**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, resident and resident room observations, and resident and staff interviews, the facility failed to maintain accurate resident records reflective of the care provided for one (Resident #17) of two residents reviewed for wounds, from a total of 34 sampled residents whose records were reviewed. The findings include: A record review for Resident #17 revealed she was admitted to the facility on [DATE]. She had diagnoses including, but not limited to, diabetes mellitus and left foot diabetic ulcer. A Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #17 had a brief interview for mental status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. She was dependent on staff for toileting, dressing and transfers. Resident #17 was care planned on 9/13/24 for compromised skin integrity with an ulcer of the left planter foot. The care plan revealed that she was readmitted status-post graft to the left foot/osteomyelitis (infection of the bone) on 10/25/24. A weekly nursing skin observation, dated 1/25/25 at 2:08 revealed, Sacrum Wound. Left plantar wound, under treatment. Resident #17 had a physician's order dated 12/6/24 for a Multi podus boot (a medical device that suspends or floats the heel and removes pressure from the back of the heel to help heal and prevent ulcers) to left foot when out of bed. She also had an order dated 1/16/25 for wound care to the left planter foot ulcer. Instructions were to clean with normal saline, pat dry, apply collagen sheet to ulcer and cover with a dry dressing. A review of the Treatment Administration Record (TAR) found the multi podus boot for the left foot when out of bed was signed off as having been worn daily on every shift up to 1/28/25. (Photographic evidence obtained) A review of the certified nursing assistant (CNA) task records also reflected that the boot was worn every day. (Photographic evidence obtained) An interview was conducted with Resident #17 on 1/27/25 at 2:19 PM. She stated her heel had been hurting and she had a history of facility-acquired pressure ulcers, but they had resolved. With consent from Resident #17, the affected left heel was observed by the Registered Nurse Specialist surveyor. Resident #17 had a sock on that foot, which was pulled back to reveal an unbandaged wound on the bottom center of her left heel. The wound was approximately quarter-sized in diameter with a deep red wound bed and raised white border. The left foot was swollen. (Photographic evidence obtained) Resident #17 explained that she required assistance with putting her sock on that foot. There was no multi podus boot on her left foot. Resident #17 was observed daily in the west and front hall throughout the survey between 1/27/25 and 1/30/25. At at no time did she have a multi podus boot on her left foot; she only wore socks. An interview was conducted with CNA A on 1/29/25 at 3:42 PM in Resident #17's room. She was asked where Resident #17's multi podus boot was. CNA A said there was no boot, only a padded footrest. She said she often put a pillow under Resident #17's left foot. Resident #17, also in the room, confirmed there was no multi podus boot. She said there used to be one, but not any more. She did not have one. With consent from Resident #17, a search of the room, including the closet and drawers, revealed no multi podus boot. The wound care doctor (WCD) was interviewed on 1/30/25 at 4:01 PM. He stated Resident #17 had a partial calconectomy (a surgical procedure that removes infected or non-viable tissue from the heel bone) before he took over management of her heel wound. He was not sure if he was the ordering physician for the multi podus boot. When asked if she wore the boot, he stated, in a perfect world, but she has rights. He stated Resident #17 worse than refuses to wear the boot. The WCD stated Resident #17 had hydrocephalus (a build-up of fluid in the cavities deep within the brain) and a decline in executive function. She still, however, made her own decisions. The WCD was advised that CNAs and nurses were documenting that the boot was in place daily; however, she had not been observed wearing the boot during the four-day survey. The WCD replied that Resident #17 was resistant to most offloading interventions; We just cant do the things we used to be able to do twenty years ago. The wound care nurse/licensed practical nurse was interviewed on 1/30/25 at 4:10 PM. He stated he had not seen Resident #17 wearing the multi podus boot; she refused. He had no comment about staff signing that the boot was being worn daily. .

Based on observations and staff interviews, the facility failed to follow proper sanitation and food handling practices to prevent foodborne illness by failing to ensure: (1) Opened refrigerated foods were labeled and dated; (2) Canned goods received from the vendor and intended for resident consumption were within the manufacturer's expiration date; and (3) Food was prepared and served from a clean, sanitary kitchen. Unsafe food handling and sanitation practices present a potential source of pathogen exposure which could result in foodborne illness. This had the potential to affect all residents who consumed foods from the facility's kitchen. The findings include: During an initial kitchen tour with the Certified Dietary Manager (CDM) on 1/27/25 at 10:28 AM, the walk-in refrigerator was observed with a large, clear plastic bin containing shredded iceberg lettuce. There was no label or date on the bin. A small cellophane-covered bowl held one half of a cut onion, and a Ziploc baggie contained fresh herbs; however, neither item was labeled or dated. The bread rack in the dry storage room held several loaves of bread that had a manufacturer's date stamp of 10/20/24. The hot dog buns manufacturer's date stamp was 12/26/24. There was no label to reflect when the baked goods were received by the facility. Inspection of the canned good rack revealed six cans of pineapple tidbits with handwritten dates on each can of 1/7/25; however, the manufacturer's expiration date on the cans was 4/23/24. (Photographic evidence obtained) The horizontal surface of the table under the food steamer was soiled with debris resembling flour and food crumbs, and the legs of the steamer had build-up resembling lime/scale or rust. Some of the buildup had come off and pooled around the base of the legs. The inside of the drain underneath was coated with wet, black mildew-like matter. The floor tiles in the corner of the kitchen near the walk-in refrigerator were coated with a buildup of a black grimy substance. The drain under the pipes in the corner was surrounded by a wet, black substance that was also built up in large patches on the surface of the drain cover. Similar buildup was seen in the drain under the two-compartment sink. Splatters of dried food and hard water marks were seen on the vertical surfaces of the serving side of the tray-line steam table. The metal cart that housed the juice machine was rusted and soiled. The CDM acknowledged the unlabeled lettuce, onion and herbs in the refrigerator, confirming that each should be dated. She explained that the baked goods were all delivered frozen. She thawed them upon receipt and placed them on the racks for use. She acknowledged that there was no date on the bread or the rack reflecting when the items were received and thawed. The CDM produced an invoice for the last bread delivery, which revealed a delivery date of 12/27/24, one month ago. The CDM could not locate a delivery slip for the hot dog buns and confirmed that the handwritten date on the pineapple chunks reflected the date they were received and stocked. The CDM also confirmed the manufacturer's date revealed they were all expired upon receipt. She said no one had recognized the products were expired, and had no explanation as to how it was missed. A final walk-through of the kitchen was conducted on 1/30/25 at 9:40 AM with the CDM. The buildup of drips, debris and crumbs were still evident on the metal table under the food steamer. The floor drain under the steamer was still soiled, and closer inspection revealed the tiles around the drain were loose. Water condensing from the drain was dripping down and pooling under the floor tiles. The exposed side of the ice machine had scale-like drip marks on it, and the juice machine rack was still rusted and soiled. The floor tiles in the corner near the walk-in refrigerator held the same black slimy substance as previously observed. Close inspection of the drain under the 2-compartment sink revealed the same black wet buildup as before. [NAME] sewer flies surrounded and flew in and out of the drain. Drips of dried-on food soiled the vertical surface of the serving side of the tray-line steam table. Food had dripped, pooled and dried on the bottom of the table at the shelf level. The face of the electrical outlet protruding from the floor in front of the the steam table was broken and the housing was coated with a buildup of unknown substance. There was a large piece of white PVC (polyvinyl chloride) pipe next to the outlet that was soiled with brown debris. The CDM explained this pipe was intended to be placed over and cover the floor outlet. (Photographic evidence obtained) The CDM confirmed each of the above findings throughout the tour. She stated housekeeping was responsible for deep-cleaning by pressure washing the kitchen. She had seen this done twice in the last year. .

Based on facility record review, staff interview, and facility policy and procedure review, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water system. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. This had the potential to affect all residents residing in the facility. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. The findings include: A review of the facility's water management program revealed a copy of the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, A Practical Guide to Implementing Industry Standards by the U.S. Department of Health and Human Services Centers for Disease Control (CDC) and Prevention, dated 06/05/2017. Page two contained a guide form to Identify Buildings at Increased Risk. This form was left blank. A review of the CDC tool kit, on pages 3 and 23 revealed, Identified control measures: Things you do in your building water systems to limit growth and spread of Legionella, such as heating, adding disinfectant, or cleaning. Control limits: The maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for Legionella growth and spread. Control points: Locations in the water systems where a control measure can be applied. Disinfectant: Chemical or physical treatment used to kill germs, such as chlorine, monochloramine, chlorine dioxide, copper-silver ionization, ultraviolet light, or ozone (Photographic evidence obtained) The water management program contained drawings showing water flow throughout the facility, resident room water temperature checks, flushing dates for the water pipes, and pressure relief valve checks. The program did not include control measures for preventing Legionella growth. It did not include points in the system where critical limits of the antigen could be monitored or where control could be applied. There were no physical controls or protocols, such as testing of the water's disinfectant levels and pH, performing visual inspections, or environmental testing for pathogens. There were no acceptable ranges or control measures within the water management plan. The Regional Maintenance Director was interviewed on 01/28/25 at 11:00 AM. He stated they did not do any water or Legionella testing in the facility, as it was not required by the Centers for Disease Control. He then produced a diagram of the water lines for both hot and cold water. The diagram did not identify the areas where Legionella could potentially grow and spread. (Photographic evidence obtained) During an interview with the Director of Maintenance on 01/30/25 at 02:30 PM, he confirmed that he had received no training on the water management program, and confirmed that water testing had not been done since he was hired in March 2024. He stated he had no testing kit for the disinfectant levels in the water. A review of the facility's policy and procedure titled Infection Control Prevention and Control Program, section 13, Water Management (effective 02/21/23) revealed: A water management program has been established as part of the overall infection prevention and control program. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. The Maintenance Director serves as the leader of the water management program. (Photographic evidence obtained) There were no guidelines within the policy for identifying or testing for Legionella. .

Based on interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse for two (Residents #2 and #4) of four residents reviewed for abuse, out of a total sample of 7 residents. Resident #2 was physically hit by a staff member after the staff member reacted to being hit by the resident in the shower. Resident #4 was verbally abused by a staff member while the resident was in the process of taking a shower. The findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 1/7/25. His diagnoses included type 2 diabetes mellitus (DM) with diabetic neuropathy, hyperlipidemia, high blood pressure (HTN), anxiety disorder, depression and low back pain. Review of the admission Medicare 5-day minimum data set (MDS) still in progress with an assessment reference date (ARD) of 1/14/25, revealed Resident #2 had a brief interview for mental status (BIMS) score of 1 out of a possible 15 points, indicating severe cognitive impairment. Rejection of care or wandering behaviors were not exhibited. On 1/23/25 at 10:50 am, Resident #2 was observed in his room, dressed and lying in bed. A bruise and dry scab was observed on his right elbow. He appeared confused and mumbled when asked about his bruised elbow. Review of physician orders for Resident #2 dated 1/7/25 revealed Buspirone 5 milligrams (mg) three times (TID) a day for anxiety, Trileptal 150 mg three times a day for mood, Trazadone 50 mg at bedtime for depression, Melatonin 5 mg -2 tablets at bedtime for insomnia, Gabapentin 800 mg two times a day (BID) for neuropathic pain and amlodipine 10 mg daily (QD) for HTN. Review of the nursing progress notes for Resident #2 dated 1/10/25, noted that Certified Nursing Assistant (CNA) called the nurse into the shower room to report resident had slid out of the shower chair onto the floor. Resident had become combative and resistive to care and slid down. Resident transferred via mechanical lift to wheelchair, skin assessed, redness to his back, no open areas, physician and family notified. Review of a social service note for Resident #2 dated 1/10/25, indicated that the abuse coordinator was notified that the resident became combative during care. He struck CNA in the stomach/face. CNA in reflex grabbed hand of resident and grazed the left side of his face/ear with the other hand. No visible injuries noted. Review of a behavior note for Resident #2 dated 1/10/25, indicated that he remained in a wheelchair all night long. He was encouraged to go to bed but would not. Behavior notes from 1/12/25- 1/22/25 noted residents behaviors of resisting care and hitting staff during care. Review of a social service note for Resident #2 dated 1/15/25, noted that he had multiple episodes of resisting care. Review of the care plan for Resident #2 initiated on 1/8/25 revealed resident is resistive to care related to adjustment to nursing home. Dementia does not allow staff to change him, hits and kicks and punches at staff - holds on to other residents wheelchair and does not understand interactions. Resident #2 was also care planned for potential to be physically aggressive related to anger and poor impulse control. On 1/23/25 at 1:45 pm, an interview was conducted with CNA F who was familiar with Resident #2. She stated that she had assisted other staff caring for Resident #2. She explained that he was combative, and required total care for activities of daily living, but can feed himself with supervision. She added resident is confused and cannot make needs know. She mentioned that when she was assisting Resident #2 yesterday, he held her hand and would not let go. She calmly got the resident to release her hand without incident. She stated the resident needs redirection and reapproaching to get care done and at times it takes several attempts. She added that staff should not force him to get the care. When asked if she had received training on dealing with combative residents. She said, I have been her for 24 years and I have received a lot of education, but I cannot remember specific training. During an interview with Licensed Practical Nurse (LPN B) on 1/23/25 at 2:15 pm, she stated that on 1/10/25, she heard yelling from the shower room. Shortly thereafter, Patient Care Attendant (PCA C) came to the nursing station and asked if she was the assigned nurse to Resident #2 because the resident was on the floor in the shower room. Upon entering the shower room, the resident was seated on the floor next to the shower chair. Some bruises were noted on the assessment. Resident #2 could not explain what happen and was still anxious and agitated. She asked CNA A (Assigned CNA) to get a Hoyer lift to assist getting the resident back on the chair. During this time, she asked PCA C what happened. The CNA told her that the resident became combative and punched CNA A in the stomach. PCA C reported that she witnessed CNA, A react and made contact with Resident #2 with an open hand on the ear. PCA C stated that she had asked CNA A to stop giving him a shower as the resident was combative, but she did not listen. When CNA A returned and asked what happened, she stated the resident was combative, but she wanted to clean him up because he was soiled. She added that as she was bending down to clean the resident, he punched her in the stomach and out of reflect, she hit him on the side of his ear. She reported the incident to the abuse coordinator. 2. Review of the medical record for Resident #4 revealed an admission date of 9/17/24. His diagnoses included metabolic encephalopathy, muscle wasting and atrophy, depression, gout, need for assistance with personal care, gastroparesis, type II diabetes mellitus, diverticulosis of large intestine and inflammatory liver disease. Review of the quarterly MDS with ARD of 12/20/24, revealed Resident #4 had a BIMS score of 15, indicating cognitively intact, with no behaviors noted. He required partial/moderate assistance with showering and personal hygiene and was totally dependent with toileting and transfer. The assessment indicated that he was frequently incontinent of urine and bowel. On 1/23/25 at 2:45 pm, an interview was conducted with Resident #4. When he was asked about the incident that happened in the shower room. He explained that the CNA E had an attitude from the time she was beginning his shower. He said that it was around 11:00 am and lunch time is around 11:30 am (his shower takes 30-45 minutes). CNA E came to get him to the shower and she said, it's almost time for lunch and I won't be dealing with you stupid cracker shitting in here because I'm not going to be cleaning it up. CNA E walked out of the shower obtained a plastic bag and placed it under the shower chair. CNA E then told him that she was an agency staff and there was nothing he could do as she would find a job somewhere else. Resident #4 stated that he felt bad and defeated and did not tell anyone at the time. The next day when he saw a familiar face (did not recall who) he told her what happened and she asked him to report it, and that's when he went to front office to report it. He continued to state that the agency staff did not seem to care and were always in hurry while providing care Review of the physician orders for Resident #4 dated 9/18/24 revealed furosemide (Lasix) 40 mg daily for fluid retention, duloxetine 60 mg daily for depression, and trazadone 50 mg at bedtime for depression. On 1/23/25 at 2:56 pm, an interview was conducted with the Social Services Assistant (SSA). She stated that on 1/21/25, Resident #4 came to the front office and stated that the CNA who was assigned to him the previous day was rude. He told her that the CNA said , You cannot Shit here cracker. She stated she helped the resident write the report and handed it to the Social Service Director (SSD). She confirmed that Resident #4 was alert and oriented x4 and was able to make needs know. On 1/23/25 at 3:00 pm, an interview was conducted with the Administrator. She explained that she was new to the facility and the investigation for Resident #2 was ongoing at the time of her hire. She went on to say the resident was combative during care. However, CNA A who was assigned to Resident #2 confirmed that she forced resident to the shower to clean him up as he was soiled. In the shower Resident #2 hit the CNA on the stomach and out of reflex the CNA grazed Resident #2 on the side of the face near his ear. She stated that the CNA was suspended after the allegation and abuse training initiated related to resident rights - Right to refuse care. The allegation of abuse was substantiated. When asked about Resident #4's abuse concerns. The administrator explained that CNA E was providing a shower. When the resident was in the shower, he had a tendency of having the bowel movement during shower. CNA E told him that he was not going to shit there and called him a cracker. She continued to state that the CNA was an agency CNA and would not be returning to the facility. When asked for the agency staff training and competency, she confirmed that the training could not be obtained. When asked about the training for Dementia and Alzheimer's training/behavior management training for CNA A prior to the incident. She confirmed that the training could not be found. She also confirmed that the facility had not conducted any training or in-service on Dementia and Alzheimer's training/behavior management after the incident with Resident #2. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury Of Unknown Source And Investigations, effective 04/01/2022 and no revision date revealed the following: PURPOSE: It will be the policy of this facility honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds, or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. DEFINITIONS: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology (mental abuse including, but not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident). Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. TRAINING: a. Training of employees will be through the following: i. Orientation program ii. Ongoing in-service training iii. Annually and more often if needed iv. One-to-one counseling when identified v. Indicators to identify staff burnout b. Training will focus on the following topics: i. Recognizing abuse, neglect, and misappropriation of resident property ii. Steps on how to report including to whom and when. iii. How to protect residents, staff, and others from immediate danger iv. Signs of and intervention techniques to be used with residents having aggressive behavior or catastrophic reaction. v. How to recognize the signs of burnout, frustration, and stress in self and co-workers. vi. Employees' responsibility upon witnessing neglect, or misappropriation of property. vii. Federal standards on resident protection, reporting, and investigation of ANEMMI. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and facility policy review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Residents #3, #2, and #4) of 5 residents on various precautions, from a total sample of 9 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. The findings include: During a tour on 2/14/24 at 10:15 AM, three resident rooms (Residents #2, #3, and #4) were observed with personal protective equipment (PPE) hangers on their door. None of the doors had a sign identifying why the PPE was needed to be used in the room. On 2/14/24 at 10:36 AM, Employee B, Certified Nursing Assistant (CNA) was observed to don PPE outside the door of Resident #2. When Employee B was asked if she knew what the precaution was for this resident. The CNA stated, I think it's Covid. She and (Resident #4) have Covid, I think. On 2/14/24 at 12:00 PM, the Infection Preventionist was asked to conduct a tour of the current residents who were on any type of precaution. 1. The Infection Preventionist identified Resident #3 as having a urine infection. The PPE hanger was observed on the door, stocked with gloves, gowns, face masks and face shields. There was no signage on the door. When she was asked if there should be signage on the door to alert staff as to the type of precaution and PPE required for entry to room. She stated, Yes, there should be a sign, there was a sign, it must have fallen down. No sign was observed on the floor or within sight of the door and PPE hanger. A review of Resident #3's medical record indicated she was admitted to the facility on [DATE] with a diagnosis that included spinal stenosis. The resident's physician's order, dated 2/8/24, revealed she was to be on Isolation Precaution for Extended Spectrum Beta Lactamase (ESBL) + urine: contact isolation- provide isolation set up with cart, barrels, red bags, stop sign and PPE. Every shift for ESBL +. (Photographic evidence obtained) 2. The Infection Preventionist identified Resident #2 as being admitted to the facility yesterday with a + Covid diagnosis. A PPE hanger was observed stocked with gloves, gowns, face masks, and face shields. No sign was observed on the door. When she was asked if there should be a sign on the door identifying the precaution type and PPE required to enter the room. She stated, Yes, I don't know where the sign is. She is droplet precautions for Covid. A review of Resident #2's medical record indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of Covid 19. The resident's physician's order, dated 2/8/24, revealed the resident was to be on contact/droplet isolation. (Photographic evidence obtained) 3. The Infection Preventionist identified Resident #4 as being on contact precautions for herpes zoster. A PPE hanger was observed stocked with gloves, gowns, face masks, and face shields. There was no sign observed on the door. She was asked if there should be a sign on the door identifying the precaution type and PPE required to enter the room. She stated, Yes, there should be a sign for contact precautions. A review of Resident #4's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included weakness and Covid 19 (2/5/24 per hospital record review). The resident's physician order, dated 2/13/24, revealed Covid 19/UR (Upper Respiratory) Symptom Monitoring: Monitor for Covid 19 and UR symptoms every shift. Her physician's order, dated 2/14/24, revealed she was to be on Isolation Precautions: Contact Isolation- provide isolation set up with cart, barrels, red bags, stop sign and PPE. (Photographic evidence obtained) During a second tour of the facility on 2/14/24 at 1:50 PM, Employee A, CNA was observed entering Resident #3's room, without donning any PPE. Employee A was observed exiting the same room without any PPE on or doffing PPE. When Employee A was asked if she had entered Resident #2's room without donning PPE. She stated, Yes. When asked if she was trained to don PPE, per the contact precaution sign posted on the door of the room, prior to entering the room. She stated, Yes, if I am going to care for the resident in the B bed, because he has a urine infection. But if I am only caring for the resident in the A bed, then no, I don't need to use the PPE. She was asked if she knew which resident was ringing the call bell before she entered the room. She stated, The B bed rang the light for the A bed, because the A bed can't ring the light because he is confused, and the B bed thought that the A bed needed some help to get out of bed. A second interview was conducted with the Infection Preventionist on 2/14/24 at 2:50 PM. She was asked to review what Resident #4 was on precautions for, and what type of precautions she is on. She stated, She just got here last night, she has herpes in her oral cavity and is on Acyclovir. She was then asked to review her chart to determine if the resident's precautions were also related to Covid 19. After reviewing the chart, the Infection Preventionist stated, Yes, she is Covid; you are correct, she is both. When asked if Resident #3 should be on both droplet and contact precautions. She stated, Yes, she should be on both precautions. When asked if the staff were trained to don required PPE for precaution every time they enter the room? She replied, Absolutely. When she was asked if staff should don the required PPE per signage on the door regardless of which resident they think they are going to provide care to once they enter the room. She stated, The staff is aware of which resident in the room is on precautions. I would expect them to always don and doff the PPE when they enter the room. My rationale is they may have to do something for either resident while they are in the room. A review of the facility's policy titled Infection Control Program Overview (Published 12/4/23) revealed the following: Purpose: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Scope of the Infection Control Program: The infection Control Program is comprehensive in that it addresses detection, prevention, and control of infections among residents, staff, volunteers, visitors, and others. Staff and resident education are done to focus on risk infection and practices to decrease risk. Policies, procedures, and aseptic practices are followed by personnel in performing procedures. (Photographic evidence obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents had a comfortable and homelike environment, by failing to utilize maintenance services to maintain baseboards, bedframes, ceiling tile framework, toilets, paint, walls, and tile, affecting rooms 110, 115, 200, 201, 203, 204, 206, 208, 210, 211, 218, 224, 301 and 304, fourteen of 68 rooms in the facility. A failure to maintain the facility's interior can result in water damage, mold, accidents, pests, and other environmental hazards which could place residents, staff, and visitors at risk. The findings include: On 08/09/2023, the facility, including all 68 resident rooms, was toured beginning at 9:55 AM. The building integrity appeared intact without any observations of pests. The lobby was clean and free of debris with adequate lighting, a comfortable temperature, and no malodor. Hallways appeared clean and were free of debris/tripping hazards. The ceiling tiles, baseboards and floors were worn. The facility is [AGE] years old. Housekeeping staff were observed cleaning resident rooms and common areas. No malodor was noted in the facility or on residents' persons during the survey. Staff/resident interactions were friendly, courteous, and professional. On the facility's central hall, the baseboard located between the Employee Lounge and the 200 hall was damaged and pulled away from the wall, leaving enough space between the baseboards and walls to harbor pests, soil/debris and/or mold. Flaking paint and plaster were observed, however, no mold or pests were observed, even when the baseboard was disturbed. The Janitor's Room located on the same hall and adjacent to the Employee Lounge had broken tile at the corner of the doorway. (Photographic evidence obtained) On 08/09/2023, beginning at 10:00 AM, observations of multiple resident rooms revealed damaged baseboards with enough space between the baseboards and walls to harbor pests, soil/debris and/or mold. Flaking paint and plaster were observed, however, no mold or pests were observed during the survey. The rooms observed with baseboard damage were rooms 200, 201, 203, 204, 206, 208, 210, 211, 218, 301, and 304. (Photographic evidence obtained) room [ROOM NUMBER], Bed A, was observed with surface rust on the front, right leg of the bed, however, the bed was secure and functional. No other beds in the facility were observed with rust damage. room [ROOM NUMBER] was observed with surface rust on the metal ceiling tile frames and air vents. No water damage was observed. Ceiling tiles were not discolored. room [ROOM NUMBER] was observed with a slightly warped wall/sheet panel. room [ROOM NUMBER] was observed with a cracked windowsill. room [ROOM NUMBER]'s toilet was off-center and had a broken caulk seal at its base, however, the toilet was secured to the floor and did not move when pressure was applied. There was no leakage at the base of the toilet; the floor was dry, and the toilet was functional. There was some surface rust on the metal fixtures securing the toilet to the floor and at the water inlet valve. (Photographic evidence obtained) room [ROOM NUMBER]'s wall, adjacent to the window, was observed with a dried, splash of liquid resembling a dark-colored beverage. No other walls in the facility were observed with spilled/smeared substances during the survey. No privacy curtains were observed to have been soiled. (Photographic evidence obtained) On 08/09/2023 at 10:03 AM, an interview was conducted with Resident #5 (room [ROOM NUMBER], Bed B) regarding his baseboards. He stated the baseboard in his room had been damaged since his admission and no one had been in to repair it. He added that he had not complained about it, because it did not bother him. (Photographic evidence obtained) Aside from this, the resident reported no concerns and stated he was happy with the care he was receiving. When asked if he knew how to file a grievance should he have one, he replied yes. On 08/09/2023 at 10:30 AM, and interview was conducted with Resident #3. She was sitting in her motorized wheelchair, dressed appropriately, and well-kempt. Numerous boxes and bags of personal belongings were observed in her room and bathroom. When she was asked about her personal items, she became agitated and stated, I don't want anybody touching my stuff! I'll [expletive] kill them! She stated the facility staff were afraid of her because she would not take any [expletive]. She further stated they took her taser away from her. On 08/09/2023 at 10:35 AM, the area Ombudsman stated their office had not received any recent complaints for this facility and that during their last visit in late June 2023, they had no concerns. On 08/09/2023 at 11:05 AM, Resident #7 (room [ROOM NUMBER], Bed A) was interviewed. He was clean and well-kempt, and his linens were clean. He stated he was able to take himself to the bathroom and felt safe in doing so. An empty urinal was observed on his nightstand. He stated the Certified Nursing Assistants (CNAs) were pretty good. They emptied his urinal when they made rounds or when he called them for assistance. He was receiving physical therapy and got his medications on time. When asked, he stated his bed controls worked and he demonstrated that. He said they had always worked. When asked how he got along with his roommate, he replied, He's something else. When asked whether he had any complaints, he stated he would prefer a higher toilet seat, but he had not mentioned that to staff. On 08/09/2023 at 11:20 AM, an interview was conducted with Certified Nursing Assistant (CNA) D regarding the facility expectation for emptying urinals. She stated she was expected to round every two or so hours to check on the residents and provide care as needed. When asked whether she was familiar with Resident #2 in room [ROOM NUMBER], Bed B, she replied that she was familiar with him. She further stated Resident #2 was always telling us he's going to sue us. When we go in to do AM care, he tells us to go away, then turns around and says we aren't taking care of him. When she was asked whether there had been any concerns with the mechanical lifts not functioning, she replied that she was not aware of any concerns. When she was asked what the protocol was for when a remote control or bed controls were not working properly, she stated she made the unit manager or maintenance department aware so the item could be repaired/replaced. On 08/09/2023 at 11:35 AM, an interview was conducted with Resident #6 (room [ROOM NUMBER], Bed B) regarding the condition of her baseboard and wall. She stated the maintenance department had pulled the baseboard away from the wall and tried to repair it about a month ago, but no one had returned since then to finish the job. She stated she had no other concerns and was happy with the care she was receiving. She further stated all the equipment in her room was functional and she had not had any trouble with her toilet or sink. Despite the damaged baseboard, she stated the facility was kept clean. She denied having seen any pests. (Photographic evidence obtained) On 08/09/2023 at 12:13 PM, Resident #7 (room [ROOM NUMBER], Bed A), admitted on [DATE], was interviewed again. He stated his television worked and he demonstrated that. He further stated it had always worked. He had no complaints about the bathroom or toilet, and stated the bathroom walls were always clean. The bathroom toilet did not smell or leak. He had no concerns about furnishings, equipment or services received. He did mention that his roommate complained about anything and everything ever since his admission. He was aware that his bed frame had some surface rust but stated it was stable. On 08/09/2023 at 4:09 PM, the Maintenance Director was interviewed about his process for maintaining a safe and homelike environment for the residents. He stated he received workorders either verbally from residents or staff, or through the facility's life safety computer software program work orders, which informed him of what needed to be repaired/addressed. When asked if he conducted walking rounds to see whether anything required his attention, he replied yes, he conducted rounds every two weeks, and every three weeks he would touch up the rooms by conducting patchwork and/or applying paint to the walls. When asked whether his observations included observing walls, baseboards, and toilets, he replied, yes, the baseboards were observed when he or his team were painting or patching the walls. When asked if he checked bathroom fixtures such as toilets, he asked, Why do I need to look at the toilets? No, he continued, explaining that he did not check toilets if nothing was specifically mentioned to him. When asked what he did when he noticed that the walls may require his attention, he replied, If baseboards are ripped or off the wall, this would constitute a replacement. Why, what's wrong? He was shown photographs taken this day of resident room and hallway walls/baseboards, windowsills, broken floor tiles, a rusty bed frame, and an off-center toilet. He was asked whether those items required repair? He reviewed the photographs that were marked with respective resident room numbers, and replied, Yes, those need repairs. On 08/09/2023 at 4:26 PM, the Environmental Director was interviewed. She stated the facility employed seven housekeepers. The facility's daily cleaning process included sweeping, mopping, dusting, emptying trash, cleaning everything in the bathrooms, and ensuring toiletry items were supplied. The facility also had a deep-cleaning process during which bed frames and furnishings were moved. She stated cleaning residents' rooms could be challenging, because they had many personal items and did not want them touched/moved. Some residents also tended to be impatient during room cleaning, wanting the staff to finish quickly. On 08/09/2023 at 5:17 PM, an interview was attempted with Resident #2 (room [ROOM NUMBER], Bed B), who had been out of the facility all day. After a brief introduction, and while on his way out again, the resident stated he wanted the facility shut down. The interview ended at that time. On 08/09/2023, a review of the facility's life safety computer software program repair logs from 06/01/2023 through 08/09/2023, revealed no evidence of repairs having been made to the aforementioned resident room and hallway walls/baseboards, windowsills, broken floor tiles, rusty bed frame, rusty ceiling tile framework, or off-center toilet. .

Based on interviews, medical record review, and facility policy and procedure review, the facility failed to ensure residents were free from any significant medication errors, by failing to administer medications within the specified timeframe based on physicians' scheduling orders for three (Residents #2, #3, and #4) of seven sampled residents, from a total census of 104. Failure to administer medications in a timely manner can result in a resident's inability to maintain the proper level of medication in the bloodstream to be effective; reduced functional ability; lower quality of life; hospitalization, disease progression, and/or death. Resident #2 received routine and sliding scale insulin more than one hour late 24 times over 10 days between July 1, 2023 and July 14, 2023. Resident #4 received insulin at least one hour late once daily over 12 of 14 days reviewed and twice daily over four of 14 days reviewed. Repeated medication administration errors (timeliness of administration) were identified for Residents #2, #3, and #4. The findings include: 1. A review of Resident #2's medical record revealed an admission date of 07/01/2023 and diagnoses including diabetes mellitus, hypertension (high blood pressure), and peripheral vascular disease (poor circulation). The resident was admitted with wounds. A review of Resident #2's Medication Administration Audit Report for 07/01/2023 through 07/14/2023, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 10 of 14 days as follows: On July 3rd, the following medication was ordered for 8:00 AM and was administered at 11:11 AM: Lispro sliding scale insulin for diabetes mellitus. On July 3rd, the following medications were ordered for 9:00 AM and were administered at 11:11 or 11:12 AM: Empagliflozin (Diabetes Mellitus (DM) Losartan (High Blood Pressure (HTN) Carvedilol (Congestive Heart Failure (CHF) Lantus Insulin (DM) Sevelamer Carbonate (Chronic Kidney Disease) Aspirin (CHF) Allopurinol (Gout) Bumetanide (CHF) Plavix (Coronary Artery Disease) Hydralazine HCL (HTN) On July 3rd, the following medication was ordered for 4:30 PM and was administered at 6:30 PM: Lispro sliding scale insulin for diabetes mellitus. On July 3rd, the following medication was ordered for 5:00 PM and was administered at 6:30 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 3rd, the following medication was ordered for 9:00 PM and was administered on July 4th at 1:29 AM: Carvedilol (Congestive Heart Failure (CHF) On July 4th, the following medication was ordered for 8:00 AM and was administered at 9:12 AM: Lispro sliding scale insulin for diabetes mellitus. On July 4th, the following medication was ordered for 11:30 AM and was administered at 1:37 PM: Lispro sliding scale insulin for diabetes mellitus. On July 4th, the following medication was ordered for 12:00 PM and was administered at 1:35 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 5th, the following medication was ordered for 8:00 AM and was administered at 9:14 AM: Lispro sliding scale insulin for diabetes mellitus. On July 5th, the following medication was ordered for 9:00 PM and was administered on July 6th at 2:01 AM: Lispro sliding scale insulin for diabetes mellitus. On July 5th, the following medications were ordered for 9:00 PM and were administered on July 6th between 1:29 AM and 2:00 AM: Carvedilol (Congestive Heart Failure (CHF) Hydralazine HCL (HTN) Atorvastatin Calcium (Hyperlipidemia) On July 6th, the following medication was ordered for 9:00 PM and was administered on July 7th at 12:25 AM: Lispro sliding scale insulin for diabetes mellitus. On July 6th, the following medication was ordered for 9:00 PM and was administered on July 7th at 12:25 AM: Lantus Insulin for diabetes mellitus. On July 8th, the following medication was ordered for 8:00 AM and was administered at 3:46 PM: Lispro sliding scale insulin for diabetes mellitus. On July 8th, the following medications were ordered for 9:00 AM and were administered between 3:34 PM and 3:48 PM: Empagliflozin (Diabetes Mellitus (DM) Losartan (High Blood Pressure (HTN) Carvedilol (Congestive Heart Failure (CHF) Lantus Insulin (DM) Sevelamer Carbonate (Chronic Kidney Disease) Aspirin (CHF) Allopurinol (Gout) Bumetanide (CHF) Plavix (Coronary Artery Disease) Hydralazine HCL (HTN) On July 8th, the following medication was ordered for 12:00 PM and was administered at 3:41 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 8th, the following medication was ordered for 4:30 PM and was administered at 6:32 PM: Lispro sliding scale insulin for diabetes mellitus. On July 8th, the following medication was ordered for 5:00 PM and was administered at 6:33 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 9th, the following medication was ordered for 8:00 AM and was administered at 11:49 AM: Lispro sliding scale insulin for diabetes mellitus. On July 9th, the following medications were ordered for 9:00 AM and were administered between 11:36 AM and 11:50 AM: Empagliflozin (Diabetes Mellitus (DM) Losartan (High Blood Pressure (HTN) Carvedilol (Congestive Heart Failure (CHF) Lantus Insulin (DM) Sevelamer Carbonate (Chronic Kidney Disease) Aspirin (CHF) Allopurinol (Gout) Bumetanide (CHF) Plavix (Coronary Artery Disease) Hydralazine HCL (HTN) On July 9th, the following medication was ordered for 4:30 PM and was administered at 6:02 PM: Lispro sliding scale insulin for diabetes mellitus. On July 9th, the following medication was ordered for 5:00 PM and was administered at 6:02 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 9th, the following medication was ordered for 9:00 PM and was administered on July 10th at 3:18 AM: Lispro sliding scale insulin for diabetes mellitus. On July 9th, the following medication was ordered for 9:00 PM and was administered on July 10th at 3:20 AM: Lantus Insulin for diabetes mellitus. On July 10th, the following medication was ordered for 8:00 AM and was administered at 9:24 AM: Lispro sliding scale insulin for diabetes mellitus. On July 10th, the following medications were ordered for 9:00 PM and were administered on July 11th between 1:08 AM and 2:09 AM: Carvedilol (Congestive Heart Failure (CHF) Lispro sliding scale insulin for diabetes mellitus. Lantus Insulin for diabetes mellitus. Atorvastatin Calcium (Hyperlipidemia) Hydralazine HCL (HTN) On July 11th, the following medication was ordered for 6:00 AM and was administered at 2:09 AM: Pantoprazole sodium (Gastroesophageal reflux disease (GERD) On July 11th, the following medication was ordered for 11:30 AM and was administered at 12:39 PM: Lispro sliding scale insulin for diabetes mellitus. On July 12th, the following medication was ordered for 11:30 AM and was administered at 12:56 PM: Lispro sliding scale insulin for diabetes mellitus. On July 13th, the following medications were ordered for 9:00 PM and were administered at 10:20 PM: Carvedilol (Congestive Heart Failure (CHF) Lispro sliding scale insulin for diabetes mellitus Lantus Insulin for diabetes mellitus. Atorvastatin Calcium (Hyperlipidemia) Hydralazine HCL (HTN) (Copy obtained) 2. A review of Resident #3's medical record revealed an admission date of 04/22/2021 and diagnoses including multiple sclerosis, hypertension (high blood pressure), depression, and peripheral neuropathy (nerve damage). A review of Resident #3's Medication Administration Audit Report for 07/01/2023 through 07/14/2023, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 14 of 14 days as follows: Nystatin fungal cream (breast redness) was administered outside of the two-hour window every day. Prostat (supplement) was administered outside of the two-hour window on four of 14 days. Senna S (constipation) was administered outside of the two-hour window on three of 14 days. Miralax (constipation) was administered outside of the two-hour window on three of 14 days. Mirabegron (urinary retention) was administered outside of the two-hour window on three of 14 days. Omeprazole (gastroesophageal reflux) was administered outside of the two-hour window on two of 14 days. Neurontin (peripheral neuropathy) was administered outside of the two-hour window on three of 14 days. Hydrocodone-Acetaminophen (pain) was administered outside of the two-hour window on four of 14 days. Lidocaine patch (pain) was administered outside of the two-hour window on two of 14 days. Magnesium Citrate (constipation) was administered outside of the two-hour window on two of 14 days. Amlodipine Besylate-Benazepril (HTN) was administered outside of the two-hour window on two of 14 days. Metformin (Diabetes mellitus) was administered outside of the two-hour window on two of 14 days. (Copy obtained) 3. A review of Resident #4's medical record revealed an admission date of 05/04/2023 and diagnoses including diabetes mellitus and depression. The resident was being treated for wounds. A review of Resident #4's Medication Administration Audit Report for 07/01/2023 through 07/14/2023, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 12 of 14 days as follows: Lispro sliding scale insulin (diabetes mellitus) was administered outside of the two-hour window once a day for 12 of 14 days reviewed and twice a day for four of 14 days reviewed. Zinc sulfate (wound healing) was administered outside of the two-hour window on five of 14 days. Paroxetine Hydrochloride (HCL) (Depression) was administered outside of the two-hour window on five of 14 days. Vitamin C (wound healing) was administered outside of the two-hour window on five of 14 days. Eliquis (blood thinner) was administered outside of the two-hour window once a day on five of 14 days reviewed and twice a day on one of 14 days reviewed. (Copy obtained) On 08/09/2023 at 11:55 AM, Licensed Practical Nurse (LPN) A was interviewed. When asked to describe the allowable administration window for resident medications, she replied, an hour before to an hour after the scheduled time. When she was asked what happened if medications were late, she stated the nurse was expected to call and notify the physician. When she was asked whether she had done that, she replied, Recently I was asked to come in because a nurse had called out. By the time I came in all the AM meds were really late. I think I documented on everyone about being late but I'm not 100% sure. When she was asked if she informed the resident's physician, she stated, When that happens, I usually just tell the doctor when he's doing rounds. When asked if she documented notification of the physician, she said no. On 08/09/2023 at 2:05 PM, an interview was conducted with the Interim Director of Nursing (IDON), a registered nurse (RN) who had initially been hired as the Assistant Director of Nursing (ADON) in June 2023, but had been the IDON for eight days. When she was asked if there was a policy regarding the timeframe for administration of medications, she replied, Nurses have an hour before and after the scheduled time to administer medications, and they are supposed to notify the doctor and document. When she was asked to run a Medication Audit Report using the facility's electronic medical record software, she stated she was not familiar with the report but she would look into it. On 08/09/2023 at 4:00 PM, a joint interview was conducted with the Administrator and the IDON. After a preliminary review of the Medication Administration Audit Report, there were indications of several occurrences of medications having been administered beyond the allowable administration time according to the facility's policy. When they were asked if they were aware that medications for some residents were not being administered in a timely manner, they acknowledged the results of the report and added that while they were aware that they were ultimately responsible, neither of them had been in their positions long enough to have discovered the issue. On the day of the survey, the Administrator had been employed by the facility for three days and the IDON was on her eighth day in her new position. On 08/09/2023 at 7:55 PM, a joint interview was conducted with the IDON and Licensed Practical Nurse (LPN) B/Evening Supervisor. When they were asked why medication administration was late, LPN B stated, On weekdays the expectation is for a manager to cover the cart (medication cart) until another staff member can be brought in if there is a call out. On a Saturday or Sunday, leadership is not in the building. The IDON stated that there had been several call outs on the weekends. When that happened the night shift nurses were asked to remain until they could arrange for nursing staff to come in. The night shift nurses stayed, however, they did not pass any medications. When the replacement nurses finally arrived, the medications were already late. A review of the facility's policy and procedure for Administering Medications (Revised April 2019) page 1, item 4: Medications are administered in accordance with prescriber orders, included any required time frame. Item 7: Medications are administered within (1) one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and clean environment for two (rooms [ROOM NUMBERS]) out of 10 rooms observed. The findings include: On 2/28/2023 at 12:23 PM, room [ROOM NUMBER] was observed to have a covered linen cart, a soiled towel, and a clear bag containing soiled linens next to the empty A-bed. (Photographic evidence obtained) An interview was attempted with the resident in B-bed; however, she was determined not to be interviewable. On 2/28/2023 at 12:30 PM, room [ROOM NUMBER] was observed to have a large round stain coming from under A-bed. The stain appeared to be a dried liquid, dark gold in color. Further observation revealed the stain extended under the B-bed to the other side of the bed leading to the middle of the room between A and B beds. Bed A had a catheter bag attached to lower side of the bed. The catheter bag hung above an area where more stains, dark goldish brown in color where observed. (Photographic evidence obtained) On 3/1/2023 at 10:12 AM, a second observation of room [ROOM NUMBER] was conducted. A clear bag containing soiled items was left next to A-bed. There was also a stain dark black in color with the appearance of a [NAME] texture observed extending from the inner side between A and B beds to the center of the room. Stains were observed on the privacy curtain between A and B beds. (Photographic evidence obtained) On 3/1/2023 at 10:17 AM, an interview was conducted with Employee C, Certified Nursing Assistant (CNA) who was assigned to room [ROOM NUMBER]. When she was asked about the bag of soiled items in the room, she acknowledged, she was responsible for leaving the bag in the room. She stated she had been in the room earlier and intended to come back later to get it. She was shown the stains on the curtain and the floor. She stated housekeeping is responsible for cleaning them. She stated there is no reporting log and that the CNAs verbally tell housekeeping when they see anything that needs to be cleaned. When asked if she had reported the dirty curtain or floor stain, she stated she had not. When asked what should be done with large items that don't fit in the small trash cans in the room, she stated they are to be taken to the soiled utility room. During an interview with Employee D, Housekeeper on 3/1/2023 at 10:31 AM, she stated, she did the daily cleaning on the 100 and 300 halls. She was responsible for emptying the trash, cleaning the bathroom, sweeping, mopping, dusting, and wiping down the bars in the room. She confirmed the housekeepers were responsible for sweeping and mopping under the beds. On 3/1/2023 at 1:31 PM, room [ROOM NUMBER] was observed for a second time. The dried liquid, golden in color remained visible under A-bed. At this time Employee E, Account Manager/Housekeeping Supervisor was observed walking on the hallway. When Employee E, was asked about the process for reporting housekeeping concerns to his department, he stated any facility staff member can submit them via TELS (electronic reporting system) or verbally to him. Employee E was shown the dried substance in room [ROOM NUMBER] under A-bed. After seeing it, he replied, Oh no, I'll get that taken care. He then exited the room without continuing the interview. During an interview with Employee E on 3/1/2023 at 2:47 PM, he stated the housekeepers had a routine cleaning list to follow. He confirmed, the housekeepers should mop the entire floor including under the beds, take out the trash every morning, and take soiled items to the soiled utility room. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/21/2023 at 11:29 AM, Resident #54 stated that she wished to go home, and no one was assisting her with discharge. She added that she was capable of taking care of herself and would get home health services if needed. The resident added that she does not know who made the decision for her to stay at the facility because she had her own home. She said, Institutional living is not for me. Resident could not recall attending any care plan meeting. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE] with a re-entry on 6/19/2022 with admitting diagnoses of muscle wasting and atrophy, cognitive deficit, and need for assistance with personal care. A review of the quarterly minimum data set assessment dated [DATE] indicated Resident #54 had a brief interview for mental status (BIMS) score of 9 out of 15 possible points, indicating moderate cognitive impairment. She required extensive assistance for bed mobility, transfer, and toilet use. She was independent with eating. According to the assessment, Resident's return to the community was uncertain. Resident #54's care plan dated 2/3/2022 indicated she wished to be discharged home. The care plan was updated on 3/10/22 and indicated the resident wished to remain in the facility for long term care. Interventions included to encourage the resident to discuss concerns. The care plan also indicated that resident is an elopement risk/wanderer related history of attempts to leave facility unattended. In an interview with the Social Services Director (SSD) on 2/22/2023 at 2:57 PM, she stated that the discharge plan is initiated upon admission. She added that she also visited the resident if there covered days were almost expiring before initiating a notice of medicate non coverage (NOMNC) to review their discharge plan. When asked about residents that were long term at the facility, but would wish to return to the community, she said, Residents who are long term can request discharge and time. The interdisciplinary team (IDT) also discuss discharge plan during care plan meeting, but I have to make sure that residents who wish to discharge have a plan on discharge location. She added that she had received requests for discharge from three long term care residents and Resident #54 was not among them. When asked if Resident #54 attended her care plan meetings, she stated that the MDS department would have a list of the attendees for each care plan. In an interview on 2/23/2023 at 12:52 PM, Employee D, Licensed Practical Nurse (LPN MDS) stated that when residents are admitted the care plan is done based on the hospital documentation and resident/ family interview. She added the care plan was updated quarterly. When asked about the process of care planning, she said, Resident family/representative are sent a letter a week prior to invite them to the care plan meeting. During the care planning meeting the staff and the families who are present sign the Care conference Card. She added that the resident should always be present and if resident does not participate in the care plan, a documentation should be included that attempts were made along with resident response. When asked if Resident #54 participates in her care plan, she stated that she would obtain the care conference cards to verify. After she obtained the care conference cards for 2022, she confirmed that Resident #54 did not attend in any of the meetings in 2022. There was no documentation proving any attempts were made to have resident attend the meeting. Review of the care conference dated 3/10/2022, 6/7/2022 and 11/29/2022 revealed that Resident #54 did not attend any of the care plan meetings. (Copies obtained) A review of facility's policy and procedures title, Care Plan Invitation (revised on 09/25/2017) read: The resident and/or the resident representatives shall be invited to attend each of the interdisciplinary care planning conference for the specific resident. The procedure included: -Deliver care plan invitation to the resident 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record. - If the resident has capacity, ask if they wish to have the resident representative at the care conference. Per resident choice or determination of capacity, mail care planning invitation to the resident representative 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record - Have all attendees to the Care Planning Conference, including resident and resident representatives sign the Care Plan Conference Record to verify their attendance. (Copy obtained) A review of the facility's policy and procedure titled, Plans of Care (revised on 09/25/2017) read: An individualized person- centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with the state and federal regulatory requirements. The procedure read, Develop and implement and individualized person- centered comprehensive plan of care by the interdisciplinary Team that include but not limited to the attending physician, a registered nurse with registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition service staff, and other appropriate staff of professionals in the disciplines as determined by the resident's needs or as requested by the resident, and to the extent practicable the participation of the resident and the resident's representative(s). (Copy obtained) Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to revise the comprehensive care plan to reflect the current level of care for one (Resident #42) of 3 residents sampled for falls, and failed to include one (Resident #54) of 2 residents sampled for care planning, out of a total of 63 sampled residents, the opportunity to participate in the development of the care plan. Failure to update the care plan puts the resident at risk of not receiving appropriate care interventions. Failure to include the resident or their representative in care planning ensures the resident lacks information that will assist the resident in making informed decisions about her health care. The findings include: 1. During an interview on 2/21/2023 at 9:32 AM with the contracted Nurse Practitioner for the facility, she stated that Resident #42 fell out of his wheelchair while his wife was pushing it and he was sent to the hospital. She could not remember the exact date. It was around Christmas time. He sustained a deep laceration to his head and needed 11 staples to close it. A review of Resident #42's medical record revealed he was admitted on [DATE]. Diagnoses included cancer, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's disease, malnutrition, anxiety disorder, depression, schizophrenia, dysphagia, muscle wasting, muscle weakness, sleep apnea, lymphedema, gastro-esophageal reflux disease without esophagitis, amnesia, benign prostatic hyperplasia with lower urinary tract symptoms, and chronic pain syndrome. The resident had one fall with major injury since the last assessment or since admission. (Copy obtained) A review of the electronic clinical record nursing notes for dated 10/13/2022 at 22:58 hours read: Patient was sent out post fall for a closed head injury. Contusion of the forehead. When he had fallen from his wheelchair. (Photographic evidence obtained) A review of the Situation, Background, Assessment and Recommendation (SBAR) form and witness statements from staff dated 12/23/2022 read that Resident #42 had a fall that occurred on 12/23/2023, resulted in a major injury and required the use of staples to close the laceration to the top of the resident's head. The fall occurred while the resident's wife was pushing him in his wheelchair to his room. As she pushed him around the corner, she was heard to be saying very loudly to her husband to pick up his feet. The nurse (Employee J) observed the resident's feet on the floor. (Copy obtained) On 2/21/2023 at 11:09 AM, a review of the resident's electronic care plan dated 5/08/2022 revealed the resident was care planned for being at risk for falls related to deconditioning, gait/balance problems, incontinence, psychoactive drug use and fall. The goal was to minimize the risk for minor injury through the next review date. The care plan included the following interventions: Anticipate the needs of the resident; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; bed in low position; educate the resident/resident's representative/caregivers about safety reminders and what to do if a fall occurs; ensure that the resident is wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheelchair; patient evaluate and treat as ordered or as needed. Further review of the care plan revealed that there was no evidence that the care plan was revised or reviewed by the interdisciplinary team after the resident fell on [DATE] or on 12/23/2022. (Photographic evidence obtained) During an interview with Employee K, Licensed Practical Nurse (LPN) on 2/23/2023 at 4:43 PM, she stated that she was the nurse that responded to Resident #42's fall on 12/23/2022. She stated, she saw it happen. She was approximately 20 feet away and could not get to him fast enough to prevent him from hitting his head. He fell forward out of the front of the wheelchair and hit his head on the double panic bolt bar on the fire door. She stated, Oh I remember it like it just happened. It was like a dolphin dive! She stated that he had fallen before. An interview was conducted with the Director of Nursing (DON) on 2/23/2023 at 5:27 PM about the falls. The DON confirmed that the care plan was not updated to reflect the falls on 10/13/2022 and 12/23/2022 and did not contain any updated interventions to prevent future falls or protections from injury. A review of the facility's policy and procedure entitled, Fall Management (effective date 11/30/2014, revised 7/29/2019) read: Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of further fall(s) and minimize the potential for a resulting injury. B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors. 2. Update the resident's care plan and the Nurse Aide [NAME] with interventions. C. Post Fall Strategies: 5. Update care plan and Nurse Aide [NAME] with interventions. 8. Update plan of care with new interventions as appropriate. (Photographic evidence obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #6) out of 63 sampled residents. The findings include: On 2/20/2023, Resident #6 was observed lying in bed under the covers. There were no physical signs of abuse or neglect. When an interview was attempted, the resident responded nonsensically to many of the questions that were asked. The resident appeared to be pleasantly confused, and the interview was ended. A record review for Resident #6 revealed she was admitted on [DATE] and was readmitted on [DATE], after being transferred out for acute care. Diagnoses included urinary tract infection (UTI); muscle weakness; unspecified atrial fibrillation; dysphagia; muscle wasting & atrophy; acute embolism and thrombosis of deep veins; long term use of anticoagulant and essential hypertension. A review of Resident #6's admissions minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 14 out of 15, indicating cognitively intact. Resident required extensive assistance with all activities of daily living. Pain assessment was completed. There was no pain or falls reported during the look back period. A review of the current physician's orders for Resident #6 revealed Eliquis 5mg by mouth twice a day; monitoring for anticoagulant usage each shift; pain monitoring each shift; complete blood count (CBC) and basic metabolic panel (BMP) each Friday; vital signs each shift; regular no added sodium (NAS) diet, dysphagia puree texture and regular thin liquids consistency A review of nursing progress note dated 1/23/2023, read: Resident found on floor next to bed 1cm X 1cm abrasion on left side forehead appeared resident hit head on bedside table. Further record review revealed Resident #6 was enrolled in hospice services on 1/27/2023. A review of the resident's most recent care plan addressed falls as: Focus: the resident is at risk for falls related to gait/balance problems, incontinence, history of fall date initiate 11/30/2022; Goal: Minimize the risk of falls through next review date Target date 4/10/2023; Interventions: Frequent toileting, anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; ensure the resident is wearing appropriate footwear/non-skid socks when mobilizing in wheelchair; physical therapy evaluate and treat as ordered or as needed dated initiated 11/30/2023. During an interview on 2/22/2023 at 12:59 PM with Employee E, Advance Registered Nurse Practitioner (ARNP), she acknowledged she was familiar with Resident #6. She confirmed the resident is currently receiving Hospice services. She was not sure how often these services were provided in the facility. She stated the facility nurse coordinates with hospice. She confirmed the resident sustained a fall with injury in the facility on 1/23/2023. She stated, she sees the resident every 30 days and/or in the event of an acute situation. When asked, she stated the fall would have been considered an acute situation, however, she did not see the resident until 1/25/2023, two days after the fall with injury, then again on 1/26/2023 and 1/30/2023. On 2/2/2023, she documented the bruise the resident sustained during the fall as it was more prominent at that time. She stated there was no x-ray nor was Resident #6 sent out for evaluation and/or treatment. During an interview with the Director of Nursing (DON) on 2/22/23 at 4:17 PM, she reviewed the details of Resident #6's fall on 1/23/2023. She confirmed the date of the fall and stated it occurred at 1:15 AM. The resident was observed next to her bed and sustained a laceration to the forehead 1 cm x 1 cm in size. The laceration was treated in house by the facility staff and the resident's physician was notified. When asked about post fall interventions, she stated the resident was re-educated to ask for assistance when getting out of bed. The DON was asked about the facility's fall process. She stated a facility wide code green is called when there is a fall. Nursing does the assessment and the doctor is called. She stated there is no physical documentation. She stated if a fall is unwitnessed neurochecks are performed. She confirmed the fall sustained by Resident #6 was unwitnessed and the resident would have needed neurochecks. She stated some of the neurochecks are done on paper as well as electronically. She stated the neurochecks are done within the first 15 minutes then every hour then every four hours after a resident sustains a fall. She was asked to provide the neurochecks done for Resident #6. She stated, they should be located in the resident's electronic chart. At this time, she was also asked to confirm the order for hospice services. She stated the facility was still verifying the order for hospice. She stated the order was put in by an agency nurse and was being investigated by the facility. She stated the facility needed to determine if the family or the doctor requested hospice services. During an interview with the DON on 2/22/2023 at 4:47 PM, she was advised the neurochecks for Resident #6 were not found in the electronic chart. She was given the physical chart retrieved from the nurses' station on the East Wing of the facility. In the presence of Administrator, the DON sorted through the resident's physical chart looking for the neurochecks that should have been done after resident sustained the fall on 1/23/2023. After several minutes, the DON confirmed there were no neurochecks in the resident's physical chart. During an interview with Employee E, the ARNP on 2/23/2023 at 11:52 AM, she confirmed she put in the consult for hospice service. She stated the diagnosis was failure to thrive. She stated the Power of Attorney for Resident #6 spoke to Hospice and the services were optional. She again stated the reason for her consult was the resident's failure to thrive. She was provided a copy of the hospice documentation showing atherosclerotic heart disease listed as admitting diagnosis. The ARNP was asked if this information was accurate. She stated, she can't prove a resident's primary diagnosis. She stated she puts in the consult, but she can't pick the resident's diagnosis. When asked about collaboration between herself, hospice, and the physician, she stated they meet in the facility. She stated the on-call team was notified after Resident #6 sustained the fall on 1/23/2023. She confirmed the resident sustained an injury as a result of the fall but stated she was fine and confirmed there were no post fall interventions put in place. She was asked in her professional opinion about residents who take anticoagulants who had falls and sustained a head injury with bleeding. She stated she would probably send the resident out, but Hospice would have to be called since this resident is on Hospice. During a phone interview with the Medical Director on 2/23/2023 at 12:01PM, he acknowledged being the Medical Director for the facility and member of the facility's Quality Assurance and Performance Improvement (QAPI) team. He stated he was aware of the fall Resident #6 sustained on 1/23/2023. He stated his on-call service took the report for the fall. He stated the specific person who took the report was currently out of the country and unavailable for interview. He stated the facility advised there was head injury and provided the resident's vitals. He stated the facility was advised to perform neurochecks for Resident #6 after the fall. He stated, When a resident is on a anticoagulant there is a low threshold there so we send them out to the hospital to make sure there is no cranial bleeding. When asked about the order for Hospice, he stated the ARNP spoke with the resident's Power of Attorney (POA). He stated there was a phone call with the POA for Resident #6 to discuss Hospice as an option. When asked how he collaborates with Hospice, he specifically replied, That's a great question. I've been trying to open the lines of communication. I've asked that we be involved when residents and their families make that decision. It's getting better. A review of the facility's policy and procedure titled, Fall Management (Effective Date: 11/30/2014 Revision Date 7/29/2019) read: C. Post Fall Strategies 2. Initiate Neurological checks as per policy or directed by physician order 6. Initiate post fall documentation every shift for 72 hours 9. Review resident weekly x 4. (Photographic evidence obtained)

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #21) of 10 residents receiving respiratory care, received oxygen as ordered, from a total sample of 63 residents. The findings include: On 2/20/2023 at 10:57 AM, Resident #21 was observed lying in bed wearing a nasal cannula. The oxygen concentrator located at bedside revealed an oxygen flow of 1.5 Liters per minute (L/min). A bag attached to the oxygen concentrator was dated 2/7/2023. (Photographic evidence obtained) A record review of Resident #21's physician's order revealed no current oxygen order. Respiratory oxygen at 2 L/min via nasal cannula as needed for shortness of breath was discontinued 8/22/2021 at 4:15 PM. (Photographic evidence obtained) On 2/21/2023 at 10:15 AM, a second observation of Resident #21 was conducted with Employee B, Unit Manager. The resident's oxygen concentrator was set at 1.5 L/min with a bag attached to the oxygen concentrator dated 2/7/2023. (Photographic evidence obtained) Employee B confirmed Resident #21's oxygen order was discontinued on 8/22/2021. A record review for Resident #21 revealed an initial admission date of 2/19/2021 and readmit date of 1/12/2023. Diagnoses included hemiplegia unspecified affecting left nondominant, weakness; unspecified lack of coordination; cognitive communication deficit; anxiety disorder, unspecified; other schizoaffective disorders; major depressive disorder, recurrent, unspecified; long term (current) use of anticoagulants; and muscle weakness. A review of the quarterly minimum data set (MDS) assessment, dated 1/16/2023, revealed Resident #21 had no interview for mental status, resident was rarely/never understood. The assessment also documented she was receiving oxygen therapy. A review of the January 2022 Medication Administration Record (MAR) for Resident #21 identified no monitoring of oxygen therapy. A review of Resident #21 care plan dated 12/1/2022 revealed she had oxygen therapy as needed via nasal prongs as ordered. Progress notes dated 2/6, 2/7, 2/10, 2/11, 2/12, and 2/13 revealed oxygen administered at 2 L/min via nasal cannula. During an interview with the Director of Nursing (DON) 2/22/2023 at 3:25 PM, the DON confirmed that nursing was responsible for providing ongoing monitoring of oxygen therapy and tube changes. She stated, the physician provides orders, and nursing follow the physician orders. Each nurse had access to the electronic medical record to identify oxygen settings. A review of the facility's policy and procedure titled, Oxygen Therapy (revision date 8/28/2017) read: Physician's order for oxygen therapy shall include Administration modality, FiO2 or liter flow, Continuous or (as needed) PRN, PRN orders must include specific guidelines as to when the resident is to use oxygen. (Photographic evidence obtained)

Based on observations, interviews, and record review, the facility failed to provide adequate staffing to respond timely to call lights for 2 (Residents #103 and #262) of 2 residents requiring assistance with activities of daily living. The facility also failed to ensure sufficient nursing staff to provide a timely medication pass for 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication. The findings include: Cross reference F759 and F760 Upon entrance to the facility on 2/19/2023 at 11:00 AM, the Director of Nursing (DON) was observed passing medication on the East wing. During an interview with the DON on 2/19/2023 at 11:05 AM, she confirmed, she was the assigned nurse for that section. She added that her shift was 7 AM - 7 PM. On 2/19/2023 at 12:35 PM, Resident #103 was interviewed. He stated that the care was terrible. He added, Sometimes I have to wait an hour for staff to answer my call light and sometimes an aide will come in, turn off the call light and say they will return, and never come back. Not to mention the weekends are the worst. He went onto say, The DON is on a med cart even today, and sometimes they have one nurse on two med carts. On 2/20/2023 at 9:30 AM, the call light for Resident #262 was observed to be on. During this time, staff were walking past the light, but no one answered it. At 10:30 AM, the call light was still on and staff were observed walking right past the light. On 2/2/2023 at 10:30 AM, Resident #262 was interviewed. He stated that he had the call light on because he needed to be changed. He added that the certified nursing assistant (CNA) assigned to him came in and stated she would be back, but it had been almost an hour and she never came back. In an interview with Employee C, LPN/Unit Manager on 2/20/2023 at 9:45 AM, she stated, all staff have the responsibility to answer the call lights. When asked who was assigned to Resident #262, she was not sure as she was working on a different unit. When she asked the other staff members, she was told the assigned CNA was providing a shower to another resident. She then asked another staff member to attend to the resident's light. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the [NAME] Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents (Residents #102, #215, #214, and #71) to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that two more residents (Residents #14 and #212) other than Resident #31 had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. In an interview with the DON on 2/20/23 at 02:49 PM, she confirmed that medications were administered late. She mentioned that there was a hick up with staffing and hence the late medication administration. During an interview with the Administrator and the DON on 2/23/2023 at 4:54 PM, they both confirmed that staffing has been a challenge, but they always try to get agency staff to cover. The DON confirmed that she worked on the cart on a rotating basis with other supervisors. .

Based on observations, record reviews, staff interviews, and facility policy and procedure review, the facility failed to ensure a medication error rate of less than 5%, based on 14 errors with 33 opportunities for errors, resulting in an error rate of 42.42%. The findings include: Cross reference F760. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the [NAME] Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. During an interview with the DON on 2/20/2023 at 11:30 AM, she confirmed that the medications were late for 4 residents (Residents #102, #215, #214, and #71). She added that late medications are considered as med errors and the physician should be notified of the medication errors. (Copies of the physician orders obtained for the four residents). During a medication administration observation on 2/20/2023 at 11:23 AM, Employee P Registered Nurse (RN) was observed preparing to obtain blood sugar for Resident #262. After gathering all the supplies, nurse donned gloves and walked into the resident room. He cleaned the resident's middle finger of the left hand and obtained a drop of blood to the testing strip. He stated that the blood sugar was 327. He walked out of the resident room, discarded the lancet in the sharps container. In the same gloves he obtained a sani wipe for cleaning the glucometer. After scrubbing the glucometer for about 30 seconds, he wrapped it in a clean sani wipe and left it on a barrier placed on the cart. He doffed gloves, (no hand hygiene was performed); obtained a Humalog insulin pen, reviewed the orders and stated that resident required 16 units of insulin. He went to the resident room, donned gloves and injected 16 units to the left upper arm. He walked out of the resident room, doffed gloves (no hand hygiene was performed) and checked the electronic medication record as administered. He then took the glucometer and placed in the cart and walked way to pick up a phone call form the facility phone. On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. While preparing the medications, Resident #31 walked up to her and stated she had a headache. She described the pain level at level 8 out 10 (10 being most severe) and requested that Employee B give her Tylenol. The nurse obtained all other mediation, but did not get the Tylenol. she stated that she did not have the 500 milligrams (mg) per orders and she would have to call the physician to request another medication or a different dosage. She explained the same to the resident. Resident #31 expressed disappointment for the medication being so late. She added, I have severe acid reflux and it bothers me if I don't get my medications on time. During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that three residents (Residents #31, #14, and #212) had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. During a follow up interview with the DON on 2/20/2023 at 2:49 PM, she confirmed that the medications were administered late. She added that the nurse should have called the physician to see if the dose or the time could be adjusted. She mentioned that there was a hick up with staffing and hence the late medication administration. On 2/20/2023 at 2:51 PM, Resident #31 stated she still had headache and was not sure if Employee B had given her the Tylenol medication. She added that the ice pack helps and she would ask the staff to give it to her. On 2/20/2023 at 3:20 PM, Employee B confirmed that she had not administered the Tylenol to Resident #31 and had not provided any non-pharmacological interventions. When asked if she had notified the physician that the dosage require was not available, she said, No , I did not call the physician because the central supplies stated that they would get the medication and I forgot to follow up to get the medication. On 2/22/2023 at 9:43 PM, an observation of medication administration was conducted for Resident #41 with Employee C, LPN (Agency). The nurse obtained one tablet for Entresto 24 mg- 26 mg, and metoprolol 25 mg one-half tablet. He then went to the resident's room and gave the medication to the resident. A review of the medication orders for Resident #41 revealed Entresto 24 mg- 26 give one tablet two times a day hold for Blood pressure (BP) less than 110/60 and Metoprolol 25 mg give 1 tablet daily and hold for BP less than 110/60. (Photographic evidence obtained) On 2/22/2023 at 9:45 PM, Employee C was asked what the blood pressure was for Resident #41. He confirmed that he did not obtain it. He added that the nursing assistants were supposed to obtain the blood pressure and he was not sure what the readings were. During an interview with the DON on 2/23/2023 at 12:07 PM, she stated that hand hygiene should be performed before donning gloves and after doffing off gloves including while administering medication. She added that if medication is not available in the cart, the nurse should try and check if its available in the pyxis system, if it's still not available the physician should be notified to see if the dose or a different medication should be given. When asked about obtaining blood pressure medication for medications with parameters, she stated that the blood pressure should be obtained by the nurse before giving the medication. A review of the facility's policy and procedure titled: Administering Medication (revised April 2019) read: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation revealed the following: 2. The Director of Nursing Services supervises and directs all personnel who administer medication and have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with the prescribers orders, including any required time frames. 5. Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication b. Preventing potential medication of food interactions; and c. Honoring resident choices and preferences, consistent with his or her plan of care. 6. Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example before and after meal orders). 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication. 11. The following information is checked/ verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication, as applicable. (Photographic evidence obtained) .

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to 1) ensure that 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication administration, remained free of significant medications errors, by failing to administer their 9:00 am medications within one (1) hour of prescribed time and failing to notify the physician of the medication errors, and 2) failed to administer blood pressure medication as ordered, following parameters set by the physician for 1 (Resident #41) of 12 residents reviewed for medication administration, by failing to obtain blood pressure readings prior to giving the medication. The findings include: 1. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the [NAME] Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. During an interview with the DON on 2/20/2023 at 11:30 AM, she confirmed that the medications were late for 4 residents (Residents #102, #215, #214, and #71). She added that late medications are considered as med errors and the physician should be notified of the medication errors. (Copies of the physician orders obtained for the four residents). A review of the current physician's orders for the four residents revealed the following orders for critical medications: Resident #102 had orders for Baclofen 20 mg every 6 hours for muscle spasms, Gabapentin 600 mg three times a day for polyneuropathy, Levetiracetam (Keppra) 750 mg 2 times a day for convulsions, Oxycontin 10 mg every 12 hours for pain and Oxcarbazepine 150 mg (give 450 mg) two times a day for spasms and neuropathy. (Photographic evidence obtained) Resident #215 had orders for Apixaban (Eliquis) 5 mg every morning and at bedtime. Insulin lispro sliding scale before meals, midodrine 5mg give three tablets three times a day for hypotension. (Photographic evidence obtained) Resident #214 had orders for Apixaban (Eliquis) 5 mg in the morning and at bedtime. Metoprolol 25 mg every morning and at bedtime. Levemir insulin 25 units one time a day for diabetes. (Photographic evidence obtained) Resident #71 had orders for Quetiapine (Seroquel) 25 mg and 50 mg two times a day for anxiety. (Photographic evidence obtained) On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that two more residents (Residents #14 and #212) other than Resident #31 had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. A review of the current physician's order for Resident #31 and other two residents revealed all three had orders for critical medications: (Photographic evidence obtained) Resident #31 had orders for Clonidine HCI 0.1 mg two times a day for hypertension and Gabapentin 300 mg two times a day for pain. Resident #14 had orders for Apixaban (Eliquis) 5 mg two times a day of thrombosis, insulin apart per sliding scale before meals and at bedtime. (Photographic evidence obtained) Resident #212 had orders for Apixaban 5 mg two times a day for blood thinner. Humalog 5 units before meals for diabetes, Lantus 10 units two times a day for diabetes. (Photographic evidence obtained) During a follow up interview with the DON on 2/20/2023 at 2:49 PM, she confirmed that the medications were administered late. She added that the nurse should have called the physician to see if the dose or the time could be adjusted. She mentioned that there was a hick up with staffing and hence the late medication administration. 2. On 2/22/2023 at 9:43 PM, an observation of medication administration was conducted for Resident #41 with Employee C, LPN (Agency). The nurse obtained one tablet for Entresto 24 mg- 26 mg, and metoprolol 25 mg one-half tablet. He then went to the resident's room and gave the medication to the resident. A review of the medication orders for Resident #41 revealed Entresto 24 mg- 26 give one tablet two times a day hold for Blood pressure (BP) less than 110/60 and Metoprolol 25 mg give 1 tablet daily and hold for BP less than 110/60. (Photographic evidence obtained) On 2/22/2023 at 9:45 PM, Employee C was asked what the blood pressure was for Resident #41. He confirmed that he did not obtain it. He added that the nursing assistants were supposed to obtain the blood pressure and he was not sure what the readings were. During an interview with the DON on 2/23/2023 at 12:07 PM, she stated that while administering blood pressure medications with parameters, the blood pressure should be obtained by the nurse before giving the medication. A review of the facility's policy and procedure titled: Administering Medication (revised April 2019) read: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation revealed the following: 2. The Director of Nursing Services supervises and directs all personnel who administer medication and have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with the prescribers orders, including any required time frames. 5. Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication b. Preventing potential medication of food interactions; and c. Honoring resident choices and preferences, consistent with his or her plan of care. 6. Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example before and after meal orders). 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication. 11. The following information is checked/ verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication, as applicable. (Photographic evidence obtained) .

Based on observations and interview, the facility failed to post the nurse staffing data specified in paragraph (g)(1) of this section [ (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.] on a daily basis at the beginning of each shift for 2 of 2 days observed. The findings include: On 2/20/2023 at 10:10 AM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) On 2/21/2023 at 8:45 AM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) On 2/21/2023 at 1:24 PM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) During an interview with the Administrator on 2/21/2023 at 4:54 PM, she was asked about the nurse staffing information posted at the entrance of the facility. Upon seeing the information posted dated 2/16/2023, she stated, Oh that's not correct. That needs to be changed. She acknowledged the nurse staffing information posted had not been updated and was out of date. .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to date mark numerous open food packages in the refrigerator and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 2/19/2023 at 11:45 AM. During the tour, no date markings were observed on and open container of mayonnaise, an open box filled with tomatoes, an open bag of cabbage, another open box filled with lettuce, a bag of cream wrapped in plastic, and another open bag of shredded cheese on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of buns sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) Another tour of the kitchen was conducted on 2/20/2023 at 9:45 AM. No date markings were observed on an open box filled with tomatoes, an open bag of cabbage, an open box filled with lettuce, and another open bag of shredded cheese on the shelf in the walk-in refrigerator on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of buns sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) An interview was conducted with Dietary Aide H on 2/23/2023 10:44 AM, who confirmed that the facility's policy for date marking was to ensure open food was covered, labeled, and dated. An interview was conducted with the Certified Dietary Manager (CDM) on 2/23/2023 at 10:53 AM. The CDM stated it was a collective responsibility of all staff to maintain food storage standards. She confirmed that the facility policy for food storage and date marking was that opened foods should be zipped locked or saran wrapped, labeled, and dated. A review of the facility's policy and procedure entitled Food Storage: Cold Foods (dated 9/2017), revealed: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures: #5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy and procedure review, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of four residents reviewed for elopement, from a total of 12 residents in the sample. The findings include: A record review for Resident #1 revealed he was admitted on [DATE] and discharged on 1/30/23, with diagnoses including fractures and other multiple trauma, difficulty walking and muscle weakness. Resident #1 was his own decision maker and had a family member listed as an emergency contact. A review of Resident #1's 5-day minimum data set (MDS) assessment dated [DATE] revealed he was admitted from an acute hospital. Resident #1 had a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. He was assessed with no wandering behavior. An Elopement Risk Evaluation dated 12/7/22 revealed he was independently mobile but was not at risk for elopement (leaving facility without supervision and permission). A review of nursing progress notes indicated Resident #1 was oriented to person, place, and time. A facsimile transmission dated 1/6/23 included a Notice of Medicare Non-Coverage (NOMNC) notifying Resident #1, his insurance would stop paying for his skilled therapy services as of 1/9/23. The form was signed in acknowledgement by Resident #1 on 1/9/23. A corresponding Social Services Progress Note dated 1/9/23 revealed Resident #1 received his NOMNC Friday. The Social Services Assistant reviewed the notice with the resident, who signed the form. Resident is VA (Veterans Administration) and has been approved with HUD-Cash program; however, it will take time to secure housing. Resident #1's plan is to remain in the facility until housing is available. A review of the resident sign-in and sign-out book found Resident #1 signed himself out and back into the facility 25 times during his stay. A review of Resident #1's physician's order dated 12/7/22 revealed he could go on leave of absence (LOA). A nursing progress note dated 1/30/23 at 12:32 reported Resident #1 called the facility to state he left the facility against medical advice (AMA). The note was authored by Licensed Practical Nurse (LPN) A. There was no other progress note or entry explaining further. An interview was conducted with LPN A on 2/2/23 at 2:20 pm. She said some residents were permitted to go out on leave. She remembered Resident #1, he was always coming and going from the facility. He was very independent, very alert, and oriented. She does not know any circumstances about his departure but recalled being told that day Resident #1 called and said he wasn't coming back. She was asked to chart it. LPN A recalled seeing him for lunch medications and saw him leave his room at one point. Then, Resident #1's roommate told her about 5:00 pm or 5:30ish that Resident #1 said he was leaving. Resident #1 was telling people he was leaving. Residents sign in and out, or are supposed to, when they leave. An interview was conducted with the Administrator on 2/2/23 at 2:50 pm. She recalled Resident #1 was admitted for short term rehabilitation services, then he was supposed to return to the community. His insurance covered up to 20 days at 100%. The Business Office Manager had a conversation with him about his co-pay of 20% to remain in the facility. Resident #1 was not happy and said he wasn't paying to stay and would just go back to where he previously was. On Sunday, he was telling everyone he was going to leave and was packing up his stuff. Someone came to the facility, picked him up, and brought him back. Then he told a staff person he was leaving again. He took his stuff, and he did. He also told a CNA he was leaving. LPN A called the Administrator and told her Resident #1 said he was leaving, that he wasn't staying here. The Administrator spoke to Resident #1 on the telephone, and he said he was leaving for good, that they were not taking his money. The Administrator started calling the emergency contact but didn't talk to her until 5:00 am the next day. She did not notify the resident's doctor but did notify the medical director. The Administrator admitted she did not document the conversations. She also confirmed Resident #1 did not sign an AMA form. When she told him, he should have signed the form, Resident #1 told her he wasn't signing nothing. A review of the facility's policy titled Leaving Against Medical Advice (AMA), policy #N-762 effective 11/30/14 revised 10/24/22 revealed, The nurse will ensure the resident has the authority or capacity to make the decision to leave. 1. Discuss/attempt to resolve concerns contributing to desire to leave AMA. 2. Inform the resident of the risk/benefits. Document in the medical record. 4. Notify the physician and document in the medical record. 5. Contact the resident representative and document in medical record. 7. Complete the AMA form and ask the resident to sign. If the resident refuses to sign, document in the medical record. (Photocopy was obtained) A follow up interview was conducted with the Administrator on 2/3/23 at 12:30 pm concerning the facility's AMA policy. She was asked about the lack of documentation in the clinical record regarding the physician and family being notified of Resident #1's departure, and lack of documentation showing that Resident #1 refused to sign the AMA form. The Administrator stated, she did speak with the emergency contact and asked if it was too late for her to write a note? She said, she did talk to the Medical Director and would call him to ask for a note. She acknowledged the lack of documentation per the AMA policy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to provide the necessary care and services for one resident (#28), dependent for all activities of daily living, from a sample of 33 residents. The findings include: A record review for Resident #28 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including metastatic breast cancer and dementia. She was totally dependent for all activities of daily living. She was bedbound, verbally non-responsive, and receiving hospice services. Her record revealed the cancer to her left breast had erupted through the skin on the left side of her chest. During an observation of Resident #28 on 7/20/21 at 10:05 am, she was seen lying in bed in a hospital gown. The gown was stained with a large amount of dried blood at the area of her left chest. There was a large dressing to the left chest area dated 7/20/21. Resident #28 was non-verbal and unable to answer questions. Further observation of the dressing found there was serosanquinous drainage seeping out from the bottom edge of the dressing onto her skin and hospital gown. An interview was conducted with the Licensed Practical Nurse (Employee D) at 10:15 am. She was asked when Resident #28's dressing was last changed. She said the wound nurse had just been in the room to change the chest dressing. She was asked to observe the dressing and the hospital gown. She said the dressing was dated 7/20/21, indicating it had been changed, however there was drainage seeping out and the hospital gown was wet and stained with old bloody drainage. She said the wound nurse should have changed her gown when she changed the dressing. She stated she would have the Certified Nursing Assistant (CNA) come and change her gown. An interview was conducted with the wound nurse on 7/20/21 at 10:20 am. She was asked if she had changed the dressing for Resident #28, and she said she had just been in her room and changed the dressing. She was asked if she had changed her hospital gown, and she said no. When asked if there was drainage on the wound when changed, she confirmed that there was. When asked how often the dressing was changed she said twice a day, she changed it in the morning and then was changed by evening nurse. On 7/21/21 at 9:20 am, Resident #28 was observed lying in bed. The left side of her hospital gown was saturated with serous drainage. Also, the sheet under her upper left side was observed with a large stained area that was dry and brown in color. The dressing to the left chest wall, dated 7/20/21, was observed with serous drainage seeping out of the edges of the dressing onto the surrounding skin and hospital gown. An interview was conducted with Employee D, LPN, on 7/21/21 at 9:25 am. She was asked how often the dressing was changed for Resident #28, and she replied Twice a day. The wound nurse changes it in the morning and she changes the dressing in the evening before she leaves at 7:00 pm. She was asked about wound drainage. She said the protruding mass on the chest wall was large and did have serosanguineous drainage often. When asked if the amount of drainage had increased, she said no, it had been draining for awhile. When asked if the dressings applied were able to absorb enough drainage to keep the skin and clothing dry, she said usually and the CNA would tell her if the dressing was leaking. She was asked if she had seen Resident #28 this morning, and she replied not yet. She was asked to observe Resident #28. Employee A stated the hospital gown was wet from drainage and the sheet under her had a ring of old, dried drainage. She said she would notify the wound nurse the dressing needed to be changed and have the CNA change the resident's gown and sheet.

Based on observations, staff and resident interviews, admission packet review and medical record review, the facility failed to ensure one resident (Resident #70), from a sample of 33 residents, received assistance with making appointments to receive proper treatment and an assistive device to maintain hearing ability. The findings include: On June 19, 2021 at 8:51 am, Resident #70 was observed in his room, sitting up in his wheelchair, dressed in his day clothes and eating breakfast. Resident #70 asked this writer to speak louder while speaking with him. When asked if he had hearing aids, he stated, No, but I need them. I need two of them. He was asked if he had ever had hearing aides. He stated, No, never. I wish I could get them. When asked if he had ever let staff know that he wanted hearing aides since his admission to the facility, he stated, Yeah, I don't know who I told, but I know I asked. On June 20, 2021 at 9:40 am, Resident #70 was observed watching television in his room with the volume excessively loud. On June 21, 2021 at 10:20 am, Resident #70 was observed working with therapy in his room. His television was on and the volume was excessively loud. On June 21, 2021 at 10:25 am, Employee B, Licensed Practical Nurse (LPN), was interviewed. She was asked if she was caring for Resident #70 on her assignment today. She replied Yes. Employee B was asked if the resident was hard of hearing and she replied, Yes, he's very hard of hearing. I have to get right up to him and talk on his right side so he can here me, and talk loud. When asked if he had hearing aides, Employee B replied No. When asked if he had had an audiology evaluation since his admission, she replied, No, not yet. We have requested a hearing evaluation but with COVID, we're not sure about him going out or having someone come in to do an evaluation. On June 21, 2021 at 1:10 pm, the Administrator was interviewed. She had been asked for a facility policy for audiology consults and hearing aids. She stated I looked, and we don't have a policy for audiology appointments. If a resident needs something like ear drops, the doctor will order them. If they need an audiology consult for hearing aides, they go out to an audiologist for an appointment. She was asked if the facility had an audiology company that came to the facility to see residents. She stated No. A review of Resident #70's medical record revealed the following: His MDS (Minimum Data Set) assessment, dated June 16, 2021, revealed he had a BIMS (brief interview for mental status) score of 9 out of a possible 15 points, indicating moderate cognitive impairment. His hearing was listed as moderate difficulty. The question asking whether the resident had hearing aids was answered No. Further review of his MDS assessments dated November 11, 2020 and February 10, 2021, revealed his hearing ability was listed as moderate difficulty. The question asking whether the resident had hearing aids was answered No on both dates. A review of Resident #70's current orders revealed an order entered on November 5, 2020 (his date of admission) which read, Audiology as needed. A review of the current care plan for Resident #70 showed the following focus/goals/interventions under Communication: Focus: The resident has a communication problem related to hearing deficit (updated 6/16/2021) Goals: The resident will be able to make basic needs known on a daily basis through the next review date. The resident will develop communication abilities by the next review date. Interventions: Anticipate and meet needs. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Communication: allow adequate time to respond, repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face when speaking, make eye contact. Turn off the TV, radio to reduce environmental noise. Ask yes/no questions when appropriate. Use simple, brief consistent words/cues. Use alternative communication tools as needed. A review of progress notes in the social services section of Resident #70's medical record did not reveal any progress notes pertaining to audiology or hearing concerns. On June 22, 2021 at 9:30 am, in an interview with the Social Services Director, she was asked how the long-term care residents were referred to audiology. She replied, We have an outside company. They can come on-site to evaluate residents for hearing aides and audiology issues. We fill out a referral form and send it to them, then they send someone out to see the resident, and they take it from there. When asked how she would know if a resident needed an audiology evaluation she replied, Well, sometimes a resident will tell me themselves, whether they come to me or maybe when I am just speaking to them in their room on other matters. Other times, a nurse or other staff member might tell me, and then I'll initiate the evaluation. Then there will be another conversation that will happen for Medicaid to determine if there is any family cost. The Social Services Director was asked if Resident #70 had been referred to audiology or set up for an audiology appointment since he was admitted in November 2020. She replied No, he hasn't. . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observations, the facility failed to ensure behavior monitoring was conducted for one (Resident #77) of five residents receiving psychotropic medications from a total sample of 33 residents. The findings include: A record review for Resident #77, revealed an [AGE] year-old female admitted on [DATE] with diagnoses including schizophrenia, anxiety, delusions, dementia and falls. Her medications included: Xanax 0.5 mg (milligrams) 3 times a day (anxiety), ABH gel 3 times a day for severe insomnia and anxiety, remeron 7.5 mg daily (depression), depakote sprinkles 125 mg 2 times a day( anxiety), and seroquel 25 mg 2 times a day (antipsychotic). Documentation indicated she was alert with confusion, very anxious, restless, wandering in her wheelchair and looking for her children. She needed assistance with activities of daily living, was incontinent of bowel and bladder, and required assistance with ambulation. A review of the Medication Administration Record (MAR) for June and July 2021, found no behavior monitoring for the use of psychotropic and antipsychotic medications. An interview was conducted with the Licensed Practical Nurse (Employee A) on 7/21/21 at 2:30 pm. She was asked where the nurses documented behavior monitoring for Resident #77, and she replied on the MAR. She was asked to locate the documentation in electronic medical record after a review of the MAR, and she stated there was no documentation of behavior moniotring in the electronic record either. An interview was conducted with Licensed Practical Nurse (Employee G) on 7/21/21 at 2:40 pm. She was asked where behavior monitoring documentation was located. She reviewed the computer and was able to locate documentation for another resident and demonstrated how to click on boxes to answer questions related to behavior. When asked if she could locate behavior monitoring for Resident #77, she stated there was none, but would add nehavior monitoring to the resident's record today. .

Based on a review of resident and facility records, and interviews with residents and staff, the facility failed to maintain complete medical records in accordance with professional standards of practice and the facility's policies and procedures for one (Resident #18) of one resident who received hemodialysis treatments, out of a total of 33 residents in the sample. The findings include: In an interview with Resident #18 on 7/19/21 at 9:45 AM, he stated he received hemodialysis treatments at a local center. The dialysis center sent written information home with him after each visit and dressed (bandaged) his dialysis access site at the center. He exposed the access site, which was on his right upper chest. It was covered with a clean gauze bandage. Resident #18 stated they were going to relocate the access site to his right forearm soon. Employee F, Licensed Practical Nurse (LPN), was interviewed on 7/19/21 at approximately 10:00 AM. She confirmed Resident #18 received dialysis treatments. Employee F explained that she took his vital signs pre- and post-dialysis, and documented it on a communication sheet. The dialysis access site was checked every shift for bleeding or infection. It was not necessary to check for bruit and thrill (the sound and feel associated with turbulent blood flow) due to the site's location on the chest. No medications were required to be held prior to dialysis. A record review for Resident #18 found an admission 5-day Minimum Data Set (MDS) assessment with an assessment reference date of 5/14/21. Resident #18 had a brief interview for mental status (BIMS) score of 15/15, indicating intact cognition, and required supervision with activities of daily living. His diagnoses included medically complex conditions and renal insufficiency/failure/end-stage renal disease (ESRD). Resident #18 received dialysis while a resident and before residing in the facility. Resident #18 was care planned on 5/17/21 for his multiple medical conditions including hemodialysis related to ESRD. The approaches included dialysis treatments on Tuesdays (T), Thursdays (TH) and Saturdays (SAT). Additional guidance instructed, may hold medications, monitor right chest port and report problems. Resident #18 had a physician's order for no medications prior to dialysis, and treatment every T, TH and SAT. A review of Resident #18's dialysis communication forms for July 2021 revealed missing pre- and post-dialysis information on the following dates: On 7/3/21, the nurse responsible for Resident #18, initiated a Dialysis Communication Record for him to take to his dialysis provider. The sending nurse did not sign, date or time stamp the form. Each of those sections were left blank. The section that was to be completed by the facility upon his return from his treatment also had missing information. The sections asking for Resident #18's blood pressure, pulse, respirations, temperature, pain level, access site location, bruit and thrill and the presence of bleeding were blank. The author, Employee H, Registered Nurse (RN), did not sign/date the form. The Dialysis Communication Record for Resident #18's 7/8/21 treatment was void of a sending nurses' signature, date or time. There was no notation upon his return related to the access site location, bruit or thrill by Employee H. On 7/14/21, Employee H did not note Resident #18's access site, bruit, thrill or presence of bleeding upon his return from treatment. On 7/17/21, the sending nurse did not sign, date or time-stamp the form. Upon return, the section asking for the access site location, and for the presence of bruit and thrill, bleeding or pain was left blank by Employee H. A review of the facility's policy and procedure titled Coordination of Hemodialysis Services (#N1359 - revised 7/2/19) noted, The dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD nurse. Upon return to the facility, nursing will . .5. Complete the post-dialysis information on the dialysis communication form and file in the resident's clinical record. (photocopy obtained) An interview was conducted with the Director of Nursing on 7/22/21 at 5:15 PM. She reviewed the forms and confirmed the missing information. She stated the nurses should be filling out the forms as that information was important. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On July 19, 2021 at 9:00 am, Resident #65 was observed in her room with her oxygen concentrator set at between 3.5 and 4 LPM. She was receiving her oxygen via nasal cannula. On July 19, 2021 at 12:19 pm, a medical record review for Resident #65 revealed an active physician's order that stated, Respiratory: Oxygen-Continuous 2 liters with an order date of 5/26/2021. On July 19, 2021 at 1:20 pm, Resident #65 was observed sitting up in her bed with her oxygen concentrator set at between 3.5 and 4LPM. Oxygen was being delivered via nasal cannula. She was asked if she ever adjusted the setting on her oxygen concentrator, and she replied, Oh no, I don't touch that. That's for the nurses to do. On July 20, 2021 at 10:15 am, Resident #65 was observed lying on her bed with her oxygen being delivered via nasal cannula. Her oxygen concentrator was set at between 3.5 and 4 LPM. On July 21, 2021 at 10:20 am, Employee B, Registered Nurse (RN), was interviewed. She was asked if she was the nurse caring for Resident #65 today. She stated Yes. She was asked for the resident's current oxygen order, adn she stated, Three liters per minute. She was asked if the order was for continuous oxygen or as needed oxygen, and she replied, Her order is continuous. On July 21, 2021 at 10:30 am, Resident #65 was observed lying on her bed, awake, with her head at the foot of the bed. Her oxygen was being delivered via nasal cannula. Her oxygen concentrator was set at between 3.5 and 4 LPM. She was asked how her breathing was. She gave an ok sign with her fingers and smiled. On July 22, 2021 at 9:15 am, Resident #65 was observed lying in her bed, awake, with her head at the foot of the bed. Her oxygen was being delivered via nasal cannula. Her oxygen concentrator was set at between 3.5 and 4 LPM. On July 22, 2021 at 10:00 am, Employee C, LPN, was interviewed. She was asked if she was caring for Resident #65 today. She stated Yes. She was asked how often she checked the oxygen concentrators to ensure they were set on the prescribed rate of oxygen for the residents. She stated I'm not sure what you mean. She was then asked, Do you check the oxygen concentrators for your residents who are receiving oxygen to see whether they are receiving the physician-ordered flow rate? She replied, Yes, obviously I check it when I check their pulse-ox rate. She was asked how often she checked her residents' pulse-ox rates. She stated, It depends, some are once a shift and some are more often. She was asked what the physician's order for Resident #65's oxygen stated. She replied, 2 liters. On July 22, 2021 at 10:15 am, Resident #65 was observed standing in her room. Her oxygen was being delivered via nasal cannula. Her oxygen concentrator was observed to be set between 3.5 and 4 LPM. On July 22, 2021 at 10:30 am, further medical review for Resident #65 revealed a care plan with the following focus/goal/intervention, dated 12/23/2020, and last revised on 6/7/2021: Focus: The resident has COPD Goal: The resident will be free of s/sx (signs and symptoms) of respiratory infections through the review date. Interventions: Give aerosols or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance. Monitor for s/sx acute respiratory insufficiency: anxiety, confusion, restlessness, SOB (shortness of breath) at rest, cyanosis, somnolence. Monitor/document for anxiety. Offer support, encouragement. Give PRN medications for anxiety as ordered. Oxygen settings: 02 via nasal prongs as ordered. Further review of Resident #65's progress notes revealed three recent notes which addressed the resident's oxygen orders as follows: 6/13/2021 15:29: if using oxygen, describe liters per minute. 3L. Comments: Pt is on 3L via NC continuous at her baseline. 6/14/2021 09:19: if using oxygen, describe liters per minute. 3Lts 6/17/2021 18:40: if using oxygen, describe liters per minute. 3L. Based on observations, record review and interviews, the facility failed to provide respiratory care as needed and ordered for four (Residents #38, #57, #65 and #29) of 13 residents receiving oxygen therapy, from a total of 33 residents in the sample. Three residents (#38, #57, #29) were receiving oxygen without physician's orders, and one resident (#65) was receiving the wrong amount of oxygen. The findings include: 1. An observation was made of Resident #38 in his room on 7/19/21 at 8:43 AM. He was in a vegetative state, had a tracheostomy and was receiving oxygen at 5 liters per minute (LPM). A second observation on 7/20/21 at 9:41 AM, revealed oxygen infusing through the trachea at 5 LPM. Resident #38 was lying in bed. A third observation made on 7/21/21 at 9:33 AM, revealed the oxygen was still infusing via the trachea at 5 LPM. A review of the medical record for Resident #38 revealed an admission date of 6/8/21 with diagnoses including quadriplegia, contractures, and chronic respiratory failure with tracheostomy. The Minimum Data Set (MDS) admission Assessment, dated 6/15/21, reported the resident in a vegetative state, requiring total care for all activities of daily living, receiving oxygen, and tracheostomy care. The care plan, updated 6/24/21, noted a tracheostomy for chronic respiratory failure with oxygen as ordered. A review of the current physician's orders revealed no order for the oxygen the resident was receiving at 5 LPM. An interview was conducted with Employee A, Licensed Practical Nurse (LPN), at 11:40 AM on 7/21/21 at the nurses' station. Employee A reviewed the current Medication Administration Record (MAR) and physician's orders. She confirmed there was no oxygen order for oxygen at a flow rate of 5 LPM through the tracheostomy, but she said she would take care of that now. An interview was conducted with the Director of Nursing (DON) at 2:00 PM on 7/21/21. She confirmed a physician's order was needed for oxygen, and Resident #38 had no such order for the oxygen he was receiving. 2. An observation was made of Resident #57 in her room on 7/19/21 at 10:31 AM, with oxygen infusing at 3 LPM via nasal cannula. A second observation Resident #57 was made on 7/20/21 at 10:00 AM. She was in her room receiving oxygen at 2 LPM via nasal cannula. On 7/21/21 at 2:00 PM, the resident was observed receiving oxygen at 2 LPM via nasal cannula. A record review was conducted for Resident #57, which noted an admission date of 6/19/21 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of the current physician's orders revealed no order for the oxygen. An interview was conducted with the DON at 9:05 AM on 7/22/21 concerning the oxygen for Resident # 57. The DON confirmed that Resident #57 had no physician's order for the oxygen and it was entered yesterday by staff (7/21/21). She reported conducting a Quality Assurance improvement plan with education of staff that was started yesterday (7/21/21), and a audit of all residents receiving oxygen for orders and following physician's orders for the accurate liters of oxygen to be infusing. 4. A record review for Resident # 29, revealed a [AGE] year-old female with diagnoses including lymphedema, morbid obesity, congestive heart failure and diabetes. She was alert and oriented and needed total assistance with all activities of daily living except for eating. During an observation of Resident #29 on 7/20/21 at 1:30 pm, she had a nasal cannula in place. Observation of the oxygen concentrator found the flow rate was at 4.5 LPM. During an interview with Resident # 29 at 1:35 pm, she was asked what rate of oxygen was she ordered and she stated, Three liters. During an observation of Resident # 29 on 7/21/21 at 9:30 am, the oxygen concentrator flow rate was set at 4.5 LPM. Also, the humidifier bottle was on the floor attached to the concentrator. The humidifier bottle did not have a date indicating when it was opened and connected to the concentrator. An interview as conducted with Employee D, LPN, on 7/21/21 at 9:35 am. She was asked what oxygen rate was ordered for Resident #29. She reviewed the Medication Administration Record (MAR) and said no oxygen order were found, but she thought the order was for 2-3 LPM. She said she would check the order when she finished the medication pass. When asked if she had observed the concentrator for flow rate, she said she had not been in the room yet. She was asked when the humidifier bottle for the concentrator last changed, and she said the date should be on the bottle. After observation of the humidifier, she said there was no date found. A review of the record found no orders for oxygen. A review of the care plan addressed Oxygen Therapy at 3-4 LPM, dated March 2021. Further review of the record found that a new order was obtained on 7/21/21 at 9:40 am for oxygen at 3-4 liters, keep oxygen saturation levels above 92%. A review of the facility's Policy and Procedure for Oxygen Therapy (revised 8/28/17), revealed the following: Physician's order for oxygen therapy shall include administration modality, FiO2 of liter flow, continuous or PRN (as needed), and PRN orders must include specific guidelines as to when the resident is to use oxygen. (Photocopy obtained) .

Based on observations and an interview with the Director of Dietary Services (DDS), the facility failed to store ice in a clean and sanitary manner, and refrigerated food and nutritional supplements at safe and proper temperatures and in accordance with professional standards in one (East Wing pantry) of two pantries in the facility. The findings include: An observation of the East Wing pantry ice machine on 7/21/21 at 12:06 PM, found significant biological growth, brownish in color and slimy in appearance, running along the length of the top interior of the machine. There was condensation covering the area and multiple droplets that were poised to drip into the clean ice. The thermometer in the refrigerator, which held containers of juice, applesauce and nutritional supplements, read 44 degrees Fahrenheit (f). (Photographic evidence obtained) In a second visit to the East Wing pantry with the DDS on 7/22/21 at 4:00 PM, the ice machine was observed in the same condition. The concern was shown to the DDS. Using his cell phone flashlight, he looked in the ice machine and said, That's disgusting. When asked what the ice was used for, he said it was for the residents' hydration carts on a daily basis. He looked at the refrigerator thermometer, which now read 50 degrees f. He stated the refrigerator had just been fixed. The DDS was asked to take the temperature of the applesauce that was in the refrigerator. He did, and the digital food thermometer registered 46 degrees f. He retrieved one of two cartons of vanilla-flavored Med Plus (a high calorie nutritional supplement) from the refrigerator, poured a cup and took the temperature. The thermometer registered 47.6 degrees f. The DDS confirmed the refrigerator was not holding at the proper temperature and would need to be repaired again. He also stated he would immediately address the ice machine. The Regional Director of Clinical Services reported on 7/22/21 at 4:39 PM, that the facility would immediately address the ice machine by emptying and cleaning it. She added that someone had turned the involved refrigerator's freezer all the way down, which sometimes froze up the unit. It would be emptied, turned off, cleaned and checked again. .