Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 1 of 3 residents, Resident #51. Findings Include:Review of the Discharge/Return Anticipated/End of PPS [prospective payment system] Part A Stay MDS for Resident #51 dated 8/12/2025, read, Section A: Discharge Status: Home/CommunityReview of the census documented Resident #51 currently resides in the facility.During an interview on 09/09/2025 at 11:32 AM, Staff C, RN/MDS Coordinator (Registered Nurse) stated, He [Resident #51] was discharged , and we thought he was coming back. He went to an appointment on that day, was admitted to the hospital and we didn't have clear information on what was going on. We thought he was discharging home from the hospital. I didn't know if he was going to come back or not. Looking back on it, I should have coded the discharge status as 04. Short-Term General HospitalDuring an interview on 09/09/2025 at 1:04 PM, Resident #51 stated, I remember going to the hospital, but I don't remember the date. Review of the policy and procedure titled, Conducting an Accurate Resident Assessment, reviewed 12/18/2024 read, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment by staff qualified to assess relevant care areas. Definition: 'Accuracy of assessment' means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status). 2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities and psychosocial status.

Based on interview and record review, the facility failed to ensure the administration of insulin and to notify the physician of elevated blood glucose values for 2 of 5 residents, Residents #25 and #22) reviewed for unnecessary medications.Findings include: 1) Review of Resident #25's admission record documented diagnosis to include myocardial infarction type 2 (a heart attack), cognitive communication deficit, type 2 diabetes mellitus without complications, chronic atrial fibrillation (an irregular heartbeat), unspecified, essential (primary) hypertension (high blood pressure), hyperlipidemia, unspecified (high cholesterol), and atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain).Review of Resident #25's physician orders dated 9/4/2025 read, Insulin Glargine-yfgn [yfgn is a unique suffix identifier assigned by the U.S. Food and Drug Administration to distinguish it from other similar products]. Subcutaneous Solution Pen-injector 100 unit/ml (milliliter) (Insulin Glargine-yfgn) inject 63 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications.Review of Resident #25's Medication Administration Record (MAR) for September 2025 documented a blood sugar value of 463 on 9/5/2025 at 2000 (8:00 PM), and a blood sugar value of 454 on 9/7/2025 at 2000, there were no notes within the medical record that documented the physician was notified per the Medical Doctor's orders.Review of Resident #25's MAR for August 2025 documented on 8/26/2025 at 2000 chart code 12 (vitals outside parameters) for Insulin Glargine-yfgn Subcutaneous Solution Peninjector 100 unit/ml (Insulin Glargine-yfgn) Inject 55 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus without complications. During an interview on 9/09/2025 at 6:03 AM Staff G, LPN (Licensed Practical Nurse) stated, I did not give the insulin it was outside the parameters.During an interview on 9/11/2025 at 4:08 AM Staff F, LPN stated, The blood sugar was above 450. I should have called the doctor. I don't know if I did or not. I can't tell you if I actually called the on call person about the high blood sugar. I have no notes in the chart. I should have called and documented that.2) Review of Resident #22's admission record documented diagnosis that include, Type 2 diabetes mellitus with diabetic neuropathy, unspecified, hypothyroidism, unspecified, chronic systolic (congestive) heart failure, unspecified dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and cognitive communication deficit.Review of Resident #22's physician orders dated 8/13/2025 read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) inject 14 units subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy unspecified. Review of Resident #22's MAR documented Lantus insulin was held without parameters on the physician order on 8/22/2025 and documented a chart code of 9 (other, see nurses notes). Dated 8/26/2025 documented a chart code of 9 (other see nurses notes), and dated 8/30/2025 documented chart code of 5 (hold see nurses notes).Review of Resident #22's EMAR (Electronic Medication Administration Record) dated 8/22/2025 at 2100 (9:00 PM) read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml inject 14 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (E11.40) hold due to bs [blood sugar] at 80.Review of Resident #22's REMAR dated 8/26/2025 at 21:24 (9:24 PM) read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml Inject 14 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (E11.40) BS 73.Review of Resident #22's EMAR dated 8/30/2025 at 2158 (9:58 PM) EMAR read, Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml Inject 14 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified (E11.40) BS 71.During an interview on 9/10/2025 at 6:00 AM Staff G, LPN stated, I did hold the insulin. It was outside parameters based on the sliding scale. The physician order was reviewed with Staff G. Staff G stated, There are no parameters on that [Lantus SoloStar insulin]. I guess I shouldn't have held it.Review of the policy and procedure titled, Medication Administration last review date of 1/9/2025 read, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination, or infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer oxygen at physician ordered flow rates according to professional standards of practice for 2 (Resident #1 and #26) of 3 residents reviewed for oxygen administration. Findings include: 1) During an observation on 9/8/2025 at 10:00 AM Resident #1 was observed in bed. Oxygen was being administered via concentrator by nasal cannula at 4 liters per minute.Review of Resident #1's admission record documented diagnosis that include acute and chronic respiratory failure with hypoxia (a condition where the lungs are unable to exchange oxygen and carbon dioxide leading to low oxygen levels-hypoxia), chronic obstructive pulmonary disease (lung disease that cause breathing problems) with acute exacerbation (a sudden worsening of the symptoms), pneumonia, unspecified organism, and acute and chronic (systolic) congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).Review of Resident #1's physician orders dated 8/1/2025 read, Oxygen at 2 liters per min [minute] via nasal cannula every shift. Verify concentrator is set to the ordered liters per minute.Review of Resident #1's comprehensive care plan read, Focus: [Resident #1's name] is at risk for altered breathing, respiratory distress secondary to COPD [chronic obstructive pulmonary disease]. Interventions: O2 [oxygen] as per MD [Medical Doctor] order.During an interview on 9/10/2025 at 9:00 AM Staff F, Licensed Practical Nurse (LPN) stated, It [the oxygen] is on 4 liters, it should be on 2 Liters. I usually check on oxygen after I do med [medication] pass. I have not checked hers [Resident #1] yet. We should follow the orders and have it on the right rate. 2) During an observation on 9/9/2025 at 7:27 AM Resident #26 was observed in bed. Oxygen was being administered via concentrator by nasal cannula at 4 liters per minute. The oxygen concentrator was outside of the resident's reach and was facing the wall.Review of Resident #26's admission record documented diagnosis that include acute and chronic respiratory failure with hypercapnia (high [NAME] dioxide levels in the blood), chronic obstructive pulmonary disease with acute exacerbation, respiratory failure unspecified with hypoxia, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), paroxysmal atrial fibrillation (an irregular heartbeat), and obstructive sleep apnea adult (a sleep disorder when you stop breathing during sleep).Review of Resident #26's physician order dated 8/20/2025 read, Oxygen at 3 liters per min via nasal cannula every shift. Verify concentrator is set to the ordered liters per minute.Review of Resident #26's comprehensive care plan read, Focus: [Resident #26's name] is at risk for altered breathing, respiratory distress secondary to COPD. Interventions: O2 as per MD order.During an interview on 9/9/2025 at 7:27 AM Resident #26 stated, I never change my oxygen, the nurses always do that.During an interview on 9/10/2025 at 9:00 AM Staff F, LPN stated, Her [Resident #26] oxygen should be at 3 liters. I'm not sure how that happened. We should check oxygen every day and check oxygen sat's [saturations]. Review of the policy and procedure titled Oxygen Administration last revision date of 3/15/2025 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanation and Compliance guidelines. 1.Oxygen is administered under orders of a physician, except in the case of emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.

Based on interview and record review the facility failed to ensure physician ordered parameters were followed related to blood pressure medications resulting in the administration of unnecessary medications for 2 (Resident #16 and #35) of 5 residents reviewed for unnecessary medications.Findings include:1) Review of Resident #16's admission record documented diagnosis that include chronic obstructive pulmonary disease, unspecified, type 2 diabetes mellitus without complications, iron deficiency anemia, unspecified, vitamin b12 deficiency anemia, unspecified, chronic pain syndrome, major depressive disorder, recurrent, mild, unspecified atrial fibrillation (an irregular heartbeat), gastro-esophageal reflux disease without esophagitis, hyperlipidemia, unspecified (high cholesterol),and essential (primary) hypertension (high blood pressure).Review of Resident #16's physician order dated 4/27/2025 read, Labetalol HCl [labetalol hydrochloride] oral tablet give 150 mg (milligrams) by mouth two times a day hold if HR [heart rate] <60 bpm [less than 60 beats per minute], hold if BP [blood pressure] systolic 100 or below related to essential (primary) hypertension. Review of Resident #16's Medication Administration Record (MAR) for July 2025 documented that Labetalol HCL 150 mg (milligrams) was administered outside of physician ordered parameters for heart rate less than 60 at 0900 (9:00 AM) on 7/7/2025 heart rate of 58, on 7/8/2025 HR 55, on 7/11/2025 HR 59, on 7/16/2025 HR 54 on 7/17/2025 HR 51, on 7/18/2025 HR 53, on 7/22/2025 HR 57, on 7/24/2025 HR 54, and on 7/28/2025 HR 58.Review of Resident #16's MAR for July 2025 Labetalol HCL 150 mg (milligrams) was administered outside of physician ordered parameters for heart rate less than 60 at 2100 (9:00 PM) on 7/4/2025 HR 56, 7/5/2025 HR 54, 7/6/2025 HR 58, 7/8/2025 HR 58, 7/17/2025 HR 58, 7/20/2025 HR 52, 7/27/2025 HR 58 and on 7/30/2025 HR 57.Review of Resident #16's MAR for August 2025 documented that Labetalol HCL 150 mg (milligrams) was administered outside of physician ordered parameters for heart rate less than 60 at 2100 on 8/9/2025 HR 59, 8/10/2025 HR 56, 8/20/2025 HR 54, 8/22/2025 HR 58 and 8/27/2025 HR 552) Review of Resident #35's admission record documented diagnosis that include unspecified combined systolic congestive and diastolic congestive heart failure, chronic obstructive pulmonary disease unspecified, unspecified protein calorie malnutrition, essential primary hypertension, major depressive disorder recurrent mild, peripheral vascular disease unspecified, chronic kidney disease unspecified, gastroesophageal reflux disease without esophagitis, chronic embolism and thrombosis unspecified deep veins of right lower extremity, unspecified atrial fibrillation, hypothyroid unspecified, age-related osteoporosis without current pathological fracture, unilateral primary osteoarthritis and right knee pain.Review of Resident #35's physician order dated 1/15/2025 read, Midodrine HCl oral tablet 10 mg (Midodrine HCl) give 1 tablet by mouth three times a day for low blood pressure give if Systolic 120 or below.Review of Resident #35's July MAR documented Midodrine was administered at 08:00 (8:00 AM) on 7/15/2025 with a blood pressure (B/P) of 142/76, on 7/17/2025 with a B/P of 126/78, and on 7/26/2025 with a B/P of 136/64.Review of Resident #35's July MAR documented Midodrine was administered at 12:00 (12:00 PM) on 7/4/2025 with a B/P of 122/60, on 7/13/2025 with a B/P of 122/64, on 7/16/2025 with a B/P of 122/72, on 7/19/2025 with a B/P of 126/82, 7/20/2025 with a B/P of 126/82, on 7/21/2025 with a B/P of 122/60 and on 7/26/2025 with a B/P of 136/64.Review of Resident #35's July MAR documented Midodrine was administered at 1600 (4:00 PM) on 7/17/2025 with a B/P of 124/74, 7/21/2025 with a B/P of 126/60 and on 7/22/2025 with a B/P of 122/60.Review of Resident #35's August MAR documented Midodrine was administered at 0800 on 8/10/2025 with a B/P of 136/64.Review of Resident #35's August MAR documented Midodrine was administered at 1200 on 8/4/2025 with a B/P of 122/60, on 8/16/2025 with a B/P of 130/86, on 8/19/2025 with a B/P of 128/64, om 8/24/2025 with a B/P of 122/64, on 8/25/2025 with a B/P of 124/79, on 8/26/2025 with a B/P of 122/60 and on 8/28/2025 with a B/P of 124/86.Review of Resident #35's September MAR documented Midodrine was administered at 1200 on 9/3/2025 with a B/P of 126/88, on 9/7/2025 with a B/P of 122/60 and on 9/9/2025 with a B/P of 122/60.Review of Resident #35's September MAR documented Midodrine was administered at 1600 on 9/9/2025 with a B/P of 122/60.During an interview on 9/9/2025 at 8:27 AM Staff E, LPN stated, I guess I gave it [the midodrine]. I should have held it.During an interview on 9/10/2025 at 9:25 AM Staff F, LPN stated, I don't know if I gave it [the midodrine] or not, maybe I did. Usually, I will document that the parameters mean I hold the medicine. My initials without that means I must have administered it. I don't really know if I did or not.Review of the policy and procedure titled, Medication Administration last review date of 1/9/2025 read, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination, or infection. 8. Obtain and record vital signs when applicable or per physician orders. When applicable hold medication for those vital signs outside the physicians' prescribed parameters.

Based on observation, interview, and record review the facility failed to ensure food was served in a sanitary manner during the 9/10/2025 midday meal, of two meals observed. Findings include:During an observation on 9/10/2025 beginning at 11:20 AM of the food services midday Staff A, [NAME] was observed using gloved hands to retrieve scoops, metal containers and other items from various areas in the kitchen. At 11:30 AM Staff A, did not remove the gloves or perform hand hygiene and lifted two pieces of cornbread from a metal tray with her gloved hands and placed the cornbread on individual residents' plates for service to the residents.During an interview on 9/10/2025 at 11:32 AM, the Certified Dietary Manager stated, She [Staff A] should use tongs to lift the cornbread from the tray and place on plates for service to residents.During an observation on 9/10/2025 at 11:34 AM, Staff A was observed lifting plates and bowls to fill with food for service to the residents. Staff A lifted two bowls and two plates with her fingers touching the interior food surface of the bowls and her thumb touching the interior food surface of the plates. At 11:35 AM, Staff A doffed gloves and donned a new pair of gloves without performing hand hygiene and returned to the tray line to prepare meal plates to serve to the residents.During interview on 9/10/2025 at 11:36 AM, the Certified Dietary Manager confirmed Staff A should not touch the interior food surfaces of the plates and bowls used to serve food to residents. Review of the policy and procedure titled Maintaining a Sanitary Tray Line, last reviewed 12/18/2024 read, The facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness. 3. During tray assembly, staff shall: Use utensils such as tongs, serving spoons, etc. [etcetera] to handle foods as much as possible. e. Perform hand hygiene before and after wearing or changing gloves. f. Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the workstation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure assessments accurately reflect the resident's status for 1 (Resident #57) of 4 residents reviewed for discharge status. Findings include: Review of the admission record documented Resident #57 was admitted on [DATE] with diagnoses including surgical aftercare, type 2 diabetes mellitus, chronic kidney disease and hypertension. Review of the social services progress note dated 5/14/24 for Resident #57 read, Discharge note: Per family/resident request, resident to discharge 05/15/2024. Resident to discharge home. Son will pick up and transport home . Review of the discharge summary progress note dated 5/15/24 for Resident #57 read, Resident, who is alert and oriented, transferred by son to Appointment then will go home . Review of Resident #57's Minimum Data Set (MDS) Discharge Return Not Anticipated assessment dated [DATE] read, discharge date , 05/15/2024. Discharge Status, Critical Access Hospital. During an interview on 6/18/24 at 10:15 AM the MDS Coordinator, Registered Nurse (RN), stated, [Resident #57's Name] discharge assessment documented him as going to the hospital and he actually discharged home. During an interview on 6/18/24 at 10:33 AM, the Social Services Director stated, Yes, that is an inaccurate assessment, it documents he [Resident #57] went to the hospital, and he [Resident #57] went home. Review of the Policy titled, Conducting an Accurate Resident Assessment, date reviewed 01/04/24, read, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received medication as per physician orders for 2 (Resident #25, #211) of 4 residents reviewed for pain medication administration and for 1 (Resident #160) of 3 residents reviewed for the care and treatment related to Peripheral Inserted Central Catheter (PICC) line dressings. Findings include: 1). Review of Resident #211's physician's order dated 6/4/2024 read, Acetaminophen Tablet Give 650 mg (milligrams) by mouth every 6 hours as needed for Mild Pain Do Not Exceed 3gm (grams) in 24 hours, pain scale 1-3 Review of Resident #211's Medication Administration Record (MAR) for June 2024 documented the resident received Acetaminophen 650 mg on June 14 at 4:15 AM with a pain level of 6. Review of Resident #211's physician's order dated 6/4/2024 read, Oxycodone HCI Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for Pain related to chronic pain syndrome. Pain scale 4-10 Review of Resident #211's MAR for June 2024 documented the resident received Oxycodone HCI 5 MG on June 6 at 1233 [12:33 PM] for a pain level of 2 and at 2021 [8:21 PM] for a pain level of 1, June 7 at 0152 [1:52 AM] for a pain level of 1 and at 1242 [12:42 PM] for a pain level of 2, June 14 at 2115 [10:15 PM] for a pain level of 3, and on June 15 at 0244 [2:44 AM] for a pain level of 2. 2). Review of Resident #25's physician's order dated 5/30/2024 reads, Oxycodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Pain pain scale 4-10 Review of Resident #25's MAR for June 2024 documented the resident received Oxycodone-Acetaminophen Tablet 5-325 MG on June 2 at 1549 [3:49 PM] for a pain level of 2, June 6 at 1244 [12:44 PM] for a pain level of 2 and at 2340 [11:40 PM] for a pain level of 2, June 14 at 2007 [8:07 PM] for a pain level of 3 and June 15 at 0422 [4:22 AM] for pain level of 2. Review of Resident #25's physician's order dated 5/30/2024 reads, Acetaminophen Tablet Give 650 mg by mouth every 6 hours as for Mild Pain Do Not Exceed 3gm every 24 hours pain scale 1-3. Review of Resident #25's MAR for June 2024 documented the resident received Acetaminophen Tablet 650mg on June 6 at 0656 [6:56 AM] for pain level of 6. During an interview on 6/19/2024 at 11:36 AM the Director of Nursing stated, The nursing staff should have not given [Resident #211's name] and [Resident #25's name] the medication if the pain level were out of the parameters ordered. Review of the facility policy and procedure titled Medication Administration date reviewed 01/04/24 read, Policy: Medication are administered by license nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 9. Obtain pain level as indicated. Administer PRN (pro re nata or as needed) analgesics according to pain scale specifications. 3). During an observation on 6/17/24 at 9:43 AM Resident #160 was sitting in bed, dressed in day clothes with a (Peripheral Inserted Central Catheter) PICC line dressing dated 6/7/24. Photographic evidence obtained. Review of the admission record documented Resident #160 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, lumbar region. During an interview on 6/18/24 at 11:55 AM the DON (Director of Nursing) stated, My expectation is the nurses look at PICC line dressings when the resident is admitted and change it if it is more than 7 days and then every week unless soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 15 reviewed residents, Resident #26 and Resident #15. Findings include: 1. Review of Resident #26's records revealed the resident was readmitted to the facility on [DATE] with the diagnoses including generalized anxiety disorder, Post Traumatic Stress Disorder (PTSD), and major depressive disorder. Review of Resident #26's Preadmission Screening and Resident Review (PASRR) dated 8/3/2020 did not reveal anxiety disorder, depressive disorder or PTSD under mental illness or suspected mental illness. During an interview on 2/8/2023 at 10:00 AM, the Social Services Director confirmed that Resident #26's PASRR dated 8/3/2020 did not denote Resident #26's pertinent diagnoses on page 2 of the PASSR. Review of the facility policy and procedure titled Resident Assessment- Coordination with PASARR Program reviewed on 1/4/2023 reads, Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 2. Review of Resident #15's records revealed the resident was readmitted to the facility on [DATE] with the diagnoses including type II diabetes mellitus. Review of Resident #15's physician order revealed Lantus Solostar Solution Pen-Injector 100 unit/ ML- inject 30 unit subcutaneously at bedtime related to type 2 diabetes mellitus ordered on 11/27/2022 and discontinued on 1/10/2023, Lantus Solostar Solution Pen-Injector 100 unit/ ML (milliliters)- inject 27 unit subcutaneously at bedtime related to type 2 diabetes mellitus ordered on 1/10/2023 and discontinued on 1/31/2023, Insulin Aspart Solution 100 unit/ ML- inject 3 unit subcutaneously before meals for diabetes ordered on 9/27/2022 and discontinued on 1/31/2023, and Novolog Solution 100 unit/ML (Insulin Asparat)- inject as per sliding, ordered on 11/29/2022. Review of Resident #15's annual Minimum Data Set (MDS) assessment dated [DATE] did not reveal Resident #15 as receiving insulin during the 7-day lookback period or as having a change in physician orders for insulin. During an interview on 2/9/2023 at 10:17 AM, the MDS coordinator confirmed the MDS dated [DATE] for Resident #15 was inaccurately completed for the resident receiving insulin injections and insulin order changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for 4 of 29 residents, Residents #2, #18, #41 and #48. Findings include: 1. Review of Resident #2's admission record revealed the resident was admitted to the facility on [DATE] with a history of heart failure, unspecified dementia, unspecified severity, anemia, other specified anxiety disorders, chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease stage 3, other reduced mobility, zoster without complications, muscle weakness, altered mental status, unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #2's progress note dated [DATE] reads, Quarterly Assessment- Met with resident who was up in wheelchair, dressed, alert, and oriented with mild confusion and able to make needs known. Daughter present for care plan. resident and daughter has [Sic.] no complaints or concerns regarding care. Resident vision and hearing appears WNL [within normal limits]. Discussed Advance Directives: Per daughter, resident is a DNR. Social Services to follow up regarding AD. Resident is social gets out of room often, attends activities and shows no signs of depression. Review of Resident #2's care plan dated [DATE] reads, No Advance Directives executed: Full Code. Dated Initiated: [DATE]. Review of Resident #2's paper chart on [DATE] at 11:00 AM revealed no Do Not Resuscitate Order signed. During an interview on [DATE] at approximately 10:45 AM, the Social Services Director stated, Daughter travels constantly. We are waiting until she comes back to do the Do Not Resuscitate (DNR) form. During an interview on [DATE] at 11:00 AM, Resident #2's Daughter stated, Mother is a DNR. I gave the forms to the facility. 2. Review of Resident #18's admission record revealed the resident was admitted on [DATE] with a history of Alzheimer's disease, aphasia, generalized anxiety disorder, ventricular tachycardia, type 2 diabetes mellitus, syncope and collapse, other symbolic dysfunctions, cognitive communication deficit, depression, unspecified mood disorder, essential hypertension. angina pectoris, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #18's care plan dated [DATE] revealed Advance Directives was executed and DNR was initiated on [DATE]. Review of Resident #18's progress note dated [DATE] reads, Quarterly Care Plan: Met with resident and daughter. Resident is alert with confusion. Able to make needs known. Resident is currently in PT. PT gave report. Nurse manager attended. Updated family on medications. Family has no concerns and happy with how her care has improved. Advance Directives review: DNR. Resident self-propels in wheel chair, is very social and attends activities. Resident has some HOH [hard of hearing], wears glasses and see podiatry. Social Services will continue to follow as needed. Review of Resident #18's paper chart revealed Full Code Agreement dated [DATE] signed by the Resident #18's Daughter. During an interview on [DATE] at 8:28 AM, Staff B, Registered Nurse (RN), stated, I would look at the code status in the electronic chart to see if the resident is a full code or Do not resuscitate. If the advance directive is not documented, I will then go to the paper chart and verify code status. Normally I assume she is a full code if the code status is empty. During an interview on [DATE] at 9:56 AM, the Regional Director of Nursing stated, Our education is to go to the chart. If Resident #18 was unresponsive, we would have done CPR [cardiopulmonary resuscitation]. During an interview on [DATE] at 9:57 AM, the Director of Nursing stated, I expect nurses to verify advance directives in resident chart. 3. Review of Resident #41's admission record revealed the resident was admitted to the facility on [DATE] with a history of chronic obstructive pulmonary disease, unspecified abnormalities of gait and mobility, essential hypertension, unspecified protein calorie malnutrition, anxiety disorder, other symbolic dysfunctions, cognitive communication deficit, chronic respiratory failure, low back pain, shortness of breath, heart failure, morbid obesity due to excess calories, major depressive disorder, recurrent, mild, unspecific mood disorder, other idiopathic peripheral autonomic neuropathy, hyperlipidemia, gastro esophageal reflux disease without esophagitis, overactive bladder, anemia, other reduced mobility, need for assistance with personal care, difficulty in walking, muscle weakness, drug induced subacute dyskinesia, COVID-19, paranoid schizophrenia, and acute respiratory failure with hypoxia. Review of the physician order dated [DATE] for Resident #41 reads, Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. Review of the physician order dated [DATE] for Resident #41 reads, Code: 0= No behaviors 1= Fear/Panic 2= Anger 3= Screaming/Yelling 4= Danger to self/others 5= Delusions 6= Hallucinations 7= Other (describe in nursing note) interventions- A= Music/aromatherapy B= Reminiscence, reality orientations C= Exercise, activities D= 1:1 E= Reduce Stimulation F=PRN [as needed] give Outcome- I =improve S=Same W=worse every day shift for Behavior monitoring. Review of Resident #41's Medication Administration Record for [DATE], [DATE], and February 2023 for Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. revealed staff initials and checkmarks for day, evening and night shifts. No Y or N was documented. Review of Resident #41's Medication Administration Record for [DATE], [DATE], and February 2023 Code: 0= No behaviors 1= Fear/Panic 2= Anger 3= Screaming/Yelling 4= Danger to self/others 5= Delusions 6= Hallucinations 7= Other (describe in nursing note) interventions- A= Music/aromatherapy B= Reminiscence, reality orientations C= Exercise, activities D= 1:1 E= Reduce Stimulation F=PRN [as needed] give Outcome- I =improve S=Same W=worse every day shift for Behavior monitoring. revealed the code 0 for [DATE], [DATE], [DATE], and [DATE]. Review of Resident #41's progress note dated [DATE] reads, Resident, who is alert yells out frequently instead of using call light for assist. Educated resident on the use of call light for assistance. Voiced understanding by verbalizing teach back method. Review of Resident #41's progress note dated [DATE] reads, Resident observed frequently licking lips and running tongue over bottom chin area resulting in chaffing to area. Lop balm applied to upper and lower lips. Review of Resident #41's progress note dated [DATE] reads, Late Entry from [DATE] Resident having increased anxiety. Sitting in her room calling out help me help me and when staff goes to help her she says she does not remember what she needed, when she was in the dining room for lunch she continued to say help me help me and wanting to go back to her room before eating. Collected urine to rule out uti [urinary tract infection]. Review of Resident #41's progress note dated [DATE] reads, Resident was in her wheelchair going down the hall saying help me help me the can [certified nursing assistant] asked her what she needed and she stated my room, the cna showed her room, this resident goes back in forth to her room mutli [Sic.] times a day with no issues. Approximately 10 minutes later she is yelling I can't breath [Sic.] went to her room and she is lying in her bed with hob [head of bed] elevated and her oxygen in place. O2 [oxygen] sats [saturation] 96% on room air. PRN neb [nebulizer] given with good results. Will continue to observe. Review of Resident #41's progress note dated [DATE] reads, Resident sitting in TV room yelling help me help me this nurse went to check on her and asked her what is the matter and she stated she was scared of the other resident that was gonna hurt her. Removed the other resident who was not bothering her at all and asked her to come out of the TV and go back to her room, she said ok. Approximately 5 minutes later she is yelling the same thing again about the other resident. Was able to get her back to her room. During an interview on [DATE] at 9:36 AM, Staff E, Licensed Practical Nurse (LPN), stated, [Resident #41's name] is anxious at times. No harm. She will shout out help me help me. When documenting for behaviors, I will check off if I see she is okay. If she has a behavior later in the day, I will write it in the notes. 4. Review of Resident #48's admission record revealed the resident was admitted to the facility on [DATE] with a history of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance mood disturbance mood disturbance and anxiety, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris, anxiety disorder, depression, lack of physical exercise repeated falls, essential hypertension, history falling, unspecified urinary incontinence, other reduced mobility, long term (current) use of antithrombotic/antiplatelet, hyperlipidemia, cerebral infraction, allergic rhinitis, muscle weakness, difficulty in walking, need for assistance with personal care, dysphagia, other symbolic dysfunctional, and cognitive communication deficit. Review of the physician order dated [DATE] for Resident #48 reads, Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. Review of Resident #48's Medication Administration Record for [DATE], [DATE], [DATE] and [DATE], for Behaviors- Monitor for the following: Yelling at staff, hallucinations, agitation, hitting, biting, kicking, spitting, cursing, delusions, psychosis, aggression, and refusal of care. Document: 'N' if monitored and none of the above observed. Document: 'Y' if monitored and the above was observed, select chart code 'Progress Note' and document findings every shift for monitoring. revealed staff initials and checkmarks for day, evening and night shifts. No Y or N was documented. Review of Resident #48's progress note dated [DATE] reads, The CNA came to this nurse for assistance with getting the resident up to toilet him and provide care. The resident refused, this nurse educated the resident on the importance of getting up and resident continued to refuse. Attempted to redirect the resident in attempts to get him up and resident still refused. After several attempts the resident still refused. Will attempt to get up the resident after lunch and try again. Review of Resident #48's progress note dated [DATE] reads, Resident refused to get a shower, cna reported to nurse and nurse attempted to get the resident up for a shower and continued to refuse. This nurse was notified and spoke with the resident and educated him on the importance of getting a shower and personal hygiene. He verbalized understanding and continue to refuse. Notified family via phone call but no answer. Review of Resident #48's progress note dated [DATE] reads, Resident refusing to let staff preform care for him, this nurse educated resident on importance of personal care and continued to refuse. This nurse reached out to his family as requested by family and daughter in-law stated someone would be there within the hour. During an interview on [DATE] at 9:42 AM, with Staff E, LPN, stated, [Resident #48's name] is pleasant. He will wander at times and go into other residents' room, but we monitor him. During an interview on [DATE] at 10:15 AM, the DON stated, My expectation is for staff to properly document the actual behaviors on the Medication Administration Record. Review of the facility policy and procedure titled Documentation in Medical Record reviewed on [DATE] reads, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practice standards during wound care to help prevent the possible development and transmission of communicable diseases and infections. Findings include: On 2/8/2023 at 9:13 AM, during an observation of Staff C, Licensed Practical Nurse (LPN), Unit Manager, and Staff D, Certified Nursing Assistant (CNA), providing wound care for Resident #11, Staff C performed hand hygiene and donned gloves. Staff C removed the soiled dressing from the resident's right heel wound. Staff C did not remove the soiled gloves and did not perform hygiene. Staff C cleansed the wound and patted it dry and completed the wound care and exited the room. After performing hand hygiene, Staff C gathered supplies to provide wound care to the resident's left heel. Staff C performed hand hygiene, entered the room, placed the wound supplies on the bedside table without applying a barrier. Staff C donned gloves and then placed a barrier on the bedside table and began to open the supplies and placed them on the barrier. Staff C removed the soiled dressing. Staff C did not remove the soiled gloves or perform hand hygiene. Staff C cleansed the wound to the left heel. Staff C removed the gloves, did not perform hand hygiene, and exited the room to collect swabs. Upon completion of the wound care, Staff C collected the soiled supplies, removed the gloves, and exited the room without performing hand hygiene. During an interview on 2/8/2023 at 9:41 AM, Staff C, LPN, Unit Manager, stated that she did not remove her gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. During an interview on 2/9/2023 at 9:24 AM, the Director of Nursing (DON) stated, I expect my staff to remove gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. Review of the facility policy and procedure titled Clean Dressing Change reviewed on 1/4/2023 reads, Policy Explanation and Compliance Guidelines . 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hand and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze . 14. Wash hands and put on clean gloves.

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment in the food preparation, storage, and sanitation area of the kitchen. Findings include: On 2/6/2023 at 9:20 AM, during a tour of the kitchen, the surveyor observed multiple areas of the ceiling with flaking and cracking appearance in the food prep area. The wall by the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier. The walk-in freezer had a large buildup of ice on the floor under the condenser unit, creating a slipping or tripping safety hazard. The kitchen had 4 of 6 light fixtures with cracked or broken light coverings. During an interview on 2/6/2023 at 9:30 AM, the Certified Dietary Manager (CDM), verified the ceiling had a flaking and cracking appearance over the food prepping area, the wall at the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier, and the freezer floor had a large buildup of ice on the floor under the condenser unit. The CDM confirmed that 4 light coverings were either cracked or broken. During an interview on 2/6/2023 at 1:15 PM, the Maintenance Director stated that the ceiling and wall needed to be repaired and light fixtures needed to be replaced. The Maintenance Director verified that there should not be a buildup of ice on the floor in the walk-in freezer. Review of the facility policy and procedure titled General Kitchen Sanitation dated October 1, 2018 reads, Procedure: 1. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities and equipment. Review of the facility policy and procedure titled Cleaning Schedules dated October 1, 2018 reads, Policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards.