Resident #1 has a history of alcohol and tobacco misuse and Resident #1 wanted to go home due to this issue. APRN #1 identified a new order has been written for Trazodone as needed as Resident #1's anxiety level is high, and Resident #1 is pushing for discharge. The APRN note dated 2/28/2024 at 3:32 P.M. by APRN #1 she identified she was called to see Resident #1 because he/she is threatening to leave against medical advice. APRN #1 identified Resident #1 has had increasing anxiety withdrawal symptoms as he/she wants to go home to drink and smoke. APRN #1 identified Resident #1 had Trazodone 25 milligrams yesterday and it was effective in calming Resident #1 down. The APRN note dated 2/28/2024 (signed on 3/21/2024 at 11:16 A.M.) by APRN #2 identified she was asked to see Resident #1 for agitation. APRN #2 identified Resident #1 was alert and agitated. Resident #1 wanted to be discharged home and was frustrated. Resident #1 was challenging to redirect at this time but does take Trazodone as needed. Resident #1 was agreeable to go back upstairs. APRN #2 identified Resident #1 had a previous episode of requesting discharge with agitation in which the medical provider gave Resident #1 as needed trazodone, trazodone is scheduled daily. The social worker note dated 2/28/2024 at 10:40 A.M. identified SW #1 was informed by staff that Resident #1 was in the lobby with a friend to leave the facility to go home. SW #1 identified she, the unit manager, APRN #1, and APRN #2 met with Resident #1 to educate him/her on the risks and benefits of leaving against medical advice versus staying for an interdisciplinary plan for a safe discharge home. Resident #1 was educated and encouraged to stay so that we could work with him/her to plan a safe discharge. Resident #1 said he/she would wait to go safely and home with services. Resident #1's friend left the facility. Resident #1 agreed and returned to the unit with the nurse manager. The nurse note dated 2/28/2024 at 12:00 P.M. by RN #1 he identified Resident #1 expressed he/she wants to go home and called a taxi. Resident #1 was able to be redirected and transferred back to his/her room. RN #1 identified Trazodone was administered as ordered with a good effect. Interview and clinical record review with the DNS on 3/22/2024 at 10:20 A.M. identified although Resident #1 verbalized he/she wanted to leave against medical advice on 2/26/24, 2/27/24, and on 2/28/24 Resident #1 called a taxi and was found in the lobby at the facility she would not have expected an elopement risk evaluation to be conducted. The DNS identified she did not feel Resident #1 was at risk for elopement because he/she was verbalizing he/she wanted to go home. The DNS could not explain why Resident #1 had a care plan implemented on 3/20/2024 that identified Resident #1 as an elopement risk related to Resident #1 expressing several times intentions to go home. Review of facility elopement prevention policy identified all residents are evaluated for risk of elopement on admission, readmission, quarterly, and with a change in condition, utilizing the elopement risk evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility policy and interviews for 2 of 3 residents (Resident #28 and Resident #71) reviewed for pressure ulcers, the facility failed to follow physician orders for every 1 hour re-positioning for Resident #28 and failed to ensure a thorough assessment was completed when a pressure area was identified and failed to ensure a wound consultant's recommendations were reviewed and implemented in a timely manner for Resident #71. The findings include: 1. Resident #28 diagnoses included a severe nerve, brain and spinal cord disease, diabetes, pressure ulcers and dementia. Physician's orders dated 9/10/21 directed a strict turn and position every 1 hour for Resident #28 related to wound care. A significant change Minimum Data Set assessment dated [DATE] identified Resident #28 had intact cognition and was totally dependent on staff for bed mobility and transfers. A Resident Care Plan (RCP) dated 10/19/21 identified Resident #28 had a pressure ulcer related to diabetes, compromised mobility and incontinence. Interventions included to avoid positioning Resident #28 on his/her buttocks except briefly for meals in bed, teach him/her and family the importance of changing position for prevention of pressure ulcers, and encourage small, frequent positioning changes. Additionally, the RCP dated 10/19/21 identified Resident #28 required monitoring, reminding, and assistance to turn/reposition at least every 1 hour and assistance of two persons more often as needed or requested. Monthly physician orders dated 12/10/21 directed strict turning and positioning every 1 hour for wound care and pressure redistribution mattress to the bed, check settings and function every shift for skin. A follow-up progress note dated 12/14/21 by MD #1 identified a sacral wound remained significant, though improved by external dimension. However, the bone was palpable within the base. Wound cultures demonstrated active infection with possible osteomyelitis now beneath the sacral wound. Resident on oral antibiotics and an MRI had been ordered to more definitely characterize the deep tissues about the injury, as the x-ray results were equivocal. The resident would like to be allowed to spend some time out of bed and in wheelchair. This should be a manageable request so long as the time out is limited to an hour at a time and he/she is positioned in a manner which will minimize pressure to his/her sacrum. Additionally, MD #1's progress note identified a Stage IV posterior sacral pressure ulcer that measured 7.9 centimeter (cm) by 7.7 cm by 2.6 cm with moderate serosanguinous exudate. Intermittent observations of Resident #28 on 12/15/21 between 11:25 AM to 2:05 PM (2 hours and 30 minutes) identified that although staff were noted to briefly go in and out of Resident #28's room during that time, the resident remained in the same position, on her/his back with the head of the bed elevated at approximately 45 degrees, and with her/his legs leaning to the right. Interview with NA #2 on 12/15/21 at 1:55 PM identified she provided incontinent care, repositioned Resident #28 on his/her back and elevated the head of the bed at 11:00 AM to prepare Resident #28 for lunch. NA #2 further identified that she left the unit to assist in the Dining Room and then went on break, Resident #28 was unable to reposition him/herself and another staff member, NA #1 was responsible to reposition the resident every hour. NA #1 identified that Resident #28 was in the same position as when she repositioned the resident last time at 11:00 AM (3 hours prior). Review of a turning chart placed on a clip board inside Resident #28's room on 12/15/21 at 2:00 PM identified on 12/15/21 the resident was last turned on his/her back at 11:00 AM at lunch time. Interview with NA #1 on 12/15/21 at 2:20 PM identified she was unaware of the physician orders directing the strict turning and repositioning of Resident #28 every hour. Interview with MD #1 on 12/16/21 at 12:00 PM identified he was concerned with Resident #28's posterior sacrum pressure ulcer deterioration and assumed that it was related to recurrent pressure, therefore requested frequent every 1 hour turning and repositioning to prevent possible further deterioration and to promote healing. Review of Pressure Ulcers/Skin Breakdown facility clinical protocol identified the physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 2. Resident #71's diagnoses included breast cancer, multiple myeloma, anemia and anxiety. The Braden Scale for Predicting Pressure Sore Risk dated 11/10/21 identified Resident #71 had a total score of 11 indicating being at a high risk for the development of a pressure ulcer. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #71 was severely cognitively impaired and required extensive assistance of 1 person for bed mobility, was at risk for developing pressure ulcers and had no pressure ulcers currently. Skin and ulcer treatments included pressure reducing devices for bed and chair and turning/repositioning program. The Resident Care Plan dated 11/30/21 identified Resident #71 had potential impairment to skin integrity related to impaired bed mobility, incontinence of bowel and bladder, history of cancer, fragile skin and having a self-care deficit. Interventions included to offload his/her heels in bed, keep skin clean and dry, monitor/document location, size and treatment of skin injuries, reporting abnormalities, failure to heal, signs/symptoms of infection, maceration, etc to physician. Physician's orders dated 12/1/21 directed weekly skin checks, bed mobility with moderate assistance of 1 from hospital bed and transfers with mechanical lift and total assistance of 2. Advanced Practice Registered Nurse (APRN) #1's progress note dated 12/3/21 identified left heel ulcer prevention; per nursing request, reordered skin prep to left heel every shift and apply Podus boots daily. A physician's order dated 12/3/21 directed skin prep to left heel every shift and apply Podus boots daily when in bed. A nurse's note dated 12/3/21 by Licensed Practical Nurse (LPN) #2 identified apply Podus boots daily and skin prep to left heel every shift. Further review of LPN #2's documentation failed to reflect a description of the left heel and the reason these treatments were implemented. Treatment Administration Record (TAR) for December 2021 directed to apply skin prep to left heel every shift with start date of 12/3/21. The Skin Observation Tool dated 12/6/21 identified a dark spot was observed to Resident #71's left heel with moderate amount of serous fluid, measuring 3 cm by 2 cm. The heel was assessed by the DNS. APRN was notified and ordered to cover with dry protective dressing until seen by the wound physician the following morning. Additionally, the clinical record failed to identify the left heel pressure ulcer was assessed by a RN on 12/3/21, when the wound was identified by LPN #2 and treatments ordered. Wound Consultant's (MD #1) initial progress note dated 12/7/21 identified Resident #71 had an unstageable left posterior heel pressure ulcer measuring 2.4 centimeters (cm) long by 2.3 cm wide with a small amount serous exudate and 100% slough. Total area debrided: 5.52 cm. Treatment recommendations included to clean with Dakin's solution 0.125% (1/4 strength) and apply Silver Alginate to the wound base with a dry, clean dressing (DCD) daily for 7 days. Additionally, MD #1's note indicated the plan of care was discussed with facility staff and patient. Treatment Administration Record (TAR) for December 2021 identified skin prep was applied to Resident #71's left heel from 12/3/21 through 12/12/21, despite the new left heel treatment recommendations to clean with Dakin's solution 0.125% (1/4 strength) and apply Silver Alginate to the wound base with a dry, clean dressing (DCD) daily for 7 days that was directed by MD #1 on 12/7/21. Physician's order dated 12/13/21 (6 days after MD #1's wound consult and treatment recommendations were provided to facility) directed to cleanse the left heel wound with Dakin's Solution, apply Silver Alginate to the wound bed and cover with dry clean dressing (DCD) daily, every 7:00 AM to 3:00 PM shift for 7 days. Wound Consultant's (MD #1) follow-up progress note dated 12/14/21 identified Resident #71's unstageable left posterior heel pressure ulcer was improving. The wound measured 1.9 cm long by 1.7 cm wide by 0.3 cm deep. Total area debrided: 3.23. Treatment recommendations included to clean with Dakin's solution 0.125% (1/4 strength) and apply Collagen Powder to the wound base with a dry clean dressing daily for 7 days. Additionally, MD #1's note indicated the plan of care was discussed with facility staff and patient. Physician's order dated 12/15/21 directed to cleanse Resident #71's left heel ulceration with Dakin's 1/4 Strength, apply Collagen Powder to wound base followed by dry clean dressing daily for 7 days. Interview and review of clinical record with APRN #1 on 12/15/21 at 11:00 AM identified she was asked by LPN #2 to order Podus boots and a skin prep treatment to Resident #71's left heel on 12/3/21 as a preventive measure. Interview and review of the clinical record with LPN #2 on 12/15/21 at 11:15AM identified that on 12/3/21 she observed that Resident #71's left heel was red, soft and unblanchable. LPN #2 identified she informed APRN #1 about her concerns and obtained an order for skin prep treatment to the left heel and to initiate Podus boots. LPN #2 identified that although she documented in a nurse's note that the treatment and boots were ordered, she did not document a description of the left heel. Further, she did not request APRN #1 or an RN assess the area, which she identified she knew she was supposed to do. On 12/6/21, 3 days later, when LPN #2 observed Resident #71's left heel, she identified a dark spot with a moderate amount of serous fluid. LPN #2 informed the DNS, who assessed the left heel which measured 3 cm by 2 cm. The APRN was notified and directed covering the left heel a dry protective dressing until seen by the Wound Consultant the following morning. LPN #2 identified that the Wound Consultant (MD) #1 comes to facility weekly on Tuesdays and assessed Resident #71's heel on 12/7/21. LPN #2 identified that on 12/13/21 when reviewing the TAR she noticed that the change in treatment to Resident #71's left heel, that MD #1 ordered on 12/7/21 directing to clean Resident #71's left heel with Dakin's solution 0.125% (1/4 strength) and apply Silver Alginate to the wound base with a dry, clean dressing (DCD) daily for 7 days had not been transcribed, and skin prep every shift was still being applied. LPN #2 identified she informed the Nursing Supervisor who reviewed MD #1's recommendations from 12/7/21 with the physician on 12/13/21 and obtained and implemented the treatment to clean Resident #71's left heel with Dakin's solution 0.125% (1/4 strength) and apply Silver Alginate to the wound base with a dry, clean dressing (DCD) daily for 7 days at that time (6 days later). Interview with MD #1 on 12/16/21 at 11:45 AM identified he usually has the wound nurse assist him during his weekly assessments, however he did not recall anyone assisting him on 12/7/21. MD #1 identified during his initial assessment on 12/7/21 when he assessed Resident #71's left heel, the wound was identified as an unstageable pressure ulcer and recommended a treatment of Dakin's solution 0.125%, Silver Alginate to wound base with a dry clean dressing every day for 7 days. MD #1 identified he informs nursing staff of his treatment recommendations when the nurse is assisting and also sends his consult via computer the following day, early morning. MD #1 identified that he was not informed by nursing that his treatment recommendation from 12/7/21 were not implemented until 12/13/21, 6 days after his consultation and recommendation. Additionally, MD#1 identified that skin prep treatment, which he recommends only for intact unopened wounds, was not an appropriate treatment for Resident #71's left heel pressure ulcer which was an open wound. Although MD #1 indicated the skin prep treatment was not appropriate for the open left heel pressure ulcer, he indicated the wound had not worsened from his initial assessment on 12/7/21. Interview and review of the clinical record with the DNS and Administrator on 12/16/21 at 1:00 PM identified that the wound consultant company uploads MD #1's consults the morning following his visit to facility. The consults appear in the miscellaneous section of each resident's electronic medical record (EMR). Additionally, a report of all wound consultations is generated for nursing management (DNS, ADNS, Wound Nurse and Unit Managers) for review. Administrator identified that nursing management, specifically the Unit Managers, would be responsible to review and address all recommendations with resident's physician/APRN, and obtain and implement the treatment order. The DNS identified that Resident #71's treatment recommendations from 12/7/21 should have been reviewed and addressed timely, not 6 days after the recommendations were provided, indicating it must have gotten overlooked. Interview with RN #2 (Unit Manager) on 12/20/21 at 10:40 AM identified that she was aware that she needed to assess any new skin areas that LPN's bring to her attention, however was not made aware of Resident #71's red/unblanchable left heel on 12/3/21. Additionally, RN #2 identified that LPN's should document description of the area in a nurses' note, but that she, as the RN, would also need to assess the area and document a note. Review of the facility's policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol identified the nursing staff and attending physician will assess and document individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall describe and document/report a full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.

Based on observation, clinical record review and staff interview for 1 of 12 residents reviewed for medication administration (Resident #92), the facility failed to ensure the medication cart and resident medications were secured. The findings include: Observation on 12/16/21 at 5:59 AM in the hallway of the second floor identified an unlocked and unattended medication cart located in front of a resident's room. Additionally, eight medication cups containing pills were located on top of the medication cart, none of the medications were identified with a room number and a resident name. A total of fourteen medications were noted in the eight medication cups. Further observation noted LPN #1 returned to the medication cart after leaving a resident room. Interview with LPN #1 on 12/16/21 at 5:59 AM indicated that he was leaving the cart unattended and unlocked for a brief amount of time and that although it was his regular practice to pre-pour resident medications, he usually would keep them in the top drawer of the medication cart. LPN #1 further indicated that the reason he did not identify the cups of medications with resident names or room numbers was because he knew who they belonged to and checked with the medication administration record. Interview with RN #1 on 12/16/21 at 7:08 AM indicated that the medication cart should always be locked when unattended and that it was an unsafe practice to leave unattended medications on top of the medication cart because of the number of ambulatory residents living on the unit. Facility policy for Administration Procedures For All Medications identified all medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse. Facility policy for Medication Storage in the Facility identified that mediations are stored safely, securely and properly. The medication supply is accessible to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications.

Based on observation, clinical record review and interview for 1 of 12 residents observed during medication administration (Resident #92) the facility failed to administer medication appropriately therefore causing the medication error rate to be above 5%. The findings include: Observation of LPN #1 during medication preparation and administration for Resident #92 on 12/16/21 at 6:36 AM identified LPN #1 poured Pantoprazole 40 mg (a medication for the treatment of gastro-esophageal reflux disease) into a medication cup. The medication package for Pantoprazole identified do not crush. LPN #1 also poured Nifedipine Extended Release 30 mg (a medication for the treatment of hypertension) and then proceeded to crush both medications and mix them with apple sauce. LPN #1 was then observed proceeding to Resident #92's bedside, checked the identification bracelet and began to administer the applesauce containing the crushed medication until surveyor intervention. Interview with LPN #1 on 12/16/21 at 6:47 AM indicated that he always crushed Pantoprazole and Nifedipine Extended Release medications because that was the way Resident #92 preferred them. Interview with RN #1 and medication review for Resident #92 on 12/16/21 at 7:08 AM indicated that Resident #92 did not have a physician's order for crushing medication and that the pharmacy direction for Nifedipine Extended Release identified do not crush. The crushing of Pantoprazole and Nifedipine for administration, despite being contraindicated caused the facility medication error rate to be 6.67%. Facility policy and procedure for Medication Preparation and Administration identified in part long acting or enteric coated dosage forms should not be crushed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, staff interviews and a review of the facilities policies and procedures for one of two residents reviewed for advanced directives (Resident #91), the facility failed to honor the resident's advance directive and initiated cardiopulmonary resuscitation (CPR). The findings included: Review of the clinical record indicated Resident #91 was admitted to the facility on [DATE] with diagnosis that included coronary artery disease, type two diabetes, schizophrenia, Alzheimer's disease, cerebral infarct and peripheral vascular disease. Review of the resident's code status dated [DATE] indicated; Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Transfer (DNT). The code status further directed no medical tests, antibiotics or artificial administration of fluids and nutrition. Physician's orders dated [DATE] directed do not resuscitate, do not intubate and do not hospitalize. The Minimum Data Set (MDS), dated [DATE] identified moderate cognitive impairment, independent with ambulation, toilet use, bed mobility and transfers. The Resident Care Plan (RCP), dated [DATE] identified a DNR, DNI, and DNT order was in place with interventions that included to activate resident's advance directive as indicated, inform the resident or healthcare decision maker of any change in status or care needs, promote opportunities for the resident or healthcare decision maker to participate in decisions regarding care, provide resident or healthcare decision maker with sufficient information to make an informed decisions, review the advance directives with resident or healthcare decision maker quarterly. Review of the facility documentation indicated on [DATE] at 10:20 PM Resident #91 was found unresponsive, absent respirations and a pulse. Cardiopulmonary resuscitation (CPR), was initiated and after seven minutes of CPR the resident was responsive. Emergency Medical Services (EMS), was notified and transferred Resident #91 to the hospital at 11:00 PM. Interview with RN #1 on [DATE] at 10:30 AM identified she initiated CPR as the resident was unresponsive, breathless and she could not palpate a pulse. RN #1 indicated she failed to check the clinical record to identify the resident's code status prior to performing CPR and she should have. Interview with the Director of Nursing on [DATE] at 1:30 PM indicated it was the responsibility of RN #1 to check the resident's code status prior to initiating CPR and she did not. The facility policy entitled cardiac and/or respiratory arrest directed in part, the facility would perform cardiopulmonary resuscitation on all patients, unless there is a written physician's order, agreed to by the patient or health care decision maker, not to resuscitate in accordance with state regulation/law. The policy further directed if a resident has a DNR order, CPR would not be initiated and advanced life support would not be activated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and review of facility policy and procedure for one of six residents reviewed for nutrition (Resident #82), the facility failed to notify the dietician with a significant weight loss when there was a need to alter the resident's treatment plan. The findings include: Resident #82 was admitted to the facility on [DATE] with diagnoses that included UTI, and dementia. The admission MDS assessment dated [DATE] identified the resident with cognitive impairment, no behaviors were exhibited, required extensive assistance with bed mobility, transfers, toilet use and personal hygiene, independence with eating, a weight of 140 pounds, received a therapeutic mechanically altered diet, a risk for pressure ulcer development and currently no pressure ulcer, no other skin problems identified, utilized a pressure reducing device for the bed and chair. The care plan dated 5/2/19 identified a concern with a nutritional risk related to poor intake. Interventions included to monitor intake at all meals, offer alternative choices as needed, alert the dietician and physician to any decline in intake, weigh per protocol and alert dietician and physician to any significant loss or gain. The weight and vitals summary sheet noted the following weights for Resident # 82: On 4/25/18 a weight of 140.2 pounds was obtained. On 5/6/19 (12 days later) a weight of 135.6 pounds was obtained identifying a 3.28% weight loss in 12 days. On 5/16/19 (10 days later) a weight of 137.2 pounds was obtained. On 5/23/19 a weight 137.5 pounds as obtained. On 6/1/19 (9 days later) a weight of 127 pounds was obtained identifying a 7.64% significant weight loss. Interview and review of the clinical record with the dietician on 7/11/19 at 10:30 A.M. identified all new admissions are to be weighed weekly for 4 weeks, if there are no problems with weight loss/gain the weights will then be obtained on a monthly basis. Additionally, the dietician indicated when there is a 5 pound change from the previous weight a re-weight will be obtained within the next 24 hours. The dietician indicated he/she is in the facility once a week and cannot possibly review all of the residents' weights, he/she depends on the staff to report any weight irregularities. The dietician indicated she/he was not notified when Resident #82 identified 7.64% significant weight loss because if he/she was he/she would have implemented new interventions. Facility policy and procedure obtaining and documenting weights identified all residents are weighed upon admission, weekly for four weeks and monthly thereafter. If a resident's weight is less than or greater than 5 pounds from the previous weight a re-weight will be obtained and the weight will be verified by a licensed nurse to determine accuracy. When a significant weight loss is identified the licensed nurse will notify the dietician of the significant loss and document this in the Point click care progress note. The clinical record failed to reflect the dietician was notified when the resident was identified with a significant weight loss.

Based on clinical record review and interview for one of three residents in the survey sample reviewed for abuse (Resident #40) facility failed to implement policy related to private duty caregivers. The findings include: Resident # 40 diagnosis included Parkinson's and dementia with behaviors. Review of the Reportable Event dated 7/08/19 identified an allegation was made by a resident who verbalized witnessing a private duty aide (PD#1) striking Resident #40. However a subsequent investigation including review of facility hallway video monitoring could not substantiate the allegation. Review of the facility private duty care givers policy identified in part that the duties of a private duty individual who does not possess a license or certification will be limited to providing companionship with the patient. The policy further notes the private duty individual agency was responsible for providing criminal background checks. The policy further identified that an access agreement for private duty caregivers is signed by each private duty individual prior to initiating services. Additional provision of a proof of liability insurance, photo identification, verification of recent physical exam indicating the individual free of infection including negative tuberculosis testing would be provided to the facility administrator and/or Director of Nursing. During an interview and review of facility private duty policy / procedure with the administrator on 7/11/19 at 10:11 A.M. identified she/he was unable to provide any of (PD#1's) documentation from the private duty agency of PD # 1's criminal background check as outlined by the facilities' use of private duty caregiver policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, interview and review of facility policy for one of five residents reviewed for unnecessary medications (Resident # 1), the facility failed to ensure a physician's order for a medication was complete and /or verified to meet professional standards. The findings include: Resident # 1 diagnoses included heart failure, cerebral infarct, dementia without behavioral disturbances, depression, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident # 1 had no cognitive impairment and required extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. The Resident Care Plan (RCP) dated 7/3/19 identified Resident # 1 was at risk for dehydration due to the use of diuretics. Interventions included to administer medications as ordered, to monitor for the effectiveness of the medication, to monitor for side effects of the medication and to report as indicated. A physician's order dated 6/27/19 directed to discontinue Lasix (Diuretic) 20 Milligrams MG every day, to start Lasix 40 MG by mouth every day for three days, then 40 MG alternating with 20 MG by mouth. The physician's order failed to identify the frequency of the alternating Lasix dose. Interview with LPN # 1 on 7/10/19 at 12:00 P.M. identified the Lasix MG that is administered to Resident # 1 is noted as the alternate dose on the Medication Administration Record (MAR) on the day the medication is administered. LPN # 1 further identified he/she is uncertain if he/she has administered the Lasix dose correctly to Resident # 1 and the Lasix order should have been clarified. Subsequent to surveyor inquiry, a physician order dated 7/10/19 directed to administer Lasix 40 MG by mouth alternating with 20 MG by mouth every day starting on 7/11/19. A review of the facility's Oral Medication policy identified medication orders should be verified with the order on the MAR for correct patient, dose, drug, route and time. If discrepancies, notify physician/mid-level provider and/or pharmacy as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews and review of facility policy and procedure for two of six residents reviewed for nutrition (Residents #82 and # 100), the facility failed to complete weekly weights and or re-weights in accordance with facility policy and procedure. The finding included: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses that included UTI, and dementia. The admission MDS assessment dated [DATE] identified the resident with cognitive impairment, no behaviors were exhibited, required extensive assistance with bed mobility, transfers, toilet use and personal hygiene, independence with eating, a weight of 140 pounds, received a therapeutic mechanically altered diet, a risk for pressure ulcer development and currently no pressure ulcer, no other skin problems identified, utilized a pressure reducing device for the bed and chair. The care plan dated 5/2/19 identified a concern with a nutritional risk related to poor intake. Interventions included to monitor intake at all meals, offer alternative choices as needed, alert the dietician and physician to any decline in intake, weigh per protocol and alert dietician and physician to any significant loss or gain. The weight and vitals summary sheet noted the following weights for Resident # 82: On 4/25/18 a weight of 140.2 pounds was obtained. On 5/6/19 (12 days later) a weight of 135.6 pounds was obtained identifying a 3.28% weight loss in 12 days. On 5/16/19 (10 days later) a weight of 137.2 pounds was obtained. On 5/23/19 a weight 137.5 pounds as obtained. On 6/1/19 (9 days later) a weight of 127 pounds was obtained identifying a 7.64% significant weight loss. Interview and review of the clinical record with the dietician on 7/11/19 at 10:30 A.M. identified all new admissions are to be weighed weekly for 4 weeks, if there are no problems with weight loss/gain weights the facility will then obtained weights on a monthly basis. Additionally, the dietician indicated when there is a 5 pound change from the previous weight a re-weight will be obtained within the next 24 hours. The dietician also indicated he/she is in the facility once a week and cannot possibly review all of the residents' weights, he/she depends on the staff to report any weight irregularities. The clinical record failed to reflect weekly weights were conducted and/or re-weights were obtained when there was a noted weight discrepancy in accordance with facility policy and procedure. Facility policy and procedure obtaining and documenting weights identified all residents are weighed upon admission, weekly for four weeks and monthly thereafter. If a resident's weight is less than or greater than 5 pounds from the previous weight a re-weight will be obtained and the weight will be verified by a licensed nurse to determine accuracy. When a significant weight loss is identified the licensed nurse will notify the dietician of the significant loss and document this in the Point click care progress note. The clinical record failed to reflect the dietician was notified when the resident was identified with a significant weight loss. 2. Resident # 100 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, major depressive disorder with psychotic features. The care plan dated 5/21/19 identified a nutritional risk related to weight loss and poor PO intake. Interventions include to provide 4 ounce house supplement BID, monitor weights, and to provide snacks and nourishments between meals. The admission Nutritional assessment dated [DATE] identified a weight of 123.6 pounds, resident with a history of dementia, intakes variable, per nursing resident noted with some refusal of meals. Weight loss not a goal of admission for quality of life/dementia. Resident not consistently meeting nutritional needs related to variable intake. Plan to liberalize diet to regular for additional calories/protein and to promote adequate intake. weight per protocol and alert dietician to significant changes. The physician orders dated 5/23/19 direct to weight every Thursday for 4 weeks. The 14 day MDS assessment dated [DATE] identified the resident with severe cognitive impairment, required extensive assistance with mobility, transfer, and supervision with eating, and indicated the resident received a mechanically altered therapeutic diet. On 6/1/19 Resident #100 was noted with a change in condition with an increase in lethargy, the physician was notified and staff was directed to send the resident to the hospital for an evaluation. Resident #100 was readmitted [DATE] with a readmission weight of 116 pounds. The Nutritional assessment dated [DATE] noted Resident # 100 was not consistently meeting nutritional needs related to variable intake. A weight of 116 pounds was obtained upon admission identifying a 6.3% weight loss. Plan included to liberalize diet to regular, nourishment 2 x day, weekly weights and to supervise/cue/assist with meals as needed. Update dietician with changes. The next weight obtained/documented was noted on 7/3/19 (16 days later) and indicated a weight of 113.9 pounds identifying a continued significant weight loss of 8.2 %. Interview with dietitian and review of clinical records 7/11/19 12:01 P.M. identified a weekly weight was not obtained during the week of 6/23/19 through 6/30/19 .The dietician further indicated continued weight loss was identified on 7/3/19 with a weight of 113.9 pounds signifying an 8.2 % weight loss. Interview with DNS 7/11/19 12:55 PM identified it is the responsibility of the charge nurses to ensure weekly weights are obtained and documented in the clinical record. The DNS indicated the missing weight was an oversite. The facility failed to ensure weights were obtained and documented in accordance with facility policy and procedure. Facility policy and procedure obtaining and documenting weights identified all residents are weighed upon admission, weekly for four weeks and monthly thereafter. If a resident's weight is less than or greater than 5 pounds from the previous weight a re-weight will be obtained and the weight will be verified by a licensed nurse to determine accuracy. When a significant weight loss is identified the licensed nurse will notify the dietician of the significant loss and document this in the Point click care progress note. The clinical record failed to reflect the dietician was notified when the resident was identified with a significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, interviews and review of facility policy for one of five residents reviewed for unnecessary medications (Resident # 1) the facility failed to ensure an antipsychotic medication was administered as directed in the physician's order and/or failed to monitor behaviors of a resident receiving antipsychotic medications. The findings included: 1.a Resident # 1 diagnoses included heart failure, cerebral infarct, and difficulty speaking, dementia without behavioral disturbances, depression, and psychotic disorder with delusions. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 1 had no cognitive impairment, no potential indicators of psychosis, and no behavioral symptoms. The Resident care Plan (RCP) dated 1/16/19 identified Resident # 1 has the potential to demonstrate verbal behaviors. Interventions included to monitor antipsychotic medications for drug toxicity, errors and to monitor Resident # 1's responses to new, changed or discontinued medications. The RCP further identified Resident # 1 was at risk for complications related to the use of psychotropic medications. Interventions included to complete the behavior monitoring flowsheet, monitor for continued need of the medication, and to obtain a psychiatric evaluation as ordered. A physician's order dated 2/27/19 directed to discontinue the daily dose of Abilify (Antipsychotic medication) from 2 MG a day to 1 MG by mouth every day. A psychiatric evaluation dated 3/6/19 identified Resident # 1 was tolerating the decreased dose of Abilify and noted discontinuation of the Abilify would be attempted. A physician's order dated 3/6/19 directed to discontinue the daily dose of Abilify 1MG by mouth. A review of the March 2019 Medication Administration Record (MAR) identified the Abilify was discontinued on 3/6/19 in accordance to physician's orders. However a review of the April 2019 MAR identified Resident # 1 received 1 MG of Abilify from 4/1/19 through 4/6/19 (6 times after the medication was discontinued). The clinical record failed to identify a physician's order that directed to administer Abilify to Resident # 1 from 4/1/19 through 4/6/19. Interview with the DNS on 7/10/19 at 4:00 P.M. identified the DNS was unable to locate a physician's order that directed to administer Abilify to Resident # 1 from 4/1/19 through 4/6/19. The DNS unable to provide an explanation as to why the Abilify had been administered. The DNS further identified he/she would not expect a medication to be administered to a resident without a physician's order. b. A review of the clinical record identified a telephone order dated 4/9/19 entered by RN # 3 that directed to administer 1 MG of Abilify by mouth once a day to Resident # 1 beginning on 4/10/19. A review of the April 2019 MAR failed to identify that Abilify was administered to Resident # 1 from 4/10/19 through 4/30/19. Interview with RN # 3 on 7/11/19 at 10:09 A.M. identified on 4/9/19 Resident # 1 was agitated. RN # 3 indicated she/he discussed Resident # 1's agitation with MD # 1. RN # 3 and MD # 1 reviewed Resident # 1's medication list together. A review of Resident # 1's medication list identified an order for Abilify 1 MG once a day despite having a previous order to discontinue the Abilify. Subsequent to medication review, MD # 1 directed RN # 3 to enter a physician's order to administer 1 MG of Abilify to Resident # 1 once a day. RN # 3 could not provide an explanation as to why Resident # 1 did not receive Abilify from 4/10/19 through 4/30/19. An attempt to reach MD # 1 was unsuccessful. The facility's medication administration policy identified accepted standards of medication administration will be followed. c. Resident # 1 diagnoses included heart failure, cerebral infarct, and difficulty speaking, dementia without behavioral disturbances, depression, and psychotic disorder with delusions. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 1 had no cognitive impairment, no potential indicators of psychosis, and no behavioral symptoms. A physician's progress note dated 3/19/19 at 2:57 P.M. identified a maintenance of dose of Abilify was recommended for Resident # 1 because Resident # 1 was agitated. A review of the March 2019 through July 2019 behavior monitoring sheets failed to identify that Resident # 1 had been monitored for any behaviors including agitation. Interview on 7/10/19 at 12:48 P.M. with LPN # 1 identified Resident # 1 was not being monitored for any behaviors. LPN # 1 further identified Resident # 1 should have been monitored for behaviors. However, LPN was unable to provide an explanation as to why the resident's behavior was not monitored. A review of the facility's psychotropic medication use policy identified facility staff should monitor the resident's behavior pursuant to facility policy using a behavioral assessment record for resident's receiving psychotropic medication for organic mental syndrome with agitated or psychotic behaviors.

Based on observation, interviews and review of facility policy for one of two medication rooms (second floor) and/or one of two medication carts (Cathedral unit) reviewed for medication storage, the facility failed to store medications that required refrigeration in the refrigerator, and/or failed to monitor temperatures of medication refrigerators according to facility policy and/or failed to store medications in accordance with manufacturer recommendations. The findings included: 1. Observation of the medication room on the second floor and with LPN # 1 on 7/9/19 at 10:55 A.M. identified a tray of medications outside the medication refrigerator. The thermometer in the tray of medications identified of reading of greater than 80 degrees Fahrenheit. The tray contained the following medications: a. Avonex for Resident # 63 b. Xalatan eye drops for Resident # 91 c. Xalatan eye drops for Resident # 8 d. Ceftriaxone for Resident # 47 e. One opened vial of Tuberculin Purified Protein Derivative dated 5/23/19 f. One un-opened vial of Tuberculin Purified Protein Derivative g. Three vials of PPV 23 h. Opened undated vial of 1% Lidocaine 10 milligrams/milliliter i. Twelve 650 milligram Acetaminophen suppositories j. Prolia 60 milligrams/milliliter k. Six Influenza vaccines Interview and observation with LPN # 1 on 7/9/19 at 10:55 A.M. identified all the medications in the tray were warm to touch. LPN # 1 identified all medications in the tray required refrigeration. LPN # 1 further identified he/she was unaware that the medications were not refrigerated and was unable to provide an explanation as to why the medications were not refrigerated. Subsequent to surveyor inquiry, all of the medications were discarded and an order to replace the medications was submitted to the pharmacy. A review of the facility's medication storage policy identified medications that require refrigeration should be stored between 36-46 degrees Fahrenheit. 2. A review of the April 2019 through July 2019 second floor medication refrigerator temperature logs identified the following: a. When medication refrigerator temperatures were documented, they were documented only once a day. b. On the days that the temperature of the medication refrigerator was outside the recommended range of 36-46 degrees Fahrenheit, no corrective action and/or additional monitoring was documented. c. The temperature of the medication refrigerator was not monitored for twenty of thirty days in June 2019. d. The temperature of medication refrigerator was not monitored for five of the eight days from 7/1/19 through 7/8/19. Interview with LPN # 1 on 7/9/19 at 10:55 A.M. identified it is the responsibility of the night supervisor to document the temperature of medication refrigerators. LPN # 1 further identified he/she was unaware that medication refrigerator temperatures should be monitored twice a day. Attempts to reach two night supervisors were unsuccessful. Interview on 7/11/19 at 9:54 A.M. with the Clinical Quality Specialist identified the temperature of any medication refrigerator that is used to store vaccines should be monitored twice a day by the nursing staff. A review of the facility's medication storage policy identified facility staff should monitor the temperature of vaccines twice a day. 3. Observation with LPN # 2 on 7/9/19 at 11:15 AM identified the following: a. An unopened box of Latanoprost 0.005% eye drops for Resident # 91 with a pink sticker that identified the eye drops should be refrigerated until opened. b. Two opened bottles of Latanprost 0.005% eye drops for Resident # 8. One box did not identify the date it was opened and the other was dated 5/1/19. c. An opened Novolog flex pen (insulin) that did not identify the date opened. A review of the package insert for Latanprost 0.005% eye drops identified un-opened bottles should be stored under refrigeration at 36-46 degrees Fahrenheit. Once a bottle is opened for use it may be stored at room temperature for six weeks. Interview on 7/9/19 at 11:15 A.M. with LPN # 2 identified he/ she forgot to date the Novolog pen when she/he opened it on 7/8/19. LPN # 2 further identified the Novolog pen is good for 28 days once opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of facility policy and procedure reviewed for the facility infection control program, the facility failed to implement transmission based precautions with a resident identified with an MDRO. The findings include: Resident #82's diagnoses included Urinary Tract Infection (UTI), with Extended Spectrum Beta-Lactamase (ESBL) in the urine. The urinalysis and culture and sensitivity test dated 7/4/19 and reported 7/6/19 identified Resident #82's urine was positive for ESBL. Observations on 7/8/19 and 7/9/19 identified Resident #82 resided in room [ROOM NUMBER] a semiprivate room with a roommate. Observations on 7/10/19 identified Resident #82 was moved to a private room. Interview with LPN # 4 on 7/10/19 at time of the observation identified Resident #82 was moved to a private room due to a urine culture testing positive for ESBL. Interview and review of the laboratory sheet with the DNS on 7/11/19 at 2:00 P.M. identified Resident #82 had Urine Analysis (U/A) and Culture and Sensitivity Test on 7/4/19. The facility was notified of the results on 7/6/19. The DNS identified when the facility was notified of the U/A results of Resident #82 on 7/6/10 the resident should have been placed on transmission based precautions. The facility failed to implement transmission based precautions in a timely manner with a resident identified with an MDRO.

Based on observations, facility documentation, facility policy, and interviews and reviewed for dietary services, the facility failed to ensure food item temperatures were obtained and monitored prior to serving foods from the steam table and/or failed to ensure proper chemical sanitization levels of three-bay-sink were obtained and monitored, and/or failed to ensure dishwasher wash and rinse temperatures were obtained and monitored and/or for 1 of 2 nourishment rooms observed, the facility failed to maintain the nourishment room refrigerator in a clean manner to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. The findings included: 1. Interview with the Dietary Director and observation on 7/08/19 8:14 A.M. during the initial tour identified the three-compartment sink log and the dishwasher temperature log were not completed for the breakfast and lunch periods on July 5, and 6, 2019 and was not completed for all three meals on July 7, 2019. Interview with [NAME] #1 on 7/08/19 08:24 A.M. identified he/she did not record the food temperatures on July 5, 6, and July 7, 2019 because the log book was missing. Interview with the Dietary Director on 7/9/19 at 1:15 P.M. identified no one knew who was responsible for recording/monitoring of the food temperatures and/or 3 bay sink chemical sanitation levels and/or recording/monitoring of the dishwasher/rinse temperatures. Although, the facility does not have a written policy for obtaining/recording/monitoring the 3 bay sink, chemical sanitation levels and/or dishwashing temperature and/or food temperature, the expectation is all staff are in-serviced to monitor and document dish washer/rinse temperature, food temperature and chemical sanitation findings. 2 .Observation on 7/8/19 at 7:30 A.M. of the 2nd floor nourishment room refrigerator noted the refrigerator to be soiled with dried up spilled juice and dried on food particles scattered on the first and second shelves. The tops of all (4) of the plastic juice containers were noted with a buildup of a gray sticky substance related to the use of the labeling stickers. Interview and review of the nourishment room with the Administrator on 7/8/19 at 7:45 A.M. identified it is the responsibility of the dietary department to ensure the nourishment room refrigerators are maintained in a clean and sanitary manner. Subsequent to surveyor inquiry, the refrigerator and plastic juice containers were cleaned.

Based on observations, review of facility documentation and interview, the facility failed to ensure that residents had personal identification and /or ensure that facility staff received yearly competencies. The findings included: During observation of morning medication administration with LPN #3 on 7/09/19 from 10:01 A.M. through 10:37 A.M., LPN#3 was noted to administer medications to Residents# 3, #28 and #52 without the benefit of checking the resident's identification. Further inquiry by the surveyor identified that the residents had no identification on his/her person. Subsequent observations and/or sampling with the Staff Development Nurse (SD) RN#2 on 7/9/19 at 10:55 A.M. identified that Residents #10, #4, #30, #75, #97, #12, #29, # 83, #76 and #2 were all without the benefit of patient identification on his/her person. 2. During an interview and review of the facility Intravenous Therapy (IV) program on 7/10/19 at 12:07 P.M. with the Infection Control Nurse (ICN) RN#2 identified she/he was unable to provide documentation that yearly competencies and/or in-service education and/or evaluation of all personnel who provide care to residents who utilized IV therapy.