Based on observations, interviews, record review, and a review of facility policy, the facility failed to report to the State Agency, injuries of unknown origin for one (Resident #43) of 31 residents in the total survey sample. The findings include: A review of Resident #43's medical record revealed an admission date of 8/12/22 with diagnoses including atherosclerotic heart disease, protein-calorie malnutrition, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and adult failure to thrive. Further review of the record revealed a progress note dated 7/18/24 at 5:25 a.m., which documented that facility staff observed a left elbow hematoma and left lower leg hematomas with dried blood. The note indicated that the resident had some confusion and was unable to explain what happened. No additional notes mentioning these injuries were found between 7/18/24 and 8/1/24. A review of the active physician's orders revealed an order dated 3/20/23 instructed nursing to complete skin observations weekly per the schedule. No orders for care of the resident's shins were located in the record. On 7/29/24 at 12:57 p.m., Resident #43 was observed with several skin tears and bruises on both of his shins. On 7/31/24 at 10:09 a.m., Resident #43 was observed with several bruises and skin tears on both of his shins. The resident's care orders for these areas and a copy of the skin check from 7/28/24 were requested from the Director of Nursing (DON). They were not received during the survey. On 8/1/24 at 9:31 a.m., the same bruises and open areas/skin tears were again observed on both of the resident's shins. (Photographic evidence obtained) A review of the Weekly Skin Checks for 6/21/24, 6/28/24, 7/5/24, 7/14/24, 7/21/24, and 7/28/24, revealed that none noted multiple bruises/hematomas or open areas to the right or left shin. A review of the Quarterly minimum data set (MDS) assessment, dated 5/10/24, revealed a brief interview for mental status (BIMS) assessment had not been conducted with the resident because he was rarely or never understood. The assessment was documented as having been conducted with staff and the resident was noted with moderately impaired cognitive skills for daily decision making. Decisions were poor and cues/supervision were required. There were no behaviors indicated. The resident required supervision or touching assistance for personal hygiene tasks, and he was receiving hospice care. A review of the resident's Care Plan revealed the following Focus Area: Resident has the potential for impaired skin integrity related to incontinence, altered cognition, decreased physical mobility, and malnutrition. Resident had a history of pressure ulcers and poor safety awareness. (initiated 8/28/2022, revised, 5/20/2024). On 8/1/24 at 10:03 a.m., a telephone interview was conducted with Licensed Practical Nurse (LPN)/Unit Manager H for the North Wing and the Hope Unit. She was asked to explain the facility's process for weekly skin checks. She stated, The skin is checked during showers. Any nurse can go in and observe the skin and document the skin check. She was asked about the most recent skin check that she documented on 7/28/24, and why the documentation did not match the current condition of the resident's skin. She stated, The nurse that works the 11-7 shift had already written a note in the medical record on 7/18/24, and he had already reported to me that the staff observed the resident's legs, so I didn't include it on the skin check report. When I did the skin check, the areas looked like they were not new. She was asked if the facility was ever able to determine how the resident acquired the injuries. She replied, No, we never found out. LPN H was asked if these injuries of unknown origin were investigated. She replied, I don't want to say that it was investigated, but I don't really know. She was asked how the facility addressed injuries of unknown origin. She stated, We notify the doctor and the family, and whatever orders we receive, we put them in and carry them out. The nurses usually treat skin tears. On 8/1/24 at 1:12 p.m., a telephone interview was conducted with Hospice Registered Nurse (RN) J. She stated, I was out to see him (Resident #43) yesterday. He was in a social setting, so honestly, I didn't disrobe him or try to take him to his room. She was asked if the facility notified her of the condition of his lower legs, specifically, an open area and several skin tears. She stated she couldn't recall being notified of that, but she was aware that he had some scratches. She stated, I was just out there yesterday and he seemed fine, but I can come back tomorrow and address the issue. On 7/31/24 at 1:17 p.m., an interview was conducted with the DON. She was asked to describe the facility's process for a circumstance in which a resident was observed with an injury of unknown origin. She stated, We ask the resident what happened first. If they can't tell us how the injury occurred, we start an investigation. We talk to the staff about the resident's behaviors , any habits that may have contributed to the injury, and any redirection issues that the resident may have. We start abuse and neglect training and continue to monitor. We also contact family and the doctor. The unit managers usually make the contact. If we cannot figure out how the resident was injured, we report it to DCF (Department of Children and Families) and ACHA (Agency for Health Care Administration. The DON was asked who was responsible for the reporting. She stated, [Administrator] keeps track of that, and the incident is documented in the medical record under incidents. She was asked what tools the facility had for making the staff aware of resident injuries of unknown origin. She stated, We typically discuss any incidents in the morning meeting. A review of facility's policy for Incidents and Accidents (implemented 4/4/24, revised: 4/4/24), revealed an accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Policy Explanation: The purpose of incident reporting can include: Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 4. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy and will be reported accordingly. The following incidents/accidents require an incident/accident report but are not limited to: unobserved injuries. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/29/24 at 12:57 p.m., Resident #43 was observed with long, jagged fingernails. On 7/31/24 at 10:09 a.m., Resident #43 was observed with long, jagged fingernails. The resident's orders and a copy of the skin check for 7/28/24 were requested from the Director of Nursing (DON). They were not provided during the survey. On 8/1/24 at 9:31 a.m., Resident #43 was again observed with long, jagged fingernails. (Photographic evidence obtained) A review of Resident #43's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, protein-calorie malnutrition, dementia without behavior disturbance, psychotic disturbance, mood disturbance, anxiety, and adult failure to thrive. A review of his active physician's orders revealed an order dated 3/20/23 instructed nursing to complete skin observations weekly per schedule. Weekly Skin Checks were reviewed revealing a note dated 7/28/24 documenting that the resident's fingernails were trimmed. (One day before the resident was observed with long, jagged nails) A review of the Quarterly minimum data set (MDS) assessment, dated 5/10/24, revealed a brief interview for mental status (BIMS) assessment had not been conducted with the resident because he was rarely or never understood. The assessment was documented as having been conducted with staff and the resident was noted with moderately impaired cognitive skills for daily decision making. Decisions were poor and cues/supervision were required. There were no behaviors indicated. The resident required supervision or touching assistance for personal hygiene tasks, and he was receiving hospice care. A review of the Care Plan revealed the following Focus Area: Impaired cognitive function and impaired thought processes related to a diagnosis of dementia. Resident has decreased ability to complete and verbalize thought processes, decreased ability to state basic needs, and long/short term memory loss. (initiated 9/1/22, revised 5/20/24). Focus Area: Resident has an ADL (activities of daily living) self-care performance deficit related to altered cognition, decreased physical mobility due to dementia. (initiated 8/28/2022, revised 5/20/2024), and Focus Area: Resident has the potential for impaired skin integrity related to incontinence, altered cognition, decreased physical mobility, and malnutrition. Resident has a history of pressure ulcers and poor safety awareness. (initiated 8/28/2022, revised, 5/20/2024). On 8/1/24 at 10:03 a.m., a telephone interview was conducted with Licensed Practical Nurse (LPN)/Unit Manager H for the North Wing and the Hope Unit. She was asked who was responsible for providing the residents' fingernail care. She stated, The CNAs (certified nursing assistants) cut the nails if the resident is not diabetic; the nurses cut the fingernails for diabetics. A policy for fingernail care was requested, but no policy was provided for review during the survey. 3. A review of Resident #66's medical record revealed that he was admitted on [DATE] with diagnoses including muscle wasting and atrophy of the right lower leg, major depression, non traumatic ischemic infarction of left lower leg, muscle weakness, and dependence on supplemental oxygen. A review of his 5-Day MDS assessment, dated 6/17/24, revealed that he had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. No behaviors were indicated. He required supervision/touching assistance for eating, and was dependent for bed mobility, transfers, toileting, and personal hygiene. A review of Resident #66's Care Plan (dated 6/24/24) revealed the following Focus Area: Risk for Self-Care Deficit: Bathing, Dressing, Feeding. Further review of the medical record revealed no documented evidence of podiatry visits from the resident's admission through 8/1/24. On 7/31/24 at 1:53 p.m., Resident #66 was observed lying in bed. His toenails were elongated. (Photographic evidence obtained) On 8/1/24 at 10:03 a.m., a telephone interview was conducted with LPN/Unit Manager H for the North Wing and the Hope Unit. She stated, The podiatrist cuts all toenails. A policy for toenail care was requested, but no policy was provided for review during the survey. Based on observations, staff and resident interviews, and medical record review, the facility failed to ensure that three residents who were unable to carry out activities of daily living (Residents #34, #43, and #66) from a total survey sample of 31 residents, received necessary care and services to maintain grooming and personal hygiene. The findings include: 1. On 7/29/24 at 1:00 p.m., Resident #34 was observed lying in bed, awake. His feet were uncovered. His toenails were elongated on both feet with his right great toenail observed to be curled around his toe. The resident was asked if he had toenail care or had been seen by podiatry since arriving at the facility. He replied no. (Photographic evidence obtained) On 7/31/24 at 8:21 a.m., Resident #34 was observed lying in bed, awake. He was asked if anyone had trimmed his toenails. He pulled his bedcovers back and said, Nope! I can't trade my feet. His toenails were observed in the same condition as on 7/29/24 at 1:00 p.m. A review of Resident #34's medical record revealed he was admitted on [DATE]. A review of his physician's orders revealed an order dated 6/15/24: Monitor skin weekly. Further review of the orders revealed no orders for podiatry services. A review of weekly skin checks for the past six weeks revealed the following: 7/27/24: nails cleaned and trimmed? No. 7/20/24: nails cleaned and trimmed? No 7/13/24: nails cleaned and trimmed? No 7/06/24: nails cleaned and trimmed? Yes 6/29/24: nails cleaned and trimmed? Yes 6/22/24: nails cleaned and trimmed? Yes A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/31/24, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were documented. He required supervision for personal hygiene. A review of the resident's person-centered care plan (3/21/24, revised 6/10/24) revealed: Resident requires supervision assistance with some activities of daily living (ADLs) related to a history of cerebral vascular accident (CVA - stroke), anemia, neuropathy, chronic obstructive pulmonary disease (COPD), and shortness of breath upon exertion during ADLs. Goal: Resident will maintain current level of function through the review date. Interventions: Personal Hygiene: Requires staff supervision. A review of the progress notes from 6/4/24 through 8/1/24 revealed no notes regarding toenails, care of toenails, or podiatry services. During an interview with the Director of Nursing (DON) on 7/31/24 at 3:52 p.m., she was asked for the facility's policy for the care of resident fingernails and toenails. She stated, We don't have a policy. She was asked to provide podiatry notes for Resident #34. She was unable to provide any notes. She was asked who provided toenail care for the residents. She stated, We have a podiatrist. She was asked how often the podiatrist came to the facility. She stated, They were here on July 21st. She was asked again how often they came to the facility. She stated, It's supposed to be monthly, but we did have one or two months we were without one. She was asked how residents were added to the schedule to be seen by the podiatrist. She stated, Social Services handles that. She was asked if staff were permitted to trim residents' toenails. She stated, No, only the podiatrist trims toenails. The DON was shown photographs of Resident #34's toenails and was asked if the length, cleanliness, and curving onto the skin of the toes in these photos was an acceptable standard of practice. She agreed that this was not acceptable. She was asked if this resident had been seen by a podiatrist since he had been at the facility. She stated she wasn't sure and would check his medical record. She was not able to provide verification of the resident having been seen by podiatry since his admission to the facility on 8/25/23. On 7/31/24 at 4:05 p.m., during an interview with the Social Services Director (SSD), she was asked if she set up podiatry services for the residents. She stated, Yes, we have a service in place that came out to see our first set of people and they'll be back next Saturday. I have asked for the entire building to be seen. I had priority people set to be seen right away. She was asked how long the facility had not had a podiatrist coming out to see the residents. She replied, We had one and asked him to leave, because he only had one set of tools, so we asked that he not come back. We have been without a podiatrist for several months. She was asked how she was made aware of which residents needed to be seen by podiatry. She replied, The nurses let me know and we keep a list. I will send that list over to the podiatrist as to who needs to be seen. She was asked if Resident #34 was on her priority list. She stated, He is on the list to be seen next for the upcoming podiatrist. She was asked when the last time was that Resident #34 had been seen by a podiatrist. She stated, I don't know. My emails don't go that far back; they are set up to auto erase. It's just how they are set up, I'm not sure why. October 2023 was the last time I can see he was seen by podiatry on my email. She was asked to provide the notes for the October 2023 visit. She stated, Yes, I just have to go to my computer to get that. She was asked how often residents should be seen by podiatry. She stated, They should be seen every six weeks. That's what I was always taught. She was asked if there was a facility policy for the frequency of toenail care or for podiatry services. She stated, No, the lady who taught me said it's every six weeks, but no longer than three months. The SSD was unable to provide any podiatry notes for Resident #34. On 7/31/24 at 4:20 p.m., in an interview with the Administrator, she stated the facility had been trying to get a podiatrist in place and had emails to show the attempts, as well as cancellations of visits with their former podiatrist. She was asked if the facility had sought an alternative for residents, such as a policy allowing registered nurses to trim residents toenails. She stated no.

Based on observations, interviews, record review, and a review of facility policy, the facility failed to ensure that a resident who required oxygen therapy received such therapy per the physician's orders for one (Resident #38) of one resident reviewed for oxygen therapy, from 31 residents in the total survey sample. The findings include: On 7/29/24 at 12:49 p.m., Resident #38 was observed lying in bed receiving oxygen via nasal cannula. The oxygen flow rate was set at 2.5 L/min (liters per minute). (Photographic evidence obtained) On 7/30/24 at 9:40 a.m., Resident #38 was observed sitting up on the side of his bed receiving oxygen via nasal cannula. The oxygen flow rate was set at 2.5 L/min. (Photographic evidence obtained) A review of Resident #38's medical record revealed an admission date of 9/3/23 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and cognitive/communicative deficit. A review of the resident's physician's orders revealed a 9/3/23 order for Oxygen at 2 liters per nasal cannula continuous via concentrator/tank. A review of the Quarterly minimum data set (MDS) assessment, dated 6/13/24, revealed a brief interview for mental status (BIMS) score of 11 out of 15 possible points, indicating moderately impaired cognition. No behaviors were indicated. He was documented with shortness of breath on exertion, when at rest, or when lying flat, and oxygen therapy was indicated. A review of the Quarterly minimum data set (MDS) assessment, dated 3/13/24, revealed a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderately impaired cognition. No behaviors were indicated. He was documented with shortness of breath when lying flat, and oxygen therapy was indicated. A review of the Quarterly minimum data set (MDS) assessment, dated 9/11/23, revealed a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderately impaired cognition. No behaviors were indicated. He was documented with shortness of breath with exertion and when lying flat. Oxygen therapy was indicated. A review of the resident's Care Plan (completed 6/24/24), revealed the following Focus Areas: Resident has oxygen therapy related to shortness of breath upon exertion and while lying flat, and Resident has a diagnosis of COPD, and he has shortness of breath upon exertion and when lying flat. A review of the resident's Progress Notes revealed no behavioral issues or non-compliance with oxygen therapy. On 8/1/24 at 1:29 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She was asked to review Resident #38's oxygen orders. She opened the electronic medical record (EMR) and stated, He has an order for 2 liters via nasal cannula, continuous for (COPD) chronic obstructive pulmonary disease. She was asked to accompany this surveyor to the resident's room to check the current flow rate against the physician's order. The flow rate was set at 2.5 L/min. The nurse stated, When he comes in from smoking he turns that oxygen up, and I told him that he is doing himself more harm than good. She adjusted the flow to the appropriate rate. A review of the facility's policy titled Oxygen Administration (implemented 4/4/24, reviewed 4/4/2024), revealed: Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. .

Based on observations, staff interview, medical record review, and a review of facility policies, the facility failed to maintain infection prevention and control standards for one (Resident #538) of 31 residents in the total survey sample, by leaving the resident's enteral nutrition line uncapped and open to air when it was not in use. The facility also failed to maintain infection prevention and control standards when one (Licensed Practical Nurse (LPN) A) of six nurses observed during medication administration failed to clean/disinfect a blood pressure cuff between resident uses. This practice could negatively impact any resident having their blood pressure checked by this nurse using this cuff. Written standards, policies, and procedures must include standard and transmission-based precautions to be followed to prevent the spread of infections. Policies must define and explain standard precautions and their application during resident care activities, including routine cleaning and disinfection of resident care equipment including equipment shared among residents (e.g., blood pressure cuffs, etc.). The findings include: On 7/29/24 at 12:50 p.m., Resident #538 was observed lying in bed with his eyes closed. His enteral nutrition bottle, dated 7/29/24, was spiked/open with approximately 100 milliliters (ml) missing from the 1000 ml bottle. The bottle was hanging on the pole but was not connected to the resident. The tubing was also hanging on the pole. The open end of the tubing had no cap or protective device, and was open to air. (Photographic evidence obtained) On 7/30/24 at 9:00 a.m., Resident #538 was observed sitting up in a Geri chair (large, padded, reclining chair). The enteral nutrition bottle was not connected to the resident. The bottle was dated 7/30/24, was spiked/open and half empty. The bottle was hanging on a pole at the resident's bedside. The tubing connected to the enteral nutrition bottle was also hanging on the pole. The open end of the tubing had no cap or protective device, and was open to air. (Photographic evidence obtained) A review of Resident #538's active physician's orders, revealed an order for Nepro (liquid nutrition) 1.8 cal (calorie) by gastric tube at 600 ml per hour, continuous for 24 hours per day. On 8/1/24 at 7:10 a.m., Licensed Practical Nurse (LPN) A was observed coming out of Resident #538's room. She confirmed that she was caring for this resident today. She was asked if the feeding was stopped or held, would the same bottle and tubing be reconnected when it was restarted. She stated, Yes, as long as it's less than 24 hours old. On 8/1/24 at 7:18 a.m., Licensed Practical Nurse (LPN) A was observed while checking a resident's blood pressure. In an interview with LPN A at the time of the observation, she stated she preferred to check her residents' blood pressures herself, as she was responsible for them. She was then observed removing the blood pressure cuff from the resident and placing it back in the case on her medication cart without cleaning it. When she was asked to explain the process for disinfecting the blood pressure cuff, she stated she usually cleaned it once per shift. A review of the facility's policy titled Standard Precautions for Infection Control (revised 4/4/24) revealed: Policy: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff, and visitors. Policy Explanation and Compliance Guideline: 5. Resident Care-Equipment and Instruments/Devices: a. Policies and procedures have been established for containing, transporting, and handling resident-care equipment and instruments that may have been contaminated with blood or bodily fluids. Personnel are trained in the use of these procedures. (No other policy and procedure was provided that addressed how staff were to contain, transport and/or handle resident care equipment and instruments that were potentially contaminated.) A review of the facility's policy titled Care and Treatment of Feeding Tubes (revised 4/4/24) revealed: Policy: It is a policy of this facility to utilize feeding tubes in accordance with the current clinical standards of practice, with interventions to prevent complications to the extent possible. 7. Direction for staff on how to provide the following care will be provided: d. Use of infection control precautions and related techniques to minimize the risk of contamination. (No specifics were included in the facility's policy regarding how to minimize contamination.) On 8/1/24 at 1:30 p.m., during an interview with the Administrator, she was asked for any other Infection Prevention and Control Policies. She stated there were no other policies. According to the National Library of Medicine at https://pubmed.ncbi.nlm.nih.gov/28079411 (accessed on 8/21/24 at 11:00 a.m.): The contamination of enteral feed can often be overlooked as a source of bacterial infection. Enteral feeds can become contaminated in a variety of different ways. Most often infections result in extended lengths of stay in hospital and patients also need additional therapies and treatments in order to resolve these infections. According to the National Library of Medicine at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086084 (accessed on 8/21/24 at 11:10 a.m.): Failure to place a sterile cap on the end of a reusable intravenous (IV) administration set that has been removed from a primary administration set, saline lock, or IV catheter hub, with the tubing left hanging between uses. Result: The tip of the set is exposed to potential contaminants; this can lead to infection if the non-sterile IV set is reconnected to the patient ' s IV access. Now it appears that many practitioners are not considering the risk of contamination; they are not placing a sterile cap on the exposed tubing. a compatible sterile covering should be aseptically attached after each intermittent use. Capping the tubing end and disinfecting the port should be documented in the institution ' s policies and procedures. The capping procedure should emphasize that a new sterile cap must be used each time the tubing is capped. According to the World Health Organization at https://www.who.int/docs/default-source/documents/health-topics/standard-precautions-in-health-care.pdf?sfvrsn=7c453df0_2 (accessed on 8/21/24 at 11:20 a.m.): Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients. The control of spread of pathogens from the source is key to avoid transmission. Promotion of a safety climate is a cornerstone of prevention of transmission of pathogens in health care. Develop policies which facilitate the implementation of infection control measures. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide documented evidence of having informed each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. This could have a potentially negative affect on 65 of the 82 residents currently in the facility who actively receive Medicare/Medicaid. The findings include: During the Entrance Conference on [DATE] at 10:37 a.m., the Administrator was asked to provide a list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past six months prior to the survey. The instructions were to exclude residents who: Received Medicare Part B benefits only; were covered under Medicare Advantage insurance; who expired during the sample date range and/or who were transferred to an acute care facility or another skilled nursing facility (SNF). On [DATE] at 3:50 p.m., the information provided for review by the facility contained the names of residents who had expired as well as residents who had been discharged to another SNF. The document was returned to the Social Services Director (SSD). She was reminded of the instructions which stated these residents were not to be included in the selection. She stated she would make the corrections. On [DATE] at 8:58 a.m., the list was returned to the survey team. The Administrator was asked to provide Beneficiary Notices for three random residents. On [DATE] at 5:13 p.m., the survey team inquired about the Beneficiary Notices requested the previous day. The Administrator stated she did not recall the request. The Administrator was given a second written request for the same three beneficiary notices. On [DATE] at 9:40 a.m., the SSD returned the notices, which were incomplete. She was advised that the entire form needed to be completed. They were returned to her for correction. On [DATE] at 11:40 a.m., the information was returned to the survey team. The Administrator was advised that the information was still not correct. The documents were incomplete and did not include the notices. On [DATE] at 12:33 p.m., the Beneficiary Notices provided were still not accurate. The SSD was asked who was responsible for providing the information to the residents. She stated the Admissions Office got the information and forwarded it to her, then she completed them. On [DATE] at 2:26 p.m., the SSD was reminded that the requested Beneficiary Notices had not been received. She stated she was still gathering the information. She asked for clarity about what was being requested. The surveyor explained to the SSD what was being requested to meet the requirement. She stated the Beneficiary Notices requested did not meet the requirements. She stated she could provide the documents for three other residents. On [DATE] at 2:54 p.m., the SSD advised the survey team that she was informed the information she previously provided to the survey team was not accurate. She stated she only had partial information. At the time of the survey exit on [DATE] at approximately 3:40 p.m., the facility still had not provided the survey team with the requested information. .

Based on observations, medical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that one (Resident #44) in a sample of 25 residents was provided respiratory care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #44 was administered oxygen at a flow rate which exceeded his physician's order. The findings include: On 7/18/22 at 12:25 PM, Resident #44 was observed lying in bed with his oxygen (O2) concentrator set at 5 liters per minute (LPM). His nasal cannula was observed in his hands. The resident then placed the prongs of the nasal cannula in his mouth. On 7/18/22 at 3:00 PM, Resident #44 was observed lying in bed, awake, with no nasal cannula in place. His oxygen concentrator was running and the flow rate was set at 5 LPM. (Photographic evidence obtained) On 7/19/22 at 10:20 AM, Resident #44 was observed lying in bed, awake. His O2 concentrator flow rate was set at 5 LPM (Photographic evidence obtained) His nasal cannula tubing was in his mouth. He was asked if he knew what his oxygen flow rate was supposed to be set at. He stated, I think 2 or 3? He was asked if he ever changed the oxygen flow rate on the concentrator by his bed. He stated, No, I don't touch that. The nurses do that. On 7/19/22 at 2:40 PM, Resident #44 was observed lying in bed, awake. His O2 nasal cannula prongs were in his mouth. The O2 concentrator flow rate was set at 5 LPM. The resident was asked why his oxygen tubing was in his mouth. He stated, It annoys me. It hurts my nose. On 7/20/22 at 10:15 AM, Resident #44 was observed lying in bed, awake. His O2 nasal cannula prongs were in his mouth. His oxygen concentrator flow rate was set at 5 LPM. (Photographic evidence obtained) A review of the resident's medical record, revealed that he was diagnosed with Chronic Obstructive Pulmonary Disease (COPD). His physician' orders read: 9/22/20: Oxygen at 2 LPM per nasal cannula via O2 concentrator and/or tank PRN for SOB (shortness of breath) 9/22/20: O2 sats: pulse oximetry every shift and PRN. A care plan review for Resident #44 revealed the following focus, goal, and interventions created on 12/27/21 (revised 6/3/22): Focus: Resident has altered respiratory status/difficulty breathing r/t COPD and takes prednisone routinely. Goal: Resident will have no s/sx (signs or symptoms) of poor oxygen absorption through the next review date. (revision 5/4/22) Interventions: Oxygen therapy as ordered. Focus, goal, and intervention created 10/20/20: Focus: The resident has Emphysema/COPD related to hx (history) of smoking. Goal: The resident will display optimal breathing pattern daily through review date. Interventions: Oxygen therapy as ordered. In an interview with Certified Nursing Assistant (CNA) J on 7/20/22 at 4:15 PM, she was asked if she monitored the rate of oxygen for Resident #44. She stated, The nurses monitor the rate but he's mostly at 2 LPM. The nurses tell us what the rate should be. She was asked if she reported to the nurse if the oxygen concentrator is not set at 2 LPM. She stated, I would tell the nurse but I haven't had to. She was asked if she had ever seen Resident #44 change the oxygen flow rate on his oxygen concentrator. She stated, No, I haven't seen him. I don't think he would change it. In an interview with Registered Nurse (RN) I on 7/20/22 at 4:30 PM, she was asked if she was caring for Resident #44 today. She stated yes. She was asked what his oxygen order was and she stated, He's at 2 liters per minute continuously by nasal cannula. She was asked if he kept his nasal cannula in place. She stated, Sometimes he takes it off and will then put it back on, The doctors is aware of that. I check his sat (oxygen saturation) often and it's always good, always above 90%. She was asked how often she checked the flow rate on his oxygen concentrator. She stated, Three or four times on my shift. She was asked if the rate ever needed to be adjusted and she stated, No, it's ordered for 2 LPM and he doesn't need that changed. She was asked if he ever changed the rate on his oxygen concentrator himself. She stated, No, he wouldn't do that. She was asked how often she checked the nasal cannula to ensure it was in place and she replied, I check that three or four times a shift when I check his rate and his oxygen sat. She was asked if she had seen Resident #44 put the nasal cannula prongs in his mouth. She stated, No, I haven't seen that. A review of the facility's policy titled Oxygen Administration, Safety, Mask Types (Reviewed/revised: 6/29/22) revealed: Purpose: To administer and store oxygen in a safe manner. To keep oxygen equipment clean and maintained in good condition. To administer various levels of oxygen concentration and/or humidity in a safe manner. Oxygen Concentrator: 8. Turn flow rate control slowly clockwise until center of ball in flow rate indicator moves up to the number of liters per minute as ordered by the physician (usually one to two LPM). 10. Place cannula on resident as follows: Fit outlet prongs into nares and place elastic band around head behind ears. Tape can be applied to make cannula stay in place if necessary and cheekbones and ears can be padded to prevent irritation. The curve of the nasal prongs should point down so that they follow the anatomy of the nasal passages. According to the National Library of Medicine at https://www.ncbi.nlm.nih.gov/books/NBK430743 (Accessed on 7/21/22 at 8:10 p.m.), Oxygen is vital to sustaining life. However, breathing oxygen at higher than normal partial pressure leads to hyperoxia and can cause oxygen toxicity or oxygen poisoning. Those at particular risk for oxygen toxicity include . patients exposed to prolonged high levels of oxygen. Extended exposure to above-normal oxygen partial pressures, or shorter exposures to very high partial pressures, can cause oxidative damage to cell membranes leading to the collapse of the alveoli in the lungs. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A record review was conducted for Resident #30, which reported an admission date of 9/19/17 with diagnoses including hypertensive heart disease with heart failure and hepatic failure. A review of the current physician's orders noted Thrombo-Embolus Deterrent (TED) hose/stockings for bilateral lower extremities (BLE) daily, on in AM, and off in PM, dated 9/28/20. The current care plan was reviewed, which noted under a focus for Activities of Daily Living (ADL) self care performance deficit related to cardiac issues, an intervention for TED stockings to BLE daily, on in AM and off in PM with an initiation date of 10/2/20. The current Treatment Administration Record (TAR) was reviewed, which did not note any TED stockings being applied or taken off. (Photographic evidence obtained) Resident #30 was observed on 1/24/21 at 12:11 PM, in his room sitting in a wheelchair. He was wearing shorts with no TED hose observed. Resident #30 was observed on 1/25/21 at 2:42 PM, in his motorized wheelchair in the hall with no TED hose on his lower extremities. Resident #30 was observed on 1/26/21 at 9:30 AM, in his room in a wheelchair with no TED hose on his lower extremities. An interview was conducted with the resident at the time of the observation, and he reported he had never had or worn TED stockings. He stated if he had them, he would wear them. An interview was conducted with Employee E, Licensed Practical Nurse (LPN), on 1/26/21 at 9:39 AM concerning Resident #30's TED stockings. The LPN reported working at the facility for the past two months, and had never seen the resident wearing TED stockings. Employee E checked the treatment Administration Record (TAR) and reported that the use of TED stockings was not listed. She was asked to check the physician's orders, and reported there was a physician's order for the resident to wear TED stockings daily. Employee E entered Resident #30's room and confirmed that the resident was not wearing TED hose/stockings. The LPN stated she would get him TED stockings. The LPN confirmed the resident did have an order for TED stockings and he was not wearing them. Based on observations, interviews, and record reviews, the facility failed to provide Activities of Daily Living (ADL) care according to the residents' needs and as care planned for one (Resident #122) of two residents reviewed for ADL care, and failed to follow the care plan intervention of Thrombo-Embolus Deterrent (TED) hose/stockings for one (Resident #30) of one resident reviewed with TED hose from a total sample of 31 residents. The findings include: 1. On 1/26/2021 at 8:41 AM, the door to Resident #122's room was observed to be closed. Upon knocking on the door, Employee F, Certified Nursing Assistant (CNA), announced she was providing resident care. Upon entry to the room, Employee F was observed changing Resident #122's brief and providing incontinent care that included application of a white barrier cream. Employee F was the only caregiver in the room at the time of the observation. A record review for Resident #122, found she was originally admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, anoxic brain damage, slow transit constipation, hyperlipidemia, type II diabetes, unspecified convulsions, encounter for attention to gastrostomy, and persistent vegetative state. A review of the 1/18/2021 quarterly Minimun Data Set (MDS) assessment for Resident #122 in Section G, the resident was assessed as totally dependent on two plus physical assist from staff members, and for transfers and personal hygiene she was totally dependent of two plus persons physical assist. A review of the care plan for Activities of Daily Living (ADL)/Self-care deficit related to status post cardiovascular accident, revealed a need for daily care along with repositioning and passive range of motion (PROM). A review of the inventions listed, revealed the intervention of a two-person assist with all ADL care. During an interview with Resident #122's nurse (Employee H) on 1/26/2021 at 12:49 PM, she stated Resident #122 needed two people to do her care because she was totally dependent on staff for care. During an interview with Resident #122's CNA, Employee F, on 01/26/21 at 1:09 PM, she was asked what kind of care was she providing to Resident #122 in the morning. She stated she was providing full care. She stated Resident #122 was a total assist. She was bathing her and cleaning her up for the day, and stated she had changed the resident's brief. She was asked how she knew what kind and how much assistance the resident required and how many care givers were needed. She stated the [NAME] (brief summary of resident care needs for each individual resident) provided the information about how many people were needed to complete the resident's care. She was asked to review the [NAME] for Resident #122. The information in the [NAME] was reviewed with the CNA, and it documented that Resident #122 required a two-person assist for all ADL care. Employee F was asked if there was another staff member assisting her with care this morning and she stated no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #34) of one resident sampled for a review of range of motion services from a total of 31 sampled residents. The findings include: On 01/24/21 at 2:09 PM, Resident #34 was observed lying in bed in Semi-Fowlers position (lying on her back with her head and torso raised between 15 and 45 degrees). Her left hand was contracted and was placed close to her chin. When Resident #34 was asked to open her hand, she stated she could not open it. The middle, ring and 5th fingers were firmly squeezed in the palm of her hand. A hand splint was observed on the nightstand beside the resident's bed. (Photographic evidence obtained) On 01/25/21 at 10:33 AM, Resident #34 was observed in the dining room participating in an activity. Her left hand was held close to her chest. She was not wearing a splint. On 01/27/21 at 2:39 PM, Resident #34 was observed lying in bed on her back. When she was asked to open her left hand, she stated, It hurts. Red fingernail marks were observed on the palm of her hand where the contracted fingers were pressing. A hand splint was observed on the nightstand at the resident's bedside. A review of Resident #34's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction and contracture of the left hand. A review of her quarterly minimum data set (MDS) assessment, dated 11/28/20, revealed the resident had a brief interview for mental status (BIMS) score of 99, indicating that she was unable to complete the interview. She also required extensive assistance with bed mobility and transfers. She required supervision with eating and she was totally dependent on staff for toileting. Resident #34 was assessed with a need for splint or brace assistance via the restorative nursing program. Further review of the record revealed physician's orders for the therapy department to assist with the resident's restorative program. A review of the resident's care plan revealed the following focus area: Resident has a need for restorative intervention to maintain wearing schedule of soft palm guard to decrease risk of skin breakdown with intervention for restorative nursing to ensure skin is clean, intact and dry. Provide gentle PROM (passive range of motion) to the left digits during hand hygiene. Apply soft palm guard as resident allows and tolerates. Remove soft palm guard on evening shift. On 01/27/21 at 10:00 AM, Employee B, Certified Nursing Assistant (CNA)/Restorative Aide, confirmed that Resident #34 had not been wearing the hand splint. She stated the resident had been refusing to wear the splint for the last three months due to a complaint of pain. She added that the facility's policy was to discontinue restorative interventions if the resident refused services on three consecutive attempts. When asked why the services for Resident #34 were not then discontinued, she reported that her restorative nurse was no longer working at the facility, and she was not sure who to report to. When asked if she had any documentation of the resident having refused care/splinting, she stated she had none. On 01/27/21 at 10:58 AM during an interview with Employee A, Licensed Practical Nurse (LPN)/Unit Manager, she confirmed that Resident #34 was still on restorative therapy and was to wear a soft hand splint every morning shift and have it removed during the evening shift. When asked whether the resident refused treatment/splinting, Employee A stated she is not aware. She checked the restorative notes and stated there was only one day (01/27/21) that the resident was documented as having refused. She added that if the resident refused treatment, it should be discontinued. She also mentioned that if the order was not discontinued, it should be carried out and documented. When asked to whom the restorative aide reported, Employee A stated she was in charge of her unit as the restorative nurse had resigned a week ago. A review of the facility policy and procedure titled,Restorative: Nursing Care Implementation and Screening- Rehab/Skilled, Therapy & Rehab (revised 12/28/2020), revealed: . To provide appropriate restorative nursing care to each resident . To provide appropriate treatment for the resident's activities of daily living - Each resident will receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as identified in nursing assessments. The restorative care will be outlined in the resident's nursing care plan. Care includes safe measures to prevent complications and contractures, maintain strength and self- care abilities including eating and dressing, promote mobility and feeling of well being. Activities of daily living - Residents are provided appropriate treatment and services to attain/ maintain functional abilities in activities of daily living. Any resident who is unable to carry out independent activities of daily living will receive necessary services to prevent further diminishing of independent abilities in bathing dressing/undressing, grooming, transfer, ambulation, toileting, eating and use of speech, language or other functional systems. - Based on the resident's comprehensive assessment, the location ensures that the resident's ability in activities of daily living does not decline except when unavoidable for reasons of disease progression, deterioration of physical condition associated with disability or refusal of care/treatment by the resident or legal representative. Evidence of any of these reasons will be reflected in the clinical record -The goal of restorative nursing acre is to attain and maintain the maximum possible independence and/or prevent rapid declines through the interventions for each resident. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that residents who required dialysis received such services and associated care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #40) of one resident receiving peritoneal dialysis, from a total of 31 residents the sample. The findings include: A medical record review for Resident #40 revealed that he was admitted to the facility on [DATE] with a re-entry on 11/30/20. His diagnoses included end-stage renal disease (ESRD) with dependence on dialysis, transient ischemic attack (TIA) and cerebral infarction without residual deficit. A review of the admission minimum data set (MDS) assessment, dated 12/06/20, revealed the resident was assessed as having a brief interview for mental status (BIMS) score of 15 out of a 15 possible points, indicating intact cognition. He was independent for all functions of daily living such as bed mobility, transferring and toileting. A review of the current physician's orders, revealed the following orders: Sevelamer HCL tablet (lowers blood phosphorus levels of dialysis patients), 800 milligrams (mg), give 2 tablets with meals for dialysis. Peritoneal dialysis to run in 6 phases different dialysate strength. Call [dialysis center] with numbers and directions 386 258 7719 weight and vital signs Heparin 1000 units/ml (units per milliliter), infuse 6 ml in the peritoneal cavity in the afternoon every Monday for fibrin in solution/insert in heater bag related to dependence on renal dialysis Gentamycin 0.1%, apply to peritoneal catheter site topically one time a day for dialysis Eliquis 5 mg two times a day (BID) for blood clots Aspirin 81 mg everyday (QD) for blood clots Resident to be monitored every hour while connected to peritoneal dialysis. Check tubing placement and ensure it is not wrapped around the foot pedals and wheels of he bed every evening and night. Exit site care - remove old dressing, cleanse with cleaning agent (except) inner to outer, pat dry, apply gentamycin on a split 2X2, cover with sterile 4X4, window frame with tape Full set of vital signs after disconnected dialysis (0800 need blood pressure, pulse, temperature and pain) Immediately report swelling, warmth or redness around the site, pus/drainage from the site. Chill or fever more than 100 degrees. Dizziness/fainting when standing up or shortness of breath (SOB) [NAME]- vite B complex folic acid QD (daily). A review of the care plans revealed the resident was careplaned for a need of dialysis treatment related to renal failure with the following interventions: Peritoneal dialysis to run in 6 phases different dialysate strength call [dialysis center] with numbers and direction 386 258 7719, resident self-administers peritoneal dialysis, monitor/document/report to health care provider as needed (PRN) for any signs and symptoms of infection of dialysis access sites to abdomen and right chest: redness, swelling, warmth or drainage. Provide exit site care and treatment as ordered. During an interview with Resident #40 on 01/26/21 at 1:55 PM, he stated he did his own peritoneal dialysis. He stated he had been trained by the [dialysis center] nurses on how to perform the treatment. He mentioned that while he lived at home, the dialysis nurse would visit weekly, but when he moved to the facility, the dialysis nurse visited once a month. He added that the facility nurses were supposed to report the weights and vital signs to the dialysis nurse weekly. Resident #40 said that it was important for the nurses to report his weights and vital signs to the dialysis center becasue he used two different dialysate which were dependent on his blood pressure and weight. When asked about the dressing chnage to the dialysis port he said, The facility staff do not do anything for me. I do it myself. The resident was on anticoagulant medication which put him at high risk of bleeding. He mentioned that he had been admitted to the hospital in November due to malfuctioning of the peritoneal dialysis access. He further stated he was put on hemodialysis for three weeks. He stated that a hemodialysis port was retained on his right upper chest. He said the nephrologist would make a determination of when it would be taken off during his next appointment. On 01/26/21 at 2:10 PM, a 4X4 gauze dressing tapped with paper tape was observed on the exit site. No date or staff initials were on the dressing. The resident stated he had changed the dressing in the morning after the treatment. During an interview on 01/27/21 at 10:40 AM with Employee C, Registered Nurse (RN), she stated she was responsible for taking care of Resident #40. When asked whether she had done a dressing change or completed an assessment on the resident's dialysis port, she replied, We do not do anything for him. He does everything for himself unless he asks for help. When asked if she reported the vitals signs to the dialysis nurse, she said only if the they are abnormal. On 01/27/21 at 10:49 AM, Employee A, Licensed Practical Nurse (LPN)/Unit Manager, stated [dialysis center] conducted an in-service for facility nurses regarding the resident's peritoneal dialysis. When asked about resident dialysis treatments, she stated that resident does his own dialysis, however, facility nurses were supposed to oversee the resident starting and stopping treatment. She also stated nurses were supposed to assess the dialysis exit site daily and performed the dressing change. She stated the facility protocol for dressing change was to initial the new dressing with staff initials and the date the bandage was changed. When asked if there was documentation to verify nursing had been changing the resident's dressing, she checked the medication administration record (MAR) and treatment administration record (TAR), and stated it was not documented. When asked whether the nursing staff notified the dialysis nurse of the resident's vital signs and weight, she stated she was not sure because it was not documented. A review of the January 2021 MAR and TAR revealed that the order for exit site care - remove old dressing cleanse with cleaning agent (except) inner to outer pat dry, apply gentamycin on a split 2X2 cover with sterile 4X4 window frame with tape, and order to immediately report swelling, warmth or redness around the site, pus drainage from the site. Chill or fever more than 100 degrees Dizziness/fainting when standing up or shortness of breath (SOB) had not be signed as having been completed from january 1-27, 2021. (Copies obtained) A review of the facility's policy and procedure titled, Physician/Practioner Orders - Rehab/Skilled revised on 11/20/20, revealed: -To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders Wounds: Orders must be obtained for wound care including product to be used when to change and when to reassess. A licensed nurse must provide the wound care. According to the National Library of Medicine at https://pubmed.ncbi.nlm.nih.gov/33225827, exit-site infections increase the risk of developing peritoneal dialysis peritonitis and peritoneal dialysis technique failure. [NAME] L, [NAME] MM, Fan S. 'Persistent Colonization of Exit Site is Associated with Modality Failure in Peritoneal Dialysis'. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure as needed antipsychotic medication was limited to 14 days, or had documented rational and an indicated duration by the attending physician or prescribing practitioner for one (Resident #62) of five residents with a medication review, from a total of 31 residents in the sample. The findings include: A record review for Resident #62 found she was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance and bipolar disorder. A review of the resident's electronic medical record found that she had current physician's orders beginning on 12/22/2020 for ABH (Ativan, Benadryl, Haldol) Transdermal Gel, apply 1 milliliter (ml) every 6 hours as needed for agitation. The order did not have an end date. A review of the resident's January 2021 Medication Administration Record (MAR) revealed that she was administered the medication 14 times from 1/1/2021 to 1/23/2021. During an interview with the Acting Director of Nursing (DON) on 1/27/2021 at 1:00 PM, she was asked for evidence that the as needed ABH gel was reviewed every 14 days. During further interview with the Acting DON on 1/27/2021 at 1:58 PM, she stated she spoke to the Pharmacist and he informed her that the as needed ABH gel should have a stop date. She added that the Pharmacist informed her that because Resident #62 was a hospice patient, it was difficult for the facility to get a stop date. She stated she was aware the medication should only be written for 14 days, and the hospice doctor or facility doctor should assess the resident and determine if the medication order should continue. During an interview with Resident #62's nurse (Employee G) on 01/27/2021 at 1:50 PM, she stated the hospice nurse came to the facility all the time and reassessed Resident #62's medication. She stated all of the paperwork would be in the facility's computer program. She was asked who was responsible for writing the orders for Resident #62's medication. She stated, Resident #62's hospice provider had a physician, and the facility had a physician that both oversaw her medications. She was asked who prescribed the as needed ABH gel and she replied that she did not know. During further interview with the Acting DON on 1/27/2021 at 2:59 PM, she stated she called Resident #62's hospice provider and they were not able to provide any evidence of having re-evaluated Resident #62 for the ABH gel. She stated the Pharmacist had identified the as needed ABH gel was limited to 14 days and hospice wrote back that they wanted the resident to no longer be reviewed by psychiatric services. She stated the previous DON was not doing her job with the pharmacy review and the Unit Manager was not aware the medication should only have been written for 14 days. During another interview with the Acting DON on 1/28/2021 at 11:41 AM, she was asked who was responsible for ensuring the accuracy of medication in the facility. She stated the individual responsible for writing the prescription would have been the physician that saw the resident in the facility. She stated the Unit Managers had the responsibility of ensuring the medication was accurately entered into the electronic medical record with an end date. During an interview on 1/28/2021 at 12:00 PM with the Unit Manager (Employee A) for the unit Resident #62 resided on, she stated she was the Unit Manager in December of 2020. She was asked who was responsible for writing the orders for the as needed ABH gel for Resident #62. She stated the hospice doctor wrote all of the resident's orders. She stated that the Psychiatrist discontinued Resident #62's ABH gel but hospice restarted it. She stated the hospice doctor wrote the orders and the resident's facility doctor signed off on all of the orders. She stated she could not recall if she checked Resident #62's medication orders. She stated she was aware the as needed ABH gel should have had a stop date and should not be for more than 14 days. She could not recall if the order was for 14 days when it was received in December and she stated she would check it. During an interview with the facility's Pharmacy Consultant on 1/28/21 at 12:15 PM, he stated the as needed ABH gel should have been written for 14 days unless it had an earlier hard stop end date. He stated he did tell the DON and supervisors about the medications that needed stop dates and it did not get addressed. He stated he completed narcotic destruction the last day the previous DON was working at the facility and he addressed his concern with her. During a telephone interview on 1/28/2021 at 1:05 PM with the Nurse Practitioner for Resident #62's physician, she stated the last prescription they wrote for ABH gel was on 9/15/2020 and it was scheduled every 4 hours. She stated any changes made after 9/15/2020 to the medication were done by the hospice physician. She stated the hospice physician should have known to write the order for 14 days so it was probable an oversight. During an additional interview with the Acting DON on 1/28/2021 at 1:47 PM, she provided an order from the hospice physician dated 11/4/2020 with the following instructions, Do not change psych order. She also provided the 12/22/2020 hospice physician's order dated 12/22/2020 to Start ABH 1/12.5/1 gel topically Q 6 PRN. There was no end date given. At the time the Acting DON presented the information she stated she had checked again and the facility had no other record past the 12/22/2020 order addressing Resident #62's continued need for the medication. .