**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in a dignified manner. The findings include: Resident #1 was admitted with diagnoses that included borderline personality disorder and depression. A quarterly MDS assessment dated [DATE] identified Resident #1 was alert and oriented, was dependent for transfer with a Hoyer lift to a customized motorized wheelchair, maximal assistance for bed mobility, and had an indwelling urinary catheter. The RCP dated 3/21/2024 identified a risk for distress related to limitations leading to initiating conflicts with staff. Interventions directed to monitor anxiety, anticipate and meet needs, explain care, and allow time to answer questions and verbalize feelings. Review of an audio recording dated 5/14/2024 identified a staff member was providing care to Resident #1 and Resident #1 called NA #3 by his/her first name. The conversation between NA #3 and Resident #1 began at approximately 1 minute and 30 seconds into the recording, and was a loud and emotional sounding exchange. Resident #1 complained of pain, was moaning, and telling NA #3 that she was a terrible NA. Resident #1 told NA #3 to wait to provide care as he/she had to wash the bedside table prior to the staff starting care. NA #3 questioned that Resident #1was not ready, and Resident #1 responded he/she did not have to be ready because NA #3 was late. NA #3 responded that Resident #1 had plenty of time to be ready prior to the staff member's entry into Resident #1's room, stating that they could have been done already (if she didn't have to wait). Resident #1 responded back that he/she did not need to do it ahead of time and continued to complete the task. Care began to be provided with Resident #1 directing the correct way to place the brief under him/her at 2 minutes 40 seconds into the audio. Resident #1 requested that the pad under him/her be checked as he/she believed it to be wet, stating if it was wet it needed to be changed and both briefs were wet, and the bed linen seemed damp. NA #3 responded to Resident #1 in a loud tone that sounded aggravated, saying, Come on, let's go, Jesus Christ at the 3 minutes, 30 seconds mark on the recording. NA #3 continued to provide care and Resident #1 directed NA #3 to change her gloves. NA #3 responded with a tense sounding voice, I know, I know, stay on your side please. Resident #1 responded that he/she only can use one (1) hand to hold his/herself over asking who else was in the room helping NA #3. NA #3 responded loudly Who do you want, stated two (2) other NA names, stated they were not coming into Resident #1's room, and stated they don't like you and they took care of you the other night (6 minutes, 3 seconds). Resident #1 directed loudly to NA #1 to change her gown and NA #3 responded loudly, I did. Resident #1 directed NA #3 loudly to fix my foot and change your gloves with NA #3 responding loudly, I did. Resident #1 then told NA #3 to move to another floor with NA responding, who is going to do you then? and Resident #1 identified another NA and stated, I don't like you. NA #3 responded You don't like me? continuing to respond to the Resident #1's negative about her. NA #3 moved on to empty Resident #1's foley bag with Resident #1 providing direction and NA #3 responding that she was doing it correctly arguing with Resident #1 in a loud voice, and Resident #1 continued to become more agitated using increasingly foul language and berating NA #3. NA #3 left room said goodbye and left the room at the 12 minute mark. A facility reportable event form dated 5/17/2024 at 3:30 PM identified an allegation of staff to resident abuse without injury. Resident #1 identified that he/she had a recording of NA #3 who told her that NA #3 did not like him/her and that it was abuse. A facility summary dated 5/19/2024 identified after an investigation, the allegation was not substantiated. Interview with the ADNS on 6/3/2024 at 1:30 PM identified should not change Resident #1's self-directed schedule as it can cause his/her behaviors to escalate; staff should work through his/her care is to address needs as per resident preferences. The ADNS stated, subsequent to the allegation reported on 5/17/2024, the plan of care was updated to direct two (2) staff members to be in the resident's room when providing care. Interview with the Administrator on 6/3/2024 at 2:00 PM identified on 5/17/2024 when she became aware of the recording, she spoke with Resident #1 and Resident #1 no longer had access to the recording for the Administrator to hear. The Administrator stated she investigated the allegation made on 5/17/2024, was unable to substantiate an allegation of abuse, and indicated staff should treat residents with respect and dignity. Although attempted, interviews with NA #3 and the DON were unable to be completed during the survey. The facility Residents' [NAME] of Rights Policy, directed in part, that residents have the right to be treated with consideration, respect and full recognition of your dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for weight loss, the facility failed to ensure significant weight loss was reported to the responsible party in a timely manner. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required supervision with set up assist with eating. A Resident Care Plan dated 5/9/23 identified Resident #1 had a potential for nutritional deficit related to advanced age, variable intake and non-compliance with therapy with interventions that directed to monitor weights as ordered, report significant changes to the Dietitian and physician and monitor labs reporting abnormal (levels) to the physician. The weight record dated 7/1/23 identified Resident #1 had a significant weight loss of 20.4 pounds (lbs.) between 6/1/23 and 7/1/23. A Dietitian progress note dated 7/5/23 identified Resident #1 experienced a significant 5% weight loss from 150.4 lbs to 131 lbs. noting Resident #1 was within h/her desired weight range. An Advance Practice Registered Nurse note dated 7/11/23 identified Resident #1 was being evaluated due to decreased weight and appetite. Resident #1's weight decreased from 151.4 lbs. to 131 lbs. in a month with decreased oral intake variably 51%-75%. Weight loss discussed with the dietitian and recommended to monitor weekly weights and increase nutritional supplements. A plan was in place to meet with the responsible party related to decreased weight. A review of the nursing, APRN and dietitian progress notes dated 7/11/23 through 8/3/23 did not identify the responsible party had been notified of the significant weight loss. A Care Plan progress note dated 8/3/23 failed to identify a documented discussion related to Resident #1's significant weight loss. An interview with the Dietitian on 11/7/23 at 12:30 PM identified Resident #1 had experienced significant weight loss between 6/1/23 and 7/1/23 of approximately 20 lbs. Resident #1 was previously obese but was then within a desired weight range. The Dietitian did not notify the responsible party of the weight loss as she thought it was the responsibility of the nursing staff to notify the responsible party. The Dietitian stated she recently understood it to be part of her role. An interview with the Director of Nursing on 11/9/23 at 3:30 PM identified she would expect the dietitian to notify the responsible party of weight significant weight changes and then discuss a plan with the interdisciplinary team to address the concern. A review of the facility policy for unplanned weight loss directed to discuss with the resident and family about nutritional goals following any unplanned weight loss. A review of the Dietitian job description identified the Dietitian collaborates with the resident /family member and health care team to assess nutrition and nutrition education needs of the resident.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to ensure an allegation of abuse was thoroughly investigated. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The baseline Resident Care Plan dated 12/28/22 identified Resident #1 had impaired cognitive function and was at risk to be a victim of abuse, neglect, or mistreatment in a congregate setting interventions directed to anticipate needs and monitor mood and behavior and provide early interventions. A social worker Plan of Care note dated 8/3/23 (initiation date 1/24/23) identified Resident #1 was accusing staff of physical abuse. A review of the nursing, Advanced Practice Progress notes dated 1/22/23 through 1/25/23 did not include a documented account of the incident. An interview with the Director of Nursing and review of the facility documentation on 11/9/23 at 2:30 PM did not identify a documented investigation regarding the incident. An interview with the Director of Nursing on 11/9/23 at 2:40 PM identified that although she was not employed at the facility at the time of the incident, however, any allegation of abuse should be investigated. An interview with (the former) Social Worker, SW #1 on 11/16/23 at 12:50 PM identified the responsible party of Resident #1 had alleged abuse but was never able to provide any specific details. While SW #1 indicated the allegation was investigated he was unable to explain why there was no documentation detailing the event or investigation. A review of the abuse policy dated 10/2022 directed that the facility immediately commence an investigation following an allegation of abuse and submit findings to the Administrator and other state officials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure the care plan was updated resident known to have frequently exhibited behaviors. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required assistance with bed mobility and transfers. The Resident Care Plan dated 2/8/23 identified Resident #1 had impaired cognitive function, required assistance with activities of daily living (ADL) and was at risk for falls with interventions that directed to anticipate needs, provide one person assist with bed mobility and provide two quarter side rails while in bed. An Advanced Practice Registered Nurse Note dated 2/23/23 at 8:15 PM identified at 2:00 PM, Resident #1 experienced a fall and sustained a 4 centimeter (cm) laceration between the left thumb and first digit. A pressure dressing was applied and resident #1 was transferred to an outside hospital for evaluation of the wound. Hospital Patient information details notes dated 2/23/23 identified Resident #1's was evaluated following a fall out of bed at the facility. A wound along the left hand was closed with seven (7) sutures. Recommendations were made to remove sutures within 7-10 days. A facility Reportable Event dated 2/23/23 at 2:20 PM identified Resident #1 was observed laying on the left side on the floor mat in h/her room. Resident #1 was combative during transfer from floor to bed. While in bed Resident #1 attempted to get out of bed again and was assisted to h/her wheelchair and brought to the nursing station. A laceration to the left hand was observed between the left thumb and left index finger. The laceration was cleansed with normal saline and dressed. Resident #1 transferred to hospital for evaluation. Seven (7) sutures were applied to the left-hand laceration. Resident #1 was holding on the side rails and the wheelchair handles during transfers and had fragile skin. The care plan was revised to include the application of lambskin to wheelchair handles and padding to the side rails. An interview with Nurse Aide, NA #1 on 11/9/23 at 11:26 AM and 11/9/23 at 2:18 PM identified she had worked the 7:00 AM to 3:00 PM shift on 2/23/23 when the unwitnessed fall occurred. NA #1 could not recall the details but did remember Resident #1 as having blood on h/her hand when NA #1 first observed h/her on the floor next to h/her bed. NA #1 indicated Resident #1 had previously exhibited behaviors including grabbing at the bed rails and wheelchair handles prior to 2/23/23 to assist in moving around. An interview with the Assistant Director of Nursing (ADON) on 11/9/23 at 2:07 PM identified Resident #1 was known to flail arms and grab at the bed/wheelchair rails prior to 2/23/23. The ADON indicated it occurred to her to have the padding placed on the bed rails and wheelchair after Resident #1 sustained the injury. An interview with the Director of Nursing on 11/9/23 at 3:30 PM identified she would expect interventions be in place as a preventive measure to reduce the risk of injury for a resident who exhibited behaviors that included grabbing at the bed rails and wheelchair handles. Review of facility Care Plan Process Policy identified the care plan are developed by the interdisciplinary team for a comprehensive care plan to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho-social well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a accidents and weight loss, the facility failed to ensure suture removal was completed timely, and to ensure that physicians orders were followed for bloodwork. The findings include: Resident #1's diagnoses included essential hypertension, congestive heart failure and history of metabolic encephalopathy. 1) The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required assistance with bed mobility and transfers. a) The Resident Care Plan dated 2/8/23 identified Resident #1 had impaired cognitive function, required assistance with activities of daily living (ADL) and was at risk for falls with interventions that directed to anticipate needs, provide one person assist with bed mobility and provide two quarter side rails while in bed. An Advanced Practice Registered Nurse Note dated 2/23/23 at 8:15 PM identified at 2:00 PM, Resident #1 experienced a fall and sustained a four (4) centimeter (cm) laceration between the left thumb and first digit. A pressure dressing was applied and resident #1 was transferred to an outside hospital for evaluation of the wound. The post Patient Visitation Information dated 2/23/23 identified Resident #1 was evaluated following a fall at the facility seven (7) sutures were placed along the left hand with suture removal in 7-10 days. An Advanced Practice Registered Nurse (APRN) progress note dated 4/5/23 Resident #1 became combative with attempts to remove (7) sutures from the left hand (40 days after sutures were placed at the hospital). The responsible party came in and the sutures were removed difficulty. An interview with APRN #1 on 11/7/23 at 12:02 PM identified she had previously attempted to remove the sutures but was only able to remove (2) due to Resident #1 being resistive to care. On 4/5/23 the Responsible party was called in and the APRN #1 was able to remove the remainder of the sutures. APRN #1 indicated she could have explored alternative interventions to ensure Resident #1's sutures were removed timely according to hospital recommendations. The facility did not have a policy on suture removal. b) The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment required supervision with set up assist with eating. The Resident Care Plan dated 5/9/23 identified Resident #1 had a potential for nutritional deficit related to advanced age, variable intake and non-compliance with therapies with interventions directed monitor weight as ordered, report significant changes to the Dietitian and physician and monitor labs reporting abnormal (levels) to the physician. The weight record dated 7/1/23 identified Resident #1 had a significant weight loss of 20.4 pounds (lbs.) between 6/1/23 and 7/1/23. A Dietitian progress note dated 7/5/23 identified Resident #1 experienced a significant 5% weight loss from 150.4 lbs. to 131 lbs. noting Resident #1 was within h/her desired weight range. An Advance Practice Registered Nurse note dated 7/11/23 identified Resident #1 was being evaluated due to decreased weight and appetite. Resident #1's weight decreased from 151.4 lbs. to 131 lbs. within a month with decreased oral intake variably 51%-75%. The weight loss discussed with the dietitian and recommended to monitor weekly weights and increase nutritional supplements. A plan was in place to meet with the responsible party related to decreased weight. A nutritional assessment dated [DATE] identified Resident #1 was consuming at least 50% of most meals and documented as taking supplements. A request was made for a basic metabolic profile or BMP (measures chemistry of blood), complete blood count or CBC (measures properties of blood, prealbumin (protein from the liver that determines if there is enough nutrition in the diet) and, thyroid stimulating hormone or TSH (measures thyroid hormones). Physician's orders dated 7/17/23 directed laboratory (lab) diagnostic testing including BMP, CBC, prealbumin and TSH. A subsequent physician's order dated 8/4/23 directed CMP, CBC, Prealbumin, TSH. A review of the clinical record did not identify that labs were obtained as ordered on 7/17 and 8/4/23. An interview with APRN #1 on 11/9/23 at 11:56 AM identified she she had ordered labs after learning of Resident #1's significant weight loss and they were not obtained and likely re-ordered the labs after learning they were not obtained. APRN #1 stated she spoke with staff about this issue and was not clear whether Resident #1 had refused the testing or that it was not done. There was no documented follow up regarding the labs in the APRN progress notes. An interview with the Director of Nursing on 11/9/23 at 3:30 PM identified she had verified with the contracted lab services that the lab testing ordered on 7/17/23 and 8/4/23 were not obtained. The DNS indicated she would expect that if it were a case where Resident #1 refused, she would expect the nurse to notify the supervisor, reapproach and document efforts in the clinical record. A review of the facility policy for weight loss directed for any unplanned weight loss recommendations would be made for pertinent lab testing including a thyroid panel, CBC, and BMP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to ensure that a resident who required feeding assistance was treated in a dignified manner during a meal. The findings include: Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia with agitation, muscle weakness. A physician's order dated 2/13/23 directed Resident #103 required a mechanically soft, thin diet. The care plan dated 2/14/23 identified Resident #103 had a potential risk of choking/aspiration. Interventions included encouraging the resident to eat slowly, and chew food thoroughly. The care plan also identified Resident #103 was at risk for nutritional deficit due to impaired cognition and a mechanically altered diet. The interventions included monitoring for chewing difficulty, swallowing, and choking. The care plan also identified Resident #103 had impaired cognitive function related to dementia. The interventions included to anticipate the resident's needs and provide care. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of 1 to 2 staff members with transfers, dressing, eating and toilet use. The nurse aide care card dated 9/14/23 identified Resident #103 had multiple safety risks which included a risk of aspiration/choking. The care card identified Resident #103 required tray set up and observation and exhibited difficulty chewing and/or swallowing. Observation on 9/15/23 beginning at 9:05 AM identified Resident #103's breakfast tray was located in his/her room on the bedside table. Further, the bedside table was positioned approximately 18 inches away from the foot of Resident #103's bed. The breakfast items were observed to be inside of a paper restaurant take out style box and placed on a plastic tray. The breakfast box appeared untouched, and Resident #103 was observed sleeping in his/her bed. The meal ticket located on Resident #103's tray identified he/she was an aspiration risk. During this observation, NA #3 was also observed at the opposite end of the unit delivering meal trays to residents on the unit. A constant observation of Resident #103's meal tray between 9:05 AM - 9:15 AM identified the meal tray remained in the resident's room and no staff entered the room to assist Resident #103 with his/her meal. Observation at 9:15AM identified Resident #103 was awake, and NA #3 then entered Resident #103 and identified that Resident #103's meal was in his/her room, and she was there to assist with the meal. At 9:17 AM, LPN #3 entered Resident #103's room to help reposition Resident #103 to an upright position to eat. At 9:19 AM, NA #3 brought Resident #103's meal tray next to his/her bed and at 9:20 AM NA #3 was observed assisting Resident #103 with his/her meal. Observation at 9:27 AM identified Resident #103 had completed his/her breakfast and consumed 100% of his/her meal. Interview with NA #3 on 9/15/23 at 9:37 AM identified she delivered Resident #103's tray to his/her room, but since Resident #103 required feeding assistance she left the tray in the room and continued to deliver meal trays until all the residents on the unit had their trays. NA #3 identified that once the residents on the unit had their meals, she then came back to provide Resident #103 feeding assistance with his/her meal. When asked why she left the meal tray in the resident's room when Resident #4 had an identified risk of falls and required feeding assistance, NA #3 reiterated she planned to return to Resident #103's room after she delivered the rest of the unit's meal trays. NA #3 also identified Resident #103 was a fall risk and that he/she always tries to get up, we have to get him/her out of bed, cleaned up, dressed and then he/she is placed in the hallway by the nurse's station during the day so we can always keep an eye on him/her. Interview with LPN #3 on 9/15/23 at 9:40 AM identified that Resident #103's meal should have remained in the food cart until NA #3 was able to provide feeding assistance. LPN #3 identified Resident #103 was at risk for aspiration which is why he/she required feeding assistance, and also had a history of multiple falls due to attempts to try to stand. LPN #3 identified that the policy of the facility was that any residents who required feeding assistance should not have their meals delivered until a staff member was available to assist the resident. Interview with the ADNS on 9/15/23 at 10:50 AM identified that Resident #103's meal tray should not have been delivered to his/her room until a staff member was able to provide feeding assistance at the time of the delivery, and the meal tray should not be in the room for 10 minutes. The ADNS identified that the facility dishwasher had malfunctioned and that resident meals were currently being delivered in paper containers as a result. The ADNS further identified that delivering Resident #103's meal prior to any staff being able to provide feeding assistance would also allow the meal to be cold by the time the food was offered to Resident #103. The ADNS further identified that Resident #103 was at risk for falls and that the meal tray in the room was a hazard risk as Resident #103 could have attempted to try to get up to retrieve it from the bedside table. The facility policy on Resident Rights directed that all residents of the facility had the right to a dignified existence with full consideration and courtesy in treatment and care of their personal needs. The facility policy on Meal Service-Assistance of Residents directed that residents who were unable to feed themselves or required assistance to finish meals would be served and assisted with their meals. The policy further directed that the CNA/Nurse would inform the resident of mealtime and assist the resident with positioning before the meal. The facility policy on Activities of Daily Living (ADLs) identified that residents of the facility would be provided the necessary care and support in all ADLs consistent with the resident's need and ability to perform ADLs, and that ADLs included eating meals and snacks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #277) reviewed for choices, the facility failed to ensure resident was receiving showers. The findings Resident #277 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, repeated falls, anemia, and hypertension. A physician's order dated 3/16/23 directed the resident out of bed to a high back wheelchair with pressure relieving cushion, and bilateral elevating leg rests via mechanical. The significant change of condition MDS dated [DATE] identified Resident #277 had intact cognition and required extensive assistance with care. Additionally, it was very important to Resident #277 to choose clothes to wear each day, choose between a tub bath or shower, participate in group activities, and go outside to get fresh air when the weather is good. The care plan dated 7/6/23 identified the resident required total 2 person assistance via mechanical lift for transfers. Interventions for bathing were not identified. Review of a census sheet identified that Resident #277 had changed units on 7/19/23. Review of progress notes dated 7/19/23 - 9/15/23 did not reflect the resident had refused showers or to get out of bed. Interview with Resident #277 on at 9/12/23 at 10:45 AM indicated he/she has not had a shower since he/she was admitted to this facility 6 months ago. Resident #277 indicated he/she could not stand to take a shower and that was why he/she had not received a shower. Resident #277 indicated the nursing staff come in and wash him/her up in bed and never offered a shower. Resident #277 indicated he did not realize he/she could get a shower because the nursing staff never informed him/her that there was a chair that goes into a shower room where he/she could get a shower. Resident #277 indicated he/she would love to take a shower and had never refused to take a shower. Resident #277 indicated he/she took showers daily at home prior to falling and breaking his/her hip. Observation on 9/13/23 at 9:20 AM and 11:40 AM resident was lying in bed watching television. Observation on 9/14/23 at 7:30 AM and 9:20 AM resident lying in bed watching television. Observation on 9/15/23 at 7:45 AM Resident #277 was lying in bed watching television. Interview with Resident #277 indicated the nursing staff still have not offered him/her a shower. Interview with LPN #1 on 9/15/23 at 7:52 AM indicated she does not recall seeing Resident #277 take a shower. LPN #1 indicated he/she does not get out of bed at all and is always in bed watching television. LPN #1 indicated Resident #277 had a hip replacement, so he/she stays in bed. LPN #1 indicated she had not discussed with Resident #277 about taking a shower, she just knows the nursing assistant gives him/her a bed bath. Interview NA #2 on 9/15/23 at 7:59 AM indicated when staff put him/her in the chair, Resident #277 would slide in the chair, so the nurse, LPN #2,s charge nurse (full time) instructed me not to get Resident #277 up so Resident #277 doesn't fall. NA #2 indicated she gives Resident #277 a bed bath on Tuesdays and Thursdays day shift based on the shower schedule. NA #2 indicated Resident #277 needed the long shower chair because he/she would slide. NA #2 indicated since the resident has been on this unit, he/she has not been in the shower. NA #2 indicated she does not offer Resident #277 a shower because since Resident #277 was transferred to this unit, there was not a long shower chair with leg extender to provide a shower. NA #2 indicated she was waiting for a safe shower chair with the leg extender because Resident #277 was tall and slides before she will give him/her a shower. Interview with LPN #1 on 9/15/23 at 8:30 AM indicated she was aware the nurse aides were giving bed baths instead of showers because there wasn't the right shower chair for Resident#277 to take a shower safely. LPN #1 indicated Resident #277 does not refuse a shower but if he/she did she would document it in the progress notes. LPN #1 indicated she was aware that he/she was getting bed baths and not showers but she is only on this floor a couple days a week, so she thought that was just normal for Resident #277 and not a problem. LPN #1 indicated she had not asked Resident #277 if he/she wanted a shower on the days she works on the unit. Interview with NA #2 on 9/15/23 at 9:17 AM indicated the long shower chair with the leg extender had been found. NA #2 indicated she will give Resident #277 a shower today. Interview with the ADNS on 9/15/23 at 10:05 AM indicated Resident #277 has a problem with the alignment of the hip, it was not right. The ADNS indicated on admission all residents get a shower the first 2 days in the facility, then are scheduled for showers twice a week. The ADNS indicated if a resident refuses the charge nurse must document it in the progress notes. The ADNS indicated if Resident #277 was unable to sit up or too tall for a standard shower chair the charge nurse would have to report it to rehabilitation. The ADNS indicated she was not aware Resident #277 was not getting showers and she was not aware that they did not have the proper shower chair. Interview with MD #1 on 9/15/23 at 10:30 AM indicated all residents in the facility should have a shower at least weekly for cleanliness and to prevent skin breakdown. MD #1 indicated if a resident does not get a shower regularly a resident could get a yeast infection or bacteria which could build up on the skin and causes infections. MD #1 indicated if Resident #277 needed a longer chair than the standard shower chair and it was the facility's responsibility to get one in a reasonable amount of time. Interview with the Rehab Director on 9/15/23 at 11:20 AM indicated the rehab department was not notified of any issues of Resident #277 needing a special shower chair. Interview on LPN #2 on 9/15/23 at 5:26 PM indicated Resident #277 had only been on the unit for a short period of time. LPN #2 indicated Resident #277 when he/she first came on the unit used to complain of pain in the left hip. LPN #2 indicated she was not aware that Resident #277 had not received a shower since being transferred to her unit. LPN #2 indicated she was the first shift full time nurse on this unit. LPN #2 indicated Resident #277 was on the schedule for showers twice a week. LPN #2 indicated the nurse aides did not report that Resident #277 had ever refused a shower. LPN #2 indicated if Resident #277 had refused a shower it would be documented in the progress notes. LPN #2 indicated Resident #277 was a tall person and she just knew that the nurse aide gave Resident #277 bed baths but did not ask why. LPN #2 indicated she had not spoken directly with Resident #277 as to whether or not he/she wanted a shower. LPN #2 indicated Resident #277 never asked for a shower when she brings in his/her medications. Interview with Resident # 277 on 9/15/23 at 6:00 PM indicated he had a shower this morning and he/she enjoyed it. Resident #277 said he enjoyed having his first shower since being at the facility. Review of the facility Activities of Daily Living (ADL) identified the facility would provide the necessary care and services based on the comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences, to maintain or improve, the resident's ability to perform ADL's and to prevent decline unless it's unavoidable. Unless otherwise specified, all residents shall be expected to bath/shower at least twice per week. A shower schedule is established upon admission and readmission. When a resident refuses to comply with ADL activities and schedules, nursing staff shall solicit assistance from other disciplines to determine cause of refusal, offer other options and alternatives, informing the resident of the risks to self and others and document refusal in the medical chart in the progress notes and the care plan. Review of the facility showers policy identified it was the policy of the facility that each resident is to have a minimum of 2 bath/showers each week including shampoos. Residents will be bathed more often as needed in order to promote cleanliness and comfort. The purpose is to maintain cleanliness and observe the skin condition of residents. Also, to promote comfort and improve circulation. The charge nurse was responsible to ensure all residents in assigned unit have scheduled shower days and monitors the provision of resident's showers on the assigned days. The charge nurse will interview residents and determine the reason for any resident refusal and makes necessary adjustments and referrals. The DNS was responsible for ensuring compliance to this policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 2 of 4 residents (Resident #45) reviewed for vital signs, the facility failed to notify the physician when the residents blood pressure was elevated on 3 occasions, and for the only sampled resident (Resident #54) reviewed for dialysis, the facility failed to notify the physician when the resident's blood pressures were elevated, and for 1 of 3 residents (Resident #87) reviewed for antipsychotic medications, the facility failed to ensure resident representative was notified when a new medication was started, and for 1 resident (Resident #103) reviewed for nutrition, the facility failed to ensure that the physician and resident representative were notified of a significant unplanned weight loss in a timely manner. The findings include: 1. Resident #45 was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease stage 4, type 2 diabetes and major depressive disorder. The annual MDS date 6/9/23 identified Resident #45 had intact cognition, required extensive assistance for bed mobility, dressing and toileting, supervision for transferring and personal hygiene and was independent with eating. Further, it identified Resident #45 had diagnoses of congestive heart failure, atrial fibrillation, anxiety disorder and depression and utilized a wheelchair for mobility. The care plan dated 7/6/23 identified a focus on altered respiratory status with interventions that included provide immediate assistance as needed for signs and symptoms of distress, administer oxygen, raise head, check vital signs and oxygen saturation and notify the physician. Physician's monthly orders dated September 2023 directed to check blood pressure, heart rate and temperature every shift for hypertension. Review of the clinical record with the ADNS on 9/15/23 at 8:40 AM identified Resident #45 had elevated blood pressures on the following dates (normal range 120/80). 6/26/23 at 3:04 PM, 155/94. 8/15/23 at 6:55 PM, 174/96. 8/29/23 at 7:59 AM, 166/91. The clinical record failed to reflect that the blood pressure had been rechecked, or that the physician had been made aware. Interview and review of the clinical record with the Medical Director on 9/15/23 at 10:10 AM identified it is his expectation that he or the APRN be notified of elevated blood pressures and a retake taken so interventions can be addressed. Interview and review of the clinical record with APRN #1 on 9:15/23 at 11:20 AM identified the blood pressures of (6/26/23 at 3:04 PM, 155/94, 8/15/23 at 6:55 PM, 174/96, and 8/29/23 at 7:59 AM, 166/91) should have been rechecked and she or the physician should have been notified. Further, APRN #1 indicated had she known, she could have evaluated the resident to determine an appropriate intervention. The policy for vital signs failed to direct staff on measures to be taken when a resident's blood pressure is elevated. 2. Resident #54 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertensive chronic kidney disease, and dependence on dialysis. The nurse's notes dated 8/10/23 at 8:59 PM identified that Resident #54 reported not feeling well upon return from dialysis and had never felt that why before, resident was shaky, sweaty, and pale. Upon assessment of vital signs Resident #54's blood pressure was 203/124 (normal range 120/80 mm Hg), pulse was 109 and temperature was 102.2. The supervisor was made aware, the physician was notified, and Resident #54 was transferred to the hospital. Resident #54 was readmitted to the facility on [DATE]. Physician's orders dated 8/14/23 directed Resident #54 to receive hemodialysis on Tuesdays, Thursdays, and Saturdays at an outside dialysis facility and to hold a blood pressure medication(s) on dialysis days, for blood pressure medications given two or more times per day, resident may miss the dose while in dialysis and be given the next scheduled dose upon return from dialysis. Review of Resident #54's blood pressure summary dated 8/14/23 through 8/31/23 identified elevated blood pressures on the following days, (normal range 120/80 mm Hg): 8/15/23 at 5:46 AM, BP was 165/105. 8/27/23 at 10:38 AM, BP was 138/100. 8/31/23 at 9:04 AM, BP was 155/99. Review of the blood pressure summary failed to identify elevated blood pressure readings were rechecked in a timely manner. Review of the progress notes dated 8/14/23 through 8/31/23 failed to identify abnormal blood pressure readings were reported to the physician or APRN. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, was independent with setup for eating and personal hygiene, and required dialysis. Review of Resident #54's blood pressure summary dated 9/1/23 through 9/14/23 identified elevated blood pressure readings on the following days (normal range 120/80 mm Hg): 9/5/23 at 2:04 PM, BP was 180/104. 9/5/23 at 9:14 PM, BP was 188/110. 9/14/23 at 12:07 PM, BP was 155/98. 9/14/23 at 10:45 PM, BP was 150/110. Review of the blood pressure summary failed to identify elevated blood pressures were rechecked in a timely manner. Review of the progress notes dated 9/1/23 through 9/14/23 failed to identify abnormal blood pressure readings were reported to the physician or APRN. The care plan dated 9/4/23 identified Resident #54 required hemodialysis related to end-stage renal disease. Interventions included to obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and blood pressure immediately. Interview and review of the clinical record with APRN #1 on 9/15/23 at 12:42 PM identified that Resident #54 tends to have elevated blood pressures on dialysis days. APRN #1 indicated that there are no parameters for reporting blood pressures in the physician's orders, but she would want to be notified for a systolic pressure greater than 150 - 160 and/or a diastolic pressure greater than 90 and the recommendation is to recheck an elevated blood pressure after one hour. APRN #1 further indicated that she and the Medical Director monitor Resident #54's blood pressures closely, and in the past, they have sent him to the hospital for further evaluation when the blood pressures were consistently elevated, due to his complicated medical history. Interview and review of the clinical record with the ADNS on 9/15/23 at 12:58 PM identified that a recheck of a resident's elevated blood pressure and parameters would be based on the physician's order or recommendation, but she would expect an elevated blood pressure would be rechecked in one hour and if it remains elevated to report the findings to the physician or APRN. Review of the facility's Notification of Significant Changes in Resident's Medical Condition and/or Status policy directed the facility to consult with the resident, if competent, and notify the resident's physician and designated representative of any significant changes in the resident's condition and/or status. Significant changes shall include: a significant improvement or decline in the resident's physical, mental, or psycho-social status in accordance with generally accepted standards of care and services. 3. Resident #87 was admitted to the facility with diagnoses that included dementia, paranoid personality disorder, and delusional disorder. The quarterly MDS dated [DATE] identified Resident #87 had moderately impaired cognition and required supervision with dressing. The care plan dated 7/13/23 identified Resident #87 received antipsychotic medications. Interventions included to administer medication(s) per order. Additionally, monitor behaviors and discuss with staff to identify patterns/causes related to episodes such as time of day, other residents, unit activities, and resident response to interventions. A physician's order dated 9/5/23 directed to give Trazodone (antidepressant medication)100mg every 8 hours as needed for anxiety for 14 days. Review of nurse's notes dated 9/5/23 - 9/14/23 failed to reflect the resident representative had been notified of the new order for Trazadone. Interview with the ADNS on 9/15/23 at 7:10 AM identified whoever confirms the medication as a new order from the physician was responsible to immediately notify Resident #87's resident representative before the first dose of medication was given and tell the resident representative the side effects of the medication. The ADNS indicated the nurse must document in the nurse's notes who and when the resident's representative was notified of the new medication. In review of the clinical record, the ADNS indicated that Resident #87's representative was not notified of the new order for Trazadone dated 9/5/23. Interview with MD #1 on 9/15/23 at 10:30 AM indicated the nurses were responsible to notify the resident representative as soon as a new medication was ordered. MD #1 indicated the resident representative should be notified before the first dose is given in case the resident's representative refuses the new medication. MD #1 indicated nursing has time for notification from the time the order is put in until the pharmacy delivers the medication to notify the resident's representative. Review of the September MAR dated 9/1/23 - 9/14/23 identified Resident #87 received the Trazadone 100mg on 9/6/23 at 5:15 PM and on 9/8/23 at 11:25 PM. Review of the facility Notification of Significant Changes in Resident's Medical Condition or status Policy identified the facility shall consult the competent resident and notify the residents physician and designated representative of any changes in the resident's condition or status. In the event of significant change in the resident's condition and status, the physician must be informed immediately. Then the nursing supervisor informs the resident, if competent and capable of understanding, and his/her family or resident representative and document the notification in the medical record. 4. Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia with agitation, and muscle weakness. A physician's order dated 2/13/23 directed Resident #103 required a mechanically soft, thin diet. The care plan dated 2/14/23 identified Resident #103 was at risk for nutritional deficit due to impaired cognition and a mechanically altered diet. The interventions included to monitor weights as ordered and report significant changes to the dietitian and physician. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of 1 to 2 staff members with transfers, dressing, eating and toilet use. Review of the electronic medical record dated 2/13/23 identified that Resident #103 weighed 149 lbs. Review of the electronic medical record dated 3/1/23 identified that Resident #103 weighed 152 lbs. Review of the electronic medical record dated 4/24/23 identified that Resident #103 weighed 142 lbs., a 10 lb. or 6.58 % loss over the course of approximately 6 weeks. The weights on 2/13/23, 3/1/23 and 4/24/23 were entered into the clinical record by the Dietitian. Review of the clinical record failed to reflect that the physician, APRN, or resident representative had been notified on 4/24/23 of Resident #103's weight loss, or that any interventions were implemented related to the weight loss. A nutritional assessment completed by the dietitian on 5/15/23 identified Resident #103 had a weight of 134.5 lbs., 7.5% weight loss since admission on [DATE]. The note further identified the weight loss was significant and unexplained. Interventions included adding a soft sandwich with lunch and dinner and Boost plus supplement 120ml twice daily. The note failed to identify that the physician, APRN, or resident representative were notified of Resident #103's weight loss on that date. An APRN note dated 5/28/23 at 8:33 AM by APRN #1 identified Resident #103 was being seen for a recent weight decrease from 142 lbs. to 134.5 lbs. within a month. The treatment plan included obtaining labs, monitoring weights weekly, continue Boost plus supplements and current mechanical soft texture diet. The clinical record failed to identify the APRN was aware prior to 5/28/23 that Resident #103 had any issues related to weight loss. A care conference note dated 6/1/23 identified that Resident #103's resident representative was present and informed on that date that Resident #103 required a mechanical soft diet and was independent with meals. The care conference note failed to reflect Resident #103's documented significant weight loss was discussed or reviewed. A nurse's note dated 7/17/23 at 11:07 AM identified Resident #103 weighed 130 lbs., on that date and was recorded at 147 lbs. in June. The note further identified the RN supervisor, APRN and resident representative were notified of Resident #103's weight loss. Review of the clinical record failed to identify any documentation that the resident representative was notified of any issues related to Resident #103's weight loss prior to 7/17/23. Interview with Person #10 on 9/12/23 at 9:54 AM identified he/she had been notified of Resident #103's weight loss approximately 6 - 8 weeks prior. Person #10 further identified that the facility had not provided any other updates regarding interventions related to the weight loss except that Resident #103 was receiving supplementation with meals. Person #10 identified that he/she felt the facility had not done a good job with communicating the plan to address the ongoing issues related to weight loss, including any additional medical work up and any other interventions outside of additional nutritional supplementation. Interview with the ADNS on 9/15/23 at 10:50 AM identified that residents admitted to the facility should have an initial weight done, a repeat weight the following day during the 7:00 AM - 3:00 PM shift, then weekly for 4 weeks, and if no issues were identified, weights monthly. The ADNS identified if a resident was identified by nursing as having a significant unplanned weight loss, that it be reported to the APRN and the resident representative. The ADNS identified the dietitian primarily entered the weights for all the facility residents into the electronic clinical records as she reviewed them, but that the nurses were also responsible to review the weights. The ADNS identified she was unsure why Resident #103 did not have any nursing assessments related to weight loss on 4/24/23, on 5/15/23 when the nutritional assessment identified a significant weight loss with interventions, or why Resident #103's resident representative was not notified until 7/17/23 that Resident #103 was having any issues with weight loss. Interview with the Dietitian on 9/15/23 at 1:58 PM identified she documented Resident #103's initial weight loss on 4/24/23 but was unable to locate any documentation that the physician, APRN, or if Resident #103's representative had been notified. The Dietitian was also unable to identify why APRN #1 was not aware of Resident #103's subsequent weight loss until 5/28/23 following the nutritional assessment on 5/15/23. The Dietitian identified that she had a form she used to communicate any nutritional issues with APRN #1, but this form was for communication purposes only and not part of the clinical record. The Dietitian further identified that she reviewed the forms she had on file and was unable to locate any documentation that she communicated any issues related to Resident #103's weight to APRN #1 until 5/28/23. The Dietitian was also unable to identify why Resident #103's representative was not notified until 7/17/23, almost 8 weeks after the facility was first aware Resident #103 had issues with unintentional weight loss. Interview with APRN #1 on 9/15/23 at 2:06 PM identified she was not notified by the Dietitian of any issues related to Resident #103's weight loss until 5/28/23. APRN #1 identified that the Dietitian used a communication sheet to inform her of any issues with residents of the facility, but if a resident was flagged for weight loss, she would be prompted to evaluate the resident since she was in the facility almost daily. APRN #1 identified that Resident #103 had been consuming 100% of most meals, and she felt Resident #103 had end stage dementia, although that information was not documented in the clinical record. APRN #1 identified that the facility staff needed to work on communicating and documenting the communications in the clinical record and that the facility would set up a meeting with Resident #103's representative to discuss the ongoing issues with weight loss. Although requested, the facility failed to provide any communication forms used by the Dietitian to the APRN for Resident #103. The facility policy on unplanned weight loss directed that residents would be nutritionally assessed no later than 72 hours of recognition that an unplanned significant, severe or insidious weight loss had occurred. The policy identified a significant weight loss as 5% over one month, severe was greater than 5% over one month, and insidious as gradual unintended weight loss over one month. The policy directed that for an identified weight loss that was unplanned, the dietitian would notify the medical provider of the weight loss and document the notification in the resident's medical record. The policy further directed that the dietitian would implement appropriate interventions for weight loss, which included determining nutritional needs, notifying unit staff (nurses and nurse aides) and discussing possible causes, talking to the resident representative about nutrition goals, and monitoring weekly weights. The facility policy on notification of significant change in medical condition or status directed a significant change in condition or status of a resident included an unplanned significant weight loss. The policy further directed that in the event of a significant change, the physician must be notified immediately, and then physician or nursing supervisor would inform the resident representative, and that notification would be documented in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #2) reviewed for tube feeding, the facility failed to follow a physician's order. The findings include: Resident # 2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, GERD, and multiple myeloma. Resident #2 was admitted to the hospital on [DATE], due to abnormal laboratory results and C-Diff. Review of hospital progress noted dated 7/29/22 identified that Resident #2 received a PEG-tube, at the request of the family. Physician's orders dated 6/9/23 directed to administer 5 mg of Amlodipine Besylate (anti-hypertensive) via PEG-tube once daily, 2.5 mg of Apixaban (blood thinner) via PEG-tube every 12 hours, 40 mg Atorvastatin Calcium (hyperlipidemia) via PEG-tube at bedtime, 20 mg Escitalopram Oxalate (anti-anxiety) via PEG-tube daily, 7.5 ml Ferrous Sulfate Elixir (supplement) via PEG-tube daily, 300 mg Gabapentin (anti-convulsant) via PEG-tube twice daily, 250 mg Keppra (anti-convulsant) via PEG-tube every 12 hours, and 20 mg Omeprazole (GERD) via PEG-tube daily. Subsequent to surveyor inquiry the physician's orders were discontinued and re-ordered to be administered by mouth on 9/12/23. The significant change in status MDS dated [DATE] identified Resident #2 had moderately impaired cognition, required an extensive two-person assist with eating, and nutritional approaches included feeding tube and a mechanically altered therapeutic diet. The care plan dated 7/28/23 identified Resident #2 required tube feeding and had a potential for nutritional deficit related to the following diagnoses: morbid obesity, diabetes, impaired skin, and increased nutritional needs. Interventions included administering feedings and fluids as ordered and providing diet plan as ordered. An APRN progress note dated 7/28/23 at 11:50 PM identified that Resident #2 had a recent weight gain, which may have been caused by eating a mechanical soft diet and receiving enteral feedings. Resident #2 was eating food provided by the facility and food brought in by family. Plan to discuss weight with dietitian, monitor weights weekly, discontinue enteral feeding, and continue mechanical soft diet. A physician's order dated 8/21/23 directed the removal of the PEG-tube due to Resident #2's increased appetite and complaints of pain to site. Interview with RN #6 on 9/12/23 at 10:47 AM identified Resident #2 had a PEG-tube, but he/she no longer received nutrition or medications through it. RN #6 indicated that Resident #2 had active orders for medications to be given via PEG-tube, but she was educated that he/she takes medications by mouth. RN #6 further indicated that she did not know why the orders had not been updated to administer medications orally. Interview with APRN #1 on 9/14/23 at 3:15 PM indicated that Resident #2 had a PEG-tube placed due to weight loss and poor oral intake, not dysphagia. APRN #1 further indicated that the facility slowly reintroduced food, and with a combination of the tube feedings and oral intake of food, Resident #2 began to gain weight and Resident #2 was no longer tolerating boluses well. The PEG-tube remained in place so the facility could trial Resident #2 on exclusive PO intake and monitor his/her weight, but a date was scheduled for the removal of the PEG-tube, with Interventional Radiology. APRN #1 indicated that she kept the PEG-tube in place to allow time to evaluate how Resident #2 tolerated the medications and food orally, but that she should have updated the medication orders to be administered PO or via PEG-tube during the trial period. Interview and clinical record review with the ADNS on 9/15/23 at 9:38 AM indicated that the route of Resident #2's medication administration orders were not changed from PEG-tube to PO because he/she was compromised and was in and out of the hospital, frequently. The ADNS further indicated that the medication could be safely administered either route. The ADNS indicated that the APRN was aware that Resident #2 was receiving medications by mouth as it was the preferable route. The ADNS identified that changing the order to administer the medications PO or via PEG-tubed would have been an appropriate change. Interview with the Medical Director on 9/15/23 at 10:11 AM identified that he would have expected Resident #2's medication administration orders to have been switched to PO, since he/she was trailing taking medications by mouth. The Medical Director indicated that APRN #1 should have changed Resident #2's order from medications being administered via PEG-tube to PO. The facility's Medication Administration Guidelines directed licensed nurses to administer medications in accordance with the physician order(s). The facility's Electronic Medication Administration Record policy directs medication prepartaion and administration must adhere to the 5 Rights: Right Patient, Right Drug, Right Dose, Right Route, and Right Time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, facility documentation and interviews for 2 of 4 residents (Resident #45) reviewed for change in condition, the facility failed to monitor blood pressures for a resident with chronic kidney disease stage 4, and for 1 resident (Resident #50) reviewed for skin, the facility failed to ensure a specialized mattress was on the correct setting for the resident's weight and was functioning and for 1 resident (Resident # 54) reviewed for dialysis, the facility failed to complete an RN assessment for a change in condition, and for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to ensure that a resident's weight was monitored per facility policy and failed to complete a change of condition assessment following a significant unintentional weight loss in a timely manner and for 1 residents (Resident #277) reviewed for activities of daily living, the facility failed to assist the resident out of bed. The findings include. 1. Resident #45 was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease stage 4, type 2 diabetes and major depressive disorder. The annual MDS date 6/9/23 identified Resident #45 had intact cognition, required extensive assistance for bed mobility, dressing and toileting, supervision for transferring and personal hygiene and was independent with eating. Further, it identified Resident #45 had diagnoses of congestive heart failure, atrial fibrillation, anxiety disorder and depression and utilized a wheelchair for mobility. The care plan dated 7/6/23 identified a focus on altered respiratory status with interventions that included provide immediate assistance as needed for signs and symptoms of distress, administer oxygen, raise head, check vital signs and oxygen saturation and notify the physician. Physician's monthly orders dated September 2023 directed to check blood pressure, heart rate and temperature every shift for hypertension. Review of the clinical record with the ADNS on 9/15/23 at 8:40 AM identified Resident #45 had elevated blood pressures on the following dates (normal range 120/80). 6/26/23 at 3:04 PM, 155/94. 8/15/23 at 6:55 PM, 174/96. 8/29/23 at 7:59 AM, 166/91. The clinical record failed to reflect that the blood pressure had been rechecked, or that the physician had been made aware. Interview and review of the clinical record with the Medical Director on 9/15/23 at 10:10 AM identified it is his expectation that he or the APRN be notified of elevated blood pressures and a retake taken so interventions can be addressed. Interview and review of the clinical record with APRN #1 on 9:15/23 at 11:20 AM identified the blood pressures of (6/26/23 at 3:04 PM, 155/94, 8/15/23 at 6:55 PM, 174/96, and 8/29/23 at 7:59 AM, 166/91) should have been rechecked and she or the physician should have been notified. Further, APRN #1 indicated had she known, she could have evaluated the resident to determine an appropriate intervention. The policy for vital signs failed to direct staff on measures to be taken when a resident's blood pressure is elevated. 2. Resident #50 was admitted to the facility in November 2016 with diagnoses that included stroke, diabetes, and obesity. The quarterly MDS dated [DATE] identified Resident #50 had severely impaired cognition, required extensive two person's physical assistance with bed mobility and was at risk for developing pressure ulcers/injuries. The care plan dated 7/13/23 identified Resident #50 has potential impairment to skin integrity related to Moisture-Associated Skin Damage (MASD). Interventions included to monitor the air mattress for proper function every shift, avoid scratching, keep hands, and body parts from excessive moisture. A physician's order dated 9/1/23 directed to check Low Air Loss (LAL) mattress every shift for function and placement. Review of the September TAR dated 9/1/23 through 9/15/23 directed to check (LAL) mattress functioning and placement every shift on the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM shifts. Review of the weights and vitals summary form dated 9/5/23 identified Resident #50 weighed 160.4 lbs. Review of nurse's notes dated 9/1/23 through 9/13/23 failed to reflect documentation that the (LAL) mattress malfunctioned. Observation on 9/14/23 at 9:00 AM and 2:00 PM and on 9/15/23 at 8:30 AM identified Resident #50 in bed with the head of bed in semi-Fowler_position facing the door. Two blue pillows were observed in between the (LAL) mattress and the bed frame. Additionally, the setting to the pump of the (LAL) mattress had a yellow light on identifying low pressure alert, and the weight control knob was on maximum (400 lbs.). Observation and interview on 9/15/23 at 10:59 AM with RN #3 identified Resident #50 was in bed with head of bed in semi-Fowler_position facing the door. Two blue pillows were observed in between the (LAL) mattress and the bed frame. Additionally, the setting to the pump of the (LAL) mattress had a yellow light on identifying low pressure alert, and the weight control knob was on maximum (400 lbs.). RN #3 was observed to turn the weight control knob down between 160 lbs. and 240 lbs. RN #3 indicated she was not aware there were two blue pillows in between the (LAL) mattress and the bed frame, that the setting to the pump of the (LAL) mattress had a yellow light on identifying low pressure alert, and the weight control knob was on maximum (400 lbs.). RN #3 indicated the weight control knob should have been set according to Resident #50's weight. RN #3 indicated the nurse's aide, and the nurse should have notified the supervisor and herself if the air mattress was damaged or malfunctioning. Observation identified a dent in the middle of the (LAL) mattress. RN #3 indicated she will replace the (LAL) air mattress immediately. Interview with NA #4 on 9/15/23 at 11:05 AM identified she was aware of the 2 blue pillows between the (LAL) mattress and the bed frame. NA #4 indicated she did not place the pillows there and she does not know who did. NA #4 indicated the pillows were placed there to prevent Resident #50 from sliding down in the bed. NA #4 indicated she should have reported the pillows to the nurse and RN #4. Review of the skin inspection on bath/shower day form dated 9/15/23 at 3:35 PM identified Resident #50 has no reddened, rashes, excoriated, open lesions, blisters, and open ulcer areas to body. No skin issues noted. Skin intact. A nurse's note dated 9/15/23 at 3:54 PM identified Resident #50 had an RN skin assessment performed in the presence of surveyor due to (LAL) mattress malfunction, low air pressure alert on. No skin breakdown noted, no open areas, no redness, skin intact. Pressure points on bilateral hips, buttock, sacrum, back, elbows, shoulders, heels, and ankles assessed with no redness, no open areas observed. Maintenance notified with new (LAL) mattress provided to Resident #50 immediately. LAL mattress adjusted to Resident #50's current weight, (LAL) mattress functioning properly at this time. APRN and resident representative notified. Subsequently to surveyor inquiry the (LAL) mattress was replaced and an RN body assessment was completed. RN #3 in-service the nursing staff regarding the (LAL) mattress and performed an audit. Interview with APRN #1 on 9/20/23 at 11:31 AM identified she was not aware of the issues. APRN #1 indicated the nurse aides should have reported the issue to the charge nurse or the supervisor. APRN #1 indicated the expectation would be that the (LAL) mattress would be replaced immediately. Although attempted, an interview with MD #1 was not obtained. Review of the facility air mattress policy identified it is the policy of the facility to provide special air mattresses for residents with pressure ulcers and residents at risk for skin breakdown. To prevent pressure ulcers and to assist in healing pressure ulcers. The selection of an air mattress will consider the individual's specific needs, mobility levels, weight, and any pre-existing medical conditions. Review of the manufacture pamphlet Supra APL Alternating Pressure Therapy Pump Overlay/Replacement Mattress System identified the system is a high quality, mattress system, suitable for the treatment and prevention of pressure ulcers. To help and reduce the incidence of pressure ulcers while optimizing patient's comfort. The pressure should be adjusted according to individual comfort preferences. Low Pressure Indicator - the low-pressure LED is a warning, indicating that the pressure in mattress is unusually low. 3. Resident #54 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertensive chronic kidney disease, and dependence on dialysis. The nurse's notes dated 8/10/23 at 8:59 PM identified that Resident #54 reported not feeling well upon return from dialysis and had never felt that why before, resident was shaky, sweaty, and pale. Upon assessment of vital signs Resident #54's blood pressure was 203/124 (normal range 120/80 mm Hg), pulse was 109 and temperature was 102.2. The supervisor was made aware, the physician was notified, and Resident #54 was transferred to the hospital. Resident #54 was readmitted to the facility on [DATE]. Physician's orders dated 8/14/23 directed Resident #54 to receive hemodialysis on Tuesdays, Thursdays, and Saturdays at an outside dialysis facility and to hold a blood pressure medication(s) on dialysis days, for blood pressure medications given two or more times per day, resident may miss the dose while in dialysis and be given the next scheduled dose upon return from dialysis. Review of Resident #54's blood pressure summary dated 8/14/23 through 8/31/23 identified elevated blood pressures on the following days, (normal range 120/80 mm Hg): 8/15/23 at 5:46 AM, BP was 165/105. 8/27/23 at 10:38 AM, BP was 138/100. 8/31/23 at 9:04 AM, BP was 155/99. Review of the blood pressure summary failed to identify elevated blood pressure readings were rechecked in a timely manner. Review of the nurse's notes dated 8/14/23 through 8/31/23 failed to reflect an RN assessment had been completed when the resident's blood pressure was elevated on 8/15, 8/27 and 8/31/23. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, was independent with setup for eating and personal hygiene, and required dialysis. The care plan dated 9/4/23 identified Resident #54 required hemodialysis related to end-stage renal disease. Interventions included to obtain vital signs and weight per protocol. Report significant changes in pulse, respirations, and blood pressure immediately. Review of Resident #54's blood pressure summary dated 9/1/23 through 9/14/23 identified elevated blood pressure readings on the following days (normal range 120/80 mm Hg): 9/5/23 at 2:04 PM, BP was 180/104. 9/5/23 at 9:14 PM, BP was 188/110. 9/14/23 at 12:07 PM, BP was 155/98. 9/14/23 at 10:45 PM, BP was 150/110. Review of the blood pressure summary failed to identify elevated blood pressures were rechecked in a timely manner. Review of the nurse's notes dated 9/1/23 through 9/14/23 failed to identify an RN assessment had been completed when the resident's blood pressure was elevated twice on 9/5 and 9/14/23. Interview and review of the clinical record with the ADNS on 9/15/23 at 12:58 PM identified for residents with an elevated blood pressure she would expect the nurse to recheck the blood pressure in one hour, complete an assessment, document the assessment in a progress note, notify the APRN or physician, and notify the resident representative (if appropriate). Review of the facility's Notification of Significant Changes in Resident's Medical Condition and/or Status policy directed the facility to consult with the resident, if competent, and notify the resident's physician and designated representative of any significant changes in the resident's condition and/or status. The nursing supervisor does the following: performs a physical assessment of the resident, informs the physician, who then orders the follow-up treatment/care if indicated, calls the designated representative, and documents the physical assessment and telephone contact in the medical record. 4. Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia with agitation, and muscle weakness. A physician's order dated 2/13/23 directed Resident #103 required a mechanically soft, thin diet. The care plan dated 2/14/23 identified Resident #103 was at risk for nutritional deficit due to impaired cognition and a mechanically altered diet. The interventions included to monitor weights as ordered and report significant changes to the dietitian and physician. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of 1 to 2 staff members with transfers, dressing, eating and toilet use. Review of the electronic medical record dated 2/13/23 identified that Resident #103 weighed 149 lbs. Review of the electronic medical record dated 3/1/23 identified that Resident #103 weighed 152 lbs. Review of the electronic medical record dated 4/24/23 identified that Resident #103 weighed 142 lbs., a 10 lb. or 6.58 % loss over the course of approximately 6 weeks. The weights on 2/13/23, 3/1/23 and 4/24/23 were entered into the clinical record by the Dietitian. Review of the clinical record failed to identify any change of condition assessments were completed on Resident #103 following the initial documented weight loss on 4/24/23. Review of weights in both the electronic record and weight book maintained at the nurse's station identified Resident #103 had weights documented on the following dates. 2/13/23, 149 lbs. 3/1/23, 152 lbs. 4/24/23,142 lbs. 5/8/23, 141 lbs. 5/15/23,134.5 lbs. 6/1/23,147 lbs. 7/17/23,130 lbs. 7/25/23,135.6 lbs. 8/3/23,132.8 lbs. 8/28/23,136 lbs. 9/11/23,130 lbs. The weight sheets from 5/8/23 to 9/11/23, over one month, identified Resident #103 required weekly weights. Review of the electronic record and weight book failed to identify any additional weights obtained by the facility or any documentation related to Resident #103's refusals of weights. Although requested, the facility failed to provide the weight sheets from the weight book for Resident #103 prior to 5/8/23. A nutritional assessment completed by the Dietitian on 5/15/23 identified Resident #103 had a weight of 134.5 lbs., 7.5% weight loss since admission on [DATE]. The note further identified the weight loss was significant and unexplained. Interventions included adding a soft sandwich with lunch and dinner and Boost plus supplement 120ml twice daily. The note failed to identify that the physician, APRN, or resident representative were notified of Resident #103's weight loss on that date. An APRN note dated 5/28/23 at 8:33 AM by APRN #1 identified Resident #103 was being seen for a recent weight decrease from 142 lbs. to 134.5 lbs. within a month. The treatment plan included obtaining labs, monitoring weights weekly, continue Boost plus supplements and current mechanical soft texture diet. A nurse's note dated 7/17/23 at 11:07 AM identified Resident #103 weighed 130 lbs. on that date and was recorded at 147 lbs. in June. Review of clinical record failed to identify a nursing assessment was completed on that date. Interview with Person #10 on 9/12/23 at 9:54 AM identified he/she had been notified of Resident #103's weight loss approximately 6 - 8 weeks prior. Person #10 further identified that the facility had not provided any other updates regarding interventions related to the weight loss except that Resident #103 was receiving supplementation with meals. Person #10 identified that he/she felt the facility had not done a good job with communicating the plan to address the ongoing issues related to weight loss, including any additional medical work up and any other interventions outside of additional nutritional supplementation. Interview with the ADNS on 9/15/23 at 10:50 AM identified that residents admitted to the facility should have an initial weight done, a repeat weight the following day during the 7:00 AM - 3:00 PM shift, then weekly for 4 weeks, and if no issues were identified, weights monthly. The ADNS identified if a resident was identified by nursing as having a significant unplanned weight loss, that it be reported to the APRN and the resident representative. The ADNS identified the dietitian primarily entered the weights for all the facility residents into the electronic clinical records as she reviewed them, but that the nurses were also responsible to review the weights. The ADNS identified she was unsure why Resident #103 did not have any nursing assessments related to the weight loss on 4/24/23, or on 5/15/23 when the nutritional assessment identified a significant weight loss with interventions. Interview with the Dietitian on 9/15/23 at 1:58 PM identified that the frequency of weights was not a physician's order but was identified in the weight book and based on facility policy. The Dietitian identified she entered the weights recorded in the weight book into the electronic clinical record, but it was also the responsibility of the nursing staff to ensure that the weights were obtained timely. Interview with APRN #1 on 9/15/23 at 2:06 PM identified she was not notified by the Dietitian of any issues related to Resident #103's weight loss until 5/28/23. APRN #1 identified that the Dietitian used a communication sheet to inform her of any issues with residents of the facility, but if a resident was flagged for weight loss, she would be prompted to evaluate the resident since she is in the facility almost daily. The facility policy on unplanned weight loss directed that residents would be nutritionally assessed no later than 72 hours of recognition that an unplanned significant, severe or insidious weight loss had occurred. The policy identified a significant weight loss as 5% over one month, severe was greater than 5% over one month, and insidious as gradual unintended weight loss over one month. The policy directed that for an identified weight loss that was unplanned, the Dietitian would implement appropriate interventions for weight loss, which included determining nutritional needs, notifying unit staff (nurses and nurse aides) and discussing possible causes, talking to the resident representative about nutrition goals, and monitoring weekly weights. The facility policy on physician notification directed that the purpose of the policy was to notify the medical provider of a change in the resident's condition. The policy further directed that in the event a licensed nurse recognized a change in the resident's condition, the unit RN or supervisor would complete an assessment of the resident, and based on the assessment the physician would be notified. The policy also directed that it was the responsibility of the unit nurse to document the signs and symptoms that were recognized indicating a possible change in status in the nursing progress notes. 5. Resident #277 was admitted to the facility on [DATE] with diagnoses that included left hip fracture, repeated falls, anemia, and hypertension. A physician's order dated 3/16/23 directed the resident out of bed to a high back wheelchair with pressure relieving cushion, and bilateral elevating leg rests via mechanical. The significant change of condition MDS dated [DATE] identified Resident #277 had intact cognition and required extensive assistance with care. Additionally, it was very important to Resident #277 to choose clothes to wear each day, choose between a tub bath or shower, participate in group activities, and go outside to get fresh air when the weather is good. The care plan dated 7/6/23 identified the resident required total 2-person assistance via mechanical lift for transfers. Interventions for bathing were not identified. Review of a census sheet identified that Resident #277 had changed units on 7/19/23. Review of progress notes dated 7/19/23 - 9/15/23 did not reflect the resident had refused showers or to get out of bed. Interview with Resident #277 on at 9/12/23 at 10:45 AM indicated he/she has not had a shower since he/she was admitted to this facility 6 months ago. Resident #277 indicated he/she could not stand to take a shower and that was why he/she had not received a shower. Resident #277 indicated the nursing staff come in and wash him/her up in bed and never offered a shower. Resident #277 indicated he did not realize he/she could get a shower because the nursing staff never informed him/her that there was a chair that goes into a shower room where he/she could get a shower. Resident #277 indicated he/she would love to take a shower and had never refused to take a shower. Resident #277 indicated he/she took showers daily at home prior to falling and breaking his/her hip. Observation on 9/13/23 at 9:20 AM and 11:40 AM resident was lying in bed watching television. Observation on 9/14/23 at 7:30 AM and 9:20 AM resident lying in bed watching television. Observation on 9/15/23 at 7:45 AM Resident #277 was lying in bed watching television. Interview with Resident #277 indicated the nursing staff still have not offered him/her a shower. Interview with LPN #1 on 9/15/23 at 7:52 AM indicated she does not recall seeing Resident #277 take a shower. LPN #1 indicated he/she does not get out of bed at all and is always in bed watching television. LPN #1 indicated Resident #277 had a hip replacement, so he/she stays in bed. LPN #1 indicated she had not discussed with Resident #277 about taking a shower, she just knows the nursing assistant gives him/her a bed bath. Interview NA #2 on 9/15/23 at 7:59 AM indicated when staff put him/her in the chair, Resident #277 would slide in the chair, so the nurse, LPN #2 charge nurse (full time) instructed me not to get Resident #277 up so Resident #277 doesn't fall. NA #2 indicated she gives Resident #277 a bed bath on Tuesdays and Thursdays day shift based on the shower schedule. NA #2 indicated Resident #277 needed the long shower chair because he/she would slide. NA #2 indicated since the resident has been on this unit, he/she has not been in the shower. NA #2 indicated she does not offer Resident #277 a shower because since Resident #277 was transferred to this unit, there was not a long shower chair with leg extender to provide a shower. NA #2 indicated she was waiting for a safe shower chair with the leg extender because Resident #277 was tall and slides before she will give him/her a shower. NA #2 indicated Resident #277 had not been out of bed in months. Interview with LPN #1 on 9/15/23 at 8:30 AM indicated she was aware the nurse aides were giving bed baths instead of showers because there wasn't the right shower chair for Resident#277 to take a shower safely. LPN #1 indicated Resident #277 does not refuse a shower but if he/she did she would document it in the progress notes. LPN #1 indicated she was aware that he/she was getting bed baths and not showers but she is only on this floor a couple days a week, so she thought that was just normal for Resident #277 and not a problem. LPN #1 indicated she had not asked Resident #277 if he/she wanted a shower on the days she works on the unit. Interview with the ADNS on 9/15/23 at 10:05 AM indicated Resident #277 has a problem with the alignment of the hip, it was not right. The ADNS indicated on admission all residents get a shower the first 2 days in the facility, then are scheduled for showers twice a week. The ADNS indicated if a resident refuses the charge nurse must document it in the progress notes. The ADNS indicated if Resident #277 was unable to sit up or too tall for a standard shower chair the charge nurse would have to report it to rehabilitation. The ADNS indicated she was not aware Resident #277 was not getting showers and she was not aware that they did not have the proper shower chair. Interview with MD #1 on 9/15/23 at 10:30 AM indicated all residents in the facility should have a shower at least weekly for cleanliness and to prevent skin breakdown. MD #1 indicated if a resident does not get a shower regularly a resident could get a yeast infection or bacteria which could build up on the skin and causes infections. MD #1 indicated if Resident #277 needed a longer chair than the standard shower chair and it was the facility's responsibility to get one in a reasonable amount of time. Interview with the Rehab Director on 9/15/23 at 11:20 AM indicated the rehab department was not notified of any issues of Resident #277 needing a special shower chair, and if they had been notified, OT would have seen the resident right away. The Rehab Director indicated the expectation was Resident #277 would be out of bed daily unless he/she refused. The Rehab Director indicated Resident #277 was alert and oriented and could decide if he/she wanted to get out of bed if offered. After review of the clinical record, The Rehab Director indicated it was Resident #277's goal back in April to increase the length of time to sit in wheelchair when out of bed daily. Observation, after surveyor inquiry, on 9/15/23 at 12:20 PM was eating lunch in the dining room in the wheelchair. After surveyor inquiry, the nurse's note dated 9/15/23 at 3:59 PM identified that Resident #277 was alert and oriented to person, place, and time. Around 12:30 PM resident had back pain and was assisted back to bed. Resident later asked to get up and go back into the dining room. Resident is now in the dining room waiting for dinner. Supervisor and APRN aware. Interview with LPN #2 on 9/15/23 at 5:30 PM indicated she thought Resident #277 wanted to stay in bed because of the hip/leg and to watch television. LPN #2 indicated she was not aware that NA #2 wasn't getting Resident #277 out of bed because she was afraid Resident #277 would slide out of the wheelchair and fall. LPN #2 indicted she had not notified rehab that Resident #277 needing a new chair because she did not recall seeing Resident #277 out of bed since he/she had transferred onto her unit. LPN #2 indicated if Resident #277 was not able to sit in the wheelchair she would have called OT to reevaluate the position in the wheelchair. LPN #2 indicated she had not educated Resident #277 of the importance of getting out of bed daily because she thought the resident was comfortable in the bed. LPN #2 indicated she did not recall asking Resident #277 if he/she wanted to get out of bed daily or why he/she did not get out of bed since being on her unit. Observation on 9/15/23 at 6:00 PM Resident #277 was sitting in the wheelchair eating dinner in the third-floor dining room. Interview with Resident #277 on 9/15/23 at 6:00 PM indicted he/she ate lunch and supper in the dining room and enjoyed being out of the room with people in the dining room. Resident #277 indicated maybe he/she can start therapy again soon and start trying to walk so he/she could work on going home. Review of the facility Activities of Daily Living (ADL) policy identified the facility would provide the necessary care and services based on the comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences, to maintain or improve, the resident's ability to perform ADL's and to prevent decline unless it's unavoidable. Resident's, when able, shall be encouraged to eat in the dining areas for socialization. All residents shall be out of bed as tolerated each day unless contraindicated. When a resident refuses to comply with ADL activities and schedules, nursing staff shall solicit assistance from other disciplines to determine cause of refusal, offer other options and alternatives, informing the resident of the risks to self and others and document refusal in the medical chart in the progress notes and the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #80) reviewed for pressure ulcer, the facility failed to ensure weekly body assessments by licensed nurses were completed 8 weeks prior to the discovery of a DTI on the sacrum and failed to ensure a pressure relieving mattress was functioning. The findings Resident #80 was admitted to the facility with diagnoses that included peripheral vascular disease, osteomyelitis to the left ankle and foot, and pressure ulcer to the right heel. The admission MDS dated [DATE] identified Resident #80 had moderately impaired cognition, was frequently incontinent of bowel, had an indwelling catheter, required extensive assistance with bed mobility and transfers, was at risk for developing pressure ulcers, and had one stage 4 pressure ulcer and one unstageable deep tissue injury on admission. Review of the Weekly Skin Inspections on Bath/Shower Day form (to be completed by the licensed nurses) identified from 6/27/23 - 9/12/23 (8 weeks) the weekly skin inspections were not completed. A nurse's note dated 8/28/23 at 1:29 PM identified the resident had a coccyx wound. The note failed to identify the type of wound, stage or any measurements. A progress note, written by APRN #1 dated 8/28/23 at 11:57 PM identified Resident #80 was being seen due to wound on coccyx. Resident #80 was observed to have an open wound to the coccyx. Wound care done, no rashes or open areas, and right heal dressing is intact. Plan to cleanse with Dermaklenz, apply xeroform and cover with a foam dressing. Additionally, follow up with wound team. A physician's order dated 8/28/23 directed to cleanse the coccyx wound with Demaklenz, pat dry, apply xeroform to site and cover every day shift and as needed for 30 days. A physician's order dated 8/29/23 directed to discontinue wound care to coccyx. A physician's order dated 8/30/23 directed wound care to coccyx cleanse with Demaklenz pat dry, cover with a foam dressing as needed for deep tissue injury every night shift. Weekly wound documentation, completed by the wound nurse, RN #3, dated 9/4/23 identified the resident has a facility acquired DTI pressure ulcer to the sacrum. Moderate amount of serous drainage. Peri wound had undermining 0.5 cm from 12:00 o'clock to 3:00 o'clock. The wound base had granulation and necrotic tissue. The surrounding tissue had dermatitis. DTI partially open wound bed had thick necrotic tissue requiring debridement. A physician's order dated 9/6/23 directed to discontinue wound care to coccyx. The nurse's note, written by wound RN #3 dated as a late entry for 8/30/23 at 5:58 PM identified Resident #80 was referred by charge nurse for a skin assessment due to a DTI to the coccyx. Maroon discoloration measuring 4.0 cm x 3.0 cm x 0 cm, no drainage, peri wound erythematous, fragile, slightly excoriated. Resident #80 with history of MASD to bilateral buttocks and coccyx and currently has a stage 4 to pressure wound to right heel and a DTI to right foot. Resident #80 was referred to dietary and rehab for evaluations. Wound treatment reviewed and updated. Resident #80 is a patient at the wound center. APRN updated and blood work ordered and weekly weights x 4 weeks. Wound physician report dated 9/11/23 identified initial evaluation of sacrum identified as a stage 4 pressure wound full thickness measuring 5.8 cm x 12.3 cm x 1.2 cm with undermining at 7:00 o'clock 1.5 cm. A physician's order dated 9/11/23 directed to cleanse wound to coccyx with Dakins solution then apply Santyl to wound bed and cover with foam dressing every day shift and as needed for DTI to coccyx. Interview with the ADNS #1 on 9/13/23 at 9:36 AM indicated on admission the nurses were to manually put in when the licensed staff were to do the weekly skin inspection. ADNS #1 indicated the weekly skin inspections were not automatically triggered on the treatment record for the nurses to sign off as a reminder to do them. ADNS #1 indicated it was up to the nurses on a weekly basis when a resident gets a shower to manually put in the weekly skin inspection. ADNS #1 indicated the nurses just know it is their responsibility to do it. Review of the clinical record, ADNS #1 indicated the weekly skin inspection were not done from 6/27/23 until 7/17/23 (2 weeks missing) and there were none from 7/17/23 until now 9/13/23. After surveyor inquiry, a weekly skin inspection was completed on 9/13/23 at 4:58 PM for Resident #80 that noted a new open area to the left buttock. Interview with RN #4 (day supervisor) on 9/13/23 at 9:42 AM indicated there is a form posted at the nurse's station, by room numbers, listing the weekly showers per day D-days, E-evenings, N- night shift and the * tells which nurse is responsible to do the weekly skin assessment. RN #4 indicated the nurses that have been here longer know just know to follow the shower sheet. RN #4 indicated there is nothing in the TAR for the nurses to sign off on to remind the charge nurse to do the weekly skin inspection. RN #4 indicated the last weekly skin inspection was done 7/17/23. RN #4 does not know why it was not done on the Saturday night shift. RN #4 indicated the night supervisor was responsible for making sure it was completed. RN #4 indicated Resident #80 had a stage 4 to the right heel and abrasion on the bottom. RN #4 indicated she only knew of these 2 areas, and she would have to speak with wound nurse. Interview with the ADNS on 9/13/23 at 9:51 AM indicated after clinical record review that the weekly skin inspection on shower days were being signed off. The ADNS handed surveyor documentation for the weekly skin inspection done on shower days. The ADNS identified the documentation was located in the task section of the clinical record. The ADNS indicated body assessments were being done by the nurse aides. The ADNS indicated it was the responsibility for the licensed nurses to do the weekly skin inspection and it was not done. Interview with RN #3 (wound nurse) on 9/13/23 at 10:58 AM indicated the new DTI on the coccyx was identified on 8/30/23. RN #3 indicated she thinks a charge nurse had notified her of the new DTI on the coccyx. RN #3 indicated once the new coccyx wound appeared there was a consult to dietary and therapy. RN #3 indicated the charge nurses were responsible to do the weekly skin inspection on the resident's shower day and document the inspection. RN #3 indicated if the charge nurse had any finding, they were responsible to notify the APRN and RN #3 as the wound nurse. RN #3 indicated the nurse aides do not assess, but they notify the charge nurses of any skin changes. RN #3 indicated she was only responsible for pressure wounds and surgical wounds. RN #3 indicated she believed the APRN notified her of the new DTI to the coccyx on 8/30/23. Interview with APRN #1 on 9/13/23 at 11:37 AM indicated based on her clinical note that she was first notified of Resident #80's coccyx DTI on 8/28/23 by NA # 1. APRN #1 indicated NA #1 asked her to look at Resident #80's buttocks. APRN #1 indicated the DTI to the coccyx appeared as an open wound, but she did not write down the measurements that the charge nurse gave to her. APRN #1 indicated the edges of open area were necrotic. APRN #1 indicated the nurses must notify her when there is a new wound. APRN #1 indicated she was not notified until 8/28/23 which was the problem. APRN #1 indicated that DTI did not happen overnight. APRN #1 indicated the expectation was that as soon as the area was red, or opening, or a blister she should have been notified right away by calling her or leaving it in her paper book on the unit. APRN #1 indicated the nursing staff must let her know when a wound first starts as a stage 1 or stage 2 not when it was already a DTI. APRN #1 indicated she was concerned that this area was not found until 8/28/23 and was already a DTI. APRN #1 indicated she had spoken to RN #3 (wound nurse) and asked how this could have happened that no one had noticed prior to becoming a DTI. APRN #1 indicated she spoke with RN #3 again and asked how Resident #80's wound could happen on Monday 9/11/23 and RN #3 informed APRN #1 she believed it was the air mattress and it was not inflating and deflating and that was maybe why the wound got bigger and the air mattress was changed. APRN #1 indicated that the coccyx wound had to start about 2 weeks prior with friction and moisture and no one had reported it. APRN #1 indicated Resident #80 was total care and the nurse aides have to boost him/her in bed, turn and reposition, and use a mechanical lift to get the resident into the wheelchair. APRN #1 indicated Resident #80 was dependent on staff. The APRN #1 progress note dated 9/13/23 at 11:20 PM identified the x-ray of sacrum was done and was incomplete due to sigmoid rectal stool obstructing view. Constipation initiate MiraLAX 17 grams x 1 dose. Interview with RN #3 (wound nurse) on 9/15/23 at 8:40 AM indicated as the wound nurse she does a nosocomial packet for all new pressure ulcers. RN #3 indicated she does not interview staff regarding the new pressure area she focusses on the resident. RN #3 indicated her investigation concluded the resident was compromised and at high risk with low score on Braden scale. RN #3 indicated the wound should have been discovered earlier during daily care by the nurse aides or the charge nurses. RN #3 indicated the air mattress was not fully inflated when the resident was seen by the wound doctor and RN #3 on 9/11/23. RN #3 then notified the charge nurse and the maintenance department. RN #3 indicated maintenance changed the air mattress out the same day. RN #3 indicated a DTI could take time to develop but could develop within a day to 2 days. Interview with MD #1 on 9/15/23 at 10:32 AM indicated a DTI would not appear in a day it would start as a stage 1 and would take about 10-14 days to get to a DTI on the coccyx. MD #1 indicated he would have expected the nurse to be aware before the wound became a DTI. MD #1 indicated at a stage 2 nursing should have been aware and put the appropriate treatments in place to prevent further breakdown. Review of the facility Pressure injury assessment, prevention, and management Policy identified it was the policy of the facility that residents will not develop pressure ulcers unless clinically unavoidable. The facility shall provide care and services consistent with professional standards of practice to prevent pressure injury/ulcer development and promote the healing of existing pressure injury/ulcer. Nurse aides are to inspect the skin of all residents under their assignment at least once every shift paying particular attention to the bony prominences. Report to nurse any changes or areas of concern. The Licensed nurses are to conduct skin inspection of resident's weekly, preferably on bath/shower days of the resident and document in electronic clinical record on the Skin Inspection on Bath/Shower Day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #81 and 103) reviewed for accidents, for Resident #81, who has severely impaired cognition, the facility failed to ensure a hazard free environment when hand wipes were observed on the residents bedside table, and for Resident #103, who has a history of falls, the facility failed to ensure a hazard free environment when the residents breakfast tray was left at the foot of the bed out of reach of the resident. The findings include. 1. Resident #81 was admitted on [DATE] with diagnosis that included, atrial fibrillation, basal cell carcinoma of skin, and unspecified toxic encephalopathy. The MDS dated [DATE] identified the resident had severely impaired cognition, required extensive assistance for bed mobility, total dependence for locomotion, toilet use and dressing. The care plan dated 6/13/23 identified a focus on skin breakdown related to edema, poor mobility after a fall with fractures, linear blanchable redness to coccyx, left medial heel, recurrent fungal rashes to bilateral breast folds, fragile skin overall, history of pressure wound, age spots, refusal to wear heel booties at times, preferred to stay in bed at times. Interventions included to watch for changes in skin condition each shift, avoid skin to skin contact, and keep clean and dry. Observation on 9/12/23 identified a container of hand wipes on Resident #81's bedside table within the residents reach. Interview with the ADNS on 9/12/23 at 12:30 PM identified that due to Covid 19 in the building, Resident #81's representative requested Resident #81 have wipes at the bedside so the resident can use at will. The ADNS identified she would provide a copy of the care plan and an assessment to support the use of wipes. The ADNS on 9/14/23 at 8:16 AM provided a care plan dated 9/12/23 for the use of the wipes at the bedside, however, failed to provide documentation that an assessment of Resident #81's ability to safely use the wipes at the bedside. Although requested a policy for the use of personal wipes was not provided. 2. Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia with agitation, muscle weakness. The hospital discharge record dated 2/13/23 identified Resident #103 had been seen at the hospital following increased weakness, increased confusion, decline in condition, inability to walk, and multiple falls at home. The care plan dated 2/14/23 identified Resident #103 had a history of falls. The interventions included to place the resident in high visibility areas for safety. The care card also identified that Resident #103 had a potential risk of choking/aspiration. Interventions included to encourage the resident to eat slowly, and chew food thoroughly. The care plan also identified Resident #103 was at risk for nutritional deficit due to impaired cognition and a mechanically altered diet. The interventions included to monitor for chewing difficulty, swallowing, and choking. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of 1 to 2 staff members with transfers, dressing, eating and toilet use. Review of facility documentation identified multiple accidents and incident reports for Resident #103 related to falls on 2/25, 3/7, 3/8, 3/13, 5/1, 5/3, 7/5 and 8/30/23. Interview with Person #10 on 9/12/23 at 9:54 AM identified Resident #103 had a history of falls prior to admission to the facility and that the facility had identified Resident #103 as a fall risk. The nurse aide care card dated 9/14/23 identified Resident #103 had multiple safety risks which included a risk of aspiration/choking and required tray set up and observation including difficulty chewing and/or swallowing. The care card also identified Resident #103 required safety interventions which included frequent visual checks and a yellow chart on the resident's bracelet to alert staff that Resident #103 was at high risk for falls and should be monitored closely. Observation on 9/15/23 beginning at 9:05 AM identified Resident #103's breakfast tray was located in his/her room on the bedside table. Further, the bedside table was positioned approximately 18 inches away from the foot of Resident #103's bed. The breakfast items were observed to be inside of a paper restaurant take out style box, and place on a plastic tray. The breakfast box appeared untouched, and Resident #103 was observed sleeping in his/her bed. The meal ticket located on Resident #103's tray identified he/she was an aspiration risk. During this observation, NA #3 was also observed at the opposite end of the unit delivering meal trays to residents on the unit. A constant observation of Resident #103's meal tray of 9:05 AM - 9:15 AM identified the meal tray remained in his/her room and no staff enter the room to assist Resident #103 with his/her meal. Observation at 9:15AM identified Resident #103 was awake, and NA #3 then entered Resident #103 and identified that Resident #103's meal was in his/her room, and she was there to assist with the meal. At 9:17 AM, LPN #3 then entered Resident #103's to help reposition Resident #103 to an upright position to eat. At 9:19 AM, NA #3 brought Resident #103's meal tray next to his/her bed and at 9:20 AM NA #3 was observed assisting Resident #103 with his/her meal. Observation at 9:27 AM identified Resident #103 had completed his/her breakfast and consumed 100% of his/her meal. Interview with NA #3 on 9/15/23 at 9:37 AM identified she delivered Resident #103's tray to his/her room, but since Resident #103 required feeding assistance she left the tray in the room and continued to deliver meal trays until all the residents on the unit had their trays. NA #3 identified that once the residents on the unit had their meals, she then came back to provide Resident #103 feeding assistance with his/her meal. NA#3 also identified Resident #103 was a fall risk and that he/she always tries to get up, we have to get him/her out of bed, cleaned up, dressed and then he/she is placed in the hallway by the nurse's station during the day so we can always keep an eye on him/her. Interview with LPN #3 on 9/15/23 at 9:40 AM identified that Resident #103's meal should have remained in the food truck until NA #3 was able to provide feeding assistance. LPN #3 identified Resident #103 was at risk for aspiration which is why he/she required feeding assistance, and also had a history of multiple falls due to attempts to try to stand. LPN #3 identified that the policy of the facility was that any residents who required feeding assistance should not have their meals delivered until a staff member was available to assist. Interview with the ADNS on 9/15/23 at 10:50 AM identified that Resident #103's meal tray should not have been delivered to his/her room until a staff member was able to provide feeding assistance at the time of the delivery, and the meal tray should not be in the room for 10 minutes. The ADNS identified that the facility dishwasher had malfunctioned and that resident meals were currently being delivered in paper containers as a result. The ADNS further identified that delivering Resident #103's meal prior to any staff being able to provide feeding assistance would also allow the meal to be cold by the time the food was offered to Resident #103. The ADNS further identified that Resident #103 was at risk for falls and that the meal tray in the room was a hazard risk as Resident #103 could have attempted to try to get up to retrieve it from the bedside table. The facility policy on falls directed that residents at risk for falls included confused residents and residents with a previous history of falls. The policy further directed that fall prevention measures included monitoring for any onsite environmental hazards and staff response to any potential or actual hazards. The facility policy on Activities of Daily Living (ADLs) identified that residents of the facility would be provided the necessary care and support in all ADLs consistent with the resident's need and ability to perform ADLs, and that ADLs included eating meals and snacks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #103) reviewed for nutrition, the facility failed to immediately ensure the Dietitian performed a nutritional assessment and implemented interventions when the resident had a significant weight loss. The findings include. Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia with agitation, and muscle weakness. A physician's order dated 2/13/23 directed Resident #103 required a mechanically soft, thin diet. The care plan dated 2/14/23 identified Resident #103 was at risk for nutritional deficit due to impaired cognition and a mechanically altered diet. The interventions included to monitor weights as ordered and report significant changes to the dietitian and physician. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of 1 to 2 staff members with transfers, dressing, eating and toilet use. Review of the electronic medical record dated 2/13/23 identified that Resident #103 weighed 149 lbs. Review of the electronic medical record dated 3/1/23 identified that Resident #103 weighed 152 lbs. Review of the electronic medical record dated 4/24/23 identified that Resident #103 weighed 142 lbs., a 10 lb. or 6.58 % loss over the course of approximately 6 weeks. Review of the clinical record failed to reflect that the physician, APRN, or resident representative had been notified on 4/24/23 of Resident #103's weight loss, or that any interventions were implemented related to the weight loss. A nutritional assessment completed by the dietitian on 5/15/23 identified Resident #103 had a weight of 134.5 lbs., 7.5% weight loss since admission on [DATE]. The note further identified the weight loss was significant and unexplained. Interventions included adding a soft sandwich with lunch and dinner and Boost plus supplement 120ml twice daily. The note failed to identify that the physician, APRN, or resident representative were notified of Resident #103's weight loss on that date. An APRN note dated 5/28/23 at 8:33 AM by APRN #1 identified Resident #103 was being seen for a recent weight decrease from 142 lbs. to 134.5 lbs. within a month. The treatment plan included obtaining labs, monitoring weights weekly, continue Boost plus supplements and current mechanical soft texture diet. The clinical record failed to identify the APRN was aware prior to 5/28/23 that Resident #103 had any issues related to weight loss. A care conference note dated 6/1/23 identified that Resident #103's resident representative was present and informed on that date that Resident #103 required a mechanical soft diet and was independent with meals. The care conference note failed to reflect Resident #103's documented significant weight loss was discussed or reviewed. A nurse's note dated 7/17/23 at 11:07 AM identified Resident #103 weighed 130 lbs., on that date and was recorded at 147 lbs. in June. The note further identified the RN supervisor, APRN and resident representative were notified of Resident #103's weight loss. Review of the clinical record failed to identify any documentation that the resident representative was notified of any issues related to Resident #103's weight loss prior to 7/17/23. Interview with Person #10 on 9/12/23 at 9:54 AM identified he/she had been notified of Resident #103's weight loss approximately 6 - 8 weeks prior. Person #10 further identified that the facility had not provided any other updates regarding interventions related to the weight loss except that Resident #103 was receiving supplementation with meals. Person #10 identified that he/she felt the facility had not done a good job with communicating the plan to address the ongoing issues related to weight loss, including any additional medical work up and any other interventions outside of additional nutritional supplementation. Interview with the ADNS on 9/15/23 at 10:50 AM identified that residents admitted to the facility should have an initial weight done, a repeat weight the following day during the 7 AM- 3PM shift, then weekly for 4 weeks, and if no issues were identified, weights monthly. The ADNS identified the nurse aides were primarily responsible to obtain residents' weights and document the weights in the weight book located at the nurse's station on the unit, and the nurses assigned to the residents were responsible to review the book and ensure the weights were obtained. The ADNS identified that a physician's order for weights was only entered if a resident required daily weights, but that if a resident required weekly or monthly weights, the sheets in the weight book were highlighted to identify the week or month. The ADNS also identified that other than the weight book located on each unit, there was no other method to prompt staff that a resident's weight was due or missing. The ADNS identified if a resident was identified by nursing as having a significant unplanned weight loss, that it was reported to the APRN and that the resident representative. The ADNS identified the Dietitian primarily entered the weights for all the facility residents into the electronic clinical records as she reviewed them, but that the nurses were also responsible to review the weights. The ADNS identified that Resident #103 could become agitated and if that occurred when staff were attempting to obtain a weight, the weight sheet would reflect an R at the area where the weight would be recorded. The ADNS identified she was unsure why Resident #103 did not have weights completed weekly on admission for 4 weeks, why there were multiple missing weights throughout Resident #103's clinical record, why there were no nursing assessments related to Resident #103's weight loss on 4/24/23 or on 5/15/23 when the nutritional assessment identified a significant weight loss with interventions. Interview with the Dietitian on 9/15/23 at 1:58 PM identified she documented Resident #103's initial weight loss on 4/24/23 in the electronic record but was unable to locate any documentation related to any assessment or interventions related to the weight loss on 4/24/23. The Dietitian also was unable to identify any documentation related to notification of the physician or APRN regarding Resident #103's weight loss on 4/24/23. The Dietitian identified that, while she reviewed the weights in the weight books weekly and entered the weights into the electronic record, the nursing staff including licensed nurses and nurse aides had a weight book located on each unit, that the nurse aides obtained the weights and added them to the book, and the nurses assigned to the resident were responsible to review weights and to notify the resident representative of any issues. The Dietitian identified that the frequency of weights was not a physician's order but was identified in the weight book and based on facility policy. The Dietitian was also unable to identify why she did not notify APRN #1 of Resident #103's subsequent weight loss until 5/28/23 following her nutritional assessment on 5/15/23. The Dietitian identified that she had a form she used to communicate any nutritional issues with APRN #1, but this form was for communication purposes only and not part of the clinical record, and that she reviewed the forms she had on file and was unable to locate any documentation that she communicated any issues related to Resident #103's weight loss. Further, the Dietitian failed to identify why, if she reviewed the weight book weekly, there were multiple weights missing and no documentation by her related to any follow up, given Resident #103 required weekly weights going back to at least 5/8/23. Interview with APRN #1 on 9/15/23 at 2:06 PM identified she was not notified by the Dietitian of any issues related to Resident #103's weight loss until 5/28/23. APRN #1 identified that the Dietitian used a communication sheet to inform her of any issues with residents of the facility, but if a resident was flagged for weight loss, she would be prompted to evaluate the resident since she is in the facility almost daily. APRN #1 identified that Resident #103 had been consuming 100% of most meals, and she felt Resident #103 had end stage dementia, although that information was not documented in the clinical record. APRN #1 identified that the facility staff needed to work on communicating and documenting the communications in the clinical record and that the facility would set up a meeting with Resident #103's resident representative to discuss the ongoing issues with Resident #103's weight loss. Although requested, the facility failed to provide any communication forms used by the Dietitian to the APRN for Resident #103. The facility policy on nutritional assessments identified that the nutritional assessment shall be completed within 7 -14 days of a resident's admission to the facility, quarterly, annually and when there is any significant change in status with the resident by the Dietitian. The policy further directed the assessment shall cover, but was not limited to, nutritional status and needs including weight history, and summary of current and potential deficiencies, and if a need for further assessment was identified, the information would be documented in the progress note section of the medical chart. The facility policy on unplanned weight loss directed that residents would be nutritionally assessed no later than 72 hours of recognition that an unplanned significant, severe or insidious weight loss had occurred. The policy identified a significant weight loss as 5% over one month, severe was greater than 5% over one month, and insidious as gradual unintended weight loss over one month. The policy directed that for an identified weight loss that was unplanned, the dietitian would notify the medical provider of the weight loss and document the notification in the resident's medical record. The policy further directed that the Dietitian evaluate the cause of the weight loss with the team, while simultaneously instituting appropriate interventions to correct or prevent further weight loss, and that appropriate interventions for weight loss included determining nutritional needs, notifying unit staff (nurses and nurse aides) and discussing possible causes, recommending nutritional supplements or snacks, and monitoring weekly weights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #119) reviewed for tube feeding, the facility failed to properly label and date the tube feed container and syringe irrigation set according to facility policy. The findings include: Resident #119 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gastrostomy status, and dysphagia oropharyngeal phase. The admission MDS dated [DATE] identified Resident #119 had moderately impaired cognition, required total assistance for bed mobility, transferring, eating, and was on tube feed. The care plan dated 9/6/23 identified a focus on tube feeding related to dysphagia, with interventions to check tube placement and gastric contents/residual volume per facility protocol and record. Physician's order dated 8/15/23 directed to administer Jevity 1.2 at a rate of 75ml/hr for 16 hours beginning at 4:00 PM and off at 8:00 AM. Further, to complete the following related to the tube feed every shift. Keep head elevated during feeding and for one hour after feeding. May interrupt feeding for medications, labs and care as needed. Check the tube for leaks, cracks, clogs and/or obstructions. Change the tube as needed as per physician's order and one time a day for enteral feeding. Change irrigation and feeding set-up. Tube Feeding/Site Care: cleanse with soap and water, apply dressing daily, and as needed for enteral feeding tube feeding/site care: cleanse with soap and water, apply dressing daily. Observation on 9/12/23 at 10:20 AM identified Jevity 1.5 hanging without the benefit of a lable with the resident's name, or date. Additionally, the syringe was in a bottle of water on the bedside table undated and not in a bag. Observation and interview on 9/12/23 at 11:50 AM with the ADNS identified Jevity 1.5 was hung and not labeled with resident's name, date, and the rate of infusion. The syringe was not in the bag, which was not dated, the syringe was in a bottle of water on the bedside table undated. The ADNS identified it is the charge nurse's responsibility and her expectation to identify the tube feed contents, resident, time administered on the tube feed container, date the tubing, as well as date the syringe bag, and return the syringe to the bag when not in use. The ADNS discarded the tube feed, the syringe as well as the container of water. The policy on Feeding Tubes: Re-insertion, Placement, Med Administration, Complication identified all shifts are responsible for following infection control practices when caring for feeding tube, insertion site and administering medication. Also, the syringe/irrigation set will be changed every twenty-four hours and will be dated and replaced by the night shift. The night shift will be responsible for discarding the irrigation sets daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #54) reviewed for dialysis, the facility failed to document daily intake and output on a resident who had orders for a fluid restriction. The findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertensive chronic kidney disease, and dependence on dialysis. A physician's order dated 2/3/23 directed Resident #54 to have a daily 1000ml fluid restriction and to document the amount consumed in the resident's intake and output record. On 8/14/23 this order was discontinued due to Resident #54's hospitalization and was not reinstated when the resident returned to the facility. The quarterly MDS dated [DATE] identified Resident #54 had intact cognition, was independent with eating and personal hygiene, and required dialysis. The care plan dated 9/4/23 identified Resident #54 had the potential for nutritional deficit related to diagnoses of end stage renal disease on dialysis, congestive heart failure, myocardial infarction, Parkinson's disease, and history of enteral tube feeding. Interventions included to maintain a 1000ml daily fluid restriction: dietary restrictions were 480ml per day and nursing restrictions were 520ml per day. Review of the September 2023 monthly intake and output log failed to identify documentation of Resident #54's intake on the following dates and shifts. 9/1/23 through 9/14/23, (14 days) during the 11:00 PM to 7:00 AM shift. 9/4/23 during the 7:00 AM to 3:00 PM shift. 9/8/23 through 9/11/23, (4 days) during the 7:00 AM to 3:00 PM shift. 9/1/23 through 9/14/23, (14 days) during the 3:00 PM to 11:00 PM shift. Urinary output was not documented on the following dates. 9/2/23 through 9/14/23, (14 days) during the 11:00 PM to 7:00 AM shift. 9/8/23 through 9/14/23, (7 days) during the 7:00 AM to 3:00 PM shift. 9/1/23 through 9/14/23, (14 days) during the 3:00 PM to 11:00 PM shift. Twenty-four hour totals were not completed from 9/1/23 through 9/14/23 (14 days). Interview with the Dietitian on 9/14/23 at 8:01 AM identified that Resident #54 is on a fluid restriction, and she would expect to see the resident's intake and output documented. The Dietitian further indicated that it is the responsibility of the nurse aide and nurse to ensure the daily intake and output documentation is completed. Interview with APRN #1 on 9/14/23 at 3:23 PM identified that she would expect Resident #54's intake and output to be monitored daily to ensure he/she is within his/her daily fluid restriction. Interview and review of the clinical record with RN #7 on 9/15/23 at 7:42 AM indicated that Resident #54 was on a fluid restriction, and that there were two places where intake and output can be documented, in the electronic health record or on the monthly intake and output form, located in a binder. RN #7 identified that the process for monitoring residents on a fluid restriction is as follows: the nurse aide will report to the nurse the amount of fluid consumed during meals, the nurse will monitor the amount of fluid consumed during medication passes, and the nurse is responsible to document the total at the end of the shift. RN #7 indicated that Resident #54 still produces some urine, and the resident will self-report to the nurse how many times he/she voided or was incontinent; it is the responsibility of the nurse to document the output occurrences. Interview and review of the clinical record with the ADNS on 9/15/23 at 9:29 AM indicated that the expectation is for the daily intake and output to be documented on residents with a fluid restriction, and it is ultimately the responsibility of the charge nurse. The ADNS was unable to identify why Resident #54's daily intake and output was not documented on the dates and times identified. The ADNS indicated that she would reeducate the nursing staff about intake and output monitoring for residents on a fluid restriction and audit their documentation. Subsequent to surveyor inquiry staff education entitled: Intake and Output, was initiated on 9/15/23. Review of the facility's Measurement of Intake and Output policy directed licensed nurses were responsible for the calculation and recording of intake and output. The charge nurse would review the nurse aide documentation and total the amount of intake and output from all sources for the shift. The 7:00 AM to 3:00 PM unit manager or designee is responsible for the twenty-four-hour totaling at 7:00 AM. The twenty-four-hour period will be calculated from 7:00 AM to 7:00 AM and recorded in PCC MAR/progress note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #5) who was admitted on an antipsychotic medication, the facility failed to complete a baseline Abnormal Involuntary Motion Scale (AIMS) assessment on admission, after 6 months and with the initiation of a new antipsychotic medication, failed to complete a thorough baseline mental health assessment, and failed to complete on-going mental health assessments including assessment after the initiation of a new antipsychotic medication, and for 1 of 3 residents (Resident #103) reviewed for behavior and emotional status, the facility failed to ensure the resident was provided ongoing evaluation and reassessment by psychiatric services following an increase in psychotropic medications. The findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, borderline personality disorder, and major depressive disorder. Review of the mental health progress note dated 1/30/23 at 7:44 PM identified the Psychiatric PA's recommendations were to continue with the following medication orders: Seroquel (antipsychotic) 25 mg at bedtime, Lamictal (anticonvulsant used for the treatment of bipolar) 150mg twice daily, and Nortriptyline (antidepressant) 10mg at bedtime. The mental health progress note failed to identify a baseline Abnormal Involuntary Motion Scale (AIMS) had been completed upon the resident's admission to the facility. The quarterly MDS dated [DATE] identified Resident #5 had moderately impaired cognition, required an extensive one-person physical assistance with eating and personal hygiene, and had received antipsychotic medications. The care plan dated 8/8/23 identified Resident #5 had a mood state problem related to a diagnosis of depression. Interventions included to administer medications as ordered, monitor and document for side effects and effectiveness, and receive psychological evaluations and therapy as prescribed. A physician's order dated 8/21/23 directed to administer Risperdal (antipsychotic) 0.5mg two times daily for bipolar disorder. The clinical record failed to identify an AIMS assessment was completed. a. Interview with the Psychiatric PA on 9/14/23 at 3:55 PM indicated that he had completed a baseline AIMS during his initial evaluation with Resident #5, on 1/30/23 but was unable to find it. The Psychiatric PA identified that on 7/17/23 he received a recommendation from the Consultant Pharmacist to complete a baseline AIMS. The Psychiatric PA indicated that he acknowledged the pharmacy recommendation and completed the AIMS, however he did not post/add the documentation to Resident #5's medical record. The Psychiatric PA further indicated that on 9/5/23 an AIMS was completed with a score of 0. b. Further interview with the psychiatric PA on 9/14/23 at 3:55 PM indicated that he had completed an initial comprehensive evaluation and behavior assessment for Resident #5, on 1/30/23. The Psychiatric PA further identified that Resident #5 also received psychiatric services on 7/5/23 and 7/17/23, but documentation was not posted/added to the resident's medical record. The Psychiatric PA indicated that he typically consults with residents monthly or more depending on if there is a clinical need. The Psychiatric PA identified that Resident #5 did not receive psychiatric services from January through June of 2023, 5 months, and indicated that the argument could be made that it was appropriate for Resident #5 to receive psychiatric services in January 2023 and not again until July 2023 because he/she was stable, however, it would be preferable to see residents receiving psychotropic medications more frequently. Subsequent to surveyor inquiry mental health progress notes dated 7/3/23, 7/17/23, and 9/5/23 were posted to Resident #5's facility electronic medical record. Interview with the ADNS on 9/15/23 at 9:15 AM indicated that she would expect the Psychiatric PA to have completed an AIMS on Resident #5's admission, quarterly, when starting new antipsychotic medications, or if there was a change in condition. Further, the ADNS indicated that residents receiving psychotropic medications should have a visit from the psychiatric provider and have documented progress notes in the medical record, at least every 90 days, if the resident is stable. The ADNS further identified that she would have expected to see a progress note following a visit in Resident #5's medical record, from the Psychiatric PA, in April of 2023 (90 days after the 1/30/23 comprehensive evaluation). The ADNS indicated that routine visits are expected quarterly, but if there was a change in condition or if the facility staff had a concern, they would contact the psychiatric provider immediately. Interview with the Psychiatric PA on 9/15/23 at 12:05 PM indicated that he was not able to locate the baseline AIMS and indicated that the documentation should have been included in the initial note, but he was unable to identify why it was not. Review of the facility's AIMS policy directed that an AIMS examination would be administered to all residents for whom psychotropic medications are prescribed. The examination would be administered by the behavioral health medical provider at the time when medications are initially prescribed. In addition, for patients taking psychotropic medication, AIMS examination procedures will be repeated at intervals of no less than every 6 months. Review of the facility's Psychotropic Medications policy directed a physician/psychiatrist will only order psychotropics based on a comprehensive assessment of a resident to treat a specific documented condition. Review of the facility's Resident Rights and Responsibilities policy directed each resident to receive adequate and appropriate medical care. 2. Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, restlessness and agitation. The hospital discharge record dated 2/13/23 identified Resident #103 had been seen at the hospital following increased weakness, increased confusion, decline in condition, inability to walk, and multiple falls at home. The hospital records further identified Resident #103 was on medications including Depakote (medication to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches) 125 mg twice daily. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of 1 to 2 staff members with transfers, dressing, eating and toilet use. The care plan dated 3/7/23 identified Resident #103 had a potential for psychotropic drug use complications related to use of Depakote, Trazadone, and Zoloft. Interventions included to monitor for target behavior symptoms (including pacing, wandering, violence/aggression) and document per facility policy; provide psychological services as ordered; and provide gradual dose reduction and behavioral interventions unless clinically contraindicated. The care plan also identified that Resident #103 had actual behaviors which included restlessness, poor safety awareness and impaired conditions. The interventions included to monitor and evaluate for signs and symptoms of confusion, change in ADL functioning, decreased nutrition/hydration/weight, difficulty in communication, and medication side effects. Physician's order dated 3/20/23 directed to administer Depakote 250 mg extended release (ER) tablet, 2 tablets twice daily for mood/anxiety. Physician's order dated 3/27/23 directed to administer Trazadone (antidepressant) 25 mg every 6 hours as needed for anxiety for 14 days. A laboratory report dated 3/28/23 identified a Valproic Acid level, (used to monitor Depakote levels), was 41.1 (normal reference range 50-100). A psychiatric note dated 4/17/23, by the Psychiatric PA, identified he evaluated Resident #103 for medication management, behavioral assessment, and for evaluation of possible GDR of medications in the context of diagnoses which included dementia, depression, and anxiety. The note further identified that facility staff had reported Resident #103 had exhibited behaviors including intermitted agitation and anxiety which caused Resident #103 to yell and be resistive to care. The treatment plan identified Resident #103 would be started on Depakote ER 750 mg twice daily (an increase in the medication). Physician's order dated 4/17/23 directed to administer Depakote ER 750 mg twice daily. A psychiatric note dated 4/24/23, by the Psychiatric PA, identified he evaluated Resident #103 for medication management, behavioral assessment, and for evaluation of possible GDR of medications in the context of diagnoses which included dementia, depression, and anxiety. The note further identified that facility staff had reported Resident #103 had exhibited behaviors including intermitted agitation and anxiety which caused Resident #103 to yell and be resistive to care. The treatment plan identified Resident #103 would continue on Depakote ER 750 mg twice daily; start Zoloft 50 mg (an antidepressant) every morning, start Trazadone 75 mg every 6 hours as needed for 14 days for anxiety, and continue Trazadone 50 mg daily at bedtime. Review of facility documentation identified multiple accidents and incident reports for Resident #103 related to falls for 2/25, 3/7, 3/8, 3/13, 5/1, 5/3, 7/5 and 8/30/23. The physician note dated 5/3/23 identified Resident #103 had a Valproic Acid level of 39. The note did not identify when the level was obtained, and review of the clinical record failed to identify the actual lab result, including a date of the result or laboratory used. Although requested, the facility failed to provide any lab results, including valproic acid levels, for Resident #103 for any dates after 3/28/23. A psychiatric note dated 5/8/23 by the Psychiatric PA identified he evaluated Resident #103 for medication management, behavioral assessment, and for evaluation of possible GDR of medications in the context of diagnoses which included dementia, depression, and anxiety. The note further identified that facility staff had reported Resident #103 had exhibited behaviors including intermitted agitation and anxiety which caused Resident #103 to yell and be resistive to care. The treatment plan identified Resident #103 would continue on Depakote ER 750 mg twice daily, continue Trazadone 50 mg at bedtime as needed for depression, start Trazadone 75 mg every 6 hours as needed for 14 days for anxiety, and increase Zoloft from 50 mg to 100 mg every morning for depression, that the prescribed medications were for specific behaviors and diagnoses, and routine follow up would be done by the prescriber to evaluate risks versus benefit of the current regimen, development of any adverse drug reactions, and to monitor for any signs or symptoms of exacerbation. Review of the clinical record failed to identify any psychiatric assessments or notes after 5/8/23, including any re-evaluation following the Zoloft dose increase, or any evaluation of the medication regimen related to Resident #103's history of multiple falls. A nutritional assessment completed by the Dietitian on 5/15/23 identified Resident #103 had a weight of 134.5 lbs., a 7.5% weight loss since admission on [DATE]. The note further identified the weight loss was significant and unexplained, and that significant medications with a nutritional impact included Depakote, Trazadone, and Zoloft. Interview with Person #10 on 9/12/23 at 9:54 AM identified Resident #103 had a history of falls prior to admission to the facility and that the facility had identified Resident #103 as a fall risk. Person #10 also identified he/she had been notified of Resident #103's weight loss approximately 6-8 weeks prior. Interview with MD #1 (Medical Director) on 9/15/23 at 10:20 AM identified that with a Depakote dose increase, he would expect that a Valproic Acid level to be drawn within one week of the increase. MD #1 further identified that when Depakote was used for mood and behavior, the dosing of the medication did not have to be as strictly monitored since it was not used for seizure control; however, a dose of 750 mg twice daily was a significant Depakote dose, and with a significant weight loss, he would expect the Valproic Acid level to be rechecked, to monitor for Valproic Acid toxicity. Interview with the Psychiatric PA on 9/15/23 at 11:33 AM identified he had not evaluated Resident #103 since 5/8/23, but he would only re-evaluate Resident #103 for an acute change, or as needed. The Psychiatric PA identified that he increased Resident #103's Zoloft dose on 5/8/23 but that he did not re assess Resident #103 to determine the outcome of the dose increase. The Psychiatric PA identified he was in the facility often and would see Resident #103 sitting at the nurse's station, but he did not complete any assessments or document any follow up related to Resident #103's medication regimen. The Psychiatric PA further identified that he was aware Resident #103 had a history of falls but was not aware that Resident #103 had any recent weight loss, and that theoretically Depakote could cause weight loss. The Psychiatric PA failed to identify why he did not re-evaluate Resident #103's response to the recent Depakote increase, or why he failed to re-evaluate Resident #103's response to the Zoloft increase on 5/8/23. Interview with APRN #1 on 9/15/23 at 2:06 PM identified she was not aware the Psychiatric PA had not documented any assessments for Resident #103 since 5/8/23, 5 months ago. APRN #1 identified the Psychiatric PA was in the facility almost daily and they often discussed issues with residents, specific to behaviors, including the need for laboratory monitoring, but APRN #1 did not remember the Psychiatric PA notifying her that Resident #103 needed a Valproic Acid level, and the most recent level she was able to locate in the chart was done 3/28/23. APRN #1 identified that the facility staff needed to work on communicating and documenting the communications in the clinical record. The facility policy on laboratory monitoring of medications directed that the purpose of the policy was to ensure optimum therapeutic response to medication and to prevent and detect toxicity and adverse drug events. The policy further directed that residents would have Valproic Acid levels and liver function tests monitored, at a minimum within 30 days of initiation of the medication, and every 6 months thereafter. The facility policy on psychotropic medications directed that a psychotropic medication included any drug that affected brain activities associated with mental processes and behavior, and that those drugs included, but were not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotics. The policy further directed that the medical provider/psychiatrist would only order psychotropics based on a comprehensive assessment of the resident to treat a specific documented condition, and never for the purpose of discipline or convenience. The policy also directed the medical provider/psychiatrist would monitor the resident and discontinue any drugs if harmful effects of the medication outweighed the beneficial effects of the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #5) who was admitted on an antipsychotic medication and had recommendations from the pharmacy for an AIMS test to be completed, the facility failed to ensure the recommendations were reviewed and acted upon by the attending physician, the DNS or the Medical Director. The findings include. Resident #5 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, borderline personality disorder, and major depressive disorder. Review of the mental health progress note dated 1/30/23 at 7:44 PM identified the Psychiatric PA's recommendations were to continue with the following medication orders: Seroquel (antipsychotic) 25 mg at bedtime, Lamictal (anticonvulsant used for the treatment of bipolar) 150mg twice daily, and Nortriptyline (antidepressant) 10mg at bedtime. The mental health progress note failed to identify a baseline Abnormal Involuntary Motion Scale (AIMS) had been completed upon the resident's admission to the facility. Review of the Drug Regimen Review - Physician Referrals/Findings documentation dated 2/1/23 and 6/5/23 identified Unable to locate recent Abnormal Involuntary Motion Scale (AIMS) test in chart. Per facility policy, baseline AIMS test is recommended after initiation of therapy and every six months thereafter to assess the potential development and progression of side effects. If not ordered already, please consider doing so now. Although the pharmacy reported the irregularity on 2/1/23 and 6/5/23 and recommended that an AIMS test be done now, the recommendation was not reviewed or acted upon by the attending physician, the DNS or the Medical Director. Review of the Drug Regimen Review - Physician Referrals/Findings documentation dated 7/17/23 recommended an AIMS test be done. The recommendation was acknowledged by a signature from the licensed provider, however, the AIMS test was not added to Resident #5's medical record. Review of the Drug Regimen Review - Physician Referrals/Findings documentation dated 8/3/23 recommended an AIMS test be done. The recommendation was not acknowledged by a signature from the licensed provider. The quarterly MDS dated [DATE] identified Resident #5 had moderately impaired cognition, required an extensive one-person physical assistance with eating and personal hygiene, and had received antipsychotic medications. The care plan dated 8/8/23 identified Resident #5 had a mood state problem related to a diagnosis of depression. Interventions included to administer medications as ordered, monitor and document for side effects and effectiveness, and receive psychological evaluations and therapy as prescribed. A physician's order dated 8/21/23 directed to administer Risperdal (antipsychotic) 0.5mg two times daily for bipolar disorder. The clinical record failed to identify an AIMS assessment was completed. Interview with the Psychiatric PA on 9/14/23 at 3:55 PM indicated that he had completed a baseline AIMS during his initial evaluation with Resident #5, on 1/30/23 but was unable to find it. The Psychiatric PA identified that on 7/17/23 he received a recommendation from the Consultant Pharmacist to complete a baseline AIMS. The Psychiatric PA indicated that he acknowledged the pharmacy recommendation and completed the AIMS, however he did not post/add the documentation to Resident #5's medical record. The Psychiatric PA indicated that the former DNS did not provide him with the 6/5/23 Drug Regimen Review - Physician Referrals/Findings, but he indicated that on 7/17/23 he received a recommendation from the Consultant Pharmacist to complete a baseline AIMS test. The Psychiatric PA indicated that he acknowledged that recommendation and completed the AIMS, however he did not post/add the AIMS into Resident #5's medical record. The Psychiatric PA further indicated that on 9/5/23 an AIMS was completed with a score of 0. Interview with the ADNS on 9/15/23 at 9:15 AM indicated that after the Consultant Pharmacist completes the Drug Regimen Review - Physician Referrals/Findings she will first send a clarification email followed by an all-house report. The ADNS indicated that she would print the recommendations and then distribute them to the appropriate providers. The ADNS identified that she was responsible for providing the medical APRN with medical recommendations and the prior DNS was responsible for providing the psychiatric provider with the monthly psychiatric recommendations. After the appropriate provider acknowledges the pharmacist's recommendations, the documents were filed in a binder. The ADNS was unable to explain why there were Drug Regimen Review - Physician Referrals/Findings without signatures from the Psychiatric PA, as she was not responsible for following up with that provider, it was the responsibility of the former DNS. Interview with the former DNS on 9/15/23 at 11:19 AM indicated that she had given the Drug Regimen Review - Physician Referrals/Findings to the Psychiatric PA, and she had messaged him multiple times with reminders to ensure the documentation was signed and the recommendations acknowledged. Review of the facility's Drug Regimen Review policy directed the consultant pharmacist shall identify, document, and report possible medication irregularities for review and action by the attending physician, where appropriate. The attending physician or licensed designee shall respond to the Drug Regimen Review within 30 days or more promptly, whenever possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #103) reviewed for mood and behavior, the facility failed to ensure that a resident's medication regimen was monitored and re-assessed following an increase in psychotropic medications. The findings include: Resident #103 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, restlessness and agitation. The hospital discharge record dated 2/13/23 identified Resident #103 had been seen at the hospital following increased weakness, increased confusion, decline in condition, inability to walk, and multiple falls at home. The hospital records further identified Resident #103 was on medications including Depakote (medication to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches) 125 mg twice daily. The admission MDS dated [DATE] identified Resident #103 had severely impaired cognition, was frequently incontinent of bowel and bladder and required the assistance of 1 to 2 staff members with transfers, dressing, eating and toilet use. The care plan dated 3/7/23 identified Resident #103 had a potential for psychotropic drug use complications related to use of Depakote, Trazadone, and Zoloft. Interventions included to monitor for target behavior symptoms (including pacing, wandering, violence/aggression) and document per facility policy; provide psychological services as ordered; and provide gradual dose reduction and behavioral interventions unless clinically contraindicated. The care plan also identified that Resident #103 had actual behaviors which included restlessness, poor safety awareness and impaired conditions. The interventions included to monitor and evaluate for signs and symptoms of confusion, change in ADL functioning, decreased nutrition/hydration/weight, difficulty in communication, and medication side effects. Physician's order dated 3/20/23 directed to administer Depakote 250 mg extended release (ER) tablet, 2 tablets twice daily for mood/anxiety. Physician's order dated 3/27/23 directed to administer Trazadone (antidepressant) 25 mg every 6 hours as needed for anxiety for 14 days. A laboratory report dated 3/28/23 identified a Valproic Acid level, (used to monitor Depakote levels), was 41.1 (normal reference range 50-100). A psychiatric note dated 4/17/23, by the Psychiatric PA, identified he evaluated Resident #103 for medication management, behavioral assessment, and for evaluation of possible GDR of medications in the context of diagnoses which included dementia, depression, and anxiety. The note further identified that facility staff had reported Resident #103 had exhibited behaviors including intermitted agitation and anxiety which caused Resident #103 to yell and be resistive to care. The treatment plan identified Resident #103 would be started on Depakote ER 750 mg twice daily (an increase in the medication). Physician's order dated 4/17/23 directed to administer Depakote ER 750 mg twice daily. A psychiatric note dated 4/24/23, by the Psychiatric PA, identified he evaluated Resident #103 for medication management, behavioral assessment, and for evaluation of possible GDR of medications in the context of diagnoses which included dementia, depression, and anxiety. The note further identified that facility staff had reported Resident #103 had exhibited behaviors including intermitted agitation and anxiety which caused Resident #103 to yell and be resistive to care. The treatment plan identified Resident #103 would continue on Depakote ER 750 mg twice daily; start Zoloft 50 mg (an antidepressant) every morning, start Trazadone 75 mg every 6 hours as needed for 14 days for anxiety, and continue Trazadone 50 mg daily at bedtime. Review of facility documentation identified multiple accidents and incident reports for Resident #103 related to falls for 2/25, 3/7, 3/8, 3/13, 5/1, 5/3, 7/5 and 8/30/23. The physician note dated 5/3/23 identified Resident #103 had a Valproic Acid level of 39. The note did not identify when the level was obtained, and review of the clinical record failed to identify the actual lab result, including a date of the result or laboratory used. Although requested, the facility failed to provide any lab results, including valproic acid levels, for Resident #103 for any dates after 3/28/23. A psychiatric note dated 5/8/23 by the Psychiatric PA identified he evaluated Resident #103 for medication management, behavioral assessment, and for evaluation of possible GDR of medications in the context of diagnoses which included dementia, depression, and anxiety. The note further identified that facility staff had reported Resident #103 had exhibited behaviors including intermitted agitation and anxiety which caused Resident #103 to yell and be resistive to care. The treatment plan identified Resident #103 would continue on Depakote ER 750 mg twice daily, continue Trazadone 50 mg at bedtime as needed for depression, start Trazadone 75 mg every 6 hours as needed for 14 days for anxiety, and increase Zoloft from 50 mg to 100 mg every morning for depression, that the prescribed medications were for specific behaviors and diagnoses, and routine follow up would be done by the prescriber to evaluate risks versus benefit of the current regimen, development of any adverse drug reactions, and to monitor for any signs or symptoms of exacerbation. Review of the clinical record failed to identify any psychiatric assessments or notes after 5/8/23, including any re-evaluation following the Zoloft dose increase, or any evaluation of the medication regimen related to Resident #103's history of multiple falls. A nutritional assessment completed by the Dietitian on 5/15/23 identified Resident #103 had a weight of 134.5 lbs., a 7.5% weight loss since admission on [DATE]. The note further identified the weight loss was significant and unexplained, and that significant medications with a nutritional impact included Depakote, Trazadone, and Zoloft. Interview with Person #10 on 9/12/23 at 9:54 AM identified Resident #103 had a history of falls prior to admission to the facility and that the facility had identified Resident #103 as a fall risk. Person #10 also identified he/she had been notified of Resident #103's weight loss approximately 6-8 weeks prior. Interview with MD #1 (Medical Director) on 9/15/23 at 10:20 AM identified that with a Depakote dose increase, he would expect that a Valproic Acid level to be drawn within one week of the increase. MD #1 further identified that when Depakote was used for mood and behavior, the dosing of the medication did not have to be as strictly monitored since it was not used for seizure control; however, a dose of 750 mg twice daily was a significant Depakote dose, and with a significant weight loss, he would expect the Valproic Acid level to be rechecked, to monitor for Valproic Acid toxicity. Interview with the Psychiatric PA on 9/15/23 at 11:33 AM identified he had not evaluated Resident #103 since 5/8/23, but he would only re-evaluate Resident #103 for an acute change, or as needed. The Psychiatric PA identified that he increased Resident #103's Zoloft dose on 5/8/23 but that he did not re assess Resident #103 to determine the outcome of the dose increase. The Psychiatric PA identified he was in the facility often and would see Resident #103 sitting at the nurse's station, but he did not complete any assessments or document any follow up related to Resident #103's medication regimen. The Psychiatric PA further identified that he was aware Resident #103 had a history of falls but was not aware that Resident #103 had any recent weight loss, and that theoretically Depakote could cause weight loss. The Psychiatric PA failed to identify why he did not re-evaluate Resident #103's response to the recent Depakote increase, or why he failed to re-evaluate Resident #103's response to the Zoloft increase on 5/8/23. Interview with APRN #1 on 9/15/23 at 2:06 PM identified she was not aware the Psychiatric PA had not documented any assessments for Resident #103 since 5/8/23, 5 months ago. APRN #1 identified the Psychiatric PA was in the facility almost daily and they often discussed issues with residents, specific to behaviors, including the need for laboratory monitoring, but APRN #1 did not remember the Psychiatric PA notifying her that Resident #103 needed a Valproic Acid level, and the most recent level she was able to locate in the chart was done 3/28/23. APRN #1 identified that the facility staff needed to work on communicating and documenting the communications in the clinical record. The facility policy on laboratory monitoring of medications directed that the purpose of the policy was to ensure optimum therapeutic response to medication and to prevent and detect toxicity and adverse drug events. The policy further directed that residents would have Valproic Acid levels and liver function tests monitored, at a minimum within 30 days of initiation of the medication, and every 6 months thereafter. The facility policy on psychotropic medications directed that a psychotropic medication included any drug that affected brain activities associated with mental processes and behavior, and that those drugs included, but were not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotics. The policy further directed that the medical provider/psychiatrist would only order psychotropics based on a comprehensive assessment of the resident to treat a specific documented condition, and never for the purpose of discipline or convenience. The policy also directed the medical provider/psychiatrist would monitor the resident and discontinue any drugs if harmful effects of the medication outweighed the beneficial effects of the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, job descriptions, and interview for 3 of 4 floors, the facility failed to ensure the environment was clean, maintained in good repair and homelike, and failed to ensure the clean linen cart covers were intact, and failed to ensure the door to a resident's room was good repair. The findings include: 1. Observation during the initial tour on 9/13/23 at 11:00 AM, and again on 9/15/23 at 10:15 AM with the Maintenance/Housekeeping Supervisor, Regional [NAME] Services, and the CEO (Interim Administrator) identified the following: One clean linen cart on each of the Two East, Two West, Three [NAME] A, and Four [NAME] B units, located in the hallway was identified damaged, torn and/or worn. Interview with the CEO (Interim Administrator) on 9/15/23 at 10:37 AM identified he was not aware of the damaged, torn and/or worn linen cart covers and identified the facility will purchase new linen covers for carts. Interview with the Regional [NAME] Services Person on 9/15/23 at 10:39 AM identified he was not aware of the issue. Interview with the Maintenance/Housekeeping Supervisor on 9/15/23 at 10:45 AM identified he was not aware of the damaged, torn, and/or worn linen cover carts. 2. Review of the environmental rounds worksheet for infection prevention control (monthly log) identified the last infection control monthly rounds were completed on 5/17/23, 3 1/2 months ago. Review of the environmental rounds audit tool dated 8/18/23 at 11:00 AM identified documentation that the environment is clean (walls, floors, drapes/blinds, furniture, linens, privacy curtains, window/sills, beds, bathrooms). The form failed to reflect what unit the environment rounds were performed. Observations on 9/13/23 at 11:00 AM through 2:00 PM, and on 9/15/23 at 10:15 AM with the Maintenance/Housekeeping Supervisor, Regional [NAME] Services, and the CEO identified the following. a. Damaged, chipped, stains and/or marred bedroom walls on Two [NAME] A unit in rooms 222, and 227. Two [NAME] B unit in rooms 233, 234, 235, 236, 237, and 240. Three [NAME] A unit in rooms 320, 321, 326, and 328. Three [NAME] B unit in rooms 331, and 339. Four [NAME] B unit in rooms 432, 434, 435, 436, 438, and 439. b. Damaged, chipped, stains, and/or marred bathroom walls on Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in room [ROOM NUMBER]. Four [NAME] B unit in room [ROOM NUMBER]. c. Damaged, chipped, stains and/or marred walls in the hallways on Three [NAME] A unit and Four [NAME] B unit. d. Damaged, chipped, marred and/or peeling doors in the bedroom on Two [NAME] B unit in room [ROOM NUMBER], Three [NAME] A unit in room [ROOM NUMBER] and Four [NAME] B unit in room [ROOM NUMBER]. e. Damaged, and/or rusty bedroom radiator on Two [NAME] B on unit in room [ROOM NUMBER]. f. Damaged, and/or rusty bathroom radiators on Two [NAME] B unit in rooms 236, and 237, and on Three [NAME] A unit in room [ROOM NUMBER]. g. Damaged, cracked, and/or stains on the bedroom ceiling on Two [NAME] A unit in room [ROOM NUMBER]. Two [NAME] B unit in rooms 234, and 238. Three [NAME] A unit in rooms 337, 338, 322, 324, 327, 329, and 330. Three [NAME] B unit in rooms 331, 335, 336, and 339. Four [NAME] B unit in room [ROOM NUMBER]. h. Damaged, cracked, and/or stained ceiling in the bathroom on Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in rooms [ROOM NUMBER]. Four [NAME] B unit in room [ROOM NUMBER]. i. Damaged, bent, and/or missing window blinds in bedroom on Three [NAME] A unit in room [ROOM NUMBER]. Three [NAME] B unit in rooms 335, and 339. Four [NAME] B unit in room [ROOM NUMBER]. j. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on Three [NAME] A unit in room [ROOM NUMBER], and 326. Four [NAME] B unit in room [ROOM NUMBER]. k. Damaged, broken, missing, peeling and/or dirty cove base in the bathroom on Three [NAME] B in rooms 333, and 336. l. Damaged, torn, stains, and/or off-track privacy curtains on Two [NAME] A unit in rooms [ROOM NUMBER]. Two [NAME] B unit in rooms 236, and 239. Three [NAME] A unit in rooms 320, 321, 322, 323, 324, 325, 326, 327, and 329. Three [NAME] B unit in room [ROOM NUMBER]. Four [NAME] B unit in rooms 434, 435, 436, and 438. m. Damaged, torn, stains, and/or off-track window curtains on Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in rooms 320, 323, 324, 325, 327, and 328. Three [NAME] B unit in room [ROOM NUMBER]. Four [NAME] B unit in rooms 434, and 438. n. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor in bedroom on Two [NAME] A unit in rooms 220, 222, 224, 226, and 229. Two [NAME] B unit in rooms 231, 233, 234, 235, 236, 238, 239, and 240. Three [NAME] A unit in rooms 320, 321, 322, 323, 324, 325, 326, 327, 328, 329, and 330. Three [NAME] B unit in rooms 331, 333, 335, 336, 337, 338, and 339. Four [NAME] B unit in rooms 431, 432, 434, 435, 436, 437, 438, and 439. o. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor in bathroom on Two [NAME] B unit in rooms 236, and 240. Three [NAME] A unit in rooms 322, 324, 325, 326, 327, 328, and 329. Three [NAME] B unit in rooms 333, 335, 336, 337, and 339. Four [NAME] B unit in rooms 431, 434, 435, 436, 437, and 438. p. Damaged, cracked, and/or missing floor tile in the bathroom on Four [NAME] B unit in room [ROOM NUMBER]. q. Damaged, cracked, and/or missing floor tile in the bedroom on Three [NAME] A unit in room [ROOM NUMBER]. Three [NAME] B unit in rooms 337, and 338. r. Damaged, chipped, missing, broken, and/or scarred dresser drawer in the bedroom on Two [NAME] A unit in rooms [ROOM NUMBER]. Two [NAME] B unit in room [ROOM NUMBER]. Three [NAME] A unit in rooms 320, 326, 327, 328, 329, and 330. Three [NAME] B unit in rooms [ROOM NUMBER]. Four [NAME] B unit in rooms 433, and 435. s. Damaged, broken, and/or missing dresser drawer knob in bedroom on Three [NAME] B unit in rooms 333, and 337. t. Two [NAME] A Dining Lounge: Damaged, cracked, and/or missing floor tile. Damaged, chipped, stains and/or marred walls. u. Two [NAME] B Hallway: Damaged, chipped, stains and/or marred walls. v. Damaged, dirt, dust, and/or rusty tray table on Three [NAME] A unit in rooms 321, and 324. w. Damaged, chipped, stains and/or marred bathroom door on Three [NAME] A unit in rooms 321, and 329. Three [NAME] B unit in rooms 331, and 335. Four [NAME] B unit in room [ROOM NUMBER]. x. Damaged, and/or stains on bed footboard in bedroom on Three [NAME] A unit in room [ROOM NUMBER]. y. Damaged, and/or rusty bedframe in bedroom on Three [NAME] A unit in room [ROOM NUMBER]. z. Four [NAME] B hallway damaged, and/or stain ceiling tile. aa. Bathroom sink faucet constant dripping water on Three [NAME] B unit in room [ROOM NUMBER]. bb. Damaged and/or rusty bathroom sink faucet on Three [NAME] A unit in room [ROOM NUMBER]. cc. Three [NAME] A Dining Lounge: Damaged, chipped, stains and/or marred walls. Damaged, broken, missing, peeling and/or dirty cove base. Refrigerator side panel and door panel rusty and/or stain. dd. Third floor elevator door frame damaged. Third floor elevator Corridor: Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor. Interview on 9/15/23 at 10:37 AM with the CEO (Interim Administrator) identified he was not aware of the environmental issues in the resident rooms. The CEO (Interim Administrator) indicated he will be having a meeting with the Maintenance/Housekeeping Supervisor, Maintenance department, and housekeeping staffs regarding the environment cleanliness, and repairs. Interview on 9/15/23 at 10:39 AM with the Regional [NAME] Services identified he was not aware of the environmental issues. The Regional [NAME] Services indicated going forward he will be meeting with the maintenance and housekeeping department staff regarding the cleanliness and repair of the environment. Interview on 9/15/23 at 10:43 AM with the Maintenance/Housekeeping Supervisor identified he was not aware of the issues. The Maintenance/Housekeeping Supervisor indicated he also oversees the housekeeping department. The Maintenance/Housekeeping Supervisor indicated that maintenance of the facility is ongoing. The Maintenance/Housekeeping Supervisor indicated that staff are responsible to notify the maintenance department with issues or problems that require repair. The Maintenance/Housekeeping Supervisor indicated going forward the maintenance department will address the environmental issues in a timely manner. Although requested, a facility environmental rounds policy was not provided. Review of the facility job description for the maintenance supervisor identified primary purpose of the job is to inspect, maintain and repair the facility environment and equipment, and maintain quality maintenance services throughout the facility. Received and follow preventative maintenance schedule/instructions as assigned. Perform routine maintenance and repair on the facility and equipment to include plumbing, plastering, electrical, carpentry, mechanical, etc., as directed, in accordance with established procedures. Review of the facility job description for the maintenance assistant identified the primary purpose of your job position is to maintain the grounds, facility, equipment in a safe and efficient manner in accordance with current applicable federal, state, and local standards, guidelines regulations, our established policies and procedures, and as may be directed by your supervisor, to assure that a successful maintenance program is maintained at all times. As the maintenance assistant, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Review of the facility job description for the director of housekeeping identified the primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the housekeeping department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a clean, safe, and comfortable manner. As the director of housekeeping, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Review of the facility job description for the housekeeping worker identified is responsible for cleanliness of facility as per training and in accordance with current federal, state and local standards, guidelines and regulations governing our facility. 4. Observation on 9/12/23 at 10:10 AM identified the door to room [ROOM NUMBER], which was occupied by two residents was closed, and was extremely difficult to open. Upon departure of the room, the surveyor was not able to close the door. The ADNS was in the corridor and was notified immediately that the door was difficult to open and now unable to be closed. An interview with the ADNS on 9/12/23 at 10:15 AM identified the door should open with less effort and should be able to close without extreme effort as well. The ADNS promptly notified the Maintenance Director who called an assistant to remove the hinge as he monitored the door's response. Interview with the Maintenance Director on 9/12/23 at 10:25 AM identified he was not aware of the malfunctioning door until the ADNS's notification. The Maintenance Director identified he was uncertain of the reason for the malfunction, however indicated he would repair the door immediately. Interview with the Administrator on 9/12/23 at 11:00 AM identified he would move the residents to different rooms to maintain droplet precautions that both residents were on and their safety. Interview with the Administrator, Regional Maintenance Director and Maintenance Director on 9/15/23 at 10:20 AM identified the screw on the top hinge of the door (room [ROOM NUMBER]'s fire door) measured at ¾ inch (standard size) had split the wood resulting in the door's inability to hang properly making the door difficult to open and close. Additionally, the Regional Maintenance Director identified all fire doors in the facility are inspected annually in September, and the fire door inspection was scheduled for 9/20/23. The Regional Maintenance Director identified the doors can become misaligned by simple activity of care givers bumping into the door with a mechanical lift or cart. The Regional Maintenance Director identified the doors are reviewed as part of the monthly environmental rounds. The environmental rounds binder for 2023 identified the unit was last inspected in June 2023 with only cosmetic concerns identified. The Maintenance Director identified every month a different location in the facility is selected and reviewed. As concerns are brought to the attention of his department, an evaluation is done, and the problem resolved. The Maintenance Director, the Regional Maintenance Director, and Administrator identified their initial awareness of the door malfunction was upon Surveyor inquiry. The Maintenance Director identified his staff review the maintenance log immediately at the start of the workday and there was no mention of the difficulty of opening and closing the door for room [ROOM NUMBER] was ever identified as a problem. The Regional Maintenance Director identified his department responded immediately and the current status of the door is the vendor will assess the door 9/20/23 and a replacement is most likely to be recommended. The Regional Maintenance Director identified fire doors are custom made for the frame, so if the vendor does not have this standard door size in inventory, the repair can be a few weeks as a custom door is made and delivered. The Administrator identified the residents assigned to the new rooms would remain in those rooms until the matter is resolved and the door for room [ROOM NUMBER] is safe. The timeline for the malfunction of the door was unable to be determined, however nurse aides and housekeeping staff had been in that room the morning of 9/12/23 prior to the Surveyor's identification of the malfunctioned door. The policy for malfunctioning equipment repair states to ensure the safety of residents, employees and others, all employees are expected to identify items or equipment that are damaged or require repair which may pose potential safety hazards. Items or equipment needing repair are to be removed from use immediately and tagged Out of Order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and interviews the facility failed to have an Administrator, licensed in the state of Connecticut, since [DATE] (over 5 months). The findings include. Observation on [DATE] at 10:00 AM identified the previous Administrator, (Administrator #2), license was posted in the first-floor lobby. Administrator #2's license expired [DATE]. Interview with the CEO (Interim Administrator) on [DATE] at 7:45 AM indicated he was the Interim Administrator and that the previous Administrator, (Administrator #2) was no longer at the facility. The CEO (Interim Administrator) indicated he had been the Interim Administrator for approximately 2 - 3 weeks. Interview with the CEO (Interim Administrator) on [DATE] at 1:50 PM indicated he was the Interim Administrator but had an administrator license in another state but did not have an administrator license in the state of Connecticut. Interview with HR #1 on [DATE] at 2:15 PM indicated she was responsible to verify all licenses for the administrators and nursing department and was responsible to get the background checks, references, and complete any employee file paperwork. HR #1 indicated there was a check list on the front of every file indicating what she needed for every employee. HR #1 initially indicated she did not have a file for the CEO (Interim Administrator) and she would have to email corporate to get it. HR #1 was on the computer and then turned to a shelf behind her and indicated this was the CEO's (Interim Administrator) file. HR #1 indicated that the CEO (Interim Administrator) was from corporate and had been around the building for years prior to taking over as the Administrator when the previous administrator left in [DATE]. HR #1 indicated she did not do a background check, get references, verify for a Connecticut license, or have him sign a job description because he had come through the back door from corporate. HR #1 indicated she had not checked to verify if the CEO (Interim Administrator) had a valid Connecticut Administrator's license. Interview with the previous administrator, Administrator #2 on [DATE] at 2:40 PM indicated his last day was [DATE]. Administrator #2 indicated his expired license should not still be on the wall in the facility when he had not been in the facility since [DATE]. Interview with the CEO (Interim Administrator) on [DATE] at 3:13 PM indicated he had been the interim administrator since [DATE]. The CEO (Interim Administrator) indicated he had been told that he could be the interim administrator, despite not having an administrator's license in the state of Connecticut, because of his position in the company. Review of the CEO (Interim Administrator) employee file lacked the job description, verification of a Connecticut administrators license, and reference checks. Review of the Facility assessment dated 2023 identified persons involved in completing assessment were Administrator- interim administrator, Director of Nursing, Governing Body Representative, and Medical Director. Review of the Administrator job description identified the purpose of this job position was to direct the day-to-day functions in accordance with current facility in accordance with federal, state, and local standards, guidelines, and regulations that govern long term care facilities to assure that the highest degree of can be provided to our residents at all times. As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Qualifications you must possess a current, unencumbered Connecticut state nursing home administrator's license or otherwise meet the licensure requirements in this state.

Based on review of facility documentation, facility policy, and interviews, the facility failed to maintain an effective antibiotic stewardship program. The findings include: Review of the infection line list dated 1/2022 through 12/2022 failed to reflect documentation regarding clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g., SBAR tool for urinary tract infection (UTI) assessment, Loeb minimum criteria for initiation of antibiotics). Review of the infection prevention program with RN #2 (previous IP without the required training and qualification) on 9/14/23 at 12:06 PM identified from 1/23 through 5/23 antibiotic use is tracked on monthly basis, by printing the month from the antibiotic e-chart, however, there is no consistency in documentation on the antibiotic tracking log, or documented communication to the prescriber that the signs and symptoms initially identified have been resolved as a result of the antibiotic. Interview with RN #2 indicated she was not the IP during 1/23 through 5/23. Although requested, documentation regarding the antibiotic stewardship program for 1/1/22 through 12/23/22 and 1/1/23 through 5/23 was not provided. Interview with RN #2 (previous IP without the required training and qualification) on 9/14/23 at 12:06 PM identified she has been employed by the facility since 5/3/23 as the Infection Preventionist (IP). RN #2 indicated she had overseen the Infection Control Program during the months of 5/4/23 to 9/1/23. RN #2 indicated she had left the faciity on 9/1/23. RN #2 indicated she cannot answer any questions prior to 5/2023. RN #2 indicated she created a tracking antibiotic log from 5/23 through 9/1/23. RN #2 indicated she does not know where the previous IP kept the documentations for the beginning of the year of 2022 and the year 2023. Interview with the previous DNS on 9/18/23 at 10:48 AM identified she was employed by the facility on 4/4/23 and left on 9/1/23. The previous DNS indicated she did not oversee the antibiotic stewardship program and the infection control program. Subsequent to surveyor inquiry, on 9/20/23 at 7:09 PM the facility provided documentation regarding the infection line list dated 1/23 through 5/23. The documentation failed to reflect documentation regarding clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g., SBAR tool for urinary tract infection (UTI) assessment, Loeb minimum criteria for initiation of antibiotics). Although requested, documentation regarding the antibiotic stewardship program for 1/1/22 through 12/23/22 was not provided. Subsequent to surveyor inquiry, on 9/21/23 at 7:57 PM the facility provided additional documentations regarding the infection line list dated 1/23 through 5/23 with clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made. Review of the facility antibiotic stewardship program policy identified the facility establishes directives for antimicrobial stewardship in order to develop antibiotic use protocols and a system to monitor antibiotic use. The DNS, Medical Director, and Administrator of the facility are responsible for ensuring that adequate staffing and resources are allocated to support the functions and efforts of the IP and the Antibiotic Stewardship Committee.

Based on review of facility documentation and interviews the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program between 3/2022 through 9/1/23. The findings include: Review of RN #5's personnel file identified she was employed by the facility 10/3/22 through 12/30/22 as the Infection Preventionist (IP) and the wound nurse. The personnel file indicated RN #5 received her Infection Preventionist Certificate on 12/3/22 (2 months after being employed as the Infection Preventionist). The facility documentation failed to reflect RN #5 (IP) had completed the specialized training in infection prevention and control prior to assuming the role of the IP and evidence of completion was available (e.g., certificate). A review of the facility Infection Control Program on 9/14/23 failed to identify that the facility had an Infection Preventionist (IP) staff with the appropriate education and training as outlined by The Centers for Medicare and Medicaid Services. A review of the facility Infection Control Program on 9/14/23 failed to reflect documentation that an Infection Preventionist (IP) was overseeing the Infection Control Program between 3/2022 through 10/2022 (7 months), 1/2023 through 5/2023, (5 months), 5/2023 through 9/1/2023 (4 months), and 9/1/23 through 9/14/23. The facility documentation failed to reflect that RN #2 (IP) had completed the specialized training in infection prevention and control prior to assuming the role of the IP and evidence of completion was available (e.g., certificate). Interview with RN #2 (previous IP 5/2023 to 9/1/23 without the required training and qualification) on 9/14/23 at 12:06 PM identified she has been employed by the facility since 5/3/23 as the Infection Preventionist (IP). RN #2 indicated she had overseen the Infection Control Program during the months of 5/2023 to 9/1/23. Interview with RN #2 on 9/15/23 at 9:47 AM identified she was not aware that she did not have an Infection Preventionist Certificate until during the survey when she was asked for her Infection Preventionist certification. RN #2 indicated she started the training on 5/2023 and thought she had completed the training. RN #2 indicated she took the final test on 9/12/23, that is the reason why her certificate is dated 9/12/23. Interview with the CEO (Interim Administrator) on 9/15/23 at 7:58 AM identified he was aware of the issue and the facility has hired a new IP that will be starting on 9/25/23. The CEO (Interim Administrator) indicated he is aware that the facility did not have an IP from 9/1/23 through 9/25/23. The CEO (Interim Administrator) indicated he was aware that the ADNS does not have an Infection Preventionist Certificate. The CEO (Interim Administrator) indicated the ADNS will be monitoring, and tracking the infections, including Covid-19 infections. The CEO (Interim Administrator) indicated he was not aware of the issue of the facility not having an IP between 3/2022 through 10/2022 (7 months), 10/2022 through 12/3/22 (2 months), and 1/2023 through 5/2023, (5 months). The CEO indicated the facility had a full time DNS at those times. Interview with the ADNS on 9/15/23 at 6:20 PM identified she was not aware of the issue. The ADNS indicated she is aware the facility did not have an IP at this time. The ADNS indicated she is overseeing the Covid infections at this time. The ADNS indicated she does not have an Infection Preventionist Certificate. The ADNS indicated the facility has hired a new IP that will be starting soon. Interview with the previous DNS on 9/18/23 at 10:48 AM identified she was employed by the facility on 4/4/23 and left on 9/1/23. The previous DNS indicated RN #2 was the IP for the facility for a short amount of time. The previous DNS indicated she was not aware that RN #2 did not have an Infection Preventionist Certificate. The previous DNS indicated Human Resource did not give her access to the employee files. The previous DNS indicated she never had a part of the infection control program. The previous DNS indicated she did not oversee the infection control program with RN #2. The previous DNS declined to provide a copy of her Infection Preventionist Certificate. Although requested, documentation detailing the Infection Preventionist Certificate for the previous DNS was not provided. Review of the facility Infection Preventionist job description identified the primary purpose of your job position is to plan, organize, develop, coordinate and direct the facility's infection prevention and control program and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs, and as may be directed by the Administrator and the Infection Control Committee to ensure that an effective infection control program is maintained at all times. As the Infection Preventionist you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Your immediate supervisor is the Director of Nursing Services. Review of the Centers for Disease Control and Prevention Nursing Homes and Assisted Living (Long-Term Care Facilities LTCF's) identified The Nursing Home Infection Preventionist Training course is designed for individuals responsible for infection prevention and control (IPC) program in nursing home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was reviewed for an allegation of being neglected, the facility failed to ensure the resident was treated in a dignified and respectful manner. The findings include: Resident #1's diagnoses included unspecified psychosis not due to a substance or known physiological condition, major depression, and paraplegia. The admission clinical record identified Resident #1 as self-responsible. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no short- or long-term memory problems and required extensive two (2) person assistance with bed mobility, transfers, and personal care. The Resident Care Plan dated 4/20/23 identified Resident #1 had a concern with psychosocial well-being related to accepting own limitations, initiating conflict situations with staff and being accusatory and physically aggressive with staff at times. Interventions directed to provide regular visits to allow Resident #1 to verbalize feelings, discuss concerns, identify and support strengths, ensure needs were met by staff and encourage to utilize positive coping skills to help Resident #1 adapt to present situation. An interview with Resident #1 on 6/26/23 at 10:50 AM identified on the 11PM-7AM shift on 6/18/23 a nurse aide, Nurse Aide (NA) #1, entered his/her room and did not close the door right away. Resident #1 indicated when he/she asked NA #1 to close the door, NA #1 responded that she would not take care of Resident #1 and exited the room. Resident #1 identified he/she reported the issue to the charge nurse, Licensed Practical Nurse (LPN) #1, and left messages with the Director of Nursing but no one came to speak to him/her regarding the concern. An interview on 6/26/23 at 11:54 AM with the Social Worker, SW #1 identified for any resident reported concern, he meets with the resident to address the concern as quickly as possible. SW #1 identified Resident #1 was known to be verbally abusive towards staff and commonly threatened to have them fired. SW #1 indicated staff were recently instructed that if Resident #1's behavior was vulgar, Resident #1 would be asked to stop the verbal insults and as long as Resident #1 was clean and safe, staff were to inform him/her they would step out of the room and return when Resident #1 was calm. An interview with NA #1 on 6/26/23 at 1:12 PM identified she was the assigned nurse aide to Resident #1 on the 11PM-7AM on 6/18/23. NA #1 identified Resident #1 was often verbally abusive toward staff and often accused staff of abuse and neglect. NA #1 indicated that when Resident #1 was abusive, staff were to step out of the room and report the concern to the nurse. NA #1 indicated she could not recall specifically if Resident #1 asked her to close his/her door and that she walked out on 6/18/23 but indicated when Resident #1 was abusive towards her, she would inform Resident #1 that she would report Resident #1's behavior to the nurse, say she was leaving which Resident #1 hated and displayed a peace sign gesture towards Resident #1. An interview with the Director of Nursing (DON) on 6/26/23 at 11:54 AM and 2:25 PM identified Resident #1 had direct communication with her via her personal cell phone and would often text any concerns. The DON indicated Resident #1 had not reported any specific care concerns to her related to resident #1's allegation. An interview with the Administrator on 6/26/23 at 2:25 PM identified he would expect staff to treat residents in a dignified and respectful manner. A review of the facility policy for Resident Rights directed that all residents be afforded the right to a dignified existence, self-determination, and respect. Attempts to interview LPN #1 were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #109) reviewed for an allegation of mistreatment, the facility failed to ensure an allegation of misappropriation of property was reported to the State Survey Agency. The findings include: Resident #109 was admitted on [DATE] with diagnoses that included type 1 diabetes mellitus (DM) and osteomyelitis of right ankle and foot. A resident belongings inventory form dated 7/15/21 identified Resident #109 had six pairs of pants, five shirts and one pair of underwear. An admission MDS assessment dated [DATE] identified Resident #109 was cognitively intact, had no behavior or mood problems and had daily preferences that identified that taking care of his/her personal belongings or things was very important. The assessment also identified that Resident #109 required extensive assistance with toilet use, bed mobility and locomotion on and off unit. Nurse's note dated 7/28/21 and timed 9:29 PM identified Resident #109 was readmitted from the hospital at 6:30 PM with a diagnosis of left lower extremity wound dehiscence. A grievance form dated 8/11/21 identified Resident #109 reported missing shorts and a T-shirt. It further identified the articles were found, returned and resident was happy they were returned. Review of Social Worker (SW) #1's documentation in response to the resident's grievance dated 8/16/21 identified Resident #109 reported missing items which included shirt, shorts, cell phone, cell phone charger and a credit card. The documentation identified that an investigation was conducted, and the shorts and shirt were found but noted that the resident's inventory sheet and the hospital admission record failed to identify a cell phone or credit card among Resident #109's personal belongings. SW#1's documentation further identified that once Resident #109 realized the credit card was missing, he/she canceled it. SW #1 identified that the cell phone was provided by the state and advised Resident #109 to contact the state for replacement of the cell phone. SW#1 also identified that the Administrator met with the resident regarding the missing items and informed Resident #109 that the facility did not have any corroboration that the items entered the facility upon Resident #109's admission. Interview with Resident #109 on 8/19/21 identified that he/she reported to the missing credit card, cell phone and charger to SW #1, Patient Advocate (PA#1) and the facility's Administrator. Interview with SW#1 on 8/25/21 at 9:58 AM identified Resident #109 reported missing a credit card and cell phone at the same time as shorts and shirt but those items were not included in the grievance because the items were not documented on the inventory sheet or anywhere in the documentation from the hospital. She indicated that the missing phone and credit card were brought up at morning report and administration was aware. Interview with facility Administrator on 8/25/21 at 11:09 AM identified Resident #109 reported that his/her credit card and phone were missing and because the resident canceled the credit card, the facility investigated the resident's allegation but did not report the potential misappropriation of property to the State Survey Agency or the outcome of the investigation conducted. The facility's abuse prohibition policy identified that any reasonable suspicion of a crime must be reported to the police and State Survey Agency within two hours after they first suspect that a crime has occurred if the suspected crime involves serious bodily injury to the individual or within twenty-four if there is no serious bodily injury involved. The policy further identified that the facility shall conduct a thorough investigation of all alleged violations involving exploitation, mistreatment, neglect or abuse and misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident #109) reviewed for an allegation of mistreatment, the facility failed to ensure that a documented investigation was completed in relation to an allegation of misappropriation of resident property. The findings include: Resident #109 was admitted on [DATE] with diagnoses that included type 1 diabetes mellitus (DM) and osteomyelitis of right ankle and foot. A resident belongings inventory form dated 7/15/21 identified Resident #109 had six pairs of pants, five shirts and one pair of underwear. An admission MDS assessment dated [DATE] identified Resident #109 was cognitively intact, had no behavior or mood problems and had daily preferences that identified that taking care of his/her personal belongings or things was very important. The assessment also identified that Resident #109 required extensive assistance with toilet use, bed mobility and locomotion on and off unit. A grievance form dated 8/11/21 identified Resident #109 reported missing shorts and a T-shirt. It further identified the articles were found, returned and resident was happy they were returned. Review of Social Worker (SW) #1's documentation in response to the resident's grievance dated 8/16/21 identified Resident #109 reported missing items which included shirt, shorts, cell phone, cell phone charger and a credit card. The documentation identified that an investigation was conducted, and the shorts and shirt were found but noted that the resident's inventory sheet and the hospital admission record failed to identify a cell phone or credit card among Resident #109's personal belongings. SW#1's documentation further identified that once Resident #109 realized the credit card was missing, he/she canceled it. SW #1 identified that the cell phone was provided by the state and advised Resident #109 to contact the state for replacement of the cell phone. SW#1 also identified that the Administrator met with the resident regarding the missing items and informed Resident #109 that the facility did not have any corroboration that the items entered the facility upon Resident #109's admission. Interview with Resident #109 on 8/19/21 identified that he/she reported to the missing credit card, cell phone and charger to SW #1, Patient Advocate (PA#1) and the facility's Administrator. Interview with SW#1 on 8/25/21 at 9:58 AM identified Resident #109 reported missing a credit card and cell phone at the same time as shorts and shirt but those items were not included in the grievance because the items were not documented on the inventory sheet or anywhere in the documentation from the hospital. She indicated that the missing phone and credit card were brought up at morning report and administration was aware. Interview with facility Administrator on 8/25/21 at 11:09 AM identified Resident #109 reported that his/her credit card and phone were missing but did not accuse the staff of theft and because the resident canceled the credit card, the facility investigated the resident's allegation but did not report the outcome of the investigation conducted to the State Survey Agency. The facility's abuse prohibition policy identified that any reasonable suspicion of a crime must be reported to the police and State Survey Agency within two hours after they first suspect that a crime has occurred if the suspected crime involves serious bodily injury to the individual or within twenty-four if there is no serious bodily injury involved. The policy further identified that the facility shall conduct a thorough investigation of all alleged violations involving exploitation, mistreatment, neglect or abuse and misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of seven sampled residents (Resident #96) reviewed for hospitalization, the facility failed to ensure recommendations for a specialized service were responded to following a hospitalization. The findings include: Resident #96 had diagnoses inclusive of encephalopathy, hypertension and seizures. The quarterly MDS assessment dated [DATE] identified Resident #96 had moderate cognitive impairment and required set up only with personal care. The resident care plan (RCP) dated 5/20/21 identified Resident #96 was at risk for a seizure disorder with interventions that included offer assist with ADL's as indicated and provide OT/PT as needed. A hospital Discharge summary dated [DATE] identified Resident #96 was admitted to the hospital from [DATE] to 5/26/21 with a diagnosis of seizures. Resident #96 was started on Keppra (anticonvulsant) 125 mg twice daily with recommendations to follow up with neurology in two weeks following discharge. A review of the clinical record failed to identify documentation that the recommendation to follow up with neurology was addressed. An interview on 8/24/21 at 1:30 PM with (nurse practitioner) NP #1 identified Resident #96's hospital discharge summary was reviewed by the nursing staff and any concerns or need for follow up should have been conveyed to her. NP #1 further identified that the nursing staff did not report any recommended follow up with neurology for Resident #96. An interview on 8/24/21 at 1:45 PM with Medical Records Specialist #1 (MRS #1) identified that she was responsible for reviewing Resident #96's hospital discharge paperwork. She further noted that she had not scheduled a follow up appointment for neurology for Resident #96 as recommended and noted that it was an oversight on her part. An interview on 8/25/21 at 9:25 AM with the DNS identified she would expect that recommendations following a hospital discharge be followed. A request was made for a policy related to how resident recommendations should be handled but the facility failed to provide the requested policy/procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #45) reviewed for unnecessary medication, the facility failed to monitor orthostatic blood pressures for a resident receiving psychotropic medication. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy bodies, anxiety and insomnia. The admission MDS assessment dated [DATE] identified Resident #45 had severe cognitive impairment, required extensive assistance with personal care and received psychotropic medications. The care plan dated 6/29/21 identified cognitive deficit and potential for psychotropic drug use complications related to use of prescribed medication with interventions that included, administer medication(s) per order, monitor medication response and monitor for medication side effects. A review of the physician's orders dated 6/5/21 through 8/23/21 noted Resident #45 was prescribed Seroquel (antipsychotic medication)12.5 mg at 4:00 PM and 25 mg in the evening with additional orders placed on 6/7/21 for orthostatic blood pressure (BP) monitoring weekly (lying and sitting) every Saturday for psychiatric medications for four weeks. Physicians orders dated 7/6/21 and 7/19/21 directed an increase in the dosing of Seroquel with additional orders dated 7/22/21 directing orthostatic BP every day shift for antipsychotic medication with parameters to notify the physician for a systolic blood pressure (SBP) change greater than 20 millimeters of mercury (mmHg) and/or diastolic blood pressure (DBP) change greater than 10 mmHg. Physician's order dated 7/26/21 directed another dose increase for Seroquel and new orders for orthostatic BP monitoring every day shift every Friday for antipsychotic medication for 4 weeks and to notify the physician for SBP change greater than 20 mmHg and/or DBP change greater than 10 mmHg. A review of the Vital Sign Flow sheet for blood pressure monitoring and Medication Administration Record dated 6/5/21 through 8/22/21 identified an orthostatic blood pressure was obtained on one occasion on 7/17/21 when there should have been orthostatic blood pressure measurements completed on at least twelve occasions. An interview on 8/25/21 at 9:31 AM with the DNS identified it would have been her expectation that orthostatic blood pressures be obtained according to physician's orders. The policy for Care and Treatment of Residents with Psychotropic Medications dated 11/2016 directs if a new psychotropic medication is ordered, orthostatic blood pressure reading will be taken once a week for a month. If there is an increase in the dose or symptoms that would indicate hypotension, orthostatic blood pressures should again be monitored once a week for a month.

Based on facility documentation and interviews, the facility failed to ensure that they were meeting annually in regard to their water management system and to mitigate and prevent the potential for Legionella infection. On 08/19/21 at 10:20 AM, the surveyor was not provided with documentation from the Director of Maintenance, to identify that the facility was meeting annually as required to discuss the facility's water management system and to review policies and procedures that addressed the mitigation and prevention of Legionella.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, review facility policy and/or procedures and interviews for one of twelve sampled residents reviewed for dining (Resident #28) and/or for one of three sampled residents (Resident # 190) who were reviewed for alleged mistreatment by a staff member , the facility failed to ensure that the residents were treated in respectful and/ or dignified manner that promoted and enhanced the resident's quality of life. The findings included: 1. Resident #28's diagnoses included failure to thrive and dementia. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was moderately cognitively impaired and required extensive assistance with eating. The Resident Care Plan (RCP) dated 9/20/19 identified a potential for dehydration and/or fluid deficit related to ADL self-care deficit. Interventions directed to provide diet and appropriate staff assistance with meals. Observation on 10/9/19 at 12:00 P.M. on the third floor dining room with at least 3 staff members present and noted seating other residents, Resident #28 was observed biting on the side of an ice cream cup with the spoon stuck in the ice cream. Constant observations beginning at 12:08 P.M. identified Resident #28 was sucking on the handle of the spoon sticking out of the ice cream like it was a straw. At 12:12 P.M. Resident #28 began to again bite on the side of the container. At 12:15 P.M. Resident #28 was moving the cup around from the table to his/her lap and at 12:19 P.M. dropped the cup on his/her lap picking it up. At 12:20 P.M. Resident #28 had taken the spoon out of the container, took two bites and was unable to find the container again. Resident #28 was scraping the table with the spoon looking for the ice cream container. At 12:21 P.M. Resident #28 took another bite and began again to spoon the table, under the placemat and around on the table. Interview and observation with Recreation Assistant #1 on 10/8/19 at 12:29 P.M. identified that Resident #28 usually is independent with eating. Recreation Assistant #1 further indicated Resident #28 did not require any assistance. Subsequent to surveyor inquiry, Resident #28 received assistance and cueing from Recreation Assistant #1. The Nurse Aide (NA) flow sheets from 10/1/19 through 10/8/19 identified Resident #28 required extensive assistance with eating breakfast and lunch, and on 10/9/19 required limited assistance. Observation on 10/9/19 at 12:30 P.M. identified Resident #28 was assisted with his/her noon meal. Interview with the Assistant Director of Nursing (ADNS) on 10/9/19 at 1:22 P.M. identified if a resident is in need of assistance with eating staff should provide the assistance. 2. Resident (R) #190's diagnoses included cellulitis of the lower left leg and morbid obesity. The Resident Care Plan (RCP) dated 5/13/19 identified R#190 had the potential for depression related to clinical conditions. Interventions directed to provide the resident with the opportunity to verbalize feelings. A facility Grievance /Complaint form dated 5/13/19 identified R#190 reported to the Director of Nurses (DON) that a male Nurse Aide (NA#1) used the phrase sexy mama during a communication with the resident, which made her/him feel uncomfortable. In a written statement NA#1 indicated that while R#2 was voiding on the bedpan NA#1 and R#190 were having a conversation. R #190 indicated NA#1 was making R#190 uncomfortable so NA#1 turned to face the door until R#190 was done with the bedpan. The facility's investigation identified that although NA#1 admitted to saying sexy mama, the comment was in reference to a women on the television (TV), R#190 indicated s/he was unsure who NA#1 was talking about. Subsequently, NA #1 was assigned to another unit, was provided with education on appropriate communication with residents, and social service followed up with R#190 to ensure the resident currently felt comfortable and safe. The admission Minimum Data set (MDS) dated [DATE] identified R #190 was without cognitive impairment and required extensive assistance with activities of daily living. In an interview on 10/9/19 at 12:15 PM the Director of Social Services identified that she met with R#190 for three consecutive days after the incident was reported to ensure the resident was comfortable and felt safe. No lasting negative effects were noted. In an interview and clinical record review on 10/9/19 at 1:00 PM, the DON indicated that the statement made by NA #1 during his interaction with the resident was inappropriate regardless of whether he was referencing something on TV or R#190. The facility Resident Rights policy directs that all residents will be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of two sampled residents (Resident #59) reviewed for ADL, the facility failed to ensure bi-weekly showers were provided. The findings include: Resident #59's diagnoses included Alzheimer's disease, anxiety and schizoaffective disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 had both long and short term memory problems, had no behavioral symptoms and was totally dependent on staff for bathing. The Resident Care Plan (RCP) dated 10/7/19 identified a self-care deficit, can be resistive to care. Interventions directed to provide Resident #59 with total assistance with bathing, if resident resists with ADL, reassure resident, leave and return 5-10 minutes later and try again. Interview with Person #4 on 10/7/19 at 2:00 P.M. identified that Resident #59 had not been receiving scheduled bi-weekly showers. Review of the behavioral flow sheet and nurse's progress notes failed to identify Resident #59 had exhibited resistive behaviors during the month of October 2019. Observations on 10/7/19, 10/8/19, and 10/9/19 identified Resident #59 was well dressed and well groomed, did not have any odors, was noted with clean hair, well-trimmed and clean fingernails and teeth were clean. Review of the shower schedule for Resident #59 directed to provided the resident with showers on Mondays and Fridays on the 3-11 P.M. shift. Review of the NA shower flow sheet identified Resident #59 had received showers/bed baths on 9/23/19, 9/27/19, 9/30/19. 10/4/19, and 10/7/19. Interview with the ADNS on 10/09/19 at 11:10 A.M. identified Resident #59's responsible party had never complained that Resident #59 had not received showers and that he/she comes in to inspect both the resident and the environment regularly. Interview with NA #2 on 10/09/19 at 11:13 A.M. identified that Resident #59's responsible party is here when the resident takes showers. NA #2 indicated that the 3-11 P.M. staff and the licensed staff told him/her that the responsible party is present during showers and that the licensed staff ensures the resident receives all his/her showers. Additionally, Resident #59's responsible party notified the managerial staff when he/she has a complaint. Re-interview and review of facility documentation with the ADNS identified that he/she had looked at the video to determine if the resident had come out of the room to receive a shower on 10/4/19 and 10/7/19 (only a week of data is saved). The ADNS was unable to find evidence that Resident #59 had received a shower. Additionally, the ADNS spoke with NA #3 who was responsible on 10/4/19 for the resident's shower and NA # 3 verbalized she/he was not sure, couldn't remember, but may have given Resident #59 a shower. The ADNS also indicated that she/he had also spoke with NA #1, who was responsible for Resident #59's shower on 10/7/19, and that NA #1 identified he/she had not given a shower to Resident # 59 due a directive to go to another unit. NA #1 identified that since he/she arrived to the floor late, he decided to give Resident #59 a bed bath instead of a shower because Resident #59 was already in bed. The ADNS further indicated that residents who require showers are not usually placed back to bed prior to receiving a shower, and that on both occasions, 10/4/19 and 10/7/19, Resident #59 should have been provided with a shower per the facility policy. Additionally, the ADNS identified that there was no documentation to indicated that Resident #59 had been resistive to care, and that if the resident had been resistive to care, the NA's should have reported the behavior to the licensed staff and the licensed staff should have documented the behavior. Review of the facility Activities of Daily Living policy notes in part unless otherwise specified, all resident shall be expected to bathe or shower at lease twice per week and assisted whereby indicated. Additionally, the policy noted when a resident refuses to comply with ADL and schedule, the nursing staff shall solicit assistance from other disciplines to determine the cause for the refusal, off other options and alternatives and document refusal on the medical chart, progress note and care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one of two sampled residents (Resident #23) reviewed for a limited range of motion, the facility failed to follow a physician's order for a splinting device. The findings include: Resident #23's diagnoses included, CVA and hemiplegia. The Rehabilitation note dated 3/8/19 identified that Resident #23 was screened for a left hand contracture, continued to be at baseline, left hand present with flexion contracture due to old Cerebrovascular Accident(CVA), recommended to continue contracture management as per care plan. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired and required extensive assistance with dressing and personal hygiene and had a functional limitation in range of motion on both sides of both the upper and lower extremities. The Resident Care Plan (RCP) dated 8/15/19 identified a left side hemiplegia/left hand contracture, refuses carrot at times. Interventions directed to check for placement of pink charm for limb alert, left side hemiplegia, left hand contracture, provide right hand carrot splint and left hand rolled towel worn at all times except for skin care. Apply a rolled towel below left side chest and left arm to decrease pressure every shift. If the resident is resistive with ADL, reassure the resident, leave and return 5-10 minutes later and try again. A physician's order dated 9/24/19 directed to place a clean rolled washcloth in Resident #23's left hand, twice daily every day and evening shift; provide a functional maintenance program for a brace/splint; right hand carrot, left hand rolled towel at all times except skin care and checks; and apply a rolled towel below left side chest and left arm to decrease pressure every shift. Observation on 10/07/19 at 9:15 A.M. identified Resident #23's right hand contracted with a positioning carrot lying next to his/her hand and on the resident's chest. Observation on 10/07/19 at 10:15 A.M. identified Resident #23 in an activity, noted with the end tip of the positioning carrot in the right hand, improperly positioned. Resident #23 had a rolled up pillowcase case in his/her lap with nothing noted for positioning in his/her left hand. Observation on 10/08/19 at 10:51 A.M. identified a right hand with contracture, carrot noted to be lying on the blanket, not in place. Observation on 10/09/19 at 11:31 A.M. identified the positioning carrot in Resident #23's left hand and no positioning device in right hand. Interview, observation and review of facility documentation with the ADNS on 10/09/19 at 12:07 P.M. identified that, according to the physician's orders, Resident #23 should be wearing the carrot in the right hand and not in the current position (the left hand). Resident #23 should have had rolled towel in place to the left hand and should have had a rolled towel between the left arm and the left side of the chest to decrease pressure per the physician's order. The ADNS also indicated Resident #23 sometimes remove the items, but Resident #23 had neither a rolled towel and/or rolled hand towel washcloth located in the resident's wheelchair. Additionally, Resident #23 had no behaviors of resisting care documented on the behavior monitoring flow sheet and/or documentation in the nursing notes. The ADNS identified that if Resident #23 was resistive to care, the NA should have informed the licensed staff and the licensed staff should have documented the behaviors in the clinical record. The ADNS identified that nurse aides are responsible for placing a splinting device and indicated the licensed staff are responsible for ensuring the placement of the device in accordance with physician's orders. Subsequent to surveyor inquiry, Resident #23 was provided with his/her corrected splinting devices.