Based on observations record review and interviews the facility failed to follow standard precaution protocols to prevent the spread of infections for two residents (Resident #512 and Resident #133) out of seven residents sampled as evidenced by staff not cleaning blood pressure cuff between residents. There were 199 residents residing in the facility at time of survey. The findings included: On 05/28/24 at 7:26 AM Staff B, Certified Nursing Assistant (CNA) was observed measuring Resident #512's vital signs. using a blood pressure machine and cuff. Staff B, CNA removed the blood pressure cuff from the resident's arm, placed cuff into a basket that was attached to the blood pressure machine, and left the room. On 05/28/24 at 7:28 AM Staff B, CNA entered Resident#133's room with the same blood pressure machine and cuff used on Resident #512, verbalized intention to take vital signs and proceeded to place cuff on Resident #133. Staff B, CNA stopped by surveyor. During an interview on 05/28/24 at 7:37 AM, (translated by Staff A, Licensed Practical Nurse (LPN)) Staff B, (CNA) revealed, when using the blood pressure machine on different residents the correct procedure is to clean the machine and the cuff using the bleach wipes located inside the basket attached to the machine. Staff B, CNA also stated: I didn't wipe the cuff between residents because I was nervous. On 5/30/24 at 12:47 PM; the Assistant Director of Nursing (ADON) stated: The blood pressure cuff should be cleaned using bleach wipes between residents. Review of the facility' Policy and Procedure indicated: Policy No.140 Dated 1/16/18 review date 11/16/23 revised date 12/7/23 Title: Infection Prevention and Control Surveillance Program I. Purpose: a) It is the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. II. Scope: a) Covers all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. V. Policy: a) The Infection Control Program is designed to prevent, identify, report, investigate and control the spread of infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with date and Federal Regulations, and national guidelines. Vi. Procedure 10. All shared medical equipment will be cleaned using an EPA- approved disinfectant wipe effective against TB and Hepatitis B. Standard Precautions: Also, equipment or items in the resident environment must be handled in a manner so as to prevent transmission of infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to refer a resident, for a Preadmission Screening and Resident Review (PASRR) Level II screening for one (Resident #128) of one resident out of seventeen residents receiving health rehabilitation services for Mental Illness (MI) and/or Intellectual Disability (ID) who exhibited behaviors. There were 207 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR) Program Policy and Procedure (effective 4/2017, reviewed 10/2022) documented the following: Intent: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission screening and Resident review, in accordance with State and Federal Regulations. Definitions: For purposes of this policy: 1) An individual is considered to have a mental disorder is the individual has a serious mental disorder, 2) An individual is considered to have an intellectual disability if the individual has an intellectual disability, 3) or is a person with a related condition and 4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. Procedure: 1) A facility will coordinate assessments with the pre-admission screening and resident review (PASRR) program as stated under Federal regulations to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes a) Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care, b) referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Observation of Resident #128 on 12/20/22 at 7:38 AM revealed the resident sitting up in bed with the television on, eating breakfast. Floor mats were noted. Review of the Preadmission Screening and Resident Review (PASRR) Level I for Resident #128 on 12/20/2022 at 9:39 AM documented the following: 1) PASRR Level I was completed on 10/07/2020 at a local Hospital; 2) Section I, PASRR Level I Screen Decision Making Mental Illness (MI) or suspected MI were not checked, the section was marked as N/A (non-applicable); 3) Section II, Other Indications for PASRR Screen Decision-Making were checked No; 4) Section IV: PASRR Screen Completion were checked for-No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR not required and 5) Resident admitted to the facility on [DATE]. Review of the Demographic Face Sheet for Resident #128 documented the resident was admitted on [DATE] with diagnoses to include acute respiratory failure and Parkinson's disease. The resident was diagnosed with Schizoaffective disorder on 5/27/2021, anxiety disorder on 3/08/2022 and psychotic disorder with hallucinations on 12/09/2022. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #128 dated 9/23/2021 documented the PASRR for the resident not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition and the Brief Interview for Mental Status (BIMS) Summary Score was not scored, indicating severe cognitive impairment. Review of the MDS Quarterly for Resident #128 dated 11/27/2022 documented (BIMS) Summary Score was not scored, indicating severe cognitive impairment and is extensive assistance to total dependence with one-two+ person physical assist for ADLs (activities of daily living). Review of the Physician' s Order Sheets (POS) and Electronic Medication Administration Records (EMAR) for Resident #128 for October 2022, November 2022 and December 2022 documented the resident was receiving antipsychotic medications and antianxiety medications: Pimavanserin Tartrate 34 mg (milligrams) cap (capsule) 1 cap PO (by mouth) one time a day for psychosis, start date 9/03/2022; Alprazolam 0.5 mg tab (tablet) 1 tab PO TID (three times a day) for anxiety disorder, start date 9/18/2022 and Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder, start date 10/05/2022. On 9/20/2022, the resident was prescribed Lorazepam Solution 2 mg/ml (milliliters) inj (inject) 0.25 ml IM (intramuscular) every 8 hours PRN (as needed) for severe anxiety/agitation for anxiety disorder. Resident #128 exhibited behaviors on the following dates: 9/20/2022 and 10/01/2022 and received PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety was reinstated for 14 days, and on 10/05/2022 received Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder. Review of the Care Plans for Resident #128 documented the resident had care plans for the following: Insomnia (initiated date 3/15/22), Psychotropic Medications (initiated date 3/15/2022), Anxiety (initiated date 3/15/2022) and Schizoaffective Disorder and Organic Brain Syndrome (initiated date 3/15/2022). The care plan for Schizoaffective Disorder and Organic Brain Syndrome (initiated date 3/15/2022) documented: Focus: Resident is on antipsychotic medication for management of behavioral problem. Resident has diagnosis of Schizoaffective Disorder and Organic Brain Syndrome; Goal: Resident will have reduced incidents of mood or behavior change by NRD (next review date); Interventions: Administer medications as ordered and Assess behavior pattern daily. Review of the Progress Notes for Resident #128 documented the following: On 9/20/2022, a psychotropic note documented the resident refusing to take oral medication and striking out at staff. PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety was reinstated for 14 days; On 10/01/22, the resident was observed screaming with aggressive behavior towards staff and was given PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety and on 10/05/22, the resident was observed being aggressive towards staff while helping with ADLs. The MD (medical doctor) was contacted and ordered to start the resident on Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder. Interview and record review with Staff A, Registered Nurse (RN) on 12/21/2022 at 10:30 AM. Staff A stated, She is alert and oriented times one. She is extensive to total care for ADLs. Her diagnoses include anxiety disorder, Schizoaffective disorder, psychosis, and insomnia. She takes Pimavanserin Tartrate 34 mg cap 1 cap PO one time a day for psychosis, Melatonin 1 mg tab 2 tabs PO HS for insomnia, Olanzapine 2.5 mg tab 1 tab PO one time for Schizoaffective disorder and Alprazolam 0.5 mg tab 1 tab PO TID for anxiety disorder. The Olanzapine was ordered on 10/05/22. Sometimes she exhibits behaviors, and they are documented on the EMAR and progress notes. Progress notes on 10/05/22, resident aggressive to staff and MD ordered and started on Olanzapine. On 10/01/22 she was screaming and was given Lorazepam. On 9/20/22 psychotropic note resident refusing to take oral medication and striking out at staff. PRN order for Lorazepam 2 mg/ml inject 0.25 ml IM every 8 hours PRN for severe anxiety was reinstated for 14 days. Residents' mood and behavior are being monitored. Interview with Staff B, CNA (Certified Nursing Assistant) on 12/21/2022 at 10:40 AM via Spanish translator. Staff B revealed, the resident requires extensive care, and the care depends on her mental state. Staff B reported she has witnessed the resident with anxiety, repeating words and confused. Sometimes the resident will fight when care is being given. Interview with the Social Services Director on 12/21/2022 at 12:17 PM. The Social Services Director stated: The PASRR for 10/07/20 did not have any diagnosis on it. This diagnosis of Schizoaffective disorder is a new one. I have to be notified by nursing when there is a change in behaviors. Once I am notified, then I request a resident review of the PASRR Level I. They look at MDS, psych notes and they are reviewed by [ local state agency] and they are pretty quick about it. I was not notified by nursing about new diagnosis and behaviors. Subsequent interview on 12/21/22 at 1:03 PM, the Social Services Director revealed she did a Resident Review Evaluation Request on 8/08/22. [local state agency] responded with a letter dated on 8/11/22 requesting Psychiatric Progress Notes and/or Psychiatric Evaluations that indicate diagnoses and current nursing progress notes for that month. On 8/22/22, the readmission Screening and Resident Review Screening; Letter documented: We can't complete the screening. The review was closed due to an incomplete referral packet. Subsequent interview on 12/21/22 at 1:31 PM, the Social Services Director stated, When I looked into the computer, I didn't see it. I went to [local state agency] website and realized I did it in August 2022. The resident had a diagnosis of Schizoaffective disorder on 6/19/2022. Interview with the Director of Nursing (DON) on 12/21/2022 at 12:42 PM. The DON stated, Our pharmacy will send me a recommendation for a new diagnosis to be added and then the PASRR should be done. The pharmacy notified me of her new diagnosis. Once I receive the new diagnosis, I am to present the diagnosis and pharmacy recommendation to the Social Worker Director so that she can review the PASRR. Review of the PASRR Resident Review Evaluation Request Form for Resident #128 dated 8/08/22 documented the resident had a significant change date of onset on 8/01/22 which was an increase in behavioral, psychiatric, or mood-related symptoms. The form was completed by the Social Services Director. Review of the Florida PASRR Level II Receipt of Referral Packet Notice of Missing Clinical Documentation for Resident #128 dated 8/11/22 documented a local state agency requested psychiatric progress notes and/or psychiatric evaluations that indicate diagnoses and current nursing progress notes for that month for the resident. Review of the local state agency letter dated 8/22/22 for Resident #128 documented the following: We can't complete the screening. The review was closed due to an incomplete referral packet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure pharmaceutical services and procedures were being followed for 1 (3rd Floor North Cart) out of 5 medication carts observed as evidenced by an incorrect narcotic count for Resident # 89. There were 206 residents in the facility receiving care and services at the time of this survey The findings included: During observation of the 3rd Floor North Cart on 12/20/22 at 10:24 AM with Licensed Practical Nurse (Staff C), the Narcotic Count for Resident #89 was incorrect- Alprazolam 0.25 milligram (MG) (1) tablet count was twenty-one (21) in narcotic book, last signed out on 12/19/22 at 21:40. The Medication Bingo card count was twenty (20), the Electronic Medication Administration Record (EMAR) revealed resident #89 received Alprazolam 0.25 milligram (MG) (1) tablet on 12/20/22 at 8:04 AM (2 hours prior to this cart observation). Review of the medical records for Resident #89 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Anxiety Disorder Unspecified. Review of the Physician's Orders Sheet for December 2022 revealed Resident #89 had orders that included but not limited to: Alprazolam 0.25 MG (1) tablet by mouth every 12 hours related to anxiety disorder. Record review of Resident # 89's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented-Brief Interview of Mental Status Score (BIMS)-14, on a 0-15 scale indicating the resident is cognitively intact. During an interview on 12/20/22 at 10:29 AM, Staff C, when asked what the facility policy is on signing out narcotics, Staff C stated: Usually I sign when I remove the medication from the cart, today I thought I signed, I don't know what happen today. We are supposed to sign the medication out immediately in the narcotic book when we take it off the bingo card and signed off on the Electronic Medication Administration Record (EMAR) after the medication is given to the patient. During an interview on 12/21/22 at 09:30 AM, the Director of Nursing (DON) stated: I heard about what happened with the narcotics with the nurse and I wanted you to know that we did an in service on controlled substances with all the nurses in the facility . The policy at this facility is to sign off on the narcotics immediately when taken out of the bingo card and signed off as given on the EMAR after giving the medications to the resident. After the incident I immediately give the nurse (Staff C), an in-service on narcotics, my Assistant Director of Nursing, Nurse Educator (Staff D), conducted an audit on 12/20/22 on every narcotic book and summarized that this was an isolated situation. We also did a new in-service on 12/20/22 with all the other nurses in the facility. Based on our findings this was an isolated event. The nurse in question has been here for 9 years and she is a very good nurse. Review of the facility's policy titled Controlled Substances revision date 12/7/2022, states: controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Upon Administration: a. The nurse administering the medication is responsible for recording: 1. Name of the resident receiving the medication 2. Name, Strength, and Dose of the medication 3. Time of administration 4. Method of administration 5. Quantity of the medication remaining 6. Signature of nurse administering medication

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to ensure a medication error rate below five percent. During the medication administration observation task, there were 29 opportunities for errors and two medication errors were observed resulting in an error rate of 6.9%. This affected 2 out of 3 residents observed (Resident #39 and Resident #261). There were 207 residents admitted to the facility at the time of the survey. The findings included: 1. During the medication observation on 12/21/2022 at 8:17 AM on the 2nd floor Meadow cart with Staff E, Registered Nurse. Staff E applied Diclofenac gel 1 % to Resident #261's bilateral knees. When Staff E was asked whether the Diclofenac was to be applied to the resident's neck, Staff E reported, they apply the medication to the resident neck, knee's and wherever the resident has pain. Review of Resident #261's medical record revealed, the resident was admitted to the facility on [DATE] with diagnoses to include but not limited to, Unspecified Fracture of the upper end of the right humerus. The resident had a physician order dated 12/16/2022 for Diclofenac Sodium 1 % Gel, apply to the neck topically three times a day for pain moderate, pain scale 4 - 6. 2. During the medication observation on 12/21/2022 at 9:28 AM on the 4th floor Hibiscus Isle, North cart with Staff F, Registered Nurse. Staff F administered Iron 325 mg/65 mg(milligrams) 1 tablet by mouth to Resident #39. Review of resident #39's medical record revealed, the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Anemia and Atherosclerotic Heart Disease. The resident had a physician order for Ferrous Sulfate Elixir 220 (44 Fe) mg/5 ml (milliliters), Give 7.5 ml by mouth one time a day for aid with H/H (hemoglobin/hematocrit) repletion related to Anemia unspecified dated 6/23/2021. The Director of Nurses was interviewed on 12/21/22 at 03:16 PM, to discuss the medication administration observations for Resident #39 and Resident #261. The facility's policy for medication administration was requested. During the review of the facility's Medication Administration policy dated 03/02/2018 and reviewed on 11/10/2022, the policy and procedure documented, the policy Statement included: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so Policy Interpretation and Implementation: 2) Medications are administered in accordance with written orders of the prescriber.

Based on interview and record review, the facility failed to demonstrate effective plans of action were implemented to correct identified quality deficiencies in problem-prone areas as evidenced by repeated deficient practice identified during consecutive annual surveys related to Pharmacy Services (F755) The facility's QAPI Program Plan, reviewed November 2022, documented, Quality Measures - shall be reviewed via monthly report by the MDS Coordinator to team members of the QA committee. Findings shall be reported by the department whose Quality Indicator met the threshold and provided in monthly report to the QAPI Nurse Director. Survey findings: Past deficiencies - obtained from previous survey visits with ongoing monitoring. for past deficiencies target will included the exact deficiency. The department director will submit a monthly report for the QAPI Nurse Director. For current deficiencies-a plan of correction (POC) will be developed and implemented. Collaboration with department directors, QAPI Nurse Director and Administrator and the CEO. During the most recent prior annual recertification survey completed at the facility, with an exit date of 06/30/21, it was noted that the facility was cited at F755 - Pharmacy Services - related to an inaccurate narcotic count. During the current annual recertification survey, with an exit date of 12/22/22, it was determined that the facility was not in compliance with the regulations for F755 - Pharmacy Services - related to inaccurate narcotic reconciliation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records reviewed, the facility failed to honor residents' rights to reasonable accommodation of needs as evidenced by failure to ensure call lights remained within reach for five Residents (Residents # 116 and Resident #70, Resident # 32, Resident # 159 and Resident # 353 ) out of 36 sampled Residents. The Resident census at the time of this survey was 212. The Findings Included: Observation on 06/27/2021 at 1:09 PM revealed, Resident #116 was sitting in her wheelchair that was located at the right side of the bed. The call light was placed on the left of the bed, out of the resident's reach to the left, non-dominant side of the resident (Photograph evidence obtained). Resident # 116 demonstrated she was not able to reach for the call light. Review of the Face Sheet for Resident #116 revealed, Resident #116 was re-admitted to the facility on [DATE]. Clinical diagnoses included but not limited to spastic hemiplegia affecting left non-dominant side. Observation on 06/29/2021 at 11:04 AM revealed, Resident #116 was sitting in her wheelchair, positioned to the right side of the bed. The resident's call light was placed on her bed to the resident's left, non-dominant side and out of Resident # 116's reach. The surveyor pressed the call light and Certified Nursing Assistant (CNA) Staff AA responded and a side by side observation conducted. During the observation, Staff AA, CNA reported that Resident #116's dominant side was to her right. Staff AA indicated that the resident was confined to the wheelchair. Staff AA, CNA stated that Resident #116 was cognitive and physically able to press the call light for assistance, but only if the call light is positioned on her right and within her reach. Staff AA, CNA proceeded to place the call light within Resident #116's reach. Observation on 06/28/2020 at 11:50 AM revealed, Resident #70's room door closed. Upon entrance to the room Resident # 70 was observed in her bed. Resident #70 appeared anxious as she attempted to disrobe. The resident's call light was on the floor (Photographic evidence). The surveyor pressed the call light and Registered Nurse (RN) Supervisor Staff BB, responded to the call light and proceeded to assist the resident. On 6/30/2021 at 12:36 PM, during an interview with Certified Nursing Assistant (CNA) Staff CC, he explained that he floated and was familiar with both Resident #116 and Resident #70. Staff CC, CNA explained that Resident #116 presses the call light with the right hand. Staff CC, stated I make sure that it remains on her right hand. Staff CC reported, Resident #70 had behaviors that included attempts to get up without assistance, she was at risk for falls, was capable of pressing the call light when she needed assistance. Staff CC stated; we should have the door open so we can monitor the patient. On 06/27/2021 between 8:42 AM to 8:53 AM, the call lights for Resident # 32 and Resident # 159 were observed on the floor and out of reach during observation of medication administration conducted by Staff J a Licensed Practical Nurse (LPN). Observation revealed Staff J, LPN completed medication administration and did not place the call lights within reach for the residents (Photograph taken). On 06/27/2021 at 8:55 Staff J revealed during rounds staff should check the call lights are in reach. Review of clinical records for Resident # 32 revealed an admission date of 01/20/2021 from a local hospital. Clinical diagnosis include but not limited to unspecified mental disorder due to known psychological condition and anxiety disorder. Review of clinical records for Resident # 159 revealed an admission date of 6/11/2021. Clinical diagnosis included but not limited to Type 2 Diabetes, Depression and Alzheimer disease. Observation on 06/27/20121 at 09:21 AM, Resident #353 was observed awake in bed. The residents call light was observed behind the head of the bed between the mattress (photograph taken). The resident was observed with nasal cannula for oxygen hanging around his resident's head from chin to top of head. During observation housekeeping staff was finishing up with cleaning the resident's room. Shortly after family member entered the room. The family member voiced concern that staff had too much residents were not able to keep up with care. Review of clinical records revealed Resident # 353 was admitted to the facility on [DATE]. Clinical diagnosis include but not limited to major depressive disorder, type 2 diabetes, acute respiratory failure unspecified without hypoxia or hypercapnia, history of falling and dysphagia. On 6/27/2021 at 10:55 AM, Staff VV a Certified Nursing Assistant (CNA) revealed the call lights should be within reach at all times and should not be on the floor or out of the residents reach. On 06/29/21 at 03:22PM, during an interview and review of photographic evidence with Registered Nurse Staff (RN) A, it was revealed that staff are required to complete rounds and check to ensure call lights are in place within reach. Review of the facility's Policy/Procedure titled Call Light (dated 5/9/19 and reviewed on 1/13/21 revealed: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines Included; when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to honor resident's right to make choices related to food for one (Resident #552) of three residents reviewed for choices of 212 residents residing in the facility at the time of the survey. The findings included: Interview with Resident # 552 on 6/27/21 at 12:17 PM revealed she has no problems with the right to make choices except for concerns related to food. They serve breakfast around 7:00 AM and they do not serve lunch until between 1:00 and 1:30 PM so I get hungry between meals. The food quality is good, but I am diabetic and they send me the wrong type of food. I talked to the dietitian when I first came and she wrote on the paper the food I want but, they still sent me too much starchy food. I am diabetic and I also have high cholesterol and they give me eggs every day with a lot of oil. I do not eat the eggs fried in oil. I want oatmeal and a banana but, because I also need protein, I would eat a boiled egg with no grease or a turkey sandwich for breakfast. I have been here for nine days. Interview with Resident # 552 on 6/29/21 at 12:17 PM, Resident # 552 stated, I am hungry. I get breakfast around 7:00 AM they continue to send me the fried eggs in oil. Every day, it is the same thing. I need to talk to the dietitian again. I have seen her twice since admission and I told her I have high cholesterol. I need protein in the morning but not the fried egg. She wrote it all down but they still send the same thing every day. She did add oatmeal and a banana which I eat but I am still hungry. I need protein. At home I eat a turkey sandwich in the morning but they will not send one here. I have been asking to see the dietitian for three days but the nurse told me she is not here. I tried to call the kitchen but the phone in my room does not work so I have no way to contact them. I need a snack in the morning. I am so hungry around 10:00 AM. The nurse told me I have to talk to the dietitian to request a snack. I asked for a sandwich more than two hours ago and they never sent me the sandwich. The only thing I ate for breakfast around 7:00 this morning was oatmeal and a banana and I am hungry. Day after day, they continue to send me that egg fried in oil and I cannot eat it. I want to alternate my protein at breakfast between a hard boiled egg and a ham or turkey sandwich. When I last saw the dietitian she told me they do not have ham or turkey for breakfast. I am diabetic and I need to have protein. I asked for a sandwich this morning over two hours ago and it still never came. When I talk to the nurse they tell me they cannot change anything. I have to see the dietitian. I have been asking to see her for three days. I do not usually eat between meals but I need to eat more protein at breakfast. The last time I saw the dietitian she wrote all this down but I still get the same thing day after day and cannot eat those eggs in oil so all I eat is oatmeal and a banana. She said I could call the kitchen but my phone does not work. Observation of the land line on 6/30/21 at 12:35 AM revealed revealed there was no dial tone when the phone was picked up. Resident # 552 stated that she was moved yesterday to this room from another room and they never turned on the phone. Observation on 6/29/21 at 12:40 PM revealed the meal cart arrived to the unit. Resident # 552 received her tray at 12:45 PM. Resident # 552 stated; finally I have something to eat. It has been six hours since breakfast. Observation at 12:50 PM revealed staff delivering a grilled ham sandwich to Resident # 552 . Resident # 552 stated, well there is the sandwich I requested over two hours ago. Review of the tray card printed on 6/29/21 revealed breakfast preferences include: standing orders for fresh banana, almond milk, oatmeal, prune juice and wheat bread. Dislikes included : Pancakes, [NAME], white bread, waffles, potatoes and fried food. Review of the tray card printed after lunch on 6/29/21 revealed changes to add standing orders for fruit cup, two hard boiled eggs on Monday, Wednesday and Friday and and sliced Turkey and two slices wheat bread on Tuesday, Thursday and Saturday. Dislikes included scrambled eggs. Interview with the dietitian, Staff T on 6/30/21 at 10:22 AM revealed on admission the dietitians visit the residents within 24 to 48 hours and assess food preferences and begin a nutritional evaluation to complete the assessment. We also do meal rounds and if there are any changes in food preferences we update the preferences. If they tell the nurse they want to see the dietitian we will go up and see them. Resident # 552 was admitted on [DATE]. I visited her on Friday 6/18/21. She offered preferences at that time. I provided her with nutrition education due to diabetes. The food preferences are placed on a communication form and sent to the diet clerk to be placed on the tray card. I also saw her again on 6/21/21 and wrote a progress note when she requested to go over food preferences. She requested not to receives starches. She preferred only protein and vegetables . I explained she could call the kitchen to request alternates. On 6/29/21 she requested to see me. The nurse contacted me and she requested alternate protein so I went to see her. Review of the facility policy titled Resident Food Preferences revised October 2017 revealed: Upon the resident's admission or within 48 hours after his/her admission the dietitian or designee will identify a resident's food preferences. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food preferences in the medical record. Food preferences are updated during meal rounds, on request/diet consult, communicated by nursing or during care plan . The Food Service Department will offer a variety of foods at each schedule meal, as well as access to nourishing snacks throughout the day and night, on request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure a resident was not placed in a physical restraint for 1 out of 3 residents (Resident #107) reviewed for accidents. The findings included: During an initial observation on 6/27/21 at 10:28 AM of Resident # 107. Observation revealed a red colored star shaped sticker noted on the door outside of Resident #107's room indicating the resident was at risk for falls and a blue star indicating, Do Not Resuscitate (DNR). Resident #107 was observed sitting in a wheelchair with a padded gel tray with bright multiple colored dots resting on the arms of the wheelchair around her. Resident #107 was observed trying to pull the padded tray over her head. The resident was asked not to pull the padded tray over her head because she could hurt herself. The resident placed the padded tray down and clapped her hands. Further observation revealed the padded tray was attached to the wheelchair by being tied in the back of the wheelchair. During an observation on 6/27/21 at 3:40 PM, Resident #107 was observed in the 3rd floor dining room during an activity with two activities staff present. The residents were playing dominoes, had pictures and other items on the tables. There were two residents at each table. Resident #107 was observed at a table sitting in a wheelchair with the padded tray around her over the arms of the wheelchair. The resident was not observed playing dominoes or playing with the dots on the padded tray. Review of clinical records revealed Resident #107 was admitted to the facility on [DATE] with clinical diagnoses that included but were not limited to, a history of falling, Alzheimer's Disease, Dysphagia, Hypertension, Osteoarthritis and unspecified Mental Disorder due to unknown physiological condition. Review of Resident #107's quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C for Cognitive Patterns - the residents Brief Interview for Mental Status (BIMS) was scored as 00 out of 15, indicating severe impairment. MDS Section G for Functional Status revealed the resident was coded for bed mobility - the resident was totally dependent and needed extensive assistance, the resident used a walker and wheelchair devices. MDS Section J for Health Conditions, J1900 indicated the resident had one fall since admission or prior assessment. MDS Section P for Restraints and Alarms was not coded as being used. Review of Resident #107's care plans and an annual progress and care plan meeting dated 6/2/21 revealed, the care plans were reviewed and updated and there were no significant changes. The resident's care plans included, Resident #107 remains cognitively impaired of short and long-term memory and orientation. Place call light within easy reach. Assistance of 2 persons with transfer and gait belt for safety. Impaired physical mobility, Range of Motion (ROM). Resident #107 has decreased mobility and is at risk for developing contractures, begin use of wheelchair sensory gel lap tray as needed to promote quality of life. Review of Resident #107's progress notes revealed, documentation in the nurses note pertaining to a fall. The progress note dated 2/6/21 at 7:24 AM documented, the nurse was called into patient's room because patient was sitting on the floor mat. The resident was able to move bilateral upper and lower extremities without complaint of pain, she denied any pain or discomfort, when I asked to resident what happened, the resident stated: I want to go to the bathroom. Resident is alert, awake and oriented times (x) 1, respiration even and unlabored, no fever, no cough, vital signs taken: BP (Blood Pressure) 130/65, P70 (Pulse), RR19 (Respiratory Rate), 02 sat (Oxygen Saturation) 98% at room air. The resident was transferred to bed with help of CNA (Certified Nursing Assistant) and nurse. Medical Doctor made aware, new orders received Bilateral hip X-RAY daughter was notified. Call light at easy reach, bed in lowest position, fall precaution in place. Review of the Resident # 107's physician orders dated 5/6/21, documented the use of the wheelchair sensory gel lap tray as needed to promote quality of life. Advance to protective weight bearing. Bilateral floor mats when in bed for safety every shift for prophylaxis and fall precaution. On 6/29/21 at 8:30 AM Resident #107 was observed in bed awake, the call light was within reach, the resident's bed was in low position, a bluish discoloration was observed on the resident's right hand, the resident was dressed and in bed. During this observation, an interview was conducted with Staff M, a Certified Nursing Assistant (CNA). Staff M, CNA was asked about the padded tray and the reason Resident #107 was using the padded tray. Staff M reported, the family requested the resident have the lap pad because the resident's hands kept falling to the side. On 6/29/21 at 12:19 PM, Resident #107 and her sister were observed in the facility's lobby, the resident's sister was asked why the resident was using the padded tray. Resident # 107's sister did not know the reason the padded tray was used, but she had seen it on the resident's wheelchair. During this observation and family interview Resident #107 did not have the padded tray on the wheelchair, but had a doll in her hands that she was holding and touching. On 06/29/21 at 2:43 PM, an interview was conducted with Staff O, a Registered Nurse (RN). Staff O was asked about the tray type padded device that was used for Resident #107 and Staff O reported, she was aware that therapy brings it to her because she needs some hand stimulation. Staff O reported, therapy brings it to her to play on because when she sits, she is not doing anything with her hands. Staff O was asked about staff documentation related to the use of the padded device. Staff O reported, the nurses do not document on the device, only the therapist. On 6/29/21 at 03:07 PM, an interview was conducted with Staff L, a Registered Nurse (RN), and MDS coordinator. Staff L was asked where in the MDS was the use of the device documented. Staff L reported, there is a doctor's order for the sensory gel lap tray and it was not coded in the MDS. An interview conducted on 06/30/21 at 09:15AM with Staff Q, an Occupational Therapist (OT) about the padded device used for Resident #107 and the reason for the device. Staff Q reported, Resident #107 is a long-term resident who known to be fidgety and has been anxious. Staff Q explained that this device helped with the fidgeting and the device was ordered to be used as needed. The device was used to help the resident to relax and feel comfortable, it can also help her with comfort and quality of life. Staff Q reported, sometimes Resident #107 used her doll and stuffed animal as therapy. Staff Q was asked, to explain what was meant by the device is used as needed, Staff Q stated, if we need to take it off, we can. Upon discussion of the device being used as a restraint, Staff Q reported, we do not use this device as a restraint, it is not to prevent [Resident #107] from getting up. Staff Q reported, Resident #107 has no history of repetitive standing or getting up. Staff Q was asked about the last time Resident #107 was evaluated. Staff Q reported the resident was evaluated this morning (6/30/21) and before that, it was over a month ago. Staff Q reported, with this type of device there is no need to do a daily follow up, a screening was performed screening this morning on how to use the device, and last month. The first screening was a month ago and had completed a follow up this morning. On 6/30/21 at 9:24 AM an interview was conducted with Staff P, Registered Nurse (RN/Charge Nurse) and Staff Q, Occupational Therapist, about the padded tray. Staff Q stated the device is a sensory gel pad. Staff Q was asked, how does staff know when to use it. Staff Q reported, when staff saw Resident # 107 fidgeting, they put it on. Staff P and Q were informed of the lack of documentation to indicate the reason the device was being used on Sunday, 6/27/21 and Monday, 6/28/21. Staff P, RN, and Staff Q, both reported, the device is not used to prevent the resident from getting up because she does not try to get up. Staff P and Staff Q were informed of the observation noted on 6/27/21 of Resident #107 trying to put the pad over her head and that it was tied in the back of the wheelchair. Staff Q reported, he completed a screening on the device this morning (6/30/21) and trained staff. He reported, he trained staff when it was given to the resident the first time. The facility's restraints policy and documentation for the screenings and trainings was requested. On 6/30/21 at 10:00 AM accompanied Staff Q to the 2nd floor Therapy Department, Resident #107 was observed in a physical therapy session with Staff N, a Physical Therapist. Staff Q demonstrated the use of the lap gel pad with velcro belt and strap attached to each side. Staff Q was shown how the lap gel pad was attached and tied to the resident's wheelchair on Sunday, 6/27/21. Staff Q observed, one of the straps had a knot and he reported, it was not supposed to have a knot in the strap and proceeded to remove the knot from the strap. On 6/30/21 at 10:41AM, Staff Q presented documents to show a screening was completed on 6/30/21 and staff trained. It was noted that seven CNAs signed the in-service form on 6/30/21 and on 5/6/21, three CNAs signed the in-service form. There was no documentation to indicate the licensed nurses were provided with training on 5/6/21 and 6/30/21 on the use of the device. Staff Q was asked how the other staff were trained on the use of the device and Staff Q reported, the CNA's shared the information at the end of the day with the oncoming staff. Staff Q reported, the CNAs could also see the care plan in their tablets on the wall and follow the order. Review of the facility's policy for the use of restraints revised April 2017 revealed, 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to resident's body that the individual cannot remove easily, which restrict freedom of movement or normal access to one's body. 2. The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that residents physical condition (i.e., side rails are put back down, rather than climbed over) and this restricts her/his typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, Geri-chairs, and lap cushion and trays that the resident cannot remove. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints are not permitted.

Based on observations, records reviewed and interviews, the facility failed to implement care planned interventions for 2 out of 36 sampled residents related to pain management and mobility for Resident #76 and 2) Respiratory treatments for Resident # 63. This facility practice has the potential to affect the health and safety of all 212 residents in the facility at the time of the survey. The Findings Included: 1. Observation on 6/27/2021 at 12:00 PM, revealed, Resident #76 reported she was in a lot of pain and was in pain all the time even though she received pain medication. Resident # 76 explained staff placed blankets underneath her to move her and they hurt her legs and shoulder and she was waiting for the pain to go away. Resident #76 showed signs of pain as she grimaced, moaned, and trembled when she spoke. Resident #76 left leg and left hand appeared contracted and no restorative devices noted in place. Observation and interview on 6/28/2021 at 8:13 AM revealed, Resident # 76 remained in her bed, wearing hospital type gown. Resident # 76 explained she was still in pain on both legs and shoulder areas. There were no restorative devices in place. Review of Care plans for Resident # 76 revealed Focus: [Resident #76] is at risk for a decline in mobility related to Osteoarthritis. Quarterly review done on 5/12/2021. The goal noted; {Resident #76} will maintain current mobility and slow process of joint stiffness over the next 90 days. Interventions included: Administer analgesics as ordered, monitor for effectiveness. Further review of care plans revealed; {Resident #76} has an alteration in neurological status left sided weakness. Goal: {Resident #76} will show improvement to maximum potential with mobility and cognition by review date. Interventions included but not limited; Pain management as needed. See MD orders. Provide alternative comfort measures as needed (PRN). The Activities of Daily Living (ADL) care plan noted: {Resident #76} requires assistance with ADLs secondary to diagnosis history left sided weakness, gait instability, functional decline, and hypertension, fall. Interventions: Left hand roll at all times except for hygiene and ADL care every shift. Provide assistance with bed mobility with 2 staff members. Provide gentle ROM (Range of Motion) exercises of the extremities. Observation and interview with Registered Nurse (RN) Staff DD and RN Supervisor, Staff BB on 6/28/2021 at 12:30 PM revealed, Resident #76 was in her room with door closed. Resident # 76 screamed loudly and consistently and was heard from the nurses' station. Staff DD RN and Staff BB, RN Supervisor reported that Resident #76 always screamed when repositioned. Observation and interview on 06/28/202 at 12:59 PM, Staff EE, a Certified Nursing Assistant (CNA) reported she cared for Resident #76. Staff EE, CNA state that Resident #76 had certain behaviors and always screamed when repositioned and complained that she was in pain. Observation during the above-mentioned interview showed, Resident #76 continued to complain that she was in pain and loudly screamed as Staff EE, CNA attempted to place a pillow underneath Resident # 76's right side. Observation and interviews on 6/29/2021 at 9:08 AM revealed, Staff DD, RN referred Resident #76 to the pain management physician and the Pain Management Physician assessed Resident #76 on 6/29/2021 at 9:13 AM. Interview on 6/29/2021 at 3:30 PM Staff HH, CNA, reported she was familiar with Resident #76, and normally cared for her during the afternoon shift. Staff HH reported she cared for Resident #76 an average of five days a week. Resident #76 usually stayed in bed, was alert and able to communicate her needs. Staff HH checked the Resident's blood pressure and provided ADL care. Staff HH reported that Resident #76 normally complained that her leg hurt when repositioned; She complains when we move her, because she does not like to be moved. Staff HH explained she normally used a blanket to reposition the resident. Staff HH stated If the resident is in too much pain, I call another CNA. During the interview, Staff HH acknowledged she cared for Resident #76 earlier that week on Sunday 6/27/2021 and explained she repositioned the resident without the assistance of another staff. Interview on 06/30/2021 at 11:10 AM Staff DD, RN reported Resident #76 transferred from the third floor about a year ago. Resident #76 had medical diagnoses that caused her pain, which included Primary Generalized Osteoarthritis, Hemiplegia Unspecified Affecting Left Non-dominant Side, other Idiopathic Peripheral Autonomic Neuropathy and Personal History of Other Diseases of the Circulatory System. Staff DD reported Resident # 76 was assessed for pain every shift and as needed. The resident was capable of expressing her needs and level of pain. Medications ordered to manage Resident #76's pain (Prior to survey) included regular Tylenol and Gabapentin tablet 300 milligrams (mg) by mouth two times a day. Staff DD, RN reported, The resident is supposed to use a hand roll, she refused it yesterday. It is supposed to be in place every shift. During the interview and record review of Resident # 76's physician orders showed order dated; 1/17/2020 for Consult with Pain Management [Doctor name]. Staff DD reported that Resident #76 was seen by pain management yesterday. She was complaining of pain. She complained yesterday, today and the day before yesterday. She always complain when she is repositioned or transferred. During the interview, Staff DD reviewed Resident #76's electronic record and stated that before yesterday Resident # 76 was not seen by pain management. The Director of Nursing later presented documented evidence of assessments and interventions previously put in place to manage pain reported by Resident #76, the documents dated January and February 2020. Staff DD explained that pain management included assessments and interventions that nurses documented on the Medication Administration Records (MAR). Documentation included pain level the resident reported (from 0-10) and nurses' interventions. Nurses also documented in the progress notes and/or behavior monitoring sheets; I understand the importance of documentation Review of the physicians orders and MAR revealed, ordered Acetaminophen Tablet 325 mg, Give 2 tablet by mouth every six hours as needed for pain scale = 1 -3 Start Date 08/28/2019. Signatures on the MAR indicated that during the months of May and June 2021, Resident #76 received the medication twice; during survey, on 06/29/21 and on 06/30/21, Pain levels documented for those days were also documented twice; pain level 3 on 06/29/2021 and pain level 2 on 06/30/2021. For the order Monitor for pain every shift with start date 08/28/2020, zero levels of pain were documented for the month of May 2021. For the month of June 2021, pain level was documented once, during survey on 06/30/2021, pain level 2. Tylenol 8-hour tablet Extended Release 650 MG (Acetaminophen ER) Give 1 tablet by mouth every 8 hours related to Primary Generalized Osteoarthritis for 7 days was initiated on 06/29/2021 (during survey). Gabapentin Capsule 300 MG; give one capsule by mouth at bedtime related to other Idiopathic Peripheral Autonomic Neuropathy start date 06/29/2021, also administered on 06/29/2021, during survey. Upon discussion of the above-mentioned, resident observations, interviews and records reviewed, Staff DD stated, I do believe we have been managing the resident's pain. Maybe not with the right frequency but yes. Staff DD, RN agreed to observe the resident. During the observation, Resident #76 continued to show signs of pain. When Staff DD asked Resident #76 about her pain level, the resident responded, continuous on both legs. Her head also hurt; she was not comfortable sitting in her chair. (Resident #76 cried and added allegations that her roommate was abused, she was also physically abused. Staff DD proceeded to tend to the resident's needs . 2.) Observation on 06/27/2021 at 8:05 AM revealed, Resident # 63 was in his room sitting in his wheelchair facing the oxygen concentrator. The oxygen concentrator was on but the nasal cannula tubing was missing. Search around the resident's room, around the bed and concentrator indicated the tubing was not in the resident's room. Resident # 63 reported he did not know what happed to the nasal tubing. Observation on 6/27/2021 at 11:08 AM revealed Resident #63 remained in his room without Oxygen therapy. CNAs noted in the room and exiting the room as they searched for the missing tubing. Continued observation on 6/27/2021 at 12:24 PM showed Resident #63 in his room, accompanied by family. Resident's oxygen therapy ongoing, nasal cannula in place. Review of care plans for Resident # 63 included. oxygen settings: Give oxygen via nasal cannula at 2 L/min (Liters per minute) continuously as per MD (Medical Doctor) order for Shortness of Breath. Date initiated: 05/03/2021, Revision on: 05/03/2021. Review of physicians' orders for Resident # 63 revealed treatment orders: Oxygen via nasal cannula at 2 L/min every shift related to Chronic Obstructive Pulmonary Disease with acute exacerbation. Check oxygen Saturation (SPO2) and give oxygen every shift for prophylaxis. Interview on 6/29/2021 at 10:38 AM with Staff BB, Registered Nurse (RN) Supervisor regarding the identified concerns, related to respiratory care concerns. Staff BB, RN Supervisor stated; The resident needs to be monitored frequently, the nurse should check all the time for specific treatment/ medication, especially if the patient has behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and records reviewed, the facility failed to obtain a timely audiology consult to ensure that residents hearing was maintained at highest attainable level, for one resident (Resident #19) sampled for hearing concerns, out of 36 sampled residents. There were 212 residents residing in the facility at the time of the survey. The Findings Included: Observation on 6/27/2021 at 11:05 AM revealed; Resident # 19 was in her bed. The resident appeared alert and oriented. Unable to hear interview questions, she appeared frustrated as she pointed to her left ear and repeated that she could not hear. No hearing or communication device noted on or around the resident. Observation and Interview on 6/28/2021 at 8:45 AM showed that Resident #19 remained in her bed, awake. The resident again reported she could not hear. No hearing nor communication device noted. Observation and interview with Staff FF, Certified Nursing Assistant (CNA) on 6/28/2021 at 8:47 AM revealed, Staff FF had to yell as she attempted to communicate with Resident #19 about the breakfast Staff FF, CNA asked the resident if she could remove the breakfast tray and Resident# 19 could not hear the CNA indicating Resident #19 had hearing problems. Resident #19 appeared frustrated as she pointed to her left ear, I can't hear the CNA reported, You need to speak really loud; she cannot hear. No hearing nor communication device noted on or around Resident #19. Interview with Staff FF, CNA on 6/29/2021 at 11:50 AM revealed that she normally had to yell loudly to communicate with Resident#19. Staff FF, CNA added that the resident could not hear well since her admission and she normally had to speak very loud into the resident's left ear so the resident could hear. Staff FF, CNA explained it was getting to the point in which staff might need to start using a communication board to communicate with Resident #19. Review of Resident #19's clinical records revealed the resident was admitted to the facility on [DATE]. Review of the Brief Interview of Mental Status (BIMS) revealed a score of 10 out of 15 indicating moderate cognitive impairment. Further review of clinical records revealed no hearing consult on file for Resident #19. Review of the facility's policies and procedures revealed the policy titled Availability of Services/ Consultations; dated August 2007. The Policy Statement noted; Medical and healthcare services (Dental, Vision, Hearing) will be provided to the residents. The Policy Interpretations and Implementation included: 1. Medical services are available to all resident requiring routine and emergency care. 3. Social Services will be responsible for making necessary appointments. 6. Residents will be promptly referred for a Medical and Healthcare service (Dental, Vision, Hearing) as needed. On 06/29/2021 at 11:57 AM,the Social Services Director (SSD) revealed during an interview that the social services department completes initial assessments on all new admission, re-admissions and quarterly. We also do discharge planning. The SSD explained that the social services department handled vision and hearing consults. The social services department also completed Quarterly and Annual Minimum Data Set (MDS) assessments for long term care residents. The SSD explained that she normally arranged for residents that needed hearing consults to go out to the community based on the resident's Long term care insurance. The SSD stated, if the resident has hearing problems, she checked the insurance. The insurance will give me information of a contracted doctor or company . then I give the information to the unit clerk. The clerk makes the appointment. I do not know. The nurses need to tell me. Usually, the nurse tells the physician that the resident is hard of hearing, then he writes an order or could get a TO (Telephone Order) . The SSD revealed she was familiar with Resident #19 and participated in Resident #19's care planning . The SSD stated, I was not aware she was hard of hearing. Now that I know she is hard of hearing, what I will do is check the insurance, once I have that information, I will give it to the clerk and she will make the appointment. The SSD explained that the unit clerk also arranged for transportation and communicated with family. Observation with the SSD on 6/29/2021 at 12: 25 PM revealed, both the SSD and Resident #19 had to speak very loudly and within close proximity to communicate. Resident # 19 kept pointing to her left ear and yelled as she asked the SSD to get closer. Resident#19 repeated I cannot Hear! The SSD later acknowledged; it definitely appears that she has problems with hearing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide adequate care and treatments for two residents (Resident #26 and Resident #76) out of six residents investigated for concerns related to positioning and limited range of motion as evidence by; 1) Failure to apply pillows and/or protective boots to bilateral heels while in bed for Resident #26 and 2) Failure to ensure hand roll device was in place as per physician's order for Resident #76. This facility practice has the potential to have an adverse effect on 165 residents in the facility with limited range of motion and 27 residents in the facility with contractures. The Findings included; Resident #26 Observation on 06/28/2021 at 8:30 AM revealed, Resident #26 was asleep in her bed. No pillows noted or offloading device noted in place protecting the resident's heels. The resident's protective boots were not in place. The protective boots were noted on the bed at the foot of the bed (photographic evidence of protective boots on bed). Observation on 06/28/2021 at 9:45 AM revealed, Resident #26 remained asleep in bed. No pillows or offloading device noted in place protecting the resident's heels. The resident's bunny boots remained on the bed at the foot of the bed. (Photographic evidence of protective boots on bed). Observation on 06/28/2021 at 2:10 PM revealed, Resident #26 asleep in her bed. No pillows noted protecting the resident's heels. The resident's bunny boots remained at the foot of the bed. (Photograph taken of boots on bed). Review of the face sheet for Resident # 26 revealed Resident #26 admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Peripheral Vascular Disease, Type II Diabetes, and hyperlipidemia. Review of treatment orders for Resident #26 revealed the orders for bunny boots to bilateral heels while in bed, every day shift for prevention and off load heels and bony prominence on pillow while in the bed; every day shift for prophylaxis. During an interview on 6/30/2021 at 10:30 AM, Registered Nurse ( R N ), Staff DD reported that Resident #26 did not refuse medications nor treatments. Staff DD,RN stated that the Certified Nursing Assistants and nurses made sure that the resident's bunny boots were in place. Upon discussion of the above-mentioned observations Staff DD, RN explained; We have in the TAR (Treatment Administration Record) a section in which we document the treatment for it. It is important to keep them in place because it helps prevent pressure ulcers, to protect her skin, circulation. Resident #76 Review of the face sheet for Resident #76 revealed, Resident #76 admitted to the facility on [DATE]. Clinical diagnosis include but not limited to: Hemiplegia unspecified affecting left non-dominant side. Record review of treatment orders for Resident # 76 revealed ordered left hand handroll at all times except for hygiene and ADL (Activities of Daily Living) care every shift for Prophylaxis. Observation on 6/27/2021, at 12:00 PM revealed, Resident #76 in her bed wearing hospital type gown. Resident # 76's left hand appeared contracted and no handrolls nor splint device noted in place. Resident # 76 reported she did not receive any type of treatment for the hand that was contracted. Observation on 6/27/2021 at approximately 1:00 PM, Resident # 76 was observed being assisted by a Certified Nursing Assistant (CNA) while she ate . No handroll device was noted in place. Observation on 6/28/2021 at 8:13 AM Resident # 76 was observed in bed, the left hand noted to appear contracted with no splint device nor handroll in place. On 6/28/2021 at 12:59 PM during observation with Staff EE, CNA revealed, Resident # 76 was in bed, no handroll or splint device in place. Observation on 6/29/2021 at 9:13 AM revealed, Resident #76 sitting up in her chair and handroll noted on Resident #76's left hand. During an interview on 6/30/2021 at 11:10 AM, Staff DD a Registered Nurse ( RN ) reported, The resident is supposed to use a hand roll, she refused it yesterday. It is supposed to be in place every shift. Staff DD agreed to observe Resident #76. During the observation, the resident's hand roll was sitting on the resident's lap. Staff DD attempted twice to place the handroll on the wrong hand, the resident's right hand. Staff DD also attempted to place the handroll on the appropriate hand, the left hand and Resident #76 screamed; it hurts! Observation and interview on 06/30/2021 at 12:00 PM accompanied by the Long Term Care Supervisor with Resident #76 revealed, Resident #76 was in bed. The handroll was not in place, and were sitting on the resident's lap. Resident #76 reported that she did not receive treatments for said hand. Record review of the facility's policies and procedures showed the policy titled Resident Mobility and Range of Motion, revision dated July 2017. The Policy Statement noted: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Resident's with limited rage of motion will receive treatment and services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. And 3. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility, unless reduction in mobility is unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, the facility failed to ensure resident safety as evidenced by ordered medications were prepared and left unattended on overbed table for one resident (Resident #122) out of 36 sampled residents. This facility practice has the potential to affect the health and safety of all 212 residents in the facility at the time of the survey. The findings included: Observation on 06/27/21 at 8:31 AM revealed, Resident# 122 in bed with eyes closed sitting up in bed. there were no staff noted in the room. there was a medicine cup with a variety of medications noted on the overbed table in front of the resident containing a combination of pills and capsules. (Photographic evidence) Record review of the Face Sheet for Resident #136 revealed, Resident #122 was admitted to the facility on [DATE] and re-admitted on [DATE]. Clinical diagnosis diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Congestive Heart Failure (CHF) and Anxiety Disorder. Record review of the Comprehensive Minimum Data Set (MDS) for Resident # 122 target dated 5/21/2021 revealed that the resident had a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was able to verbalize her needs and was not cognitively impaired. During record review and interview with Staff DD, a Registered Nurse (RN) on 6/29/21 at 8:50 AM. Staff DD explained that Resident #122 was alert and oriented and recognized her medications. Resident # 122's diagnoses included, COPD, Congestive Heart Failure, A fib, anxiety, a skin condition and hypertension. Staff DD reported that Resident # 122 is administered psychotropic medications that included Xanax, for a diagnosis of anxiety. Xanax was administered twice a day; .5 mg ½ tablet in the morning a whole tablet at night and Resident #122 received Tramadol for pain every morning. During the interview, Staff DD, RN explained she always delivered the resident's medications in a medicine cup and made sure that the resident swallowed the medication in front of her and monitored for aspiration precautions. Resident #122 was not care-planned to self-administer medications. Upon discussion of above observation Staff DD explained; {Resident #122} could not administer her own medications because we have a policy and for her safety. Interview on 06/29/2021 at approximately 9:30 AM, Staff BB, RN Supervisor reported, We have a policy for administering medications. Nurses are not supposed to leave the residents medication at bedside. If the patient is not ready, the nurses keep the medications with them .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Observation on 06/27/20121 at 09:21 AM revealed housekeeping staff in Resident # 353's room placing garbage bags in the bins. Resident #353 was observed in bed. The nasal cannula for oxygen was noted hanging around the resident's head from chin to top of head and the resident was noted confused an not nterviewable. The oxygen concentrator was on and the level on the concentrator's meter was noted at 8 liters per minute. Further observation of Resident # 353 revealed the resident then placed the nasal cannula around his neck. At 09:26 AM a family member entered the room and identified himself as being Resident # 353's son. The son sat on the bed with the resident and placed the nasal cannula in the nares. The family member stated that the staff had too many people to care for and unable to keep up with taking care of his father. == Observation on 06/28/2021 at 8:50 AM revealed Resident # 353 in bed. The oxygen concentrator was on. The oxygen level was noted at 5 liters per minute and the nasal cannula was not in place and was around the resident's neck. Observation on 06/28/2021 at 10:05 AM revealed Resident # 353 was not in bed (in restroom with staff). The oxygen concentrator was on and level set at 3 liters per minute. The nasal cannula was on the bed. Review of clinical records revealed Resident # 353 was initially admitted to the facility on [DATE]. Clinical diagnosis include but not limited to major depressive disorder, type 2 diabetes traumatic subdural hemorrhage without loss of consciousness, obstructive sleep apnea, acute respiratory failure unspecified without hypoxia or hypercapnia, history of falling and dysphagia. Review of Resident # 353's physician's orders revealed, ordered oxygen via nasal cannula at 2 L/min (Liters per Minute) continuously every shift related to acute respiratory failure unspecified whether with hypoxia or hypercapnia. Check oxygen saturation ( SPO2 ) every shift. Review of baseline care plan dated 06/28/21 indicate Resident # 353 has a potential for respiratory complication related to Diagnosis of Acute respiratory failure, Bronchitis, Obstructive sleep apnea, History of COVID-19 , Pneumonia and Shortness of breath. Goals and interventions noted [Resident # 353] will be free of respiratory complications / distress such as SOB (Shortness of Breath), dyspnea, severe cough, etc. through next review date. Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Oxygen settings: Give oxygen via nasal cannula at 2 L/min as needed or continuously as per MD (Medical Doctor) order for Shortness of Breath. On 06/29/2021 at 3:20 PM Staff B, a Registered Nurse revealed Resident # 353 was sent to the hospital for altered mental status. Staff B, RN revealed that as part of the rounds the nurses are required to make sure the resident's oxygen is in place and the level is correct. Staff B stated that if the Certified Nursing Assistant (CNA)is providing care they should not remove the resident's oxygen and the CNA should notify the nurse if the oxygen is not in place. On 06/29/21 at 03:22PM, during an interview with Registered Nurse Staff (RN) A, it was revealed that nurses are required to complete rounds and check to ensure residents that have orders for oxygen have the oxygen in place and at the right level. The photographs related to Resident # 353's oxygen level was viewed by Staff A, RN and Staff B, RN who stated the setting was excessive and acknowledged the concern. Staff B added that the resident was transferred to the hospital for altered mental status on 6/28/2021 and is in intensive care at [ local hospital name] for altered mental status, heart failure and urinary tract infection. On 06/29/21 at 12:39 PM during an interview the Director of Nursing (DON) stated that staff are required to complete rounds at beginning of shift ensure oxygen are in place and also during regular rounds. The DON revealed that it is a concern if the oxygen level is not at the correct level and not in place. Review of the facility's policies and procedures revealed policy number 0071 revision dated 11/29/17 and titled; Respiratory Care: Oxygen. It noted; 1. Staff will be educated on the following: safe handling of oxygen, humidification, cleaning, storage and dispensing of oxygen. 5. Development of a care plan addressing resident's oxygen use and needs. The Procedure noted; 1. Oxygen Therapy: Nurse will gather equipment to use (such as nasal cannula, Oxygen Mask, Oxygen Flow Meter, Oxygen concentrator . Humidification bottle is recommended for oxygen flow rate above 3 LPM. On 06/30/2021 at 11:02 AM, the DON revealed that Resident # 353's family member had provided a statement that she had adjusted the oxygen level. Review of the statement provided by the facility indicated that the wife wrote that on June 28th, she increased the oxygen level from 2 liters to 4 liters. On 06/30/2021 at 11:08 AM Resident 353's spouse stated that she came to the facility today to pick up her husband's belongings because he is in intensive care at the hospital. Based on observations, interviews, and records reviewed, the facility failed to provide adequate respiratory care and services for two sampled residents that required continuous oxygen therapy (Resident # 63 and Resident # 353) out of 38 sampled residents. As Evidenced by 1) Missing nasal cannula tubing on oxygen equipment used by Resident #63 2.) Inaccurate flow rate of oxygen setting for Resident # 353. This practice has the potential to have an adverse effect on 79 residents in the facility identified to require respiratory treatments out of 212 residents residing in the facility at the time of the survey. The Findings Included: Observation on 06/27/2021 at 8:05 AM revealed, Resident # 63 in his room sitting in a wheelchair facing the oxygen concentrator. The oxygen concentrator was on and the nasal cannula tubing was missing. Search around the resident's room, around the bed and concentrator indicated the tubing was not in the resident's room. Resident #63 reported he did not know what happened to the nasal tubing. (Photographic evidence) Observation on 6/27/2021 at 11:08 AM revealed Resident #63 remained in his room without oxygen therapy. Observation revealed Certified Nursing Assistants (CNAs) noted in the room and exiting the room as they searched for the missing tubing. Continued observation on 6/27/2021 at 12:24 PM showed Resident #63 in his room, accompanied by family the Resident's oxygen therapy was ongoing with nasal cannula in place. Record review of the face sheet for Resident #63 revealed he was admitted to the facility on [DATE] and re-admitted on [DATE]. Clinical diagnoses included Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Hypertensive Heart And Chronic Kidney Disease, Major Depressive Disorder. Review of physicians' orders for R#63 revealed treatment orders for oxygen via nasal cannula at 2 L/min (liters per minute) every shift related to Chronic Obstructive Pulmonary Disease with (acute) Exacerbation. Review of the care plans for Resident # 63 included, oxygen settings: Give oxygen via nasal cannula at 2 L/min continuously as per MD (Medical Doctor) order for shortness of breath. Date initiated: 05/03/2021, Revision on: 05/03/2021. Observation and interview with Resident #63 on 06/29/2021 at 9:50 AM revealed, Resident #63 was in sitting on his wheelchair facing the overbed table leaning forward. The oxygen concentrator was on and level set at 2 L/min. The nasal cannula was not in the resident's nares and was noted hanging around his ear. When asked, the resident responded that he was breathing ok and Resident #63 demonstrated he was able to place the nasal cannula on properly. Interview on 06/29/2021 at 9:56 AM with Staff GG a Registered Nurse (RN) revealed, Resident #63 has an order for continuous oxygen. Staff GG, RN stated that both CNAs and nurses worked together to ensure that the resident received the continuous oxygen therapy. The resident was alert and oriented times two. Resident #63 did not show any concerning behavior of removing the oxygen treatment and responded well to education. Upon discussion of above-mentioned observations Staff GG, RN indicated she was not aware that Resident # 63 spent about three hours without oxygen therapy. Staff GG, RN explained; Ideally, if a resident has continuous oxygen, we do not leave them without it for any extended period of time, we have portable oxygen that they use when they need to get out of the room or go to activity. Review of the progress notes for Resident #63 revealed no nurses notes that addressed the above mentioned observations. Interview on 6/29/2021 at 10:38 AM, Staff BB, RN Supervisor revealed she had just learned about the above mentioned respiratory care concerns from staff GG. Staff BB, RN Supervisor reported; The resident needs to be monitored frequently, the nurse should check all the time for specific treatment medication, specially, if the patient has behaviors. The nurses' aides and the nurses are responsible for monitoring. Staff BB explained the policy is if a patient with an order for continuous oxygen was found without it, we need to check the O2 saturation, and document the incident in nurses notes we also document and care plan the resident condition and behavior, if they have the tendency of removing the nasal cannula. The nurse is the one that would retrieve the nasal cannula tubing from the med storage room . our policy is for the nurses to replace nasal cannula every (Wednesday) and as needed.

Based on records reviewed, observations and interviews, the facility failed to ensure the monitoring assessment and consistent response to manage the pain verbally reported by one resident (Resident #76) out of five residents reviewed for pain concerns. This facility practice has the potential to affect 52 residents in the facility on pain management program. The Findings Included: Record review of the facilities policies and procedures revealed the policy titled Pain Assessment and Management with revision dated March 2015. The purpose of the procedures was to help staff identify pain in residents, and to develop interventions consistent with Resident's goals and that addressed underlying causes of pain. General Guidelines noted: 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain Management is a multidisciplinary care process that includes the following: a) Assessing the potential for pain b) Effectively recognizing the presence of pain c) Identifying the characteristics of pain d) Addressing the underlying causes of pain e) Developing and implementing approaches of pain management f) Identifying and using specific strategies for different levels and sources of pain. g) Monitoring for effectiveness of interventions; and h) Modifying approaches, as necessary. Observation on 6/27/2021 at 12:00 PM, revealed Resident #76 alert and oriented. Resident #76 reported she was in a lot of pain, she was in pain all the time and received pain medication. Resident #76 explained that staff had placed blankets underneath her to move her and they hurt her legs and shoulder and she was waiting for pain to go away. Resident #76 showed signs of pain as she grimaced, moaned, and trembled when she spoke. Resident # 76's left leg and left hand appeared contracted and no restorative devices noted in place. Observation and interview on 6/28/2021 at 8:13 AM revealed, Resident #76 in bed, wearing a hospital type gown. Resident # 76 remembered previous interview and reported, I think the pain was from the weather, it's probably raining outside. Resident # 76 explained she was still experiencing pain in both legs and shoulder areas. On 6/28/2021 at 12:30 PM revealed, Resident #76 was in her room with door closed. She screamed loudly and consistently and could be heard from the nurses' station. At the nurses' station, Staff DD Registered Nurse (RN) and Staff BB RN Supervisor reported that Resident #76 always screamed when repositioned. On 06/28/202 at 12:59 PM, during observation and interview Staff EE a Certified Nursing Assistant (CNA) reported she cared for Resident #76 and that the resident had certain behaviors. Staff EE, CNA stated that Resident #76 always screamed when repositioned and complained that she was in pain. Observation during the above-mentioned interview showed, Resident #76 continued to complain that she was in pain and loudly screamed as Staff EE, CNA attempted to place a pillow underneath the resident's right side. Observations and interviews on 6/29/2021 at 9:08 AM showed, Staff DD,RN referred Resident # 76 to the pain management physician. The Pain Management Physician assessed Resident #76 on 6/29/2021 at 9:13 AM. Interview on 6/29/2021 at 3:30 with Staff HH, CNA, revealed,she was familiar with Resident # 76, and normally cared for Resident # 76 during the afternoon shift an average of five days a week that included providing ADL (Activities of Daily Living) care. Staff HH, CNA reported that Resident #76 usually stayed in bed, was alert and able to communicate her needs and Resident # 76 normally complained that her leg hurt when repositioned. She complains when we move her, because she does not like to be moved. Staff HH explained staff normally used a blanket to reposition the resident; If the resident is in too much pain, I call another CNA. During the interview, Staff HH acknowledged she cared for resident #76 earlier that week on Sunday 6/27/2021 without the assistance of another staff. Interview on 06/30/2021 at 11:10 AM, Staff DD,RN reported that Resident # 76 was transferred from the third floor about a year ago. Resident # 76 had medical diagnoses that caused her pain, which included primary generalized osteoarthritis, hemiplegia unspecified affecting left nondominant side, other idiopathic peripheral autonomic neuropathy and personal history of other diseases of the circulatory system. Staff DD, RN reported she assessed the resident for pain every shift and as needed and Resident #76 was capable of expressing her needs and level of pain. Medications ordered to manage Resident #76's pain (Prior to survey) included regular Tylenol and Gabapentin tablet 300 mg (milligram) by mouth two times a day. During the interview, record review of physician orders showed order dated; 1/17/2020; Consult with Pain Management Dr . Staff DD reported that Resident #76 was seen by pain management yesterday, because she was complaining of pain. Staff DD, RN stated that Resident # 76 complained yesterday, today and the day before yesterday and always complains when she is repositioned or transferred. During the interview, Staff DD reviewed Resident #76's electronic record. She reported; Before yesterday, she was not seen by pain management. Staff DD explained that pain management included assessments and interventions that nurses documented on the MAR. Documentation included pain level the resident reported (from 0-10) and nurses' interventions. Nurses also documented in the progress notes and/or behavior monitoring sheets; I understand the importance of documentation The Director of Nursing later presented documented evidence of assessments and interventions previously put in place to manage pain reported by Resident #76, the documents were dated January and February 2020. Record review of the Medication Administration Records (MAR) revealed ordered Acetaminophen tablet 325 mg, give 2 tablet by mouth every six hours as needed for pain (Scale = 1 to 3 ). Start date 08/28/2019. Signatures on the MAR indicated that during the months of May and June 2021, Resident #76 received the medication twice; during survey, on 06/29/2021 and on 06/30/2021. Pain levels documented for those days were also documented twice as a pain level of 3 on 06/29/2021 and a pain level of 2 on 06/30/2021. For the order Monitor for pain every shift with start date 08/28/2020, zero levels of pain were documented for the month of May 2021. For the month of June 2021 pain level was documented once, during survey on 06/30/2021 as a pain level 2. Further review of orders revealed that an order was initiated on 06/29/2021 (during survey) for Tylenol 8-hour tablet Extended Release 650 MG (Acetaminophen ER) give 1 tablet by mouth every 8 hours related to primary generalized osteoarthritis for 7 days and Gabapentin Capsule 300 mg; give one capsule by mouth at bedtime related to other Idiopathic Peripheral Autonomic Neuropathy was started date 06/29/2021, also administered on 06/29/2021, during survey. Upon discussion of the above-mentioned, resident observations, interviews and records reviewed, Staff DD stated, I do believe we have been managing the resident's pain. Maybe not with the right frequency but yes. Staff DD, RN agreed to observe the resident. During the observation, Resident #76 continued with facial grimacing and complained of pain. When Staff DD asked the resident about her pain level, the resident responded, continuous on both legs. Her head also hurt; she was not comfortable sitting on her chair. Resident #76 cried and added allegations that her roommate was abused, she was also physically abused. Staff DD proceeded to tend to the resident's needs and the abuse protocol initiated. The Resident reported same allegations to the Director of Nursing (DON). The DON initiated the abuse prevention protocol. On 06/30/2021 at 12:00 PM a follow up observation and interview with Resident #76 was conducted in the presence of the survey team's Registered Nurse Consultant. Resident #76 was observed in bed with facial grimacing and complained of constant pain in the shoulder and legs. The resident was asked on scale of 0 to 10 what was the pain level being experienced, the resident responded that the pain was constant and revealed that while staff were moving her she think her shoulder was dislocated the night before. Resident # 76 reported that last night while the staff was moving her, the person that cared for yelled at her to stop and used a dirty towel and covered her mouth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). On 06/28/21 at 9:20 AM, observation of the medication administration for Resident #13 on the 3rd floor South unit, performed by Staff O, a Registered Nurse (RN) revealed, Staff O removed a disposable white foam tray from the medication cart and placed it on top of the cart, Staff O pulled bingo cards from the medication cart and popped the tablets into the medication cup. Staff O administered the medications to Resident #13. Staff O returned to the medication cart and proceeded to prepare medications for another resident. The Surveyor did not see Staff O sign out that the medications were administered to Resident #13. Staff O (RN) was asked if and when the medications administered to Resident # 13 signed out. Staff O reported, I signed the medications out as I popped the tablets from the bingo cards. Staff O was asked, what is the policy and procedure for administering medication. Staff O stated that after administering medications to the resident, they must sign out that the resident received or refused the medication. Staff O was asked, what if the resident had refused the medications that was already signed out as given and how would that be corrected. Staff O did not respond. When asked why the the medications were signed out before they were given; Staff O, RN stated, I always sign out then give the medications. Staff O, acknowledge the error and it is wrong to sign that medications as given before actually administering the medication. The following medications were given during the observation Lasix 20 mg (milligrams) 1-tablet PO (By Mouth), Gabapentin 600 mg 1 tablet PO, Baclofen 5 mg 1 tablet PO, Linzess 145 mcg (micrograms) 1 capsule PO and Multivitamins with minerals 1 tablet PO. It was noted, the facility utilized an electronic medication administration record and system. On 6/28/21 at 10:45 AM Staff O, RN called the surveyor to the medication cart and demonstrated how turned on the computer and demonstrated how she could have corrected mistakes. Staff O acknowledged the error made and explained that she asked her manager what to do if residents refused medications that were already signed off instructions were provided including documenting refused in the progress notes. Review of the facility's policy titled, Administering Medications, revised on December 2012 revealed, in the section for Policy Interpretation and Implementation revealed, on Item # 19, the individual administering medication must initial the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. Item # 20 indicated that, As required or indicated for a medication, the individual administrating the medication will record in the residents medical record: (a) the date and time the medication was administered, (b )the dosage; (c) the route of administration; (g) the signature and title of the person administering the drugs. Based on observations, interviews and record reviews, the facility failed to ensure the availability of ordered medication to be administered for 1 out of 5 residents (Resident # 32) observed for medication administration. 2. One out of two nurses (Staff O)on the facility's third floor presigned the medications as given prior to the Resident #13 taking the medications. The findings included: 1) On 06/27/2021 at 8:38 AM, observation of medication administration conducted by Staff J a Licensed Practical Nurse (LPN) for Resident # 32. Staff J, LPN performed hand hygiene and poured Aspirin 81 milligrams (mg) one tablet in medication cup, pulled the bingo pill card to prepare Lexapro 5 mg one tablet and noted the bingo card was empty. Staff J, LPN searched the medication cart to see if the medication was misplaced, and did not find the medication. Staff J, LPN and revealed that ordered medication Lexapro 5 mg; give 1 tablet one time a day for anxiety disorder was not available to be administered. Staff J, LPN stated that the medications should be reordered a week before it is finished and the doctor will be called. Staff J, LPN proceeded to administer the aspirin 81 mg tablet, but did not inform the resident of the Lexapro 5 mg tablet that was not available. During side by side review with Staff J, LPN of the bingo card for the Lexapro 5 mg that indicated 30 tablets were dispensed on 6/04/2021. Staff J, LPN could not explain the discrepancy between the amount of medications dispensed on 06/04/2021 and no medications available at the time of observation on 06/27/2021. Review of clinical records for Resident # 32 revealed an admission date of 01/20/2021 from a local hospital. Clinical diagnosis include but not limited to unspecified mental disorder due to known psychological condition and anxiety disorder. Resident # 32's Brief Interview of Mental Status (BIMS) documented a score of 7 out of 15 on the quarterly Minimum Data Set (MDS) dated [DATE] to indicate Resident #32 is cognitively impaired. On 06/29/21 at 12:31 PM during an interview with the Director of Nursing (DON) it was stated, if a medication is not available they should go the EKit (Emergency Kit) and check if the medication is available to be given to the resident. In case we do not have the medication on hand the Medical Doctor (MD) should be notified if it is ok to hold the medication until it is available. The DON stated, the medications are to be ordered seven days out anyone can reorder. Review of the facility's emergency medication supply and EKit list did not include Lexapro.

Based on observations, records reviewed and interviews, the facility failed to ensure medications and biologicals are stored and discarded to meet professional standards for 2 out of 4 medication carts and 3 out of 8 medication rooms reviewed. As evidenced by loose medication observed in the north cart on the second floor. Stock medication noted with no open date in the south cart on the second floor. Narcotic (Ativan injectable) removed from Emergency Kit (EKit) and pharmacy not notified to have EKit replaced. Medications removed from emergency kits not accurately documented, emergency kits unlocked, emergency glucagon removed from EKIt unaccounted for. Medications discarded in the garbage with resident's information visible on label in medication room on the fourth floor. The findings included: 1. On 06/27/2021 at 10:09 AM, review of north medication cart on the second floor revealed in the second from the right first drawer one oblong yellow tablet imprinted E-11 identified as Levetiracetam a medication used for seizures. Staff ZZ, LPN revealed the cart was not checked at start of shift and acknowledged the concern of a resident missing a dosage of a seizure medication. Review of the south medication cart on the second floor with Staff J, LPN on 06/27/2021 at 10:14 AM revealed stock medication Mylanta with no opened date. Staff J, LPN stated I did not check the other areas of the cart, I only checked the narcotics. Observation of the fifth floor's north medication room on 06/27/21 at 01:00 PM with Staff E, a Registered Nurse (RN) revealed narcotic Ativan one milligram per milliliter (mg/ml) injectable vial was removed from the emergency kit (EKIt) on 6/18/2021 for Resident # 129. Review of the emergency drug slip did not indicate the lock seal information for when the kit was opened and the lock seal information when the EKIt was closed. On 06/27/21 at 01:12 PM Staff E, RN stated that the when the nurses opened the EKit they are required to notify the pharmacy that the EKIt has been opened to have it replaced. Staff E acknowledged the EKIt did not have Ativan injectable available and stated they can borrow the missing medication from another floor and she will call to replace the EKIt. On 06/27/2021 at 1:45 PM observation of the fourth floor north medication room with Staff G, a Registered Nurse (RN) revealed the emergency medication kit unlocked. Review of the contents and the emergency medication slips revealed antibiotic Cefuroxime 250 mg 2 tablets were removed on 6/25/2021. The emergency slip was not documented with the time the medications were removed and the lock seal information was incomplete. On 06/27/21 at 01:49 PM Staff G, RN stated that the staff must complete all the information on the emergency kit form and lock the kit with the red lock and place the lock numbers on the form. Staff G stated, the doctor must also be informed that we did not have the medication and it had to be taken from the EKIt. Further observation of the medication room revealed Ativan 2 mg was missing from the EKIt. Review of the emergency kit slip revealed Ativan 2 mg was removed from the EKit for Resident #104 on 6/26/2021 at 2100. Review of the EKit containing emergency glucagon revealed the kit was opened and one out of three glucagon was missing and no documentation. On 06/27/21 at 01:51 PM Staff G,RN revealed that for the glucagon, the person that removed it should have completed the emergency kit form. The person that took it did not do the form we do not know who removed the glucagon or for what resident. Staff G, RN acknowledged it is a concern. Observation of the cabinets bottom shelf in the medication room revealed an opened bottle of chlorhexidine gluconate 0.12% oral rinse for Resident # 363 with opened date 02/27/20, Staff G stated that Resident #363 no longer resided in the facility. observation revealed personal items belonging to Staff S, LPN on the metal shelf in the medication room. On 06/27/2021 at 2:11 PM surveyor performed hand hygiene and upon opening of the garbage bin to dispose tissue paper that was provided to dry hands (no hand towel in med room) revealed two bottles containing lactulose and names of residents visible on both bottles. On 06/27/2021 at 2 :13 PM, Staff G, RN acknowledged both bottles had medication in them and the names of the residents were visible. Staff G, RN stated, if the bottle is empty we put them in the trash and remove the resident's name but if any tablets or liquids are left we return them to the pharmacy. On 06/27/2021 at 2:18 PM, Staff S, LPN was asked about the personal items in the medication room, Staff S, LPN stated that sometimes she put her personal items in the medication room to declutter the desk at the nurse's station. Staff S, LPN revealed that the medication room is not meant for personal items only medications and treatments. On 6/29/2021 during and interview with the pharmacy representatives it was stated that when the nurses removed an item or before they remove a narcotic from the EKit, documentation should be sent to the pharmacy, they should get an authorization number and document it so that the kit can be replaced by the next delivery. Regarding the disposal of medications; the pharmacy representatives reported that liquid medications are not sent back for credit but if the facility can return liquids to the pharmacy and the pharmacy would destroy it for the facility because the facility does not have drug busters as yet. On 06/29/21 at 08:55 AM , review of the 4th floor north- Staff H, RN supervisor and pharmacy representative revealed the EKit was unlocked. and medication cefdinir 300 mg capsule was removed for Resident #138 on 06/2/2021 at 9:00 PM. Staff H, RN acknowledged the incomplete slip and opened EKit. Staff H, RN stated the EKit should be kept locked and the nurses should fill out the slip with the lock numbers and lock the kit after removing medication. On 06/29/21 at 09:12 AM, observation of the 2nd floor medication room revealed Cefepime 1 gram intravenous (IV) was removed from the iv emergency kit for Resident # 47 on the fifth floor on 6/28/2021. Review of the emergency kit slip revealed no documented time to indicate when the medication was removed. Staff YY, RN acknowledged the concerns and stated that the EKit was opened by a nurse from the fifth floor. Staff YY, RN stated that when removing anything from the EKit a doctor's order is needed. We must fill out the slip completely put the lock numbers place the paper inside and seal with red tag and put in the black box and we must report to the pharmacy that we remove a medication. On 06/29/21 at 09:24 AM the Director of Nursing ( DON) was informed of the concerns identified in presence of pharmacy representatives. The facility's policies and procedures were requested, Review of the facility's policy and procedure-Pharmacy Services for nursing facilities. Revised January 2018 indicates:-The nurse records the medication use from the emergency kit on the medication order form/use form and calls the pharmacy for replacement of kit/dose as soon as possible after the medication has been administered . flags the kit with the color coded lock to indicate need for replacement of kit or dose as soon as possible after the medication has been administered. Use of the emergency medication is noted on the resident's Medication Administration Record (MAR). Emergency Kits and or contents are replaced according to facility policy or state regulations. For schedule II (CII) medications, the prescriber prepares and sends a written Authorization for Emergency Dispensing to the pharmacy within seven (7) days. Review of document titled Storage of Medications. Revised April 2007-Policy Statement indicated : The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Item 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biological. All such drugs shall be returned to the dispensing pharmacy or destroyed. Discarding and Destroying Medications. Revised October 2014- Policy statement indicate: Medications will be disposed of in accordance with federal , state, and local regulations governing management of non- hazardous pharmaceuticals, hazardous waste, and controlled substances. Review of facility's document with title Emergency pharmacy services and emergency kits Policy documented : Emergency supply is maintained at a designated area along with a list of supply contents and expiration dates as follows: 1) Emergency non-parenteral medications are kept at XX units/with other emergency medications in sealed portable containers locked drawer or cabinet. 2) Antibiotics starter doses are kept at XX unit/with other emergency medications in a sealed portable container/ locked drawer/ cabinet. 3) Emergency infusion therapy kids are kept at XX unit/ with other emergency medications in a sealed portable container/ lock drawer/ cabinet. 4) Emergency controlled substances are kept at unit XX/ with other emergency medications in a sealed portable container/ lock drawer/ cabinet.

Based on observation, interview, and record review the facility failed to maintain food sanitation and safety requirements with storage, preparation, and distribution in accordance with professional standards as evidenced by 1.) Failure to serve food under sanitary conditions during dining and 2.) Failure to store food at safe temperatures and under sanitary conditions in the kitchen. This has the potential to affect 203 residents who eat orally of 212 residents residing in the facility at the time of the survey. The findings included: 1.) Observation on 6/27/21 at 11:26 AM revealed a meal cart being delivered to the 3rd floor dining room. Observation at 11:38 AM revealed a Licensed Practical Nurse (LPN), Staff V carrying a chair to the table. No hand hygiene was observed prior to providing feeding assistance to the resident. At 11:40 AM, Staff V was observed leaving the table to call the kitchen. Staff V handled the telephone and did not practice hand before assisting the resident. At 11:42 AM, Staff V's cell phone rang. Staff V reached into her pocket, removed the cell phone and then proceeded to feed the resident without practicing hand hygiene. Staff V was observed throughout this entire process repeated touching her surgical mask to readjust the mask with no hand hygiene. Interview with LPN, Staff V on 6/30/21 at 2:51 PM revealed the procedure for hand hygiene during tray delivery is to use the hand sanitizer first before the tray is pulled from the cart. Before I remove each tray from the cart I use the sanitizer. If I am feeding a resident I will pull the chair to the table and sit down to feed the residents. I have to sanitize my hands before I sit down to feed the patient. Once I have touched the chair, I would sanitize again. If I had to call the kitchen to ask for an alternate for the patient, I would have to sanitize my hands after I use the phone. If I touch my mask my hands are no longer clean. Each time I touch my mask I would sanitize my hands. If I touch something that is not clean I sanitize especially before feeding the patient. Interview with the Infection Preventionist, Staff D on 6/30/21 at 3:00 PM revealed the expectation is to do hand hygiene before and after feeding a resident. If you are feeding a resident and during the meal if your hands get soiled you should do hand hygiene again. If you touch or move furniture before feeding a resident you have to do hand hygiene. If the staff touches the telephone in the dining room or their cell phone, hand hygiene would be required again. If the staff has to adjust their mask the expectation would be to do hand hygiene before feeding the resident. Review of the facility policy titled Handwashing/Hand Hygiene revised August 2015 revealed 7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: before and after direct contact with residents ., before and after eating or handling food, before and after assisting a resident with meals . 2.) Observation during the initial kitchen tour conducted with the Food Service Director (FSD), staff W on 6/27/21 at 8:16 AM revealed the following concerns: Observation at 8:16 AM revealed food items prepared for the lunch meal were being held on the steam table. Observation revealed pans containing ground pork, pureed pork, mashed potatoes, chicken soup, and pureed chicken soup. At 8:34 AM, Staff W used a dial stem thermometer to check the temperature of the food items held on the steam table: ground Pork 168 degrees Fahrenheit (Fé), pureed pork 128 degrees Fé, mashed potato 152 degrees Fé, chicken soup 162 degrees Fé, pureed chicken soup 170 degrees Fé, and mashed potatoes 170 degrees Fé. Interview with the Consultant Dietitian, Staff U on 6/29/21 at 10:45 AM revealed the tray line should not be set up for lunch before 10:00 AM. The food should not be placed in the stream table before 10:00 AM. The staff knows they cannot hold the food on the line more than an hour before they start to served at 11:00 AM. Maybe they were trying to get ahead of themselves on Sunday but this is not the correct procedure. Interview with the Food Services Director (FSD ) Staff W on 6/29/21 at 10:50 AM revealed when the food was observed on the steam table on Sunday morning, the cook was cleaning the steamer. They should not have the food on the steam table that early. They know they need to use the ovens if the steamer is not available. They should should not be setting up that early. The food should not be held on the steam table more than an hour before they start the tray line service which begins at 11:00 AM. Interview with the Cook, Staff X on 6/30/21 at 9:52 AM conducted by a spanish speaking surveyor to interpret revealed he works as a cook on the morning shift and is responsible for preparing breakfast and lunch. Staff X explained that he start to prepare breakfast at 6:00 AM for service beginning at 6:30 AM. When the line finishes for breakfast they begin preparation for the lunch meal. Once the food is prepared for lunch if it is not time for the tray line service the food is placed in the hot box where it is stored until the tray line is started. The food is not placed on the steam table for lunch until 10:30 AM to 11:00 AM. The lunch tray line starts at 11:00 AM and it ends between 12:30 PM and 1:00 PM. In reference to the food observed on the steam table early Sunday morning, Staff X stated this is not things are normally done. Staff X explained that the food is not usually placed on the tray line until 10:30 AM. At the time the hot box was not hot because it was unplugged and that was the reason the food being placed on the line. The electricity for the hot box was being used for something else at the time so the hot box was not hot. Interview with the FSD, Staff W on 6/30/21 at 10:00 AM revealed the hot box is emptied and unplugged after breakfast. The same outlet is used for the emulsifier and the hot box. This is used for the soup and then the hot box is cleaned and plugged back in. It takes about 15 minutes to reach temperature. The box is set between 170 - 180 degrees. I would love to say there is a valid reason for the food items being prepared so early on Sunday. Usually they start to pan up the food around 9:30 AM and place it in the hot box until the finish panning up the rest of the food. They set up the steam table around 10:00 AM for the lunch meal. Review of the Cook's Daily Assignments revealed: 10:00 AM begin set up of trayline, 11:00 AM lunch trayline, puree and regular on steam table. Review of the facility policy titled Food Preparation and Service revised October 2017 revealed: PHF (potentially hazardous food) must be maintained below 41 degrees Fé or above 135 degrees Fé. The maximum length of time that food will be held on steam tables is 4 hours total. Steam tables are not used to reheat foods. Review of the facility policy titled Food Receiving and Storage revised July 2014 revealed: Refrigerated foods must be stored below 41 degrees Fé unless specified by law. Additional concerns identified during the initial kitchen tour conducted on 6/27/21 beginning at 8:15 AM are as follows: The integrity of the cutting board attached to the steam table was damaged. The cutting board had deep cuts leaving the surface discolored and uncleanable. Observation revealed no external or internal thermometer in the ice cream freezer. The ice cream was soft to touch. Observation at 8:39 AM revealed a reach in cooler in the cook's preparation area which registered 44 degrees Fé. There was a large cooked pork roast stored inside the unit. Observation at 9:03 AM in the dry storage room revealed bulk storage bins containing sugar and rice. The scoops were observed lying inside the bins with the handles in direct contact with the food product. During a follow up visit to the kitchen on 6/29/21 beginning at 10:35 AM revealed the reach in cooler unit in the cook's preparation area was out of service. Interview with the Consultant Dietitian, Staff U on 6/29/21 at 10:45 AM revealed this cooks box was taken out of service. On Monday the temperature was ranging between 40-44 degrees. All items were disposed of and a call was placed for service. They came today and reported the thermostat had been turned up in the wrong direction causing the unit to overheat. Review of the service invoice revealed repair of maintenance cooler included uncontrolled thermostat service, evaporator drain cleaning, gas pressure and temperature control, middle door gasket fit, compressor cooling by high temperatures, and new gaskets. Note: general maintenance of the cooler every two months is important.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to accurately document information for one resident (Resident #150) out of 35 sampled residents. The facility census was 212 at the time of survey. The findings included: On 06/28/2021 at 10:32 AM Resident #150 reported during observation and interview that he did not want the Certified Nursing Assistant (CNA) to wash his hair because she was rough, and that he wanted to wash his hair by himself. Resident #150 stated he wanted to change to another CNA because he previously had another CNA the new CNA did not know how to wash his hair. Record review revealed Resident # 150 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE] section G for bathing revealed extensive assistance and one person to assist resident. During an interview with Staff Z CNA on 06/29/2201 at 1:24 PM. Staff Z, CNA revealed she is CNA assigned to Resident #150. She stated she has been his CNA for about 6 days and she floats on the same floor. Staff Z, CNA reported that Resident #150 is able to express what bothers him. I always try to do the care and if he does not want anything specific I don't do it for him. To get out of his bed, we help him with two people, in the bed he helps a lot and he is able to move around from side to side. To do perineal care, he is able to help but to clean him it is total care. In the bed he is able to help. Staff Z, CNA reported that 3 days ago she had wanted to wash his hair, but he did not want her to, and that he wanted to do it on his own, but when we go to do it he does not want to and he states that he is clean. Staff Z reported that Resident #150 does not even want to change his shirt. Staff Z, CNA reported that Resident # 150 came from another floor and if a staff from therapy does not come the resident does not want to do anything. Staff Z, CNA reported that if the resident does not want to wash his head or states that something is bothering them it is reported to the nurse. Staff Z, CNA stated, yesterday I was going to write a paper to tell the nurse. Interview with Staff Y, Registered Nurse (RN) on 06/30/2021 at 10:32 AM revealed the CNA the day before had reported that Resident #150 refused to wash his face and hair. Staff Y reported that when the residents refused to take a bath or care provided, the CNA would report it to the nurse and it would be documented, and the information should be faxed or sent to the social worker and they would revise the care plan. Review of clinical records revealed no documentation related to the residents concern. There was no documentation of the residents refusal of care as reported during the above interviews.

Based on observations, interviews, and records reviewed, the facility failed to demonstrate effective plans of action were implemented to correct identified quality deficiencies in problem-prone areas. As evidenced by repeated deficient practice identified during consecutive annual surveys, related to Reasonable Accommodation of Needs (F558), Pharmacy Services (F755) and Essential Equipment, Safe Operating Condition (F908). The findings included: Record review of the facility's policies and procedures revealed the Quality Assurance and Performance Improvement (QAPI) Program. With revision dated April 2014 noted; This facility shall develop, implement and maintain an ongoing facility -wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. The Policy implementation and interpretation noted: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Strategic elements included 4. Performance Improvement Projects: a. Performance improvement projects are initiated when problems are identified. Record review of the facility's survey history revealed, during annual surveys exit dated 07/25/2019 and 04/12/2018, deficient practice was cited related to Essential Equipment, Safe Operating Condition (F908). The facility was also cited F908 during the current annual recertification survey exit dated 06/30/2021. Reasonable Accommodation of Needs (F558) and Pharmacy Services (F755) was cited during annual surveys exit dated 07/25/2019, and during the current annual recertification survey exit dated 06/30/2021. During an interview the Risk manager reported, the facility's Quality Assessment Assurance (QAA) committee meets monthly. The committee included, the Director of Nursing (DON), The Administrator, The Medical Director, and other department heads. Accommodation of resident's needs was a topic discussed in all of their meetings. The committee did not identify this as a systemic issue deficiency. The committee identified issues with falls and implemented a plan of corrective action and the other issues identified were not systemic issues and were addressed during the meetings. The Risk manager expressed understanding related to the identified repeated deficient practices and the effectiveness of the QAA committee

Based on observation, interview and record review the facility failed to ensure essential equipment was maintained in safe operating condition as evidenced by not maintaining a reach in cooler located in the kitchen under safe, functional operating conditions and maintain the unit at 41 degrees Fé (Fahrenheit) or below. The findings included: Observation during the initial kitchen tour conducted with the Food Service Director (FSD), Staff W on 6/27/21 at 8: 39 AM revealed a reach in cooler in the cook's preparation area which registered 44 degrees Fé. There was a large cooked pork roast stored inside the unit. Observation during a follow up visit to the kitchen on 6/29/21 beginning at 10:35 AM revealed the reach in cooler unit in the cook's preparation area was out of service. Interview with the Consultant Dietitian, Staff U on 6/29/21 at 10:45 AM revealed this cook's box was taken out of service. On Monday the temperature was ranging between 40-44 degrees. All items were disposed of and a call was placed for service. They came today and reported the thermostat had been turned up in the wrong direction causing the unit to overheat. Review of the service invoice revealed repair of maintenance cooler included uncontrolled thermostat service, evaporator drain cleaning, gas pressure and temperature control, middle door gasket fit, compressor cooling by high temperatures, and new gaskets. Note: general maintenance of the cooler every two months is important. Review of the facility policy titled Food Preparation and Service revised October 2017 revealed: PHF (potentially hazardous food) must be maintained below 41 degrees Fé.