**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat residents in a dignified manner for 5 of 5 sampled residents observed during dining observations, Resident #48, Resident #38, Resident #311, Resident #115, and Resident #67, as evidenced by calling residents 'feeders' and staff standing to feed residents. The findings included: Review of the facility's policy, titled, Dignity, dated 11/14/24, revealed the following, in part: The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. Staff always speak respectfully to residents, and not labeling or referring to the residents by his or her room number, diagnoses, or care needs. 1. In an observation conducted on 12/10/24 at 8:25 AM, Staff A, Registered Nurse, was noted on the 100's Hallway, passing the breakfast trays to staff. He was observed taking a breakfast tray and giving it to a staff member and said she is a feeder as he was passing the breakfast tray to the staff member. 2. In an observation conducted on 12/10/24 at 8:28 AM, Staff B, Certified Nursing Assistant (CNA), was noted sitting near Resident #32, assisting her with the breakfast meal. Resident #32's roommate (Resident #48) was in bed with her breakfast tray at the bedside. At 8:37 AM, about 10 minutes later, Staff B took Resident #32's breakfast tray out of the room and placed it in the meal cart in the Hallway. At 8:49 AM, which was about 20 minutes later, Staff B came back into the room and started assisting Resident #48 with her breakfast tray. 3. Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of Dementia and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #38 was severely cognitively impaired. In an observation conducted on 12/11/24 at 8:49 AM, Staff D, CNA, was noted feeding Resident #38 while standing over his bed. Closer observation revealed a chair at the corner of the room that was empty and not in use. 4. In an observation conducted on 12/11/24 at 8:45 AM, Resident #311 was in the room with her breakfast tray at the side table. During the continued observation at 9:10 AM, Staff E, CNA, was noted standing over Resident #311 and attempting to feed her some of the food on the breakfast tray. In an interview conducted on 12/12/24 at 10:10 AM with Staff F, Certified Nursing Assistant, stated that when assisting a resident during dining they need to ensure that they are sitting near the residents at an eye level. All residents need to be treated with dignity and respect. 5. On 12/09/24 at 1:36 PM, during in-room dining observation at the facility's south area, revealed Resident #67 sitting in a wheelchair by the nurses station. Subsequently, an interview was conducted with Staff C, CNA, who stated Resident #67's tray was in the tray's cart because he was a 'feeder'. Review of Resident #67's MDS quarterly assessment dated [DATE] documented the resident needed supervision or touching assistance during eating. 6. On 12/09/24 at 1:35 PM, during in-room dining observation at the facility's south area, revealed Resident #115 sitting in a wheelchair by the nurses station. Subsequently, an interview was conducted with Staff C, CNA who stated Resident #115's tray was in the tray's cart because she was a 'feeder'. Review of Resident #115's MDS quarterly assessment dated [DATE] documented the resident needed set-up or clean up assistance during eating. On 12/11/24 at 2:23 PM, an interview was conducted with Staff C, CNA who was apprised of calling Resident #67 and Resident #115 'feeders' during lunch time on 12/09/24. Staff C and replied No and added she had to say 'assist' the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessments related to medications and diagnosis for 3 of 5 sampled resident reviewed for unnecessary medications, Resident #77, Resident #167, and Resident #168. The findings included: 1. Review of Resident #77's clinical record documented an admission on [DATE] with no readmissions. The resident's diagnoses included Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Fall, Chronic Pain, Tobacco Use, Cognitive Communication Deficit, Major Depressive Disorder, Nicotine Dependence, Persistent Mood Disorders, Generalized Anxiety Disorder, and Unspecified Dementia. Review of the physician order dated 08/20/24 documented, Nicotine Patch 24 Hour 7 MG (milligrams) /24 HR (hour), apply 1 patch transdermally one time a day for Smoking Cessation and remove per schedule. Review of Resident #77's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating the resident had no cognition impairment. On 12/11/24 at 4:47 PM, an interview was conducted with the Consultant Pharmacist (CP) who was apprised of Resident # 77 having a physician order for Nicotine patch and she had been observed smoking on 12/10/24 late in the afternoon. The CP stated she did not know the resident was smoking and the Nicotine patch is usually done for two months. During the interview, the CP stated that the Nicotine patch was a psychotropic medication, and she had not done a Gradual Dose Reduction (GDR) as required. The CP stated Nicotine needed to be monitored and coded in the resident's record as a psychotropic medication. On 12/12/24 at 10:39 AM, an interview was conducted with the facility's MDS Director and Staff CC, MDS Coordinator. A side-by-side review of the resident's Quarterly MDS assessment dated [DATE] was conducted. Staff CC stated the assessment was not coded for a psychotropic medication. The MDS Director stated she was aware Resident #77 had a nicotine patch, and they (staff) were aware. She added she communicated to nursing and had a psychiatry consult who said it is okay for resident to do both (nicotine patch and smoke) as it would help to get the resident to stop smoking. 2. Review of Resident #167's clinical record documented an admission on [DATE] and a readmission on [DATE]. Review of Resident #167's clinical diagnoses documented on the face sheet included Schizoaffective Disorder, Bipolar Type dated 08/12/24. The face sheet did not list a diagnosis of Schizophrenia. Review of Resident #167's quarterly MDS assessment dated [DATE], section Active Diagnoses-Psychiatric/Mood Disorder, was not coded for Bipolar Disorder or psychotic disorder and was coded for Schizophrenia. On 12/10/24 at 3:22 PM, a side-by-side record review and interview was conducted with the MDS Director who stated Resident # 167 was initially admitted to the facility on [DATE] and had a readmission [DATE]. The resident's quarterly MDS assessment dated [DATE] documented a BIMS score of 15 indicating no cognition impairment. During the review, the MDS Director stated Resident #167 had a new diagnosis of Schizoaffective Bipolar type on 08/12/24. On 12/12/24 at 10:26 AM, an interview was conducted with Staff CC, MDS Coordinator, who was asked where he gets the resident's diagnoses information and replied, 'from the doctors notes and hospital records.' Staff CC was asked where he got Resident #167's diagnosis of Schizophrenia that was coded on the MDS assessment. Staff CC replied from the diagnoses list. Staff CC reviewed the resident's diagnoses list and stated that the Schizoaffective diagnosis was always there on the list. Staff CC stated, 'it was miscode, there was not a Schizophrenia diagnosis listed'. 3. Review of Resident #168's clinical record documented an initial admission on [DATE] with a readmission [DATE]. The resident's diagnoses included Effusion of Left Knee, Type 2 Diabetes Mellitus, Arteriovenous Fistula- Acquired, Hypertension, Respiratory Disorders, Generalized Anxiety and Major Depression. Review of Resident #168's MDS, the five (5) days Medicare assessment dated [DATE], documented a BIMS score of 15 indicating no cognition impairment. Review of Resident #168's physician orders during the MDS review period (10/29/24 to 11/05/24) provided by the MDS Director, documented the following medications: *10/29/24, Aspirin EC (enteric coated) tablet Delayed Release 81 MG (Aspirin) give 1 tablet by mouth one time a day for antiplatelet. *10/29/24, Cefuroxime Axetil (an antibiotic) oral tablet 250 mg, give one (1) tablet by mouth two times a day for Sepsis for 7 days. *10/29/24, Doxycycline oral tablet 100 mg, give one tablet every 12 hours for Sepsis for 19 administrations. *10/29/24, Lantus Solostar subcutaneous solution Pen Injector 100 unit/ml inject 10 units subcutaneously at bedtime for Diabetes. *10/29/24, Insulin Glargine-100 UNIT/ML (millimeters) Solution pen injector, inject 10 unit subcutaneously at bedtime for Diabetes. *10/29/24, Sertraline oral tablet 100 mg, give one tablet by mouth at bedtime for Depression. Further review revealed there was not a physician order for an anticoagulant. On 12/10/24 at 11:00 AM, an interview and a side-by-side record review of Resident #168's MDS for five (5) days Medicare assessment dated [DATE] was conducted with the MDS Director. The MDS Director stated the assessment documented the resident took an antiplatelet and anticoagulant medications seven (7) days prior to the assessment completion on 11/05/24. The MDS Director was asked to check the physician orders for anticoagulant and antiplatelet during the look back period and stated she did not see an order for anticoagulant or antiplatelet. The MDS coordinator stated she would do a modification to the assessment. The MDS Director stated the assessment was miscoded for anticoagulants and the physician's order-read Aspirin for antiplatelet. The Director added it was a click on error. The Director added the resident's assessment should have been coded for hypoglycemic and antidepressant and it was not. On 12/10/24 at 3:15 PM, during an interview with the MDS Director and Staff CC, MDS Coordinator, Staff CC stated he looked up Aspirin and it is classified as an anticoagulant, antiplatelet. The MDS Director stated Resident #168 was care planned for Aspirin medication as an antiplatelet. Staff CC was asked why the assessment was coded for an anticoagulant and replied because of the Aspirin order. On 12/10/24 at 3:36 PM, a telephone interview with the MDS Director, Staff CC and the Consultant Pharmacist (CP) was conducted. The CP stated that Aspirin can be used as an antiplatelet but not as an anticoagulant. The CP was apprised that Aspirin was coded as an anticoagulant. Review of Resident #168's MDS assessment revealed the assessment was not coded for antibiotics, antidepressant and hypoglycemic administered seven (7) days prior to the assessment completion on 11/05/24. The MDS assessment was coded for anticoagulant and there was no physician order for it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review showed that Resident #86 was admitted on [DATE] with diagnosis of Major Depressive Disorder and seizure disorder. The MDS quarterly assessment dated [DATE] revealed the BIMS score was 00, which indicates severe cognitive impairment. Review of the physician orders indicated the following: Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth at bedtime for Psychosis for 14 Days dated 10/03/24. A thorough review of the care plan dated 09/12/2024 indicated that Resident #86 is prone to side effects related to the use of: Antipsychotic, Antidepressant, Anticoagulant, Anticonvulsant, which need to be observed for potential side effects such as: hypotension, tachycardia, nausea, vomiting, diarrhea, blurred vision, chest pain, rash, drowsiness, lethargy. The facility failed to implement a Care Plan to monitor side effects for Antipsychotic medications. 2. Record review revealed Resident #198 was admitted on [DATE] with diagnoses that included Hyperlipidemia, Type 2 Diabetes Mellitus with Foot Ulcer, Benign Prostatic Hyperplasia, Chronic Viral Hepatitis, Atherosclerotic Heart Disease of Native Coronary Artery, and Venous Insufficiency. Review of the MDS assessment revealed a BIMS score of 13, indicating the resident was cognitively intact. Record review of the physician orders dated 11/13/24 revealed to give Meropenem I GM. (gram) into venous catheter every 12 hours. Review of nursing progress notes dated 11/13/24 revealed: The resident started on 11/13/2024 with Intravenous (IV) Medications of Meropenem Intravenous Solution Reconstituted 1 GM (gram)(Meropenem), related to cellulitis until 11/28/2024. Additional review of the nursing care plan dated 11/13/24 revealed that if the IV (intravenous) is infiltrated: stop infusion and thoroughly examine the site. If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made to lessen the amount of drug at the site. After removing the cannula, elevate the affected arm, notify the physician (for large infiltrations and extravasations), and apply cool compresses (warm, if [NAME] alkaloids are involved). Additional nursing care plan interventions dated 11/13/24 revealed to check IV dressing site daily. Review of Medication Administration Record (MAR) dated 11/14/24 revealed to flush left upper arm midline catheter every shift. The same MAR revealed that nurses documented their initials from 12/01/24 until 12/10/24 indicating flushings of the midline catheter on these dates were performed. Additional review of MAR with input date of 11/14/24 revealed to perform midline to left arm check every shift and code with the following: 1= no problem, 2= edema, 3= redness, 4=pain. Further review of MAR from 12/01/24 until 12/10/24 revealed that nurses put their initials but no codes were documented on all these dates, indicating the midline left arm checked was not done per order. Further review of MAR dated 11/14/24 revealed an order to change the midline IV dressing to left upper arm as needed. From 12/01/24 until 12/11/24, there were no nurses initials recorded indicating nurses did not change the dressing as needed. Further review of nursing progress notes did not show dates when IV sites dressings were changed and documented. During observation on 12/09/24 at 9:35 AM, the resident was sitting on bed with left arm IV dressing with no date and tag. The square surrounding area had a brownish coloration and the Tegaderm (transparent medical dressing) shield was loosely covering the bottom and some sides of a white gauze dressing. When asked if he is receiving medication through the IV catheter, Resident #198 replied No. During another observation and interview on 12/11/24 at 9:30 AM, Resident #198's IV dressing were loose, and the surrounding area had reddish fluid drainage on the dressing and the surrounding area that smelled like blood. Resident #198 stated IV antibiotic was discontinued a long time ago. When asked why he still has the IV catheter on left arm, he stated he did not know, and no one informed him of why IV catheter is on his left arm. When asked if the staff were checking on the catheter, he stated not recently. During another observation on 12/11/24 at 9:35 AM, it revealed the left arm IV access had reddish drainage around the white dressing gauze, the Tegaderm shield was 90% off the white gauze dressing, and the fluid around the dressing area smelled like blood. When asked, Resident #198 stated that the dressing and the IV access were very loose. During interview with the Director of Nursing (DON) on 12/11/24 at 2:47 PM, regarding (Intravenous) site and IV antibiotic, he added that he is aware that resident's antibiotic was discontinued on 11/28/24. He stated the resident kept the intravenous access line on left inner upper arm per Doctor's order. Only doctors may continue and discontinue IV . When asked if the IV access site is monitored, he stated, Nurses flush the Midline access and change the IV site dressing. In another interview with the DON on 12/11/24 at 3:59 PM, when asked regarding the IV access site and the antibiotic administered at the IV access site of Resident #198, he stated nurses change the dressing as ordered. When asked when the last administration of antibiotic was given to the IV access site, he responded, The last dose was administered on 11/28/24. When asked when the IV catheter was to be discontinued, since the IV antibiotic was discontinued a few weeks ago, he did not respond. He added that he spoke with Resident #198's physician, and he was not informed of why the IV catheter access site was kept after the IV antibiotic course was completed. He added that the Physician Assistant (PA) of Resident #198's Physician makes rounds to the facility every day, but no order was given to the facility regarding the discontinuation of IV catheter access. Based on observations, interviews and record review, the facility failed to implement care plans to meet the medical, physical, mental and psychosocial needs for residents on psychotropic medications for 5 of 5 sampled residents reviewed for psychotropic medications, Residents #145, #73, #86, #77 and #167; and failed to implement care plans for 1 of 1 sampled resident reviewed for antibiotic therapy, Resident #198. The findings included: Review of the facility's policy, titled, Care Plans, Comprehensive Person-Centered, dated 09/25/24, included the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the service that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Record review for Resident #145 revealed the resident was admitted to the facility on [DATE] with re admission on [DATE] with the following diagnoses: Fracture of Neck of Left Femur, Type 2 Diabetes Mellitus, Major Depressive Disorder, and Primary Insomnia. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Review of the physician's orders documented Resident #145 had an order dated 11/22/24 for Trazodone HCl 50 mg tablet, to give 0.5 tablet by mouth at bedtime for Depression (Give 1/2 tablet to equal 25 mg). Review of the physician's orders documented Resident #145 had no orders to monitor side effects for Trazodone 50 mg tablet. Review of the Quarterly Care Plan dated 11/30/24 documented Resident #145 was on psychotropic medications (Trazodone) for Depression. The goals were to be free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions included the following: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/record/report to MD as needed side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Offer nonpharmacologic interventions such as conversation, hand massage, diversional activities, music therapy, redirection, reassurance, education on deep breathing and relaxation techniques, or assist to a quieter environment. Review of the Psychiatry assessment dated [DATE] documented Resident #145 was unstable and required medication changes as per collected information and interview. Resident #145's symptoms are occurring almost daily due to exacerbation of underlying depressive disorder and causing severe distress. The plan of action is to start Resident #145 on Trazodone 25 mg at bedtime. An interview was conducted on 12/11/24 at 10:50 AM with Staff Z, Licensed Practical Nurse (LPN) who stated she has worked at the facility for 2 months and has been Resident #145's nurse for 2 weeks. She stated a physician's order is needed to monitor side effects of psychotropic medications and then the nurses can document in the Medication Administration Record (MAR) and progress notes for any side effect observations. An interview was conducted on 12/11/24 at 11:59 AM with Staff V, Unit Manager/UM of the [NAME] Unit, who stated she has worked at the facility for 6 months. She stated in order to monitor side effects of medications, an order is required and the nurses document the side effects in the MAR and nursing progress notes. In addition, Staff V stated MDS (coordinators) can input orders for behavior and side effect monitoring for psychotropic medications. An interview was conducted on 12/11/24 at 4:31 PM with the Director of Nursing (DON). He stated the order listing report (new medication orders) is reviewed every morning by him and the unit managers, and any addition or changes to the order will be made at that time. The DON also stated physician's orders can be input by nurses, unit managers, pharmacists, and psychology staff. He stated the psychology nurse practitioner can add an order into the computer system and only be seen under the MAR and not under the orders; however, he was not aware that side effects needed to be monitored for psychotropic medications. 3. Record review revealed Resident #73 was admitted on [DATE] with diagnoses of Hyperlipemia and Major Depressive Disorder. The physician's order showed an order for Sertraline (depression medication) 50 milligrams one time a day, which was dated 08/09/24. Continued review of orders did not show an order to monitor the side effects of the Sertraline. The Annual MDS dated [DATE] revealed Resident #73 had a BIMS score of 13, which is cognitively intact. The Care Plan initiated on 05/23/24 showed that Resident #73 was on psychotropic medication Sertraline. Interventions are in place to monitor, record, and report to the doctor side effects and adverse reactions to the psychoactive medications. In an interview conducted on 12/12/24 at 12:05 PM, the facility's MDS Director stated that once a care plan for psychotropic medication is initiated, a batch order is generated to include monitoring of behaviors and side effects of the medicines. The staff will later document any side effects of the medications in the electronic system. The care plan will be reviewed to ensure that the orders are placed for monitoring of side effects and will be communicated to nursing. 4. Review of Resident #77's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Tobacco Use, Cognitive Communication Deficit, Nicotine Dependence, Persistent Mood Disorders, Generalized Anxiety Disorder, and Unspecified Dementia. Review of Resident #77's MDS quarterly assessment dated [DATE] documented a BIMS score of 14 indicating the resident had no cognition impairment. Review of Resident #77's clinical record documented the Smoking assessment was conducted in for July, August and November 2024. . Review of a physician order dated 08/20/24 documented, Nicotine Patch 24 Hour 7 MG (milligrams) 24HR (hour). Apply 1 patch transdermally one time a day for Smoking Cessation and remove per schedule. Review of Resident #77's active care plan, titled, Resident has history smoking, initiated and updated on 11/20/24. The care plan interventions included Nicotine patch 24 hour 14 mg/24 hour one time a day for smoking cessation for two months . The care plan lacked written interventions related to monitoring of side effects of a psychotropic medication - Nicotine. Resident #77's clinical record did not include an active care plan related to the use of psychotropic medication (Nicotine). On 12/09/24 at 11:36 AM, during initial observational tour, an interview was conducted with Resident #77 who stated she had the oxygen on 24 hours a day seven (7) days a week. The resident stated she had Emphysema. On 12/10/24 at 4:35 PM, observation revealed Resident #77 in the smoking area with a lit cigarette in her hand. On 12/11/24 at 1:54 PM, an interview was conducted with Staff DD, LPN who stated Resident #77 continues to smoke but did not know how many cigarettes the resident was smoking. Staff DD stated the resident was getting a nicotine patch daily. Staff DD was asked how she would monitor the Nicotine medication side effects and stated she did vital signs daily. Staff DD stated that she would ask the Certified Nursing Assistants if the resident was having any problems like constipation and she would document it on a progress note. During the interview, Staff DD was asked regarding the resident's care plan interventions and replied she did not check the care plans, and added the Manager checks the care plans. A side-by-side and interview of Resident #77's care plan was conducted with Staff DD and replied, 'did not see any monitoring of the resident medication'. Staff DD stated they should be monitoring that. On 12/11/24 at 4:47 PM, an interview was conducted with the Consultant Pharmacist (CP) who was apprised of Resident #77 having a physician order for Nicotine patch and she was observed smoking on 12/10/24 late in the afternoon. The CP stated she did not know the resident was smoking and that the Nicotine patch is usually done for two months. The CP stated that they have lack of monitoring resident efficacy, and needs to have a behavior monitoring. During the interview, the CP stated that Nicotine patch was a psychotropic medication and she had not done a Gradual Dose Reduction (GDR) as per required. The CP stated Nicotine they needed to be monitoring it as a psychotropic medication for side effects and behaviors. On 12/12/24 at 9:25 AM, an interview was conducted with Resident #77 who stated that she was trying to stop smoking but it was hard to do. The resident stated the nurses were putting one Nicotine patch and rotate the arm, and did not remember if she was told for how long she was to wear the patch. The resident stated she smoked twice this week, one on yesterday evening (12/11/24) and on Tuesday. On 12/12/24 at 9:55 AM, an interview was conducted with Staff DD, LPN, who stated she had been putting one Nicotine patch seven (7) mg dosage to Resident #77 daily. On 12/12/24 10:39 AM, a joint interview was conducted with MDS Director and Staff CC, MDS Coordinator. The MDS Director stated last quarterly MDS assessment completed on 10/31/24 was coded for smoking but was not coded for psychotropic medication use. The MDS Director stated the resident's last smoking assessment was completed on 11/20/24 and that she was aware that the resident had a nicotine patch and continue to smoke regardless of using the patch. On 12/12/24 at 10:55 AM during an interview Staff CC, MDS coordinator, was asked who educated the nurses about resident's care plans and stated he did not know and added the care plan are available for them to see.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review showed Resident #144 was admitted on [DATE] with diagnosis of Epilepsy and Hypothyroidism. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the BIMS) score is 7 indicating moderate cognitive impairment. Section GG of the MDS showed Resident #144 needs setup or cleanup assistance during dining. Review of the Order Summary Report showed the following: an order dated 09/30/24 for regular diet regular texture, thin liquid consistency, fortified foods. Review of the Certified Nursing Assistant (CNA) tasks stated the following: Eating: (3) Partial / moderate assistance required X 1 Staff dated 10/12/24. A thorough review of Resident #144's care plan dated 09/29/24 stated the following: Monitor oral intake of food and fluid and provide fortified foods (fortified cereal w/ breakfast-487 calories/8 grams of protein, high calorie pudding w/ lunch and dinner-140 kcal/0 g protein). In an observation conducted on 12/09/24 at 1:30 PM, the surveyor observed Resident #144 in his room attempting to eat his regular diet lunch from the tray without assistance of staff in the room. Resident #144 had a towel on his lap that was filled with food. In an observation conducted on 12/10/24 at 1:35PM, the surveyor observed Resident #144 in his room attempting to feed himself the regular diet food that was on his tray without assistance with most of his food on the towel on his lap. In an interview conducted on 12/10/24 at 3:30 PM with Staff X, Certified Nurse Assistant/CNA, stated that she's been working at this facility full time for one year. Staff X said that she is familiar with Resident #144 and the resident can drink on his own but needs assistance with feeding. She additionally said that when she is assigned to this particular resident, she feeds him. 5. Record review showed Resident #59 was admitted on [DATE] with diagnosis of Age-related physical debility. The MDS quarterly assessment dated [DATE] revealed the BIMS score was 6 indicating severe cognitive impairment. Section GG of the MDS showed that Resident #59 needs setup or cleanup assistance during dining. In an observation conducted on 12/10/24 at 1:35PM, the surveyor was desperately called by Resident #59 asking for help to eat. Resident #59 was observed with her milk all over her face, neck and clothes. The surveyor proceeded to call a staff member. Staff A, Registered Nurse Manager was found in the hallway and stated this particular resident usually eats alone. 3. Record review revealed Resident #36 was admitted on [DATE] for Coronary Heart Disease, Hypertension, Benign Prostatic Hyperplasia, Renal Insufficiency, Diabetes Mellitus, Hyperlipidemia, and Depression. The BIMS score, per Minimum Data Set assessment dated [DATE], was 6 indicating severe cognitive impairment. Record review of Resident #36's baseline care plan, created on 11/01/24 and completed on 11/05/24, noted this resident required partial to moderate assistance with personal hygiene activities. The focus of the care plan dated 11/06/24 noted the resident had an ADL self-care performance deficit related to activity intolerance and limited mobility. The goals of the care plan updated on 11/22/24 were to improve the current level of function in ADLs. This included personal hygiene. Interventions included therapeutic exercises, therapeutic activities, and ADL retraining. In an interview with Resident #36 on 12/09/24 at 12:18 PM in his room, Resident #36 rubbed his chin and said that he didn't like his beard. He voiced his preference was to be shaved. When asked how his facial hair used to be before he was admitted to the facility, Resident #36 said that he usually went to the barber and that the barber shaved it off. He verbalized that he felt like a bum. Resident #36 was observed on 12/10/24 at 2:37 PM in his room. His facial hair was approximately ¾ inch in length above his lip, on his chin, and along the lower sides of his face. In a phone interview conducted on 12/10/24 at 4:15 PM with this resident's 1st contact, step-daughter, revealed that a female employee at the facility provided shaving services for Resident #36 in the past. The 1st contact said that she was at the facility earlier that day and that she told her father that his shaver was in the closet. She shared that she reminded him he should ask someone to help him shave. An interview was conducted with LPN, Staff BB, on 12/12/24 at 3:01 PM. Staff BB stated she provided care for Resident #36 during the day shift on 12/12/24. When asked what the process was for shaving residents, Staff BB stated an aide on any shift could assist a resident with shaving. She stated the aide always checks with the LPN or RN (Registered Nurse) prior to shaving so that the resident can be assessed for safety reasons. She explained the nurse reviews the medications and the integrity of the skin during the assessment. Based on observations, interviews, and record review, the facility failed to provide proper mouth care (Resident #40), failed to provide adequate grooming (Resident #36), and failed to provide assistance during dining (Residents #144, Resident #59, and Resident #311) for 5 of 39 sampled residents reviewed for Activities of Daily living (ADLs). The findings included: 1. Review of the facility's policy, titled, Activities of Daily Living (ADL), Supporting, dated 09/26/24 revealed the following: appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents in accordance with plan of care, including appropriate support and assistance with: Hygiene (dressing, bathing, grooming and oral care, and dining meals and snacks. Record review revealed Resident #311 was readmitted to the facility on [DATE] with diagnoses of type 2 Diabetes and Dementia. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #311 has a Brief Interview of Mental Status (BIMS) score of 05, indicating moderate to severe cognitive impairment. Section GG for eating revealed Resident #311 needed partial to moderate assistance with eating. In an observation conducted on 12/11/24 at 8:45 AM, Resident #311 was in the room with her breakfast tray on the bedside table. No staff was noted in the room at the time of this observation. At 9:00 AM, 15 minutes later, there was no staff in the room, and the breakfast tray was still untouched. At 9:05 AM, 20 minutes later, Staff C, certified Nursing Assistant (CNA), came into the room. At 9:10 AM, she started feeding Resident #311, and at 9:12 AM, Staff C left the room. Continued observation at 9:20 AM showed that Resident #311 ate 25% of her meal. In an interview conducted on 12/12/24 at 12:05 PM, the MDS Director stated that when a resident is coded for partial assist to moderate assist, they need assistance with feeding and that the staff needs to be in the room for encouragement or queuing if needed. Staff may need to help the resident sometimes if they cannot eat on their own. 2. Review of the facility policy and procedure, titled, Activities of Daily Living (ADL), provided by the Director of Nursing (DON) published 09/26/24, documented in the Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily (ADLs). Residents who are unable to carry out activities of daily (ADLs) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care); .6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revises as appropriate. Record review documented Resident #40 was admitted to the facility on [DATE] with diagnoses which included Cerebral Atherosclerosis, Adult Failure to Thrive, Diabetes Mellitus Type II, Hypertension, Dementia, Major Depressive Disorder and Cerebral Infarction. She had a BIMS score of 5 indicating severe cognitive impairment. On 09/25/24, the Physician's Order documented Regular diet, Mechanically Altered Chopped texture, Thin Liquids consistency, with small portions for nutrition. This indicated the resident was capable on consuming liquids/water for Hydration. On 04/22/24, the Complete Blood Count (CBC) with differential lab work (indicative of Dehydration) documented Potassium 4.0, Chloride 109 high, Hemoglobin 9.1 low, Hematocrit 28.2 low, Blood Urea Nitrogen (BUN) 24, Bicarbonate 22 and Osmolality calculated 292. On 10/18/24, the Complete Blood Count (CBC) with differential lab work (indicative of Dehydration) subsequently documented Potassium 5.3, Chloride 116 high, Hemoglobin 11.6 low, Hematocrit 37.3, Blood Urea Nitrogen (BUN) 53 high, Bicarbonate 15 and Osmolality calculated 306.6. Record review of the Resident #40's Monthly Personal Hygiene CNA ADL (Activities of Daily Living) Task Flowsheet Record dated 11/28/24 through 12/11/24 revealed the resident's (ADL)s for Personal and Oral Hygiene indicated the resident required dependent-helper does all of the effort. Resident does none of the effort to complete the activity ., during the day and evening shifts. Record review of the Resident #40's care plan initiated 09/23/23 and revised 06/17/24 indicated Focus: Resident is at risk for Oral/Dental health problems .Interventions: Provide mouth care as per ADL personal hygiene. Goal: The resident will comply with mouth care at least daily through review date. Further record review of the Resident #40's care plan initiated and revised 11/26/24 indicated Focus: Resident is at nutritional risk: . diagnosis of Cerebral Atherosclerosis. Average meal intake < 25% comfort care, Terminal Condition, Total Dependence of ADL. Interventions: Glycerine swabs to alleviate symptoms of Dehydration .Provide favorite foods and beverages Provide mouth care as needed Goal: Resident #40 will be comfortable with food/fluids provided. During an observation of Resident #40 conducted on 12/09/24 at 11:11 AM, she was observed resting in bed and breathing with her mouth wide open in which her mouth, lips, teeth, tongue and gums were all dry and non-moist in appearance. It was observed that there was also some dry, cracked areas on the edges of her lips and mouth, indicative of improper mouth care. There was no water pitcher, no covered cup of water, nor any Glycerin moisture stick packs noted/kept at her bedside. Photographic Evidence Obtained. On 12/09/24 at 4:23 PM, Resident #40 was still observed resting in bed and breathing with her mouth wide open with her mouth, lips, teeth, tongue and gums all remaining dry and non-moist, in appearance. It was still observed that there was also some dry, cracked areas on the edges of her lips and mouth, and still with no water pitcher, no covered cup of water, nor any Glycerin moisture stick packs noted/kept at her bedside. On 12/10/24 at 11:32 AM, Resident #40 was again observed resting in bed and breathing with her mouth wide open with her mouth, lips, teeth, tongue and gums all remaining dry and non-moist, in appearance. It was still observed that there was also some dry, cracked areas on the edges of her lips and mouth, and still with no water pitcher, no covered cup of water, nor any Glycerin moisture stick packs noted/kept at her bedside. An interview was conducted on 12/11/24 at 11:50 AM with Staff C, Certified Nursing Assistant (CNA), regarding the appearance and care of Resident #40's mouth. Staff C revealed she uses the small, dry mouth sponges which she dips and wets it in either some water or mouth wash, instead of using the Glycerine swabs to clean the resident's mouth. The CNA acknowledged that there was no water pitcher nor cup of water at the resident's bedside, and she also acknowledged that the resident's lips were dry at the time. An interview was conducted with Staff S, Licensed Practical Nurse (LPN), on 12/11/24 at 1:22 PM, regarding the appearance and care of Resident #40's mouth. Staff S stated the CNAs are to use the Glycerin swabs for cleaning the resident's mouth during AM care and throughout the shift as needed. She stated she did not know why there were no Glycerine swabs kept at the resident's bedside for regular routine mouth care. The nurse acknowledged the resident's mouth did appear to be a little dry, at the time. An interview was conducted with Staff T, LPN/Unit Manager, regarding the appearance and care of Resident #40's mouth. Staff T stated that the CNAs are to provide regular/daily mouth care to this resident during ADL care, before and after meals and as needed. She added that Resident #40 should have a pitcher or a cup of water at her bedside. She said that she did not know why there were no Glycerine swabs, nor water at the resident's bedside for mouth care. Staff T acknowledged that Resident #40's lips did not look moist, at that time. There was no documentation in the nursing progress notes for the past four (4) weeks dated 11/12/24 to 12/10/24, referencing that the resident was receiving proper and regular ADL personal hygiene mouth care. There were no observations noted to indicate that the facility had been regularly providing proper mouth care for Resident #40, as evidenced by the fact that the Resident #40's mouth, lips, teeth, tongue and gums still appeared to remain dry, cracked and non-moistened, at various random times, throughout the survey. The DON recognized and acknowledged on 12/11/24 at 5:11 PM that Resident #40 was to be provided proper and adequate assistance to maintain ADLs for oral hygiene; and this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure appropriate urinary catheter care for 1 of 1 sampled resident reviewed for urinary catheter care, Resident #102. The finding included: Review of the facility's policy, titled, Catheter Care Urinary, published on 10/07/24, revealed that the purpose of urinary catheter care is to prevent urinary catheter-associated complications, including urinary tract infections. Under infection control on page 1, statement #2, revealed that catheter tubing and drainage bag are kept off the floor. Under the complications on page 2, statement #1, revealed to observe the resident for complications associated with urinary catheters; and to report unusual findings to the physician or supervisor immediately if, urine has unusual appearance (i.e., color, blood, etc.). Routine Perineal hygiene on page 3, under statement 18, revealed that after urinary perineal care is done, and disposable items were discarded, staff must remove gloves, and wash and dry hands thoroughly. Record review revealed Resident #102 was admitted on [DATE] with diagnoses that included Atrial Fibrillation, Type I Diabetes Mellitus, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Chronic Kidney Disease. Review of Minimum Data Set (MDS) assessment, dated 11/20/24, Section C, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #102 had moderate cognitive impairment. The MDS' Section GG dated 09/26/24, revealed Resident #102's ability to 'come to a standing position from sitting in a chair', as the resident needed partial to moderate assistance. Section E, regarding chair/bed-to-chair transfer, revealed Resident #102 needed partial to moderate assistance during transfer to and from a bed to a chair (or wheelchair). Review of Medication Administration Record (MAR), dated 08/24/24, revealed Foley (urinary catheter, inventor's name of a flexible tube inserted into the bladder to drain urine) catheter care every shift PRN (as needed). Further review revealed that from 12/01/24 until 12/10/24, no urinary catheter care was documented as performed, even when resident was complaining of blood-tinged urine from the night of 12/08/24 until the evening of 12/10/24. Further record review of MAR, dated 08/26/24, revealed to 'change urinary drain bag when there are signs and symptoms of blockage, leakage, obstruction or infection as needed, every 8 hours as needed daily, to maintain catheter patency'. From 12/01/24 until 12/10/24, there were no nurses' initials recorded on MAR that indicated the urinary drainage bag was not changed even when resident's urine was red tinged. Review of quarterly nursing care plan dated 09/11/24 revealed to monitor / record / report to Medical Doctor (MD) for signs and symptoms of Urinary Tract Infection (UTI), like blood-tinged urine, cloudiness, and deepening of urine color. Review of the MAR from 12/01/24 to 12/10/24 noted there were no recorded nurses initials and blood tinged-colored urine recorded on the MAR or notes, indicating the nurses did not monitor the Foley for red or blood-tinged urine as reported by resident since the night of 12/08/24. Additional nursing care plan dated 09/11/24 revealed to practice Enhanced-Barrier Precautions: wear gown and gloves during assistance with dressing, bathing, transferring, hygiene, changing linens, changing briefs & toileting, and catheter care. Review of the MAR, dated 10/19/24, revealed to irrigate foley catheter with 30-50 mL sterile Normal Saline as needed for occlusion, and as needed for obstruction. From 12/01/24 until 12/10/24, there were no recorded nurses' initials on the MAR or notes, indicating the nurses did not irrigate the urinary tubing even when resident was complaining of blood-tinged urinary tubing. During observation on 12/09/04 at 11:30 AM, Resident #102 was sitting in the wheelchair, with legs down, both feet on the wheelchair pedals with no elevation, and the urine tubing had blood-tinged color. During another observation on 12/10/24 at 10:00 AM, Resident #102 in the wheelchair with legs down on foot pedals, no elevation, and resident's legs covered with white blanket. The urinary tubing was observed to have a blood-tinged color. In another observation on 12/10/04 at 3:00 PM, Resident #102 stated he has not seen a doctor for a month, his legs are getting more swollen, and staff are not elevating legs in bed or in wheelchair. He stated that the urine color on his tubing is still red, and he informed the nurse, but nurses did not irrigate. During a perineal care observation on 12/12/24 at 9:30 AM, Staff K, Certified Nursing Assistant (CNA), was wearing gloves on both hands, and stated urinary tubing care was done. Staff K was observed wearing a blue Personal Protective Equipment (PPE) gown. Staff K was putting a pair of shorts on the resident's right leg, with the urinary tubing observed to have red-tinged color and the urinary bag was hanging on the left side of the bed. The urinary privacy blue cover was hanging a few inches away from the urinary bag. Staff K continued with putting on resident's short, then afterwards, touched the green chucks (disposable impermeable pads) under the resident's bottom. She went to the other side of bed and touched her hair, touched the resident's top drawer, and touched the resident's wheelchair handle, with the same set of gloves. Staff K removed the square bath basin from the resident's bedside table and washed it in resident's bathroom using the same gloves. She dried the square bath basin, went back inside the resident's room, opened the drawer of resident's side table and put the square bath basin inside the drawer. Staff K was still wearing the same set of gloves, when she touched the resident's socks on both feet, grabbed the orange shirt and put it on the resident. Staff K proceeded to move the wheelchair, which was 2 feet away from the left foot part of resident's bed, and wheeled it next to resident's bed closer to the middle. Using the same set of gloves, she removed the urine bag hanging on the side of the bed and placed it on the floor. She stated that the urine bag must be on the floor so resident will not accidentally trip on it, while resident is transferring from bed to a wheelchair. The urinary bag had no privacy protection when it was placed on the floor by Staff K. Using the same gloves, Staff K continued holding the back handle of the wheelchair while the resident was trying to get out of bed. Then at 9:52 AM, Staff K removed her blue PPE gown and removed her blue gloves. She stepped out of the room and performed ABHR (alcohol-based hand rub) at 9:54 AM. In an interview with Staff P, CNA, on 12/11/24 at 9:32 AM, she stated she is responsible for checking the urinary tubing of residents. She checks if the tubing is draining, secured on resident's leg, and the urinary bag has a privacy covering. She makes sure the urinary tubing is not bloody or cloudy, and if she sees these colors, she lets the nurse know. She added that she makes sure to clean the connection to the urinary opening of a male resident, free from any crusts, and for a female resident, she makes sure she wipes it clean from the vaginal opening downward. She uses gentle cleaning baby wipes to perform urinary catheter tubing care. She rinses the catheter, then dries it well. She added that she empties the urinary bag when needed and document the amount in the CNA task field of the electronic health record. When asked how often she checks on residents with urinary catheter, she stated that she frequently checks the urinary catheter every time she passes by the resident. Staff P added she makes sure the urinary tubing is securely attached to resident on every visit she makes. In an interview with Resident #102 on 12/11/24 at 9:52 AM, he stated that no staff member saw him and checked his urinary bag for the whole night. The surveyor noticed reddish colored urinary tubing. The tubing remained reddish colored for the whole day during the survey. Resident #102 stated that he told a nurse who works from 3:00 PM until nighttime to check on his urinary catheter tubing. Resident added that after he told her, the nurse did not come back. In another interview with Staff P, CNA on 12/11/24 at 10:37 AM, she stated the CNAs document the personal care they performed on resident like urinary care and applying barrier cream. She stated the care in Medication Administration Record (MAR) is signed by the CNA using initials only. This Staff showed this surveyor that in facility's computer there is no way for them (CNAs) to record if urinary catheter tubing is cloudy or bloody, but she as a CNA will inform the nurse, if she sees these colors or conditions. In an interview with Staff N, Registered Nurse (RN), on 12/11/24 at 10:49 AM, when asked regarding the resident's red colored urine, she stated she never asked the resident regarding red colored urine in urinary catheter tubing and had never flushed the resident's urinary catheter. When asked why, she stated she had never observed blood-tinged urine or red colored urine in Resident #102's urinary catheter tubing. When asked if she had read the nursing care plan regarding blood-tinged urine, or reviewed Resident #102's MAR, she stated she did not read the care plan or the MAR regarding Resident #102's urinary catheter tubing. When asked why, she did not respond. In an interview with Staff O, RN Unit Manager, on 12/11/24 at 10:58 AM, she stated nurses document the findings of bloody urine in their nursing progress notes. When asked if it was also recorded on the PRN (as needed) in MAR, she stated, nurses document it there too. Staff O added, The facility's nurses document in the MAR the urinary care they performed on residents, using initials only, on the indicated shift. In an interview with the Director of Nursing (DON) on 12/11/24 at 4:20 PM, he stated, The urinary catheter care is performed by CNAs and documented on the CNA task form. The CNAs perform the urinary tubing care every shift. The urinary catheter care includes checking the urinary bag, securing bag, providing urinary bag with privacy covering, checking the urinary output, and making sure the urinary tubing is attached securely to resident. When there is cloudy or bloody urine output observed, the CNA reports it to the nurse right away. The nurse is responsible for documenting the findings of cloudy or bloody urine in progress notes or MAR. The nurse reports the bloody or cloudy urine findings to the resident's physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation conducted on 12/10/24 at 10:30 AM revealed that the Stationery Scales from the South Unit, [NAME] Unit, North Unit and East Unit respectively were dated as follows: Next due date for the Standing scale calibration were: 08/2024, 08/2024, 05/2024, 08/2024. It was also observed that there was a Standing Scale in the [NAME] Unit that had a due date for calibration of: 08/2024. Observation conducted on 12/10/24 at 2:10PM revealed that the East Wing 4 Hoyer lift, the South Wing 3 Hoyer Lift and the 2 Hoyer Lift respectively had stickers that had no dates under the sections: completed and next due or tech. An interview was conducted on 12/12/24 at 11:35AM with the Director of Plan Operations, who stated that he's been working in this facility for a little over a year. He stated that they have a subcontracted private company that comes twice a year that is in charge of calibrating the scales and that he checks the scales every other month to make sure that everything works properly. The Director of Plan Operations stated the facility had 7 Hoyer Lifts and 4 Stationary Scales, and also that the due date that is indicated in the stickers means that the service is supposed to be conducted by that date. An observation was conducted on 12/12/24 at 11:45 AM with the Director of Plan Operations who was taken to one of the scale rooms in the East Wing and was shown the missing due date for calibration on the label. In this observation, he further explained that he did see the staff from outside private companies calibrating the scales. They usually come to calibrate the scales and send the paperwork to corporate and because he is fairly new, they probably didn't have his email and sent the report to the old Director. He further stated that the outside company is the one responsible for updating the dates on the machines. At this time, the Director of Plant Operations stated that he had a log associated mostly with the Hoyer Lifts and not with the Scales, and the process that he follows when he checks the scales every month is the following: he puts a certain weight on the scale and if it's not accurate he calls the outside company. He also indicated that if a staff member finds a discrepancy while weighing a resident, the staff inform, him and most of the time it's a simple battery issue. Review of the outside company showed that they conducted a visit on 08/26/24, which showed only the location of the scaled was reported and the type of scales that were calibrated, and that the next inspection due date was 11/2024. When asked as to why the outside company did not come to inspect the scales on 11/2024, the Director of Plans of Operations did not have an answer. The Director of Plant Operations could not provide a contract. Based on observations, interviews and record review, the facility failed to ensure that the facility's scales were calibrated for accuracy and failed to ensure that nutritional supplements were provided in a timely manner for 2 of 10 sampled residents reviewed for nutrition, Resident #100 and Resident #311. The findings included: Review of the facility's policy, titled, Interdisciplinary Management and Prevention of Significant Weight Loss of Nursing Facility Residents, dated 09/20/22, documented in part the following: the purpose is to provide guidelines for detection of early unplanned weight loss, which includes communication and appropriate action by the team to maintain acceptable parameters of nutritional status of nursing facility residents. Residents who lose weight will be identified and managed in a timely manner. Reweigh residents with significant weight discrepancies within 24 hours if needed and monitor all interventions for efficacy and feasibility. Further review of the policy showed that preventative maintenance and calibration of scales should be performed by the engineering department or outside vendors as applicable. 1. Record review revealed Resident #100 was readmitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease and Anemia. The Quarterly Minimum Data Set, dated [DATE], showed Resident #100 has a Bried Interview of Mental Status (BIMS) score of 12, which is moderate cognitive impairment. Review of the weight logs revealed the following weights for Resident #100: On 08/06/24 recorded weight of 142.8 pounds. On 09/09/24 recorded weight of 132.0 pounds. On 10/09/24 recorded weight of 118.0 pounds. On 11/05/24 recorded weight of 126 pounds. On 12/03/24 recorded weight of 127.6 pounds. This showed a weight loss of 7.5% in one month from 08/06/24 to 09/09/24 and a 17% weight loss of 17% in two months from 08/06/24 to 10/09/24. Review of the Dietary progress note dated 10/07/24 showed that Resident #100 had decreased meal intake and a weight loss of 8%. Resident #100 was on fortified foods and receiving Glucerna (nutritional supplement) once a day. In this note, the facility's Dietitian updated the food preferences and liberalized the diet but did not at this time increase the nutritional supplements from once a day or add an additional nutritional supplement, as monitoring to see if the resident liked the supplement. Review of the Dietary note dated 10/22/24 showed that the facility's Dietitian increased the Glucerna supplements from once a day to three times a day. The increase was made approximately 40 days after the first weight loss of 7.5% was identified on 09/09/24. Review of the dietary note dated 11/13/24 showed the RD documented the following: in 30 days there is 7% significant gain, in 90 days there is 12% significant and in 180 days there is 15% significant. An interview was conducted on 12/12/24 at 1:08 PM with Staff W, the Registered Dietitian, who stated that for any severe or significant weight loss, she would try and follow up with the resident as soon as possible and provide additional interventions. When asked why the Glucerna supplements were only increased to 3 times a day on 10/22/24 and not earlier, she said that the food approach is tried first. If that does not work, then she will add nutritional supplements as needed. According to Staff W, Resident #100's diet was liberalized as an intervention for significant weight loss. The record showed that the resident was slowly gaining weight. Interventions were in place. 2. Record review revealed Resident #311 was readmitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, Acute Neurologic Dysphagia, Anemia, Subdural Hemorrhage, and Dementia. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #311 has a Brief Interview of Mental Status (BIMS) score of 05 indicating severe cognitive impairment. Section GG for eating revealed that Resident #311 needs partial to moderate assistance with eating. Review of the weight log for Resident #311 was as following: On 04/03/24, a weight of 165.0 pounds. On 08/22/24, a weight of 176.4 pounds. On 09/09/24, a weight of 162 pounds. On 10/04/24, a weight of 155 pounds. On 12/03/24, a weight of 152.4 pounds. This showed a 13.6% weight loss in less than 6 months, from 08/22/24 to 12/03/24. Review of the Dietary note dated 10/09/24 showed a possible weight discrepancy but no reweight was obtained for Resident #311. Furter review of the Dietary progress notes showed that the 13.6% weight loss was not addressed after it was identified on 12/03/24. An interview was conducted on 12/12/24 at 1:08 PM with Staff W, the Registered Dietitian, who stated that if any discrepancies with weights, she would ask for a reweight as soon as possible. When asked as to why the 13.6% weight loss was not addressed after 12/03/24, she did not have an answer. Various observations during the survey showed the resident was receiving her mighty shakes. Interventions were in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #198 was admitted on [DATE] with diagnoses that included Hyperlipidemia, Type 2 Diabetes Mellitus with Foot Ulcer, Benign Prostatic Hyperplasia, Chronic Viral Hepatitis, Atherosclerotic Heart Disease, and Venous Insufficiency. Review of the Minimum Data Set (MDS) assessment revealed a score of 13, indicating mild cognitive impairment. Review of physician orders dated 11/11/24 documented to give meropenem I Gm. (gram) into venous catheter every 12 hours. Review of the nursing care plan dated 11/13/24 revealed that if an IV (intravenous) is infiltrated: stop infusion and thoroughly examine the site. If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made to lessen the amount of drug at the site. After removing the cannula, elevate the affected arm, notify the physician (for large infiltrations and extravasations), and apply cool compresses (warm, if [NAME] alkaloids are involved). Review of the Medication Administration Record (MAR), dated 11/14/24, revealed to flush left upper arm midline catheter every shift. The same MAR revealed that nurses documented their initials from 12/01/24 until 12/10/24 indicating flushings of midline catheter on these dates were performed. Additional review of MAR with a date of 11/14/24, revealed to perform midline to left arm check every shift and code with the following: 1= no problem, 2= edema, 3= redness, 4=pain. Review of MAR from 12/01/24 until 12/10/24 revealed that nurses put their initials, but no codes were documented on all these dates, indicating the midline left arm checked was not done per order. Further review of MAR dated 11/14/24 revealed an order to change the midline IV dressing to left upper arm as needed. From 12/01/24 until 12/11/24, there were no documented nurses' initials which indicated the nurses did not change the dressing as needed. During observation on 12/09/24 at 9:35 AM, Resident #198 was sitting in bed with a left arm IV catheter dressing with no date and nurse's initials markings. The square surrounding area had a brownish coloration and the Tegaderm (transparent medical dressing) shield was loosely covering the bottom and sides of white gauze dressing. When asked if he was receiving medication through the IV catheter, Resident #198 replied, No. During another observation and interview on 12/11/24 at 9:30 AM, Resident#198's IV dressing were observed to be loose, and the surrounding area had reddish fluid drainage on the dressing and the surrounding areas, that smelled like blood. Resident #198 stated the IV antibiotic was discontinued a long time ago. When asked why he still has the IV catheter on left arm, he stated he did not know, and no one informed him of why the IV catheter was in his left arm. When asked if the staff were checking on the catheter, he stated, not recently. An interview was conducted with the Director of Nursing (DON) on 12/11/24 at 3:59 PM. When asked regarding the IV catheter access site and the antibiotic administered at the IV access site of Resident #198, the DON stated the nurses change the dressing as ordered. When asked when the last administration of antibiotic was given through the IV access site, he responded, the last dose was administered on 11/28/24. When asked when the IV catheter was to be discontinued, since the IV antibiotic course was completed a few weeks ago, he did not respond. He added that he spoke with Resident #198's Physician, and he was not informed of why the IV catheter access site was kept for few more weeks after the IV antibiotic course was completed. He stated the Physician Assistant (PA) of Resident #198's Physician makes facility rounds everyday, but no order was given to the facility regarding the discontinuation of IV catheter access for Resident #198. Based on review of policies and procedures, observation, record review and interview, the facility failed to obtain a current specified physician's order to address the care and maintenance of an Intravenous (IV) / Peripherally Inserted Central Catheter (PICC) line and to label and date the resident's PICC line site dressing for 3 of 3 sampled residents observed, Resident #308, Resident #185 and Resident #198. The findings included: Record review of the facility policy and procedure, titled, Peripheral and Midline IV Dressing Changes, provided by the Director of Nursing (DON), published 09/26/24 documented in the Policy Statement: Purpose: This purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g. damp, loosened or visibly soiled) 4. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for Transparent Semi-permeable Membrane (TSM) dressing .c. Immediately if the dressing or site appears compromised .6. Assess the peripheral/midline access device at least every 4 hours (every 1-2 hours for residents with cognitive impairment.) .c. Assess the patency of the vascular access device; d. Palpate and inspect the skin, dressing and securement device for signs of complications .7. Assess the integrity of securement devices with each dressing change .Documentation: 1. The following should be documented in the resident's medical record: a. Date, time, type of dressing and reason for dressing change. b. Any complications/intervention related to insertion site or surrounding area. c. Resident's response to procedure . 1. Record review revealed Resident #308 was admitted to the facility on [DATE] with diagnoses that included Fracture of Left Shoulder Girdle Part and Displaced Fracture of Upper End of Left Humerus, Adjustment Disorder, Diabetes Mellitus Type II, Hypertension, Atherosclerotic Heart Disease and Chronic Kidney Disease Stage 3. The documented Brief Interview Mental Status (BIM) score was 10 indicating moderate impairment. Resident #308 was subsequently transferred to the hospital on [DATE] for further evaluation for possible aspiration, following a lunch meal. Review of the record revealed that on 11/29/24, the physician's order documented for the insertion of the IV PICC line. There was no physician's order written to specify the details for the care and maintenance for Resident# 308's IV PICC line, to include: regular dressing changes and flushing of the line to maintain patency. There were no documented current indications for use of the resident's PICC line. During an observation of Resident #308 conducted on 12/09/24 at 12:27 PM, the resident was observed with a right arm PICC line in place. Observation of the PICC line dressing revealed there was no date and time noted, with illegible writing noted on the old, stained, dingy-colored PICC line dressing tape which was also observed to be peeling off and loosened at the edges of the PICC line dressing and not securely attached. Photographic Evidence Obtained. On 12/09/24 at 3:27 PM, Resident #308 was observed with his right arm PICC line in place with no date and time noted on the PICC line dressing, and with no physician's order for the maintenance of the PICC line. On 12/10/24 at 10:18 AM, Resident #308 was observed with his right arm PICC line in place with no date and time noted on the PICC line dressing, and with no physician's order for the maintenance of the PICC line. On 12/10/24 at 4:00 PM, Resident #308 was observed with his right arm PICC line in place with no date and time noted on the PICC line dressing, and with no physician's order for the maintenance of the PICC line. On 12/11/24 at 12:17 PM, Resident #308 was again observed with his right arm PICC line in place with no date and time noted on the PICC line dressing, and with no physician's order for the maintenance of the PICC line. An interview was conducted with Staff T, LPN, on 12/11/24 at 12:16 PM, regarding Resident #308's right arm PICC line and the current status of the dressing. She acknowledged that the dressing had no date or time on it. She also revealed that she did not know whether there was an order for the PICC line dressing to be changed, nor did she know if the PICC line dressing was being changed regularly by nursing staff. An interview was conducted with Staff V, Registered Nurse / Unit Manager (RN/UM), on 12/11/24 or 12:43 PM, regarding Resident #308's right arm PICC line and the current status of the dressing. She acknowledged that the PICC line dressing should be dated and maintained but she did not know if this was being done. Staff V acknowledged there was no physician order for care and maintenance of the PICC line. There was no care plan in place for Resident #308's IV PICC and no documentation noted in the nursing notes from 11/22/24 through 12/10/24 regarding the presence or existence of the resident's right arm PICC line, by facility staff. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) lacked evidence of care performance of the PICC line by facility staff. The DON acknowledged that Resident #308 had an IV PICC line in place. He recognized that there was no date, initial nor time on either of the resident's IV PICC dressing, nor were there any physician orders in place to address the specified care and maintenance of the IV PICC line. 2. Record review revealed Resident #185 was re-admitted to the facility on [DATE] with diagnoses that included Disruption or Dehiscence of Closure of Internal Operation (Surgical Wound), Displaced Intertrochanteric Fracture of Femur and of Coccyx, Dysphagia, Major Depressive Disorder, Diabetes Mellitus Type II, Hypertension, Atherosclerotic Heart Disease, Atrial Fibrillation and Chronic Hepatitis. The documented BIMS score was 15, indicating intact cognition. Review of the 3008 Agency for Healthcare Administration (AHCA) Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, date 11/08/24, documented the resident was transferred from the hospital and admitted to the facility with an IV PICC in place in her right upper arm. On 11/08/24, the physician's order documented, Monitor IV PICC line site every shift .for 39 days. There were no current physician's orders written to specify the details to address the care and maintenance for Resident #185's IV PICC line, to include: regular dressing changes and flushing of the line to maintain patency. On 12/09/24 at 1:30 PM, Resident #185 was observed with a right upper arm PICC line in place. There was no date and time noted on the old, stained, dingy-colored PICC line dressing tape which was also observed to be peeling off and loosened at the edges of the PICC line dressing and not securely attached. Photographic Evidence Obtained. On 12/09/24 at 1:30 PM, Resident #185 was observed as having a PICC line in her right arm with no date and time noted on the PICC line dressing or tape. On 12/10/24 at 11:56 AM, Resident #185 was observed as having a PICC line in her right arm with no date and time noted on the PICC line dressing or tape. On 12/10/24 at 4:20 PM, Resident #185 was observed as having a PICC line in her right arm with no date and time noted on the PICC line dressing or tape. On 12/11/24 at 11:41 AM, Resident #185 was again observed as having a PICC line in her right arm with no date and time noted on the PICC line dressing or tape. An interview was conducted with Staff S, LPN, on 12/11/24 at 1:16 PM, regarding Resident #185's right arm PICC line and the current status of the dressing. Staff S acknowledged there was an order to monitor the dressing, but no specifics as to when to change the dressing and flush it for maintenance, patency and care. Staff S added that she did not know, if the PICC line dressing was being changed by nursing staff. An interview was conducted with Staff T, LPN/UM South wing, on 12/11/24 at 4:21 PM regarding Resident #185's right arm PICC line and the current status of the dressing. Staff T acknowledged there was no current, specific order for the PICC line dressing to be changed. Staff T added that she did not know if the PICC dressing was being changed by nursing staff. There was no care plan in place for Resident #185's IV PICC. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked evidence of a documented initial / signed evidence of current care performance to address the PICC line site, by facility staff. The record lacked evidence of Resident #185's skin being assessed with her PICC line dressings being changed by the Wound Care Nurse, until after surveyor intervention. The DON acknowledged that Resident # 185 had an IV PICC line in place. He recognized that there was no date, initial nor time on either of the resident's IV PICC dressing, nor were there any physician orders in place to address the specified care and maintenance of the IV PICC line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility's policy, titled, Respiratory Medication Administration - via Small Volume Nebulizer, updated on 08/17/24, revealed that nebulization is used to deliver medications along the respiratory tract, and is indicated for various respiratory problems and diseases; The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Statement #3 under 'Policy Interpretation and Implementation' revealed to closely monitor and document respiratory status, breath sounds (pre-and post-treatment), respiratory rate (pre-and post-treatment), and pulse rate (pre, middle, and post-treatment), and document on Flow sheet. Additional policy statements under #3 revealed the following: 3.1: Evaluate chest wall expansion, depth, and pattern of respirations, cough, and chest pain; 3.2: Watch for restlessness, which may indicate that the patient is hypoxic, requiring suctioning, repositioning, or more aggressive oxygen therapy. The same policy revealed under statement #7, to position the resident in semi-Fowler's position (head and upper body raised to a 30-45-degree angle while lying on back). Record review revealed Resident #120 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Acute Respiratory Failure with Hypercapnia, Atrial Fibrillation and Sleep Apnea. Review of Minimum Data Set (MDS) assessment, dated 11/20/24 at 10:23 AM, revealed a BIMS score of 14, indicating intact cognition. Record review of a nursing care plan dated 08/21/24 revealed the resident has altered respiratory status, and difficulty of breathing related to anxiety, acute hypercapnia (condition where body has too much carbon dioxide in the blood), respiratory failure, sleep apnea, emphysema (lung disease that damages air sacs, forming into large packets and trapping oxygen), and COPD. The nursing care plan additionally revealed the following goals: the resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date; the resident will have no complications related to Shortness of Breath (SOB) through the review date; and resident will breathe easily and comfortably. Further review of nursing care plan interventions, dated 08/21/24, revealed the following: assess the degree or level of anxiety, breathing treatment as ordered, and oxygen therapy per physician order. Review of Resident #120's hospital's history and physical dated 08/15/24, completed by a Medical Doctor, revealed the following: Resident #120's chief complaints include shortness of breath (resident was at nursing facility when oxygen saturation's remained low, after a breathing treatment was administered; resident was given a DuoNeb treatment in route, and came in with oxygen at 10 Liters per minute on a simple mask; resident states she is having breathing difficulty, and chest discomfort). Review of physician orders revealed the following: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligram)/3mL (milliliter), 3 mL inhale orally, via nebulizer, four times a day for Bronchospasm; Toleration of Treatment: G-Good ; F-Fair ; P-Poor: Document # of minutes breathing treatment was administered; Respiratory Evaluation: Breath Sound Code: 1=Clear, 2=Diminished, 3=Rhonchi, 4=Crackles, 5=Wheezing, 6=Other (Explain); Quality: A=Unlabored. Review of the Medication Administration Record (MAR) for a nebulizing treatment order, with a start date of 11/12/24 at 6:00 PM, revealed the following: Ipratropium-Albuterol solution 0.5 -2.5, (3) MG/3mL, to be inhaled orally via a nebulizer four times a day for Bronchospasm; Toleration of treatment coded as follows: G= good, F=fair, P=poor; Document the number of minutes breathing treatments was administered; Respiratory evaluation: breath sounds code as follows: 1=clear, 2=diminished, 3=rhonchi, 4=crackles, 5=wheezing, 6=other and explain; quality as follows: a=unlabored. Further review of the above MAR revealed the documented nurses' initials and check marks indicating the nebulizing treatments were administered by nurses. Review of the MAR revealed there was no information about the resident's toleration of treatments, number of minutes the breathing treatments were administered, respiratory evaluations, quality of breath sounds and other explanations while administering the nebulizing treatments from 12/01/24 until 12/07/24, and on 12/11/24 and 12/12/24. During observation on 12/09/24 at 10:35 AM, Resident' #120's head was about 10 to 15 degrees elevated (closer to lying flat in bed), while receiving nebulizing breathing treatment, with no staff nurse inside the resident's room. The nebulizing machine created loud noises, and after a few minutes on 12/09/24 at 10:38 AM, the resident took the breathing treatment mask off from her lower face and held it at her side. Resident #120 showed signs of breathing difficulty when Staff M, LPN came inside the room, which subsided after the nebulizer treatment. Staff M took the breathing mask from the resident, and after donning on gloves, went inside the bathroom and cleaned the mask. Staff M left the room at 10:40 AM. She did not assess Resident #120's breath sounds or take vital signs such as respiratory rates and pulses. She was observed without stethoscope upon entering resident's room. In an interview with Staff M on 12/09/24 at 10:58 AM, when asked why she was not in the room during Resident #120's nebulizing treatment, she did not respond. In an interview with Resident #120 on 12/09/24 at 4:29 PM, when asked if staff stay with her during the duration of nebulizing treatment, she stated Sometimes, staff stay for few minutes, then, would leave, and come back when the treatment is over. In an interview with Staff O, North Wing Unit Manager Registered Nurse (RNUM), on 12/11/24 at 11:10 AM, when asked about the process of providing nebulizing treatment to a resident, she stated that nurses always stay with the resident to monitor changes before and after the nebulizing treatment. She added that nurses check resident's vital signs, lung sounds, respiratory changes and resident's tolerance of the treatment. Staff O stated the nurses document the amount of time they stayed with the resident together with the amount of treatment tolerated by the resident. In an interview with the Director of Nursing (DON) on 12/11/24 at 4:00 PM, he stated facility nurses stay with residents during nebulizing treatments. He added that during a two-day orientation, nurses were educated about monitoring residents until the end of nebulizing treatments. In an interview with Staff BB, Respiratory Therapist (RT), on 12/12/24 at 1:31 PM, regarding nebulizing treatment, she stated that it is a recommended guideline that nurses stay with residents during the entire duration of nebulizing the treatments. When asked if she observed nurses leaving residents while receiving nebulizing treatments, she stated that she has been working in the facility for two weeks. When asked why staff nurses must stay with residents during nebulizing treatments, she stated that bronchospasms and difficulty of breathing might occur to residents receiving the treatments. Staff BB stated that When nurses are monitoring the residents, they (RT) are readily available to respond to residents' breathing difficulties. Based on review of policy and procedure, observation, record review and interview, the facility failed to ensure that it obtained current physician's orders for Oxygen therapy administration for 1 of 6 sampled residents observed receiving continuous Oxygen on the South wing, Resident #309; and failed to monitor residents receiving Nebulizer treatments, according to standards of care, for 1 of 1 sampled resident, Resident #120. The findings included: 1. Review of the policy and procedure, titled, Oxygen Administration, provided by the Director of Nursing (DON), published 10/07/24, documented in the Policy Statement: Purpose: The purpose of this procedure is to provide guidelines for safe Oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for Oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Assessment: Before administering Oxygen, and while the resident is receiving Oxygen therapy, assess for the following: 1. Signs or symptoms of Cyanosis .2. Signs or symptoms of Hypoxia .3. Signs or symptoms of Oxygen toxicity .4. Vital Signs, 5. Lung sounds, 6. Arterial Blood Gases and Oxygen saturation, if applicable; .Documentation: After completing the Oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of Oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for as needed (p.r.n.) administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. Record review revealed Resident #309 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Hypertension and Atherosclerotic Heart Disease. The documented Brief Interview Mental Status (BIM) score was 13, indicating intact cognition. Record review of the Resident #309's care plan initiated and revised 08/23/24 indicated Focus: The resident has Oxygen Therapy. Interventions: Auscultate lung sounds Change nasal cannula tubing as needed Monitor Oxygen saturation every shift. Oxygen therapy as per physician order. Goal: Resident #309 will breathe easily and comfortably. During an observation of Resident #309 conducted on 12/09/24 at 11:07 AM, he was observed resting in bed with Oxygen infusing at three to four (3-4) liters via Oxygen concentrator, but with no current Physician orders noted. Oxygen signage was posted outside the resident's door. On 12/09/24 at 3:39 PM, Resident #309 was still observed resting in bed with Oxygen infusing at three to four (3-4) liters via Oxygen Concentrator, but still with no current Physician orders noted in place. On 12/10/24 at 11:16 AM Resident #309 was observed resting in bed with Oxygen infusing at three to four (3-4) liters via Oxygen Concentrator, but was still with no current Physician orders noted in place. On 12/10/24 at 4:07 PM, Resident #309 was observed resting in bed with Oxygen infusing at three to four (3-4) liters via Oxygen Concentrator, but still with no current Physician orders noted in place. On 12/11/24 at 1:02 PM, Resident #309 was again observed resting in bed with Oxygen infusing at three to four (3-4) liters via Oxygen Concentrator, but still with no current Physician orders noted in place. An interview was conducted on 12/09/24 at 11:10 AM with Resident #309, who stated that he wears it [oxygen] a lot. A side-by-side record review was conducted with Staff S, Licensed Practical Nurse (LPN), in which it was noted there was no current order on record for Oxygen therapy for Resident #309. There was no documentation pertaining to Oxygen Therapy in the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). The MARs and TARs lacked evidence of documentation that the Oxygen was being initialed / signed off as having been administered to the resident. An interview was conducted with Staff S on 12/11/24 at 1:08 PM, regarding the resident receiving continuous Oxygen therapy without a physician's order. Staff S acknowledged there was no current order on file for the Oxygen and stated that she could not recall how long he had been receiving it. An interview was conducted with Staff T, LPN/Unit Manager (LPN/UM) on 12/11/24 at 2:32 PM regarding the resident receiving continuous Oxygen therapy without a physician's order. Staff T acknowledged there was no current order on file for the Oxygen. A physician's order for Oxygen was not obtained until after surveyor intervention. On 12/11/24 at 4:32 PM, the DON further recognized and acknowledged that the resident was currently receiving Oxygen therapy without a physician's order in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #89 was admitted on [DATE] with diagnoses that included Acute Kidney Failure, Chronic Kidney Disease, Hyperkalemia, Fluid Overload, Chronic Metabolic Acidosis related to Secondary Hyperparathyroidism and Diabetes Mellitus. Review of the current Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of physician orders dated 11/26/24, revealed in house-dialysis, every day shift on Monday, Wednesday, and Friday at 8:30 AM. Review of physician orders dated 12/03/24 at 3:00 PM revealed fluid restriction: 240 ml (milliliter), (LPS (Liquid Protein Supplement) 1X [one time]), every day (AM) shift. Additional orders dated 12/04/24 revealed a 1200 ml fluid restriction: 120 ml every evening (PM) shift, and fluid restriction: 120 mL every night shift, with a total of 1200 mL daily fluid restriction, and an allotment of 480 mL for nursing and 720 mL for dietary. Review of facility's carbon copied document, titled, Fluid Restriction Pattern, submitted by the Registered Dietician on 12/12/24 at 12:30 PM, revealed the following: breakfast of 120 mL juice; lunch of 240 mL tea and 180 mL soup; dinner of 180 mL water. The document revealed 240 ml of Nursing provided fluids in AM shift, 120 ml during PM shift, and 120 ml at night shift. The document included the following notations: no water pitcher and follow pattern on card; daily total of 1200 mL; distribution for Nursing of 480 mL and Dietary for 720 ml. The document was signed by a Dietician and by Staff O, Unit Manager Registered Nurse (UM/RN) on 12/03/24. Further review of this facility's document revealed blackened lines on items under AM snack, lunch, on and under shift total. Review of Resident #89's meal tickets dated 12/09/24 until 12/14/24, provided by the Kitchen Manager on 12/12/24 at 10:00 AM, revealed no written information regarding fluid restriction. Additional review of facility's paper, titled, Task: Fluids consumed in cubic centimeter (cc's) and percent (%), (breakfast, lunch, dinner), provided by the Director of Nursing (DON) on 12/12/24 at 2:30 PM, revealed: on 12/06/24 at 12:53 PM, Resident #89 consumed 180 ml; at 2:31 PM, 180 ml; and at 10:15 PM,120 ml, for a total of 480 ml fluids provided by Nursing staff. Further review of the document revealed the following: On 12/07/24, Resident #89 consumed a total of 600 mL fluids; on 12/08/24, 580 ml; on 12/09/24, 360 ml; on 12/10/24, 600 ml; on 12/11/24, 720 ml; and on 12/12/24, Resident #89 consumed fluids at 10:47 AM and at 1:55 PM totaling 480 ml of fluids provided by Nursing staff. During observation on 12/11/24 at 9:00 AM, Resident #89's breakfast meal ticket revealed the following: on top of the horizontal black line showed Resident's name, room number, North Cart 1-28, renal/chronic kidney disease-dialysis diet/CCD, date, and breakfast; below the black horizontal line showed garden scrambled eggs for 2 ounces (oz), oatmeal for 6 oz (180 mL), coffee cake for one piece, apple juice for 4 oz (120 ml), hot tea for 2 cups (480 ml), milk 2% for 4 oz (120 ml), sugar substitute for 2 pieces (pc). The total fluids on the breakfast tray provided by Dietary Services was 900 ml. There was no written information on Resident #89's meal ticket regarding fluid restriction. During observation on 12/12/24 at 9:30 AM, Resident #89's meal ticket revealed the following: on top of the horizontal black line showed Resident's name, room number, North Cart 1-28, renal/chronic kidney disease-dialysis diet, day, (W3-D19), breakfast, 12/12/2024; below the black horizontal line showed turkey sausage for one oz, oatmeal for 6 oz (180 ml), cinnamon French toast for 2 each, apple juice for 4 oz (120 ml), hot tea for 2 cups (480 ml), milk 2% for 4 oz (120 ml) and sugar substitute for 2 pc. The total breakfast fluids provided by Dietary Services was 900 ml. There was no written information on Resident #89's meal ticket regarding fluid restriction. An interview was conducted with Staff FF, Certified Nursing Assistant (CNA) on 12/12/24 at 1:27 PM, who stated she has been working in the facility for one year. When asked if she documents the amount of fluid Resident #189 consumes during her AM shift, she stated she does and added that she is aware Resident #189 is on fluid restriction. When asked how much fluid Resident #89 is allowed on her shift, she stated she must check the records. When asked if she could provide the printed daily amount of liquids she documented on her CNA task, she replied, I will ask one of the nurses to print it for me. The DON provided the printed task sheet on 12/12/24 at 2:30 PM. In an interview with the Kitchen Manager on 12/12/24 at 1:57 PM, she stated the Registered Dietician (RD) tells her the names of residents on fluid restriction. When asked if she is aware Resident #89 is on fluid restriction, she stated I have to check my record. When showed the resident's meal ticket showing that fluid restriction was not written, she stated she did not know Resident #89 was on fluid restriction. Based on observations, interview and record review, the facility failed to follow physicians' orders for fluid restrictions for 2 of 2 sampled residents reviewed for dialysis, Resident #123 and Resident #89. The findings included: 1. Record review revealed Resident #123 was readmitted to the facility on [DATE] with a diagnosis of End-Stage Renal Disease and is dependent on dialysis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #123 has a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Review of the physician's orders showed an order dated 12/09/24 for fluid restrictions of 1500 milliliters (ml) a day, with 420 ml allocated for nursing and 1080 ml allocated for dietary. Further orders showed that Resident #123 was receiving dialysis three times a week in-house. In an observation conducted on 12/09/24 at 12:55 PM, Resident #123 was not in the room, and her lunch tray was noted at the bedside. The lunch tray was noted with a meal ticket that showed a Renal Dialysis diet and fluid restriction of 1140 ml a day. The lunch tray was noted to have 4 ounces of cranberry juice, 8 ounces of diet ginger ale, and 16 ounces of Styrofoam cup of water near the lunch tray. The above observation showed that Resident #123 received 28 ounces of fluids, which was about 829 ml of fluids for one meal. In an interview conducted on 12/10/24 at 7:50 AM, Resident #123 stated that she goes to dialysis three days a week in the facility. When asked if she was on fluid restrictions, she said yes and that it was around 1500 ml a day but she was not sure. Resident #123 reported that she was not educated on the fluid restrictions and how many fluids she is allowed a day. In another interview conducted on 12/10/24 at 8:50 AM, Resident #123 said that her meal ticket this morning showed that she was on 1080ml fluid restrictions and then said, I wish someone explained this to me in ounces because I do not understand ml. In this interview, Resident #123's meal ticket showed a Renal Dialysis diet with 1080 ml fluid restrictions and 8 ounces of juice. The Breakfast tray consisted of 12 ounces of coffee and 8 ounces of juice for a total of 20 ounces of fluids (640 ml). In an interview conducted on 12/12/24 at 11:47 AM, Staff Q, Certified Nursing Assistant / CNA, stated that Resident #123 was not allowed to get too many fluids but did not know how many ounces of water Resident #123 was allowed. In an interview conducted on 12/12/24 at 11:59 AM with Staff R, Registered Nurse, the nurse stated that the fluids restrictions are written in the medial chart which showed that exact number of fluids that are allocated for Dietary and the fluids allocated for Dietary. The meal ticket will also have the exact number of fluids allowed for the day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 4 of 12 sampled residents reviewed during the controlled substance record review, Residents #14, #168, #186, and #201. The findings included: Review of the facility's policy, titled, Controlled Substances, dated 11/2022, included the following: The facility complies with all laws, regulations, and other requirement related to handling, storage, disposal, and documentation of controlled medications. Dispensing and Reconciling Controlled Substances: 1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 1. Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Acute Kidney Failure, Metabolic Encephalopathy, Generalized Anxiety Disorder, Primary Insomnia, and Chronic Obstructive Pulmonary Disease. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the Physician's orders showed that Resident #14 had an order dated 12/04/24 for Alprazolam (Xanax) 1 mg tablet, give one tablet every 12 hours as needed for anxiety. On 12/11/24 at 5:28 PM, a record review of Resident #14's Controlled Drug Disposition sheet was conducted. The disposition sheet for Alprazolam (Xanax) 1 mg (30 tablets), to be given every 12 hours as needed for anxiety, was received by the facility from the pharmacy on 12/04/24, and revealed there were 23 tablets left in the controlled substance box. Further review of the disposition sheet revealed between 12/04/24 and 12/10/24, seven (7) tablets of Xanax 1mg were dispensed and removed from the controlled substance box. Review of Resident #14's December Medication Administration Record (MAR) revealed no documentation for the administration of Xanax 1mg tablet on 12/04/24 and 12/05/24 (which was documented as dispensed and removed for administration on the Controlled Drug Disposition sheet). The resident's controlled substance was not reconciled. An interview was conducted on 12/12/24 at 1:13 PM on the South-2 wing with Staff S, Licensed Practical Nurse (LPN), who stated working at the facility for 17 years. She stated she verifies physician's orders, dispense the controlled medication and administers to the resident. Staff S then stated after the administration, she signs both the Controlled Drug Disposition Sheet and the MAR. A side-by-side review of Resident #168 Controlled Drug Disposition sheet was conducted with Staff S and Staff T, South wing Unit Manager. Both staff were unable to explain as to why there were discrepancies in the controlled-drug administration. 2. Record review for Resident #168 revealed the resident was admitted to the facility on [DATE] and had a readmission dated10/29/24 with diagnoses that included: End Stage Renal Disease, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Hereditary and Idiopathic Neuropathy. Review of Section C of the MDS assessment dated [DATE] revealed Resident #168 had a BIMS score of 15, indicating he was cognitively intact. Review of the Physician's Orders showed Resident #168 had an order dated 11/05/24 for Tramadol HCl 50 mg tablet, give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #168's Controlled Drug Disposition sheet for Tramadol HCL 50 mg (24 tablets) was received at the facility from the pharmacy on 10/11/24, and revealed Resident #168 was given the medication on the following days in November: 11/10/24 at 12:20AM and at 2021(8:21 PM), 11/11/24 at 9:40 PM, 11/13/24 at 12:30 PM and at 9:00 PM, 11/16/24 at 9:00 PM, and 11/17/24 at 8:00 PM. Further review of the Disposition sheet revealed 2 tablets of Tramadol HCL were left in the controlled substance box with the last recorded date of administration on 11/27/24 at 12:33 AM. Review of Resident #168's November MAR revealed that Tramadol 50 mg was documented with nurses' initials and times on all the above dates except for 11/13/24 at 12:30 PM, 11/13/24 at 9:00 PM and on 11/17/24 at 8:00 PM (which was documented in Resident #168's Controlled Drug Disposition sheet as dispensed and removed from the controlled substance box). The resident's controlled substance was not reconciled. An interview was conducted on 12/12/24 at 1:13 PM on the South-2 wing with Staff S, Licensed Practical Nurse (LPN), who stated working at the facility for 17 years. She stated she verifies physician's orders, dispense the controlled medication and administers to the resident. Staff S then stated after the administration, she signs both the Controlled Drug Disposition Sheet and the MAR. A side-by-side review of Resident #168 Controlled Drug Disposition sheet was conducted with Staff S and Staff T, South wing Unit Manager. Both staff were unable to explain as to why there were discrepancies in the controlled-drug administration. 3. Record review for Resident #186 revealed the resident was admitted to the facility on [DATE] and had a re-admission date of 10/21/24 with the following diagnoses: Fracture of Unspecified Part of Neck of Right Femur, Dysphagia following Cerebral Infarction, Adjustment Disorder with Depressed Mood, and Pain in Left Hip. Review of Section C of the MDS assessment dated [DATE] revealed Resident #186 had a BIMS score of 05, indicating he was severely cognitively impaired. Review of the Physician's Orders showed Resident #186 had an order dated 11/22/24 for Oxycodone w [with] / Acetaminophen [Percocet] 5-325 mg tablet, give 1 tablet by mouth every 12 hours as needed for Pain. Review of the Physician's Orders showed that Resident #186 had an order dated 12/04/24 for Oxycodone w / Acetaminophen [Percocet] 5-325 mg tablet, give 1 tablet by mouth one time a day for pain for 7 days, give prior to therapy. Hold for sedation, if Systolic Blood Pressure (SBP) <100, Respiration rate (RR) <12, Oxygen levels <92%. Review of Resident #186's Controlled Drug Disposition sheets revealed Percocet 5-325 mg (8 tablets), to be given every 12 hours as needed for Pain, was received by the facility from the pharmacy on 10/22/24, and revealed there were 4 tablets left in the controlled substance box. Further review of the disposition sheet documented that on 10/27/24, 11/30/24, 12/04/24 and 12/05/24 Percocet tablets were dispensed and removed from the controlled substance box. Review of the disposition sheet for Percocet 5-325 mg (6 tablets) to be given daily for 7 days prior to therapy, was received by the facility from the pharmacy on 12/04/24, and revealed there were 5 tablets left in the controlled substance box (one tablet was dispensed and removed from the controlled substance box on 12/09/24). Review of Resident #186's December Medication Administration Record (MAR) revealed no documentation of any administration of Percocet 5-325 mg tablet, give every 12 hours as needed for pain. Further review of the MAR revealed Resident #186 was administered Percocet 5-325 mg prior to therapy on 12/04/24, 12/05/24, 12/07/24, 12/09/24, and 12/10/24 at the scheduled time of 9:00 AM. An interview was conducted on 12/12/24 at 12:37 PM with Staff U, LPN. She stated after dispensing the controlled medication, she would fill in the date, time, amount and sign the Controlled Drug Disposition sheet and initial in the MAR as well as part of the administration process. Staff U then stated, for controlled medications that are discontinued or there was a change in the orders, the requirement is for two nurses to sign the Controlled Drug Disposition sheet and the medication with the sheet are given to the Director of Nursing (DON). A side-by-side review of Resident #186's Controlled Drug Disposition sheet was conducted with Staff U. She acknowledged signing the MAR for Percocet 5-325 mg as administered on 12/07/24 and 12/10/24. Staff U was not sure why or what happened that she did not sign the Percocet's disposition sheet. 4. Record review for Resident #201 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Displaced Bimalleolar Fracture of Right Lower Leg, Primary Insomnia, and Major Depressive Disorder. Review of Section C of the MDS assessment dated [DATE] revealed Resident #201 had a BIMS score of 12, indicating she had moderate cognitive impairment. Review of the Physician's Orders showed Resident #201 had an order dated 11/19/24 for Tramadol HCl 50 mg tablet, give 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #201's Controlled Drug Disposition sheet for Tramadol HCL 50 mg (5 tablets) was received at the facility from the pharmacy (date received not entered) and revealed Resident #201 was given the medication on the following days: 11/19/24 at 10:27 AM, 11/25/24 at 12:26 AM, and 12/09/24 at 11:25. Further review of the Disposition sheet revealed there were 2 tablets of Tramadol HCL left in the controlled substance box. Review of Resident #201's December MAR revealed that Tramadol 50 mg tablet was not administered on 12/09/24 (which was documented in Resident #201's Controlled Drug Disposition sheet as dispensed and removed from the controlled substance box). The resident's controlled substance was not reconciled. An interview was conducted on 12/12/24 at 1:35 PM with the Director Of Nursing (DON) and the Consultant Pharmacist. The DON stated narcotics medications are administered to the resident and then the nurse is to document almost at the same time in the Controlled Drug Disposition sheet and the MAR. The DON also stated he does audits of the medication carts randomly, but just compares the Controlled Drug Disposition sheet amount with the medication's blister packet to confirm the count. The Consultant Pharmacist stated she and her team do audit counts of the medication carts monthly. A side-by-side review of the 4 residents' Controlled Drug Disposition sheet was conducted with the DON and the Consultant Pharmacist, in which both acknowledged the nurses require more education of controlled substance documentation and reconciliation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review revealed Resident #86 was admitted on [DATE] with diagnoses that included: Major Depressive Disorder and Seizure Disorder. The quarterly MDS assessment dated [DATE] revealed a BIMS score is 00, indicating severe cognitive impairment. A thorough review of the care plan dated 09/12/24 indicated that Resident #86 is prone to side effects related to the use of: Antipsychotic, Antidepressant, Anticoagulant, Anticonvulsant, which need to be observed for potential side effects such as: hypotension, tachycardia, nausea, vomiting, diarrhea, blurred vision, chest pain, rash, drowsiness, lethargy. Review of the physician orders, the Medication Administration Reports (MARs) and the Treatment Administration Reports (TARs) indicated the facility failed to obtain an order and implement intervention to monitor side effects related to the use of antidepressant medications for Resident #86. 5. Record review revealed Resident #198 was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Foot Ulcer, Benign Prostatic Hyperplasia, Anxiety Disorder, and Atherosclerotic Heart Disease. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #198 had a documented BIMS score of 13, indicating intact cognitive. Record review of the Medication Administration Record (MAR) on 12/11/24 at 2:44 PM, revealed oxycodone was administered orally on 12/01/24 for pain. The documented pain level was 10, followed by the administration of medication, but no follow up documentation regarding the effectiveness of medication as ordered by physician, had been documented. The same MAR revealed that on 12/02/24, 12/04/24,12/06/24, 12/07/24, 12/08/24 and 12/09/24, the effectiveness of the administered oral oxycodone tablets was not documented. Review of the nursing care plan interventions revealed to evaluate the effectiveness of pain interventions (frequency). Review for compliance, symptoms, dosing scheduled and resident satisfaction with results, impact on functional ability and impact on cognition. In an interview with Staff O, Unit Manager Registered Nurse (UN/RN) on 12/11/24 at 10:50 AM, when asked how the facility staff monitored residents on several medications including anti-anxiety, anti-depressant and pain medications, she responded, All the medications were monitored according to their side effects and the symptoms presented by resident. The residents were additionally monitored for pain level after the administration of medication, with their mental status and affects and their degree of sedation. In an interview conducted on 12/11/24 at 11:56 AM with the DON, he stated that residents on psychotropic medications need to be monitored for behaviors and side effects. In an interview conducted on 12/11/24 at 12:00 PM with the CP, she stated that residents on psychotropic medications need to be monitored for side effects and behaviors. She stated that they usually write a two-part order that includes the side effects and behaviors. When asked how the facility ensures a review of medications for Gradual Dose Reduction (GDR), she responded, Psychiatry evaluation is done. In an additional interview with the facility's CP on 12/11/24 at 2:33 PM, she stated nurses should have documented the effectiveness of oxycodone oral medications on these dates (12/02/24, 12/04/24,12/06/24, 12/07/24, 12/08/24 and 12/09/24). She added that Resident #198 had experienced a lot of pain, had anxiety issues and needed to be monitored. She said that facility nurses have not been monitoring the outcomes or the effectiveness of oxycodone medication after administration to Resident #198. 4. Record review for Resident #145 revealed the resident was admitted to the facility on [DATE] with a re-admission on [DATE] with the following diagnoses: Fracture of Neck of Left Femur, Type 2 Diabetes Mellitus, Major Depressive Disorder, and Primary Insomnia. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had a BIMS score of 15, indicating intact cognition. Review of Section N revealed Resident #145 was on anticoagulant, opioid, antiplatelet, hypoglycemic, and anticonvulsant. Review of the physician's orders showed that Resident #145 had an order dated 11/22/24 for Trazodone HCl 50 mg tablet, to give 0.5 tablet by mouth at bedtime for Depression (Give 1/2 tablet to equal 25 mg). Further review of the physician's orders showed that Resident #145 had no orders for monitoring of behaviors and side effects for Trazodone 50 mg tablet. Review of the Quarterly Care Plan dated 11/30/24 documented that Resident #145 uses psychotropic medications (Trazodone) for Depression. The goals included: the resident will be free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation / impaction or cognitive / behavioral impairment through review date. Interventions were to: Administer medications as ordered and to monitor/document for side effects and effectiveness. Review of the September Medical Administration Record (MAR) revealed no documentation that Resident #145 was monitored for behaviors and side effects for the psychotropic medication, Trazodone. Review of the Medication Regimen Reviews (MRR) performed by the CP for the prior 6 months for Resident #145 reported no recommendations for monitoring of behaviors or side effects for the psychotropic medication, Trazodone. An interview was conducted on 12/11/24 at 10:50 AM with Staff Z, LPN, who stated she has worked at the facility for 2 months and has been Resident #145's nurse for 2 weeks. She stated a physician's order is needed to monitor behaviors and side effects for psychotropic medications. She acknowledged these medications require monitoring the resident's behavioral changes for all 3 (nursing) shifts. An interview was conducted on 12/11/24 at 2:27 PM with the CP, who stated side effects of psychotropic medications would be monitored by the psychiatrist and the nurses. When asked if residents on psychotropic medications should also be monitored for behaviors, she stated, yes. A side-by-side review of Resident #145's MAR and the physician's orders was conducted with the pharmacist. She acknowledged there were no behavior or side effect monitoring orders from the physician or psychologist for Resident #145 and could not believe she missed it. 3. Record review revealed Resident #73 was admitted on [DATE] with diagnoses of Hyperlipemia and Major Depressive Disorder. Review of the physician's order showed an order for Sertraline (depression medication) 50 milligrams one time a day, which was dated 08/09/24. Continued review of the orders did not show an order to monitor the side effects of the Sertraline. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #73 had a BIMS score of 13, indicating intact cognition. The Care Plan initiated on 05/23/24 showed that Resident #73 was on the psychotropic medication Sertraline. Interventions were in place to monitor, record, and report to the doctor side effects and adverse reactions to the psychoactive medications. In an interview conducted on 12/11/24 at 11:56 AM with the facility's Director of Nursing (DON), he stated that residents on psychotropic medications need to be monitored for behaviors and side effects. He stated that there is no order to monitor the side effects of the medication for Resident #73, and when asked if the side effects are being monitored, he said no. In an interview conducted on 12/11/24 at 12:00 PM with the Consultant Pharmacist, she stated that residents on psychotropic medications need to be monitored for side effects and behaviors. She stated that they usually write a two-part order that includes the side effects and behaviors. She said that they have not been monitoring the side effects for Resident #73. Based on record review, observations and interviews, the facility failed to ensure residents' medication regimen (psychotropic's, antipsychotic, antiplatelet and hypoglycemic medications) were monitored appropriately as evidenced of the lack of written documentation of medication side effects, medication efficacy and behavior that were being monitored for 5 of 5 sampled residents, Resident #77, #86, #167, and #145, for unnecessary medications, and for 1 of 1 sampled resident, Resident #73, reviewed for Mood / Behavior. The findings included: Review of the facility policy, titled, Pharmacy Services-Role of the Consultant Pharmacist, with a revision date of 04/2019, documented in part, .the facility shall have the services of a consultant pharmacist .collaborates on other aspects of pharmacy services, including .recommending current resources to help staff identify .medications side effects and/or adverse effects .the consultant pharmacist will provide specific activities related to medication regimen review including .appropriate communication of information to prescribes' and facility leadership about .pertinent resident-specific documentation in the medical record as indicated . 1. Review of Resident #77's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Type 2 Diabetes Mellitus, Major Depressive Disorder-Recurrent, Tobacco Use, Nicotine Dependence, Persistent Mood Disorders, Generalized Anxiety Disorder, Cognitive Communication Deficit, and Unspecified Dementia. Review of Resident #77's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating no cognition impairment. Review of Resident #77's physician orders documented the following active medications orders: *Trazodone HCl Oral Tablet 50 MG (milligrams), give 0.5 tablet by mouth one time a day for Depression Give 1/2 tablet to equal 25 mg - start dated 11/12/24. *Trazodone HCl Oral Tablet 100 MG Give 1 tablet by mouth at bedtime for Depression - start dated 11/11/24. *Cymbalta Oral Capsule Delayed Release Particles 30 MG (Duloxetine HCl) Give 2 capsule by mouth one time a day for Depression Start Date -11/02/24. *Percocet Oral Tablet 5-325 MG Give 1 tablet by mouth every 12 hours as needed for pain - start date 08/20/24. *Obtain and record accu-check blood sugar twice daily without coverage, NOTIFY MD if BS [blood sugar] less than 70 or greater than 300 two times a day for Diabetic Monitoring before breakfast and dinner. *Novolog FlexPen 100 UNIT/ML Solution pen-injector Inject 6 unit subcutaneously before meals for DM (Diabetes Mellitus) - start date 08/20/24. *Humalog KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin-Lispro) Inject 6 unit subcutaneously in the evening for Hyperglycemia until Start Date -12/03/24. *Insulin Glargine -100 UNIT/ML Solution pen-injector Inject 10 unit subcutaneously at bedtime for DM-Start Date-08/20/24. *Nicotine Patch 24 Hour 7 MG\/24 HR Apply 1 patch transdermally one time a day for Smoking Cessation and remove per schedule (Active). Review of Resident #77's active care plan, titled, Resident has history smoking, initiated and updated on 11/20/24. The care plan interventions included Nicotine patch 24 hour 14 mg/24 hour one time a day for smoking cessation for two months . The care plan lacked written interventions related to monitoring of side effects of a psychotropic medication - Nicotine. Review of Resident # 77's care plan, titled, The resident uses antidepressant medication, initiated on 08/20/24, revision date 11/14/24,documented interventions to include Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor/document/report to MD (medical doctor) prn (as needed) ongoing s/sx (sign/symptoms) of depression unaltered by antidepressant medication: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with other, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance . Review of Resident # 77's care plan, titled, The resident has Diabetes Mellitus, initiated on 08/20/2024, revision date 11/14/24, documented interventions to include: Monitor/document/report to MD PRN (as needed) s/sx (signs and symptoms) of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma . Review of Resident #77's clinical record lacked written evidence that care plan interventions were documented and monitored across all shifts. Review of Resident # 77's December 2024 Medication Administration Record (MAR) revealed the lack of written evidence of monitoring the resident for psychotropic medication side effects and the lack of monitoring for hypoglycemia and hyperglycemia signs and symptoms as per the resident's care plan developed on 08/20/24 and revised on 11/14/24. Review of Resident #77's, Medication Regimen Review, documented no recommendations for the reviews on 09/20/24, 10/30/24 and 11/29/24. On 12/11/24 at 1:54 PM, an interview was conducted with Staff DD, LPN, who stated Resident #77 continues to smoke and was getting a nicotine patch daily. Staff DD was asked how she monitors the Nicotine medication side effects and stated she did vital signs daily. Staff DD stated that she would ask the CNAs if the resident is having any problems like constipation and she would then document it on a progress note. Staff DD was asked how she would monitor the resident's psychotropics and hypoglycemic medications side effects and stated she does vital daily, monitor for pain and would ask the CNA if the resident had an any problems or side effects. A side-by-side review of Resident #77's MARs and physician orders was conducted with Staff DD who stated she did not see any monitoring of the medications side effects and verbalized that they should be monitoring according to the care plan. On 12/11/24 at 4:47 PM, an interview was conducted with the Consultant Pharmacist (CP) who was apprised of Resident #77 having a physician order for Nicotine patch and she was observed smoking on 12/10/24 late in the afternoon. The CP stated she did not know the resident was smoking and that the Nicotine patch is usually done for two months. During the interview, the CP stated that Nicotine patch was a psychotropic medication and needed to be monitored for psychotropic medication side effects and behavior. The CP agreed there was a lack of monitoring resident efficacy and needs to have behavior monitoring. The CP was asked for a GDR and stated she had not done one. A side-by-side review of Resident #77's August, September, October and December 2024's MAR was conducted with the CP, who acknowledged that Resident #77's psychotropics and hypoglycemic's medications were not monitored. On 12/12/24 at 9:25 AM, an interview was conducted with Resident #77 who stated she was trying to stop smoking but it is hard to do. The resident stated the nurses are putting on one patch and rotates the arm, did not remember if she was told for how long she was to wear the patch. The resident stated she smoked twice this week, one on yesterday evening (12/11/24) and on Tuesday. 2. Review of Resident #167's clinical record documented an admission on [DATE] and a readmission on [DATE]. Review of Resident #167's clinical diagnoses documented on the face sheet included the following: Schizoaffective Disorder, Bipolar Type dated 08/12/24, Depressive Disorder-Recurrent, Schizoaffective Disorder, Bipolar Type, Generalized Anxiety, Metabolic Encephalopathy and Chronic Pain Syndrome. Review of Resident #167's active care plan documented, The resident uses anti-anxiety medications r/t (related to) Anxiety Disorder initiated on 04/22/24 with a revision on 04/22/24 with interventions that included: Monitor / document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations- initiated on 04/22/2024. Review of Resident #167's active care plan documented, The resident uses psychotropic medications r/t Seroquel initiated on 08/19/24 with a revision on 08/19/24 and interventions to include: Monitor/record/report to MD prn (as needed) side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS- Extrapyramidal symptoms (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person, initiated on 08/19/24. Review of Resident #167's active care plan documented, At risk for pain related to chronic pain syndrome, metabolic encephalopathy .Constipation, Chronic pain pump initiated on 04/02/24 revised on 08/19/24 with interventions to include: Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician initiated on 04/02/24. Review of Resident #167's physician orders documented the following: *10/10/24 - Lorazepam (antianxiety) Tablet 0.5 MG Give 0.5 tablet by mouth two times a day for Anxiety Give 0.5 tablet to equal 0.25 mg. *11/26/24 - Oxycodone-Acetaminophen (opioid-controlled substance) Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Pain. *09/05/24 Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 50 mg by mouth in the evening for Schizoaffective Disorder. *10/11/24 Fentanyl Patch (opioid-controlled substance) 72 Hour 12 MCG/HR Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Review of Resident #167's clinical record lacked written evidence that care plan interventions were documented and monitored across all shifts. Review of Resident #167's December 2024 MAR revealed the lack of written evidence of monitoring the resident for psychotropic, antianxiety and opioid's medication side effects as per care plans. Review of Resident #167's Medication Regimen Review, dated 10/30/24, documented under nursing recommendations, revealed, Please .ensure that .adverse effects are also being tracked .Please note that any medication used as a Psychotropic .must be tracked for specific behaviors and adverse effects . The report documented under outcome, agreed on 11/06/24. On 12/10/24 at 12:45 PM, attempted to interview Resident #167, but the resident was cursing and agitated. On 12/10/24 at 3:22 PM, a side-by-side record review and interview was conducted with the MDS Director who stated Resident #167 was initially admitted to the facility on [DATE] and had a readmission [DATE]. The resident's quarterly MDS assessment dated [DATE] documented a BIMS 15 indicating no cognition impairment. During, the review, the MDS Director stated Resident #167 had a new diagnosis of Schizoaffective Bipolar type on 08/12/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to store residents glucometers in a sanitary manner; failed to securely lock the North wing medication storage door, and failed to secure medications at the bedsides for 1 resident, Resident #407. The resident census at the time of survey was 196. The findings included: Review of the facility's policy and procedure, titled, Medication Labeling and Storage, provided by the Director of Nursing (DON) published 11/08/24, documented in the Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Statement #2 revealed the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Statement # 3 of the same policy revealed if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 1. During observation of the North wing medication storage room on 12/11/24 at 4:40 PM, a glucometer was observed on top of the first drawer on the right side of North Wing Medication cart. The glucometer was not contained in a plastic container or wrap, and its back part was directly touching several blue sterile lancets contained in a blue plastic box. These sterile blue lancets are used for pricking residents' fingers to check blood glucose levels. In an interview with Staff N, Registered Nurse, on 12/11/24 at 4:55 PM, she stated that a glucometer must be plastic wrapped when placed on top of Assure sterile blue lancets. When asked why it was not done, she kept quiet. 2. In an observation on 12/11/24 at 5:45 PM, the North wing medication storage room door was observed to be halfway opened. A closer observation revealed there were no staff present inside the North wing medication storage room. Further observation revealed staff were in the hallways, some residents wheeling on wheelchairs, some visitors walking around, but there was no visible staff sitting at the nurse's station on the left side of North wing medication storage. The surveyor continued the observation of the door for 10 minutes, and on 12/11/24 at 5:56 PM she informed one of the staff, that the door was left open for a long time without staff supervision. The staff member from central service stated she would close it. The surveyor left the area as soon as the central service staff locked the North wing medication storage door. The North wing medication storage room key was hanging outside on the desk below and to the right of a printer at the nurses' station next to the medication storage room. In another interview with the Director Of Nursing (DON) on 12/12/24 at 9:00 AM, he stated there is no facility policy for glucometer storage in the Medication cart, but he educates nurses during the 2-day orientation upon hire that glucometers are cleaned and stored, contained in a plastic bag before putting inside the medication cart. 3. Record review revealed Resident #407 was admitted to the facility on [DATE] with the following diagnoses: Urinary Tract Infection, Type 2 Diabetes Mellitus (DM) with Hypoglycemia Without Coma, and Adjustment Disorder with Depressed Mood. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #407 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive response. Review of Section N revealed that Resident #407 was on a hypoglycemic medication. Review of the physician's orders showed that Resident #407 had an order dated 11/30/24 for Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector, inject 20 unit subcutaneously at bedtime for DM. During observation of Resident #407's room on 12/09/24 at 10:41 AM, it was observed that there was a (Toujeo Max SoloStar) insulin dispenser pen with an expiration date of 05/31/25 sitting on Resident #407's nightstand bedside table with her glasses. Photographic .Evidence Obtained. The insulin dispenser pen was unsecured, in plain sight and accessible to other residents, staff members and visitors. An interview was conducted on 12/09/24 at 10:41 AM with Resident #407, who stated the insulin dispenser pen belonged to her and she brought it from home. She stated she had it since admission and believes the insulin pen is empty. During a second observation conducted on 12/11/24 at 10:29 AM, Resident #407 was in bed sleeping, no insulin dispenser pen was noted on her nightstand bedside table. An interview was conducted on 12/11/24 at 11:21AM with Staff Y, Certified Nursing Assistant (CNA), who stated she has worked at the facility for about 10 years and 2 years on the [NAME] 2 wing. Staff Y stated she has not seen any medications in residents' rooms. She stated if there were medications in the rooms, she would remove them and give them to the floor nurse or supervisor. She acknowledged residents are not to have any medications from home in their rooms. An interview was conducted on 12/11/24 at 11:29 AM with Staff U, Licensed Practical Nurse (LPN), who stated she started working at the facility about 2 months ago and always scheduled to the [NAME] 2 wing. She stated that upon a resident's admission, the floor nurse does an assessment, and the supervisor inputs the medications into the computer. Staff U also stated that any medications the resident has brought in from home are collected by either the floor nurse or supervisor and the family is called to pick them up. Staff U stated residents and family are educated not to bring any medications from home. She stated she has not seen any medications in residents' rooms but she did recently have to educate a resident because she had medications at the bedside. An interview was conducted on 12/11/24 at 12:50 PM with the Director of Nursing (DON). He stated the floor nurses and unit managers are responsible for collecting any medications brought from home, then they contact the family member. The DON stated the staff have been educated to retrieve any medications brought from home. A side-by-side review of the photograph obtained from Resident #407's room of the insulin pen was conducted. The DON acknowledged that the medication was not collected, but they cannot search through the resident's belongings. The DON was reminded that Resident #407 has been in the facility since 11/29/24 and she stated she had the insulin pen since admission.

Based on observations, interviews and record reviews, the facility failed to follow their menu for the regular diet during 1 of 2 observations in the main kitchen. This has the potential to affect 117 residents on a regular diet. The census at the time of survey was 196. The findings included: Review of the fall/winter 2024 diet guide sheet provided to the surveyors included the following menu for the regular diet consistency: 4-ounces (oz) of seasoned cauliflower, 4-oz of spanish rice and 3-oz of apple butter pork loin. In an observation conducted in the main kitchen on 12/11/24 at 11:25AM, the surveyor observed that a lunch tray consisted of pieces of Apple Butter Pork Loin that were pre-sliced. The surveyor asked to put a piece of the Pork Loin on a facility's scale which showed the slice of Pork had a weight of 2.25 ounces. The piece of the Pork was not the correct weight according to the facility's menu that should have been for 3 ounces. An interview was conducted on 12/12/24 at 2:00 PM with the Food Service Director IFSD) who stated that the cook is supposed to pre-cut the slices of Pork before plating it for the lunch meal, and to weigh each slice to ensure that it is around 3 ounces each.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review and record review, the facility failed to provide food in a form designed to meet individual needs for the Pureed diet consistency for 2 of 2 sampled residents observed during dining, Resident #22 and Resident #48. This has the potential to affect 17 residents on a Pureed diet. The findings included: Review of the facility's policy, titled, Modified Solid/Liquid Diet Consistency Policy and Procedure, not dated, showed the following: the purpose of this policy is to promote safe swallowing and minimize the risk of aspiration of solids/liquids for patients with impaired swallowing abilities. When prepared appropriately, it allows patients to exert less effort with mastication and allows the ability to control the solids and Liquids in the mouth. This yields a more efficient and safer swallow with less risk of aspiration or choking. It further showed that for the Pureed consistency diet, the food that is allowed on this plan must be pureed, cohesive, pudding-like food in a form without particles. 1. Record review showed that Resident #22 was admitted on [DATE] with diagnoses of Cerebral Atherosclerosis and Hypertension. The admission Minimum Data Set (MDS) assessment showed a Brief Interview of Mental Status (BIMS) score of 06, indicating severe cognitive impairment. In an observation conducted on 12/10/24 at 8:20 AM, Resident #22 was in his room eating the breakfast meal. The meal ticket was noted to have pureed breakfast meat and pureed pancakes. Closer observation revealed the pureed pancakes that were not of a smooth consistency and were noted to have lumps. 2. Record review showed that Resident #48 was admitted on [DATE] with diagnoses of Dementia and Depressive Disorder. The Quarterly MDS assessment showed that Resident #48 cognitive status was severely impaired. In an observation conducted on 12/10/24 at 8:37 AM, Resident #48 was noted in her bed with the breakfast tray at the side table. The meal ticket showed a regular pureed diet with pureed breakfast meat, pureed fortified oatmeal, and pureed pancakes. Closer observation revealed the pureed breakfast meat and pureed pancakes were not smooth and noted to have lumps. Continued observation at 8:49 AM revealed the pureed breakfast meat and pureed pancakes were grainy in consistency with large pieces of lumps. In an observation conducted on 12/10/24 at 12:36 PM, Resident #48 was in the room eating her lunch meal. The meal ticket was noted to have pureed cranberry-glazed turkey, pureed broccoli, and pureed mashed sweet potatoes. Closer observation showed that the pureed turkey did not have one smooth uniformed consistency and was noted to be lumpy. An interview was conducted on 12/11/24 at 9:22 AM with Staff GG, the Speech Therapist, who stated that they follow a national standard guideline for pureed diets. For the Pureed consistency, the food items need to have a cohesive texture that is pudding-like and easy to swallow. It should have no particles or lumps and should require no chewing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review showed that Resident #144 was admitted on [DATE] with diagnosis of Epilepsy and Hypothyroidism. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed BIMS score was 7, indicating severe cognitive impairment. Section GG of the MDS showed that Resident #144 needed setup or cleanup assistance during dining. Residents #144's care plan indicates that the resident is on a fortified food regimen. Review of the Order Summary Report showed the following: an order dated 09/30/24 for regular diet regular texture, thin liquid consistency, fortified foods. A thorough review of Resident #144's Care Plan dated 09/29/2024 stated the following: Monitor oral intake of food and fluid and provide fortified foods (fortified cereal w [with] / breakfast-487 calories/8 grams of protein, high calorie pudding w/ lunch and dinner-140 kcal/0 g protein). In an interview conducted on 12/11/24 at 11:45 AM, the Food Director stated the fortified food of the day and the remaining of the week on the menu is fortified mashed potato. In an observation conducted on 12/11/24 at 1:51 PM, Resident #144's lunch tray and meal ticket consisted of Apple Butter Pork Loin Baked chicken, Spanish Rice, Seasoned Cauliflower, Beef Barley Soup, Pineapple Crisp High Calorie Pudding, Juice of choice Ginger Ale. Closer observation indicated that no fortified mashed potatos were served on the tray. In an observation conducted on 12/12/24 at 1:31 PM, Resident #144 tray and meal ticket consisted of Swedish Meatballs, Buttered Parslied Noodles, Italian [NAME] Beans, Split Pea Soup, Chilled Fruit Cup, Ginger Ale. Closer observation indicated that no fortified mashed potato were served on the tray. Based on observations, interviews, and record review, the facility failed to accommodate resident allergies, intolerance, and preferences for 3 of 3 sampled residents observed during dining observation, Resident #32, Resident #100, and Resident #144. The findings included: 1. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of protein-calorie malnutrition and dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 03, indicating severe cognitive impairment. In an observation conducted on 12/09/24 at 12:59 PM, Resident #32 was noted in the room with the lunch tray. The lunch meal ticket was noted with the following food items: regular mechanical chopped diet, pureed carrot ginger soup, juice, ½ cups canned fruit, coffee, and 4 ounces of Mighty shake of choice (nutritional supplement). Closer observation of the lunch tray did not show any Mighty Shake provided on this lunch tray. An interview was conducted on 12/12/24 at 3:00 PM with the Food Service Director, who stated the tray line has staff members who check to make sure that the correct food items and supplements are on the meal tray as needed for each resident. 2. Record review revealed Resident #100 was readmitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease and Anemia. The Quarterly MDS assessment showed that Resident #100 has a BIMS score of 12, iindicating moderate cognitive impairment. In an observation conducted on 12/11/24 at 8:38 AM, Resident #100 was in the room with the breakfast tray. The meal ticket was noted as having a high-calorie pudding and asked to please send chocolate. Closer observation of the breakfast tray did not show that a high-calorie pudding was provided to Resident #100. An interview was conducted on 12/12/24 at 3:00 PM with the Food Service Director, who stated the tray line has staff members who check to make sure that the correct food items and supplements are on the meal tray as needed for each resident. 3. Review of the facility policy and procedure, titled, Resident Food Preferences, provided by the Director of Nursing (DON) published 03/13/23, documented in the Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent Policy Interpretation and Implementation: 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietician or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The dietician and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences .10. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night Resident #100 was re-admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Sepsis, Chronic Kidney Disease, Anemia, Unspecified Convulsions, Diabetes Mellitus Type II, Hypertension, Shortness of Breath. The documented Brief Interview Mental Status (BIMS) score was 12, indicating moderate impairment. Record review of the Resident #100's Care plan initiated and revised 11/22/24 indicated Focus: Nutrition: [Resident #100] is at high risk related to diagnoses: COPD, HTN,T2DM, low Basal Metabolic Index (BMI) <21, Constipation, Malnutrition, Anemia, Depression and Chronic Kidney Disease. Interventions: Provide fortified foods daily . high calorie pudding .Goal: Resident # 100 will gain at least 1-2# per month by next review date. An interview was conducted on 12/09/24 at 2:28 PM with Resident #100, who revealed he did not receive the high calorie pudding on his lunch meal tray. He emphasized to the surveyor that this bothered him that he had not gotten his meal preference during lunch. An observation was conducted on 12/09/24 at 2:29 PM of Resident #100's lunch meal tray. It was observed that he only had the following items on his lunch tray: Talapia (fish), a portion of mashed potatoes and gravy, a bowl of broth and a cup of Mandarine oranges with two (2) cups of liquids to drink. There was no high calorie pudding on his lunch meal tray. Photographic Evidence Obtained. On 10/07/24, the physician's meal order documented, Regular texture, thin liquids consistency. On 12/09/24, Resident 100's meal ticket documented, (highlighted in yellow): High calorie pudding; please send chocolate waffle when it is not on the menu .Monday Lunch 12/9 On 11/13/24, the progress note written by Staff W, Registered Dietician / Licensed Dietitian Nutritionist (RD/LDN), documented, .Continued to encourage fortified foods (i.e. high calorie pudding) daily with meals . An interview was conducted on 12/11/24 at 2:19 PM with Staff C, Certified Nursing Assistant (CNA), regarding the contents of Resident #100's lunch meal tray for 12/09/24. She acknowledged the resident's high calorie pudding preference was missing, and stated that nursing staff are also responsible to ensure the resident's preferences are honored. On 12/11/24 at 1:59 PM, an interview was conducted with the Certified Dietary Manager (CDM), regarding the contents of Resident #100's lunch meal tray for 12/09/24. She acknowledged Resident #100's high calorie pudding preference was missing, and she stated the resident was supposed to receive the High calorie pudding if it was on the menu. She tated she was not sure why the Resident #100 did not receive what was recorded on his menu. On 12/11/24 at 2:39 PM, an interview was conducted concurrently with both Staff X, Registered Dietician Nutritionist) RDN/LDN, and with Staff W, Registered Dietician/ Licensed Dietitian Nutritionist (RD/LDN) , regarding the contents of Resident #100's lunch meal tray for 12/09/24. Both acknowledged Resident #100's high calorie pudding preference was missing. They indicated the resident's preferences were not honored, according to what the menu had written on it and what the resident actually received. There was no High calorie pudding item on Resident #100's Lunch meal tray for Monday 12/09/24, as per his preference. The DON recognized and acknowledged on 12/11/24 at 2:51 PM that the resident's meal preferences should be honored.'

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to meet professional standards and ensure that Hospice documentation was readily available for 1 of 1 sampled resident reviewed for Hospice, Resident #59. The findings included: Review of the facility Agreement provided by the facility with the Hospice company and signed on 07/27/2023 documented, in part: Facility shall prepare and maintain medical records for each Hospice patient receiving services pursuant to this Agreement. The medical records shall consist of progress notes and clinical notes detailing all Inpatient Services and events. At the request of the Hospice, a copy of the patient's medical history, records and discharge summary shall be provided to the Hospice. Additionally, a review of the Integrated Plan of Care between the Skilled Nursing Facility and the [company] Hospice dated 10/16/2024 stated the following: [company] Hospice Nurse and SNF [Skilled Nursing Facility] representative or staff designee will discuss patient case at minimum of once per week, and every time a concern arises. Medications will be reconciled by [complany] Hospice Nurse at each visit. Record review showed Resident #59 was admitted on [DATE] with diagnosis of Age-related Physical Debility. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 6, which indicates severe cognitive impairment. Resident #59 was admitted on Hospice on 05/31/2024. Review on 12/12/24 at 10:05AM was conducted of the care plan in the Hospice book that stated a representative or staff designee will discuss patient case at minimum of once per week and every time a concern arises and also that the Medications will be reconciled by Hospice Nurse at each visit. Review of the Hospice binder showed that 10 visitations were conducted from 06/2024 to 12/2024 by the Hospice nurse. Further review did not show any of the progress notes from the Hospice nurse in the hospice binder. In an interview conducted on 12/12/24 at 10:15AM with Staff A, Registered Nurse (RN) Manager, Staff A stated that the Hospice Nurses come weekly, and the Certified Nursing Assistant (CNA) comes daily. The RN's weekly Progress Notes are sent to the Hospice company and are not kept in the facility. He acknowledged that no Hospice staff progress notes were located in the Hospice binder for Resident #59.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's policy on Respiratory Medication Administration-via Small Volume Nebulizer, updated on 08/17/2020, stated that after a nebulizing treatment is completed, all of the nebulizer equipment should be rinsed and disinfected. It specified to rinse all pieces with sterile water (not tap water, bottled water, or distilled water); and to allow all pieces to air dry on a paper towel. It also said that when the equipment is completely dry, it must be stored in a plastic bag. Record review revealed Resident #507 was admitted to the facility on [DATE] with diagnoses that included Pelvic Fracture, Lumbar Fracture, Malignant Neoplasm of Prostate, Chronic Obstructive Pulmonary Disease, Generalized Muscle Weakness, Unspecified Protein Calorie Malnutrition, Speech and Language Deficits following Cerebrovascular disease, and Dysphagia following Cerebrovascular Disease. The BIMS score per the Minimum Data Set (BIMS) assessment dated [DATE] was 9, indicating moderate cognitive impairment. On 12/09/24 at 12:44 PM, Resident #507 was observed coughing during an interview process. When asked if he usually coughs so much, the resident pointed to the bedside table and said that there was a breathing machine over there. The surveyor lifted a crumpled-up sheet from on top of the bedside table that covered up most of the nebulizer machine and the entire mask. The mask was resting on top of what appeared to be a double layer of thick plastic. The mask was leaning on the telephone handset. On 12/09/24 at 1:34 PM, Resident #507 notified the surveyor that he requested a breathing treatment from the nurse about 10 min ago. The resident stood in the doorway of his room, and he coughed several times. He appeared uncomfortable. The nurse called to the resident from down the hallway and said that she would be in shortly. She requested the resident go back into his room and wait there. The surveyor waited in the hallway to observe when the nurse attended to the resident. The nurse was observed entering Resident #507's room at 1:56 PM and provided him with the nebulizer treatment. She then exited the resident's room. Photographic Evidence Obtained. Based on observations, interviews and record reviews, the facility failed to follow the Enhanced Barrier Precautions (EBP) guidelines for 4 of 4 sampled residents reviewed for EBP, Resident #26, Resident #465, Resident #139, and Resident #460; failed to ensure employees kept fingernails trimmed as per facility's policy; and failed to keep a nebulizer mask stored in a sanitary manner. The findings included: Review of the Center for Disease Control and Prevention (CDC) Enhanced-Barrier Precautions guidelines revealed, in part, the following: Everyone must clean their hands including when both entering and leaving the room; Providers and Staff must also; wear gloves and a gown for the following: high-contact care resident care activities, dressing, bathing-showering; transferring; changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing. The CDC website included: https://www.cdc.gov/long-term-carefacilities/media/pdfs/EBP :KeepResidentsSafe-Poster-508.pdf. 1. Record review revealed Resident #26 was admitted on [DATE] with diagnoses including Fracture of the Neck of Left Femur, Left Artificial Hip Joint Replacement, Coronary Atherosclerosis, Pressure Induces Deep Tissue Damage of Left Heel, and Pressure Induced Deep Tissue Damage of Right Heel. Review of Minimum Data Set (MDS) assessment, Section C, dated 12/05/24, revealed a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate impaired cognition. Review of the record revealed physician orders, dated 12/10/24, were in place for the resident's wounds. Review of the nursing care plan dated 10/29/24 revealed no Enhanced Barrier Precaution guidelines were included for Resident #26's interventions. Observations revealed the resident had an EBP signage at the door. During an observation on 12/09/24 at 10:48 AM, Resident #26 pressed her call light button to inform staff to change her socks. Staff J, Certified Nursing Assistant (CNA), came into the room, and with her bare hands touched resident's socks and lower legs, went to the bedside table of Resident #26, opened the first drawer and tried to find another pair of socks. Staff M, Licensed Practical Nurse (LPN), then came in, turned off the call light switch, and reminded Staff J to put on gloves. Both Staff J and Staff M donned gloves on both hands. Staff J removed the resident's socks from her feet, and replaced them with another pair. On 12/09/24 at 11:00 AM, Staff J then removed both gloves, left the room without performing hand hygiene, and went to a storage room a few doors down. She was observed touching and twitching the doorknob with her bare hands, touching and opening a plastic container of green chucks (impermeable pad for bed sheet protection). She returned to Resident #26's room without performing hand hygiene. Staff J then obtained a pair of gloves from her top scrub pocket, touched resident's curtain with a bare hand, put on the right-hand glove, touched the resident's bed control with right gloved hand and asked the resident to turn to the left, while she was donning a glove on her left hand. Staff J slid the green chucks under Resident #26's buttock, moved to the opposite side of the bed and adjusted the chucks underneath this resident. Staff J removed both gloves, did not perform hand hygiene, left Resident #26's room, and went into another resident's room at 11:07 AM. On 12/09/24 at 11:09 AM, without performing hand hygiene, Staff J put on a new pair of gloves, touched Resident #139's bed control to lower the bed and manipulated the Hoyer lift to attach Resident #139's blue pad. Shen then helped another Staff CNA in positioning another resident (Resident #139) into a wheelchair from the Hoyer lift. When the resident was sitting on the wheelchair, Staff J removed her gloves, and without performing hand hygiene, touched the Hoyer lift's stick like control, moved the Hoyer lift out of Resident #139's room, parked it 3 doors down and stated someone is going to use it. She did not clean or disinfect the parts of Hoyer lift that made contact with Resident #139. On 12/09/24 at 11:25 AM, Staff J went inside a room [ROOM NUMBER], touched the door of the room, the bathroom door and then washed her hands inside the bathroom. 2. Record review revealed Resident #465 was admitted on [DATE] with diagnoses that included Acute Kidney Failure, Chronic Kidney Disease, Essential Primary Hypertension, Peripheral Vascular Disease, Peripheral Vascular Angioplasty with Implants and Grafts, and Compression Fracture of Second Lumbar Vertebra. Review of admission MDS revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. On 12/10/24 at 5:54 PM, during observation and interview with Resident #465's roommate and spouse, they stated they just came back from a hospital [name provided] and wanted to go inside the room. Staff I, CNA, opened the door using her gloved hand, and stated she would let them in after providing care of Resident #465. Staff I was observed wearing a mask covering her nose and mouth, and had a set of blue gloves on both hands. Closer observation revealed that Resident #465 was uncovered lying flat in bed, with the bedsheet down on the bottom of the bed, and green chucks on the right side of the bed not covering the resident. An EBP sign was posted outside the room above the room number, but Staff I was not wearing a personal protective gown (PPE). When asked how long she had been working in the facility, she stated for three years. 3. Record review revealed Resident #139 was admitted on [DATE] with diagnoses that included Gastro-Esophageal Reflux Disease, without Esophagitis, Unspecified Abdominal Hernia with Obstruction, without Gangrene, Essential Primary Hypertension, and Aftercare following Joint Replacement Surgery. Review of the MDS assessment, dated 11/25/24, revealed a BIMS score of 15, indicating intact cognition. On 12/09/24 at 11:07 AM, an observation was conducted of Staff J, CNA, who left a room with an EBP sign above the room number without performing hand hygiene. She was observed to put on a new pair of gloves, touched Resident #139's bed control to lower the bed, and manipulated the Hoyer lift to attach the blue pad. She then positioned Resident #139's wheelchair next to bed and tilted it when the resident was ready to be put down from Hoyer lift to the wheelchair by another Staff CNA. When the resident was sitting on the wheelchair, Staff J removed her gloves, and without hand sanitizing, touched the Hoyer lift stick like control, and moved the Hoyer lift out of Resident #139's room. She parked it 3 doors down, and stated someone is going to use it. Staff J did not clean the Hoyer lift after it was used by 2 CNAs, and made contact with Resident #139. On 12/09/24 at 11:25 AM, Staff J went towards another room, touched the door of the room, touched the bathroom door and washed her hands inside another bathroom. She did not perform any hand hygiene before entering the other room. 4. Record review revealed Resident #460 was admitted on [DATE] with diagnoses including Paroxysmal Atrial Fibrillation, Moderate Protein Calorie Malnutrition, Unspecified Convulsions, Ischemic Cardiomyopathies, Elevated [NAME] Blood Cell Count and Urinary Tract Infection. Review of physician orders dated 11/26/24 revealed: Enhanced Barriers Precautions to coccyx wound, Foley (inventor's name of a urinary catheter tubing), and peg (percutaneous and endoscopically inserted gastrostomy) tube every shift. Review of Nursing Care plan dated 11/27/24 revealed Enhanced Barrier Precautions: Wear gown and gloves during assistance with dressing, bathing, transferring, hygiene, changing linens, changing briefs & toileting, and catheter care. During observation on 12/09/24 at 12:04 PM, Resident #460 was observed lying with 30 degrees head elevation in bed. Beside her bed was a metal pole with an attached machine for tube feeding, and a plastic bag containing a plastic syringe inside. Closer observation on 12/09/24 at 3:30 PM revealed no Enhanced Barrier Precaution (EBP) signage on top of resident's room number as seen at other rooms. There were no EBP supplies at or near Resident #460's door. An EBP cart was observed parked several doors away from Resident #460's door. During an observation on 12/10/24 at 3:30 PM, Resident #460's room had no EBP sign on top of room number. During an observation on 12/11/24 at 12:00 PM, an EBP signage was observed on top of Resident # 460's room number. 6. Review of the Center for Disease Control (CDC) guideline, titled, Clean Hands-Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 accessed on 12/12/24 documents, Natural nails should not extend past the fingertip . Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing .Healthy Habits: Nail Hygiene documents .Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, more dirt and bacteria can gather under long nails than short nails. This can contribute to the spread of germs . Review of the WHO GUIDELINES ON HAND HYGIENE IN HEALTH CARE 2009- accessed on 12/12/24 documents . HCWs (healthcare workers) who wear artificial nails are more likely to [NAME] Gram-negative pathogens on the fingertips than those who have natural nails, both before and after handwashing .Long, sharp fingernails, either natural or artificial, can puncture gloves easily. They may also limit HCWs' performance in hand hygiene practices .Consensus recommendations are that HCWs do not wear artificial fingernails or extenders when having direct contact with patients and natural nails should be kept short ( 0.5 cm long or approximately ¼ inch long) . On 12/10/24 at 9:40 AM, medication administration observation for Resident #201 was performed by Staff U, Licensed Practical Nurse (LPN), who started to pour the following medications: Aspirin low dose EC (enteric coated) 81 mg (milligrams), Stool softener (Docusate Sodium) 100 mg, Liquid Protein 30 cc (cubic centimeters) and Juven packet Nutrition powder which she poured into 120 cc of water. Staff U was observed struggling while donning gloves on. Staff U was observed with long glitter polished fingernails, entered the reAsicent's room, performed handwashing and assisted the resident with her medications. At 9:53 AM, an interview was conducted with Staff U who stated working in the facility since October 2024, and had 22 residents assigned to her. An inquiry was made regarding her fingernails and Staff U stated she had artificial Gel polished nails about 2 inches long. Staff U added she did them yesterday (12/09/24) for her personal / family holiday picture. Staff U was asked for the facility's policy dress code and stated she was to wear blue uniform, and they did not talk about fingernails. Staff U was asked if during orientation, the facility talked about the use of artificial nails and stated she did not remember. On 12/11/24 at 9:27 AM, observation revealed Staff U inside Resident #188's room. An interview was conducted with Staff U who stated she was very busy, and she was assisting Resident #188 who wanted to go to the bathroom. Further observations revealed Staff U continue to wear artificial fingernails noted during medication administration observation conducted with her on 12/10/24. The unit nursing staff assignment board documented that Staff U was assigned Resident #188 plus 21 more residents. On 12/12/24 at 10:19 AM, observation revealed Staff U seating at the nurses station with Staff V, Registered Nurse/Unit Manager. Further observation revealed Staff U continued to wear artificial nails and had 22 residents assigned to her. 6. On /12/12/24 at 10:10 AM, an interview was conducted with Staff V, Registered Nurse/Unit Manager who stated she had been working at the facility for six (6) months. Staff V stated her role was to oversee the unit, and assist the residents with everything that pertains to resident's care. Observation revealed Staff V with long fingernails approximately 1 inch long. An inquiry was made regarding her long fingernails and stated they were supposed to be kept the nails are a reasonable length. Staff V was asked what a reasonable length meant and she did not specify exact length. Staff V stated her fingernails nails were her own nails and had acrylic gel over them. Staff V was asked how long her fingernails were and replied that she did not measure her nails and had no idea how long they were. On 12/12/24 at 1:21 PM, a joint interview was conducted with the Director of Nursing (DON) and the facility's Regional Nurse. They were asked for nursing dress code policy. The DON was asked for the role of the unit manager (UM) and stated the UM monitors the floor, monitor nurses and Certified Nursing Assistant (CNAs) to make sure the unit is running well. The DON stated that if need be the UM has to provide resident's direct care, and added the UM is the third nurse in the unit. On 12/12/24 at 2:15 PM, a side-by-side review of the facility employee handbook and an interview was conducted with the Human Resources Director. The employee handbook documented under appearance .for the safety of our Residents natural nail tips should be keep to 1/4 inch in length. Artificial nails should not be worn when having direct contact with residents The Director was apprised of nurses with longer than 1/4 natural nails and artificial nails working in the units. The Director stated the nurses know better than to wear artificial nails and they know to keep them short.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and to ensure the prevention of foodborne illnesses for 187 of 196 residents. The findings included: 1. During tour of the Main Kitchen on 12/09/24 at 9:30 AM, and accompanied by the Dietary Manager (DM), the following was observed and noted: a. The handwashing station near the entry door had a dark substance on the grout just above the sink. DM made aware. b. There was thick, burnt-yellow colored residue approximately 8 inches long, with varying widths, on the exterior side walls of the two Vulcan ovens. c. The back left corner of the Arctic walk-in refrigerator had brown debris splattered on the tiles close to the wall and close the leg of the shelving fixture. The leg of the fixture was resting on top of a folded-up piece of white paper soiled with various colors of debris. A yellow food substance was on the floor close to the dark sticky looking substance. d. The prepared food cart in the Arctic refrigerator had individual portions of food on plates covered with plastic wrap. The shelf with the tossed salads had a sticker on it that said 12/6 to 12/7. When the DM was asked what the dates meant, the DM answered that she didn't know what the dates meant. She went to get Staff HH, whose job functions included cooking and preparing cold foods. The DM indicated that Staff HH knew when the salads were made. Staff HH said that the second date is the last date that the food can be served. e. The dry foods storage area was observed. A crumpled ball of brown paper, and a small, dark brown, solid, oblong shaped substance was observed on the tile floor under the shelf fixtures in the back right corner of the room. f. At approximately 10:10 AM, Staff H, dietary aide, was observed preparing food while his beard was not covered with a facial covering. g. The [NAME] Bay Dishwasher temperature was 170 degrees Fahrenheit (F). According to the manufacturer's instructions posted on the wall, if the temperature goes above 140 degrees, the company should be called for service. h. A double handle stock pot had dark brown residue covering the bottom exterior of the pot and on the areas surrounding the bolts that secured both handles. Photographic Evidence Obtained.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate that an effective plan of actions was implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F550, Resident Rights / Exercise of Rights; F692, Nutrition / Hydration Status Maintenance; F755, Pharmacy Services / Procedures / Pharmacist / Record; F809, Frequency of Meals / Snacks at Bedtime; and F880, Infection Prevention and Control. These repeated deficient practices have the potential to affect all 196 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited at F550, F692, F755, F809 and F880 during the recertification survey with an exit date of 08/31/23. The repeated deficient practices was identified for F550, Resident Rights / Exercise of Rights; F692, Nutrition / Hydration Status Maintenance; F755, Pharmacy Services / Procedures / Pharmacist / Record; F809, Frequency of Meals / Snacks at Bedtime; and F880, Infection Prevention and Control. During QAPI review, there was no evidence of an effective plan for the above cited deficienies. During an interview with the facility's Administrator on 12/12/24 at 4:30 PM, the Administrator was apprised that these 5 deficiencies would be cited on this current survey. The Administrator stated he will be working to remedy this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to maintain residents' privacy in a dignified manner for 3 of 5 sampled residents observed, Resident #130, Resident #268 and Resident #267. The findings included: Review of the facility policy and procedure, on 08/30/23 at 2:35 PM, titled, Dignity, provided by the Director of Nursing (DON) published 05/19/23 documented, in part, in the 'Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times .11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .' Review of Certified Nursing Assistant (CNA) job description on 08/31/23 at 9:35 AM dated January 2023 provided by the DON documented, in part, 'Purpose of your Job Position: Main duties: A. Support the facility's philosophy of care and strive to achieve its goals and objectives. B. Be sensitive to resident's families and respond in an appropriate professional way as the situation requires .' Review of facility Licensed Practical Nurse (LPN) job description on 08/31/23 at 9:52 AM dated January 2023 provided by the DON documented, in part, 'Purpose of your Job Position: Core Competencies. The LPN staff nurse should demonstrate the ability to: Behave sensitively to persons who are frail, dependent, and/or with compromised health status .Respond appropriately to residents Apply best practices in the care of persons with cognitive loss .' Review of facility Registered Nurse (RN) job description on 08/31/23 at 10:05 AM dated January 2023 provided by the DON documented, in part, 'Purpose of your Job Positioning: .Maintain resident's confidentiality and privacy. Assure quality of care by adhering to DOH standards of practice and facility standards of care.' 1. Resident #130 was admitted to the facility on [DATE] with diagnoses that included Encounter for Orthopedic Aftercare following Surgical Amputation, Major Depressive Disorder, Diabetes Mellitus Type II, Hypertension, Dysphagia and Gastroesophageal Reflux Disease. He had a Brief Interview Mental Status (BIMS) score of 15 of 15, indicatingthe resident was cognitively intact. During an observation of Resident #130 conducted on 08/28/23 at 10:25 AM, the resident was undressed, in a nightgown pulled halfway up his body, with his lower body and bilateral status post-surgical above the knee amputee stumps exposed for a period of over an hour, from hallway with room door open and with several staff members observed walking by, with no attempts made to close the privacy curtain. There were no attempts made by facility staff to fully close the bedroom door after providing care to this resident. Photographic Evidence Obtained. During a brief interview with Resident #130 regarding his preference, he stated to this surveyor that he prefers to have either his privacy curtain pulled or his door closed so that his uncovered lower body is not exposed. He said that it does bother him when he has to ask staff more than once to close the curtain or door. During an interview conducted with Staff I, CNA, on 08/30/23 at 11:20 AM, regarding the resident's privacy curtains and bedroom door both being left open, Staff I acknowledged the bedroom door and privacy curtains should not have been left open, exposing the resident's person. During an interview conducted with Staff J, LPN, on 08/30/23 at 11:25 AM, regarding the resident's privacy curtains and bedroom door, both being left open, Staff J acknowledged the bedroom door and privacy curtains should not be left open, exposing the resident's person. 2. Resident #268 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction due to Embolism Left Middle Cerebral Artery, Diabetes Mellitus Type II, Morbid Obesity, Aphasia, Dysphagia, Heart Failure, Hypertension and Chronic Obstructive Pulmonary Disease. She had a BIMS score that indicated the resident was severely impaired cognitively. During an observation of Resident #268 conducted on 08/28/23 at 1:51 PM, the resident was sitting up in her Gerichair in her room with the TV (television) on. Upon further entry into the room, the resident was observed with her left leg bent up and open and her night gown left partially opened at the bottom for over an hour, with the privacy curtain only partially closed exposing the lower portion of her abdomen to other residents, staff members and visitors. There were no attempts by staff members entering the room to cover the resident or to close her privacy curtain. Photographic Evidence Obtained. During a second observation of Resident #268 conducted on 08/30/23 10:59 AM, the resident was resting in her bed in her room with the TV on. Upon further entry into the room, the resident was again observed with her left leg bent up and open and her night gown left partially opened at the bottom for over an hour, with the privacy curtain only partially closed exposing the lower portion of her abdomen to other residents, staff members and visitors. 3. Resident #267 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Chronic Kidney Disease and Gastroesophageal Reflux Disease. The resident had BIMS score of 15, indicting cognition was intact. During an observation of Resident #267 conducted on 08/28/23 at 11:00 AM,the resident was sitting up in bed with the head of the bed elevated and the top half of his nightgown, still on, hanging off his body with his bare chest hairs exposed and uncovered, as well as the lower portion of his legs which were uncovered and exposed to other residents, staff members and visitors for over an hour with multiple staff members observed walking by room, with no attempts made by staff to either cover resident, close his privacy curtain or to close his door. Photographic Evidence Obtained. During an interview conducted with Staff K, CNA, on 08/30/23 at 11:45 AM, regarding the resident's privacy curtains and bedroom door, both being left open, Staff K acknowledged the privacy curtains and bedroom door should not have been left open, exposing the resident's person. During an interview conducted with Staff L, Registered Nurse (RN), on 08/30/23 11:50 AM, regarding the resident's privacy curtains and bedroom door being left open, Staff L acknowledged the privacy curtains and bedroom door should not have been left open, exposing the resident's person. There were no documented behaviors relative to this observation, for any of these residents noted, in either of their care plans, or anywhere in the progress notes. During an interview conducted with the DON, on 08/30/23 at 2:41 PM, regarding the resident's privacy curtains and bedroom doors, both being left open, she acknowledged the bedroom doors and privacy curtains should not have been left open, exposing the resident's person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to transmit Resident Assessments in a timely manner for 20 of 24 sampled residents reviewed for Minimum Data Set (MDS) discrepancies, Residents #142, 143, 26, 120, 13, 20, 65, 136, 118, 140, 135, 95, 63, 117, 77, 67, 92, 48, 51 and 146. The findings included: Following the Survey Day 2 Transition Meeting, the surveyors noted the Resident Assessment Facility Task was triggered for review. Twenty-four (24) residents were identified in this task to be reviewed for Minimum Data Set (MDS) Record over 120 days old. On 08/30/23 at 10:23 AM, the 24 triggered residents' records were reviewed with Staff Q, MDS Coordinator and Staff R, MDS Coordinator. During this record review, it was noted that 20 of the 24 triggered residents had MDS's which were not transmitted properly per the Federal Regulations. During this record review, Staff R stated the facility was aware that there was an issue with transmitting MDS's due to the changing of Electronic Health Records (EHR) systems during June and July 2023. Staff R further stated that the facility had recognized this issue and had a Performance Improvement Plan (PIP) in place 'for a while'. She clarified that the PIP had been in place for months but that the transmission of MDS's was a continued issue. The following are the 20 identified residents with MDS's that were not transmitted in a timely manner: 1. Resident #142 was admitted to the facility on [DATE]. A Quarterly MDS was Open / Completed on 06/14/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. 2. Resident #143 was admitted to the facility on [DATE]. A Quarterly MDS was Open / Completed on 06/14/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. 3. Resident #26 was admitted to the facility on [DATE]. An Annual MDS was Open / Completed on 06/13/23 (in the old EHR system) but was never submitted. This Annual MDS was the identified issue. 4. Resident #120 was admitted to the facility on [DATE]. An Annual MDS was Open / Completed on 06/30/23 (in the old EHR system) but was never submitted. This Annual MDS was the identified issue. 5. Resident #13 was admitted to the facility on [DATE]. A Quarterly MDS was 'In Progress' since 08/04/23 but was not submitted by the Exit of the survey. This Quarterly MDS was the identified issue. 6. Resident #20 was admitted to the facility on [DATE]. A Quarterly MDS was Open / Completed on 06/23/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. 7. Resident #65 was admitted to the facility on [DATE]. A Quarterly MDS was Closed / Completed on 06/16/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. 8. Resident #136 was admitted to the facility on [DATE]. A Discharge Return Not Anticipated MDS was Closed / Completed on 04/18/23 (in the old EHR system) but was never submitted. This Discharge MDS was the identified issue. 9. Resident #118 was admitted to the facility on [DATE]. A Discharge Return Not Anticipated MDS was Open / Completed on 05/10/23 (in the old EHR system) but was never submitted. This Discharge MDS was the identified issue. 10. Resident #140 was admitted to the facility on [DATE]. A Quarterly MDS was Open / Completed on 06/17/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. 11. Resident #135 was admitted to the facility on [DATE]. A Discharge Return Not Anticipated MDS was Open / Completed on 05/02/23 (in the old EHR system) but was never submitted. This Discharge MDS was the identified issue. 12. Resident #95 was admitted to the facility on [DATE]. A Discharge Return Not Anticipated MDS was Open / Completed on 04/20/23 (in the old EHR system) but was never submitted. This Discharge MDS was the identified issue. 13. Resident #63 was admitted to the facility on [DATE]. A Quarterly MDS was Open / Completed on 06/30/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. 14. Resident #117 was admitted to the facility on [DATE]. A Quarterly MDS was 'In Progress' since 07/21/23 but was not submitted by the Exit date of the survey. This Quarterly MDS was the identified issue. 15. Resident #77 was admitted to the facility on [DATE]. A Quarterly MDS was 'In Progress' since 07/21/23 but was not submitted by the Exit date of the survey. This Quarterly MDS was the identified issue. 16. Resident #67 was admitted to the facility on [DATE]. A Quarterly MDS was Open / Completed on 06/17/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. 17. Resident #92 was admitted to the facility on [DATE]. An Annual MDS was Open / Completed on 06/07/23 (in the old EHR system) but was never submitted. This Annual MDS was the identified issue. 18. Resident #48 was admitted to the facility on [DATE]. A Discharge Return Anticipated MDS was Open / Completed on 03/23/23 (in the old EHR system) but was never submitted. This Discharge MDS was the identified issue. 19. Resident #51 was admitted to the facility on [DATE]. An Annual MDS was Open / Completed on 10/20/22 (in the old EHR system) but was never submitted. A Quarterly MDS was Open / Completed on 01/15/23 (in the old EHR system) but was never submitted. Also, a Quarterly MDS was Open / Completed on 06/15/23 (in the old EHR system) but was never submitted. All 3 of these MDS's were identified issues. 20. Resident #146 was admitted to the facility on [DATE]. An Quarterly MDS was Open / Completed on 06/28/23 (in the old EHR system) but was never submitted. This Quarterly MDS was the identified issue. During the Quality Assurance Performance Improvement meeting conducted on 08/31/23, it was verbalized by the facility's administration that the PIP for MDS transmissions had been in place for approximately 6 months. They admitted that MDS transmission continues to be a problem at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure proper usage and documentation of hand splints for 1 of 2 sampled residents reviewed for hand splints, Resident #265. The findings included: Review of the facility policy and procedure on 08/31/23 at 11:35 AM, titled, Medication and Treatment Orders, provided by the Director of Nursing (DON) published 05/19/23, documented in part, the following: Under Policy Statement: Orders for medications and treatments will be consistent principles of safe and effective order writing. Policy Interpretation and Implementation: 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record 5. The signing of orders shall be by signature or a personal computer key . Review of the facility policy and procedure on 08/31/23 at 11:45 AM, titled, Activities of Daily Living (ADLs), provided by the DON published 12/28/22 documented, in part, the following: under the Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry our ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene . b. Mobility . c. Elimination . d. Dining . and e. Communication. 3. Care and services to prevent and/or minimize functional decline will include appropriate pain-management, as well as treatment for depression and symptoms of depression .7. The resident's response to interventions will be monitored, evaluated and revised as appropriate . Review of Certified Nursing Assistant (CNA) job description on 08/31/23 at 12:05 PM, dated January 2023, provided by the DON documented, in part, Purpose of your Job Position: .Main duties .H. Report any changes in resident's condition-e.g. eating habits, behavior, temperature, etc. to the charge nurse of the unit .M. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty P. Detect and report situations that have a high probability of causing accidents or injuries to residents and/or staff . Review of facility Licensed Practical Nurse (LPN) job description on 08/31/23 at 12:17 PM, dated January 2023, provided by the DON documented, in part, the following: Purpose of your Job Position: Major Responsibilities Administrative . 3. Receives and records physician's orders . 12. Assures nursing assistants comply with policies and procedures . Clinical . 3. Assesses residents .6. Identifies and reports changes in resident's status to physicians, responsible family members, and supervisory nursing staff . 11. Administers treatments and other direct care . 13. Implements restorative and rehabilitative nursing programs . Review of facility Registered Nurse (RN) job description on 08/31/23 at 12:45 PM, dated January 2023, provided by the DON documented, in part, the following: Purpose of your Job Position: . Document resident care services by charting in resident medical record and department records . Consult with resident's physician regarding resident's plan of care as well as notifying them of any changes . Review of facility Occupational Therapy Assistant (OTA) job description on 08/31/23 at 4:10 PM, dated January 2023, provided by the DON, documented, in part, the following: Purpose of your Job Position: 1 .Provides comprehensive appropriate patient treatment in accordance with patient's individual treatment plan as stipulated by supervising Occupational Therapist Communicating with supervisor and interdisciplinary team members regarding patient progress, problems and treatment plans . Review of facility's Occupational Therapist (OT) job description on 08/31/23 at 4:19 PM, dated January, provided by the DON, documented, in part, the following: Purpose of your Job Position: .Communicating with supervisor and interdisciplinary team members regarding patient progress, problems, and treatment plans . Resident #265 was originally admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Senile Degeneration of Brain, Metabolic Disorder and Cerebrovascular Disease. The resident had a documented Brief Interview Mental Status (BIMS) score of 0 (severely impaired). review of the physician orders, dated 08/17/23 documented: Palm pillow to Bilateral hands as tolerated with regular skin checks completed with hand hygiene during ADL [Activities of Daily Living] care. During an initial observation of Resident #265 conducted on 08/28/23 at 10:53 AM, it was observed that she was sitting up in her Geri-chair in her room with TV (television) on. The resident was observed with her right palm pillow or roll located next to her person atop her blanket and not observed in place, as ordered. While there was no left palm pillow or roll observed on or near resident for a time frame of well over two (2) hours for a total of five (5) different observations, over the course of three (3) different days. Photographic Evidence Obtained. During a second observation of Resident #265 conducted on 08/28/23 at 2:01 PM, she was still observed with her (right) palm pillow or roll located next to her person atop her blanket, and not observed in place, as ordered. There was still no left palm pillow or roll observed on or near resident, at all. During a third observation of Resident #265 conducted on 08/29/23 at 10:42 AM, the resident was now observed resting in bed on her left side without her bilateral palm pillows or rolls in place as ordered: one palm pillow was observed on top of her dresser drawer and the other one was located visibly inside the top drawer of the resident's bedside dresser. During a fourth observation of Resident #265 on 08/29/23 at 2:13 PM, the resident was still observed resting in bed on her left side without her bilateral palm pillows or rolls in place as ordered: one palm pillow was still observed on top of her dresser drawer and the other one was still visibly located inside the top drawer of the resident's bedside dresser. During a fifth observation of Resident #265 on 08/30/23 10:23 AM, the resident was still observed resting in bed on her left side without her bilateral palm pillows or rolls in place as ordered: one palm pillow was still observed on top of her dresser drawer and the other one was still visibly located inside the top drawer of the resident's bedside dresser. On 08/30/23 at 11:50 AM, an interview was conducted with Staff K, Certified Nursing Assistant (CNA), who was asked if the resident was supposed to be wearing her bilateral palm pillows or rolls. Staff K answered, yes, she is supposed to be wearing them on both hands. She was then asked why the resident has not been using them and she responded, because she did not see them. She was asked if she notified the nurse or bring this to her attention, and Staff K replied, no On 08/30/23 at 11:55 AM, an interview was conducted with Staff L, Registered Nurse (RN), who was asked if the resident had an order dated 08/17/23 for Palm pillow to bilateral hands as tolerated with regular skin checks completed with hand hygiene during ADL care. Staff L responded, yes, she does. The nurse was asked if this order was being followed and replied, No, not at this time. The nurse stated she was not aware of this order. During a side-by-side computerized record review with the nurse, she was asked if the resident refused them or if the palm pillows were poorly tolerated by the resident and documented in the nursing notes, captured in the care plan or if the doctor had been contacted and made aware. The nurse responded, no, she did not see any of the above, but she said that she would have to check on it. On 08/30/23 at 12:20 PM, an interview was conducted with Staff M, Licensed Practical Nurse (LPN), covering as the Supervisor, who when asked if the resident had an order dated 08/17/23 for Palm pillow to bilateral hands as tolerated with regular skin checks completed with hand hygiene during ADL care, responded, yes, she does. When asked if the order was being followed, she replied, No, not at this time. When asked why the order was not followed, she responded, she was not aware of this order. During a side-by-side computerized record review, when asked if the resident refused the palm pillows or if they were poorly tolerated, was this documented in the nursing notes, captured in the care plan and was the doctor contacted and made aware along with the resident's current palm skin condition, she responded, no, she did not see any of the above. She stated she would have to check on it. On 08/30/23 at 12:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who was asked if the resident had an order dated 08/17/23 for Palm pillow to bilateral hands as tolerated with regular skin checks completed with hand hygiene during ADL care, she responded, yes, she does. The ADON was asked if this order was being followed and she replied, No, not at this time. She was asked why the order was not followed and responded she had recorded the order as a Rehabilitation order. She acknowledged that it was not captured on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). The ADON was asked during a side-by-side computerized record review, if the resident refused the palm pillows or if these were poorly tolerated, was this documented in the nursing notes, captured in the care plan and was the doctor contacted and made aware along with the resident's palm skin condition, and she responded, no, she did not see any of the above, but she too would have to check on it, as well. On 08/30/23 at 2:14 PM, an interview was conducted with Staff N, Occupational Therapist (OT), covering for the Director of Therapy, who was asked if the resident had an order dated 08/17/23 for Palm pillow to bilateral hands as tolerated with regular skin checks completed with hand hygiene during ADL care, and responded, yes, she does. The OT stated Resident #265 did make some progress in Occupational Therapy for upper extremity tone, range of motion and positioning. She stated the purpose of the palm pillows is to help prevent decubitus ulcers in the palms, decrease pressure areas and to maintain functional range of motion (ROM) in order to decrease the burden of care. She stated the resident tolerated the palm pillows or rolls, during her therapy. When asked if this order was being followed based upon her review, she replied, No, not at this time. When asked who was responsible to ensure the palm pillows or rolls are applied daily as ordered, she replied, it is the nursing staff's responsibility to do this once the resident is discharged from therapy. On 07/05/23, review of the care plan documented the palm pillow be placed to bilateral hands as tolerated with regular skin checks to be completed and with hand hygiene during Activities of Daily Living (ADL) care; and for skin inspection to monitor for redness, open areas, scratches, cuts, bruises and immediately report changes to the nurse. The resident's care plan did not document or capture any type of behaviors or refusals by this resident related to wearing or not wearing her palm pillows or rolls. Record review revealed that neither the MAR nor the TAR captured the palm pillows or rolls physician orders. Further record review indicated that there was no assessment documentation recorded in the facility's licensed nursing notes to describe the current actual condition of the resident's skin bilaterally, of her hand palms. There was no documentation recorded in the facility's nurses' notes, or any other facility records, to reflect that the resident had a poor tolerance to wearing her palm pillows or rolls. There was no documentation that this was communicated to the resident's physician. The facility nursing assistant staff had not been checking off on the computerized task list for dates from 08/28/23 through 08/30/23, as to whether or not the palm pillows or rolls had actually been in use and applied to the resident, as ordered. An interview was conducted with the Director Of Nursing on 08/30/23 at 2:41 PM, regarding Resident #265's not wearing her bilateral palm pillows as ordered by the physician, no documented resident refusals or poor toleration documented in the nursing notes, captured in the care plan and no doctor contacted to make aware of the resident's palm skin condition, revealed the palm pillows or rolls should be in place as ordered and the resident's skin condition should be documented and assessed by the licensed nursing staff. There was no evidence this was done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide nutritional interventions in a timely manner for 2 of 6 sampled residents, reviewed for nutrition, Resident #365 and Resident #340. The findings included: Review of the facility's policy, titled, Nutrition Assessment, dated 05/19/23, documented, in part, the following: the dietitian, in conjunction with the nursing staff, will conduct a nutritional assessment for each resident upon admission (within 14 days). The nutritional assessment will include the current nutritional status and risk factors for impaired nutrition. Review of the facility's policy, titled, Weight Assessment and Intervention, dated 05/19/23, documented, in part, the following: residents' weights are monitored for unintended weight loss. Any weight change of 5 percent or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. 1. Record review documented Resident #365 was admitted to the facility on [DATE] with diagnoses to include Protein-Calorie Malnutrition and Anxiety Disorder. An interview was conducted on 08/28/23 at 10:20 AM with Resident #365, who stated that all he wants to eat is two peanut butter sandwiches a day and that the facility refused to give them to him. He also said that he preferred something other than the food consistency that is given to him (pureed consistency) daily. In an observation conducted on 08/30/23 at 8:40 AM, Resident #365 was noted in his room with the breakfast tray. Closer observation showed that he ate about 50% of his meals. In this observation, Resident #365 said that he ate about 50% of his dinner last night but that he did not like the food that was served to him. Record review documented a physician order for a regular, pureed-texture diet dated 06/14/23. Review of the weight log showed the following: the first initial weight taken on 06/28/23 showed that Resident #365 weighed 143 pounds (#). The next weight taken was on 07/06/23, which showed that Resident #365 weighed 122.5 pounds. This showed a significant / severe weight loss of 14% from 06/28/23 to 07/06/23. Record review did not show that an Initial Nutrition Risk Assessment was completed for Resident #365 on admission. The care plan for nutrition showed that Resident #365 was at nutritional risk, which was only initiated on 07/14/23. Review of the nutrition progress note dated 07/14/23 showed that Resident #365 had a 14.3% weight loss in 30 days. It further revealed that he was triggered by malnutrition and that he eats about 60% of his meals. In this note, the facility's clinical dietitian recommended Ensure Plus three times a day (TID), which was ordered on 07/14/23 (eight days after the severe weight loss was identified). A Nutritional History Assessment that was provided by the Director of Nursing (taken from the previous electronic system) showed that an initial assessment was completed for Resident #365 but that it did not have a date, time, or signature of the staff member who completed this assessment. An interview was conducted on 08/31/23 at 2:00 PM, with Staff G, Clinical Dietitian, who was asked why she had not completed the nutritional initial assessment on time when Resident #365 was admitted to the facility. She reported that she completed the assessment and that it was on the old electronic system. She was asked by the surveyor why it took her eight days after the severe weight loss to reassess Resident #365 and she did not know. A Speech Language Reassessment was conducted on 08/30/23 related to surveyor intervention for Resident #365. The new recommendations showed a diet upgrade from pureed to ground texture diet consistency. An interview was conducted on 08/31/23 at 8:45 AM with Resident #365, who stated that he was so happy that his diet was upgraded and was happy with his meal this morning. Continued observation showed that the resident ate over 75% of his breakfast meal. 2. Resident #340 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included weakness, Rhabdomyolysis and Hepatocellular Carcinoma (liver cancer). Review of the admission assessment dated [DATE] revealed the resident had a small open area noted to left heel and a weight of 146 pounds (#). On 03/31/23, a nutrition assessment was done by Staff G, clinical dietician, which revealed she recommended house shakes three times a day (TID) for increased kcals (calories) to augment intake. On 08/30/23 at 3:49 PM an interview was conducted with Staff G. She stated she would put an order into the Meal Tracker. She stated the system is new and corporate was not able to put the amount given for the mighty shakes in the system. The Meal tracker started after March 2023 which enabled an amount taken to be put into the system. There was no evidence that mighty shakes were being given to the resident. On 04/07/23, a second weight was taken on Resident #340. The resident's weight was 137 pounds. This indicated a 9-pound weight loss in 9 days. On 04/07/23, the order was entered for Ensure Plus 237 ml (milliliters) give one carton by mouth two times daily. This was given to the resident on 04/07/23 and 04/08/23. On 04/08/23, the resident was discharged to the hospital per family request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review, observations and interviews, the facility failed to ensure that residents medications refills were reorder in a timely manner for 3 of 7 sampled residents reviewed for medications and timeliness of administration, Resident #44, # 89, and #434. The findings included: Review of the facility's policy, titled, Medication Ordering and Receiving from Pharmacy, revised dated January 2018, documented, in part, .the facility maintains accurate records of medication order and receipt . Review of the facility's policy, titled, Medication and treatment Orders, published dated 05/19/23, documented, in part, .drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available . 1. Review of Resident #44's clinical record documented an admission on [DATE] with no readmission. The resident's diagnoses included Dry Eye Syndrome, Dementia and Cerebral Infarction. Review of Resident #44's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 10, indicating the resident had moderate cognition impairment. Review of Resident #44's clinical record documented a physician order dated 07/19/23 for Muro 128 Ophthalmic Solution one drop in both eyes four (4) times a day for Dry Eye Syndrome, scheduled on military time at 0800 (8:00 AM), 1200 (noon), 1600 (4:00 PM) and 2000 (8:00 PM). Review of Resident #44's August 2023 Medication Administration Record (MAR) for Muro 128 Ophthalmic Solution eye drops was conducted. The review revealed documentation of code #9, meaning-other/see nurses notes, for the eye drops from 08/22/23 at 1600 hours through 08/25/23 at 2000 hours. Further review revealed that Resident #44 was administered Muro 128 eye drops on 08/26/23, 08/27/23, and on 08/28/23 at 0800 and 1200 hours, then code #9 was documented on 08/26/23 and 08/27/23 at 1600 and 2000 hours. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/22/23 1725 hours (5:15 PM) documented Muro 128 Ophthalmic Solution- not found in the cart, request refill. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/22/23 2036 hours (8:36 PM) documented Muro 128 Ophthalmic Solution- pending delivery. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/23/23 1737 hours (5:37 PM) documented Muro 128 Ophthalmic Solution-pending delivery. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/23/23 2044 hours (8:44 PM) documented Muro 128 Ophthalmic Solution-pending delivery. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/24/23 at 1809 hours (6:09 PM) documented Muro 128 Ophthalmic Solution-pending delivery. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/25/23 at 1425 hours (2:25 PM) documented Muro 128 Ophthalmic Solution-med unavailable. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/25/23 at 2040 hours (8:40 PM) documented Muro 128 Ophthalmic Solution-pending delivery. Review of Resident #44's electronic medication administration note (code #9 note) dated 08/28/23 at 1703 hours (5:03 PM) documented Muro 128 Ophthalmic Solution-medication not available/call pharmacy. Review of Resident #44's electronic medication administration note dated 08/28/23 at 1823 hours (6:23 PM) documented not available in stock, pharmacy contacted at 6:24 PM, will be delivered by the end of the shift. On 08/28/23 at 4:24 PM, medication administration observation for Resident #44 performed by Staff S, Licensed Practical Nurse (LPN) started. Staff S proceeded to review the resident's medications scheduled for 4:00 and 5:00 PM and stated Resident #44 was due for Muro 128 Ophthalmic Solution (eye drops) at 4:00 PM (1600 hours). Observation revealed Staff S looking through the medication cart's drawers and stated she did not see Resident #44's Muro 128 ophthalmic solution bottle in the medication cart. During the interview, Staff S stated that Resident #44's Muro 128 eye drops were scheduled to be given four (4) times a day at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Staff S stated she would call the pharmacy to reorder it and for a delivery. On 08/28/23 at 6:35 PM, during an interview, the Assistant Director of Nursing (ADON) was apprised of Resident #44's Muro 128 eye drops not being available for administration at 4:00 PM. The ADON replied she was not informed about it. On 08/28/23 at 6:45 PM, during an interview, Staff S stated that Resident #44's Muro 128 eye drops had not been delivered from the pharmacy as of yet. On 08/29/23 at 1:40 PM, an interview was conducted with Staff Y, Registered Nurse (RN). Staff Y stated that she remembered Resident #44 not having her eye drops, but that she had not been scheduled back to work on this unit. Staff Y stated she looked that it was reordered and was waiting to be delivered. Staff Y stated she did not call the doctor regarding the resident missing the eye drops and did not call the pharmacy to follow up on the reordering of the resident's eye drops. Staff Y was apprised that Resident #44 missed two doses on her shift on 08/25/23. A side-by-side review of the facility's pharmacy electronic reordering system was conducted with Staff Y. The screen displayed that Resident #44's last eye drops reorder was on 08/22/23 and dispensed on 08/28/23. On 08/29/23 at 3:27 PM, an interview was conducted with Staff U, RN. A side by side of Resident #44's August 2023 MAR was conducted with Staff U. The review revealed that he coded the resident's Muro 128 ophthalmic eye drops with a code number nine (#9). Staff U stated that code #9 is used when a medication is not given, and they have to document the reason. Staff U stated that when a medication is not available at the pharmacy, they will call the doctor, and added if the pharmacy does not tell them that they don't have the medication when it is reordered, they wait until it is delivered. Staff U stated that they don't call the doctor because the pharmacy takes time to send the refills. Staff U added that he had made many calls in the past to get medications. Staff U was apprised that Resident #44 did not get her eye drops as order for many days in a row. Staff U was asked why he did not communicate with the Director of Nursing (DON) regarding the delay on refills from the pharmacy. Staff U replied the DON should have been notified and added will do better next time. On 08/30/23 at 8:19 AM, during an interview, the Consultant Pharmacist (CP) was apprised regarding Resident #44 Muro 128 Ophthalmic (eye drops) not being available for administration during medication administration observation on 08/28/23 at 4:00 PM. The CP was asked to provide evidence of the eye drops receipt of reordering from pharmacy. The CP stated that Muro 128 was an eye lubricant, and that Refresh Tears was a house stock compatible that the staff could use. The CP stated that the staff did not need to call the pharmacy for a refill because it was a house stock item. A side-by-side review of the Resident #44's Muro eye drop entry in the electronic system revealed that it was not entered as a house stock medication. On 08/30/23 at 8:35 AM, an interview was conducted with Staff T, LPN who stated the process about reordering medications refills was calling the pharmacy, especially if running very low, or reorder via the electronic medical record when the medications had three days left. Staff T stated having no issues reordering medications during the month of August 2023. Staff T was asked if she administered Resident #44 Muro 128 eye drops on 08/26/23, 08/27/23, and on 08/28/23 at 0800 and 1200 hours and stated she did not. Staff T was asked why she documented it as administered if she did not and replied, My error, I probably got interrupted and initialed as given. Staff T was asked if she called the pharmacy to reorder the eye drops and stated she did not. Staff T was asked if she called the doctor to inform about the medication not given as ordered, and replied she did not. On 08/30/23 at 10:15 AM, the CP provided an e-mail from the pharmacist that documented the Muro 128 Ophthalmic Solution was ordered on 07/21/23 and there were no other requests via phone call regarding the eye drops. The CP stated the drops were good for 30 days and should have been reordered by 08/21/23. On 08/30/23 at 2:45 PM, during an interview, the DON was apprised of the findings. The DON stated that Muro 128 ophthalmic drops were not a house stock medication and should have been ordered from the pharmacy. On 08/31/23 at 3:10 PM, during an interview, the DON stated she was not able to find any written nursing documentation of notification to the doctor regarding Resident #44's Muro 128 eye drops not been administered as ordered by the physician. 2. Review of Resident #89's clinical record documented an admission on [DATE] with no readmissions. The resident's diagnoses included Hypothyroidism, Protein-Calorie Malnutrition, Vitamin D deficiency and Alcohol Abuse. Review of Resident #89's MDS annual assessment dated [DATE] documented a BIMS score of 15 indicating no cognition impairment. Review of Resident #89's physician order dated 04/28/23 documented, Slow Release tab (tablets) 45 mg (milligrams) give one tablet orally in the afternoon with meals related to Anemia scheduled at 1700 hours (5:00 PM). The physician's order did not state the medication name. Review of Resident #89's August 2023 MAR documented refusal of the medication 23 of 27 days during the month of August 2023. Review of Resident #89's nurse progress notes lacked written evidence regarding physician notification of Resident #89 refusal of Slow Release tablets 23 of the 27 days in August 2023. On 08/28/23 at 4:42 PM, medication administration observation for Resident #89 performed by Staff S, LPN started. Staff S proceeded to review the resident's medications scheduled for the observation time. Staff S stated the resident was scheduled for Slow Release 45 mg and added Slow release what? Staff S stated that she could not find Slow Release tablets in the medication cart for Resident #89 and added that if she found it, she did not want to give it because it did not state the medication name. Observation revealed Staff S reordered Slow Release 45 mg medication via the EMR. Staff S stated the medication was for anemia. On 08/28/23 at 6:25 PM, an interview was conducted with the ADON who stated the facility did not have Slow Release Iron in house stock. The ADON added that the medication was reordered as 'expedite delivery today'. On 08/30/23 at 8:45 AM, an interview was conducted with Staff T, LPN who stated that Resident #89 refuses to take her Slow Release medication a lot of times. Staff T was asked if she notified the doctor about refusal of the medication and replied she believes she did but did not know how to find the note. On 08/30/23 at 8:50 AM, observation revealed Staff T receiving medications from the pharmacy Technician (tech). An interview was conducted with the pharmacy tech who stated that they do delivery medications to the facility two times a day. On 08/30/23 at 9:30 AM, an interview was conducted with the DON regarding Resident #89's Slow Release 45 mg tablets not being available for administration on 08/28/23 5:00 PM dose. The DON stated Slow Release medication was not available and was not an over the counter medication (OTC). On 08/30/23 at 2:15 PM, a side-by-side review of Resident #89's Slow Release 45 mg tablets delivery card documented date of delivery as of 08/28/23. On 08/31/23 at 3:10 PM, during an interview, the DON stated she was not able to find any written nursing documentation of notification to the doctor regarding Resident #89's refusal of taking Slow Release - Iron tablets as ordered by the physician. 3. Review of Resident #434's clinical record documented an admission on [DATE] with no readmissions. The resident's diagnoses included Type 2 Diabetes Mellitus, Heart Failure and Dementia. Review of Resident #434's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 9, indicating that the resident had moderate cognition impairment. Review of Resident #434's care plan, titled, The resident has Diabetes Mellitus, initiated on 08/08/23, documented interventions to include: diabetes medication as ordered by the doctor. Review of Resident #434's physician order dated 08/08/23 documented Insulin Lispro Solution Pen-injector inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus. Review of Resident #434's August 2023 MAR documented Insulin Lispro Solution Pen-injector inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus scheduled for 0730 (7:30 AM), 1130 (11:30 AM) and 1630 (4:30 PM). Review of Resident #434's August 2023 MAR documented on 08/28/23 a number 12 (#12) above the nurse initials (Staff V, LPN). On 08/28/23 at 5:16 PM, medication administration observation for Resident #434 performed by Staff W, LPN started. Staff W stated the resident was scheduled for a blood sugar check and insulin administration at 4:30 PM. Staff W, performed the resident's blood sugar and stated the result was 226 [mg/dl]. Observation revealed Staff W walked to the medication cart and started to look for the resident's insulin pen and stated he could not find it. Staff W walked to the medication room, looked into the emergency kit in the refrigerator and stated he did not find any Insulin-Lispro for Resident #434. The ADON came to the medication room, looked in the refrigerator and stated they had to call the doctor to get an order for another insulin since they did not have Insulin - Lispro in the facility for Resident #434. On 08/28/23 at 5:20 PM, an interview was conducted with the facility evening supervisor who stated the pharmacy had not done any medications delivery yet. Subsequently, a joint interview with the supervisor and the ADON was conducted. They were apprised that Resident #434 was scheduled for Insulin-Lispro 20 units at 4:30 PM and the insulin was not available as per Staff W, LPN. On 08/28/23 at 5:43 PM, during an interview, the evening supervisor and the ADON stated that Resident #434's Insulin-Lispro insulin pen was reordered on 08/08/23 as per the pharmacy staff. The supervisor stated that the insulin pen has only 5 doses and should have been reordered on 08/13/23. The pharmacy did not have any record of the Resident #434's Insulin-Lispro Pen Injector reordered since 08/08/23. The supervisor stated she would call the doctor and added that if there is a substitute the physician would let her know, she would check the emergency kit and would administer it. On 08/28/23 at 5:55 PM, during an interview, the evening supervisor stated the doctor had not call back yet regarding Resident #434's 4:30 PM scheduled dose of Insulin that was not available. The supervisor stated that the pharmacy would be sending an Insulin-Lispro Pen Lispro 100,000 units per ml, a three (3) ml pen, which would last 5 days. On 08/28/23 at 6:09 PM, the surveyor left Resident #434's unit and no insulin had been delivery yet as per ADON. On 08/28/23 at 6:41 PM, per ADON, no insulin for Resident #434 had been delivered. On 08/29/23 at 2:02 PM, an interview was conducted with Staff Z, LPN, who stated she was not sure of the facility's reordering medications protocol. Staff Z added the night shift staff tend to check on insulins for the residents and reorders them. Staff Z was asked if she notices that an insulin pen was going low what she would do and replied, she was not sure. A side by side review of Resident #434's Insulin Lispro Pen 100,000 units per ml three (3) ml was conducted with Staff Z. The Insulin-Lispro Pen pharmacy label was dated as opened on 08/29/23. Staff Z was not able to tell how many doses of insulin the pen had. Staff Z added that Insulin is important, as if not given as ordered, the resident's blood sugar would be high, may need to be sent to the hospital and the doctor would not be happy. On 08/29/23 at 2:44 PM, an interview was conducted with Staff AA, RN, who he worked 3 PM - 11 PM shifts most of the time. Staff AA stated that if a resident was getting insulin three times a day, it will go fast. On 08/29/23 at 3:13 PM, an interview was conducted with Staff W, LPN, who stated that on 08/28/23 Resident #434's doctor called back and ordered 20 units of Novolog Insulin. Staff W stated he checked the resident's blood sugar at 2000 hours (8:00 PM) and the result was 321 mg/dl and at 2026 hours (8:26 PM) administered 20 units of Novolog (short acting insulin), and 10 units of Insulin Glargine (long acting insulin) as scheduled for 2000 hours (8:00 PM). On 08/29/23 at 3:16 PM, a side by side review of Resident #434 medication administration record was conducted with Staff W. The review revealed the resident was administered 20 units of Novolog insulin at 2026 hrs (8:26 PM), a one time dose. The resident was scheduled for Insulin coverage at 1630 hours (4:30 PM). On 08/30/23 at 8:19 AM, during an interview, the Consultant Pharmacist (CP) was apprised of the findings during medication administration observation on 08/28/23. The CP stated they could have gotten the Insulin-Lispro from the Cubex medication supply system. On 08/30/23 at 9:40 AM, an interview was conducted with the ADON who stated the Cubex did not have Insulin Pens because it needed refrigeration before opening. On 08/31/23 at 9:24 AM, an interview was conducted with Staff V, LPN who confirmed she worked on 08/28/23 and was assigned to Resident #434. A side by side review of the resident's August 08/28/23 MAR was conducted with Staff V. Staff V stated she did not have to give any insulin to Resident #434 on 08/28/23 at 7:30 AM because the blood sugar result of 126 mg/dl. Staff V added that insulin was usually given for blood sugar higher than 200 mg/dl. On 08/31/23 at 3:29 PM, an interview was conducted with the DON who was apprised that on 08/28/23 at 7:30 AM, Staff V, LPN, stated that she did not administer Resident #434's scheduled insulin because of the blood sugar. The DON was apprised that Staff V documented a code #12 that indicated Insulin no required. The DON was apprised of concerns related to the resident's Insulin-Lispro insulin administration for 14:30 hour (2:30 PM) not given until 2026 hours (8:26 PM) and no record of reordering of the insulin to pharmacy since 08/08/23. The DON was apprised that the insulin pen only had 5 doses according to the pharmacy and should have been reordered on 08/13/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that PRN (as needed) physician orders for psychotropic drugs are limited to 14 days for 1 of 5 sampled residents for unnecessary medication (Resident #144). The findings included: Record review documented that Resident #144 was admitted on [DATE] with diagnoses to include Major Depressive Disorder and Unspecific Psychosis. Review of the Physician's orders showed the following order, dated 04/17/23 with no stop date, for Lorazepam 0.5 milligrams to be given every 6 hours as needed for anxiety. Review of the Pharmacy recommendation book showed the following: no recommendations were provided on 04/25/23 regarding the above medication PRN status; no recommendations were provided on 05/09/23 for the above medication PRN status; and no recommendation was provided on 06/29/23 for the above medication PRN status. Further review showed that it was not until 07/29/23 that a recommendation was given regarding the Lorazepam PRN order that was PRN with no stop date. In this note, the Pharmacist recommended either discontinuing the medication, adding a stop date, or even considering updating to scheduled dosing as appropriate. The Physician addressed the recommendation on 07/30/23 and noted to renew the PRN order for 30 days and that he would reassess later. An interview conducted on 08/30/23 at 3:10 PM with the facility's Pharmacist who stated she comes into the facility at least once a month to conduct medication reviews on all residents. For any orders of PRN with no stop date, she submits the recommendation to discontinue, make a routine, or to reassess the resident. The pharmacist stated this is then given to the Director of Nursing who is the one who prints out the recommendations and executes them. She will check out the progress of the recommendations with the Director of Nursing the next month when she comes in. When asked about Resident #144 order, which started on 04/17/23 and was not addressed until 07/29/23, she said it was incorrect. The Pharmacist said the PRN order was started on 04/17/23 and stopped on 05/01/23. It only started again for a PRN status on 07/19/23. A review of Resident #144's Medication Administrator Record for May 2023 showed that Resident #144 had an order for Ativan 0.5 milligrams every 6 hours PRN with a start date of 05/05/23 and was recorded as given on different days for the entire month of May 2023. In an interview conducted on 08/30/23 at 3:44 PM, the Director of Nursing stated that she reviews the pharmacy recommendations and would contact the specific doctors for the pharmacy recommendations. Each doctor has a folder where she will place the recommendations. She leaves the doctors a note for them to return it to her, and she would move forward from that point.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the correct fluid consistency for 1 of 6 sampled residents reviewed for nutrition, Resident #63. The findings included: Record review documented Resident #63 was admitted to the facility on [DATE] with diagnoses that included Lupus, Anemia, and Major Depression. Review of the physician ordered diet included: diet order dated 06/14/23 for no added salt diet with regular texture and nectar-thickened liquids. The annual Minimum Data Set (MDS) dated [DATE] documented Resident #63 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The care plan initiated on 07/10/23 documented Resident #63 is at high nutritional risk for dysphagia and is on thickened liquids by the Speech Language Pathologist (ST). It further showed that Resident #63 is blind in one eye. In an observation conducted on 08/28/23 at 10:34 AM, Resident #63 was in her room with the breakfast tray. The meal ticket showed an order for a no-added salt diet with thick nectar liquids. Closer observation showed thickened apple juice, Mighty Shake nutritional supplement, regular milk that was not thickened, and hot tea that was not thickened. Further observation showed there was no thickened powder on the tray. In an observation conducted on 08/28/23 at 12:00 PM, Resident #63 was noted in the room. Closer observation showed a regular water pitcher with 800 ml of water at the bedside, which was not thickened. In this observation, Resident #63 asked the surveyor if she could take the water pitcher out of the room. An interview was conducted on 08/28/23 at 12:05 PM, with Staff A, Licensed Practical Nurse, who stated the regular water pitcher should not have been given to Resident #63, and that it was a mistake. In an observation conducted on 08/29/23 at 9:12 AM, Resident #63 was noted in her room with a breakfast tray on her side table. Closer observation showed the name on the breakfast tray belonged to another Resident (Resident #39). In this observation, Resident #63 said, I do not think this is my breakfast tray. In an interview conducted on 08/29/23 at 9:15 AM, with Staff B, Certified Nursing Assistant, was asked if she had brought Resident #63 the wrong tray. Staff B replied, yes. She further said that she is new to this side of the unit and that it is her first time serving the meal trays to the residents. In an interview conducted on 08/31/23 at 9:22 AM, the Dietary Manager stated the nursing staff told her that Resident #63 was okay to have thickened powder on the meal tray and that she would mix her fluids independently. In an interview with the Director of Nursing on 08/31/23 at 8:00 AM, she was told of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that a nourishing snack was available at bedtime if more than 14 hours passed between the evening and breakfast meals. This was observed for 3 of 3 sampled residents during dining observations, Resident #138, Resident #39 and Resident #92. It had the potential to affect 33 residents who resided on the 300 Unit, of the census of 181 residents. The findings included: A review of the facility's Bulk Snack list provided by the Dietary Manager showed the following: a pitcher of orange juice, a pitcher of cranberry juice, graham crackers or soft cookies, ½ peanut butter and jelly sandwich, fresh fruit, apple sauce, yogurt, tea bags, and sugar. Review of the census list provided by the facility on 08/28/23 showed there were 49 residents in the 300 Unit, 47 in the 100 Unit, 47 in the 200 Unit, and 38 in the 400 Unit. Review of the Diabetic snack list provided by the facility showed that 16 residents had diabetic snacks ordered at night (bedtime) in the 300 Unit. The mealtimes for dinner and breakfast provided by the facility's Administrator showed the following: the dinner meal cart on the [NAME] (300 unit) Wing Cart 2 showed from 6:15 PM to 6:30 PM; and the breakfast meal cart on the [NAME] Wing Cart 2 showed 8:15 AM to 8:25 AM. In an observation conducted on 08/28/23 at 5:50 PM, the first meal cart arrived at the 300 Unit (West) at 6:05 PM, and the second dinner cart arrived at the 300 Unit (West) at around 6:00 PM. At 6:05 PM, the dinner trays were taken into Resident #39's and Resident #138's rooms. The last meal tray on the 300's Unit was given at 6:30 PM. In an observation conducted on 08/29/23, the first meal cart arrived at the 300 Unit (West) at 8:35 AM; and at 9:00 AM, the second meal cart arrived at the 300 Unit. Further observations showed that at 9:06 AM, the breakfast trays were taken into Resident #39 and Resident #138 rooms. This was about 15 hours between the dinner meal and the breakfast meal. In this observation, Resident #138 said that she kept her cake (dessert) from the night before to have something to eat between dinner and breakfast. Record review showed Resident #138 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #138 had a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident is cognitively intact. Resident #39 was admitted on [DATE], and the Quarterly MDS dated [DATE] showed a BIMS score of 10, indicating moderate cognitive impairment. In an interview conducted on 08/28/23 at 1:04 PM with Resident #138, the resident stated she eats her dinner at around 6:00 PM to 6:30 PM. The breakfast meal may be at 9:00 AM and sometimes not until 10:00 AM the next day. She further stated she asks for a snack between meals but was told by staff that it was only for residents who have Diabetes. She gets hungry between meals and tries to drink more water to get full. In an interview conducted on 08/28/23 at 1:10 PM, Resident #39 stated she eats her dinner from around 6:00 PM to 6:30 PM. The breakfast tray may be at 9:00 AM and sometimes not until 10:00 AM the next day. She further stated she asked for a snack between meals but was told that it was only for residents who have Diabetes. In an interview conducted on 08/28/23 at 5:55 PM, Staff C, Certified Nursing Assistant, stated the snacks cart arrives from the kitchen around 6:30 PM to 7:00 PM. It will have the residents' names on the specific snacks, and some snacks will not have any residents' names on them, in case other residents want snacks. She further stataed the snacks are placed in the pantry room in each Unit. Record review showed that Resident #92 was admitted to the facility on [DATE], and the MDS, dated [DATE], showed a BIMS score of 15, indicating the resident is cognitively intact. In an interview conducted on 08/28/23 at 6:10 PM, Resident #92 stated that dinner is usually served between 6:00 PM and 6:30 PM. The breakfast is sometimes at 10:00 AM, and they hardly have any snacks at night. And when he asked for snacks, he was only given crackers. An interview was conducted on 08/28/23 at 6:43 PM, in the central kitchen, with Staff D, Dietary Aide, who stated that he was making bulk snacks for the different units. Staaff D stated each bulk tray has the following: 5 ½ peanut butter and jelly sandwiches, 10-15 either cookies or graham crackers, six apple sauces, five pieces of fruit, and three single yogurts. In an interview conducted on 08/28/23 at 6:48 PM, the Dietary Manager stated that four bulk snack trays are taken into each Unit (100, 200, 300, and 400) and placed in the pantry room. Other snacks are also given, which are specific to the residents' names and room numbers. In an interview conducted on 08/31/23 at 9:00 AM, Staff E, Licensed Practical Nurse, stated that she does not work the night shift, but the Diabetic residents must get a night snack and that it is given to them after dinner labeled with their name and room number. In an interview conducted on 08/31/23 at 9:22 AM, the Dietary Manager stated that the facility's nursing staff and the Administrator would request the number of snacks that are needed in each of the 4 Units. She stated she has been sending the same number of snacks to each Unit. When asked if she was told by nursing staff that the number of snacks that were sent on the floor was not enough for most residents, she said no. In an interview conducted on 08/31/23 at 8:00 AM, with the Director of Nursing, she was told of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility's staff failed to encourage and ensure that residents practiced hand hygiene before eating meals for 5 of 5 sampled residents observed during mealtimes, Resident #127, Resident #123, Resident #133, Resident #138, and Resident #39. This had the potential to affect 49 residents that are on the 300 unit. The facility also failed to follow proper infection control standards during medication administration observation for 2 of 7 sampled residents, Resident #15 and Resident #9. The findings included: Review of the facility's policy, titled, Handwashing/hand Hygiene, dated 05/18/23, documented that the facility considers hand hygiene the primary means to prevent the spread of infections. It further directs using hand washing or alcohol-based hand rub before and after eating or handling food. In an observation conducted on 08/28/23 at 12:15 PM on the 300 unit, the first meal cart arrived. Staff started passing out the trays to the individual resident rooms and did not encourage or ask the residents to practice hand hygiene before eating their meals. The second meal cart arrived on the 300 unit, and staff started passing out the trays to the individual rooms without asking residents to practice hand hygiene. Continued observation showed that the lunch meal tray was brought to Resident #127's room at 12:20 PM, and staff was not observed encouraging or asking Resident #127 to wash his hands before eating his lunch meal. A lunch meal tray was brought to Resident #123's room at 12:23 PM, and the staff was not observed encouraging or asking Resident #123 to wash his hands before eating his lunch meal. Resident #133's lunch meal was brought to the resident at 12:35 PM, and the staff was not observed encouraging or asking Resident #133 to wash his hands before eating his lunch meal. In an observation conducted on 08/28/23 at 5:45 PM on the 300 unit, the first meal cart arrived. Staff started passing out the trays to the individual resident rooms and did not encourage or ask the residents to practice hand hygiene before eating their meals. The second meal cart arrived on the 300 unit, and staff started passing out the trays to the individual resident rooms without asking residents to practice hand hygiene. 1. Record review documented Resident #127 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 14 (indicating the resdient is cognitively intact) and that he needed extensive assistance with personal hygiene. An interview was conducted on 08/28/23 at 12:36 PM with Resident #127 who stated that facility staff do not encourage or remind him to wash his hands before eating his meals. He further said that they do not have a small mini hands sanitizer that he can use or any wipes that are given on the meal trays. 2. Resident #123 was admitted to the facility on [DATE]. The MDS dated [DATE] showed a BIMS score of 15, indicating the resident is cognitively intact. It further revealed that the resident needed extensive assistance with personal hygiene. An interview conducted on 08/28/23 at 12:40 PM with Resident #123 stated that facility staff do not encourage or remind him to wash his hands before eating his meals. He further said that they do not have a small mini hands sanitizer that he can use or any wipes that are given on the meal trays. 3. record review documented Resident #133 was admitted to the facility on [DATE]. The MDS dated [DATE] showed a BIMS score of 13, indicating the resident is cognitively intact, and required limited assistance with personal hygiene. In an interview conducted on 08/28/23 at 12:43 PM, Resident #133 stated that he has been in this facility for the last seven months and was never told even once that he needed to wash his hands before eating his meals. He was also never reminded or encouraged to wash his hands. 4. Record review documented Resident #138 was admitted on [DATE]. The quarterly MDS dated [DATE] showed a BIMS score of 13, indicating the resident is cognitively intact. It further showed that she needs extensive assistance with personal hygiene. In an interview conducted on 08/28/23 at 1:04 PM, Resident #138 stated that she was never told or encouraged to wash her hands before eating her meals. In an interview conducted on 08/29/23 at 9:00 AM with Resident #138, she stated that she had a box of wipes in her room that she could use to clean her hands before meals. The resident stated the staff took away the pack of wipes last night. 5. Record review showed Resident #39 was admitted on [DATE]. The Annual MDS dated [DATE] showed a BIMS score of 10, indicating moderate cognitive impairment. It further revealed that she needed extensive assistance with personal hygiene. In an interview conducted on 08/28/23 at 1:10 PM, Resident #39 stated that she was never told or encouraged to wash her hands before eating her meals. In an interview conducted on 08/31/23 at 9/05 AM, Staff F, Certified Nursing Assistant, stated that for the alert and oriented residents, she would remind them and ask them to practice hand hygiene before eating their meals. For the residents who are not able to practice hand hygiene, she would clean their hands for them. In an interview conducted on 08/31/23 at 10:55 AM, Staff H, Certified Nursing Assistant, stated that for the alert and oriented residents, she would remind them and ask them to practice hand hygiene before eating their meals. For residents who could not practice hand hygiene, she would use wipes or washcloths to clean their hands. In an interview conducted on 08/31/23 at 8:00 AM with the Director of Nursing, she was told of the findings. 6. On 08/28/23 at 4:32 PM, medication administration observation for Resident #15 was performed by Staff S, Licensed Practical Nurse (LPN). Staff S stated that Resident #15 had one tablet to give and one powder to apply under the resident's breast. Observation revealed Staff S pulled a bottle of Nystatin (antifungal) Powder 100,000 units bottle from the treatment cart. Staff S returned to the medication cart and retrieved one tablet of Ezetimibe (for high cholesterol)10 mg. At 4:38 PM, Staff S, LPN walked to Resident #15's room, hand carrying the medication cup containing the Ezetimibe tablet and the Nystatin bottle. Staff S entered the resident's room to find out that the resident's was not in her room. Observation revealed Staff S started to talk to Resident #15's roommate who was in the room and Stff S was holding the medication cup with her left thumb flexed into the medication cup. Staff S continued talking to the roommate, then was observed placing the bottom of the bottle of Nystatin inside the medication cup that contained Resident #15's Ezetimibe tablet. Further observation revealed, Staff S walked out of the resident's room, placed the Nystatin bottle and the medication cup containing the Ezetimibe tablet inside her uniform pocket. Staff S stated Resident #15 was in the hallway and proceeded to wheel the resident into the room. During an interview, Staff S stated that the resident refused the administration of the Nystatin powder. Staff S pulled the medication cup from her pocket and assisted Resident #15 to take the Ezetimibe tablet. Staff S then walked out of the resident's room to the treatment cart, pulled the Nystatin powder bottle from her uniform pocket and without disinfecting it, placed the bottle in a drawer in the treatment cart with other resident's medications. 7. On 08/28/23 at 4:52 PM, medication administration observation for Resident #9 was performed by Staff S, LPN. Observation revealed Staff S poured 30 millimeters (ml) of Protein liquid, walked to the resident's room and repositioned the resident's bed using the bed control remote. Observation revealed Staff S donned gloves without performing hand hygiene previously and with gloved hand opened the bathroom door retrieved a paper towel, returned to Resident #9's beside and administered the resident's Protein liquid. Further observation revealed Staff S removed the pair of gloves, walked out of the resident's room without performing hand hygiene, then placed her hands into her uniform pocket. Staff S, LPN was not available for an interview. On 08/31/23 at 4:45 PM, during an interview, the Director Of Nursing was apprised of the findings during the medicaion observation pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to conduct proper admission, readmission, and quarterly smoking assessments for 10 of 10 sampled residents, reviewed for smoking safety, and as identified by the facility as smokers. The findings included: Review of the facility's policy, titled, Smoking Policy-Residents, published 05/19/23, included, in part, the following: Resident smoking status is evaluated upon admission. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change, and as determined by the staff. The facility provided a Smoker List upon request during the Entrance Conference conducted on 08/28/23. Of the residents named on this list, 10 remained as active residents of the facility. The following are the 10 identified residents who smoke who were found to have discrepancies in smoking assessments, either upon admission, readmission, or quarterly: 1. Resident #422 was admitted to the facility on [DATE]. An admission MDS was done on 08/28/23. This MDS documented Resident #422 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Resident #422 had a medical history significant for Fracture of Left Femur. During tour of the facility conducted on 08/28/23, the surveyor observed a carton of cigarettes in Resident #422's room. The surveyor interviewed Resident #422 and he confirmed that he was a current smoker. Review of the Smoker List provided by the facility revealed Resident #422 was not included on the list. There was no Smoking Assessment found for Resident #422. No Care Plan was found regarding smoking status. An admission Assessment, which included a smoking history, was done on 08/24/23 and documented Resident #422 was not a smoker. An interview was conducted with the facility's Director of Nursing (DON) on 08/29/23 at 3:00 PM. The DON stated that all smoking residents were assessed and found to be safe smokers. The surveyor explained that a resident who smokes was identified that was not included on the provided Smoker List. She stated she was unaware that Resident #422 was a smoker, but she would ensure that an assessment was completed. 2. Resident #75 was admitted to the facility on [DATE] and was readmitted on [DATE]. An admission Minimum Data Set (MDS) was done on 07/15/23. This MDS was In Progress at the time of this survey and did not document a Brief Interview of Mental Status (BIMS) score for Resident #75. Resident #75 had a medical history significant for Type 2 Diabetes Mellitus, Hemiplegia following a Cerebral Infarction, Poly osteoarthritis, Anemia, and Hypertension. An Initial Smoking Assessment was done on 11/27/18 and a Smoking Assessment was done on 06/01/23. A Care Plan was documented on 11/26/18 which stated, smokes with partner at times with supervision. There was an additional care plan written on 07/11/23 which stated, resident chooses to smoke. These assessments and care plans do not correlate with the policy of admission, readmission, and quarterly assessments. 3. Resident #31 was admitted to the facility on [DATE]. There was no MDS found in the electronic chart (due to a recent change in charting systems). Resident #31 had a medical history significant for Major Depressive Disorder, Generalized Anxiety Disorder, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease. Smoking Assessments were done on 09/26/13 and 06/02/23. A Care Plan was documented and undated, which stated, resident chooses to smoke. These assessments and care plan do not correlate with the policy of admission, readmission, and quarterly assessments. 4. Resident #119 was admitted to the facility on [DATE]. A Quarterly MDS was done on 07/11/23. This MDS documented Resident #119 had a BIMS score of 8, indicating she was moderately cognitively impaired. Resident #119 had a medical history significant for Type 2 Diabetes Mellitus, Cerebral Infarction, Dementia, Mixed Anxiety Disorder, and Epileptic Seizures. Review of the Smoking Assessments revealed they were done on 03/31/22 and 06/02/23. A Care Plan was documented, and undated, which stated, resident chooses to smoke. There was an additional care plan written on 03/31/22, which stated, resident smokes with supervision - escort resident to and from outside with a goal of resident will be able to smoke safely in designated areas by the next review date of 09/25/23. These assessments and care plans do not correlate with the policy of admission, readmission, and quarterly assessments. 5. Resident #13 was admitted to the facility on [DATE]. A Quarterly MDS was done on 08/04/23. This MDS documented Resident #13 had a BIMS score of 15, indicating she was cognitively intact. Resident #13 had a medical history significant for Chronic Obstructive Pulmonary Disease, Insomnia, Tachycardia, and Gastric Reflux. An admission Assessment, which included a smoking history, was done on 11/02/21. The Smoking Assessments were done on 04/11/22 and 04/07/23. A Care Plan was documented on 11/02/21 and updated on an unknown date which stated, resident is a cigarette smoker and smokes with supervision with a goal of resident will be able to smoke safely in designated areas by the next review date of 09/25/23. These assessments and care plans do not correlate with the policy of admission, readmission, and quarterly assessments. 6. Resident #216 was admitted to the facility on [DATE]. A Quarterly MDS was done on 07/21/23. This MDS documented Resident #216 had a BIMS score of 15, indicating he was cognitively intact. Resident #216 had a medical history significant for Heart Failure, Major Depressive Disorder, Type 2 Diabetes Mellitus, Cardiomyopathy, and Peripheral Vascular Disease. A Smoking Risk Form was documented on 08/15/23. No Care Plan was found regarding smoking status. This assessment and lack of care plan does not correlate with the policy of admission, readmission, and quarterly assessments. 7. Resident #109 was admitted to the facility on [DATE] and was readmitted on [DATE]. A Quarterly MDS was done on 08/18/23. This MDS documented Resident #109 had a BIMS score of 14, indicating he was cognitively intact. Resident #109 had a medical history significant for Heart Failure, Aphasia following Cerebral Infarction, Syncope, Generalized Anxiety Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, and Psychosis. No Smoking Assessment was found for Resident #109. A Care Plan was documented on 06/13/23 which stated, cigarette smoker and smokes independently. This care plan and lack of assessments do not correlate with the policy of admission, readmission, and quarterly assessments. 8. Resident #11 was admitted to the facility on [DATE] and was readmitted on [DATE]. A Quarterly MDS was done on 07/17/23. This MDS documented Resident #11 had a BIMS score of 14, indicating he was cognitively intact. Resident #109 had a medical history significant for Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Asthma, Type 2 Diabetes Mellitus, and Heart Attack. No Smoking Assessment was found for Resident #11. A Care Plan was documented on 07/07/23 which stated, chooses to smoke. This care plan and lack of assessments do not correlate with the policy of admission, readmission, and quarterly assessments. 9. Resident #26 was admitted to the facility on [DATE]. A Quarterly MDS was done on 03/13/23. This MDS documented Resident #26 had a BIMS score of 14, indicating he was cognitively intact. Resident #26 had a medical history significant for Insomnia, Major Depressive Disorder, Type 2 Diabetes Mellitus, and Bipolar Disorder. The Smoking Assessments were done on 10/18/21 and 06/10/23. A Care Plan was documented on 10/18/21 and updated on an unknown date which stated, smokes with supervision with a goal of resident will be able to smoke safely in designated areas by next review date of 09/26/23. These assessments and care plans do not correlate with the policy of admission, readmission, and quarterly assessments. 10. Resident #92 was admitted to the facility on [DATE]. A Quarterly MDS was done on 12/12/22. This MDS documented Resident #92 had a BIMS score of 15, indicating he was cognitively intact. Resident #92 had a medical history significant for Insomnia, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Anxiety Disorder, Major Depressive Disorder, and Type 2 Diabetes Mellitus. An admission Assessment, which included a smoking history, was done on 06/11/19. A Smoking Assessment was done on 06/07/23. A Care Plan was documented on 06/12/19 which stated, smokes with supervision and an updated care plan was written on 07/12/23 which stated, resident chooses to smoke. These assessments and care plans do not correlate with the policy of admission, readmission, and quarterly assessments. An interview was conducted with the facility's DON on 08/31/23, in which the DON was told the lack of assessments and care plans was an identified issue. The DON asked the surveyor to give her time to review the old facility policy and resident's charts. She approached the surveyor later in the day and stated she was unable to find additional information or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to monitor and follow the care plan for eating assistance for 1 out of 28 sampled Residents (Resident #2). The findings included: Review of the facility's policy titled Activities of Daily Living, supporting revised in March 2018, showed that residents who are unable to carry out activities of daily living independently will receive the necessary to maintain good nutrition, grooming, and personal and oral hygiene. It further showed that total dependence is full staff performance of an activity with no participation by the resident. In an observation conducted on 04/26/22 at 8:35 AM, the breakfast tray was brought into Resident #2's room. Staff went into the room at 8:40 AM to help set up the tray and left the room at 8:42 AM. Continued observation at 9:00 AM, showed that Resident #2's tray was 100% untouched. At 9:10 AM the breakfast tray was taken out of the room by staff untouched. In an observation conducted on 04/27/22 at 8:04 AM, staff was observed in the room setting up the breakfast tray for Resident #2. At 8:20 AM, the Resident was observed sleeping with the breakfast tray only 10% consumed and no staff noted in the room for assistance. Continued observation showed that Resident #2 was in the room with no assistance from staff and the breakfast tray was still 10% consumed (photographic evidence obtained). Record review revealed Resident #2 was readmitted to the facility on [DATE] with diagnoses of Dementia, Alzheimer's, and Failure to Thrive. The Minimum Data Set (MDS) dated [DATE] showed that for Section G under eating, Resident #2 requires total dependence and one person assist. Section C of the MDS, showed that Resident #2 has no Brief Interview of Mental Status (BIMS) score which is an indication of severely impaired cognition. The care plan dated 03/25/22 showed that Resident #2 is with self-care deficit and requires total assistance with all Activities of Daily Living. In an interview conducted on 04/27/22 at 10:19 AM, with Staff A, Licensed Practical Nurse (LPN), it was stated that Resident #2 can eat on her own and some days she needs help with her meals. In an observation conducted on 04/28/22 at 8:40 AM, Staff E, Certified Nursing Assistance (CNA), was observed assisting Resident #2 with her breakfast tray. In this observation Staff A was asked if Resident #2 needs assistance with her meals. She stated that at times Resident #2 can eat on her own and at times she needs assistance with her meals. In an interview conducted on 04/28/22 at 4:30 PM, with the facility's Administrator she was told of he findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to order, receive and administer pain medications for 1 of 2 sampled residents reviewed for pain management (Resident #49). The findings included: The facility's policy for 'Pain Assessment and Management', dated 2001 and most recently revised March 2015, documented: General Guidelines 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Recognizing pain 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavior signs of pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs. The facility's policy for 'Medication and Treatment Orders' dated 2001 and most recently revised July 2016, documented: 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Resident #49 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. According to Resident #49's most recent complete assessment, an admission Minimum Data Set (MDS), dated [DATE], Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, indicating 'cognitively intact'. The assessment documented that Resident #49 required assistance with Activities of Daily Living (ADLs), with the exception of eating. Resident #49's diagnoses at the time of the assessment included: Atrial fibrillation; Hypertension; GERD; Drug-induced polyneuropathy; Nicotine dependence; History of falling; Pressure ulcer of sacral region; Escherichia coli as the cause of diseases classified elsewhere. Resident #49's orders included: Gabapentin 300 mg capsule - give one capsule by mouth, one time a day - 04/25/22. Gabapentin 600 mg capsule - Administer one tablet by mouth at 2PM and 10PM daily - 04/25/22. Acetaminophen 325 mg tablet - give two tablets (650 mg) by mouth daily prior to wound care - 02/10/22. Acetaminophen 325 mg tablet - give two tablets (650 mg) by mouth every four hours as needed for pain - 02/10/22 Oxycodone HCL (IR) 10 mg tab - one tab by PO every 4 hours PRN, on ucute pain - 02/10/22. Resident #49's care plan, dated 01/21/22, documented, risk for pain related to multiple wounds upon admit, diagnosis of neuropathy The goal of the care plan was documented as, Will verbalize pain relief/show non-verbal signs or symptoms of pain/discomfort ½ to 1 hour after medication intervention with a target date of 06/21/22 Interventions to the care plan included: * Observe for non-verbal signs and symptoms of pain (eg. Changes in breathing, grunting, mons, constant motion, grimacing and other resident specific changes) nd provide interventions as indicated. * Medicate ½ to 1 hour prior to treatment (therapy or wound care as indicated. * Monitor for any patterns of pain and documented on positive findings. * Administer pain medication as requested/ordered. Document effectiveness, location, severity. A Nursing note, dated 02/19/22 at 3:23, documented, Resident complained of Methadone making him very lethargic. Resident stated that he would rather the PRN as needed Oxycodone instead of the routine Methadone. 2PM Methadone was refused. Report given to Oncoming Nurse. A Nursing note, dated 03/19/22 at 3:35 PM, documented, Writer called for script for oxycodone. Writer spoke to Medical Doctor and MD (name) to fax script pharmacy. Endorsed to on coming shift to follow up. A Nursing Note, dated 03/19/22 at 11:27 PM, documented, (Pharmacy) had not received prescription from Doctor (name) by 8pm. Left message at (name) phone. A Nursing Note, dated 04/11/22 at 1:24 PM, documented, Script for Oxycodone sent to Pharmacy by Pain Management. (Pharmacy) called, script received, will be delivered next delivery. A Nursing Note, dated 04/19/22 at 4:27 AM, documented, Resident yelling and in pain. Oxycodone hci (ir) 10 mg tablet given at 4:17 AM from PIXX machine on North wing Res calming. Rx (prescription) was called and stated resident med would be on the next delivery. Awaiting delivery. A Nursing Note, dated 04/19/22 at 4:38 PM, alert and oriented documented, Resident received in bed AAO X3 able to voice needs. Resident in bed Screaming at Staff I need my [sic] pain pills from pharmacy now. Resident is reminded by writer to not respond verbal aggression towards staff. Resident is also reminded that Pharmacy has beed called, and delivery is pending. Pharmacy called, authorized 2 from Pixis (Auth 22321) both given during shift. Per Pharmacy will be delivered on afternoon delivery. A Nursing Note, dated 04/25/22 at 11:31 AM, documented, Resident was given last PRN pain med @ 6:34 AM, per report from previous shift Nurse, Pharmacy called , stated will deliver on next shift. 9AM Writer also called Pharmacy x 2 ordered med Stat. Per Pharmacy tech will send stat with a time frame delivery of 4 hours. Tylenol 650MG were administered with routine medication, with little effect. Pixis check, none available. Pharmacy also made aware of Pixis with 0 tabs. Writer explained to Resident the occurrence. Resident verbalized understanding and stated to Writer, Ill wait til the delivery, I can wait it out. 11:30AM NP (Nurse Practioner) in to see and assess Resident. A Nursing Note, dated 04/25/22 at 12:24 PM, documented, 1219 Stat pain med arrived from Pharmacy and administered. During an interview with Resident #49, on 04/25/22 10:52 AM, when asked about any problems with pain, Resident #49 replied, I am supposed to have my pain pills every 4 hours and they don't have any to give me right now. They say that they don't have any. When asked the location of the pain, Resident #49 replied, Both my shoulders, my right hip and my lower back. During the interview, Resident #49 was showing facial expressions indicative of significant pain. During an interview, o 04/25/22 at 10:56 AM, with Staff G, LPN, when asked about pain medication for Resident #49, Staff G replied, we called the pharmacy and they said that they are on the way. He was on the last pill this morning. He gets it every 6 hours. It was taken at 7 this morning. We offered Tylenol, he took it and he said that it worked. The other nurse talked to the doctor to send a prescription. He already had some in the Pixis and we gave it to him. During an interview, o 04/25/22 at 10:59 AM, when Staff H was asked about Resident #49's pain medication, Staff H replied, they refill it and he takes it every four hours. He got the last one at 6:34 AM. We are just waiting for the delivery. This morning, he had Tylenol, he had Baclofen. He is out of the Oxycodone and he gets it Q 4 (every four) hours, PRN. We are going to ask to send it stat. We usually have it in the pixis. We gave it out of the Pixis this morning. He just got thirty last week, but he takes them every 4 hours. He had quite a few on Friday when I worked. Usually when we order it stat, it takes about an hour - give or take. Usually we pull it and order within a couple of days remaining. I told the DON (Director of Nursing) that we needed it now. I gave him some Tylenol and Baclofen at 9:00. I talked to him and he knows that we are working with the pharmacy. They called the order in on Saturday 04/23/22 On 04/25/22 at 11:16 AM, Staff H reached out to pharmacy for order, Staff H reported that the pharmacy representative said that from the pharmacy it usually takes up to four hours. Staff H stated, We have a NP and I am going to talk with her and see what else we can do for him. On 04/25/22 at 11:26 AM, Staff H reported that Resident #49 would rather wait until pharmacy delivery than have other interventions. On 04/25/22 at 12:23 PM, Staff H reported that the medicine had arrived and given to Resident #49. During a follow up interview, on 04/26/22 at 10:39 AM, with Resident #49, when asked about pain medication, Resident #49 replied, They run out of the medications about every 3 weeks. That's the only thing that seems to work (referring to the Oxycodone). They inform the pharmacy that they need them, but they just don't get here unless they pay to have them delivered guaranteed within 4 hours, otherwise, they have to go to the pixus that is on another wing and the Pixus ran out twice already. During an interview with the Consultant Pharmacist, on 04/26/22 at 1:30 PM, when asked about the Oxycodone for Resident #49, the Consultant Pharmacist replied, He had some Oxycodone stat yesterday. I got a call from the DON to have the pharmacy send it so I called the pharmacy and they ordered it and then they brought it over. I did not know of any requests for pain medication. This is the first time hearing about it. He has Oxycodone around the clock, Percocet every 6 hours and methadone 15 mg every 6 hours for non-acute pain, Gabapentin for nerve pain. We sent 30 yesterday, but that was upon your prompting. I saw him when I was walking through the unit this morning. I haven't seen where they ordered or didn't order. During an interview, on 04/26/22 at 3:36 PM, with Staff I, when asked about Resident #49's Oxycodone order, Staff I replied, I had a doctor assess him and he was saying that his pain wasn't addressed, he said that he wanted to manage his pain better. He had Methadone and that didn't work, and he went back to the Oxycodone. Our nurses have been very good at giving it to him every four hours. Sometimes pharmacy falls through, sometimes the doctor doesn't write the order. This is not the first time that this has happened.

Based on observation, interviews, record review and policy review; the facility failed to remove narcotics from 2 of 8 medication carts for 3 of 3 sampled residents who did not have current orders for the narcotics, Resident #84, #135 and #438. The findings included: The facility's policy titled Storage of Medication revised April 2007 reveals The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. On 04/28/22 at 9:30 AM, the Medication Cart for Team 1 in the 100 unit was reviewed with Staff J, a Registered Nurse (RN). Resident #84's medication card for Ativan 0.5 milligrams (mg) was in the narcotic lock box with no current order. The order stopped on 04/22/22. On 04/28/22 at 9:45 AM, the Medication Cart for Team 2 in the 300 unit was reviewed with Staff K, a Licensed Practical Nurse (LPN). Resident #135's medication card for Tramadol 50 mg was in the narcotic lock box. The order stopped on 04/15/22. Additionally, in the Medication Cart for Team 2 in the 300 unit, was a medication card for Resident #438. Resident #438's medication card for Tramadol 50 mg was in the narcotic lock box. The order stopped on 04/27/22. On 04/28/22 at 11:45 AM, an interview was conducted with the Director of Nursing who stated that medication should not be in the cart without a physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a psychotropic (drugs that affect a person's mental state) medication ordered by the practitioner were necessary and the resident's representative was aware and involved in the decision for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #110). The findings included: Review of the facility policy titled Administering Medications revised in April 2019 showed that following: if medication and dosage is believed to be excessive for the resident, or has been identified as having potential adverse consequences, the person preparing the medication will contact the prescriber and the resident's attending physician to discuss the concerns. In an interview conducted on 04/25/22 at 12:30 PM, with Resident #110's son, he stated that his mom was placed on psychotropic medication without their knowledge. He further said that the only reason he knew that his mom was placed of the new psychotropic medication was after the facility called him regarding his mom's behaviors. According to him, this was the first time that his mom was placed on antipsychotic medication and that he was never told as to why or signed the consent for the new medication. Resident #110's son further stated that he spoke to the facility's Director of Nursing on 04/08/22 and asked her to stop the medication until the prescribing physician called him back. In this interview, Resident #110's son, also called Resident #110's niece who verified the information that was reported by the son. Resident #110 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of Dementia without behavioral disturbances, Alzheimer's and Anxiety. Review of the Minimum Data Set (MDS) dated [DATE] showed that under Section E for behavior, Resident #110 did not use physical behavior symptoms directed at others. Further review of the Behavior Monitoring from 04/01/22 to 04/26/22 showed that for most days Resident #110 had no problem behavior noted. The Behavior Monitoring documented from 02/01/22 to 02/14/22 showed that Resident #110 did not have any problem behavior noted. Review of the Medication Administration record showed the following orders: Ativan 0.5 milligrams (mg) tablet to give by mouth 3 times a day as needed for agitation which started on 03/22/22 and discontinued on 04/08/22, another order of Ativan 3 times a day as needed from 04/08/22 and stopped on 04/22/22, Dekapote 500 milligrams one tablet a day which started on 04/01/22 and stopped on 04/22/22. Review of the psychiatrist consultation Staff M (Psychiatrist doctor) dated on 08/26/21 and 11/02/21, showed that Resident #110 was diagnosed with depression and confusion, but no other additional medications were recommended. Review of the Initial Psychiatric Evaluation which was completed on 03/31/22 by the nurse's practitioner showed the following, Resident #110 is receiving Ativan around the clock with little effect and diagnosed Resident #110 with unspecific dementia and Behavioral disturbances. She further recommended to start Resident #110 on Depakote 500 mg and discussed with nursing. Review of the Subsequent Psychiatrist evaluation which was done on 04/08/22 by Staff C (Psychiatrist doctor) showed the following, Resident #110 had periods of wandering and exit seeking behaviors and had to be on Depakote 500 mg regimen to maintain functional status. Review of progress notes showed the following, a note dated 04/15/22 showed that Resident #110 was unable to redirect, and the son was called so he can speak to his mom. In this note the son asked about the new medication Depakote and asked Staff C, to call him, which the Director of Nursing was aware. Another note dated 04/25/22 which was 10 days later showed that Resident #110's son requesting to speak to Staff C. A progress note dated 04/25/22 showed that the son was informed of the discontinuation of the Depakote which was on 04/22/22. A note dated 04/26/22 showed that Staff M, saw Resident #110 and ordered Ativan 0.5 mg twice daily as needed for Agitation and Anxiety. She also ordered an additional Ativan 0.5 mg every eight hours. In a phone interview conducted on 04/27/22 at 11:00 AM, with Staff C, he stated that he did not do the first initial consultation for Resident #110 on 03/31/22. He further stated that he was first told that Resident #110's son wanted to speak with him regarding the Depakote on 04/25/22, when he was in the facility. Staff C said that he reassessed Resident #110 on 04/08/22. In an interview conducted on 04/26/22 at 4:30 PM, With Staff M, she stated that she assessed Resident #110 in the past and stated that she was asked to take over the case and reassessed Resident #110. In an interview conducted on 04/28/22 at 12:00 PM, Staff P, Certified Nursing Assistant, stated Resident #110 had good days and bad days and at times can be resistant to care. In an interview conducted on 04/28/22 at 11:08 AM, with the facility's Consultant Pharmacist, it was stated that when Depakote (new medication) is being prescribed by a psychiatrist, it is used as a mood stabilizer and in this case, it is considered psychotropic medication. She further said that when residents are on Depakote, she will also attempt a gradual dose reduction for the resident. The care plan showed that Resident #110 is taking an Anxiety medication for generalized Anxiety, which was initiated on 04/26/22 after surveyor interventions. In an interview conducted on 04/28/22 at 4:30 PM, with the Administrator, she was informed of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to secure medications for 1 of 1 sampled residents (Resident #190) identified in the north wing. The findings included: Review of the facility's policy titled Storage of Medications revised on 04/2007 documented .drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems . Review of the facility's policy titled Preparation and General Guidelines-Self-Administration of Medications revised on 01/2018 documented .if the residents desires to self-administer medications, an assessment is conducted by the interdisciplinary team .the interdisciplinary team verifies the resident's ability to self-administer medications . Review of Resident #190's clinical record documented an admission to the facility on [DATE]. The resident's diagnoses included Left Hip repaired, Hypertension, Diabetes Mellitus, Depression, Macular Degeneration, Glaucoma and Muscle weakness. The residents baseline care plan included a care plan related to Impaired Vision. Review of the resident's physician orders documented,Latanoprost 0.005% eye drops one drop both eyes once daily at bedtime, wish was discontinued on 04/18/22. Physician order dated 04/18/22 documented, Dorzolamide 2% eye drop instill one drop to both eye three times a day for Glaucoma. Further review revealed a lack of a physician's order for Latanoprost eye drops and Systane eye drops. Review of Resident #190's April 2022 Medication Administration Record (MAR) documented Dorzolamide 2% eye drops instill one drop to both eye three times a day at 8:00 AM; 2:00 PM and 8:00 PM. Further review revealed Latanoprost 0.005% eye drops discontinued on 04/18/22. On 04/25/22 at 11:36 AM, observation revealed Resident #190;s room door wide open and the resident was not in the room. On 04/25/22 at 12:10 PM, observation revealed Resident #190 was being wheeled down the hallway and into her room, by a therapist. Subsequently, an interview was conducted with the resident and she stated that she went to therapy. During the interview, further observations revealed three bottles of eye drops on top of her nightstand. One bottle label read Systane lubricant eye drops another bottle label read Dorzolamide HCL ophthalmic solution 2% and a third bottle label read Latanoprost 0.005% ophthalmic solution. During the interview, Resident #190 stated that she puts the drops in when the nurses do not come. On 04/26/22 at 10:07 AM, observation revealed Resident #190 sitting in a wheelchair in her room. The aforementioned three eye drop bottle observed on 04/25/22 were on top of her nightstand. An interview was conducted with the resident and she stated that staff had not come today to put her eye drops in and she did it herself. She stated she does the Dorzolamide eye drops three times a day, the Systane drops, as needed for dry eyes and Latanoprost at night. Resident #190 further stated the directions on the bottle were wrong and added that she needed the prescription drop on her right eye only. The resident was asked if any nurse from the facility had observed her putting her drops in and stated that no one had watched her putting the eye drops in her eyes. Observation revealed Resident #190 administered Systane eye drops to both eyes during the interview. Resident #190 was asked if the facility knew that she had her eye drop bottles in her room and she stated that her son gave them a list of all her personal items brought into the facility. Review of Resident #190's clinical record contained the following: Resident Inventory Sheets dated 04/18/22 and documented resident stated my son made a list and gave it to the office. Review of a list in the resident clinical record documented the resident name- personal possessions .3 eye drop bottles . On 04/26/22 at 10:17 AM, an interview was conducted with Staff Q, a Licensed Practical Nurse, (LPN) who stated she had not administered Resident #190's eye drops because the surveyor was in her room. On 04/26/22 at 10:24 AM, the surveyor was approached by Staff L, a Registered Nurse (RN) who stated she was calling Resident #190's physician's because her eye drop was due at 8:00 AM and Staff Q, LPN had not administered the drops yet. Subsequently, a side-by-side review of the resident's electronic Medication Administration Record (e-MAR) was conducted with Staff Q and Staff L. The review revealed Resident #190 Dorzolamide eye drop was scheduled at 8:00 AM, 2:00 PM and 8:00 PM. Staff Q stated the Latanoprost eye drop was discontinued on 04/18/22 and there was not an order for Systane eye drops. On 04/26/22, at 10:32 AM, observation revealed Resident #190's daughter visiting. During an interview, the resident's daughter stated the resident had to have the aforementioned eye drops and she knew how to do it. On 04/26/22 at 10:33 AM, a side-by-side review of Resident 190's eye drops bottle on top of her nightstand was conducted with Staff L, RN and Staff Q, LPN. Staff L stated she helped the resident with her hearing aid around 8:30 AM on 04/25/22 and did not see the bottles on her nightstand. Staff L was apprised that the resident's three eye drop bottles were observed on her nightstand on 04/25/22 before and during lunch time and on 04/26/22. On 04/26/22 at 10:41 AM, an interview was conducted with the Director of Nursing (DON) who stated that Staff L, informed her of the findings. She stated they will complete an assessment and will find out where she obtained her eye drops from. The DON was asked if Resident #190 was assessed to do self-administration of medications and stated she did not see one in the residents' paper chart nor the electronic chart. On 04/26/2022 at 11:21 AM, an interview was conducted Staff X, MDS Coordinator and the facility's Staff Development Coordinator (SDC). They both stated that Resident #190 was not assessed for Self-administration of medications. 04/26/22 at 02:34 PM, an interview was conducted with Staff R, a Certified Nursing Assistant (CNA) who stated she assisted the resident to the bathroom. Staff R stated she saw two bottles of eye drops, one with a blue top and another with an orange top that morning on her stand. She stated she was going to bring them to the nurses but did not and she also did not tell the nurse. On 04/27/22 at 1:25 PM, a side-by-side review of Resident #190's Resident Inventory Sheets dated 04/18/22 and a list of the resident personal possessions was conducted with Staff L, RN. She had no comments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow physician's orders for 3 of 3 sampled resident reviewed for nutrition, therapeutic diets (mechanical soft) for Residents #110, #51, and #34. The findings included: A review of the facility's guidelines utilized the the main kitchen titled, Nutritional Education for Mechanical Soft Diet from the Manual of Medical Nutrition Therapy 2019 Edition showed the following: foods allowed in the mechanical soft diet are eggs, ground or chopped moist meats, baked fish, stewed made with tender chopped meat, finely ground chicken and well-cooked vegetables. A review of the facility's Speech Language Pathologist guidance titled Understanding Mechanical Soft Diets, undated, showed the following: Level-2 consist of foods that are moist, soft texture and easily swallowed. Meats are ground or finely cut to equal size no bigger than ¼ inch. A review of the Nutrition Care Manual under section Dysphagia Level 3: Advanced or Mechanical Soft, showed the following: no hard sticky or crunchy foods, foods should be moist, meat cut up and chopped, food particles are served in bite-sized pieces and less than 1 inch. (https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=273657). 1. In an observation conducted on 04/27/22 at 12:15 PM, Resident #110 was observed in her room eating her lunch meal with no assistance from staff. Closer observation showed a lunch meal that consisted of a hamburger bun, round hamburger patty, and diced carrots with various sizes with some sizes larger than 2 inches. After the resident finished her meal, the surveyor completed hand hygiene and placed on gloves. In this observation the surveyor was unable to cut the meat patty and the diced carrots with a knife and had to use moderate force to cut through the foods. The meal ticket for Resident #110 showed a Mechanical soft diet, finger foods and pleasure food (photographic evidence obtained). Review of the Speech assessment dated [DATE], which was completed by Staff D, Speech Language Pathologist (SLP), showed the following: Resident #110 has mild impairment between 25-50 percent with risk of aspiration on liquids. It further showed mild oral residue and may need meats ground or chopped with intermittent supervision. Resident #110 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecific dementia without behavioral disturbances, Alzheimer's and Anxiety. 2. In an observation conducted on 04/27/22 at 12:18 PM, Resident #51 was observed in her room with the lunch tray at the bedside. The meal ticket showed a Mechanical soft diet. The tray consisted of hamburger bun, round hamburger patty, and diced carrots with various sizes with some sizes larger than 2 inches. Closer observation also showed a grilled cheese sandwich with dry crusty bread that was hard to the touch (photographic evidence obtained). Record review showed that Resident #51 was admitted to the facility on [DATE] with diagnoses of anxiety disorder and Dementia. Review of the Speech assessment dated [DATE] which was completed by Staff D, Speech Language Pathologist (SLP) showed the following: Resident #51 has impaired cognition that can impact chewing skills. Patient can safely tolerate cut up meat, with diagnosis of dysphagia. In an interview conducted on 04/27/22 at 12:25 PM with Staff D, SLP, stated that the Mechanical soft diets in the facility are general and are modified as needed. The meats on a Mechanical Soft Diet, can be chopped, grounded, and may even be meat that is not chopped according to resident's preferences. Staff D reported that some residents may want to cut their meat themselves and did not think that the size of the meats provided in the aforementioned observations were a problem. When asked by surveyor as to the specific consistency of the mechanical soft diet she said, Dietary will be better at answering these questions. When asked again, Staff D then said that on the Mechanical soft diet the meats need to be with soft texture, and no raw carrots allowed. According to her, the size of the vegetable is not an issue in the Mechanical soft diet if they are soft. Surveyor stated that the carrots in the above observations were not easy to cut and a moderate force was used to slice through them. To that Staff D said that may be a problem. 3). Resident #34 was admitted to the facility on [DATE]. According to the residents most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, indicating 'cognitively intact'. The MDS documented that Resident #34 required 'supervision' for Activities of Daily Living (ADLs), including eating. Resident #34's diagnoses at the time of the assessment included: Hypertension; Diabetes mellitus; hyperlipidemia; Seizure disorder; Depression; Bipolar Disorder; Ulcer of esophagus without bleeding; GERD. The MDS documented that Resident #34 did not have any swallowing disorders and no oral/dental concerns. Resident #34's diet order included: LCS (Limited Concentrated Sweets), Mechanical Soft. Chopped Meat - 01/31/22 During an observation of lunch served to Resident #34 in the resident's room, on 04/25/22 at 12:24 PM, Resident #34 was served intact and large pieces of sausage and large pieces of potato. It was noted that the large pieces of potato were also cooked in a manner to have a rigid and hard texture on the outside of the potato. During an interview, on 04/28/22 at 11:42 AM with the Speech Language Pathologist (SLP), when asked about the meal being appropriate for the resident based on the order, the SLP stated that she would not be able to conclude because she would have had to see the resident eat, masticate and swallow the meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews; the facility failed to carry out a physician's order for blood testing for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia without behavioral disturbances, atrial fibrillation, and major depressive disorder. A 5 day Minimum Data Set with an assessment reference date of 11/17/21 revealed in Section C a Brief Interview for Mental Status of 0, which indicates the resident has severe cognitive impairment. A review of the physician's orders dated 04/01/22 reveals an order for Depakote DR (delayed-release) 125 milligrams (mg) sprinkle cap administer two by mouth three times daily. An additional order dated 04/01/22 reads Depakote level in one week, Thyroid profile all in one week along with FBS (fasting blood sugar). Further record review revealed there was no evidence the orders were completed. An interview was conducted with Staff F, the consultant pharmacist, and the Director of Nurses on 04/27/22 at 3:30 PM. They acknowledged the blood tests were never ordered and a new order was written for the blood to be drawn on 04/28/22.