**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the medical record was complete related to Activities of Daily Living (ADLs) for 3 of 3 sampled residents (#1, #2, #3)Findings included: 1. Resident #2 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Parkinson’s, dementia, anemia, and hypotension. Review of the Minimum Data Set (MDS) dated [DATE] showed Section GG, Functional Abilities dependent for toileting hygiene, showering and bathing, upper and lower body dressing. Review of the care plans showed the resident had an ADL self-care deficit related to chronic medical conditions. ADL needs and participation vary as of 07/18/2022. Interventions included but not limited to encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 07/18/2022. Review of the Activities of Daily Living for June 2025 showed bed mobility, behavior symptoms, bladder continence, bowel management, dressing, float heels while in bed, evening snack, locomotion off unit, locomotion on unit, oral care, personal hygiene, skin observation, toilet use, transferring, turning and positioning, walking in corridor, walk in room, amount eaten with fluids, eating, incontinence care every 2 hours and as needed was not documented as performed on the following dates: 07/03/25, 07/05/25, 07/07/25, 07/08/25, 07/10/25, 07/11/25, 07/16/25, 07/1925, 07/21/25, 07/2325, 07/24/25. During an interview on 07/28/2025 at 12:43 p.m. the Director of Nursing (DON) stated the ADLs for Resident #2 had not been documented as performed on the above dates. She stated she expected to see documentation of tasks performed. 2. Resident #3 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to diabetes, Alzheimer’s disease, hypertension and dementia. Review of the quarterly MDS dated [DATE] showed a BIMs score of “0” or resident is rarely, never understood. Section GG, Functional Abilities showed she was dependent for toileting hygiene, shower and bathing, upper and lower dressing, and personal hygiene. Review of the care plan showed Resident #2 has an ADL self-care deficit related to chronic medical conditions as of 04/15/2025. Interventions included but not limited to the resident may need dependent assistance of one or two for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status as of 04/15/2025. The resident is not able to participate in this task as at all (toileting) and will need staff to move, cleanse, and dress them. This may require the dependent assistance of 2 people to be done thoroughly and safely as of 11/21/2024. Review of the Activities of Daily Living from 06/29/225 to 07/28/2025 showed Urinary Incontinence the following dates only has 1 or 2 incontinence activities performance documentation: 06/29/2025, 06/30/2025, 07/03/2025, 07/04/2025, 07/06/2025, 07/08/2025, 07/10/2025, 07/13/2025, 07/14/2025, 07/18/2025, 07/22/2025, 07/27/2025 and no documentation on 07/26/2025. Bowel Incontinence the following dates only has 1 or 2 incontinence activities performance documentation 06/29/2025, 06/30/2025, 07/03/2025, 07/04/2025, 07/06/2025, 07/08/2025, 07/10/2025, 07/13/2025, 07/14/2025, 07/18/2025, 07/22/2025, 07/27/2025 and no documentation on 07/26/2025. Toilet Use Self Performance the following dates only has 1 or 2 incontinence activities performance documentation: 06/29/2025, 06/30/2025, 07/03/2025, 07/04/2025, 07/06/2025, 07/08/2025, 07/10/2025, 07/13/2025, 07/14/2025, 07/18/2025, 07/22/2025, 07/27/2025 and no documentation on 07/26/2025. During an interview on 07/28/2025 at 1:06 p.m. the DON verified documentation was missing for Resident #3 regarding incontinence care. The DON stated she expected the staff to document incontinence care. Review of the facility’s policy, “Documentation,” revised 01/2024 showed services provided to the resident shall be documented on the resident’s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident’s condition and response to care. Procedure: 2. The following information is to be documented in the resident medical record: C treatments or services performed; 8. Documentation of procedures and treatments will include care specific details, including: a) the date and time the procedure / treatment was provided; B) the name and title of the individual (s) who provided the care; D) whether the resident refused the procedure / treatment; f) the signature and title of the individual documenting. Review of the facility’s policy, “ADL Care and Services,” revised 01/2024 showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Guideline: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure: 1. Residents will be will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, nail care and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting). Review of the Record for Resident # 1 indicated diagnoses which included Type II Diabetes mellitus with foot ulcer, Type 2 Diabetes mellitus with Hyperglycemia, Encounter for removal of internal fixation device, Hyperthyroidism, PVD, Obesity, Hyperlipidemia, Gastro-esophageal Reflux Disease and Gastritis. Review of a discharge Minimum Data Set Assessment) dated 5/20/25 indicated Section GG Functional Abilities: Substantial /maximal assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene Review of the care plan for ADL Care, initiated 3/25/25, revealed: BED MOBILITY: the resident needs EXTENSIVE help to move and reposition the bed. Will need one- or two-person assistance to change position or scoot up in the bed. This may involve some lifting of the legs or boosts. TOILETING: the resident will need the EXTENSIVE help of one or two staff to stand and transfer on and off the commode or bed pan. The resident will probably need you to wipe, redress, and wash their hands, but allow the resident to do any part of the activity they can to promote independence. Be prepared with 2 people to assist for resident safety during the transfer Transfer: the resident IS LIMITED TO EXTENSIVE and may need assistance x1 or x2 for transfers in and out of chair or bed BATHING: The resident NEEDS ASSIST LIMITED TO EXTENSIVE of 1-2 based on fatigue, weightbearing, weakness. Review of the Activities of Daily Living documentation from May 1 through May 20,2025 revealed bed mobility, behavior symptoms, bladder continence, bowel management, dressing, locomotion off unit, locomotion on unit, oral care, personal hygiene, , toilet use, transferring, turning and positioning incontinence care were not documented for the day shift and evening shifts on May 5,7,8,9,11, 12, 14,15, 19 2025. During an interview with the DON, on 7/28/25 at 3: 37 pm, the DON confirmed the documentation of ADL care for the above dates was not documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to code the Minimal Data Set (MDS) accurately at discharge for one resident (#111) of three residents reviewed for close records. Findings included: Review of the admission record showed Resident #111 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to malignant neoplasm of unspecified part of right bronchus or lung, chronic obstructive pulmonary disease, unspecified atrial fibrillation, chronic kidney disease, stage 3 B and generalized muscle weakness. Review of a physician order dated 04/22/24 showed, Send to Hospital for [treatment]Tx and [Evaluation] Eval. Review of progress notes revealed the following two progress notes: Change in Condition dated 04/20/24 showed, Situation: The change in conditions reported on the Evaluation are/were: Falls Nausea/Vomiting. Primary Care Provider Feedback Recommendations: Send to ER for treatment and evaluation. Physical Medicine and Rehabilitation Subsequent Evaluation dated late entry 04/23/24 showed, hospitalized . Review of the Discharge Return Anticipated /End of PPS Part A Stay MDS dated [DATE] revealed Section A 2105. Discharge Status was marked 01. Home/Community. During an interview on 07/17/24 at 3:20 p.m., Staff M, MDS Director reviewed Resident #111's medical record and stated stated Resident #111 was hospitalized at discharge. Staff M, MDS Director confirmed Resident #111's Discharge MDS was marked incorrectly as Resident #111 did not go home to the community but was hospitalized .

Based on record review and staff interviews, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate for two residents (# 7, #19) of 25 residents sampled. Findings included: 1. Review of Resident #19's admission Record revealed an admission date of 05/24/2023 with diagnoses to include Anxiety Disorder and Major Depressive Disorder. Review of the Level I PASRR, dated 08/24/2023, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) the diagnosis of Depressive Disorder was not marked. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 2. Review of Resident #7's admission Record revealed an admission date of 07/21/2021 with diagnoses to include Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder and Generalized Epilepsy and Epileptic Syndromes. Review of the Level I PASRR, dated 08/30/2023, showed in Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness) the diagnoses of Bipolar Disorder and Depressive Disorder were marked. Part B Intellectual Disability (ID) or suspected Intellectual Disability (ID) the related condition of Epilepsy was not marked. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. An interview was conducted on 07/17/2024 at 2:55 p.m. with the Nursing Home Administrator (NHA) and the Admissions Director. The Admissions Director said she receives the PASRR's from the hospital and uploads them into the system. She also said once the resident is in the building the PASRR is reviewed by the clinical team; it does not get reviewed pre-admission. The NHA said the clinical team has a daily clinical meeting in which PASRR's are reviewed. She said the clinical team consists of the Director of Nursing (DON), the Assistant Director of Nursing (ADON), Unit Managers and Social Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the Resident Assessment Instrument (RAI), the facility failed to ensure one resident (#106) of five residents reviewed for unnecessary medications had the care plan revised after a medication was discontinued. Findings included: Review of the Admissions Record showed Resident #106 was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified convulsions, muscle weakness, and cognitive communication deficit. Review of the Medication Review Report showed Resident #106 had no antipsychotic drug regimen. Review of the Discontinued Physician Orders revealed Olanzapine Tablet 5 [milligrams] MG- Give 0.5 tablet by mouth two times a day for psychotic disorder. with discontinued date 06/12/24. Review of Care Plan showed the following care area: Focus- The resident uses antipsychotic medications r/t Behavior management Date Initiated: 05/31/2024. Goal- The resident will be/remain free of antipsychotic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions: · Administer antipsychotic medications as ordered by physician. · Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms as indicated. · Medication review as indicated/PRN. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. · Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 05/31/2024 · Psych Services consult and follow up as ordered/indicated. During an interview on 07/16/24 at 3:44 p.m., the Director of Nursing (DON) reviewed Resident #106 current physician orders and care plan and stated the care plan should have been revised to reflect the discontinued antipsychotic use. During an interview on 07/17/24 at 1:55 at p.m., the Director of Nursing (DON) was asked for the facility's care plan policy. The DON stated the facility did not have a policy for care plans as the facility followed the RAI manual for care plans instructions. Review of the MDS 3.0 [Resident Assessment Instrument] RAI User's Manual for Long-Term Care Version 1.18.11 dated October 2023 showed, Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Plan of Care was followed for 1 of 39 sampled residents (#267) related to an order for a medication, documentation of administering the medication and follow-up documentation. Findings included: During an interview on 07/15/24 at 12:00 p.m. Resident #267 was sitting at bedside in his wheelchair. He was dressed and groomed for the day. The resident's family member was with the resident. No odors were noted. The resident had a dollar size wound area on the right side of his head with smaller areas circling it. The left foot had a dressing in place. He stated he was non-weight bearing (NWB) at this time due to the heel wound. He had a right above the knee amputation. The facility used a Hoyer lift due to his NWB of left foot, ulcer. They stated that on Saturday at 3 p.m., they told the aide he was in pain due to constipation. They requested a suppository. They stated the nurse came in an hour later and stated she would come back after she performed medication pass. The stated it was 3-4 hours later before he got a suppository. The wife stated she performed the majority of the care, bathing, cleaning him, lotion. She stated he wants her to provide his care. They stated he had an ulcer on his bottom. Resident #267 was admitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to surgical amputation (Right above knee), diabetes, protein-calorie malnutrition, dementia, chronic kidney disease, anemia, hypertension, squamous cell carcinoma of skin on right lower limb, muscle weakness, and abnormal gait. Review of the admission MDS dated [DATE] showed a BIMs of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident required maximum assistance. Review of the physician orders showed no orders for bowel regimen, Dulcolax suppository. Review of the physician orders showed no order for Dulcolax suppository on 07/13/2024. Review of the July 2024 MAR (medication administration record) did not show a Dulcolax Suppository had been administered on 07/13/2024. Review of the progress notes for 07/13/2024 showed no documentation related to abdominal pain, notification of physician for an order, receiving an order for a suppository or suppository administration for constipation. There was lack of documentation of results of the suppository. Review of the care plan for at risk for bowel irregularity related decreased mobility as of 07/08/2024. Interventions included but not limited to administer medications as per MD orders as of 07/08/2024. Monitor for and document resident's bowel movements as of 07/08/2024. Monitor medications for side effects of constipation/loose stools. Notify MD as indicated as of 07/08/2024. Monitor/observe for abdominal distention, abdominal pain/tenderness/discomfort, decreased bowel sounds, N/V, s/s of constipation, unresolved diarrhea, changes in mental status and notify MD/NP/PA as indicated as of 07/08/2024. During an interview on 07/17/2024 at 3:45 p.m. the Director of Nursing (DON) stated they normally review the bowel needs on admission, including review of the drugs and diagnoses to see if constipation or diarrhea medications are needed to be a standing order. The DON stated she would have to look into it (administration of suppository for constipation). The DON verified the resident did not have any bowel regimen orders. She stated the staff can call the medical provider 24-hours a day to get a medication order. During an interview on 07/17/2024 at 4:43 p.m. the DON confirmed there was not an order or a progress note about the constipation and suppository in the chart. The DON stated the wife told her the resident normally takes an oral medication daily at home. The DON stated she called the MD (medical doctor) for an order for Senna at bedtime for constipation while he was at the facility. During an interview on 07/17/2024 at 5:15 p.m. the DON stated she spoke with the resident's APRN (advanced practice registered nurse). The APRN told her she gave a nurse an order for a suppository. The APRN told the her she does not remember the nurse's name but it was an order for Docusate. The DON stated the Docusate suppository was an over-the-counter medication. The DON stated she spoke with Staff I, Licensed Practical Nurse (LPN) and Staff I stated she gave Resident #267 a suppository but forgot to document it. Staff I told the DON she gave the suppository around 5 p.m. She told the resident she would check on him again after medication pass. The DON state the normal process was for the nurse to call the MD for orders, document the order and give the medication, and document. During an interview on 07/18/2024 at 9:47 a.m., the APRN stated a nurse from the facility called her over the weekend about Resident #267 being constipated. The APRN stated she does not remember which nurse called. APRN stated she ordered a bowel regime. She stated she will either order an oral or a suppository depending on the resident's needs. She stated she ordered a suppository, because the nurse stated the resident had not had a bowel movement in a couple days, and that (suppository) works best. The APRN stated she expected the nurse to write an order based on the verbal order, give the medication and document. During an interview on 07/18/2024 at 9:56 a.m. Staff I, LPN stated she worked the weekends on the .3-11 p.m. shift. She stated she got report from the prior nurse. She stated she checked the resident's room and was told he was constipated and needed a suppository. She told the resident she would need an order for the suppository. She told him she would have to see if he had an order and if he didn't, she would need to call the MD for an order. Staff I, LPN told the resident to give her time to get the order. Staff I stated she got an order from the APRN between him asking and him getting it. She stated, He got the suppository about 5 pm. It was a crazy day. I was running. I went back around 7 p.m. and asked him any results. He had a bowel movement. She stated he said he was okay and relieved. The resident thanked her for the suppository. She stated she saw the resident during p.m. rounds. Staff I, LPN stated the resident told the nurse he was trying to pass the stool and needed help. The APRN gave her the order, but she did not write the order for the suppository. Staff I, stated, She was trying to just give it to him and try to eliminate (another task), made sure he had results. She stated she could not remember if the resident got any other meds. Staff I stated, When I get orders I am putting it in while talking to them, reading it back to them. I was trying to focus on the patient. I was making sure the patient was okay. I normally after giving the med, document. People were on the computer. She stated she normally document prn medications, new orders. Staff I stated, I did not document the results of the bowel movement, went back and asked him, if it worked. Review of the facility's policy, Standards and Guidelines: Medication Administration, revised 01/2024 showed Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescriber orders, including any required time frame. 15. During administration of medications, the medication cart is kept closed and locked when out of sight of the individual administering the medication. It may be kept in the doorway of the residence room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart when not within sight of the individual administering medications. The cart should be clearly visible to the personnel and ministering medications, and all outward sides should be inaccessible to residents or others passing by. 17. As required or indicated for a medication, the individual administering the medication records in the residence medical record: a. The date and time the medication was administered; B. The dosage; C. The route of administration; E. Any complaints or symptoms for which the drug was administered if applicable; F. Any results achieved and when those results were observed if applicable; and G. The signature and title of the person administering the drug. 19. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy, Standards and Guidelines: Physician Orders, revised 01/2024 showed Guideline: Orders and administration of medications and treatments will be consistent with principles of safe and effective order writing. Procedure: 1. Medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable. 2. Authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 3. Drug and biological orders must be recorded on the physician's order sheet and the resident's electronic chart. 4. The staff and practitioner shall use approved abbreviations and symbols when ordering and or charting medications. 5. Verbal orders should be recorded in the resident's chart by the authorized person receiving the order and should include the prescriber's name, credentials, the date and the time of the order. 6. Verbal telephone orders may be received by licensed personnel. Orders should be transcribed by the authorized personnel receiving the order and recorded in the resident's medical record. 7. The entry should contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. 8. Orders for medication should include: a. Name and strength of the drug b. Number of doses, start and stop date, and or specific duration of therapy; c. Dosage and frequency of administration; d. Route of administration; e. Clinical condition or symptoms for which the medication is prescribed and 9. Physician orders should be followed and prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated. 10. The resident will be informed of medication changes as they occur. If the resident is deemed incapable of making health care decisions, the residents responsible party will be informed of medication changes as they occur.

Based on observation, interview and record review, the facility failed to ensure medications were stored properly for 2 (#272 and #19) out of 6 medication administration observations. Findings included: On 07/16/2024 at 8:40 a.m. Resident #272 was observed during medication pass with Staff J, Licensed Practical Nurse (LPN). Staff J was observed entering the resident's room with her inhaler. Staff J exited the room and placed the inhaler on the medication cart and went into the bathroom to wash her hands. The LPN was unable to visualize the unattended medication while she was in the bathroom. On 07/16/2024 at 10:50 a.m. Resident #19 was observed during blood glucometer monitor use and insulin injection by Staff H, LPN. The LPN placed the insulin bottle on the computer keyboard on the medication cart, entered the resident's room and injected the insulin. The LPN was unable to visualize the unattended medication while in the resident's room. During an interview on 07/17/2024 at 5;32 p.m. the DON was apprised of the medication administration observation. The DON the expectations were medications were not to be left unattended out of a locked medication cart. Review of the facility's policy, Standards and Guidelines: Medication Storage and Labeling, revised 01/2024 showed Guideline: the facility stores all drugs and biological in a safe, secure, and orderly manner. Procedure: 1 drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.

Based on observation, interview, record review and review of the facility's policy Menu and Meals Service: Nourishment/Snacks, the facility failed to ensure one resident (#73) of one resident reviewed was provided a snack when requested. Findings included: During an interview on 07/15/24 at 10:56 a.m., Resident #73 stated, I am still hungry, I got two eggs but I still would like a snack. During an interview on 07/15/24 at 11:00 a.m., Staff C, Certified Nursing Assistant (CNA) was notified of Resident #73's snack request. Staff C, CNA stated, I am not his CNA but he gets double portions for his meals. An observation on 07/15/24 at 11:19 a.m., revealed Resident #73 continued to sit beside his bed in wheelchair with no snack visible on the bedside table. During an interview on 07/15/24 at 11:20 a.m., Resident #73 stated, No one ever brought me that snack. During an interview on 07/15/24 at 11:22 a.m., Staff D, Registered Nurse (RN) Nurse stated, I will go get him a snack and the CNA should have provided it when requested. During an interview on 07/15/24 at 11:36 a.m., Staff C, CNA stated, she never got the snack for Resident #106 but she told Resident #106's assigned CNA. During an interview on 07/15/24 at 11:51 a.m., Staff E, CNA stated Staff C, CNA never told her Resident #73 wanted a snack or she would have provided him one. During an interview on 07/15/24 at 11:55 a.m., Staff D, RN stated that any CNA could have provided Resident #73 with a snack, it did not have to be the assigned CNA. During an interview on 07/17/24 at 3:58 p.m., the Director of Nursing (DON) stated that any CNA can provide a resident a snack when requested, even if they are not assigned to that Resident. The DON stated the only consideration and what the facility educates on with snack requests is the CNA talks with the nurse prior to providing the snack so that the appropriate snack may be given. Review of the facility's policy Menu and Meals Service: Nourishment/Snacks revised date July 2024 showed, Snacks will be available for residents between meals based on request or as part of appropriate therapeutic diet, dietitian recommendation, or physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medical record was accurate and complete related to to documentation of Skilled Nursing Documentation Notes for 3 (#8, #19, #267) of 39 sampled residents. Findings included: 1. On 07/15/2024 at 4:30 p.m. Resident #19 was observed sitting in her wheelchair at bedside. She was dressed and groomed for the day. She stated she went out to breakfast with her son. Her oxygen via nasal cannula was in place and at 2 liters per minute. Resident #19 stated that the staff cares for her. They answer the call lights and give her showers. She stated she had been to the hospital a couple of times for breathing problems. No odors were noted. No skin impairments were observed. Her personal items were noted. Resident #19 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to Chronic Respiratory Failure with hypoxia, diabetes, Chronic Obstructive Pulmonary Disease (COPD), obesity, Congestive Heart Failure (CHF), hypertension with HF, stage IV chronic kidney disease, ischemic cardiomyopathy, anemia, muscle weakness, Transient Ischemia Attack (TIA). Review of the annual, Minimum Data St (MDS) dated [DATE] showed Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). Section GG, Functional Abilities and Goals showed the resident needed moderate assistance. Review of the physician orders showed Resident #19 was receiving therapy services, physical therapy, speech therapy and occupational therapy. Review of the Medication Administration Record (MAR) for July 2014 showed Skilled Patient to be charted daily in assessment as of 06/11/2024 to 07/09/2024. Review of the Skilled Documentation notes showed the following were not documented: 06/07/2024, 06/10/2024, 06/11/2024, 06/12/2024, 06/16/2024, 06/17/2024, 06/21/2024, 06/27/2024, 06/28/2024, 06/29/2024, 07/01/2024 07/05/2024, 07/07/2024, 07/11/2024, 07/13/2024, 07/14/2024, 07/15/2024 2. On 07/15/24 12:29 p.m. Resident #8 was sitting in her wheelchair beside her bed, eating her lunch, of hamburger, carrots, soup, pudding, salad and fluids. She was dressed and groomed for the day. She stated she had no complaints or concerns. She stated the staff answers all the call lights. She stated she was able to take her own shower. A bruise was observed on her left upper hand. Resident #8 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included but were not limited to Urinary Tract Infection (UTI), diabetes, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, obesity, CHF, Pulmonary HTN, atrial fibrillation, stage III chronic kidney disease, anemia, and weakness. Review of the MDS dated [DATE] showed a BIMS score of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident needed maximal assistance with care. Review of the physician orders showed Resident #8 was receiving therapy services, physical therapy and occupational therapy as of 07/05/2024. Admit resident to facility for skilled services as of 07/04/2024. Review of the Skilled Documentation notes showed the following were not documented: 07/05/2024, 07/06/2024, 07/08/2024, 07/09/2024, 07/12/2024, 07/13/2024, 07/15/2024 During an interview on 07/17/2024 at 12:10 p.m. the Director of Nursing (DON) verified the bruise was documented but location was not documented, and it should be. The DON verified the Weekly Skin Check was not performed weekly. The DON verified the chart was missing Skilled Documentation notes. 3. During an interview on 07/15/24 at 12:00 p.m. Resident #267 was sitting at bedside in his wheelchair. He was dressed and groomed for the day. The resident's family member was with the resident. No odors were noted. The resident had a dollar size wound area on the right side of his head with smaller areas circling it. The left foot had a dressing in place. He stated he was non-weight bearing (NWB) at this time due to the heel wound. He had a right above the knee amputation. The facility used a Hoyer lift due to his NWB of left foot, ulcer. They stated that on Saturday at 3 p.m., they told the aide he was in pain due to constipation. They requested a suppository. They stated the nurse came in an hour later and stated she would come back after she performed medication pass. The stated it was 3-4 hours later before he got a suppository. The wife stated she performed the majority of the care, bathing, cleaning him, lotion. She stated he wants her to provide his care. They wanted him to go home so he does not get COVID. They stated he had an ulcer on his bottom. Resident #267 was admitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to surgical amputation (Right above knee), diabetes, protein-calorie malnutrition, dementia, chronic kidney disease, anemia, hypertension, squamous cell carcinoma of skin on right lower limb, muscle weakness, and abnormal gait. Review of the admission MDS dated [DATE] showed a BIMs of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident required maximum assistance. Review of the physician orders showed: Resident #267 was receiving therapy services, physical therapy and occupational therapy. Skilled patient to be charted daily in assessment as of 07/09/2024. Review of the July MAR showed skilled patient to be charted daily in assessment every day as of 07/10/2024. Review of the Skilled Documentation notes showed the following were not documented: 07/05/2024, 07/06/2024, 07/07/2024, 07/08/2024, 07/09/2024 Review of the facility's policy, Standards and Guidelines: Documentation, revised 01/2024 showed Guideline: Services provided to the resident shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Procedure: 1. Documentation in the medical record may be electronic, manual, or combination. 2. The following information is to be documented in the resident medical record: a) Objective observations; b) Medication administered; c) Treatments or services provided performed; d) Changes and the resonance condition; 3. Documentation in the medical record is required as updates / changes and the resident's plan of care are made. 8. Documentation of procedures and treatments will include care specific details, including: a) the date and time the procedure slash treatment was provided; b) the name and title of the individual (s) who provided the care; c) the assessment data and / or for any unusual findings obtained during their procedure / treatment; e) notification of family, physician or other staff, if indicated; and f) the signature and title of the individual documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to 1.) failing to ensure proper storage of medication and biologicals, for 3 of 4 treatment carts, on 1 of 2 hallways (F761) and 2.) failing to maintain an effective infection control and prevention program to prevent the spread of infection by failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one (Resident #3) of 2 residents under transmission based precautions (F880) during the revisit survey conducted on 09/11/2024. Findings included: 1.) An observation on 09/11/2024 at 0917 AM revealed 3 treatment carts unlocked and unsecured across from the nurse's station. There were no staff near the carts, and the carts contained prescription medications for treatments. Photographic evidence was obtained. An interview was conducted on 09/11/2024 at 01:45 PM with Staff C, Licensed Practical Nurse (LPN). The LPN confirmed the treatment carts should not be left unlocked. She also stated the nurse is assigned a treatment cart correlates with their medication cart and assignment. An interview was conducted on 09/11/2024 at 02:02 PM the Director of Nursing, RN (DON). The DON stated the nurse has the keys to the treatment cart and there was also an extra set for the wound care nurse. She also stated all the carts should be locked when not being used. The facility policy titled Standards and Guidelines: Medication Storage and Labeling reveals under the section titled Procedure Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2.) A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) infection. A review of Resident #3's physician orders revealed an order dated 9/7/2024 for contact precautions for MRSA every shift until 9/19/2024 at 9:43 AM. An observation was conducted on 9/11/2024 at 10:07 AM outside of Resident #3's room. A sign was posted to Resident #3's room door indicating Resident #3 was on contact precautions. The posted signage included directions for providers and staff to put on gloves before room entry, discard gloves before room exit, put on gown before room entry, and discard gown before room exit. An caddy was observed outside of Resident #3's room containing isolation gowns and gloves. Staff A, Occupational Therapist Assistant (OTA) was observed in Resident #3's room speaking to the resident at the bedside. Staff A, OTA was not observed wearing an isolation gown or gloves while inside of the resident's room. After Staff A, OTA exited Resident #3's room, an interview was conducted. Staff A, OTA stated she spoke to a nurse prior to entering Resident #3's room to find out why Resident #3 was on contact isolation precautions and was told she did not have to don PPE because the infection was in the resident's urine. Staff A, OTA also stated she did not touch the resident while she was inside of the resident's room. Staff A, OTA observed the signage posted to Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff A, OTA stated she received in-service education from the facility a few weeks ago related to infection control and the proper procedures for donning and doffing PPE. An observation was conducted on 9/11/2024 at 10:16 AM outside of Resident #3's room. Staff B, Registered Nurse (RN) and Unit Manager (UM) was observed pushing a cart with boxes of disposable gloves on it down the unit hallway. Staff B, RN UM was also observed entering Resident #3's room. Staff B, RN UM did not don an isolation gown or gloves before entering the resident's room. After Staff B, RN UM exited the room an interview was conducted. Staff B, RN UM stated she was conducting rounds on the unit and ensuring gloves inside of the resident rooms were stocked. Staff B, RN UM also stated Resident #3 was on contact isolation precautions and she did not don PPE before entering the room because she did not touch the resident. Staff B, RN UM observed the signage posted on Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff B, RN UM stated she received in-service education from the facility about two weeks ago related to infection control and the proper procedures for donning and doffing PPE. An interview was conducted on 9/11/2024 at 1:33 PM with the facility's Infection Preventionist (IP). The IP stated when a resident is on contact isolation precautions, all staff are to don an isolation gown and gloves prior to entering the resident's room. The IP also stated it does not matter if the staff member touches the resident or not while they are inside of the room, the staff don the appropriate PPE any time they enter the resident's room. The IP stated he conducted in-service education with the facility staff and discussed the difference between transmission based precautions and enhanced barrier precautions and the PPE required for each type of precautions used. An interview was conducted on 9/11/2024 at 2:22 PM with the DON. The DON stated facility staff should follow the instructions on the posted signage for a resident under transmission based precautions and donning the PPE is not optional when entering the resident's room. The DON also stated it does not matter what the staff member is doing inside of the room, all staff should be donning the appropriate PPE as ordered by the physician because the disease could be transmitted to other residents if PPE is not used. An interview was conducted on 9/11/2024 at 3:32 PM with the facility's Nursing Home Administrator (NHA) and DON. The NHA stated the facility's QAPI committee met following the previous survey to discuss the findings and began to develop a plan of correction. A facility wide audit was conducted to identify residents who were potentially effected by the deficient practice and facility wide education was conducted to all of the related areas identified during the previous survey. Audits were put into place to ensure the facility's education and processes had improved. The DON stated weekly audits of the medication carts were initiated and all nursing staff received education related to medication storage to ensure compliance. The DON also stated the audits mainly focused on the medication carts and not the treatment carts in the facility. The NHA stated four separate audits were put into place related to infection control, including sanitizing equipment, hand washing, PPE use, and glucometers. All types of transmission based precautions were reviewed as part of the education and explained to facility staff to ensure they understand. A review of the facility policy titled Standards and Guidelines: Transmission Based Precautions, last revised in February of 2024, revealed under the section titled Standard, all staff receive training on transmission based precautions upon hire and at least annually. The policy also revealed under the section titled Procedure: Initiation of Transmission-Based Precautions (Isolation), an order for isolation will be obtained for residents who are known or suspected to be infected with infectious agents that require additional controls to prevent transmission effectively. The policy revealed the following under the section titled Procedure: Contact Precautions: - Intended to prevent transmission of infectious agents which are spread by direct of indirect contact with the resident or the resident's environment. - Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. - Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens. A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised in February of 2020, revealed under the section titled Policy Statement, this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The policy also revealed under the section titled Policy Interpretation and Implementation the objectives of the QAPI program are to: - Provide a means to measure current and potential indicators for outcomes of care and quality of life. - Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. - Reinforce and build upon effective systems and processes related to the delivery of quality care and services. - Establish systems through which to monitor and evaluate corrective actions. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A review of Resident #362's admission Record revealed an admission date of 07/14/2021 with a readmission date of 11/22/2023 and diagnoses to include pressure ulcer of sacral region, stage 4. A review of Resident #362's July 2024 physician orders revealed the following: -Cleanse Coccyx with Normal Saline/wound cleanser pat dry Apply skin prep to coccyx skin prep, apply collagen particle (collagen particle with Normal saline slurry) to wound bed cover with border foam dressing. QD (every day) and PRN (as needed). every day shift for wound AND as needed for damaged or missing dressing Active 7/3/2024 08:00 (a.m.). An attempt to interview Resident #362 was conducted on 7/15/2024 at 10:30 a.m. Resident #362 is not interviewable. A record review of the resident's Quarterly Minimum Data Set (MDS) revealed in Section C- Cognitive Patterns, dated 07/12/2024, a Brief Interview for Mental Status (BIMS) summary score of 00, showing the resident is not cognitively intact. In section M- Skin Conditions it revealed the presence of 1 stage 4 pressure injury that was present on admission. A review of Resident #362's care plan, dated 05/16/2024, revealed Resident #362 had an unavoidable pressure injury to his coccyx and was at risk for further skin impairment. The goal was to show signs of improvement. Interventions included: Skin checks to be weekly and as indicated. A review of the Resident #362's Skin Check records from 05/24/24 through 07/16/24 revealed four Skin Checks dated: 07/11/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: Treatment is in place to coccyx. no new skin concerns noted. 07/01/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: no new skin concern. 06/22/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: under wound care provider with tx [treatment] noted improving at this time no other skin integrity abnormalities noted at this time. 06/14/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: Treatment continue. No new skin concern noted. An interview was conducted on 07/17/2024 at 9:43 AM with the Director of Nursing (DON). The DON stated if a resident has an identified wound they should have a weekly wound assessment. She went on to state the bedside nurse and wound care nurse will do a weekly wound assessment not just a weekly skin check. 6. A review of Resident #58's admission Record revealed an admission date of 01/01/2023 and diagnoses to include type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus with foot ulcer, unspecified open wound, right foot, subsequent encounter. A review of the July 2024 physician orders revealed the following: -cleanse Right lateral foot with normal saline/ wound cleanser apply collagen powder to wound bed, biopad collagen dressing, tritec silver cover with border gauze and PRN. every day shift for wound care AND as needed for missing/ damaged dressing, Active 5/28/2024 15:00 (3:00 p.m.). A review of Resident #58's care plans, initiated on 01/11/2023, revealed Resident #58 was at risk of skin impairment. Interventions included: Skin checks to be weekly and as indicated. A review of Resident #58's Quarterly MDS, Section M, dated 04/08/2024, revealed the presence of 1 pressure wound that was facility acquired. It revealed Resident #58 has a stage 3 pressure injury. A review of Resident #58's Skin Check documents revealed skin checks dated: 07/10/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: Treatment to right lateral foot in place, no new skin concerns noted. 07/03/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: no new areas. Treatment in place for wound to foot. 06/25/2024 - Section 1. Site/description are absent from the form; Section 2. Comments: no new skin concerns noted. 7. A review of Resident #5's admission Record revealed an admission date of 11/07/2022 with diagnoses to include unspecified superficial injury of right ankle, subsequent encounter. A review of Resident #5's July 2024 physician orders revealed: -cleanse Right Medial Ankle with ns [normal saline]/ wound cleanser pat dry apply Honey gel, Calcium Alginate cover with Border Gauze. QD & PRN every day shift for DTI (deep tissue injury) AND as needed, start date:7/16/2024. A review of Resident #5's care plans, dated 11/09/2022, revealed Resident #5 is at risk for skin impairment with a goal of no new skin impairments. Interventions included: monitor/observe skin while providing routine care, notify nurse of any area of concern as indicated, skin checks weekly and as indicated. Report any s/s (signs and symptoms) of skin breakdown to MD/wound team as indicated. A review of Resident #5's Quarterly MDS, 07/07/2024, revealed in Section C- Cognitive Patterns a BIMS score of 09, which showed moderate cognitive impairment. Section M- Skin Conditions showed the resident had a stage 3 pressure injury present at the time of that assessment. A review of Resident #5's Skin Check documents revealed skin checks dated: 07/16/2024 -Section 1: site: is a body diagram that is not marked; Section 2. Comments: open dti found to the inner right heel, family and MD (Medical Doctor) made aware. 07/09/2024 - Section 1. site, Other (specify) no further documentation in that area; Section 2: comments: open dti to the inner right heel family and MD made aware. 07/02/2024 -Section 1: site: 49) right heel- dti; Section 2: Comments: open dti found to the inner right heel family and md made aware. An interview conducted on 07/17/2024 at 11:31 AM with Staff A, Licensed Practical Nurse (LPN)/wound care, and stated she has not had a chance to document the current wound assessments, but she has the measurements and descriptions in her personal notes. She stated Resident #5 wasn't seen last week because she was off sick. Staff A went on to state that she loaded the wound care doctor's note from yesterday. Staff A stated typically anything in the wound evaluation assessment would be done by the wound care nurse. She also stated Skin Checks were not her responsibility, but that generally when she is already seeing the resident she will do the Skin Check in addition to the Wound Evaluation. She stated Because a weekly skin assessment is done, I don't do measurements in the weekly skin check, wound assessments should be done weekly She further stated, I don't monitor [Resident #5] , she is seeing outside wound care. I would still take measurements. I still try to assess her weekly. During an interview conducted on 07/17/2024 at 11:51 AM the DON stated the outside doctor should send measurements. She stated that she would expect the staff to document measurements and descriptions of wounds weekly. The DON stated she was going to call the doctor this week to get measurements, but without them being uploaded the bedside nurses wouldn't have access to the records. She stated Staff A is responsible for uploading the note so the nurse can see them. The nurses have access to review the notes. She also stated if the doctors don't send notes the unit managers should call for the documents. She said, I follow who has appointments. She stated she expects weekly documentation on wounds the wound care doctor is following to be uploaded to the electronic medical record weekly. They should also have weekly skin assessments. She stated skilled notes are not skin assessments. Every week there should be an assessment apart from the Daily Skilled Nurses Note A review of the facility policy titled Standards and Guidelines: Prevention of Skin Impairments/Pressure Injury, effective October 2020, revised January 2024, revealed under the section titled Procedure: Risk Assessment: 1. Assess the resident on admission for existing wound risk factors. 2.Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity- any evidence of existing or developing pressure ulcers or injuries; b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. a. Identify any signs of developing skin wound (i.e. nonblanchable erythema/rashes). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) c. Wash the skin after episodes of incontinence. d. Reposition resident as indicated on the care plan. A review of the facility policy titled, Standards and Guidelines: Documentation, effective October 2020, revised January 2024, revealed under the section titled Procedure: 1. Documentation in the medical record may be electronic, manual or a combination. 2.The following information is to be documented in the resident medical record: a) objective observations; c) Treatments or services performed; d) Changes in the resident's condition; 3. documentation in the medical record is required as updates/ changes in the resident's plan of care are made. 4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 8. Documentation of procedures and treatments will include care-specific details, including: a) the date and time the procedure /treatment was provided; b) the name and title of the individual(s) who provided the care; c) the assessment data and/or any unusual findings obtained during the procedure/treatment; d) whether the resident refused the procedure/ treatment; e) whether the resident refused the procedure/treatment; e) notification of family, physician or other staff, if indicated; and f) the signature and title of the individual documenting. Based on observation, interview and record review the facility failed to ensure the weekly skin assessments were performed for 8 of 39 sampled residents (#19, #362, #90, #58, #8, #267, #5). The facility also failed to ensure wound care assessments were performed for 2 of 2 sampled residents of 14 non-pressure wounds (#90, #267). Findings included: 1. On 07/15/2024 at 4:30 p.m. Resident #19 was observed sitting in her wheelchair at bedside. She was dressed and groomed for the day. She stated she went out to breakfast with her son. Her oxygen via nasal cannula was in place and at 2 liters per minute. Resident #19 stated that the staff cares for her. They answer the call lights and give her showers. She stated she had been to the hospital a couple of times for breathing problems. No odors were noted. No skin impairments were observed. Her personal items were noted. Resident #19 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included but not limited to Chronic Respiratory Failure with hypoxia, diabetes, Chronic Obstructive Pulmonary Disease (COPD), obesity, Congestive Heart Failure (CHF), hypertension with HF, stage IV chronic kidney disease, ischemic cardiomyopathy, anemia, muscle weakness, Transient Ischemia Attack (TIA). Review of the annual, Minimum Data St (MDS) dated [DATE] showed Brief Interview of Mental Status (BIMS) score of 14 (cognitively intact). Section GG, Functional Abilities and Goals showed the resident needed moderate assistance. Review of the Weekly Skin Checks dated 06/21/2024 showed no areas of concern at this time. Weekly Skin Checks were not documented 06/28/2024, 07/05/2024, 07/12/2024. Review of the care plans showed Resident #19 was at risk for skin impairment related to anemia, diabetes, incontinence, obesity, use of antiplatelet medications, weakness/decreased mobility, initiated on 06/20/2023. Interventions included but not limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 06/20/2023; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD [medical doctor]/wound team as indicated as of 06/20/2023. 2. On 07/15/24 12:58 p.m. Resident #90 was sitting in bed eating her lunch. She was slumped down in the bed, her feet were almost touching the footboard. She was dressed in a hospital gown. A dressing was noted on her right lower leg and was dated 7/14/24. The television was playing. She had juice and fluids on her overbed table. She stated she had been in the hospital a few times for surgery. She stated she had been on antibiotics since being in the hospital for a urinary tract infection. She stated she had a nephrotomy tube. She stated she was not walking but receiving therapy. She stated the last time she was in the hospital was for her leg injury. She gets transferred to the wheelchair in the Hoyer lift. She stated, she was walking, something happened, started screaming. they called 911 and sent her to the hospital. Resident #90 was admitted on [DATE] 24 and readmitted on [DATE]. Review of the admission record showed diagnoses but not limited to laceration without foreign body right lower leg on 06/27/2024, Urinary Tract Infection (UTI), diabetes, Chronic Obstructive Pulmonary Disease (COPD), cirrhosis of the liver, obesity, hypertensive heart disease, muscle weakness, anemia. Review of the 5-day MDS showed a BIMS score of 10 (moderately impaired). Section GG, Functional Abilities and Goals showed the resident was dependent for care. Review of the admission / readmission Nursing Evaluation dated 06/27/2024 showed under the Skin Evaluation: warm and intact. The skin diagram was blank. The wound of the right lower leg was not documented. Review of the Weekly Skin Check dated 06/28/2024 showed a right lower leg (front) with soft cast in place. Review of the Weekly Skin Check dated 07/02/2024 showed right lower leg hematoma ruptured. Review of the e-chart showed the Weekly Skin Checks for 07/09/2024 and 07/16/2024 was not documented. Review of the Wound Care Physician note dated 07/16/2024 showed the visit was the initial visit. The right lower leg trauma wound was not healed. It was 1 x 2 x 0.1 in size. There was 10% slough and 90% granulation. Wound to right lower leg with open wound from hematoma due to traumatic injury. Sutures in place with wound well approximated. Review of the Resident #90 care plans showed the resident was at risk for skin impairment related to anemia, diabetes, incontinence, obesity, weakness/decreased mobility, history of chronic stasis ulcers to bilateral lower extremities, initiated 06/19/2024. Interventions included but limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 06/19/2024; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD/wound team as indicated as of 06/19/2024. Review of the Resident #90 care plans showed the resident had an open area on the right anterior lower leg as of 06/19/024. Interventions included but not limited to administer medications and treatments as ordered by the MD as of 06/19/2024, complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress. Monitor for signs and symptoms of infection. Report changes to MD as indicated as of 06/19/2024; encourage and assist resident to float heels when in bed, as tolerated as of 06/19/2024; medicate prior to wound treatments if indicated. Notify MD for unrelieved pain as of 06/19/2024. During an interview on 07/17/2024 at 9:20 a.m. the Director of Nursing (DON) stated the wound care nurse performs the weekly skin checks on the residents who have wounds and are followed by the wound care doctor. If the resident was not followed by the facility's wound care nurse the floor nurses were responsible for performing the weekly skin assessment. The wound sizes are documented on the wound care doctor's notes and are to be uploaded weekly. The wound care doctor was not here last week due to being ill. The facility's wound care nurse was to measure the wounds last week and document them. The DON stated whether the skin impairment was new or old, it should be documented on the Weekly Skin Assessment. The admission nurse does look at the skin and then the wound care nurse follows-up with a skin assessment the next day or Monday if it was a weekend. The wound nurse schedules the wound care doctor, if needed. If the resident does not have a pressure ulcer or major surgical wound a Weekly Skin Check was to be scheduled. The floor nurse has to do a head-to-toe and document anything found. The DON stated if the note stated, nothing new it meant there was nothing on the body. The DON verified there was not a Weekly Skin Check performed on 07/09/2024 and 07/1602024 for Resident #90. She also verified the Weekly Skin Sheets were not performed as per the protocol for Resident #19. The DON stated the wound nurse follows the pressure ulcers which are stage III or IV or complicated surgical wounds, the floor nurses follow the other wounds. During an interview on 07/17/2024 at 11:30 a.m. Staff A, Licensed Practical Nurse (LPN), facility wound care nurse stated Resident #90 was seen by the wound care doctor yesterday (07/16/2024). Staff A stated Resident #90 was to be seen last week but the wound care doctor did not visit the facility. Staff A stated she was out after the wound care doctor was out ill for a few days. Staff A stated she does not normally follow the surgical wounds. The nurse on the floor will normally follow the small wounds and surgical wounds. Staff A stated she did not know when the soft cast was removed from Resident #90. Staff A, LPN stated she saw the wound for the first time on 07/02/2024. She stated she did not document in the chart what the wound looked like on 07/02/2024. Staff A stated it looked like a surgical site, with the incision intact, and a blistering hematoma around the surgical area. She stated she did not measure the wound at that time. Staff A stated she did not count the sutures at that time. She stated wound care orders had been put in. She stated she had seen the wound every day due to the hematoma and was performing the wound care. Staff A stated the wound care doctor saw the wound per the nurse practitioner's request. The wound care doctor changed the wound care on 07/16/2024. Staff A, LPN stated the expectation was for the wound to be seen and documentation to occur. She stated the admission nurse was to look at it (wound) and document that they looked at it (the wound). She will follow up the next day or Monday. She stated she follows the residents herself. She stated she does a head-to-toe assessment on them. The nurses are expected to go to the weekly wound care doctor notes if needed to check for wound changes. She stated weekly they were supposed to do skin assessments. During an interview on 07/17/2024 at 11:52 a.m. the Director of Nursing (DON) stated a Weekly Skin Sheet Assessment should be performed once a week. She stated all the nurses have access to the wound doctor's notes. The Wound Nurse was responsible for uploading the wound doctor's assessment notes weekly. The DON stated all the nurses have access to the wound care doctor's notes. The wound care doctor visits on Tuesday and turns his notes in on Tuesday afternoon for Wednesday to upload into the computer system. The DON stated the wound care nurse performs the Weekly Skin Sheets on residents with wounds and the other nurses are to perform the Weekly Skin Sheets weekly. The DON stated the Skilled Documentation Notes were not a substitute for the Weekly Skin Sheets. The DON verified the Weekly Skin Sheets were missing as well as the Skilled Documentation Notes. 3. On 07/15/24 12:29 p.m. Resident #8 was observed sitting in her wheelchair beside her bed, eating her lunch, of hamburger, carrots, soup, pudding, salad and fluids. She was dressed and groomed for the day. She stated she had no complaints or concerns. She stated the staff answers all the call lights. She stated she was able to take her own shower. A bruise was observed on her left upper hand. Record reviewed revealed Resident #8 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included but were not limited to Urinary Tract Infection (UTI), diabetes, Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, obesity, CHF, Pulmonary HTN, atrial fibrillation, stage III chronic kidney disease, anemia, and weakness. Review of the MDS dated [DATE] showed a BIMS score of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident needed maximal assistance with care. Review of the Resident #8 care plans showed the resident was at risk for skin impairment related to diabetes, incontinence, obesity, weakness/ decreased mobility, routine use of antiplatelet, initiated 09/12/2023. Interventions included but limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 09/12/2023; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD/wound team as indicated as of 09/12/2023. Review of the admission / readmission Nursing Evaluation dated 07/04/2024 showed no skin impairments or no documentation. Review of the Weekly Skin Check dated 07/05/2024 showed right lower leg (front) vascular ulcer 1 x 1 x 0. Upon re-admission from hospital rest of skin clear and intact at this time. Review of the e-chart showed the Weekly Skin Checks for 07/12/2024 was not documented Review of the Skilled Documentation Note showed the following: On 07/07/2024, under skin: bruise On 07/10/2024, under skin: bruise On 07/11/2024, under skin: bruise On 07/14/2024, under skin: bruise On 07/16/2024, under skin: abrasion, see below. Skin check today and nurse reported her observation on the Botox area, redness on the left side, and the right side is starting to change in color. Wound nurse for resident needs, to consult wound care doctor for evaluation and treatment. Review of the nursing progress note for 07/17/2024 showed upon skin assessment the resident was noted with unknown boil-like mass to left buttocks with purulent drainage and right lower buttocks with an excoriation, and bilateral lower extremity with redness. No edema noted at this time. When resident was asked how it happened, the resident claims to have history of boils to the buttock area. Resident made aware and MD made aware. During an interview on 07/17/2024 at 12:10 p.m. the DON verified the bruise was documented but location was not documented, and it should be. The DON verified the Weekly Skin Check was not performed weekly. The DON verified the chart was missing Skilled Documentation notes. 4. During an interview on 07/15/24 at 12:00 p.m. Resident #267 was sitting at bedside in his wheelchair. He was dressed and groomed for the day. The resident's family member was with the resident. No odors were noted. The resident had a dollar size wound area on the right side of his head with smaller areas circling it. The left foot had a dressing in place. He stated he was non-weight bearing (NWB) at this time due to the heel wound. He had a right above the knee amputation. The facility used a Hoyer lift due to his NWB of left foot, ulcer. They stated he had an ulcer on his bottom. Resident #267 was admitted on [DATE]. Review of the admission record showed the diagnoses included but not limited to surgical amputation (Right above knee), diabetes, protein-calorie malnutrition, dementia, chronic kidney disease, anemia, hypertension, squamous cell carcinoma of skin on right lower limb, muscle weakness, and abnormal gait. Review of the admission MDS dated [DATE] showed a BIMs of 15 (cognitively intact). Section GG Functional Abilities and Goals showed the resident required maximum assistance. Review of the physician orders showed: cleanse the right above knee amputation site with normal saline, pat dry, apply abdominal pad, wrap with kerlix secure with ace wrap daily and as needed as of 07/03/2024 cleanse left 1st digit / lateral foot with normal saline/wound cleanser, pat dry, apply Santyl and calcium alginate, cover with border gauze daily and as needed for the diabetic ulcer as of 07/03/2024 cleanse sacrum with normal saline/wound cleanser, pat dry, apply nystatin cream cover with border gauze daily and as needed for stage II ulcer as of 07/03/2024. cleanse left heel with normal saline/wound cleanser pat dry, apply Santyl and calcium alginate, cover with border gauze daily and as needed for stage II pressure ulcer. Review of the admission / readmission Nursing Evaluation dated 07/02/2024 showed skin tear to right antecubital, redness blanchable and open on coccyx, right knee (front) surgical incision, left heel Deep Tissue Injury (DTI), bilateral bruises to upper extremities, and bottom of left foot DTI. Review of the Weekly Skin Check dated 07/03/2024 showed 6 hemorrhoids nodules not in coccyx, AKA with 26 sutures noted right knee front, left heel DTI, fungal rash/MASD on sacrum, first digit lateral foot diabetic ulcer, and right forearm skin tear. Review of the Weekly Skin Check dated 07/13/2024 showed no new abnormalities noted. Review of the wound doctor's note dated 7/16/24 showed the visit was an initial visit. The left, medial diabetic foot ulcer was 1 x 1.5 x 1, grade I, with moderate sero-sanguineous exudate, 20% slough, and 80% granulation. The wound was to be cleansed, pat dry, apply Santyl, calcium alginate daily and prn. The left heel pressure ulcer was not healed. It was not healed. It was 3 x 5 x 0 and an unstageable pressure injury with 100% eschar. The wound was to be cleaned with betadine and leave open to air daily and prn. Review of the care plans for Resident #267 showed resident was at risk for further skin impairment related to anemia, diabetes, risk for malnutrition, weakness/ decreased mobility and cancer of right lower extremity including the hip as of 07/04/2024. Interventions included but limited to monitor/observe skin while providing routine care. Notify nurse for any area of concern as indicated as of 07/08/2024; skin checks weekly and as indicated. Report any signs and symptoms of skin breakdown to MD/wound team as indicated as of 07/08/2024. Review of the care plan open area left heel and sacrum initiated 07/04/2024. Interventions included but not limited to complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress. Monitor for signs and symptoms (s/s) of infection. Report changes to MD as indicated as of 07/04/2024. PT/OT consult/referral as needed as of 07/04/2024. Wound Care MD/APRN consult as ordered/indicated as of 07/04/2024. Review of the care plan for surgical wound to (R) above knee amputation and was at risk for complications as of 07/04/2024. Interventions included but not limited to notifying MD for any s/s of infection (redness, increased pain, purulent drainage, swelling, foul odor, etc.) as of 07/04/2024. Observe/monitor for s/s of potential complications of wound. Notify MD as indicated as of 07/04/2024. Review of the care plan for diabetic ulcer of the 1st digit lateral foot as of 07/04/2024. Interventions included but not limited monitor for worsening of wound, change in skin status ie: s/s infection, non-healing, new areas to MD and update resident/representative as indicated as of 07/08/2024. Monitor/document wound: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify MD as indicated as of 07/08/2024. Monitor/document/report PRN any s/sx of infection: [NAME] drainage, Foul odor, Redness and swelling, Red lines coming from the wound, Excessive pain, Fever as of 07/08/2024. During an interview on 07/17/2024 at 3:40 p.m. Staff A, Licensed Practical Nurse (LPN) wound care nurse stated the resident was admitted with a (R) AKA and he had multiple wounds before admission. She stated he had a diabetic ulcer on the side of his big toe on the left foot. He had a DTI on the left heel as well. She stated the resident came in with a fungal rash on his sacrum. Staff A stated there were no wound sizes or assessment since on the resident since 07/02/2024. She stated the resident was admitted after the wound care doctor had left the faciity on [DATE]. Staff A stated on 07/09/2024 she was not at the facility and the wound care doctor did not send anyone to the facility either. Staff A, LPN stated the expectation for someone to have documented something about the wounds. Staff A stated she saw the resident yesterday (07/17/2024) and today (07/18/2024) and the coccyx was closed. She stated he scratches his head constantly. On admission it looked like a regular old skin area on his head. She stated when she saw him today, it looked like he had scratched the area. Staff A stated it should have been added to a Weekly Skin Sheet when it was observed. She stated that she had not documented yes today. Staff A stated the negative outcome for lack of assessment and documentation was not being able to see if the wounds had increased and got worse. Staff A stated, No one would know. She stated the head area was a scabbing area on his head. She stated, His wound on his toe had improved, more granulation than first when she first saw it. She stated the heel wound was still bothering him and was tender. She stated they were offloading his heel. She stated she called for an order to add more cushion to the dressing for the heel. During an interview on 07/17/2024 at 3:45 p.m. the DON verified the lack of wound care assessments for the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure treatment and services for pressure ulcers were consistent with professional standards for three residents (#5, #362, and #58) of three sampled residents. Findings included: 1. A review of Resident #362's admission Record revealed an admission date of 07/14/2021 with a readmission date of 11/22/2023 and diagnoses to include pressure ulcer of sacral region, stage 4. A review of Resident #362's July 2024 physician orders revealed the following: -Cleanse Coccyx with Normal Saline/wound cleanser pat dry Apply skin prep to coccyx skin prep, apply collagen particle (collagen particle with Normal saline slurry) to wound bed cover with border foam dressing. QD (every day) and PRN (as needed). every day shift for wound AND as needed for damaged or missing dressing Active 7/3/2024 08:00 (a.m.). A review of Resident #362's July 2024 Treatment Administration Record revealed the resident's wound care was being completed as ordered. An attempt to interview Resident #362 was conducted on 07/15/2024 at 10:30 a.m. Resident #362 is not interviewable. A record review of the resident's Quarterly Minimum Data Set (MDS) revealed in Section C- Cognitive Patterns, dated 07/12/2024, a Brief Interview for Mental Status (BIMS) summary score of 00, showing the resident is not cognitively intact. In section M- Skin Conditions it revealed the presence of 1 stage 4 pressure injury that was present on admission. A review of Resident #362's care plan, dated 05/16/2024, revealed Resident #362 had an unavoidable pressure injury to his coccyx and was at risk for further skin impairment. The goal was to show signs of improvement. Interventions included: Skin checks to be weekly and as indicated. A review of Resident #362's Wound Evaluation- Weekly forms dated 06/20/2024 through 07/16/2024 revealed three Wound Evaluation forms in the electronic medical record (EMR). The Wound Evaluations were as follows: 06/20/2024: I. Wound Summary: Length: 1.4, Width: 1, Depth:0.2 1. Site: coccyx, 2. Type: Pressure Ulcer (In-House Acquired),2b. Pressure Ulcer Stage: e) Stage IV IV. Wound bed - 2. Evaluation: a. Erythema, b. warm to touch, 3b. granulation %-100%; 4. Wound color: a. Pink. 06/26/2024: I. Wound Summary: Length: 1, Width: 0.6, Depth: 0.2 1. Site: coccyx, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: e) Stage IV IV. Wound bed - 2. Evaluation: a. Erythema, b. warm to touch, 3b. granulation %-100%, 4. Wound color: a. Pink. 07/04/2024: I. Wound Summary: Length: 1.2, 3b. Width: 0.5, 3c. Depth:0.1 1. Site: coccyx, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: e) Stage IV IV. Wound bed - 2. Evaluation: a. Erythema, b. warm to touch, 3b. granulation %-100%, 4. Wound color: a. Pink. An interview was conducted on 07/17/2024 at 9:43 AM with the Director of Nursing (DON). The DON stated if a resident has an identified wound they should have a weekly wound assessment. She went on to state the bedside nurse and wound care nurse will do a weekly wound assessment not just a weekly skin check. 2. A review of Resident #58's admission Record revealed an admission date of 01/01/2023 and diagnoses to include type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus with foot ulcer, unspecified open wound, right foot, subsequent encounter. A review of the July 2024 physician orders revealed the following: -cleanse Right lateral foot with normal saline/ wound cleanser apply collagen powder to wound bed, biopad collagen dressing, tritec silver cover with border gauze and PRN. every day shift for wound care AND as needed for missing/ damaged dressing, Active 5/28/2024 15:00 (3:00 p.m.). A review of Resident #58's July 2024 Treatment Administration Record revealed the resident's wound care was being completed as ordered. A review of Resident #58's care plans, initiated on 01/11/2023, revealed Resident #58 was at risk of skin impairment. Interventions included: Skin checks to be weekly and as indicated. A review of Resident #58's Quarterly MDS, Section M, dated 04/08/2024, revealed the presence of 1 pressure wound that was facility acquired. It revealed Resident #58 has a stage 3 pressure injury. A review of Resident #58's Wound Evaluations revealed three Wound Evaluations in the EMR from 04/30/2024 through 07/16/2024. The Wound Evaluations were as follows: 05/08/2024: I. Wound Summary: Length: 1.5, Width: 1.7, Depth:0.01, 1. Site: Other: 1a. Other: Right lateral foot, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: f) Unstageable IV. Wound Bed - 4. Wound color: a. Pink, b. White. 05/23/2024: I. Wound Summary: Length: 0.4, Width: 0.5, Depth:0, 1. Site: Other: 1a. Other: Right lateral foot, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: f) Unstageable IV. Wound bed - 3b. granulation %-100%, 4. Wound color: a. Pink, b. white. 05/29/2024: I. Wound Summary: Length: 2.3, Width: 3.5, Depth:0, 1. Site: Other: 1a. Other: Right lateral foot, 2. Type: Pressure Ulcer (In-House Acquired) 2b. Pressure Ulcer Stage: f) Unstageable IV. Wound bed - 3b. granulation %-100%, 4. Wound color: a. Pink, b. white. 3. A review of Resident #5's admission Record revealed an admission date of 11/07/2022 with diagnoses to include unspecified superficial injury of right ankle, subsequent encounter. A review of Resident #5's July 2024 physician orders revealed: -cleanse Right Medial Ankle with ns [normal saline]/ wound cleanser pat dry apply Honey gel, Calcium Alginate cover with Border Gauze. QD & PRN every day shift for DTI (deep tissue injury) AND as needed, start date:7/16/2024. A review of Resident #5's July 2024 Treatment Administration Record revealed the resident's wound care was being completed as ordered. A review of Resident #5's care plans, dated 11/09/2022, revealed Resident #5 is at risk for skin impairment with a goal of no new skin impairments. Interventions included: monitor/observe skin while providing routine care, notify nurse of any area of concern as indicated, skin checks weekly and as indicated. Report any s/s (signs and symptoms) of skin breakdown to MD/wound team as indicated. An interview conducted on 07/15/2024 at 11:00 a.m. Resident #5 was found to be verbal but not interviewable. A review of Resident #5's Quarterly MDS, 07/07/2024, revealed in Section C- Cognitive Patterns a BIMS score of 09, which showed moderate cognitive impairment. Section M- Skin Conditions showed the resident had a stage 3 pressure injury present at the time of that assessment. A review of Resident #5's Electronic Medical Record revealed no weekly Wound Evaluations were completed between 6/17/2024 and 07/16/2024. Review of the EMR revealed skin checks dated: 07/16/2024: section 1: site: is a body diagram that is not marked. Section 2. Comments: open dti found to the inner right heel, family and MD (Medical Doctor) made aware., 07/09/2024: section 1. site, Other (specify) no further documentation in that area. Section 2: comments: open dti to the inner right heel family and MD made aware07/02/2024: section 1: site: 49) right heel- dti. Section 2: Comments: open dti found to the inner right heel family and md made aware. An interview conducted on 07/17/2024 at 11:31 AM with Staff A, Licensed Practical Nurse (LPN)/wound care, stated she has not had a chance to document the current wound assessments, but she has the measurements and descriptions in her personal notes. She stated Resident #5 wasn't seen last week because on Tuesday, she tested positive for COVID-19; which was about the same time the wound care doctor was out with COVID-19 also. Staff A stated she loaded the wound care doctor's note yesterday. Staff A stated typically anything in the wound evaluation assessment would be done by the wound care nurse. She also stated skin checks were not her responsibility, but that generally when she is already seeing the resident she will do the skin check in addition to the Wound Evaluation. She stated, Because a weekly skin assessment is done, I don't do measurements in the weekly skin check; wound assessments should be done weekly. She further stated, I don't monitor [Resident #5]. She is seeing outside wound care. I would still take measurements. I still try to assess her weekly. During an interview conducted on 07/17/2024 at 11:51 AM the DON stated the outside doctor should send measurements. She stated that she would expect the staff to document measurements and descriptions of wounds weekly. The DON stated she was going to call the doctor this week to get measurements, but without them being uploaded the bedside nurses wouldn't have access to the records. She stated Staff A is responsible for uploading the note so the nurse can see them. The nurses have access to review the notes. She also stated if the doctors don't send notes, the unit managers should call for the documents. She said, I follow who has appointments. She stated she expects weekly documentation on wounds the wound care doctor is following to be uploaded to the electronic medical record weekly. They should also have weekly skin assessments. She stated skilled notes are not skin assessments. Every week there should be an assessment apart from the daily skilled nurses note. A review of the facility policy titled, Standards and Guidelines: Prevention of Skin Impairments/Pressure Injury, effective October 2020 and revised January 2024, revealed under the section titled Procedure: Risk Assessment: 1. Assess the resident on admission for existing wound risk factors. 2.Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity- any evidence of existing or developing pressure ulcers or injuries; b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs (activities of daily living). a. Identify any signs of developing skin wound (i.e. nonblanchable erythema/rashes). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) c. Wash the skin after episodes of incontinence. d. Reposition resident as indicated on the care plan. A review of the facility policy titled, Standards and Guidelines: Documentation, effective October 2020 and revised January 2024, revealed under the section titled Procedure: 1. Documentation in the medical record may be electronic, manual or a combination. 2.The following information is to be documented in the resident medical record: a) objective observations; c) Treatments or services performed; d) Changes in the resident's condition; 3. documentation in the medical record is required as updates/ changes in the resident's plan of care are made. 4. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 8. Documentation of procedures and treatments will include care-specific details, including: a) the date and time the procedure /treatment was provided; b) the name and title of the individual(s) who provided the care; c) the assessment data and/or any unusual findings obtained during the procedure/treatment; d) whether the resident refused the procedure/ treatment; e) whether the resident refused the procedure/treatment; e) notification of family, physician or other staff, if indicated; and f) the signature and title of the individual documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy Dialysis Care, the facility failed to ensure ongoing communication was established between the facility and dialysis center for three residents (#33, #35 and #268) of three residents reviewed for dialysis services. Findings included: Review of the admission Record showed Resident #33 was admitted to the facility on [DATE] with diagnoses that included but not limited to End stage renal disease, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, and Dysphasia following cerebral infarction. Review of the Order Summary Report showed a current physician order dated 07/15/24 that revealed Dialysis [Tuesday]T, [Thursday]TH, {Saturday}Sat, [Local Dialysis Center] [Local Dialysis Center phone number] chair time: 12 Noon Transport Through [Local Transport Company] between 11:00- 11:15 am. Review of the Care Plan showed,Focus- At risk for complications r/t Hemodialysis dx: ESRD [end stage renal disease]. Goal- The resident will be compliant with dialysis appointments, nursing interventions and physician orders through the review date. Interventions: - Hemodialysis-Resident receives [Hemodialysis]HD every [Tuesday]T-[Thursday]TH-[Saturday]S at [Local Dialysis Center], Local Dialysis Center Phone Number]. Chair time is 11:30 am-transported by [Local Transport Company], [Local Transport Company phone number], via W/C with P/U time of 10:45 am. - Hemodialysis-Right Upper Chest dialysis access port. Monitor site for s/s of infection, pain, drainage, increased temp, edema, etc. Notify physician of abnormal findings. · Encourage resident to attend the scheduled dialysis appointments. · Avoid blood pressure, blood work, IV insertion on affected arm. · Monitor for dry skin and apply lotion as needed. · Monitor VITAL SIGNS as ordered and PRN. Notify MD of significant abnormalities. · Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Review of Resident #33's Dialysis Communication Book on 07/16/24 at 4:20 p.m., showed no communication book available and one single Dialysis Communication Form found at the nurses station. Review of the single Dialysis Communication Form dated 07/13/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. During an interview on 07/15/24 at 1:48 p.m., Resident #33 stated he went to dialysis on Tuesdays, Thursdays and Saturdays. During an interview on 07/16/24 at 4:21 p.m. Staff D Registered Nurse (RN) stated, sometimes Dialysis writes back but most of the time they do not. Staff D stated the facility was responsible for completing pre and post checks on Residents before and after dialysis treatments. Review of Resident #33's dialysis book on 07/17/24 at 8:45 AM showed no communication dialysis book available. During an interview on 07/17/24 at 9:02 a.m., the Director of Nursing (DON) stated that Resident # 33's communication book must have been left at the dialysis center yesterday as the facility cannot find it. The DON stated the Nurse was calling the Dialysis Center to see if they have it. Review of Resident #33's Progress Notes revealed no ongoing communication between the facility and dialysis center. Review of the admission Record showed Resident #35 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to End Stage Renal Disease [ESRD], Type 2 Diabetes Mellitus, muscle weakness (generalized), need for assistance with personal care and aneurysm of unspecified site. Review of the Order Summary Report showed a current physician order dated 10/27/23 Hemodialysis-Resident receives [Hemodialysis] HD every [Monday] M - [Friday]F at [Local Dialysis Center] - [Local Dialysis Center phone number]. Chair time is 0900 -transported by [Local Transport Company] , [Local Transport Company phone number] via wheelchair with P/U time of 0815. Review of the Care Plan showed, Focus- At risk for complications related to Hemodialysis dx: ESRD. Goal- The resident will be compliant with dialysis appointments, nursing interventions and physician orders through the review date. Interventions: - Hemodialysis- Right Chest Permacath dialysis access port/line. Monitor site for s/s of infection, pain, drainage, increased temp, edema, etc. Notify physician of abnormal findings. - Provide snacks/meals to go with resident on dialysis days - Resident receives [Hemodialysis] HD every [Monday] M - [Friday]F at [Local Dialysis Center] - [Local Dialysis Center phone number]. Chair time is 0900 -transported by [Local Transport Company] , [Local Transport Company phone number] via wheelchair with P/U time of 0815. - Avoid blood pressure, blood work, IV insertion on affected arm- right. - Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. - Monitor for dry skin and apply lotion as needed. - Monitor VITAL SIGNS as ordered and PRN. Notify MD of significant abnormalities. - Report abnormal labs to doctor as indicated. - Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Review of Resident #35's Dialysis Communication Book revealed the following Dialysis Communication Form entries: - Resident #35's Dialysis Communication Form dated 07/15/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. - Resident #35's Dialysis Communication Form dated 07/08/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. - Resident #35's Dialysis Communication Form dated 07/01/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. Review of Resident #35's Progress Notes revealed no ongoing communication between the facility and dialysis center. Review of the admission Record showed Resident #268 was admitted to the facility on [DATE] with diagnoses that included but not limited to Chronic kidney disease stage four (severe), chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, recurrent, mild and muscle weakness (generalized). Review of the Order Summary Report showed a current physician order dated 07/15/24 Hemodialysis-Resident receives [Hemodialysis] HD every Tuesday, Thursday and Saturday at [Local Dialysis Center]-[Local Dialysis Center address]-Chair time is-10:20 am. Transported by [Local Transport Company] [Local Transport Company phone number] w/c with P/U time of 9:30 am. Review of the Care Plan showed,Focus- At risk for complications related to Hemodialysis dx: [Chronic Kidney Disease] CKD 4. Goal- The resident will be compliant with dialysis appointments, nursing interventions and physician orders through the review date. Interventions: - [Hemodialysis] HD-Type: Right upper chest port-Permacath. Dialysis access port/line: Do not access this line-for Hemodialysis use only. - Hemodialysis- Right upper chest port-Permacath) dialysis access port/line: HD center to complete routine dressing changes. May reinforce the dressing if dislodged. May replace the dressing if unable to reinforce using sterile technique. - Hemodialysis-Offer Resident a packaged meal and/or snack on Tuesday., Thursday., Saturday. before HD appointment. -Hemodialysis-Resident receives [Hemodialysis] HD every [Monday] M - [Friday]F at [Local Dialysis Center] - [Local Dialysis Center phone number]. Chair time is 0900 -transported by [Local Transport Company] , [Local Transport Company phone number] via wheelchair with P/U time of 0815. - Avoid blood pressure, blood work, IV insertion on affected arm HD- Right upper chest port precautions-no lab draws, no BP's, etc. - Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. - Monitor VITAL SIGNS as ordered and PRN. Notify MD of significant abnormalities. - Report abnormal labs to doctor as indicated. - Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. - Work with resident to relieve discomfort for side effects of the disease and treatment. (Cramping, fatigue, headaches, itching, anemia, bone demineralization, body image change and role disruption.) Review of Resident #268's Dialysis Communication Book revealed the following Dialysis Communication Form entries: - Resident #268's Dialysis Communication Form dated 07/04/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. - Resident #268's Dialysis Communication Form dated 07/11/24 showed section Dialysis Nurse completes this section was blank. Photographic evidence obtained. Review of Resident #268's Progress Notes revealed no ongoing communication between the facility and dialysis center. During an interview on 07/17/24 at 10:50 a.m., Staff F Licensed Practical Nurse (LPN), Unit Manager (UM) stated that the Dialysis Center will fill out the Dialysis Communication Form sometimes and sometimes not. Staff F LPN, UM stated that she does not call the Dialysis Center for an update when the Dialysis Communication Form was blank but stated I will call monthly to the Dialysis Center to get updated treatment and care notes. Staff F LPN, UN stated, when the forms are not completed, I do not want to bother the Dialysis Center all the time so I just call and get the dialysis care notes monthly and then have them scanned in the resident's medical record. Staff F LPN, UM stated the facility was completing resident pre and post assessments when a Resident goes out and returns from dialysis services. Staff F LPN, UM stated we just do not always get communication back from the dialysis center. During an interview on 07/17/24 at 11:00 a.m., Staff G Licensed Practical Nurse (LPN), Unit Manager (UM) stated it is my responsibility to make the dialysis books and have flow sheets in those books. Staff G LP, UM stated if the facility did not get any communication back from the dialysis center I will call and ask for each residents' treatment notes weekly. Staff G LPN, UM stated sometimes we get a call from the Dialysis Center or we call them for ongoing communication. Staff G LPN, UM stated when phone communication occurs with the dialysis center it will be documented in the progress notes. Staff G LPN, UM stated she called the Dialysis Center and they found Resident #33's dialysis communication book and will send the book back to the facility with the Resident #33 on his next scheduled dialysis appointment tomorrow 07/18/24. During an interview on 07/17/24 at 11:36 a.m., the Director of Nursing (DON) stated that she would expect the nurses to follow up with the dialysis center every time a resident comes back from dialysis. The DON stated there should be some sort of follow up whether it is on the communication form or by a phone call. The DON stated, if the Dialysis Communication Form comes back incomplete by the dialysis center the nurse should call the dialysis center, get a follow up, and then document communication in a progress note. The DON stated that the all Dialysis Communication Forms should be scanned into the medical record under the documents tab. The DON stated, there should be ongoing communication with the dialysis center every time a Resident returns from the Dialysis Center and be documented in the Resident's medical record. Review of the facility's policy Dialysis Care revised date 08/2023 showed, Procedure: 4. Correspondence from the dialysis center will be addressed by facility staff and will be recorded in the plan of of care. 5. The facility will communicate nonadherence of the dialysis regimen to the dialysis center as well as attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation on 07/16/24 at 12:01 p.m., revealed Staff A, Licence Practical Nurse (LPN) exiting room [ROOM NUMBER] with the face shield still donned. The signage on the door stated Droplet Precautions. The Droplet Precautions sign showed, Remove face protection before room exit. Photographic evidence obtained. During an interview on 07/16/24 at 12:03 p.m., Staff A, LPN stated Sorry that was my bad; the face shield should have been taken off before I left the room. An observation on 07/16/24 at 12:13 p.m., revealed Staff B Certified Nursing Assistant (CNA) exiting room [ROOM NUMBER] with a blue surgical mask under the face shield still donned. The signage on the door stated Droplet Precautions. The Droplet Precautions sign showed, Remove face protection before room exit. Photographic evidence obtained. During an interview on 07/16/24 at 12:13 p.m., Staff B, CNA stated , I forgot to take it off when I left the room. During an interview on 07/17/24 at 5:46 p.m., the Director of Nursing (DON) stated, she would have expected the staff to don a N95 mask prior to entering a droplet precaution room and also doff the face shield and mask prior to leaving the room. The DON stated staff are expected to follow the instructions on the transmission based precaution signs. A review of the facility's Policy Standards and Guidelines: Screening, Testing, Return to work, Personal Protective Equipment, Isolation, Reporting revised date 06/24/24 showed, PPE (Personal Protective Equipment)/Hand Hygiene 1. Covid Unit- If the facility has an active Covid unit, then facility staff and visitors on the unit should wear full PPE including N95 mask and eye wear. 3. Transmission Based Precautions will be implemented and signage instructing the appropriate use of PPE's will be posted outside the resident's door. Based on observations, record review and interviews, the facility failed to ensure hand hygiene was performed during medication administration, the blood glucose monitoring machines were adequately disinfected, and blood pressure cuffs were cleaned between residents for 6 (#66, #86, #272, #67, #19, and #97) of 39 sampled residents; and the facility failed to ensure staff doffed Personal Protective Equipment (PPE) before entering/exiting two resident rooms (234 and 248) on droplet precautions. Findings included: On 07/16/2024 at 8:00 a.m. Resident #66 was observed during medication pass with Staff D, Registered Nurse (RN). Staff D, RN pushed the medication cart from the nurse's station to the resident's room. She was observed to not hand sanitize prior to medication pass. She entered the resident's room with a blood pressure machine. Staff D sat the blood pressure machine on the resident's bed and proceeded to take his blood pressure. The blood pressure was 117/68. Staff D exited the room with the blood pressure machine and sat it on the top of the mediation cart without cleaning it. Staff D proceeded to open the medication cart and started removing his medications. She had not hand sanitized. After administering the resident's medications, she exited the room and still had not performed hand sanitizing or cleaned the blood pressure machine. On 07/16/2024 at 8:15 a.m. Resident #86 was observed during medication pass with Staff H, Licensed Practical Nurse (LPN). Staff H was observed pushing the medication cart from the nurses' station and entered the resident's room with a blood pressure cuff, without hand sanitizing. Staff H took the resident's blood pressure. Staff H exited the room, applied gloves and cleaned the blood pressure cuff, removed his gloves, and did not hand sanitize. Staff H was observed touching his hair throughout the medication pass. Staff H entered the resident's room with gloves in place and took the box with the inhaler in it, into the resident's room. The resident was handed the inhaler to the resident and he took his medication. Staff put the inhaler back into the box and brought it back out of the resident's room. Staff H removed his gloves at the medication cart, he did not hand sanitize. He opened the cart and replaced the boxed inhaler back into the medication cart. He still had not hand sanitized. Staff H left the medication cart, went to the nurses' station, then down the hallway to another nurse's medication cart and retrieved insulin syringes. While returning to his medication cart, he stopped in room [ROOM NUMBER] due to the call light being on. He progressed to his cart. On his return he still had not hand sanitized. Staff H opened the medication cart and retrieved a multiple dose bottle of insulin. Staff H applied gloves without hand sanitizing. He removed the alcohol wipe from the cart and cleaned the top of the vial. He withdrew 10 units of insulin. Staff H entered the resident's room with glove in place and injected the insulin in the right arm of the resident. He removed his gloves, disposed of the syringe and washed his hands. On 07/16/2024 at 8:40 a.m. Resident #272 was observed during medication pass with Staff J, LPN. Staff J was observed applying gloves without hand sanitizing before entering the resident's room with her inhaler. Staff J exited the room and placed the inhaler on the medication cart without a barrier. Staff J removed her gloves and washed her hands. On 07/16/2024 at 8:45 a.m. Resident #67 was observed during medication pass with Staff J, LPN. Staff J was observed to not perform hand sanitizing prior to medication administration. Staff J took a blood pressure machine into the resident's room and the blood pressure was taken, 141/65. Staff J returned to the medication cart and placed the used blood pressure cuff on the medication cart. Staff J did not clean the blood pressure cuff or hand sanitize. Staff J administered the medications to the resident. She returned to the medication cart and did not hand sanitize. Staff J was observed taking the dirty blood pressure cuff back into room [ROOM NUMBER]B and taking the blood pressure of the roommate in the room. She returned to the cart with the blood pressure cuff and laid it on the cart. On 07/16/2024 at 8:50 a.m. Resident #97 was observed during medication pass with Staff K, RN. Staff K did not hand sanitize prior to medication administration. Staff K placed the used blood pressure cuff on the medication cart without cleaning it. Upon leaving the room, she had not hand sanitized. Hand sanitizing was not performed after passing the medications. Staff K was observed using the uncleaned blood pressure cuff on Resident #12. On 07/16/2024 at 10:50 a.m. Resident #19 was observed during blood glucometer monitor use and insulin injection by Staff H, LPN. Staff H was sitting at nurses' station, moved the medication cart to the resident's room. Staff H washed his hands. Staff H laid the blood glucose monitor, lancet, bottle of strips and plastic cup on top of medication cart as well as 2 alcohol wipes. Staff H applied gloves. Staff H took the blood glucose monitor, lancet, bottle of strips and laid them on the (dirty) overbed table. The table had not been cleaned and had personal items as well as food on it. Staff H placed a strip in the blood glucose monitor. He laid the blood glucose monitor back on the overbed table as well as the bottle of strips. He opened an alcohol wipe and wiped the left pointer finger. He used a lancet. wiped the finger again with alcohol and placed a drop of blood on the strip. The blood sugar level was 140. He laid the blood glucose monitor on overbed table. He then picked up the blood glucose monitor, bottle of strips and used lancet and exited room. He put the used lancet and strip in the hazardous waste. He placed the dirty blood glucose monitor in the plastic cup and placed the bottle of strips on the cart. He took the blood glucose monitor out of the cup and wrapped a wipe from the Microdot Minute container and replaced into the same cup. 1/4 of the blood glucose monitor was not covered by the wrap. Staff H removed his gloves and hand washed. He had left the computer open to names and a paper with names on the medication cart while performing the blood glucose monitoring. During an interview Staff H, LPN stated he wraps the blood glucose monitor and leaves it for 3 minutes. During the interview he locked his cart and left and walked toward the nurses' station and then down the hallway out of view. The blood glucose monitor, and bottle of strips were left on the medication cart. He returned with insulin syringes in his hand. When he returned, he washed his hands. He replaced his gloves. He removed the insulin from the medication cart, removed it from the baggie and box. He used an alcohol wipe and cleaned the top of the insulin bottle. He removed 4 units on insulin. He entered the resident room and injected the insulin into her left arm post use of alcohol. Staff H returned to the cart and threw away the syringe in the hazardous container and removed his gloves. Staff H washed his hands. During an interview following the observation, Staff H stated he wraps the blood glucose monitor and leaves it for 3 minutes. then removes the wipe and lets it dry. He stated the blood glucose monitor was to be cleaned after each use and placed in the cart. Staff H stated the blood pressure cuffs are to be cleaned with the Microdot wipes also, after each resident. Staff H stated he lets the blood pressure cuff sit also. He stated he was supposed to hand sanitize between each resident, before and after medication pass, before and after glove changes. Staff H stated he washes his hands after gloves are removed and before gloves are put on. Staff H stated he washes his hands because the hand sanitizer breaks his hands out, so he just hand washes. During an interview on 07/17/2024 at 5;32 p.m. the DON was apprised of the medication administration observation. The DON stated the staff was supposed to clean the blood pressure cuffs between residents. She stated they are supposed to hand sanitize before and after med pass, with gloves changes. The expectations were for medication boxes to not go into the resident's room, insulin was not to be left on the computer and out of a locked medication cart. The blood pressure cuffs, and blood glucose monitors need to be cleaned between residents. The DON stated they needed to instruct the staff on infection control, which included hand sanitizing or hand washing. Review of the facility's policy, Standards and Guidelines: Medication Administration, revised 01/2024 showed Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 19. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's policy, Standards and Guidelines: Hand Hygiene Infection Control, revised 6/2023 showed Standard: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: The facility acknowledges the CDC (Centers for Disease Control) guidelines to improve adherence to hand hygiene and healthcare settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in healthcare settings to promote resident safety. These guidelines state that hand washing is necessary when health care personnel hands are visibly soiled. When the hands are not visibly soiled, the CDC recommends the use of alcohol-based hand rubs by healthcare personnel for resident care to address the obstacles that health care professionals face when taking care of residents. Situations that require hand hygiene include, but are not limited to: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) Before and after performing any invasive procedure (e.g., finger stick blood sampling) Before and after entering isolation precaution settings Before and after medication administration After removing gloves or aprons Review of the facility's policy, Standards and Guidelines: Disinfecting, revised 01/2024 showed Guideline: The facility will ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal regulations, and national guidelines. Procedure: 1. EPA-registered healthcare disinfectant wipes will be used in accordance with manufacturer's instructions. An EPA- approved intermediate level disinfectant wipe is required for surfaces soiled with body fluid. Disinfectant wipes are used to clean the following items: B. Non-critical (i.e. contact with intact skin only) resident care equipment. Review of the EvenCare Proview Blood Glucose Monitoring System User's Guide, dated 2018 showed on page 40, 6. Caring for the Meter: caring for the meter is easy. Single-use medical protective gloves should be worn during disinfection procedures and also by anyone performing blood glucose testing on another person. Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Use gloves should be removed and hands washed before proceeding to the next patient. Cleaning and Disinfecting Procedures for the Meter: the EVENCARE are ProView meter should be cleaned and disinfected between each patient. Disinfection Instructions: the meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. Disinfection Instructions: step 1. Before disinfecting, clean the meter as described in Cleaning Your Meter process. Step 2. Wash hands with soap and water, put on single-use medical protective gloves. Step 3. Prepare the CaviWipe towelette or EPA-registered disinfecting wipe. Take out a wipe from the container and follow the instructions on the package. If needed squeeze the wipe slightly to remove the excess liquid. Step 4. Wipe the glucose meter thoroughly including the front, back and sides and take care not to get any liquid in the test strip port or serial port. Do not wrap the meter in a wipe. Step 5. If using the CaviWipe towelette, allow to remain wet for two minutes. For other EPA- registered disinfectant wipes allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipes instructions for use. Dispose of wipe when finished. Step 6. After disinfection, users should take off gloves and wash hands thoroughly with soap and water before proceeding to the next patient

Based on observations, interviews, and review of facility policy, the facility failed to maintain storage and labeling of drugs and biologicals in accordance with professional standards for 3 of 3 medication carts inspected. Findings included: An inspection was conducted on 1/5/2023 at 11:38 AM of a medication cart on the 400 unit of the facility with Staff A, Licensed Practical Nurse (LPN). The inspection revealed the following: - A plastic medication storage bag containing two open bottles of Brimonidine 0.2% eye drops and a bottle of Dorzolamide Hydrochloride (HCl) and Timolol 22.3 milligrams (mg)/6.8 mg solution eye drops. The medication bag was labeled to contain Brimonidine 0.2% eye drops. - A brown plastic medication storage bag containing Retacrit 4000 units injection within a clear plastic storage bag labeled refrigerate. - A plastic medication storage bag containing a bottle of Latanoprost 0.005% eye drops. The yellow Date Opened label on the plastic bag had no date documented. - A green plastic container containing a bottle of Latanoprost 0.005% eye drops. The yellow Date Opened label on the plastic bag had no date documented. - A brown plastic medication storage bag containing Prevnar 20 injection within a clear plastic storage bag labeled refrigerate. - An silver colored metal container containing a Trelegy Ellipta 100 micrograms (mcg)/62.5 mcg/25 mcg inhaler. The metal container had a white sticker affixed to it which read Discard after 42 days. The cover of the metal container had a hand written date of 11/14/22, indicating the inhaler expired on 12/26/2022. - Two silver colored metal containers containing Breo Ellipta 200 mcg/25 mcg inhalers. The metal containers each had a white stick affixed to it which read Discard after 42 days with no date documented. - A plastic medication storage bag containing a Novolog Insulin Aspart Flexpen. The bag had a hand written date of 12/6/22 written on the label. The Novolog Flexpen had a white label reading Discard after 28 days, indicating the pen expired on 1/3/2023. An interview was conducted following the observation with Staff A, LPN. Staff A, LPN stated she attempted to check the medication cart daily to ensure the medication cart contained no expired medications and to ensure medications were properly dated. Expired medications should be discarded and medication should be dated when opened. Staff A, LPN stated if a medication is supposed to be refrigerated it should remain in the refrigerator until it is ready to be administered. An inspection was conducted on 1/5/2023 at 12:23 PM of a medication cart on the 200 unit of the facility with Staff B, LPN. The inspection revealed brown plastic medication storage bag containing Aplisol 0.1 ml (milliliters) injection within a clear plastic storage bag labeled refrigerate. An interview was conducted during the observation with Staff B, LPN. Staff B, LPN stated the Aplisol 0.1 ml should be stored in the refrigerator and not in the medication cart. An inspection was conducted on 1/5/2023 at 12:30 PM of a medication cart on the 200 unit of the facility with Staff C, LPN. The inspection revealed an open vial of Novolin 70/30 insulin stored in the manufacturer's box. No dated was documented on the box or the vial to indicate when the vial was opened. Staff C, LPN stated the medication should be labeled to indicate when it was opened. An interview was conducted on 1/5/2023 at 1:55 PM with the facility's Director of Nursing (DON). The DON stated nurses should be checking the medication carts to ensure medications are not expired and medications are labeled with the appropriate date. Nurses should be filling out the included label on the medication to indicate when the medication was opened. The DON stated medications should be stored properly and if they require refrigeration, they should be stored in the refrigerator. A telephone interview was conducted on 1/5/2023 at 2:05 PM with the facility's Consultant Pharmacist (CP). The CP stated if a medication has a label on it, it should be dated when opened as a general practice. Multiple medications should not be stored in one bag and the bag should contain only the information related to the medication that it's meant for. The CP stated if a medication would require refrigeration, it should be stored in the refrigerator until it is ready to be administered. A review of the facility policy titled Storage of Medications, revised November of 2020, revealed under the section titled Policy heading the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy also revealed the following, under the section titled Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers. 4. Drug containers that have missing, incomplete, improper,, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain and promote a resident's dignity related to personal hygiene for one resident (#368) of three sampled residents. Findings included: During an interview with Resident #368 on 05/23/22 at 10:28 a.m., Resident #368 revealed he spoke to a staff member an hour ago, as they were making his bed, and told them he was wet. He stated the staff member told him she would return in twenty to thirty minutes to help. Resident #368 revealed he was still wet and this situation happens frequently. An observation made from the hall on 05/24/22 at 8:39 a.m. revealed Resident #368 sitting in his wheelchair in a hospital gown on leaving his back open and exposed. Resident #368 stated he needs to be dressed and has been sitting in his gown since 5:30 a.m. Resident #368 revealed he was not sure if anybody was going to help change him. An observation on 05/24/22 at 8:47 a.m. revealed Resident #368 was still not dressed, and his back was exposed to the hallway. During an interview with Staff U, Certified Nursing Assistant (CNA) on 05/25/22 at 9:27 a.m., Staff U stated Resident #368 will use the bathroom while he is in bed sleeping. She revealed Resident #368 wears pull ups and will rarely wet himself, will go to the bathroom if he is up and ambulating. She stated he will let her know if he wets himself and she would take him to the shower room and clean him up. During an interview with Staff W, CNA, on 05/26/22 at 11:57 a.m., Staff W stated the process for residents with pull ups for care is the same for those residents who wear briefs. Staff W revealed she checks on residents with pull ups every two hours because even though they might be able to toilet themselves, they might not wipe well on their own. Record review of Resident #368's admission Record revealed Resident #368 was admitted on [DATE] with diagnoses of morbid obesity due to excess calories, muscle weakness, need for assistance with personal care, benign prostatic hyperplasia without lower urinary tract symptoms, mood disorder due to know physiological condition and generalized anxiety disorder. Record review of the Minimum Date Set (MDS) assessment, dated 05/15/22, revealed in Section C (Cognitive Patterns) the resident had a Brief Interview for Mental Status (BIMS) score of a 13 out of 15 score indicating the resident was cognitively intact. Section G (Functional Status) revealed Resident #368 needed extensive assistance with one person to physically assist with dressing and toilet use. Section H (Bladder and Bowel) revealed Resident #368 was frequently incontinent with seven or more episodes of urinary incontinence. Review of the medical record revealed the Task Response History for Toilet Use for the dates between 05/09/22 - 05/25/22 revealed Resident #368 needed limited to extensive assistance daily. Review of the medical record revealed the Task Response History for Urinary Continence for the dates ranging between 05/10/22 - 05/25/22 revealed Resident #368 was incontinent 37 times. Review of the medical record revealed the Task Response History for Dressing for the dates ranging between 05/09/22 - 05/25/22 revealed Resident #368 needed limited to extensive assistance daily for fastening or taking off all items of clothing. Review of the facility's policy titled, Quality of Life- Dignity, revised February 2020, revealed the Policy Statement as: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. The policy further revealed: 1. Residents are treated with dignity and respect at all times .3. Some examples of ways in which respect for choices and values are exercised include .Residents are encouraged and assisted to dress in their own clothes .c. Clothing - residents are encouraged to dress in clothing that they prefer .10. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example .b. Promptly responding to a resident's request for toileting assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to develop and implement a care plan with goals and interventions related to dentures for one resident (#14) of forty-seven residents. Findings included: During observed times on 5/23/2022 at 12:20 p.m.; 5/24/2022 at 8:10 a.m. and 12:00 p.m.; 5/25/2022 at 7:50 a.m. and 12:30 p.m.; and on 5/26/2022 at 7:30 a.m., Resident #14 was observed either being assisted with eating from staff or was lying in bed with her eyes closed and with her mouth open. Resident #14 was observed with no upper or lower dentures or natural teeth. Observations during the breakfast and lunch meal service on 5/23/2022, 5/24/2022, 5/25/2022, and 5/26/2022 revealed Resident #14 was not wearing any dentures while being assisted from staff with eating. Resident #14 was unable to speak related to her medical care and services during an attempted interview in relation to her mouth care and if she had dentures. Resident #14 could not remember if she had dentures or not. Review of the medical record also revealed a Physician's Incapacity Statement, dated 2/10/2021. On 5/25/2022 at 9:33 a.m. Staff E, Certified Nursing Assistant (CNA) confirmed Resident #14 had dentures. She revealed, usually, the resident will be assisted from staff with inserting dentures in her mouth for meal services only. She was not sure if Resident #14 had dentures in her mouth for breakfast but did confirm she was not wearing dentures currently. Staff E opened the bedside dresser drawer and pulled out an orange cup with only one denture in it. She confirmed it was the upper denture and the lower denture was missing. She was not aware of how long the lower denture was missing. On 5/25/2022 at 12:30 p.m., during the lunch meal service, Resident #14 was being assisted with eating. Staff E, CNA and Staff F, CNA both confirmed Resident #14 did not have any dentures in her mouth and further confirmed they did not offer to place the upper denture in Resident #14's mouth, prior to eating both the breakfast and lunch meal today. Also, Staff E and F confirmed they were aware they should place the denture or dentures in Resident #14's mouth for meals but did not know if they were specifically care planned. On 5/26/2022 at 8:10 a.m. Resident #14 was observed in her bed with her mouth open and with her eyes closed. Resident #14, while resting and with her mouth open wide, was observed without any teeth and without any dentures. Staff E, CNA brought a breakfast tray into the resident's room and began to set up the meal, and at 8:47 a.m. she began to take a forkful of hot cereal and brought it to the resident's mouth. Resident #14 accepted the bite of food and swallowed it. The resident received a puree textured diet. Staff E assisted with a few bites of food and she confirmed the resident did not have dentures in her mouth. Staff E was not sure exactly when the resident should have her dentures in but stated the resident does not really need dentures in while she eats, because she has a pureed texture diet. Staff E did confirm staff document in the electronic record daily when the dentures are placed in the resident's mouth. Review of the admission Record revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE]. The diagnoses included senile degeneration of brain, and encounter for palliative care. Review of the current Physician Order Summary Report for the month of 5/2022 revealed orders to include: No Added Salt Pureed diet texture with thin liquids, start date of 11/9/21. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 1/27/2022, revealed: Section C - Cognitive Patterns the Brief Interview for Mental Status score was a 4, which indicated Resident #14 was not able to be interviewed with relation to care and services; Section L - Oral/Dental Status indicated No was checked for broken or loosely fitting full or partial dentures, and No for no natural teeth. Review of the most current Quarterly MDS assessment, dated 4/29/2022 revealed Section L -Oral/Denture Status had No checked for broken or loosely fitting full or partial dentures and Yes for no natural teeth. Review of the following assessments revealed: 1. Admission/readmission Nursing assessment dated [DATE]; Section A. evaluation revealed Resident has Full upper and Full lower Dentures and wears the dentures only when eating. Assessment further revealed the dentures fit properly. 2. Nutrition Full assessment dated [DATE]; Section K revealed the resident has Full/Partial dentures. The comments section of Section K revealed full dentures. 3. Quarterly/Annual Significant Change Nursing assessment dated [DATE]; Section IX Oral/Denture Evaluation, revealed the resident has no natural teeth and uses full upper and lower dentures, only when eating. 4. Quarterly/Annual Significant Change Nursing assessment dated [DATE]; Section IX Oral/Denture Evaluation, revealed the resident has no natural teeth and uses full upper and lower dentures, only when eating. The initial review of the current care plans, with the next review date of 8/8/2022, did not reveal any problem areas, with goals and interventions in relation to denture use, and denture maintenance. Review of the electronic medical record in the Task section, identified as the Certified Nursing Assistant [NAME] daily task sheets, indicated the areas where the Certified Nursing Assistants review, implement and document Activities of Daily Living tasks. Review of the [NAME] daily task sheet revealed a section for Denture use and care. The [NAME] daily task sheet revealed the following dates as Denture in use: a. Dentures used on 5/12/2022, during times to include 14:59 (2:59 p.m.) and 19:52 (7:52 p.m.). b. Dentures used on 5/13/2022, during times to include 20:30 (8:30 p.m.). c. Dentures used on 5/14/2022, during times to include 07:57 (7:57 a.m.). d. Dentures used on 5/15/2022, during times to include (did not use). e. Dentures used on 5/16/2022, during times to include 20:32 (8:32 p.m.). f. Dentures used on 5/17/2022, during times to include 08:09 (8:09 a.m.), 17:13 (5:13 p.m.). g. Dentures used on 5/18/2022, during times to include 07:40 (7:40 a.m.), 22:39 (10:39 p.m.). h. Dentures used on 5/19/2022, during times to include 16:16 (4:16 p.m.). i. Dentures used on 5/20/2022, during times to include 12:03 (12:03 p.m.). j. Dentures used on 5/21/2022, during times to include 01:55 (1:55 a.m.), 08:20 (8:20 a.m.), 16:35 (4:35 p.m.). k. Dentures used on 5/22/2022, during times to include 10:48 (10:48 a.m.). l. Dentures used on 5/23/2022, during times to include 03:19 (3:19 a.m.), 17:33 (5:33 p.m.). m. Dentures used on 5/24/2022, during times to include 14:54 (2:54 p.m.). The [NAME] also indicated documentation showing Dentures cleaned and stored for dates to include: 5/14/2022, 5/16/2022, 5/17/2022, 5/19/2022, 5/22/2022, and 5/24/2022. An interview was conducted with Resident 14's family member on 5/25/2022 at 7:35 a.m. The family member confirmed the resident should have dentures and staff are to assist her with them daily. On 5/26/2022 at 10:33 a.m. an interview with Staff GG, Care Plan Coordinator/MDS Coordinator confirmed Resident #14 had been assessed upon her admission back in 2021 related to denture use, for both upper and lower dentures. He confirmed she does not have any natural teeth and was admitted with both lower and upper dentures. He was only made aware, as of 5/25/2022, of the resident missing her lower denture. He also indicated, prior to 5/25/2022, the facility did not develop a care plan problem area to identify denture use and maintenance, with goals an interventions. Staff GG confirmed they developed one now, as of 5/25/2022, but there should have been a denture use care plan developed upon her original admission back in 2021. Staff GG also confirmed the daily task sheets for the CNAs indicate Denture in use, but does not necessarily indicate if it is both, or just lower or upper in use. A review of the Care Plans, Comprehensive Person-Centered policy and procedure, with the last revision date of December 2016, revealed the policy statement as: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The following areas in the Policy Interpretation and Implementation sections revealed: (2.) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. (7.) The care plan process will; (b) Include an assessment of the resident's strength and needs. (8.) The comprehensive, person-centered care plan will: (a) Include measurable objectives and timeframes; (b) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; ( e. ) Include the resident's stated goals upon admission and desired outcomes; (g) Incorporate identified problem areas; (k) Reflect treatment goal, timetables and objectives in measurable outcomes; (l) Identify the professional services that are responsible for each element of care; (n) Enhance the optimal functioning of the resident by focusing on the rehabilitative program, and (o) Reflect currently recognized standards of practice for problem areas and conditions. (9.) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. (12.) The comprehensive, person - centered care plans is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). (13.) Assessments of residents are ongoing and care plans are revised as information about the residents and residents' condition change. (14.) The Interdisciplinary Team must review and update the care plan; (d) At least quarterly, in conjunction with required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and interviews, the facility failed to provide treatment and services related to not assisting one resident (#72) with donning of a palm guard of a total of 21 residents with contractures. Findings included: Resident #72 on 05/23/22 at 9:59 a.m. was observed with a left-hand contracture. The resident stated she did not know where to get a splint but would like one. An observation was made on 05/24/22 at 8:30 a.m. of Resident #72. Resident #72 was without a splint/palm protector on the left hand. Review of Resident #72's admission Record indicated an admission date of 04/04/22 with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left-dominant side; hypo-osmolality and hyponatremia. Review of the Minimum Data Set (MDS) assessment, dated 04/10/22, revealed in Section G (Functional Status) Resident #72 needed extensive assistance with bed mobility, transfer, dressing, and toilet use. Resident #72 had an impairment to one side to the upper extremity (shoulder, elbow, wrist, hand). Section O (Special Treatment/Procedures/Programs) revealed Resident #72 was receiving occupational therapy that started on 04/05/22, physical therapy that on started 04/05/22, and no restorative programs being used. Review of the care plan, dated 04/12/22, revealed a focus area of Resident #72 having functional limitations R/T (related to) disease process. The goal stated the resident will receive appropriate therapy. The interventions are refer to OT, PT, and SLP (speech language pathology) treatment as ordered. During an interview on 05/24/22 at 4:26 p.m. with the Rehabilitation Director, he stated a resident was on a trial if it is necessary for a resident to have a palm protector or splint. The Rehabilitation Director stated the process for a resident to have a splint or palm protector was for them to go to therapy and therapy will determine if they would benefit from the splint or palm guard. He revealed once the referral was made and accepted then nursing was supposed to put in the order. He stated the Director of Nursing (DON) is supposed to put in the order. Review of the Occupational Therapy (OT) Evaluation & Plan of Treatment, dated 04/05/22, revealed a new goal for Resident #72. The goal stated patient will safely wear palm protector for L (left) hand as tolerated or at all times . The assessment summary under impressions revealed Resident #72 had a LUE (left upper extremity) shoulder/elbow/wrist and finger contracture due to old CVA (Cerebrovascular Accident).The Object Progress/Short-Term Goals revealed patient only able to tolerate rolled wash cloth this time. Review of the OT Therapy Progress Report, dated 04/18/22, revealed Resident #72 tolerated palm guard for ~ 2 hours w/o (without) c/o (complain of) pain . Review of the OT Therapy Progress Report dated 05/02/22 revealed Resident #72 had no redness/irritation and no c/o pain after 2.5 hours. Review of the OT Recertification & Updated Plan of Treatment revealed on 05/05/22 the goal as Patient will safely wear palm protector for L hand as tolerated or 4 hrs (hours) on/ 4 hrs off . Review of the OT Discharge summary, dated [DATE], revealed Resident #72 will safely wear palm protector for L hand as tolerated or 4 hrs on/ 4 hrs off . Review of the facility's Referral to Restorative Nursing Program, dated 05/12/22, revealed Resident #72 was referred to wear a palm protector on the L hand for 6 hours or as tolerated. The document had the signatures of the therapist, the unit manager, and restorative certified nursing assistant (CNA). Review of the Nursing In-service Form dated 05/12/22 revealed instructions of restorative splinting program with palm protector L hand x 6 hrs or as tolerated, 5 x wk (week) to maintain skin integrity, for Resident #72. An observation was made on 05/25/22 at 9:04 a.m. of Resident #72 without a palm protector on. During an interview on 05/25/22 at 9:27 a.m. with Staff U, CNA, she stated sometimes [Resident #72] goes to therapy, or the therapists come and get her from activities or from her room. She stated therapy was the one who puts on her palm guard. During an interview on 05/25/22 at 11:46 a.m. with Staff V, CNA, she confirmed she was the restorative aide and she was aware of Resident #72's palm protector. She confirmed she signed the referral about a week ago but did not put the palm protector on until today. She stated, it fell through the cracks and that's why she has not put it on until today. She stated she did not receive education on putting on the palm protector from therapy. Staff V revealed she could not put Resident #72's palm guard until the DON puts the order into the system. During an interview on 05/25/22 at 1:40 p.m. with the DON, she stated she checks all therapy referrals during the daily morning meetings. She stated if the referral is accepted, she will put in the standing order for restorative. The DON revealed she will try to put in the orders at the end of each week. The DON confirmed she was the only one who puts in the therapy orders. She stated the expectations are for restorative to wait until the order is put in before placing a splint or palm protector onto the residents. The expectation was for therapy to conduct education with restorative on how to place a splint or palm guard onto the resident. The DON revealed the reason why the order was not placed into Resident #72's chart until the 24th (5/24/22) was because she was behind. The DON revealed she was not aware of the order until therapy came and told her about Resident #72's palm protector yesterday. The DON confirmed her signature on the Referral To Restorative Nursing Program dated 05/12/22. Review of the facility's policy titled, Resident Mobility and Range of Motion, revealed in the Policy statement .2. Residents with limited range of motion (ROM) will receive treatment and services to increase and/or prevent further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure one (#115) out of five residents sampled for unnecessary medications received medications according to physician orders regarding a duplication of insulin orders and administration of anti-hypertensive medication outside of parameters. Findings included: Review of the admission Record revealed Resident #115 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified type 2 Diabetes Mellitus with diabetic neuropathy, atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm, and hypertensive heart disease with heart failure. A review of Resident #115's May 2022 Medication Administration Record (MAR) identified the following orders: - Admelog SoloStar 100 unit/milliliter (u/mL) Solution pen-injector. Inject as per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus. The order started on 4/16/22 and was discontinued on 5/24/22. - Humalog KwikPen 100 u/mL Solution pen-injector. Inject as per sliding scale subcutaneously before meals and at bedtime for diabetes. The order started on 5/21/22. - Norvasc 2.5 milligram (mg) - Give one tablet by mouth one time a day for hypertension (HTN). Hold if systolic blood pressure (SBP) less than 140. The order started on 4/15/22. A review of Resident #115's May MAR indicated the resident was administered 4 units of the fast-acting insulin Admelog for a blood glucose level of 222 on 5/21 scheduled at 8:00 p.m. and 2 units of Admelog for a blood glucose level of 164 at 10:00 a.m. on 5/23/22. A continued review of the MAR identified the resident was administered the fast-acting insulin Humalog at 8:00 p.m. on 5/21 for a blood glucose level of 224 and 2 units on 5/23 at 10:00 a.m. for a blood glucose level of 164. The review of the resident's MAR identified the resident received 2 doses of different fast-acting insulins on 5/21 at 8:00 p.m. and at 10:00 a.m. on 5/23/22. On 5/24/22 at 5:25 p.m. a review of Resident #115's May MAR was conducted with the Director of Nursing (DON) and the Regional Director of Nursing (RDON). The RDON stated good nursing practice would be for nursing to clarify the orders for both fast-acting insulins, Admelog and Humalog. She stated they [the facility] would clarify the orders right now. On 5/25/22 at 12:52 p.m. Staff M, Station 1 Unit Manager, stated that usually when pharmacy recommends changing Admelog to Humalog they send a discontinue order but this recommendation did not indicate to discontinue the Admelog. The staff member reviewed and identified the resident received 2 units of Admelog and 2 units of Humalog on 5/23/22. The DON stated, on 5/25/22 at 1:29 p.m., the physician identified that Resident #115 was not supposed to receive 2 different insulins per sliding scale. She stated when the pharmacy sent the medication interchange, they did not send a discontinue order for the other insulin. She stated the facility did an in-service the night before regarding all pharmacy orders are to be clarified and confirmed with the physician. She stated staff were to review the medication list and confirm there are no duplicates. She indicated the facility did not receive The Automatic Therapeutic Interchange until 5/25/22 at 3:19 p.m. The Automatic Interchange identified on 5/19/22 the facility was to discontinue Insulin Lispro Kwikpen (Admelog) and to start Humalog Kwikpen per sliding scale. The interchange was not signed by the nurse. A review of Resident #115's April 2022 MAR identified the resident was administered 2.5 milligrams of Norvasc (amlodipine) on 4/15 ( blood pressure 128/77), 4/16 (132/71), 4/17 (129/79), 4/18 (135/89), 4/20 (137/77), 4/23 (120/76), 4/25 (137/78), 4/26 (129/89), 4/27 (135/76), 4/28 (132/67), and 4/29/22 (131/66). The MAR indicated the anti-hypertensive was to be held if the systolic blood pressure was less than 140. The April MAR identified Resident #115 received Norvasc 11 times out of 15 opportunities outside of the parameters set by the physician. The May 2022 MAR for Resident #115 indicated the medication Norvasc was to be held for a SBP less than 140. The MAR identified the resident had been administered the medication on the following despite a systolic blood pressure that was less than 140: 5/4 (127/77), 5/5 and 5/6 (111/75), 5/7 (120/68), 5/9 - 5/11 (136/78), 5/12 (130/70), 5/14 (138/68), 5/15 (124/65), 5/16 (132/74), 5/20 - 5/21 (136/72), 5/22 (131/87), 5/23 (126/78), 5/24 (128/73), and 5/25/22 (128/68). The MAR indicated the resident received Norvasc 17 out of 25 opportunities despite the parameters set by the physician. On 5/26/22 at 11:32 a.m., the DON reviewed the May MAR and stated staff should have been holding Norvasc for a systolic blood pressure of less than 140 as ordered then notify the physician. She confirmed that a checkmark on the MAR did indicate the medication was administered and a review of the progress notes indicated staff did not document the medication was held. The policy titled, Administering Medications, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed. The Interpretation and Implementation identified that Medications are administered in accordance with prescriber orders, including required time frame, and If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure one (#115) out of five residents sampled for the administration of unnecessary medications was monitored for behaviors and side effects related to the use of psychotropic medications. Findings included: Review of the admission Record revealed Resident #115 was admitted on [DATE]. The admission Record included diagnoses not limited to generalized anxiety disorder and primary insomnia. The April 2022 Medication Administration Record (MAR) indicated Resident #115 received the psychotropic medication Buspirone twice daily and Alprazolam three times a day for anxiety, both of which began on 4/15/22. A review of the April MAR and Treatment Administration Record (TAR) did not indicate staff were monitoring the resident for exhibited behaviors or side effects related to the administration of the psychotropic medications. The May 2022 MAR and TAR identified Resident #115 was administered 30 milligrams (mg) of Buspirone twice daily and 0.25 mg of Alprazolam three times daily for anxiety. The psychotropic medications were started on 4/15/22. A review of the May MAR and TAR identified staff were not documenting the monitoring of behaviors or possible side effects related to the administration of the psychotropic medications. The care plan for Resident #115 identified the following: - Used anti-anxiety medications related to anxiety disorder and instructed staff to monitor for side effects and effectiveness every shift, with a target date of 5/6/22. - Used psychotropic medications related to behavior management, disease process bipolar disorder (d/o), with a target date of 7/22/22. The interventions identified staff were to monitor for side effects and effectiveness every shift and to monitor/document/report as needed any adverse reactions of psychotropic medications. - Exhibits the following behaviors: mood disorders, resists care, verbally aggression, diagnosis (dx) bipolar d/o, requested room change then refused the room offered. The interventions instructed staff to monitor and document behaviors and potential causes. The Director of Nursing (DON) stated, on 5/26/22 at 11:40 a.m., staff should be monitoring behaviors for psychotropic medications every shift. She reviewed Resident #115's May MAR and TAR and confirmed that neither the behaviors and/or side effects were being documented for Resident #115. The policy, Behavioral Assessment, Intervention, and Monitoring, revised December 2016, indicated The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy identified that The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: onset, duration, intensity, and frequency of behavioral symptoms. When medications are prescribed for behavioral symptoms, documentation will include: a. Rational for use; b. Potential underlying causes of the behavior; c. Other approaches and interventions tried prior to the use of antipsychotic medications. d. Potential risks and benefits of medications as discusses with the resident and/or family; e. Specific target behaviors and expected outcomes; f. Dosage; g. Duration; h. Monitoring for efficacy and adverse consequences; and i. Plans (if applicable) for gradual dose reduction.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Forty medication administration opportunities were observed and five errors were identified for four residents (#42, #268, #17, and #49) of seven residents observed. These errors constituted a 12.5% medication error rate. Findings included: 1. On 5/24/22 at 4:29 p.m., an observation of medication administration with Staff P, Licensed Practical Nurse (LPN), was conducted with Resident #42. The staff member dispensed the following medications: - Humalog Kwikpen 4 units - Humulin N 37 units - Carvedilol 6.25 milligram (mg) tablet - Acetaminophen 325 mg - 2 tablets. Staff P, LPN primed the Humalog pen appropriately then primed the Humulin N insulin pen while holding the pen with the needle pointing downwards. Staff P injected the Humulin and she was taking the pen away the insulin squirted in an arc out of the tip. Staff P identified that had never happened before. According to the manufacturer (https://uspl.lilly.com/humulinn/humulinn.html#ppi), users should prime the pen prior to each injection. The manufacturer instructions identified that by priming the pen it removes the air that collects during the normal use and ensures the pen was working correctly. The method for priming was to turn the dose knob to 2 units, hold the pen with the needle pointing upwards, tap the cartridge to collect air bubbles at the top, and while continuing to hold the pen upwards press the dose knob until it stops, and hold for 5 slow seconds. 2. On 5/24/22 at 5:03 p.m., an observation of medication administration with Staff Q, Registered Nurse (RN), was conducted with Resident #268. The staff member dispensed the following medications: - Oxycodone/Acetaminophen 10/325 mg tablet - Fluticasone/Salmeterol 100/50 microgram (mcg) inhalation - Gabapentin 300 mg capsule - Lamotrigine 25 mg - 2 tablets - Topiramate 200 mg tablet - Insulin Lispro (Humalog) 12 units. Staff Q dialed the Humalog pen to 12 units and injected the insulin into the resident's left upper arm without priming the pen. Staff Q stated, on 5/24/22 at 5:21 p.m., that kind of pen (Humalog) did not have to be primed after priming it for the first time. A review of the manufacturer instructions for Humalog (https://uspl.lilly.com/humalog/humalog.html#ug1) revealed priming of the insulin pen should be done prior to each injection. The literature indicated priming the insulin pen is meant to remove the air from the needle and cartridge that may collect during normal use and ensures the pen was working correctly. The priming to the pen was done by turning the dose knob to 2 units and while holding the pen with the needle up, tap the cartridge gently to collect air bubbles at the top, while holding the pen upwards, push the dose knob until it stops and hold the dose knob for 5 slow seconds. 3. On 5/25/22 at 9:24 a.m. an observation was conducted with Staff D, LPN with Resident #17. The staff member dispensed the following medications: - Keflex 500 mg capsule - Multi-Vitamin with mineral tablet - Sodium Chloride 1 gram (gm) tablet - Vitamin C 500 mg tablet - Prezcobix 800 mg/150 mg tablet - Tivicay 50 mg tablet Staff D administered oral medications and then obtained a blood glucose level of 193. During the observation the breakfast meal cart was observed being removed from the hallway. Staff D removed a Flexpen of Novolog from the medication administration refrigerator. The administration of the resident's Novolog continued at 10:08 a.m. on 5/25/22. Staff D primed the Novolog Flexpen with 2 units, then injected 2 units per sliding scale into the resident's left upper extremity. A review of the May 2022 Medication Administration Record (MAR) for Resident #17 indicated an order: - Novolog FlexPen 100 unit/milliliter (mL) pen injector per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus (DM). The MAR identified the scheduled time for administration of the Novolog for the resident was at 6:00 a.m., 10:00 a.m., 4:00 p.m., and 8 p.m. According to the Meal Times and Tray Delivery Schedule provided by the facility, the delivery of the lunch meal cart to Resident #17's hall was scheduled to be delivered for 12:40 p.m. (2 hours and 40 minutes after the scheduled administration of Novolog). The manufacturer website, https://www.mynovoinsulin.com/insulin-products/novolog/home.html, indicated NovoLog® is a rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes. It has been proven to help control high blood sugar in people with diabetes when taken with a long-acting insulin. NovoLog® starts acting fast. Eat a meal within 5 to 10 minutes after taking it. The policy titled, Insulin Administration, revised September 2014, identified The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. The policy did not include instructions on the administration of insulin via an insulin pen. 4. On 5/25/22 at 9:48 a.m., an observation was conducted with Staff D, LPN with Resident #49. The staff member dispensed the following medications: - Ibuprofen 800 mg as needed tablet - Magnesium oxide 400 mg tablet - Aspirin 81 mg chewable tablet - Buspirone 10 mg tablet - Furosemide 20 mg - 3 tablets - Famotidine 20 mg tablet - Gabapentin 600 mg tablet - Pantoprazole 40 mg tablet - Carvedilol 3.125 mg tablet - Oxcarbazepine 300 mg tablet - Spironolactone 25 mg tablet. Staff D identified the resident's Calcium was not available in the prescribed dosage and Staff C, RN/Unit Manager offered to obtain the resident's Potassium and Lisinopril from the Emergency Drug Kit (EDK). The medication administration for Resident #49 continued at 11:27 a.m. on 5/25/22 with Staff D dispensing the following: - Lisinopril 2.5 mg - 2 tablets - Potassium Chloride granules 20 milliequivalent (meq) tablets - Calcium with Vitamin D 600-200 mg/unit (one time order obtained during administration) - Lactulose 10 g/15 milliliter (mL) - 15 mL - Fluticasone/Salmeterol 100 mcg/50 mcg one inhalation. Staff D confirmed she dispensed 15 mL of Lactulose and the observation identified the 30 mL medication cup was approximately half full. Staff D was observed, on 5/25/22 at 10:07 a.m., dispensing the oral medications, then Lactulose, then the resident was observed inhaling one puff of the activated inhalation powder. Staff D did not instruct Resident #49 to rinse mouth after use. A review of the May 2022 MAR for Resident #49 identified the following: - Lactulose 30 mL by mouth three times a day for constipation - Fluticasone/Salmeterol 100-50 dose Aerosol Powder. The physician order indicated the resident was to rinse mouth after use, do not swallow. According to https://www.mayoclinic.org/drugs-supplements/fluticasone-and-salmeterol-inhalation-route/proper-use/drg-20063110?p=1, the proper use of a Fluticasone/Salmeterol inhaler is to rinse mouth with water after each dose to possibly prevent hoarseness, throat irritation, and mouth infection but do not swallow the water after rinsing. The policy titled, Specific Medication Administration Procedures, dated April 2018, identified For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup. An interview on 5/26/22 at 9:01 a.m. was conducted with the Consultant Pharmacist. The Consultant stated the optimal administration of (fast-acting) insulin was within an hour of the meal and the insulin pens are to be primed to ensure the dosage was accurate, per the manufacturer's recommendation. On 5/26/22 at 2:01 p.m., the Director of Nursing (DON) reported insulin pens should be primed before each injection and it did not matter what type of insulin or pen it was. She stated after Fluticasone/Salmetrol inhalation the mouth should be rinsed out. The DON stated the times for insulin administration were going to be changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to 1. ensure one medication cart (400-hall) out of four medication carts and two out of two treatment carts (Station One carts) were locked while unattended, 2. opened insulin vials/pens (9) were dated to ensure the medication was discarded when expired, and 3. ensure one insulin vial (Lispro) was refrigerated when unopened. Findings included: 1. An observation was made, on [DATE] at 10:31 a.m. of two unlocked treatment carts parked across from Station One nursing station. (Photograph Evidence Obtained) The Director of Nursing (DON) was standing at the nursing station with her back to the carts. Staff M, Unit Manager (UM), confirmed the carts should have been locked and they (facility) were possibly doing treatments and did not lock the carts. On [DATE] at 11:12 a.m., an observation was made of an unlocked medication cart outside of room [ROOM NUMBER]. The observation indicated a person could move in between the cart and the doorway of the room. Staff R, Licensed Practical Nurse (LPN) came out of room [ROOM NUMBER] and confirmed the cart should not be left unlocked. 2. An observation was made on [DATE] at 7:52 a.m. of Station 1 Cart 2 medication cart. Staff S, LPN began the observation when an insulin pen was identified as opened and undated. The Staff S asked for the off going LPN (Staff T) to continue the observation. The review of the medication cart revealed the following and was confirmed by Staff T: - One opened, undated Novolog FlexPen. - One insulin Glargine opened and undated. - One insulin Lispro KwikPen opened and undated. Label indicated the pen should be discarded after 28 days. - One insulin Lispro KwikPen (Humalog) opened and undated. - One Humalog 75/25 insulin pen opened and undated. - One insulin Glargine Injection pen, opened and undated. - One insulin Lispro KwikPen (Humalog) opened and undated. - One insulin Lispro KwikPen (Humalog) opened and undated. - One vial of insulin Lispro unopened and undated. The pharmacy label indicated the vial was dispensed on [DATE]. - One vial of insulin Glargine opened and undated. - One vial of Humulin R insulin indicated Do Not Use After 31 Days. The label did not indicate an opened date or specific expiration date. - One vial of insulin Lispro, unopened and undated. The labeled indicated the insulin should be discarded after 28 days. - One 30 fluid ounce Pro-Stat liquid protein, approximately 1/4 full that was undated as to when the bottle was opened. The label identified to Discard 3 months after opening. The Consultant Pharmacist stated, on [DATE] at 9:15 a.m., that insulin (containers) should be dated as to when it was opened. The policy, Storage of Medications, revised [DATE], indicated Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. The policy, Insulin Administration, revised [DATE], instructed staff to Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening.) A review of the manufacturer instructions for Lispro (also known as Humalog), found at https://uspl.lilly.com/humalog/humalog.html#ug1, revealed: 16.2 Storage and Handling Dispense in the original sealed carton with the enclosed Instructions for Use. Do not use after the expiration date. Unopened HUMALOG should be stored in a refrigerator (36° to 46°F [2° to 8°C]), but not in the freezer. Do not use HUMALOG if it has been frozen. In-use HUMALOG vials, cartridges, and HUMALOG prefilled pens should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded, even if they still contain HUMALOG. (Photographic Evidence Obtained)

Based on observations, facility record review and staff interviews, the facility failed to ensure one courtyard, where residents frequent during the day to engage in smoking activities, was maintained and cleaned related to multiple used cigarette butts found on sidewalks, grass, dry landscaping and tabletops for three days (5/23/2022, 5/24/2022 and 5/25/2022) of four days observed. Findings included: During tours of the facility's outdoor courtyard on 5/23/2022 at 11:30 a.m. and 1:45 p.m.; 5/24/2022 at 9:08 a.m. and 11:10 a.m.; 5/25/2022 at 10:00 a.m. and 11:40 a.m.; and on 5/26/2022 at 7:55 a.m., the outside courtyard area where residents frequented daily either to get fresh air or to participate in group smoking activities, was observed with multiple used cigarette butts flicked and strewn on the various grassed and landscaped areas as well as on concrete walking surfaces and table tops. (Photographic Evidence Obtained) During various times of each of the days observed, there were approximately ten to fifteen residents who came out during scheduled smoking times (8:00 a.m., 11:00 a.m., 1:30 p.m.), to smoke and were supervised by staff. The above observations revealed many cigarette butts strewn near the cigarette butt disposal can and on the ground at and near the tables with ashtrays. On 5/23/2022 at 11:30 a.m. Staff A, Activities Aide and Staff B, Central Supply revealed they supervise the residents with smoking during the scheduled times and they pass out cigarettes, lighting devices, smoking aprons if needed, watch the residents smoke, and monitor for safety. Staff A and B confirmed there were various ash trays throughout the courtyard and residents should be using them when they are done smoking a cigarette. Neither Staff A or B would confirm if they saw residents flick or throw cigarette butts in the grass and landscaped areas but did confirm that residents should not be doing that. Staff A and Staff B also confirmed the many cigarette butts strewn throughout the courtyard and did not know who's responsibility it was to pick them up. On 5/26/2022 at 7:55 a.m. a tour was conducted with the Maintenance Director out in the facility courtyard. The Maintenance Director confirmed the many used cigarette butts strewn throughout the courtyard landscaping and grass areas and said he tries to get out and pick up the cigarette butts daily. He confirmed residents were not following rules by sticking or dropping used cigarette butts into the safety ashtray or cigarette butt can. He stated the staff monitoring for smoking should see when cigarette butts are thrown on the ground and should either tell residents they can't do that or report it to management. The Maintenance Director did confirm he picks up cigarette butts from the courtyard landscaped area often but did not have a set schedule for it. An interview with the Director of Nursing and the Regional Nursing Consultant on 5/26/2022 at 2:00 p.m. revealed the facility did not have a specific policy that included outside smoking rules when and where to dispose of cigarette butts. They both revealed staff should be trained and in-serviced to monitor residents during the entire smoking scheduled times and if they see residents flicking, throwing, or dropping cigarette butts in areas that are not designated; to include cigarette ash trays, they should educate the residents and or report it to management. A review of the policy titled, Smoking Policy - Residents, revised July 2017, revealed the policy statement as, The facility shall establish and maintain safe resident smoking practices.

Based on observations, facility record review and staff and resident interviews, the facility failed to ensure implementation of an effective pest control program for four of four days observed to include 5/23/2022, 5/24/2022, 5/25/2022 and 5/26/2022. It was determined there were wasp/hornet like flying insects and several wasp/hornet like nests and mud dauber (type of wasp) nests in the facility courtyard where residents frequent most of the day. Findings included: During brief tours of the facility courtyard frequented by residents daily, on 5/23/2022 at 11:30 a.m., 5/24/2022 at 9:08 a.m. and 1:20 p.m., 5/25/2022 at 10:00 a.m. and on 5/26/2022 at 8:00 a.m., many wasp/hornet like nests were observed attached to the inside door wall light housings and stuck on various areas under roof overhangs. (Photographic Evidence Obtained) While residents were outside and spread throughout the courtyard, the outside doors leading into the facility's 200 and 400 unit television lounges, were observed with five flying wasp like/hornet like insects. Further observations revealed wasp/hornet like nests inside two of two door wall light housings. There were several wasp like/hornet like inside the light housing as well. Further observations revealed wasp/hornet like flying insects buzzing around residents, who were entering and exiting the doorway area. There were two observations of wasp/hornet like insects landing on the back of a resident occupied wheelchair and then flying away. Also, along all four outer walls in the courtyard, to include roof overhangs and over resident room windows, over ten mud dauber (type of wasp) nests with holes leading into the nests were observed. Some nests were verified with actual flying insects and some of these nests were vacated. (Photographic Evidence Obtained) On 5/23/2022 at 11:23 a.m. an interview with Staff A, Activities Aide and Staff B, Central Supply both confirmed residents come out to the courtyard during specified times and are supervised, especially during smoking times. Staff A and B confirmed various wasp/hornet like nests throughout the outdoor courtyard area, to include two mud dauber nests on the upper wall overhang, where they were both standing. A continued interview with Staff A and Staff B revealed they did not really think about the nests but have been seeing more and more wasp/hornet like insects flying around the entire courtyard and entrance/exit door areas at the 400 and 200 lounges. Neither Staff A or Staff B reported wasp/hornet like insects, or the nests to management or the maintenance department. Interviews with Residents #49, #108, #32, #97, #33, #318, who confirmed they frequent the courtyard several times a day, and every day; all confirmed they had seen hornets/wasps when coming out to the courtyard from the 400 unit lounge area. Some indicated they swat at the hornets/wasps but have never been stung. The residents interviewed could not remember if they have reported the nests or flying insects to staff but would want for them to be removed so they do not get stung. On 5/26/2022 at 7:55 a.m. a tour was conducted of the facility courtyard with the Maintenance Director. The Maintenance Director confirmed the wasp/hornet like nests inside both wall light housings near the entrance/exit doors on both the 400 and 200 halls. He also confirmed the mud dauber nests along various walls near and at the roof overhangs and throughout the entire courtyard. The Maintenance Director confirmed there was a pest control program but was not aware if the pest control company treats for wasps, hornets, or mud daubers. He revealed he has a wasp/hornet spray and treats wasp/hornet nests and knocks down the mud dauber nests that are built up on the facility walls and roof overhangs. He indicated he does not have a specific timeframe to look out for various nests in resident frequented area but looks often and also relies on staff to tell him when they identify nests. The facility's pest control contract, which was prepared and revised as of 5/25/2021, revealed in Section B, the targeted pests included bees, wasps, yellow jackets, up to 10 feet on the structure and within 20 feet of the structure perimeter. It was indicated the pest control company was responsible for the treatment of wasps, hornets, bees, and yellow jackets. Review of the pest control visits for the dates of 5/24/2022, 5/6/2022, 4/15/2022 and 4/1/2022 did not indicate treatment for wasps, hornets, yellow jackets, or bees. On 5/26/2022 at 11:00 a.m. an interview with the Nursing Home Administrator, and the Maintenance Director confirmed they were not aware if the pest control company was to treat for hornets/wasps, bees; but the facility staff, to include the maintenance department, should have treated the courtyard for these flying insects on their own.

Based on observations, interviews and policy reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen related to not labeling or dating foods, not maintaining refrigerator and freezer temperature logs, not implementing cleaning schedules and not utilizing sanitizing buckets for three days (5/23/22, 5/24/22 and 5/25/22) of four days observed. Findings included: On 05/23/2022 at 9:26 a.m., the initial kitchen tour was conducted with Staff J, [NAME] Manager. An observation of the walk-in cooler revealed no thermometer found inside the cooler. Also observed were food items not properly labeled and or dated to include: two opened containers of cottage cheese, white sliced cheese wrapped in clear plastic, an opened package of sliced turkey, a container of fruit (pale yellow in color and appeared to be diced) and a partially used pan of red gelatin with no date. Staff J, [NAME] Manager stated (red gelatin) was used as a dessert and was not sure exactly when, but it was for a supper meal. In addition, several food products were found with labels but no dates to include pound cake, chocolate pie, and whipped topping. Four packages of opened and partially used bread and rolls were located on the top shelf with no dates. On a cart were three trays with spilled liquid on them and lidded cups, approximately a total of 20-24 cups per tray which appeared to be filled with orange juice. The cups or trays were not labeled or dated. The floor of the walk-in was found to have a build-up of dirt and debris in the corners and running alongside of the wall and floor underneath the shelving unit. Staff J stated she was unsure of why there was no thermometer in the cooler or why staff were not labeling and dating products. Continuing with the tour an observation of the walk-in freezer revealed no thermometer was found inside. No dates of receipt were observed on cases of frozen parbaked rolls, mighty shakes, magic cups, pound cake, pie shells, and stuffed shells. Frozen meat products of roast beef and ground beef that were removed from the original box sitting on a metal, two tier cart was observed with no dates. In addition, an observation of the reach in refrigerator revealed no thermometer inside and three gallons of opened milk, not dated. The initial tour continued with Staff J and the observation of the dry storage room revealed no dates on several opened and or partially used food products, which included: a half-used bag of pasta, a bag of opened breadcrumbs, several packages of opened hot dog rolls. Additional observations during the tour revealed no sanitizing buckets being used and only one green bucket for cleaning was located under the cook's shelf with dirty water. Staff J, [NAME] Manager was not able to confirm if there was a policy or procedure related to the use of sanitizing buckets. In addition, a large industrial size circulating fan, located near the end of the tray line station was observed to have buildup of greasy dirt and debris covering the protective metal screen and the blades of the fan. At the time of the observation the fan was plugged in but not on. An observation was made of the four air vents located in the kitchen ceiling and dish room ceiling were noticeably wet with moisture and had signs of rust. During the tour, no cleaning schedules were observed posted or in binders anywhere in the kitchen to confirm kitchen cleaning was assigned and being completed daily. Staff J was not sure where they were located. An observation of the kitchen on 5/23/2022 at 12:00 p.m. revealed the large circulating fan was turned on and pointed in the direction of the steamtable and tray line during meal service. The fan still had dirt and debris on the protective screen. Also observed were several light fixtures in the ceiling, located above the steam table and reach in freezer with clear visibility of dead bugs inside the base of the light covers. A request was made at this time of Staff H, Regional Dietary Manager for documentation of recorded temperatures for the refrigerators and freezer and cleaning policies and schedules. This information was not provided to the survey team at the time of exit on 5/26/22. On 05/24/2022 at 4:43 p.m. an observation of the kitchen and interview with Staff H, Regional Dietary Manager revealed no sanitizing buckets in use. An observation inside the walk-in-cooler revealed on the shelf an open box containing portions of one ounce pre-package cream cheese and several 4-ounce cups of juice opened and leaking inside the box, along with an undated opened bag of whipped topping. An observation of the dry storage room revealed a clear plastic zip-closed bag of biscuits not labeled or dated, an opened box of jelly packets which contained several packets split open and a dark purplish-red dried substance was observed on the inside of the box. Staff H, at this time, stated he has not been in the facility in about seven months and was unaware of the issues. On 05/25/2022 at 10:00 a.m. an observation and interview with Staff H, Regional Dietary Manager, during an additional walk through of the kitchen revealed, three red sanitizing buckets not filled or being used. Also observed was a foam carton of food left over from breakfast and stored inside the microwave. Staff H stated it must be for an employee to have on break. Staff H, disposed of the container. The observation also showed dried food splatter inside of the microwave. Additional observations revealed five large boxes of juice base concentrate attached to the juice machine and undated. Further observations at this time of the walk-in cooler revealed a bucket of cottage cheese with a use by date of 5/23/2022, two open jugs of Italian salad dressing undated, and a roasting pan covered with plastic wrap with unknown food items that was not labeled or dated. On 05/25/2022 at 12:05 p.m. Staff H was provided with a second request for the missing documentation for staff cleaning schedules, and a policy for use of the sanitizing buckets. On 05/26/2022 at 10:56 a.m., an interview was conducted with Staff H, Regional Dietary Manager. Staff H stated he was unable to locate the cleaning policies or schedules. On 05/26/2022 at 11:45 p.m. Staff H, Regional Dietary Manager confirmed food items should be labeled, dated, and stored in sanitary conditions per regulation and policy. He stated the cleaning task should be completed after each shift and daily. Staff H, Regional Dietary Manager stated he will begin to in-service all employees regarding labeling and dating, taking, and recording of dish machine temperatures, implement daily weekly and monthly cleaning schedules, recording of temperatures for all refrigerators and freezers as well as cleaning and sanitizing of all equipment with regards to the proper use of the sanitizing buckets with documentation. A review of a policy titled, Food Receiving and Storage, with an effective date of 01/15/2021, showed the policy statement was to ensure: 1) Food Services staff will always maintain clean food storage areas. 7) Dry foods that are stored in bins will be removed from original packaging, labeled, and dated, such foods will be rotated using a first-in-first out system, 8) All foods in the refrigerator or freezer will be covered, labeled, and dated (use by date) 12) Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee. Photographic Evidence Obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interview, telephone interview with the Ombudsman and review of facility policies and procedures, the facility failed to ensure notification of transfers was made to the Office of the State Long-Term Care Ombudsman for one (#79) of three residents reviewed for transfer and discharge rights. Findings included: Review of Resident #79's admission Record revealed she was originally admitted to the facility in June of 2021, re-admitted on [DATE], and discharged to a local hospital on 9/1/2021. A review of a nursing progress note dated 9/1/2021 noted: Resident discharged to hospital via Emergency Medical Services due to respiratory distress. A review of the Nursing Home Transfer and Discharge Notice (AHCA Form 3120) revealed no indication that the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer. On 9/22/21 at 10:59 AM, the local Long-Term Care Ombudsman Council (LTCOC) was contacted via telephone. The ombudsman stated that they had not received any notice of transfers from this facility. On 9/22/21 at 1:00 PM, the Nursing Home Administrator confirmed that transfer notices were not being sent to the LTCOC on a regular basis or in a monthly log format. A review of the facility's policy titled Transfer or Discharge Notice revised December 2016 revealed: 1. A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility. 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 4. A copy of the notice will be sent to the Office of the State-Long Term Care Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure accuracy of functional status in the comprehensive assessment for one (Resident #20) of 29 residents sampled. Findings included: A review of Resident #20's medical record revealed that Resident #20 was admitted to the facility on [DATE] with diagnoses to include Urinary Tract Infection, Abnormalities of Gait and Mobility, Muscle Weakness, and Need for Assistance with Personal Care. A review of Resident #20's admission Minimum Data Set (MDS) Assessment, dated 07/08/2021, revealed under Section G - Functional Status the following information related to Resident #20's self-performance: - Bed Mobility: 7 - Activity occurred only once or twice. - Transfer: 7 - Activity occurred only once or twice. - Walk in room: 7 - Activity occurred only once or twice. - Locomotion on unit: 7 - Activity occurred only once or twice. - Locomotion off unit: 7 - Activity occurred only once or twice. - Dressing: 7 - Activity occurred only once or twice. - Eating: 7 - Activity occurred only once or twice. - Toilet Use: 7 - Activity occurred only once or twice. - Personal hygiene: 7 - Activity occurred only once or twice. On 09/23/2021 at 10:35 AM, the MDS Coordinator stated that the purpose of the MDS Assessment was to get an overall picture of the resident related to areas such as functionality, cognition, and therapy services. The MDS staff obtained information related to the resident's functional status by speaking with care providers, such as the Certified Nurses Aide (CNA) to assess for self performance of Activities of Daily Living (ADLs). An interview was also conducted with the resident to assess for things such as range of motion and functional abilities. Resident assistance needs are documented in the tasks portion of the resident's record and therapy would document what type of assistance the resident needed. The MDS Coordinator stated that entries would be coded as only occurred once or twice if they did not have three occurrences of the particular task happening. For example, if the resident was in bed for 5 out of the 7 days assessed, then the task would be marked as only occurred once or twice. The MDS Coordinator stated that coding some tasks, such as Eating as only occurred once or twice would not make sense because the resident eats three times a day. The MDS Coordinator continued on to state that marking all of the self-performance section with activity occurred only once or twice would not give a complete picture of the resident's functional status. The MDS Coordinator stated that the staff member that completed the assessment was no longer at the facility, but stated the staff member could have reviewed other documentation in the resident's record to get an idea of their functional status. A review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 1.17.1, dated October of 2019, revealed under the section titled Overview that the RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. The manual also revealed under section G0110: Activities of Daily Living (ADL) Assistance coding instructions that for each ADL activity, consider all episodes of the activity that occur over a 24-hour period during each day of the 7-day look-back period, as a resident's ADL self-performance and the support required may vary from day to day, shift to shift, or within shifts. There are many possible reasons for these variations to occur, including but not limited to, mood, medical condition, relationship issues (e.g., willing to perform for a nursing assistant that he or she likes), and medications. The responsibility of the person completing the assessment, therefore, is to capture the total picture of the resident's ADL self-performance over the 7-day period, 24 hours a day (i.e., not only how the evaluating clinician sees the resident, but how the resident performs on other shifts as well). A request for a policy related to MDS Assessments was made on 09/21/2021 at 02:44 PM to the facility's Nursing Home Administrator (NHA). The policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, policy review, and review of the medical record, the facility failed to ensure that a baseline care plan was developed and provided to one (#78) of 29 sampled residents. Findings included: A review of Resident #78's medical record revealed that he was admitted to the facility on [DATE]. Resident#78 was cognitively intact according to the Brief Interview of Mental Status (BIMS) score of 13 on his most recent Minimum Data Set (MDS) assessment dated [DATE]. On 09/21/21 at 11:13 AM, Resident#78 stated that he didn't recall participating in or being provided with a written copy of his baseline care plan. A review of Resident #78's medical record revealed no documentation related to a baseline care plan. On 9/21/2021 at 2:00 p.m., the Regional Nurse Consultant reviewed the electronic medical record for Resident #78 and confirmed that there was no baseline care plan. The Regional Nurse Consultant stated that the resident was scheduled to have a care plan meeting the following day, 09/22/21. A review of the Nursing Admission/readmission Nursing Packet dated 8/18/21 for Resident #78 revealed the section titled: Baseline Care Plan Summary was marked as n/a (not applicable), and the section titled: Baseline Care Plan provided to Resident and/or representative was marked with no answer provided. A review of the facility policy titled Care Plans- Baseline revealed: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: (a) the initial goals of the resident, (b) a summary of the resident's medications and dietary instructions; (c) any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and (d) any updated information based on the details of the comprehensive care plan, as necessary.

Based on observation, interview, and record review the facility failed to review and revise the resident centered care plan for one (#78) of 29 sampled residents related to skin issues. Findings included: On 9/21/2021 at 10:55 a.m., Resident #78 was observed with several scabs on his arms, face and shoulders. He reported that he has had them for a few weeks and that the staff were aware. The resident stated that there have been no new orders or treatment related to the scabbed areas. On 09/21/21 at 11:00 a.m., Staff E, Licensed Practical Nurse (LPN) reported that she was unaware of any skin issues for Resident #78 and no one had informed her of any skin issues. Follow-up interview with Staff E on 09/22/21 at 1:34 p.m. revealed the doctor came in to see the resident yesterday (9/21/21) and ordered Bactroban ointment to be applied on his arms, face and legs three times a day for 10 days. She stated the resident has a rash/excoriation. She reported that she wrote a change in condition report yesterday after the surveyor had notified her of the concern. She again confirmed that the Certified Nursing Assitants (C.N.A.) had not notified her of any skin changes. She stated that skin changes were completed weekly and the last one in the medical record was on 9/15/21, which indicated that the resident's skin was intact. She further reported that there had been no new interventions for his skin change issues prior to the doctor's visit on 9/21/21. Follow-up interview with Resident#78 on 09/22/21 at 1:43 PM revealed that finally yesterday the doctor was made aware of the scabs, and they are putting a cream on my arms.

Based on staff interviews, medical record review, and policy review the facility failed to ensure code status was accurately reflected in the clinical record for one (#74) of two sampled residents reviewed for advance directives out of a total sample of 29 residents. Findings included: Record review of Resident #74's admission record, contained in the paper/hard chart, revealed the resident's advance directive status was recorded as FULL CODE. Additional review of the paper/hard record for Resident #74 revealed a yellow Florida Do Not Resuscitate Order signed by the resident and the attending physician on 6/22/21. A review of Resident #74's Electronic Medical Record (EMR) revealed an active physician's order with a code status of Do Not Resuscitate (DNR) dated 8/22/21. On 09/22/21 at 9:56 a.m., interview with Staff B, Licensed Practical Nurse (LPN) revealed that if there were a code, she usually checks for the resident code status in the EMR. She stated that she never checks the resident's hard chart. On 09/22/21 at 10:03 a.m., interview with Staff C, LPN revealed that if there were a code, she would look in the resident's hard chart for a signed yellow sheet that identifies the resident code status, usually DNR. She stated that the yellow sheet was signed by the resident and the resident's primary care physician. She stated that she follows the signed yellow copy in the chart and not the face sheet. She stated that she would check the resident's EMR but would follow the signed yellow copy in the hard chart. On 09/23/21 at 11:04 a.m., the Regional Director of Nursing stated that she would not expect the face sheet/admission record in Resident #74's paper chart to be updated related to her code status. She stated that when there was a code in the facility, everything related to the resident's code status was printed from the EMR. She stated that the staff respond to a code based on the information in the residents' EMR and not the face sheet/admission record. On 9/23/21 at 11:07 a.m., the Nursing Home Administrator (NHA) stated that when a code was called, the resident's hard chart was grabbed, and the nurses verify the resident's code status with the resident's EMR as a team. A review of the facility's policy titled Advance Directives revised December 2014 revealed .7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directive so that appropriate orders can be documented in the resident's medical record and plan of care . A review of the facility's policy titled Do Not Resuscitate Order revised April 2017 revealed 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record .

Based on observation, resident interviews and policy review the facility failed to honor resident rights in holding group resident council meetings as desired by 6 of 6 residents present in the resident group council meeting. Findings included: On 9/22/2021 at 10:30 a.m., a resident council meeting was held by the surveyor with six residents in the main dining room with ample space for social distancing. During the meeting, the residents revealed that they had not had group resident council meetings for several months. The residents reported that they were told that some staff members had tested positive for COVID-19 and this was why they could not meet. A review of the resident council minutes revealed no group meetings had occurred since June 2, 2021. According to the residents, the Nursing Home Administrator (NHA) had informed them in August 2021 that there would be no group meetings until further notice. The residents stated that there was no reason not to have group meetings and activities since most residents had their vaccines and wore their masks in the common areas. On 9/22/21 at 11:21, the NHA was informed of the voiced concern during resident council. She stated that they had some staff members and two residents that tested positive for COVID-19 at the beginning of August, and they also had just hired a new Director of Nursing. A review of the facility's test results and notification to families revealed the last positive case occurred on 8/23/21. A review of the policy revised April 2017 and titled Resident Council revealed: The facility supports residents' rights to organize and participate in the Resident Council. All residents are eligible to participate in the Resident Council. The facility encourages residents who are willing to participate. Council meetings are scheduled monthly or more frequently if requested by residents.