**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote the right to self-administer medication for 2 of 7 residents reviewed for choices, out of a total sample of 48 residents, (#87 and #161). Findings: 1. Review of the medical record revealed resident #87 was admitted to the facility on [DATE] with diagnoses including accidental poisoning by unspecified drugs, spinal stenosis, abnormality of gait and mobility, and weakness. The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date (ARD) of 2/01/24 revealed resident #87 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he had moderate cognitive impairment. The document revealed the resident had no behavioral symptoms and did not exhibit inattention, disorganized thinking, or altered level of consciousness in the look back period. The MDS assessment showed resident #87 received scheduled and as needed pain medication for occasional, moderate pain. Review of the medical record revealed a care plan for potential and/or actual pain was initiated on 7/25/23. The goals were the resident would not experience an overall decline in function or have an interruption in normal activities due to pain. The interventions included administer pain medication as ordered and monitor for effectiveness, consider premedication for treatments, and report changes in type and location of pain. On 4/02/24 at 10:07 AM, a bottle of Biofreeze was observed on resident #87's tray table. The container was approximately 1/3 full and the resident explained he purchased the medication and used it regularly. He said, I put it on my legs and CNAs [Certified Nursing Assistants] put it on my back. Biofreeze is a topical medication used to treat muscle or joint pain. The manufacturer's instructions read, Use exactly as directed on the label, or as prescribed by your doctor. (Retrieved on 4/08/24 from www.drugs.com/mtm/biofreeze.html). On 4/02/24 at 10:11 AM, the 400 unit Unit Manager (UM) explained residents were not permitted to keep any medication at the bedside unless there was a physician order for the drug and the resident was assessed for the ability to self-administer the medication safely. The UM was not aware resident #87 had a container of Biofreeze in his room. He reviewed the resident's electronic medical record (EMR) and stated there was no physician order for Biofreeze and no documentation of an assessment for safe self-administration of medication. On 4/02/24 at 10:14 AM, resident #87's assigned nurse, Licensed Practical Nurse (LPN) M validated the bottle of Biofreeze remained on the resident's tray table. The resident informed LPN M he had been using the medication and wanted to keep it in his room. 2. Review of the medical record revealed resident #161 was admitted to the facility on [DATE] with diagnoses including right hip fracture, neuropathy, and generalized muscle weakness. The MDS admission assessment with ARD of 3/18/24 revealed resident #161 had adequate hearing and vision. She had a BIMS score of 13 which indicated she was cognitively intact. On 4/02/24 at 9:21 AM, resident #161 had a box with a bottle of eye drops on her tray table. The pharmacy label on the box indicated the bottle contained Polymyxin B-Trimethoprim Ophthalmic Solution to be administered to the left eye, four times daily. The resident also had a small tube of antibiotic ointment on the tray table. The resident pointed across the room at a box of Refresh lubricant eye drops and explained she had been using the non-prescription eye drops but it had not been effective. She stated she called her eye doctor who prescribed new eye drops, and her husband retrieved the medication from the pharmacy. Resident #161 stated she managed her medications at home, and she had been doing her own eye drops, which she kept in her room, since admission to the facility. On 4/02/24 at 10:35 AM, LPN O checked resident #161's room and discovered Polymyxin B-Trimethoprim eye drops with a box of Refresh eye drops. She confirmed all medication used in the facility required a physician order. LPN O explained resident #161 was not supposed to have any medication at the bedside unless she was assessed to verify she was capable of safely administering her own medication. Polymyxin B and Trimethoprim ophthalmic solution is a medication used to treat bacterial eye infections (retrieved on 4/08/24 from www.drugs.com/mtm/polymyxin-b-and-trimethoprim-ophthalmic.html). On 4/02/24 at 10:52 AM, the 300 unit UM validated residents were not allowed to have medication in their rooms unless facility staff completed the appropriate self-administration assessment. She explained if staff determined the resident could safely administer her medication, a nurse would obtain physician orders for the medication and authorization to keep it at bedside. The 300 unit UM acknowledged the facility's policy and procedures were not implemented. Review of the Order Summary Report revealed as of 4/02/24 at approximately 11:00 AM, there was no physician order for resident #161's eye drops and no assessment to show the resident was capable of administering her medications safely. Review of the facility's policy and procedure for Self-Administration of Meds, revised on 3/27/21, read, .residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. The guidelines indicated staff would assess the resident's mental and physical abilities to determine if he/she was capable of self-administering medications. The policy revealed the assessment would include the resident's ability to read and understand labels, comprehension of the purpose and proper dosage and administration times, and the ability to recognize the risks and side effects of medications. The document indicated medications would be stored in a safe and secure place in the resident's room and nurses were responsible for documenting the doses administered by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor resident's rights to choose their preferred shower days and time for 1 of 9 residents reviewed for choices, of a total sample of 48 residents (#21). Findings: Review of the medical record revealed resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Her diagnosis included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, morbid (severe) obesity, abnormalities of gait and mobility, heart failure, and type 2 diabetes. Resident #21's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/15/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated she did not have cognitive impairment. The MDS assessment also indicated resident #21 required maximal assistance with bathing and participated in her assessment and goal setting. The MDS assessment dated [DATE] revealed it was very important to the resident to choose her bathing preferences. It also noted the resident did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Review of resident #21's medical record revealed a care plan was initiated on 1/18/22. The care plan indicated the resident expressed personal and lifestyle preferences with goals that included resident's preferences would be honored as able and interventions that included showers as her bathing preference on Monday, Wednesday, and Friday during the day shift. The bathing task report for resident #21 noted her scheduled shower days were Tuesday and Fridays on the 3-11 shift. In March and April 2024, the task report revealed she had a bed/towel bath on Tuesday, March 5th, at 10:50 PM. Additionally, she received showers on Friday, March 8th, at 6:06 PM and the following Tuesdays: March 12th, at 10:48 PM, March 19th, at 10:16 PM, and March 26th, at 8:38 PM. However, the task report indicated she refused bathing on the following Fridays: March 15th, at 8:16 PM, March 22nd, at 7:49 PM, and March 29th, at 9:59 PM, as well as on Tuesday April 2nd, at 9:55 PM. On 4/01/24 at 11:52 AM, resident #21 stated the Certified Nursing Assistants (CNA)s consistently offered her baths in the evening and on days she did not prefer. She conveyed she had made known to staff she preferred showers on Monday, Wednesday, and Fridays, however, staff insisted those were not her shower days and did not accommodate her preference. On 4/03/24 at 1:04 PM, CNA H confirmed resident #21 received showers on the 3-11 PM shift. On 4/03/24 at 11:33 AM, resident #21 stated she was again offered a shower the previous evening, Tuesday, April 2nd, but declined because she was feeling tired. On 4/03/24 at 11:45 AM, the Licensed Practical Nurse Unit Manager (UM) on the 200 unit accessed resident #21's care plan and confirmed the care plan, initiated on 1/18/22, indicated the resident preferred to receive showers on Mondays, Wednesdays, and Fridays during the day shift. Upon checking the resident's CNA task report, she commented the resident was scheduled to receive showers on Tuesday and Friday during the 3-11 shift, rather than the preferred day shift. The UM acknowledged resident #21's current shower schedule did not honor the resident's choices and stressed it was very important the resident received showers on the days and times she selected, as it was her right. On 4/03/24 at 12:40 PM, the Assistant Director of Nursing stated resident #21's care plan indicated a preference for showers on Monday, Wednesday, and Friday during the day. She verified the resident's scheduled shower days were Tuesday and Friday in the evening, which did not honor the resident's choices. She emphasized the importance of ensuring resident #21's right to receive showers on the days she preferred. The facility's Resident Right's policy read, The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility .The facility will make every effort to assist each resident in exercising his/her rights .observing resident's choices whenever able .The facility will provide for residence and reception of services with reasonable accommodation of resident needs and preferences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident's wishes for a Do Not Resuscitate Order (DNRO) were honored for 1 of 3 residents reviewed for hospice, of a total sample of 48 residents (#151) . Findings: Resident #151 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), acute kidney failure, idiopathic pulmonary fibrosis (lung scarring of unknown origin), acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia (difficulty swallowing). The admission Minimum Data Set assessment with Assessment Reference date [DATE], revealed the resident's cognitive status was intact with a Brief Interview of Mental Status score of 14/15. The assessment indicated she required partial to moderate assistance with her activities of daily living. Review of the resident's physician orders on [DATE] revealed an Advanced Directive order dated [DATE] for full code. This order conflicted with an order dated [DATE] which was signed by the resident and hospice physician for DNRO. The yellow DNRO order was noted in the Hospice notebook found on the counter of the 300-unit nurses' station. The current comprehensive care plan initiated on [DATE], showed resident #151 to be a full code with the goal: If the resident's heart stops, or if they stop breathing, Cardio Pulmonary Resuscitation (CPR) be initiated in honor with their full code wishes. On [DATE] at 1:10 PM, resident #151 was observed in her room, alert and oriented to person, place, and time. She sat in her wheelchair feeding herself lunch and said it was her choice to have Hospice services. Review of the medical record showed a Hospice Medicare Election form signed and dated by the resident on [DATE] and a certification of terminal illness for [DATE] to [DATE] with primary diagnosis of idiopathic pulmonary fibrosis. On [DATE] at 4:01 PM, Licensed Practical Nurse (LPN) A said she was the usual day nurse for resident #151 and was familiar with her care. LPN A stated should she find the resident without a pulse or not breathing she would first look on the dashboard on the computer. LPN A confirmed the dashboard for resident #151 currently had her code status as full code, so she would call the code and start CPR. LPN A added they also have a DNR Code Status Book on the code cart which she checked and did not find a DNRO for the resident #151. LPN A verified she would not look in the Hospice notebook at the nurses' station for a residents' code status. On [DATE] at 4:18 PM, a telephone interview was conducted with Hospice Team manager B who verified that it was Hospice physician D who signed the DNRO order for the resident #151 on [DATE]. Hospice Team Manager B explained the process when Hospice Registered Nurse (RN) I did the admission she would have placed the DNRO form in the Hospice notebook at the nurses' station. Hospice Team manager B reviewed RN I's notes and said the nurse only mentioned having a discussion with the patient regarding the DNR but did not document any communication with the facility staff regarding the change in code status. Hospice Team manager B said she would inform Hospice admission manager E about the concerns regarding lack of communication with the facility staff for change in code status. On [DATE] at 5 PM, the Director of Nursing acknowledged resident #151's Advanced Directive would not have been honored from [DATE] to [DATE] till brought to their attention by surveyor on [DATE]. On [DATE] at 10:19 AM, a telephone interview was conducted with Hospice admission manager E and Hospice Clinical Team Lead F. They were informed the facility staff was not aware of the change in code status for resident #151 which was obtained by Hospice RN I while doing the admission on [DATE]. The hospice management staff was also made aware that resident went 6 weeks with potential that the facility or emergency medical staff could have performed CPR on her if her breathing or heart stopped. admission manager E stated, she would follow up with Hospice Executive Director regarding concern the Hospice staff did not communicate code status with the facility staff regarding change in Advance Directive from Full code to DNR. Review of the facility Standards and Guidelines for Advance Directive revised [DATE] read, It will be the standard of this facility that the resident has the right to request, refuse, an/or discontinue treatment Advance Care Planning is a process of communication between individuals and their healthcare agent

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change in status assessment within the required timeframe of 14 days for 1 of 3 resident reviewed for Hospice services, of a total sample of 48 residents, (#151). Findings: Resident #151 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), acute kidney failure, idiopathic pulmonary fibrosis (lung scarring of unknown origin), acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia (difficulty swallowing). The admission Minimum Data Set assessment with assessment reference date (ARD) 1/23/24, revealed the resident's cognitive status was intact with a Brief Interview of Mental Status score of 14/15, and she required partial to moderate assistance with her activities of daily living. The assessment did not indicate resident #151 received Hospice services. Although the physician order in the electronic medical record for Hospice services was dated 3/10/24 resident #151 had signed the election for Medicare Election Statement on 2/15/24. The facility payer source showed Hospice Medicaid pending status as of 2/15/24. On 4/03/24 a telephone interview was conducted with the Hospice Case manager C who said her start of care date for Hospice services was on 2/15/24. Review of the medical record for resident #151 revealed certification of terminal illness for period dates: 2/15/24 to 5/15/24 with primary diagnosis of idiopathic pulmonary fibrosis. Review of the facility documentation in the electronic medical record showed the most recent MDS assessment with the ARD 1/23/24. No Significant Change in Status Assessment (SCSA) MDS was located in resident #151's medical record. On 4/03/24 at 4:32 PM, the Registered Nurse MDS Coordinator confirmed the SCSA had not been initiated by the facility and should have been done within 14 days when resident #151 went on Hospice 2/15/24. She stated the reason it was not done in a timely manner was due to a lack of communication between Social Services, MDS and nursing staff. She explained the usual process was at the morning or clinical meeting they would go over who went onto Hospice then they would update care plans, Advanced Directives as well as initiate the SCSA. The MDS Coordinator verified the SCSA was now out of compliance, and they were not aware till brought to their attention by surveyor. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment instrument Version 3.0 Manual, October 2023 Chapter 2 Page 2-25 read, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop comprehensive person-centered plan of care for end-of-life care for 1 of 3 residents reviewed for Hospice, of a total sample of 48 residents, (#151). Findings: Resident #151 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infarction (stroke), acute kidney failure, idiopathic pulmonary fibrosis (lung scarring of unknown origin), acute respiratory failure, repeated falls, weakness, anxiety, depression, and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS) assessment with Assessment Reference date 1/23/24, revealed the resident's cognitive status was intact with a Brief Interview of Mental Status score of 14/15, and she required partial to moderate assistance with her activities of daily living. Review of the medical record showed a Hospice Medicare Election form signed and dated by the resident on 2/15/24 and a certification of terminal illness for 2/15/24 to 5/15/24 with primary diagnosis of idiopathic pulmonary fibrosis. Further review revealed no care plan for Hospice or end-of-life care for resident #151 in her medical record. On 4/01/24 at 1:10 PM, resident #151 was observed in her room alert and oriented to person, place, and time. She sat in a wheelchair feeding herself lunch and indicated it was her choice to receive Hospice services. On 4/03/24, a telephone interview was conducted with Hospice case manager C who said resident #151's start of care date for Hospice services was 2/15/24. On 4/03/24 at 4:32 PM, the Registered Nurse MDS Coordinator acknowledged a comprehensive person center care plan was never initiated for resident #151 when she went onto Hospice service for end-of-life care on 2/15/24. She stated the reason it was not done was due to a lack of communication between Social Services, MDS and nursing staff. She explained the usual process was at the morning or clinical meeting they would go over who went onto hospice then update the care plans, advanced directives, as well as initiate the significant change in status assessment. Review of the facility policies and procedures for Comprehensive Assessments and Care Plans revised on 4/05/21 read, The facility will develop and implement a comprehensive person-centered care plan for each resident .prepared by the interdisciplinary team to formulate and advance directive and participate in advance care planning .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an effective discharge planning process to prevent a delay in provision of necessary care and services after discharge from the facility for 1 of 4 residents reviewed for discharge planning, out of a total sample of 48 residents, (#166). Findings: Review of the medical record revealed resident #166 was admitted to the facility on [DATE] with diagnoses including left hip fracture, abnormal gait and mobility, weakness, stroke with left side weakness and paralysis, and brain cancer. The face sheet indicated the resident was discharged home with family on 1/23/24, with no Home Health Care (HHC) services. The Minimum Data Set (MDS) Discharge - return not anticipated assessment, with assessment reference date of 1/23/24, revealed resident #166 required supervision or touching assistance for bathing and lower body dressing, and set up assistance for placing or removing footwear and completing personal hygiene tasks. Review of the medical record revealed resident #166 had a care plan for wish to be discharged to his prior living arrangement, initiated on 1/03/24. The interventions included establish a pre-discharge plan with the resident and family, evaluate progress, and revise the plan as needed. The document indicated Social Services staff and nurses would make arrangements with required community resources such as HHC and physician services to support the resident's independence post discharge, and prepare and give the resident, family member, caregiver contact numbers for all community referrals as indicated. A care plan for activities of daily living (ADL) self-care performance deficit initiated on 1/03/24, revealed resident #166 needed assistance with ADLs due to weakness and fatigue. A care plan for actual skin impairment, initiated on 1/17/24 revealed resident #166 developed a left buttock abscess in the facility. The interventions included administer and apply ointments as ordered by the physician and report any changes in skin status. Review of the medical record revealed resident #166 had a physician order dated 1/22/24 for discharge home with all medications and HHC for skilled nursing, physical therapy, and occupational therapy services. Another order dated 1/22/24 indicated the resident was to be discharged home with wound care orders to, cleanse the left buttock wound with [normal saline], pat dry, apply skin prep to the peri-wound, apply Mupirocin 2% [antibiotic] ointment to the wound bed, cover with a superabsorbent pad, cover with gauze, cover with a waterproof island border dressing. The physician order revealed wound care and dressing changes were to be done once daily and as needed. Review of an Interdisciplinary Discharge Home form dated 1/19/24 revealed resident #166 had a planned discharge scheduled for 1/23/24. The document included contact information for the HHC agency that was to provide the physician-ordered services in the resident's home. The facility's Rehabilitation Director noted the resident required a commode and a wheelchair. However, the facility's Social Services Director (SSD) at that time added a final discharge note that indicated resident #166 did not require arrangements for durable medical equipment as he had all necessary items. The Discharge Form revealed resident #166 left the facility with his son on 1/23/24 at approximately 10:00 AM. On 4/01/24 at 12:53 PM and 4/05/24 at 8:49 AM, in a telephone interview, resident #166's son explained he had concerns regarding his father's transition from the facility to home. He recalled he was told the HHC agency would order all necessary medical equipment, but that did not happen. The son stated his father was not independently ambulatory, and he required a significant amount of assistance to get into and around the house as he was not provided with a walker. The resident's son said, When I contacted the Home Health Care company, I was informed that my father was not in their network. I received a follow up call from the same company telling me the facility was having a hard time finding a home healthcare company that was in [insurance] network. The son explained he called the facility and spoke with the Business Office Manager (BOM) about his concerns. He explained the facility never arranged the HHC services for his father and he had to purchase a walker and do the dressing changes until he found a HHC agency, with the assistance of personnel at the initially referred HHC agency, that took his father's insurance. The resident's son said, I was taken aback that I had to arrange home health myself. On 4/02/24 at 4:15 PM, the BOM confirmed resident #166's son called the facility on the day his father was discharged home. She said, He was beyond ballistic that his father could not get [medical equipment] and [the Home Health Care agency] did not take his insurance. The BOM stated she immediately notified the previous SSD by telephone and he stated it was a misunderstanding with the insurance company as services should be covered. On 4/02/24 at 4:27 PM, the Administrator stated she became aware of issues surrounding resident #166's discharge when his son posted a negative online review in February 2024, approximately one month after the resident left the facility. She stated the previous SSD arranged home health services with [name of HHC agency] and the resident was discharged on 1/23/24. The Administrator provided email communication dated 1/22/24, the day before discharge, from the HHC agency to the facility with notification that they checked the resident's insurance and discovered they were not in his network. The Administrator stated the previous SSD communicated with the staff at the HHC agency who informed him they would forward the referral to another HHC agency. Review of an email from the second HHC agency revealed resident #166's start of care date for skilled nursing and therapy services was 1/26/24, three days after discharge from the facility. The Administrator confirmed she did not know the staff at the first HHC agency, but she relied on their promise regarding making arrangements with the second HHC agency. She acknowledged the facility's Social Services department, not an outside provider, was ultimately responsible for planning and ensuring a safe discharge. On 4/02/24 at 5:44 PM, the facility's Senior SSD validated if discharge referrals fell through while resident #166 was still in the facility, it was possible to extend the resident's stay if another referral could not be made in a timely manner. She acknowledged there was no documentation by the previous SSD of any issues related to the discharge or confirmation of another HHC referral. The Senior SSD validated it was not acceptable that the resident was discharged home without the care and services ordered by the physician. She explained Social Services staff were expected to oversee discharge arrangements and provide necessary follow-up. On 4/03/24 at 4:15 PM, the Rehabilitation Director confirmed resident #166 required a walker for mobility and prior to discharge, Social Services staff were to order medical equipment and arrange for delivery to ensure the resident's safety at home. On 4/05/24 at 8:29 AM, the Wound Nurse recalled when she last assessed resident #166's buttock wound it had drainage. She said, Treatments should be done as ordered. If ordered daily it should be done to allow for assessment and healing. The Wound Nurse explained the topical antibiotic was necessary for healing, and if the dressing was not changed, there was increased risk of infection and maceration of the skin caused by moisture from the drainage. The facility's policy and procedure for Discharge Planning Process, revised 3/21/21, read, The facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals.and effectively transition them to post-discharge care. The document indicated the discharge planning process began with identification of each resident's goals and needs and continued with development, implementation, and evaluation of interventions throughout the resident's stay to ensure a successful discharge. The policy revealed the facility would identify post-discharge needs to include nursing and therapy services, and medical equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate assistance with activities of daily living (ADLs) related to bathing, skin care, and shaving for 2 of 3 residents reviewed for ADLs, out of a total sample of 48 residents, (#134 and #87). Findings: 1. Review of the medical record revealed resident #134 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, recurrent depressive disorder, and weakness. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 3/07/24 revealed resident #134 had clear speech and a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact. The document showed during the look back period, resident #134 had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed the resident depended on staff for assistance with self-care as his performance was either unsafe or of poor quality. He required partial to moderate assistance for personal hygiene and bathing, and substantial to maximal assistance for lower body dressing and putting on and taking off footwear. Review of the medical record revealed a care plan for personal and lifestyle preferences was initiated on 6/08/23. The interventions included the resident's preference for three bed baths or showers every week during the day shift. A care plan for ADL self-care performance deficit related to limited mobility, initiated on 6/03/23, had a goal the resident would be free of complications related to ADL deficit. The interventions included assistance of one to two staff for ADL care and praise all efforts at self-care. On 4/01/24 at 11:25 AM, resident #134 showed his hands and all fingernails were square-shaped with sharp edges and approximately one third inch long. The resident's hair was long and greasy and his facial hair was unkempt. The resident explained nursing staff did not cut his fingernails or shave him regularly. He stated he felt those tasks took more time than the staff wanted to spend. Resident #134 stated he received occasional bed baths, got showers approximately once monthly, and nursing staff, Pass the water through my hair once a week or so. The resident complained his hair was too long and he needed someone to check his toenails. On 4/01/24 at 11:32 AM, the 400 unit Unit Manager (UM) stated resident #134 was scheduled for baths twice weekly, on Wednesdays and Saturdays. He explained nail care was to be done on these days and additionally as needed. He validated the resident's fingernails were over 1/3 inch long and described them as, way longer than normal. The UM confirmed the resident's fingernails should definitely have been cut by staff, and nurses who completed his weekly skin checks should have noticed the issue. Resident #134 informed the UM he wanted to be shaved daily and the UM acknowledged the resident did not have a well-groomed appearance. The UM removed the resident's socks and a large amount of dried skin flakes fell from each sock, visibly landing on the mattress and forming a small pile. On 4/01/24 at 11:45 AM, the 400 unit UM provided a shower sheet dated Wednesday 3/27/24 which indicated resident #134 refused a shower but the Certified Nursing Assistant (CNA) gave a bed bath instead. The UM stated he was not able to find a shower sheet for Saturday 3/30/24. He confirmed CNAs were expected to wash the resident's entire body during a bed bath, which required removing his socks to wash his feet. The UM validated the appearance of resident #134's feet and the quantity of dried skin in his socks indicated he probably did not receive a full bed bath or shower as scheduled. Review of the 400 unit Shower Schedule revealed resident #134 was to have showers on Wednesdays and Saturdays during the 3:00 PM to 11:00 PM shift and as needed on Sundays. The document read, Please notify the nurses of any shower refusals and skin impairments. Review of nursing progress notes dated 3/01/24 to 4/05/24 revealed no documentation of refusal of ADL care by resident #134. 2. Review of the medical record revealed resident #87 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, type 2 diabetes, spinal stenosis, and abnormality of gait and mobility. The MDS Significant Change in Status assessment with ARD of 2/01/24 revealed resident #87 had a BIMS score of 12 which indicated moderate cognitive impairment. The document showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed the resident required substantial to maximal assistance for bathing and partial to moderate assist for personal hygiene tasks. A care plan for ADL self-care performance deficit related to limited mobility and weakness, dated 7/25/23, revealed goals to keep the resident clean and comfortable and maintain his current level of ADL function. The interventions instructed staff to assist resident #87 with ADLs. On 4/01/24 at 11:54 AM, resident #87 had a scruffy appearance. His moustache was thick and untrimmed, and he had a significant amount of unkempt, long facial hair on his cheeks and chin. The resident explained he preferred a moustache only and staff either assisted with shaving him or he attempted to shave himself if provided with razors. He said, I've been asking all my CNAs for razors for the past three days. Nobody brings them. The resident stated no staff had offered to shave him for a while. On 4/01/24 at 12:02 PM, the 400 unit UM confirmed resident #87's facial hair was untidy and stated he definitely needed to be shaved. Review of the 400 unit Shower Schedule revealed resident #87 was to have showers on Wednesdays and Saturdays during the 7:00 AM to 3:00 PM shift and as needed on Sundays. The document read, Please notify the nurses of any shower refusals and skin impairments. Review of nursing progress notes dated 3/01/24 to 4/05/24 revealed no documentation of refusal of ADL care by resident #87. Review of the CNA job description (undated) revealed CNAs would perform necessary care and services for residents. Essential job functions and duties included, Assist residents with activities of daily living including bathing, grooming. The document revealed CNAs would ensure residents' comfort while assisting them to achieve their highest functional level. The expectation for implementation of nursing care was CNAs would provide hygiene care, nail care, bathing and grooming according to residents' plans of care. Review of the facility's policy and procedure for ADL Care and Assistance revised on 3/27/21, revealed the facility would provide residents with assistance for bathing and maintenance of personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a right-hand resting splint was applied per physician order and the resident's plan of care, for 1 of 1 resident reviewed for range of motion/mobility, of a total sample of 48 residents, (#66). Findings: Resident #66, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side, aphasia, major depressive disorder, conversion disorder with seizures or convulsions, and weakness. Review of the quarterly Minimum Data Set assessment with Assessment Reference date of 1/22/24, revealed resident #66 was rarely/never understood, and was assessed with functional limitation in range of motion (ROM) to one side of his upper and lower extremities. The resident's physician's order dated 10/23/23 directed staff to apply splint to his right wrist following morning care, and doff the splint prior to bedtime. Instructions were, Monitor skin integrity when applying and removing, discontinue wear if skin becomes red or pt (patient) is in pain. Review of the Physical Therapy/Occupational Therapy (PT/OT) annual screen conducted on 3/05/24 revealed the, Therapist completed OT screen today (3/05/24) and found pt (patient) has decrease in RUE (right upper extremity) ROM. Recommendation: OT indicated. Review of the Occupational Therapy discharge summary for dates of service 3/05/24 through 3/25/24 revealed upper extremity resting hand splint training was provided for staff. The training sign-in sheet dated 10/16/23, indicated staff were trained how, To don/doff resting hand splint and the wear schedule was Don in AM, doff in PM Observations on 4/01/24 at 11:50 AM, 4/02/24 at 10:00 AM, and on 4/02/24 at 3:42 PM, showed resident #66 sat up in bed watching television. The resident had right hand weakness and did not have a splint on. The splint was noted on the resident's chest of drawers. Resident #66 said the splint was not applied by therapy, and when asked who applied the splint, the resident's response was, No one. On 4/03/24 at 11:28 AM, and at 11:35 AM, Licensed Practical Nurse (LPN) J stated resident # 66 was awake, alert, oriented, had right arm paresis/hemiplegia, wore a splint on his right hand, and was currently on therapy caseload. The LPN stated the resident's right hand splint was applied by the Certified Nursing Assistant (CNA) or therapy, and nurses signed off on the Treatment Administration Record (TAR) to indicate the splint was applied. The surveyor shared with LPN J there were no observations of resident #66 wearing his splint for the days of survey to date, and the splint was seen on the resident's bed side table. Observation of the resident conducted with the LPN, showed no splint to the resident's right hand, and the splint was again noted on the resident's bedside table. This was acknowledged by the LPN, who also acknowledged the physician order to don the right hand splint following morning care, and to doff prior to bedtime. LPN J stated the administration details on the resident's TAR revealed documentation and signatures by nurses which indicated the splint was applied, and there were no problems. On 4/03/24 at 11:39 AM, CNA L stated he worked on the 7 AM to 3 PM shift and provided care for resident #66. He stated the resident required total assistance with activities of daily living, and he was aware of the resident's splint. CNA L said he had not signed off on the task for donning the resident's splint and confirmed PT had not been applying the splint. He said the resident's splint had not been applied for a couple of days, since the resident was no longer on therapy caseload, and he could not apply the splint since he was not trained to don/doff the splint. On 4/03/24 at 3:34 PM, the Rehabilitation Director stated once splint/orthotics had been trialed on residents, and deemed to be safe, the CNAs were trained to perform the task by therapy. The Rehabilitation Director stated when the resident was discharged from therapy, nursing staff were then responsible to apply the splint/orthotic. She stated resident #66 was discharged from OT on 3/25/24, and nursing was responsible for the splint application. On 4/03/24 at 4:00 PM, the Director of Nursing stated the expectation was for nurses to follow physician orders in the electronic medical record, and sign off on the TAR to indicate the resident's splint was applied, and skin integrity monitored. On 4/04/24 at 9:47 AM, the Assistant DON (ADON) reviewed physician orders for the resident, and stated the order pertaining to the splint was inclusive of donning the splint and monitoring skin integrity. The ADON stated she was not sure if nurses were checking off on the TAR regarding donning the splint or for monitoring the resident's skin integrity. She stated they should be checking for skin integrity prior to applying the resident's splint. On 4/04/24 at 10:00 AM, LPN K stated if the resident was on therapy caseload, they would apply the splint, otherwise the splint would be placed by nursing staff on the unit. She stated she signed off on the resident's TAR to indicate she monitored the resident's skin for redness, irritation, and pain. LPN K verbalized that on 4/01/24, she did not apply the resident's splint, but signed off on the TAR for monitoring the resident's skin integrity. The facility did not provide a policy pertaining to splint application.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care and services for an intravenous (IV) access site according to professional standards of practice to prevent infection for 1 of 1 resident reviewed for IVs, of a total sample of 48 residents, (#18). Findings: Review of the medical record revealed resident #18 was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included ischemic cardiomyopathy, moderate protein-calorie malnutrition, type 2 diabetes, and dementia. Review of the Minimum Data Set (MDS) Medicare Part A Discharge assessment with assessment reference date of 3/12/24 revealed resident #18 received antibiotic medication during the seven day look back period. Review of the medical record revealed an Infectious Disease Consultant Provider Note dated 3/26/24. The specialist physician assessed resident #18 and noted a non-healing right heel wound with osteomyelitis or a bone infection. The note read, Plan: Will start Ertapenem as the wound had a foul smell and had profuse drainage. Ertapenem is an antibiotic that is used to treat severe infections. It is administered by injection into a muscle or infused through a vein (retrieved on 4/18/24 from www.drugs.com/mtm/ertapenem.html). Review of the Order Summary Report revealed resident #18 had a physician order dated 3/27/24 for Ertapenem 1 gram IV once daily for 14 days, to treat his wound infection. There was an order dated 3/28/24 for insertion of a midline IV and orders dated 3/29/24 to change the transparent dressing every seven days and as needed. The physician orders instructed nurses to measure the external catheter length during dressing changes and observe for leakage, loosening or soiling of the dressing, and for signs and symptoms of infection, infiltration, and extravasation, or leaking from the IV into surrounding tissue. A midline catheter is a small tube that is inserted into a vein in the arm. The catheter is used to administer medications and take blood samples and can remain in place for up to 30 days. After insertion, the catheter is secured with a sterile, transparent dressing which prevents infection and permits easy monitoring of the insertion site for signs of infection. The dressing should be changed as directed or whenever it is loose, wet, or soiled, (retrieved on 4/18/24 from www.drugs.com/cg/midline-catheter.html). Resident #18 had a care plan for IV therapy related to a wound infection initiated on 3/29/24. The goal was the resident would not suffer any complications related to IV therapy. The interventions instructed nurses to change the IV dressing and maintain the IV device per the facility standard, and monitor the catheter insertion site every shift for signs of infiltration and infection. On 4/01/24 at 12:28 PM, resident #18 had a left upper arm IV access line with a transparent dressing dated 3/30/24 covering the insertion site. Beneath the clear dressing, there was a bloody, folded gauze pad at the insertion site. On 4/01/24 at 12:34 PM, Licensed Practical Nurse (LPN) M confirmed resident #18 had a bloody gauze under his left arm dressing. She recalled she was informed the area bled a lot when the IV was inserted. LPN M confirmed she was assigned to care for resident #18 during the 7:00 AM to 7:00 PM shift but she had not yet assessed the resident's IV access site. When asked if the dressing needed to be changed, LPN M stated she was unsure as it was scheduled once weekly. On 4/03/24 at 1:53 PM and 2:11 PM, LPN N stated she was aware resident #18 had a midline to the left upper arm. She confirmed she had not inspected the dressing since the start of the 7:00 AM shift as she would check the site close to the end of her shift when she administered his IV medication at 6:00 PM. LPN N was asked to check the resident's dressing. She confirmed there were no initials on the dressing to indicate which nurse performed IV site care and said, It's just dated, 3/30/24 on dressing. Joint observation of the transparent dressing revealed the gauze was now totally saturated with blood and yellow-colored fluid. Review of the Medication Administration Record for March 2024 revealed LPN N initialed the document to confirm she changed resident #18's IV dressing on 3/30/24. On 4/03/24 at 2:02 PM and 2:16 PM, the 400 unit Unit Manager (UM) reviewed resident #18's medical record and noted the midline was inserted on 3/28/24 but the resident pulled it out and another midline was inserted on 3/29/24. He explained the gauze must have been placed during a dressing change done over the weekend. The UM reviewed nursing progress notes and acknowledged there was no documentation of issues with bleeding at the site or the need to use gauze, and no instructions to change the dressing more frequently due to bleeding. On 4/03/24 at 2:25 PM, the Regional Director of Clinical operations assessed resident#18's left upper arm IV site and validated the bloody gauze remained under the transparent dressing for four days, since 3/30/24. She was informed when the issue was brought to LPN M's attention on 4/01/24, the nurse stated the dressing was to be changed every seven days. The Regional Director of Clinical operations confirmed the current dressing posed an infection control concern and stated her expectation was nurses would monitor IV sites appropriately and address concerns in a timely manner. On 4/03/24 at 2:32 PM, the facility's Medical Director validated the bloody gauze pad left underneath resident #18's transparent dressing placed him at risk for infection as it was a medium for bacterial growth. On 4/05/24 at 11:22 AM, the Assistant Director of Nursing (ADON) stated she discovered the gauze was placed under the resident's transparent dressing by LPN N as the site was still bleeding the day after the midline was inserted. The ADON explained if it was necessary to use gauze, the dressing should be changed every 48 hours to prevent negative outcomes. Review of the Pharmascript Infusion IV Access Line Maintenance Protocol, effective 2/07/20, revealed midline transparent dressings should be changed 24 hours after insertion and then weekly as needed. The document read, Gauze should only be used if patients are sensitive to clear, transparent dressings and must be changed[every] 2 days. The facility's policy and procedure for Site Care of Peripheral Venous Catheter, revised in February 2019, provided general guidance on routine IV insertion site inspection, site care, and application of a sterile dressing to reduce or prevent the complications of catheter related infection. The document indicated a sterile, transparent dressing would be used to cover IV sites and the dressing would be labeled with the date, the nurse's initials, and the insertion date from the previous dressing. The policy revealed nurses would document the dressing change procedure, characteristics of the site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a copy of the notice for transfer/discharge to the hospital was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents reviewed for hospitalization, of a total sample of 48 residents, (#136). Findings: Resident #136 was admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospitalization. Her diagnoses included metabolic encephalopathy, hemiplegia/hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, acute and chronic respiratory failure, dysphagia following cerebral infarction, tracheostomy status, gastrostomy status, diabetes type II, major depressive disorder, and hypertension. Review of the resident census revealed resident #136 was hospitalized on [DATE], and readmitted to the facility on [DATE]. The eInteract Change in Condition Evaluation form dated 2/29/24 indicated the resident was sent to the Emergency Department for further evaluation and treatment. Review of the resident's clinical records revealed the Nursing Home Transfer and Discharge Notice for the resident could not be found. On 4/04/24 at 3:26 PM, the Social Services Director (SSD) stated that Social Services was responsible to submit a copy of the Nursing Home Transfer and Discharge Notice to the office of the Ombudsman. She stated the notifications were submitted monthly. Review of the resident's medical record, and a binder located in the SSD's office did not reveal a copy of the Nursing Home Transfer and Discharge Notice, or any evidence to indicate a copy of the notice was submitted to the Ombudsman. This was acknowledged by the SSD, who explained she was hired three weeks ago and was told all documents would be scanned into the facility's electronic medical record. On 4/04/24 at approximately 5:00 PM, and at 5:17 PM, the SSD provided a Nursing Home Transfer and Discharge Notice for the resident dated 2/29/24. However, no documentation/evidence could be identified to indicate the notice was submitted to the Ombudsman's office. The SSD then provided a fax transmission log dated 4/01/24 for discharges for March 2024 that were submitted to the office of the Ombudsman. She stated she could not locate a transmission log to indicate discharges/transfer for February 2024 were submitted to the Ombudsman's office as required. Review of the facility's discharges revealed that fifteen (15) residents were discharged to the hospital for the period 2/01/24 to 2/29/24. The facility could not provide documentation to indicate the Ombudsman office was provided with a list/copy of the discharges for February 2024. Request to the facility for a corresponding policy/procedure regarding notification of discharges was not met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records were accurate pertaining to splint application for 1 of 1 resident reviewed for Range of Motion (ROM)/Mobility, (#66), and failed to ensure medical records were accurate, and systematically organized for 1 resident (#136), of a total sample of 48 residents. Findings: 1. Resident #66, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side, aphasia (inability to speak), major depressive disorder, conversion disorder with seizures or convulsions, and weakness. The resident's physician's order dated 10/23/23 directed staff to apply a splint to his right wrist following morning care, and to doff the splint prior to bedtime. Instructions were, Monitor skin integrity when applying and removing, discontinue wear if skin becomes red or pt (patient) is in pain. Review of the resident's Treatment Administration Record (TAR) for the period 3/01/24 through 4/03/24 revealed that nurses signed off on the task. However, there was ambiguity pertaining to what was being signed off, the donning of the splint, or the monitoring of the resident's skin integrity. Observations on 4/01/24 at 11:50 AM, 4/02/24 at 10:00 AM, and on 4/02/24 at 3:42 PM, showed resident #66 sitting up in bed watching television. The resident had right hand weakness and did not have a splint on. The splint was noted on the resident's chest of drawers. Resident #66 said the splint was not placed by Therapy, and when asked who placed the splint on, the resident's response was no one. On 4/03/24 at 11:28 AM, and at 11:35 AM, Licensed Practical Nurse (LPN) J stated the resident's right hand splint was placed by the Certified Nursing Assistant (CNA) or Therapy, and nurses signed off on the TAR to indicate that the splint was applied. Observation of the resident conducted with the LPN, showed no splint to the resident's right hand, and the splint was again noted on the resident's bedside table. This was acknowledged by the LPN, who also acknowledged the physician order to don the right hand splint following morning care, and to doff prior to bedtime. LPN J stated the administration details on the resident's TAR revealed documentation and signatures by nurses which indicated the splint was applied, and there were no problems. LPN J's signature was noted on the resident's TAR fourteen (14) times for the period reviewed. On 4/03/24 at 11:39 AM, CNA L stated he worked on the 7 AM to 3 PM shift and provided care for resident #66. He stated the resident required total assistance with activities of daily living, and he was aware of the resident's splint. CNA L said he had not signed off on the task for donning the resident's splint and confirmed PT had not been applying the splint. He said the resident's splint had not been applied for a couple of days, since the resident was no longer on therapy caseload, and he could not apply the splint since he was not trained to don/doff the splint. On 4/04/24 at 9:47 AM, the Assistant DON (ADON) reviewed physician orders for resident #66, and stated the order pertaining to the splint was inclusive of donning the splint and monitoring skin integrity. The ADON stated she was not sure if nurses were checking off regarding donning the splint or for monitoring of the resident's skin integrity. She stated they should be checking for skin integrity prior to applying the resident's splint. On 4/04/24 at 10:00 AM, LPN K stated she signed off on the resident's TAR to indicate she monitored the resident's skin for redness, irritation, and pain. LPN K verbalized that on 4/01/24, she did not apply the resident's splint, but signed off on the TAR for monitoring the resident's skin integrity. LPN K's signature was noted on the resident's TAR three (3) times for the period reviewed. 2. Resident #136 was admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospitalization. Her diagnoses included metabolic encephalopathy, hemiplegia/hemiparesis following cerebral infarction (stroke) affecting the left non dominant side, acute and chronic respiratory failure, dysphagia following cerebral infarction, tracheostomy status, gastrostomy status, diabetes type II, major depressive disorder, and hypertension. Review of the resident's Electronic Medical Record (EMR) revealed the Provider progress notes dated 5/20/23, 6/11/23, 6/14/23, 6/23/23, 7/07/23, 8/12/23, 9/03/23, 9/22/23, 9/24/23, 10/08/23, 11/12/23,12/11/23, 12/24/23,1/05/24, 1/09/24, 1/25/24, 1/27/24, 1/31/24, 2/05/24, and 2/21/24 for another resident were uploaded to resident #136's EMR. A total of twenty (20) progress notes in resident #136's medical record did not belong to resident #136. On 4/04/24 at 2:47 PM, the Regional Director of Clinical Services reviewed the resident's EMR, and acknowledged scanned documents were for another resident. She stated the facility's Health Information Coordinator was currently on leave, and findings would be reported to the Executive Director, who would contact the facility's legal department for correction of the affected residents' EMR. On 4/04/24 at 3:06 PM, resident #136's EMR was reviewed with the Executive Director. She acknowledged the Provider progress notes uploaded to the resident's EMR for the dates listed belonged to another resident. The Executive Director stated it, Looked like an oversight, and verbalized she had contacted the facility's Corporate office and informed them of the discrepancy. When asked who reviewed EMR to ensure accuracy, the Executive Director stated she did not know who reviewed the residents' EMRs to ensure documents uploaded belonged to the correct resident. The Standards and Guidelines: Disposition of Medical Records after Scanning/Imaging issued 2/19/2016, and revised 3/27/21 read, Documents should be scanned and uploaded individually .Ensure that the document was uploaded to the correct patient's EHR (Electronic Health Record).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct a thorough investigation after a fall with major injury for 1 of 3 residents reviewed for accidents of a total sample of 47 residents, (#106). Findings: Resident #106 was admitted to the facility on [DATE] and most recently readmitted from an acute care hospital on 3/25/22 with diagnoses that included advanced dementia, depression, polyarthritis and displaced right hip fracture with corrective surgery. Review of the Minimum Data Set (MDS) discharge-return anticipated assessment with reference date 3/07/22, revealed resident #106 had memory problems and severely impaired cognitive skills for daily decision making. The assessment noted the resident had intermittent disorganized thinking, required extensive assistance with bed mobility and transfers and had one fall with major injury since admission or last assessment. Review of a care plan for at risk for falls related to impaired cognition, impaired safety awareness, impaired balance or walking was initiated 1/13/22. The goal noted to prevent a serious fall related injury. Review of a nursing progress note dated 3/06/22 at 5:57 PM, revealed Licensed Practical Nurse (LPN) C was informed a resident was observed on the ground in the resident's lounge area. The note indicated another resident witnessed the fall and stated resident #106 had slid out of the wheelchair. The note also showed the nurse asked the witness, who was said to be alert, if the resident had hit her head. The nurse noted resident #106 was unable to say how she slid out of the wheelchair and denied pain. LPN C documented she notified the attending physician and family of the fall. Review of a progress note dated 3/07/22 at 7:00 AM, revealed LPN A received report from the previous nurse that resident #106 had fallen at approximately 6:00 PM the previous evening with no apparent injuries. She noted when she arrived that morning, she could hear the resident moaning in pain as she entered her room. LPN A indicated Certified Nursing Assistant (CNA) B was with her in the room and she noticed the resident's right hip was, Swollen, warm and bruised. LPN A documented she called the attending physician and received an order for an Xray of the right hip. A progress noted dated 3/07/22 at 12:50 PM, revealed LPN A received the X-ray results which showed a right hip fracture, informed the attending physician and family and sent the resident to the hospital emergency room as ordered by the physician. Review of the hospital progress note dated 3/08/22 revealed the resident sustained an acute right hip fracture in which several bones were broken and moved out of their normal positions along with soft tissue swelling. Review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form from the hospital dated 3/8/22, revealed resident #106 had right hip surgery and required fall precautions. The form indicated the resident was not ambulatory and had fair rehabilitation potential. In an interview on 4/27/22 at 11:49 AM, the Regional Director of Clinical Operations and the Regional Director of Operations stated resident #106 had four falls since her admission on [DATE]. They explained she had two falls on 1/14/22, one on 3/06/22 which resulted in her transfer to the hospital with right hip fracture and again on 3/26/22 after she returned from the hospital. The Regional Director of Operations stated she was Administrator and Risk Manager (RM) of the facility in February and March of 2022. She explained she was notified on 3/07/22 of the resident's fall and subsequent transfer to the hospital but stated the previous Director of Nursing (DON) was responsible for completing the investigation. At 2:55 PM, the Regional Director of Operations reported she was unable to provide the investigation of resident #106's fall on 3/06/22. She noted investigations were kept on paper, but they could not find it. She explained they could not provide statements from the staff involved nor from the witness. She recalled the former DON spoke to the CNA who found the resident on the morning of 3/07/22, but she never saw an actual statement by the CNA, nor could she recall who it was. She reported all involved parties should have been interviewed in detail to form meaningful interventions for future fall prevention. On 4/28/22 at 10:00 AM, in a telephone interview, CNA B recalled she had worked on the 300 unit the morning resident #106's hip injury was discovered. She explained she had received report from the previous CNA about resident #106's fall the prior evening. CNA B stated when she did her morning rounds, she heard resident #106 complaining of pain, so she uncovered her and saw part of her hip was red and swollen. She remembered she informed LPN A who came to the room and assessed the resident. CNA B explained the previous DON did not interview her or get her statement about the morning she found resident #106's injuries nor was she asked by anyone at the facility for a statement until yesterday when the Regional Director of Operations called her. On 4/28/22 at 12:01 PM, in a telephone interview, LPN A stated she worked as an agency nurse on 3/07/22. She recalled CNA B informed her resident #106's hip was swollen, and she was in pain. She had asked the night nurse why the resident was crying and was told she had fallen the evening before. She explained when she examined the resident, her right hip looked swollen, so she called the doctor and a stat X-ray was ordered. She said when she received the X-ray results, she called the doctor and was told to send the resident to the hospital emergency room. LPN A indicated no one from the facility asked her for a statement or interviewed her about what happened. She stated the only documentation of the incident she provided was the change in condition and progress notes she wrote that day. LPN A stated she had worked at the facility since the incident, but no one had spoken to her about the resident's fracture until she received a call from the facility yesterday. On 4/28/22 at 5:38 PM, the Regional Director of Operations and the DON stated if a fall with major injury occurred, the DON would investigate. They explained the nurse would notify the DON immediately and the DON would investigate what happened by interviewing the staff. They stated the nurse, the CNAs, witnesses and anyone else involved in the resident's care should be interviewed within 24-48 hours. They explained the interviews and witness statements were an important part of the investigation and should be collected as soon as possible so that memories would be more accurate. They indicated the statements and interviews were used in the investigation to help determine the root cause of the incident and put meaningful interventions in place for future prevention. Review of the undated document, Job Description for the Director of Nursing revealed the essential job function to, Comply with, support and enforce policies involving Risk Management. Review of the Standards and Guidelines: SG Abuse, Neglect, Exploitation and Investigations with revision date of 3/27/21 revealed a guideline for staff to conduct internal investigations of adverse incidents which include but not limited to staff interviews, resident and family interviews, medical record reviews, 24-hour report reviews, and full body skin exams. The document directed staff to notify the resident's representative and the physician of an on-going investigation regarding the alleged incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected health conditions regarding weight loss for 1 of 3 sampled residents reviewed for nutrition (#88) and failed to accurately assess antipsychotic drug use on a routine basis for 1 of 5 residents reviewed for unnecessary medications, (#51) of a total sample of 47 residents. Findings: 1. Resident #88 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy Bodies, Parkinson's disease, congestive heart failure and anemia. On 12/9/2021, the resident weighed 145 pounds (lbs.). On 03/3/2022, the resident weighed 130 lbs. which was a 10.34% weight loss. Review of the Quarterly MDS assessment dated [DATE], revealed Section K: Swallowing/Nutritional Status question K 0300 titled Weight Loss was coded with the number 0. This code inaccurately indicated resident #88 had no or unknown weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The number 2 should have been selected since the resident did have weight loss and was not on physician prescribed weight-loss program. On 4/28/22 at 2:08 PM, Licensed Practical (LPN) MDS Coordinator verified that weight loss was assessed inaccurately for resident # 88 on her assessment dated [DATE]. The LPN MDS Coordinator said she and the Registered Nurse (RN) MDS Coordinators needed to check the dietary section of the MDS for weight accuracy and educate dietary staff as well. The RN MDS Coordinator explained the kitchen manager had assessed resident #88 for no weight loss which was inaccurate as the resident lost 15 lbs. between December 2021 to March 2022. The RN said he only verified the completion of the MDS assessment and not the accuracy. Review of the RAI version 3.0 Manual revealed instructions for completing Section K 0300: Weight Loss. Code 2, yes, not on physician-prescribed weight-loss regiment: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses including depression, anxiety and schizoaffective disorders. A review of the physician order dated 2/3/22 noted Seroquel 25 milligrams by mouth at bedtime for dementia. A review of the Medication Administration Record revealed the resident had received Seroquel since 2/3/222 to present. Seroquel may be used alone or with other medications. Seroquel belongs to a class of drugs called Antipsychotics. (Retrieved from https://www.rxlist.com 4/29/22). Resident #51's Quarterly MDS assessment dated [DATE] section 0410 Medications Received read, Indicate the number of DAYS the resident received the following medications by pharmacological classification .during the last 7 days .Enter 0 if medication was not received by the resident during the last 7 days. Antipsychotic was coded 7, indicated the resident received antipsychotic medication during the review period. Section 0450 Antipsychotic Medication Review read, Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA (Omnibus Budget Reconciliation Act) assessment, whichever is more recent This was coded 0 and read, No-Antipsychotics were not received. On 4/28/22 at 2:12 PM, the RN MDS coordinator acknowledged he did the assessment dated [DATE] Section 0450. The MDS RN Coordinator said this was an oversight as he went over it too quickly and should have been marked 1 Yes, since antipsychotics were received on a routine basis, and the resident received them 7/7 days in the look back period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an on-going activity program for 1 of 2 residents reviewed for activities, of a total sample of 47 residents, (#516). Findings: Resident #516 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Alzheimer's Disease and cognitive communication deficit. The Minimum Data Set admission assessment with assessment reference date 4/15/22 revealed resident #516 had a Brief Interview for Mental Status score of 4 which indicated he had severe cognitive impairment. He required extensive assistance with transfers and locomotion. The assessment indicated the resident's preferred language was Spanish and he had interest in listening to music and participating in favorite activities. A care plan for activities initiated 4/26/22 indicated resident #516 had expressed interest in both self-directed independent and formal group activities. The goal was for him to have all needed items and materials to fully engage in preferred independent activities and for him to attend formal group activities of choice. The document indicated resident #516 enjoyed playing cards and games, watching television and movies and listening to music. Interventions included activity staff to provide playing cards, crossword and word find puzzles, a channel line-up, radio and a schedule of planned live performances. Review of resident #516's medical record revealed an Activities/Recreation Progress Note dated 4/11/22 which read, Patient requires assistance with activities of daily living, transfers and ambulation to attend daily scheduled activities of choice. On 4/25/22 at 12:12 PM, resident #516 was observed in his wheelchair at a table in the 300-unit dining room with his eyes closed and head lowered. At 1:58 PM, he was observed in his wheelchair at the same table with his head lowered and eyes closed. Resident #516 did not have any activity supplies in front of him during either of these observations. On 4/26/22 at 9:42 AM, resident #516 was observed in his wheelchair at a table in the 300-unit dining room with his back to the hallway and facing an exterior wall. The resident was not able to see the television which was to his left. At 10:58 AM and 12:02 PM, he was observed in same position in the 300-unit dining room. At 1:09 PM, resident #516 was observed at the same table with his back to the television. At 2:17 PM, he was observed at the same table facing the hallway with the television to his right and not visible to him. The resident did not have any activity supplies in front of him during any of these observations. On 4/27/22 at 10:18 AM, resident #516 was observed at a table in the 300-unit dining room facing the hallway. He could not see the television as it was to his right side and he did not have any activity supplies on the table. On 4/27/22 at 1:05 PM, Certified Nursing Assistant (CNA) D stated resident #516 was in the 300-unit dining room most of the day for supervision because he was at risk for falls. She said she was not aware if he attended any activities. On 4/27/22 at 1:19 PM, the 300/400 Registered Nurse Unit Manager stated resident #516 was always in the 300-unit dining room. She explained he needed to be supervised as he was at risk for falls. She indicated he did not speak much English and would probably not understand some of the activities. On 4/27/22 at 1:43 PM, the Activities Director stated he interviewed resident #516's family and identified his interest in dominoes and music. He said he did not know why resident #516 was in the 300-unit dining room all day and explained if a resident needed assistance to attend activities, it was the CNA's responsibility to get the resident to the activity. He reported the resident had attended one group activity since admission. He verbalized the activities staff had not provided the resident with any independent activity supplies. The Activity Director acknowledged there was not a program specifically for cognitive impaired residents nor a formalized one-to-one activity program for residents. On 4/28/22 at 11:44 AM, the Director of Nursing (DON) stated every employee was responsible for assisting residents to activities including the Activities Director, Activities Assistants and CNAs. She verbalized the importance of a resident attending activities was for socialization. On 4/28/22 at 12:07 PM, the Administrator stated the expectation was for the activities department to provide a variety of activities to residents and to honor resident choices. She explained if a resident chose to stay in their room, the expectation was for the activity department to provide books or crafts for the resident to do in their leisure time. She stated the activities department was expected to serve every resident population. Review of the job description for Activities Director revealed the Activity Director's role was to ensure the development, organization and coordination of facility and community resources to provide comprehensive therapeutic recreation services and programs that meet the needs and interest of each resident. The essential job functions included interview and assess all residents, develop an individual recreation plan and develop monthly calendars that reflect and meet the needs of the resident population. Additional job duties included transporting residents to and from activity room as required and working with other departments to promote the best possible care for the residents. The facility's Standards and Guidelines: SG Social and Recreational Programming policy dated 8/29/20 read, It is the standard of this facility to encourage residents to participate in social, recreation, educational and other activities within the facility and the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent medication errors greater than 5 per cent for 1 of 4 residents sampled for medication administration, (#26). There were 3 errors in 26 opportunities on 1 of 2 units by 1 of 4 nurses observed, for a medication error rate of 11.54%. Findings: Resident #26 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, major depressive disorder, rheumatoid arthritis and conversion disorder with seizures or convulsions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident #26 had moderately impaired cognition. She was able to eat independently with minimal help and was on mechanically altered diet. The resident's physician orders read, 07/27/21, Carbamazepine tablet Chewable 100 milligrams (mg), give 2 tablets by mouth three times a day for seizures; 10/14/21, Hydroxychloroquine Sulfate 200 mg. tablet, give 400 mg by mouth one time a day for rheumatoid arthritis; and 07/28/21, Prednisone 2.5 mg tablet, give 7.5 mg by mouth one time a day for rheumatoid arthritis. On 04/27/22 at 10:34 AM, Registered Nurse (RN) E prepared 9:00 AM medications for resident #26. She pulled 1 Aspirin 81 mg tablet, 1 Carbamazepine 100 mg Chewable tablet, 1 Fluoxetine 10 mg capsule, 1 Hydroxychloroquine 200 mg tablet, 1 Potassium Chloride 20 milliequivalents (mEq) tablet, 1 Prednisone Tablet 2.5 mg, 1 PreserVision AREDS capsule and 1 Multivitamins with minerals tablet. RN E confirmed she had prepared a total of 8 pills for resident #26 which were verified by comparing the actual pills against the medication cards. On 04/27/22 at 10:53 AM, medications were administered to resident #26. RN E was then asked to review the medication cards for Carbamazepine, Hydroxychloroquine and Prednisone. Medication cards were verified with orders in the electronic system. RN E acknowledged she administered 1 Carbamazepine 100 tablet instead of 2, 1 Hydroxychloroquine 100 mg tablet instead of 2 and 1 Prednisone 2.5 mg tablet instead of 3. On 04/28/22 at 6:00 PM, the Director of Nursing (DON) stated if a nurse failed to administer the correct dose of medication, she was expected to notify the physician about the situation and follow his orders to either give the additional dose as soon as possible or continue with the next dose at the scheduled time. She added whatever the case may be, the physician needed to be notified. Standards and Guidelines on Medication Administration revised on 03/27/21 read, Guideline #8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time and right method of administration are verified

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow physician orders for medication administration and failed to provide an explanation for medications not administered for 7 of 11 residents reviewed for medication administration of a total sample of 47 residents, (#57, #54, #46, #521, #60, #109, #520). Findings: 1. Resident #57 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, type 2 Diabetes, hypertension, anxiety and major depressive disorder. Review of the Minimum Data Set admission assessment with assessment reference date of 3/09/22 revealed resident #57 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. Review of the physician orders revealed resident #57 had orders for Amantadine Hydrochloride (HCL) Extended Release (ER) 129 milligrams (mg) at bedtime for Parkinson's Disease; Clonazepam 1 mg at bedtime for anxiety; Fluoxetine HCL 40 mg at bedtime for major depressive disorder; Insulin Glargine Solution 18 units subcutaneously at bedtime for diabetes; Eliquis 2.5 mg two times a day for blood thinner; Mirapex 1 mg two times a day for Parkinson's Disease; Senna Plus 50 mg two times a day for constipation; Carbidopa-Levodopa 100 mg four times a day for Parkinson's Disease; and Humalog Insulin Solution per sliding scale. On 4/25/22 at 12:15 PM, resident #57 stated she did not receive any medications on the night of 4/23/22. She explained she usually received her medications by 10:30 PM but she fell asleep and woke up at 12:30 AM. She recalled she put on her call light which was answered by a Certified Nursing Assistant (CNA) who informed her none of the residents on that hallway received their medications. Review of the Medication Administration Record (MAR) for April 2022 revealed no documentation on 4/23/22 for resident #57's evening and bedtime medications. The document was blank for the nurse's electronic signature for her 6:00 PM dose of Carbidopa-Levodopa and 9:00 PM doses of Amantadine HCL ER, Clonazepam, Fluoxetine HCL, Insulin Glargine Solution, Eliquis, Mirapex, Senna Plus and Humalog. Additionally, the resident's blood glucose levels were not documented on the MAR. Review of the MARs for residents on the 300/400 hallway revealed six additional residents did not receive their prescribed medications on 4/23/22. There were blank spaces on the MAR with no indication residents #54, #46, #521, #60, #109 and #520 received their evening and bedtime medications. 2. Resident #54 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Chronic Kidney Disease, Atrial Fibrillation and nonrheumatic mitral valve insufficiency. Review of the physician orders revealed resident #54 had orders for Niacin 500 mg at bedtime for cholesterol; Senna Plus 50 mg at bedtime for constipation; Colace 100 mg two times a day for constipation; Eliquis 5 mg two times a day for clot prevention; Glucosamine-Chondroitin 400 mg two times a day for nutritional support; Levocarnitine 500 mg two times a day related to stage 3 chronic kidney disease; Multaq 400 mg two times a day for Atrial Fibrillation; and Hydralazine HCL 10 mg three times a day for hypertension. Review of the MAR for April 2022 revealed on 4/23/22, resident #54 did not receive her 9:00 PM doses of Niacin, Senna Plus, Colace, Eliquis, Glucosamine-Chondroitin, Levocarnitine, Multaq and Hydralazine HCL. 3. Resident #46 was admitted to the facility on [DATE] with diagnoses including stage 2 pressure ulcer of sacral region, hypertension and nonrheumatic aortic valve stenosis. Review of the physician orders revealed resident #46 had orders for Docusate Sodium 100 mg two times a day for constipation; Hydralazine HCL 50 mg two times a day for hypertension; Polysaccharide Iron Complex 150 mg two times a day for deficiency; Symbicort Aerosol 2 puffs by oral inhalation two times a day for shortness of breath; and Gabapentin 600 mg three times a day for pain. Review of the MAR for April 2022 revealed on 4/23/22, resident #46 did not receive her 1:00 PM dose of Gabapentin nor her 5:00 PM doses of Docusate Sodium, Hydralazine HCL, Polysaccharide Iron Complex and Symbicort Aerosol. 4. Resident #521 was admitted to the facility on [DATE] with diagnoses including depression, hyperlipidemia, anxiety, hypertension, Atrial Fibrillation and Chronic Obstructive Pulmonary Disease. Review of the physician orders revealed resident #521 had orders for Atorvastatin Calcium 10 mg at bedtime for hyperlipidemia; Montelukast Sodium 10 mg in the evening for allergies; Eliquis 5 mg two times a day for stroke prophylaxis; Guaifenesin ER 600 mg every 12 hours for cough for 10 days; Hydralazine HCL 50 mg two times a day for hypertension; and Diltiazem HCL 60 mg three times a day for hypertension. Review of the MAR for April 2022 revealed on 4/23/22, resident #521 did not receive her 9:00 PM doses of Atorvastatin Calcium, Montelukast Sodium, Eliquis, Guaifenesin ER, Hydralazine HCL and Diltiazem HCL. 5. Resident #60 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, anxiety and bipolar disorder. Review of the physician orders revealed resident #60 had orders for Midodrine HCL 5 mg every 8 hours for hypotension and to obtain vital signs every shift. Review of the MAR for April 2022 revealed on 4/23/22, resident #60 did not receive her 2:00 PM dose of Midodrine HCL and her blood pressure was not documented. 6. Resident #109 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension and an automatic cardiac defibrillator. Review of the physician orders revealed resident #109 had orders for Carvedilol 25 mg two times a day for cardiomyopathy and to obtain vital signs every shift. Review of the MAR for April 2022 revealed on 4/23/22, resident #109 did not receive her 5:00 PM dose of Carvedilol and her vital signs were not documented. 7. Resident #520 was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes, hypothyroidism, hypertension and Atherosclerotic Heart Disease. Review of the physician orders revealed resident #520 had an order for Ozempic Solution to be injected subcutaneously one time a day every Saturday for diabetes. Review of the MAR for April 2022 revealed on 4/23/22, resident #520 did not receive her 6:00 PM dose of Ozempic. On 4/26/22 at 5:00 PM, the Director of Nursing (DON) stated the facility had initiated an investigation based on resident #57's report of not receiving her evening and bedtime medications on 4/23/22. She explained the investigation was still in process and at this time she had identified two additional resident that had not received their medications on that shift. On 4/28/22 at 5:55 PM, the Regional Director of Clinical Operations (RDCO) stated the facility ran a Medication Administration Audit Report and identified a total of eight residents whose medications were not documented as having been administered. She confirmed during the facility's investigation, residents #57 and #60 reported they did not receive all their medications on 4/23/22. The RDCO reconciled resident #57's narcotics and verified her scheduled 9:00 PM dose of Clonazepam had not been removed from the medication cart. On 4/28/22 at 6:31 PM, the Housekeeping Supervisor explained she was the Manager on Duty on 4/24/22 and recalled resident #60 requested to see her. She stated resident #60 informed her she had not received her medication the previous night. She stated she informed the Administrator on 4/24/22. On 4/28/22 at 7:04 PM, CNA H acknowledged resident #60 informed her on the day shift on 4/24/22 that she did not receive her medications the previous night shift. She said she did not inform anyone of the resident's concern. The facility's Standards and Guidelines: SG Medication Administration policy revised 3/27/21 read, It will be the standard of this facility to administer medications in a timely manner and as prescribed by the physician. The document contained guidelines including, 7. Medications should be administered within one (1) hour before or after their prescribed time and 14. When medications are administered, the individual administering the medication must record in the resident's medical record/MAR. The document indicated if a medication was withheld, refused or not administer as scheduled, the nurse must indicate this deviation from the physician's order on the MAR or noted in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure accurate dispensing of a medication as ordered, failed to identify concerns related to inappropriate route of administration, and failed to conduct safe medication administration according to manufacturer's instructions and accepted standards of practice for 1 of 7 residents reviewed for medication administration, of total sample of 11 residents, (#105). Findings: Resident #105 was admitted to the facility on [DATE] with diagnoses which included hypertension and gastrostomy status. A gastrostomy is a surgical procedure to insert a tube through the wall of the abdomen, directly into the stomach. The gastrostomy tube (G-tube) is used for feeding or administering medications. (Retrieved on 12/11/20 from www.webmd.com). Review of the Admission/re-admission Nursing Note dated 11/06/20 revealed resident #105's admission medications were reviewed and no potential issues were identified. The admission nurse noted resident #1 received cardiac medication and initiated a cardiovascular baseline care plan which included the intervention, Administer medications as ordered by physician. A care plan initiated on 11/17/20 indicated resident #105 required tube feeding related to difficulty swallowing and could not receive anything by mouth. On 12/08/20 at 9:23 AM, Registered Nurse (RN) A was observed during medication administration for resident #105. She crushed and placed each medication in a separate plastic cup. One of the pills prepared by RN A was Isosorbide Mononitrate Extended Release (ER) 60 milligrams (mg). RN A added water to each cup to dissolve the pills. On 12/08/20 at 9:41 AM, during medication administration, resident #105's G-tube became blocked. RN A explained she was having difficulty dissolving one of the pills, the Isosorbide Mononitrate ER, because of the coating on the pill. Review of the medication blister pack revealed it contained Isosorbide Mononitrate ER and directions read, Give 60 mg via G-tube one time a day for [hypertension] . DO NOT CRUSH OR CHEW. Review of resident #105's medical record revealed a physician's order dated 11/06/20 for Isosorbide Mononitrate 60 mg via G-tube once daily, but not the Extended Release form of the tablet. The order was transcribed to the Medication Administration Record (MAR) as written by the physician. The Order Audit Report revealed the order for Isosorbide Mononitrate 60 mg was created in the electronic medical record (EMR) on 11/06/20 at 4:59 PM. The order supply summary indicated the facility's pharmacy supplied Isosorbide Mononitrate ER 60 mg tablet extended release 24 [hour] instead, to be administered via G-tube. Isosorbide Mononitrate is a medication that widens blood vessels and prevents chest pain by making it easier for blood to flow through them and easier for the heart to pump. The manufacturer instructs Do not crush, chew, or break an extended-release tablet. Swallow it whole. Crushing an extended release drug breaks the protective film or membrane, causing the release of a large dose at once rather than a gradual release of small doses over time. (Retrieved on 12/11/20 from www.drugs.com). On 12/08/20 at 1:58 PM, Charge Nurse B explained all newly admitted residents' medications are reviewed on admission by the Director of Nursing (DON) and both Charge Nurses. She confirmed the medication blister pack clearly directed nurses not to crush the medication. Charge Nurse B said, We missed that the medication was extended release and should not be crushed. Charge Nurse B stated her expectation was nurses would read directions and administer medications appropriately. On 12/08/20 at 5:24 PM, the DON stated medication orders for all newly admitted residents were entered into the EMR by the admission nurse after reviewing them with the physician. She explained the orders were then transmitted electronically to the pharmacy. The DON stated she expected pharmacy staff to conduct an additional review of the orders to ensure any concerns are identified and brought to the facility's attention. The DON stated the order was entered into the EMR accurately by nursing staff, but the pharmacy changed it to the extended release form of the drug. She said, They should have called and clarified with us and they should have seen that it was via G-tube. The DON acknowledged all nurses should have read and noted the instructions printed on the blister pack regarding not crushing the medication, and contacted the physician and/or pharmacy for appropriate orders. The Pharmacy Services policy and procedure, issued on 8/01/17 read, It will be the standard of this facility to provide pharmacy and pharmacist services to meet the needs of the residents. The guidelines indicated a licensed pharmacist would review each resident's medication regimen at least monthly and report any irregularities to the physician, medical director and DON. The pharmacy conducted an Interim Review of resident #105's medication regimen on 11/08/20, and a monthly review on 11/29/20. The concern regarding crushing an extended release pill for G-tube administration was not identified, and the pharmacists made no recommendations. Review of the MARs for resident #105 revealed she received Isosorbide Mononitrate ER 60 mg via G-tube once daily from 11/07/20 to 12/08/20. The extended release medication was crushed, dissolved and administered via G-tube 32 times, contrary to the instructions by the manufacturer and pharmacy. During her 1-month stay in the facility, this medication was administered to resident #105 by 8 of 8 assigned nurses, RNs A, F and I, and Licensed Practical Nurses C, D, E, G and H. The policy and procedure for Medication Administration Via an Enteral Feeding Tube revised in November 2016 read, Some medications and dosage forms should not be crushed. If there are any questions regarding the crushing of medications, call pharmacy. The facility's policy and procedure for Medication Administration revised 11/01/16 revealed medications should be administered according to physicians' orders. The document indicated nurses would follow accepted standards of practice related to medication administration to ensure .the right medication, right dosage, right time and right method of administration are verified.