Based on interview and record review, the facility failed to ensure appropriate certification for Nursing Aides within four months of the dates of hire for four (Staff members A, B, C, and D) of four staff members reviewed. Findings included: On 02/27/2025 at 9: 00 a.m., the Human Resources Director brought documentation of the nursing aides hired by the facility to the conference room. Review of the documentation revealed four nursing aides had been working for the facility over four months without obtaining certified nursing assistant certification: Staff A, Nursing Aide was hired on 6/18/2024. Staff B, Nursing Aide was hired on 9/24/2024. Staff C, Nursing Aide was hired on 9/24/2024. Staff D, Nursing Aide was hired on 10/22/2024. During an interview on 2/27/2025 at 1:40 p.m. with the Human Resource Director, she confirmed Employee A, B, C, and D were not certified and were employed as nursing assistants During an interview on 2/27/2025 at 1:40 p.m. with the Director of Nurses (DON), she stated she was not aware Staff A, B, C, and D were not Certified Nursing Assistants. During an interview on 2/27/2025 at 3:00 p.m. with the Nursing Home Administrator (NHA), he stated he was told they could hire nursing assistants if they received their certification within the four months after being hired. The NHA stated he was not aware of Staff members A, B, C, and D working outside the period allowed without their certifications. He stated the expectations when it came to hiring nursing assistants, was that they follow the guidelines required for the nursing assistants to work in the building and that they were certified to maintain employment. Review of 2024 Florida Status, Titled XXIX Public Health Chapter 400 Nursing Homes and Related Health Care Facilities, No Date, showed Section 211 Persons employed as nursing assistants; certification requirement; qualified medication aids designation and requirements. 400.211 Persons employed as nursing assistants; certification requirement; qualified medication aids designation and requirements- 2. The following categories of persons who are not certified as nursing assistants under part II f chapter 464 may be employed by a nursing facility for a single consecutive period of 4 months: The certification requirements must be met within 4 months after initial employment as a nursing assistant in a licensed nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three (#6, #25, and #33 ) of seven residents observed for assisted dining in hall 100 received a dignified dining experience during two of four days of survey. Findings included: 1. On 06/17/24 at 12:47 p.m., Resident #6 was observed in her room in her wheelchair positioned in front of her bed facing the window. The resident's lunch tray was observed positioned behind her. When asked if she was going to eat her lunch, Resident #6 proceeded to attempt to move herself, but her wheelchair was locked. This resident was not able to position herself in front of her lunch tray. On 06/17/24 at 12:52 p.m., the Social Services Director (SSD) walked into the room. She stated Resident #6 did not ambulate independently. She stated the resident could not unlock her wheelchair. She confirmed the resident needed help to position herself in front of her meal tray. The SSD proceeded to position the resident in front of her tray. She stated resident needed meal set up assistance and sometimes she needed encouragement to eat. Review of the admission record showed Resident #6 was admitted to the facility on [DATE] with diagnoses of unspecified protein-calorie malnutrition and personal history of traumatic brain injury. Review of Resident #6's care plan, dated 01/08/22, under daily care/ADLs (Activities of Daily Living) focus, showed the resident had a self-care deficit related to decline in overall function secondary to illness and hospitalization and decreased activity tolerance. The goal, revised on 04/17/24, showed interventions for eating included , I require set up and as needed assistance from staff to eat. Open packets and cartons and such to set me up for meal. Review of Resident #6's quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C-Cognitive and Patterns, a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Section GG - Eating, showed the resident required set-up or clean-up assistance. An interview was conducted on 06/17/24 at 12:52 p.m. with Staff R, Registered Nurse (RN). She stated Resident #6 ate on her own, but she needed to be set up. She stated this resident could not open containers. On 06/18/24 at 12:55 p.m., Resident #6 was observed in her room during lunch. The resident asked this surveyor to open her milk carton and her apple juice. The two items were observed unopened. The resident stated she could not do it herself. (Photographic evidence was obtained). On 06/18/24 at 1:02 p.m., an interview with Staff S, RN confirmed Resident #6 needed assistance with meal set up. She stated meal set up meant position wheelchair accordingly, place tray in front of resident, and open everything. 2. During a facility tour on 06/18/24 at 8:40 a.m., Resident #25 was observed in his bed and stated he needed staff to assist him with his meal. His tray was observed at his bedside. An immediate interview was conducted with Staff O, Certified Nursing Assistant (CNA). She stated they started passing trays between 8:00 a.m. and 8:15 a.m. She stated once they passed the trays, they were to go to the residents they were assigned to assist with meals. Review of the admission record showed Resident #25 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, muscle weakness, contracture of left hand, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #25's care plan, dated 06/17/22, under ADLs (Activities of Daily Living) focus, showed the resident had a self-care deficit related to impaired mobility with weakness and a history of CVA (Cerebrovascular Accident). The goal, revised on 06/07/24, showed interventions to provide total assistance with meal trays. Review of Resident #25's quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns, a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Section GG showed the resident was dependent for eating. On 06/18/24 at 8:56 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN)/ Unit Manager. He stated he had seven residents who were dependent on staff for meal assistance. He confirmed Resident #25 was waiting for a CNA to assist him with his meal. He stated he did not know why the resident was not being assisted having waited approximately 45 minutes. He said, I will check. We can warm up his tray if necessary. 3. On 06/18/24 at 12:57 p.m., Resident #33 was observed waiting for meal assistance. The residents in his hall were noted having finished their meal and CNA's were observed removing trays from the resident's rooms. An interview was conducted on 06/18/24 at 1:02 p.m. with Staff S, RN. She stated Resident #33 was dependent on staff for meals. She said, He should be assisted. The aide assigned to the hall is supposed to feed him. I did not know he was waiting. I will look for the aide. Review of the admission record showed Resident #33 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and dementia. Review of Resident #33's care plan, dated 04/19/22, under daily care/ADLs (Activities of Daily Living) focus, showed the resident had a self-care deficit decline in overall function secondary to illness and hospitalization related to decreased activity tolerance due to weakness and CVA, impaired cognition due to diagnosis of dementia. The goal, revised on 04/18/24, showed interventions for eating included , I require total assistance from staff to eat. Review of Resident #33's annual Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns, a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. Section GG showed the resident was dependent for eating. On 06/18/24 at 1:05 p.m., an interview was conducted with Staff A, CNA who was observed assisting residents from the dining room. She stated the staff assigned to hall 100 was supposed to assist with feeders in this hall. She said, I can go see where Resident #33's aide is. Or maybe I should stop pushing people and feed him. On 06/18/24 at 1:07 p.m., an interview was conducted with Staff T, CNA. She said, I know he is waiting. She [her aide] should be here. She confirmed the tray was dropped off to the resident's room approximately 45 minutes earlier. On 06/18/24 at 1:07 p.m., an interview was conducted with Staff D, LPN/UM. He stated, my apologies. He [Resident #33] should not be waiting. I will find out what is going on. A follow -up interview was conducted with Staff D, LPN/UM on 06/19/24 at 1:40 p.m. He stated he was aware there was a problem with ensuring assisted residents received their meals in a timely manner. He confirmed a resident should not be waiting 45 minutes to be assisted. He stated he expected the CNAs to work together as a team and prioritize resident's needs. He stated he would have expected to be notified if there was a reason why a CNA could not assist a resident in a timely manner. He stated their procedure was to bring the tray to the resident when they were ready to feed them and not leave it in the room for extended periods. He stated part of delivering trays included preparing the resident for the meal, seating them up, opening containers, and positioning them accordingly. He stated he would in-service the CNAs. Staff D said, Residents should not be referred to as Feeders it's an undignified term. During an interview on 06/19/24 at 4:30 p.m., the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) stated their expectation was for their residents to receive prompt assistance with their meals. Review of a facility policy titled, Dignity and Respect, dated 04/06/24, showed each resident shall be cared for in a manner that promotes and enhances quality of life dignity respect and individuality . Procedure: (1.) Residents shall be treated with dignity and respect at all times. (2.) Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. (7.) Staff should speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number diagnosis or care needs.

Based on observation, interview, and record review, the facility did not ensure confidentiality of records was maintained for one resident (#58) of 59 residents on Hall 100, and failed to ensure two of five medication cart computer screens on Hall 100 were locked. Findings included: 1. On 6/17/24 at 1:05 p.m., an observation was made of an MDI (metered dose inhaler) box with Resident #58's chart sticker on the side of it, in the medication cart trash. The medication cart was in the middle of the common hallway on Hall 100 and visible to approximately five non staff persons walking through the hall at the time. During an interview conducted on 6/17/24 at 12:54 p.m. Staff R, Registered Nurse (RN) stated they normally remove PHI (protected health information) from packaging, shred the portion with the PHI and put the rest in the trash. During an interview conducted on 6/19/24 at 11:20 a.m., the Director Of Nursing (DON) stated she would expect the staff would shred all PHI. During an interview conducted on 6/19/24 at 1:47 p.m., Staff D, Licensed Practical Nurse/First Floor Unit Manager (LPN/UM) stated he would expect his staff to obliterate all PHI before putting it in the trash. 2. On 6/18/24 at 1:04 p.m., an observation was made of Staff S, Licensed Practical Nurse (LPN) walking away from the medication cart, leaving the cart and computer unlocked. The cart and computer were positioned outside the nurses' station in Hall 100. A resident's information page on the computer screen was visible to others. During this time residents were observed walking/wheeling to their rooms from the dining room. An observation was made of a family standing at the other end of the nurses' station. Staff S returned approximately three minutes later. Staff S, LPN stated she should have locked the cart and computer before walking away. On 6/19/24 at 9:22 a.m., an observation was made of a medication computer screen open with a resident's information open to the public outside Hall 100. The nurse was not within sight. Staff B, LPN came out of a resident's room and said, I'm sorry, I did not mean to leave the computer unlocked. It was my mistake. I should have locked it before walking away. During an interview on 6/19/24 at 1:36 p.m., Staff D, LPN/UM stated the nurses should lock the computer screen when stepping away and the medication cart should be locked. Review of a facility policy titled, Health Information Manual, dated 07/01/23, showed the facility will protect and safeguard all medical records; medical records will be maintained . following state and/or federal regulations. Under Procedure (2.) The facility shall protect and safeguard all medical records (a) current medical records are maintained on the nursing unit and/or in an electronic health record. (Photographic Evidence Obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for five (#43, #18,#24, #31 and #56) of nine residents reviewed for PASARRs . Findings included: 1. Review of Resident #43's admission record revealed an admission date of 11/09/23 with diagnoses to include Unspecified Dementia, Anxiety Disorder and Major Depressive disorder. Review of a level I PASARR for Resident #43 dated 09/29/23 revealed the qualifying diagnoses were not checked and recommendations for a level II PASARR were not acted upon. 2. Review of Resident #18's admission record revealed an original admission date of 12/26/19 with diagnoses to include Schizophrenia, Major Depressive disorder and Bipolar disorder and Anxiety disorder. Review of a level I PASARR for Resident #18 dated 04/29/24 revealed the qualifying diagnoses were not checked and recommendations for a level II PASARR were not acted upon. 3. Review of Resident #24's admission record revealed an admission date of 08/27/19 with diagnoses to include Schizophrenia, Major Depressive disorder and generalized anxiety disorder. Review of a level I PASARR for Resident #24 dated 08/26/19 revealed the qualifying diagnoses were not checked and recommendations for a level II PASARR were not acted upon. On 06/18/24 at 3:39 p.m., an interview was conducted with the Regional Nurse Consultant (RNC), Director of Nursing (DON), and the Social Services Director (SSD). The RNC stated they had initiated revising the PASARRs in December with the previous DON. The DON stated they had submitted a bunch of level II PASARRs for review. She said, We do not have any evidence. I cannot pull the record. We are unable to find it. The RNC stated they did not identify their system had an issue until the surveyor requested the PASARRs. The DON stated their expectation was to review the PASARRs prior to admission, when the residents are newly admitted , or if readmitted with newly acquired mental health diagnoses. On 06/18/24 at 3:47 p.m., the RNC stated they did not have a PASARR policy. She stated they follow state regulations. The RNC presented an undated document titled Level I Screen. The document showed an accurate and complete level I screen is required prior to admission into a Medicaid- certified nursing facility. If relevant PASARR information was missing, such as mental health diagnosis, then a new level I and level II if indicated, must be completed prior to admission. 4. Resident #31 was initially admitted to the facility on [DATE] with diagnoses of psychotic disorder with delusions due to known physiological condition, bipolar disorder, and major depressive disorder. Review of Resident #31's Preadmission Screening and Resident Review (PASARR) dated 5/6/24 revealed qualifying mental health diagnosis of anxiety disorder, bipolar disorder, Psychotic Disorder with delusions due to known physiological condition and no PASARR Level II was required. Review of the admission Minimum Data Set (MDS), Section I, Active Diagnoses, with an Assessment Reference Date (ARD) of 4/17/24 and significant change MDS with ARD of 5/8/24 revealed medical diagnoses of depression, bipolar disorder, and psychotic disorder. Review of Resident #31's medical record revealed Resident #31 was not assessed for PASARR Level II. An interview was conducted on 06/20/24 at 11:44 a.m. with the Director of Nursing (DON). She said the resident had the diagnosis of anxiety on the PASARR because the resident was on hospice services and she received Ativan for agitation and anxiety. She reviewed Resident #31's medical diagnoses and confirmed she did not have a diagnosis of anxiety. 5. Review of Resident #56's admission Record revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of post traumatic stress disorder (PTSD), major depressive disorder, mood disorder due to known physiological condition with mixed features, and dementia. Review of Resident #56's PASARR dated 7/14/22 revealed a mental illness diagnoses of Depressive disorder and a recommendation for a level II assessment. Review of Resident #56's PASARR dated 7/27/23 revealed no mental illness diagnoses and no recommendation for a level II assessment. Review of Resident #56's medical record revealed Resident #56 was not assessed for PASARR Level II. An interview was conducted on 06/20/24 at 11:45 a.m. with the DON. She reviewed Resident #56' PASARR and confirmed it was not accurate and Resident #56's mental illnesses were not identified. She also confirmed the resident did not have a PASARR level II assessment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure negative wound pressure was monitored and maintained for one (#94) of one sampled resident, and failed to ensure an upper extremity elevation support wedge was ordered and monitored after application for one (#47) of two residents sampled for positioning devices. Findings Included: 1. On 6/17/24 at 2:01 p.m., during an interview and observation, Resident #94 was laying in bed. His negative pressure wound machine tubing was hanging on the floor. The machine was not functioning. On 6/18/24 at 10:07 a.m., Resident #94 was observed without the negative pressure wound machine connected. Resident #94 said the negative pressure wound machine causes pain and always comes off the day after replacement. On 6/18/24 at 12:56 p.m., Resident #94 said he had weekly appointments at the wound care center and did not want to continue using the negative pressure wound machine after his next appointment. Resident #94's next appointment was scheduled for 6/21/24. Review of Resident #94's admission record, with an admission date of 6/5/23, showed diagnoses to include necrotizing fasciitis and Fournier gangrene. Review of Resident #94's order dated 6/7/24, start date 6/7/24, showed negative pressure wound therapy dressing change three times per week and as needed. Attach negative pressure wound therapy at [specified setting] [intermittent/ continual] to [specify wound/dressing site] [specify color(s) of foam] as needed for any leaking. Review of Resident #94's order dated 6/7/24, start date 6/10/24, showed negative pressure wound therapy dressing change three times per week and as needed. Attach negative pressure wound therapy at [specified setting] [intermittent/ continual] to [specify wound/dressing site] [specify color(s) of foam] every shift every Monday, Thursday for surgical side scrotal perineum: cleanse with normal saline, pat dry then apply the granulation black foam to cover wound vac and apply the wound vac. Review of Resident #94's Burn and Plastic Surgery Center discharge instructions, dated [DATE], showed negative pressure wound therapy to the scrotum wound at 125 millimeters of mercury) (mm) pressure (Hg) continuous. Special instructions written showed: in the event you lose suction to negative pressure wound machine, place normal saline wet to dry [dressing] and call for sooner appointment. Review of Resident #94's order dated 6/19/24, showed check for placement, function, seal, and negative pressure wound therapy setting every shift for wound vac therapy/ prevention. Review of Resident #94's eMAR Medication administration note, dated 6/13/24 at 3:35 p.m. showed negative pressure wound therapy dressing change three times a week and PRN. Attach negative pressure wound therapy at [specify setting] [intermittent/ continuous] to [specify wound/dressing site] [specify color (s) of foam] every Monday, Thursday for surgical side scrotal-perineum: cleanse with NS, pat dry then apply the granulation black foam to cover wound vac and apply the wound vac. As per patient wound vac dressing changed yesterday it is working properly and he refuses dressings at this time. Review of Resident #94's care plan initiated on 6/5/24 showed focus, my open skin areas, I have a wound vac dressing on my scrotum .The care plan's goal is to show signs of healing. Interventions to include: -Negative pressure wound therapy dressing change three times a week and PRN. Attach negative pressure wound therapy at 125 mm/hg continual to scrotal/ perineum wound [with] foam as ordered, initiated 6/10/24 -wound vac at 125 mm hg continuous pressure, change Monday /Thursday, dated 6/10/24 On 6/19/24 at 2:55 p.m., an interview was conducted with Staff G, Registered Nurse (RN), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON). The DON said all resident orders should be entered in the resident's medical record. She confirmed orders to document the negative pressure of Resident #94's machine had not been entered into the orders. Staff G said he had tried for several days to contact Resident #94's wound care doctor. 2. On 6/17/24 at 11:34 a.m., during an interview and observation Resident #47 was sitting in a geriatric chair in the 2nd floor activities area watching the television. A black foam forearm and hand elevation support wedge was laying in Resident #47's left armchair rest. Resident #47's flaccid arm was on his lap parallel to the support wedge with a foam strap secured above his elbow. Resident #47 said his left arm paralysis was due to a motor vehicle accident when he was 9 years old. Review of Resident #47's admission record showed 6/14/18, admission date and diagnoses to include unspecified fracture of shaft of humerus and left arm. Review of the Resident #47's task list, dated June 2024 did not reveal directions for the nursing staff to apply positioning devices. Review of Resident #47's care plan, review last completed on 3/12/24 did not show a focus, goal, or interventions related to positioning devices. On 06/17/24 at 12:47 p.m., Resident #47 was in the TV room with his left arm and hand out of the wedge support and laying on his lap. During an interview on 6/18/24 at 1:24 p.m., Staff H, Occupational Therapist (OT) said the last time Resident #47 was evaluated by OT was after a hospitalization in 2023. Staff H, said OT did not follow residents with chronic conditions, the residents were referred for restorative nursing therapy. The expectation was for the restorative care staff to notify the OT department with therapy related concerns. During an interview on 6/18/24 at 1:32 p.m., Staff L, Certified Occupational Therapist Assistant (COTA), Director of Rehabilitation (DOR), said the therapy department staff evaluated or screened residents after admission. Staff L, COTA, DOR said splinting directions and schedule would be added to the nursing staff task list for application and monitoring. During an interview on 6/19/24 at 12:16 p.m., the Director of Nursing (DON) said a Certified Nurse Assistant (CNA) observed Resident #47's girlfriend positioning Resident #47's arm on the positioning device the girlfriend brought to the facility. She said CNAs continued to use the support device for Resident #47. The DON said PT and OT evaluate residents to determine if positioning devices were needed. Residents who required positioning devices were listed on the nursing staff list. Review of facility's policy titled Consultants, last revised 3/5/24 revealed. Policy: .it is the policy of the facility to obtain additional information or assessment form outside source about/for a resident to assist in care and treatment. Procedure upon return and/ or completion of a consultation visit: a) check consult sheet for consultant's findings, diagnosis, recommendations, date and signature of consultant . b) notify attending physician of consultant's findings and recommendations. C) no recommendations by a consultant may be initiated before the attendant physician gives the order. Review of the facility's Care Planning Process and Care Conference policy, last revised on 7/3/23. In the procedure section 11) All resident/patient care and interventions must be carried out per the care plan (ex. Adaptive equipment, such as braces, restraints, dentures, hearing aids; transfers, ADL's, skin care, etc.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure splints were applied to prevent the decrease of range of motion for two (#50 and #88) of eight sampled residents. Findings included: 1. On 6/17/2024 at 10:27 a.m. and 3:00 p.m., Resident #50 was observed sitting forward in a recliner watching TV. Resident #50's bilateral feet were pointing down with heel protectors on both feet. Resident #50's bilateral hands were in fist like positions. Nothing was in the resident's palms. 2. On 6/17/2024 at 10:55 a.m., Resident #50 was observed and interviewed in bed. She was lying on her back with her right wrist bent and her hand with her fingers curled toward her palm. Resident #50 stated her hand did not open like it used to. She said she had splints, but the staff did not put them on very often and she forgets to request them. On 6/18/2024 at 10:41 a.m., Resident #50 was observed sitting in a recliner with no splints or rolls in her hands. Both of her hands were observed closed with her fingers bent and touching her palms. On 6/18/2024 at 8:26 a.m. and 2:11 p.m., Resident #50 was observed sitting in a recliner with no splints or rolls in her hands. Both of her hands were observed each time closed, fingers bent, and touching palms. On 6/19/2024 at 11:55 a.m., Resident #50 was observed in bed, lying on her back, with no splint on either hand. Review of Resident #50's admission Record revealed diagnoses that included hemiplegia (partial paralysis) following cerebral infarction (stroke) affecting right non-dominant side, limitation of activities due to disability and other co-morbidities. Review of the Minimum Data Set (MDS) assessment, dated 10/24/2023, Section GG Functional Status revealed Resident #50 was dependent on staff with mobility and activities of daily living (ADL) performance and had functional limitations in range of motion on one side for upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides for lower extremity (hip, knee, ankle foot). Review of the MDS assessment, dated 4/25/2024, Section GG Functional Status revealed Resident #50 was dependent on staff with mobility and ADL performance and had functional limitations in range of motion on two sides for upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides for lower extremity (hip, knee, ankle foot). Review of the Order Summary Report with active physician orders as of 6/19/2024 for Resident #50 revealed the following: May have restorative/maintenance programs as indicated, order date 9/1/2023; Splint: right palm roll or wash cloth roll or as tolerated every shift, order date 8/3/2023. The care plan for Resident #50 revealed a focus area for MY DAILY CARE/ADLS: I have an ADL self care deficit r/t reduced mobility, weakness, and pain d/t (due to) dx (diagnosis) of seizure D.O. (disorder), muscle weakness, contractures, and anoxic brain damage r/t (related to) hx (history) of ischemic CVA. (cerebral vascular accident (stroke)). AD-Towel roll(wash cloth) in Rt. hand for skin integrity, On in the am [morning] and out in the pm [evening] or as tolerated. Provide hand hygiene daily before and after use, notify nurse/therapy of any concerns. Always leave resident in reclined position when in recliner to minimize risks for falls. History of refusal of having teeth brushed. Revised 4/28/2024. The following intervention was in place Encourage me to participate with my therapy or restorative programs on a regular basis. The care plan for Resident #50 revealed a focus area for Resident has a restorative program related to contracture management. Revised. 4/28/2024 and Date Initiated: 02/05/2024. The goal for this focus was for Resident #50 to participate in the restorative program as tolerated/as ordered and will improve or maintain present level of contracture through the review date. Date Initiated: 02/05/2024. The interventions showed: Right Palm roll or wash cloth roll as ordered/as tolerated. Date Initiated: 02/05/2024; Inspect skin around and under brace when donning, doffing, and every shift. Date Initiated: 02/05/2024; Restorative program will be reviewed by the interdisciplinary team on a periodic basis. Date Initiated: 02/05/2024; Provide education to resident and family regarding the purpose and benefits of restorative nursing programs. Date Initiated: 02/05/2024; Motivate and encourage by praising effort, not just successes. Date Initiated: 02/05/2024. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 6/19/2024 at 12:50 p.m. Staff J, LPN confirmed being assigned to Resident #50. Staff J stated only cleaning Resident #50's hands and did not leave anything in the resident's palm(s). An interview was conducted with Staff A, Restorative CNA, on 6/19/2024 at 2:52 p.m. Staff A explained restorative nursing received direction from therapy on what was needed for each resident who was on the restorative nursing program. Staff A explained, restorative nursing provided treatment to the residents on their list, 3 days per week for 15 minutes. Restorative provided a short recap of what was done with each resident. Staff A continued to state for resident's who had splints, range of motion (ROM) was completed, then the splint was placed on the resident. The CNAs were supposed to put the splints on but we (restorative) usually had to put them (splints) on when we got to the resident. 2. Review of Resident #88's admission Record revealed diagnoses that included hemiplegia (partial paralysis) following cerebral infarction (stroke) affecting right dominant side, critical illness polyneuropathy, cognitive communication deficit, and other co-morbidities. Review of the MDS assessment, dated 5/4/2024, Section GG Functional Status showed Resident #88 was dependent on staff with mobility and ADL performance and had functional limitations in range of motion on one side for upper extremity (shoulder, elbow, wrist, hand) and impairment on one side for lower extremity (hip, knee, ankle foot). Review of the Order Summary Report with active physician orders as of 6/19/2024 for Resident #88 showed the following: May have restorative/maintenance programs as indicated, order date 8/31/2023; Restorative Nursing: PROM (passive range of motion) bilateral upper extremities and lower extremities, all joints, 15 minute 3x/weekly x 12 weeks, order date 4/15/2023; Restorative Nursing: Resident received gentle PROM 3x/days week to right hand, order date 2/20/2024; Splint: Right resting hand splint with AM care to PM care or as tolerated every shift, order date of 8/3/2023. The care plan for Resident #88 showed a focus area for splinting/ bracing restorative related to prevention of functional decline through daily activity. Resident may refuse to wear splint Rev. 5/6/2024 Date Initiated: 01/08/2024. The goal for this focus was for the resident to participate in the splinting/ bracing restorative program daily, as tolerated/accepted and will improve or maintain present level functional ability through the review date. Date Initiated: 01/08/2024 Target Date: 08/09/2024. The interventions showed Resident has an splinting/ bracing restorative program for: [Splint Program - Right resting hand splint, prevent further deterioration, am-hs (at night) as tolerated. Date Initiated: 01/08/2024. An interview was conducted with Staff N, Certified Nursing Assistant (CNA) on 6/17/2024 at 10:29 a.m. Staff N stated she was responsible for the care of Resident #88. Staff N continued to state splint responsibility was for restorative, she did not have to put the splint on the resident. An interview was conducted with Staff M, Registered Nurse (RN) on 6/17/2024 at 10:34 a.m. Staff M, RN stated restorative placed splints on all residents. An interview was conducted with the Director of Rehabilitation (DOR) on 6/19/2024 at 2:37 p.m. The DOR stated therapy screened all residents not on current case load, quarterly, for position/contracture management and other declines. If any change in status, then therapy would request orders for evaluation and treatment from the physician. Nursing also could give the therapy department a request for therapy to screen based on observation of a problem. An interview was conducted with the Director of Nursing (DON) on 6/19/2024 at 4:09 p.m. The DON stated the CNAs were responsible for placing splints on the residents. Restorative could put them on but the primary responsibility was for the CNA, as restorative was only 3 days per week. The DON continued to state the order should be followed and related care should be on the care plan. Review of the facility's policy and procedure titled ADL Care Limited Joint Mobility; and Restorative Splint/Brace Program dated 3/12/24 revealed: Policy: a resident who is admitted without a limited range of motion/joint mobility does not experience reduction unless the residents clinical condition demonstrates that a reduction in a range of motion/joint mobility is unavoidable. A resident with a limited range of motion/joint mobility receives appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/joint mobility. The facility will ensure that the resident reaches and/or maintains their highest level of range of motion/joint mobility to prevent avoidable decline. The resident's comprehensive assessment should identify individuals risk which could impact the residents range of motion/impair joint mobility including, but not limited to: immobilization (e.g., bed fast, reclining in a chair or remaining seated in a chair/wheelchair); neurological conditions causing functional limitations such as cerebral vascular accidents, multiple sclerosis, Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrigsdisease, [NAME] beret syndrome, muscular dystrophy, or cerebral palsy, etc.; any condition where improvement may result in pain, spasms or loss of movement such as cancer, presence of pressure ulcers, arthritis, gout, late stages of Alzheimer's, contractures, dependence on mechanical ventilation, etc.; or clinical conditions such as immobilized limbs or digits because of injury, fractures, or surgical procedures including amputations. a restorative nursing program may be recommended to improve/maintain function of joint mobility. A restorative program can be implemented upon admission, readmission, during course of stay, or after being discharged from therapy services based on needs. Nursing staff will receive education/training from the therapy department on the restorative nursing program(s) prior to the residents participation in the restorative program(s). Procedure: 1. Nursing staff performs/supervises application of splints and or braces based on a wearing schedule established after assessment of need. Physical therapy and Occupational Therapy will educate staff as necessary, if special splint/brace application instructions are required, when resident is discharged from therapy. 5. Based on PT/OT evaluation for joint limitation needs and/or treatment, in collaboration with nursing, the resident may be placed on a restorative nursing program.* The restorative program will provide appropriate treatment and services to improve joint mobility and/or prevent further decline in joint mobility;* a specific restorative nursing plan will be developed for the resident for the splint/brace program as indicated based on assessment needs established by PT/OT;* the splint/brace program includes checking residents skin condition and circulation under the splint/brace device, cleansing the resident's skin, and repositioning the affected limb in correct alignment.* The splint/brace program does not include range of motion before applying the device; Those ROM needs are to be captured in a separate ROM program if the need is identified. * restorative nursing services will be provided at least six days a week with a goal that least 15 minutes of treatment services period time services may be divided over a 24 hour period and or as tolerated by the resident; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure respiratory equipment was stored appropriately on one (1st) of 2 floors, for three (#51, #24 and #6) of nine residents observed. The facility also failed to ensure tracheostomy care and suctioning was provided according to standards of practice for one (#59) of one resident sampled with a tracheostomy tube. Findings included: On 06/17/24 at 9:58 a.m., an observation was made of Resident #51's Nebulizer mask stored on her nightstand. The mask was resting on the top surface, exposed to the elements. The tubing was not labeled/dated. (Photographic evidence was obtained). Review of the admission record showed Resident #51 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Review of June 2024 physician orders for Resident #51 showed orders to change nebulizer tubing every night shift every Sunday, please label tubing with date and time. During an observation on 06/17/24 at 10:22 a.m., Resident #24's CPAP (Continuous Positive Airway Pressure) mask was observed on her bedside table, detached from the hose. The hose attachments were observed on the floor. (Photographic evidence was obtained). Review of the admission record showed Resident #24 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Review of June 2024 physician orders for Resident #24 showed orders to clean CPAP machine weekly as directed. Every Thursday day shift as resident used the machine at night. Wash mask daily in mild, fragrance-free soap and warm water, then rinse well in warm water and air dry. On 06/17/24 at 10:09 a.m., an observation was made of Resident #6's nebulizer mask stashed inside a drawer, not stored in a bag. (Photographic evidence was obtained). Review of the admission record showed Resident #6 was admitted to the facility on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Review of June 2024 physician orders for Resident #6 showed orders to change nebulizer tubing to every night shift every Sunday for hygiene, please label tubing with date and time. On 06/19/24 at 12:40 p.m., an interview was conducted with Staff P, Licensed Practical Nurse (LPN). She stated the nurses should clean respiratory equipment after use and put it in a dated bag. She stated equipment should not be on the floor and it should not be stashed in a drawer without a dated bag. An interview was conducted on 06/19/24 at 12:46 p.m. with Staff A, LPN. She stated the expectation was to store the equipment in a sanitary manner. She stated it should be cleaned and stored in a bag with a date. She stated the tubing should be changed weekly or per orders. On 06/19/24 at 12:53 p.m., an interview was conducted with Staff Q, Registered Nurse (RN)/ Infection Preventionist. She stated she had educated all nurses on appropriate handling and storage of respiratory equipment. She stated the expectation was to prevent infections, therefore store all equipment in a sanitary manner inside a bag that was dated. She stated she expected nurses to clean respiratory machines as directed and replace equipment as ordered. Staff Q reviewed photographic evidence and stated, That's totally unacceptable. The nurses should have the know-how as professionals. she stated she would re-educate the nurses. A follow -up interview was conducted on 06/19/24 at 1:44 p.m. with Staff D, LPN/Unit Manager. He stated all respiratory equipment should be stored appropriately per their policy. Review of a facility policy titled, Handheld nebulizer / small volume nebulizer, revised 03/23, showed (11.) Store nebulizer equipment in a storage bag. Nebulizer tubing should be changed every two weeks or more often if malfunction or is visibly contaminated. Clean compressor per manufacturer's recommendation. 2. An observation and interview was conducted with Resident #59 on 6/17/2024 at 10:51 a.m. Resident #59 was observed sitting in the doorway of her room, in a wheelchair with oxygen via a nasal canula (NC) connected to a concentrator located next to her bed, set at 1 l/m (liter per minute). Resident #59 had a tracheostomy tube, no ties were visible, gauze was surrounding the tube. Resident #59 stated being able to suction herself and the nursing staff changed the dressing. Review of Resident #59's admission Record revealed resident was admitted on [DATE] with the diagnoses that included acute and chronic respiratory failure with hypoxia, acute on chronic diastolic (congestive) heart failure and other co-morbidities. Review of the Minimum Data Set (MDS) assessment, dated 4/2/2024, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition. Review of the Order Summary Report with active physician orders as of 6/19/2024 for Resident #59 revealed the following: Suction via trach as needed for excessive secretions, as needed for Trach Care, dated 3/29/2024; Change trach collar, mask & O2 weekly as well as PRN (as needed) for Preventative Measure and as needed for soiled, dated 3/29/2024; Oxygen at 2L/min via NC continuously for SOB, dated 3/29/2024. The care plan for Resident #59 revealed a focus are for: BREATHING: I have difficulty breathing related to recent hospitalization for pneumonia, Resp. failure w(with)/hypoxia, asthma, and Congestive Heart Failure (CHF). I am on oxygen and have a tracheostomy w/suctioning as ordered, see current MD orders, date Initiated: 03/29/2024. Interventions include: I am able to let the staff know if I am feeling short of breath, date initiated: 03/29/2024; I am not able to let the staff know when I am short of breath so monitor me for accessory muscle breathing, tachypnea, lethargy, change in mental status, agitation, cyanosis, date initiated: 03/29/2024; Focus Area: I have a tracheostomy r/t (related to) Impaired breathing mechanics, date initiated: 04/01/2024; Interventions include: Change oxygen tubing weekly and PRN (as needed) if soiled, date initiated: 04/01/2024; Change trach collar, mask and o2 weekly as well as PRN every night shift Sunday for preventative measures, date initiated: 04/01/2024; Change trach collar, mask, and o2 weekly and PRN as needed for soiling, date initiated: 04/01/2024; Ensure that trach ties are secured at all times, date initiated: 04/01/2024; Oxygen at 2L/min via NC continuously every shift for SOB, date initiated: 04/01/2024; Suction via trach as needed for excessive secretion as needed for trach care, date initiated: 04/01/2024. No other documentation was provided from the resident's medical record regarding education of suctioning of the tracheostomy. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 6/19/2024 at 12:48 p.m. Staff J, LPN stated being Resident #59's primary nurse and had been caring for her since her admission. Staff J stated the resident could suction herself although sometimes we (staff) suction her. Staff J reviewed Resident #59's physician's orders and confirmed no order for trach size, no order for the resident to suction herself, and oxygen was ordered for 2 l/m not 1 l/m. During an interview on 6/19/2024 at 4:09 p.m., the Director of Nursing (DON) stated Resident #59's tracheostomy order should include specifics of type and size. The DON stated the order was incomplete and needed to be fixed. The DON continued to state the resident should have an order to complete self-suctioning and assessment to include education. The DON stated not sure why the orders were not complete. Review of the facility's policy and procedure titled Tracheostomy Care dated 4/14/23 revealed: Policy: this policy will guide the facility to maintain patency of the airway, to prevent infection of the Airways and the area around the tracheostomy tube, to prevent excoriation of the area around the tracheostomy tube and to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. Tracheostomy care is to be performed at least BID (twice daily) and PRN (as needed) as ordered by a physician. An extra tracheostomy tube should be available at bedside for emergency situations; The tube should be same size as currently used. Also, an additional tube should be available that is one size smaller than current size. Procedure: Preparation and Assessment - 1. Verify physician order for care and treatment. General Guidelines: . 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly). 5. Tracheostomy care should be provided as often as needed, at least once daily/BID for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to thoroughly and accurately identify resident specific triggers related to Post Traumatic Stress Disorder (PTSD) and develop a resident specific plan of care to prevent re traumatization for two Residents (#32 and #56) out of two residents reviewed with diagnoses of PTSD. Findings included: 1. Review of Resident #32's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD, bipolar disorder, anxiety disorder, schizophrenia,), and major depressive disorder. An interview was conducted on 06/19/24 at 10:20 AM with Resident #32. She said she was very shaky today because she had tardive dyskinesia. Resident #32 became tearful and said she did not know if she saw a psychiatrist or a psychologist. The resident then said she was tired and wanted to lay down. During the interview Resident #32 was observed to have hand tremors. An interview was conducted on 06/17/24 at 10:50 AM with Staff A, Restorative Certified Nursing Assistant (CNA). She said Resident #32 had a behavior of being tearful regarding her diagnoses and she calmed with music or talking about the dogs and horses. She said Resident #32's behaviors could be sporadic. An observation was conducted on 06/17/24 at 10:56 AM of Resident #32. She was observed to be tearful on her way to restorative therapy with Staff A pushing her in the wheelchair. Staff A was overheard saying she would put on some music for the resident in the restorative room. An interview was conducted on 06/19/24 at 10:25 AM with Staff B, Licensed Practical Nurse (LPN). She said she had been taking care of Resident #32 for 2 years and was very familiar with her. She said the resident was very anxious in the morning and she tended to be much better by the afternoon. Staff B confirmed Resident #32 had PTSD. She said she reviewed her record, and it was not very clear as to why she had PTSD other than she was sexually assaulted and the resident said she was kidnapped. Staff B said she did not know what the resident's triggers were and confirmed there was nothing in the record to identify the resident's triggers or how to avoid the triggers to prevent re traumatization. Review of Resident #32's Social Services admission History (Premier) dated 10/7/2020 revealed section B. Primary Care PTSD Screen. A. Sometimes things can happen to people that are unusually or especially frieghtening[sic], horrible, or traumatic. For Example: A serious accident or fire, a physical or sexual assault[sic] or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. 1. Have you ever experienced this kind of event?: Yes In the Past Month, have you: 2a. Had nightmares about the event(s) or thought about the event(s) when you did not want to? No 2b. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes 2c. Been constantly on guard, watchful, or easily startled? No 2d. Felt numb or detached from people, activities, or your surroundings? No 2e. Felt guilty or unablet [sic] o[sic] stop blaming yourself or others for the events(s) or any problems the event(s) may have caused? No .Outcome .2. Based on the results of the Primary Care PTSD Screener: Psychology Services consulted . Life Events Checklist .6. Physical Assault (for example being attacked, hit, slapped, kicked, beaten up) Happened to me .8. Sexual Assault (rape, attempted rape, made to perform any sexual act through force or threat of harm) Happened to me .15. Sudden, unexpected death of someone close to you. Happened to me. Based on the information from the Life event Checklist: Psychiatric Services Consulted. Review of Resident #32's psychiatry physician note dated 7/15/22 revealed .As an adult, patient states, I was placed in a sex house, where black men rape white women. She was not able to recall for how long she was held captive or who the men were, she just recall that one of the men who was involved helped her escape because .he felt bad. Patient states she never reported the incident to the police . Review of Resident #32's psychology note dated 6/7/24 revealed .Description of what the psychotherapy entailed and how it addressed the presenting problem: Pt [patient] presents with positive mood. Explored use of coping skills prior to session. Practiced reframing negative thoughts. Engaged in role play to practice reframing negatives. Review of Resident #32's psychology note dated 5/31/24 revealed .Description of what the psychotherapy entailed and how it addressed the presenting problem: Explored mood and pt expressed thoughts of death. Explored emotions and assessed for SI. No SI at this time. Discussed pt use of art as coping strategy. Explored link to purpose and self esteem [sic]. An interview was conducted on 06/19/24 at 11:42 AM with Staff C, Social Services Director (SSD). She said she was familiar with Resident #32 and confirmed she had a diagnosis of PTSD. She said when she spoke to Resident #32 about her diagnoses she became tearful and shook. She said Resident #32 received psychology and psychiatry services and when there was an acute concern the psychiatrist and the psychologist would come to her and they would talk about a plan of care. Staff C, SSD also said there was a monthly meeting and psychiatry was involved in the meeting and concerns and plans of care were discussed. Staff C, SSD reviewed the psychiatry note dated 7/15/22 and said she kind of remembers that. She said a care plan was developed to identify Resident #32 had PTSD. Staff C, SSD said an assessment was completed to identify if a resident had PTSD. Psych services were consulted if the resident did have PTSD and psych physicians would come and speak to the social services department if there were concerns. She confirmed there was no documentation related to Resident #32's triggers and how to prevent re traumatization. Review of Resident #32's mood and behavior care plan revised on 4/17/24 showed MOOD/BEHAVIOR: The resident may/may not have a mood/behavior problems r/t [related to] depressed, PTSD, see psych consult/notes. 1/18/2021 Handling and or resolving issues or concerns/thoughts making statements for not knowing how to deal with situations (easily redirected). 3/18/22 indications of financial/material need, life event(s), concerns about daughter's health. The goals revealed o Improve mood state or anxiety level by next review o Will improve/minimize sadness, crying, restlessness, anxiety o Will not harm self o Participate in activities of choice The interventions showed: o Administer psychotropic medications as ordered [Refer to POS for current order]. Report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician) o Encourage resident, to express feelings. o Speak softly & clearly when communicating o Observe for changes in mood/depression and notify physician o Discuss procedures & mediations prior to administration o Psychiatry Services as needed o Psychological Services o Encourage to talk about problems o Encourage to participate in activities of choice o Diversional Activity if upset: TV o When restless or anxious, provide calm, quiet atmosphere o Assist the resident, family, caregivers) to identify strengths, positive coping skills and reinforce these. o Observe/record/report immediately to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, States that life isn't worth living, wishes for death. An interview was conducted on 06/19/24 at 1:00 PM with the Director of Nursing (DON). She said Resident #32 has had PTSD since she was admitted , and she had psychiatry and psychology services. She said she would have to review the record to know what the resident's triggers were and what the facility was doing to prevent re traumatization outside of psychiatry and psychology services. An interview was conducted with Staff D, LPN, first floor Unit Manager (UM). He said he has worked with Resident #32 since her admission and was very familiar with her. He said Resident #32 had a lot of chronic anxiety; she came from another building to be with her with her [family]. Staff D said for the most part Resident #32 had done well but she did get a little anxious at times. He said in his opinion medical things gave her anxiety such as going out to outside doctor's appointments. So, we now send someone with her for the outside doctor appointments. He said Resident #32 went out to a doctor's appointment alone and the doctor's office called the facility and let them know her anxiety got so bad she could not clearly talk. So, after the incident the facility started sending someone with her to all outside doctor appointments and he thinks that had helped her. Staff D confirmed Resident #32 had a diagnosis of PTSD and said I don't know what that is about because she has not shown any triggers. I think she was involved in some bad marital relationships, but we have not gotten into that conversation. Staff D said he did not know what her triggers were. She does like music and coloring. 2. Review of Resident #56's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses of chronic post traumatic stress disorder (PTSD), Major depressive disorder, mood disorder due to known physiological condition with mixed features, and dementia. An interview was conducted on 6/17/24 at 10:50 a.m. with Resident #56. She said PTSD? I don't have that crap. Review of Resident #56's psychology re-assessment note dated 12/13/22, revealed Resident #56 had a diagnosis of PTSD, was raped at 15-had baby. Review of Resident #56's Social Services admission History (Premier) dated 8/1/23 revealed PTSD screen: Sometimes things can happen to people that are unusually or especially frieghtening [sic], horrible, or traumatic. For Example: A serious accident or fire, a physical or sexual assult [sic] or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. .A2. Have you ever experienced this kind of event? Yes (If Yes, please answer the questions below) The questions below were not completed. .B1. Based on the results of the PTSD Screener: No further intervention is required . Review of the Life events checklist revealed none of the life events happened to Resident #56. Outcome: 1. Based on the information from the Life Event Checklist: Resident requires no further intervention. Review of Resident #56's psychiatry note dated 3/21/24 showed, There is no known history of physical, sexual, emotional abuse, or emotional neglect. Post Traumatic Stress Disorder: Patient denies symptoms of PTSD. Denies experiencing traumatic events that involved actual or threatened death or serious injury . Review of Resident #56's quarterly Minimum Data Set (MDS), dated [DATE], 2/10/24, 11/10/23, 4/20/2023, 1/18/23, and 10/18/2022, section I, Active Diagnoses revealed a Psychiatric/Mood Disorder diagnosis of PTSD. Resident # 56's significant change MDS, dated [DATE], section I, revealed a diagnosis of PTSD. Resident # 56's Medicare 5-day MDS, dated [DATE], section I, revealed a diagnosis of PTSD. Resident # 56's Annual MDS, dated [DATE], section I, revealed a diagnosis of PTSD. Resident # 56's admission MDS, dated [DATE], section I, did not reveal a diagnosis of PTSD. Resident # 56's 5-day MDS, dated [DATE], section I, did not reveal a diagnosis of PTSD. Review of Resident #56's psychosocial care plan revised on 5/2/24 revealed PSYCHOSOCIAL: The resident has,a [sic] potential/actual psychosocial well-being problem related to may/may not have post-traumatic stress, life event(s) The goals showed Will verbalize feelings related to emotional state by review date and will utilize effective coping mechanisms as through the review date. The interventions showed, Allow the resident, time to answer questions and to verbalize feelings perceptions, and fears o Support/ Encourage/ Assist to set realistic goals o Determine resident's expectations and discuss eah [sic] in realistic terms o Encourage family/friend to remain involved o Psychiatry Services as needed o Psychological Services as needed o Discuss resident's concerns or fears o Discuss with resident feelings, reminiscence, issues Review of Resident #56's mood care plan revised on 5/2/24 revealed MOOD: The resident has a mood problem r/t States with trouble falling asleep or staying asleep. 8/26/22 Depression/anxiety per consult. PTSD. The goals revealed o Participate in activites [sic] of choice o Will receive adequate sleep. The interventions revealed o Encourage resident, to express feelings. o Speak softly & clearly when communicating o Psychiatry Services as needed o Psychological Services as needed o Encourage to talk about problems o Encourage to participate in activites [sic] of choice o When restless or anxious, provide calm, quiet atmosphere o Assist the resident, family, caregivers) to identify strengths, positive coping skills and reinforce these. An interview was conducted on 06/19/24 at 1:47 PM with Staff D, LPN, first floor UM he said he was not aware that Resident #56 had a diagnosis of PTSD. He said he did not know anything about what happened or her triggers. An interview was conducted with the Director of Nursing (DON) on 06/19/24 at 1:50 PM. She said she would have to look at Resident #56's chart to know if she had PTSD and recommended talking to Staff D. An interview was conducted on 06/20/24 at 11:43 AM with the DON. She said she thought she read somewhere in the resident's medical record she had an episode during COVID isolation where she was remembering things from her past. The DON confirmed there were no documented PTSD triggers or an attempt to identify the triggers to prevent re traumatization. Review of the facility's Trauma Informed Care policy, revised on 9/8/22 revealed Policy To ensure that residents who are trauma survivors receive culturally competent trauma informed care in accordance with professional standards of practice and take in account Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The facility will provide the necessary behavioral health care services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the individual resident assessment and plan of care. To train and assist staff to avoid re-victimization of those residents who have survived trauma and create an environment where the resident feels safe and secure. Individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being. Guidelines: While care and services must always be person-centered and honor residents' choice and preferences, what is different about providing care and services to a trauma survivor is that theses residents may have lost the ability to trust caregivers, and to feel safe in their environment. As a result, the principles of trauma-informed care must be addressed and applied purposefully. .Collaboration-There is an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care. There is recognition that healing that healing happens in relationships and in the meaningful sharing of power and decision-making. .PTSD Post-Traumatic Stress Disorder involves the development of symptoms following exposure to one or More [sic] traumatic, life-threatening events. Symptoms usually develop within the first 3 months after The [sic] trauma occurs, although there may be a delay in months or even years. Symptoms may include, but not limited to, the re-experiencing or re-living of the stressful event . Dissociation (e.g. detachment from reality, avoidance, or social withdrawal), hyperarousal (e.g. Increased[sic] startle response or difficulty sleeping). Symptoms may be severe or long-lasting when the Stressor[sic] is interpersonal and intentional (e.g., torture or sexual violence). .Triggers Facilities must identify triggers which may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. For many trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. While most triggers are highly individualized, some common triggers may include: Experiencing a lack of privacy or confinement in a crowded or small space; Exposure to loud noises, or bright/flashing lights; Certain sights, such as objects that are associated with those that used to abuse, and/or Sounds, smells, and even physical touch. .Procedure 1. On admission an assessment/screening tool will be completed by the Social Service staff to Identify [sic] any trauma, post life events and/or post-traumatic stress disorder that the resident has Experienced or is currently experiencing so that our understanding of their traumatic events can Be [sic] more meaningful. An IDT approach will be used to identify a resident's history of trauma as Well [sic] as his or her cultural preferences. Screening and assessment tools such as the Resident Assessment Instrument (RAI), admission assessment, history/physical, social service History[sic]/assessment etc will provide information regarding resident's history. Additional Information may be obtained from the medical record, family members or other additional Assessments[sic] completed. 2. Evaluation of the information received will be completed by the Interdisciplinary team and Physicians to identify those risk factors/areas that may need to be included in the resident's plan of care to Mitigate[sic]/eliminate triggers. .4. Facility staff will have education/training in caring for residents identified with mental and Psychological [sic] disorders, as well as residents with a history of trauma and/or post traumatic stress Disorder [sic], including non-pharmacological interventions when appropriate. Trauma informed care Trainings [sic] will be conducted at least annually and will be included in orientation for all new Employees [sic]. .6. Trauma Specific interventions will be placed in their individualized person-centered care plan Upon [sic] admission and revised as necessary. Care plans will be reviewed quarterly and more often If [sic] necessary based on any change in their physician and psychosocial well-being. The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, Mental [sic] health professionals) to develop and implement individualized interventions. Facility/Social Services might consider establishing a support group, run by a qualified Professional [sic], or allowing a support group to meet in the facility. If a trauma survivor is reluctant to share his/her history, facility must still try to identify Triggers which may re-traumatize the resident; care plan interventions will be added Which [sic] minimize or eliminate the effect of the trigger on the resident. Trigger-specific interventions should identify ways to decrease the resident's exposure to Triggers [sic] which re-traumatize the resident, as well as identifying ways to mitigate or Decrease [sic] the effect of the trigger on the resident. Staff must understand the cultural preferences of the individual and how it impacts Delivery [sic] of care; .Trauma-specific interventions should recognize the interrelation between trauma and Symptoms [sic] of trauma such as substance abuse, eating disorder, depressions, anxiety; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During medication administration observation on 6/19/24 at approximately 9:05 a.m., Resident #34 appeared short of breath at the doorway to his room. Staff E, Licensed Practical Nurse (LPN) offered to administer his inhaler. Resident #34 said he had already taken the medication. Review of the Medication Administration Record for Resident #34 showed an order, with a start date of 6/6/24, for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for wheezing unsupervised self-administration rinse mouth after use. On 6/19/24 at 11:30 a.m. during an observation, Resident #34's inhaler was in a plastic bag taped to his bed siderails (Photographic Evidence Obtained). On 6/19/24 at 3:36 p.m. an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON said medications stored at the resident's bedside should be secured. On 6/20/24 at 10:22 a.m. during an interview, Resident #34 said he liked to keep his inhaler handy, he said he had an attack four days ago. Review of facility's policy titled Medication Administration; last review date 9/13 /22 showed. Policy: medication shall be administered in a safe and timely manner and as prescribed. Procedure: only persons licensed are permitted by the state to prepare administer and document the administration of medications may do so. 19) For narcotic medication administration, the nurse must sign them Medication Administration Record (MAR) as well as the narcotic book /control substance sheet at the time the medication is administered indicating the date and time the [medication] Med administration. 24) residents may self-administer their own medications if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision making capacity to do so safely. 5. On 06/18/24 at 1:04 p.m., an observation was made of Staff S, Licensed Practical Nurse (LPN) walking away from the medication cart, leaving the cart and computer unlocked. The cart and computer were positioned outside the nurse's station in hall 100. A resident's information page was visible to others. During that time, Residents were observed walking/wheeling to their rooms from the dining room. An observation was made of a family standing at the other end of the nurse's station. This surveyor walked to the cart and waited for the nurse to return for approximately 3 minutes. Staff S, LPN stated she should have locked the medication cart and computer before walking away. Review of a facility policy titled, medication storage, Revised 02/24, showed medications and biologicals are to be stored safely, securely, and properly, following manufacturer's recommendations for the supplier. The medication supply is accessible only to nursing personnel, pharmacy personnel, or staff members authorized to administer medications. (2.) The nursing staff shall be responsible for maintaining medication storage (med cart and med room) and preparation areas in a clean, safe and sanitary manner. (8.) compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (11.) Only persons authorized to prepare and administer medications shall have access to the medication room, including keys. Review of a facility policy titled, Self-Administration of Medications - Resident, dated 03/24, showed to abide by the individual right to self-administer medications unless determined unsafe by the interdisciplinary team. Under procedure (2.) (g.) The resident will have the ability to lock and unlock the storage drawer and manage the key. Based on observation, interview and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for four (#24, #111, #58 and #34) of 58 residents sampled, and in one of five medication carts left unlocked on one (1st) of two floors. Findings included: 1. During a facility tour on 06/18/24 at 12:47 p.m., an observation was made of Resident #24's eye drops at the bedside. There were two vials observed on her the bedside table named [brand name of lubricant eye drops]. These medications were not secured. Resident #24 stated she could administer the medications on her own, but she was supposed to keep them locked in her bedside drawer. (Photographic evidence was obtained). Review of the admission record showed Resident #24 was admitted to the facility on [DATE] with a diagnosis of dry eye syndrome of bilateral lacrimal glands. Review of the June 2024 physician orders for Resident #24 showed self-administration orders for three types of eye drops, but not the eyedrops observed at the bedside. Review of the Medication self-administration screener dated 12/21/23 showed Resident #24 was assessed for self-administration of [name of eye drops] multi dose emulsion 0.05% and [Brand name] gel. Section B- Evaluation showed (7.)The resident can demonstrate secure storage of medication. On 06/19/24 at 4:30 p.m., an interview was conducted with the Regional Nurse Consultant (RNC) and the Director of Nursing (DON). The DON stated all medications should be locked up with or without self-administration orders. They stated residents with self-administration orders had lockable drawers at their bedside. (Photographic evidence was obtained). 2. During tour on 06/17/24 at 10:02 a.m., an observation was made of Resident #111's medication at the bedside (name brand inhaler/decongestant). Review of the admission record showed Resident #111 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease unspecified. Review of June 2024 physician orders for Resident #111 showed there were no orders for the inhaler/decongestant found at the bedside. 3. During a tour of Resident #58's room on 06/17/24 10:04 a.m., an observation was made of a medication, [Brand name of medicated powder] placed on a chair by the resident's bedside. (Photographic evidence was obtained). Review of June 2024 physician orders showed Resident #58 did not have current orders for the [Brand name of medicated powder]. On 06/19/24 at 12:40 p.m., an interview was conducted with Staff P Licensed Practical Nurse (LPN). She stated all medications were to be stored in the medication cart and administered by nurse unless the resident had self-administration orders. An interview was conducted on 06/19/24 at 12:46 p.m. with Staff B, LPN. She stated all medications were to be secured. She stated if she observed a resident with medications at bedside, she would remove them and check with the physician if orders were needed to self-administer. On 06/19/24 at 1:40 p.m., an interview was conducted with Staff D, LPN/Unit Manager. He stated he had one resident on self-administration orders for eye drops. He confirmed residents with self-administration orders had bedside lockable drawers. He reviewed the photographic evidence for the residents of concerned and stated these residents should not be keeping the medications in their rooms. The expectation was to have an assessment completed to ensure the resident was able to self-administer and obtain orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to assure accurate acquiring of medications for 3 (Resident #4, Resident #5, and Resident #7) of 3 residents sampled for availability of medications, and failed to assure accurate accountability of medications in 3 (100 unit, one cart and 200 unit, two carts) of 3 medication carts inspected. Findings included: An inspection of a medication cart on the 100 unit of the facility was conducted on 1/17/2023 at 09:27 AM with Staff A, Licensed Practical Nurse (LPN). A review of the narcotics inventory log revealed the following: - A medication card for Resident #8 containing 12 pills labeled as Xanax 0.25 milligrams (mg). The inventory sheet documented the card contained 13 pills. - A medication inventory sheet for Hydromorphone 4 mg ordered for Resident #9. An entry on the inventory sheet dated 1/15/2023 at 12:00 PM revealed a hand written note reading wasted. The sheet only contained one nurse's signature on the entry line and did not document the name of a witness to the medication being wasted. - A medication inventory sheet for Diazepam 10 mg ordered for Resident #10. An entry on the inventory sheet dated 1/6/2023 at 9:00 AM revealed a hand written note reading waste. The sheet only contained one nurse's signature on the entry line and did not document the name of a witness to the medication being wasted. An interview was conducted following the inspection with Staff A, LPN. Staff A, LPN stated she had just administered a dose of Xanax 0.25 mg to Resident #8 at 9:00 AM and forgot to document the administration on the medication inventory sheet. Staff A, LPN also stated she would normally sign off on the medication inventory sheet at the time the medication was administered but she did not. Staff A, LPN identified the signatures on the medication inventory sheets for Resident #9 and Resident #10 as her own and another nurse should have signed as a witness to the wasted medications. An observation of medication administration for Resident #4 was conducted on 1/17/2023 at 9:54 AM with Staff B, LPN. Staff B, LPN removed the following medications from the medication cart for administration for Resident #4: - Allopurinol 100 mg, 1 tablet - Coreg 25 mg, 1 tablet - Gabapentin 100 mg, 1 tablet - Losartan 100 mg, 1 tablet - Chlorthalidone 50 mg, 1 tablet During the observation, Staff B, LPN stated Resident #4's Apixaban 5 mg and Nifedical 90 mg scheduled for administration at 9:00 AM could not be found inside of the medication cart and she would make a note in the resident's chart to document the medications were not available. Staff B, LPN was not able to state why the medications were not available for Resident #4 but stated she would call the pharmacy and Resident #4's physician following the completion of her medication pass. Staff B, LPN administered the 5 medications to Resident #4 and did not inform the resident of the missing medications. A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of hypertension, peripheral vascular disease, heart failure, and embolism and thrombosis of vein. A review of Resident #4's physician's orders revealed an order, dated 8/11/2022 for Nifedical 90 mg by mouth one time daily at 9:00 AM for hypertension. Resident #4's physician's orders also revealed an order, dated 5/27/2020, for Apixaban 5 mg by mouth two times a day at 9:00 AM and 5:00 PM for embolism and thrombosis of vein. A review of Resident #4's progress notes revealed an electronic medication administration record (eMAR) note, dated 1/17/2023 at 9:56 AM, documenting Apixaban 5 mg for Resident #4 was not in the medication cart and needed to be reordered. Resident #4's progress notes also revealed an eMAR note, dated 1/17/2023 at 9:58 AM, documenting Nifedical 90 mg for Resident #4 was not in the medication cart and needed to be reordered. An inspection of a medication cart on the 200 unit of the facility was conducted on 1/17/2023 at 10:11 AM with Staff C, LPN. A review of the narcotics inventory log revealed a medication inventory sheet for Tramadol 50 mg for Resident #11. Entry line #2 of the inventory sheet revealed a remaining count of 23 tablets. Entry line #3 of the inventory sheet, dated 1/9/2023 at 1:10 PM, revealed the on hand amount of medication was covered up in black ink and changed to 22 tablets, one tablet was documented as amount given, and the remaining count of pills was 22 tablets. Entry line #4 of the inventory sheet dated 1/9/2023 with no time documented revealed a hand written note reading error. The Name of person Administering line contained one signature crossed out with a single line in black ink and another signature next to it. The amount given box was left blank and the on hand count of pills was changed from 22 to 21. An interview was conducted following the inspection with Staff C, LPN. Staff C, LPN stated I don't know what that situation is, it's not me. An interview was conducted on 1/17/2023 at 10:28 AM with Resident #5. Resident #5 stated she was feeling dizzy because she needed her morning blood pressure medication and the facility did not have it available. Resident #5 was not able to state which medications she was supposed to take but stated she had been taking them for a while. A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with a diagnosis of hypertension. A review of Resident #5's physician's order revealed an order, dated 8/23/2022 for Furosemide 20 mg by mouth one time daily for hypertension. Resident #5's physician's orders also revealed an order, dated 8/5/2022 for Metoprolol Tartrate 50 mg by mouth three times a day for hypertension. A review of Resident #4's progress notes revealed the following: - An eMAR note, dated 1/16/2023 at 10:38 AM, documenting Metoprolol Tartrate 50 mg for Resident #5 was not administered and the medication was reordered. - An eMAR note, dated 1/16/2023 at 3:43 PM, documenting Metoprolol Tartrate 50 mg for Resident #5 was not available and the medication was awaiting delivery from the pharmacy. - An eMAR note, dated 1/17/2023 at 9:50 AM, documenting Metoprolol Tartrate 50 mg for Resident #5 was not in the medication cart and the pharmacy was notified. - An eMAR note, dated 1/17/2023 at 9:50 AM, documenting Furosemide 20 mg for Resident #5 was not in the medication cart and the pharmacy was notified. An inspection of a medication cart on the 200 unit of the facility was conducted on 1/17/2023 at 10:30 AM with Staff D, Registered Nurse (RN) and Staff E, LPN. An inspection of the controlled medication drawer revealed a medication card for Resident #12 containing 3 pills labeled as Xanax 1 mg. The inventory sheet documented the card contained 4 pills. An interview was conducted following the observation with Staff D, RN and Staff E, LPN. Staff D, RN stated she administered a dose of Xanax 1 mg to Resident #12 and forgot to sign the medication off on the inventory sheet. Staff E, LPN stated nurses are to sign for the medication on the inventory sheet at the time it is administered to the resident. A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE] with a diagnosis of primary insomnia. A review of Resident #7's physician's orders revealed an order, dated 1/31/2022, for Melatonin 3 mg, 2 tablets at bedtime for primary insomnia. A review of Resident #7's progress notes revealed an eMAR note, dated 1/15/2023 at 8:21 PM, documenting Melatonin 3 mg, 2 tablets for Resident #7 was unavailable. A review of Resident #7's progress notes, dated 1/15/2023 at 10:33 PM, also revealed Resident #7 was very angry due to not being administered his Melatonin as ordered and he was tired of not sleeping due to not receiving the medication. It was explained to Resident #7 the medication was not available. An interview was conducted on 1/17/2023 at 1:34 PM with the facility's Director of Nursing (DON). The DON stated when a medication runs out in the medication carts, the nurse can select the reorder button in the electronic medical record and the medication will arrive from the pharmacy. Nurses are expected to reorder medications when the resident has about 5 or so left in the package. If a nurse was not able to locate a medication, they should check in the emergency drug kit (EDK) or call the pharmacy to let them know they do not have the medication in stock. If the medication was not able to be administered, the nurse should notify the MD for further orders and note the communication in the resident's progress notes. The DON also stated she was recently put in charge of ordering the over-the-counter medications, such as the Melatonin for Resident #7, and they had arrived late. The DON stated if a narcotic medication needed to be wasted, another nurse must sign the inventory sheet to witness the destruction of the medication and narcotic medications should be signed out of the inventory sheet as soon as they are administered to the resident. Nursing staff should be verifying the correct medication counts at shift change. A review of the facility policy titled Narcotic Management, last revised in May 2018, revealed under the section titled Policy, narcotics and schedule II medication will be counted with two (2) professional nurses at the beginning and end of each shift. Documentation that a count was completed and accurate will be completed at the beginning and end of each shift. Narcotics and schedule II medications will be logged into a bound book or a separate master index page once received from the pharmacy as well as individual countdown records. The policy also revealed the following under the section titled Procedure: 5. Use the prescribing information on the sheet from pharmacy for documenting on the individual page of the bound book or countdown record. Complete all applicable sections. Photographic evidence obtained.

Based on observations, interviews and record review the facility failed to ensure one resident (#62) out of thirty-three residents was properly assessed and monitored for self-administration of eye drop medications. Findings included: During a facility tour on 4/7/22 at 9:12 a.m. an observation was made of a bottle of artificial tears eye drops and a vial of eye drops [Restasis] on Resident #62's bed side table. On 4/7/22 at 9:12 a.m. an interview was conducted with Resident #62. Resident #62 stated she takes the eye drops on her own. Resident #62 stated the nurses usually bring the medicine to her. Resident #62 said, I need them to lubricate my eyes. Resident #62 stated she did not know if she has an order for self-administration. A review of Resident #62's admission Record showed an admission date of 2/8/22 with a diagnosis, to include but not limited to, peripheral vascular disease. A Minimum Data Set (MDS) assessment for Resident #62, dated 2/15/22, showed in Section C-Cognitive Abilities, a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Section G-Functional Abilities showed Resident #62 required extensive assistance for activities of daily living (ADLs). A review of the Physician Orders dated 4/5/22, for Resident #62 showed an order for artificial tears. 1.4% instill 1 drop in both eyes two times a day for dry eyes, and Restasis Emulsion 0.05%, (cyclosporine) instill 2 drops in both eyes every 12 hours for dry eye. There was no order for self-administration of medications. A review of the Medication Administration Record (MAR) for Resident #62 dated 4/8/22 showed nurses' documentation confirming administration of Artificial Tears two times daily and Restasis emulsion two drops in both eyes every 12 hours. A review of the Comprehensive Care Plan for Resident #62 dated 2/18/22 showed a focus area for ADL self-care deficit related to decline in overall function secondary to illness and hospitalization with an intervention to give Resident #62 medications as ordered. There was no focus area for self-administration of medications on the care plan for Resident #62. On 4/7/22 at 09:45 a.m. an interview was conducted with Staff S, Unit Manager. Staff S stated she was not aware of any residents who had self-administration orders for medications. Staff S stated a few residents have orders for eyedrops. Staff S stated if a resident was on self-administration orders, there would be a physician's order and plan of care. On 4/8/22 at 9:52 a.m. a second observation was made of Resident #62's Restasis eyedrops on her bedside table. The vial was noted unopened. Photographic evidence was obtained. In an immediate interview, Resident #62 stated she would administer the eye drops later. Resident #62 stated the nurse had removed the artificial eye drops from the room and left the Restasis vial. On 4/8/22 at 9:55 a.m. an interview was conducted with Staff X, LPN. Staff X stated the expectation for medication administration is for the nurse to stay with the resident. When asked about eye drops, Staff X stated the expectation was the same, to provide supervision. Staff X stated the nurse should make sure administration is complete before walking away. On 4/8/22 at 10:02 a.m. an interview was conducted with Staff V, Licensed Practical Nurse (LPN). Staff V stated she was assigned to Resident #62 the two days eye drops were left at bedside. Staff V confirmed having left the Resident #62's eye drops on her nightstand. Staff V said, I should not have done that. I thought she had completed the administration. I thought she started to administer. I guess she must have put it down. Staff V stated Resident #62 does not have self-administration orders. Staff V said, she should be supervised. A follow -up interview was conducted with the Director of Nursing (DON) on 4/8/22 at 10:42 a.m. The DON stated residents should be supervised during medication administration by nursing. The DON said, the nurse should stay with the resident. The expectation is the same for oral pills or eye drop.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure behavior monitoring was in place for one resident (#59) out of five residents sampled for unnecessary medications. Findings included: A review of the admission Record for Resident #59 indicated the resident was admitted on [DATE] with a diagnoses, including but not limited to, anxiety, dementia in other disease classified elsewhere without behavioral disturbance, and major depressive disorder. A review of Physician Orders for Resident #59 showed the following: Buspirone Hydrochloride tablet 7.5 milligram (mg) give 7.5 mg by mouth two times a day related to anxiety disorder, unspecified. Start date: 4/23/2021 Effexor XR capsule extended release 24-hour 150 mg give one capsule by mouth one time a day related to major depressive disorder, recurrent, unspecified. Start date: 8/12/2021 Gabapentin capsule 400 mg give 1 tablet by mouth three times a day for neuropathy. Start date: 4/21/2021 Norco tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain management. Start date 4/7/2022 A review of the Comprehensive Care Plan for Resident #59 revealed the following: A focus area of Mood Disorder was in place and had interventions, including but not limited to, monitor my mood and behaviors for change and notify psychiatric doctor of any concerns. A focus area of Behavior was in place and had interventions, including but not limited to, observe/document for side effects and effectiveness of medications. A review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for April 2022 revealed no behavior monitoring was in place for Resident #59. An interview was conducted on 4/8/22 at 10:22 a.m. with Staff O, Licensed Practical Nurse (LPN). Staff O looked in Resident # 59's clinical record to check for behavior monitoring for psychotropic medication use. Staff O stated behavior monitoring should be on the MAR and monitoring should be completed every shift by the nurse. Staff O was unable to find any behavior monitoring in Resident #59's clinical record. Staff O opened another resident's record to confirm the location of behavior monitoring and to demonstrate how it should be displayed in the record. Staff O confirmed Resident #59 should have behavior monitoring in place and the monitoring was not present in the record. An interview was conducted on 4/8/22 at 10:50 a.m. with the Director or Nursing (DON). The DON stated if a resident is prescribed psychotropic medication the resident should have a proper diagnosis for the medication. The DON stated her and the Advanced Registered Nurse Practitioner (ARNP) review the orders and the resident when any resident is prescribed a psychotropic medication. She stated a gradual dose reduction (GDR) is done if needed. The DON stated behavior monitoring and modifications should be completed every shift for residents on psychotropic medications. The DON stated the order for monitoring should be entered into the MAR when the medication order is entered. She confirmed the behavior monitoring would be completed by the nurse and documented in the MAR. A review of the facility policy titled Psychotropic Medication Use, revised 5/2019 was conducted on 4/8/2022. The policy indicated: 3. The facility supports the goals of determining the underlying cause of behavior symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident.

Based on observations, interviews and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for one resident (#70) out of thirty-three residents, and for one (second floor medication cart) of two medications carts observed. Findings included: During a facility tour 4/7/22 at 09:44 a.m. an observation was made of two tablets in a plastic med cup on resident's nightstand. Resident #70 was not in the room at the time. Her roommate stated Resident #70 had gone to the store to pick up some snacks. On 4/7/22 10:02 a.m. an interview was conducted with Staff R, LPN. Staff R stated she had administered Resident #70's medications earlier in the morning. Staff R stated the resident had taken her medications. Staff R walked into the room and observed two tablets in a plastic cup on Resident #70's nightstand. Staff R said, I am surprised. She usually takes her medications. It is my fault. I should have stayed and watched her swallow. Staff R stated she was assisting Resident #70's roommate and had assumed she took her medications. Staff R could not confirm what they were. On 4/7/22 at 10:40 a.m. an interview was conducted with Resident #70 and Staff R. Resident #70 stated she had just returned from the store. Resident #70 said, I got distracted. I didn't have enough water to swallow the pills. I spit them out. I forgot to take my meds. It was not the nurse's fault. It was me. I forgot. I will take them now. Resident #70 stated she usually takes her morning meds between 8 a.m. and 9 a.m. A review of Resident #70's admission Record showed an admission date of 9/11/20 with a primary diagnosis, including but not limited to, neuropathy unspecified. A review of the MDS assessment for Resident #70, dated 2/15/22, showed a BIMS of 14, indicating intact cognition. A review of the Comprehensive Care Plan for Resident #70 revealed a focus area, dated 2/15/21, as ADL self-care deficit related to decline in overall function secondary to illness and hospitalization with an intervention to give Resident #70 medications as ordered. Another focus area in the care plan, initiated on 4/8/22, revealed Mood and Behavior: behaviors include pocketing medications and spitting out meds after administering from nurse with interventions to include nursing staff to monitor and check for pocketing of medications and validate no pills left in mouth with each med pass. An interview was conducted on 4/7/22 at 10:50 a.m. with Staff S, Unit Manager. Staff S confirmed medications should not be left unattended. Staff S stated the expectation is to stay with the resident until they swallow the medications. On 4/7/22 at 10:10 a.m. an observation was made of the medication cart on the second floor, the cart was unlocked and the keys were left on the cart. The nurse was not by her cart. Residents, staff, and families were observed walking by the medication cart. Photographic evidence was obtained. An interview was conducted on 4/7/22 at 10:16 a.m. with Staff V, LPN. Staff V stated the medication cart should be locked all the times. Staff V said, I know, I should have locked the cart and taken the keys with me. It's my fault, I'm sorry. Staff V stated the expectation is not to leave the medication cart unlocked. An interview was conducted on 4/7/22 at 10:50 a.m. with Staff S, Unit Manager. Staff S confirmed medications should not be left unattended. The medication cart should be locked any time the nurse is walking away. Staff S stated the nurse should have the keys on them. Staff S said, It is for the safety of everyone. On 4/8/22 at 9:55 a.m. an interview was conducted with Staff X, LPN. Staff X stated the expectation for medication administration is for the nurse to stay with the resident and make sure they swallow all their pills. When asked about eye drops, Staff X stated the expectation was the same, to provide supervision. Staff X stated the nurse should make sure administration is complete before walking away. A follow -up interview was conducted with the Director of Nursing (DON) on 4/8/22 at 10:42 a.m. The DON stated residents should be supervised during medication administration. The DON said, the nurse should stay with the resident. The expectation is the same for oral pills or eye drop. A review of a facility policy titled, Medication Storage, revised 3/21, indicated: Policy: for medications and biological's to be stored safely, securely, and properly, following manufacturer's recommendations for the supplier. The medication is accessible only to nursing personnel, pharmacy personnel, or staff members authorized to administer medications. (8.) compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use, trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (11.) Only persons authorized to prepare and administer medications shall have access to the medication room, including keys.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure food preferences and meal choices were honored for one resident (#94) out of two residents investigated for choices, during two meals observed on 4/5/2022 and 4/7/2022. It was determined Resident #94 had expressed his food preferences related to not receiving eggs during the breakfast meal to multiple staff members and he continued to receive eggs on a routine basis. Findings included: On 4/5/2022 at 9:30 a.m. Resident #94 was visited in his room and interviewed with permission. The resident was observed seated in his wheelchair next to his bed and had his over the bed table placed in front of him. He still had his breakfast meal tray placed in front of him on the table. The lid was still in place as if he did not eat anything. Resident #94 was observed dressed for the day and pleasant to speak with. Resident #94 expressed he routinely receives food items he hates and he has spoken with the Dietary Manager, Staff A about his choices. Resident #94 indicated he hates eggs and gets them almost every morning. Resident #94 pointed to the wall next to the bathroom door and said to look at the menu sheet. Upon review of weekly menu sheet, the word eggs was penned out and with large bold letters all over the sheet, indicating NO EGGS. Photographic evidence was taken. Resident #94 stated he has spoken to his care aides as well when they drop off the tray. He continued to state staff drop off the tray so fast and leave before he can lift the lid off and see if he had eggs or not. Resident #94 was asked about the meal tray in front of him and he lifted the lid. An egg omelet was observed on his plate. Resident #94 did not touch or eat anything due to the fact he does not like the sight of eggs. He stated he was hungry and would eat something if they brought him something else. However, it was 9:30 a.m. and staff were observed in the hallways picking up trays for residents who have already eaten. There was a meal slip/ticket on his meal tray and it had documentation printed light in color and not clear to read. Most of the ticket was unreadable. It appeared that the printer where this ticket was printed was either out of ink or almost out of ink. No preferences were able to be seen. On 4/5/2022 at 11:00 a.m. the Kitchen Manager Staff A confirmed he was aware Resident #94 did not like eggs and they have tried to accommodate the resident by not providing eggs. Staff A stated the tray ticket system only indicates food allergies and does not indicate food likes and dislikes. Staff A was asked how he and his dietary line staff would know and honor resident food preferences, and he indicated he does not have a good tracking system for preferences. On 4/7/2022 at 8:20 a.m. Resident #94 was observed in his room and seated in a wheelchair next to his bed. He was observed with the over the bed table placed in front of him and with his breakfast meal tray placed on the table. The lid was on and the resident appeared to be upset. He shook his head in a no manner and revealed, they did it again. He pointed to his breakfast tray and lifted the lid. The meal he was provided was a double portion of scrambled eggs, one round sausage patty, and one Danish. The tray also included one bowl of hot oatmeal, a glass of juice, and a carton of 2% milk with an empty glass. Photographic evidence was obtained. Resident #94 expressed he was not going to touch anything on his plate because he hates eggs and further expressed the staff were completely aware of his likes and dislikes, especially eggs. The meal ticket placed on the meal tray was reviewed and indicated: 4/7/22 Regular diet, apple juice, assorted Danish, hot coffee, creamer, low fat fruited yogurt. Photographic evidence was taken. Resident #94 placed the lid back on the plate and stated staff just placed it on his table and left before he could lift the lid and see what he got. He stated he was hungry and wanted to eat but would not eat what was provided on the plate. On 4/7/22 at 8:25 a.m. the floor nurse, Staff F stated she was not aware if Resident #94 liked or disliked eggs until she heard him call out he did not want eggs during the breakfast meal service on 4/5/2022. She stated she floats to different floor assignments and does not know the resident well. She did express she would follow up with the resident. On 4/7/2022 at 8:33 a.m. the Certified Nursing Assistant (CNA) Staff I, who had Resident #94 on her work assignment, stated she knew the resident and also knew he did not like eggs. Staff I, CNA stated she did not serve him his meal this a.m. and didn't know who did. She stated Resident #94 does receive eggs and when she sees this she will tell the kitchen and get another tray. She confirmed she has seen Resident #94 receive eggs often. A review of Resident #94's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the Advance Directives revealed Resident #94 was his own responsible party. A review of the current Minimum Data Set (MDS) quarterly assessment, dated 3/7/2022, revealed: In Section C-Cognition, a Brief Interview of Mental Status (BIMS) score of 13, which indicated Resident #94 was able to speak on behalf of himself and his care and services. In Section G-Functional Abilities, Activities of Daily Living indicated Resident #94 was able to eat independently with set up only and was on a regular diet. A review of the Physician's Order sheet for the month 4/2022, revealed a diet order to include: Regular Diet, Regular texture, thin liquid consistency. A review of the Progress Notes revealed, dietary notes dated from 1/2022 through 4/7/2022, did not indicate any food likes/dislikes or food preference documented for Resident #94. A note dated 4/7/22 at 9:54 a.m. was added to the record and indicated, Resident food preference updated by Kitchen Staff/Management and tray cards have been updated. Will continue to monitor and follow up with needs as needed. A review of the Comprehensive Care Plan for Resident #94 revealed the following: Focus: Potential for nutrition decline: (last revised on 3/7/2022) with interventions, to include but not limited to, Registered Dietician to evaluate and make diet change recommendations. An interview with the Interim Certified Dietary Manager, Staff B, confirmed Resident #94 does not like eggs and they are going to update the tray slip to show his dislikes. She revealed she had spoken to some staff to include dietary and nursing, and the staff had confirmed Resident #94 does not like to receive eggs. She indicated she was just hired on as the manager of this facility and her first observation indicated the kitchen did not have a good ticket tracker and food preference identification system. On 4/7/2022 at 11:00 a.m. an interview with the Director of Nursing (DON), Staff A, and Staff B was conducted. They stated they did not have specific policies and procedures with relation to food preferences and or food likes/dislikes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure respiratory equipment was stored appropriately during three days of four days surveyed, for one floor (second floor) of two floors in the facility, and for nine residents (#56, #28, #52, #51, #102, #213, #313, #314 and #315) of 15 residents receiving respiratory care. Findings included: On 4/5/22 at 1:28 p.m. Resident #56's nebulizer equipment was observed stored on the nightstand, the cannula and tubing were exposed to the air. A review of the admission Record for Resident #56 showed an admission date of 4/25/21 with a diagnosis, to include but not limited to, chronic obstructive pulmonary disease (COPD). The Physician Orders for Resident #56, dated 4/7/21, showed an order for Albuterol Sulfate nebulization solution 2.5 mg (milligrams)/0.5 ml (milliliters), 3 ml inhale orally via nebulizer every 6 hours as needed (PRN) for SOB (shortness of breath) related to COPD. On 4/7/22 at 12:29 p.m. Resident #28's Continuous Positive Airway Pressure (CPAP) machine was observed stored on her bedside, her mask and tubing on her bed. Resident #28 stated she wears her CPAP every night. Resident #28 stated it is always on the bed. The resident did not know how often the tubing and mask were replaced. A review of the admission Record showed Resident #28 was admitted to the facility on [DATE] with a diagnosis of Obstructive Sleep Apnea (OSA). On 4/6/22 at 11:47 a.m. an observation was made of Resident #52's oxygen and nebulizer cannula's on the nightstand not stored in a bag. Resident #52 did not know how often she used either one of them. A review of Physician Orders for Resident #52 showed orders, dated 3/23/22, to administer oxygen at 2 L (liters) via NC (nasal cannula) for oxygen percentage under 90% as needed; Albuterol Sulfate nebulization solution 2.5 mg/3 ml 0.083%, 3 ml inhale orally via nebulizer every 6 hours for wheezing; DuoNeb solution 3 ml inhale orally via nebulizer every 6 hours as needed for SOB; and DuoNeb solution 3 ml inhale orally via nebulizer two times a day for SOB for oxygen percentage under 90%. An observation was made on 4/7/22 at 9:21 a.m. of Resident #51's nebulizer machine stored on the floor, oxygen cannula and tubing were noted on the floor. An immediate interview was conducted with Resident #51. Resident #51 stated she used the nebulizer 2-3 times a day. A review of Resident #51's admission Record showed an admission date of 11/13/21 with a diagnosis of COPD. A review of the Physician Orders for Resident #51 showed orders, dated 2/1/22, for oxygen at 3 liters per nasal cannula continuously for COPD, and an order, dated 4/5/22, for Albuterol Sulfate nebulization solution 2.5 mg/3 ml 0.083%, 3 ml inhale orally via nebulizer every 8 hours as needed for SOB. On 4/7/22 at 12:20 p.m. an observation was made of Resident #102's oxygen tubing and cannula on the floor. Resident #102 stated he is supposed to be on his oxygen. Resident #102 stated the oxygen tubing fell off. A review of Resident #102's admission Record showed an admission date of 3/7/22, with a diagnosis, including but not limited to, chronic respiratory failure and shortness of breath. A review of the Physician Orders showed an order, dated 3/7/22, for oxygen at 3 liters/minute via nasal cannula for SOB / dyspnea. An observation was made on 4/7/22 at 9:39 a.m. of a CPAP machine/tubing stored inside the bedside drawer, mask not stored in a bag for Resident #213. A review of Resident #213's admission Record showed an admission date of 2/17/22 with a diagnosis, including but not limited to, COPD and acute respiratory failure. A review of the Physician Orders showed an order, dated 3/24/22, to use CPAP daily at bedtime related to COPD, acute respiratory failure with hypoxia. On 4/5/22 at 11:58 a.m., an observation was made of Resident #313's nebulizer mask on top of a bedside table not stored in a bag. Resident #313 was not interviewable. A review of the admission Record for Resident #313 showed an admission date of 3/14/22. A review of Physician Orders for Resident #313, dated 3/20/22, showed to change nebulizer tubing every night shift and to administer Ipratropium-Albuterol Solution 0.5-2.5 (3 mg / 3 ml), inhale orally every 6 hours as needed for SOB. On 4/7/22 at 12:44 p.m., an observation was made of Resident #314's oxygen tubing and cannula on the floor. Resident #314 did not respond to interview. A review of the admission Record for Resident #314 showed an admission date of 3/28/22. A review of the Physician Orders for Resident #314 showed an order for oxygen at 2 liters as needed dated 3/29/22. An observation was made on 4/7/22 at 12:48 p.m. of Resident #315's CPAP supplies resting on the nightstand mask not stored in a bag. The tubing was observed to be on the floor. Resident #315 stated he wears his CPAP every night. Resident #315 was not aware if his CPAP should be stored in a bag. A review of the admission Record for Resident #315 showed an admission date of 3/31/22 and diagnosis, including but not limited to, COPD. A review of the Physician Orders for Resident #315 showed orders to wear CPAP at bedtime every evening for apnea, dated 4/6/22. On 4/7/22 at 12:57 p.m. an interview was conducted with Staff Q, Licensed Practical Nurse (LPN). Staff Q stated the nebulizer's tubing, CPAP masks, and oxygen cannula's should be stored in a clear bag. Staff Q said, it should be dated and labeled. Staff Q indicated it was third shift nurse's responsibility to place clean bags and tubing. An interview was conducted with Staff R, LPN on 4/7/22 at 1:01 p.m. Staff R stated the nebulizer's should be unplugged when not in use, cleaned, and stored appropriately. Staff R stated appropriate storage means as ordered, covered, and dated. Staff R stated she would conduct an audit of her assigned areas and replace cannula's and masks. On 4/7/22 at 1:08 p.m. an interview was conducted with Staff U, LPN. Staff U stated the nurse administering the respiratory treatment should take responsibility and make sure to clean and store the equipment in a dated bag after each use. An interview was conducted on 4/7/22 at 1:10 p.m. with Staff S, Unit Manager. Staff S said, respiratory equipment should not be on the floor. Staff S reviewed photographic evidence and said, no, that is not appropriate storage. Tubing should not be on the floor. Masks and cannula's should be in a dated bag. Staff S stated some residents refuse to store their units in bags or they remove them. Staff S said, yes ultimately it is our responsibility to ensure sanitary storage. On 4/7/22 at 1:27 p.m., a follow-up was conducted with the Director of nursing (DON). The DON stated respiratory equipment is expected to be in a bag, sometimes it is in a drawer, but it is supposed to be in a bag either way. The DON stated tubing should be changed weekly, on Sundays. The DON said, it should be dated and labeled with the resident's name and room number. The DON stated the expectation is for patients to wear it as ordered and if resident does not follow orders, the physician should be notified. The DON stated equipment is kept on beside table. The DON said, mask should be kept in a bag, placed on the machine and not on the floor. The DON stated if resident refuses appropriate storage, it should be documented, and care planned. An interview was conducted on 4/8/22 at 9:22 a.m. with the DON. The DON confirmed respiratory equipment should be stored and changed per physician order and policy. A review of a facility policy titled, Handheld nebulizer / small volume nebulizer, revised 3/2020, showed (11.) Store nebulizer equipment in a storage bag. Nebulizer tubing should be changed every two weeks or more often if malfunction or visibly contaminated. Clean compressor per manufacturer's recommendation. A review of the facility policy titled, BIPAP CPAP, revised 5/2021, showed (7.) the machine, tubing and masks must be cleaned according to facility policy. A review of a facility policy titled, Oxygen Administration policy and procedure, revised 3/27/2020, showed (11.) all tubing will be changed and dated every two weeks or more if malfunction or visibly soiled. (12.) Oxygen concentrators will be maintained by vendor per facility.

Based on observation, interviews, and record review the facility failed to ensure adequate staffing in the kitchen in order to provide residents with timely meals, during three of four meal services observed on 4/6/2022 and 4/7/2022. It was determined one hundred and nine residents out of one hundred and fourteen residents in the building receive meal trays and meal service. Findings included: On 4/5/2022 at 9:20 a.m. the kitchen was toured with Staff A, Kitchen Manager. During the tour, Staff A pointed out he had two dietary aides, Staff E and Staff Y, in the kitchen as well as himself, a total of three dietary staff members. He confirmed there were one hundred and fourteen residents in the building as of 4/5/2022. Staff A was asked if he had enough staff to prepare, cook and send out food to all the residents in the building in timely manner. He indicated he works up to seventy hours a week to ensure appropriate staffing in the kitchen. He did not offer any information as to why he had to work so much. Staff A confirmed the kitchen staff is contracted and there have been new hires recently but they don't stay. He was asked what number of kitchen staff would be appropriate in the kitchen and he could not answer. Staff A did confirm he could use more help and does not know if his agency is trying to hire new staff or not. Staff A revealed he had been working at the facility for about five months now and has had a large staff turnover. He also confirmed he works seven days a week. At 9:25 a.m. an interview was conducted with Staff E, Dietary Aide and Staff Y, Dietary Aide, neither staff member would answer if they felt the kitchen was short staffed. They did, however, reveal they do the best that they can with what they have. Staff members A, E and Y were asked if meal trays were being sent out to the floor and dining room late on a routine basis. None wanted to answer the question with a clear yes or no. On 4/5/2022 at 9:45 a.m. both the first floor and second floor hallways were still observed with meal tray carts and with staff picking up completed meal trays from resident rooms. Interviews with Certified Nursing Assistants (CNAs) Staff I, J, K, L, and M all revealed meals generally come out late in the mornings and they try to pass the meal trays to residents as quickly as they can, when the cart arrives. None of the aides interviewed were able to say why the meal tray carts come out late from the kitchen. Staff I and K stated they felt the Kitchen was short on staff. On 4/5/2022 at 11:00 a.m. the Kitchen Manager, Staff A provided the Tray Meal Service times document for review. The breakfast meal service times revealed the following: Cart 1 Rooms 134 - 132 7:15 a.m. Cart 2 Rooms 111 - 121 7:30 a.m. Cart 3 Rooms 101 - 110 7:40 a.m. Cart 4 Rooms 223 - 232 7:50 a.m. Cart 5 Rooms 211 - 222 8:00 a.m. Cart 6 Rooms 201 - 209 9:00 a.m. During tour of the facility on 4/5/2022 from 11:30 a.m. through to 1:00 p.m. random interviews with Residents #94, #38, #17, #101, #49, #86, #11, and #34 all revealed they typically eat all three meals in their rooms and confirmed the kitchen is routinely late sending out food. The residents revealed breakfast meals are typically the main meal that is sent out late. They were all aware of when they are supposed to receive their tray and further revealed they typically receive their trays in their room about thirty to forty minutes later than what is posted. On 4/6/2022 the facility was entered at 7:08 a.m. to observe the breakfast meal service. There were three dietary aides working in the kitchen, Staff Y, E, and Z. Staff Z stated she was asked to come in from her regular working facility to help out. Staff Z was not listed as an employee at the facility. The Kitchen Manager, Staff A was not in the kitchen at the time of the observation. An interview was conducted with Staff Y, and E. They stated they did not know where Staff A was. An observation of the breakfast meal was conducted on 4/6/22, the meal trays made it out to the floor during the following times: a. Cart for rooms 101 - 110 arrived on the floor at 8:46 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:40 a.m. It was found the cart arrived on the floor one hour and six minutes late. b. Cart for rooms 111 - 121 arrived on the floor at 8:36 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:30 a.m. It was found the cart arrived on the floor one hour and six minutes and one hour and sixteen minutes late. c. Cart for rooms 132 - 134 arrived on the floor at 8:26 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:15 a.m. It was found the cart arrived on the floor one hour and eleven minutes late. d. Cart for rooms 223 - 232 arrived on the floor at 8:20 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:50 a.m. It was found the cart arrived on the floor thirty minutes late. An observation of the breakfast meal was conducted on 4/7/22, the meal trays made it out to the floor during the following times: e. Cart for rooms 101 - 110 arrived on the floor at 8:24 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:40 a.m. It was found the cart arrived on the floor one hour and nine minutes late. f. Cart for rooms 111 - 121 arrived on the floor at 8:05 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:30 a.m. It was found the carts arrived on the floor thirty-five minutes late. g. Carts 132 - 134 arrived on the floor at 8:30 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:15 a.m. It was found the cart arrived on the floor one hour and fifteen minutes late. Interviews conducted on 4/7/22, during the meal observation, with Staff F, Licensed Practical Nurse (LPN), Staff K, CNA, and Staff M, CNA, all confirmed the meals are still getting out late and they felt there was not enough staff in the kitchen to prepare and get meals out in a timely manner. Staff F, K, and M stated residents continually ask where their breakfast is and all they (staff) can do is to serve them coffee and hydration. On 4/8/2022 at 6:30 a.m. the building was entered to review 11-7 shift staffing for both nursing staff and the kitchen staff and also meet with the Staffing Coordinator. She confirmed she completes daily staffing for direct care and does not handle staffing for the kitchen, as they are contracted. She revealed sometimes the facility will pull activities staff during meal service to assist with meal tray pass and to get tray carts from the kitchen. The Staffing Coordinator confirmed there used to be sufficient staffing in the kitchen prior to the contracted company taking over and she does not know why kitchen staffing at this time constantly has turn over. The Staffing Coordinator did not have any further information to provide with relation to appropriate staffing in the kitchen. On 4/8/2022 an interview with the Kitchen Manager, Staff A, the other new Dietary Manager Staff B, and the Regional Dietary Manager, all revealed they believed they had sufficient kitchen staffing numbers in the kitchen during the lunch and dinner meal service but confirmed they could have more kitchen staff during the breakfast meal service. They confirmed having more staff in the kitchen could have ensured breakfast tray carts getting out from the kitchen and to the floor in a timelier manner, and in a manner with following the meal tray service times sheet. They were aware meals were brought out from the kitchen in an untimely manner, resulting in residents receiving their meals late. The Kitchen Manager, the Director of Nursing and the Regional Dietary Manager revealed the facility did not have a specific Kitchen Staffing policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that ordered splinting interventions for preserving range of motion and mobility were in place for two (Resident #161, Resident #23) out of four residents sampled for range of motion. Findings included: 1. On 11/04/20 at 10:42 a.m., 11/05/20 at 5:10 p.m., and 11/06/20 at 10:16 a.m., Resident #161 was observed with no splint on the right wrist and hand, and no splint was observed on visible surfaces in his room. During observations, the resident's right wrist and fingers were observed in a flexed position with his hand forming into a fist. Review of the admission record for Resident #161 revealed he was a long term care resident and had resided in the facility for over 4 years with diagnoses to include cerebral infarction (stroke), altered mental status, and aphasia (inability to comprehend or formulate language). The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief inventory of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS revealed that the resident was totally dependent for all mobility, required extensive assistance for dressing, toilet use, and personal hygiene. A review of the physician orders for Resident #161 revealed an order for, Resident to wear Right Wrist hand orthosis. Donn (put on) with AM care, Doff (remove) at HS (hour of sleep) or as tolerated with a start date of 02/14/2019. The treatment administration record (TAR) for Resident #161 revealed the splint order with an apply time of 6:00 a.m. and splint removal time of 9:00 p.m. The November 2020 TAR revealed that for the dates of 11/01/20 - 11/06/20 splint application and removal was entered with a check mark with according to the charting codes meant Administered. The care plan for Resident #161 revealed a focus area documented as Contractures: I have an alteration in musculoskeletal stats r/t (related to) contracture of the right hand . initiated 06/28/2019 and last revised 09/30/2020. Interventions related to that focus area included Assist me with the use of supportive device, splint to right hand, as recommended .Right hand splint daily, on with AM care, off at hs (hour of sleep) as tolerated . Positions documented as responsible for the interventions were Certified Nursing Assistant (CNA), Registered Nurse (RN), Licensed Practical Nurse (LPN). On 11/06/20 at 10:16 a.m., Staff G, Certified Nursing Assistant (CNA) was interviewed at the bedside of Resident #161. She confirmed that she was assigned care for the resident that day and confirmed that there was no splint on the right wrist/hand of the resident. She stated she didn't know anything about a splint and said that was something that restorative nursing or therapy staff did. Staff G was unable to locate the splint from the room. She stated that she did not know where it was and could not recall seeing it. She said the resident had changed rooms, and maybe it got left in the old room. 2. On 11/04/20 at 11:00 a.m.,11/05/20 at 5:20 p.m., and 11/06/20 at 10:12 a.m., Resident #23 was observed with no splints on and no splints were visible on surfaces in her room. Review of the admission record for Resident #23 revealed that she was a long term care resident and had resided in the facility for approximately 6 years with diagnosis to include contracture. The MDS completed on 08/20/20 revealed a BIMS score of 00, indicating severe cognitive impairment. The MDS revealed that the resident was totally dependent for all mobility and care and had upper extremity (shoulder, elbow, wrist, hand) impairment on both sides. Review of physician orders for the resident revealed an order for a right palm guard and left soft splint during the day as tolerated. The TAR did not contain the splint order or documentation of application. The care plan for Resident #23 did not reveal any focus area or interventions related to splinting. On 11/06/20 at 10:12 a.m., Staff J, Certified Nursing Assistant (CNA) was interviewed at the bedside of Resident #23. She confirmed she was assigned care for the resident that day and confirmed that there were no splints on the resident. She stated she saw them on the resident sometime last week .therapy or restorative puts them on. She searched in the drawer of the resident's bedside table and found the splints. She began to apply the splints and said, I don't even know how these are supposed to go on. 3. At 10:31 a.m. on 11/06/20, Staff H, Restorative CNA, was interviewed and confirmed that neither Resident #23 nor Resident #161 were on caseload with restorative nursing and that any splinting application was the responsibility of the floor nursing staff. Staff I, Licensed Practical Nurse (LPN) was interviewed on 11/6/20 at 10:37 a.m. She confirmed that she was in charge of the facility's restorative nursing program and confirmed that Resident #161 was not on the restorative nursing caseload and said, he should be on floor maintenance. She reviewed the electronic health record (EHR) for Resident #161 and confirmed there was an order for a splint but said, we never got that one .I have no idea what happened .I'm clueless. Regarding Resident #23, she confirmed that she was not on caseload with restorative nursing. She reviewed the EHR for Resident #23, confirmed there was an order for splints and said, the therapist never gave that to me. She reported that the process for putting a resident on caseload with restorative nursing was that a referral form was completed by a therapist and given to her. She reported that once restorative nursing program was completed, management of needs was transferred to the floor staff. She said, getting the aides to pick up what they're supposed to do is a problem. On 11/06/20 at 11:16 am. the facility Director of Rehabilitation (DOR) was interviewed. She confirmed that when a resident was discharged from therapy with a splint, the process was for the therapist to provide a referral form to restorative nursing. She revealed that Resident #161 had been transferred to restorative nursing in the past with instructions for splinting. Regarding Resident #23, she consulted the EHR and confirmed there was an order for splints but stated she did not have any other information and could not locate the referral form for restorative nursing. She asked Staff K, Occupational Therapist (OT) to join the interview. Staff K confirmed she had been the treating therapist for Resident #23 and had initiated the splinting and confirmed that the resident was no longer on therapy caseload. Regarding transfer of care for splinting she said, I worked with the CNA .can't tell you her name .I dropped the ball .I didn't have her sign anything and I didn't send anything to restorative about her. Staff K said, typically I would go through a series of sessions with the restorative aides to train them, then write up a restorative form and give one to [Staff I]. She confirmed again that she had not completed a restorative nursing referral form for Resident #23. She confirmed that she had entered the order for splinting in the EHR. She said, I thought I communicated well enough with the aid .was a total fail on my part .I should have gone through the process. An interview was conducted on 11/06/20 at 11:54 a.m. with the facility MDS Coordinators Staff L, RN and Staff M, LPN, and the facility Director of Nursing (DON). The DON confirmed that the facility process for splinting was transfer from therapy to restorative nursing and then from restorative nursing to floor staff management. She confirmed that splinting interventions for floor management should be on the CNA task list and said, '[Staff I] takes form from therapy and enters into tasks. She confirmed that splinting was not on task lists for Resident #161 and Resident #23. Regarding no entry for splinting on the TAR for Resident #23 she stated that the person putting the order in the system had to select that option and revealed that the EHR reflected that didn't happen for the order for Resident 23 and said, [Staff K] didn't do that .that's why its not there. The DON did not have an explanation for the nurses signing off on the TAR for Resident #161 to indicate that the splint had been administered when it wasn't. The DON stated that her expectation was that if a nurse signed off on something as administered, they would have seen it to verify before signing off. The DON followed up on 11/06/20 after the interview and reported that she had spoken with nurse who had last entered on the TAR for Resident #161. The DON stated that the nurse acknowledged that she knew the splint was in a drawer in the resident's room. The nurse told the DON that the resident refuses the splint, and the nurse acknowledged that she should have documented refusal on the TAR rather than administered. The DOR followed up at approximately 4:00 p.m. on 11/06/20 and reported that the splint for Resident #161 had been found in a drawer in his room and applied. The facility policy titled, Restorative Nursing Program with creation date of 01/20 revealed the following within the section titled Procedure: 2. Therapy will send a restorative referral sheet to the Licensed Restorative Nurse/designee for initiation of restorative program(s) indicating the resident's current level of participation and anticipated goals/interventions. 4. Licensed Restorative Nurse will review the program with the therapy staff and implement the recommended program(s). 5. A care plan will be developed and information shared with involved staff. 7. The nursing staff will be educated on the established program by the restorative nurse or therapist if special instructions required regarding the service needed.

Based on observations, interviews, and record review the facility did not ensure that a controlled substance was locked and stored in a permanently affixed compartment and separate from other medications in one (Hibiscus) of two medication storage rooms. Findings included: During the task of Medication Storage and Labeling the locked medication room for the Hibiscus unit was accessed on 11/04/20 at 3:56 PM by the evening Unit Manager/Staff A, Registered Nurse (RN). The small refrigerator was unlocked by Staff A to reveal a small plastic case unsecured in the refrigerator. The clear plastic box was closed with a green tamper proof seal and the contents could be seen through the plastic. It contained two, 2mg/ml vials of the controlled substance lorazepam and two, 10ml insulin multidose vials. The box was not secured in the affixed compartment present in the refrigerator and the box did not have an accompanying label for its contents. Staff A stated that they probably couldn't find the key to lock it up and that the box was their emergency kit. Closer observation revealed the small case was closed with a green tie wrap and was not labeled with anything other than the pharmacy name and the large numeral 5. A subsequent interview was conducted on 11/04/20 at 4:28 p.m. with the Director of Nursing (DON) and Staff B, Licensed Practical Nurse (LPN) about the storage of the box containing the lorazepam. They stated that they received and signed for the controlled meds from the pharmacy and then placed them in the fridge or the lockbox on the wall. They stated that two nurses were required to access the medication because one nurse had the door key, and the other had the key to the lockboxes. They could not find the key to the small affixed lockbox in the refrigerator to store the lorazepam securely. Staff B stated that she did not recall the last time she had seen the small case containing the lorazepam locked in the affixed compartment. The DON stated on 11/06/20 at approximately 4:00 p.m. that she had procured new boxes to secure the controlled substance in a separate permanently affixed compartment in the refrigerators. The DON was asked for their medication storage policy on 11/04/20 at approximately 4:30 p.m. and provided a document with a subject of Medication Storage in the Facility. Section 10 of the document revealed Schedule II through V controlled medications were stored separately from other medications in a designated double locked drawer. A telephone interview with the pharmacist consultant was conducted on 11/10/20 at 2:43 p.m. The pharmacist confirmed that he had observed the Hibiscus medication room during his most recent visit in October, 2020. He stated that he made a verbal recommendation for the small case containing the controlled substance lorazepam to be moved to the inside of the locked and permanently affixed box inside the refrigerator. Photographic evidence was obtained.