**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Residents #43, 47, 61 and 65) the facility failed to notify the physician and/or resident representative when required. For 1 of 2 residents, (Resident #43) reviewed for death, the facility failed to ensure the physician was notified when medications were not administered according to the physician's orders, when blood sugar and blood pressures were not obtained as ordered, and when blood sugars were noted to be outside the parameter. For 1 of 3 residents (Resident #47) reviewed for accidents the facility failed to notify the physician of a fracture after a fall and a lung nodule.For 1 resident (Resident #61) reviewed for pain, the facility failed to notify the physician with the onset of new pain. For 1 of 5 residents (Resident #65) reviewed for infection control the facility failed to notify the resident representative following a change in condition. The findings include:1a. The hospital Discharge summary dated [DATE] identified Resident #43 was admitted to the hospital on [DATE] with diagnoses of acute heart failure with reduced ejection fraction (HFrEF) with hypertensive emergency due to medication nonadherence. Newly reduced Left Ventricular Ejection Fraction (LVEF) of 32%, hypertension emergency due to medication noncompliance. Comorbidities present on admission were diabetes type 2, hypertension, gout, gunshot wound to abdomen, chronic back pain, status post splenectomy, and Covid-19. Secondary diagnoses occurred during hospitalization included acute kidney injury, and diabetes with hyperglycemia. Resident #43 was discharged from the hospital on 2/26/25. Resident #43 was admitted to the facility on [DATE] with diagnoses that included chest pain, chronic congestive heart failure, hypertension, and diabetes.The care plan dated 2/27/25 identified Resident #43 was at risk for abnormal glucose levels, hypo/hyperglycemia secondary to diabetes. Interventions included to administer diabetic medications and/or Insulin as ordered.The admission MDS dated [DATE] identified Resident #43 had intact cognition and was independent with personal hygiene.The consultant cardiologist recommendations dated 4/30/25 included to start on SGLT2 inhibitor (medication used to treat type 2 diabetes) either Jardiance or Farxiga 10mg daily.The consultant visit summary dated 4/30/25 identified the heart failure with reduced ejection fraction was addressed. The form indicated to pick up Jardiance at an outside Pharmacy.The physician's order dated 5/1/25 directed to administer Jardiance 10 mg tablet (used to manage type 2 diabetes, heart failure, and chronic kidney disease (CKD) once a day at 8:30 AM. Review of the pharmacy documentation dated 5/1/25 at 8:47 AM identified medication not covered (Jardiance 10mg tablet once daily). An outside pharmacy filled and dispensed the medication. Resident #43 called the outside pharmacy yesterday (4/30/25) and requested all medications be filled and delivered to his/her significant other at his/her prior address.The nurse's note dated 5/1/25 at 12:38 AM identified Resident #43 was seen by the cardiologist on 4/30/25 related to recent heart failure and ejection fraction diagnoses. Recommendations to start either Jardiance or Farxiga 10mg daily. The care plan dated 5/1/25 identified Resident #43 had a recent diagnoses of chronic systolic heart failure (4/30/35) and was at risk for or complication due to disease process. Interventions included monitoring cardiorespiratory symptoms, increasing fatigue, and to administer medications as ordered. Further, the care plan dated 5/1/25 identified Resident #43 was at risk for alteration in cardiac output related to recent diagnosis of chronic systolic heart failure on 4/30/25. Interventions included to administer medications as ordered. The nurse's note dated 5/2/25 at 12:21 AM by RN #9 identified she spoke with the facility pharmacy regarding Resident #43 calling and telling the outside pharmacy that the medication would be picked up by his/her significant other. RN #9 indicated she would educate Resident #43 to not have anyone pick up medication while residing in the facility. The note failed to reflect that the physician, APRN, cardiologist, or the DNS were notified.Review of the APRN notes dated 5/8/25 and 5/13/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. The physician's order dated 5/29/25 directed to check blood pressure and pulse once a day at 9:30 AM. Review of the MAR dated 5/1/25 - 6/3/25 identified although the Jardiance 10mg was scheduled to be administered daily at 8:30 AM, the medication was not administered. The MAR identified the drug was unavailable and awaiting delivery from the pharmacy from 5/1/25 - 6/3/25, a total of 34 days.Review of the APRN note dated 6/3/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, APRN, cardiologist, or the DNS were notified that Resident #43 was not receiving the Jardiance per the physician's order from 5/1/25 - 6/3/25 (total of 34 days). Interview with APRN #3 on 6/6/25 at 2:53 PM identified she was not aware that Resident #43 was not receiving the Jardiance as ordered from 5/1/25 - 6/3/25, and that the pharmacy had not sent the medication to the facility. APRN #3 indicated the Jardiance was prescribed by a specialist (cardiologist). APRN #3 indicated when Resident #43 was first admitted to the facility, the facility was having issues with the medications being sent to his/her personal pharmacy. APRN #3 indicated if she had known the resident was not receiving the Jardiance due to a pharmacy issue, she would have had a discussion with the DNS and called the pharmacy.Interview with the DNS on 6/6/25 at 3:02 PM identified she was not aware that Resident #43 was not receiving the Jardiance from 5/1/25 - 6/3/25 (34 days), or that the Jardiance was never delivered to the facility. The DNS indicated had she known, she would have called the pharmacy and had the pharmacy bill the facility for the Jardiance. The DNS indicated that she would expect the licensed nurses to administer medication per the physician's order. Interview with MD #5 (cardiologist) on 6/10/25 at 10:27 AM identified he last saw Resident #43 on 4/30/25 at his office. MD #5 indicated Resident #43 had been admitted to the hospital in February 2025, with systolic heart failure, and heart failure with reduced ejection fraction (32%) with hypertensive emergency which caused pulmonary edema, and other comorbidities. MD #5 indicated on 4/30/35 he ordered Resident #43 to receive Jardiance 10mg once a day. MD #5 indicated he was not aware that Resident #43 never received the medication. MD #5 indicated his expectation is that the nurses should have administered the medication per the physician's order. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not aware that Jardiance 10mg was recommended to be given daily. MD #1 indicated he did not receive a phone call from the facility on 4/30/25 or 5/1/25 informing him that the cardiologist recommended Jardiance to be administered daily. MD #1 indicated he did not order Jardiance to be administered, and he was not aware that Resident #43 did not receive the Jardiance from 5/1/25 - 6/3/25 (total of 34 days). MD #1 indicated the nurse should administer medication per the physician's order. Review of the facility medication unavailable policy identified in the event that medication is unavailable for any reason the facility shall act promptly to notify appropriate practitioners for orders to be followed and the pharmacy to obtain medications in accordance with the updated orders. The facility shall investigate all instances where medications are not available, to assess whether appropriate actions were taken to ensure continuity of care. Upon identifying that a medication is apparently unavailable, immediately notify the nursing supervisor. Contact the pharmacy to determine when medication will be available. Inform the prescriber/attending; and in their absence, the Medical Director and obtain orders. Document actions and prescriber orders on 24 hour report, MD order sheet, and chart.b. The physician's order dated 5/1/25 - 5/31/25 directed to administer the following medications: Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Gabapentin 300mg capsule (for pain) at bedtime at 8:30 PM.Lantus Insulin U-100 unit/ml (diabetes) give 25 units subcutaneous at bedtime at 8:30 PM. Lipitor 80mg tablet (for hyperlipidemia) once a day at 8:30 PM. Miralax 17grams (for constipation) twice a day at 8:30 AM and 8:30 PM.Ozempic 4mg/3ml, 1mg/dose subcutaneous (for diabetes) on Mondays at 8:30 AM.Senna 8.6mg tablet (for constipation) twice a day at 8:30 AM, and 8:30 PM. Review of the May 2025 MAR identified the following. Coreg 25mg was not administered on 5/1/25 at 4:30 PM, 5/2/25 at 8:30 AM, 5/5/25 at 8:30 AM, 5/6/25 at 8:30 AM, 5/19/25 at 8:30 AM, and 5/28/25 at 8:30 AM. Gabapentin 300mg was not administered on 5/20/25 at 8:30 PM.Lantus Insulin U-100 unit/ml was not administered on 5/20/25 at 8:30 PM.Lipitor 80mg was not administered on 5/20/25 at 8:30 PM.Miralax 17grams was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 PM.Ozempic 4mg/3ml give 1mg/dose was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 AM.Senna 8.6mg was not administered on 5/20/25 at 8:30 PM. c. The physician's order dated 6/1/25 - 6/3/25 directed the following. Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Daily Blood Pressure and Pulse once a day at 9:30 AM.Daily Weights before breakfast (for chronic systolic congestive heart failure) once a day at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous (for diabetes) once a day on Mondays at 8:30 AM.Review of the June 2025 MAR dated identified the following. Coreg 25mg was not administered on 6/2/25 at 8:30 AM, and 4:30 PM.Daily Blood Pressure and Pulse was not recorded on 6/2/25 at 9:30 AM. Daily Weights were not obtained on 6/2/25 at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous was not administered on 6/2/25 at 8:30 AM.Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, or the APRN, were notified that Resident #43 did not receive medications on 5/1/25, 5/2/25, 5/5/25, 5/6/25, 5/19/25, 5/20/25, 5/28/25, and 6/2/25. d. The physician's orders dated 5/1/25 - 6/3/25 directed the following. Check Blood Sugar before meals (for diabetes) at 7:30 AM, 11:30 AM, and 4:30 PM. Special Instructions: If Blood Sugar is less than 80mg/dl and greater than 450mg/dl call MD/APRN. Review of the May 2025 and June 2025 MAR identified the following.The blood sugar on 5/6/25 at 11:30 AM was 76mg/dl.The blood sugar on 5/14/25 at 7:30 AM was 73mg/dl.The blood sugar on 5/15/25 at 7:30 AM was 71mg/dl.The blood sugar on 6/2/25 at 7:30 AM was 54mg/dl. Review of the nurse's note dated 5/1/25 - 6/4/25 failed to reflect documentation that the physician was notified when the residents blood sugar was low 5/6/26, 5/14/25, 5/15/25, and 6/2/25. e. The care plan dated 5/1/25 identified Resident #43 has a history of hypertension. Interventions included to monitor blood pressure every shift. The physician's order dated 5/1/25 - 5/28/25 directed to monitor blood pressure every shift, Days, Evening, and Nights.Review of the vital sign form identified the following missing blood pressures.5/1/25 evening and night, 5/2/25 day and night, 5/3/25 evening and night, 5/4/25 evening and night, 5/5/25 day and night, 5/6/25 day and night, 5/7/25 and 5/8/25 nights, 5/9/25 evening and night, 5/10 /25 - 5/13/25 nights, 5/14/25 evening and night, 5/15/25 night, 5/16/25 evening and night, 5/17/25 evening and night, 5/18/25 night, 5/19/25 day and night, 5/20/25 night, 5/21/25 - 5/27/25 nights, 5/28/25 day, evening, and night.The nurse's note dated 5/1/25 - 5/28/25 failed to reflect documentation that the physician was notified that blood pressure was not monitored as ordered. Interview with RN #1 on 6/9/25 at 12:26 PM identified she was not aware Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. RN #1 indicated it is the responsibility of the licensed nurses to administer the medication per the physician's order. RN #1 indicated the licensed nurses should have notified the physician or the APRN when the medications were not given and document the omissions in the resident clinical record. Interview with the DNS on 6/10/25 at 10:11 AM identified she was not aware that Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. The DNS indicated the licensed nurses should have notified the physician, or the APRN when Resident #43 did not receive his/her medications, when the blood sugars were low, and when blood pressure was not monitored as ordered. The DNS indicated that she would expect the licensed nurses to administer the medication per the physician's order. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not notified that Resident #43 was not receiving some of the medications between 5/1/25 - 6/3/25 on multiple occasions and when blood pressure was not monitored as ordered. Further, MD #1 indicated the licensed nurses should have notified him or the APRN when Resident #43's blood sugar was low on multiple occasions, and blood pressure was not monitored as ordered. MD #1 indicated the license nurse should administer the medication per the physician's order.Review of the facility change of condition policy identified the facility is to ensure that changes in resident's conditions are reported to providers and families. The facility must immediately inform the resident, consult with the resident's physician, APRN, and notify the resident's legal representative when there is a need to alter treatment significantly. Documentation will be noted in the resident's medical record and on the 24 hour report to ensure shift to shift communication and continuity of care.Review of the facility compliance with and implementation of physician's orders policy identified all physician orders are implemented accurately, timely, and in accordance with applicable federal and state regulations. Review of the facility taking a blood pressure policy identified to measure the force at which the heart pumps and returns blood. Notify the provider of the results and correctly document the results in the resident's record in the electronic record. 2. Resident #47 was readmitted to the facility on [DATE] with diagnoses that included ventricular tachycardia, atrial fibrillation, bradycardia, frontal temporal neurocognitive disorder, osteoarthritis right knee, spinal stenosis, and muscle weakness. The February 2025 monthly physician's orders directed Resident #47 to be provided supervision with stand pivot transfers, sand by assistance for gait using a 4 wheeled walker and independent with the wheelchair use in the facility. The quarterly MDS dated [DATE] identified Resident #47 had intact cognition and required maximum assistance with toileting, bathing, and personal hygiene. Additionally, Resident #47 required moderate assistance with toilet transfers, and from the bed to the chair and chair to the bed. Resident #47 required supervision or touching assistance for sitting to stand and ambulation walking 10 feet. The care plan dated 2/6/25 identified has had falls. Interventions included educating and to remind Resident #47 to use the call bell for assistance. a. A reportable event form dated 2/9/25 at 5:00 PM identified Resident #47 had an unwitnessed fall and sustained a skin tear to the right elbow. Resident #47 indicated he/she fell in the bathroom. Resident #47 was unable to stand up. Resident #47 was transferred to the emergency room. The nurses note dated 2/9/25 at 5:00 PM identified Resident #47 was alert and responsive with complaints of pain. This writer didn't witness the fall as it was reported by staff, but this writer observed Resident #47 in the room on the floor unable to get up with assistance. Resident #47 has a skin tear noted on the right elbow. Resident sent to emergency room for further observation. On call APRN and resident representative were made aware. The hospital Discharge summary dated [DATE] identified Resident #47 was diagnosed with Influenza and recurrent falls. Resident #47 had 2 unwitnessed falls at nursing facility over the last 2 days. X-ray of the pelvis identified minimally displaced fracture of the right inferior ramus and right sacral area. The nurses note dated 2/15/25 at 4:02 PM identified Resident #47 arrived back from the hospital and is alert and verbal. Resident #47 denies any pain or discomfort. Resident #47 has a cough and cough medication was given. Review of the nursing notes and physician notes dated 2/15/25 to 3/10/25 failed to reflect the physician or the APRN had been notified of the fracture identified after the fall on 2/9/25. Interview with the DNS on 6/4/25 at 7:09 AM indicated the intervention for the fall on 2/8/25 was to have a physical therapy screen and the intervention for the 2/9/25 fall was to remind Resident #47 to call for assistance and use call bell. The DNS indicated she did not see the Discharge summary dated [DATE] and did not see the x-ray results that identified a minimally displaced fracture of the right inferior ramus and right sacral area. The DNS indicated the supervisor was responsible to read the discharge summary when Resident #47 returned to the facility, but she has had a lot of different supervisors lately and has let them go because they were not doing what they should have. The DNS indicated she was responsible to read the discharge summary the next day, and she tries but does not always have time. The DNS indicated that if the supervisor had notified her when Resident #47 returned to the facility she would have notified the physician and the state agency of the fractures. b. A reportable event form dated 3/14/25 at 7:55 AM identified Resident #47 had an unwitnessed fall and sustained a bruised left brow and skin tear to the left lateral arm. Resident #47 was transferred to hospital for evaluation. The hospital Discharge summary dated [DATE] identified Resident #47 had an unwitnessed fall at nursing facility and has a laceration to the left eyebrow and left elbow. CT Scan of the cervical spine noted no fracture but noted a 6 mm pulmonary nodule at the left apex. If the patient was a smoker or at high risk for malignancy, follow up unenhanced chest CT scan in 12 months for further surveillance. The nurses note dated 3/14/25 at 1:10 PM identified Resident #47 returned to the facility alert and responsive via stretcher, noted with hematoma to left eyebrow with 9 sutures and bruising to the left eye and an abrasion to left elbow which resident sustained during unwitnessed fall. Resident #47 denied any pain or discomfort at this time. Review of the nursing notes and physician notes dated 3/14/25 to 3/20/25 failed to refelct the physician or the APRN were notified of the lung nodule noted at the hospital on 3/14/25. Interview with the DNS on 6/4/25 at 7:42 AM indicated after review of the hospital discharge summary, she was not aware of the 6mm nodule on the left lung. The DNS indicated she had not seen the Discharge summary dated [DATE]. Additionally, the DNS indicated she had reviewed the physician and nurses notes and they did not identify the physician was notified of the nodule in the left lung. Interview with RN #1 on 6/4/25 at 7:43 AM indicated she does not recall seeing in the discharge summary from 3/15/25 that identified Resident #47 had returned with a fracture to the pelvis and she indicated she left the discharge summary in the APRN folder. RN #1 indicated she had reviewed the discharge summary when Resident #47 had returned on 3/14/25 but did not notice the results of the test showing the nodule in the left lung. RN #1 indicated she did not notify the APRN or physician of the fracture of lung nodule when Resident #47 returned from the hospital, but she did inform the APRN of the 9 sutures in the forehead and when they would have to be removed. Interview with APRN #2 on 6/4/25 at 8:49 AM indicated the nursing staff should have notified her or the physician of the new fractures and lung nodule right away and if she had been notified she would have done a clinical assessment and treated Resident #47 for pain if needed and maybe sent the resident to a pulmonologist. The interview with the MD #4 (prior medical director) on 6/4/25 at 11:20 AM indicated that when a resident returns from the hospital the supervisor is responsible to inform her of what the hospital's findings are and then leave the discharge summary for her to review. MD #4 indicated she does not recall receiving the discharge summary. MD #4 indicated she was not informed of Resident #47 having a fracture after the fall. MD #4 indicated she recalls being informed of the Influenza but not a fracture. MD #4 indicated that if she was notified, she would have first done a physical assessment then she would have ordered medication for pain management and physical therapy because there was not a surgical option. MD #4 indicated that she was not informed of the lung nodule and indicated with a new nodule she would have done a physical assessment and would have spoken to Resident #47 and the resident's representative to see what they would or would not want done. MD #4 indicated that she would have ordered an x-ray in 6 months to see if it was the same size or bigger and maybe sent him/her to a pulmonology. Although attempted multiple times, an interview with APRN #1 was not obtained. Review of the Change of Condition Policy identified the facility was to ensure that changes in residents' condition are reported to the providers and families. This is to ensure every resident's change in condition is assessed and documented properly. The facility must immediately inform the residents, consult with the residents' physician, and if known notify the residents legal representative or an interested family member when there is an accident involving the resident which resulted in an injury, a significant change in the resident's physical, mental, or psychosocial status including a new onset of pain or increased pain. The LPN is to collect data and administer provider ordered treatments or medications. The RN will assess and determine if a change of condition has occurred. The RN will make the APRN or MD aware of a resident's current condition by in person or telephone call. 3. Resident 61 was admitted to the facility in August 2024 with diagnoses that included diabetes, stroke, osteoarthritis of the left shoulder. The monthly physician's orders dated 2/1/25 to 2/28/25 directed to apply lidocaine patch to the left shoulder in the morning and remove at bedtime for chronic pain. Additionally, Voltaren arthritic pain gel apply 2 grams topically to the right foot as needed every 6 hours. Tramadol 50 mg every 8 hours as needed for chronic pain. Review of the nursing and physician notes from 2/1/25 to 3/18/25 failed to reflect right shoulder pain. The quarterly MDS dated [DATE] identified Resident #61 had moderately impaired cognition and required set up or clean up assistance with toileting, dressing, and personal hygiene. Additionally, Resident #61 had occasional pain in the last 5 days and received pain medication as needed. The care plan dated 2/21/25 identified Resident #61 had a right foot wound. Interventions included monitoring signs and symptoms of infection. The nurse's note dated 3/19/25 at 2:51 PM identified Resident #61 complained of pain in his/her right shoulder and was given pain medication. The nurses note dated 3/20/25 at 2:33 PM indicated Resident #61 complains of limiting pain located in the right shoulder, in the acromion region, compared with the left shoulder, swelling is detected in that region. The nurses note dated 3/21/25 at 2:46 PM indicated Resident #61 has complaints of pain in his/her right shoulder and right foot. Resident #61 was given the as needed pain medication. The interview with Resident #61 on 6/1/25 at 8:30 AM indicated that he/she has pain in his/her bilateral shoulders and his/her right foot. Resident #61 indicated that he/she does receive pain medications as needed. Interview with RN #1 on 6/4/25 at 7:50 AM identified after clinical record review, there were notes for Resident #61 identifying a new onset of pain to the right shoulder for 3 days and that the RN supervisor, the APRN, and physician were not notified. RN #1 indicated that she was the supervisor on duty 3/19, 3/20 and 3/21/25 and was not notified of the new onset pain to the right shoulder. RN #1 indicated if she was notified, she would have done an assessment and notified the APRN. The interview with the DNS on 6/4/25 at 7:51 AM indicated that the new onset of right shoulder pain should have been reported to the RN who would have done an assessment and notify the APRN or physician. After clinical record review, the DNS noted that the physician nor APRN had been notified. The interview with APRN #3 on 6/4/25 at 8:44 AM indicated that she was not notified Resident #61 had a new onset of pain in the right shoulder. APRN #3 indicated that her expectation is that new onset of pain with any resident is communicated to her. APRN #3 identified had she been notified, an assessment would have been done. The interview with MD #4 (former medical director) on 6/4/25 at 11:19 AM indicated that she does not recall anyone notifying her that Resident #61 had a new onset of right shoulder pain. MD #4 indicated if she was notified, she would have done a physical assessment and would have done an x-ray to rule out a fracture versus arthritis. MD #4 indicated if she had seen Resident #61 for the new onset of pain to the right shoulder she would have written a note. Although multiple attempts were made, an interview with APRN #1 and LPN #6 was not obtained. The review of the Change of Condition Policy identified the facility was to ensure that changes in residents' condition are reported to the providers and families. This is to ensure every resident's change in condition is assessed and documented properly. The facility must immediately inform the residents, consult with the residents' physician, and if known notify the residents legal representative or an interested family member when there is an accident involving the resident which resulted in an injury, a significant change in the resident's physical, mental, or psychosocial status including a new onset of pain or increased pain. The LPN is to collect data and administer provider ordered treatments or medications. The RN will assess and determine if a change of condition has occurred. The RN will make the APRN or MD aware of a resident's current condition by in person or telephone call. 4. Resident #65 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, spinal stenosis, and chronic obstructive pulmonary disease (COPD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing, and dressing.The care plan dated 1/23/25 identified Resident #65 was at risk for contracting influenza and had refused the influenza vaccine. Interventions included to reapproach the resident to offer the vaccine as indicated. Review of an influenza outbreak surveillance tracking list for 2/2025 identified that the facility had an influenza outbreak that began on 2/3/25.A physician's order dated 2/13/25 directed to administer Tamiflu (an antiviral medication for influenza) prophylactic once daily at 8:30 AM.A nurse's note dated 2/14/25 identified that Resident #65 was notified of an influenza outbreak in the facility but declined prophylactic treatment. A nurse's note dated 2/15/25 at 10:35 PM identified Resident #65 reported feeling hot and coughing all day. The note further identified that an on call APRN was notified and treatment orders included influenza testing, Tussin (a cough suppressant) 10 ml every 6 hours for 3 days, and vital signs every shift for 3 days.Review of the clinical record failed to identify that Resident #65's representative had been notified of the resident's symptoms of feeling hot and coughing all day, or the new orders to administer Tussin and obtain an influenza test. Interview with the DNS on 6/4/25 at 10 AM identified that she was unsure of the facility policy regarding change of condition, but did not believe Resident #65's representative should have been contacted since Resident #65 was responsible for self. The DNS identified she would have to look into the matter.The facility policy on change of condition directed that it was the policy of the facility to ensure that changes in the residents' conditions were reported to providers and families. The policy further directed that any alteration in the resident's baseline indicated a potential change of condition. The policy also directed that the facility must immediately inform the resident, consult the resident's physician, and if known, notify the resident's legal representative or interested family member when there was a need to alter treatment significantly.

**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 #44) reviewed for hospitalization, the facility failed to ensure the resident or resident representative were notified of the bed hold policy at the time the resident was sent to the hospital. The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included seizure disorder, chronic lower back pain, and dementia. The census report identified the resident was sent to the hospital on 3/9/25, 3/21/25, and 4/23/25. Review of the clinical record failed to reflect that written notice, which specifies the duration of the bed-hold policy, had been provided to the resident and/or the resident representative when the resident was transferred to the hospital on 3/9/25, 3/21/25, and 4/23/25. Interview with the DNS on 6/2/25 at 10:21 AM indicated that she was not sure but thinks the supervisor sending the resident to the hospital was responsible to send a copy of the bed hold policy with the resident at the time of transfer. The DNS indicated that the supervisor is responsible to make a copy of the discharge packet being sent with the resident to the hospital for the facility's records, but she was aware the supervisors were not doing that. The DNS indicated that she was not sure if the supervisors had been educated to send a copy of the bed hold policy with resident's when they are being transferred to the hospital. After reviewing the clinical record, the DNS indicated there was not documentation that the bed hold policy had been provided to the resident and/or the resident representative when the resident was transferred to the hospital on 3/9/25, 3/21/25, and 4/23/25. Interview with SW #1 on 6/2/25 at 10:27 AM indicated she does not notify the resident or resident representative of the bed hold policy when a resident is sent to the hospital. After review of the clinical record, SW #1 indicated there no documentation regarding the bed hold policy for the hospitalizations on 3/9, 3/21, or 4/23/25. The interview with the Chief Clinical Officer (CCO) on 06/02/25 at 10:42 AM indicated that the nursing supervisor was responsible to provide the bed hold policy to the resident and/or resident representative and make a copy of all the documents being sent with the resident at the time of a hospital transfer. The COO indicated she was aware the facility was not providing the bed hold policy or making copies of the forms being sent with the resident to the hospital. Review of the Notice Regarding Reservation of the Residents Bed if the Resident is hospitalized identified the facility will for a Medicaid - assisted resident, the facility will reserve the bed for up to 7 days if the facility has not received information that the resident is not expected to return to the facility. The facility reserves the bed for up to an additional 8 days if the facility has not received information that the resident is not expected back to the facility. If a Medicaid -assisted resident wishes to reserve the bed during a period of hospitalization for any longer period, the bed will be reserved if payment is made by the resident or resident representative at the facilities usual Medicaid per diem rate. Review of the Bed Hold and readmission Rights Policy identified the purpose was to ensure compliance with federal and state regulations governing the rights related to bed hold. The bed hold is defined as a reservation of a resident's bed during a temporary absence such as hospitalization. Notification requirements upon admission and in advance of any transfer, the resident and his/her representative shall be provided with a copy of the facility's bed hold policy, specifics of any state Medicaid bed old coverage if applicable, and written notice regarding the duration of the bed hold and the residents' rights regarding readmission. A resident's bed will be held for up to 15 days for Medicaid beneficiaries provided the resident is hospitalized , Medicaid or other payer sources authorize the hold, and the resident agrees to any applicable private pay rate if Medicaid does not cover the full bed hold period. The following must be documented: provision of the bed hold notification to the resident or resident representative, bed hold acceptance or decline and applicable payer source, and dates of hospitalization.

**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 6 residents (Resident #19) reviewed for PASARR, the facility failed to ensure the state mental health authority was notified when the resident received a new mental health diagnosis. The findings include: The PASARR dated 9/27/23 indicated a level 2 approval without specialized services. Resident #19 has a diagnosis of major depression, anxiety, and opioid dependance. Resident #19 was admitted to the facility in 10/5/23 with diagnoses that included stoke, fibromyalgia, and chronic pain. The quarterly MDS dated [DATE] identified Resident #19 had moderately impaired cognition, required maximum assistance with toileting and touching assistance with dressing and personal hygiene, had a diagnosis of depression and was receiving antianxiety, antidepressant and opioid medications. a. Review of the census report identified Resident #19 went to the hospital on 8/15/24 to 8/21/24.A physician's order dated 8/21/24 directed to administer Seroquel (antipsychotic medication) 12.5 mg daily at bedtime for delusional disorder. The annual MDS dated [DATE] identified Resident #19 had moderately impaired cognition, had a diagnosis of depression, chronic pain, stroke, and anxiety and was receiving antianxiety, antidepressant, opioid, and antipsychotic medications. Review of the diagnosis page identified Resident #19 received the diagnosis of delusional disorder on 9/19/24.The care plan dated 9/29/24 identified Resident #19 was receiving an antipsychotic medication. Interventions included initiating nonpharmacological interventions and attempting a gradual dose reduction to the lowest possible therapeutic level as indicated by the physician.A psychiatric note, written by APRN #2 dated 10/17/24 identified Resident #19 was on the medication Seroquel for diagnosis of delusional disorder that is moderate in severity. Interview with APRN #2 on 6/3/25 at 8:04 AM indicated Resident #19 had gone to the hospital in August 2024 and returned on Seroquel with a diagnosis of mood and sleep disorder. APRN #2 indicated that Resident #19 started with delusions in the hospital but continues with the delusions now. APRN #2 indicated after her initial reevaluation from the hospital Resident #19 was started on a low dose of Seroquel but due to the delusional symptoms she had increased the Seroquel, and she gave Resident #19 the diagnosis of delusional disorder by 10/17/24. APRN #2 indicated Resident #19 still has periods of delusions and it is still an active diagnosis. b. The quarterly MDS dated [DATE] identified Resident #19 had severely impaired cognition and has a diagnosis of chronic pain. Resident #19 is receiving antidepressant, opioid, and antipsychotic medications. Review of Resident #19's diagnosis report identified a new diagnosis of dementia and paranoia disorder on 12/12/24. A Neurological Consult dated 12/12/24 identified Resident #19 has dementia with hallucinations and paranoia with severe brain atrophy. The nurses note dated 12/12/24 at 12:00 PM noted Resident #19 had returned from the neurological appointment with recommendations to start Donepezil 5 mg at bedtime and Abilify 2mg as needed if Donepezil was not effective for a diagnosis of dementia with hallucinations and paranoia. APRN and resident representative updated. The psychiatric note written by APRN #2 dated 12/19/24 identified Resident #19 had a consultation with a neurological clinic and was started on Donepezil, and Abilify will be added as needed. APRN #2 noted she will add the diagnosis of dementia with hallucinations and paranoia. Interview with the psychiatric APRN, APRN #2, on 6/3/25 at 8:04 AM indicated the resident representative took Resident #19 to a neurological appointment to see if Resident #19 had dementia in mid-December 2024. APRN #2 indicated Resident #19 was given a diagnosis of dementia, hallucinations, and paranoia at that visit. Interview with the Director of social work, SW #1, on 6/3/25 at 8:32 AM indicated that she was responsible for the PASARRs for the residents in the facility. SW #1 indicated she would inform the DNS and MDS of new mental health diagnosis and she would do the new PASARR with the new diagnosis. SW #1 indicates that she took over as the Director earlier this year and did not go back and audit any PASARR's or diagnosis prior to her taking over the position. SW #1 indicates that she has only reviewed PASARR's for the new admissions and for and changes in diagnosis going forward. After clinical record review, SW #1 identified Resident #19 had a level 2 PASARR approval ion 9/27/23 that included the diagnosis of major depression and anxiety. SW #1 indicated when Resident #19 received the new diagnosis of delusional disorder in October 2024 there should have been a new PASARR submitted and when Resident #19 received a new diagnosis of hallucinations, paranoia, and dementia in December of 2024 there should have been another submission to PASARR for re-evaluation. SW #1 indicated that she will submit today to PASARR for a new level 2 re-evaluation with the new diagnosis. Interview with SW #2 on 6/3/25 at 8:38 AM indicated she is a part time social worker now but was the full-time social worker prior to SW #1. SW #2 indicated she was responsible for Level 1 and level 2 PASARR's. SW #2 indicated she was not aware that a PASARR would need to be updated with a new mental health diagnosis until today after discussing it with SW #1. Review of the PASARR Policy identified to ensure compliance with federal and state regulations by identifying residents with mental illness (MI), intellectual disability (ID), or related conditions prior to admission to the facility and providing appropriate care and services. Residents prior to admission will undergo the federal mandated PASARR screening process, consisting of a level 1 and needed then a level 2 screening. Maintain the PASARR documentation in the resident's medical record. Re-screening is required upon a significant change in condition. Notify the PASARR authority if a current resident shows signs of MI or ID not previously identified.

**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 #19 and 86) reviewed for dementia care and/or pain, for Resident #19, the facility failed to develop and implement a comprehensive person centered care plan for dementia and for 1of 2 residents (Resident #86) the facility failed to ensure a comprehensive care plan was developed for a resident with a history of pain. The findings include:2. Resident #86 was admitted to the facility on [DATE] with diagnoses that included anxiety, hypertension, and pain. The physician's orders dated 2/26/25 directed to administer the following.Diclofenac sodium gel 1%, 2 grams topically, apply to the right shoulder, every 6 hours as needed, for pain.Lidocaine adhesive medicated patch 4%, 2 patches topically, apply to both shoulders once daily at 9:00AM and remove at 9:00 PM, for pain.Ibuprofen tablet; 600 mg; 1 tablet by mouth, every 6 hours as needed, for chest or back pain.Tylenol (Acetaminophen); 325 mg: 2 tablets by mouth, every 6 hours as needed, for pain. A physician's order dated 3/5/25 directed that Resident #86 may go LOA independently. The quarterly MDS dated [DATE] identified Resident #86 had intact cognition, was independent with upper and lower body dressing, personal hygiene, and ambulating 10 feet, and had been on a scheduled pain mediation regimen in the last 5 days. Review of the care plan dated 3/26/25 failed to identify Resident #86 had a comprehensive, person-centered care plan that included measurable objectives and goals for his/her diagnosis of pain. The nurse's note dated 4/30/25 at 6:51 PM identified that Resident #86 was alert and oriented, makes his/her own decisions and was seen in Urgent Care today, 4/30/25. Recommendations: x-ray: LS Spine, APRN was made aware. The Urgent Care progress note dated 4/30/25 identified Resident #86 presented today with complaints of lower back pain after falling, while in the hospital, last year. Resident #86 now resides at short term rehab (STR), and reports that the more he/she walks and moves the more the pain hurts; pain is mainly in the lower back and sometimes he/she has pain down the left leg. Resident #86 receives medications and care at STR but wants medications more frequently. The treatment plan directed for Resident #86 was to order an x-ray: LS Spine. The progress note further identified that Resident #86 was getting medications at the STR and there were providers on staff; it was not appropriate to prescribe more medications that were not being reconciled by the STR. The facility's medical APRN's progress note dated 5/1/25 identified Resident #86 was seen today for complaints of bilateral knee pain; resident reported this pain was not new and was requesting pain management. Voltaren cream was ordered to be applied topically 3 times a day. Resident reports that he/she had good effect with Voltaren cream in the past. Resident #86 previously had an Orthopedic (ortho) consult in October of 2024 where knee replacement was not recommended. Follow up with ortho outpatient for chronic knee pain. Interview with Resident #86 on 6/1/25 at 8:30 AM identified that last year he/she fell off a stretcher while in the hospital and has experienced back pain ever since. Resident #86 further identified that in April of this year he/she did not feel like his/her back pain was being well managed at the facility and that the facility staff did not understand that the pain was crippling, at times; Resident #86 took an Uber to the Urgent Care because the facility was not giving him/her the medications that he/she needed. Resident #86 identified that the Urgent Care doctor told him/her that he/she will always have back pain but would need to ensure his/her pain was well managed in order to remain active. Resident #86 further identified that the facility has since made alterations to his/her pain management regimen and he/she is in a much better place with pain management and is also happy to be working with OT (Occupation Therapy). Resident #86 indicated that while his/her pain has been better managed and he/she remains independent with his/her own care and ambulation, he/she would like additional assistance from the nurse aides with tasks that require bending, such as making his/her bed. Interview with the MDS Coordinator (LPN #1) on 6/4/25 at 8:01 AM identified that she had been in her current role for approximately 6 months, and when she first stepped into the position there was a lot of catch-up that needed to be completed with MDS assessments and updating the care plans accordingly. LPN #1 indicated that Resident #86's comprehensive care plan should have included his/her diagnosis of pain with interventions and goals for pain management. LPN #1 further indicated that it was an oversight that Resident #86 did not have a care plan for pain management and that when she identified the oversight on 6/2/25, she created a pain management care plan. LPN #1 identified that she put into place self-audits to ensure all resident care plans are up to date. Interview with the DNS on 6/4/25 at 9:52 AM identified that she would expect Resident #86 to have a comprehensive care plan for pain and it would be the responsibility of the MDS Coordinator to ensure that the care plan was in place. The DNS further indicated that, recently, a new process was put in place to ensure baseline care plans reflect pain management and that pain management care plans were carried over to the comprehensive care pan, in order to ensure residents were properly managed for pain. The facility's Comprehensive Care-Planning policy directs nursing to develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timelines to meet the physical, psychosocial, and functional needs for each resident. The comprehensive, person-centered care plan will: include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, include the resident's stated goals upon admission and desired outcomes, incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strength, reflect the residents expressed wishes regarding care and treatment goals, and identify professional services that are responsible for each element of care. 1. Resident #19 was admitted to the facility in 10/5/23 with diagnoses that included stoke, fibromyalgia, and chronic pain. The quarterly MDS dated [DATE] identified Resident #19 had severely impaired cognition and required maximum assistance with dressing and personal hygiene and total assistance with toileting and dressing. Resident #19 had a diagnosis of chronic pain and was receiving antidepressant, opioid, and antipsychotic medications. The care plan dated 12/1/24 identified Resident #19 was receiving an antipsychotic medication. Interventions included initiating nonpharmacological interventions and attempting a gradual dose reduction to the lowest possible therapeutic level as indicated by the physician. Review of Resident #19's diagnosis report identified a new diagnosis added on 12/12/24 of dementia and paranoia disorder. A Neurological Consult dated 12/12/24 identified Resident #19 has dementia with hallucinations and paranoia with severe brain atrophy. The nurses note dated 12/12/24 at 12:00 PM noted Resident #19 had returned from the neurological appointment with recommendations to start Donepezil 5 mg at bedtime and Abilify 2mg as needed if Donepezil was not effective for a diagnosis of dementia with hallucinations and paranoia. The psychiatric note written by APRN #2 dated 12/19/24 identified Resident #19 had a consultation with a neurological clinic and was started on Donepezil, and Abilify will be added as needed. APRN #2 noted she will add the diagnosis of dementia with hallucinations and paranoia. The care plan dated 2/14/25 failed to reflect the residents diagnoses of dementia or interventions to address such. The interview with APRN #2 on 6/3/25 at 8:04 AM indicated Resident #19 was given a diagnosis of dementia, hallucinations, and paranoia at that visit. The interview with LPN #1 (MDS Coordinator) on 6/3/25 at 9:30 AM indicated she was responsible for updating the care plans. LPN #1 indicated she updates the care plans after admission by day 21 and then quarterly with the care conferences. LPN #1 indicated that there were 2 care plans specific for a diagnosis of dementia that she uses in the EMR for residents. After clinical record review. LPN #1 indicated that Resident #19 did not have a care plan for dementia. LPN #1 indicated that although Resident #19 had care conferences on 2/7/25 and 5/13/25 and she did not add a dementia care plan. Interview with the DNS on 6/3/25 at 9:35 AM indicated that the charge nurse or supervisor were responsible to update the care plans when a resident receives a new diagnosis, but the MDS coordinator, LPN #1, was responsible to make sure the care plans were updated to reflect any changes within the last 90 days. Review of the Comprehensive Care Planning Policy identified nursing was to develop a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs are developed and implemented for each resident. The care planning process will include an assessment of the residents' strengths and needs, incorporate the residents' personal and cultural preferences in developing the goals of care, include measurable objectives and timeframes, incorporate identified problem areas and any risk factors, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident condition changes. Review of the Dementia Care Management Policy identified the facility shall individualize person-centered care for residents with dementia, supporting cognitive function, managing behavioral and psychological symptoms, and ensuring safety. Care plans will be tailored to the residents' cognitive abilities, cultural background, preferences, and history. This policy applies to all licensed nurses, nurse's aides, physicians, consultants, mental health professionals, and the interdisciplinary team members involved in the care of a resident with dementia.

**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 6 residents (Resident #19) reviewed for PASARR and for 1 of 3 residents (Resident #32) reviewed for falls, for Resident #19 the facility failed to have a care plan for the resident who had positive level 2 PASARR and for Resident #32, the facility failed to revise the care plan following a fall with major injury that resulted in hospitalization. The findings include: 1. The PASARR dated 9/27/23 indicated that Resident #19 received a level 2 approval without specialized services. Resident #19 has a diagnosis of major depression, anxiety, and opioid dependance. Resident #19 was admitted to the facility on [DATE] with diagnoses that included stroke, fibromyalgia, and chronic pain. A physician's order dated 10/5/23 directed to administer Cymbalta extended release 30 mg once a day for depression. The quarterly MDS dated [DATE] identified Resident #19 had moderately impaired cognition and required maximum assistance with toileting and required touching assistance with dressing and personal hygiene. Resident #19 had a diagnosis of depression and was receiving antianxiety, antidepressant and opioid medications. The care plan dated 9/29/24 identified Resident #19 was receiving an antipsychotic medication. Interventions included initiating nonpharmacological interventions and attempting a gradual dose reduction to the lowest possible therapeutic level as indicated by the physician.The psychiatric note, written by APRN #2 dated 10/17/24 identified Resident #19 was on the medication Seroquel for diagnosis of delusional disorder that is moderate in severity. The psychiatric note written by APRN #2 dated 12/19/24 identified Resident #19 had a consultation with a neurological clinic and was started on Donepezil, and Abilify will be added as needed. APRN #2 noted she will add the diagnosis of dementia with hallucinations and paranoia. The care plan dated 1/1/25 failed to reflect Resident #19 has dementia, hallucinations, paranoia, or delusions or interventions to address such. Interview with SW #2 on 6/3/25 at 8:38 AM indicated she was the social worker when Resident #19 was admitted but she thought the MDS Coordinator was responsible to develop the care plan related to level 2 PASARR's. After clinical record review. SW #2 indicated there was not a care plan for the positive level 2 PASARR. SW #2 indicated that any resident that has a positive level 2 should have a specific care plan for the positive level 2 care plan. The interview with LPN #1 (MDS Coordinator) on 6/3/25 at 9:30 AM indicated she was responsible for updating all the care plans. LPN #1 indicated indicate social service was responsible to develop the initial level 2 PASARR care plan and she was responsible to update them quarterly if needed. The interview with the DNS on 6/3/25 at 9:40 AM indicated that the charge nurse or supervisor was responsible to do the baseline care plan on admission and the MDS Coordinator was responsible to develop the comprehensive care plan by day 21. The DNS indicated the social workers were responsible for all level 2 PASARR care plans. After surveyor inquiry, the care plan dated 6/3/25 identified Resident #19 had been determined a positive Level II. Resident #19 has the potential for altered thought process and difficulty adjusting to situations. Resident has the potential for alteration in psycho-social wellbeing. Interventions included for social services consult as needed, psychiatric supportive care as ordered and as needed, AIMS testing per facility protocol. Gradual dose reduction as ordered.Review of the Dementia Care Management Policy identified the facility shall individualize person-centered care for residents with dementia, supporting cognitive function, managing behavioral and psychological symptoms, describe any specialized services to be provided because of PASARR recommendations, and ensuring safety. Care plans will be tailored to the residents' cognitive abilities, cultural background, preferences, and history. This policy applies to all licensed nurses, nurse's aides, physicians, consultants, mental health professionals, and the interdisciplinary team members involved in the care of a resident with dementia. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, congestive heart failure, and hypertension.The quarterly MDS dated [DATE] identified Resident #32 had moderately impaired cognition, was always continent of bowel and bladder, was independent with dressing and toileting, and required set up for bathing.The care plan dated 3/13/25 identified Resident #32 was at risk for falls. Interventions included to monitor for changes in ADL status, cognition, mood, behaviors, continence, and gait/balance.Review of a facility A&I report dated 4/17/25 identified Resident #32 had an unwitnessed fall on 4/17/25. The A&I report identified Resident #32 had no visible injuries but reported chest pain and was transported to the hospital for evaluation. Review of the clinical record identified Resident #32 was hospitalized from [DATE] - 4/25/25 for acute kidney injury on chronic kidney injury and fluid volume overload. The documentation also identified Resident #32 sustained left rib fractures (5th, 6th, 7th and 8th) related to the unwitnessed fall prior to hospital admission. Review of the clinical record failed to identify any revisions of Resident #32's care plan related to falls including interventions following readmission to the facility on 4/25/25.Interview with the DNS on 6/4/25 at 10:00 AM identified that Resident #32's care plan should have been revised related to Resident #32's unwitnessed fall on 4/15/25. The DNS identified while she had reviewed the hospital discharge paperwork and documentation related to Resident #32's hospitalization, she was not aware that Resident #32 sustained multiple rib fractures as a result of the 4/15/25 fall. The facility policy on falls directed that all residents would be assessed for falls upon admission and reassessments would be done upon a change of condition and as needed (i.e. after a fall incident) and that interventions would be implemented according to the resident's identified needs.The facility policy on Comprehensive Care Planning directed that assessments of residents were ongoing and care plans were revised as information about the residents and residents' condition changed. The policy also directed that the resident care plan must be reviewed and updated when the resident had a significant change in condition and when the resident was readmitted to the facility following a hospital stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #43, 32, 44, 62 and 65) the facility failed to provide care according to professional standards of practice. For 1 resident (Resident #43) reviewed for death, the facility failed to ensure medications were administered according to the physician's orders, failed to obtain blood sugar and blood pressures as ordered, failed to follow the physician's order to notify the physician with a blood sugar outside the parameter and failed to complete ongoing assessments after the resident experienced a change in condition. For Resident #32 the facility failed to obtain weights according to the physician's order.For 1 of 4 residents (Resident #44) reviewed for skin condition, the facility failed to ensure a newly identified open area was assessed upon identification and weekly until healed.For 1 of 4 residents (Resident #62) reviewed for skin conditions, the facility failed to complete and document skin checks as per the physician's order and facility policy. For Resident #65 the facility failed to complete vital signs according to the physician's order. 1a. The hospital Discharge summary dated [DATE] identified Resident #43 was admitted to the hospital on [DATE] with diagnoses of acute heart failure with reduced ejection fraction (HFrEF) with hypertensive emergency due to medication nonadherence. Newly reduced Left Ventricular Ejection Fraction (LVEF) of 32%, hypertension emergency due to medication noncompliance. Comorbidities present on admission were diabetes type 2, hypertension, gout, gunshot wound to abdomen, chronic back pain, status post splenectomy, and Covid-19. Secondary diagnoses occurred during hospitalization included acute kidney injury, and diabetes with hyperglycemia. Resident #43 was discharged from the hospital on 2/26/25. Resident #43 was admitted to the facility on [DATE] with diagnoses that included chest pain, chronic congestive heart failure, hypertension, and diabetes.The care plan dated 2/27/25 identified Resident #43 was at risk for abnormal glucose levels, hypo/hyperglycemia secondary to diabetes. Interventions included to administer diabetic medications and/or Insulin as ordered.The admission MDS dated [DATE] identified Resident #43 had intact cognition and was independent with personal hygiene.The consultant cardiologist recommendations dated 4/30/25 included to start on SGLT2 inhibitor (medication used to treat type 2 diabetes) either Jardiance or Farxiga 10mg daily.The consultant visit summary dated 4/30/25 identified the heart failure with reduced ejection fraction was addressed. The form indicated to pick up Jardiance at an outside Pharmacy.The physician's order dated 5/1/25 directed to administer Jardiance 10 mg tablet (used to manage type 2 diabetes, heart failure, and chronic kidney disease (CKD) once a day at 8:30 AM. Review of the pharmacy documentation dated 5/1/25 at 8:47 AM identified medication not covered (Jardiance 10mg tablet once daily). An outside pharmacy filled and dispensed the medication. Resident #43 called the outside pharmacy yesterday (4/30/25) and requested all medications be filled and delivered to his/her significant other at his/her prior address.The nurse's note dated 5/1/25 at 12:38 AM identified Resident #43 was seen by the cardiologist on 4/30/25 related to recent heart failure and ejection fraction diagnoses. Recommendations to start either Jardiance or Farxiga 10mg daily. The care plan dated 5/1/25 identified Resident #43 had a recent diagnoses of chronic systolic heart failure (4/30/35) and was at risk for or complication due to disease process. Interventions included monitoring cardiorespiratory symptoms, increasing fatigue, and to administer medications as ordered. Further, the care plan dated 5/1/25 identified Resident #43 was at risk for alteration in cardiac output related to recent diagnosis of chronic systolic heart failure on 4/30/25. Interventions included to administer medications as ordered. The nurse's note dated 5/2/25 at 12:21 AM by RN #9 identified she spoke with the facility pharmacy regarding Resident #43 calling and telling the outside pharmacy that the medication would be picked up by his/her significant other. RN #9 indicated she would educate Resident #43 to not have anyone pick up medication while residing in the facility. The note failed to reflect that the physician, APRN, cardiologist, or the DNS were notified.The nurse's note dated 5/8/25 at 8:34 PM by RN #6 identified Resident #43 was seen by the nephrologist on 5/7/25 and the plan of care was to continue Entresto, start Jardiance, and follow up with the cardiologist for perfusion scan and echocardiogram.Review of the APRN notes dated 5/8/25 and 5/13/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. The physician's order dated 5/29/25 directed to check blood pressure and pulse once a day at 9:30 AM. Review of the MAR dated 5/1/25 - 6/3/25 identified although the Jardiance 10mg was scheduled to be administered daily at 8:30 AM, the medication was not administered. The MAR identified the drug was unavailable and awaiting delivery from the pharmacy from 5/1/25 - 6/3/25, a total of 34 days.Review of the APRN note dated 6/3/25 identified Resident #43 had a nephrologist consultation on 5/7/25. Nephrologist recommendations included to continue Entresto and Jardiance. Chronic systolic heart failure (LVEF 32%). The APRN note failed to reflect documentation that she had been notified by the nursing staff that Resident #43 was not receiving the Jardiance daily at 8:30 AM per the physician's orders. Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, APRN, cardiologist, or the DNS were notified that Resident #43 was not receiving the Jardiance per the physician's order from 5/1/25 - 6/3/25 (total of 34 days). Interview with APRN #3 on 6/6/25 at 2:53 PM identified she was not aware that Resident #43 was not receiving the Jardiance as ordered from 5/1/25 - 6/3/25, and that the pharmacy had not sent the medication to the facility. APRN #3 indicated the Jardiance was prescribed by a specialist (cardiologist). APRN #3 indicated when Resident #43 was first admitted to the facility, the facility was having issues with the medications being sent to his/her personal pharmacy. APRN #3 indicated if she had known the resident was not receiving the Jardiance due to a pharmacy issue, she would have had a discussion with the DNS and called the pharmacy.Interview with the DNS on 6/6/25 at 3:02 PM identified she was not aware that Resident #43 was not receiving the Jardiance from 5/1/25 - 6/3/25 (34 days), or that the Jardiance was never delivered to the facility. The DNS indicated had she known, she would have called the pharmacy and had the pharmacy bill the facility for the Jardiance. The DNS indicated that she would expect the licensed nurses to administer medication per the physician's order. Interview with RN #6 on 6/6/25 at 3:18 PM identified she recalled a conversation with the pharmacy at the beginning of May 2025 regarding the Jardiance. RN #6 indicated she passed the information onto the on-coming supervisor. RN #6 indicated she does not remember which supervisor. Interview with RN #1 on 6/9/25 at 12:26 PM identified she was not aware Resident #43 was not receiving the Jardiance from 5/1/25 - 6/3/25 (34 days), or that the Jardiance was never delivered to the facility. RN #1 indicated if she was aware of the Jardiance had not been delivered, she would have called the pharmacy and notified the DNS immediately. RN #1 indicated she would have informed the pharmacy to send the medication, and the facility would have been billed.Interview with MD #5 (cardiologist) on 6/10/25 at 10:27 AM identified he last saw Resident #43 on 4/30/25 at his office. MD #5 indicated Resident #43 had been admitted to the hospital in February 2025, with systolic heart failure, and heart failure with reduced ejection fraction (32%) with hypertensive emergency which caused pulmonary edema, and other comorbidities. MD #5 indicated on 4/30/35 he ordered Resident #43 to receive Jardiance 10mg once a day. MD #5 indicated he was not aware that Resident #43 never received the medication. MD #5 indicated his expectation is that the nurses should have administered the medication per the physician's order. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not aware that Jardiance 10mg was recommended to be given daily. MD #1 indicated he did not receive a phone call from the facility on 4/30/25 or 5/1/25 informing him that the cardiologist recommended Jardiance to be administered daily. MD #1 indicated he did not order Jardiance to be administered, and he was not aware that Resident #43 did not receive the Jardiance from 5/1/25 - 6/3/25 (total of 34 days). MD #1 indicated the nurse should administer medication per the physician's order. Although attempted, an interview with RN #7, and RN #8 was not obtained.Review of the facility medication unavailable policy identified in the event that medication is unavailable for any reason the facility shall act promptly to notify appropriate practitioners for orders to be followed and the pharmacy to obtain medications in accordance with the updated orders. The facility shall investigate all instances where medications are not available, to assess whether appropriate actions were taken to ensure continuity of care. Upon identifying that a medication is apparently unavailable, immediately notify the nursing supervisor. Contact the pharmacy to determine when medication will be available. Inform the prescriber/attending; and in their absence, the Medical Director and obtain orders. Document actions and prescriber orders on 24 hour report, MD order sheet, and chart.b. The physician's order dated 5/1/25 - 5/31/25 directed to administer the following medications: Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Gabapentin 300mg capsule (for pain) at bedtime at 8:30 PM.Lantus Insulin U-100 unit/ml (diabetes) give 25 units subcutaneous at bedtime at 8:30 PM. Lipitor 80mg tablet (for hyperlipidemia) once a day at 8:30 PM. Miralax 17grams (for constipation) twice a day at 8:30 AM and 8:30 PM.Ozempic 4mg/3ml, 1mg/dose subcutaneous (for diabetes) on Mondays at 8:30 AM.Senna 8.6mg tablet (for constipation) twice a day at 8:30 AM, and 8:30 PM. Review of the May 2025 MAR identified the following. Coreg 25mg was not administered on 5/1/25 at 4:30 PM, 5/2/25 at 8:30 AM, 5/5/25 at 8:30 AM, 5/6/25 at 8:30 AM, 5/19/25 at 8:30 AM, and 5/28/25 at 8:30 AM. Gabapentin 300mg was not administered on 5/20/25 at 8:30 PM.Lantus Insulin U-100 unit/ml was not administered on 5/20/25 at 8:30 PM.Lipitor 80mg was not administered on 5/20/25 at 8:30 PM.Miralax 17grams was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 PM.Ozempic 4mg/3ml give 1mg/dose was not administered on 5/5/25 at 8:30 AM, and 5/20/25 at 8:30 AM.Senna 8.6mg was not administered on 5/20/25 at 8:30 PM. c. The physician's order dated 6/1/25 - 6/3/25 directed the following. Coreg 25mg tablet (for hypertension) with breakfast and dinner twice a day at 8:30 AM and 4:30 PM.Daily Blood Pressure and Pulse once a day at 9:30 AM.Daily Weights before breakfast (for chronic systolic congestive heart failure) once a day at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous (for diabetes) once a day on Mondays at 8:30 AM.Review of the June 2025 MAR dated identified the following. Coreg 25mg was not administered on 6/2/25 at 8:30 AM, and 4:30 PM.Daily Blood Pressure and Pulse was not recorded on 6/2/25 at 9:30 AM. Daily Weights were not obtained on 6/2/25 at 7:30 AM. Ozempic 4mg/3ml give 1mg/dose subcutaneous was not administered on 6/2/25 at 8:30 AM.Review of the nurse's note dated 5/1/25 - 6/3/25 failed to reflect documentation that the physician, and the APRN, were notified that Resident #43 did not receive medications on 5/1/25, 5/2/25, 5/5/25, 5/6/25, 5/19/25, 5/20/25, 5/28/25, and 6/2/25. d. The physician's orders dated 5/1/25 - 6/3/25 directed the following. Check Blood Sugar before meals (for diabetes) at 7:30 AM, 11:30 AM, and 4:30 PM. Special Instructions: If Blood Sugar is less than 80mg/dl and greater than 450mg/dl call MD/APRN. Review of the May 2025 and June 2025 MAR identified the following.The blood sugar on 5/6/25 at 11:30 AM was 76mg/dl.The blood sugar on 5/14/25 at 7:30 AM was 73mg/dl.The blood sugar on 5/15/25 at 7:30 AM was 71mg/dl.The blood sugar on 6/2/25 at 7:30 AM was 54mg/dl. Review of the nurse's note dated 5/1/25 - 6/4/25 failed to reflect documentation that the physician was notified when the residents blood sugar was low 5/6/26, 5/14/25, 5/15/25, and 6/2/25. Further, the notes failed to reflect documentation of an RN assessment and follow up assessment regarding the low blood sugars.e. The care plan dated 5/1/25 identified Resident #43 has a history of hypertension. Interventions included to monitor blood pressure every shift. The physician's order dated 5/1/25 - 5/28/25 directed to monitor blood pressure every shift, Days, Evening, and Nights.Review of the May 2025 MAR failed to reflect blood pressure monitoring. Review of the vital sign form identified the following missing blood pressures.5/1/25 evening and night, 5/2/25 day and night, 5/3/25 evening and night, 5/4/25 evening and night, 5/5/25 day and night, 5/6/25 day and night, 5/7/25 and 5/8/25 nights, 5/9/25 evening and night, 5/10 /25 - 5/13/25 nights, 5/14/25 evening and night, 5/15/25 night, 5/16/25 evening and night, 5/17/25 evening and night, 5/18/25 night, 5/19/25 day and night, 5/20/25 night, 5/21/25 - 5/27/25 nights, 5/28/25 day, evening, and night.The nurse's note dated 5/1/25 - 5/28/25 failed to reflect documentation that the physician was notified that blood pressure was not monitored as ordered. f. The nurse's note dated 6/3/25 at 5:39 PM by RN #6 identified Resident #43 complained of feeling nauseated with no vomiting and was observed with visible tremors. Vital signs identified a temperature of 98.2 F, pulse 135, respiration rate 18, blood pressure 120/85, oxygen saturation 98% on room air. APRN #3 was notified and recommended Zofran 4mg every 6 hours as needed for nausea times 5 days. Will reassess. Review of the nurse's note dated 6/3/25 after 5:39 PM - 6/4/25 at 5:07 AM failed to reflect documentation of an RN reassessment following the pulse of 135 and feeling of nausea. Interview with RN #1 on 6/9/25 at 12:26 PM identified she was not aware Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. RN #1 indicated it is the responsibility of the licensed nurses to administer the medication per the physician's order. RN #1 indicated the licensed nurses should have notified the physician or the APRN when the medications were not given and document the omissions in the resident clinical record. Interview with the DNS on 6/10/25 at 10:11 AM identified she was not aware that Resident #43 had missed several medications between 5/1/25 - 6/3/25 on multiple occasions. The DNS indicated the licensed nurses should have notified the physician, or the APRN when Resident #43 did not receive his/her medications, when the blood sugars were low, and when blood pressure was not monitored as ordered. The DNS indicated that she would expect the licensed nurses to administer the medication per the physician's order. The DNS indicated she was not aware Resident #43 had complained of nausea and had a pulse of 135, and indicated a follow-up RN assessment should have been performed. Interview with MD #1 on 6/10/25 at 6:27 PM identified he was not notified that Resident #43 was not receiving some of the medications between 5/1/25 - 6/3/25 on multiple occasions and when blood pressure was not monitored as ordered. Further, MD #1 indicated the licensed nurses should have notified him or the APRN when Resident #43's blood sugar was low on multiple occasions, and blood pressure was not monitored as ordered. MD #1 indicated the license nurse should administer the medication per the physician's order.Review of the facility medication administration policy identified the facility is to provide a safe and effective medication management framework to help eliminate any harm that could be caused at any level of the medication management process. To ensure that licensed facility staff will adhere to proper safety precautions in the administration of all medications. Administration: The medication should be administered using the 5 Rights. Right resident, right medication, right dose, right route, and right time. Review of the facility compliance with and implementation of physician's orders policy identified all physician orders are implemented accurately, timely, and in accordance with applicable federal and state regulations. Review of the facility taking a blood pressure policy identified to measure the force at which the heart pumps and returns blood. Notify the provider of the results and correctly document the results in the resident's record in the electronic record. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, congestive heart failure, and hypertension.The quarterly MDS dated [DATE] identified Resident #32 had moderately impaired cognition, was always continent of bowel and bladder, was independent with dressing and toileting, and required set up for bathing.The care plan dated 3/13/25 identified Resident #32 was at risk for falls. Interventions included to monitor the resident for changes in ADL status, cognition, mood, behaviors, continence, and gait/balance.Review of a facility A&I report dated 4/17/25 identified Resident #32 had an unwitnessed fall on 4/17/25. The A&I report identified Resident #32 had no visible injuries but reported chest pain and was transported to the hospital for evaluation. Review of the clinical record identified a hospital discharge which identified Resident #32 was hospitalized from [DATE] - 4/25/25 for acute kidney injury on chronic kidney injury and fluid volume overload. The documentation also identified Resident #32 sustained left rib fractures (5th, 6th, 7th and 8th) related to the unwitnessed fall prior to hospital admission. A physician's order dated 4/25/25 directed to obtain daily weights and report any weight gain of 2 - 3 lbs. to the physician.The care plan dated 4/26/25 identified Resident #32 was at risk for decline in condition due to acute kidney injury. Interventions included to monitor for fluid buildup including edema, cough, congestion, and weight gain. Review of the clinical record failed to identify any weight documentation for Resident #32 on the following dates: 4/27, 5/1, 5/2, 5/4, 5/5, 5/6, 5/9, 5/17, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, and 5/27/25.Interview and review of Resident #32's clinical record with the DNS on 6/4/25 at 10:00 AM identified Resident #32 frequently refused to allow care and the missing weight documentation was likely related to this. The DNS identified that the nursing staff should document in the clinical record when Resident #32 refused weights and notify the physician if weights were refused for multiple days.The facility policy on weights directed that the facility would utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in residents. The policy also directed weights would be obtained on admission, weekly for 4 weeks, and then monthly unless otherwise ordered by the physician. The facility policy on Compliance with and Implementation of Physician's Orders directed that orders must be carried out as written unless contraindicated, and in such cases, the physician must be notified, and the documentation must reflect clinical rationale. 3. Resident #44 was admitted to the facility on [DATE] with diagnoses that included seizure disorder, chronic lower back pain, and dementia. The quarterly MDS dated [DATE] identified Resident #44 had severely impaired cognition, was frequently incontinent of bowel and always incontinent of bladder and required moderate assistance with personal hygiene and touching assistance with transfers and ambulation. Further, the MDS identified Resident #44 was at risk for developing a pressure ulcer or injury and had a pressure reducing device for the bed. The care plan dated 3/19/25 identified the resident was at risk for skin breakdown related to incontinence. Interventions included elevating the heels while in bed and turning and repositioning resident at least every 2 hours. A physician's order dated 3/19/25 directed a stand pivot transfer with assistance of 2 staff, may use a mechanical lift (hoyer) as needed. The nurses note dated 3/20/25 at 1:57 PM, written the wound nurse, (RN #1) identified Resident #44 was lethargic lying in bed and had a change in mental status. Resident #44 was noted to have a pinpoint opening to the right ankle. RN #1 noted order in place for zinc oxide daily then cover with a dry clean dressing. The nurses note dated 3/20/25 at 1:59 PM, written by LPN #2, identified Resident #44 has a pinpoint opening to the right ankle, treatment ordered and done. Blue boots applied to off load pressure on the right ankle. The APRN #1's progress note dated 3/20/25 identified Resident #44 had a pinpoint open area to the lateral right ankle with treatment. A physician's order dated 3/20/25 directed to cleanse the right ankle with normal saline then apply zinc oxide daily during the 3:00 PM - 11:00 PM shift. Review of the nurses and ARPN/physician notes dated 3/20/25 to 4/17/25 failed to reflect an assessment of the right ankle including wound classification, size, description of the wound bed, description of the surrounding tissue, or if there was drainage or an odor. A physician's order dated 4/17/25 directed to discontinue right ankle treatment.A physician order dated 5/4/25 directed to apply heel boots while in bed.Interview with the RN #1 (wound nurse) on 6/2/25 at 10:57 AM indicated when there is a new wound or pressure area there would be an RN assessment in the progress notes or in the wound documentation section. RN #1 indicated she would be responsible to notify the physician and obtain an order for treatment and place the resident on the weekly wound rounds with the Wound Physician, (MD #2). RN #1 indicated that once MD #2 is notified of a new wound, he follows the wound weekly on Tuesdays until it is healed. RN #1 indicated as the facility RN wound nurse she makes weekly wound rounds with MD #2. RN #1 indicated the initial RN assessment should be documented in a progress note and must include the site, classification of pressure or non-pressure, description and measurements, drainage or not, and the surrounding tissue. RN #1 indicated that the weekly wound assessments would include all the same documentation. After clinical record review, RN #1 indicated she was the RN that evaluated the new right ankle wound on 3/20/25 but did not measure the wound, document a description of the wound or surrounding tissue, or classify the wound. RN #1 indicated that it was a small round open area on the lateral right ankle. RN #1 indicated that she put the treatment order in the EMR, but after review identified the treatment order was not a complete order. RN #1 indicated that she would expect weekly measurements until healed but did not see any documentation of such. RN #1 indicated when a treatment gets discontinued there should be a progress note explaining why it was discontinued. RN #1 indicated that she discontinued the treatment to the ankle on 4/17/25 but does not recall why and there was not a progress note explaining such. RN #1 indicated she would assume it healed. Interview with LPN #2 on 6/2/25 at 11:27 AM, who wrote a note on 3/20/25 at 1:59 PM, indicated that during morning care that day, the nurse aide had notified her that Resident #44 had an open area to the outside of the right ankle. LPN #2 indicated that she notified RN #1 who was the supervisor. LPN #2 indicated she thought the area was pressure from how Resident #44 would lie on the bed. LPN #2 indicated that the APRN had seen Resident #44 that day and ordered a treatment and she obtained the blue pressure relieving boots. Interview with the DNS on 6/2/25 at 11:34 AM indicated that if a new open area is found her expectation is that the RN supervisor would complete and document a wound assessment of the area including measurements, description of the wound bed and surrounding tissue, odor or drainage. Further the DNS indicated weekly wound assessments should be done until healed. After clinical record review, the DNS indicated there was not a complete initial RN assessment, weekly wound assessments documented, and MD #2 was not following weekly. The DNS indicated that her expectation RN #1 should have written a note when she discontinued the treatment to the right ankle on 4/17/25. Interview with MD #2 (wound physician) on 6/3/25 at 8:20 AM indicated if he was notified that the resident had a new open area on the ankle he would have assessed the wound, wrote a consultation note making recommendations, and ordered bilateral heel lift boots and a treatment. Further, MD #2 identified he would have followed the resident weekly until the wound healed. MD #2 indicated that he was not informed of the open area to the resident's ankle. Although attempted, an interview with APRN #1 was not obtained. Review of the Skin and Wound Management Policy identified the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers for example, immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall describe and document the following: full assessment of pressure sores including location, stage, length, width, and depth, presence of exudate or necrotic tissue. Pain assessment, resident's mobility status, current treatments and al active diagnosis. A registered nurse will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Residents with pressure ulcers and/or other skin conditions will be seen and followed by the facilities wound physician. Review of the Pressure Ulcer Identification Policy identified a pressure ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. Pressure ulcers occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of soft tissue. 4. Resident #62 was admitted to the facility on [DATE] with diagnoses that included stage 3 pressure ulcer of the left buttock, disorder of the skin and subcutaneous tissue, cellulitis of an unspecified part of limb, and diabetes mellitus due to an underlying condition with diabetic neuropathy. A physician's order dated 3/27/25 directed to complete a body audit weekly on shower days, Monday; 7:00AM - 3:00 PM and complete quarterly observations: Braden Scale (Braden Scale is a tool used to assess a resident's risk of developing a pressure ulcer), every 90 days on the 27th day of March, June, September, and December; 3:00 PM - 11:00 PM.The quarterly MDS dated [DATE] identified Resident #62 had intact cognition, was frequently incontinent of bowel and bladder, required substantial/maximal assistance with toileting hygiene, required partial/moderate assistance with rolling left to right, sitting to standing, and chair/bed-to-chair transfers, had one or more unhealed pressure ulcers/injuries, and was at risk for developing pressure ulcers/injuries.The care plan dated 4/13/25 identified Resident #62 had an actual skin impairment as evidenced by: left ischial tuberosity opening. Interventions included reporting any skin changes to the physician/APRN, as necessary, and completing weekly skin checks.Review of the 2025 Weekly Nurses Note and Skin Check documents failed to identify documentation that skin checks were completed weekly as ordered between 1/1/25 through 5/4/25, and 5/19/25 through 5/31/25. Two weekly skin checks were completed during the week of 5/12/25 (1 out of 22 weeks). Interview and review of the clinical record with the DNS on 6/3/25 at 9:45 AM failed to provide documentation that weekly skin checks were completed, in accordance with the physician's orders. The DNS indicated that she had already identified that some nursing observations were not being documented in the clinical record, including weekly skin observations. The DNS further indicated that she has implemented a new process for the RN Supervisor to review the Charged Nurses' observation documentation, at the end of each shift. The DNS identified that she would expect to see weekly skin observations being completed, but the nurses had been completing frequent Braden Scales. The DNS indicated that additional staff education would be initiated to ensure that the nurses were completing both weekly skin observations and Braden Scales in accordance with the physician's order. Interview with LPN #3 on 6/3/25 at 12:35 PM identified that she could not recall if she had ever been assigned to Resident #62 on his/her shower day, as she floated to different units within the facility. LPN #3 indicated that it was the responsibility of the nurse assigned to the resident on the resident's shower day to complete the weekly skin observations. LPN #3 further indicated that after the skin observation has been completed, the nurse should document that the task was completed on the Treatment Administration Record (TAR) and document if the skin was intact or if a new skin issue has been identified on the Weekly Skin Check document. LPN #3 identified that Braden Scale and weekly skin observations were different, and both should be completed, per the physician's order. The facility's Skin and Wound Management policy directs a risk assessment to be completed if there is a significant change in condition, or as often as is required based on the resident's condition. The following information should be recorded in the residence medical record utilizing facility forms: type of assessment conducted, date, time, and type of skin care provided, name and title of the individual who conducted the assessment, any change in the resident's condition, the condition of the skin, how the resident tolerated the procedure or his/her ability to participate in the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment, observations of anything unusual exhibited by the resident, and documentation addressing family, guardian, or resident notification if a new skin alteration was noted. 5. Resident #65 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, spinal stenosis, and chronic obstructive pulmonary disease (COPD).The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing, and dressing.The care plan dated 1/23/25 identified Resident #65 was at risk for contracting influenza and had refused the influenza vaccine. Interventions included to reapproach the resident to offer the vaccine as indicated. Review of an influenza outbreak surveillance tracking list for 2/2025 identified that the facility has an influenza outbreak that began on 2/3/25.A nurse's note dated 2/14/25 at 11:27 AM identified that Resident #65 was notified of an influenza outbreak in the facility but declined prophylactic treatment. A nurse's note dated 2/15/25 at 10:35 PM identified Resident #65 reported feeling hot and coughing all day. The note further identified that an on call APRN was notified and treatment orders included influenza testing, Tussin (a cough suppressant) 10 ml every 6 hours for 3 days, and vital signs every shift for 3 days.A physician's order dated 2/16/25 directed to obtain vital signs every shift (days,

**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 #142) reviewed for pressure ulcers, the facility failed to ensure an RN assessment of a pressure ulcer was completed on admission. The findings included:Review of the hospital Discharge summary dated [DATE] identified Resident #142 was admitted to the hospital on [DATE] and discharged on 1/25/25. Resident #142 had left foot osteomyelitis, and a debridement with a left trans metatarsal amputation (TMA). Surgery was consulted for wound debridement to sacral wound growing pseudomonas. Recommendations included to continue local wound care and no plan for surgical debridement given resident's heart failure exacerbation and Covid-19 status.Resident #142 was admitted to the facility on [DATE] with diagnoses that included diabetes, congestive heart failure, and osteomyelitis. The diagnoses form failed to reflect documentation of the stage 4 sacral pressure ulcer, and left trans metatarsal amputation (TMA).The nurse's note dated 1/25/25 at 6:00 PM by RN #2 identified Resident #142 arrived from the hospital with oxygen at 2 Liters via nasal cannula with no complaints of pain. Left arm PICC line and foley catheter in place. Left foot amputation wrapped with gauze, and stage 4 coccyx wound covered with Mepilex foam dressing. Review of the admission Braden Scale by RN #2 dated 1/25/25 at 6:28 PM identified Resident #142 was at mild risk for skin breakdown.Review of the admission observation form by RN #2 dated 1/25/25 at 6:54 PM identified Resident #142 alterations in skin assessment were not completed. The admission observation form failed to reflect documentation of a pressure ulcer assessment.Review of the physician's order dated 1/25/25 - 1/29/25 failed to reflect documentation for an order to apply an LAL mattress, and specialty cushion for the wheelchair.A physician's order dated 1/26/25 directed to medicate prior to wound care twice a day at 8:30 AM and 4:30 PM. Tylenol 650mg tablet every 6 hours for pain at 12:30 AM, 6:30 AM, 12:30 PM, and 6:30 PM. Oxycodone 5mg tablet every 8 hours as needed for pain. Morphine 15mg tablet at bedtime at 8:30 PM for pain management. A physician's order dated 1/27/25 directed to monitor for pain every shift with appropriate pain scale, wound consult as needed and administer Amoxicillin-Potassium Clavulanate (antibiotic) 875mg - 125mg tablet every 12 hours at 8:30 AM and 8:30 PM for osteomyelitis. Further, perform weekly body audit on shower day during 3:00 PM - 11:00 PM shift every Wednesday.Additionally, pack sacral wound with 1/4 strength Dakin's solution wet to dry gauze followed by dry clean dressing once a day on the 7:00 AM - 3:00 PM shift and as needed. The wound physician consult dated 1/29/25 identified Resident #142 was seen for initial evaluation and treatment recommendations regarding stage 4 pressure injury to sacrum. Resident #142 was on Doxycycline and Amoxicillin (antibiotics). A wound care assessment was performed, measurement 13 cm x 12 cm x 3 cm, with moderate serosanguinous drainage, 100% necrotic, foul-smelling drainage, and debridement done on 1/29/25. Treatment Dakin 1/4 strength wet to moist packing for now. Recommended Resident #142 to be sent back to the hospital for evaluation of the sacrum wound. Wound needs surgical debridement under anesthesia as wound is infected that showed necrotic tissue to bone with foul smell. Resident #142 would not be able to tolerate bedside debridement performed today needs more invasive intervention. A physician's order dated 1/29/25 directed to send Resident #142 to the hospital for evaluation due to sacral wound infection. The nurse's note date 1/29/25 failed to reflect documentation for the 7:00 AM - 3:00 PM shift regarding the wound physician's assessment and recommendation.The nurse's note dated 1/29/25 at 8:52 PM by RN #3 identified the 7:00 AM - 3:00 PM supervisor indicated to her that the wound physician assessed Resident #142 sacral pressure ulcer wound today and directed to transfer Resident #142 to the hospital for evaluation secondary to sacral pressure ulcer wound infection. Resident #142 was transferred to the hospital at 4:05 PM. Interview and clinical record review with the DNS on 6/3/25 at 6:45 AM identified she was not aware that the stage 4 sacral pressure ulcer was not assessed by a Registered Nurse upon the resident's admission to the facility. The DNS indicated it is the RN supervisor's responsibility to assess wounds on new admissions. The DNS indicated if she was aware that a wound assessment was not completed on Resident #142 on admission day, she would have completed the assessment on Monday 1/27/25. Interview and clinical record review with RN #1 on 6/3/25 at 12:42 PM identified she was not aware that a wound assessment was not performed and documented on Resident #142 on admission. RN #1 indicated if she was aware of the issue she would have performed the wound assessment. RN #1 indicated it is the responsibility of the RN supervisor on admission to perform the wound assessment and document.Interview with MD #2 on 6/4/25 at 10:04 AM identified his initial assessment of Resident #142 was on 1/29/25. MD #1 indicated Resident #142 should not have been discharged from the hospital with an infected stage 4 sacral pressure ulcer. MD #2 indicated Resident #142 was compromised and had many comorbidities and was on antibiotics. MD #2 indicated he assessed the wound and recommended that Resident #142 be transferred to the hospital for wound evaluation. MD #2 indicated the nursing supervisor should have completed a thorough wound assessment with measurements, description of the wound, and documented the findings in Resident #142 clinical record on admission.Although attempted, an interview with MD #4, and RN #2 was not obtained.Review of the facility skin and wound management policy identified the nursing staff will assess and document an individual's significant risk factors for developing pressure ulcer, for example, immobility, recent weight loss, and a history of pressure ulcers. A registered nurse will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The nurse shall describe and document/report the following: Full assessment of pressure ulcer including location, stage, length, width, depth, presence of exudates or necrotic tissue, and pain.

**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 #36) reviewed for discharge, the social worker failed to assist the resident when he/she requested to be transferred to another facility. The findings include: Resident #36 was admitted to the facility in January 2023 with diagnoses that included chronic pain, thoracic intervertebral disc degeneration, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #36 had intact cognition and required supervision with toileting, dressing, and personal hygiene. Review of the January 2025 monthly physician's orders identified Resident #36 may go on a leave of absence (LOA) independently. The social worker note dated 1/22/25 at 10:37 AM identified she called Facility 1 and Facility 2 to follow up on Resident #36's request for transfer to another facility. The social worker note dated 1/27/25 at 1:50 PM identified she spoke with the resident at bedside and updated the resident she had made the calls for a transfer. The social worker identified she had called a facility and left a message for the admission director.The care plan dated 4/29/25 failed to reflect discharge planning or goals.The care plan meeting note dated 4/29/25 identified Resident #36 would like a transfer to another facility. Interview with Resident #36 on 6/1/25 at 8:30 AM indicated that he/she had informed the social worker and Administrator he/she wanted to be transferred to another nursing facility starting in January of this year after a bed bug problem and has continued to ask but nothing is being done. Resident #36 indicated that he/she does not understand why he/she is being held here in this facility when he/she has requested for months to be transferred to any other nursing facility. Resident #36 indicated that he/she just wants out of this facility. Resident #36 indicated he/she has a friend that does entertainment at other facilities and informed him/her that they do have empty beds, but the social worker here keeps telling him/her there are no beds available in any other nursing home. Resident #36 indicated that the social worker keeps informing him/her that all the beds in the area are full and he/she cannot be discharged at this time. Resident #36 indicated that this has gone on since January and he/she is very mad that he/she cannot be moved to another facility and wonders why it is taking so long to occur. The interview with SW #1 on 6/1/25 at 1:30 PM indicated that it would be the social workers' responsibility to assist a resident that wanted to transfer to another facility. The social worker note dated 6/1/25 at 2:56 PM identified Resident #36 approached her expressing interest in transferring to another facility located in Connecticut. Resident #36 specifically inquired about Facility #3. This writer contacted the facility to request an update on current bed availability via phone. Will follow up with the resident once a response is received. The writer will continue to assist with the transfer process as needed. The interview with SW #2 on 6/3/25 at 11:06 AM indicated if a resident wanted to transfer to another facility, she would send the referral and document what facility she sent the referral to and the response. SW #2 indicates that it shouldn't take more than a couple of weeks for a resident to transfer if that is what he/she wants and there is a bed available. SW #2 indicated that since January she was the only social worker, and she was doing the best she could. SW #2 indicated that she was aware Resident #36 wanted to be transferred to another facility since January 2025 but was waiting for Resident #36 to provide her with names of nursing homes. SW #2 indicated that Resident #36 initially gave her one name of a nursing home and 2 names for assisted livings. SW #2 indicated that Resident #36 was not appropriate for the assisted living and needed long term care. SW #1 indicated she did not go back to Resident #36 and inform him/her the names were for assisted living facilities and not long-term care facilities. SW #2 indicated that she was not sure if Resident #36 knew any names of the nursing facilities in the area. SW #2 indicated that she had not provided Resident #36 with a list of nursing homes in the area or within the state of Connecticut to pick from. SW #2 indicated she does not recall if she every called back facility #1 or facility #2 to see if they had a bed available and would accept Resident #36 and noted she does not have any notes as follow up from those facilities. SW #2 indicated she was sure she had spoken to Resident #36 multiple times because Resident #36 wanted to go to another facility but didn't put notes in and does not really recall what the conversations were about other than Resident #36 still wanted to be discharged somewhere else. After surveyor inquiry, the social worker note dated 6/3/25 at 11:40 AM identified she met with the resident at bedside. Per Resident #36's request, this writer placed calls to facility #3, facility #4, and facility #2 to inquire about potential transfer options. Resident #36 was present during the calls but was unable to personally speak with any staff and left voicemails requesting return calls. Resident #36 was educated on the process, and informed the social worker will follow up with the resident once additional information is received. Interview with the Administrator on 6/3/25 at 11:25 AM identified the social worker was responsible for discharge planning and responsible to send out referrals to other facilities when a resident wants to be transferred. The Administrator indicated that the social worker would be able to fax all documents for the referral within a day and no more than 2 days. The Administrator indicated that if a resident wants to transfer to another facility, it should not take more than a couple of weeks to occur or until a bed is available. The Administrator indicated that the social worker must document in the resident's clinical record every facility that a referral was sent to and then a note if the facility accepted or denied the resident. The Administrator indicated the social worker must inform the resident if they are accepted or declined and what the resident's response is to the outcome. The Administrator indicated that if a resident wants to be discharged to another facility it is the social workers' responsibility to assist in the process and provide information regarding other facilities in the area to the resident to find out the resident's preferences. The Administrator indicated that it should not have taken months to transfer Resident #36 to another facility and if it did there must be documentation to explain why it was taking so long to happen. Review of the Resident Initiated Transfer or Discharge Request identified is the policy of the facility to uphold each resident right to make informed decisions regarding their care and place of residence, including the right to voluntarily request transfer or discharge. All such requests will be reviewed, honored when appropriate, and executed timely, coordinated, and safe manners in accordance with applicable federal and state regulations. A transfer is the movement of a resident to another facility for care. A resident or representative may initiate the request for a transfer verbally or in writing. All requests must be documented in the medical record and reviewed with the interdisciplinary team. The social services will coordinate with the resident, resident representative, and the receiving facility to ensure continuity of care. Documentation must include the date and time of the request, reason for the transfer, the resident's decision making capacity, notification to the physician, and care plan updated and discharge summary. Discharges and transfers should occur in a timely manner. Review of the facility Resident [NAME] of Rights identified residents have the right to be treated equally with other residents in receiving care and services, and regarding transfer and discharge, regardless of the source of payment for your care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident 36) reviewed for choices, the facility failed to ensure food choices were honored. The findings include: Resident #36 was admitted to the facility in January 2023 with diagnoses that included chronic pain, thoracic intervertebral dis degeneration, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #36 had intact cognition, required supervision with toileting, dressing, and personal hygiene and was independent with eating. The care plan dated 12/30/24 identified Resident #36's has behaviors of hoarding and hiding hard boiled eggs in dresser drawers. Interventions included getting psychiatric evaluation for food insecurity and to provide specific food preferences. Review of physician's order dated 1/1/25 to 1/31/25 directed a regular diet. The dietitian note dated 3/27/25 at 1:29 PM indicated that she was asked to see Resident #36 for meal preferences. Spoke with resident at chairside in room this afternoon. Reviewed meal preferences such as request for he/she likes tilapia, hard boiled eggs, and salads. Preferences relayed to dietary/kitchen. The dietitian quarterly assessment dated [DATE] at 12:24 PM identified the resident is on a regular diet and eats independently. Resident #36's food preferences reviewed and updated with the kitchen. Spoke with Resident #36 and he/she likes hard boiled eggs, bacon and sausage. Resident meal intakes varied, and Resident #36 was at risk for malnutrition related to chronic conditions. Recommendations and goals were to honor food preferences as needed. The dietitian note dated 5/12/25 at 10:48 AM identified she was asked to see Resident #36 because of food complaints. Spoke with Resident #36 and he/she reports discrepancies on his/her meal tickets, and that he/she dislikes scrambled eggs. Concerns and meal preferences relayed to the food service director, kitchen staff, and social worker. Interview with Resident #36 on 6/1/25 at 8:30 AM indicated that the resident has verbalized his/her preference of 2 hard-boiled eggs daily, which is on the meal ticket. Resident #36 identified he/she does not like scrambled eggs and it has been over 3 weeks since he/she has received a hard-boiled egg. Resident #36 indicated that he had spoken to the Administrator last Friday and notified him that he/she was not receiving the 2 hard-boiled eggs daily with breakfast. Resident #36 indicated the Administrator then questioned Resident #36 if he/she was aware of the price of eggs currently being over $5 a dozen. Resident #36 indicated that the Administrator did nothing to fix his/her problem of not receiving hard boiled eggs. Observation on 6/1/25 at 8:45 AM identified Resident #36 did not receive hard boiled eggs with breakfast. Resident #36's meal ticket identified Resident #36 wanted 2 hard boiled eggs daily.Interview with [NAME] #1 on 6/1/25 at 9:35 AM indicated residents that requested hard boiled eggs receive them when they are available. [NAME] #1 indicated Resident #36 requested hard boiled eggs daily and it is on the meal ticket for breakfast. [NAME] #1 indicated when the hard-boiled eggs are not available, she substitutes them with toast or sausage for Resident #36. [NAME] #1 indicated that there have not been any eggs to make hard boiled eggs for at least a month. [NAME] #1 indicated that there were not any eggs this morning to make hard boiled eggs to give to Resident #36. [NAME] #1 indicated that Resident #36 has complained about not receiving hard boiled eggs daily and she has reported it to the Food Service Director (FSD) a few times every week and FSD informs her that he will take care of it. The interview with the Food Service Director on 6/1/25 at 10:15 AM indicated he places the food orders on Wednesdays, and the deliveries are on Mondays or Tuesdays. The FSD indicated that the food order must be approved by the purchase company before the food is delivered. The FSD indicated that he did not receive the egg order for the last 2 Mondays, so he resubmitted the order on Thursday those weeks. The FSD indicated that he was not aware the facility was not receiving eggs and Resident #36 was not receiving hard-boiled eggs daily. Review of the Resident [NAME] of Rights identified residents have the right to be treated equally with other residents in receiving care and services. Residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality. Residents have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interview, the facility failed to ensure that surveillance monitoring for a respiratory outbreak was accurate and thorough, failed to ensure that the laundry area was maintained in a clean and sanitary manner and for 1 resident (Resident #65) the facility failed to ensure that infection control protocols were implemented following the onset of respiratory symptoms during an active outbreak. The findings include:1. During a review of the infection control program with RN #1 and the DNS on [DATE] at 8:54 AM, the DNS identified that the facility had one outbreak since the prior recertification survey. The DNS identified that the facility had an influenza A outbreak in February 2025 and approximately 8 residents were involved. The DNS identified she did not have the surveillance tracking list available for surveyor review as she kept it in her office and would need to locate it for review.Subsequent to surveyor inquiry, the DNS provided a February 2025 influenza surveillance tracking log, which identified a total of 10 residents who tested positive for influenza A from [DATE] - [DATE]. A review of the clinical record for Resident #65 identified that on [DATE], Resident #65 reported symptoms of feeling feverish and coughing. The clinical record identified treatment orders including influenza testing and Tamiflu (an antiviral medication used to treat influenza A and B). Further review of the clinical record failed to identify any documentation related to the influenza testing results for Resident #65.A review of the February 2025 influenza surveillance tracking log failed to identify surveillance tracking or documentation related to Resident #65 including onset of symptoms, initiation of Tamiflu, or influenza test results. Subsequent to surveyor inquiry, the DNS provided a report dated [DATE] for Resident #65 identified as a rapid viral respiratory culture result. Review of the report identified negative results for adenovirus, influenza A, influenza B, parainfluenza 1, 2, and 3, and RSV.Interview with the DNS on [DATE] at 10:00 AM identified Resident #65 should have been added to the influenza surveillance tracking log following the report of symptoms and need for influenza testing. The DNS identified she did not have a rationale why this was not done but identified it should have been.The facility policy on Outbreaks of Communicable Disease directed that outbreaks within the facility would be promptly identified and appropriately handled. The policy further directed that the Infection Preventionist and DNS would be responsible for receiving surveillance information and tabulating data and maintaining a line listing of identified cases with the appropriate line listing report.The facility policy on the Infection Prevention Program directed that if a problem was identified with an outbreak or infection cluster, surveillance continues to determine whether the problem was controlled. The policy also directed documentation related to surveillance data must include the date an infection was detected, the resident's name, signs and symptoms and type of infection. 2. Review of the monthly environmental rounding log documentation from 12/2024 - 5/2025 failed to identify issues with the facility laundry area.Observation during a tour of the facility laundry area with RN #1 and the DNS on [DATE] at 10:00 AM identified a large basin (approximately 96 long x 18 across x 24 deep) positioned directly behind 4 out of service washing machines. The basin was observed to be approximately 50% full of cloudy light gray liquid, and approximately 25 % of the surface appeared to have a light beige film covering. The basin was also observed to have 10 deceased black winged insects on the surface of the liquid and 2 black winged insects flying directly above the surface. Interview with RN #1 and the DNS during the observation identified they were both not aware of the liquid in the basin and that the washing machines directly in front of the basin had not been in use for at least a year. Interview with the Director of Maintenance on [DATE] at 10:15 AM identified she was first notified of the liquid in the basin on [DATE] sometime in the afternoon. The Director of Maintenance identified that she had not had any reports of drain issues for the basin prior to [DATE] and that she had contacted a plumber to address the issue. The Director of Maintenance also identified that she believed the housekeeping staff were pouring mop water into both the basin and into 2 utility sinks in the laundry area that fed into the basin and that was causing the issue. The Director of Maintenance identified she would be contacting a plumber to address the issue.Observation on [DATE] at 6:30 AM of the laundry room basin identified that all water had been drained. The entire basin bottom was observed to be covered in thick black (approximately 2 inches) sludge material.Interview with Laundry Aide #1 on [DATE] at 8:05 AM identified that she had worked at the facility for 8 years. Laundry Aide #1 identified that for the past 5 years, the facility had been sending out all laundry including linens and personal items and that the laundry area with the basin was used for holding washed items that had been returned by the outside laundry service provider. Laundry Aide #1 identified that she was aware of the basin with standing water and identified the issue had been ongoing for at least a year. Laundry Aide #1 identified that she had not observed any housekeeping staff using the basin or dumping any water into the utility sinks and she was unsure where the water was coming from but identified she reported the water multiple times to the Director of Maintenance and Maintenance Assistant #1, most recently the week prior. Laundry Aide #1 identified that Maintenance Assistant #1 had attempted to fix the drain for the basin but was not successful. Laundry Aide #1 also identified that the basin had a crack in the far-left corner which sometimes would leak under the wall and into her sorting area located on the other side of the wall when the basin, which also happened the week prior. Laundry Aide #1 identified that Maintenance Assistant #1 would place blankets at the wall to prevent the water from entering her area. Laundry Aide #1 identified that the Director of Maintenance was also aware of the issue and had contacted a plumber to fix the drain for the basin a few times over the last year and estimated the drain had to be addressed every 3 months. Laundry Aide #1 also identified that the basin would only fill halfway and never filled enough to overflow.Interview with Maintenance Assistant #1 on [DATE] at 8:22 AM identified that he first became aware of the issue with the basin a couple of days prior. Maintenance Assistant #1 identified that he was not aware of any issues with the basin prior, and that he had never attempted to fix the basin or drain. Maintenance Assistant #1 identified that he was aware of water seeping through the wall into Laundry Aide #1's work area, but then identified he had no information regarding this and did not place any blankets down related to any leaks in the laundry area. Observation on [DATE] at 7:21 AM of the laundry room basin identified that the sludge material had been removed, and positioned next to the left side of the base was a flat shovel with black sludge material. Interview with Person #2 (the owner and representative for 1 of 2 plumbing service providers contracted by the facility) on [DATE] at 8:42 AM identified that plumbing services were requested related to the laundry basin on [DATE]. Person #2 identified that the laundry basin issue was related to a washcloth lodged in the sewer line which was found several feet inside of the sewer drainage pipe. Person #2 also identified he did not have any other documentation of service requests specific to the laundry basin, but there had been multiple prior calls from the facility related to issues with the sewer lines, specifically related to trash including candy wrappers being flushed into the facility toilets. The facility policy on linens directed that facility personnel must handle and store linens as to prevent the spread of infections. The policy also directed that laundry equipment must be used and maintained according to the manufacturer's instructions in order to prevent microbial contamination. 3. Resident #65 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, spinal stenosis, and chronic obstructive pulmonary disease (COPD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, was frequently incontinent of bowel and bladder and was dependent on staff to assist with toileting, bathing, and dressing.The care plan dated [DATE] identified Resident #65 was at risk for contracting influenza and had refused the influenza vaccine. Interventions included to reapproach the resident to offer the vaccine as indicated. Review of an influenza outbreak surveillance tracking log for February 2025 identified that the facility has an influenza outbreak that began on [DATE].A physician's order dated [DATE] directed to administer Tamiflu (an antiviral medication for influenza) prophylactic once daily at 8:30 AM.A nurse's note dated [DATE] identified that Resident #65 was notified of an influenza outbreak in the facility but declined prophylactic treatment. A nurse's note dated [DATE] at 10:35 PM identified Resident #65 reported feeling hot and coughing all day. The note further identified that an on call APRN was notified and treatment orders included influenza testing, Tussin (a cough suppressant) 10 ml every 6 hours for 3 days, and vital signs every shift for 3 days.Further review of the clinical record failed to identify documentation related to the influenza testing results for Resident #65.Review of the clinical record failed to identify any documentation related to transmission-based precautions initiated or implemented for Resident #65 following the onset of symptoms and influenza testing on [DATE].A review of the February 2025 influenza surveillance tracking log failed to identify any surveillance tracking or documentation related to Resident #65 including onset of symptoms, initiation of Tamiflu, or influenza test results. Subsequent to surveyor inquiry, the DNS provided a report dated [DATE] for Resident #65 identified as a rapid viral respiratory culture result. Review of the report identified negative results for adenovirus, influenza A, influenza B, parainfluenza 1,2, and 3, and RSV.Interview with the DNS on [DATE] at 10 AM identified Resident #65 should have been placed on droplet precautions following the report of symptoms and need for influenza testing. The DNS identified she did not have a rationale why this was not done. The facility policy on influenza prevention and control directed that the purpose of the policy was to ensure that the safety and well-being of residents, healthcare personnel, and visitors by implementing a comprehensive approach to prevent and manage influenza outbreaks in long term care facilities. The policy further directed that residents with suspected or confirmed influenza should be placed on droplet precautions, begin antiviral treatment for residents with suspected or confirmed influenza within 48 hours of symptom onset, and continue infection control measures during treatment. The facility policy on Outbreaks of Communicable Disease directed that outbreaks within the facility would be promptly identified and appropriately handled. The policy further directed that symptomatic residents and employees were considered to be potentially infected and would be assessed for the appropriate actions. The policy also directed that nursing staff were responsible to initiate isolation precautions as necessary and confine symptomatic residents to their rooms as much as feasible if indicated.

Based on review of facility documentation, facility policy, and interview, the facility failed to ensure the Infection Preventionist (IP) worked at least part-time at the facility managing the Infection Prevention and Control Program. The findings include:A review of the Infection Control program with RN #1 (IP) and the DNS on 6/2/25 at 8:54 AM identified that RN #1 was working in multiple roles at the facility including managing the Infection Prevention and Control Program, wounds, staff development, and supervision during the 7:00 AM - 3:00 PM shift. RN #1 identified that she worked on the Infection Prevention and Control Program when she was able but did not have a specific amount of time set aside to cover the program. The DNS identified that she and RN #1 worked together on the program when time allowed but they were unable to quantify the amount of time that had been designated to the Infection Prevention and Control Program. Review of an influenza outbreak surveillance tracking list for February 2025 identified that the facility had an influenza outbreak that began on 2/3/25 and ended 2/26/25. Review of the 2025 influenza outbreak surveillance tracking log failed to identify Resident #65 as a potential resident, who had symptoms consistent with the influenza, who required influenza testing. Review of the nurse staffing daily assignment sheets for February 2025 identified RN #1 was assigned as the RN supervisor during the 7:00 AM - 3:00 PM shift 21 of 28 days in February. A review of RN #1's punch details for February 2025 identified that RN #1's (RN Supervisor) schedule corresponded to her assigned RN Supervisor dates on the daily assignment sheets. Further review of the punch details failed to identify any additional punches (or additional hours worked) outside of the assigned RN Supervisor role. The facility job description for the Infection Control Coordinator, RN, identified that the primary purpose of the position was to plan, organize, develop, and direct the infection control program and its' activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs to ensure that an effective infection control program was maintained at all times. The facility assessment directed that the administrative personnel included one designated Infection Preventionist.

Based on review of facility documentation, facility policies, and interviews, the facility failed to ensure nurse aides received no less than 12 hours of in-services, annually, including dementia management training. The findings include:Review of the facility's 2024 - 2025 nursing staff in-servicing and competency documents failed to identify documentation that nurse aides completed no less than 12 hours, per year, of in-servicing and failed to identify dementia management training was completed.Facility documentation review and interview with the DNS and the Staff Development Nurse (RN #1) on 6/3/25 at 11:45 AM identified that the facility's prior Staff Development Nurse left the facility in August of 2024. RN #1 indicated that the staff development position wasn't filled, and sometime around October or November of 2024, she and the DNS took on the role of educating the nursing staff. The DNS indicated that the facility provided competency evaluations and education, on the following topics upon hire and annually: body mechanics, falls, fear of retaliation, fires safety, HIPPA, infection control, Covid-19, personal protective equipment (PPE), abuse, neglect, misappropriation, resident rights, workplace violence, codes, black out take out, hazardous materials, QAPI, and emergency preparedness. The DNS further indicated that staff in-services and competency evaluations were on-going and completed on an as needed basis, but they did not always document when training was completed; additionally supportive services had also come to the facility to provide staff education. RN #1 identified that she was unaware that nurse aides required no less than 12 hours of in-servicing, per year, and that she would estimate that the nurse aides had completed approximately 8 hours of training, in 2024. The DNS also identified that she was unaware that nurse aides required no less than 12 hours of in-servicing, per year. The DNS further indicated that the prior Staff Development Nurse did not leave a lot of records for in-servicing or competencies that had been completed. RN #1 indicated that while annual in-servicing was completed by approximately 80% of nursing staff, dementia education was not provided, in 2024 or to date in 2025. The DNS identified that she and RN #1 got the majority of the nursing staff caught up with the mandatory annual education, but dementia in-serving had fallen through the cracks. The DNS identified that she would implement a system for tracking nurse aide in-servicing hours and ensure documentation was completed for all in-services and competency evaluations. The DNS further identified that the nursing staff would be provided dementia management training.The facility's In-servicing of Nursing Assistants policy directs that all nurse aides receive regular, structured in-service education that is relevant, competency-based, and compliant with federal and state regulations to promote quality care delivery. The facility shall implement and maintain an in-service education program for nursing assistants that: includes at least 12 hours of in-service training per calendar year, addresses identified knowledge and skills deficit, and includes topics relevant to the nurse aide role and resident care, including areas such as infection control, resident rights, abuse prevention, dementia care, communication techniques, and proper body mechanics.The facility's Dementia Care Management policy directs all staff shall receive dementia-specific training upon hire and annually thereafter. Training shall include techniques for effective communication with cognitively impaired residents, de-escalation, and non-pharmacologic behavior management strategies, and recognition of abuse, neglect, and exploitation.The facility's Dementia Education policy directs that all staff working in long-term care facilities receive comprehensive training on dementia care to provide high quality, person-centered support for residents living with dementia. The training aims to enhance staff knowledge, improve communication skills, and promote a compassionate, safe, and dignified environment for residents. Staff should complete dementia training upon hire, annually, and refresher courses or additional training sessions will be provided as needed.

Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure the DNS did not serve as the nursing supervisor. The findings include:Review of the Daily Staffing Breakdown dated 2/10/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Night Shift RN Supervisor, from 11:00 PM through 7:00 AM.Review of the Daily Staffing Breakdown dated 2/15/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Day Shift RN Supervisor, from 7:00 AM through 3:00 PM.Review of the Daily Staffing Breakdown dated 2/27/25 identified that subsequent to an RN Supervisor call-out, the DNS served as the Evening Shift RN Supervisor, from 3:00 PM through 11:00 PM.Interview with the DNS on 6/4/25 at 11:00 AM identified that the facility had an average daily census that was greater than 60 residents, and she had served as the RN Supervisor on 2/10/25, 2/15/25, and 2/27/25 subsequent to staff callouts. The DNS indicated that she could not recall how many additional shifts or hours she had put in as an RN Supervisor, since becoming the DNS. The DNS further indicated that she had picked up the additional hours and served as the RN Supervisor in an effort to meet the needs of the residents, following staff call-outs. The DNS identified that in the last month, the facility had hired an evening shift supervisor, a night shift supervisor, and a few per diem nurses that will pick up supervisor shifts, and finding supervisor coverage had improved following the new hires.During an interview with the Chief Clinical Officer (CCO), the Administrator, the DNS, and the survey team on 6/4/25 at 10:30 AM, the CCO identified that she was aware that there had been staffing shortages and the facility was actively recruiting and hiring nursing staff, including RN Supervisors. The facility's Staffing Guidelines policy directs the DNS will determine numbers and assignments of staff. The staffing coordinator will be responsible each month to complete a 28-day schedule and ensure that there is adequate staffing scheduled to meet the needs of each unit/floor. The DNS and staffing coordinator will assess and ensure coordination and maintain adequate staffing. The number of staff will be determined based on resident care, acuity, facility assessment, and services needed. This would include the type of staff members and healthcare professionals required to provide those services. Based on this assessment, adequate qualified staff will be maintained and recruited/hired as needed to maintain sufficient staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, facility documentation, and staff interviews for 1 of 3 residents (Resident #1) reviewed for quality of care, the facility failed to properly transcribe physician wound treatment orders. The findings include: Resident #1 had a diagnosis of Parkinson's, mild cognitive impairment, artificial hip joint, and malignant neoplasm of the thyroid. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition and was dependent of care and transfers. The Resident Care Plan (RCP) dated 5/1/25 identified Resident #1 refuses incontinent care and has the potential for skin impairment. Interventions directed to encourage and elevate resident's heels while in bed and to educate resident on the risks of non-compliance. A review of the wound care progress note dated 4/22/25 identified treatment recommendations for the right heel as follows: zinc to the peri-wound (PW), collagen, Hydrofera Blue, and a dry protective dressing to be changed once a day and as needed. The physician's order dated 4/22/25 directed to cleanse the right heel with wound cleanser, apply collagen, Hydrofera Blue, and wrap in kerlix. The record review failed to identify an order to apply zinc to the peri-wound of the right heel. A review of the treatment records failed to identify Zinc was applied to the peri-wound in accordance with physician treatment recommendations. Interview with MD #1 (Wound MD) on 5/27/25 at 2:20 PM identified zinc was a part of the order and was supposed to be applied to the peri-wound of the right heel with wound cleanser, collagen, Hydrofera Blue, and wrapped in a dry dressing like a 4x4 gauze or kerlix. MD # 1 indicated that his treatment recommendations should have been followed. MD # 1 stated that if it was not applied, he could not say the wound would get worse. Interview with the Director of Nursing (DNS), Administrator, and RN #1 on 5/27/25 at 2:42 PM identified the treatment recommendation by MD # 1 on 4/22/25 stated to apply zinc to the peri-wound but, does not know why the physician order placed did not indicate the application of zinc to the peri-wound. The physician order that was placed should have matched the treatment recommendation by the wound MD. Facility Compliance with and Implementation of Physician Orders Policy dated 1/19/18 directed that orders must be entered into the resident's electronic health record promptly and accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure fall risk assessments were conducted in accordance with the standards of practice. The findings include: Resident #1 had diagnoses that included cerebral infarction due to embolism, hemiplegia affecting left non-dominant side, anxiety, and vascular dementia. A care plan dated 7/21/24 identified that the resident had an ADL deficit related to a cerebral infarction with interventions that directed to assist the resident with ADL's as needed and for the resident to transfer and ambulate independently. A physician's order dated 8/18/24 directed to complete quarterly observations (assessments) for falls once day on the 9th of March, June, September, and December. The annual MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of 14 indicative of intact cognition, was occasionally incontinent of bowel, continent of bladder, independent with bed mobility and able to self-propel wheelchair, required set-up for transfers and with personal hygiene, and supervision with ambulation. The MDS identified Resident #1 had no falls since admission. Review of Resident #1's clinical record on 10/29/24 identified Resident #1's most recent fall risk assessment was completed on 12/20/2022. Interview and clinical record review with the DNS on 10/29/24 at 12:35 P.M. was unable to provide documentation to reflect Resident #1 had any fall risk assessments conducted since 12/20/2022. The DNS identified although Resident #1 was independent with transfers, not a fall risk, the quarterly fall risk assessments should have been conducted on Resident #1. The DNS could not explain why Resident #1's fall risk had not been assessed since 12/20/2022. The DNS identified the nurses are responsible for conducting the residents' quarterly fall risk assessments. The DNS indicated it is her expectation all residents have quarterly fall risk assessments conducted. Review of facility admission/quarterly observations policy identified all nursing observations are to be completed on admission and quarterly and nursing is to complete assessments on admission and quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to notify the physician for a resident who exhibited signs and symptoms and complained of pain and was not due for pain medication administration for several hours. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable vascular ulcer of the Left ankle. Review of the admission assessment dated [DATE] identified Resident #1 as oriented, had clear and organized thinking with a pain score 10 on a 0-10 pain scale (zero (0) being no pain and ten (10) being the worst pain), the pain was described as sharp, and was alleviated by medication and was increased with change of position. The Resident Care Plan dated 6/5/2024 identified Resident #1 had an actual skin impairment/potential for skin impairment as evidenced by a vascular ulcer to the Left ankle with interventions that included to turn and position resident at least four times per shift, and to educate resident to shift body positions. A physician's order dated 6/5/2024 directed oxycodone 5 milligrams (mg) (a narcotic pain medication), 1 tablet by mouth every 6 hours as needed for pain, acetaminophen (an over-the-counter pain medication) 500 mg, 2 tablets by mouth every 8 hours as needed for pain, and pain monitoring every shift. Review of the June 2024 Medication Administration Report (MAR) identified on 6/5/24 Resident #1 was administered two (2) 500 mg tablets of acetaminophen for pain at 7:35 PM on 6/5/24 with good effect and one 5 mg tablet of oxycodone at 9:15 PM on 6/5/24 for complaints of Left leg pain with effect. Further review of the MAR on 6/6/24 at 3:06 AM identified that the resident was medicated with two (2) 500 mg tablets of acetaminophen on 6/5/24 and one 5 mg tablet of oxycodone for a pain level of six (6) with good effect (4 hours after the initial complaints of pain were noted by the nursing staff). Interview with NA #2 on 6/12/24 at 10:17 PM identified Resident #1 was placed on a bedpan on 6/5/24 at approximately 11:45 PM and had groaned when the bedpan was placed and when it was removed. NA #2 had also noted that the dressing to the Left ankle wound had fallen off and needed to be replaced. NA #2 identified that Person #1 (a family member), who was in the resident's room at the time, had asked if Resident #1 could be given his/her pain medication. NA#2 indicated he/she informed LPN #1 of the request for pain medication and the need for the dressing to be replaced. NA #2 was told by LPN #1 that Resident #1 was not scheduled to receive his/her pain medication at the current time. Interview with LPN #1 on 6/12/24 at 11:23 AM identified that she was informed by NA #2 that the resident's family member had requested pain medication for Resident #1, however, it was too early for the resident to receive the pain medication. Further, Resident #1's dressing fell off his/her leg within the first hour of the 11:00 PM to 7:00 AM shift and that he/she had entered Resident #1's room with RN #1 to perform wound care and a dressing change. LPN #1 identified the resident appeared to be in pain during the dressing change because the resident winced during the dressing change. LPN #1 further identified he/she didn't think the physician should have been notified of Resident #1's pain as his/her pain medication(s) were due soon after his/her dressing change, (however, LPN #1 could not specify how long after the dressing change his/her pain medications were due). LPN #1 further indicated that because his/her nursing supervisor (RN #1) was present during the dressing change and Resident #1's expressions of pain, and further, RN #1 had asked the resident during the dressing change if he/she was in pain and the resident replied yes it was the responsibility of the nursing supervisor to contact the physician to report the pain, and the concern that pain medications were not due for administration. Interview with RN #1 the 11:00 PM to 7:00 AM nurse supervisor, on 6/12/24 at 11:06 AM identified he/she was in Resident #1's room when the dressing was changed and identified that the resident was in moaning and appeared to be in pain as he/she and LPN #1 re-dressed the wound. RN #1 indicated he/she was aware Resident #1's pain medications were not due to be administered and believed the resident's next dose of pain medication was going to be given within 30 minutes of performing the dressing change. (However, Resident #1 was not scheduled to receive her scheduled dose of either acetaminophen or oxycodone until approximately 3:00 AM according to the MAR). RN #1 indicated had he/she known her next dose of pain medications was not due until 3:00 AM (approximately 4 hours from the time of the dressing change), he/she would have called the physician to ask if the resident could receive his/her pain medications earlier that the prescribed time frames. Interview with Medical Director on 6/12/24 at 1:07 PM identified he/she would expect staff to contact him/her regarding a resident's pain and pain management options, including the administration of pain medication. Interview with the Director of Nursing Services (DNS) on 6/12/24 at 1:29 PM identified facility practice was to offer Tylenol for breakthrough pain, if it was available. If the order for Tylenol was not scheduled to be offered until a later time, the Advanced Practicing Registered Nurse or Medical Director should be contacted to discuss pain management options. Review of the facility Pain Management Policy dated 1/19/18 directed pain management was a multidisciplinary care process that included assessing the potential for pain, effectively recognizing the presence of pain, developing and implementing approaches to pain management, to conduct a comprehensive pain assessment when there is a new onset of new pain or worsening pain of existing pain. The policy further directs to contact the physician when there are significant changes in the level of the resident's pain and/or for prolonged, unrelieved pain despite care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews, and facility policy for one (1) of three (3) residents reviewed for neglect, (Resident #1), the facility failed to ensure incontinent care was provided to a resident according to the plan of care and facility policy, resulting in a finding of neglect. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable pressure ulcer of the ankle. Review of the admission assessment dated [DATE] identified Resident #1 was oriented, with memory intact, and had clear and organized thinking. The admission Assessment further indicated Resident #1 was unable to transfer and use the toilet, and utilized a bed pan and adult briefs to manage h/her bladder incontinence. Review of the Resident Care Plan dated 6/5/2024 identified Resident #1 had potential for skin impairment as evidenced by occasional incontinence with interventions that directed to apply barrier cream with incontinent care, turn and position resident at least four times per shift, and to educate resident to change positions. Interview with Person #1 (Resident #1's responsible party) on 6/12/24 at 9:53 AM identified Resident #1 was admitted to the facility at approximately 1:45 PM on 6/5/24 and h/she had stayed with Resident #1 until 9:30 AM on 6/6/24. Person #1 had requested incontinent care for Resident #1 at 4:30 PM by ringing the call bell and received no assistance or inquiry. Person #1 indicated utilizing the call bell again at 6:30 PM and 8:30 PM as Resident #1 had still not received incontinent care and again received no response. At approximately 9:00 PM, LPN #1 came into the room and administered pain medication, Person #1 requested incontinent care be provided to Resident #1. LPN #1 stated that h/she would inform NA #1 that incontinent care was needed. Person #1 further indicated that NA #1 did not provide incontinent care, and further identified that incontinent care was not provided until the beginning of the 11:00 PM to 7:00 AM shift. Interview with NA #1 on 6/12/24 at 9:19 AM identified he/she was assigned Resident #1 on 6/5/24 on the 3:00 PM to 11:00 PM shift, she had introduced his/herself to Resident #1 before dinner (he/she was unable to recall the exact time), however, she did not provide incontinent care to Resident #1. NA#1 identified that she provided Resident #1 incontinent care after collecting the dinner trays from Resident #1's room and identified that the resident had been incontinent (unsure of the time, however, dinner is served around 5:30-6:00 PM, further, the family was not in the room at the time incontinent care was provided). NA #1 identified that she provided incontinent care one time on the 3:00 PM to 11:00 PM to Resident #1. NA #1 further identified he/she was not informed of what Resident #1's care needs were and did not know what the facility's incontinent care policy was. Interview with NA #2 on 6/12/24 at 10:17 AM who worked on the 11:00 PM to 7:00 AM shift from 6/5 into 6/6/24 identified he/she checked in on Resident #1 at the start of the 11:00 PM to 7:00 AM shift and identified that Resident #2 had been incontinent and performed incontinent care. Interview with the Director of Nurses on 6/12/24 at 1:25 PM identified residents who required incontinent care should be checked four times per shift and changed if necessary. The undated facility policy for incontinent care dated directed that a resident be checked for incontinence every 2 hours and clean skin when soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews and facility policy for one (1) of three (3) residents reviewed for pain management, (Resident #1), the facility failed to address the resident complaints of pain. The findings included: Resident #1 had diagnoses of neuralgia and neuritis, peripheral vascular disease, and an unstageable vascular ulcer of the Left ankle. Review of the admission assessment dated [DATE] identified Resident #1 as oriented, had clear and organized thinking with a pain score 10 on a 0-10 pain scale (zero (0) being no pain and ten (10) being the worst pain), the pain was described as sharp, and was alleviated by medication and was increased with change of position. The Resident Care Plan dated 6/5/2024 identified Resident #1 had an actual skin impairment/potential for skin impairment as evidenced by a vascular ulcer to the Left ankle with interventions that included to turn and position resident at least four times per shift, and to educate resident to shift body positions. A physician's order dated 6/5/2024 directed oxycodone 5 milligrams (mg) (a narcotic pain medication), 1 tablet by mouth every 6 hours as needed for pain, acetaminophen (an over-the-counter pain medication) 500 mg, 2 tablets by mouth every 8 hours as needed for pain, and pain monitoring every shift. Review of the June 2024 Medication Administration Report (MAR) identified on 6/5/24 Resident #1 was administered two (2) 500 mg tablets of acetaminophen for pain at 7:35 PM on 6/5/24 with good effect and one 5 mg tablet of oxycodone at 9:15 PM on 6/5/24 for complaints of left leg pain with effect. Further review of the MAR on 6/6/24 at 3:06 AM identified that the resident was medicated with two (2) 500 mg tablets of acetaminophen and one 5 mg tablet of oxycodone for a pain level of six (6) with good effect (4 hours after the initial complaints of pain were noted by the nursing staff). Interview with NA #2 on 6/12/24 at 10:17 PM identified Resident #1 was placed on a bedpan on 6/5/24 at approximately 11:45 PM and had groaned when the bedpan was placed and when it was removed. NA #2 had also noted that the dressing to the Left ankle wound had fallen off and needed to be replaced. NA #2 identified that Person #1 (a family member), who was in the resident's room at the time, had asked if Resident #1 could be given his/her pain medication. NA#2 indicated he/she informed LPN #1 of the request for pain medication and the need for the dressing to be replaced. NA #2 was told by LPN #1 that Resident #1 was not scheduled to receive his/her pain medication at the current time. Interview with LPN #1 on 6/12/24 at 11:23 AM identified that she was informed by NA #2 that the resident's family member had requested pain medication for Resident #1, however, it was too early for the resident to receive the pain medication. Further, Resident #1's dressing fell off his/her leg within the first hour of the 11:00 PM to 7:00 AM shift and that he/she had entered Resident #1's room with RN #1 to perform wound care and a dressing change. LPN #1 identified the resident appeared to be in pain during the dressing change because the resident winced during the dressing change. LPN #1 further identified he/she didn't think the physician should have been notified of Resident #1's pain as his/her pain medication(s) were due soon after his/her dressing change, (however, LPN #1 could not specify how long after the dressing change his/her pain medications were due). LPN #1 further indicated that because his/her nursing supervisor (RN #1) was present during the dressing change and Resident #1's expressions of pain, and further, RN #1 had asked the resident during the dressing change if he/she was in pain and the resident replied yes it was the responsibility of the nursing supervisor to contact the physician to report the pain, and the concern that pain medications were not due for administration. Interview with RN #1, the 11:00 PM to 7:00 AM nurse supervisor, on 6/12/24 at 11:06 AM identified he/she was in Resident #1's room when the dressing was changed and identified that the resident was in moaning and appeared to be in pain as he/she and LPN #1 re-dressed the wound. RN #1 indicated he/she was aware Resident #1's pain medications were not due to be administered and believed the resident's next dose of pain medication was going to be given within 30 minutes of performing the dressing change. (However, Resident #1 was not scheduled to receive her scheduled dose of either acetaminophen or oxycodone until approximately 3:00 AM according to the MAR). RN #1 indicated had he/she known her next dose of pain medications was not due until 3:00 AM (approximately 4 hours from the time of the dressing change), he/she would have called the physician to ask if the resident could receive his/her pain medications earlier that the prescribed time frames. Interview with Medical Director on 6/12/24 at 1:07 PM identified he/she would expect staff to contact him/her regarding a resident's pain and pain management options, including the administration of pain medication. Interview with the Director of Nursing Services (DNS) on 6/12/24 at 1:29 PM identified facility practice was to offer Tylenol for breakthrough pain, if it was available. If the order for Tylenol was not scheduled to be offered until a later time, the Advanced Practicing Registered Nurse or Medical Director should be contacted to discuss pain management options. Review of the facility Pain Management Policy dated 1/19/18 directed pain management was a multidisciplinary care process that included assessing the potential for pain, effectively recognizing the presence of pain, developing and implementing approaches to pain management, to conduct a comprehensive pain assessment when there is a new onset of new pain or worsening pain of existing pain. The policy further directs to contact the physician when there are significant changes in the level of the resident's pain and/or for prolonged, unrelieved pain despite care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident, (Resident #34), reviewed for wheelchair maintenance, the facility failed to ensure the residents power wheelchair was in good repair. The findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included history of stroke, obstructive sleep apnea, and systolic congestive heart failure. A physician's order dated 5/5/22 directed Occupational Therapy (OT) to evaluate only for power wheelchair mobility and safety. Resident #34 was readmitted to the facility on [DATE]. The quarterly MDS dated [DATE] identified Resident #34 had intact cognition, required total assistance with transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene, and supervision for locomotion, and eating. Further, the MDS identified Resident #34 was wheelchair dependent and used a BIPAP/CPAP (CPAP and BiPAP machines are both forms of positive airway pressure therapy which uses compressed air to open and support the upper airway during sleep). The care plan dated 7/14/23 identified a focus on the custom wheelchair with interventions that included wheelchair to be provided by rehab, rehab will screen for appropriateness as needed and ensure least restrictive device is used. Observation on 10/30/23 at 9:25 AM identified Resident #34's power wheelchair with a tattered side cushion, torn armrests, worn out seat cushion, which appeared to be inserted backwards, and an overall unclean appearance. Interview with PT #1 on 11/1/23 at 2:15 PM with the Regional Director of Physical Therapy present, identified she noted the wear and tear of Resident #34's wheelchair and some parts needed to be replaced during onboarding for physical therapy on 7/23/23. However, the wheelchair continued to function, and she did not refer the chair for inspection or parts replacement with the contracted vendor. The Regional Director of Physical Therapy indicated she just completed a phone call with the corporate liaison responsible for coordination with the power wheelchair vendor and was awaiting a commitment date for an onsite visit for Resident #34's wheelchair as well as 2 additional residents. The Regional Director of Physical Therapy identified she was recently hired and is now coordinating powerchair maintenance and notified their appointed liaison 20 minutes prior to the interview with an anticipated commitment prior to 11/3/23 with the date for a field visit to the facility. The Regional Director of Physical Therapy also indicated the wheelchairs should be in good condition, and fully functional and the wheelchair evaluation and repair would be a priority for the department. Although requested, a policy on wheelchair maintenance was not provided. Review of the wheelchair cleaning policy identified wheelchairs are cleaned on an as-needed basis.

**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 #63) reviewed for participation in care planning, the facility failed to invite the resident and the resident representative to participate in the quarterly care plan meetings. The findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included stroke affecting right dominant side, a feeding tube, and respiratory failure. The care plan dated 11/24/22 identified a goal directed to initiate a person-centered care plan including objectives to meet the residents medical, nursing, and psychosocial needs. Additionally, to have resident participate in his/her own health care management. The Medicare 5-day MDS dated [DATE] identified Resident #63 had intact cognition and required total assistance with all care. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition and required total assistance for all care. Interview with the DNS on 11/2/23 at 8:50 AM indicated all resident are to have quarterly and annual care plan meeting including the resident and the resident's representatives. The DNS indicated that care plan meetings have not been done in the last year that she was aware of, and the facility just started having them after the new MDS coordinator started in mid-September 2023. Interview with corporate RN #8 on 11/2/23 at 10:45 AM indicated Resident #63 has not had a care plan meeting since 11/24/22, almost a year ago. RN #8 indicated the facility was not doing the care plan meetings for at least a year and indicated the ombudsman had reported the issue and in September 2023 the facility just started to have the care plan meetings. Interview with MDS Coordinator, (RN #7) on 11/6/23 at 11:30 AM indicated that since the facility went to the electronic medical record in 11/2021 there was no record of any care plan meetings being done until he started on 9/11/23. RN #7 indicated that when he started on 9/11/23 there was not even a template or a used letter to give to residents or to mail to the resident representative to invite them. RN #7 indicated there was no sign in sheet or progress notes in the paper medical record or the electronic medical record indicating that Resident #63 had a quarterly care plan meeting or was invited to participate since initial admission on [DATE]. Review of the facility Comprehensive Care Planning Policy identified the interdisciplinary team, in conjunction with the resident and his/her representative, develops and implements a comprehensive, person-centered care plan for each resident. The interdisciplinary team includes the attending physician, a registered nurse, a nurse's aide, a food service staff person, the resident and the resident's representative. Each residents comprehensive person centered care plan will be consistent with the resident's rights to participate in the development and implementation of his/her plan of car, including the right to: participate in the planning process, identify the individuals to be included, request meetings, request revisions of the plan of care, participate in establishing the expected goals and outcomes of care, participate in determining the type, amount, frequency and duration of care, receive the services and/or items included in the plan of care, and see the plan of care and sign it after significant changes are made. The car plan meeting must happen by day 21 after admission and at least quarterly, any significant change in condition, when outcomes are not met, readmitted to the facility from a hospital stay, and at least quarterly.

**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 #63 and 87) reviewed for code status, the facility failed to receive the code status in a timely manner, signed by the resident or resident representative, and failed to have the code status physician's order in place. The findings: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included stroke affecting right dominant side, a feeding tube, and respiratory failure. The hospital Discharge summary dated [DATE] identified code status was not addressed. The physician's order dated [DATE] directed Resident #62 was a DNR, DNI, and RNP. (A signed Advance Directive form for code status was not in place at the time of this order). Review of the APRN/PA/and MD progress notes dated [DATE] - [DATE] did not reflect the code status for Resident #63. Review of the nursing notes dated [DATE] - [DATE] did not reflect the facility discussed code status with resident or resident's representative. The Medicare 5-day MDS dated [DATE] identified Resident #63 had intact cognition and required total assistance with all care. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition and required total assistance for all care. Review of the nursing progress notes dated [DATE] - [DATE] did not reflect the facility discussed the code status with the resident or resident's representative. The Advance Directive form for code status dated [DATE], completed as a telephone consent by the resident's representative was signed by only one RN. The form identified DNR status. This form was signed by an APRN on [DATE]. A physician's order dated [DATE] directed Resident #63 was a DNR. The care plan dated [DATE] identified the physician order was for a DNR. Intervention was to ensure residents or residents representative wishes are conveyed to any other facility should transfer occur. Interview with RN #3 on [DATE] at 2:11 PM indicated when a resident is admitted or re-admitted to the facility the RN supervisor is responsible to get the code status form signed by the resident or the resident's representative. RN #3 indicated if they must call the resident representative via the phone there must be 2 nurses as a witness for the code status form. RN #3 indicated both nurses must sign the form and one nurse needs to write a progress note. RN #3 indicated the code status should be completed on the day of admission by the resident or resident's representative. RN #3 indicated if the code status was obtained verbally over the phone, the resident representative must sign the code status form when they come in to sign the admission paperwork. RN #3 indicated if the nurse was not able to reach the resident representative there must be a progress note stating attempted to call for code status but unable to get. After review of the medical record, RN #3 indicated there was only one nurse signature for the telephone consent on [DATE] and there was no second nurse signature as a witness. RN #3 indicated the APRN who signed the form was not the witness because she signed the next day. RN #3 indicated it was not done at the time for readmission in [DATE] and she did not see any progress notes in [DATE] or before or after [DATE] to explain about the code status not being done. Interview with the DNS on [DATE] at 8:50 AM indicated when a resident is admitted to the facility the RN must get the code status signed by the resident or resident representative within 24 hours. The DNS indicated if the nurse must call the residents representative to get a telephone consent for a code status it must be signed by 2 registered nurses to verify what the resident representative wanted for code status. The DNS indicated the physician that signs the code status form must write a progress note for the code status the date that it was signed. After review of the clinical record, the DNS indicated Resident #63 was readmitted on [DATE] and the code status should have been done within 24 hours and was not done until [DATE], 3 months later. The DNS indicated there was only one nurse's signature on the code status form and Resident #63 was a DNR so it is not valid. The DNS indicated their APRN that signed the code status did not write a progress note for the code status on [DATE]. The DNS after review of the physician and APRN notes indicated the code status was not in any of the notes from [DATE] -until now. The DNS indicates the resident's representative comes into the facility every Sunday to visit and should have been directed by nursing to sign the code status form right after the admission in [DATE]. The DNS indicated the nurses cannot follow the advanced directive form in the chart only signed by 1 nurse because it is not valid as it was not witnessed by a second nurse. The DNS indicated so technically Resident #63 should be a full code because the 1 nurse signing is not valid. After surveyor inquiry, the Advance Directive form for code status dated [DATE] identified Resident #63 was a full code. The nursing progress note dated [DATE] at 2:10 PM noted as a late entry for [DATE] at 2:00 PM identified the DNS spoke with the resident and resident's representative. Resident #63 stated he/she would like to have CPR performed in the event his/her heart stopped and breathing had stopped. Resident #63 stated he/she wanted to be a full code and was adamant about being the status he/she signed for. The resident's representative was in agreement. Two RN's signed advance directive and MD will be in facility to complete form when available. MD updated regarding code status, and all updated in the electronic medical record with new order. A physician's order dated [DATE] identified Resident #63 was a full code. 2. Resident #87 was admitted to the facility on [DATE] with diagnoses that included dementia and pneumonia. A physician's order dated [DATE] directed to ensure resident signs advance directives form and place form in chart. Review of the APRN/MD notes dated [DATE] - [DATE] failed to identify information regarding the resident's code status. Review of the nursing notes dated [DATE] - [DATE] failed to identify information regarding the resident's code status. The advance directive form for code status dated [DATE] indicated Resident #87 requested DNR status. The care plan dated [DATE] identified to follow code status per the physicians or APRN order. The admission MDS dated [DATE] identified Resident # 87 had severely impaired cognition. Interview with the DNS on [DATE] at 11:30 AM indicated after review of the clinical record the physician nor the APRN addressed the resident's code status in their notes. The DNS indicated there was not a physician's order for the resident's code status. The DNS indicated there was not a progress note or MD order for the code status. The DNS indicated there is only an alert but that is not an actual MD order that the nurses can follow. After surveyor inquiry, the advance directive form for code status dated [DATE] indicated Resident #87 was a full code and wanted resuscitation. Interview with the DNS on [DATE] at 12:15 PM indicated she had received the new advanced directive form for the code status for Resident #63 and Resident #87 after she had spoken to the residents and the resident representatives. The DNS indicated Resident #63 was now a full code and wanted resuscitation and Resident #87 was also a full code and wanted resuscitation. Interview with APRN #1 on [DATE] at 1:30 PM indicated the advanced directives for code status initially is signed by the nurses and then she will receive it and co-sign the form and put the order in the chart and she sometimes address the code status in her note. APRN #1 indicated she was not sure if there must be a progress note addressing the code status when it is first signed. The nursing progress note dated [DATE] at 2:35 PM, as a late entry for [DATE] at 2:31 PM, identified this writer spoke with resident and resident representative regarding code status. Resident was educated on code status and indicated he/she would prefer to have CPR. Advance directive signed by resident and resident representatives were in agreement for code status. Two RN nurses signed the advance directive form, and the MD was updated. A physician's order date [DATE] directed Resident #87 was a full code and to perform CPR. Although attempted, an interview with MD #1 and APRN #2 was not obtained. Review of the facility Advance Directive Policy identified resident's preferences regarding end-of-life decisions and medical decisions are always respected. The procedure is if a resident was admitted without a living will, they will be given the advanced directive handouts upon admissions. These handouts are in the nursing admission packets and are to be completed by nursing staff within 24 hours of admission. The form once completed will be filed in the medical chart. A physician's order will be placed in the electronic medical record. If the resident is unable to make the decision the resident's representative has the power to make that decision. Advance directives are reviewed quarterly by nursing in the care plan meetings.

**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 4 residents (Resident #20, 34, 87 and 399) the facility failed to notify the physician and/or the resident representative when indicated. For Resident #20, reviewed for unnecessary medications, the facility failed to notify the physician and document the notification, of a blood sugar that exceeded the sliding scale parameters, and for Resident #34, reviewed for respiratory care, the facility failed to notify the physician and the cardiologist of the resident's inability to wear a prescribed CPAP, and Resident #87, reviewed for notification, the facility failed to notify the physician and resident representative when weights were not obtained, and for Resident #399, reviewed for pain management, the facility failed to ensure the physician and resident representative were updated in a timely manner when medication was not available. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, type 1 diabetes mellitus with hyperglycemia, and congestive heart failure. A physician's order dated 5/2/22 directed to administer Novolog Insulin Aspart solution (a medication for diabetes mellitus) 100 unit/ml subcutaneously before meals per sliding scale. Blood Sugar (BS) is less than 70 call, MD/APRN. BS 0 - 200, administer 0 units. BS 201 - 250, administer 2 units. BS 251 - 300, administer 4 units. BS 301 - 350, administer 6 units. BS 351 - 400, administer 8 units. BS 401- 450, administer 10 units. If blood sugar is greater than 450, call the MD/APRN. A physician's order dated 10/17/22 directed to administer 5 units of Novolog Insulin Aspart solution 100 unit/ml subcutaneously three times daily, at 8:00 AM, 12:00 PM, and 5:00 PM. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition and required insulin injections in the last 7 days. The care plan dated 9/22/23 identified Resident #20 was at risk for abnormal glucose levels (hypo/hyperglycemia) secondary to diabetes mellitus. Interventions included providing diabetic medications and/or Insulin as ordered, providing fingersticks as ordered and record and report abnormal findings to the physician, and as applicable provide sliding scale Insulin, per the physician's order. The medication administration history document dated 9/21/23 at 11:30 AM identified that Resident #20 had a blood sugar reading of 458 and 0 units of Insulin was administered. The nurse's note dated 9/21/23 failed to identify the physician/APRN and resident representative were notified of the blood sugar reading of 458. The nurse's notes also failed to identify a nursing assessment was completed for Resident #20 or interventions taken to address the elevated blood sugar reading of 458. Interview and review of the clinical record with LPN #4 on 11/1/23 at 1:10 PM identified that on 9/21/23 she had notified an APRN of Resident #20's blood sugar reading of 458, which exceeded the sliding scale parameters, and she was directed to administer 10 units of Novolog Insulin per the sliding scale and 5 units of Novolog Insulin per the standard order. LPN #4 further indicated that she was unsure why her documentation was not showing up in the comment section of the medication administration history documentation or the progress notes. Interview and review of the clinical record with the DNS on 11/2/23 at 12:44 PM failed to provide documentation that the physician/APRN and resident representative were notified of the blood sugar reading exceeding sliding scale parameters. The DNS indicated that she would expect to see a progress note written by LPN #4 and that she would have expected LPN #4 to notify the nursing supervisor to assess the resident for signs and symptoms of hyperglycemia. The DNS further indicated that the nursing supervisor should have notified the physician/APRN and documented her assessment and the physician/APRN's plan of care, including any new orders if they were obtained, in the clinical record. Interview with APRN #1 on 11/6/23 at 1:20 PM identified that she began covering this facility on 10/17/23, but she would expect to be notified if a resident had a blood sugar exceeding the ordered parameters; she would have reevaluated the resident and treatment plan, and possibly written new orders. Although attempted, an interview with APRN #2 was not obtained. Review of the facility's nurse assessment/observation policy directs nurses to conduct an assessment/observation every shift or when a resident's condition changes. Any concerns/change in condition will be assessed by the RN and reported to the MD/APRN. Any new orders will be carried out and POA/Conservator will be updated if applicable. Any changes to the plan of care will be updated. Review of the facility's Insulin administration policy directs the nurse shall notify the DNS and attending physician of any discrepancies, before giving the Insulin. 2. Resident #34 was admitted to the facility on [DATE] with diagnoses that included stroke, obstructive sleep apnea, systolic congestive heart failure. The resident was readmitted to the facility on [DATE]. The quarterly MDS dated [DATE] identified Resident #34 had intact cognition, required total assistance for transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene; supervision required for locomotion, and eating. Further, the MDS identified Resident #34 used a BiPap/CPAP and was wheelchair dependent. The care plan dated 7/14/23 identified a focus on BiPAP/CPAP use with interventions that included providing supplemental oxygen via BiPAP/CPAP per physician's order. A physician's order dated October 2023 (original order dated 11/10/22) directed to apply CPAP, settings of 5-20 cmH2O FIO2 21 - 100%, on at hour of sleep and as needed, off in the morning, once an evening 3:00 PM - 11:00 PM. Review of the October 2023 TAR identified Resident #34 had the CPAP applied daily with the exception of the following dates. 10/7/23 - the CPAP was not administered, waiting for new mask. 10/21/23 - the CPAP was not administered, mask on order. The nurse's note dated 10/14/23 at 3:38 PM identified that Resident #34 continues to refuse to wear CPAP with connecting oxygen at night, no acute exacerbation related to respiratory this shift, no shortness of breath, no coughing noted this shift. Head of bed elevated while sleeping with good results noted. An interview with Resident #34 on 11/6/23 at 11:20 AM identified he/she has not worn the CPAP for more than 4 months because there has not been a comfortable face mask. Resident #34 indicated both nursing and the DNS were aware there was no face mask for use with the CPAP, and the resident was told someone would come to the facility to fit one for him/her. Resident #34 also indicated he/she falls asleep more frequently during the day unexpectedly in his/her wheelchair, as a result of not wearing the CPAP. Interview with the DNS on 11/6/23 at 11:40 AM failed to reflect that a mask for Resident #34 was on order, or that the oxygen supplier had been notified of the request for Resident #34 to have a mask fitting. The DNS indicated over the past 4 months several masks have been trialed with no success and she would contact the oxygen supplier for a visit to the facility to properly fit Resident #34. The DNS also indicated that documentation failed to reflect that the physician or cardiologist were notified of Resident #34's inability to wear the CPAP for the 4-month period. Although requested a policy for CPAP was not provided. Review of the facility Change of Condition Policy identified the policy was to ensure that changes in a resident's condition are reported to providers and families. The purpose was to ensure that all resident's change in condition is assessed and documented properly and reported to the physician and family. 3. Resident #87 was admitted to the facility on [DATE] with diagnoses that included dementia, localized swelling due to a mass, and cancer. A physician's order dated 7/10/23 directed to obtain a daily weight at 6:00 AM, and if there was a weight gain of 2 - 3 lbs. a day or more, or worsening swelling in the ankles, legs or abdomen, notify the physician. The care plan dated 7/10/23 did not reflect the resident had orders for daily weights. Review of the clinical record, including nurse's notes dated 7/10/23 - 11/5/23 identified that daily weights were not done on 23 days, there was a weight gain on 8 days, and there was a weight loss on 2 days. Further, the review failed to reflect that the physician and resident representative had been notified of the weight gain and loss or that the weights had not been obtained on 23 days. The admission MDS dated [DATE] identified Resident # 87 had severely impaired cognition. a. Review of the daily weights document dated 7/10/23 - 7/31/23 identified the following. Daily weights were not done 7/10/23 - 7/19/23. Daily weights were missing 14 out of 22 opportunities. On 7/24/23 the resident's weight was 119 lbs. On 7/26/23 the resident's weight was 124 lbs., a weight gain of 5 lbs. without documentation of physician notification. On 7/27/23 the resident's weight was 102.6 lbs. On 7/31/23 the resident's weight was 125 lbs., a weight gain 22.4 lbs. without documentation of physician notification. b. Review of the daily weights document dated 8/1/23 - 8/31/23 identified the following. Daily weights were missing 4 out of 31 days. On 8/1/23 the resident's weight was 121 lbs. On 8/2/23 the resident's weight was 126 lbs., a weight gain of 5 lbs. without documentation of physician notification. On 8/8/23 the resident's weight was 126 lbs. On 8/10/23 the resident's weight was 115 lbs., a weight loss of 11 lbs. without documentation of physician notification. On 8/28/23 the resident's weight 114.6 lbs. On 8/29/23 weight 119 lbs. weight gain of 4.4 lbs. without documentation of physician notification. c. Review of the daily weights document dated 9/1/23 - 9/30/23 identified the following. Daily weights were missing 4 out of 30 days. On 9/21/23 the resident's weight was 114.5 lbs. On 9/22/23 the resident's weight was 119 lbs., a weight gain of 4.5 lbs. without documentation of physician notification. On 9/25/23 the resident's weight was 114 lbs. On 9/26/23 the resident's weight was 119 lbs., a weight gain of 5 lbs. without documentation of physician notification. On 9/27/23 the resident's weight was 114 lbs. On 9/28/23 the resident's weight was 119 lbs., a weight gain of 4 lbs. without documentation of physician notification. d. Review of the daily weights document dated 10/1/23 - 10/31/23 identified the following. Daily weights were missing 1 out of 31 days. On 9/31/23 the resident's weight was 114 lbs. On 10/1/23 the resident's weight was 119 lbs., a weight gain 5 lbs. without documentation of physician notification. On 10/15/23 the resident's weight was 118 lbs. On 10/16/23 the resident's weight was 114 lbs., a weight loss of 4 lbs. without documentation of physician notification. Interview with the DNS on 11/2/23 at 2:53 PM indicated Resident #87 had a physician order for daily weights with parameters since 7/10/23. The DNS indicated that staff did not start obtaining the daily weights until 7/20/23 and there were days missing each month. The DNS indicated Resident #87 would not refuse to be weighed, but if he/she did refuse, the staff should write a note and reattempt to weigh the resident a little while later that day. The DNS indicated the physician must be notified every day that the daily weight was not obtained, for reevaluation and direction. The DNS indicated there was a parameter for notification of a weight gain of 2 or more lbs., to notify the physician. The DNS indicated there were a few times that Resident #87 had a weight gain, and the physician was not notified. The DNS indicated if a weight was not done on a day, the physician and family should be notified, and the lack of the weight be documented in the progress notes. Review of the clinical record, the DNS indicated there were no notes that the physician and or representative were notified of the missing weights or the weight gains between 7/8/23 to current. Interview with APRN #1 on 11/6/23 at 1:30 PM indicated that her expectation was that Resident #87's weights would be done according to the physician's order and notification to the physician based on the parameters. APRN #1 indicated nursing was responsible to get the daily weights and if not to evaluate why they were not done and notify the APRN/MD by that day and no later than day 2 if weight was not done. APRN #1 indicated she has not been notified of weights not done or of weight gains. Although attempted, an interview with APRN #2 was not obtained. Review of the facility Change of Condition Policy identified the policy was to ensure that changes in a resident's condition are reported to providers and families. The purpose was to ensure that all residents' change in condition is assessed and documented properly and reported to the physician and family. Although requested, a facility policy on obtaining weights was not provided. 4. Review of the hospital Discharge summary dated [DATE] identified Resident #399 was to receive Lyrica 100mg twice a day. Resident #399 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region, neuropathy, and diabetes. A physician's order dated 10/10/23 directed to monitor pain level every shift and give Lyrica (pregabalin) 100 mg twice a day at 9:00 AM and 9:30 PM for pressure ulcer. The care plan dated 10/11/23 identified a risk for pain due to physical condition, psychological condition, and pressure ulcer. Interventions included administering pain medication as ordered and evaluating effectiveness. Additionally, update MD/APRN as needed. The Medicare 5-day MDS dated [DATE] identified Resident #399 cognitive assessment and pain assessment were not completed. A nurses note dated 10/22/23 at 9:01 AM identified Lyrica was not available, MD notified, medication in route from pharmacy. The nurse's note, written by LPN #2, on 10/23/23 at 6:10 PM identified a call was placed to the pharmacy for Lyrica. The pharmacy indicated a new script was needed. Placed in APRN book to update. Will follow up with APRN tomorrow. A Controlled Substance Disposition Record dated 10/24/23 identified the facility had received 28 capsules of Lyrica 100mg for Resident #399. Resident #399 received the first dose on 10/24/23 at 9:00 PM (Resident had missed 28 doses). Interview with LPN #2 on 10/31/23 at 7:24 AM indicated she was the full-time nurse on the unit and was the primary nurse for Resident #399. LPN #2 indicated Resident #399 did not receive the Lyrica medication from 10/10/23 - 10/24/23, 15 days. LPN #2 indicated the nurses were responsible for notifying the APRN or MD and the resident representative that Resident #399 was not receiving the medication per the physician's order. Interview with RN # 3 (day supervisor) on 10/31/23 at 10:48 AM indicated after clinical record review, RN #3 indicated the physician was not notified the medication was not available until 10/22/23 and the resident or resident representative was not notified. Interview with APRN #1 on 10/31/23 at 10:53 AM indicated she started to cover this facility since 10/17/23 and comes in a partial day once a week on Tuesdays. APRN #1 indicated she cannot do electronic narcotic scripts; she can only do them on paper until she gets approval from the Administrator of her company. APRN #1 indicated Resident #399 was on Lyrica for chronic neuropathy and Resident #399 had complaints of pain in his/her legs from the neuropathy. APRN #1 indicated her expectation was that the resident would receive the Lyrica per the physician's orders. APRN #1 indicated her expectation was when the resident did not receive the first dose of Lyrica, that the APRN and the family would be notified. APRN #1 indicated Resident #399 not receiving the scheduled Lyrica would cause him/her increased nerve pain. Interview with the DNS on 10/31/23 at 11:30 AM indicated when a resident is admitted to the facility the residents should have all their medications within 24 hours. The DNS indicated if a medication was not available that the APRN /MD and the residents' representative would be notified the first day and then daily after that until it was available. The DNS indicated the resident representative should have been notified after the first dose was missing and maybe the family could have indicated if any other medications would be as effective. After clinical record review, the DNS indicated the resident representative was not notified and the physician was not notified from 10/10/23 until 10/22/23. Review of the facility Change of Condition Policy identified the policy was to ensure that changes in a resident's condition are reported to providers and families. The purpose was to ensure that all residents' change in condition is assessed and documented properly and reported to the physician and family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #17) reviewed for resident-to-resident abuse, the facility failed to protect the resident from physical abuse by Resident #57, who had a history of wandering in the facility. The findings include: a. Resident #57 was admitted to the facility in June 2019 with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, and anxiety. The quarterly MDS dated [DATE] identified Resident #57 had severely impaired cognition and required limited assistance with personal hygiene. A physician's order dated 7/20/22 directed to apply a wander guard bracelet related to elopement risk, check placement of wander guard every shift, notify supervisor immediately if wander guard needs to be replaced, and monitor skin integrity. The care plan dated 7/20/22 identified Resident #57 exhibits verbally abusive behaviors, wandering, exit seeking and packing of belongings. Physician's orders dated 8/1/22 directed that Resident #57 was independent with transfers, and ambulation, and directed to apply a wander guard bracelet related to elopement risk, check placement of wander guard every shift, notify supervisor immediately if wander guard needs to be replaced, and monitor skin integrity. b. Resident #17 was admitted to the facility in September 2021 with diagnoses that included schizoaffective disorder, bipolar disorder, and depressive episodes. The care plan dated 4/5/22 identified Resident #17 has the potential for altered thought process and difficulty adjusting to situations due to schizophrenia/depressive disorder. Interventions included administering psychotropic medications, staff to offer support when needed and group therapy as desired. The quarterly MDS dated [DATE] identified Resident #17 had moderately impaired cognition and required limited assistance with personal hygiene. The reportable event form dated 8/4/22 at 7:45 PM identified Resident #57 wandered into Resident #17's room and Resident #17 began yelling for Resident #57 to get out of the room. Resident #57 picked up a laundry hamper and hit Resident #17 on the left arm. Both residents were immediately separated, and Resident#17 was assessed by a RN. Subsequent to APRN notification, Resident #57 was sent to the hospital for evaluation and treatment. The nurse's note dated 8/4/22 at 9:03 PM identified Resident #57 was sent to the hospital for abnormal behavior. Resident #57 went into Resident #17's room taking his/her belongings. When Resident #17 asked Resident #57 to put his/her belonging back, Resident #57 hit Resident #17 with a hamper. Resident #57 was alert and pacing the facility. The police, APRN, and resident representative were notified. The care plan dated 8/4/22 identified Resident #57 was involved in an altercation with another resident and Resident #57 was identified as the aggressor. Interventions included to remove from over stimulating situations. Immediately separate residents. Psychiatric consultant. Send to the hospital for evaluation and treatment. The care plan dated 8/4/22 identified Resident #17 has been the victim of alleged abuse. Interventions included psychiatric consultation, assess for injury, and provide validation and support. Review of the Resident #17's clinical record failed to reflect documentation related to the incident on 8/4/22 at 7:45 PM when Resident #57 picked up a laundry hamper and hit Resident #17 on the left arm. Review of Resident #57's nurse's note dated 8/5/22 at 3:34 AM identified Resident #57 had returned from the hospital at 2:30 AM. Resident #57 was alert, pleasant, confused, and no aggressive behavior noted. No new orders. A physician's order dated 8/5/22 directed to monitor Resident #57 every 15 minutes until tomorrow. Review of the psychiatric APRN progress note dated 8/11/22 identified Resident #17 was seen and evaluated for peer altercation, and for mood. Resident #17 was calm and cooperative. No ill effects from peer altercation. Resident #17 verbalized feeling safe at the facility. Coping skills, and supportive care provided. Resident #17 was not a danger to self or others. Review of the psychiatric APRN progress note dated 8/12/22 identified Resident #57 was seen for peer altercation. Resident #57 was a poor historian, cognitive communication impairment. Resident #57 was observed ambulating safely in the facility. Resident #57 has no recollection of the incident. Resident #57 was pleasantly confused with a short attention span. Supportive care was provided. Resident #57 was not a danger to self or others. The facility failed to provide documentation that a thorough investigation was completed after the resident-to-resident physical abuse on 8/4/22. The summary report (undated) identified on 8/4/22 at 7:45 PM Resident #17 was heard yelling and had called the police. Resident #17 indicated that Resident #57 had entered his/her room and hit him/her on the left arm with the laundry hamper. Resident #57 was observed with the laundry hamper in his/her hands. The two residents were immediately separated. RN assessment revealed no apparent injury to Resident #17 and Resident #57. Resident #17 was seen by the psychiatrist with no new recommendations. Resident #17 was offered a stop sign for the door to his/her room to prevent residents from wandering into his/her room and Resident #17 declined. Resident #17 indicated she feels safe. Resident #17 to be seen by social services for ongoing support. Resident #17 care plan has been updated. Resident #57 was sent to the hospital for evaluation and treatment. Resident #57 was placed on special checks and monitored by staff. Both residents' care plan was updated. Interview with the DNS on 11/1/23 at 8:18 AM identified she was unable to find the reportable event form or the investigation documents for the resident-to-resident physical altercation on 8/4/22. The DNS indicated she was not employed by the facility in 2022. The DNS indicated the file cabinets were empty when she first started at the facility, and there were no reportable event forms in the file cabinets. Interview with Administrator #2 (previous Administrator) on 11/6/23 at 8:08 AM identified she does not remember the incident between Resident #17 and Resident #57. Administrator #2 indicated to contact DNS #2 (previous DNS). Interview with DNS #2 (previous DNS) on 11/6/23 identified she remembered the incident on 8/4/22. DNS #2 indicated she does not recall if she completed a summary investigation document. DNS #2 indicated it happened a long time ago. DNS #2 indicated if there were any documents pertaining to the incident it was placed in a red folder in the file cabinet in the DNS office. Interview with Administrator #3 (previous Administrator) on 11/14/23 at 9:32 AM identified he was employed by the facility from 5/30/23 - 9/4/23. Administrator #3 indicated he did not move any files out of the file cabinet in the previous DNS office. Administrator #3 indicated when he was there, there were no organizations in the DNS office and the Administrator office. The Administrator indicated in both offices' documents were scattered around. Administrator #3 indicated he tried to organize the documents in the office and placed them in a box. Administrator #3 indicated the boxes contained incident reports from 2022 and anything from the beginning of 2023. Administrator #3 indicated he left the boxes in the Administrator's office. Administrator #3 indicated 4 to 5 boxes with documents of incident report were placed downstairs. Interview with DNS #3 (previous DNS) on 11/14/23 at 10:11 AM identified she was employed by the facility from November 2022 - August 2023. DNS #3 indicated she did not remove any reportable event forms from the file cabinet in the DNS office during her employment at the facility. DNS #3 indicated all the reportable event forms were put in a box and given to Administrator #2 and corporate and the owner had told Administrator #2 that she had to go through the box. DNS #3 indicated when Administrator #2 left she had given the box to Administrator #3. DNS #3 indicated she had left all the reportable event forms on top of the file cabinet in the DNS office. DNS #3 indicated when she first came to the facility, she was unable to find any reportable event forms before November 2022. DNS #3 indicated there were files and reportable event forms in boxes downstairs. DNS #3 indicated corporate came to the facility one day and shredded a lot of the documents that were downstairs. Review of the facility resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the facility ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of property, and retaliation. Abuse: the infliction of injury, unreasonable confinement, intimidation, punishment, or exploitation with resulting physical harm, pain, or mental anguish. This also includes the deprivation by any individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Physical abuse: the intentional infliction of physical pain, bodily harm, or physical coercion.

**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 #17) reviewed for resident-to-resident abuse, the facility failed to ensure a thorough investigation of the incident was completed, documented and available for review. The findings include: a. Resident #57 was admitted to the facility in June 2019 with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, and anxiety. The quarterly MDS dated [DATE] identified Resident #57 had severely impaired cognition and required limited assistance with personal hygiene. A physician's order dated 7/20/22 directed to apply a wander guard bracelet related to elopement risk, check placement of wander guard every shift, notify supervisor immediately if wander guard needs to be replaced, and monitor skin integrity. The care plan dated 7/20/22 identified Resident #57 exhibits verbally abusive behaviors, wandering, exit seeking and packing of belongings. Physician's orders dated 8/1/22 directed that Resident #57 was independent with transfers, and ambulation, and directed to apply a wander guard bracelet related to elopement risk, check placement of wander guard every shift, notify supervisor immediately if wander guard needs to be replaced, and monitor skin integrity. b. Resident #17 was admitted to the facility in September 2021 with diagnoses that included schizoaffective disorder, bipolar disorder, and depressive episodes. The care plan dated 4/5/22 identified Resident #17 has the potential for altered thought process and difficulty adjusting to situations due to schizophrenia/depressive disorder. Interventions included administering psychotropic medications, staff to offer support when needed and group therapy as desired. The quarterly MDS dated [DATE] identified Resident #17 had moderately impaired cognition and required limited assistance with personal hygiene. The reportable event form dated 8/4/22 at 7:45 PM identified Resident #57 wandered into Resident #17's room and Resident #17 began yelling for Resident #57 to get out of the room. Resident #57 picked up a laundry hamper and hit Resident #17 on the left arm. Both residents were immediately separated, and Resident#17 was assessed by a RN. Subsequent to APRN notification, Resident #57 was sent to the hospital for evaluation and treatment. The nurse's note dated 8/4/22 at 9:03 PM identified Resident #57 was sent to the hospital for abnormal behavior. Resident #57 went into Resident #17's room taking his/her belongings. When Resident #17 asked Resident #57 to put his/her belonging back, Resident #57 hit Resident #17 with a hamper. Resident #57 was alert and pacing the facility. The police, APRN, and resident representative were notified. The care plan dated 8/4/22 identified Resident #57 was involved in an altercation with another resident and Resident #57 was identified as the aggressor. Interventions included to remove from over stimulating situations. Immediately separate residents. Psychiatric consultant. Send to the hospital for evaluation and treatment. The care plan dated 8/4/22 identified Resident #17 has been the victim of alleged abuse. Interventions included psychiatric consultation, assess for injury, and provide validation and support. Review of the Resident #17's clinical record failed to reflect documentation related to the incident on 8/4/22 at 7:45 PM when Resident #57 picked up a laundry hamper and hit Resident #17 on the left arm. Review of Resident #57's nurse's note dated 8/5/22 at 3:34 AM identified Resident #57 had returned from the hospital at 2:30 AM. Resident #57 was alert, pleasant, confused, and no aggressive behavior noted. No new orders. A physician's order dated 8/5/22 directed to monitor Resident #57 every 15 minutes until tomorrow. Review of the psychiatric APRN progress note dated 8/11/22 identified Resident #17 was seen and evaluated for peer altercation, and for mood. Resident #17 was calm and cooperative. No ill effects from peer altercation. Resident #17 verbalized feeling safe at the facility. Coping skills, and supportive care provided. Resident #17 was not a danger to self or others. Review of the psychiatric APRN progress note dated 8/12/22 identified Resident #57 was seen for peer altercation. Resident #57 was a poor historian, cognitive communication impairment. Resident #57 was observed ambulating safely in the facility. Resident #57 has no recollection of the incident. Resident #57 was pleasantly confused with a short attention span. Supportive care was provided. Resident #57 was not a danger to self or others. The facility failed to provide documentation that a thorough investigation was completed after the resident-to-resident physical abuse on 8/4/22. The summary report (undated) identified on 8/4/22 at 7:45 PM Resident #17 was heard yelling and had called the police. Resident #17 indicated that Resident #57 had entered his/her room and hit him/her on the left arm with the laundry hamper. Resident #57 was observed with the laundry hamper in his/her hands. The two residents were immediately separated. RN assessment revealed no apparent injury to Resident #17 and Resident #57. Resident #17 was seen by the psychiatrist with no new recommendations. Resident #17 was offered a stop sign for the door to his/her room to prevent residents from wandering into his/her room and Resident #17 declined. Resident #17 indicated she feels safe. Resident #17 to be seen by social services for ongoing support. Resident #17 care plan has been updated. Resident #57 was sent to the hospital for evaluation and treatment. Resident #57 was placed on special checks and monitored by staff. Both residents' care plan was updated. Interview with the DNS on 11/1/23 at 8:18 AM identified she was unable to find the reportable event form or the investigation documents for the resident-to-resident physical altercation on 8/4/22. The DNS indicated she was not employed by the facility in 2022. The DNS indicated the file cabinets were empty when she first started at the facility, and there were no reportable event forms in the file cabinets. Interview with the Administrator on 11/1/23 at 8:25 AM identified the facility was unable to locate the reportable event form or the investigation documents for the resident-to-resident physical altercation on 8/4/22. The Administrator indicated she was not employed by the facility in 2022. Interview with Administrator #2 (previous Administrator) on 11/6/23 at 8:08 AM identified she does not remember the incident between Resident #17 and Resident #57. Administrator #2 indicated to contact DNS #2 (previous DNS). Interview with DNS #2 (previous DNS) on 11/6/23 identified she remembered the incident on 8/4/22. DNS #2 indicated she does not recall if she completed a summary investigation document. DNS #2 indicated it happened a long time ago. DNS #2 indicated if there were any documents pertaining to the incident it was placed in a red folder in the file cabinet in the DNS office. Interview with Administrator #3 (previous Administrator) on 11/14/23 at 9:32 AM identified he was employed by the facility from 5/30/23 - 9/4/23. Administrator #3 indicated he did not move any files out of the file cabinet in the previous DNS office. Administrator #3 indicated when he was there, there were no organizations in the DNS office and the Administrator office. The Administrator indicated in both offices' documents were scattered around. Administrator #3 indicated he tried to organize the documents in the office and placed them in a box. Administrator #3 indicated the boxes contained incident reports from 2022 and anything from the beginning of 2023. Administrator #3 indicated he left the boxes in the Administrator's office. Administrator #3 indicated 4 to 5 boxes with documents of incident report were placed downstairs. Interview with DNS #3 (previous DNS) on 11/14/23 at 10:11 AM identified she was employed by the facility from November 2022 - August 2023. DNS #3 indicated she did not remove any reportable event forms from the file cabinet in the DNS office during her employment at the facility. DNS #3 indicated all the reportable event forms were put in a box and given to Administrator #2 and corporate and the owner had told Administrator #2 that she had to go through the box. DNS #3 indicated when Administrator #2 left she had given the box to Administrator #3. DNS #3 indicated she had left all the reportable event forms on top of the file cabinet in the DNS office. DNS #3 indicated when she first came to the facility, she was unable to find any reportable event forms before November 2022. DNS #3 indicated there were files and reportable event forms in boxes downstairs. DNS #3 indicated corporate came to the facility one day and shredded a lot of the documents that were downstairs. Review of the facility resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, and retaliation policy identified the facility ensure residents are free from abuse, mistreatment, neglect, exploitation, misappropriation of property, and retaliation. Investigation Components: the investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. The information gathered is given to the administration. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator, DNS, or designee will investigate the incident with the assistance of appropriate personnel. All staff must cooperate during the investigation to assure the resident is fully protected. The investigation will be documented and reported accordingly.

**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 4 residents (Resident #8, 59, 70 and 89) the facility failed to develop a comprehensive care plan as follows: for Resident #8 reviewed for communication, the facility failed to develop a care plan that addressed the resident's inability to hear and effectively communicate, for Resident #59 reviewed for respiratory care, the facility failed to develop a care plan to address the resident's tracheostomy, for Resident #70 reviewed for behaviors, the facility failed to develop a care plan to address the globus sensation (sensation of having a lump or something stuck in the throat) which was exhibited as an expression of anxiety, and for Resident #89 the facility failed to develop a care plan to address the residents diagnoses of psychoactive substance abuse with withdrawal and attention and concentration deficit. The findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included sensorineural hearing loss - bilateral, type 2 diabetes, and cardiac arrhythmia. A physician's order dated 9/23/23 directed to provide audiometry screen every 5 years. The care plan dated 9/24/23 identified a focus on communications with interventions that included Resident #8 to read lips, staff to speak slowly and directly to resident and use picture books. The admission MDS dated [DATE] identified Resident #8 had moderately impaired cognition and was totally dependent for bed mobility, transfer, dressing, and personal hygiene. Further, Resident #8 had adequate hearing (this is in conflict with the residents diagnoses of hearing loss). Observation on 10/30/23 at 7:30 AM identified Resident #8 was lying in bed watching television. Upon attempting to speak with Resident #8, the resident's response was I cannot hear you, I cannot understand you, I am deaf. Further, the observation identified that the resident's television was on a major network news channel, was not in a closed captioning mode and no communication devices were observed in the room. Interview with the Social Worker on 11/2/23 at 9:20 AM identified Resident #8 communicates via writing on paper. The Social Worker identified although she communicated with Resident #8's family, the resident's history of hearing impairment and the resident's capacity to use sign language was unknown. Further, the Social Worker identified there have been no referrals made to address Resident #8's hearing loss. Interview with the Director of Admissions on 11/2/23 at 9:30 AM noted the resident was identified as hearing impaired prior to admission and all admissions required approval of the Director of Nursing. The Director of Admissions identified she was not made aware of any special communication needs for Resident #8, other than a white board utilized in the hospital. The Director of Admissions did not know if Resident #8 was deaf from birth or if he/she communicated via sign language. Interview and review of the clinical record with the DNS on 11/2/23 at 10:40 AM failed to reflect any information on Resident #8's history of hearing loss (hearing loss identified at birth or the result of illness or trauma) or the facility's attempts to enhance Resident #8's communication. The DNS identified she was recently employed by the facility and had not an opportunity to review the resident. Interview with the Director of Recreation on 11/2/23 at 12:20 PM identified she had seen Resident #8 on 9/27/23 with no further documentation of information regarding subsequent visits. The Director of Recreation indicated she met with Resident #8, and the resident participated in a coloring exercise. The Director of Recreation identified she was unaware Resident #8 was deaf and indicated she had not been trained on how to communicate with deaf people and stated nobody told me Resident #8 was deaf. The facility's policy on the care of hearing-impaired residents states it is our responsibility to assist the resident and representatives in locating available resources (e.g., Medicare, Medicaid or local organizations), scheduling appointments and arranging transportation to obtain needed services. 2. Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, gastrostomy status, and tracheostomy status. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, nutritional approaches performed in the last 7 days were a feeding tube, and respiratory treatments that were performed in the last 14 days were oxygen therapy, suctioning, and tracheostomy care. The care plan dated 9/2/23 failed to identify Resident #59's tracheostomy status, including goals and approaches to care. Interview with the DNS on 11/6/23 at 12:08 PM identified that Resident #59 was not comprehensively care-planned for his/her tracheostomy. The DNS indicated that Resident #59's care plan should go beyond being at risk for respiratory distress and should include (but not limited to) cleaning of the tracheostomy, application of oxygen therapy, signs and symptoms of respiratory distress, suctioning, secretion management, and monitoring for discoloration. The DNS further identified that the facility was without a social worker and MDS coordinator prior to her start date at the facility (8/8/23). Care plans were being updated by nursing as new issues arose, and support was being provided by the consulting and regional teams. The DNS further identified that, in September 2023, the current team had initiated a QAPI action plan to update the resident care plans, and the new MDS coordinator had aggressively been working on updating all the resident care plans. Review of the facility's comprehensive care-planning policy directs the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy further directs the comprehensive, person-centered care plan will include: measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. 3. Resident #70 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism, dementia, and anxiety disorder. A physician's note dated 9/11/23 identified worsening anxiety; start Lorazepam (used to treat anxiety) 0.5mg twice daily, and Lorazepam 1mg every 12 hours as needed; with psychiatry to review, emotional support to be provided, and to monitor closely. The annual MDS dated [DATE] identified Resident #70 had moderately impaired cognition, required supervision with personal hygiene, independent with bed mobility, transferring, locomotion, dressing, eating, and toilet use. Resident #70 had a colostomy and used a walker and wheelchair for mobility. The care plan dated 9/12/23 identified a focus on anxiety disorder and seeks medical attention with interventions that include approaching the resident in a calm consistent manner, re-approach resident with refusal of care, monitor changes in mood and provide resident opportunity to express feelings through a 1:1 (one to one) group visit. A physician's order dated 9/21/23 directed to administer Lorazepam 0.5mg every 12 hours and Lorazepam 1mg every 12 hours as needed. A physician's order dated 10/21/23 directed to discontinue the Lorazepam 0.5mg and the Lorazepam 1.0mg. Interview and review of the clinical record with LPN #3 on 11/1/23 at 11:58 AM identified Resident #70 used Lorazepam 0.5mg to control anxiety which was expressed in the form of globus sensation, but currently had no order for an anti-anxiety medication since 10/21/23 when the Lorazepam 0.5mg and the Lorazepam 1.0mg were discontinued. A reconciliation of controlled substances for Resident #70's Lorazepam identified 60 Lorazepam 0.5mg tablets were delivered to the facility 10/26/23, however, the order for Lorazepam administration was discontinued by the physician on 10/21/23, 5 days prior. LPN #3 identified when Resident #70 has anxiety, (the globus sensation), currently Tramadol (a pain reliever) is all that is available for relief on an as needed basis. LPN #3 indicated she referred the arrival of the 60 Lorazepam 0.5 mg tablets to the supervisor. Review of the clinical record and interview with the DNS on 11/1/23 at 12:55 PM failed to reflect that a care plan or behavior tracking for the globus sensation and failed to explain the arrival of 60 Lorazepam 0.5mg tablets on 10/26/23, 5 days after the physician's order was discontinued. The DNS indicated Resident #70 globus sensation is such that he/she gets nervous, makes a noise, then experiences globus. The DNS indicated Resident #70 does good when administered Lorazepam and she indicated she would get an order from the physician as soon as possible to restart the medication. The DNS indicated it is her expectation that residents with anxiety are treated as ordered by the physician and although the Lorazepam was delivered to the facility, she would secure an order for administration. The DNS also stated the care plan is important to ensure the resident is being provided appropriate care and her expectation is care must be specific to ensure better quality of life. The policy on behavioral assessment, intervention and monitoring indicates the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. The policy also states, the care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. Further, the policy states when medications are prescribed for behavioral symptoms, documentation will include in part: the rational for use, potential underlying causes of the behavior, specific target behaviors and expected outcomes, dosage, duration, monitoring for efficacy and adverse reactions, and plans for a gradual dose reduction if applicable. 4. Resident #89 was admitted to the facility on [DATE] with diagnoses that included psychoactive substance abuse with withdrawal, and attention and concentration deficit following a stroke. Physician's orders dated 9/13/23 directed to administer the following medications. Adderall (dextroamphetamine-amphetamine) 20 mg, (a schedule II medication), twice daily at 8:00 AM and 1:00 PM for attention and concentration deficit following a stroke. Buprenorphine-Naloxone (Schedule III medication) 8mg-2 mg sublingual every 12 Hours at 9:00 AM and 9:00 PM. The admission MDS dated [DATE] identified Resident #89 had moderately impaired cognition, required extensive assistance with toilet use and received injections and Insulin. The care plan dated 9/21/23 identified the resident was at risk for mild nutritional risk, pain and falls. The care plan did not identify interventions to address the resident's history of substance abuse or attention deficit. Based on review of documentation, Resident #89 missed 18 doses of Adderall between 10/17/23 - 10/26/23 and missed 12 doses of Buprenorphine-Naloxone over 6 days between 10/17/23 - 10/26/23. Although requested, a care plan with interventions to address the resident's diagnoses of substance abuse or attention deficit was not provided.

**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 4 residents (Resident #2 and 59) reviewed for PASARR and respiratory care, the facility failed to conduct quarterly care plan meetings and for 1 of 5 residents (Resident #35) reviewed for unnecessary medications, the facility failed to ensure the care plan addressed target behaviors for a resident who required psychotropic medications. The findings include: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia, schizophrenia, and hypertension. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition. The care plan, last revised on 10/28/23, identified Resident #2's last resident care plan meeting occurred on 5/10/22, 17 months ago. Interview with SW #1 on 10/31/23 at 12:12 PM identified that the last care plan meeting held with for Resident #2 and his/her representative was on 5/10/22. SW #1 further identified that care plan meetings should be conducted quarterly or as needed for falls, abuse allegations, and other instances. SW #1 indicated that care plan meetings are attended by the resident and/or resident representative, the MDS coordinator, social worker, occasionally the DNS and other disciplines depending on the nature of the meeting. SW #1 indicated that she began working at the facility on 8/1/23, and she was unaware of the duration of time the facility was without a social worker, prior to her arrival. SW #1 indicated that she was unaware of the last time Resident #2's representative had been updated on his/her plan of care. SW #1 further indicated that during her time at the facility she has been working with interdisciplinary team members to get residents up to date with their care plan meetings. Interview with the DNS on 11/3/23 at 12:35 PM identified that when she began working at the facility on 8/8/23, the prior Administrator informed her that care plan meetings had not been completed in a while due to staffing, specifically lack of an MDS coordinator and social worker. The DNS further identified that the current team had initiated a QAPI action plan as a result of the lack of care plan meetings, and they were monitoring and evaluating the performance of the plan. The DNS indicated that care plan meetings resumed during the first part of September for residents and staff, and letters were sent to resident representatives inviting them to participate in a scheduled care plan meeting, mid-to-late September. The DNS further indicated that they were scheduling additional resident care plan meetings in an effort to get caught up. The facility's care planning-interdisciplinary team policy directs that the resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development and revisions to the resident's care plan. Care plan conferences are scheduled quarterly. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. 2. Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, gastrostomy status, and tracheostomy status. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, nutritional approaches performed in the last 7 days were a feeding tube, and respiratory treatments that were performed in the last 14 days were oxygen therapy, suctioning, and tracheostomy care. The care plan last revised on 9/2/23 identified Resident #59's last care conference meeting occurred on 3/4/22, 20 months ago. Although requested the resident care conference signature sheets from the prior 24 months were not provided. Interview with SW #1 on 10/31/23 at 12:12 PM identified that care conferences should be conducted quarterly or as needed for falls, abuse allegations, and other instances. SW #1 indicated that resident care conferences are attended by the resident and/or resident representative, the MDS coordinator, social worker, occasionally the DNS and other disciplines depending on the nature of the meeting. SW #1 indicated that she began working at the facility on 8/1/23, and she was unaware of the duration of time the facility was without a social worker, prior to her arrival. SW #1 further indicated that during her time at the facility she has been working with interdisciplinary team members to get residents up to date with their care plan meetings. Interview with the DNS on 11/3/23 at 12:35 PM identified that when she began working at the facility on 8/8/23, the prior Administrator informed her that care conferences had not been completed in a while due to staffing, specifically lack of an MDS coordinator and social worker. The DNS further identified that the current team had initiated a QAPI action plan because of the lack of care conferences, and they were monitoring and evaluating the performance of the plan. The DNS indicated that resident care conferences resumed during the first part of September for residents and staff, and letters were sent to resident representatives inviting them to participate in a scheduled care conference. The DNS further indicated that they were scheduling additional resident care conferences, in an effort to get caught up with resident care conferences, in a timely manner. The facility's Care Planning-Interdisciplinary Team policy directs that the resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development and revisions to the resident's care plan. Care plan conferences are scheduled quarterly. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. 3. Resident #35 was admitted to the facility on [DATE] with diagnoses that included anxiety, chronic kidney disease, and dependence on renal dialysis. The care plan dated 12/8/22 identified that Resident #35 had a potential for alteration in psychosocial well-being. Interventions included administering medications as ordered and psych/supportive care consult as needed. Review of the care plan failed to identify any additional interventions related to psychotropic medications or behaviors. The quarterly MDS date 8/12/23 identified Resident # 35 had intact cognition and required supervision with transfers, toileting, and was independent with eating. An APRN note dated 9/26/23 identified Resident #35 complained of intermittent worsening anxiety prior to dialysis. The treatment plan included continuing Trazadone 50 mg at bedtime and starting Trazadone 50 mg every 12 hours as needed. A physician's order dated 9/26/23 directed to administer Trazadone (medication for anxiety) 50 mg every 12 hours as needed for anxiety. The order failed to identify an end date. Review of Resident #35's clinical record failed to identify any behavioral logs or resident care plan updates including target behavior monitoring following the order for as needed Trazodone on 9/26/23. Interview with the DNS on 11/6/23 at 1:20 PM identified that she was aware there was an issue with open ended orders for as needed psychotropic medications. The DNS identified that the facility policy for psychoactive medication included identifying behavior monitoring with target behaviors and that these should be maintained in a behavioral monitoring log, along with interventions. The DNS also identified that the resident's care plan should be updated, and that the as needed order should written for a maximum of 14 days and then the order should be discontinued, extended another 14 days, or changed to a standing order. The DNS identified she only began employment at the facility on 8/3/23 and that the facility also had a recent change in the medical director, which made it difficult to facilitate changes. The facility policy on comprehensive care planning directed that the comprehensive centered care plan should include measurable outcomes and timeframes, incorporate identified problem areas, and reflect treatment goals, timetables, and objectives in measurable outcomes. The policy further directed that assessments of residents were ongoing and care plans were revised as information about the resident and resident's conditions change. The facility policy on psychoactive medications directed that all residents receiving psychoactive medication therapy would be monitored for detection of side effects and other adverse drug reactions. The policy further directed that residents receiving psychoactive medications would have a care plan developed that would consist of measurable goals in behavioral terms for use of the psychoactive medication, list of potential medication side effects, and list of behavioral interventions.

**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 #95) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on the scheduled shower days. The findings include: Resident #95 was admitted to the facility in August 2023 with diagnoses that included subdural abscess, diarrhea, and thyrotoxicosis. Review of the [NAME] unit shower schedule form identified Resident #95 is scheduled for a shower on Thursdays on the 7:00 AM - 3:00 PM shift. The physician's order dated 9/1/23 - 9/30/23 directed to conduct a weekly body audit on shower days, on Thursday 7:00 AM - 3:00 PM shift. The care plan dated 9/4/23 identified Resident #95 had an Activity Daily Living (ADL's) functional status deficit related to neurological deficit, epidural abscess. Interventions included to provide assistance with ADLs, and shower on Thursday on the 7:00 AM - 3:00 PM shift. Review of the nurse aide care card dated 9/4/23 identified the residents shower day was scheduled on Thursday on the 7:00 AM - 3:00 PM shift. The admission MDS dated [DATE] identified Resident #95 had intact cognition and required extensive assistance with personal hygiene and required total assistance with bathing. Review of the September 2023 TAR identified that Resident #95 had a weekly body audit performed on his/her shower days on Thursday 7:00 AM - 3:00 PM shift. Review of the nurse aide flowsheets dated 9/1/23 - 9/30/23 failed to reflect documentation that Resident #95 had been provided a shower on his/her scheduled day Thursday 9/7, 9/14, 9/21, and 9/28/23 during the 7:00 AM - 3:00 PM shift. Review of the nurse's note dated 9/1/23 - 9/30/23 failed to reflect documentation that Resident #95 had been provided a shower and/or had refused the shower on the scheduled shower days on Thursday 7:00 AM - 3:00 PM shift. The physician's order dated 10/1/23 - 10/31/23 directed to provide weekly body audit on shower days on Thursday 7:00 AM - 3:00 PM shift. Review of the October 2023 TAR identified that Resident #95 had a weekly body audit performed on his/her shower days on Thursday 7:00 AM - 3:00 PM shift. Review of the nurse aide flowsheet dated 10/1/23 - 10/31/23 failed to reflect documentation that Resident #95 had been provided a shower on his/her scheduled day Thursday 10/5, 10/12, 10/19, and 10/26/23 during the 7:00 AM - 3:00 PM shift. Review of the nurse's note dated 10/1/23 - 10/31/23 failed to reflect documentation that Resident #95 had been provided a shower and/or had refused the shower on his/her scheduled shower days on Thursday 7:00 AM - 3:00 PM shift. Interview with Resident #95 on 10/30/23 at 8:50 AM identified he/she has been at the facility since August 2023 and has not been provide a shower until Saturday 10/28/23, which was the first time he/she had a shower since admission. Resident #95 indicated he/she had complained to the DNS on 10/28/23 that he/she had not had a shower since being at the facility and the DNS provided him/her with a shower on Saturday (10/28/23) on the evening shift. Resident #95 indicated he/she has asked for a shower and the nurse aides has not given him/her a shower. Resident #95 indicated his/her shower day are on Thursdays on the 7:00 AM - 3:00 PM shift. Resident #95 indicated all he/she wants is a shower once a week like he/she supposed to have. Interview and review of the clinical record with the DNS on 11/2/23 at 11:57 AM identified she was not aware that Resident #95 had not been receiving showers. The DNS indicated Resident #95 reported to her on Saturday (10/28/23) on the 3:00 PM - 11:00 PM shift that he/she had not had a shower since his/her admission to the facility. The DNS indicated she provided Resident #95 with a shower on Saturday (10/28/23) and the resident was happy. The DNS indicated she failed to document in the clinical record that Resident #95 had a shower on Saturday (10/28/23). The DNS indicated Resident #95 shower days are scheduled for Thursday 7:00 AM - 3:00 PM shift. The DNS indicated the nurse aides should have provided Resident #95 with a shower on his/her schedule shower days. The DNS indicated the assigned nurse aide should have reported to the charge nurse if shower was not given and/or if resident had refused the shower. The DNS indicated the assigned nurse aide should have documented if the was given or not. The DNS indicated that all nursing staff will be in-service regarding showers. Interview with the Administrator on 11/2/23 at 12:00 PM identified she was not aware that Resident #95 had not been receiving showers. The Administrator indicated that all nursing staff will be in-service regarding showers. Interview with NA #5 on 11/3/23 at 9:20 AM identified she had been employed by the facility for 20 plus years. NA #5 indicated Resident #95 is on her assignment. NA #5 indicated Resident #95's shower day is on Thursdays on the 7:00 AM - 3:00 PM shift. NA #5 indicated she did not give Resident #95 a shower because the resident had an IV and required a mechanical lift for transfers in the beginning. NA #5 indicated Resident #95 uses a sliding board for transfer now. NA #5 indicated Resident #95 requested to have his/her shower in the evening shift. NA #5 indicated she did not tell the charge nurse or the supervisor regarding Resident #95 request for changing his/her shower time, and refusal of shower. NA #5 indicated whenever Resident #95 refused his/her shower she had notified the charge nurse. NA #5 indicated she did not document Resident #95 had refused his/her shower on the nurse aide flowsheet. Interview with LPN #3 on 11/6/23 at 9:06 AM identified she was not aware that Resident #95 had not been receiving showers. LPN #3 indicated she had performed the body audits on shower days. LPN #3 indicated the nurse aides had not notified her that Resident #95 had not been receiving his/her shower and/or any refusals. LPN #3 indicated going forward she will document resident shower in the clinical record. Interview with LPN #1 on 11/6/23 at 11:24 AM identified she was not aware that Resident #95 had not been receiving showers. LPN #1 indicated she had performed the body audits on shower days. LPN #1 indicated going forward she will document resident shower in the clinical record. Review of the facility bathing and grooming care policy identified it is the policy of the facility to promote and maintain skin integrity. All residents are provided care as needed to maintain personal hygiene and comfort. All residents are provided the opportunity and support to maintain proper hygiene. Rooms are assigned to either a day or evening shift to enable those residents to be provided with at least a weekly shower. Any resident can request and will be provided with additional shower times upon request. Nail care, facial hair care and skin care is provided as a standard of care with bathing and grooming.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy and interviews, the facility failed to ensure licensed clinical staff maintained active CPR certifications. The findings include: A review of facility documentation on [DATE] identified the following licensed staff members without current CPR certification, or without any documentation of a current skills validation after completion of online curriculum. a. LPN #7 identified with a CPR certification expiration date of [DATE]. b. LPN #5 identified with a CPR certification expiration date of [DATE]. c. LPN #3 identified with a CPR certification expiration date of [DATE]. d. RN #6 identified with a CPR certification expiration date of [DATE]. e. LPN#8 identified with a CPR certification expiration date of [DATE]. f. RN #3 identified with a CPR certification expiration date of [DATE]. Further review of facility documentation identified on [DATE] that LPN #1 and LPN #2 each participated in 4.0 hours of an internet based educational activity related to healthcare provider BLS. The documentation failed to identify completion of any hands on or in person skill assessment associated with the online educational activity. The documentation for LPN #1 and LPN #2 also failed to identify any certification associated with BLS including documentation of proficiency to provide CPR or any recertification date. Interview with the DNS on [DATE] at 11:02 AM identified that both she and RN #4 (the previous Infection Prevention Nurse) were responsible for staff development as the facility did not have a staff development nurse. The DNS identified that RN #4 resigned and that she was aware that several licensed clinical staff had expired CPR certifications, and that she had not had time to review the certifications to determine which staff needed to renew their CPR certifications. The DNS also identified that other than a binder that the facility utilized to keep the CPR certifications, there was no central database or location to prompt her that CPR certifications needed to be renewed. The facility policy on training guidelines for staff directed that ongoing education and competency-based training would be a mandatory and routine part of the facility culture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #8) reviewed for communication, the facility failed to develop and provide an ongoing program of activities for the resident who is hearing impaired and for 1 resident (Resident #95) reviewed for recreation, the facility failed to develop and provide an ongoing program of activities including music and television. The findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included sensorineural hearing loss - bilateral, type 2 diabetes, and cardiac arrhythmia. A physician's order dated 9/23/23 directed to provide audiometry screen every 5 years. The care plan dated 9/24/23 identified a focus on communications with interventions that included Resident #8 to read lips, staff to speak slowly and directly to resident and use picture books. The admission MDS dated [DATE] identified Resident #8 had moderately impaired cognition and was totally dependent for bed mobility, transfer, dressing, and personal hygiene. Further, Resident #8 had adequate hearing (this is in conflict with the residents diagnoses of hearing loss). Observation on 10/30/23 at 7:30 AM identified Resident #8 was lying in bed watching television. Upon attempting to speak with Resident #8, the resident's response was I cannot hear you, I cannot understand you, I am deaf. Further, the observation identified that the resident's television was on a major network news channel, was not in a closed captioning mode and no communication devices were observed in the room. Interview with the Social Worker on 11/2/23 at 9:20 AM identified Resident #8 communicates via writing on paper. The Social Worker identified although she communicated with Resident #8's family, the resident's history of hearing impairment and the resident's capacity to use sign language was unknown. Further, the Social Worker identified there have been no referrals made to address Resident #8's hearing loss. Interview with the Director of Admissions on 11/2/23 at 9:30 AM noted the resident was identified as hearing impaired prior to admission and all admissions required approval of the Director of Nursing. The Director of Admissions identified she was not made aware of any special communication needs for Resident #8, other than a white board utilized in the hospital. The Director of Admissions did not know if Resident #8 was deaf from birth or if he/she communicated via sign language. Interview and review of the clinical record with the DNS on 11/2/23 at 10:40 AM failed to reflect any information on Resident #8's history of hearing loss (hearing loss identified at birth or the result of illness or trauma) or the facility's attempts to enhance Resident #8's communication. The DNS identified she was recently employed by the facility and had not an opportunity to review the resident. Interview with the Director of Recreation on 11/2/23 at 12:20 PM identified she had seen Resident #8 on 9/27/23 with no further documentation of information regarding subsequent visits. The Director of Recreation indicated she met with Resident #8, and the resident participated in a coloring exercise. The Director of Recreation identified she was unaware Resident #8 was deaf and indicated she had not been trained on how to communicate with deaf people and stated, nobody told me Resident #8 was deaf. The facility's policy on the care of hearing-impaired residents states it is our responsibility to assist the resident and representatives in locating available resources (e.g., Medicare, Medicaid or local organizations), scheduling appointments and arranging transportation to obtain needed services. 2. Resident #95 was admitted to the facility in August 2023 with diagnoses that included subdural abscess, diarrhea, and thyrotoxicosis. The physician's order dated 9/1/23 - 9/30/23 directed to assist of one with slide board transfers and ambulation using walker. The admission MDS dated [DATE] identified Resident #95 had intact cognition and required extensive assistance with personal hygiene. The care plan failed to reflect interventions related to the resident's program of recreation. Interview with Resident #95 on 10/30/23 at 8:50 AM identified he/she has been at the facility since August 2023 and there was not a television on his/her side of the room since admission. Resident #95 indicated you see I still don't have television and my roommate has a television on his/her side of the room. Resident #95 indicated he/she does not watch what the roommate watches. Observation indicated loose cable wires and no television on the resident's side of the room. Interview with Resident #95 on 11/1/23 at 10:00 AM identified sometime in September 2023 he/she had told one of the nurse aides that he/she would like a television however, he/she does not remember who he/she told. Resident #95 indicated the nurses give me my medicine every day, the nurse aides bring my food and help me get dressed, and the housekeepers cleans the room, and everyone can see I do not have a television. Observation on 11/1/23 at 10:39 AM with the Director of Environmental Services on [NAME] Front unit in room [ROOM NUMBER] no television just cable wires. Interview the Director of Environmental Services on 11/1/23 at 10:54 AM identified he was not aware that room [ROOM NUMBER] did not have a television. The Director of Environmental Services indicated that the nursing staff should have notified the maintenance department, and they would have provided television to room [ROOM NUMBER]. Interview with the DNS on 11/1/23 at 11:00 AM identified she was not aware of the issue and indicated Resident #95 should have had a television in his/her room. The DNS indicated she will address the issue. Interview with the Administrator on 11/1/23 at 11:05 AM identified she was not aware and identified Resident #95 should have had a television in the room on admission. Subsequent to surveyor inquiry on 11/1/23 at 1:00 PM Resident #95 received a television in his/her room. An interview with Recreation was not obtained.

**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 #87) reviewed for positioning, the facility failed to provide an appropriate wheelchair on admission which resulted in the resident not being able to get out of bed for 107 days. The findings include: Resident #87 was admitted to the facility on [DATE] with diagnoses that included dementia, back pain, L2 compression fracture, and severe protein-calorie malnutrition. The care plan dated 7/10/23 identified a concern with activities of daily living and that Resident #87 was totally dependent for transfers to a wheelchair. Interventions included to reposition the resident every hour when in the wheelchair. A physician's order dated 7/10/23 directed to transfer with the assistance of 2 via mechanical lift and apply the TLSO back brace when out of bed. Physical Therapy Evaluation and Treatment notes dated 7/10/23- 7/24/23 reflected no time was utilized for wheelchair management. The admission MDS dated [DATE] identified Resident #87 had severely impaired cognition and requires total assistance with care. A physician's order dated 10/6/23 directed for physical therapy to treat resident for therapeutic exercise and activity, manual therapy, wheelchair management, and orthotic training. Physical Therapy Evaluation and Plan for Treatment dated 10/6/23 indicated the reason for the referral was Resident #87 exhibits a new onset of decreased postural alignment and increased need for assistance from others. Physical Therapy Evaluation and Treatment dated 10/6/23 - 10/25/23 identified wheelchair management was only provided on 10/23/23 for 15 minutes. Observation on 10/30/23 at 9:38 AM, 10:30 AM and 11:30 AM identified Resident #87 was lying in bed. Observation on 11/1/23 at 11:00 AM and 1:00 PM identified Resident #87 was lying in bed. Observation on 11/2/23 at 11:34 AM identified Resident #87 was sitting in an adaptive wheelchair slightly tilted back wearing a TLSO back brace with a metal clip seat belt on with no head rest. Resident #87 was holding his/her head forward. Interview with LPN #2 on 11/2/23 at 11:34 AM indicated she was the full-time nurse for years on East unit. LPN #2 indicated until last week, Resident #87 had not gotten out of bed into any type of wheelchair since he/she was admitted because Resident #87 did not have a wheelchair to get up into since admission. LPN #2 indicated therapy did not give Resident #87 a wheelchair and Resident #87 was always in bed. LPN #2 indicated she did not ask anyone to get Resident #87 a wheelchair because she just did not think about it, because Resident #87 was just always in bed. LPN #87 indicated last week therapy gave Resident #87 the tilt in space adaptive wheelchair, so now Resident #87 has been out of bed a few times. Interview with NA #2 on 11/2/23 at 11:41 AM indicated Resident #87 was on her consistent assignment, and she has been the full-time nursing assistant on East unit. NA #2 indicated this morning she washed and dressed and put on the TLSO back brace. NA #2 indicated then she got Resident #87 up into the adaptive wheelchair via the mechanical lift and put the seatbelt on. NA#2 indicated there wasn't any resident care card for the nurse aides anymore. NA #2 indicated that the care cards used to be in the resident's room behind the door, but management had taken them away a while ago. NA #2 indicated she saw the seat belt on the chair, so she assumed he/she needed it. NA #2 indicated last Tuesday after her day off see came in and a wheelchair was available for Resident #87, so she got the resident out of bed twice last week and today. NA #2 indicated Resident #87 did not get out of bed until last Tuesday because he/she did not have a chair to get into. Interview with PT #1 on 11/2/23 at 12:04 PM indicated she has worked with Resident #87. PT #1 indicated Resident #87 has a tilt in space adaptive wheelchair and was discharged from therapy on 10/31/23. PT #1 indicated Resident #87 did not have a wheelchair from admission 7/8/23 until 10/23/23 because Resident #87 needed a tilt in space adaptive wheelchair, and she did not have one available until 10/23/23. PT #1 indicated as soon as a tilt in space chair became available, she was going to give it to Resident #87. PT #1 indicated she did not inform anyone that she needed a tilt in space adaptive wheelchair for Resident #87 she was just waiting for one to become available. PT #1 indicated she started working with Resident #87 on 10/6/23 for postural alignment in bed because of increased needs by the resident from others for bed mobility. PT #1 indicated on when she came in one morning a day or 2 before 10/23/23 there was a tilt in space adaptive wheelchair left in the rehab gym. PT #1 indicated she does not know where it came from but on 10/23/23 she brought the chair to Resident #87. PT #1 indicated she placed Resident #87 in the adaptive wheelchair and then assigned the chair to him/her. PT #1 indicated she was aware that the chair did not have a head rest and had the seat belt on it. PT #1 indicated that Resident #87 definitely did not need the seat belt and she wanted him/her to have the chair even though it did not have a headrest so he/she could get out of bed. PT #1 indicated she had not asked anyone to remove the seatbelt from the wheelchair. PT #1 indicated she had not informed anyone that she needed the headrest for the wheelchair since last week. PT #1 indicated she did not implement an out of bed schedule for the adaptive tilt in space wheelchair for Resident #87. PT #1 indicated she was only responsible to put in a transfer order not what type of chair a resident gets into, or a position schedule for the adaptive chair. PT #1 was not able to explain how nursing would know how much to tilt the adaptive wheelchair. PT #1 indicated she verbally told the nursing staff to slightly tilt it when he/she was out of bed. Interview with LPN #2 on 11/2/23 at 1:00 PM indicated since Resident #87 moved to her unit on 8/14/23 Resident #87 has not been out of bed until last week when physical therapy started working with Resident #87 and gave him/her this new tilt in space wheelchair. LPN #2 indicated Resident #87 did not get out of bed because there wasn't a wheelchair available. Interview with the DNS on 11/2/23 at 2:36 PM indicated she was not aware that Resident #87 did not get out of bed from admission 7/8/23 until 10/23/23 when therapy gave Resident #87 a tilt in space adaptive wheelchair. The DNS indicated there was not an order for bed rest on admission or any other time, so Resident #87 should have gotten out of bed almost daily. The DNS indicated all residents should be out of bed daily to a wheelchair unless a resident refuses. The DNS indicated Resident #87 was at risk for aspiration so he/she should be out of bed daily to decrease risk of aspiration, pneumonia, pressure ulcers, increase socialization, and off load buttocks with a tilt in space chair. The DNS indicated that when she started about 8/8/23 corporate had taken down all the care cards in the resident's rooms informing the nurse aides how to care for each resident. The DNS indicated that the corporation was working on getting the nurse aides more kiosks for the resident care cards. The DNS indicated all the residents are in the kiosk, but the nursing staff have not been educated yet. Interview with LPN #4 on 11/6/23 at 12:10PM indicated Resident #87 was on the west unit for over month and did not get out of bed because he/she did not have a wheelchair. LPN #4 indicated she had asked therapy for a wheelchair for Resident#87, but rehab had stated they did not have the right wheelchair for him/her. Interview with NA #4 on 11/6/23 at 12:15 PM indicated Resident #87 while on west unit did not get out of bed because he/she did not have a wheelchair. NA #4 indicated she had asked therapy for a wheelchair and the therapy person said they did not have an appropriate wheelchair for Resident #87. NA #4 indicated Resident #87 was a mechanical lift and would not be safe in a standard wheelchair. Interview with APRN #1 on 11/6/23 at 1:30 PM indicated she was not aware that Resident #87 did not get out of bed for 4 months because the facility did not have an appropriate wheelchair. APRN #1 indicated if a resident does not get out of bed daily it will increase the risk of aspiration, pneumonia, and skin breakdown. APRN #1 indicated Resident #87 was already at risk for pneumonia and aspiration pneumonia. APRN #1 indicated there should be documentation on why Resident #87 was left in bed. Review of the facility Activities of Daily Living Policy identified residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Review of the facility Assistive Devices and Equipment Policy identified the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety, and independence are provided to residents. These include but not limited to wheelchairs (manual and powered), walkers, and canes. Although requested, a facility policy for adaptive tilt in space wheelchairs and positioning schedules, and bedrest policy it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #2) reviewed for accidents, the facility failed to ensure a resident's environment was free from an accident hazard. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia, GERD, and schizophrenia. The speech therapy Discharge summary dated [DATE] identified Resident #2's prognosis to maintain his/her current level of functioning was good with consistent staff follow-through. Dietary recommendations for Resident #2 included a mechanical soft and chopped texture diet. A physician's order dated 3/28/23 directed Resident #2 to receive a regular, ground, low lactose diet. The care plan dated 3/28/23 identified Resident #2 was at increased risk for alterations in nutritional status. Interventions included providing a regular, ground consistency diet and to monitor for difficulties with chewing/swallowing and need for a modified consistency or speech evaluation. The care plan dated 5/29/23 identified Resident #2 was a risk for falls. Interventions included removing Resident #2 from the dining room immediately following meals and to keep Resident #2 within close eye view of staff during waking hours. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, required an extensive one-person physical assist with locomotion on the unit, and utilized a wheelchair for a mobility device. The quarterly MDS further identified that Resident #2 required supervision and assistance with set-up for eating, and nutritional approaches for the last seven days included a mechanically altered diet. The nurse's note dated 9/17/23 at 9:58 PM identified Resident #2 was observed in the hallway around 8:10 PM with difficulty breathing and coughing after ingesting a piece of tomato. The Heimlich maneuver was successfully performed, and the food particle was expelled. EMS (911) was called, the APRN was notified, and a message was left for Resident #2's representative. Vital signs were stable, and Resident #2 was transferred to the hospital for further evaluation. The reportable event form dated 9/17/23 identified that at 8:10 PM Resident #2 was observed with difficulty in breathing after ingesting a piece of tomato. Hospital documentation dated 9/17/23 identified Resident #2 belongs on a ground diet but got a hold of a piece of whole tomato, began choking, the Heimlich was performed, and the tomato was coughed up. Resident #2 returned to baseline. The chest x-ray was negative for any acute pathology. Interview with LPN #7 on 11/1/23 at 12:27 PM identified that on 9/17/23 at approximately 8:10 PM NA #10 alerted her that Resident #2 was coughing continuously. LPN #7 indicated that she observed Resident #2 in the hallway and his/her lips were turning blue. LPN #7 directed NA #10 to call the nurse supervisor while she performed the Heimlich maneuver. When RN #5 (nurse supervisor) arrived on the scene, he took over performing the Heimlich maneuver, dislodging a piece of tomato, and LPN #7 called 911. LPN #7 was unable to identify where Resident #2 acquired a piece of tomato. LPN #7 further identified that the nurse aides were still in the process of picking up dinner trays, at the time of the incident. LPN #7 indicated that Resident #2 was sitting by another resident's room but was not in the vicinity of where the dinner trays were being loaded onto the cart, for removal. Interview with the DNS on 11/3/23 at 12:30 PM identified that she was not in the facility at the time of the incident, and the incident was reported to her via telephone call, by the nurse, on the evening of 9/17/23. The DNS indicated that the report she received was that there was a dinner tray, which included a salad, belonging to another resident in the hallway, and Resident #2 obtained a tomato from the salad. The DNS further indicated that this resulted in an incident that caused Resident #2 to continuously cough and experience a color change, and the Heimlich maneuver was performed resulting in the expulsion of the tomato. The DNS further indicated that Resident #2 was a supervised feed and had an order for a ground diet. The DNS identified that staff education began immediately on the following topics: appropriate tray pick-up times, not leaving trays in the hallway, and adhering to diet orders. Although attempted, an interview with RN #5 and NA #10 was not obtained. Although requested, a choking or accident prevention policy was not provided. Review of the facility's accident and incidents policy directs incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

**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 the only resident (Resident #59) reviewed for enteral feeding, the facility failed to follow the physician's order related to enteral feedings and free water flushes including documentation of the daily totals of each. The findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, gastrostomy status, and tracheostomy status. The care plan dated 7/24/23 identified Resident #59 had a need for enteral nutrition via feeding tube as a primary source of nutrition. Interventions included administration of tube feed regimen as ordered and monitoring of weights regularly. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, nutritional approaches performed in the last 7 days were a feeding tube, the proportion of total calories the resident received through tube feeding was 51% or more, and the average fluid intake per day by tube feeding was 501cc per day or more. A physician's order dated 9/27/23 directed to administer Glucerna 1.2 (a tube feeding formula) at a rate of 70ml per hour, over 24 hours, daily. The physician's order further directed the administration of a 110 ml free water flush every 4 hours. Special instructions included documentation of total volume administered each day at 7:00 PM. (Rate of 70ml per hour over 24 hours should provide a 1680ml daily). Review of the medication administration history documents dated 10/1/23 through 10/18/23 identified the following Glucerna and free water flush daily totals. (Glucerna at a rate of 70ml per hour over 24 hours should provide a 1680ml daily. Free water flushes of 110 ml every 4 hours should equal 660 ml). 10/1/23 - 110 ml. 10/2/23 - 880 ml. 10/3/2 3 - 110 ml. 10/4/23 - 140 ml. 10/5/23 - 160 ml. 10/6/23 - 140 ml. 10/7/23 - 140 ml. 10/8/23 - 140 ml. 10/9/23 - no volume recorded. 10/10/23 - 110ml. 10/11/23 - no volume recorded. 10/12/23 - no volume recorded. 10/13/23 - 110ml. 10/14/23 - no volume recorded. 10/15/23 - no volume recorded. 10/16/23 - no volume recorded. 10/17/23 - 200ml. 10/18/23 - 110ml. The nurse's note dated 10/19/23 at 7:51 PM identified that Resident #59 was sent to the hospital for replacement of a dislodged feeding tube. The nurse's note dated 10/22/23 at 7:51 PM identified that Resident #59 returned to the facility. A physician's order dated 10/22/23 through 10/24/23 directed to administer Glucerna 1.2 at a rate of 60ml per hour, over 24 hours. The physician's order further directed the administration of a 200ml free water flush every 8 hours. Special instructions included documentation of total volume administered each day at 7:00 PM. Review of the medication administration history documents dated 10/22/23 through 10/24/23 identified the Glucerna and free water flush daily totals. (Glucerna at a rate of 60ml per hour over 24 hours should provide a 1440ml daily. Free water flushes of 200 ml every 6 hours should equal 600 ml). 10/22/23 - 200ml. 10/23/23 - 200ml. 10/24/23 - no volume recorded. A physician's order dated 10/25/23 directed to administer Glucerna 1.2 at a rate of 70ml per hour, until total volume of 1680ml is administered daily. The physician's order further directed the administration of a 110 ml free water flush, every 4 hours. Special instructions included documentation of total volume administered each day at 7:00 PM. Review of the medication administration history documents dated 10/25/23 through 10/31/23 identified the following Glucerna and free water flush daily totals. (Glucerna at a rate of 70/ml per hour until 1680ml is administered daily and Free water flushes of 110 ml every 4 hours should equal 660 ml). 10/25/23 - 900ml. 10/26/23 - no volume recorded. 10/27/23 - 780ml. 10/28/23 - no volume recorded. 10/29/23 - 1600ml. 10/30/23 - 860ml. 10/31/23 - 780ml. Interview and review of the clinical record with the DNS on 11/6/23 at 12:26 PM identified that the 24-hour volume totals for Resident #59's tube feeding and free water flushes were not documented accurately. The DNS further identified that she was unsure if the nurses knew the expectation for documentation of tube feed totals, as it appeared the documentation included a flush volume or a portion of the daily total. The DNS indicated that she would expect to see the 24 volume totals to be in the neighborhood of the daily goal, 1440ml or 1680ml respectively, and for any volume outside of the goal range she would expect documentation of the variance in a progress note, as well as physician and resident representative notifications. Interview with APRN #1 on 11/6/23 at 1:09 PM identified that she began covering the facility on 10/17/23 and she had not yet worked with Resident #59. APRN #1 indicated that she was not able to see the daily tube feed volume totals from the view on her computer, but she would expect to see documentation of the daily volume administered. APRN #1 further identified that she would expect to be notified by the facility nurse if the daily volume goals were not met. Although attempted, an interview with APRN #2 was not obtained. Review of the facility's tube feeding policy directs for the nursing staff to administer the tube feeding as written in the physician's orders, monitor how the resident tolerates the tube feed, and document how much of the tube feed was administered each day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy and interview for 2 residents, (Resident #34 and 63), reviewed for respiratory care, for Resident #34 the facility failed to ensure a properly fitting CPAP mask was available, which resulted in the resident's inability to wear the CPAP for 4 months and for Resident #63 the facility failed to store a portable oxygen cylinder properly per facility policy. The findings include: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses that included history of stroke, obstructive sleep apnea, and systolic congestive heart failure and was readmitted to the facility on [DATE]. The quarterly MDS dated [DATE] identified Resident #34 had intact cognition, required total assistance with transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene, and supervision for locomotion, and eating. Further, the MDS identified Resident #34 used a BiPAP/CPAP (CPAP and BiPAP machines are both forms of positive airway pressure therapy which uses compressed air to open and support the upper airway during sleep). The care plan dated 7/14/23 identified a focus on BiPAP/CPAP use with interventions that included providing supplemental oxygen and BiPAP/CPAP per physician's order. Physician's orders for October 2023 (original order date 11/10/22) directed to apply CPAP, settings of 5 - 20 cmH2O FIO2 21 - 100%, on at hour of sleep and as needed, off in the morning, once an evening 3:00 PM - 11:00 PM. Review of the October 2023 TAR identified Resident #34 had the CPAP applied daily with the exception of the following dates. 10/7/23, the CPAP was not administered, waiting for new mask. 10/21/23, the CPAP was not administered, mask on order. The nurse's note dated 10/14/23 at 3:38 PM identified that Resident #34 continues to refuse to wear CPAP with connecting oxygen at night, no acute exacerbation related to respiratory this shift, no shortness of breath, no coughing noted this shift. Head of bed elevated while sleeping with good results noted. Interview with Resident #34 on 11/6/23 at 11:20 AM identified he/she has not worn the CPAP for more than 4 months because there has not been a comfortable face mask. Resident #34 indicated both nursing and the DNS were aware that there was no face mask for use with the CPAP, and the resident was told someone would come to the facility to fit one for him/her. Resident #34 also indicated he/she falls asleep more frequently during the day unexpectedly in his/her wheelchair as a result of not wearing the CPAP. Interview with the DNS on 11/6/23 at 11:40 AM failed to reflect that a mask for Resident #34 was on order, or that the oxygen supplier had been notified of the request for Resident #34 to have a mask fitting. The DNS indicated over the past 4 months several masks had been trialed with no success and she would contact the oxygen supplier for a visit to the facility to properly fit Resident #34. Although requested, a policy for CPAP was not provided. 2. Resident #63 was admitted to the facility with diagnoses that included pneumonia and respiratory failure. The quarterly MDS dated [DATE] identified Resident #63 had severely impaired cognition and required total assistance with care. Additionally, Resident #63 has shortness of breath while lying flat and utilized oxygen therapy. A physician's order dated 10/5/23 directed to administer oxygen at 2 liters per minute via nasal cannula continuous every shift. The care plan dated 10/29/23 identified oxygen therapy with interventions that included to encourage the resident to keep the nasal cannula in the nose. Observation on 10/30/23 at 7:50 AM identified Resident #63 was in a semiprivate room in the bed by the window. Resident #63 was in bed on oxygen via nasal cannula connected to a concentrator. The observation identified there was a portable oxygen e-tank cylinder, leaning in a cloth bag, in the corner of the room by the head of the left side of the resident's bed. The oxygen cylinder was leaning against the radiator, not in a caddy or approved stand. Interview with NA #1 on 10/30/23 at 8:35 AM indicated Resident #63 gets out of bed every Sunday only because that is when resident representative visits. NA #1 indicated the nurse aides do not touch the portable oxygen cylinders only the nurses do and indicated the oxygen cylinder was not in use leaning against the corner of the room against the radiator. Interview with LPN #3 on 10/30/23 at 8:37 AM indicated the nurses were responsible to transfer residents from the portable tanks to the concentrators. LPN #3 indicated that when a resident is removed from the portable e-tank it was that nurse's responsibility to immediately bring the portable e-tank to the oxygen storage room and place it in the rack. LPN #3 indicated the portable e-tanks are stored in the oxygen room by the kitchen and laundry area. Observation by LPN #3 indicated the portable e-tank for Resident #63 was not in use and never should have been left in the room leaning against the wall and radiator. LPN #3 indicated she would immediately remove it and bring it to the storage room. Interview with RN #3 on 11/1/23 at 2:06 PM indicated the nurses are responsible to change a resident from the portable oxygen e-tank to the concentrator. RN #3 indicated when the resident was done with the portable oxygen e-tank it must go to the storage room right away. RN #3 indicated Resident #63's portable oxygen e-tank must not be left in room when not in use leaning against the corner of the room and against the radiator that was on. Interview with the DNS on 11/2/23 at 3:03 PM indicated only the nurse can transfer the portable oxygen e-tanks from the concentrator to the portable e-tank. The DNS indicated that oxygen is a drug and only nurses can touch it. The DNS indicated when the nurse takes the resident off of the portable e-tank the nurse must take the portable e-tank to the oxygen storage room and place it in the used oxygen e-tank rack and secure. The DNS indicated the oxygen e-tank should not be left leaning against a radiator. The DNS indicated the oxygen tank was not stored securely leaning in the corner of the room like that. Review of the facility Oxygen Tanks and Oxygen Storage Policy identified all oxygen tanks are to be properly restrained at all times or in an approved caddy. The Director of Environmental Services and/or the Director of Maintenance will check for oxygen tanks on their daily rounds. They will ensure all oxygen tanks are properly stored in the appropriate tank storage rooms and all other tanks in the facility that are not being used are properly restrained or in an approved caddy.

Based on observation, review of the clinical record, review of facility documentation, facility policy, the facility failed to ensure adequate staffing to meet the needs of the resident, including staff to escort the resident to a follow up orthopedic appointment. The findings include: Review of the census daily detail report dated 10/31/23 identified the facility census was 92. Observation on 10/31/23 at 10:03 AM identified Resident #93 yelling from his/her bedroom at LPN #1, RN #3, and SW #1 who was in the hallway in front of the room regarding he/she missed his/her orthopedic appointment because the facility did not have enough nurse aides to escort him/her to the appointment. Interview with Resident #93 on 10/31/23 at 10:05 AM identified his/her orthopedic appointment at 11:00 AM was cancelled today by the 11:00 PM - 7:00 AM RN #2 (supervisor). Resident #93 indicated the facility cancelled the appointment because they did not have enough nurse aides to escort him/her to the appointment this morning. Resident #93 indicated he/she is very upset about the appointment being called. Resident #93 indicated the appointment was very important to him/her because he/she would like to go back home, and he/she is aware that the orthopedic physician has to clear him/her, so he/she does not want to miss any appointments to the orthopedic physician. Interview with RN #3 on 10/31/23 at 10:16 AM identified Resident #93 had an orthopedic follow up appointment at 10:20 AM. RN #3 indicated she received report from RN #2 that the facility did not have any nurse aides available to escort Resident #93 to the appointment. RN #3 indicated RN #2 had the appointment rescheduled. RN #3 indicated the reason Resident #93 missed the orthopedic appointment was because there were no staff to escort the resident. RN #3 indicated she thought RN #2 had notified Resident #93 that the orthopedic appointment was cancelled. RN #3 indicated Resident #93 was upset and she explained to Resident #93 that the orthopedic appointment was cancelled because the facility did not have a nurse aide to escort him/her to the appointment. RN #3 indicated she observed Resident #93 getting more upset, so she walked away and went to get SW #1 to come and have a talk with Resident #93. Interview with SW #1 on 10/31/23 at 11:54 AM identified Resident #93 had an orthopedic appointment that was cancelled because there were two call outs and not enough staff. SW #1 indicated Resident #93 was upset when he/she learned the appointment had been cancelled. SW #1 indicated Resident #93 would have preferred to be notified before the appointment was cancelled by nursing. SW #1 indicated she was trying to calm down Resident #93 and explained that the facility is rescheduling the appointment. SW #1 indicated the Administrator reached out to the physician's office to reschedule the appointment for today at a later time with SW #1 accompanying Resident #93. SW #1 indicated the orthopedic office was unable to reschedule the appointment for 10/31/23 at a later time. Interview with the Administrator on 10/31/23 at 12:20 PM identified she was not aware of the two call outs. The Administrator indicated she was notified that Resident #93's orthopedic appointment had been cancelled due to not enough staffing. The Administrator indicated the facility had other staffing that could have escorted Resident #93 to the orthopedic appointment. The Administrator indicated she had called the office to see if they could reschedule the appointment back to 10/31/23 at a later time and the facility would have sent SW #1 with Resident #93. The Administrator indicated RN #2 will be educated regarding cancelling appointments. The Administrator indicated staffing is challenging when there's call outs. Interview with the DNS on 11/2/23 at 12:02 PM identified she was informed by Resident #93 that he/she had missed his/her orthopedic appointment on 10/31/23 because the facility did not have enough staff to escort him/her to the appointment. The DNS indicated the supervisor on the 11:00 PM - 7:00 AM shift had cancelled the appointment because she did not want to pull nurse aides off the floor that morning. The DNS indicated the appointment was rescheduled. The DNS indicated she had educated the supervisor regarding cancelling appointments. Interview with RN #2 on 11/2/23 at 3:06 PM identified she has been employed by the facility for 2 years. RN #2 indicated Resident #93 had an orthopedic appointment on 10/31/23 at 11:00 AM. RN #2 indicated the staff schedule was short and there was no one to escort Resident #93 to the appointment. RN #2 indicated she told the receptionist to cancel and reschedule the appointment. RN #2 indicated the facility was short of nurse aides and she did not want to pull any of the nurse aides off the units because the Department of Public Health was in the facility. RN #2 indicated the facility has an issue with staffing escorting the residents to their medical appointments. RN #2 indicated many appointments have gotten cancelled and rescheduled due to not enough staff to escort the residents to their appointments. RN #2 indicated she should have left the cancelling of the appointment to the 7:00 AM - 3:00 PM supervisor. RN #2 indicated the 7:00 AM - 3:00 PM supervisor has cancelled many appointments because the facility does not have enough staff to escort the residents to their medical appointments. Although requested, a facility policy was not provided.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure that the DNS served as the director of nursing on a full-time basis. (According to Appendix PP §483.35(b)(2) the facility must designate a registered nurse to serve as the director of nursing on a full-time basis, and §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents, and Full-time is defined as working 40 or more hours a week). The findings include: Review of the daily staffing schedules from 10/12/23 - 11/6/23 identified that the DNS worked as the RN supervisor for the 7:00 AM - 3:00 PM shift on the following dates: 10/19/23, 10/20/23, 10/23/23, and 10/26/23. Interview with the DNS on 11/6/23 at 11:02 AM identified she was aware of the staffing shortages and that she worked as the RN supervisor to help alleviate the issues. The DNS identified that she fulfilled her DNS duties by working from home to complete any administrative work, and that due to the volume of her workload, she had resigned effective 11/30/23. Interview with the Administrator on 11/6/23 at 12:58 PM identified she was aware of the nursing staff shortages but was not aware that the DNS could not be included as part of the licensed nursing staff hours. The facility assessment annual review completed 6/22/23 directed that the facility had an average daily census of 89 residents. The assessment also directed that the facility resources needed to provide competent support and care for residents of the facility should include the DNS and licensed nursing staff. The assessment further directed that staffing, based on that average census, should have included 68 nurse aides and 25 licensed nurses to provide direct care.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure annual evaluations were completed for nurse aide staff. The findings include: A review of facility documentation on 11/6/23 failed to identify annual evaluations were completed for NA #7 for 2022 or 2023. Review of facility documentation also failed to identify any annual evaluations completed for NA #11 or NA #12. Interview with the DNS on 11/6/23 at 1:20 PM identified that she was responsible to ensure nurse aide staff had annual evaluations completed, but that she had only been employed at the facility since 8/3/23. The DNS further identified she was also working as an RN supervisor at the facility due to staffing issues, covering as the IP nurse due to a recent staff resignation, and covering staff development and was often working after hours off the clock to fulfill her DNS duties. Although requested, the facility failed to provide a policy on annual evaluations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Resident #20 and 89) reviewed for unnecessary medications, the facility failed to ensure a physician/APRN reviewed and responded to the pharmacy consultant's monthly recommendations. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, bipolar disorder, and type 1 diabetes mellitus with hyperglycemia. A physician's order dated 10/17/22 directed to administer 5 units of Novolog Insulin Aspart solution (a medication for diabetes mellitus) 100 unit/ml subcutaneously three times daily, at 8:00 AM, 12:00 PM, and 5:00 PM. A physician's order dated 6/19/23 directed to administer one 0.5mg tablet of Lorazepam (a medication used to manage symptoms of anxiety) by mouth, every 8 hours, as needed (prn) for increased anxiety. Review of the drug regimen review document dated 9/1/23 identified that Resident #20 had an active order for Lorazepam prn without a specified stop date and this order had not been used recently. The consultant pharmacist's recommendations were to evaluate and consider discontinuing the order for Lorazepam prn, if appropriate. The recommendation further identified that CMS guidelines do not allow for open-ended orders for prn psychotropics. The drug regimen review failed to identify whether a physician reviewed the recommendations, acted on the recommendations, or provided a rationale if no action was taken. The drug regimen review document further failed to identify a signature of the licensed prescriber acknowledging the review of the consultant pharmacist's recommendations. Review of the drug regimen review document dated 9/9/23 identified that Resident #20 was admitted on Novolog (Insulin aspart) 5 units subcutaneous, three times a day. The consultant pharmacist's recommendations were to evaluate and update the order to three times a day with meals, to avoid the risk of hypoglycemia. The drug regimen review failed to identify whether a physician reviewed the recommendations, acted on the recommendations, or provided a rationale if no action was taken. The drug regimen review document further failed to identify a signature of the licensed prescriber acknowledging the review of the consultant pharmacist's recommendations. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition, exhibited no physical or verbal behavioral symptoms, and received daily Insulin injections over the last 7 days. The care plan last revised on 9/22/23 identified Resident #20 exhibited behaviors related to his/her diagnoses of anxiety and bipolar. Interventions included monitoring for changes in mood state or routines and to report findings to the physician. Long term goals included Resident #20 would receive the lowest needed dose of psychoactive medications. The care plan identified Resident #20 has been determined a positive Level II PASARR and had the potential for altered thought process and difficulty adjusting to situations due to major depression, bipolar, and psychotic disorder. Interventions included on-going evaluation of the effectiveness of the current psychotropic medications on target symptoms. The care plan further identified Resident #20 was at risk for abnormal glucose levels (hypoglycemia and hyperglycemia) secondary to diabetes mellitus. Interventions included the provision of diabetic medications and/or insulin as ordered, evaluate the response of the medications, and record/report abnormal findings to the physician/APRN. Interview and review of the clinical record with the DNS on 11/2/23 at 12:08 PM failed to provide documentation that identified that the consultant pharmacist's recommendations dated 9/1/23 and 9/9/23 were reviewed by a physician/APRN. The DNS indicated that the facility's medical providers receive the monthly medication regimen review from the consultant pharmacist via email. The medical providers are expected to review the recommendations, act or decline to act on the recommendations, and return the reviewed recommendations to the DNS by the end of the month. The DNS further indicated that the facility's previous APRN's (APRN #2) progress note dated 9/30/23 failed to identify that the pharmacy recommendations were reviewed, and the DNS failed to identify a copy of the 9/1/23 and 9/9/23 drug regimen reviews signed by the licensed prescriber. The DNS further indicated, that in collaboration with the facility's corporate team, education will be provided for the new medical providers and the pharmacy consultant to ensure a process exists where the monthly medication regimen reviews are received and completed, timely. Interview with APRN #1 on 11/6/23 at 1:20 PM identified that she had begun covering this facility on 10/17/23, and that she had not received any drug regimen review recommendations for this facility, yet. APRN #1 indicated that she wasn't familiar with this specific facility's policy for the drug regimen review, but that the general process was that all consultant pharmacist recommendations should be reviewed by a medical provider monthly. APRN #1 further identified that the review for psychotropic medications were facility specific if they are to be reviewed by the psychiatric or medical provider. Although attempted, an interview with APRN #2 was not obtained. Although requested a facility policy related to monthly medication regimen review was not provided Review of the facility's psychoactive medications policy directs each resident will receive only those medications, in doses and for the duration felt clinically indicated to treat the resident's assessed condition(s) by their attending or designee. 2. Resident #89 was admitted to the facility on [DATE] with diagnoses that included diabetes, psychoactive substance abuse with withdrawal, and attention and concentration deficit following a stroke. Physician's order dated 9/13/23 directed the following: Insulin Aspart U-100 Insulin pen; 100 unit/ml) subcutaneous, call APRN for blood sugar over 200 mg/dl, before meals and at bedtime 9:15 AM, 12:00 PM, 6:00 PM, 8:00 PM. A medication regimen review dated 9/15/23 identified the consultant pharmacist recommendations included the following: currently with routine fingerstick blood sugar monitoring with order to notify the physician if result are elevated. Please consider adding order to notify the physician if results are less than 70 as well, if appropriate. The admission MDS dated [DATE] identified Resident #89 had moderately impaired cognition, required extensive assistance with toilet use and received injections and Insulin. A medication regimen review dated 10/19/23 identified the consultant pharmacist recommendations included the following: resident currently has Insulin Aspart order without a specific amount of Insulin to administer. Please evaluate short acting Insulin needs and update order to include dose or consider discontinuing order, if appropriate. Review of the clinical record failed to reflect that the pharmacy recommendations dated 9/15/23 or 10/19/23 had been responded to by facility staff. Interview with the DNS on 11/3/23 at 11:00 AM identified that she usually gets emailed all of the pharmacy recommendations and then she will email the APRN, who will address the recommendations. The DNS identified that since 9/11/23, she has not received pharmacy recommendations for the unit that this resident resides, so they have not been responded to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #20 and 35) reviewed for unnecessary medications, the facility failed to ensure a prn psychotropic medication order was limited to 14 days. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, bipolar disorder, and type 1 diabetes mellitus with hyperglycemia. An open-ended physician's order dated 6/19/23 directed to administer one 0.5mg tablet of Lorazepam (a medication used to manage symptoms of anxiety) by mouth, every 8 hours, as needed (prn) for increased anxiety. Review of the drug regimen review document dated 9/1/23 identified that Resident #20 had an active order for Lorazepam prn without a specified stop date and this order had not been used recently. The consultant pharmacist's recommendations were to evaluate and consider discontinuing the order for Lorazepam prn, if appropriate. The recommendation further identified that CMS guidelines do not allow for open-ended orders for prn psychotropics. The drug regimen review failed to identify whether a physician reviewed the recommendations, acted on the recommendations, or provided a rationale if no action was taken. The drug regimen review document further failed to identify a signature of the licensed prescriber acknowledging the review of the consultant pharmacist's recommendations. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition, exhibited no physical or verbal behavioral symptoms, and received daily Insulin injections over the last 7 days. The care plan last revised on 9/22/23 identified Resident #20 exhibited behaviors related to his/her diagnoses of anxiety and bipolar. Interventions included monitoring for changes in mood state or routines and to report findings to the physician. Long term goals included Resident #20 would receive the lowest needed dose of psychoactive medications. The care plan identified Resident #20 has been determined a positive Level II PASARR and had the potential for altered thought process and difficulty adjusting to situations due to major depression, bipolar, and psychotic disorder. Interventions included on-going evaluation of the effectiveness of the current psychotropic medications on target symptoms. Interview and review of the clinical record with the DNS on 11/2/23 at 12:08 PM failed to provide documentation that the open-ended order with a start date of 6/19/23 for prn Lorazepam was reevaluated by the physician/APRN to continue or discontinue the medication. The DNS indicated that a prn order for a psychotropic medication should only be ordered for 14 days, after 14 days the provider should reevaluate the need for the medication and if the resident is not using the medication, it should not be renewed. The DNS further indicated that PRN orders for psychotropic medications can exceed 14 days but there needs to be documentation in the resident's clinical record indicating the reason to continue with the medication beyond 14 days. Interview with APRN #1 on 11/6/23 at 1:20 PM identified that she had begun covering this facility on 10/17/23, and that she had not received any pharmacy recommendations for this facility, yet. APRN #1 indicated that she wasn't familiar with this specific facility's policy for the monthly medication regimen review, and she further indicated that the review for psychotropic medications were facility specific if they are to be reviewed by the psychiatric or medical provider. APRN #1 identified that an order for prn Lorazepam should have a stop date after 14 days or a 30 - 60 day maximum, with a documented rationale to extend the order. Although attempted, an interview with APRN #2 was not obtained. Review of the facility's psychoactive medications policy directs for a behavior log to be initiated upon a physician's order for a prn psychopharmacological medication, in order to monitor residents who present with behavioral problems and the need/justification for administration of a prn psychopharmacologic medication. The behavior log will track the interventions attempted to manage the behaviors and the resident's response to the intervention. Information derived from this documentation will be utilized in developing a specific comprehensive care plan and as part of the physician assessment in determining the need to continue or modify the PRN medication order. PRN medication, antipsychotics or antidepressants will be written for a maximum of 2 weeks and then changed to a standing order based on medication. 2. Resident #35 was admitted to the facility on [DATE] with diagnoses that included anxiety, chronic kidney disease, and dependence on renal dialysis. The care plan dated 12/8/22 identified that Resident #35 had a potential for alteration in psychosocial well-being. Interventions included administering medications as ordered and psych/supportive care consult as needed. The care plan failed to identify any additional care planning related to psychotropic medications or behaviors. The quarterly MDS date 8/12/23 identified Resident #35 had intact cognition and required supervision with transfers, toileting, and was independent with eating. An APRN note dated 9/26/23 identified Resident #35 complained of intermittent worsening anxiety prior to dialysis. The treatment plan included continuing Trazadone 50 mg at bedtime and starting Trazadone 50 mg every 12 hours as needed. A physician's order dated 9/26/23 directed to administer Trazadone (medication for anxiety) 50 mg every 12 hours as needed (prn) for anxiety. The order failed to identify an stop date. Review of Resident #35's clinical record failed to identify any behavioral logs or resident care plan updates including target behavior monitoring following the order for prn Trazodone on 9/26/23. Interview with the DNS on 11/6/23 at 1:20 PM identified that she was aware there was an issue with open ended orders for prn psychotropic medications. The DNS identified that the facility policy for psychoactive medication included identifying behavior monitoring with target behaviors and that these should be maintained in a behavioral monitoring log, along with interventions. The DNS also identified that the resident's care plan should be updated, and that the prn order should be written for a maximum of 14 days and then the order should be discontinued, extended another 14 days, or changed to a standing order. The DNS identified she only began employment at the facility on 8/3/23 and that the facility also had a recent change in the medical director, which made it difficult to facilitate changes. The facility policy on psychoactive medications directed that with a physician's order for a prn psychoactive medication, a behavior log would be initiated to monitor the need/justification for administration of the prn psychopharmacological medication. The policy further directed that the behavior log would track the interventions attempted (at least 3 nonchemical interventions) to manage the resident's behavior and response to the interventions, and information derived from the behavior log would be utilized to develop a specific comprehensive care plan as part of the physician's assessment to determine the need to continue or modify the as needed medication order. The policy also directed that prn medication, antipsychotics or antidepressant would be written for a maximum of 2 weeks and then would be changed to a standing order based on the medication.

**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 #70) reviewed for behaviors, the facility failed to remove a discontinued controlled medication from the medication cart according to the facility policy, and subsequently, staff borrowed the medication for another resident's use. The findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism, dementia, anxiety disorder and readmitted [DATE]. A physician's order dated 9/21/23 directed to administer Lorazepam 0.5mg every 12 hours and Lorazepam 1mg every 12 hours as needed. A physician's order dated 10/21/23 directed to discontinue Lorazepam 0.5mg every 12 hours and Lorazepam 1mg every 12 hours as needed. Review of a controlled substance distribution record for Resident #70 identified Lorazepam 0.5mg (60 tablets) was delivered to the facility 10/26/23. The controlled substance distribution record form identified that 2 tablets of Lorazepam 0.5mg were removed and administered to another resident, Resident #73. Interview and review of the clinical record with LPN #3 on 11/1/23 at 11:58 AM identified per the controlled substance distribution record, 2 tablets of Lorazepam 0.5mg were borrowed for Resident #73. Review of the clinical record and interview with the DNS on 11/1/23 at 12:55 PM failed to identify why 60 tablets of Lorazepam 0.5mg were delivered to the facility and accepted by facility staff on 10/26/23, 5 days after the physician's order for the medication was discontinued. The DNS indicated the nursing staff has been trained not to borrow any medications, including controlled substances and indicated it is her expectation if a resident does not have the prescribed medication on hand, the nurse will either secure the medication from the e-box (emergency box) or contact the physician or APRN to secure an alternative medication. The policy for controlled substance handling indicates that discontinued controlled drugs are returned to the nursing office after the count of controlled substances is verified. The drugs are then stored in a double-locked cabinet in the nursing office until permission to destroy has been obtained.

**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 1 resident (Resident #95) reviewed for transmission based precautions, the facility failed to adhere to PPE standards, and failed to ensure the infection control program policies were in place for the facility in accordance with actual facility type, and failed to ensure an annual review was completed of the infection control program policies. The findings include: 1. Resident #95 was admitted to the facility on [DATE] with diagnoses that included extradural abscess, hypertension, and localized edema. The clinical record identified that Resident #95 was placed on contact precautions from 9/5/23 - 10/26/23 for methicillin-resistant staphylococcus aureus (MSA) bacteremia. Observation on 11/3/23 at 10:50 AM identified that Resident #95 had signage posted on the door to his/her room identifying that Resident #95 was on contact precautions. During this observation, a clear plastic bin with gowns was observed to be located inside the room to the left of the door entryway. The observation failed to identify any disposal area for PPE. During a review of the infection control program with RN #4 (former IP nurse) on 11/3/23 at 10:57 AM, RN #4 identified Resident #95 was on active contact precautions. Observation with RN #4 on 11/3/23 at 11:40 AM of Resident #95's room identified the clear plastic bin with gowns remained in the same location as the prior observation at 10:50 AM. The observation with RN #4 also identified a large red biohazard bin was positioned against the wall in between the two beds of the room, and to the right of Resident #95's bed. Interview with Resident #95 immediately following this observation identified that the red biohazard bin had been placed next to his/her bed for an unknown period of time. Resident #95 identified that he/she had requested that it be moved several times. Resident #95 also identified sometimes there are gnats or bugs flying around it, and requested RN #4 remove the red biohazard bin. Interview with RN #4 on 11/3/23 at 11:45 AM identified that the red biohazard bin should have been placed next to the door to the room so any staff doffing PPE would be able to dispose of used PPE prior to exiting the room, and that the clear plastic bin with disposable gowns should have been placed outside the room to ensure the PPE remained clean. The facility policy on Isolation-Initiating Transmission-Based Precautions, directed that transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. The policy further directed that when transmission-based precautions were implemented, the IP nurse (or designee) should ensure that protective equipment (i.e gloves, gown, masks, etc.) were maintained near the resident's room so that everyone entering the room could have access to what they needed and that the appropriate waste container would be placed in or near the resident's room. The policy further directed that transmission-based precautions should remain in place until the attending physician or IP nurse discontinued them. 2. During a review of the infection control program policies with RN #4 (former IP nurse) on 11/3/23 at 10:57 AM, a request was made to review the infection control program policies. RN #4 identified that the policy the facility utilized was for home health and hospice, and not for a skilled nursing facility. RN #4 provided a facility document the infection control program utilized titled Infection Program Overview-Home Health and Hospice and included guidelines and directives for infection control related to Home Health Agencies (HHA). RN #4 identified this was the policy the facility provided to her to follow when she took over the infection control nurse position in 3/2023. RN #4 failed to identify why the facility utilized infection control program policies and protocols for home health and hospice. Subsequent to surveyor inquiry, RN #4 provided a facility policy titled Infection Prevention and Control Program on 11/3/23 at 11:35 AM. RN #4 identified that this document was applicable to skilled nursing and that it was provided to her by corporate staff for the facility. RN #4 further identified that it was the first time she had seen the policy. Review of the facility environmental logs for 2022 and 2023 on 11/3/23 at 11:53 AM identified that the policy Infection Program Overview-Home Health and Hospice was included as part of the environmental logs, and that further review of the logs failed to identify any policies or guidelines related to skilled nursing. 3. A review of the infection control program policies with RN #4 (former IP nurse) on 11/3/23 at 10:57 AM failed to identify documentation related to completion of an annual review of the infection control program policies or antibiotic stewardship program for 2022 or 2023. RN #4 identified that the facility had not held any infection control meetings during her tenure as the infection control nurse from 3/2023 through her resignation from the position on 9/29/23. RN # 4 identified she was still employed by the facility as a per diem RN. RN #4 identified when she worked as the IP nurse, she would contact the medical director or facility APRNs directly if she had issues that she needed to be addressed, but that it was on a case-by-case basis, and she was not aware of any formal meetings related to infection control or the antibiotic stewardship program. RN #4 further identified if there were any formal meetings, she was not invited to participate. Subsequent to surveyor inquiry, the facility provided documents labeled Quarterly Medical Staff and Quality Improvement Meeting/Quarterly Infection Control Meeting 10/19/23 on 11/3/23 at 11:35 AM. The documentation identified meeting minutes which identified the DNS provided an update on infection control practices with an attached report, and also identified that the DNS reviewed the antibiotic stewardship program. Further review of the document failed to identify any additional documentation related to infection control reporting or antibiotic stewardship reporting. Review of the meeting sign in for staff identified that RN #4 did not participate in the meeting. Although requested, the facility failed to provide any further documentation related to quarterly infection control meetings for 2022 and 2023. The facility policy on Infection Program Overview-Home Health and Hospice directed that a summary of infection prevention activities would be presented to the governing body at least annually. The facility policy on the Infection Prevention and Control (IPC) Program directed that elements of the program included coordination and oversight that would be conducted by the IP nurse. The policy further directed that the facility would have an IPC committee that would meet at least quarterly, and that the IP nurse, IPC committee, medical director, DNS, and other key clinical and administrative staff would meet at least annually to review IPC policies. The policy also directed that the annual review would include updating or supplementing policies and procedures as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, review of job descriptions, and interviews for 1 resident (Resident #34) reviewed for wheelchair maintenance, the facility failed to ensure the residents power wheelchair was in good repair and for 4 out of 4 units, the facility failed to ensure the environment was clean, and maintained in good repair. The findings include: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses that included history of stroke, obstructive sleep apnea, and systolic congestive heart failure. A physician's order dated 5/5/22 directed Occupational Therapy (OT) to evaluate only for power wheelchair mobility and safety. Resident #34 was readmitted to the facility on [DATE]. The quarterly MDS dated [DATE] identified Resident #34 had intact cognition, required total assistance with transfers, extensive assistance for bed mobility, dressing, toilet use and personal hygiene, and supervision for locomotion, and eating. Further, the MDS identified Resident #34 was wheelchair dependent and used a BIPAP/CPAP (CPAP and BiPAP machines are both forms of positive airway pressure therapy which uses compressed air to open and support the upper airway during sleep). The care plan dated 7/14/23 identified a focus on the custom wheelchair with interventions that included wheelchair to be provided by rehab, rehab will screen for appropriateness as needed and ensure least restrictive device is used. Observation on 10/30/23 at 9:25 AM identified Resident #34's power wheelchair with a tattered side cushion, torn armrests, worn out seat cushion, which appeared to be inserted backwards, and an overall unclean appearance. Interview with PT #1 on 11/1/23 at 2:15 PM with the Regional Director of Physical Therapy present, identified she noted the wear and tear of Resident #34's wheelchair and some parts needed to be replaced during onboarding for physical therapy on 7/23/23. However, the wheelchair continued to function, and she did not refer the chair for inspection or parts replacement with the contracted vendor. The Regional Director of Physical Therapy indicated she just completed a phone call with the corporate liaison responsible for coordination with the power wheelchair vendor and was awaiting a commitment date for an onsite visit for Resident #34's wheelchair as well as 2 additional residents. The Regional Director of Physical Therapy identified she was recently hired and is now coordinating powerchair maintenance and notified their appointed liaison 20 minutes prior to the interview with an anticipated commitment prior to 11/3/23 with the date for a field visit to the facility. The Regional Director of Physical Therapy also indicated the wheelchairs should be in good condition, and fully functional and the wheelchair evaluation and repair would be a priority for the department. Although requested, a policy on wheelchair maintenance was not provided. Review of the wheelchair cleaning policy identified wheelchairs are cleaned on an as-needed basis. 2. Observation during the initial tour on 11/2/23 at 9:44 AM through 10:15 AM, and on 11/6/23 at 11:45 AM through 12:00 PM, and on 11/6/23 at 12:12 PM with the Director of Environmental Services identified the following. a. Damaged, chipped, hole, stains and/or marred bedroom walls on [NAME] Front unit in rooms 127, 128, 129, 131, and 133. [NAME] Back unit in rooms 135, 136, 137, 138, 139, 142, 146, 147, 148, and 150. East Front unit in rooms 101, 105, 107, 108, and 109. East Back unit in rooms 111, 112, 115, 116, 117, 118, 120, 121, 122, 123, 124, 125, and 126. b. Damaged, broken, missing, peeling and/or dirty cove base in the bedroom on [NAME] Front unit in rooms 128, 129, [NAME] Front Hallway, and 131. [NAME] Back unit in rooms [ROOM NUMBER]. East Front unit in rooms 102, 103, 105, 106, 108, and 109. East Back in rooms 112, 113, 117, 120, and East Back Hallway. c. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor in bedroom on [NAME] Front unit in rooms [ROOM NUMBER]. [NAME] Back unit in rooms 135, 136, 138, 139, 142, 143, 144, 145, 146, 148, 149, 150, and 152. East Front unit in rooms 105, 106, 107, 108, and 109. East Back unit in rooms 110, 111, 113, 114, 110, 212, 122, 123, and 124. d. Damaged, broken, and/or missing toilet paper holder on the bathroom wall on [NAME] Front unit in rooms 131, and 133. [NAME] Back unit in rooms 135, and 139. e. Out of reach industrial double roll toilet paper holder on the bathroom wall (resident unable to reach toilet paper holder) on [NAME] Front unit in rooms 127, 128, 129, 131, 132, 133, and 134. [NAME] Back unit in rooms 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150, 151, and 152. East Front unit in rooms 105, 106, 107, 108, and 109. East Back unit in rooms 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, and 126. f. Damaged, stains, and/or rust pipe/wall underneath bedroom sink on [NAME] Front unit in room [ROOM NUMBER]. g. Damaged, rust, and/or stains Intravenous Pole (IV) in bedroom on [NAME] Front unit in room [ROOM NUMBER]. East Front unit in room [ROOM NUMBER]. h. Damaged, broken, and/or bent window blinds in bedroom on [NAME] Back unit in room [ROOM NUMBER]. East Front unit in room [ROOM NUMBER], and 108. i. Damaged, and/or not working wall clock in bedroom on [NAME] Front unit in room [ROOM NUMBER]. j. Damaged, cracked, stained, and/or sagging ceiling in bedroom on [NAME] Front unit in room [ROOM NUMBER]. [NAME] Back unit in room [ROOM NUMBER]. East Front unit in rooms 105, and 107. East Back unit in rooms [ROOM NUMBER]. k. Damaged, peeling, and/or cracked bathroom wall tiles on [NAME] Front unit in room [ROOM NUMBER]. l. Damaged, and/or rusty bedroom radiator on [NAME] Back unit in room [ROOM NUMBER]. m. Damaged, torn, stains, and/or off-track privacy curtains on [NAME] Front unit in room [ROOM NUMBER]. [NAME] Back unit in rooms 146, and 152. East Front unit in room [ROOM NUMBER]. East Back unit in room [ROOM NUMBER]. n. Damaged, cracked, and/or missing floor tile in the bedroom on [NAME] Back unit in rooms [ROOM NUMBER]. East Back unit in room [ROOM NUMBER]. o. Damaged, broken, and/or missing dresser drawer knob in bedroom on [NAME] Front unit in room [ROOM NUMBER], and 132. [NAME] Back unit in rooms 137, 143, 146, and 150. East Front unit in room [ROOM NUMBER]. p. Damaged, and/or cracked dresser drawer in bedroom on East Front unit in room [ROOM NUMBER]. q. Damaged, and/or peeling nightstand in bedroom on [NAME] Front unit in room [ROOM NUMBER]. r. Damaged, broken, and/or missing nightstand drawer knob in bedroom on [NAME] Front unit in room [ROOM NUMBER]. s. Damaged, broken, and/or loose electrical outlet in bedroom on [NAME] Back unit in room [ROOM NUMBER]. t. Damaged, dirt, dust, and/or rusty tray table in bedroom on [NAME] Front unit in room [ROOM NUMBER]. u. Damaged, hole, chipped, stains and/or marred bathroom door on [NAME] Front unit in rooms [NAME] Back unit in room [ROOM NUMBER], and 151. East Front unit in rooms 105, and 109. v. Damaged, chipped, stains and/or marred bedroom door and/or bedroom door frame on [NAME] Front unit in room [ROOM NUMBER]. East Front unit in room [ROOM NUMBER]. East Back unit in room [ROOM NUMBER]. y. Damaged, cracked, and/or toilet bowl cover does not fit in bathroom on [NAME] Front unit in room [ROOM NUMBER]. x. Damaged, and/or cracked sink tile in bedroom on [NAME] Back unit in room [ROOM NUMBER]. Rehabilitation Services: Damaged, chipped, hole, stains and/or marred walls. Damaged, chipped, stains and/or marred door. Stains, dirt, debris, discoloration, spider web, and/or wax build up on the floor. Interview on 11/6/23 at 12:02 PM with the DNS identified she has been employed by the facility since September 2023. The DNS indicated she was not aware of all the issues. The DNS indicated she will be having a meeting with the maintenance department, and the housekeeping department regarding the environment cleanliness, and repairs. Interview on 11/6/23 at 12:12 PM with the Director of Environmental Services identified he has been employed by the facility since December 2022. The Director of Environmental Services indicated he oversees the housekeeping and laundry department. The Director of Environmental Services indicated he was not aware of all the issues identified in the rooms. The Director of Environmental Services indicated he will be having a meeting with the maintenance department, and the housekeeping department regarding the environment cleanliness, and repairs. The Director of Environmental Services indicated that staff are responsible to notify the maintenance department with issues or problems that require repair. The Director of Environmental Services indicated going forward the maintenance department will address the environmental issues in a timely manner. Interview on 11/6/23 at 12:18 PM with the Administrator identified she has been employed by the facility for approximately 2 months. The Administrator indicated she was aware of the issues. The Administrator indicated the maintenance department is working on these issues. The Administrator indicated a renovation is planned. The Administrator indicated the maintenance department, and the housekeeping department will be in-serviced. Review of the maintenance manager job description identified the primary purpose of the job position is to plan, organize, develop, and direct the general and preventive maintenance of physical plant and grounds as directed by the Administrator, to assure that our facility is maintained according to policy. Develop and implement repair and maintenance schedules for all areas of facility and grounds. Ensure that the facility and department is maintained as required by regulation. Review of the housekeeping services manager job description identified the primary purpose of the job position is to plan, organize, develop, and direct the overall operation of environmental services department in accordance with current federal, state, and local standards, guidelines, and regulations governing facility, as may be directed by the Administrator, to assure facility is maintained in an efficient, clean, safe, and comfortable manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #60 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, metabolic encephalopathy, and type 2 diabetes mellitus. The care plan dated 7/14/23 identified Resident #60 was at risk for falls. Interventions included to encourage the use of non-skid footwear, perform a fall assessment, remind resident to use call bell to request assistance before getting out of bed, and to toilet at regular intervals. The admission MDS dated [DATE] identified Resident #60 had intact cognition, required a limited one-person physical assistance with bed mobility, walking in the room, walking in the corridor, dressing, and toilet use. The nurse's note dated 9/22/23 at 8:56 PM identified that Resident #60 was sitting on the floor in front of his/her bed, without socks or shoes, and stated he/she was going to the bathroom. Resident #60 denied hitting his/her head, neurological checks were within normal limits, and bilateral upper and lower extremities had baseline range of motion. Review of a vital signs document dated 9/22/23 failed to identify that staff checked Resident #60's vital signs from 4:40 PM when a temperature of 97.8 F through 11:20 PM when a full set of vital signs were documented at 11:20 PM, 2 hours and 23 minutes after the fall. A pain assessment of 0/10 was recorded at 8:32 PM. The post A & I monitoring sheet dated 9/22/23 at the top, indicated an initial assessment was done on 9/23/23 at 8:38 PM (this date and time has been altered, not in accordance with professional standards, and is mostly illegible) and again on 9/23/23 at 8:44 PM (this date and time has been altered, not in accordance with professional standards, and is mostly illegible) prior to the resident being sent to the hospital. Review of the vital signs document dated 9/23/23 failed to identify documentation of Resident #60's vital signs from 2:28 PM through the time he/she was transferred to the hospital. A pain assessment of 0/10 was recorded at 8:38 PM. Review of a reportable event form dated 9/23/23 identified Resident #60 was observed on the floor in the hallway at 8:15 PM. Resident #60 had sustained a head laceration and was being transferred to the hospital. The reportable event form further identified that the APRN and resident representative were notified, and a physical exam was completed. The nurse's note dated 9/23/23 at 8:39 PM, written by RN #5, identified Resident #60 was observed in the hallway on his/her left side around 8:14 PM. The resident was bleeding from the forehead, noted to have a 2 cm long laceration and no loss of consciousness. Resident #60 admitted to hitting his/her head on the wall and reported a headache. EMS was called, the APRN and resident representative were notified, and Resident #60 was transferred to the hospital. (The clinical record identified that this nurse's note was edited by the DNS on 11/2/23 at 1:39 PM, reason: more data available). Additional information added by the DNS on 11/2/23 at 1:39 PM is as follows. (Initial blood pressure was 124/68, heart rate was 68, respiratory rate was 20, oxygen saturation was 96% on room air, and temperature was 98.0 F. Pupils were 3mm and equally reactive to light. No facial droop, but Resident #60 complained of 8/10 pain to his/her lower left extremity, with Tylenol administered. Resident #60 was observed to have left limb shortening, positive sensation and movement to bilateral upper extremities, no range of motion to left lower extremity and positive range of motion to right lower extremity). Resident #60 was readmitted to the facility on [DATE] and the hospital Discharge summary dated [DATE] identified Resident #60 sustained a mechanical fall and was found to have a left knee patellar fracture and right-hand fracture. Resident #60 was also noted to have worsening confusion in the setting of a UTI. Interview with the DNS on 11/2/23 at 1:25 PM identified that the post A & I monitoring sheet dated 9/22/23 was not dated correctly and that the document reflected the complete assessments from the fall with injury that Resident #60 sustained on 9/23/23. The DNS further identified that she was unable to locate the post A & I monitoring sheet for the unwitnessed fall that Resident #60 sustained on 9/22/23. Subsequent interview with the DNS on 11/3/23 at 12:56 PM identified that after a resident sustains a fall with injury or an unwitnessed fall, she would expect a nursing assessment to be completed, including vital signs and neurological assessments, and documented in the resident's clinical record. The DNS further identified that while the facility policy directs for documentation in Situation-Background-Assessment-Recommendation (SBAR) format. The DNS identified that she and some of the newer nurses were unaware of this expectation and wrote progress notes. Although attempted, an interview with RN #5 was not obtained. Review of the facility's assessing falls and their causes policy directs that after a resident sustains a fall or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. Obtain and record vital signs as soon as it is safe to do so. Observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and document findings in the medical record. Although multiple requests were made, the facility did not provide documentation of a thorough RN assessment or neurological vital signs after Resident #60's unwitnessed fall on 9/22/23. Additionally, although requested, the facility did not provide a neurological vital sign policy that described the frequency and duration of neurological vital signs after an unwitnessed fall. 7a. Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, gastrostomy status, and tracheostomy status. A physician's order dated 11/14/22 directed to weigh Resident #59 weekly, on Monday during the 7:00 AM- 3:00 PM shift. The care plan, last edited on 7/24/23, identified Resident #59 had a need for enteral nutrition via feeding tube as a primary source of nutrition. Interventions included administration of tube feed regimen as ordered and monitoring weights regularly. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, nutritional approaches performed in the last 7 days were a feeding tube, the proportion of total calories the resident received through tube feeding was 51% or more, and the average fluid intake per day by tube feeding was 501cc per day or more. Further, a weight loss or weight gain of 5% or more in the last month or a weight loss or gain of 10% or more in the last 6 months was not indicated in the annual MDS. Review of the weight variance report dated 9/1/23 through 10/31/23 identified that Resident #59's weights were not recorded weekly as follows. Week of 9/4/23 - 133.4 lbs. Week of 9/11/23 - 134.4 lbs. Week of 9/18/23 - 134.4 lbs. Week of 9/25/23 - no weight recorded. Week of 10/2/23 -130.0 lbs. Week of 10/9/23 - no weight recorded. Week of 10/16/23 - no weight recorded. Resident #59 was hospitalized from 10/19 - 10/22/23. Week of 10/23/23 - no weight recorded. Week of 10/30/23 - no weight recorded. Interview and review of the clinical record with the DNS on 11/6/23 at 12:08 PM identified that Resident #59 had a physician's order for weekly weights, but the clinical identified some weeks had missing weights. The DNS further identified that Resident #59 was last weighed on 10/3/23, and had gone a month without being weighed. The DNS indicated that Resident #59 was hospitalized from [DATE] through 10/22/23. The DNS further indicated that the expectation is that weights are completed and recorded as ordered by the physician or APRN. The DNS identified that the facility would provide reeducation to staff members ensuring residents' weights are monitored and documented per the physician order and that there currently is a QAPI plan in place for weight monitoring. Interview with APRN #1 on 11/6/23 at 1:09 PM identified that she began covering this facility on 10/17/23, and that she has not yet worked with Resident #59. APRN #1 further identified that she would expect to see weekly weights recorded for a resident with a physician's order for weekly weights. APRN #1 indicated that if Resident #59 had refused his/her weekly weights she would expect to see documentation of the refusals in the nursing progress notes. Subsequent to surveyor inquiry Resident #59's recorded weight on 11/8/23 was 127.8 lbs. Although attempted, an interview with APRN #2 was not obtained. Review of the facility's weight policy directed the facility to weigh each resident on admission, then weekly for (4) four weeks, then monthly thereafter, unless otherwise ordered by physician/IDT team. The facility would utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain. b. Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, gastrostomy status, and tracheostomy status. The care plan, last edited on 7/24/23, identified Resident #59 was at risk for dehydration related to tube feedings. Interventions included administering medications as per the physician's order. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, and had active diagnoses that included hypertension, GERD, and hyperlipidemia. A physician's order dated 9/26/23 directed to administer Acidophilus 175mg via gastric tube, daily, Amlodipine (a medication for hypertension) 10mg via gastric tube, daily (with special instructions directed to hold if systolic blood pressure is less than 100), and Atorvastatin (a medication for hyperlipidemia) 80mg via gastric tube, daily. Review of the medication administration history documents dated 10/1/23 through 10/18/23 failed to identify the administration or a rationale for withholding the administration of: Acidophilus on: 10/7/23, 10/13/23, and 10/16/23. Amlodipine tablet on: 10/6/23, 10/7/23, 10/10/23, 10/13/23, and 10/16/23 (the documentation also failed to provide a blood pressure reading). Atorvastatin tablet on: 10/10/23 and 10/15/23. Review of the nurse's notes dated 10/1/23 through 10/18/23 failed to identify documentation of a rationale related to the medications not being administered, and failed to identify documentation that the physician and resident representative were notified that the medications were not administered per the physician's order. The nurse's note dated 10/19/23 at 7:51 PM identified that Resident #59 was sent to the hospital for replacement of a dislodged G-tube. The nurse's note dated 10/22/23 at 7:51 PM identified that Resident #59 returned to the facility. Interview and review of the clinical record with the DNS on 11/6/23 at 12:26 PM indicated that she was unable to identify why the documentation on the medication administration record was left blank, and that the nurse should have documented if the medication was unavailable or not given. The DNS indicated that she would need to identify the root causes as to why there was no documentation for the specified instances. The DNS further identified that she would continue to reeducate the nursing staff on medication administration documentation and initiate weekly random chart and medication pass audits, until the facility was back in compliance. Interview with APRN #1 on 11/6/23 at 1:09 PM identified that she began covering the facility on 10/17/23, and she had not yet worked with Resident #59. APRN #1 indicated that she would expect all scheduled medications to be administered according to the physician's order; if the medication was not available, she would expect the nursing staff to contact the pharmacy to obtain the medication and notify her if the medication was not given. APRN #1 further indicated that if a resident refused a medication or if there was an issue with the order or parameters surrounding an order, she would expect to be notified, allowing her the opportunity to change or modify the order, if necessary. APRN #1 identified that any instance of a mediation being held she would expect a notification. Although attempted, an interview with APRN #2 was not obtained. Review of the facility's medication administration policy directs a provider order is required before administration of any medication and after the medication is administered, the person administering the medication should document in the EMR as soon as possible. Review of the facility's change of condition policy directs the facility to immediately inform the resident, consult with the physician, and notify the resident's legal representative with there is a need to significantly alter treatment. 5. Resident #79 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, anxiety disorder, and insomnia. The care plan dated 6/23/23 identified a focus for abnormal blood glucose levels secondary to diabetes with interventions to administer diabetic medications as ordered. A physician's order dated 6/23/23 directed to administer Insulin Glargine (long-acting Insulin) 100 unit/ml 12 units subcutaneous at bedtime at 8:00 PM. The quarterly MDS dated [DATE] identified Resident #79 had intact cognition, required limited assistance with personal hygiene, required supervision with bed mobility, transfers, locomotion, and was Insulin dependent. The nurse's note dated 10/27/23 at 6:18 AM identified that Resident #79 refused evening meds because they were administered later than his/her usual time. Resident #79 was agitated and raising his/her voice loudly. This RN tried to give Resident #79 emotional support but to no avail. Resident #79 continued to refuse medications, despite education on the importance of taking prescribed medication. Review of the October MAR identified Insulin Glargine, which is scheduled to be administered at 8:00 PM, was administered late on the following dates. 10/1/23 at 9:11 PM, 1 hour and 11 minutes late. 10/2/23 at 9:39 PM, 1 hour and 39 minutes late. 10/3/23 at 9:06 PM, 1 hour and 6 minutes late. 10/4/23 at 9:04 PM, 1 hour and 4 minutes late. 10/5/23 at 9:25 PM, 1 hour and 25 minutes late. 10/6/23 at 10:01 PM, 2 hours and 1 minute late. 10/7/23 no documentation of Insulin administration. 10/8/23 no documentation of Insulin administration. 10/9/23 at 9:39 PM, 1 hour and 39 minutes late. 10/10/23 no documentation of Insulin administration. 10/11/23 no documentation of Insulin administration. 10/12/23 at 9:46 PM, 1 hour and 46 minutes late. 10/13/23 at 9:18 PM, 1 hour and 18 minutes late. 10/14/23 at 9:01 PM, 1 hour and 1 minute late. 10/15/23 at 10:35 PM, 2 hours and 35 minutes late. 10/16/23 at 11:58 PM, 3 hours and 58 minutes late. 10/17/23 no documentation of Insulin administration. 10/18/23 at 9:18 PM, 1 hour and 18 minutes late. 10/19/23 at 9:41 PM, 1 hour and 41 minutes late. 10/20/23 at 9:29 PM, 1 hour and 29 minutes late. 10/21/23 at 9:26 PM, 1 hour and 26 minutes late. 10/22/23 at 10:31 PM, 2 hours and 31 minutes late. 10/23-23 no documentation of Insulin administration. 10/24/23 at 9:01 PM, 1 hour and 1 minute late. 10/25/23 no documentation of Insulin administration. 10/26/23 no documentation of Insulin administration. 10/27/23 MAR says (see nursing note above). 10/28/23 at 9:58 PM, 1 hour and 58 minutes late. 10/29/23 at 11:01 PM, 3 hours and 1 minute late. Interview with Resident #79 on 10/30/23 at 9:30 AM identified that staff usually administers his/her 8:00 PM Insulin late, at times as late as 10:00 PM or 11:00 PM, and they are waking the resident up to give it to him/her. Resident #79 also indicated that the nurse assigned to him/her has patients on both sides of the building, so she gets stuck on the other side and comes back late to give out medications. Resident #79 indicated being awakened at night to get late medications is difficult because it is difficult to get to back to sleep. Interview and review of the clinical record with APRN #1 on 10/31/23 at 11:20AM failed to reflect that she or a physician had been notified of the late Insulin Glargine administration. APRN #1 further indicated although it is her expectation that medications are administered utilizing the 5 rights of medication administration, which include on time administration, she identified for this medication, the efficacy is not impaired with the late dose, however, it is expected that medications are administered on time as ordered. Interview with the DNS on 11/2/23 at 10:40 AM noted that it is her expectation that medications are administered using the 5 rights of medication administration which includes administration at the right time. The policy for medication administration states the 5 rights of medication administration are to be adhered to: Given to the right resident. The right medication is administered. The right dose is administered. Medications are administered via the right route, oral medications by mouth etc. Medications are administered at the time the provider ordered. The policy for Insulin administration indicates that if the resident refuses the insulin injection, the supervisor is to be notified 4. Resident #87 was admitted to the facility on [DATE] with diagnoses that included dementia and pneumonia. A physician's order dated 7/8/23 directed to administer Lasix 20 mg daily for lower extremity swelling or greater than 3 lbs. weight gain as needed. A physician's order dated 7/10/23 directed to obtain a daily weight at 6:00 AM, and if there is a weight gain of 2 - 3 lbs. a day or more, or worsening swelling in the ankles, legs or abdomen, notify the physician. Review of the nursing notes dated 7/10/23 - 11/5/23 failed to identify the resident had refused any daily weights. Review of the daily weights record dated 7/10/23 - 7/31/23 identified weights were missing 14 out of 22 days. The admission MDS dated [DATE] identified Resident #87 had severely impaired cognition. A physician's order dated 7/28/23 directed to discontinue Lasix 20 mg daily for lower extremity swelling or greater than 3 lbs. weight gain as needed. Review of the daily weights record dated 8/1/23- 8/31/23 identified weights were missing 4 out of 31 days. Review of the daily weights record dated 9/1/23 - 9/30/23 identified weights were missing 4 out of 30 days. Review of the daily weights on 10/1/23 - 10/31/23 identified weights were missing 1 out of 31 days. Interview with the DNS on 11/2/23 at 2:53 PM indicated the expectation is that the nurses would follow the physician's orders and that Resident #87 had a physician order for daily weights with parameters since 7/10/23. The DNS indicated the daily weights were not started until 7/20/23 and there were multiple days missing each month. The DNS indicated Resident #87 would not refuse to be weighed but if he/she did refuse, the staff should write a note and reattempt a little while later that day. The DNS indicated there was a parameter of a weight gain of 2 or more pounds to notify the physician. Review of the clinical record, the DNS indicated there were weights missing each month July 2023 - October 2023 and there was no documentation that indicated why the weights were not done. Interview with APRN #1 on 11/6/23 at 1:30 PM indicated that her expectation was that Resident #87's weights would be done by the physician's order, daily, and based on the parameters notify the physician. APRN #1 indicated nursing was responsible to get the daily weights and if not to evaluate why they were not done and notify the physician or herself that day, and no later than day 2 if a weight was not done. APRN #1 indicated she has not been notified that weights were not done or of weight changes according to the parameters. Although attempted, an interview with APRN #2 was not obtained. Review of the facility Change of Condition Policy identified the policy was to ensure that changes in a resident's condition are reported to providers and families. The purpose was to ensure that all resident change in conditions are assessed and documented properly and reported to the physician and family. Although requested, a facility policy on obtaining weights was not provided. 3. Resident #93 was admitted to the facility in August 2023 with diagnoses that included multiple fractures of the left ribs, and pain. The admission MDS dated [DATE] identified Resident #93 had intact cognition and required extensive assistance with personal hygiene. The care plan dated 8/15/23 identified Resident #93 is at risk for falls related to impaired ability to use trunk for mobility. Interventions included to assess for signs/symptoms of pain and provide pain management as appropriate. Rehabilitation screen to determine presence of fall risk factors. Review of the physician's order for October 2023 directed to provide assist of one for transfers and gait with front wheeled walker, apply Thoraco-Lumbo-Sacral-Orthosis (TLSO - is a brace that provides support from mid to the lower portion of the spine) when out of bed, left upper extremity weight bearing as tolerated and bilateral lower extremities weight bearing as tolerated. Review of the facility appointment sign up form dated 10/27/23 identified Resident #93 was listed on the list with an appointment time at 11:00 AM and pick up time of 10:30 AM. The form failed to reflect documentation that a nurse aide had was signed up to escort Resident #93 to the appointment. Review of the census daily detail report dated 10/31/23 identified the facility census was 92. Observation on 10/31/23 at 10:03 AM identified Resident #93 yelling from his/her bedroom at LPN #1, RN #3, and SW #1 who were in the hallway in front of the room that he/she missed the scheduled orthopedic appointment because the facility did not have enough nurse aides to escort him/her to the appointment. Interview with Resident #93 on 10/31/23 at 10:05 AM identified his/her orthopedic appointment at 11:00 AM was cancelled today by the 11:00 PM - 7:00 AM shift RN #2 (supervisor) because they did not have enough nurse aides to escort him/her to the appointment that morning. Resident #93 indicated he/she is very upset that the orthopedic appointment was cancelled. Resident #93 indicated the appointment was very important to him/her because he/she would like to go back home, and he/she is aware that the orthopedic physician has to clear him/her, and he/she does not want to miss any appointments to the orthopedic physician. Review of the facility notification for need for transportation to an appointment form dated 10/31/23 identified Resident #93 had an appointment with the orthopedic on 10/31/23 at 11:00 AM. Interview with RN #3 on 10/31/23 at 10:16 AM identified Resident #93 had an orthopedic follow up appointment at 10:20 AM. RN #3 indicated she received report from RN #2 that the facility did not have any nurse aides available to escort Resident #93 to the appointment. RN #3 indicated RN #2 reported that no nurse aides had signed up that they were available to escort Resident #93 to the appointment that morning. RN #3 indicated RN #2 had the orthopedic appointment rescheduled. RN #3 indicated the reason Resident #93 missed the appointment was because there were no staff to escort the resident. RN #3 indicated she thought RN #2 had notified Resident #93 that the appointment was cancelled. RN #3 indicated Resident #93 was upset and she explained to Resident #93 that the appointment was cancelled because the facility did not have a nurse aide to escort him/her to the appointment. RN #3 indicated she observed Resident #93 getting more upset, so she walked away and went to get SW #1 to come and have a talk with Resident #93. The social services note dated 10/31/23 at 10:39 AM identified Resident #93 was upset about missing an appointment. SW #1 indicated she listened to details from Resident #93 and the nursing staff. SW #1 indicated the Administrator was updated about concern and nursing staff is rescheduling appointment. Interview with SW #1 on 10/31/23 at 11:54 AM identified Resident #93 had an orthopedic appointment that was cancelled because there were two call outs and not enough staff. SW #1 indicated Resident #93 was upset when he/she learned of the appointment being cancelled. SW #1 indicated Resident #93 would have preferred to be notified before the orthopedic appointment was cancelled by nursing. SW #1 indicated she was trying to calm down Resident #93 and explained that the facility is rescheduling the appointment. SW #1 indicated the Administrator reached out to the physician's office to reschedule the appointment for today at a later time with SW #1 accompanying Resident #93. SW #1 indicated the orthopedic office was unable to reschedule the appointment for 10/31/23 at a later time. Interview with the Administrator on 10/31/23 at 12:20 PM identified she was not aware of the two call outs. The Administrator indicated she was notified of Resident #93 orthopedic appointment being cancelled due to not enough staffing. The Administrator indicated the facility had other staffing that could have escorted Resident #93 to the orthopedic appointment. The Administrator indicated she had called the orthopedic office to see if they could reschedule the appointment back to 10/31/23 at a later time and the facility would have sent SW #1 with Resident #93. The Administrator indicated RN #2 will be educated regarding cancelling appointments. The Administrator indicated staffing is challenging when there's call outs. The nurse's note dated 10/31/23 at 2:36 PM identified Resident #93 orthopedic appointment at 10:30 AM was cancelled due to a transportation miscommunication. The orthopedic appointment was rescheduled for 11/16/23. The facility had requested for the orthopedic physician to give an order for Resident #93's x-rays to be completed at the facility to clear Resident #93 for a safe discharge. The facility will follow up with the orthopedic office the next day. Review of the daily staffing sheet dated 10/31/23 identified the facility failed to meet the staffing levels required for direct care staff. Interview with the DNS on 11/2/23 at 12:02 PM identified she was informed by Resident #93 that he/she had missed his/her orthopedic appointment on 10/31/23 because the facility did not have enough staff to escort him/her. The DNS indicated the supervisor on the 11:00 PM - 7:00 AM shift had cancelled Resident #93's appointment because she did not want to pull nurse aide off the floor that morning. The DNS indicated the orthopedic appointment was rescheduled. The DNS indicated she had educated the supervisor regarding cancelling appointments. The DNS indicated the facility has a sign-up form by the time clock where any staff who wishes to pick up extra shifts or time can sign up to escort residents to their appointments. The DNS indicated that no staff members have been signing the form for transporting residents to their appointments. The DNS indicated she was not aware that the facility did not meet the staffing requirements for 10/31/23. The DNS indicated she will have a meeting with the Administrator regarding staffing. Interview with the Administrator on 11/2/23 at 12:20 PM identified she was not aware that the facility did not meet the staffing requirements for 10/31/23. The Administrator indicated she will have a meeting with the DNS regarding staffing. Interview with RN #2 on 11/2/23 at 3:06 PM identified she has been employed by the facility for 2 years. RN #2 indicated Resident #93 had an orthopedic appointment on 10/31/23 at 11:00 AM. RN #2 indicated the staff schedule was short and there was no one to escort Resident #93 to the appointment. RN #2 indicated she told the receptionist to cancel and reschedule the orthopedic appointment. RN #2 indicated the facility was short of nurse aides and she did not want to pull any of the nurse aides off the units because the Department of Public Health was in the facility. RN #2 indicated the facility has an issue with staffing escorting the residents to their medical appointments. RN #2 indicated many appointments have gotten cancelled and rescheduled due to not enough staff to escort the residents to their appointments. RN #2 indicated she should have left the cancelling of the appointment to the 7:00 AM - 3:00 PM supervisor. RN #2 indicated the 7:00 AM - 3:00 PM supervisor has cancelled many appointments because the facility does not have enough staff to escort the residents to their medical appointments. Interview with NA #13 on 11/9/23 at 11:38 AM identified she has been employed by the facility for 18 years. NA #13 indicated she worked on 10/30/23 on the 11:00 PM - 7:00 AM shift. NA #13 indicated on 10/31/23 at 7:00 AM RN #2 did not ask her to escort Resident #93 to an appointment. Interview with NA #14 on 11/9/23 at 3:20 PM identified she has been employed by the facility for 1 year. NA #14 indicated she worked on 10/30/23 on the 11:00 PM - 7:00 AM shift. NA #14 indicated on 10/31/23 at 7:00 AM RN #2 did not ask her to escort Resident #93 to an appointment. Although attempted, an interview with the orthopedic office was not obtained. Review of the facility transportation policy identified the facility ensures residents appointments are scheduled and transportation is coordinated as indicated. Resident appointments are scheduled by facility nursing staff in coordination with facility transportation coordinator. Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #20) reviewed for unnecessary medications, the facility failed to conduct an RN assessment of the resident's condition at that time, and for Resident #93 the facility failed to escort the resident to an orthopedic follow up appointment, according to the plan of care, and for 1 resident (Resident #87) reviewed for edema, the facility failed to do daily weights per the physician order, and for 1 of 3 residents (Resident #60) reviewed for accidents, the facility failed to conduct a thorough RN assessment or neurological vital signs after an unwitnessed fall, and for 2 residents (Resident #79 and 89) reviewed for diabetes, for Resident #79, the facility failed to administer Insulin on time according to the physician's order, for Resident #89 the facility failed to do blood sugar tests before meals, and for the only sampled resident (Resident #59) reviewed for tube feeding, the facility failed to ensure weekly weights were obtained and medication was administered and documented according to the physician's order. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, type 1 diabetes mellitus with hyperglycemia, and congestive heart failure. A physician's order dated 5/2/22 directed to administer Novolog Insulin Aspart solution (a medication for diabetes mellitus) 100 unit/ml subcutaneously before meals per sliding scale. Blood Sugar (BS) is less than 70 call, MD/APRN. BS 0 - 200, administer 0 units. BS 201 - 250, administer 2 units. BS 251 - 300, administer 4 units. BS 301 - 350, administer 6 units. BS 351 - 400, administer 8 units. BS 401 - 450, administer 10 units. If blood sugar is greater than 450, call the MD/APRN. A physician's order dated 10/17/22 directed to administer 5 units of Novolog Insulin Aspart solution 100 unit/ml subcutaneously three times daily, at 8:00 AM, 12:00 PM, and 5:00 PM. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition, [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 resident (Resident #399) reviewed for pain management, the facility failed to administer the scheduled pain medication for 15 days because it was not available. The findings include: Hospital Discharge summary dated [DATE] identified Resident #399 was to receive Lyrica (medication used to treat nerve pain) 100mg twice a day. Resident #399 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region, neuropathy, and diabetes. A physician's order dated [DATE] directed to monitor pain level every shift and administer Lyrica 100 mg twice a day at 9:00 AM and 9:30 PM. The care plan dated [DATE] identified a risk for pain due to physical condition, psychological condition, and pressure ulcer. Interventions included administering pain medication as ordered and evaluating effectiveness. Additionally, update MD/APRN as needed. Review of the medication administration history dated 10/10, 10/11, 10/15, 10/16, 10/17, 10/21, 10/22 and [DATE] indicated the Lyrica was not available to be administered. A nurses note dated [DATE] at 9:01 AM identified Lyrica was not available, and the physician was notified (12 days after medication ordered). The nurse's note written by LPN #2 on [DATE] at 6:10 PM identified call placed to the pharmacy for Lyrica. The pharmacy stated a new script was needed. Placed in APRN book to update. Will follow up with APRN tomorrow. Review of the Controlled Substance Disposition Record dated [DATE] identified the facility received 28 capsules of Lyrica 100mg. (Resident #399 received the first dose of Lyrica on [DATE] at 9:00 PM and had missed 28 doses. Interview with LPN #2 on [DATE] at 7:24 AM indicated she was the full-time nurse on the unit and was the primary nurse for Resident #399. LPN #2 indicated Resident #399 did not receive Lyrica from [DATE] - [DATE] (15 days). LPN #2 indicated the Lyrica was not delivered to the facility and the facility did not have an APRN at that time to sign the script for the Lyrica. LPN #2 indicated the nurses were responsible to get a script from the APRN or MD. LPN #2 indicated she had called the pharmacy and the pharmacy said they had not received the script yet. LPN #2 indicated then the nurse would call the physician again. Interview with the DNS on [DATE] at 9:31 AM indicated when she had started on [DATE] she went through the narcotic emergency box and all the narcotic e-box medications were expired. The DNS indicated she had removed them and placed them in her office. The DNS indicated she had to have the new medical director fill out and sign a new DEA-222 form so she could fax it to the pharmacy to be able to receive narcotics for the emergency box. The DNS indicated there was nothing in the narcotic e-box since at least mid-August and the new medications have not come in yet. Interview with RN # 3 (day supervisor) on [DATE] at 10:48 AM indicated she had notified the APRN or MD to send a script to the pharmacy on [DATE] when she was made aware Resident #399 still had not received the Lyrica since admission on [DATE]. RN #3 indicated there had been a problem getting narcotics for the residents because the APRN had left by [DATE] and the new APRN started last week. RN #3 indicated the new APRN did not have access to do the electronic narcotic prescriptions and it took a little while to develop a procedure to do paper narcotic scripts and fax them to the pharmacy. RN #3 indicated the facility APRN #1 had a problem until last week when she started doing the scripts on paper. RN #3 indicated the first script she did for Resident #399 dated [DATE] for Lyrica did not have the quantity so the pharmacy would not fill it. RN #3 indicated when she was notified, she filled in the quantity and refaxed the script. RN #3 indicated the pharmacy did send the Lyrica on [DATE] but only for a 2-week supply. RN #3 indicated there was not another resident to borrow from for this medication and the narcotic e-box had been empty for months. RN #3 indicated Resident #399 did not receive the Lyrica 100 mg from admission until [DATE] because there were problems getting a prescription completed correctly and having it signed by the APRN or MD. Interview with APRN #1 on [DATE] at 10:53 AM indicated she started to cover this facility since [DATE] and comes in a partial day once a week on Tuesdays. APRN #1 indicated she cannot do electronic narcotic scripts she can only do them on paper until she gets approval from the Administrator from her company before she can do electronic scripts. APRN #1 indicated Resident #399 was on Lyrica for chronic neuropathy and Resident #399 had complaints of pain in his/her legs from the neuropathy. APRN #1 indicated her expectation was that the resident would receive the Lyrica per the physician's orders. APRN #1 indicated her expectation was when the resident did not receive the first dose that the APRN and the family would be notified. APRN #1 indicated Resident #399 not receiving the scheduled Lyrica would cause him/her increased nerve pain. Interview with the DNS on [DATE] at 11:30 AM indicated when a resident is admitted to the facility the residents should have all their medications within 24 hours. The DNS indicated if a medication was not available her expectation was the nurse would call the doctor that day and get an order to hold that dose or change the medication to another medication for a 1-time dose. After clinical record review, the DNS indicated there was no documentation that the APRN or physician had been notified so they could change the medication until the Lyrica was available or that the APRN or physician needed to fill out the prescription for the narcotic. The DNS indicated per the documentation the APRN or physician were not notified until [DATE] (12 days later). The DNS indicated she was not aware that Resident #399 did not receive the Lyrica twice a day from admission until [DATE] until after review with the surveyor. The DNS indicated the problem was the charge nurse and supervisor did not follow up with the pharmacy regarding the script and why it was not being delivered. The DNS indicated the nurse failed to follow the protocol. Interview with LPN #2 on [DATE] at 11:34 AM indicated she made a mistake and documented that Resident #399 had received the Lyric on 10/12, 10/14, 10/15, and [DATE]. LPN #2 indicated she must have accidentally clicked off on it, because she knows Resident #399 did not receive the Lyrica from admission on [DATE] until [DATE]. Review of the facility Medication Administration Policy identified the facility will provide a safe and effective medication management framework to help eliminate any harm that could be caused at any level of the medication management process. Review of the facility Pain Management Policy identified the purpose was to help the staff identify pain in the resident and to develop interventions that are consistent with the residents' goals and needs and that address the underlying causes of pain. Identifying the causes of pain such as pressure ulcer or venous or arterial ulcers and neuropathy. Implementing pain management strategies either non-pharmacological or pharmacological interventions may be prescribed to manage pain. Strategies could include administering medications around the clock rather than as needed. Although requested, a facility policy for medication errors was not provided.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure that nurse aide staff completed annual competencies. The findings include: A review of a facility provided staff education list on 11/6/23 identified that NA #3 completed annual competency training on 9/13/23, and NA #7 completed training on 9/17/23. The staff education list identified NA #3 and 7 completed annual training that included abuse, fire safety, emergency preparedness, compliance, HIPPA, infection control, body mechanics, fear of retaliation, resident rights, workplace violence, and lock out. Review on 11/6/23 of the annual competency fair post test packet, located in NA #3's employee file failed to identify any signature on the packet that identified NA #3 had completed the training, and failed to identify a signature on page 4 of the test related to employee certification of fear of retaliation training. Review on 11/6/23 of the annual competency fair post test packet located in NA #7's employee file identified that the information on the test did not match the surname as other documentation, completed by NA #7. The annual competency post test located in NA #7's employee file was dated 9/9/23 and did not include the surname utilized by NA #7 on all employee documents signed in NA #7's file from 2019 through 2023. Review on 11/6/23 of the annual competency fair post test packet located in LPN #7's employee file identified that the staff identifier information on the test had been altered. The name and signature of NA #7 was identified as the original staff member who completed the packet. NA #7's name and signature were crossed out, although still legible, and LPN #7's printed handwritten name, along with an illegible signature were added to the test. Further review of the test packet identified that NA #7's signature was located on page 4 of the test related to employee certification of fear of retaliation training. The handwriting and signature on the annual competency post test packet located in LPN #7's employee appeared to match all handwriting and documentation completed by NA #7 upon review of NA#7's employee file. Interview with the DNS on 11/6/23 at 1:20 PM identified, upon review of the annual competency post test document for LPN #7 with this surveyor, LPN #7 had not completed competencies during the 9/2023 skills fair and the post test packet did not belong to LPN #7. The DNS also identified that the original handwriting and signature on LPN #7's annual competency post test packet belonged to NA #7. The DNS further identified that the annual competency fair post test packet located in NA #7's employee file did not belong to NA #7 based on the surname and handwriting. The DNS also identified that the annual competency post test packet for NA #3 was not valid as the packet did not have a signature. The DNS identified that maybe someone was just trying to help out, the nursing staff all sat in a room together and told them if the competencies weren't completed within a week, they would be pulled off the schedule. The facility policy on training guidelines for staff directed that, in alignment with public health law, ongoing education and competency-based training would be a mandatory and routine part of the facility culture to maintain standard quality control and address any newly identified areas requiring staff education. The policy also directed that specific areas of mandatory education were identified for all existing employee on a yearly and as needed basis, and these areas included abuse prohibition, fire safety, emergency preparedness, compliance and ethics, infection control, resident rights, and workplace violence. The policy further directed that nurse aides would be provided with specific training and outlined in the policy on mandatory training for certified nursing assistants. Although requested, the facility failed to provide the policy on mandatory training for certified nursing assistants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interview, the facility failed to have an emergency supply of narcotics available for resident use, and failed to establish a system of records of all controlled drugs to enable an accurate reconciliation, failed to ensure drug records were in order, and that an account of all controlled drugs was maintained and periodically reconciled. The findings include: 1a. Interview with RN #2 (night supervisor) on [DATE] at 7:50 AM identified she was the full time 11:00 PM - 7:00 AM supervisor and the only one with access to the emergency medications. RN #2 indicated she has not had access to the non-narcotic pyxis for over a month and the narcotic emergency box had been empty for months. RN #2 indicated she had told the day supervisor, RN #3, and the DNS many times, but still does not have access. RN #2 indicated there was not a list of emergency medication for the Pyxis available. RN #2 indicated she would have to ask the administrator to call the pharmacy and get a list of the medications. Interview with the Administrator on [DATE] at 8:01 AM indicated she was not aware that the night supervisor, RN #2, did not have access to the emergency medication box. The Administrator indicated she thought all the supervisors had access to the emergency medication Pyxis and the narcotic emergency box. The Administrator indicated the DNS was aware and was working on it now. Interview with the DNS on [DATE] at 10:11 AM indicated she was not aware that the RN #2 did not have access to the Pyxis for the last month until after surveyor inquiry. The DNS indicated after investigating this morning, she was informed that RN #3 was aware, but RN #3 did not inform her. The DNS indicated that RN #2 was the only person to access the Pyxis at night. The DNS indicated she just reset the fingerprint for RN #2 and now it works. 1b. Review of the Facility Controlled Drug E-box Medication list dated [DATE] identified there were 11 scheduled II narcotic medications and 11 scheduled III/V narcotic medications on the list. Interview with the DNS on [DATE] at 9:31 AM indicated when she had started on [DATE] she went through the narcotic emergency box in mid-August and all the medications were expired. The DNS indicated at that time she had removed all the expired narcotics and brought them to her office. The DNS indicated she had to have the new medical director fill out and sign a new DEA-222 form so she could fax it to the pharmacy to be able to order new narcotics. The DNS indicated there was nothing in the narcotic emergency box since mid-August and the new medications have not come in yet. Interview with RN #3 (day supervisor) on [DATE] at 10:48 AM indicated the emergency narcotic box was empty. RN #3 indicated it was empty prior to this DNS starting in [DATE]. RN #3 indicated she does not have a list of what was or should be in there. RN #3 indicated if a new admission or if a resident runs out of a narcotic, they have to wait until the physician does another script for the pharmacy to send the medication. Interview with APRN #1 on [DATE] at 10:53 AM indicated she started to cover this facility on [DATE] once a week on Tuesdays. APRN #1 indicated she cannot do electronic narcotic scripts that she can only do them on paper until she gets approval from the Administrator of her company and the pharmacy. APRN #1 indicated the facility should have a narcotic e-box to be able to give the first dose until the pharmacy can deliver the medication. Interview with the DNS on [DATE] at 11:30 AM indicated she has been working with the new medical director to get a narcotic emergency box again. The DNS indicated she had a list of what medications should be in the narcotic emergency box. The DNS indicated the last inventory list of the narcotic emergency box was on [DATE]. (Facility DEA inventory dated [DATE] listed name of medication and amount in the inventory for 10 scheduled II narcotics and 9 scheduled III/V narcotics signed by the prior DNS and another RN). Observation and interview with the RN #3 with the DNS present on [DATE] at 2:35 PM indicated the narcotic emergency box had been empty since beginning of [DATE]. RN #3 opened the narcotic emergency box there we no narcotics present. Interview with Pharmacy Manager #1 on [DATE] at 9:50 AM indicated she could send the narcotic report for the narcotic emergency box for [DATE] - [DATE]. Review of the Narcotic Emergency Box Profile dated [DATE] - [DATE] identified the last narcotic ordered was on [DATE], a year ago. Review of the facility Emergency Drug Kit identified the facility shall maintain the emergency drug kit(s) on site with medications in quantities to meet the needs of the residents. Review of the facility Controlled Substance Ordering Policy identified it is the facility's responsibility to contact the physician first, in order to obtain the required prescription. If the physician is not in the facility and a controlled substance is needed and is not in the controlled emergency box the physician will be contacted. 2. According to Appendix PP §483.45 Pharmacy Services. The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Observation on [DATE] at 1:00 PM identified the DNS office door was open and no staff was present in the office. Subsequently, the DNS entered her office. Inside the opened DNS office was an unlocked file cabinet with 2 drawers filled with controlled medications (Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence.) Further, on the floor of the DNS office were 2 clear plastic garbage bags and a box full of blister packs of medications. Upon a reconciliation of the controlled medications in the drawers, the following was identified: A blister pack of Lorazepam 0.5mg with 6 missing. A blister pack of Tramadol 50mg with 14 missing. A blister pack of Lorazepam 0.5mg with 4 missing. A blister pack of Lorazepam 0.5 with 2 missing. A blister pack of Tramadol 50mg with 2 missing. A blister pack of Clonazepam 0.5mg with 7 missing. The following blister packs did not have a controlled substance disposition record and were unable to be reconciled. Ativan 0.5mg 28 dispensed, 24 remaining. Ativan 0.5mg 28 dispensed, 27 remaining. Ativan 0.5mg 30 dispensed, 30 remaining. Diazepam 5mg 21 dispensed, 8 remaining. Suboxone 2 films dispensed, 1 remaining. Belbuca 600mg 14 dispensed, 7 remaining. Ativan 14 dispensed, 1 remaining. Ativan 0.25mg 90 dispensed, 12 remaining. Diazepam 5mg 6 dispensed, 5 remaining. Xanax 0.5mg 4 dispensed, 9 remaining. Belbuca 28 patches dispensed, 19 patches remaining. Two handwritten controlled substance disposition records were found. One for Clonazepam 0.5mg, and one for Lorazepam 0.5mg. Interview with the DNS on [DATE] at 1:00 PM identified that when she took the position of DNS in August of 2023, there were multiple drawers of controlled medications in her office. The DNS identified that she and another staff member destroyed approximately 250 controlled medications that had been stored in her office. The DNS identified that she had asked maintenance several times to put a lock on the file cabinet to secure the controlled medications but it had not been done. Further, the DNS identified that the missing controlled substance disposition record could not be found. Review of the controlled substance handling policy identified all controlled drugs will be subject to special receipt, handling, storage, disposal and record keeping. All controlled substances received shall be delivered to the nursing unit, and logged into the official count by two nurses; the nurse who received the delivery, and the nurse in charge of the unit. If the nurse receiving is also the charge nurse, a nurse from another unit shall be asked to verify the count and log the receipt. All controlled drugs shall be stored in a 2 door double-locked cabinet with 2 separate keys designed for that purpose, separate from all other drugs. The access key to controlled drugs is not the same key giving access to other drugs. A controlled drug accountability record shall be prepared when receiving and checking in a controlled drug. Discontinued controlled drugs are returned to the nursing office after count is verified. The drugs are then stored in a double-locked cabinet in the nursing office until permission to destroy has been obtained. Review of the controlled substance destruction policy identified unused or expired controlled substances will be destroyed in a manner consistent with Connecticut DCP regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 5 residents, (Resident #89) reviewed for unnecessary medications, the facility failed to ensure the resident was free from significant medication errors when staff failed to administer 18 doses of a medication for attention and concentration deficit and 12 doses of a medication for substance abuse with withdrawal. The findings include: Resident #89 was admitted to the facility on [DATE] with diagnoses that included diabetes, psychoactive substance abuse with withdrawal, and attention and concentration deficit following a stroke. Physician's orders dated 9/13/23 directed to administer the following medications. Adderall (dextroamphetamine-amphetamine) 20 mg, (a schedule II medication), twice daily at 8:00 AM and 1:00 PM for attention and concentration deficit following a stroke. Buprenorphine-Naloxone (Schedule III medication) 8mg-2 mg sublingual every 12 Hours at 9:00 AM and 9:00 PM. The admission MDS dated [DATE] identified Resident #89 had moderately impaired cognition, required extensive assistance with toilet use and received injections and Insulin. The care plan dated 9/21/23 identified the resident was at risk for mild nutritional risk, pain and falls. The care plan did not identify interventions to address the diagnoses of diabetes, administration of Insulin, history of substance abuse or attention deficit. a. Review of a controlled substance disposition record identified that 28 tablets of Adderall (dextroamphetamine-amphetamine) 20 mg had been delivered to the facility on 9/28/23. The staff administered the last Adderall 20 mg of that delivery, on 10/12/23 at 1:00 PM. Review of the October 2023 medication administration history identified that Adderall was not administered on 10/13/23 at 8:00 AM and 1:00 PM because the drug was not available, and staff were waiting on the pharmacy for delivery. Review of a controlled substance disposition record identified that 6 tablets of Adderall 20 mg had been delivered to the facility on [DATE]. The staff administered the last Adderall 20 mg of that delivery on 10/16/23 at 1:00 PM. Although the medication was not available, the medication administration history identified that Adderall was administered at 8:00 AM and 1:00 PM on 10/17/23. There was no documentation on the October 2023 medication administration history that Adderall was administered on 10/18/23 at 8:00 AM. The October 2023 medication administration history identified that Adderall was not administered on 10/18/23 at 1:00 PM because the drug was not available. There was no documentation on the October 2023 medication administration history that Adderall was administered on 10/19/23 at 8:00 AM. The October 2023 medication administration history identified that Adderall was not administered on 10/19/23 at 1:00 PM because the drug was not available, and the Director of Nurses would follow up. The October 2023 medication administration history identified that Adderall was not administered on 10/20/23 at 8:00 AM at 1:00 PM because the drug was on order. The October 2023 medication administration history identified that Adderall was not administered on 10/21/23 at 8:00 AM at 1:00 PM because the drug was not available. There was no documentation on the October 2023 medication administration history that Adderall was administered on 10/22/23 at 8:00 AM. The October 2023 medication administration history identified that Adderall was not administered on 10/22/23 at 1:00 PM because the prior shift. There was no documentation on the October 2023 medication administration history that Adderall was administered on 10/23/23 at 8:00 AM. The October 2023 medication administration history identified that Adderall was not administered on 10/23/23 at 1:00 PM because the need new script. The October 2023 medication administration history identified that Adderall was not administered on 10/24/23 at 8:00 AM at 1:00 PM because the drug was not available. The October 2023 medication administration history identified that Adderall was not administered on 10/25/23 at 8:00 AM at 1:00 PM because the drug had not been delivered and was not available. Review of a controlled substance disposition record identified that 30 tablets of Adderall 20 mg had been delivered to the facility on [DATE]. Based on the documentation, Resident #89 missed 18 doses of Adderall between 10/17/23 - 10/26/23. b. Review of a controlled substance disposition record identified that 28 tablets of Buprenorphine-Naloxone 8mg-2 mg had been delivered to the facility on 9/30/23. The staff administered the last Buprenorphine-Naloxone of that delivery, on 10/13/23 at 8:00 PM. Review of the October 2023 medication administration history identified Buprenorphine-Naloxone was not administered on 10/14, 10/15, 10/17, 10/18 and 10/19/23 (10 doses) because the facility was waiting for the delivery of the drug from the pharmacy. However, despite the drug being not available, staff documented on the October 2023 medication administration history that the Buprenorphine-Naloxone was administered on 10/16/23 at 9:00 AM and 9:00 PM. Review of a controlled substance disposition record identified that 60 tablets of Buprenorphine-Naloxone had been delivered to the facility on [DATE]. Based on the documentation, Resident #89 missed 12 doses of Buprenorphine-Naloxone over 6 days between 10/17/23 - 10/26/23. Interview with the DNS 11/1/23 at 12:00 PM identified failed to reflect why Resident #89 missed 18 doses of Adderall or 12 doses of Buprenorphine-Naloxone during October 2023, or why staff documented that they administered medications not available. Review of the ordering and obtaining medication policy identified drugs will be obtained and administered only upon the clear and complete and signed order of a person lawfully authorized to prescribe. Review of the controlled substances handling policy identified all controlled drugs will be subject to special receipt, handling, storage, disposal and record keeping. Controlled drugs will be delivered to the facility only upon the written order of a licensed practitioner.

Based on observation, review of facility policy, and interviews, the facility failed to maintain sanitizing solution at acceptable parameters (200 ppm or above) and ensure the ice machine was free from dark black spots in the interior. The findings include: 1. Observation and interview with the Food Services Director (FSD) on 10/30/23 at 7:25 AM identified the quat solution (red bucket solution used to sanitize countertops during food preparation) was registering less than the minimum required rating of 200 ppm (parts per million). Interview with [NAME] #1 identified the solution was secured from the spicket just recently and had been used to wipe the countertops as needed. The FSD indicated the solution did not contain quat and consisted of water only. [NAME] #1 insisted the solution was secured from the quat spicket. The FSD on 10/30/23 at 7:45 AM discarded the previous bucket acquired by [NAME] #1 and prepared a new quat solution bucket which when measured, registered greater than the required minimum of 200 ppm. Both the FSD and [NAME] #1 indicated that the quat solution should register greater than 200 ppm to ensure sanitation of the kitchen during food preparation. 2. Observation and interview on 11/6/23 at 11:15 AM with the FSD identified black spots on the interior upper rack or ice cube plastic mold. The FSD indicated a new ice machine was on order with anticipated delivery of 11/16/23. The FSD indicated rather than clean the machine, he would simply take it out of service and purchase ice for the facility use until the delivery date and also indicated it is his expectation that the machine is clean and free from residue or debris. The policy on kitchen sanitation identified employees will be trained on how to perform cleaning tasks. No policy for the ice machine was provided.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure review of the antibiotic stewardship program was completed at least annually. The findings include: A review of the infection control program with RN #4 (former IP nurse) on 11/3/23 at 10:57 AM failed to identify documentation related to annual review of the infection control program or antibiotic stewardship program for 2022 or 2023. RN #4 identified that the facility had not held any infection control meetings during her tenure as the IP nurse from 3/2023 through her resignation from the position on 9/29/23. RN # 4 identified she was still employed by the facility as a per diem RN. RN #4 identified when she worked as the infection control nurse, she would contact the medical director or facility APRNs directly if she had issues that she needed to be addressed, but that it was on a case-by-case basis, and she was not aware of any formal meetings related to infection control or the antibiotic stewardship program. RN #4 further identified if there were any formal meetings, she was not invited to participate. Subsequent to surveyor inquiry, the facility provided documents labeled Quarterly Medical Staff and Quality Improvement Meeting/Quarterly Infection Control Meeting 10/19/23 on 11/3/23 at 11:35 AM. The documentation identified meeting minutes which identified the DNS provided an update on infection control practices with an attached report, and also identified that the DNS reviewed the antibiotic stewardship program. Further review of the document failed to identify any additional documentation related to infection control reporting or antibiotic stewardship reporting. Review of the meeting sign in for staff identified that RN #4 did not participate in the meeting. Although requested, the facility failed to provide any further documentation related to quarterly infection control meetings for 2022 and 2023. The facility policy on Infection Program Overview-Home Health and Hospice directed that a summary of infection prevention activities would be presented to the governing body at least annually. The policy failed to identify any directives related to antibiotic stewardship. The facility policy on the Infection Prevention and Control (IPC) Program directed that elements of the program included antibiotic stewardship, coordination, and oversight that would be conducted by the IP nurse. The policy further directed that the facility would have an IPC committee that would meet at least quarterly, and that the IP nurse, IPC committee, medical director, DNS, and other key clinical and administrative staff would meet at least annually to review IPC policies. The policy also directed that the annual review would include updating or supplementing policies and procedures as needed.

Based on review of facility documentation, facility policy and interviews, the facility failed to have a designated Infection Preventionist (IP) with the required specialized training in infection control, after 9/29/23. The findings include: A review of the IPC (Infection Prevention and Control) program with RN #4 (former IP nurse) on 11/3/23 at 10:57 AM identified RN #4 had resigned from the IP position on 9/29/23. RN # 4 identified she remained employed by the facility as a per diem RN Supervisor. RN #4 identified that the facility had recently hired a new IP nurse who started in the position on 10/30/23, however the newly hired IP nurse did not have the required specialized training. RN #4 identified following her resignation on 9/29/23, she had not covered any of the job duties of the IP nurse, which included antibiotic stewardship, infection control audits, and environmental rounds. Review of facility documentation including environmental rounds, infection tracking forms for antibiotic stewardship, and infection control audits failed to identify any monitoring after 9/29/23. Review of the DNS's employee file failed to identify any certifications or specialized training related to infection prevention. Interview and observation with the DNS on 11/6/23 at 1:20 PM identified that she was unsure if RN #4 was still covering the IP position following RN #4's resignation on 9/29/23 from the IP position. The DNS identified since RN #4 was still employed at the facility per diem, the DNS believed that RN #4 was still covering the IP position, but no longer on a full-time basis. The DNS further identified that she also had an IP certification but had not completed any job duties of the IP nurse following RN #4's resignation from the IP position. Although requested, the DNS failed to provide a copy of her IP specialized training. The facility policy on the Infection Prevention and Control (IPC) Program directed that the program would be coordinated and overseen by an infection preventionist, and that the qualifications and responsibilities of the infection preventionist were outlined in the infection preventionist job description. Although requested, the facility failed to provide any documentation related to the infection preventionist job description.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interviews the facility failed to maintain an environment free of pests. The findings include: Review of a maintenance request log entry dated 8/6/23 identified a mouse had been spotted in room [ROOM NUMBER]. The notation was signed off on 8/11/23 by the Maintenance Assistant. The invoicing from the contracted exterminator identified the following: 9/18/23-Technician met with the Administrator and Front Desk, the Administrator reported several units with mouse activity. The technician spoke with the kitchen Chef who reports no pest activity since the last services; rooms 116, 113, 115, 114, 105 reported mice activity. The technician inspected all units and spoke to residents that were vocal and stated mouse activity along radiators. Glue boards were placed along radiators in all units listed. 10/6/23-Technician met with the Maintenance Assistant who reported mouse activity in almost all rooms. The technician inspected all rooms and placed 2 - 3 glue boards in all rooms. The technician observed some mouse evidence throughout rooms listed, Technician also found multiple rodent entry points in 6 rooms. The other rooms were inspected, however had no visible signs of mouse activity at the time of service. The recommendation to Maintenance Assistant is that the entry points be sealed to stop further mouse activity. 10/13/23-Technician met with Maintenance Assistant who provided a list of rooms with mice caught and glue boards replaced as needed. No further mouse activity observed, residents with mice caught identified no further activity. The Maintenance Assistant identified the gaps under the baseboards will be fixed shortly as the baseboards need to be ordered. Interview with an anonymous resident on 10/30/23 identified he/she recently was eating chocolate and a when a piece dropped on the floor, within seconds, a mouse appeared, grabbed the chocolate, and immediately dashed into the closet. Interview with an anonymous resident on 10/30/23 at 6:00AM identified the facility staff removed glue traps from his/her room this morning. Interview with the Maintenance Director and the Maintenance Assistant on 11/1/23 at 1:10 PM identified a mouse problem began in October 2023 and the exterminator was notified at that time. The Maintenance Assistant identified he works closely with the exterminator to identify areas of entry and seal them off. The Maintenance Director and the Maintenance Assistant were both unclear of the activity associated with the mouse identification of 8/6/23, neither could recall the response to the identified concern or why the concern was considered resolved on 8/11/23. The Maintenance Assistant identified all work is done at the direction of the Maintenance Director. Also identifying the maintenance log is prioritized by the Maintenance Director, who determines the appropriate, and timely response to address the identified concern. The policy for pest control identified the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

**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 #21) reviewed for rough care, the facility failed to immediately notify the DNS of the allegation and failed to ensure timely removal of persons identified as allegedly delivering rough care, pending the investigation. The findings include: Resident #21's diagnoses included rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was cognitively intact, required extensive assist with bed mobility and total assist with toileting and personal care. The Resident Care Plan dated 5/27/21 identified Resident #21 had the potential for impaired vision and required full assistance with activities of daily living. Interventions included ensuring personal care items were within reach, set up basin/supplies at bedside and assist with care needs. An interview on 8/2/21 at 10:30 AM with Resident #21 identified within the preceding half hour, two aides (Nursing Student #3 and Nursing Student #4) were rough with care. Resident #21 stated he/she had arthritis and therefore was unable to some of the tasks the Nursing Students wanted. Resident #21 requested beforehand that Nursing Student #3 and Nursing Student #4 be gentle with care. Resident #21 indicated the alleged event had not yet been reported to facility staff. On 8/2/21 at 10:50 AM, RN #5 was notified of the allegation by the State Surveyor immediately following the interview with Resident #21. An interview on 8/2/21 at 1:17 PM with Person #2 identified she was the Nursing Instructor for the nursing students providing resident care within the facility for that day. Tasks the nursing students were able to complete included changing linen, personal care and assessments. Person #2 indicated the facility was short staffed and no formal report was provided to the students about resident care, however the assigned NA answered any questions. Person #2 indicated she learned there was a resident complaint made earlier in the day but that the issue was resolved. An interview on 8/2/21 at 1:17 PM with RN #5 indicated Nursing Student #3 and Nursing Student #4 were counseled in customer service and that the DNS had been notified of the incident. An interview on 8/2/21 at 1:58 PM with Social Worker (SW) #1 identified he was notified by RN #5 immediately following the allegation and went to speak to the resident about the incident. Resident #21 reported caregivers (Nursing Student #3 and Nursing Student #4) were rough with care. SW #1 asked Resident #21 to further define what was meant by rough. According to SW #1, Resident #21 described care as quick and rushed and that the staff did not speak to him/her, feeling as if they were not aware he/she was blind. SW #1 determined nursing students provided care for Resident #21 and went to speak with Person #2 about the incident. RN #5 was also present during the discussion where it was determined the matter was more very poor customer service rather than rough care. SW #1 indicated the nursing students were provided with inservicing. SW #1 further indicated while he did not know what the policies were specifically regarding abuse, he was aware that his role was to follow up with the resident to assure the resident was assessed and felt safe, but did not notify the DNS. An interview on 8/2/21 at 2:15 PM with the DNS identified that while RN #5 stated the allegation was reported to the her after it occurred, she was not notified until 1:15 PM. The nursing students were immediately relieved of their assignments following her notification (allowed to work for 2 hours and 35 minutes after the allegation was reported to RN #5). A subsequent interview on 8/2/21 at 2:30 PM with RN #5 identified she had notified RN #1 and not the DNS upon learning of the reported allegation. An interview on 8/5/21 at 1:20 PM with Person #2 identified RN #5 reported the allegation to her on 8/2/21 late in the morning where it was reported the students were rude to a resident. Person #2 spoke to the nursing students about communicating with the residents, and then the students, including Nursing Student #3 and Nursing Student #4 returned to the unit to pass lunch trays. Person #2 observed Nursing Student #3 feeding a resident and Nursing Student #4 passing out food trays. Nursing Student #3 and Nursing Student #4 were relieved from duty at 1:45 PM after RN #5 returned and directed them to leave (after being in contact with other residents for 2 hours and 55 minutes after the allegation of roughness). An interview on 8/5/21 at 1:32 PM with Nursing Student #4 identified she and Nursing Student #3 provided care to Resident #21 earlier in the day. Shortly after, RN #5 told Nursing Student #4 that it was reported care was rushed and that she and Nursing Student #3 were rude. Nursing Student #4 indicated that although Resident #21 moaned at times and seemed fragile, there was no indication to her that there was a concern. Nursing Student #4 indicated after speaking with her nursing instructor she returned to the unit and passed out lunch trays to other residents. She was asked to complete a statement and was then directed to leave at 1:40 PM. An interview on 8/5/21 at 1:52 PM with Nursing Student #3 identified she was providing care to Resident #21 earlier that day. They were joking and laughing. Shortly after they were done, RN #5 told them it was reported she and Nursing Student #4 were rough and rude with Resident #21's care. Nursing Student #3 indicated Resident #21 did state the lotion was cold thinking it was water but did not express any other concerns. Nursing Student #3 indicated she and Nursing Student #4 spoke with the nursing instructor about the incident and then returned to the unit to pass lunch trays. Nursing Student #3 indicated she provided feeding assistance to another resident during that time. Nursing Student #3 provided a statement and then was told to leave the facility at 1:40 PM. The policy for Abuse and Neglect dated 4/2017 directs any witnessed or alleged report of a resident abusive action, The Administrator or on-call designee and Director of Nursing Services are to be notified immediately. If an employee is the alleged abuser, he/she will be removed from the care of the resident and suspended pending the outcome of the investigation. The facility failed to follow the policy for the immediate reporting of an allegation of rough care to the DNS and failed to ensure timely removal of the Nursing Students from resident care pending an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 1 resident (Resident #45) reviewed for activities of daily living (ADL), the facility failed to provide timely incontinent care to a resident requiring assistance. The findings include: Resident #45's diagnoses included end stage renal disease, Type II Diabetes and morbid obesity. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 was without cognitive impairment and required extensive assistance of 1 with bed mobility, toileting and personal care and total assistance of 2 with transfers. The Resident Care Plan dated 7/26/21 identified Resident #45 had a deficit in ADL's with interventions that included ensuring the call light was within reach, set up basin and supplies at bedside and assist with care needs. An interview on 8/3/21 at 1:59 PM with Resident #45 identified incontinent care was not being provided in a timely manner, sometimes being left for hours without care being provided. A continuous observation beginning 8/4/21 at 9:08 AM through 8/4/21 at 12:50 PM identified Resident #45 received personal care at 9:08 AM. At 11:03 AM therapy staff entered the room to see Resident #45. The call light was on before being turned off by rehabilitation staff at the request of Human Resource Specialist #1 (HR #1) who was also on the unit at the time. Therapy staff exited Resident #45's room shortly after and spoke to NA #1 and HR #1 before leaving the unit. Resident #45 confirmed at that time he/she was unable to participate in therapy because he/she was incontinent of stool, needed to be changed and therefore requested that therapy staff return after lunch. At 11:50 AM, NA was on the unit passing lunch trays. NA #1 peered into Resident #45's room and asked, Do you want something? and continued to pass trays. LPN #4 was also observed going into Resident #45's room responding to a call light but exited a short time later. Resident #45 confirmed she requested incontinent care a second time and that NA #1 indicated she would return to provide care. Resident #45 was already served and had eaten lunch (without the benefit of incontinent care). At 12:50 PM, Resident #45 was observed receiving incontinent care (1 hour and 47 minutes after being incontinent of feces). An interview with Physical Therapy Assistant (PTA) #1 on 8/4/21 at 12:56 PM identified she went to Resident #45's room in the late morning to initiate physical therapy. Resident #45 requested she come back as Resident #45 needed to be changed. PTA #1 notified HR #1 and NA #1 that Resident #45 needed to be changed. An interview on 8/4/21 at 12:59 PM with LPN #4 identified although she was unaware Resident #45 had required personal care earlier, she did respond to his/her call light reporting a need to be changed. LPN #4 offered assistance but Resident #45 declined. LPN #4 stated Resident #45 preferred that NA #1 provide personal care. LPN #4 informed NA #1 (who was feeding residents at the time), that Resident #45 needed to be changed, but did not relieve NA #1 so that NA #1 could provide care to Resident #45). An interview on 8/4/21 at 1:04 PM with HR #1 identified she was notified earlier in the day from therapy staff that Resident #45 required assistance with personal care. HR #1 told NA #1, who indicated she was just in Resident #45's room but would return once she finished with another resident. An interview on 8/4/21 at 1:16 PM with the DNS identified it would be her expectation that incontinent care be performed timely following an incontinent episode of stool. Over one and a half hours to was too long to wait. The policy for incontinent care dated 4/2017 directed that a resident be checked for incontinence every 2 hours and clean skin when soiled. The facility failed to ensure incontinent care was provided to a resident requiring assist in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and procedures and interviews for one of one sampled resident (Resident #2) reviewed for mood and behavior, the facility failed to ensure Resident #2 was assessed for safety or that a physician's order was in place to address the resident's leave of absence (LOA) privileges and for 1 of 4 residents (Resident #35) reviewed for pain, the facility failed to ensure recommendations for a specialty provider were responded to in a timely manner. The findings include: 1. Resident #2 diagnoses included cerebral infarct, cardiac pacemaker, altered mental status, attempted suicide, Diabetes Type II, and acute stress reaction. A quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 as being cognitively intact, without behaviors and independent for most activities of daily living. On 8/4/21 a 11:30 AM an interview with the Resident #2 indicated he/she leaves the facility via self driving to apply for employment in the community. On 8/5/21 at 12:39 PM an interview and review of the clinical record and facility documentation with the Administrator in the presence of Social Worker (SW) #2 identified Resident #2 was recently granted independent leave of absence privileges to include the use of a friend's car to self drive in the community to apply for work, most recently during the month of July 2021. Additionally, SW #2 identified Resident #2 normally parked the car he/she utilized on the street, however the car was no longer parked in its usual area on the street at the time of this interview, and it was believed that the car may have been picked up by its owner. Subsequent to surveyor inquiry, attempts were made by the Administrator to contact the owner of the vehicle but were unsuccessful. Although the facility provided copy of a valid driver's license for Resident #2 and was able to demonstrate that the key to the car was locked and stored in the Administrator's office and made available to the resident upon request, review of the clinical record with the Administrator failed to reflect the facility had assessed Resident #2 to be safe to self drive and also failed to reflect a physician's order directing independent LOA privileges related to Resident #2 self driving, utilizing a friend's automobile. Subsequent to surveyor's inquiry, a physician order dated 8/5/21 at 1:44 PM was obtained directing that Resident #2 was approved for driving, however an assessment deeming Resident #2 to be safe for driving during independent LOA privileges was not forthcoming. 2. Resident #35's diagnoses included Type II Diabetes, chronic pain syndrome and Opioid dependence. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 was without cognitive impairment, required limited assist with personal care and experienced pain frequently. A Resident Care Plan dated 6/2/21 identified Resident #35 had the potential for pain due to neuropathy and past opiate abuse. Interventions included the administration of analgesics, observe for effectiveness, pain assessments, evaluations and refer to pain clinic as ordered. An Orthopedic Physician Assistant (PA) progress note from the facility's Orthopedic PA, dated 8/2/21 at 11:06 AM noted Resident #35 was being evaluated for an orthopedic assessment for a complaint of right shoulder pain. An examination revealed moderate cervical radiculopathy (symptoms from a pinched nerve) with pain radiating to the right shoulder. Recommendations were made for a Medrol (a medication to treat inflammatory conditions) dose pack to decrease nerve irritation, a trial a Gabapentin (a medication for nerve pain) to have been considered next after Medrol, should the pain have persisted and Physical/Occupational therapy to increase range of motion and strength in the cervical spine. Physician orders dated 8/2/21 through 8/4/21 failed to reflect orders for the Medrol dose pack as recommended by the Orthopedic PA. An interview on 8/4/21 at 11:15 AM with RN #5 identified she was a Nursing Supervisor/Unit Manager at the facility. After consulting with the DNS, RN #5 indicated recommendations from specialty services (the Orthopedic PA) were provided to admissions personnel and then later to the Unit Managers for follow up. RN #5 did not know the reason the Orthopedic PA's recommendation for the Medrol dose pack was not followed up on with the facility medical personnel. An interview on 8/4/21 at 11:15AM with the DNS identified orders from specialty services were not written directly by the consulting provider. The specialist provides a list of residents seen to admissions personnel and then the Nursing Supervisors follow up with facility medical personnel to ensure any recommendations were reviewed. An interview on 8/4/21 at 11:20 AM with Admissions Staff #1 identified she would be provided a list of residents seen by the specialists with recommendations. The list would then be provided to Nursing Supervisor/ Unit Manager. An interview on 8/4/21 at 12:15 PM with APRN #1 identified she was employed at the facility for approximately one month. During that time, she had never written an order based on the Orthopedic specialty recommendations as she had never been directed to do so. APRN #1 indicated if she knew it was her responsibility to review and respond to specialty recommendations that included writing orders, she would have written the order for the Medrol dose pack for Resident #35 as recommended by the Orthopedic PA. The facility policy for Utilization of Medical Consultants/Specialists dated 4/2013 directed consultants are not permitted to write orders except for the Ophthalmologist. Following a consultative service, the Attending Physician or Nurse Practitioner is to review the recommendations and document the response in the interdisciplinary progress notes and if in agreement with the consultant's recommendations, writes the order. Subsequent to surveyor inquiry, orders for the Medrol dose pack were written on 8/4/21. The facility failed to ensure recommendations for a specialty provider were responded to in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #21) reviewed for pressure ulcers, the facility failed to ensure the nutritional status was re-evaluated following the development of a facility acquired pressure ulcer. The findings include: Resident #21's diagnoses included rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was without cognitive impairment, required extensive assistance with bed mobility, total assistance with toileting and personal care and did not have any unhealed pressure ulcers. The Resident Care Plan dated 2/25/21 identified Resident #21 had the potential for impaired skin due to decreased mobility and incontinence, and a history of declining care/medication. Interventions included frequent toileting/incontinent care, encourage good nutrition with dietary review as needed and provide education on risk versus benefit of refusals. A Dietician note dated 3/15/21 noted Resident #21 was being seen for a significant weight change with refusal of recommendations and interventions for fortified foods/ supplements. The skin was also noted to be intact with no pressure ulcers. A goal was in place for healthy weight stability and oral intake intakes greater than 50% for all meals. A nurse's note dated 3/16/21 identified Resident #21 with noted erythema and boggy heels bilaterally. Resident #21 refused an air mattress. The responsible party was notified. A Wound Specialty note dated 3/18/21 noted Resident #21 had a new deep tissue injury to the left heel and new pressure ulcer to the right heel. New orders directed to apply skin prep and cover with ABD dressing to be changed daily and as needed. A Dietician note dated 5/3/21 (48 days after Resident #21 presented with a new deep tissue injury to the left heel and a new pressure ulcer to the right heel) noted Resident #21 was being seen because of being at high risk related to wounds. Unstageable wounds were noted on right and left heel with medical treatments in place. Resident #21 had declined all supplements, fortified foods, double portions, stating he/she was not going to eat things he/she does not like and does not want to enhance his/her nutrition in any way. A plan was in place to continue to promote food for comfort and respect resident rights. Preferences were reviewed and updated to include the continuation of fortified cereal daily, encourage intake of protein rich foods and begin a trial fortified mashed potatoes at supper 3 times weekly. An interview in 8/6/21 at 9:00 AM with Registered Dietician (RD) #1 identified a resident's nutritional status would be evaluated as soon as possible after notification of a new wound. RD #1 indicated that although Resident #21 had a history of refusing supplements and treatments, Resident #21 would have benefited from the implementation of the additional fortified supplementation of fortified mashed potatoes three times weekly at the time of discovery on 3/16/21 rather than on 5/3/21 as Resident #21's intake remained variable. An interview on 8/6/21 with the DNS identified it was her expectation that a resident's nutritional status be evaluated by the Dietician as soon as a new wound had developed. The policy for Wound Care dated 4/2017 directed the clinician, in conjunction with the patient and caregiver will develop an appropriate plan of care based on resident needs and assessment findings. Each patient will be evaluated and treated using an individualized care plan based on the patient's unique medical condition. The facility failed to ensure Resident #2's nutritional status was re-evaluated in a timely manner following the development of a facility acquired pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #39) reviewed for nutrition, the facility failed to ensure the Dietician evaluate a significant weight loss in a timely manner. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, adult failure to thrive, multiple pressure ulcers and an above the knee amputation. A physician's order dated 5/5/21 directed to weigh Resident #39 every week for 4 weeks and then monthly. The Resident Care Plan dated 5/7/2021 identified Resident #39 had a problem with swallowing and required tube feedings (TF) to meet 100 % of his/her needs with a goal for Resident #39 to maintain weight and nutritional balance through the next review date. Interventions included to follow prescribed diet, nothing by mouth and to monitor post hemodialysis weight trends weekly and labs as available. A physician's order dated 5/19/21 directed to administer Dolutegravir Sodium (an antiretroviral medication) tablet 50 mg, give 1 tablet via gastrostomy tube (G-tube) one time a day, hold tube feed (TF) 2 hours before and after administration. A physician's order dated 5/21/21 directed to on Tuesdays, Thursdays and Saturdays provide every 16 hours, turning TF off at 4:00 AM, administer Nephro 65 milliliters (mls) per hour times 16 hours or until 1040 mls infused and on Mondays, Wednesdays, and Sundays run Nephro 54 mls for 20 hours, turning on at 10:00 AM and off at 6:00 AM or until 1080 mls is infused. A Dietician note dated 5/21/21 at 11:44 AM identified that Resident #39 was admitted to the facility with a current dry weight at 132 pounds (lbs) with a goal for weight gain and wound healing. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #39 had severely impaired cognition and was totally dependent with 2 staff for bed mobility, eating and personal hygiene. A physician's order dated 6/1/21 directed to provide enteral feeding every 20 hours, turn off at 6:00 AM, administer Diabetisource at 80 mls per hour for 20 hours or until 1600 mls is infused. A Dietician progress note dated 6/1/21 at 4:55 PM identified that Resident #39's new tube feed regimen was to provide Diabetisource 80 ml per hour times 20 hours or until 1600 mls is infused. Resident #39's monthly hemodialysis dry weight documented in the medical record for 6/5/21 at 2:28 PM was 139.26 lbs. A physician's order dated 6/16/21 directed to provide hemodialysis every Tuesday, Thursday, and Saturday, a 5:30 AM appointment with ambulance transport at 4:45 AM. Resident #39's monthly hemodialysis dry weight documented in the medical record for 7/5/21 at 2:06 PM was 131.8 lbs, a significant weight loss of 5.35 percent in one month. A Dietician progress note dated 8/3/21 at 1:59 PM identified that Resident #39's weight on 6/5/21 Resident #39's weight was 139.26 lbs, on 6/14/21 Resident #39's weight was 136.8 lbs, and on 7/5/21 Resident 39's weight was 131.8 lbs which is a loss of 7.46 lbs or a 5.35% loss in 1 month, that was a significant weight loss and additionally noted that Resident #39's ideal body weight was 166 lbs. A physician's order dated 8/4/21 directed every 20 hours turn TF on at 10:00 AM, turn off at 6:00 AM. Administer Nepro (tube feed formula) at 55ml/ hour for 20 hours or until 1100 ml is infused. Interview and review of medical record with LPN #1 on 8/4/21 at 10:00 AM identified that based on the recorded weights for June 2021 and July 2021, Resident #39 had experienced a weight loss that would need to be reported. LPN #1 stated that in general, if a resident had a 5 lb change, staff would first reweigh the resident and if there continued to be a 5 lb change, the Dietician would be notified. The weights recorded for Resident #39 were dry weights that were completed when Resident #39 was at hemodialysis and that he/she would not be reweighed. She further identified that the Dietician also ran a weekly report that would be a second check. Interview and review of Resident #39's medical record with LPN #1 on 8/4/21 at 1:00 PM identified that Resident #39's tube feed orders directed the tube feed start at 10:00 AM and to be discontinued at 6:00 AM (run for 20 hours). LPN #1 stated that when Resident #39 returned from dialysis at 10:00 AM, the tube feed was not immediately restarted. She continued that she did not restart Resident #39's tube feed upon his/her return from dialysis at 10:00 AM as she would give Resident #39 the Dolutegravir Sodium tablet 50mg and that medication required the tube feed to be held 2 hours after it was administered. LPN #1 continued by stating that she usually restarted the tube feeding around 12:00 PM depending upon when the 2 hours had elapsed, and later than the physician directed start time of 10:00 AM. A review of Resident #39's medical record and interview with the Corporate Dietician on 8/4/21 at 1:30 PM identified that the medical record lacked documentation of a Dietician evaluation of the 7/5/21 significant weight loss stating that the facility Dietician had vacated the position around the end of June 2021 and that the new facility Dietician had just started in July. She continued by stating that it would be an expectation for a Dietician to evaluate Resident #39's weight loss documented on 7/5/21 as it would have been considered significant as it was 5% weight loss in 1 month. Interview with the Dialysis Technician at the Dialysis Center on 8/5/21 at 8:30 AM identified that Resident #39 generally arrived at the Dialysis Center timely for the 5:30 AM appointment. He further identified Resident #39 arrived without tube feeding being administered as the Dialysis Center does not handle tube feedings. A review of the medical record identified that based on the booked transport time for Resident #39 of 4:45 AM the tube feeding would be stopped prior to transport to dialysis, an hour, and 15 minutes earlier than the physician ordered end time of 6:00 AM. Interview with the Corporate Dietician on 8/5/21 at 9:30 AM identified that she was unaware that Resident #39's tube feed was stopped for transport to dialysis and not restarted at 10:00 AM due to a medication requirement resulting in Resident #39 not meeting the ordered amount of tube feed, 180 ml less than the ordered 1600 mls that was required to meet Resident #39's daily nutritional needs. She continued by stating had she been informed she would have worked with nursing to schedule the delivery of the tube feed so that the resident would receive the ordered volume. Subsequent to surveyor inquiry, a physician's order dated 8/5/21 directed every 18 hours turn TF on at 10:00 AM, turn off at 4:00 AM. Administer Nepro at 67 ml/ hour for 18 hours or until 1200 ml is infused. A review of the facility's Weight Measurement policy in part directed to re-weigh a resident if a 5 pound or greater weight loss occurred, and upon notification of 5 lb., the dietician will review resident weight and make recommendations accordingly. The facility failed to complete a Dietician evaluation when Resident #39 had a change in tube feeding on 6/1/21 and then experienced significant weight loss on 7/5/21. Additionally, the facility failed to identify that Resident #39's tube feeding was shut off earlier than physician directed and re-connected later on dialysis days, therefore receiving 180 cc less of tube feeding three times weekly.

Based on observations, staff interviews and review of facility policies for 1 of 2 medication storage rooms, the facility failed to ensure expired medications were discarded, failed to ensure the narcotic/medication and the nourishment freezer was defrosted, and for 1 of 4 medication carts, the facility failed to maintain the medication cart in a clean and sanitary manner. The findings include: a) Observation of the East unit medication storage room on 8/3/21 at 10:31 AM with Registered Nurse (RN) #1 identified the following expired medications: 1. An unopened bottle of Lactulose 10 gm/15mg suspension with a dispense date of 2/3/21 and an expiration date of 6/2021 for Resident #7. 2. An unopened bottle of Lactulose 10 gm/15mg suspension with a dispense date of 2/3/20 and an expiration date of 6/2021 for Resident #7. 3. An unopened bottle of Lactulose 10 gm/15mg suspension with a dispense dated 3/16/21 and expiration date of 7/2021 for Resident #9. 4. An unopened bottle of Glucerna w/carb steady 1.2 Cal with an expiration date of 5/1/2021. 5. An opened bottle of Lansoprazole 3 mg/ml suspension with 40 ml remaining from a 300 ml bottle with a dispensing date of 4/23/21 and an expiration date of 5/24/21 for Resident #41. Interview with RN #1 on 8/3/21 at 10:50 AM identified she was not aware of the expired medication in the East unit medication storage room. She indicated it was the responsibility of the nurses to check the medications and discard all expired medications. Subsequent to surveyor inquiry, RN #1 discarded the outdated medications and indicated all nurses would be in-serviced. b) Observation of the East Front unit medication cart on 8/3/21 at 10:55 AM with Licensed Practical Nurse (LPN) #1 identified a moderate amount of loose pills of assorted sizes and colors, blister pack back covers at the bottom of the first drawer and stains and spilled liquids at the bottom of the second drawer. Interview with LPN #1 on 8/3/21 at 10:58 AM identified she was not aware of the loose medication pills, blister pack back covers, stains and spilled liquids at the bottom of the medication drawers. LPN #1 indicated it was the responsibility of all the nurses to keep the medication cart clean at all times. Interview with RN #2 on 8/3/21 at 11:00 AM identified the Maintenance department cleaned the medication carts on 7/15/21 and as needed when nurses notify the Maintenance department. She also indicated it was the responsibility of all the nurses to keep the medication cart clean at all times. RN #2 indicated all nurses would be in-serviced. Observation of the [NAME] unit medication storage room on 8/3/21 at 11:08 AM with RN #1 identified the following: 1. The narcotic refrigerator/freezer was noted with a moderate accumulation of frost/ice. 2. The nourishment refrigerator/freezer was noted with a large amount of accumulation of frost/ice. Observation of a memo taped to the [NAME] unit narcotic refrigerator door identified the 11:00 PM to 7:00 AM nurse needs to unplug the refrigerator in the medication room on Wednesdays, so that Housekeeping can clean them on Thursday morning. Interview with RN #1 on 8/3/21 at 11:19 AM identified she was not aware that the [NAME] unit narcotic and nourishment refrigerator freezer had an accumulation of ice. She indicated it was the responsibility of the 11:00 PM to 7:00 AM nurse to unplug the refrigerator in the medication room on Wednesdays, and on Thursday mornings Housekeeping can clean the refrigerator/freezer and as needed in between routine cleanings. The facility Medication Use and Storage policy identified to provide guidelines for proper storage of medications within the facility. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Refrigerator should be defrosted regularly, if required (every 3 to 4 weeks). Note that refrigerated medications do not have to be removed during the defrosting process. Additionally, nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility failed to ensure expired medications were discarded, failed to ensure the narcotic/medication and the nourishment freezer was defrosted, and for 1 of 4 medication carts, the facility failed to maintain the medication cart in a clean and sanitary manner.