**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 resident (Resident #1) reviewed for ADLs, the facility failed to ensure weekly skins were performed in accordance with facility policy. The findings include: Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 resident (Resident #1) reviewed for ADLs, the facility failed to ensure weekly skins were performed in accordance with facility policy. The findings include: Resident #1 had diagnoses that included anemia, diabetes mellitus, chronic kidney disease, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen (9/15), indicative of moderately impaired cognition, was at risk for alteration in skin integrity and was always incontinent of bowel and bladder. The Resident Care Plan dated 7/23/25 identified Resident #1 had the potential for alteration in skin integrity related to fragile skin and had an actual stage III pressure ulcer on his/her coccyx. Interventions directed to conduct weekly body audits. Review of the clinical documentation identified the following for Resident #1's weekly skin evaluations:1. During the month of July 2025, Resident #1 only had a skin evaluation performed on 7/7/2025.2. During the month of June 2025, the record failed to identify any skin evaluations were completed.3. During the month of May 2025, Resident #1 had a skin evaluations performed on 5/1, 5/8, and 5/28/2025.4. In the month of April 2025, Resident #1 had a skin evaluation performed on 4/1, 4/13, and 4/24/2025. Review of the nursing notes failed to identify Resident #1 had refused any skin evaluations from 4/2025 through 8/2025. Interview with the DON on 8/5/25 at 2:00 PM identified weekly skin checks are documented in the electronic medical records (EMR) under the weekly skin evaluations. The DON identified Resident #1 refuses care/treatment services at times, and indicated nursing staff should document refusals and update the provider accordingly. The DON was unable to provide documentation that the weekly skin checks were performed during the weeks of 4/7, 5/12, 5/19, the month of June, and 7/14, 7/21, and 7/28/2025, and stated they should have been completed. Review of the undated Skin Check Policy directed in part, skin checks will be conducted by Certified Nursing Assistants during daily care. Skin checks by Licensed Nursing personnel will be routinely conducted on all resident care units in addition to daily checks by the nursing assistants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for 2 of 43 residents (Resident #1 and Resident #3) reviewed for ADL care, the facility failed to ensure facility staffing was utilized across the facility to ensure residents received personal care and incontinent care in a timely manner. The findings include: Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for 2 of 43 residents (Resident #1 and Resident #3) reviewed for ADL care, the facility failed to ensure facility staffing was utilized across the facility to ensure residents received personal care and incontinent care in a timely manner. The findings include: A) Resident #1 had diagnoses that included bipolar disorder, depression, and anxiety. The quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen (9/15), indicative of having moderately impaired cognition, required maximum assistance with ADL's (activities of daily living) and bed mobility, and was always incontinent of bowel and bladder. The Resident Care Plan dated 7/23/25 identified Resident #1 had an alteration in ADL function and was incontinent of bowel and bladder. Interventions directed to provide personal care, provide incontinent care and reposition every two hours. Interview with Resident #1 on 8/5/25 at 10:15 AM identified he/she had not received AM care or incontinent care since approximately 5:00 AM. Resident #1 indicated he/she called for assistance, but it was not assisted. Observation of Resident #1 at the time of the interview identified he/she appeared to not have received AM care at the time of the observation (still in bed wearing johnny). Observation on 8/5/25 at 10:30 AM identified Resident #1's door was closed with staff providing care. Interview with NA #2 on 8/6/25 at 12:20 PM identified her shift started at 7 AM and Resident #1 was on her assignment for care. NA #2 stated Resident #1 received incontinent care at approximately 10:15 AM (3 hours and 15 minutes after her shift started). NA #2 identified Resident #1 was not that wet (referring to incontinent level) and she was providing care as quickly as possible to all her residents due to being short staffed. NA #2 identified Resident #1 had not refused care (she was busy and had not given the care) and she did not receive any report that Resident #1 refused incontinent care during night shift. NA #2 identified although she was not able to provide incontinent care for Resident #1 prior to 10:30 AM, she did not notify any staff that she needed assistance to provide care for the residents on her assignment. Record review identified NA #3 worked the night shift that ended at 7 AM on 8/5/2025. Although attempted, an interview with NA #3 was unable to be obtained during survey. B) Resident #3 had diagnoses that included diabetes mellitus and anemia.The quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen (11/15), indicative of moderately impaired cognition, was dependent with ADLs and bed mobility, and was always incontinent of bowel and bladder. The Resident Care Plan dated 7/22/25 identified Resident #3 had an alteration in ADL function, and was incontinent. Interventions directed to assist with ADLS and bed mobility, and provide incontinent care. Interview with NA #1 on 8/5/25 at 11:40 AM identified her shift started at 7 AM, and she had not provided AM care or incontinent care for Resident #3 since her shift started (4 hours and 40 minutes). NA #1 stated the unit was short staffed and she did not notify anyone that she needed assistance; NA #1 stated as staffing is aware they are short staffed. Interview with Resident #3 on 8/5/25 at 11:45 AM identified he/she last received incontinent care at 5:30 AM and had been waiting to be washed up. Resident #3 identified he/she rang the call bell but care was not provided. Observation of Resident #3 at the time of the interview identified he/she appeared to not have received AM care at the time of the observation (still in bed wearing johnny). Continued observation on 8/5/25 at 11:48 AM (4 hours and 48 minutes after the shift stated) identified NA #1 entered Resident #3's room to perform AM care. Record review identified NA #4 worked the night shift that ended at 7 AM on 8/5/2025. Although attempted, an interview with NA #4 was unable to be obtained during survey. Facility documentation review identified Resident #1 and Resident #3's unit/floor had a census of 43. The usual staffing pattern on Resident #1 and Resident #3's unit/floor was two (2) licensed staff and four (4) NAs on the unit during the 7 AM to 3 PM shift. Observations and facility documentation review identified on 8/5/2025 the unit was staffed with two (2) licensed staff and three (3) NAs. Additional review identified the alternate unit/floor had a census of 32 residents (11 less residents than the other unit) and was staffed with two (2) licensed staff and four (4) NAs. Review failed to identify why there were not four (4) NAs as per the usual staffing pattern. Interview with the DON on 8/5/25 at 2:00 PM identified nursing staff should provide residents with incontinent care every two (2) hours. The DON stated all residents should receive care in a timely manner, and nursing staff should document if there are any refusals. Further, the DON stated if staff are unable to provide care in a timely manner, they should notify their supervisor. Interview failed to identify why the care was not provided timely for Resident #1 and Resident #3. Review of the Incontinence Care Policy dated 12/13/2022 directed in part, all residents that are incontinent will receive appropriate treatment and services. Although requested, DON stated the facility did not have a staffing policy, and stated the facility follows the CT Public Health Code requirements to ensure appropriate staffing levels. Interview with [NAME] (Director of Human Resource) on 8/5/25 at 3:50 PM identified she was responsible to ensure staffing levels on the units. The [NAME] stated that on 8/5/2025 a NA called out (absent from work). Interview failed to identify why the shift was not covered by another staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility documentation, the facility failed to provide residents with a comfortable environment. The findings include: Facility tour and observations on 6/6/2025 at 8:31 AM identified the first-floor dining room temperature was 81 degrees Fahrenheit (F) with a stand-alone window vented air conditioner in use. Further observations of the upper/second floor resident wall mounted digital thermometers identified the following room temperatures: 8:32 AM: room [ROOM NUMBER] was 82.9 degrees F, no air conditioning unit 8:38 AM: room [ROOM NUMBER] was 87 degrees F, no air conditioning unit 8:39 AM: room [ROOM NUMBER] was 89 degrees F, no air conditioning unit 8:47 AM: room [ROOM NUMBER] was 84 degrees F with a stand-alone floor air conditioning unit that was not turned on 8:50 AM: room [ROOM NUMBER] was 86 degrees F, no air conditioning unit Further observations of the lower/first floor resident wall mounted digital thermometers identified the following room temperatures: 9:16 AM: room [ROOM NUMBER] was 80.2 degrees F, no air conditioning unit 9:32 AM room [ROOM NUMBER] was 81 degrees F, no air conditioning unit Interview and observation on 6/6/2025 at 8:32 AM with Resident #2 identified his/her room was too warm, he/she had the windows open, the windows only opened a few inches, and the observed temperature on the wall mounted thermostat was 82.9 degrees F. There was no air conditioning unit in the room. Interview on 6/6/2025 at 8:52 AM with the Director of Maintenance identified the resident rooms air conditioning system was not working due to leaks in the cooling system lines outdoors, the air conditioning contractor was out the prior week, a second contractor scanned the lines and identified materials within the lines and determined pipes would need to be replaced, and the repair would take a week due to supplies needed.The Director of Maintenance further indicated he obtained a quote on 6/2/2025 from the contractor and signed the work proposal on 6/5/2025. He identified that he communicated daily updates, pertaining to the air conditioning system, to the facility administrator. He identified the Administrator ordered air conditioning units when it was identified the repair work would be delayed due to supply needs. He indicated the facility had 35 resident rooms but currently only had 10 to 12 portable air conditioning units on site and functioning. The facility recived a delivery on 6/6/25 for a total of 34 air conditioning units which needed to be installed. Interview on 6/6/2025 at 9:16 AM with Resident #4 identified that on 6/5/25, when he/she was in the therapy/rehab room, the temperature was 90 degrees F and further indicated, his/her room was more comfortable at the current temperature of 80.2 degrees F (observed temperature on wall mounted thermostat) than it was in the therapy/rehab room. There was no air conditioning unit in Resident #4's room. Interview with the Administrator on 6/6/25 at 9:35 AM identified an air conditioning contractor was at the facility to evaluate the air conditioning system the week prior. She further identified she was not aware the air conditioning system was not functioning properly until 6/5/25 and indicated she was unaware of the pending heat wave. She indicated that the Director of Maintenance did not communicate the outcome of the contractor visit nor did she inquire with the Director of Maintenance regarding the outcome of the contractor visit the week prior. She identified that she did not report the air conditioning system failure to the state agency since the facility had a corrective action plan in place. Review of the Mechanical Project Proposal dated 6/2/2025 from the contractor identified the Director of Maintenance signed the proposal dated 6/4/2025. During an interview on 6/6/2025 at 1:45 PM with the Administrator, DNS and Director of Maintenance, the Administrator identified she did not understand how the air conditioning cooling tower worked, was unable to identify when she was first notified of an issue with the air conditioning system, and indicated she ordered air conditioning units once she was notified it would take a week for the contractor to obtain the reapair supplies. The Maintenance Director indicated he was not aware, until recently, that the facility had rooftop cooling units for common areas and hallways, but indicated the units had coil issues and were not in working order. The facility failed to report the loss of air conditioning to the state agency prior to surveyor arrival at the facility and upon inquiry. Review of facility Resident Environmental Quality Policy directed in part the facility shall have adequate ventilation by means of windows, or mechanical ventilation, or a combination of the two, resident rooms and activity areas should be of a comfortable temperature for the residents. All facility personnel are responsible for reporting broken, defective, or malfunctioning equipment or furnishing immediately upon identification of the issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1), reviewed for quality of care, the facility failed to ensure daily weights were obtained and failed to notify the physician of a weight gain greater in accordance with physician orders. The findings include: Resident #1 had a diagnosis of chronic kidney disease. Quarterly MDS dated [DATE] identified Resident #1 had a BIMS of 12 indicating moderately impaired cognition and required assistance with ADLs. The Resident Care Plan (RCP) dated 1/23/2025 identified variations in weight and appetite. Interventions directed to monitor weight, and notify the provider of significant weight changes. Physician order dated 12/23/2024 directed to obtain a daily weight and to notify the provider of an increase greater than two (2) pounds in one (1) day or five (5) pounds in three (3) days. Record review identified during January 2025, Resident #1 weights were obtained on the following dates: 1/6, 1/7, 1/15, 1/16, 1/22, 1/25, and 1/31/2025. Additional review identified Resident #1 refused to be weighed on nine (9) days (1/1, 1/2, 1/8, 1/9, 1/14, 1/18, 1/19, 1/20, and 1/21/2025). Weights were not recorded on fifteen (15) out of 31 days (1/3, 4, 5, 10, 11, 12, 13, 17, 23, 24, 26, 27, 28, 29, and 30/2025). Interview and record review with the Dietician on 2/14/2025 at 11:41 AM identified Resident #1 was not weighed daily during the month of January but should have been weighed daily. The Dietician indicated she did not know why the weights were not obtained. Interview and record review with LPN #1 on 2/14/2025 at 12:46 PM identified Resident #1 was not weighed daily during January 2025 but should have been, per physician order. LPN #1 further stated that it was her responsibility and the nurse on each shift's responsibility to ensure the resident was weighed daily. LPN #1 stated she did not know why the weights were not obtained, and she never checked to ensure daily weights were obtained as ordered. Interview and record review with the DNS and Administrator on 2/14/2025 at 1:36 PM identified although the physician ordered daily weights, and Resident #1 refused weights at times, the interview failed to identify why weights were not obtained on the fifteen (15) days without documentation. Interview identified the weights should have been obtained, and if the resident refused the weight, then the refusal should have been documented. a. Weight on 1/22/2025 was recorded as 115 pounds (lbs). Weight recorded on 1/25/2025 was 125 lbs (increase of 10 lbs). Record review failed to identify the physician was notified of the 10-pound weight gain in accordance with physician order. Interview and record review with the DNS and Administrator on 2/14/2025 at 1:36 PM identified the facility was unable to provide documentation that the physician/APRN was notified of the 10-pound weight gain identified on 1/25/2025. Interview identified the physician/APRN should have been notified, and the DNS and Administrator did not know why they were not notified. Although requested, a facility policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure staff coverage timely to ensure a blood sugar measurement was obtained prior to a meal in accordance with physician orders. The findings include: Resident #1 was admitted with diagnoses that included diabetes mellitus (DM). A resident care plan (RCP) dated 9/3/2024 identified Resident #1 had insulin dependent diabetes. Interventions directed to access and record blood glucose levels and labs as ordered. An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a BIMS of 11 meaning mildly impaired cognition, had a diagnosis of diabetes and received insulin seven out of the prior seven days. A physician's order dated 11/20/2024 directed to check blood sugar (via blood glucose monitor) before meals and at bedtime for DM. A late entry nursing progress note written by the Director of Nurses (DON) dated 12/7/2024 (Saturday) at 3:14 PM identified Resident #1's blood glucose was monitored two (2) hours late today (12/7/2024). No acute distress was noted, blood glucose was done immediately by supervisor (RN # 2); reading was 243 and the APRN and family were updated. A facility written interview of RN #2 by the DON dated 12/12/2024 identified she was informed by LPN #1 at 2:00 PM on 12/7/2024 that Resident #1's family was upset that Resident #1's blood sugar had not been checked prior to eating lunch. LPN #1 indicated that she was waiting for RN #2 to come and did not ask the other nurse on the unit to assist her when RN #2 did not respond. RN #2 identified that she assessed Resident #1 at that time and completed the blood sugar check with a result of 243 that was reported to the APRN and family with no new orders obtained. A facility corrective counseling report dated 12/21/2024 for LPN #1 identified on 12/7/2024, LPN #1 failed to communicate with the supervisor about Resident #1 who needed a blood glucose monitored prior to lunch, leading to a delay in treatment. LPN # 1 had been previously directed to not go into Resident #1s room due an issue that had happened in the past. The counseling report indicated the direction for LPN #1 not to enter the room should not have prevented LPN #1 from ensuring Resident #1's blood sugar was monitored timely. Interview and review of facility investigative documentation and Resident #1's medical record with the DON on 12/30/2024 at 1:00 PM identified LPN #1 had previously been requested to not provide care for Resident #1 by the family, and LPN #1 had been recently reassigned to Resident #1's unit. The DON stated the assignments were made for the day prior to LPN #1's arrival to work, and there was a second LPN (LPN #4) working on the floor who had already started her assignment. LPN #1 was aware that she should not care for Resident #1 and upon learning she had been assigned to Resident #1, LPN #1 notified RN #1 (night supervisor) who provided care to Resident #1 instead of LPN #1 on the morning of 12/7/2024. When the ordered blood sugar was due prior to lunch, LPN #1 attempted to contact the day supervisor (RN #2) who did not respond. The DON continued that RN #2 was addressing another resident's urgent need on another floor and she would have expected LPN #1 to seek out the other nurse on the unit to assist her to complete the blood sugar check. The DON stated LPN #1 did not request assistance from the LPN #4, and was waiting for RN #2 to assist. Interview failed to identify why LPN #1 was assigned to the unit where she was not allowed to provide care for all residents who resided there. Review of facility documentation identified although the facility provided education to LPN #1 regarding obtaining timely blood sugars and provided education to additional nursing staff regarding preventing treatment delays, review failed to identify education was provided regarding staffing and communication when a staff member is prevented from providing care for any resident. The facility completed a QAPI meeting on 12/7 and audits were initiated on 12/9/2024, however review failed to identify past non-compliance. Interview with RN #1 on 12/30/2024 at 1:37 PM identified on 12/7/2024 she assessed Resident #1, completed the ordered blood sugar prior to breakfast, and provided Resident #1 her/his scheduled medications. RN #1 stated she reported to the oncoming supervisor (RN #2) the need to follow up with Resident #1's care needs until the end of LPN #1's shift at 3:00 PM. RN #1 stated she was specific to include that LPN #1 could not provide care for Resident #1. Although attempted, interviews with LPN #1, LPN #4, and RN #2 were not obtained during the survey. The facility policy Blood Glucose Monitoring dated 3/2024 directed in part, that blood glucose monitoring is performed as per physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documents, and interviews for one (1) of (3) residents (Resident #2), reviewed for hydration, the facility failed to notify the Advanced Practice Registered Nurse (APRN) that an order was not promptly initiated . The findings included: Resident #2 had diagnoses that included failure to thrive, metabolic encephalopathy, and unspecified dementia. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #2 as severely cognitively impaired and required moderate assistance with eating. Review of the Resident Care Plan dated 8/22/24 identified Resident #2 was at nutritional risk due to poor oral intake with interventions that included to provide the diet as ordered and notification of nurse for consumption of less than 50% of a meal. Review of a physician's order dated 8/23/24 directed placement of a peripheral intravenous line (IV) for hydration. Review of a nurse's note dated 8/25/24 at 11:41 PM identified Resident #2 had pulled out his/her IV. Review of a physician's order dated 8/27/24 directed insert a peripheral IV line one (1) time for IV fluids. Review of the Medication Administration Report (MAR) dated 8/27/24 identified an order for Dextrose-NaCl Solution 5-0.45% (Dextrose Sodium Chloride), use a three (3) liter bag intravenously at a rate of 60 milliliters per hour for three days for poor intake/dehydration, further review of the MAR failed to identify fluids were administered on 8/27/24. A nurse's note dated 8/28/24 that the resident was sent to the hospital due to increased lethargy. Review of the Clinical Infusion Nursing Document dated 8/28/24 at 12:45 PM identified the IV line was not placed as Resident #2 was transferred to the hospital. Interview with RN #1 on 9/19/24 at 10:10 AM identified Resident #2 had completely dislodged his/her IV the evening of 8/25/24 and that he/she did not inform the provider as he/she saw that the resident's order for IV fluids fluids on 8/27/24. Interview with APRN #1 on 9/19/24 at 3:20 PM identified he/she expected to be notified by the facility that Resident #2 could not be started on IV fluids on 8/27/24 as he/she was unaware the resident did not have an IV access. Interview with the Director of Nursing Services on 9/19/24 at 4:35 PM identified that, generally speaking, communication with the APRN and/or physician should have occurred and should occur when an order cannot be initiated on the day it was placed. Review of the Continuous Infusion of Medications and Solutions policy directed infusion therapy must be administered as ordered to maintain a therapeutic response in the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record and facility documentation for one resident (Resident #1) reviewed for meal intake, the facility failed to document daily food consumption. The findings included: Resident #1 had diagnoses that included cerebral infarction, hypertensive urgency, and cerebral ischemia. Review of the Nursing admission assessment dated [DATE] identified Resident #1 was alert to person and required assistance with activities of daily living Review of the Resident Care Plan dated 8/2/24 identified Resident #1 was at nutritional risk due to dietary restrictions and stroke with interventions that directed to monitor weight, labs and intake as available. Review of Resident #1's meal intake documentation failed to identify meal intake percentages on the following days: 8/3/24 and 8/4/24 for breakfast, lunch, and dinner, 8/5/24 for dinner, 8/6/24 for breakfast and lunch, 8/8/24 for dinner, and 8/10/24 for dinner. Interview with the Director of Nurses on 9/19/24 at 4:03 PM identified that NA are responsible to document daily meal intake percentages. Review of the Charting and Documentation policy directed all services provided to the resident, or any changes in the residents' medical or mental condition, shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based clinical record, observation, facility documentation review, policy review and interviews for 1 of 1 sampled resident (Resident #41) reviewed for Resident Assessments, the facility failed to ensure the resident's admission assessment included a specialized respiratory treatment and ensure care areas were triggered as part of the comprehensive assessment. The findings include: Resident #41's diagnoses included: Peripheral Vascular Disease (PVD), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A physician's progress history noted dated 9/17/23 from a previous facility indicated resident known to have COPD, obstructive sleep apnea on CPAP. A nursing admission assessment dated [DATE] identified respiratory care needs included CPAP (continuous positive airway pressure) (machine that uses mild air pressure to keep breathing airways open while you sleep for better sleep quality, reduction or elimination of shoring, and less daytime sleepiness) use. An Advanced Practice Registered Nurse's progress history note dated 9/18/23 from previous facility indicated the resident had a past medical history of obstructive sleep apnea and on CPAP. A nursing progress note dated 9/29/23 indicated patient has a history of COPD. Advanced Practice Registered Nurses notes dated 10/1/23 and 10/2/23 by two different APRN's indicated resident had a history of obstructive sleep apnea and on CPAP. An admission MDS assessment dated [DATE] identified Resident # 41 as alert and cognitively intact, with no behavior issues and indicated the resident required extensive assistance with bed mobility, limited assistance with transfers, and toilet use, supervision with meals. However, the assessment failed to indicate Resident # 41's special treatment CPAP use. A review of the October 2023 to January 2024 Medication Administration Record (MAR) failed to identify oxygen or CPAP use. A physician's order dated 12/7/23 directed keep head of bed elevated to prevent shortness of breath while lying flat secondary to COPD/Asthma. Observation and interview on 1/30/24 at 12:35 PM with Resident #41 identified an oxygen cannula line was attached to the wall on head of bed. The cannula line was lying on the bed near the resident's right side. Resident # 41 also indicated s/he wears the oxygen at night and further indicated s/he has sleep apnea and uses a CPAP machine at home. Observation and interview on 1/31/24 at 1:28 PM with Licensed Practical Nurse (LPN #2) identified Resident #41 had an oxygen cannula connected to the wall at the head of the bed that s/he did not have an order for oxygen, had a diagnosis of COPD, the resident should have CPAP or BiPAP with the diagnosis of obstructive sleep apnea, and indicated the resident was not care planned for oxygen. On 2/1/24 at 9:40 AM interview with Resident # 41 identified s/he had been wearing oxygen at night because it makes him/her snore less, and if he/she had a CPAP at the facility to wear s/he would use it. . Review of facility policy annual review dated 9/29/23 titled Oxygen Safety indicated the purpose of the policy is to ensure the safe storage, use, and transportation of oxygen by all health care workers handling oxygen. The procedure indicated that oxygen is a medication that requires a physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for 2 of 2 sampled residents (Residents #29 and 39) reviewed for Care Planning, the facility failed to complete the cognitive and mood care areas of the Minimum Data Set assessments per facility policy. The findings included: 1. Resident #29's diagnoses included depression, chronic congestive heart failure, dilated cardiomyopathy, and type 2 diabetes mellitus. A physician's order dated 8/30/23 directed paroxetine 10 mg daily by mouth for depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #29 required substantial assistance with toileting hygiene, lower body dressing, and putting on, taking off footwear, however, sections c (cognition) and d (mood) were not completed 2. Resident #39's diagnoses included schizoaffective disorder, dementia, and type 2 diabetes mellitus. The quarterly Minimum Data Set, dated [DATE] identified Resident #39 required partial assistance with toileting, bathing, and personal hygiene, however, sections c (cognition) and d (mood) were not completed. A physician's order dated 7/14/23 directed Risperidone 0.5 mg twice daily by mouth for schizoaffective disorder. A physician's order dated 8/11/23 directed bupropion 150 mg daily by mouth for depression, anxiety, and weight gain. Review of the Resident Care Plan dated 1/4/24 identified a decline in cognitive function or impaired thought processes related to dementia and schizoaffective disorder. Interventions directed to monitor for decline in activities of daily living function, evaluate the need for psych/behavioral health consult if indicated, and provide consistent, trusted caregivers and structured daily routine when possible. Interview with SW #1 on 2/2/24 at 9:41 AM indicated both sections c and d of the Minimum Data Sheet assessment (MDS) should always be completed, policy directs that the social worker interview the resident and input data into the MDS system by the due date. SW #1 identified s/he was unsure as to why these sections were not completed as she was not the social worker at the time the assessment was due. Interview with the Director of Nursing on 2/5/24 at 9:07 AM indicated it was the social worker's responsibility to complete her assigned sections of the MDS assessment and that all sections of the MDS should have been completed by the due date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for 1 of 2 sampled residents (Resident #39) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to update the level of care in a timely manner. The findings included: Resident #39's diagnoses included schizoaffective disorder, dementia, and type 2 diabetes mellitus. A review of PASRR Level I with determination date of 10/30/20 identified Resident #39 required no further Level I screening unless he/she was suspected of having a serious mental illness or intellectual or developmental disability and exhibited a significant change in treatment needs. The quarterly Minimum Data Set, dated [DATE] identified Resident #39 required partial assistance with toileting, bathing, and personal hygiene. Review of the Resident Care Plan dated 1/4/24 identified a decline in cognitive function or impaired thought processes related to dementia and schizoaffective disorder. Interventions directed to monitor for decline in activities of daily living function, evaluate the need for psychiatric/behavioral health consultation if indicated, and provide consistent, trusted caregiver and structured daily routine when possible. Resident #39 was diagnosed with schizoaffective disorder 1/13/21 during his/her stay at the facility. The facility failed to provide evidence that an updated PASRR evaluation had been conducted after the resident was diagnosed with a new mental health condition. Interview with the DNS on 2/2/24 at 8:38 AM identified social services was responsible for the PASRR evaluations and the facility practice directed staff to follow the PASRR policy for level of care updates. Review of the Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients policy revised on 9/29/23 directed social services to coordinate updates as needed and per state requirements and to evaluate individuals identified with a mental disorder or intellectual disability to ensure care and services are provided in the most integrated setting and appropriate to their needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and interviews for 1 of 3 residents (Resident #41) reviewed for discharge, the facility failed to ensure the clinical record identified the resident's discharge plans post discharge from the facility. The findings included: Resident #41's diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A nursing admission assessment dated [DATE] failed to identify resident's discharge plan or goal. A social worker's progress note dated 8/8/23 by SW #2 (from prior facility) indicated patient's stay is expected to be short term, length of stay 15-21 days, goals of care related to transitioning back to community discussed. A social worker's progress note dated 9/8/23 by SW #2 (from prior facility) indicated patient discharged with belongings and discharge packet, information sent to home health and primary care providers office. A social worker's progress note dated 10/3/23 by SW #2 indicated patient's stay is expected to be short term, expectations, and goals of care related to transitioning back to community discussed, discharge to home when back to baseline. The progress note further indicates this baseline person-centered care plan is developed within 48 hours and is reviewed post admission patient/family conference, discussed home care, patient stated he/she has friends that will assist him/her. A social worker's progress note dated 10/4/23 by SW #2 indicated social worker discussed long term insurance with patient and suggested resident call state insurance program to determine if s/he could be switched to long term and reviewed the process. A quarterly MDS assessment dated [DATE] identified Resident # 41 as alert and cognitively intact and was dependent for toilet use, substantial maximum assistance for rolling side to side, sit to stand, dressing, bathing, set-up assistance for personal hygiene and independent with meals. MDS assessment failed to indicate resident's overall goal for discharge and indicated that the active discharge plan in place for resident to return to the community. A Resident Care Plan dated 12/17/23 failed to indicate resident's discharge plan or goals. Surveyor requested to review November 2023 to January 2024 social worker notes, facility provided August 2023 through October 2023. A second request again was made by Surveyor to review November 2023 to January 2024 notes. However, the facility failed to provide the social service notes from November 2023 or December 2023. Interview on 1/30/24 at 10:45 AM with social worker #1 indicated she began working for the facility the day before, was not aware Resident #41 would like to be discharged home and she would investigate further. A social worker's note dated 1/30/24 by SW #1 indicated she met with the resident regarding concerns and questions about discharge and a discharge planning meeting would take place on 1/30/24. A social worker progress note dated 1/30/24 indicated the social worker met with resident, facility staff and resident's community support system regarding discharge to home. Additionally, the note indicated the SW would be following up with the resident's friend to assist him/her in the completion of insurance applications. On 2/1/24 at 12:06 PM interview with Physical Therapy Aide (PTA # 1) and Occupational Therapy Aide (OTR #1) indicated they were aware of Resident #41's discharge plan, a discharge plan meeting had occurred the day before, PTA #1 indicated she was aware the resident had spoken to the previous social worker regarding his/her plans for discharge. PTA #1 further indicated she had been working with the resident the entire time at the facility, the resident was clear on his/her discharge plan, the goal was to get him/her home, she identified therapy progress note dated 12/19/23 indicated focus was training patient for discharge to home. On 2/5/24 at 2:00 PM interview with DNS, RN #14 and RN #15, the DNS identified the process at the facility under the previous ownership was to document in discharge planning in the care conference notes. RN #14 indicated the best practice would be to revise care plans. The DNS further indicated the Interdisciplinary notes are documented in the social worker notes. RN #14 also indicated under current ownership company the procedure is to use a sign in sheet and to write a note. Review of facility policy annual review dated 9/29/23 titled Discharge Planning Process indicates The Center must develop and implement an effective discharge planning process that focuses on the patient's/resident's discharge goals, preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions. Review of facility Interprofessional Care Management Utilization Management and Discharge Planning Meeting Guidelines dated 9/2019, purpose indicates to manage the flow of discharges from the Center on any given day to achieve consistent census and balanced nursing staff workload. Best practices include report any unresolved barriers to discharge so the disciplines can identify additional measures to enable discharge and the CRC (Clinical Reimbursement Coordinator) can identify if the patient warrants ongoing skilled care in the SNF (skilled nursing facility) and update of care plans as needed. It further indicates that everyone on the Interprofessional Team must understand their responsibility in relation to the whole Utilization Management and Discharge Planning Processes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for 2 of 3 residents (Resident #52, Resident #57) who required assistance with medication administration, the facility failed to ensure physician's orders were followed as prescribed. The findings included: 1. Resident #52's diagnoses include dementia, hypertension (HTN), and atrial fibrillation. The annual minimum data set (MDS) assessment dated [DATE] identified Resident #52 as severely cognitively impaired and required setup/clean up assistance with eating, needed supervision for hygiene/showering and was independent for toileting. The physician's orders dated 2/9/23 directed to give 1, 50 mg (milligram) tablet of Metoprolol Tartrate by mouth two times a day for HTN, hold for systolic blood pressure (SBP) of less than 110 or a heart rate (HR) of less than 55. The Treatment Administration Record (TAR) dated 11/1/23 through 11/30/23 identified Resident #52 had Metoprolol Tartrate administered 6 out of 52 times outside of the SBP or HR parameters. The treatment administration record (TAR) dated 12/1/23 through 12/31/23 identified Resident #52 had Metoprolol Tartrate administered 2 out of 56 times outside of the SBP or HR parameters. The treatment administration record (TAR) dated 1/1/24 through 1/31/24 identified Resident #52 had Metoprolol Tartrate administered 2 out of 60 times outside of the SBP or HR parameters. Interview with RN #1(supervisor) on 2/1/24 at 10:55 AM indicated when specific vital sign parameters are in place and part of the physician's orders, she would expect the order to be followed as directed. Although a policy was requested regarding physician's orders, a policy was not provided. 2. Resident #57's diagnoses included chronic obstructive pulmonary disease, hypertension, and fibromyalgia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #57 as independent with eating, toileting hygiene, dressing and personal hygiene. The Resident Care Plan dated 12/31/2023 indicated a diagnosis of depression and behavior history of suicidal ideation, resident is on medications to manage diagnosis and behaviors, and a risk for distressed/fluctuating mood symptoms related to sadness/depression caused by not having housing in the community. Interventions directed to observe signs and symptoms of a new psychiatric disorder, observe for worsening symptoms, and to refer to behavioral health specialist as needed. A physician's order dated 12/3/23 directed venlafaxine HCl oral tablet 75 mg daily at bedtime for depression. Review of the Medication Administration Record dated January 2024 identified Resident #57 did not receive her bedtime dose of venlafaxine 75 mg on 1/22/24, 1/23/24 and 1/24/24. Review of nursing note by LPN #6 on 1/23/24 at 9:32 PM and 10:28 PM indicated venlafaxine 75 mg was not administered due to awaiting delivery from the pharmacy. Interview with Pharmacist #1 on 1/31/24 at 2:56 PM identified an order for Resident #57's 75 mg dose of venlafaxine was called into the pharmacy on 1/24/24 at 6:46 PM for a refill. Pharmacist #1 further indicated there was always a running stock of the venlafaxine 75 mg dose. The pharmacy was not out of stock at the time the refill was called in. Interview with LPN #6 on 2/1/24 at 2:40 PM indicated he/she did not remember what date the venlafaxine 75 mg was ordered. LPN #6 indicated he/she did check the Pixus for a back-up supply and notified the nurse supervisor Resident #57 was out of the venlafaxine 75 mg dose. LPN #6 further indicated he/she was not aware if the physician was notified but s/he called the pharmacy to reorder the prescription. Interview with APRN #1 on 2/1/24 at 2:48 PM identified he/she was notified on both 1/23/24 and 1/24/24 Resident #57 did not receive her/his venlafaxine 75 mg dose, however, s/he was not aware Resident #57 had not received the 75 mg dose on 1/22/24 as well. APRN #1 further indicated it was not okay for Resident #57 to miss three consecutive doses of the 75 mg venlafaxine. APRN #1 further indicated he/she had assessed Resident #57 on 1/24/24 to ensure there were no ill effects from the missed doses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, review of facility policy and interviews for 1 of 1 resident (Resident #53), at risk for pressure ulcer development, the facility failed to appropriately identify the residents wound treatment. The findings include: Resident #53's diagnoses include type 2 diabetes mellitus, rheumatoid arthritis, and polyneuropathy. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #53 as cognitively intact and required supervision with eating and hygiene and was dependent on toileting. The RCP dated 10/23/24 identified Resident #53 had a deep tissue injury (DTI) to right and left heel, abrasions, skin tears related to fragile skin and disease process. Interventions included: treatment order was updated per wound MD, staff education in progress to ensure offloading of the heel daily and to monitor for signs and symptoms of infection and report to physician. The physician's orders dated 12/5/23 indicated an unstageable right heel wound. Staff were directed to apply betadine, followed by an abdominal (ABD) pad, kerlix, change 3 x per week and as needed (PRN) one time a day every Monday, Wednesday, Friday. The end date for this order was indicated. The physician's orders dated 12/28/23 indicated an unstageable pressure ulcer to right heel with directions to cleanse with normal saline (NS) and apply betadine, cover with dry dressing, wrap with kerlix as needed for wound and everyday shift for wound. The end date for this order was not indicated. b. The treatment administration record (TAR) dated 1/1/24 through 1/31/24 for physician's order of unstageable right heel wound with directions to apply betadine, followed by an abdominal (ABD) pad, kerlix, change 3 x per week and as needed (PRN) one time a day every Monday, Wednesday, Friday indicates that this treatment was identified and performed for 12 out of 13 treatments. The treatment administration record (TAR) dated 1/1/24 through 1/31/24 for physician's order of unstageable pressure ulcer to right heel with directions to cleanse with normal saline (NS) and apply betadine, cover with dry dressing, wrap with kerlix as needed for wound and everyday shift for wound indicates that this treatment was identified and performed 30 out of 31 treatments. Observation and interview with MD #2, the attending wound MD on 2/1/24 at 9:54 AM indicated that his order for Resident #53's wound dressing change should be: remove old dressing, cleanse with betadine, then add an abdominal dressing, kerlix, daily and as needed. Interview with RN #3, the 1st floor RN supervisor on 2/1/24 at 10:47 AM identified that there were 2 different treatment orders for Resident #53's dressing change and one order should have been discontinued. She also indicated that if she was a new employee, she would not know which physicians order to follow regarding the dressing change to the right heel. She further identified that it was her responsibility to ensure accurate and updated MD orders were in the computer. Although a policy was requested for physician's orders related to pressure ulcers, no policy was provided.

Based observations of dining and the environment, policy review and interviews for 3 of 3 residents (Resident #2, Resident #31, Resident #57) observed during dining, the facility failed to ensure the residents had a way to access staff in case of a choking incident to ensure residents were free from accidents and the facility failed to consistently monitor hot water temperatures per practice and as directed to ensure safe and acceptable water temperatures. The findings included: 1. An observation on 2/1/2023 at 8:05 AM in the second-floor dining area near the nurse's station identified Resident # 2, Resident # 31 and Resident # 57 seated at a circular table in the dining room located off the nurse's station which was unoccupied. Further observations noted at 8:16 AM a nurse aide entered the dining area, went to the refrigerator, and left the dining area at 8:17 AM. On 2/1/2023 at 8:17 AM an interview and observation with RN#1 indicated there was no call system located in the dining area. Since the residents in the area were independent, they do not require supervision, the staff frequently provide help when needed. RN #1 further indicated one of the residents has a cell phone with all the facility numbers who could call for assistance or one of the residents could wheel their wheelchair out to get help. On 2/1/2023 at 8:58 AM an interview, observation and policy review with the DNS indicated the facility policy for independent residents does not need supervision. Review of the policy indicated staff members needed to sit next to residents who required assistance with eating. The DNS further indicated there was frequent rounding by staff and residents could come out of the dining room or use their cell phone to obtain assistance. After discussion regarding the potential for choking or another type of emergent situation, the DNS indicated the placement of hand bells would be instituted immediately on each dining table for Resident's to use in an emergency. An observation on 2/1/2024 at 9:40 AM of the dining area tables identified no residents eating at this time and a hand bell on the center of each dining table. 2. A review of the facility's water temperature log binder on 2/1/24 identified missing hot water temperature checks for 11/24/23 and 12/1/23. On 2/2/24 at 9:47 AM, the Director of Maintenance identified the software company that provided the facility with the water check was unable to open documentation on their systems to verify the hot water temperatures were checked the week of 11/24/24 and 12/1/24. Interview with the Director of Maintenance on 2/1/24 at 11:31 AM identified the missing temperature log sheets are related to the time when the computer programs were changed over after the Change of Ownership, and he/she was unable to find the missing documents. Review of the Hot Water Temperature Inspection policy revised directed hot water temperature testing weekly. 3. Elevated hot water temperatures of 129.2 degrees, 128.8 degrees, 129.5 degrees, and 129.9 degrees were identified on 1/31/24 between 8:28 AM and 8:35 AM in rooms #201, 206, 209, and 213. The facility Administrator was immediately made aware of the elevated temperatures on 1/31/24 at 8:40 AM with the Maintenance Director. The state agency Buildings Fire and Safety Inspector (BFSI) were also informed of the concern at 8:43 AM. The Director of Maintenance immediately began facility wide hot water temperature checks, turned the mixing valve temperature down from 130 degrees to 121 degrees, and per the directive of the state agency BFSI onsite directed to continue checking and logging hot water temperatures for 24 hours. BFSI directed hot water temperature checks were to be done every twenty minutes, with the understanding that as the temperatures were consistently within acceptable limits (105 degrees to 120 degrees), the hot temperature checks could be extended to every forty minutes, 1 hour, 2 hours, etc. if the temperatures remained within acceptable limits. If temperatures did not remain within acceptable limits, the Maintenance Director was directed to reinitiate checking hot water temperatures every twenty minutes. Review of the hot water temperature log sheet provided by the facility identified hot water checks were performed every twenty minutes for two hours, then hourly for nine hours, and hot water temperature checks twice daily as hot water temperatures were consistently within acceptable limits. Interview with the Maintenance Director on 2/2/24 at 9:47 AM indicated instructions for hot water checks communication may have not been clear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, observation, policy review and interviews for 1 of 1 sampled resident (Resident #41) reviewed for respiratory care, the facility failed to ensure the resident had a physician's order for the utilization of oxygen and failed to implement a sleep device for sleep apnea. The findings include: Resident #41's diagnoses included: Peripheral Vascular Disease (PVD), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A physician's progress history noted dated 9/17/23 from a previous facility indicated resident known to have COPD, obstructive sleep apnea on Continuous Positive Airway Pressure (CPAP). An Advanced Practice Registered Nurse's progress history note dated 9/18/23 from previous facility indicated the resident had a past medical history of obstructive sleep apnea and on CPAP. A nursing admission assessment dated [DATE] identified respiratory care needs included CPAP (machine that uses mild air pressure to keep breathing airways open while you sleep for better sleep quality, reduction or elimination of shoring, and less daytime sleepiness) use. A nursing progress note dated 9/29/23 indicated patient has a history of COPD. Advanced Practice Registered Nurses notes dated 10/1/23 and 10/2/23 by two different APRNs indicated resident had a history of obstructive sleep apnea and on CPAP. An admission MDS assessment dated [DATE] identified Resident # 41 as alert and cognitively intact, with no behavior issues and indicated the resident required extensive assistance with bed mobility, limited assistance with transfers, and toilet use, supervision with meals. However, the assessment failed to indicate Resident # 41's special treatment CPAP use. A review of the October 2023 through January 2024 Medication Administration Record (MAR) failed to identify oxygen or CPAP use. A physician's order dated 12/7/23 directed keep head of bed elevated to prevent shortness of breath while lying flat secondary to COPD/Asthma. A Resident Care Plan dated 12/17/23 failed to indicate the resident's respiratory care or condition needs, or to address the use of oxygen or need for a CPAP machine. Observation and interview on 1/30/24 at 12:35 PM with Resident #41 identified an oxygen cannula line was attached to the wall on head of bed. The cannula line was lying on the bed near the resident's right side. Resident # 41 also indicated s/he wears the oxygen at night and further indicated s/he has sleep apnea and uses a CPAP machine at home. Observation and interview on 1/31/24 at 1:28 PM with Licensed Practical Nurse (LPN #2) identified Resident #41 had an oxygen cannula connected to the wall at the head of the bed that s/he did not have an order for oxygen, had a diagnosis of COPD, the resident should have CPAP or BiPAP with the diagnosis of obstructive sleep apnea, and indicated the resident was not care planned for oxygen. On 2/1/24 at 9:40 AM interview with Resident # 41 identified s/he had been wearing oxygen at night because it makes him/her snore less, and if he/she had a CPAP at the facility to wear s/he would use it. After surveyor inquiry, on 2/1/24 at 10:15 AM interview with DNS indicated she would obtain an order for the oxygen order and provided a physician's order dated 1/31/24 directed oxygen at 1-3 liters per minute as needed and oxygen tubing to be changed weekly. Review of facility policy annual review dated 9/29/23 titled Oxygen Safety indicated the purpose of the policy is to ensure the safe storage, use, and transportation of oxygen by all health care workers handling oxygen. The procedure indicated that oxygen is a medication that requires a physician's order. Review of facility policy annual review dated 9/29/23 titled Bi-level Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) including Trilogy is set up by a licensed nurse or Respiratory Therapist (RT) with a physician's/advanced practice provider's order. Purpose: to deliver positive airway pressure therapy for the treatment of obstructive sleep apnea. Practice Standards: orders for CPAP must include pressure and hours of use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, review of facility policy and interview for 1 of 1 resident (Resident #32) reviewed for specialized treatment, the facility failed to consistently conduct weights per physician's orders and failed to provide ongoing communication and collaboration with the specialized treatment center regarding care and services consistent with facility policy and the plan of care. The findings included: 1. a. Resident #32's diagnoses include renal disease, high blood pressure, and muscle weakness. The physician's orders dated 5/20/23 directed to obtain and document post specialized treatment weight only, every evening shift every Tuesday, Thursday, and Saturday. The quarterly MDS assessment dated [DATE] identified Resident # 32 as cognitively intact and required set up or clean up assistance with eating and personal hygiene and required moderate assistance with toileting and showering. A review of weights and vitals from 5/20/23 through 1/31/24 identified the facility failed to follow physician's orders to obtain and document post specialized weights, every evening shift every Tuesday, Thursday, and Saturday. b. The review of the communication book between the specialized treatment center and the facility dated 12/12/23 through 1/30/24 failed to identify 18 out of 36 occasions weights had been conducted per physician's and failed to provide evidence communication between the facility and the specialized treatment center for 18 out of 36 occasions. Interview with LPN # 4 on 1/30/24 at 11:30 AM identified the facility to monitor the residents' weights for weight loss and notify the physician of any loss. The facility policy review of Specialized Treatment Center Communication and Documentation notes the facility center staff will communicate with the certified treatment facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after treatments received at a certified facility. The policy further indicates upon return of the patient to the center/facility, a licensed nurse will: review the certified specialized treatment center facility communication, evaluate/observe the patient, and complete the post specialized treatment section on the communication record. Additionally, the policy notes the facility should be notified if the form is not returned with the patient and ask that it be faxed to the facility. The policy also notes to maintain the Specialized Treatment Center Communication record or state required form in the patients record.

Based on clinical record reviews, observations, facility policy and interviews for 2 of 5 residents reviewed during medication administration (Resident #72 and #119), the facility failed to ensure the residents received the prescribe dose to ensure the facility's medication error rate was less than 5 percent. The findings included: 1. Resident #72's diagnoses included aftercare of closed fracture and chronic kidney disease. A physician's order dated 1/12/2024 directed to provide MiraLAX powder give 17 grams by mouth once daily for constipation in 4-8 ounces of fluid if resident has not had a bowel movement in 72 hours. The Care Plan dated 1/13/2024 indicated Resident #72 had an alteration in musculoskeletal status related to a fracture of the left knee. Interventions include in part to give analgesic as ordered by the physician and to monitor for side effects. An observation of medication administration with LPN #1 on 1/31/2023 at 8:18 AM for Resident #72 identified the following: After asking Resident #72 if wanted a laxative, LPN #1 prepared Clearlax powder (aka MiraLAX or Polyethylene Glycol) 15 cc (measured in a medication cup) then poured into a glass of water and mixed well. The Clearlax in liquid form (in the glass of water) was administered to Resident #72. A nursing progress note dated 1/31/2024 6:19 PM indicated Resident #72 indicated having a formed bowel movement. A nursing progress note dated 1/31/2024 6:24 PM indicated notification of the physician for Resident #72 as resident #72 received less than the prescribed dose of Clearlax. A phone call to APRN #1 on 2/02/24 at 9:00 AM indicated when s/he saw Resident #72 no adverse effects had occurred after receiving less than the required dose of the Clearlax. APRN #1 indicated the resident was noted with bowel movement after the medication administration of less than required dose. 2. Resident #119's diagnosis included malignant neoplasm. The admission patient information dated 1/20/2024 indicated Resident #119 was cognitively intact. The care plan dated 1/24/2024 indicated Resident #119 received pain mediation therapy due to disease process. Interventions included administering medication as ordered and to review efficacy of the pain medication regimen. An observation of medication administration with LPN #1 on 1/31/2024 at 8:12 AM for Resident #119. LPN #1 prepared Clearlax powder (aka MiraLAX or Polyethylene Glycol classified as a laxative) 15 cc (measured in a medication cup) then poured into a glass of water and mixed well. The Clearlax in liquid form (in a glass of water) was administered to Resident #119 along with other scheduled medications. On 1/31/2024 at 2:58 PM an interview and record review of Resident #72 and #119 with the DNS and RN #15 indicated the correct dose for the Clearlax powder was 17 grams not 15 cc. RN#15 indicated s/he would check to see if 15 cc is equivalent to 17 grams in the cap of the bottle. On 1/31/2024 at 3:00 PM RN #15 and LPN#1 were observed in the medication room. RN#15 showed LPN#1, the line inside the cap of the medication that marks 17 grams, and the cap of the bottle is what is used to measure the dose. LPN #1 indicated the mark on the inside of the cap is difficult to see and s/he was not aware of the way to measure the Clearlax powder. RN#15 indicated the instructions on the medication container label indicated 17 grams equals one capful. RN #15 poured a capful (17 grams into a medication cup and LPN #1 indicated the 17 grams equaled 25 cc (10 cc less than the prescribed dose of 17 grams). RN #15 indicated education would be provided and the physician notified for each of the two residents. A nursing progress note dated 1/31/2024 4:45 PM indicated notification of the physician and responsible party as Resident #119 received less than the prescribed dose of Clearlax and to monitor the effect. The facility policy labeled General Dose Preparation and Medication Administration noted in part facility staff should verify that the medication name and dose are correct and compared to the physician's order on the Medication Administration Record.

Based on observation, interviews, and review of facility policy, the facility failed to ensure Level 3 medications were stored in a locked box and failed to discard expired medications. The findings included: a. On 1/29/24 at 10:55 AM, observation of the first-floor medication room with Licensed Practical Nurse (LPN) #1 identified 2 bubble packages of Level 3 medication were in the unlocked black refrigerator located inside an unlocked metal box (containing 32 tabs and the other containing 16 tabs) of Dronabinol (a Level 3 drug used to increase appetite and/or to prevent nausea) 5 mg tablets. Interview with LPN #1 at 10:55 AM identified the box in the black refrigerator should be locked, he was responsible for locking it and indicated he thought he locked the metal box. b. Observation on 1/29/24 at 11:05 AM with LPN #1 and at 11:15 AM with RN #1 identified the second-floor medication room white refrigerator was soiled and unclean. Interview with LPN #1 on 1/29/24 at 11:05 AM identified the Infection Control Nurse was responsible for cleaning the refrigerator, should be cleaned monthly, and indicated the Infection Control had a log for cleaning it. LPN # 1 also indicated the facility position for Infection Control Nurse was unfilled at that time. Review of the cleaning schedule identified although clean medication room refrigerator was depicted 3 times a month, the schedule did not identify which of the 4 refrigerators were to be cleaned and failed to identify a sign off that cleaning had occurred. c. On 1/29/24 at 11:20 AM observation of the storage room that contained over the counter medications with RN #1 identified 17 bottles of Thiamin 100 mg tablets with an expiration date of 10/23 (3 months past the expiration date), 1 bottle of Vitamin B-1, 100 tablets with an expiration date of 5/23 (8 months past the expiration date), and 1 bottle of Docusate Sodium 250 mg 100 tablets with an expiration date of 5/23 (8 months past the expiration date). After surveyor inquiry, RN #1 disposed of the expired medications. Interview on 1/29/24 at 11:20 AM with RN #1 identified the medical staff was responsible for checking for expired medication, disposing, and restocking of the medications. Interview with Medical Supply Staff on 1/29/24 at 1:35 PM identified she was responsible for disposing expired medications in the over-the-counter medication storage room and the last time she went through the stock was at the end of November 2023 at which time s/he must have overlooked the expired medications. She also indicated the facility policy directs to remove any expired medications and there was not a log for checking stock medications on a regular basis for expiration dates. Review of the facility pharmacy and procedure policy notes the facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. Review of the facility pharmacy and procedure policy identified that Controlled Substance Storage (Level 3 Medication) should be stored in the refrigerator in a separate container and double locked. Review of the facility policy for Cleaning and disinfection of environmental surfaces identifies that devices that are used by staff but not in direct contact with residents shall be cleaned and disinfected regularly (according to facility schedule) by environmental services staff and as needed by the nursing staff.

Based on observation, interviews, and the facility policy the facility failed to ensure snacks were consistently offered to all residents in the afternoon and prior to bedtime. The findings include. A meeting with residents on 1/31/24 1:16 PM (Resident # 25, #31, # 35, #42, #43 and #48) identified snacks are in a box in the kitchenette and residents are expected to help themselves. The staff do not offer snacks after supper, or in the afternoon. Additionally, there are no snacks at times because they are consumed by non- residents. On 1/31/2024 at 2:15 PM an interview with the DNS and the Administrator to follow up on residents' concerns indicated the snacks come up after the noon meal and some come up on the evening dinner trays for specific residents, and other snacks for the other residents. The Administrator indicated the snacks the residents receive are the same as what the staff can obtain out of the vending machine. Although, the Administrator indicating having seen snacks offered to residents in the past, s/he was unable to indicated snacks had been consistently passed out or if it was assigned to a particular person who would be held responsible for the task completion. The DNS indicated the staff works as a team but was unable to share how s/he could ensure the task was being completed if a resident indicated they did not receive a snack. The Administrator indicated revising the current process so the residents could see a consistent routine and feel comfortable with the process. On 2/2/2024 at 10:32 AM the Administrator provided a copy of an invoice for 3-tiered snack carts, one for each floor in pink so the carts would not be confused with other facility carts. The Administrator further indicated the process will be offering snacks to all resident's room to room. The facility policy labeled Snacks dated 9/29/2023 indicated snacks and beverages will be provided as identified in individual care plan and bedtime snacks will be provided for all residents. Additional snacks would be provided, available upon request for all residents who want to eat at nontraditional times. The policy further indicated dining services is responsible for assembling and delivering to each unit the individually planned snack items and bulk snack items are to be offered at bedtime and nursing services is responsible for delivering the individual snacks to the identified resident and for offering evening snack to all other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and interview for 1 of 1 resident (Resident # 31) reviewed for anticoagulant use, the facility failed to ensure laboratory results related to Coumadin(anticoagulant) use was available in the resident's clinical record. The findings include. Resident #31's diagnosis' include Atrial Fibrillation and Arteriosclerotic Heart Disease. The quarterly minimum Data Set (MDS) assessment dated [DATE] identified resident can make needs known and has no acute mental status change and noted the utilization of an anticoagulant medication which was considered a high-risk drug. An interview and record review on 2/2/24 at 1:59 PM with RN#1 indicated no international ratio (INR) laboratory results to follow the use of Warfarin ( Coumadin) were available in the paper or electronic clinical record. RN#1 further indicated the APRN obtains the electronic laboratory results, reviews then act on accordingly when necessary. An interview and record review on 2/5/2024 at 3:20 PM with APRN #2 indicated the transition to the current laboratory vendor occurred in December 2023 was difficult because APRN's had to go online to obtain all laboratory results. APRN #2 indicated that even though it was difficult it was done timely. APRN #2 further indicated the December 2023 laboratory results were just printed so that is why Resident #31's laboratory sheet is signed with the date 2/2/2024. APRN #2 indicated s/he will now print the results, sign the form, and have the unit secretary scan them into the electronic record. An interview with the DNS on 2/5/2024 at 3:32 PM indicated a new laboratory vendor will be starting next week and will interface with the facility's electronic charting system so laboratory results will be readily available. Although a policy and procedure for the use of anticoagulants was requested, one was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and interview for 1 of 2 residents (Resident # 117) reviewed for accidents, the facility failed to ensure a bathroom emergency call bell system allow residents to call for staff assistance during a potential fall. The finding include: Resident #117's diagnoses included multiple malignancies of the lung and brain. The Nursing admission assessment dated [DATE] indicated Resident #117 was cognitively intact. The Resident Care Plan dated 1/22/2023 indicated Resident #117 had limited physical mobility related to weakness. Interventions included in part to provide toileting assistance with frequent toileting and every 2 hours at bedtime. A Care Plan dated 1/23/2024 indicated Resident #117 was at risk for falls related to poor safety awareness and unsteady gait. Interventions included: to encourage proper footwear half side rails, keep frequently used items within reach, staff to assist with transfers and to provide therapy as ordered. An environmental rounds report dated 1/24/2024 indicated Resident #117 s' bathroom call bell string was short and needed to be replaced. A nursing progress note dated 1/25/2024 at 4:05 PM, post fall, indicated Resident #117 was alert and oriented and roommate called to report Resident #117 fell in the bathroom. The resident was found on the floor by staff and denied hitting head. The note further indicated neurological assessment was benign and vital signs were stable. A care plan intervention was added to the risk for falls care plan on 1/25/2024 directing staff to remind Resident #117 to call for assistance. On 2/2/2024 at 9:39 AM an interview and observation of Resident #117's bathroom with the DNS identified the Maintenance Director and his/her assistant were in the bathroom at the time working on the bathroom shower basin. The emergency call cord was noted to be short (approximately several inches below the cords insertion into the wall) while pulling the cord the Maintenance Director indicated the emergency call light lit up outside the room but not in the room and indicated the emergency call light fixture would be changed out on today. The Maintenance Director identified the emergency call light that needed to be replaced as it was noted during Environmental rounds on 1/24/2024 that the cord was too short and not reaching the floor. The Maintenance Director and the assistant left the bathroom. The DNS then indicated the emergency call bell would be replaced so the cord is long enough to reach the floor. On 2/2/2024 at 10:27 AM an interview with the Maintenance Director indicated the call bell plate and cord was replaced in Resident #117's bathroom. Observation on 2/2/24 identified a new call bell plate with the cord reaching the floor. The facility policy labeled Call lights dated 9/29/2023 notes all resident's will have a call light or alternative communication device within reach at all times when unattended to ensure safety and communication between staff and residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, review of facility policy and staff interviews for 3 of 5 residents reviewed for care planning for (Resident # 31), the facility failed to develop a person-centered care plan for the resident medication and for( Resident # 41), the facility failed to develop a comprehensive care plan regarding the resident's respiratory treatment and discharge needs and for( Resident # 66), the facility failed to develop a discharge care plan to address the residents needs post discharge. The findings included: 1. Resident #31's diagnoses included atrial fibrillation and Arteriosclerotic Heart Disease. The care plan dated 7/25/2023 indicated Resident #31 exhibited or was at risk for gastrointestinal symptoms or complications related to constipation. Interventions included diet as ordered, to monitor and record bowel movements, consumption of fluids during meals and to monitor for signs of dehydration. The quarterly minimum Data Set (MDS) assessment dated [DATE] identified the resident can make needs known and secondary to no acute mental status change and noted the utilization of anticoagulant medication considered a high-risk drug. A review of the clinical record on 2/5/24 failed to reflect that Resident # 31 had a comprehensive care plan to address the utilization of the anticoagulant medication. An interview with the DNS on 2/5/2024 at 3:30 PM indicated Resident #31 was on Coumadin since 7/20/23 and noted no care plan to address the medication. The DNS indicated the resident should have a care plan for the Coumadin. After surveyor inquiry, on 2/5/2024 Resident #31's care plan was updated to include a care plan for anticoagulant therapy related to disease process. Interventions included: laboratory work as ordered and to report abnormalities to the MD, monitor, document and report to the physician signs and symptoms of anticoagulant complications such as bleeding, bloody stools, or changes in vital signs. 2. a Resident #41's diagnoses included Peripheral Vascular Disease (PVD), chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. A physician's progress history noted dated 9/17/23 identified the resident had COPD, obstructive sleep apnea on CPAP. An Advanced Practice Registered Nurse's progress history note dated 9/18/23 from extended care facility indicated the resident had a past medical history of obstructive sleep apnea and on CPAP. A nursing admission assessment dated [DATE] identified respiratory care needs included CPAP (continuous positive airway pressure) (machine that uses mild air pressure to keep breathing airways open while you sleep for better sleep quality, reduction or elimination of shoring, and less daytime sleepiness) use. Advanced Practice Registered Nurses notes dated 10/1/23 and 10/2/23 by two different APRN's indicated resident had a history of obstructive sleep apnea and the resident was on CPAP. An admission MDS assessment dated [DATE] identified Resident # 41 as alert and cognitively intact, with no behavior issues, the resident required extensive assistance with bed mobility, limited assistance with transfers, and toilet use, supervision with meals. However, the assessment failed to indicate Resident # 41's special treatment CPAP use. A review of the October 2023 through January 2024 Medication Administration Record (MAR) failed to identify oxygen or CPAP use. A physician's order dated 12/7/23 directed keep head of bed elevated to prevent shortness of breath while lying flat secondary to COPD/Asthma. A Resident Care Plan dated 12/17/23 failed to indicate a comprehensive person-centered care plan for the resident's respiratory care to address the use of oxygen or need for a CPAP machine. Observation and interview on 1/30/24 at 12:35 PM with Resident #41 identified an oxygen cannula line attached to the wall on head of bed. The cannula line was lying on the bed near the resident's right side. Resident # 41 also indicated s/he wears the oxygen at night and further indicated s/he has sleep apnea and used a CPAP machine at home. Observation and interview on 1/31/24 at 1:28 PM with Licensed Practical Nurse (LPN #2) identified Resident #41 had an oxygen cannula connected to the wall at the head of the bed which the resident did not have an order for oxygen, had a diagnosis of COPD. LPN #2 also indicated the resident should have CPAP or BiPAP with the diagnosis of obstructive sleep apnea, and indicated the resident was not care planned for oxygen. On 2/1/24 at 9:40 AM interview with Resident # 41 identified s/he had been wearing oxygen at night because it makes him/her snore less, and if he/she had a CPAP at the facility to wear s/he would use it. After surveyor inquiry, on 2/1/24 at 10:15 AM interview with DNS indicated she obtained an oxygen order for the resident and provided a physician's order dated 1/31/24 directed oxygen at 1-3 liters per minute as needed and oxygen tubing to be changed weekly. Review of facility policy annual review dated 9/29/23 titled Oxygen Safety indicated the purpose of the policy is to ensure the safe storage, use, and transportation of oxygen by all health care workers handling oxygen. The procedure indicated that oxygen is a medication that requires a physician's order. Review of facility policy annual review dated 9/29/23 titled Bi-level Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) including Trilogy is set up by a licensed nurse or Respiratory Therapist (RT) with a physician's/advanced practice provider's order. Purpose: to deliver positive airway pressure therapy for the treatment of obstructive sleep apnea. Practice Standards: orders for CPAP must include pressure and hours of use. b. On 1/30/24 at 10:45 AM interview with SW #1, indicated she had just started yesterday at the facility and she was not aware Resident #41 wanted to be discharged . She further indicated that she would investigate this further. A social worker progress note dated 1/30/24 indicated the social worker met with Resident # 41, staff and resident's community support system. The social worker also indicated s/he would be following up with resident's friend to assist him/her in the completion of insurance applications. On 2/5/24 at 2:00 PM interview with DNS, RN #14 and RN #15 identified that the Interdisclinary notes are located in the social service notes with a sign in sheet that discuss residents needs. Review of facility policy annual review dated 9/29/23 titled Person-Centered Care Plan indicated the center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Person-centered care means to focus on the patient as the locus of control and support the patient in making their own choices and having control over their daily life. A comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment (admission, annual or significant change in status) and review and revise the care plan after each assessment. After each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS). The care plan includes measurable objectives and timetables to meet patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. 3. Resident #66's diagnoses included: radiculopathy (injury to nerve roots) lumbar region, spinal stenosis, cystitis (inflamed bladder), and ulcerative colitis. A MDS 5 day assessment dated [DATE] indicated Resident #66 was admitted to the facility on [DATE], was alert and cognitively intact and required partial/moderate assistance with toilet use and lower body dressing, supervision/touching assistance for bathing, setup/clean up assistance for upper body dressing and eating, and indicated the resident participated in the assessment and goal setting, and identified the overall goal was discharge to the community. A Resident Care Plan dated 10/24/23 failed to indicate the resident's discharge plan or goals. A social worker's progress note titled Post admission Patient/Family Conference dated 10/27/23 indicated transition back to community goal, discharge plan to home, social worker and the resident were in attendance. An Advanced Practice Registered Nurse's note dated 10/31/23 indicated resident was discharged on 11/1/23 to home with outpatient physical therapy. On 2/5/24 at 2:00 PM interview with DNS, RN #14 and RN #15 at which time the DNS identified the process at the facility is to document in care conference notes. RN# 14 indicated the best practice would be to revise the care plan. The DNS further indicated that interdisciplinary notes are documented in the social worker notes which also contain a sign in sheet. Review of facility policy annual review dated 9/29/23 titled Discharge Planning Process indicates The Center must develop and implement an effective discharge planning process that focuses on the patient's/resident's discharge goals, preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions. Upon admission, all patients will be asked about their discharge goals and anticipated length of stay and assessed for discharge potential. Discharge planning will begin upon admission and be completed as part of the Person-Centered Care Plan process. Process item #3. The facility software Discharge Plan Documentation will begin as early as admission and no later than seven days prior to patient discharge. Review of facility Interprofessional Care Management Utilization Management and Discharge Planning Meeting Guidelines dated 9/2019, purpose indicates to manage the flow of discharges from the Center on any given day to achieve consistent census and balanced nursing staff workload. Best practices include report any unresolved barriers to discharge so the disciplines can identify additional measures to enable discharge and the CRC (Clinical Reimbursement Coordinator) can identify if the patient warrants ongoing skilled care in the SNF (skilled nursing facility) and update of care plans as needed. It further indicates that everyone on the Interprofessional Team must understand their responsibility in relation to the whole Utilization Management and Discharge Planning Processes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for 1 of 1 resident ( Resident # 8) reviewed for call bell , the facility failed to ensure the resident's call bell was within reach per facility practice and plan of care and for 7 of 10 sampled residents (Residents # 8, 32, 35, 39, 50, 52 and 53) reviewed for Care Plans, the facility failed to review and/or revise care plans in a timely manner. The findings included: 1. Observation on 1/30/24 at 9:35 AM identified call bell placed on left side of Resident # 8 and voice automated call button system was out of resident's reach (not on over bed table or bed) as well. Interview with LPN #3 at 9:40 AM identified Resident #8 is frequently checked on and his/her roommate communicates with him/her. LPN #3 placed the blue and red call buttons in front of the resident on her/his bed table, however when the resident and LPN #3 pressed the buttons, they weren't working (not charged). LPN #3 indicated there was no checklist identifying the buttons were functional every shift. LPN #3 further indicated when the call bell is placed in the resident's hand, the resident will constantly push it. LPN #3 indicated she would order a push pad for the resident to use. Observation on 1/30/23 at 1:13 PM identified Resident #8's call bell was again out of reach, resting near left arm on mattress when it should have been centered or to the right side of her body. Interview with NA # 4 identified the call bell should have been placed on her/his lap next to the resident's good hand (right hand) and indicated staff's responsibility for making sure the resident's call bell was within reach. NA # 4 she could not explain why the call bell was on the left side of her body. Observation on 2/2/24 at 8:05AM identified Resident #8's call bell was again out of the resident's reach, pinned to the bed sheet next to her/his head on her/his left side. Interview with NA # 4 at 8:07 AM on 2/2/24 identified Resident #8's call bell was stationed on his/her left side, pinned to her bed sheet next to her head. NA #4 verified the call bell was in an area the resident could not reach and that it should have been pinned to the blanket in front of her/his right so that the resident could access it. NA # 4 indicated policy was to answer call bells as soon as possible, to place it on the side of the resident that's most comfortable for the resident and where they can most easily access it. NA # 4. also indicated she was unsure as to why the call bell was not placed correctly as she started her shift shortly before he/she was brought to the room. Interview with the DNS on 2/2/24 at 8:35AM identified the facility's policy/practice was for the call bell to be placed within the resident's reach at all times. 2. Resident #8's diagnoses included multiple sclerosis, metabolic encephalopathy, and adjustment disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #8 was dependent with eating, toileting hygiene, and mobility. The Resident Care Plan dated 1/4/24 identified dependence for activities of daily living care, impaired communication as evidenced by difficulty making self-understanding (expressive) and difficulty understanding others (receptive), and at risk for falls. Interventions directed to provide extensive assist of one for all activities of daily living, encourage the resident to participate in activity programs that integrate communications and socialization, and place the call bell within reach while in bed or proximity to the bed. Review of the care plan history screen on the electronic medical record identified a care plan for Resident #8 was started on 7/16/22 and completed on 5/25/23 and a care plan for Resident #8 was started on 5/25/23 and completed on 1/4/24. Review of a social work note dated 10/24/23 at 2:10 PM identified a care plan meeting took place with the social worker and resident's family members. Review of a social work late entry note dated 7/25/23 at 1:00 AM identified a care plan meeting took place with the social worker, nurse, and resident's family members. 3. Resident #32's diagnoses include renal disease, high blood pressure, muscle weakness. The quarterly MDS assessment dated [DATE] indicated that Resident #32 was cognitively intact and required set up or clean up assistance with eating and personal hygiene and required moderate assistance with toileting and showering. Review of Resident #32's quarterly MDS dated [DATE], 5/10/23, 8/9/23 and annual MDS assessment dated [DATE] identified the facility failed to review and revise the resident's care plan. The social services notes dated 8/18/23 identified a Care plan meeting was documented. From 8/24/23 through 2/2/24. However, the social work failed to document further care plan meetings or revision of care plan. Interview with the Administrator on 1/30/24 at 12:50 PM indicated he/she was not aware of any software issues related to the implementation or revision of care plans since the facility changed ownership. The Administrator further indicated the electronic medical record accurately reflected the residents care plans including any revisions. The facility policy for Person-Centered Care Plan indicates that a comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment, which includes admission, annual, and significant change in status and review and revise care plans after each assessment, including both the comprehensive and quarterly review assessments. According to facility policy after each assessment means after each Resident Assessment instrument (RAI) or MDS. The facility policy for Person-Centered care plans identifies that a comprehensive person-centered care plan must be developed for each patient must describe the following: services that are to be furnished, any services that would otherwise be required but are not provided due to the patients exercise of rights, including the right to refuse treatment, any specialized services or specialized rehabilitative services the center will provide as a result of PASRR, in consultation with the patient and resident representatives goals for admission and desired outcomes, preference and potential future discharge. The policy further indicates that documentation will show evidence of patient's status in triggered CAA's, development of care planning interventions for all CAA's triggered by the MDS, and rationale for not care planning for the specific triggered CAA. 4. Resident #35's diagnoses included Parkinsonian, schizophrenia, and bipolar disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #35 as cognitively intact and required moderate assistance with eating, oral hygiene, and transfers. The Resident Care Plan dated 10/26/22 identified risk for suicidal impulses/ideation, of self-harm related to a personal history of suicidal ideation and behaviors, impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium, and a potential for discharge. Interventions directed to provide social service support visits as needed or requested, provide a consistent, trusted caregiver and structured daily routine when possible, and evaluate discharge planning needs taking into consideration care plans, resident/patient goals, cognitive skills, functional mobility and need for assistive devices. Review of the care plan history in the electronic medical record identified Resident #35's care plan was started on 10/26/22, with no completion date attached and no other care plans initiated or in cue after 10/26/22. Review of a social work late entry note dated 10/28/22 at 10:14 PM identified a care plan meeting took place and involved the patient HCDM and family social services. Review of a social work note dated 8/10/23 at 1:17 PM identified a care plan meeting took place and involved the social worker and resident only. 5. Resident #39's diagnoses included schizoaffective disorder, dementia, and type two diabetes mellitus. The quarterly Minimum Data Set, dated [DATE] identified Resident #39 required partial assistance with toileting, bathing, and personal hygiene. Review of the Resident Care Plan dated 1/4/24 identified a decline in cognitive function or impaired thought processes related to dementia and schizoaffective disorder. Interventions directed to monitor for decline in activities of daily living function, evaluate the need for psych/behavioral health consultation if indicated, and provide consistent, trusted caregiver and structured daily routine when possible. Review of the care plan history in the electronic medical record identified Resident #39's care plan was started on 11/30/22 with a completion date 1/4/24. A social work note dated 10/4/22 at 4:23 PM identified a care plan meeting took place with the social worker, business office manager, nurse supervisor, and resident's spouse in attendance. Review of a social work dated 12/8/22 at 3:27 PM identified a care plan meeting took place with the social worker, nurse, and Resident #39's spouse in attendance. 6. Resident #50's diagnoses included Alzheimer's Disease, cerebral infarction, and unspecified psychosis. The annual Minimum Data Set, dated [DATE] identified Resident #50 as severely cognitively impaired and required substantial assistance with toileting, dressing and transfers. The facility failed to provide a copy of the Resident Care Plan dated 8/16/22. Review of social work notes failed to identify a care plan meeting that had taken place in August 2022. Interview with the Administrator on 1/30/24 at 12:50 PM indicated he/she was not aware of any software issues related to the implementation or revision of care plans since the facility changed ownership. The Administrator further indicated the electronic medical record accurately reflected the residents care plans including any revisions. Review of the Person-Centered Care Plan policy revised on 9/29/23 indicated care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. 7. Resident #52's diagnoses include dementia, high blood pressure, muscle weakness. The annual minimum data set (MDS) assessment dated [DATE] identified Resident #52 as severely cognitively impaired and required setup/clean up assistance with eating, needed supervision for hygiene/showering and was independent for toileting. The physician's orders dated 2/9/23 directed Resident #52 take 5 mg (milligrams) Eliquis oral tablet, give 1 tablet by mouth two times a day for anticoagulation. The physician's orders dated 2/9/23 directed take 50 mg Seroquel oral tablet, give 1 tablet by mouth two times a day for dementia with behaviors. The significant change in condition MDS assessment for Resident #52 dated 2/14/23 failed to identify the resident was taking anticoagulants (Eliquis) or antipsychotics (Seroquel). The care area assessment (CAA) identified care areas were triggered and addressed in the care plan for cognitive loss/dementia, communication, activities of daily living (ADL's), urinary incontinence, mood state, behavioral symptoms, falls, nutritional status, pressure ulcers, psychotropic drug use, and pain. The MDS indicated the facility failed to address dehydration/ fluid maintenance. According to the 2023 through 2024 yearly calendar, there were 342 days between identifying the CAA being triggered and the resident's care plan being reviewed and revised. The social services notes dated 8/24/23 identified that a Care plan meeting was documented. From 8/24/23 through 2/2/24 the social work failed to document further care plan meetings. Interview with the Administrator on 1/30/24 at 12:50 PM indicated that what was in the computer system as of that date and time should accurately reflect the residents updated care plans with any revisions. She further indicated that she had not noticed any problems/issues with care plans since the facility changed ownership. The facility policy for Person-Centered Care notes documentation will show evidence of patient's status in triggered CAA's, development of care planning interventions for all CAA's triggered by the MDS, and rationale for not care planning for the specific triggered CAA. 8. Resident #53's diagnoses include type 2 diabetes mellitus, rheumatoid arthritis, and polyneuropathy (Damage to multiple peripheral nerves). The admission minimum data set (MDS) assessment dated [DATE] identified resident #53 as cognitively intact and required setup/clean up assistance with eating and hygiene and was dependent on toileting. The admission minimum data set assessment (MDS) for Resident #53 dated 9/28/23 further identified in the care area assessment (CAA) that care areas were triggered and addressed in the care plan for activities of daily living (ADL's), falls, pressure ulcers and pain. The MDS indicated the facility failed to address urinary incontinence, nutritional status, and return to community. The care plan provided by the facility indicated on 9/26/23 the facility initiated the focus area of while in the facility, resident/patient states that it is important that s/he can engage in daily routines that are meaningful/relative to their preferences. The goal for this focus was initiated on 10/3/23. The interventions for this focus were initiated on 10/3/24. The care plan provided by the facility indicated on 10/23/23 the facility initiated the focus area of deep tissue injury to right and left heel, abrasions, skin tears related to fragile skin and disease process. The interventions for this focus were initiated on 10/23/23. The goal is not to show signs of skin breakdown x 90 days for this focus area was initiated on 11/9/23. The next goal of resident will have no complications through the date of 4/30/24 was initiated on 1/24/24. However, the EMR from 11/9/23 through 1/24/24 identified the facility failed to review and revise a care plan. Interview with the Administrator on 1/30/24 at 12:50 PM indicated what was in the computer system as of that date and time should accurately reflect the residents updated care plans with any revisions. She further indicated she had not noticed any problems/issues with care plans since the facility change of ownership. The facility policy for Person-Centered Care Plan indicates that a comprehensive, individualized care plan will be developed with 7 days after completion of the comprehensive assessment, which includes admission, annual, and significant change in status and review and revise care plans after each assessment, including both the comprehensive and quarterly review assessments. After each assessment means after each known as the Resident Assessment instrument (RAI) or MDS. A baseline care plan must be developed with 48 hours and include the minimum healthcare information necessary to properly care for a patient including but not limited to: initial goals based on admission orders, physician's orders, dietary orders, therapy services, and preadmission screening and services required (PASRR) if applicable. The facility policy for Person-Centered care plans further identifies that a comprehensive person-centered care plan must be developed for each patient must describe the following: services that are to be furnished, any services that would otherwise be required but are not provided due to the patients exercise of rights, including the right to refuse treatment, any specialized services or specialized rehabilitative services the center will provide as a result of PASRR, in consultation with the patient and resident representatives goals for admission and desired outcomes, preference and potential future discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records, review of policy and interviews for 1 of 3 residents (Resident #2) observed dining, the facility failed to clarify a physician's diet order for a resident who had 2 active orders and for 2 of 3 residents ( Resident # 52) who require assistance with medication administration, the facility failed to monitor the resident's blood pressure as prescribe and for (Resident # 53), the facility failed to clarify and administer treatment orders and for 1 of 5 residents ( Resident # 57) reviewed for Unnecessary Medication, the facility failed to administer an antidepressant medication as prescribed. and for 1 of 2 (Resident # 117) reviewed for accidents, the facility failed to conduct assessments to meet professional standards. The findings included. 1. Resident #2's diagnosis included acute and chronic respiratory failure, diabetes mellitus and Congestive Heart Failure (CHF). A physician's order dated 6/4/2021 directed to provide a 2 Gram Na(sodium) diet regular texture, for CHF. A physician's order dated 8/21/2022 directed to provide a Consistent Carbohydrate diet dysphagia advanced texture, low sodium diet Dysphagia level 7. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was cognitively intact, required set up assistance for eating and had a therapeutic and mechanically altered diet and no swallowing issues, and no oral or dental concerns. A review of the clinical record on 2/2/24 identified the facility failed to clarify which of the 2 diets the staff should be implementing for the resident. An interview and record review on 2/2/24 at 11:07 AM with the Rehabilitation Director indicated Resident #2 had 2 separate diet orders one for a Dysphagia advanced 7 diet and another for a 2-gram sodium diet. The Rehabilitation Director indicated s/he could not locate any speech therapy evaluations related to the dysphagia diet and would need to clarify with the supervisor or DNS as the Dysphagia level 7 diet may have come from the hospital as the physician's order for the diet began upon return from the hospital in 2022. An interview and record review on 2/2/2024 at 11:55 AM with RN # 1 the second-floor supervisor, indicated the electronic face sheet for Resident #2 indicated the diet as 2-gram sodium, dysphagia advanced but when the original physicians' orders were reviewed two separate diet orders were active. RN #1 indicated a dysphagia diet might be in place due to chewing issues. Review of the care plan indicated Resident #2 had dentures and no noted indication of dysphagia or chewing difficulties. 2. Resident #52's diagnoses include dementia, hypertension (HTN), and atrial fibrillation. The annual minimum data set (MDS) assessment dated [DATE] identified Resident #52 as severely cognitively impaired and required setup/clean up assistance with eating, needed supervision for hygiene/showering and was independent for toileting. The physician's orders dated 2/9/23 directed to give 1, 50 mg (milligram) tablet of Metoprolol Tartrate by mouth two times a day for HTN, hold for systolic blood pressure (SBP) of less than 110 or a heart rate (HR) of less than 55. The Treatment Administration Record (TAR) dated 11/1/23 through 11/30/23 identified Resident #52 had Metoprolol Tartrate administered 6 out of 52 times outside of the SBP or HR parameters. The treatment administration record (TAR) dated 12/1/23 through 12/31/23 identified Resident #52 had Metoprolol Tartrate administered 2 out of 56 times outside of the SBP or HR parameters. The treatment administration record (TAR) dated 1/1/24 through 1/31/24 identified Resident #52 had Metoprolol Tartrate administered 2 out of 60 times outside of the SBP or HR parameters. Interview with RN #1(supervisor) on 2/1/24 at 10:55 AM indicated when specific vital sign parameters are in place and part of the physician's orders, she would expect the order to be followed as directed. Although a policy was requested regarding physician's orders, a policy was not provided. 3. a. Resident #53's diagnoses include type 2 diabetes mellitus, rheumatoid arthritis, and polyneuropathy. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #53 as cognitively intact and required supervision with eating and hygiene and was dependent on toileting. The RCP dated 10/23/24 identified Resident #53 had a deep tissue injury (DTI) to right and left heel, abrasions, skin tears related to fragile skin and disease process. Interventions included: treatment order was updated per wound MD, staff education in progress to ensure offloading of the heel daily and to monitor for signs and symptoms of infection and report to physician. The physician's orders dated 12/5/23 indicated an unstageable right heel wound. Staff were directed to apply betadine, followed by an abdominal (ABD) pad, kerlix, change 3x per week and as needed (PRN) one time a day every Monday, Wednesday, Friday. The end date for this order was indicated. The physician's orders dated 12/28/23 indicated an unstageable pressure ulcer to right heel with directions to cleanse with normal saline (NS) and apply betadine, cover with dry dressing, wrap with kerlix as needed for wound and everyday shift for wound. The end date for this order was not indicated. b. The treatment administration record (TAR) dated 1/1/24 through 1/31/24 for physician's order of unstageable right heel wound with directions to apply betadine, followed by an abdominal (ABD) pad, kerlix, change 3x per week and as needed (PRN) one time a day every Monday, Wednesday, Friday indicates that this treatment was identified and performed for 12 out of 13 treatments. The treatment administration record (TAR) dated 1/1/24 through 1/31/24 for physician's order of unstageable pressure ulcer to right heel with directions to cleanse with normal saline (NS) and apply betadine, cover with dry dressing, wrap with kerlix as needed for wound and everyday shift for wound indicates that this treatment was identified and performed 30 out of 31 treatments. Observation and interview with MD #2, the attending wound MD on 2/1/24 at 9:54 AM indicated that his order for Resident #53's wound dressing change should be: remove old dressing, cleanse with betadine, then add an abdominal dressing, kerlix, daily and as needed. Interview with RN #3 (supervisor) on 2/1/24 at 10:47 AM identified that there were 2 different treatment orders for Resident #53's dressing change and one order should have been discontinued. She also indicated that it was unclear as to which order to do and that if she was a new employee, she would not know which physician's order to follow regarding the dressing change to the right heel. She further identified that it was her responsibility to ensure accurate and updated MD orders were on the computer. Although a policy was requested regarding physician's orders, a policy was not provided. 5. Resident #57's diagnoses included chronic obstructive pulmonary disease, hypertension, and fibromyalgia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #57 as independent with eating, toileting hygiene, dressing and personal hygiene. The Resident Care Plan dated 12/31/2023 indicated a diagnosis of depression and behavior history of suicidal ideations, resident is on medications to manage diagnosis and behaviors, and a risk for distressed/fluctuating mood symptoms related to sadness/depression caused by not having housing in the community. Interventions directed to observe signs and symptoms of a new psychiatric disorder, observe for worsening symptoms, and to refer to behavioral health specialist as needed. A physician's order dated 12/3/23 directed venlafaxine HCl oral tablet 75 mg daily at bedtime for depression. Review of the Medication Administration Record dated January 2024 identified Resident #57 did not receive her bedtime dose of venlafaxine 75 mg on 1/22/24, 1/23/24 and 1/24/24. Review of nursing note by LPN #6 on 1/23/24 at 9:32 PM and 10:28 PM indicated venlafaxine 75 mg was not administered due to awaiting delivery from the pharmacy. . Interview with Pharmacist #1 on 1/31/24 at 2:56 PM identified an order for Resident #57's 75mg dose of venlafaxine was called into the pharmacy on 1/24/24 at 6:46 PM for a refill. Pharmacist #1 further indicated there was always a running stock of the venlafaxine 75 mg dose. The pharmacy was not out of stock at the time the refill was called in. Interview with LPN #6 on 2/1/24 at 2:40 PM indicated he/she did not remember what date the venlafaxine 75 mg was ordered. LPN #6 indicated he/she did check the Pixus for a back-up supply and notified the nurse supervisor Resident #57 was out of the venlafaxine 75 mg dose. LPN #6 further indicated he/she was not aware if the physician was notified but s/he called the pharmacy to reorder the prescription. Interview with APRN #1 on 2/1/24 at 2:48 PM identified he/she was notified on both 1/23/24 and 1/24/24 Resident #57 did not receive her/his venlafaxine 75 mg dose, however, s/he was not aware Resident #57 had not received the 75 mg dose on 1/22/24 as well. APRN #1 further indicated it was not okay for Resident #57 to miss three consecutive doses of the 75 mg venlafaxine. APRN #1 further indicated he/she had assessed Resident #57 on 1/24/24 to ensure there were no ill effects from the missed doses. Interview with the Director of Nurses on 2/1/24 at 2:02PM identified facility practice to follow up when a resident is out medication. The nursing staff would first check the Pixus for a back-up supply of the medication. If there was no emergency supply, the nurse would then notify the nurse supervisor who would then notify the provider. The provider would then give orders for an alternative medication to administer or authorize the missed dose. Additionally, the pharmacy would be contacted to refill the medication. Although requested, a medication administration policy was not provided. 6. a. Resident #117's diagnoses included multiple malignancies of the lung and brain. The Nursing admission assessment dated [DATE] indicated Resident #117 was cognitively intact. The Care Plan dated 1/22/2023 indicated Resident #117 had limited physical mobility related to weakness. Interventions included in part to provide toileting assistance with frequent toileting and every 2 hours at bedtime. A Care plan dated 1/23/2024 indicated Resident #117 was at risk for falls related to poor safety awareness and unsteady gait. Interventions included: to encourage proper footwear half side rails, keep frequently used items within reach, staff to assist with transfers and to provide therapy as ordered. The facility fall investigation dated 1/25/2024 indicated the resident had an unwitnessed fall at 3:30 PM. A nursing progress note dated 1/25/2024 at 4:05 PM indicated Resident #117 was alert and oriented and the roommate called to report Resident #117 fell in the bathroom. The progress notes further indicated Resident #117 was found on the floor by staff and denied hitting his/her head. The note further indicated neurological assessment was benign and vital signs were stable. A care plan intervention was added to the risk for falls on 1/25/2024 indicating to remind Resident #117 to call for assistance. An interview and record review with the DNS on 2/5/2024 at 8:48 AM indicated post fall nursing documentation would include an evaluation every shift for 72 hours after the fall to follow-up on the resident's condition. The DNS further indicated not finding documentation every shift and no documentation on 1/27/2023 post fall but indicated there were neurological sheets were completed. However, s/he was unable to locate the missing neurological sheets. On 2/05/24 at 10:10 AM an interview and record review with the DNS indicated nursing should complete follow up evaluations of the resident for 72 hours. The computerized follow-up prompts are generated from the initial fall/change in condition evaluation in the computerized system. In this case the initial assessment at the time of the fall was completed in the system assessment did not generate follow ups every shift for 72 hours which could be the reason why neurological assessment was not completed. The facility policy labeled Neurological Evaluation dated 9/29/2023 indicated Neurological evaluation will be performed as indicated or ordered and when a resident sustains an injury to the head, face and or has an unwitnessed fall neurological evaluation will be performed every 15 minutes x 2 hours then every 30 minutes x 2 hours then every 60 minutes x 4 hours then every 8 hours until 72 hours has elapsed to monitor the Resident for neurological compromise. b. The Care Plan dated 1/22/2023 indicated Resident #117 had limited physical mobility related to weakness. Interventions included in part to provide toileting assistance with frequent toileting and every 2 hours at bedtime. A Care plan dated 1/23/2024 indicated Resident #117 was at risk for falls related to poor safety awareness and unsteady gait. Interventions included encouraging proper footwear half side rails, keeping frequently used items within reach, staff to assist with transfers and therapy as ordered. A physician's progress note dated 1/24/2024 at 10:21 PM indicated Resident #117 was alert and oriented to time place and person. The facility fall investigation dated 1/25/2024 status post fall indicated Resident #117 was admitted within the last 7 days, was disoriented, had impaired memory was assisted to the bathroom by a nurse aide who advised Resident #117 to call for assistance when finished using the toilet. Resident # 117 attempted self- transfer back to the wheelchair independently when the resident slid out of the wheelchair to the floor. Predisposing factors included impaired memory and recent illness. A nursing progress note dated 1/25/2024 at 4:05 PM, post fall, indicated Resident #117 was alert and oriented and roommate called to report Resident #117 fell in the bathroom. The resident was found on the floor by staff and denied hitting head. The note further indicated neurological assessment was benign and vital signs were stable. A care plan intervention was added to the at risk for falls care plan on 1/25/2024 which directed staff to remind Resident #117 to call for assistance. An interview and record review with the DNS on 2/5/2024 at 8:48 AM indicated even though there was documentation of Resident #117 having memory impairment post fall, the DNS indicated, since Resident #117 was alert and oriented it was appropriate to leave the resident unattended while on the toilet in the bathroom and advised by the nurse aide to use the call bell. The facility policy labeled Falls management dated 8/7/2023 indicated residents would be assessed for risk of fall and the risk of reoccurrence of falls. The policy directs to adjust and document individualized intervention strategies as resident condition changes. .

Based on observations of the noon meal, interviews, test tray for palatability and staff interviews for 3 out 5 residents screened for dining (Resident #5, Resident #29, Resident #31), the facility failed to ensure that food was appetizing, and palpable to taste. The findings included: 1. Resident #5 identified the tater tots on her/his lunch plate were hard as bricks on 1/30/24. 2. Resident #29 identified dissatisfaction with her/his meal options, stating his/her 1/30/24 lunch was unpalatable, the tater tots were hard and cold, the meatball grinder was unappetizing, and the food in general was horrible. Resident #29 further identified the soup was too salty and the food was too greasy. 3. The test tray ordered by the surveyor on 2/1/24, which consisted of hot roast beef sandwich and tater tots, was found to be cool in temperature and the tater tots were overcooked and difficult to chew. 4. Resident #31 identified his/her tater tots were hard and difficult to chew on during his/her lunch on 2/1/24. Interview with the Dietary Manager on 2/1/24 at 12:48 PM identified food temperature and texture concerns. The Dietary Manager on 2/1/24 also indicated the test tray was not served immediately, instead it rested on top of the food cart and was cold because of not being served. The Dietary Manager further indicated he/she was unaware of the textural concerns of the tater tots.

Based on observations of the kitchen, facility policy and interviews, the facility failed to properly label opened packaged food items/individual servings, remove expired foods and to perform hand hygiene after touching face with gloved hand to prevent cross contamination. The findings included: 1. During a tour of the kitchen with the Dietary Manager on 2/1/24 from 9:10 AM to 10:00 AM identified the following: a. The walk-in refrigerator located in the kitchen contained a gallon container of garlic cloves with an expiration date of 12/8/23, a container of Nature's Promise Deli Pickle Chips with an expiration date of 1/4/24, and a 7.5 oz container of Philadelphia Strawberry Cream Cheese with an expiration date of 1/2/24. Further observations of the kitchen identified an opened and undated Pit Ham with water added (for sandwiches), and an opened and undated Turkey Breast (for sandwiches). b. The dry storage closet contained three bowls of prepared breakfast cereal with a labeled or dated, and a partial case of individual servings of International Delight Creamers with an expiration date of 11/4/23. Interview with the Dietary Manager on 2/1/24 at 9:21 AM identified expired and unlabeled food items should have been discarded. Review of the Cold Food Storage policy revised on 9/29/23 directed all foods would be covered, wrapped, or in covered containers, labeled and dated. Review of the Label and Dating Inservice document provided directed proper labeling and dating ensures that all foods are stored, rotated, and utilized in a first in first out manner to minimize waste and ensure all items past their due date are discarded. 2. During tray line on 2/1/24 at 11:38 PM, Dietary Aide #2 (DA #2) was observed touching her/his right cheek with an ungloved hand while working on the tray line. DA#2 proceeded to apply new gloves without washing his/her hands first and resume preparing food orders. DA#2 was stopped prior to preparing the next lunch plate and was informed he/she had touched his/her face with an ungloved hand. DA#2 identified s/he should wash her/his hands following contact with her/his face and indicate s/he was not aware that s/he had touched her/his face with ungloved hands. DA#2 proceeded to wash his/her hands, applied new gloves, and continued serving food. Interview with the Dietary Manager on 2/1/24 at 11:44 AM indicated he/she was not present when DA#2 had touched her /his right cheek with an ungloved hand. The policy directed to wash hands following contact with skin and to apply new gloves to prevent cross contamination. Review of the Meal Service policy revised on 9/29/23 directs to avoid touching hands and face when handling food and use of proper hygienic practices during meal service.

Based on observations of the kitchen, the facility policy, and staff interviews, the failed to ensure dietary staff covered facial hair with a hairnet while in the kitchen and failed to ensure staff handled linen to prevent the spread of infection and reviewed of the facility Infection Control Program identified the facility failed to provide infection surveillance per policy and adhere to the legionella water management program per policy .The findings included. 1. An observation during the initial tour of the kitchen on 1/29/24 at 9:10 AM identified Dietary Aide (DA) #1 in the kitchen without a hairnet covering a mustache and beard. Dietary Aide #1 indicated he/she should have a hairnet over the facial hair and applied a hairnet prior to resuming duties in the kitchen. An interview with Dietary Manager #1 on 2/2/2024 at 10:25 AM indicated when staff are in the kitchen, they should have a hairnet covering facial hair including beard and mustache. 2. On 2/1/2024 at 5:56 AM an observation on unit 2 in the hallway outside a resident room identified 2 clear plastic bags full of dirty linen and diapers on the hallway floor. Interview with NA #2 indicated the bags are full of dirty linen and trash and the bags are on the floor secondary to having one cart that squeaks loudly causing residents to complain about the noise at night. NA #2 further indicated we had asked for a replacement cart but never received one. An interview and observation on 2/1/2024 at 6:00 AM with LPN #5 indicated being aware of the use of bags on the floor in the hallway for linen and trash. LPN # 5 further indicated in the past residents had complained of being woken by the loud sound the cart made at which time the previous management provided the unit one new cart. However, new management had staff complete a survey a few months ago regarding linen carts' needs. LPN #5 indicated the linen cart was still in the closet and upon observation and movement the cart was loud upon movement. LPN #5 further indicated there should be one cart for linen and another cart for trash. On 2/1/2024 at 6:34 AM an interview with RN #4 the 11-7 AM supervisor indicated he/she was also aware of the need for more carts and the practice of using plastic bags for dirty linen and trash on the hallway floor. RN #4 indicated the dirty linen and trash bags should not be on the floor and he/she has not mentioned this to the new management yet but had told previous management in the past. On 2/02/24 at 9:40 AM an interview with the DNS and Administrator regarding observations made on 2/1/2024 and a request for the policy and procedure for nursing staff to follow regarding handling linen and trash. The Administrator indicated s/he could not provide a policy at this time. On 2/02/24 at 10:40 AM the Administrator provided a copy of a purchase order for 4 double hampers ordered with an indication of expected delivery on 2/3/24. The facility policy labeled environmental Services Policies and Procedures- soiled linen Handling, dated 9/29/2023 indicated the policy is provided so linen is moved throughout the facility in a safe and sanitary manner further indicating to prevent cross contamination. The policy further indicated soiled linen is stored in specific areas of the facility and soiled linen containers are made of fluid impervious material and covered, the soiled items are placed in plastic liners and tied before placing in the container. 3. Interview and Observation with the DNS on 2/5/24 at 10:29 AM identified she currently did not have an active Infection Prevention nurse (IPN) in place and that she, herself, was acting as the IPN. The DNS further indicated she currently did not have a monthly infection control report system or means of surveillance in place for the month since new ownership. Review of the Surveillance for Infections policy directed the IP would conduct ongoing surveillance for healthcare associated infections and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The policy further states that the IP or designated infection control personnel is responsible for gathering and interpreting data surveillance data. 4. Interview and observation with the Director of Maintenance (DOM) on 2/5/24 at 11:48 AM indicated that he had not participated and/ or held any water management meetings since he had started at the facility, which was approximately 1 year prior. He further indicated he was unable to find the yearly review of the water management program sign in for the years of 2022 and 2023. Review of the legionella water management program policy states that the Director of Maintenance will be included as part of the water management team and the program will be reviewed at least once a year, or sooner.

Based on review of facility documentation and interviews, the facility failed to ensure all staff received Abuse and Dementia training annually since the last survey. The findings include: An interview and review of facility documentation on 2/02/24 at 2:30 PM with RN #1 of the Inservice training for staff in all departments within the facility identified no training was found for Abuse and Dementia care from 3/6/2023 through 1/9/2024. RN # 1 indicated when the documentation was requested (1/30/2023) s/he was able to print some of the in-service training. However, since the Change of Ownership the documents were unavailable. Additionally, the facility on 2/2/24 were unable to provide evidence of any education training for Abuse and Dementia for 2022 for all departments. An interview with the administrator on 2/6/2024 at 10:12 AM indicated the facility is trying to obtain the 2022 staff Roster from the prior owner that the facility requested on 2/5/24 and 2/6/2024 and provided copies of the emails requesting documentation. The facility policy labeled Abuse prohibition dated 9/26/2023 indicated facility staff will be provided to all employees through orientation, code of conduct training and a minimum of annually. On 2/5/2023 At 11:30 AM RN#1 indicated he/she was still looking for any in-service training completed but was able to provide many in-service trainings on dementia and abuse for nurse aides for 2023 and in-service on abuse allegation, however, the documents were not dated with signatures from 8/17/2023 through 8/22/2023. The documents did not identify the department receiving the training. A second in-service sheet dated 8/10/23 contained nursing administration, Infection control, nurse practice educator and nursing staff but lacked other departments that work in the facility, social service, recreation, dietary, housekeeping, and therapy. Rosters of all employees that worked at the facility during 2022, 2023 and currently was requested. A roster for 2023 and 2024 was signed by the Human resource manager department on 2/5/2024 and provided to the survey team on 2/6/2024. An interview with the administrator on 2/6/2024 at 10:12 AM indicated the facility is trying to obtain the 2022 staff Roster from the prior owner that the facility requested on 2/5/24 and 2/6/2024 and provided copies of the emails requesting documentation.

Based on review of facility documentation and interviews, the facility failed to ensure NA nurse aides received the required 12 hours of training annually since the last survey. The findings included: An interview and review of facility documentation on 2/02/24 at 2:30 PM with RN #1 of the Inservice training for staff in all departments within the facility identified no training was found for nurse aides receiving the required 12 hours of training annually since the last survey. An interview with the administrator on 2/6/2024 at 10:12 AM indicated the facility is trying to obtain the 2022 staff Roster from the prior owner that the facility requested on 2/5/24 and 2/6/2024 and provided copies of the emails requesting documentation. The facility policy labeled Abuse prohibition dated 9/26/2023 indicated facility staff will be provided to all employees through orientation, code of conduct training and a minimum of annually. On 2/5/2023 At 11:30 AM RN #1 identified s/he was unable to provide the required 12-hour annual nurse aide training for all nurse aides. Rosters of all employees that worked at the facility during 2022, 2023 and currently was requested. A roster for 2023 and 2024 was signed by the Human resource manager department on 2/5/2024 and provided to the survey team on 2/6/2024. An interview with the administrator on 2/6/2024 at 10:12 AM indicated the facility is trying to obtain the 2022 staff Roster from the prior owner that the facility requested on 2/5/24 and 2/6/2024 and provided copies of the emails requesting documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents reviewed for advanced directives, (Resident #1), the facility failed to ensure the Advanced Directive was addressed upon admission to the facility in accordance with facility policy. The findings include: Resident #1 was admitted to the facility on [DATE] and had diagnoses included hypertension and chronic obstructive pulmonary disease. Review of the clinical record from [DATE] through [DATE] failed to identify that advanced directives were addressed. The Advanced Practice Registered Nurse's (APRN) progress note dated [DATE] identified no code status was on file. The Resident/patient health Care Instructions form dated [DATE] identified Resident #1 elected yes, attempt cardiopulmonary resuscitation (CPR), transfer to hospital for any condition requiring hospital-level care, all medical tests, antibiotics, artificial ventilation even indefinitely, artificially administered fluids and nutrition even indefinitely, and other life-sustaining treatments even indefinitely or repeatedly. The verbal order was obtained via telephone from Resident #1's emergency contact and signed by two (2) nurses. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as having no cognitive impairment. Interview with the 8:00 AM to 4:30 PM Nursing Supervisor, Registered Nurse (RN) #2, on [DATE] at 5:05 PM identified she was checking charts on [DATE] and realized Resident #1 did not have a code status signed since admission on [DATE]. RN #2 indicated she had a conversation with Resident #1 and in the midst talking with Resident #1 she asked Resident #1 if she wanted to sign his/her admission paperwork, including code status. RN #2 identified Resident #1 wanted her to call Resident #1's emergency contact and discuss the code status with him/her as well. The responsible party was contacted and a an order for code status was obtained on [DATE]. Interview with the Director of Nursing (DON) on [DATE]/21 at 3:00 PM identified the nurses were responsible to address code status on admission. Review of the Health Care Decision making policy directed to approach a capable resident who does not have an advanced directives upon admission, the resident will be approached by the Social Worker or another designated staff person on admission, quarterly and with any change in condition to discuss whether he/she wished to consider developing advanced directives. Upon admission determine whether the resident had an advanced directive and/or portable medical orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), who was reviewed for a change in condition, the facility failed to ensure a Registered Nurse (RN) assessment was completed when a resident experienced a change in condition. The findings include: Resident #1's diagnoses included hypertension and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had -no cognitive impairment, required extensive assistance of two persons with bed mobility and transfer. The Resident Care Plan dated 8/30/23 identified Resident #1 had chronic obstructive pulmonary disease, clinical management chronic respiratory failure with interventions directed to administer oxygen as ordered/indicated, observe for worsening shortness of breath (SOB), notify physician of unrelieved or new SOB at rest. The nurse's note, written by the 7:00 AM-3:00 PM charge nurse, LPN #1 dated 9/4/23 at 4:23 PM identified at 8:15 AM NA #1 reported to LPN #1 Resident #1 was not looking good, LPN #1 went in to assess Resident #1, shortness of breath was noted, and Resident #1 felt clammy. Nebulizer treatment was administered, and blood sugar was checked and noted to be 222. Vital signs were as follows: blood pressure 117/84, pulse 98, respirations 20, temperature 96.5 degrees Fahrenheit and oxygen saturation level 98% on 2 liters of oxygen. After administration of nebulizer treatment Resident #1 was asked by LPN #1 how do you feel and Resident #1 stated I feel a little tired, and when asked if he/she was feeling pain, Resident #1 stated no. Interview with the 7:00 AM-3:00 PM charge nurse, Licensed Practical Nurse (LPN) #1, on 9/7/23 at 12:02 PM identified she assessed Resident #1 when NA #1 reported to her Resident #1 did not look good. LPN #1 indicated she did not report the change of condition to the nursing supervisor, RN #1 at the time when Resident #1 experienced shortness of breath because the supervisor would come and do her own rounds. LPN #1 identified Resident #1 stated he/she was ok, he/she said just tired, and was not in any pain. LPN #1 indicated normally the supervisor would come and asked if there were any residents with problems/issues and LPN #1 would give the supervisor the rundown on report of what was going on. Interview and review of the clinical record with the Director of Nursing (DON) on 9/8/23/21 at 10:00 AM identified if a resident experienced a change in condition the expectation was for the Registered Nurse supervisor to complete a change in condition assessment. The DON indicated LPN can input the information into the change in condition form, LPN can initiate the assessment, however the RN supervisor oversee the entire assessment and input her information, her assessment in the change in condition form. The DON identified the change in condition assessment on 9/4/23 at 8:15 AM was not completed by RN #1 and it should have been. The DON identified that RN #1 captured the information regarding SOB and nebulizer treatment in her note, however RN #1 did not assess Resident #1 when he/she experienced SOB.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #2) who was reviewed for a medication error, the facility failed to ensure Resident #2's insulin was readily available to prevent two doses from being omitted, the facility failed to ensure the physician was notified when the Insulin was not available and failed to ensure the resident's blood glucose was monitored per the physician's order. The findings include: Resident #2's diagnoses included Diabetes Mellitus, metabolic encephalopathy, acute respiratory failure, and schizoaffective disorder. A physician's order dated 7/18/23 directed to give a medication to decrease blood sugar, Novolog Insulin Flex Pen Subcutaneous Solution pen injector 100 units per ml inject per sliding scale before meals and at bedtime: if blood sugar is 150-200 give 2 units, if blood sugar is 201-250 give 4 units, if blood sugar is 251-300 give 6 units, if blood sugar is 301-350 give 8 units, if blood sugar is 351-400 units give 10 units, notify provider if blood glucose is >400. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily life and received insulin injects daily. The Resident Care Plan dated 8/31/23 identified Diabetes Mellitus. Interventions directed to record blood glucose, administer medications as ordered, diabetic foot checks and blood work as ordered. A physician's order dated 8/9/23 directed to give Insulin Aspart (Novolog Insulin) Flex Pen Subcutaneous Solution pen injector 100 units per ml inject 10 units subcutaneously before meals and at bedtime. The nurse's note dated 9/9/23 at 5:53 PM identified Insulin Aspart (Novolog) 10 units was not available, the pharmacy was notified and the insulin will be delivered within the next day. The nurse's note dated 9/9/23 at 5:54 PM identified Novolog Flex Pen sliding scale before meals and at bedtime was not available, the pharmacy was notified, and the insulin will be delivered within the next day. The nurse's note dated 9/9/23 at 9:27 PM identified Novolog Flex Pen sliding scale before meals and at bedtime was not available waiting for delivery. The nurse's note dated 9/9/23 at 9:29 PM identified the Insulin Aspart (Novolog) 10 units before meals and bedtime was not available awaiting delivery. The nurse's note dated 9/9/23 at 9:45 PM identified Resident #2 was out of Novolog Insulin, the pharmacy was notified and reported the Novolog Pen had been delivered to the facility on 9/8/23, but the medication was not found in the refrigerator or cart, another pen was requested, awaiting delivery. Review of the September 2023 Medication Administration Record (MAR) identified the Novolog Insulin was not administered on 9/9/23 for both the 4:30 PM and the 9:30 PM doses per the physician's order dose due to medication not being available. Review of the clinical record from 9/9/23 through 9/10/23 failed to reflect documentation the physician or Advanced Practice Registered Nurse were notified the Novolog Insulin was not available to be administered at 4:30 PM and 9:30 PM. The medication error documentation dated 9/10/23, written by the Night Supervisor, Registered nurse (RN) #3, identified the charge nurse, Licensed Practical Nurse (LPN) #3, reported and admitted to administering Novolog Insulin to Resident #2 that belonged to another resident because Resident #2's medication was not available. The documentation identified while the Supervisor was doing rounds, it was learned that Resident #2 had an elevated blood sugar, which was not documented, and LPN #3 had documented the medication was not available. The documentation identified the Night Supervisor questioned LPN #3 as to what steps were taken and provided education on the importance and policies regarding medication not readily available. The documentation identified Resident #2 was closely monitored after the supervisor learned the medication was not given, the pharmacy was called and stated the Novolog Insulin would be delivered on the morning run on 9/10/23. The Facility Reported Incident form dated 9/10/23 identified on 9/9/23 at approximately 9:00 PM LPN #3 reported to the Night Supervisor, RN #3, that Resident #2's blood sugar was elevated, RN #3 checked the MAR and saw Resident #2 had not received the afternoon and the nighttime short acting insulin (Novolog) to which LPN #3 stated it was not available, so she did not give it. The report identified during morning report on 9/10/23 the Director of Nursing (DON), who had been the supervisor on 9/9/23 during the evening shift, was updated. The report identified when interviewed Resident #2 indicated he/she did receive the Novolog Insulin on 9/9/23, but it was administered with a regular needle and not the usual insulin pen. The report identified the DON had received report that LPN #3 had not given Resident #2 the Novolog Insulin per the physician's order, to which LPN #3 stated that she reported the situation to the supervisor and the supervisor told her it was ok to hold the insulin. The report indicated the DON was the supervisor in question and did not have any such conversation with LPN #3. The report identified LPN #3 was asked if Resident #2 received the insulin and if not, was the medical provider updated with LPN #3's response being I gave the resident the insulin, however in review of the documentation, the medication had not been charted as given and there was no documentation to indicate the supervisor or provider had been updated. Interview with Resident #2 on 9/14/23 at 10:40 AM identified he/she did get his/her Insulin but received it via a regular insulin syringe and not the resident's Insulin Flex Pen. Resident #2 identified when he/she questioned the nurse for the reason why it was in a regular syringe, the nurse replied, you are out of your pen. Interview with LPN #3 on 9/14/23 at 11:12 AM identified after giving Resident #2 the 11:30 AM insulin dose on 9/9/23, she called the pharmacy as the Novolog Insulin had run out and the pharmacy had informed LPN #3 the Novolog Insulin had been delivered on 9/8/23 and it was too soon to refill the medication. LPN #3 identified she did not give Resident #2 any Novolog Insulin after the 11:30 AM dose due to it not being available. LPN #3 identified she did not notify the provider regarding Resident #2 not getting his/her scheduled Novolog Insulin, just documented in the MAR that it was not available. Interview with the Director of Nursing (DON) on 9/14/23 at 11:35 AM identified on 9/10/23 it was reported to her by the night supervisor, RN #3, that Resident #2 did not receive the Novolog Insulin. The DON identified she then questioned LPN #3 regarding who this was reported to, and LPN #3 stated she reported it to the supervisor on the evening shift and did not report it to any care provider. The DON identified she was the supervisor who worked the evening shift on 9/9/23, and when she further questioned LPN #3 about who it was reported to, LPN #3 stated she had never said she reported it to the supervisor. The DON identified Resident #2's medical record reflected the Novolog Insulin was not given as it was not available for both the scheduled 4:30 PM and 9:30 PM dose. The DON indicated LPN #3 did not notify the provider at any time, which is policy when a medication is not available, and she should have notified the physician or APRN (provider). Interview with the Night Supervisor, RN #3, on 9/14/23 at 2:54 PM identified on 9/9/23, LPN #3 reported to her Resident #2's Novolog Insulin had not been delivered and was not administered. RN #3 identified she asked LPN #3 what Resident #2's blood sugar reading was, and she reported it was in the 300 range. RN #3 indicated at that time she informed LPN #3 that a solution had to be obtained, asked if there was a multi-dose vial available, which there was not, and LPN #3 stated she did give Resident #2 his/her long-acting insulin for the scheduled doses. RN #3 identified during morning meeting on 9/10/23 she informed the DON about Resident #2's missed doses of Novolog Insulin on 9/9/23 at both the 4:30 PM and 9:30 PM scheduled times. Although attempted, an interview with APRN #2 was unable to be obtained. Review of the facility policy titled Point of Care Testing directed, in part, documentation of testing should include date, time and results on the MAR/treatment administration record (TAR) and document physician/provider notification and actions taken, if applicable. Review of the facility policy titled Nursing Documentation directed, in part, nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's condition, situation and complexity. The policy further directed, in part, charting by exception is a term used to describe the documentation method where only a deviation from defined assessment elements or a variation from a standard of care is documented. Review of the facility policy titled Medication administration directed, in part if there are discrepancies in medication, notify the physician or advanced practice provider as indicated and to document if the drug is withheld, record reason and provider notification, if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy, and interviews for one of three residents, (Resident #1), who required oxygen therapy, the facility failed to obtain a physician's order for oxygen administration. The findings include: Resident #1's diagnoses included hypertension and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had -no cognitive impairment, required extensive assistance of two persons with bed mobility, transfer and received oxygen therapy while a resident. The Resident Care Plan dated 8/30/23 identified Resident #1 had chronic obstructive pulmonary disease, and chronic respiratory failure. Interventions directed to administer oxygen as ordered/indicated. Review of the nurse's notes from 8/28 through 9/4/23 identified Resident #1 received two (2) or three (3) liters of oxygen via nasal cannula. Review of the clinical record from 8/28 through 9/4/23 failed to reflect a physician's order was obtained for the type of oxygen delivery system, the settings, and when to administer or discontinue oxygen therapy. Interview and review of the clinical record with the DON on 9/7/23 at 3:00 PM identified Resident #1 had a diagnosis of chronic obstructive pulmonary disease, sleep apnea and used oxygen at home. The DON indicated the documentation in nurse's notes indicated Resident #1 received 3 liters of oxygen via nasal cannula, however, was unable to provide a physician order for the type of oxygen delivery system, the settings, and when to administer or discontinue oxygen therapy. The DON identified a physician's order should have been obtained for oxygen administration, at least for as needed administration.

Based on review of employee files, interviews, and policy, for five of five Nurse Aide (Nurse Aide #1, #2, #3, #4, and #5) who were reviewed for performance evaluations, the facility failed to ensure that yearly evaluations were completed. The findings include: 1. Nurse Aide (NA) #1 had a hire date of 7/20/1998. Review of the employee file identified that the last performance evaluation was completed on 7/9/19 (4 years past due). 2. NA #2 had a hire date of 6/6/2000. Review of the employee file identified that the last performance evaluation was completed on 4/30/20 ( 3 years past due). 3. NA #3 had a hire date of 5/9/2006. Review of the employee file identified that the last performance evaluation was completed on 5/26/19 (4 years past due). 4. NA #4 had a hire date of 9/8/21. Review of the employee file filed to identify that the performance evaluation was completed since date of hire (3 years past due). 5. NA #5 had a hire date of 5/13/22. Review of the employee file filed to identify that the performance evaluation was completed since date of hire ( 1 year past due). Interview with the Director of Nursing (DON) on 9/14/23 at 3:30 PM identified that performance evaluations were to be completed on an annual basis, and nursing supervisors were responsible for completing the evaluations. Review of the Performance Appraisal policy and procedure directed managers will meet with their regular full-time, regular part-time and regular casual employees at least annually to conduct a performance appraisal or have a performance-based conversation. In-service education will be provided based on the outcome of these reviews.

Based on facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care timely to maintain the highest practicable physical, mental, and psychosocial well-being of residents. The findings include: The facility administration failed to: Ensure cardiopulmonary resuscitation was fully performed when the resident was noted to be unresponsive and pulseless. Ensure the Advanced Directive was addressed upon admission to the facility. Ensure a Registered Nurse (RN) assessment was completed when a resident experienced a change in condition. Ensure medication administration was documented in the clinical record when the medication was administered in accordance with standards of practice. Ensure a physician's order was obtained for the type of oxygen therapy. Please cross reference F578, F658, F678, and F695. Based on the deficiencies during the survey, immediate jeopardy and substandard care was identified in the areas of Quality of Life, and Quality of Care. Interview with the Director of Nurses, and the Administrator on 9/8/23 at 10:15 AM failed to identify administrative oversight of the facility processes to ensure the resident was free from significant medication error. The facility failed to utilize resources effectively to attain/maintain the resident's well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #15) who were reviewed for missing personal property, the facility failed to ensure an inventory list was completed upon the resident's admission or during an emergency transfer to another long-term care facility and failed to safeguard the resident's personal property during the time the resident was temporarily relocated. The findings include: Resident #15's diagnoses included vascular dementia with behavioral disturbances. The admission Minimum Data Set assessment dated [DATE] identified Resident #15 made poor decisions regarding tasks of daily living. The social service note dated 10/20/20 at 1:43 PM identified Resident #15's family member was notified on 10/19/20 Resident #15 would be moved to another facility secondary to facility maintenance. The nurse's note dated 10/20/20 at 3:01 PM identified the Medical Director was notified of a plan to transfer Resident #15 to another facility secondary to upcoming construction work on the unit. The note indicated Resident #15 was successfully transferred. The Inventory Personal of Personal Affects failed to reflect documentation of Resident #15's personal belongings brought in on admission or up until the transfer on 10/20/20. Further review, the clinical record and the Inventory Personal of Personal Affects failed to reflect documentation an inventory of personal items was completed to indicate which items were placed in storage during the emergency transfer on 10/20/20. The grievance/concern form dated 12/23/20 identified upon return to the facility, Resident #15 told the former Administrator, Administrator #2, he/she would like to have the reminder of his/her belongings retrieved from the storage area. The investigation identified the Administrator met with Resident #15 and explained that items in the storage were not accessible currently, however once the storage area was accessible, Resident #15's belongings would be given to him/her. The resolution of the grievance/concern dated 12/23/20 identified the Administrator met with Resident #15 and updated him/her that items would be given once storage area was accessed. Review of facility documentation identified an email was sent on 12/23/20 at 8:01 AM to the former Administrator #2 and Social Worker #2 regarding Resident #15's request to get his/her belongings from the storage area. The belongings had been in the storage since October, when residents were sent to other facilities. The email indicated Resident #15 would like to get these items as soon as possible, Resident #15 had asked several people, and no one did anything, could the facility please get these items and Resident #15 was getting very upset. Interview with Resident #15 on 10/13/21 at 11:00 AM identified he/she was moved to another facility due to a flood and when he/she returned, he/she did not receive his/her belongings. Resident #15 indicated the missing personal items included a Movado watch, a ring, a neckless, two pairs of jeans, black dressy slacks, a white dressy blouse, and a pair of shoes. Resident #15 identified about six (6) months ago Resident #15 provided a list of missing personal items he/she was still missing to the current Administrator. Resident #15 indicated the missing personal items had not been returned yet. Interview with the Director of Housekeeping on 10/13/21 at 11:45 AM identified he was working when the facility was flooded in October 2020. The Director of Housekeeping indicated the nursing staff packed the residents' belongings then the housekeeping and maintenance staff moved all the resident's belongings downstairs to the basement. The Director of Housekeeping identified Resident #15 complained to him that he/she was missing items and he told Resident #15 everything he/she had here was back in his/her room. The Director of Housekeeping indicated he did not document anything, he did not know that he had to. The Director of Housekeeping identified Administrator #2 had an inventory list. Interview and review of facility documentation with Director of Nursing (DON) on 10/13/21 at 12:55 PM identified the inventory of Resident #15's personal items form should have been filled out on admission and even during the emergency transfer. The DON indicated the staff should had documented the items they were storing as well as the items that were transferred with Resident #15 to the other facility. The DON identified the facility staff packed Resident #15's personal belongings and moved it, so the facility was responsible to safeguard Resident #15's personal property and was responsible for the missing items. Interview with former Administrator, Administrator #2 on 10/13/21 at 2:30 PM identified a bag of missing clothes was located and returned to Resident #15. Administrator #2 indicated a lot of furniture was moved and locked outside in the storage in the parking lot. Administrator #2 identified if there was personal property left in the bedside table, then it was moved and locked in the storage container located in the parking lot. Administrator #2 indicated the facility staff could not get in the storage because it was locked, so it would have to be opened, furniture had to be moved out in order to find Resident #15's missing items. Administrator #2 identified some of Resident #15's items were found, however the watch, the neckless, and the ring might have been locked outside in the storage and he did not know if those items were found because he resigned the Administrator's position in March. Administrator #2 indicated he did not have an inventory list of Resident #15's personal belongings at the time of the emergency transfer. Multiple attempts were made, and the current Administrator was not available for an interview. Multiple attempts were made, and Social Worker #1 and Social Worker #2 were not available for an interview. The Personal Property: Resident's Policy directed personnel to identify and record the resident's belongings upon admission. The facility was prohibited from requesting or requiring patients or potential patients to waive any potential facility liability for losses of personal property. All items brought into the facility was to be listed on the Inventory of Personal Effects form and kept in the resident's clinical chart. Any additional items brought into the facility after admission must be added to the list. The resident or resident representative was to be notified of the loss or breakage of personal items and advised if the loss or brakeage will or will not be replaced or repaired at the facility's expense. The facility was to be presumed to have made reasonable efforts to safeguard resident property.

**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 6 residents (Resident #2, 23, 24, 30, 299 and 499) reviewed for notification of change, the facility failed to notify the physician and responsible representatives when required. The findings include: 1. Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. The Braden Scale dated 7/31/21 identified Resident #499 was at moderate risk for the development of a pressure ulcer. A skin check dated 7/31/21 identified Resident #499 did not have skin injuries to the left and right shin and no injuries consistent with a vascular wound. An APRN progress note dated 7/31/21 noted skin redness on the upper back and buttocks with a protective dressing applied. Multiple bruises on the upper arms, open area on the right heel, skin healthy with no signs or symptoms of infection. The initial care plan dated 8/1/21 identified Resident #499 was at risk for skin breakdown with interventions that included weekly wound assessment to include measurements and description of wound status, supplements as ordered, weekly skin checks, wound treatments as ordered, OT/ PT to improve function, provide dietician services as needed, offload while in bed, observe skin condition daily with ADL care and report abnormalities and apply barrier cream with each cleansing. The MDS dated [DATE] identified Resident #499 had moderately impaired cognition, required assistance with care, had 2 or more stage I unhealed pressure ulcers and no venous or arterial wounds. A nurse's note dated 8/16/21 at 9:44 AM identified Resident #499 had a skin tear on the right calf noted on admission. The area had slough and serous drainage. Subsequent nurse's notes at 8:17AM and 11:33AM identified the resident had a skin tear on the right calf which had been noted on admission, that now had slough and serous drainage. The skin tear was again mentioned in a nurse's note on 8/18/21 at 10:35 AM. The notes failed to document action taken. Review of the August 2021 TAR 8/1/21 - 8/23/21 failed to reflect a treatment to the right or left calf skin tears. A nurse's note dated 8/23/21 at 11:57 PM identified deep tissue injuries to both calves and Xerofom and a dry sterile dressing was applied. A nurse's note dated 8/24/21 identified Resident #499 was seen by the wound consultant that morning, however, a wound consultation note could not be found. Review of nurse's notes, medical progress notes and skin check assessments dated 7/31/21 through 8/31/21 failed to reflect a documented complete assessment of the skin tears to the left or right calf. A wound consultation dated 8/31/21 identified Resident #499 received an initial evaluation for skin conditions which included an arterial wound to the right calf that measured 7.0cm x 2.0cm x 0.5cm, present for greater than 14 days. A left calf arterial wound present for greater than three days that measured 10cm x 3.0cm x 0.5cm. Recommendations included to treat with calcium alginate/silver dressing every three days for 30 days. Interview on 10/8/21 at 1:01 PM with the Medical Director identified he was not notified of the residents open areas on the calves on admission or on 8/16/21 when they deteriorated. The Medical Director indicated any wound left untreated could lead to further decline, and because of Resident #499's health conditions, decline would likely occur more rapidly. The Medical Director indicated any change in condition should be reported for early treatment and identified the APRN (APRN #1) provided much of the care for the residents at the facility, but that she was in close contact with him regarding care. The Medical Director identified that had the skin conditions been reported to him or the APRN, there would have been a treatment plan put in place to address the concern. An interview on 10/8/21 at 12:00 PM with RN #5 identified treatment began on the vascular wounds on 8/25/21 when it was identified Resident #499's condition was deteriorating, so the facility consulted with the wound specialist. Nursing documentation began on 8/16/21 and appeared as though staff originally thought the area was a skin tear. Interview on 10/8/21 at 4:42 PM with LPN #11 indicated he was a former employee of the facility who worked as an LPN until 9/17/21. LPN #11 indicated he recalled Resident #499 had the skin tears on the back of his/her both calves on admission, but that they developed yellowing that was described as slough and drainage. LPN #11 stated he measured the wounds and although he may have forgotten to document, he notified the supervisor, physician and family but was unable to recall who. Interview on 10/9/21 at 12:52 PM with RN #6 identified he did not recall being notified of Resident #499's skin condition deterioration on 8/16/21. RN #6 indicated had he been notified; he would have completed a wound assessment with wound measurements and notify the physician. Although attempts were made, interviews with the former agency RN Supervisor, the DNS and APRN #1 were not obtained. Although a policy on change in condition was requested, it was not provided. Although Resident #499 was admitted on [DATE] with open areas to both calves (originally thought to be skin tears), the physician/APRN were not made aware of the areas. Subsequently, when the areas deteriorated on 8/16/21 and were noted with slough and serous drainage, again, the physician/APRN were not notified which led to a delay in treatment until 8/23/21 when Xeroform was applied and finally when the resident was seen by the wound physician on 8/31/21 who implemented calcium alginate/silver dressing every three days for 30 days. 2. Resident #2 was admitted to the facility in June 2021 with diagnoses that included chronic kidney disease, diabetes, kidney stones, and urinary tract infection. The discharge MDS dated [DATE] identified Resident #2 had intact cognition. The care plan dated 9/24/21 identified Resident #2 was at risk for impaired renal function and at risk for complications related to renal insufficiency related to recent kidney stones and placement of a stent. Interventions included to monitor blood pressure, pulse, peripheral edema and report to physician as indicated. The APRN progress note dated 9/25/21 at 8:50 PM identified Resident #2 had laser lithotripsy, stone extraction, and stent exchange on 9/24/21. Subsequently, Resident #2 was placed on Bactrim (antibiotic) every 12 hours. The nurse's note dated 9/27/21 at 2:04 PM noted Resident #2 left early in morning for stent removal and stone removal and returned at 2:00 PM. A physician's order dated 9/27/21 directed to give Bactrim DS tab 800/160mg 1 tab by mouth every 12 hours for 7 days. The nurse's note dated 9/29/21 at 9:11 AM and 10:24 PM noted Resident #2 refused medication. The nurse's note dated 9/29/21 at 10:21 PM noted Resident #2 was on antibiotic for urinary tract infection and refused antibiotic during shift but took all other medications. The supervisor was notified. The nurse's note dated 9/30/21 at 9:11 AM and 8:33 PM noted Resident #2 refused antibiotic and the RN supervisor was made aware. The nurse's note dated 10/1/21 at 10:36 AM noted Resident #2 refused antibiotic. The nurse's note dated 10/1/21 at 10:15 PM noted Resident #2 continues to refuse taking the Bactrim DS stated it makes him/her sick. The nurse ' s note dated 10/2/21 at 10:02 AM noted Resident #2 refused antibiotic because he/she complained of stomach pain while taking the medication Bactrim DS. The nurse's note dated 10/2/21 at 8:25 PM noted Resident #2 refused antibiotic because he/she does not like the side effects. The nurse's note dated 10/3/21 at 9:38 AM identified Resident #2 indicated the antibiotic Bactrim upsets his/her stomach. The nurse's note dated 10/3/21 at 8:14 PM identified Resident #2 had refused antibiotic Bactrim and supervisor was aware. Review of the MAR's dated 9/1/21-10/30/21 identified to start on the evening of 9/27/21 Bactrim DS give 1 tab every 12 hours scheduled at 9:00 AM and 9:00 PM with the last dose the morning of 10/4/21. Resident #2 took the first 4 doses and refused the last 10 does. Observations and interview with Resident #2 on 10/5/21 at 12:09 PM he/she indicated the doctor had put him/her on antibiotics, but the antibiotic made him nauseous and upset his stomach, so he had been refusing the antibiotic. Resident #2 indicated he had told the nurse's why he was refusing the antibiotic, but no one did anything about it. Resident #2 indicated he had not seen the physician or APRN since he had come back from the hospital so he/she would tell the APRN him/herself. Interview with APRN #2 on 10/7/21 at 12:15 PM indicated on 9/24/21 she had placed Resident #2 on antibiotics when he/she returned from the hospital with the recommendation for antibiotics status post the stent placement. APRN #2 indicated she was not notified that Resident #2 had been refusing any doses of the antibiotic. APRN #2 indicated the APRN or physician should have been notified when Resident #2 started to refuse the antibiotic. APRN #2 indicated if she was notified, she would have gone and spoke with Resident #2, spoke with the nurses, and based on the information from the resident and vital signs she would have potentially ordered a urine, blood work and maybe change the antibiotic. Review of the APRN communication log on the second floor dated 8/30/21 - 10/7/21 did not identify that Resident #2 had been refusing the antibiotic. Interview with APRN #1 on 10/7/21 at 1:50 PM indicated she was not made aware that Resident #2 had refused his/her antibiotic until Tuesday 10/5/21 and that was after they were supposed to be completed. APRN #1 indicated since the antibiotic were over, she would have nursing monitor the resident because the antibiotic was to be given after the stent placement. APRN #1 indicated she did not go to see Resident #2 because she had to triage her time based on importance. APRN #1 indicated nursing should have notified her after the first or second refused dose. APRN #1 noted it was concerning that staff had not made her aware that Resident #2 was refusing of the antibiotic until it was after it was completed. Interview and review of clinical record with the DNS 10/7/21 at 2:01 PM indicated the APRN or physician should be notified if any dose of antibiotic is refused by the resident and every dose refused thereafter. The DNS indicated the charge nurse, or the supervisor were responsible to notify the physician right away. Review of Notification of Change in Condition policy indicated the facility must immediately inform the resident, consult with the physician/APRN, and notify, consistent with his/her authority, when there was a need to alter treatment significantly, such as a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. The purpose is to provide appropriate and timely information relevant to the resident's condition. Although requested, a facility policy on refusal of medications was not provided. 3. Resident #24 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease requiring dialysis 3 times a week, diabetes, and heart failure. The annual MDS dated [DATE] identified Resident #24 was cognitively intact and needed limited assistance with dressing. The care plan dated 9/24/21 indicated Resident #24 had decrease ability to perform ADL's. Interventions included to provide assist of 1 with rolling walker for ambulation and assist of 1 with a slide board transfer from bed to wheelchair. An SBAR Communication Form dated 10/3/21 at 12:00 AM completed by LPN #2 noted Resident #24 had a new painful rash. The nursing documentation dated 10/4/21 at 7:00 AM completed by LPN #2 noted a deep red rash to the resident's mid upper chest, posterior neck, and scalp. Resident #24 continues to complain of pain to rash on neck and mid chest. APRN to follow up in morning. Observations and interview with Resident #24 on 10/4/21 from 10:00 AM - 10:30 AM identified Resident #24 had indicated he/she was waiting for the APRN to come into the facility and see him/her. Resident #24 noted he/she did not go to dialysis today because he/she did not feel well and was having some pain and itchiness where he/she had rash areas. Interview and clinical record review with the DNS on 10/4/21 at 2:13 PM indicated if Resident #24 had a new rash that was painful as soon as it was identified, the LPN should have had the RN do an assessment at that time and notify the APRN at that time. The DNS indicated the RN should have placed Resident #24 on precautions if the nurse suspected shingles until the resident was seen by the APRN and the APRN could determine if it was shingles or not. The DNS noted if RN #1 suspected it was shingles, she should have immediately placed Resident #24 on isolation. The DNS reviewed the residents medical record and indicated the APRN was not notified between 10/3/21 at 12:00 AM until 10/4/21 per the progress notes. Interview with RN #1 on 10/4/21 at 2:23 PM indicated she was not aware that Resident #24 had a rash when she had received report from the prior shift supervisor, RN #6, who did a double and worked 7:00 AM -11:00 PM on 10/2/21. RN #1 indicted the charge nurse had asked her to come to the second floor and look at the rash on Resident #24 on Sunday 10/3/21 at 3:30 AM but she did not document on the rash because she was the nurse on the first floor and the supervisor. RN #1 indicated she forgot to write the note and she did not call the APRN or physician at that time because she returned to first floor to give a resident a pain medication. RN #1 indicated she thought the vesicles looked like shingles but she was not a doctor so she could not diagnosis and she did not place the resident on precautions. RN #1 indicated that there was a patch of small pustules on the center of Resident #24's chest, a patch of pustules on the posterior neck area, and posterior scalp in the hairline. RN #1 noted the areas appeared that the pustules were being scratched and were in a linear line on his/her chest. RN #1 noted the resident indicated the rash was there for about a week. RN #1 noted she told the day supervisor RN #6 to have the weekend APRN look at the rash on Sunday 10/3/21. RN #1 indicated when she came in on Sunday 10/3/21 at 11:00 PM going into Monday 10/4/21 the rash was still there, and they didn't do anything during the day of 10/3/21 so she made sure and put it in the APRN book. RN #1 indicated when APRN #1 came in the facility today Monday 10/4/21 she updated the APRN #1 and asked her to see Resident #24 as the first resident. RN #1 noted APRN #1 went to assess Resident #24 and when APRN #1 came out of Resident #24's room she informed RN #1 resident had shingles and place Resident #24 on isolation. An interview with the DNS on 10/4/21 at 2:30 PM indicated that she was notified right after the APRN saw Resident #24 and the DNS notified the Infection Control Nurse who was instructed to place the resident on isolation and bring the cart and sign to be posted. The DNS indicated she will start education with the nurses indicating if the nurse assesses a resident who has a rash and is suspected to be shingles the resident should be place on precautions right away until seen by the APRN/MD. The DNS instructed that RN #1 to do a late entry for the evaluation she did on 10/3/21 at 3:30 AM. Interview with RN #1 with the DNS present on 10/4/21 at 3:27 PM indicated RN #1 forgot to write a note on Resident #24 because she went back to first floor as the charge nurse to give a pain medication and then forgot about writing a note or notifying the APRN of the resident rash. RN #1 indicated her assessment on 10/3/21 at 3:30 AM she had seen a patch of small vesicles on the center of Resident #24's chest, a patch of vesicles on the posterior neck area, and one patch on the posterior scalp. RN #1 indicated the areas appeared that the pustules were being scratched and moist. RN #1 indicated Resident #24 noted the rash had been there for about a week. RN #1 indicated the patch on the posterior scalp Resident #24 indicated he/she had put hair grease on the vesicles, so RN #1 noted she was not able to see if the vesicles were draining due to the grease. Interview with APRN #1 on 10/4/21 at 3:40 PM indicated she was first notified about the rash today on 10/4/21 at approximately 10:45 AM when she came into the facility and looked at her communication book on second floor and it was written to see Resident #24 first due to rash. APRN #1 indicated she interviewed Resident #24 and indicated the rash started a week ago with the small vesicles behind the neck and posterior neck and posterior left ear on the scalp. APRN #1 indicated there was a rash posteriorly at the scalp line that had vesicles that are starting to crust over, a patch of vesicles on the posterior neck, and anteriorly on the chest. The APRN #1 indicated the vesicles are in different stages from staring to crust over to new ones. APRN #1 indicated there was a new patch of vesicles starting today over the left eye. APRN #1 indicated as soon as the LPN was aware of the rash, she should have had the Registered Nurse do an assessment and notify the APRN right away. APRN #1 indicated when staff first noticed the rash, they should have called the APRN on call and used the IPAD so the on-call APRN could see the rash and diagnosis it as shingles right away and place the resident on precautions and medication. APRN #1 indicated Resident #24 should have been placed right away on airborne and contact precautions. Furthermore, staff who have not had chicken pox or who are pregnant should absolutely not have gone into Resident #24's room since RN #1 assessed the resident and suspected it was shingles. APRN #1 indicated if the weekend APRN was aware she would have seen the rash and written a progress note if there was not one present. Additionally, APRN #1 indicated dialysis should have been notified right away. An APRN order dated 10/4/21 directed to place Resident #24 on contact precautions and administer Valacyclovir (antiviral) HCL 500 mg daily every other day for shingles until 10/16/21. The care plan dated 10/4/21 identified Resident #24 had shingles. Interventions included to follow physician orders for medications, resident placed on contact precautions. The APRN noted dated 10/4/21 indicated asked to see Resident #24 for a rash. Resident #24 indicated the rash started about a week ago and first lesion started over the weekend. Area to left scalp hairline may have some crusting and there were 4 - 5 lesions in various stages of development and a new area noted to the left forehead above the eyebrow. These lesions are painful per resident. All other lesions the vesicles were intact with no crusting yet. Two lesions are linear with several vesicles that were purple in color. All lesions were on the left side of the body. Resident #24 reports they were all painful and he/she was taking hydromorphone every 4 hours for the pain. Resident #24 had history of childhood varicella and had not been vaccinated against zoster. Resident complaints of open area on right buttock. Painful lesions 1. Left scalp at hairline 2. Posterior neck below hairline 3. Anterior neck upper chest 4. Behind left ear and scalp 5. Newest one no vesicle yet above left eyebrow. The APRN plan add diagnosis of herpes zoster, because lesions are still developing will treat with valacyclovir 500 mg every 48 hours x 7 days for renal dosing, contact and airborne precautions to be maintained until all lesions are crusted over, no contact with pregnant women, call dialysis to inform them of diagnosis of herpes zoster, and give Dilaudid 2 - 4 mg every 4 hours as needed for pain. An interview with RN #1 on 10/06/21 at 10:00 AM indicated she did not know about the rash until 10/3/21 at 3:30 AM and she did not notify the APRN until the morning of 10/4/21 when the APRN came into the facility. Review of facility Notification of a Change in Condition dated 6/2021 identified the facility must immediately inform the resident. Consult with the Physician/APRN, and notify, consistent with his/her authority, when there is a significant change in condition in a resident's physical, mental or psychosocial status such as deterioration in health. Additionally, when there was need to alter treatment significantly such as a need to discontinue or change an existing treatment due to adverse consequences or commence a new form of treatment. The purpose is to provide appropriate and timely information relevant to the resident's condition. Review of Physician/APRN Notification Policy identified upon identification of a resident who has a change in condition, a licensed nurse will perform appropriate clinical observations, and collect pertinent resident information such as age, diagnosis, prior vital signs, labs, recent change in medications, code status, and report to the Physician or APRN. If unable to contact the Physician or APRN, the Medical Director will be contacted. The purpose was to communicate a change in residents' condition to the Physician or APRN and initiate interventions as needed or ordered. 4. Resident #299's diagnoses that included iron deficiency anemia, seizure disorder, and cerebrovascular accident. The admission Minimum Data Set assessment dated [DATE] identified Resident #299 made poor decisions regarding tasks of daily life. A physician's order dated 9/21/20 directed to administer Keppra 500 milligrams (mg) twice daily for seizures. A physician's order dated 10/7/20 directed to discontinue the Keppra 500 mg. The physician's progress note dated 10/7/20 identified Resident #299 was awake and alert, subdued but not sedated nor somnolent, and was not participating with therapy. The progress note failed to reflect documentation that explained why the Keppra was discontinued or that the Resident #299's Representative was contacted. An Advanced Practice Registered Nurse (APRN) order dated 10/9/20 directed to administer Keppra 250 mg three (3) times daily. The APRN progress note dated 10/9/20 failed to reflect documentation that explained why the Keppra was restarted at a lower dose or that the Resident #299's Representative was contacted. Review of the nurse's note from 10/6/20 through 10/18/20 failed to reflect documentation Resident #299's Representative was notified of the discontinuation of the Keppra on 10/7/20 or that the Keppra was restarted at a lower dose on 10/9/20. The Social Service note dated 10/19/20 at 4:47 PM identified a meeting was held via phone with Resident #299's Representative, the Administrator, the Director of Nurses and the Social Worker regarding concerns of the medications and communication. A follow up meeting was scheduled for 10/21/20. Interview with the Director of Nursing (DON) on 10/13/21 at 12:51 PM identified the charge nurse, APRN, or physician are responsible to notify a resident's representative when there are changes in the medications. The DON was unable to locate documentation Resident #299's Representative had received notification of the changes to the Keppra on 10/7/20 or 10/9/20. Interview with MD #1 on 10/13/21 at 2:22 PM identified the protocol for notification of changes to a resident's medication was the responsibility of the Nursing Department. Interview with the former Administrator, Administrator #2 on 10/13/21 at 2:26 PM identified he had spoken with Resident #299's Resident Representative and the Representative had complained to him about the lack of communication related to medications changes. Review of facility change in condition Policy identified, in part, that a center must immediately inform the Health Care Decision Maker when there is a need to alter treatment significantly. 5. Resident #23 was admitted to the facility in June 2019 with diagnoses that included dementia, heart disease, and bilateral cataracts. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition, had no behaviors, and required extensive assistance for dressing, personal hygiene, toileting, bed mobility, and transfers. The care plan, undated, identified Resident #23 had impaired/declined cognition function or impaired thought process related to dementia. Interventions included to use short phrases that required yes/no answers and allow extra time after speaking for resident to process thoughts and respond. A physician's order dated 3/29/21 directed to give Cymbalta (antidepressant) 30mg daily for depression. Additionally, utilize quarter side rails for turning and positioning while in bed. The nurse's note dated 4/3/21 at 4:39 PM identified Resident #30 was alert and oriented. Resident #30 had increased verbal behavior noted towards roommate (Resident #23) and stated, I'm going to pull this curtain around your neck if you don't shut up. Supervisor notified and intervened and told resident to calm down and its never okay to speak to each other this way. Frequent monitoring ongoing. A nurse's note dated 4/3/21 at 8:45 PM identified Resident #23 was alert and verbal. No signs or symptoms of pain or discomfort on 3:00 PM - 11:00 PM shift. Call bell in place and safety maintained. A reportable event form dated 4/9/21 at 7:30 PM identified on 4/3/21, (6 days prior), Resident #30, (Resident #23's roommate), was heard by staff verbalizing he/she was going to pull the curtain around Resident #23's neck if he/she did not shut up. Resident #23 did not recollect event. The physician was notified on 4/9/21 at 8:30 PM and DPH (Department of Public Health) on 4/9/21 at 8:30 PM. Action taken on 4/9/21: Resident #23 has now been separated from his/her roommate and Resident #23 will follow up with physiatrist and social services as needed to meet psychosocial needs. Responsible party notified on 4/9/21 at 9:00 PM. The care plan dated 4/9/21 noted Resident #23 had a resident-to-resident altercation on 4/3/21. Intervention is resident was separated from his/her roommate. The nurse's note dated 4/9/21 at 9:00 PM identified Resident #23 was interviewed by the DNS to follow up regarding roommate's verbal interaction with him/her. Resident #23 was unable to recall event. No complaints of pain, discomfort, or distress. Responsible party updated and physician notified. The care plan for Resident #30, dated 4/9/21, identified a resident-to-resident altercation occurred on 4/3/21. Interventions included to follow up with social services as needed to continue meeting psychosocial needs, resident separated from his/her roommate and relocated to another room, Resident #30 was placed on 1:1 until cleared by psychiatry services. Additionally, the care plan indicated that Resident #30 required assistance of 1 contact guard with a rolling walker for ambulation and transfers. The care plan dated 4/12/21 noted Resident #23 was at risk for distressed/fluctuating mood symptoms related to the 4/9/21 report of inappropriate interaction with roommate and roommate's recent transfer of his/her room. Interventions included to observe for signs/symptoms of worsening sadness, depression, anxiety, fear, anger, and agitation. Additionally, allow time for expression of feelings and provide empathy, encouragement, and reassurance. The social services note dated 4/12/21 at 12:51 PM identified that on 4/11/21 she met with Resident #23 in efforts to provide emotional support and assess resident's mood and behavior status post reported event related to his/her interaction with roommate. Mood and behavior remain stable, and Resident #23 had no recollection of reported incident. The psychiatric evaluation note dated 4/12/21 at 9:10 PM noted Resident #23 did not recall incident. Resident #23 was not a danger to him/herself or others. Interview with Resident #23 on 10/5/21 at 11:00 AM noted he/she didn't recall any problems or concerns with any roommates. A statement, written by LPN #4, dated 4/9/21 indicated on 4/4/21, NA #4 notified her that she overheard Resident #30 tell Resident #23 that if he/she didn't shut up he/she would tie the curtain around his/her neck. LPN #4 stated she went into the room and spoke to Resident #23 and indicated that he/she should not use that type of language and behavior in the facility. LPN #4 identified that since the incident, the roommates have seemed to get along great with no complaints or occurrences. An in-service regarding the reporting process for resident-to-resident altercations dated 4/9/21 at 7:30 PM identified to immediately separate the residents, immediately place the aggressor on 1:1 monitoring, immediately notify the supervisor who will notify the DNS or designee for review of situation and further instructions. The nurse's note dated 4/9/21 at 8:42 PM identified Resident #30 was moved from the room and temporarily placed in another room until further notice due to incident that occurred on 4/3/21. The psychiatric evaluation dated 4/9/21 identified Resident #30 made some threatening remarks to another resident. This was processed with the resident. Resident #30 had no intent or plan to harm anyone. Reviewed coping skills and mechanisms to help manage frustration tolerance in support of therapy. Resident #30 does not require a one to one at this time and was not a danger to self or others. The nurse's note dated 4/11/21 at 8:59 PM noted on 4/9/21 at 9:00 PM the physician was notified of reported event related to interaction of resident with his/her roommate with no new orders given at this time. The social services progress note dated 4/12/21 at 12:01 PM identified noted she met with Resident #30 on 4/5/21 in an effort to provide emotional support and assess mood and behavior status post reported event related to interaction with his/her roommate. Resident #30 verbalized he/she was not serious and doesn't understand what the bid deal was. Social worker provided education on why Resident #30 was transferred to a different room. The Psychiatric APRN progress note dated 4/12/21 at 9:10 PM noted saw Resident #30 because she/he made threatening comments to roommate. Resident #30 reported she/he was just kidding and would not do this to his/her roommate. The Educational Intervention Form dated 4/12/21 indicated LPN #4 was educated because Resident #30's nursing note entry on 4/3/21 highlighted a resident to resident altercation. LPN #4 noted she had notified the supervisor and social worker of the event by her. The DNS educated LPN #4 that reporting events related to resident to resident must be very clear to state exactly what was stated and nursing supervisor and or social worker will determine the severity of event and how event needs to be handled. An interview with Resident #30 on 10/4/21 at 11:23 AM noted he/she did have one issue a while back with his/her old roommate. Resident #30 indicated he/she was joking with his/her roommate and told the roommate he/she would take the curtain and wrap it around his/her neck and a nursing assistant overhead it and reported him/her. Resident #30 indicated that was why she/he was now in a private room. An interview with the DNS on 10/07/21 at 10:34 AM the DNS indicated she was not here at the time but after review of the clinical record the nursing assistant should have report the altercation to the charge nurse who would have reported it to the supervisor immediately. The DNS noted the supervisor should investigate and inform the DNS. The DNS review of the clinical record and the reportable event form noted the supervisor should have separated the 2 resi[TRUNCATED]

**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 #23) reviewed for an allegation of abuse, the facility failed to ensure the resident was free from verbal abuse and the facility failed to protect the resident for 6 days after the incident. The findings include: Resident #23 was admitted to the facility in June 2019 with diagnoses that included dementia, heart disease, and bilateral cataracts. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition, had no behaviors, and required extensive assistance for dressing, personal hygiene, toileting, bed mobility, and transfers. The care plan, undated, identified Resident #23 had impaired/declined cognition function or impaired thought process related to dementia. Interventions included to use short phrases that required yes/no answers and allow extra time after speaking for resident to process thoughts and respond. A physician's order dated 3/29/21 directed to give Cymbalta (antidepressant) 30mg daily for depression. Additionally, utilize quarter side rails for turning and positioning while in bed. The nurse's note dated 4/3/21 at 4:39 PM identified Resident #30 was alert and oriented. Resident #30 had increased verbal behavior noted towards roommate (Resident #23) and stated, I'm going to pull this curtain around your neck if you don't shut up. Supervisor notified and intervened and told resident to calm down and its never okay to speak to each other this way. Frequent monitoring ongoing. A nurse's note dated 4/3/21 at 8:45 PM identified Resident #23 was alert and verbal. No signs or symptoms of pain or discomfort on 3:00 PM - 11:00 PM shift. Call bell in place and safety maintained. A reportable event form dated 4/9/21 at 7:30 PM identified on 4/3/21, (6 days prior), Resident #30, (Resident #23's roommate), was heard by staff verbalizing he/she was going to pull the curtain around Resident #23's neck if he/she did not shut up. Resident #23 did not recollect event. The physician was notified on 4/9/21 at 8:30 PM and DPH (Department of Public Health) on 4/9/21 at 8:30 PM. Action taken on 4/9/21: Resident #23 has now been separated from his/her roommate and Resident #23 will follow up with physiatrist and social services as needed to meet psychosocial needs. Responsible party notified on 4/9/21 at 9:00 PM. The care plan dated 4/9/21 noted Resident #23 had a resident-to-resident altercation on 4/3/21. Intervention is resident was separated from his/her roommate. The nurse's note dated 4/9/21 at 9:00 PM identified Resident #23 was interviewed by the DNS to follow up regarding roommate's verbal interaction with him/her. Resident #23 was unable to recall event. No complaints of pain, discomfort, or distress. Responsible party updated and physician notified. The care plan for Resident #30, dated 4/9/21, identified a resident-to-resident altercation occurred on 4/3/21. Interventions included to follow up with social services as needed to continue meeting psychosocial needs, resident separated from his/her roommate and relocated to another room, Resident #30 was placed on 1:1 until cleared by psychiatry services. Additionally, the care plan indicated that Resident #30 required assistance of 1 contact guard with a rolling walker for ambulation and transfers. The care plan dated 4/12/21 noted Resident #23 was at risk for distressed/fluctuating mood symptoms related to the 4/9/21 report of inappropriate interaction with roommate and roommate's recent transfer of his/her room. Interventions included to observe for signs/symptoms of worsening sadness, depression, anxiety, fear, anger, and agitation. Additionally, allow time for expression of feelings and provide empathy, encouragement, and reassurance. The social services note dated 4/12/21 at 12:51 PM identified that on 4/11/21 she met with Resident #23 in efforts to provide emotional support and assess resident's mood and behavior status post reported event related to his/her interaction with roommate. Mood and behavior remain stable, and Resident #23 had no recollection of reported incident. The psychiatric evaluation note dated 4/12/21 at 9:10 PM noted Resident #23 did not recall incident. Resident #23 was not a danger to him/herself or others. Interview with Resident #23 on 10/5/21 at 11:00 AM noted he/she didn't recall any problems or concerns with any roommates. A statement, written by LPN #4, dated 4/9/21 indicated on 4/4/21, NA #4 notified her that she overheard Resident #30 tell Resident #23 that if he/she didn't shut up he/she would tie the curtain around his/her neck. LPN #4 stated she went into the room and spoke to Resident #23 and indicated that he/she should not use that type of language and behavior in the facility. LPN #4 identified that since the incident, the roommates have seemed to get along great with no complaints or occurrences. An in-service regarding the reporting process for resident-to-resident altercations dated 4/9/21 at 7:30 PM identified to immediately separate the residents, immediately place the aggressor on 1:1 monitoring, immediately notify the supervisor who will notify the DNS or designee for review of situation and further instructions. The nurse's note dated 4/9/21 at 8:42 PM identified Resident #30 was moved from the room and temporarily placed in another room until further notice due to incident that occurred on 4/3/21. The psychiatric evaluation dated 4/9/21 identified Resident #30 made some threatening remarks to another resident. This was processed with the resident. Resident #30 had no intent or plan to harm anyone. Reviewed coping skills and mechanisms to help manage frustration tolerance in support of therapy. Resident #30 does not require a one to one at this time and was not a danger to self or others. The nurse's note dated 4/11/21 at 8:59 PM noted on 4/9/21 at 9:00 PM the physician was notified of reported event related to interaction of resident with his/her roommate with no new orders given at this time. The social services progress note dated 4/12/21 at 12:01 PM identified noted she met with Resident #30 on 4/5/21 in an effort to provide emotional support and assess mood and behavior status post reported event related to interaction with his/her roommate. Resident #30 verbalized he/she was not serious and doesn't understand what the bid deal was. Social worker provided education on why Resident #30 was transferred to a different room. The Psychiatric APRN progress note dated 4/12/21 at 9:10 PM noted saw Resident #30 because she/he made threatening comments to roommate. Resident #30 reported she/he was just kidding and would not do this to his/her roommate. The Educational Intervention Form dated 4/12/21 indicated LPN #4 was educated because Resident #30's nursing note entry on 4/3/21 highlighted a resident to resident altercation. LPN #4 noted she had notified the supervisor and social worker of the event by her. The DNS educated LPN #4 that reporting events related to resident to resident must be very clear to state exactly what was stated and nursing supervisor and or social worker will determine the severity of event and how event needs to be handled. An interview with Resident #30 on 10/4/21 at 11:23 AM noted he/she did have one issue a while back with his/her old roommate. Resident #30 indicated he/she was joking with his/her roommate and told the roommate he/she would take the curtain and wrap it around his/her neck and a nursing assistant overhead it and reported him/her. Resident #30 indicated that was why she/he was now in a private room. An interview with the DNS on 10/07/21 at 10:34 AM the DNS indicated she was not here at the time but after review of the clinical record the nursing assistant should have report the altercation to the charge nurse who would have reported it to the supervisor immediately. The DNS noted the supervisor should investigate and inform the DNS. The DNS review of the clinical record and the reportable event form noted the supervisor should have separated the 2 residents immediately on 4/3/21. The DNS indicated the LPN should have notified the supervisor immediately. The supervisor should have notified the responsible party and the physician immediately. The DNS and/or the administrator were responsible the notify DPH within 2 hours of the incident occurring on 4/3/21. The DNS noted the incident occurred on 4/3/21 and the 1:1 did not start until 4/9/21 and the resident was seen by psychiatric services on 4/9/21. The DNS indicated that psychiatric services should have been called immediately on 4/3/21 and if they were not available then staff should have placed Resident #30 on a 1:1 on 4/3/21 or send the resident to the emergency room and when the resident returned from the emergency room been placed in a different room. The DNS noted Resident #30 should have had a room change on 4/3/21 but it did not occur until 4/9/21. Interview on 10/8/21 at 3:33 PM with RN #4 indicated she was not informed by the LPN when she worked on 4/3/21 the day shift that a resident had threatened another resident. RN #4 indicated she was not aware when the incident had occurred on 4/3/21. RN #4 indicated she learned of the resident-to-resident altercation when the DNS called her and asked her for a statement. An interview with NA #4 on 10/8/21 at 4:03 PM indicted on 4/3/21during breakfast the housekeeper called her to Resident #23 and Resident #30's room stating Resident #30 was threatening Resident #23. NA #4 noted as she was heading to the room, she could hear Resident #30 being loud and nasty. NA #4 indicated she did not think Resident #30 was joking because the tone of voice and the resident was not smiling but appeared serious. NA #4 noted she was concerned. Resident #30 mentioned wrapping the curtain around the roommates' neck, so NA #4 stayed there to make sure Resident #30 did not do it. NA #4 noted Resident #30 was up in the wheelchair at the time and was able to transfer and stand independent with transfers. NA #4 noted Resident #30 was able to self-propel in the room and hallway. NA #4 indicated LPN # 4 came right down to the room and calmed Resident #30. Additionally, NA #4 noted Resident #23 was in bed and needs assistance to get out of bed. NA #4 did not think Resident #23 understood what was happening. NA #4 told LPN #4 to call the supervisor and make sure RN #4 was aware of what happened. An interview with Housekeeper #1 on 10/8/21 at 4:22 PM identified on 4/3/21 during breakfast she was in the room cleaning and both residents were arguing, and Resident #30 said she would take the curtain and put it around Resident #23's head. Resident #23 and Resident #30 were yelling at each other and then started to talk to each other. Resident #30 was in the wheelchair by the window and Resident 23 was in bed. Resident #23 yelled back at Resident #30 but did not recall what was said. Housekeeper #1 called for NA #4 in the hallway for help. Housekeeper #1 indicated she heard NA #4 report incident to LPN #4. Housekeeper #1 noted she then left the room. Although attempted, an interview with LPN #4 was not obtained. Review of facility Abuse Prohibition Policy indicated the facility prohibits abuse, mistreatment, neglect, and exploitation. If the suspected abuse was resident to resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The facility will provide adequate supervision when the risk of resident-to-resident altercation was suspected. The family and physician will be notified and any follow up recommended will be completed such as a psychiatric evaluation. Options for room changes will be provided based on situation. Additionally, the facility will protect residents from further harm during the investigation. Provide the resident with a safe environment.

**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 #30) reviewed for an allegation of abuse, the facility failed to report the allegation according to established requirements. The findings include: Resident #23 was admitted to the facility in June 2019 with diagnoses that included dementia, heart disease, and bilateral cataracts. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition, had no behaviors, and required extensive assistance for dressing, personal hygiene, toileting, bed mobility, and transfers. The care plan, undated, identified Resident #23 had impaired/declined cognition function or impaired thought process related to dementia. Interventions included to use short phrases that required yes/no answers and allow extra time after speaking for resident to process thoughts and respond. A physician's order dated 3/29/21 directed to give Cymbalta (antidepressant) 30mg daily for depression. Additionally, utilize quarter side rails for turning and positioning while in bed. The nurse's note dated 4/3/21 at 4:39 PM identified Resident #30 was alert and oriented. Resident #30 had increased verbal behavior noted towards roommate (Resident #23) and stated, I'm going to pull this curtain around your neck if you don't shut up. Supervisor notified and intervened and told resident to calm down and its never okay to speak to each other this way. Frequent monitoring ongoing. A nurse's note dated 4/3/21 at 8:45 PM identified Resident #23 was alert and verbal. No signs or symptoms of pain or discomfort on 3:00 PM - 11:00 PM shift. Call bell in place and safety maintained. A reportable event form dated 4/9/21 at 7:30 PM identified on 4/3/21, (6 days prior), Resident #30, (Resident #23's roommate), was heard by staff verbalizing he/she was going to pull the curtain around Resident #23's neck if he/she did not shut up. Resident #23 did not recollect event. The physician was notified on 4/9/21 at 8:30 PM and DPH (Department of Public Health) on 4/9/21 at 8:30 PM. Action taken on 4/9/21: Resident #23 has now been separated from his/her roommate and Resident #23 will follow up with physiatrist and social services as needed to meet psychosocial needs. Responsible party notified on 4/9/21 at 9:00 PM. The care plan dated 4/9/21 noted Resident #23 had a resident-to-resident altercation on 4/3/21. Intervention is resident was separated from his/her roommate. The nurse's note dated 4/9/21 at 9:00 PM identified Resident #23 was interviewed by the DNS to follow up regarding roommate's verbal interaction with him/her. Resident #23 was unable to recall event. No complaints of pain, discomfort, or distress. Responsible party updated and physician notified. The care plan for Resident #30, dated 4/9/21, identified a resident-to-resident altercation occurred on 4/3/21. Interventions included to follow up with social services as needed to continue meeting psychosocial needs, resident separated from his/her roommate and relocated to another room, Resident #30 was placed on 1:1 until cleared by psychiatry services. Additionally, the care plan indicated that Resident #30 required assistance of 1 contact guard with a rolling walker for ambulation and transfers. The care plan dated 4/12/21 noted Resident #23 was at risk for distressed/fluctuating mood symptoms related to the 4/9/21 report of inappropriate interaction with roommate and roommate's recent transfer of his/her room. Interventions included to observe for signs/symptoms of worsening sadness, depression, anxiety, fear, anger, and agitation. Additionally, allow time for expression of feelings and provide empathy, encouragement, and reassurance. The social services note dated 4/12/21 at 12:51 PM identified that on 4/11/21 she met with Resident #23 in efforts to provide emotional support and assess resident's mood and behavior status post reported event related to his/her interaction with roommate. Mood and behavior remain stable, and Resident #23 had no recollection of reported incident. The psychiatric evaluation note dated 4/12/21 at 9:10 PM noted Resident #23 did not recall incident. Resident #23 was not a danger to him/herself or others. Interview with Resident #23 on 10/5/21 at 11:00 AM noted he/she didn't recall any problems or concerns with any roommates. A statement, written by LPN #4, dated 4/9/21 indicated on 4/4/21, NA #4 notified her that she overheard Resident #30 tell Resident #23 that if he/she didn't shut up he/she would tie the curtain around his/her neck. LPN #4 stated she went into the room and spoke to Resident #23 and indicated that he/she should not use that type of language and behavior in the facility. LPN #4 identified that since the incident, the roommates have seemed to get along great with no complaints or occurrences. An in-service regarding the reporting process for resident-to-resident altercations dated 4/9/21 at 7:30 PM identified to immediately separate the residents, immediately place the aggressor on 1:1 monitoring, immediately notify the supervisor who will notify the DNS or designee for review of situation and further instructions. The nurse's note dated 4/9/21 at 8:42 PM identified Resident #30 was moved from the room and temporarily placed in another room until further notice due to incident that occurred on 4/3/21. The psychiatric evaluation dated 4/9/21 identified Resident #30 made some threatening remarks to another resident. This was processed with the resident. Resident #30 had no intent or plan to harm anyone. Reviewed coping skills and mechanisms to help manage frustration tolerance in support of therapy. Resident #30 does not require a one to one at this time and was not a danger to self or others. The nurse's note dated 4/11/21 at 8:59 PM noted on 4/9/21 at 9:00 PM the physician was notified of reported event related to interaction of resident with his/her roommate with no new orders given at this time. The social services progress note dated 4/12/21 at 12:01 PM identified noted she met with Resident #30 on 4/5/21 in an effort to provide emotional support and assess mood and behavior status post reported event related to interaction with his/her roommate. Resident #30 verbalized he/she was not serious and doesn't understand what the bid deal was. Social worker provided education on why Resident #30 was transferred to a different room. The Psychiatric APRN progress note dated 4/12/21 at 9:10 PM noted saw Resident #30 because she/he made threatening comments to roommate. Resident #30 reported she/he was just kidding and would not do this to his/her roommate. The Educational Intervention Form dated 4/12/21 indicated LPN #4 was educated because Resident #30's nursing note entry on 4/3/21 highlighted a resident to resident altercation. LPN #4 noted she had notified the supervisor and social worker of the event by her. The DNS educated LPN #4 that reporting events related to resident to resident must be very clear to state exactly what was stated and nursing supervisor and or social worker will determine the severity of event and how event needs to be handled. An interview with Resident #30 on 10/4/21 at 11:23 AM noted he/she did have one issue a while back with his/her old roommate. Resident #30 indicated he/she was joking with his/her roommate and told the roommate he/she would take the curtain and wrap it around his/her neck and a nursing assistant overhead it and reported him/her. Resident #30 indicated that was why she/he was now in a private room. An interview with the DNS on 10/07/21 at 10:34 AM the DNS indicated she was not here at the time but after review of the clinical record the nursing assistant should have report the altercation to the charge nurse who would have reported it to the supervisor immediately. The DNS noted the supervisor should investigate and inform the DNS. The DNS review of the clinical record and the reportable event form noted the supervisor should have separated the 2 residents immediately on 4/3/21. The DNS indicated the LPN should have notified the supervisor immediately. The supervisor should have notified the responsible party and the physician immediately. The DNS and/or the administrator were responsible the notify DPH within 2 hours of the incident occurring on 4/3/21. The DNS noted the incident occurred on 4/3/21 and the 1:1 did not start until 4/9/21 and the resident was seen by psychiatric services on 4/9/21. The DNS indicated that psychiatric services should have been called immediately on 4/3/21 and if they were not available then staff should have placed Resident #30 on a 1:1 on 4/3/21 or send the resident to the emergency room and when the resident returned from the emergency room been placed in a different room. The DNS noted Resident #30 should have had a room change on 4/3/21 but it did not occur until 4/9/21. Interview on 10/8/21 at 3:33 PM with RN #4 indicated she was not informed by the LPN when she worked on 4/3/21 the day shift that a resident had threatened another resident. RN #4 indicated she was not aware when the incident had occurred on 4/3/21. RN #4 indicated she learned of the resident-to-resident altercation when the DNS called her and asked her for a statement. An interview with NA #4 on 10/8/21 at 4:03 PM indicted on 4/3/21during breakfast the housekeeper called her to Resident #23 and Resident #30's room stating Resident #30 was threatening Resident #23. NA #4 noted as she was heading to the room, she could hear Resident #30 being loud and nasty. NA #4 indicated she did not think Resident #30 was joking because the tone of voice and the resident was not smiling but appeared serious. NA #4 noted she was concerned. Resident #30 mentioned wrapping the curtain around the roommates' neck, so NA #4 stayed there to make sure Resident #30 did not do it. NA #4 noted Resident #30 was up in the wheelchair at the time and was able to transfer and stand independent with transfers. NA #4 noted Resident #30 was able to self-propel in the room and hallway. NA #4 indicated LPN # 4 came right down to the room and calmed Resident #30. Additionally, NA #4 noted Resident #23 was in bed and needs assistance to get out of bed. NA #4 did not think Resident #23 understood what was happening. NA #4 told LPN #4 to call the supervisor and make sure RN #4 was aware of what happened. An interview with Housekeeper #1 on 10/8/21 at 4:22 PM identified on 4/3/21 during breakfast she was in the room cleaning and both residents were arguing, and Resident #30 said she would take the curtain and put it around Resident #23's head. Resident #23 and Resident #30 were yelling at each other and then started to talk to each other. Resident #30 was in the wheelchair by the window and Resident 23 was in bed. Resident #23 yelled back at Resident #30 but did not recall what was said. Housekeeper #1 called for NA #4 in the hallway for help. Housekeeper #1 indicated she heard NA #4 report incident to LPN #4. Housekeeper #1 noted she then left the room. Although attempted, an interview with LPN #4 was not obtained. Interview with DNS on 10/7/21 at 10:34 AM indicated the DNS and/or the Administrator are responsible the notify DPH within 2 hours of an allegation of abuse and should have notified DPH of the incident with Resident #30 on 4/3/21. The DNS noted the state agency wasn't notified until 4/9/21 at 8:30 PM because that was when the DNS was first aware. Review of facility Abuse Prohibition Policy dated 4/9/21 indicated the facility prohibits abuse, mistreatment, neglect, and exploitation. This includes but was not limited to any physical or chemical restraints. The purpose was to ensure the facility staff are doing all that was within their control to prevent occurrences of abuse, mistreatment, and neglect for all residents. Training and reporting obligations will be provided to all employees. Staff will identify resident to resident abuse. Any staff who witness an incident of suspected abuse, neglect was to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. All reports of suspected abuse must be reported to the resident's family and physician. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report allegations involving abuse (verbal, physical, sexual or mental) not later than 2 hours after the allegation was made.

**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 #30) reviewed for an allegation of abuse, the facility failed to immediately start an investigation according to established requirements. The findings include: Resident #23 was admitted to the facility in June 2019 with diagnoses that included dementia, heart disease, and bilateral cataracts. The quarterly MDS dated [DATE] identified Resident #23 had intact cognition, had no behaviors, and required extensive assistance for dressing, personal hygiene, toileting, bed mobility, and transfers. The care plan, undated, identified Resident #23 had impaired/declined cognition function or impaired thought process related to dementia. Interventions included to use short phrases that required yes/no answers and allow extra time after speaking for resident to process thoughts and respond. A physician's order dated 3/29/21 directed to give Cymbalta (antidepressant) 30mg daily for depression. Additionally, utilize quarter side rails for turning and positioning while in bed. The nurse's note dated 4/3/21 at 4:39 PM identified Resident #30 was alert and oriented. Resident #30 had increased verbal behavior noted towards roommate (Resident #23) and stated, I'm going to pull this curtain around your neck if you don't shut up. Supervisor notified and intervened and told resident to calm down and its never okay to speak to each other this way. Frequent monitoring ongoing. A nurse's note dated 4/3/21 at 8:45 PM identified Resident #23 was alert and verbal. No signs or symptoms of pain or discomfort on 3:00 PM - 11:00 PM shift. Call bell in place and safety maintained. A reportable event form dated 4/9/21 at 7:30 PM identified on 4/3/21, (6 days prior), Resident #30, (Resident #23's roommate), was heard by staff verbalizing he/she was going to pull the curtain around Resident #23's neck if he/she did not shut up. Resident #23 did not recollect event. The physician was notified on 4/9/21 at 8:30 PM and DPH (Department of Public Health) on 4/9/21 at 8:30 PM. Action taken on 4/9/21: Resident #23 has now been separated from his/her roommate and Resident #23 will follow up with physiatrist and social services as needed to meet psychosocial needs. Responsible party notified on 4/9/21 at 9:00 PM. The care plan dated 4/9/21 noted Resident #23 had a resident-to-resident altercation on 4/3/21. Intervention is resident was separated from his/her roommate. The nurse's note dated 4/9/21 at 9:00 PM identified Resident #23 was interviewed by the DNS to follow up regarding roommate's verbal interaction with him/her. Resident #23 was unable to recall event. No complaints of pain, discomfort, or distress. Responsible party updated and physician notified. The care plan for Resident #30, dated 4/9/21, identified a resident-to-resident altercation occurred on 4/3/21. Interventions included to follow up with social services as needed to continue meeting psychosocial needs, resident separated from his/her roommate and relocated to another room, Resident #30 was placed on 1:1 until cleared by psychiatry services. Additionally, the care plan indicated that Resident #30 required assistance of 1 contact guard with a rolling walker for ambulation and transfers. The care plan dated 4/12/21 noted Resident #23 was at risk for distressed/fluctuating mood symptoms related to the 4/9/21 report of inappropriate interaction with roommate and roommate's recent transfer of his/her room. Interventions included to observe for signs/symptoms of worsening sadness, depression, anxiety, fear, anger, and agitation. Additionally, allow time for expression of feelings and provide empathy, encouragement, and reassurance. The social services note dated 4/12/21 at 12:51 PM identified that on 4/11/21 she met with Resident #23 in efforts to provide emotional support and assess resident's mood and behavior status post reported event related to his/her interaction with roommate. Mood and behavior remain stable, and Resident #23 had no recollection of reported incident. The psychiatric evaluation note dated 4/12/21 at 9:10 PM noted Resident #23 did not recall incident. Resident #23 was not a danger to him/herself or others. Interview with Resident #23 on 10/5/21 at 11:00 AM noted he/she didn't recall any problems or concerns with any roommates. A statement, written by LPN #4, dated 4/9/21 indicated on 4/4/21, NA #4 notified her that she overheard Resident #30 tell Resident #23 that if he/she didn't shut up he/she would tie the curtain around his/her neck. LPN #4 stated she went into the room and spoke to Resident #23 and indicated that he/she should not use that type of language and behavior in the facility. LPN #4 identified that since the incident, the roommates have seemed to get along great with no complaints or occurrences. An in-service regarding the reporting process for resident-to-resident altercations dated 4/9/21 at 7:30 PM identified to immediately separate the residents, immediately place the aggressor on 1:1 monitoring, immediately notify the supervisor who will notify the DNS or designee for review of situation and further instructions. The nurse's note dated 4/9/21 at 8:42 PM identified Resident #30 was moved from the room and temporarily placed in another room until further notice due to incident that occurred on 4/3/21. The psychiatric evaluation dated 4/9/21 identified Resident #30 made some threatening remarks to another resident. This was processed with the resident. Resident #30 had no intent or plan to harm anyone. Reviewed coping skills and mechanisms to help manage frustration tolerance in support of therapy. Resident #30 does not require a one to one at this time and was not a danger to self or others. The nurse's note dated 4/11/21 at 8:59 PM noted on 4/9/21 at 9:00 PM the physician was notified of reported event related to interaction of resident with his/her roommate with no new orders given at this time. The social services progress note dated 4/12/21 at 12:01 PM identified noted she met with Resident #30 on 4/5/21 in an effort to provide emotional support and assess mood and behavior status post reported event related to interaction with his/her roommate. Resident #30 verbalized he/she was not serious and doesn't understand what the bid deal was. Social worker provided education on why Resident #30 was transferred to a different room. The Psychiatric APRN progress note dated 4/12/21 at 9:10 PM noted saw Resident #30 because she/he made threatening comments to roommate. Resident #30 reported she/he was just kidding and would not do this to his/her roommate. The Educational Intervention Form dated 4/12/21 indicated LPN #4 was educated because Resident #30's nursing note entry on 4/3/21 highlighted a resident to resident altercation. LPN #4 noted she had notified the supervisor and social worker of the event by her. The DNS educated LPN #4 that reporting events related to resident to resident must be very clear to state exactly what was stated and nursing supervisor and or social worker will determine the severity of event and how event needs to be handled. An interview with Resident #30 on 10/4/21 at 11:23 AM noted he/she did have one issue a while back with his/her old roommate. Resident #30 indicated he/she was joking with his/her roommate and told the roommate he/she would take the curtain and wrap it around his/her neck and a nursing assistant overhead it and reported him/her. Resident #30 indicated that was why she/he was now in a private room. An interview with the DNS on 10/07/21 at 10:34 AM the DNS indicated she was not here at the time but after review of the clinical record the nursing assistant should have report the altercation to the charge nurse who would have reported it to the supervisor immediately. The DNS noted the supervisor should investigate and inform the DNS. The DNS review of the clinical record and the reportable event form noted the supervisor should have separated the 2 residents immediately on 4/3/21. The DNS indicated the LPN should have notified the supervisor immediately. The supervisor should have notified the responsible party and the physician immediately. The DNS and/or the administrator were responsible the notify DPH within 2 hours of the incident occurring on 4/3/21. The DNS noted the incident occurred on 4/3/21 and the 1:1 did not start until 4/9/21 and the resident was seen by psychiatric services on 4/9/21. The DNS indicated that psychiatric services should have been called immediately on 4/3/21 and if they were not available then staff should have placed Resident #30 on a 1:1 on 4/3/21 or send the resident to the emergency room and when the resident returned from the emergency room been placed in a different room. The DNS noted Resident #30 should have had a room change on 4/3/21 but it did not occur until 4/9/21. Interview on 10/8/21 at 3:33 PM with RN #4 indicated she was not informed by the LPN when she worked on 4/3/21 the day shift that a resident had threatened another resident. RN #4 indicated she was not aware when the incident had occurred on 4/3/21. RN #4 indicated she learned of the resident-to-resident altercation when the DNS called her and asked her for a statement. An interview with NA #4 on 10/8/21 at 4:03 PM indicted on 4/3/21during breakfast the housekeeper called her to Resident #23 and Resident #30's room stating Resident #30 was threatening Resident #23. NA #4 noted as she was heading to the room, she could hear Resident #30 being loud and nasty. NA #4 indicated she did not think Resident #30 was joking because the tone of voice and the resident was not smiling but appeared serious. NA #4 noted she was concerned. Resident #30 mentioned wrapping the curtain around the roommates' neck, so NA #4 stayed there to make sure Resident #30 did not do it. NA #4 noted Resident #30 was up in the wheelchair at the time and was able to transfer and stand independent with transfers. NA #4 noted Resident #30 was able to self-propel in the room and hallway. NA #4 indicated LPN # 4 came right down to the room and calmed Resident #30. Additionally, NA #4 noted Resident #23 was in bed and needs assistance to get out of bed. NA #4 did not think Resident #23 understood what was happening. NA #4 told LPN #4 to call the supervisor and make sure RN #4 was aware of what happened. An interview with Housekeeper #1 on 10/8/21 at 4:22 PM identified on 4/3/21 during breakfast she was in the room cleaning and both residents were arguing, and Resident #30 said she would take the curtain and put it around Resident #23's head. Resident #23 and Resident #30 were yelling at each other and then started to talk to each other. Resident #30 was in the wheelchair by the window and Resident 23 was in bed. Resident #23 yelled back at Resident #30 but did not recall what was said. Housekeeper #1 called for NA #4 in the hallway for help. Housekeeper #1 indicated she heard NA #4 report incident to LPN #4. Housekeeper #1 noted she then left the room. Although attempted, an interview with LPN #4 was not obtained. Interview with DNS on 10/7/21 at 10:34 AM the DNS was not notified of the incident until 4/9/21 at 8:30 PM and that's when the investigation started. Review of facility Abuse Prohibition Policy identified the facility prohibits abuse, mistreatment, neglect, and exploitation. This includes but is not limited to any physical or chemical restraints. The purpose is to ensure the facility staff are doing all that was within their control to prevent occurrences of abuse, mistreatment, and neglect for all residents. Training and reporting obligations will be provided to all employees. Staff will identify resident to resident abuse. Any staff who witness an incident of suspected abuse, neglect was to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. All reports of suspected abuse must be reported to the resident's family and physician. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report allegations involving abuse (verbal, physical, sexual or mental) not later than 2 hours after the allegation was made.

**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 #499) reviewed for falls, the facility failed to develop a comprehensive care plan for a resident at risk for falls, who later sustained a fall. Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. A fall assessment dated [DATE] identified Resident #499 was at risk for falls. The MDS dated [DATE] identified Resident #499 had moderately impaired cognition and a history off falling prior to admission. The care plan dated 9/20/21 identified Resident #499 required assistance with ADL care with interventions that included extensive assistance for bed mobility, transfers and toileting. A reportable event form dated 9/27/21 at 10:00AM identified Resident #499 was found on the floor by his/her roommates family member. Resident #499 stated he/she was trying to fix something on the bed when he/she fell out. Vital signs were stable, ROM was at baseline, strength of extremities at baseline and resident was neurologically at baseline. Resident #499 was transferred to a chair from the floor using a Hoyer lift where it was observed he/she sustained a small cut to the right knee that measured 1.0cm x 2.0cm. The APRN and family were notified, and an investigation was completed. The care plan was revised to include Resident #499 identified at risk for falls secondary to impaired mobility with interventions that included placing call light within reach and place all necessary items with reach. A review of the care plan prior to the fall on 9/27/21 failed to reflect interventions to address Resident #499's risk for falls. An interview with the DNS on 10/7/21 at 3:12 PM identified she was made aware there was no fall care plan in place after noting the revision after the fall. The Falls Management policy directs that patients will be assed for fall risk as part of the nursing process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Although a request was made for policies related to the development of a care plan, none was provided. The facility failed to develop a comprehensive care plan for a resident at risk for falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #17 and 26) reviewed for person centered care planning and timing, the facility failed to ensure there were interdisciplinary care plan meetings held timely. The findings include: 1. Resident #17 was admitted to the facility in April 2021 with diagnoses that included cerebral infarction and memory deficit following the cerebral infarction. A Social Services Assessment and Documentation dated 5/5/21 was blank and not signed by a Social Worker. The admission MDS dated [DATE] identified Resident #17 had severely impaired cognition and required extensive assistance of 1 person for hygiene, dressing, toileting, and bed mobility. The care plan dated 8/18/21 identified Resident #17 had a court appointed conservator. Interventions included to involve the conservator in care planning. A Social Services Assessment and Documentation effective date of 8/5/21 indicated Resident #17 had a legal conservator. Each section of the Assessment was dated 9/14/21 as completed. An interview with the Corporate RN #5 and DNS present on 10/8/21 at 1:45 PM indicated Resident #17 did not have any documentation of an interdisciplinary team meeting from admission on [DATE] until today 10/8/21. The Corporate RN indicated they do not have sign in sheets for the meeting that the Social Worker puts in a note listing who had attended the IDT care plan meetings. Corporate RN #5 indicated she was aware that the facility was behind having the IDT care plan meetings for residents and they hired a new social worker who started 2 days ago. An interview and clinical record review with the MDS Coordinator, RN #7 on 10/8/21 at 2:33 indicated she did not know why Resident #17 had not had an initial or quarterly IDT care plan meeting sine admission in April 2021, because it was required, and Social Services was in charge of arranging those meetings. RN #7 indicated she makes the schedules based on the MDS and gives the calendar to social services and the social worker gave it to the front receptionist who mails out the invitation letters. Review of Person-Centered Care Plan indicated the facility must develop and implement a baseline person centered care plan within 48 hours for each resident. The Person-Centered care means to focus on the resident as the locus of control and support the resident in making his/her own choices and having control over his/her daily life. The resident had the right to participate in development and implementation of the person-centered care plan. A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each resident. The care plan will be prepared by the interdisciplinary team that includes the physician, a registered nurse, a nurse's aide, dietary, and the participation of the resident and the resident ' s representative. An explanation must be included in the resident ' s medical record if the participation of the resident and resident representative was determined not practicable for the development of the care plan. The interdisciplinary team in conjunction with the resident and/or representative will establish the expected goals and outcomes, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. And be documented. The post admission patient/family conference will be held with the resident/family, and care team. For short stay residents, the conference will be held within 72-hour after admission. The Conference will be documented on the Post admission Resident/Family Conference UDA. Care Plan meetings the facility had the responsibility to assist residents /family to participate by extending invitations to the resident and residents representative sent in advance, holding care plan meetings at the time of day when the resident functions best, facilitating the inclusion of the resident and resident representative to attend. Care Plan meetings will be by use of the Care Plan Meeting note. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses that included delusional disorder, communication deficit and Alzheimer's disease. A Durable Statutory Power of Attorney (POA) form dated 4/15/20 identified Person #6 as appointed POA. The Care Plan dated 5/24/21 identified the resident had impaired cognition related to dementia with the goal to make simple decisions by responding yes or no on most days. Interventions included to use short phrases that required a yes or no answer, stressed key words and presented one thought, question or command at a time. Post admission Patient-Family Conference form dated 5/24/21 identified the resident's baseline care plan and further patient and family expectation were reviewed. The attendees included the resident, family, nurse, rehab, and CNA. The MDS dated [DATE] identified the resident had a diagnosis of Alzheimer's disease, anxiety and psychotic disorder. It further identified that the resident would usually understand others but missed some part and or intent of the message. Nursing progress notes dated 9/23/21 identified the resident's care plan was reviewed, was still appropriate, and continued with plan of care. Interview with resident's POA, Person #6, on 10/7/21 at 10:15 AM identified he/she was present for the post admission care plan conference held on 5/27/21 and had not been invited to any since. Interview and record review with the DNS on 10/7/21 at 2:45 PM identified the resident has only had one care plan conference held on 5/27/21. She further identified she went through and updated the resident's care plan to ensure it was up to date without holding a care plan conference. Interview and record review with the cooperate nurse, RN #5, on 10/8/21 at 10:30 AM identified the resident had one care plan conference held on 5/27/21 and has not had any since because the facility hired a new social worker and will be catching up on care plan conferences. She further identified the facility notifies residents/family members/POA of care plan conferences through a letter in the mail. Interview with the Administrator on 10/8/21 at 2:15 PM identified the previous social worker was employed until August 2021 and a social worker from another facility was helping out after the previous social worker left. The Administrator further identified the fill in social worker was responsible for completing quarterly and annual assessments. The administrator identified the social worker is responsible for organizing care plan conferences. Follow up interview with the DNS on 10/8/21 at 2:25 PM identified that the resident did not have a care plan conference when her care plan was updated because the social worker left the facility around the time the care plan was due, so it was not completed. Person Centered Care Plan policy identified care plans will be communicated to appropriate staff, patient, resident representatives, and family. It further identified care plans will be reviewed and revised by the interdisciplinary team after each assessment, including the quarterly review assessment, and as needed to reflect the response to care and changing needs and goals.

Based on clinical record review and staff interview for one of five sampled resident who utilized a CPAP respiratory device, the facility failed to identify when resident ' s CPAP device was discontinued by a physician and failed to ensure an assessment was conducted after the Continuous Positive Airway Pressure (CPAP) device was discontinued to meet professional standards of practice. The findings included: Resident # 49 ' s diagnoses included chronic diastolic heart failure, depression, obesity, spinal stenosis of the lumbar, respiratory failure and sleep apnea. A review of the facility Grievance/Concern Form dated 5/1/20 identified that the resident ' s family member expressed a concern about Resident # 49 complaining about not having his/her oxygen connected to the CPAP on couple of nights causing the resident to feel anxious the next morning. The resident ' s family member could not recall the specific dated the reported to incident to him/her. For action taken noted interview staff, check physician order and nurse ' s documentation of CPAP use and noted resolution date of 5/15/20. The Recommended Corrective Action noted staff will double check CPAP for oxygen connection nightly. The readmission 9/26/20 MDS assessment identified the resident ' s cognition was intact required extensive assistance with bed mobility, toileting and personal hygiene, and total care with transfers. Additionally, noted no CPAP. However, the nurse ' s notes 9/8/20, 9/9/20 and 9/10/20 identified Resident # 49 utilized a CPAP machine but nurse ' s notes from 9/11/20 through 12/17/20 failed to identify any utilization of CPAP and or why the resident no longer used the CPAP machine. A review of Medication Administration Record and Treatment Administration Record dated 9/2020, 10/2020, 11/2020 and 12/2020 failed to identify any utilization of a CPAP machine. A review of the clinical record on 10/5/21 failed to reflect why Resident# 49 ' s CPAP machine was discontinued, a physician ' s order for discontinuing the CPAP, an assessment of the respiratory status after discontinuing the device and what happened to the resident ' s CPAP machine from 5/1/2020. Interview with the DNS on 10/5/21 at 5:00 P.M. identified she was new to her DNS role and could not identify why the resident no longer used the CPAP machine and what happened to the resident ' s CPAP machine from 5/1/2020 and could not provide a respiratory assessment after the CPAP machine was discontinued and a physician ' s order for the discontinuing of the CPAP. Interview with the RN # 15 on 11/3/21 at 2:20 P.M. identified she could not recall why she documented the resident had a CPAP machine in the nurse ' s notes dated 9/8, 9, and 10/ 2020. RN #15 also indicated she did recall the resident had CPAP machine and expressed concerns about CPAP machine causing eye irritation and she reported the incident to the unit manager but does not recall which date of the incident. RN # 15 indicated she believed the unit manager was going to follow up with the son but did not get back her about why the CPAP machine was removed. In accordance with the Clinical Guidelines for Nursing for CPAP a physician ' s order is required for the initiation, to alter the amount of CPAP and to discontinue the CPAP.

**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 Resident (Resident #17) reviewed for Code Status, the facility failed to ensure the code status were the wishes of the resident or resident representative. The findings include: Resident #17 was admitted to the facility in [DATE] with diagnoses that included cerebral infarction, memory deficit following the cerebral infarction, and congestive heart failure. The Hospital Discharge summary dated [DATE] indicated Resident #17 had orders, in the event of cardiopulmonary arrest, to not be resuscitated, (Do Not Resuscitate, DNR) at the hospital. Additionally, while at the hospital, a conservator/lawyer was assigned to Resident #17. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, DNR. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, the residents status was to be resuscitated, do CPR, (Full code). Both orders were active. The admission MDS dated [DATE] identified Resident #17 had severely impaired cognition. and required extensive assistance of 1 person for hygiene, dressing, toileting, and bed mobility. The Resident/Patient Health Care Instructions from Admission, undated, identified that residents representative was called multiple times and messages were left with no response. The form remained unsigned by whomever wrote the note on the form. A physician progress note dated [DATE], [DATE], and [DATE] indicated there was no code status on file. A Social Services Assessment and Documentation dated [DATE] indicated Resident #17 had a legal conservator, and the health care form had not yet been completed. Resident #17 will be a full code until completed. The care plan dated [DATE] identified an established advanced directive as Do Not Resuscitate. Interventions included the residents wishes as expressed in the advance directive will be followed, promote opportunities for Resident/Patient/Health Care Decision Maker to participate in decisions regarding care. Interview with LPN #1 on [DATE] at 9:15 AM indicted in the event of cardiopulmonary arrest, she would look in the electronic medical record for the code status before heading to Resident #17. LPN #1 indicated in the electronic medical record under physicians' orders there was an order for a DNR, written on [DATE], and another order for a full code (CPR) on [DATE]. LPN #1 indicated she would go with the newest order even though both orders were in place. LPN #1 indicated she would not go to the chart and look at the Advanced Directive form because she would just want to get to Resident # 17. Interview and clinical record review with the DNS on [DATE] at 9:40 AM identified on admission the supervisor or charge nurse and if resident is unable to make decisions the nurse will call the family/representative/conservator and use the code status from the hospital. The DNS expectation would be to get the advance directive within 24 hours and at the latest would be 3-4 days if a resident came in on a Friday. The DNS indicated if the nurses were not able to get ahold of the conservator for the code status withing 3-4 days they should have sent a certified letter. The DNS noted on the advance directive form she would have expected whoever wrote the note on the form to date it and sign their name. Review of clinical record with DNS from [DATE] - [DATE] indicated there was not a nursing or social service progress note indicating someone reached out to the conservator regarding the wishes of the code status. The DNS indicated Resident #17 had 2 physician orders in place for a code status one as a do not resuscitate (DNR) and one for Resident #17 to be resituate (CPR). The DNS indicated from reviewing of the clinical record it looks like the hospital sent Resident #17 as a do not resuscitate (DNR) and then because they did not reach the conservator the physician changed Resident #17 to a full code (CPR) and then did not follow up on the code status. The DNS stated she would expect the nurse on the unit to follow the newest order for code status which was the full code (CPR). The nurse's note dated [DATE] at 10:51 AM identified a phone call was placed to the conservator regarding Resident #17's code status. Resident #17 was a DNR in the hospital prior to admission at the facility in [DATE]. Resident #17 was still a DNR until [DATE] when he/she was changed to full code status since we did not have a signed code status form. Today a phone call was placed and emailed the conservator to validate resident code status. APRN updated. Will follow up again [DATE] if no response today with a certified letter and social services was made aware. An interview on [DATE] at 8:35 AM indicated the conservator left the DNS a voice message the evening of [DATE] indicating Resident #17 wishes were to be a Do Not Resuscitate (DNR). The DNS indicated 2 nurses could call the conservator and sign as witnesses that those were the wishes of the resident and conservator. The Resident/Patient Health Care Instructions dated [DATE] identified Resident #17''s conservators wishes were for Resident #17 to be a DNR, the form was signed as a verbal order by 2 Registered Nurses. A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, Resident #17 will be DNR. Review of the Code Status Orders Policy identified code status communicates to the clinical staff whether the resident desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The Resident identification mechanism and information about the residents' code status either a full code (CPR) or a do not resuscitate (DNR) will be easily accessible to the clinical staff for all residents. The Purpose was to ensure the residents desired resuscitation wishes are documented in the medical record. Upon admission and re-admission, a code status order was required as soon as possible as part of the resident's admission order set. The orders for code status include full code OR DNR. Staff should verify the residents wishes about code status upon admission. At minimum a verbal code status by a patient representative must be witnessed by 2 staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 21) reviewed for unnecessary medications, the facility failed to respond to a pharmacy recommendation. Resident #21 was admitted on [DATE] with diagnoses that included Alzheimer's disease, anxiety and insomnia. The initial 48-hour care plan resident care plan dated 8/11/21 identified impaired/decline in cognitive function Alzheimer's disease with interventions that included observe and evaluate types of changes in cognitive status such as confusion, orientation, forgetfulness, and notify physician as needed. Physician's order dated 8/11/21 directed to administer trazadone 25mg every 8 hours as needed for agitation without a 14-day documented expiration date. The admission MDS dated [DATE] identified Resident #21 required limited assist with personal care and received medications that included antidepressants. Interview on 10/7/21 at 11:54 AM with DNS identified pharmacy recommendations should be responded to and that the APRN usually does. Interview on 10/8/21 at 11:35 AM Pharmacy Consultant #1 identified a recommendation was made on 8/27/21 to provide a stop date for the PRN Trazadone. Although a policy for responding to pharmacy recommendations was requested, none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #21) reviewed for unnecessary medications, the facility failed to ensure an initial PRN (as needed) order for a psychotropic medication was limited to 14 days according to policy. The findings include: Resident #21 was admitted on [DATE] with diagnoses that included Alzheimer's disease, anxiety and insomnia. The initial 48-hour care plan dated 8/11/21 identified decline in cognitive function Alzheimer's disease with interventions that included observe and evaluate types of changes in cognitive status such as confusion, orientation, forgetfulness, and notify physician as needed. Physician's order dated 8/11/21 directed to administer Trazadone 25mg every 8 hours PRN for agitation. The admission MDS dated [DATE] identified Resident #21 required limited assistance with personal care and received medications that included antidepressants. An interview on 10/7/21 at 11:54 AM with DNS identified initially prescribed PRN psychotropic medications require a 14-day expiration and that it should have been done. The facility psychotropic medication use policy directed PRN orders for psychotropic medications are to be limited to 14 days. If the prescribing practitioner believes it is appropriate for the PRN orders to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order. The facility failed to ensure an initial PRN order for a psychotropic medication was limited to 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and staff interviews for 1 of 3 residents (Resident #50), reviewed for abuse, the facility failed to ensure that all staff received re-education regarding customer service after an allegation of rough handling to prevent potential future abuse. The findings included: Resident #50's diagnoses included a history of a stroke. The quarterly MDS dated [DATE] identified Resident 50 had moderately impaired cognition, required total assistance with transfers and locomotion and extensive assistance with toileting, dressing and personal hygiene. The care plan dated 1/22/20 identified to encourage Resident #50 to take meals in dining room on non - specialized treatment days, provide extensive assistance of one person for bed mobility, provide total assist of one with eating and to provide two people to transfer using a mechanical lift. A reportable event form dated 2/17/20 identified Resident #50's family member informed administration of an allegation of abuse that took place on 2/16/20. The report noted Resident #50 telephoned his/her family member on Sunday (2/16/20) and alleged that two nurse aides placed something hard inside her/his private area. Resident #50 was able to give the name of the two NA's who were immediately suspended pending investigation. The resident indicated in a statement the NA's were faster than normal with care and did not explain the process. Although, the facility investigation was unable to substantiate the allegation of abuse. The corrective action plan to prevent reoccurrence noted NA's were provided with education relevant to care plan review, to refer to psychiatry service and notified social service to provide support. A review of the facility In-Serviced Sign - In Sheet dated 2/20/20 for Customer Service includes explaining care and providing care at a comfortable pace after the allegation on 2/16/20. The In-Service Sign - In sheet identified only one of the nurse aides had received the training. Interview with the DNS on 10/5/21 at 5:30 PM identified she could not provide evidence of the other NAs training regarding Customer Service on 2/20//21 after Resident # 50's allegation of rough handling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, CDC guidance and interviews for 2 residents (Resident #24 and 499) reviewed for skin conditions, the facility failed to ensure that the registered nurse assessed a new rash and/or skin condition on admission and when it deteriorated, documented the assessments and communicated those assessment timely to the physician. The findings include: 1 . Resident #24 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease requiring dialysis 3 times a week, diabetes, and heart failure. The annual MDS dated [DATE] identified Resident #24 had intact cognition and needed limited assistance with dressing. The care plan dated 9/24/21 indicated Resident #24 had decrease ability to perform ADL's. Interventions included to provide assistance of 1 with rolling walker for ambulation and assistance of 1 with a slide board transfer from bed to wheelchair. An SBAR Communication Form dated 10/3/21 at 12:00 AM completed by LPN #2 noted Resident #24 had a new painful rash. The nursing documentation dated 10/4/21 at 7:00 AM completed by LPN #2 noted a deep red rash to the mid upper chest, posterior neck, and scalp. Resident #24 continues to complain of pain to rash on neck and mid chest. APRN to follow up in morning. Observations and interview on 10/4/21 from 10:00 AM - 10:30 AM identified Resident #24 had indicated he/she was waiting for the APRN to come into the facility and see him/her. Resident #24 noted he/she did not go to the scheduled medical procedure today because she/he did not feel well and was having some pain and itchiness where she/he had rash areas. Interview and clinical record review with the DNS on 10/4/21 at 2:13 PM indicated if Resident #24 had a new rash that was painful, as soon as it was identified the LPN should have had the RN do an assessment at that time and notify the APRN at that time. The DNS indicated the RN should have placed Resident #24 on precautions if the nurse suspected shingles was the cause of the rash, until the resident was seen by the APRN and the APRN could determine if it was shingles or not. The DNS noted if RN #1 suspected it was shingles, she should have immediately placed Resident #24 on isolation. After review of the medical record, the DNS indicated the APRN was not notified of Resident #24's rash on 10/2/21 or 10/3/21. An interview with RN #1 on 10/4/21 at 2:23 PM indicated she was not aware that Resident #24 had a rash when she had received report from the prior shift supervisor RN #6 who did a double and worked 7:00 AM - 11:00 PM on 10/2/21. RN #1 indicted the charge nurse had asked her to come to the second floor and look at the rash on Resident #24 on Sunday 10/3/21 at 3:30 AM but she did not document on the rash because she was the nurse on the first floor and supervisor. RN #1 indicated she forgot to write the note and she did not call the APRN/MD at that time. RN #1 indicated she returned to first floor to give a resident a pain medication. RN #1 indicated she thought the vesicles looked like shingles but she was not a doctor so she could not diagnosis and she did not place the resident on precautions. RN #1 indicated that there was a patch of small pustules on the center of Resident #24's chest, a patch of pustules on the posterior neck area, and posterior scalp in the hairline. RN #1 noted the areas appeared that the pustules were being scratched and were in a linear line on his/her chest. RN #1 noted the resident indicated the rash was there for about a week. RN #1 noted she told the day supervisor RN #6 to have the weekend APRN look at the rash Sunday 10/3/21. RN #1 indicated when she came in on Sunday 10/3/21 at 11:00 PM going into Monday 10/4/21 the rash was still there, and staff hadn't addressed it during the day of 10/3/21 so she made sure and put it in the APRN book. RN #1 indicated when APRN #1 came in the facility today Monday 10/4/21 she updated the APRN #1 and asked her to see Resident #24 as the first resident. RN #1 noted APRN #1 went to assess Resident #24 and when APRN #1 came out of Resident #24's room she informed RN #1 resident had shingles and place Resident #24 on isolation. An interview with the DNS on 10/4/21 at 2:30 PM indicated that she was notified right after the APRN saw Resident #24 and the DNS notified the Infection Control Nurse who was instructed to place the resident on isolation and bring the cart and sign to be posted. The DNS indicated she will start education with the nurses today indicating if the nurse assesses a resident who has a rash and is suspected to be shingles the resident should be place on precautions right away until seen by the APRN/MD. The DNS instructed that RN #1 to do a late entry for the evaluation she did on 10/3/21 at 3:30 AM. An interview with RN #1 and DNS present on 10/4/21 at 3:27 PM RN #1 indicated she forgot to write a note after she saw Resident #24's rash because she went back to first floor as the charge nurse to give a pain medication and then forgot about writing a note or notifying the APRN. RN #1 indicated her assessment on 10/3/21 at 3:30 AM indicated she had seen a patch of small vesicles on the center of Resident #24's chest, a patch of vesicles on the posterior neck area, and one patch on the posterior scalp. RN #1 indicated the areas appeared that the pustules were being scratched and moist. RN #1 indicated Resident #24 noted the rash had been there for about a week. RN #1 indicated the patch on the posterior scalp Resident #24 indicated he/she had put hair grease on the vesicles, so RN #1 noted she was not able to see if the vesicles were draining due to the grease. Interview with APRN #1 on 10/4/21 at 3:40 PM indicated she was first notified about the rash today on 10/4/21 at approximately 10:45 AM when she came into the facility and looked at her communication book on second floor and it was written to see Resident #24 first due to rash. APRN #1 indicated she interviewed Resident #24 and indicated the rash started a week ago with the small vesicles behind the neck and posteriorly neck and posterior left ear on the scalp. APRN #1 indicated there was a rash posteriorly at the scalp line that had vesicles that are starting to crust over, a patch of vesicles on the posterior neck, and anteriorly on the chest. The APRN #1 indicated the vesicles are in different stages from staring to crust over to new ones. APRN #1 indicated there was a new patch of vesicles starting today over the left eye. APRN #1 indicated as soon as the LPN was aware of the rash, he/she should have had the Registered Nurse do an assessment and notify the APRN right away. APRN #1 indicated when staff first noticed the rash, they should have called the APRN on call and used the IPAD so the on-call APRN could see the rash and diagnosis it as shingles right away and placed resident on precautions and medication. APRN #1 indicated Resident #24 should have been placed right away on airborne and contact precautions. Furthermore, staff should have made sure if staff had not had chicken pox or were pregnant absolutely should not have gone into Resident #24's room since RN #1 assessment and if she suspected it was shingles. APRN #1 indicated if the weekend APRN was aware he/she would have seen the rash he/she would have written a progress note and there was not one present. Additionally, APRN #1 indicated the medial appointment provider should have been notified right away. An APRN order dated 10/4/21 directed to place Resident #24 on contact precautions and administer Valacyclovir (antiviral medication) HCL 500 mg give 1 tablet daily every other day for shingles until 10/16/21. An interview with the Infection Control Nurse on 10/5/21 at 10:30 AM indicated as soon as she was notified that Resident #24 had the shingles, she brought the isolation cart and sign to Resident #24's room before lunch. Interview with RN #1 on 10/6/21 at 10:00 AM indicated when she came to work on Saturday at 11:00 PM during shift to shift report she was not told that Resident #24 had any rash or if that any APRM/MD was notified. RN #1 indicated she did not know about the rash until 10/3/21 at 3:30 AM and the APRN was not informed until 10/4/21 when the APRN came into the facility. RN #1 indicated a nursing assistant had come to her and indicated she/he worked with Resident #24 the night shift of 10/3/21 and had never had chicken pox or the vaccine so RN #1 indicated she told the nursing assistant do not go into Resident #24's room tonight and not to worry about it. Interview with APRN #2 on 10/6/21 at 11:13 AM indicated when she came to the facility on Saturday 10/2/21 around 2:00 PM the supervisor told her Resident #24 had a minor rash and if she had a chance to look at it. APRN #2 indicated she was informed it was a minor rash and she did not have time to see Resident #24. APRN #2 indicated she was not informed the rash may be shingles because she would have looked at the rash, she was just informed it was a minor rash, so it was not a priority. Review of Nursing Documentation Policy identified nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the residents' condition, situation, and complexity. Clinical judgement is used to determine the need for additional data collection. Practice standards were to have timely entry of documentation must occur as soon as possible after provision of care and in conformance with time frames for completion as outlined by other policies and procedures. The facility failed to conduct a thorough assessment, including documentation, and to notify the physician/APRN when Resident #24 was identified with a painful rash that was later diagnosed as shingles. This failure led to a delay in treatment of the rash with the antiviral medication valacyclovir. According to the CDC, several antiviral medicines-acyclovir, valacyclovir, and famciclovir-are available to treat shingles and shorten the length and severity of the illness. These medicines are most effective if you start taking them as soon as possible after the rash appears. If you think you have shingles, contact your healthcare provider as soon as possible to discuss treatment. 2. Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. Physician's orders dated 7/31/21 directed a 2GM sodium regular diet and house supplements 120cc twice daily. The Braden Scale dated 7/31/21 identified Resident #499 was at moderate risk for the development of a pressure ulcer. A skin check dated 7/31/21 identified Resident #499 did not have skin injuries to the left and right shin and no injuries consistent with a vascular wound. An APRN progress note dated 7/31/21 noted skin redness on the upper back and buttocks with a protective dressing applied. Multiple bruises on the upper arms, open area on the right heel, skin healthy with no signs or symptoms of infection. The initial care plan dated 8/1/21 identified Resident #499 was at risk for skin breakdown with interventions that included weekly wound assessment to include measurements and description of wound status, supplements as ordered, weekly skin checks, wound treatments as ordered, OT/ PT to improve function, provide dietician services as needed, offload while in bed, observe skin condition daily with ADL care and report abnormalities and apply barrier cream with each cleansing. The MDS dated [DATE] identified Resident #499 had moderately impaired cognition, required assistance with care, had 2 or more stage I unhealed pressure ulcers and no venous or arterial wounds. A nutritional assessment dated [DATE] noted intake was excellent, able to meet needs. Receiving house supplement shakes twice daily, remains appropriate. No skin concerns noted. Recommendations included monitoring intakes, weights, supplement tolerance, consult as needed and liberalizing diet to regular. The care plan dated 8/10/21 noted Resident #499 was at nutritional risk related to severe protein calorie nutrition. Interventions included to provide diet and supplements as ordered, monitor for changes in nutritional status and monitor meal intake, notify the physician dietician of significant loss or gain. A nurse's note dated 8/16/21 at 9:44 AM identified Resident #499 had a skin tear on the right calf noted on admission. The area had slough and serous drainage. Subsequent nurse's notes at 8:17AM and 11:33AM identified the resident had a skin tear on the right calf which had been noted on admission, that now had slough and serous drainage. The skin tear was again mentioned in a nurse's note on 8/18/21 at 10:35 AM. The notes failed to document action taken. Review of the August 2021 TAR 8/1/21 - 8/23/21 failed to reflect a treatment to the right or left calf skin tears. A nurse's note dated 8/23/21 at 11:57 PM identified deep tissue injuries to both calves and Xerofom and a dry sterile dressing was applied. A nurse's note dated 8/24/21 identified Resident #499 was seen by the wound consultant that morning, however, a wound consultation note could not be found. Review of nurse's notes, medical progress notes and skin check assessments dated 7/31/21 through 8/31/21 failed to reflect a documented complete assessment of the skin tears to the left or right calf. A wound consultation dated 8/31/21 identified Resident #499 received an initial evaluation for skin conditions which included an arterial wound to the right calf that measured 7.0cm x 2.0cm x 0.5cm, present for greater than 14 days. A left calf arterial wound present for greater than three days that measured 10cm x 3.0cm x 0.5cm. Recommendations included to treat with calcium alginate/silver dressing every three days for 30 days. A nutritional assessment dated [DATE] noted Resident #499 had multiple skin issues that included arterial wounds to the left and right calves requiring increased nutritional needs for wound healing. Recommendations included increase the order for house supplement to three times daily, honoring preferences and monitoring intakes, weights, supplement tolerance, and consult as needed. Interview on 10/7/21 at 11:15 AM with RD #1 identified she has 14 days to conduct a nutritional assessment for a newly admitted resident, although she tries to see earlier if there was a need. Information related to skin integrity issues becomes known to her through review of skin check reports, skin rounds and nursing staff report. She also used to receive wound reports weekly through the email system, however the staff member who sent the reports no longer worked at the facility, so the reports were no longer received. RD #1 indicated wound issues were also discussed in Risk meetings but those meeting were not held consistently. Although skin injuries were noted on the Skin Check assessment dated [DATE], RD #1 stated she was not aware and did not see the report. RD #1 indicated had she been aware at an earlier time, she would have increase supplements at that time when resident #499's intake was better. Interview on 10/7/21 at 11:35 AM with the DNS identified the interdisciplinary team including the dietician becomes involved when managing a resident with a wound. RD #1 should have referred to assess Resident #499 at an earlier time when changes in the wound were first identified. Interview on 10/8/21 at 1:01 PM with the Medical Director identified he was not notified of the residents open areas on the calves on admission or on 8/16/21 when they deteriorated. The Medical Director indicated any wound left untreated could lead to further decline, and because of Resident #499's health conditions, decline would likely occur more rapidly. The Medical Director indicated any change in condition should be reported for early treatment and identified the APRN (APRN #1) provided much of the care for the residents at the facility, but that she was in close contact with him regarding care. The Medical Director identified that had the skin conditions been reported to him or the APRN, there would have been a treatment plan put in place to address the concern. An interview on 10/8/21 at 12:00 PM with RN #5 identified treatment began on the vascular wounds on 8/25/21 when it was identified Resident #499's condition was deteriorating, so the facility consulted with the wound specialist. Nursing documentation began on 8/16/21 and appeared as though staff originally thought the area was a skin tear. Interview on 10/8/21 at 4:42 PM with LPN #11 indicated he was a former employee of the facility who worked as an LPN until 9/17/21. LPN #11 indicated he recalled Resident #499 had the skin tears on the back of his/her both calves on admission, but that they developed yellowing that was described as slough and drainage. LPN #11 stated he measured the wounds and although he may have forgotten to document, he notified the supervisor, physician and family but was unable to recall who. Interview on 10/9/21 at 12:52 PM with RN #6 identified he did not recall being notified of Resident #499's skin condition deterioration on 8/16/21. RN #6 indicated had he been notified; he would have completed a wound assessment with wound measurements and notify the physician. Although attempts were made, interviews with the former agency RN Supervisor, the DNS and APRN #1 were not obtained. Although a policy on change in condition was requested, it was not provided. Although Resident #499 was admitted on [DATE] with open areas to both calves (originally thought to be skin tears), the physician/APRN were not made aware of the areas. Subsequently, when the areas deteriorated on 8/16/21 and were noted with slough and serous drainage, again, the physician/APRN were not notified which led to a delay in treatment until 8/23/21 when Xeroform was applied and finally when the resident was seen by the wound physician on 8/31/21 who implemented calcium alginate/silver dressing every three days for 30 days. The Policy for Skin Integrity Management directs notification to dietician as indicated. Although a request for a Nutritional Assessment policy was requested, none was provided. The facility failed to comprehensively address the residents wounds on admission, including documentation, notification to the physician and nutritional intervention to promote healing and prevent decline.

**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 # 499) reviewed for pressure ulcers, the facility failed to complete weekly skin assessment with measurements for a resident with known pressure injuries in a timely manner and failed to ensure a nutritional assessment addressed the needs of a newly admitted resident with identified pressure injuries in a timely manner. The findings include: Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. The hospital Discharge summary dated [DATE] noted Resident #499 had stage I pressure injuries on the left heel measuring 1.2 x 1.5 x 0 cm, right heel measuring 1.2 x 1.4 x 0 cm, left ischial tuberosity measuring 2 x 2 x 4 cm right ischial tuberosity measuring 4 x 4 x 0 cm and coccyx measuring 1 x 1 x 0 cm with recommendations that included cleansing bilateral heels and coccyx with normal saline, apply a foam dressing with changes every three days. Braden Scale dated 7/31/21 identified Resident #499 was at moderate risk for the development of a pressure ulcer. Skin check dated 7/31/21 identified Resident #499 identified skin injuries to the bilateral heels and buttocks without any documented measurements. APRN progress note dated 7/31/21 noted redness to the upper back and buttock with a protective dressing applied and that the right heel was open, skin healthy with no signs and symptoms of infection. admission Nursing assessment dated [DATE] noted Resident #499 had skin injuries noted on the bilateral heels and bilateral buttocks without any documented measurements. a. The baseline care plan dated 8/1/21 identified Resident #499 was at risk for skin breakdown with interventions that included weekly wound assessment to include measurements and description of wound status, supplements as ordered, weekly skin checks wound treatments as ordered, OT/ PT to improve function, provide dietician services as needed, offload while in bed, observe skin condition daily with ADL care and report abnormalities and apply barrier cream with each cleansing. A physician's order dated 8/2/21 directed a dry protective dressing to the right heel. Physician's order dated 8/4/21 directed to apply skin prep to the right heel daily. The MDS dated [DATE] identified Resident #499 had moderately impaired cognition, required assistance with ADL skills and had 2 or more stage I unhealed pressure ulcers and no venous or arterial wounds. Nursing progress notes, medical progress notes, and assessments dated 7/31/21 through 8/31/21 did not identify initial and ongoing wound measurements for Resident #499. Additionally, there were no subsequent weekly skin checks completed until 9/28/21 which also did not include measurements with any identified skin pressure injuries. Wound Consult dated 8/31/21 identified Resident #499 received an initial evaluation for skin conditions which included a healing stage II pressure wound greater than 3 days, measuring 3 x 1.5cm x 0.2 cm. New treatment orders were placed for calcium alginate/silver every three days for 30 days. An interview with the DNS and RN #5 on 10/7/21 at 11:35 AM and 10/8/21 at 12:00 PM identified weekly wound tracking with measurements should have been completed for Resident #499 from the time the wounds were first identified according to policy. The policy for Skin Integrity Management dated 6/1/21 directs skin inspections to be performed on admission, re-admission and weekly. Wound observations and measurements are to be completed on a Skin Integrity Report upon initial identification of altered skin integrity, weekly and with any anticipated decline of the wound. The facility failed to complete weekly skin assessments with measurements for a resident with known pressure injuries in a timely manner. b. Physician's orders dated 7/31/21 directed a 2GM sodium regular diet and house supplements 120cc twice daily. Nutritional assessment dated [DATE] noted intake was excellent, able to meet needs. Receiving house supplement shakes twice daily, remains appropriate with no skin concerns noted. Recommendations included monitoring intakes, weights, supplement tolerance, consult as needed and liberalizing diet to regular. Resident Care Plan dated 8/10/21 noted Resident #499 was at nutritional risk related to severe protein calorie nutrition. Interventions included provide diet and supplements as ordered, monitor for changes in nutritional status and monitor meal intake, notify the physician dietician of significant loss or gain. Nutritional assessment dated [DATE] noted Resident #499 had multiple skin issues that included stage II pressure ulcer to the coccyx and unstageable pressure ulcers to the heels with increasing nutritional needs for wound healing. Recommendations included increase the order for house supplement to three times daily, honoring preferences and monitoring intakes, weights, supplement tolerance, and consult as needed. An interview on 10/7/21 at 11:15 AM with RD #1 identified she has 14 days to conduct a nutritional assessment for a newly admitted resident, although she tries to see earlier if there was a need. Information related to skin integrity issues become known to her through review of skin check reports, skin rounds and nursing staff report. She also used to receive wound reports weekly through the email system, however the staff member who sent the reports no longer worked at the facility, so the reports were no longer received. RD #1 indicated wound issues were also discussed in Risk meetings but those meeting were not held consistently. Although skin injuries were noted on the Skin Check assessment dated [DATE], RD #1 stated she was not aware and did not see the report. RD #1 indicated had she been aware at an earlier time, she would have increase supplements at that time when resident #499's intake was better. An interview on 10/7/21 at 11:35 AM with the DNS identified interdisciplinary team were to be involved when managing a resident with a wound. The dietician was expected to be involved in care right away when a wound was identified. Because all new admissions were discussed in report, RD #1 should have been referred to assess Resident #499 at an earlier time. The Policy for Skin Integrity Management dated 6/1/21 directs notification to dietician as indicated. Although a policy on Nutritional Assessments was requested, none was provided. The facility failed to ensure a nutritional assessment addressed the needs of a newly admitted resident with identified pressure injuries in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3 Resident #24 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease requiring dialysis 3 times a week, diabetes, and heart failure. The annual MDS dated [DATE] identified Resident #24 was cognitively intact and needed limited assistance with dressing. The care plan dated 9/24/21 indicated Resident #24 had decrease ability to perform ADL's. Interventions included to provide assist of 1 with rolling walker for ambulation and assist of 1 with a slide board transfer from bed to wheelchair. An SBAR Communication Form dated 10/3/21 at 12:00 AM completed by LPN #2 noted Resident #24 had a new painful rash. The nursing documentation dated 10/4/21 at 7:00 AM completed by LPN #2 noted a deep red rash to the resident's mid upper chest, posterior neck, and scalp. Resident #24 continues to complain of pain to rash on neck and mid chest. APRN to follow up in morning. Observations and interview with Resident #24 on 10/4/21 from 10:00 AM - 10:30 AM identified Resident #24 had indicated he/she was waiting for the APRN to come into the facility and see him/her. Resident #24 noted he/she did not go to dialysis today because he/she did not feel well and was having some pain and itchiness where he/she had rash areas. Interview and clinical record review with the DNS on 10/4/21 at 2:13 PM indicated if Resident #24 had a new rash that was painful as soon as it was identified, the LPN should have had the RN do an assessment at that time and notify the APRN at that time. The DNS indicated the RN should have placed Resident #24 on precautions if the nurse suspected shingles until the resident was seen by the APRN and the APRN could determine if it was shingles or not. The DNS noted if RN #1 suspected it was shingles, she should have immediately placed Resident #24 on isolation. The DNS reviewed the residents medical record and indicated the APRN was not notified between 10/3/21 at 12:00 AM until 10/4/21 per the progress notes. Interview with RN #1 on 10/4/21 at 2:23 PM indicated she was not aware that Resident #24 had a rash when she had received report from the prior shift supervisor, RN #6, who did a double and worked 7:00 AM -11:00 PM on 10/2/21. RN #1 indicted the charge nurse had asked her to come to the second floor and look at the rash on Resident #24 on Sunday 10/3/21 at 3:30 AM but she did not document on the rash because she was the nurse on the first floor and the supervisor. RN #1 indicated she forgot to write the note and she did not call the APRN or physician at that time because she returned to first floor to give a resident a pain medication. RN #1 indicated she thought the vesicles looked like shingles but she was not a doctor so she could not diagnosis and she did not place the resident on precautions. RN #1 indicated that there was a patch of small pustules on the center of Resident #24's chest, a patch of pustules on the posterior neck area, and posterior scalp in the hairline. RN #1 noted the areas appeared that the pustules were being scratched and were in a linear line on his/her chest. RN #1 noted the resident indicated the rash was there for about a week. RN #1 noted she told the day supervisor RN #6 to have the weekend APRN look at the rash on Sunday 10/3/21. RN #1 indicated when she came in on Sunday 10/3/21 at 11:00 PM going into Monday 10/4/21 the rash was still there, and they didn't do anything during the day of 10/3/21 so she made sure and put it in the APRN book. RN #1 indicated when APRN #1 came in the facility today Monday 10/4/21 she updated the APRN #1 and asked her to see Resident #24 as the first resident. RN #1 noted APRN #1 went to assess Resident #24 and when APRN #1 came out of Resident #24's room she informed RN #1 resident had shingles and place Resident #24 on isolation. An interview with the DNS on 10/4/21 at 2:30 PM indicated that she was notified right after the APRN saw Resident #24 and the DNS notified the Infection Control Nurse who was instructed to place the resident on isolation and bring the cart and sign to be posted. The DNS indicated she will start education with the nurses indicating if the nurse assesses a resident who has a rash and is suspected to be shingles the resident should be place on precautions right away until seen by the APRN/MD. The DNS instructed that RN #1 to do a late entry for the evaluation she did on 10/3/21 at 3:30 AM. Interview with RN #1 with the DNS present on 10/4/21 at 3:27 PM indicated RN #1 forgot to write a note on Resident #24 because she went back to first floor as the charge nurse to give a pain medication and then forgot about writing a note or notifying the APRN of the resident rash. RN #1 indicated her assessment on 10/3/21 at 3:30 AM she had seen a patch of small vesicles on the center of Resident #24's chest, a patch of vesicles on the posterior neck area, and one patch on the posterior scalp. RN #1 indicated the areas appeared that the pustules were being scratched and moist. RN #1 indicated Resident #24 noted the rash had been there for about a week. RN #1 indicated the patch on the posterior scalp Resident #24 indicated he/she had put hair grease on the vesicles, so RN #1 noted she was not able to see if the vesicles were draining due to the grease. An interview with NA #1 on 10/04/21 3:19 PM indicated she assisted Resident #24 out of bed into the wheelchair after she had put the booties on both feet for Resident #24 and brought Resident #24 to the bathroom for morning care and did not wear any person protective equipment because she was not aware at that time Resident #24 had shingles and needed to be on precautions. NA #1 indicated when Resident #24 was done in the bathroom she transferred resident from the toilet back to the wheelchair. NA #1 noted she had a total of 11 residents on her assignment to do morning care. NA #1 indicated she was informed Resident #24 was on going to be on precautions when the Infection Control Nurse brought the isolation cart and sign while she was passing lunch trays. Interview with APRN #1 on 10/4/21 at 3:40 PM indicated she was first notified about the rash today on 10/4/21 at approximately 10:45 AM when she came into the facility and looked at her communication book on second floor and it was written to see Resident #24 first due to rash. APRN #1 indicated she interviewed Resident #24 and indicated the rash started a week ago with the small vesicles behind the neck and posterior neck and posterior left ear on the scalp. APRN #1 indicated there was a rash posteriorly at the scalp line that had vesicles that are starting to crust over, a patch of vesicles on the posterior neck, and anteriorly on the chest. The APRN #1 indicated the vesicles are in different stages from staring to crust over to new ones. APRN #1 indicated there was a new patch of vesicles starting today over the left eye. APRN #1 indicated as soon as the LPN was aware of the rash, she should have had the Registered Nurse do an assessment and notify the APRN right away. APRN #1 indicated when staff first noticed the rash, they should have called the APRN on call and used the IPAD so the on-call APRN could see the rash and diagnosis it as shingles right away and place the resident on precautions and medication. APRN #1 indicated Resident #24 should have been placed right away on airborne and contact precautions. Furthermore, staff who have not had chicken pox or who are pregnant should absolutely not have gone into Resident #24's room since RN #1 assessed the resident and suspected it was shingles. APRN #1 indicated if the weekend APRN was aware she would have seen the rash and written a progress note if there was not one present. Additionally, APRN #1 indicated dialysis should have been notified right away. An APRN order dated 10/4/21 directed to place Resident #24 on contact precautions and administer Valacyclovir (antiviral) HCL 500 mg daily every other day for shingles until 10/16/21. The care plan dated 10/4/21 identified Resident #24 had shingles. Interventions included to follow physician orders for medications, resident placed on contact precautions. The APRN noted dated 10/4/21 indicated asked to see Resident #24 for a rash. Resident #24 indicated the rash started about a week ago and first lesion started over the weekend. Area to left scalp hairline may have some crusting and there were 4 - 5 lesions in various stages of development and a new area noted to the left forehead above the eyebrow. These lesions are painful per resident. All other lesions the vesicles were intact with no crusting yet. Two lesions are linear with several vesicles that were purple in color. All lesions were on the left side of the body. Resident #24 reports they were all painful and he/she was taking hydromorphone every 4 hours for the pain. Resident #24 had history of childhood varicella and had not been vaccinated against zoster. Resident complaints of open area on right buttock. Painful lesions 1. Left scalp at hairline 2. Posterior neck below hairline 3. Anterior neck upper chest 4. Behind left ear and scalp 5. Newest one no vesicle yet above left eyebrow. The APRN plan add diagnosis of herpes zoster, because lesions are still developing will treat with valacyclovir 500 mg every 48 hours x 7 days for renal dosing, contact and airborne precautions to be maintained until all lesions are crusted over, no contact with pregnant women, call dialysis to inform them of diagnosis of herpes zoster, and give Dilaudid 2 - 4 mg every 4 hours as needed for pain. An interview with RN #1 on 10/06/21 at 10:00 AM indicated she did not know about the rash until 10/3/21 at 3:30 AM and she did not notify the APRN until the morning of 10/4/21 when the APRN came into the facility. An interview with the Infection Control Nurse on 10/5/21 at 10:30 AM indicated as soon as she was notified that Resident #24 had the shingles, she brought the isolation cart and sign to Resident #24 ' s room before lunch. An interview with RN #1 on 10/06/21 at 10:00 AM indicated when she came to work on Saturday at 11:00 PM during shift to shift report she was not told that Resident #24 had any rash or if that any APRM/MD was notified. RN #1 indicated she did not know about the rash until 10/3/21 at 3:30 AM and her late entry progress note was not accurate, and she would correct the note because the APRN was not informed until 10/4/21 when the APRN came into the facility. RN #1 indicated a nursing assistant had come to her and indicated she/he worked with Resident #24 the 11-7 shift of 10/3/21 and had never had chicken pox or the vaccine so RN #1 indicated she told the nursing assistant do not go into Resident #24 ' s room tonight and not to worry about it. An interview with APRN #2 on 10/06/21 at 11:13 AM indicated when she came to the facility on Saturday 10/2/21 around 2:00 PM the supervisor told her Resident #24 had a minor rash and if she had a chance to look at it. APRN #2 indicated she was informed it was a minor rash and she did not have time to see Resident #24. APRN #2 indicated she was not informed the rash may be shingles because she would have looked at the rash, she was just informed it was a minor rash, so it was not a priority. Review of Shingles Zoster policy directed to implement transmission-based precautions according to residents immune status and extent of disease: disseminated infection or a localized disease in an immunocompromised resident until dissemination infection ruled out requires Airborne Infection Isolation Precautions and Contact Precautions. Limit contact to staff that are immune. Susceptible people are those who have never had chicken pox or vaccine will not enter the room. Review of the Airborne Infection Isolation identified it will be used to prevent transmission of infectious organisms that remain suspended in the air and travel great distances due to their small size or dust particles containing agent. Examples of these diseases include varicella (chicken pox), rubella (measles), and tuberculosis (TB). When entering a room wear proper PPE including an N95 mask prior to entering the room of a person requires Airborne Isolation Precautions. Susceptible persons should not enter the room of residents known or suspected to have chicken pox or disseminated zoster (varicella zoster virus) if other staff are available Additionally, immunocompromised and pregnant staff should also be restricted from these residents. 4. Interview and review of the covid screening log with RN #1 on 10/7/21 at 6:10 AM identified there were 3 out of 7 staff members in nursing that did not screen prior to starting work on 10/6/21 at 11:00 PM and RN #1 indicated that no one from the kitchen had screened/signed in this morning. RN #1 indicated it was the responsibility of the staff member to screen before every shift. Interview with NA #2 on 10/7/21 at 6:25 AM indicated she was rushing in and went straight to the time clock and forgot to go back to the front lobby and screen prior to starting her shift. NA #2 indicated she was educated in the past that she had to screen in every day. Interview with LPN #1 on 10/7/21 at 6:30 AM indicated she was running late and went straight past the front desk to the time clock. Additionally, she was working the night shift and would be staying for the day shift. LPN #1 indicated she knew she needs to be screened before every shift. Interview with LPN #2 on 10/7/21 at 6:35 AM indicated when she came in, she was talking with other staff members and got sidetracked and went straight upstairs to work. Interview with DA #1 on 10/7/21 at 6:40 AM in the kitchen he indicated he was just getting the bowls of cereal ready for breakfast. DA #1 indicated he waited at the front entrance and no one came to let him in, so he went around to the back door and put the code in and went straight to the kitchen. DA #1 indicated he did not screen prior to working because no one let him in the front entrance. DA #1 indicated he was aware he was supposed to be screen each day before work, but he did not do it today. Interview with the [NAME] #1 on 10/7/21 at 6:45 AM indicated she came in at 4:50 AM and when she came through the front entrance did not see the screening in rooster, so she went straight downstairs to the kitchen. [NAME] #1 indicated she does sign in if there was someone at the front desk. Interview with the DNS on 10/7/21 at 8:00 AM indicated all staff in all departments must be screened at the front entrance prior to going to work in the facility. The DNS indicated the front receptionist starts at 6:30 AM until 8:00 PM. The DNS indicated the 3-11 supervisor was responsible to screen all the 11-7 staff as they come into the facility and the 11-7 supervisor was responsible to screen the dietary staff as she unlocks the front door and allows them into the facility. Interview with the Administrator on 10/7/21 at 8:30 AM indicated all staff must be screened at the front desk prior to entering the facility for the start of their shift Review of facility Covid-19 Policy identified the purpose was to prevent the development and transmission of Covid-19. Practice standards were to screen all people entering the facility (such as employees, visitors, vendors, and medically necessary personnel) will be done upon entry into the facility. Any person who refuses to be screened, has a temperature, signs or symptoms will not be allowed into the facility. 2. Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and, heart failure. The care plan dated 8/1/21 identified Resident #499 was at risk for skin breakdown with interventions that included weekly wound assessment to include measurements and description of wound status, supplements as ordered, weekly skin checks, wound treatments as ordered, OT/PT to improve function, provide dietician services as needed, offload while in bed, observe skin condition daily with ADL care and report abnormalities and apply barrier cream with each cleansing. The MDS dated [DATE] identified Resident #499 had moderate cognitive impairment, required assistance with ADL skills and had 2 or more stage I unhealed pressure ulcers and no venous or arterial wounds. Physician's order dated 10/1/21 directed to cleanse the right knee with skin cleanser followed by xeroform dressing and cover with a dry protective dressing to be changed every three days; cleanse left lateral knee skin tear with wound cleanser followed by xeroform dressing, change every three days and as needed; cleanse right shin with normal saline, add Flagyl gel followed by silver alginate then ABD and wrap in Kerlex dressing daily and as needed; cleanse left shin with normal saline, followed by silver alginate then ABD and wrap in Kerlex dressing daily and as needed; skin prep to bilateral knees two times daily; cleanse wound to coccyx with normal saline followed by silver alginate then cover with border gauze every three days and as needed. An observation on 10/7/21 between 1:56 PM - 3:05 PM of LPN #1 completing wound care identified that she failed to remove her gloves and perform hand hygiene including with alcohol based hand sanitizer, after removing soiled dressings from the left shin, the right shin and the coccyx, and before attempting to place a medicated clean dressing to the wound sites of the left and right shin and handling the clean dressing for the coccygeal wound. LPN #1 was stopped prior to cross contamination before re-preparing and applying medicated dressing to the wound sites. An interview on 10/7/21 at 3:05 PM with LPN #1 identified although she was aware that hand hygiene followed by a glove change was to be performed after removing soiled dressings, she was nervous and did not. An interview on 10/7/21 at 3:10 PM with RN #5 identified LPN #5 should have performed hand hygiene and changed her gloves between tasks. The policy for hand hygiene directs hand hygiene to be performed after any contact with blood or body fluids, even if gloves are worn. Based on observations, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #24) the facility failed to place Resident #24 on isolation precautions according to professional standards and facility policy, and for 3 of 5 residents (Resident #4, 149 and 153) who were recently admitted to the suspected COVID-19 unit, the facility failed to ensure isolation signs were posted and isolation bins with supplies were available outside the door according to policy, and for 1 resident (Resident #499) reviewed for pressure ulcers, the facility failed follow infection control practices with regard to hand hygiene during wound care and the facility failed to ensure all staff were screened prior to entering the facility. The findings include: 1a. Resident #4 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, diabetes, and heart failure. The physician order dated 9/26/21 directed residents who have completed a 10-day observation period without the presentation of COVID 19 symptoms, on the COVID-19 screening assessment, and have tested negative at the completion of the quarantine period should be moved from the admission observation unit/status into other parts of the center that are COVID-naive. The admission MDS dated [DATE] identified Resident #4 had intact cognition, required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. b. Resident #149's diagnoses included chronic kidney disease, heart disease, malignant neoplasm of bladder and diabetes. The physician order dated 9/26/21 directed residents who have completed a 10-day observation period without the presentation of symptoms on the COVID-19 screening assessment and have tested negative at the completion of the quarantine period should be moved from the admission observation unit/status into other parts of the center that are COVID-naive. The admission MDS dated [DATE] identified Resident #149 had moderately impaired cognition, required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. c. Resident #153's diagnoses included dementia with behavioral disturbance hand injury, and hypertension. The physician order dated 9/29/21 directed residents who have completed a 10-day observation period without the presentation of symptoms on the COVID-19 screening assessment and have tested negative at the completion of the quarantine period should be moved from the admission observation unit/status into other parts of the center that are COVID-naive. The admission MDS dated [DATE] identified Resident #153 had moderately impaired cognition and required limited assistance with dressing and personal hygiene. Review of a social service assessment dated [DATE] identified the resident was transferred upstairs secondary to wandering on 10/1/21. Observation on 10/4/21 at 10:30 AM of the upstairs unit where Resident #153 resided failed to identify signage at the doorway of the resident's room to indicate the specific precautions that were required prior to entering the resident's room on COVID-19 transmission-based isolation precautions. Observations with the DNS on 10/4/21 at 10:55 AM identified that Resident #4 and 149's rooms were on a nursing unit designated for residents who required 10-day COVID-19 transmission-based isolation precautions following admission to the facility according to facility policy and physician's orders. Further observation identified there were no PPE disposal bins inside those residents' rooms, no isolation precautions signs, and no PPE supply bins outside the rooms. The DNS identified that Resident #4 and Resident #149 were no longer on COVID-19 isolation. Observation and interview with the Infection Control Nurse, (RN #2) on 10/4/21 at 11:00 AM identified that all residents that required COVID-19 transmission-based isolation precautions reside on the 1st floor, however, Resident #4 and Resident #149 were no longer on COVID-19 isolation precautions. RN #2 further identified that all residents that require COVID-19 transmission-based isolation precautions must have PPE disposal bins inside their rooms, bins with PPE outside their rooms, and isolation precautions signage posted outside rooms with information identifying that isolation precautions were to be implemented and required the use of full PPE including N95, face shield, isolation gown, and gloves. Upon further observation on 10/4/21 at 12:20 PM, NA #3 left Resident #4's room wearing a surgical mask without the benefit of an N95 mask, face shield, or gown. NA #3 identified at that time she just finished providing care to the resident. Further interview with NA #3 identified that Resident #4 and Resident #149 were not on COVID-19 isolation precautions because they had no signage and no bins with PPE outside their rooms. Interview and observation with the Recreation Director on 10/4/21 at 12:30 PM identified that Resident #153 and Resident #149 were no longer on COVID-19 isolation precautions identified by not having precaution isolation signs outside their rooms therefore, both residents were permitted to attend all activities with other residents without additional precautions. Interview with the DNS on 10/4/21 at 2:28 PM identified that Resident #4, Resident #149, and Resident #153 should be on COVID-19 isolation precautions because they had not been in the building for a full 10 days since admission. The DNS identified she did not know the reason those newly admitted residents were not on COVID-19 precautions. The DNS indicated it is the responsibility of the nursing staff to place newly admitted residents on COVID-19 precautions to protect other residents, staff, and visitors to prevent potential spread of COVID-19 infection. Subsequent to surveyor inquiry, on 10/4/21 the DNS stated that signage identifying the need for transmission-based precautions were posted at the doorways of Resident #4 and Resident #149 considered to be exposed to COVID-19. Staff education was started regarding the need to place signage outside residents' rooms when they were on transmission-based precautions to alert others to the need for isolation per facility COVID-19 policy, and audits to ensure compliance were implemented. Interview with RN #2 on 10/5/21 at 11:20 AM identified she was not aware that Resident #153 was transferred to the 2nd unit, therefore she did not ensure that an isolation sign and bin with PPE was placed outside the resident's room. RN #2 stated that she placed Resident #153 on COVID-19 isolation precautions when she came in to work this morning. Additionally, RN #2 identified that on 10/5/21 she immediately started in-services instructing staff that when transferring a resident prior to 10-day quarantine ends to ensure that the residents remain on COVID-19 isolation precautions and to notify management of transfer to ensure compliance. The facility policy and procedure for COVID-19 indicated all new admitted and readmitted residents require quarantine regardless of vaccination status. Under all circumstance's patients admitted or readmitted must be cared for using person-specific Airborne and Contact Precautions for the entire 10-day observation period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #13 and 268) who required extensive assistance with Activities of Daily Living (ADL), the facility failed to ensure good grooming related to facial hair and fingernails. The findings include: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia, abnormal posture and a contracture of the left hand. The quarterly MDS dated [DATE] identified Resident #13 had severely impaired cognition, required extensive assistance with bed mobility, toilet use, required total assistance with personal hygiene, and did not walk. The care plan dated 2/28/19 identified Resident #13 was dependent on staff for all care. Interventions included to provide extensive assistance with all care. The current nurse aide care card directed to provide extensive assistance with all ADL's. Intermittent observations on 5/6/19 and 5/7/19, 10:00 AM through 3:00 PM identified Resident #13 had a moderately thick amount of chin hair, more than stubble. Observation of Resident #13's chin hair with the DNS on 5/8/19 at 10:15 AM the DNS identified the resident needed to be shaved. The ADL policy identified a patient who is unable to carry out ADL's receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Although requested, a policy on facial hair was not provided. 2. Resident # 268 was admitted to the facility on [DATE] with diagnoses that included osteoporosis with pathological fracture of vertebrae, repeated falls, and unspecified dementia without behavioral disturbance. The nursing admission assessment dated [DATE] identified Resident #268 was alert, oriented to person only, not place or time, had moderate alteration in judgement, ate only about half of any food offered, was incontinent of bowel and bladder, and required assistance for mobility. The nurse aide care card dated 4/28/19 identified that Resident #268 is to be encouraged to brush teeth and gums twice daily. The care plan dated 4/28/19 identified Resident #268 required assistance with ADL's related to limited mobility. Interventions included to provide Resident #268 assistance for bed mobility, and transfers. Furthermore, the care plan identified Resident #268 had cognitive loss, and lacked safety awareness. Interventions included to maintain a clutter free environment. Additionally, the care plan identified Resident #268 was at risk for skin breakdown related to limited mobility. Interventions included to observe Resident #268 for signs and symptoms of skin breakdown, and complete weekly skin assessments. Facility documentation dated 4/29/19 identified Resident #268 was admitted to the facility for short term rehabilitation following a 5 day inpatient admission for complaints of abdominal and back pain and was diagnosed with a new compression fracture of the back. Resident #268's psychiatric status was described as confused and the plan of care involved physical and occupational therapy evaluations, related to unsteady gait and debility. The admission assessment dated [DATE] identified Resident #268 was alert and confused with moderate impairment of judgement. Facility documentation for ADL's identified extensive assistance provided to Resident #268 during day and evening shifts from 5/1/19 - 5/7/19. A skin check dated 5/5/19 at 7:15 PM identified Resident #268 was at risk for skin breakdown. Observations on 5/6/19 at 2:20 PM, 5/7/19 at 10:00 AM and 5/8/19 at 7:20 AM identified Resident #268 had long jagged fingernails on both hands with a blackish brown substance visible under the nails. Interview with NA #1 on 5/8/19 at 10:30 AM identified that residents on the short term care unit don't have a specific day for nail care, rather they are to have nails kept clean and trimmed as needed. NA #1 identified that although she had provided care to Resident #268, including washing him/her up on 5/7/19 and/or 5/8/19, NA #1 did not notice Resident #268's nails were long, jagged and had a blackish brown colored substance visible under the nails. NA #1 identified that it was nursing's responsibility to ensure that resident's nails were clean and well groomed. NA #1 further identified that she felt nail care was an important part of skin care and identified that sometimes it was difficult to obtain supplies to care for resident's nails. Interview and observation of Resident # 268's fingernails with the DNS on 5/8/19 at 10:56 AM identified that the facility provides nail care to residents as needed with goal of keeping them well-groomed. The DNS could not explain why the nails had not been groomed previously. DNS identified that Resident #268's nails were long and jagged with a blackish brown colored substance visible under the nails. Resident #268 readily agreed to have his/her nails cleaned and cut when it was offered by DNS. Review of facility policy for activities of daily living identified that the center will ensure a patient who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal oral hygiene.

**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 5 residents (Resident #267) reviewed for accidents, the facility failed to ensure medications were administered with a physician's order. The findings include: Resident #267 was admitted to the facility on [DATE] with diagnoses that included acute cystitis without hematuria, sepsis, and acute bronchitis. A nursing admission assessment dated [DATE] identified Resident #267 was alert and oriented to person, place and time, had intact judgement, and was admitted for rehabilitation related to an exacerbation of a chronic illness. The care plan dated 5/3/19 identified Resident #267 had a risk for decreased ability to perform activities of daily living. Interventions included that Resident #267 be monitored for shortness of breath, fatigue and or change in condition. A physician order dated 5/3/19 directed to administer of ProAir HFA inhaler 2 puffs via inhalation every 4 hours as needed for shortness of breath or wheezing. Facility documentation dated 5/4/19 identified Resident #267 had a past medical history that included congestive heart failure, coronary artery disease and some difficulty with breathing upon exertion. Facility documentation dated 5/6/19 identified Resident #267 was admitted to the facility for short term rehabilitation following a 6 day inpatient admission for weakness, acute kidney injury and sepsis. Additionally, Resident #267 had a history of heart failure and acute bronchitis. Observations on 5/6/19 at 1:06 PM identified a white rectangular box labeled Asmanex Inhaler on Resident #267's night stand table. Resident #267 indicated at that time that the Asmanex inhaler was provided by the cardiologist during the resident's most recent hospitalization. Additionally, Resident #267 identified that his/her family member had brought the inhaler into the facility the 5/5/19 as the cardiologist directed Resident #267 to utilize the inhaler twice a day. Observation 5/7/19 at 10:00 AM identified the Asmanex Inhaler was on Resident #267's night stand table. Observation on 5/8/19 at 7:19 AM identified the Asmanex inhaler was on Resident #267's night stand table. Interview with the Consultant Pharmacist #1 on 5/8/19 at 9:32 AM identified that Asmanex inhaler is an inhaled steroid like medication and is used to decrease inflammation in the airways, in contrast to the physician's ordered ProAir, which is considered a rescue inhaler and has a different mechanism of action. Consultant Pharmacist #1 identified that Asmanex and ProAir are different medications and not interchangeable. Interview with Resident #267 on 5/8/19 at 10:12 AM identified that during the hospitalization preceding his/her stay at the facility, the cardiologist directed Resident #267 to take Asmanex twice a day, and provided the Asmanex inhaler to the resident. Resident #267's family member delivered the Asmanex during a visit to the facility. Although Resident #267 did not recall explicitly telling the nursing staff about the Asmanex being in his/her room, Resident #267 identified that the Asmanex has been on the night stand and staff had been in and out of the room. Additionally, Resident #267 identified that he/she had self-administered the Asmanex several times since it was delivered by his/her family member. Interview and review of the physician's orders with LPN #2 on 5/8/19 at 10:18 AM identified that Resident #267 had an order for a ProAir inhaler every 4 hours as needed for shortness of breath or wheezing, and that Resident #267 had not been assessed as able to self-administer medications. LPN #2 identified nursing staff is responsible to ensure medications are not left in a resident's room. LPN #2 identified that although she had been caring for Resident #267 and in Resident #267's room earlier in the morning, she did not observe any medications in the room. Observation of Resident #267's night stand table on 5/8/19 at 10:20 AM identified the Asmanex inhaler beside Resident #267 on the night stand. Dialogue between Resident #267 and LPN #2 identified that the Asmanex medication was given to Resident #267 by the cardiologist with directions to take twice a day during his/her most recent hospitalization. Furthermore, Resident #267 identified that his/her family member delivered the Asmanex inhaler during a visit at the facility and since then, Resident #267 had been taking the Asmanex inhaler as the cardiologist had instructed. With permission from Resident #267, LPN # 2 removed the Asmanex inhaler from the room and identified that there would need to be a physician's order for the medication. LPN #2 explained to Resident #267 she would work with the DNS to obtain an order and follow up about keeping the medication in Resident #267's room. Interview with the DNS and LPN #2 on 5/8/19 at 10:25 AM regarding the box of Asmanex inhaler on the resident's night stand, the DNS indicated she was not aware that Resident #267 had an Asmanex inhaler on the night stand and would expect staff to observe for medications at a resident bedside for removal. Furthermore, the DNS identified that there would need to be a physician's order for the medication, an assessment to determine if the resident could self-administer the medication, and then the medication would need to be kept in a locked drawer, not on top of a night stand. Interview with NA #1 on 5/8/19 at 10:30 AM identified that although she had provided care to Resident #267 on 5/7/19 and 5/8/19, she did not observe any medications in the resident's room. NA #1 identified she may not have seen the medication as she was focused on sharing with the nurse changes related to Resident #267's physical status. Although NA #1 did not notice any medication in Resident #267's room during care on 5/7/19 or 5/8/19, she noted that any medications found at a resident's bedside are to be taken directly to a supervisor as they are not to be in a resident room. Review of facility medication administration policy identified medications are not to be left at the patient's bedside. Review of the self-administration policy identified that patients requesting to self-administer medications will be assessed for capability and if determined capable, then a physician order to self-administer a medication is required. Although multiple staff members were in and out of Resident #267's room for 3 days on 5/6, 5/7 and 5/8/19, the facility failed to identify the resident had an Asmanex inhaler, unsecured, on the bedside table, and failed to identify the resident was self-administering the medication. Additionally, although Resident #267 was taking the Asmanex as prescribed by the cardiologist, the resident had not been assessed as safe to self-administer the Asmanex, did not have a physician's order to receive the Asmanex, and did not have a physician order to self-administer the Asmanex.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record and interviews for 1 resident (Resident #13) reviewed for range of motion, the facility failed to provide care in accordance with professional standards, to maintain the resident's highest practicable well-being, in regards to a hand contracture. The findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia, abnormal posture and a contracture of the left hand. An OT evaluation dated 9/7/18 identified the nursing staff reported increased difficulty with donning left hand splint for the left hand contracture. Resident #13 has a left hand contracture, previously on OT services for the contracture and was discharged with left hand splint schedule to reduce contracture. Resident #13 is now refusing large hand splint, however open to wear air carrot in left hand to allow for hand to breathe and reduce risk for further left hand contracture. Without therapeutic intervention, Resident #13 is at risk for decreased skin integrity. Resident #13 was educated on importance of skin integrity and care and able to tolerate left air carrot splint. Pt represents 80% - 100% impairment due to chronic left hand contracture. The quarterly MDS dated [DATE] identified Resident #13 had severely impaired cognition, required extensive assistance with bed mobility, toilet use, required total assistance with transfers and hygiene, did not walk and had an impairment of range of motion to the upper extremity on one side. The care plan dated 2/28/19 identified Resident #13 was dependent on staff for all care. Interventions included to provide extensive assistance with all care, and apply a left hand splint on after morning care, and off during evening care as tolerated. May remove for skin checks. Additionally, the care plan indicated Resident #13 was resistive to care, interventions included to encourage the resident to keep the left hand splint on. The current nurse aide care card directed to apply a left hand splint on after morning care and off during evening care as tolerated. May remove for skin checks and encourage the resident to keep the left hand splint on. Intermittent observations on 5/6/19 and 5/7/19, 10:00 AM through 3:00 PM identified Resident #13 was without the benefit of the left hand splint, the residents left hand was clenched in a fist, and the residents fingernails were noted to be thick, yellow and longer that the tips of his/her fingers, which were pressing into the palm of the hand. Interview and observation of Resident #13's left hand with LPN #3 on 5/8/19 at 9:20 AM identified the resident is without a splint in the left hand, and the hand is in a fist. LPN #3 stated she had cut the residents nails last week and indicated they look good. LPN #3 indicated that the resident frequently refuses the splint, however, she may not have documented the refusals. The resident exhibits pain when the left hand is manipulated and pulls it away. Observation on 5/8/19 at 10:00 AM (by a second surveyor) identified Resident #13 was without the benefit of the left hand splint, the left hand was tightly closed, with thick, yellow nails on the index, middle and ring fingers that extended beyond the fingertips. The nails were noted to be pressing into the palm of her the resident's hand. Observation of Resident #13's left hand with the DNS on 5/8/19 at 10:15 AM identified that LPN #3 had reported that she had cut the resident's nails last week, and the DNS stated the nails must have started growing. The resident's left hand was without the benefit of a splint, and the nails were pressing into the palm. Resident #13 expressed signs of pain when the hand was manipulated. Review of the clinical record with the DNS failed to reflect that staff documented when the splint was applied and/or removed, and/or when the resident refused the splint. Interview and observation of the residents left hand with the Director of Therapy on 5/8/19 at 10:20 AM identified the splint is in place and there is an odor emanating from the hand. It was unclear if the odor was from the splint (carrot) or from the hand, and there was a whitish crusty substance on the top portion of the carrot. When asked, the Director of Therapy indicated the whitish substance on the splint is probably what is in the resident's hand, and it gets on the splint as they pull it through the hand. Therapy has encouraged the use of the carrot to prevent skin breakdown. Additionally, the Director of Therapy indicated that the resident's nails should be cut. A nurse's note dated 5/8/19 at 10:31 AM, written by the DNS, identified Resident #13 has a left hand contracture, unable to assess the palm of the hand due to contracture, and the resident's resistance. Nails are clean and short, no nail indentation noted to skin. An observation of the residents left hand with the DNS on 5/9/19 at 10:20 AM identified a splint is not in place, the hand is in a fist, nails pressing into the palm and there is an odor emanating from the palm of the hand. The DNS indicated that there is an odor emanating from the hand. When asked to clarify the nurse's note of 5/8/19 which documented that Resident #13's nails are clean and short, the DNS stated the resident's nails are short for him/her (the resident). Review of the clinical record and the nurse's notes 5/1/19 - 5/7/19 failed to reflect that Resident #13 had the splint applied daily as ordered and/or that the resident had refused the application of the splint. A nurse's note dated 5/8/19 at 10:50 AM (a late entry), written by LPN #3, documented on 5/7/19 attempted to put hand splint in left hand, resident refused, pushing hand away from nurse denies pain, APRN made updated. Subsequent to surveyor inquiry a physician's order dated 5/8/19 directed to monitor the left hand (contracture) for pain and skin impairment. Notify provider if resident has pain or skin impairment. Additionally, apply Penlac Solution (a topical antifungal medication used to treat fungal infections of the toenails and fingernails) to all fingernails daily for onychomycosis, (a fungal infection of the nail, symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed). An interdisciplinary therapy screen dated 5/9/19 identified no change in left hand contracture. Resident resistive to air carrot splint at times. Recommend continuing to trial daily as well as send splint to laundry 3 times weekly to promote increased hand hygiene. Although requested, the DNS indicated that there is not a facility policy for the care of a contracture. Although the staff identified in interview that the resident frequently refused application of the splint (carrot), and observation identified the splint was not in place, as ordered, during the survey (5/6/19 - 5/9/19), the nursing staff failed to document the attempts made to place the splint, failed to document the resident refusals of the splint application, and/or failed to revise the interventions to meet the needs of the resident, including the residents pain when the left hand was manipulated and/or on cleaning the hand to keep it odor free. Subsequently, during observations, the resident exhibited pain when the hand was manipulated, the resident had an odor emanating from the left hand, the nails were long, extended past the fingertips and were pressing into the palm, and the carrot had a crusty whitish substance on the top. Further, the facility failed to develop resident care policies in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultants to address the care of contractures.

**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 4 residents (Resident #8, 53, 266 and 267) the facility failed to ensure medications were securely stored in a locked cabinet/cart in accordance with facility's policies and/or for 2 of 4 medication carts, the facility failed to ensure medications were labeled and/or stored according to professional standards or policy. The findings include: 1. Resident #8 was admitted on [DATE] with diagnoses that included adjustment disorder. The quarterly MDS dated [DATE] identified Resident #8 had intact cognition, required extensive assistance with bed mobility, transfers, toilet use and hygiene. A self-administration of medication assessment dated [DATE] at 4:11 PM identified Resident # 8 was approved to self-administer Hair and Nail supplement. Additionally, the supplement was to be kept in a locked drawer in the bedroom at night. A physician's order dated 5/6/19 directed to administer Hair/Skin/Nails/Biotin Tablet, (Multiple Vitamins-Minerals) 1 capsule by mouth in the afternoon for supplement, Resident #8 may self-administer and use own supply. The care plan dated 5/6/19 identified Resident #8 chooses to self-administer medications, (Hair and Nail Biotin supplement). Interventions included to complete the self-medication assessment, establish means of resident nurse documentation of self-administered medication, if resident requests, obtain a physician's order to store the medication at the bedside, and obtain a physician's order for the resident to self-administer the medication. Intermittent observations on 5/6/19 between 10:00 AM and 3:00 PM identified the bottle of Hair/Skin/Nails/Biotin Tablet, (Multiple Vitamins-Minerals) was unlocked on Resident #8's bedside table. Intermittent observations on 5/7/19 identified the bottle of Hair/Skin/Nails/Biotin Tablet was unlocked on Resident #8's bedside table. Interview with LPN #3 on 5/8/19 at 2:15 PM identified that Resident #8 recently started taking those vitamins, and they should be locked in the room. LPN #3 indicated that she locked up the vitamins yesterday after she administered them to the resident. When asked, LPN #3 could not recall if the vitamins were locked yesterday morning, 5/7/19, when she administered them, and she could not say what time she locked the vitamins. The self-administration of medications policy directed to secure medications in a locked drawer at the patient's bedside. The facility failed to safeguard medications when upon intermittent observations on 5/6 and 5/7/19, a bottle of Hair/Skin/Nails/Biotin Tablet was noted to be unlocked on the resident's bedside table. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, chronic atrial fibrillation, hypertension, and diabetes. The care plan dated 2/13/19 identified Resident #53 was at risk for complications related to hemodialysis. Interventions included to send a communication book to dialysis with Resident #53, and review the book upon the resident's return from dialysis. A physician's order dated 2/14/19 directed to send Midodrine HCL (a medication used to treat low blood pressure) 10 mg, to dialysis with Resident #53 every Tuesday, Thursday and Saturday for blood pressure control. The admission MDS dated [DATE] identified Resident #53 had intact cognition and received dialysis. A nurse's note dated 5/7/19 identified Resident #53 went to dialysis, and returned to facility at approximately 11:00 AM on 5/7/19. Observation on 5/8/19 at 1:40 PM identified a package containing one tablet of Midodrine 10mg was in the pocket of Resident #53's dialysis communication book, which was located at the nurse's desk. Interview with LPN #1 on 5/8/19 at 1:45 PM identified that the Midodrine is usually returned to the locked cart after Resident #53 returns from dialysis. LPN #1 reported that the charge nurse is responsible to secure the medication after the resident returns from dialysis, and was unsure of the reason the medication was not returned to the cart after Resident #53's dialysis treatment on 5/7/19. Interview with LPN #4 on 5/9/19 at 10:45 AM identified that LPN #4 received Resident #53 back to the facility after dialysis on 5/7/19. LPN #4 indicated that her responsibilities included checking the dialysis communication book and returning the Midodrine tablet to the locked medication cart after Resident #53 returned from dialysis. LPN #4 indicated that she was nervous and forgot to return the Midodrine to the locked medication cart. Review of the storage and expiration dating of medications, biologicals, syringes and needles' policy identified the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 3. Resident #266 was admitted to the facility on [DATE] with diagnoses that included fracture of lumbar vertebrae, nondisplaced fracture of sacrum and subdural hemorrhage. Facility documentation dated 5/2/19 at 4:50 PM identified that Resident #266 was admitted for rehabilitation following an accident. Resident #266's mental status was alert and he/she was oriented to person, place and time, and had intact judgement. Resident #266 was incontinent of bowel and bladder. Integumentary review identified very moist skin as Resident #266 incontinent once a shift. Additionally, documentation identified skin impairment present. The care plan dated 5/2/19 identified Resident #266 had a risk for skin breakdown. Interventions included to pat Resident #266's skin, not to rub it when drying, to provide preventative skin care lotions, as ordered, to observe skin for signs of breakdown and to evaluate for any localized skin problems. A physician's order dated 5/2/19 identified Resident #266 may not administer his/her own medications, and directed to apply antifungal powder to Resident #266's groin every shift. Review of facility documentation dated 5/2/19 through 5/6/19 identified that antifungal powder was applied to Resident #266's groin each shift. Observation on 5/6/19 at 10:20 AM identified a container of antifungal foot powder, unsecured, on the resident's bedside table. Observation on 5/6/19 at 12:50 PM identified a container of antifungal foot powder, unsecured, on the resident's bedside table beside the resident's partially consumed lunch. Observation on 5/6/19 at 3:15 PM identified a container of antifungal foot powder, unsecured, on the resident's bedside table. Observation on 5/7/19 at 10:05 AM identified Resident #266's room was changed. Interview with the DNS on 5/8/19 at 10:25 AM identified that she would expect staff to observe for medications at a resident bedside for removal. Interview with the DNS on 5/8/19 at 10:50 AM identified antifungal foot powder should not be stored on Resident #266's bedside table. Observation on 5/9/18 at 9:05 AM identified an open bottle of foot powder in the top of Resident #266's dresser drawer. Review of the bottle listed the ingredients including talc, salicylic acid and methyl salicylate. Interview with the DNS on 5/9/19 at 10:18 AM identified that upon Resident #266's admission, the nursing staff identified the resident had medications from home amongst his/her belongings and requested they be removed from facility. The DNS further identified that Resident #266's family failed to identify foot powder as a medication, and did not remove it from the facility. Review of the facility medication administration policy identified medications are not to be left at the patient's bedside. Review of the facility pharmacy services and procedures manual identified the facility should ensure that all medications and biologicals including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Review of facility self-administration policy identified that patients requesting to self-administer medications will be assessed for capability and if determined capable, then a physician order to self-administer a medication is required. 4. Resident #267 was admitted to the facility on [DATE] with diagnoses that included acute cystitis without hematuria, sepsis, and acute bronchitis. A nursing admission assessment dated [DATE] identified Resident #267 was alert and oriented to person, place and time, had intact judgement, and was admitted for rehabilitation related to an exacerbation of a chronic illness. The care plan dated 5/3/19 identified Resident #267 had a risk for decreased ability to perform activities of daily living. Interventions included that Resident #267 be monitored for shortness of breath, fatigue and or change in condition. Observations on 5/6/19 at 1:06 PM identified a white rectangular box labeled Asmanex Inhaler on Resident #267's night stand table. Resident #267 indicated at that time that the Asmanex inhaler was provided by the cardiologist during the resident's most recent hospitalization. Additionally, Resident #267 identified that his/her family member had brought the inhaler into the facility the 5/5/19 as the cardiologist directed Resident #267 to utilize the inhaler twice a day. Observation 5/7/19 at 10:00 AM identified the Asmanex Inhaler was on Resident #267's night stand table. Observation on 5/8/19 at 7:19 AM identified the Asmanex inhaler was on Resident #267's night stand table. Interview with Resident #267 on 5/8/19 at 10:12 AM identified that during the hospitalization preceding his/her stay at the facility, the cardiologist directed Resident #267 to take Asmanex twice a day, and provided the Asmanex inhaler to the resident. Resident #267's family member delivered the Asmanex during a visit to the facility. Although Resident #267 did not recall explicitly telling the nursing staff about the Asmanex being in his/her room, Resident #267 identified that the Asmanex has been on the night stand and staff had been in and out of the room. Additionally, Resident #267 identified that he/she had self-administered the Asmanex several times since it was delivered by his/her family member. Interview and review of the physician's orders with LPN #2 on 5/8/19 at 10:18 AM identified that Resident #267 had an order for a ProAir inhaler every 4 hours as needed for shortness of breath or wheezing, and that Resident #267 had not been assessed as able to self-administer medications. LPN #2 identified nursing staff is responsible to ensure medications are not left in a resident's room. LPN #2 identified that although she had been caring for Resident #267 and in Resident #267's room earlier in the morning, she did not observe any medications in the room. Observation of Resident #267's night stand table on 5/8/19 at 10:20 AM identified the Asmanex inhaler beside Resident #267 on the night stand. Dialogue between Resident #267 and LPN #2 identified that the Asmanex medication was given to Resident #267 by the cardiologist with directions to take twice a day during his/her most recent hospitalization. Furthermore, Resident #267 identified that his/her family member delivered the Asmanex inhaler during a visit at the facility and since then, Resident #267 had been taking the Asmanex inhaler as the cardiologist had instructed. With permission from Resident #267, LPN # 2 removed the Asmanex inhaler from the room and identified that there would need to be a physician's order for the medication. LPN #2 explained to Resident #267 she would work with the DNS to obtain an order and follow up about keeping the medication in Resident #267's room. Interview with the DNS and LPN #2 on 5/8/19 at 10:25 AM regarding the box of Asmanex inhaler on the resident's night stand, the DNS indicated she was not aware that Resident #267 had an Asmanex inhaler on the night stand and would expect staff to observe for medications at a resident bedside for removal. Furthermore, the DNS identified that there would need to be a physician's order for the medication, an assessment to determine if the resident could self-administer the medication, and then the medication would need to be kept in a locked drawer, not on top of a night stand. Interview with NA #1 on 5/8/19 at 10:30 AM identified that although she had provided care to Resident #267 on 5/7/19 and 5/8/19, she did not observe any medications in the resident's room. NA #1 identified she may not have seen the medication as she was focused on sharing with the nurse changes related to Resident #267's physical status. Although NA #1 did not notice any medication in Resident #267's room during care on 5/7/19 or 5/8/19, she noted that any medications found at a resident's bedside are to be taken directly to a supervisor as they are not to be in a resident room. Review of facility medication administration policy identified medications are not to be left at the patient's bedside. Review of the self-administration policy identified that patients requesting to self-administer medications will be assessed for capability and if determined capable, then a physician order to self-administer a medication is required. Although multiple staff members were in and out of Resident #267's room for 3 days on 5/6, 5/7 and 5/8/19, the facility failed to identify the resident had an Asmanex inhaler, unsecured, on the bedside table. 5. Observation of the medication cart on the [NAME] Twain unit on 5/7/19 at 8:45 AM identified an open box of artificial tears marked with a room number. The box contained an open container of eye drops. Observation of medication box and bottle failed to reflect a resident name. Interview and observation of the open box of artificial tears with LPN #3 on 5/7/19 at 8:47 AM identified that LPN #3 was unable to identify any label or markings that indicated a resident name. LPN #3 identified that nurses are to ensure all medications are to be labeled with a resident's name. LPN #3 was unable to identify why the container and eye drops were only labeled with a room number, as she identified she had been on vacation for the past week. Review of second floor medication cart DW unit on 5/7/18 at 8:55 AM with RN #1 identified an open bottle of Latanoprost .005% ophthalmic solution labeled with a resident name, but lacked the date the bottle was opened. RN #1 identified that the bottle of Latanoprost was not labeled with an open date and that nursing is responsible for dating medications when they are opened so the medication can be appropriately discarded in a timely fashion. Interview with Pharmacy Consultant #1 on 5/8/19 at 9:26 AM identified that Latanoprost ophthalmic solution is to be dated when opened, and discarded after 6 weeks. Review of the pharmacy services and procedures manual related to storage of medications identified that facilities should ensure that medications have an expiration date on the label. Furthermore, the pharmacy services guidelines identify that Latanoprost is to be dated when opened, and discarded after 6 weeks.