Based on observations, interview and record review, the facility failed to treat residents in dignified manner during catheter care for 1 of 1 sampled resident observed for catheter care, Resident #35; during medication administration in the hallway for 1 of 25 sampled residents, Resident #249; and staff referring to residents who need assistance with dining as feeders. The findings included: Review of the facility's policy, titled, Dignity, with a revised date of February 2021, included in part the following: 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 feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 1. On 10/02/24 at 10:59 AM, an observation was conducted of catheter care for Resident #35 performed by Staff K, Certified Nursing Assistant (CNA). Staff K adjusted the bed, pulled the covers down, said to resident I am going to remove your diaper as she was removing the adult brief from the resident. Once the CNA was finished with the catheter care, she then had resident roll side to side to remove and replace the pad under resident. The CNA then proceeded to place a new adult brief under the resident, and as she did, she asked the resident to turn again so she could but the diaper on him. An interview was conducted on 10/02/24 at 11:19 AM with Staff K who stated she has worked at the facility for 4 months. When asked about referring to the adult brief as a diaper, she said that is what it is. During an interview conducted on 10/02/24 at 11:46 AM with Resident #35 who was asked how it made him feel that Staff K CNA had referred to his adult brief as a diaper during his catheter care, he said it is not very nice. 2. On 10/01/24 at 5:00 PM, an observation was made of Staff C, Licensed Practical Nurse (LPN), who was administering medication to Resident #249 in the hallway next to the med cart. An interview was conducted on 10/01/24 at 5:07 PM with Staff C who stated she has worked at the facility since February 2024. When asked if she normally administers medications to residents in hallway next to the med cart, she said 'normally yes'. Staff C said sometimes it is the resident's choice. If the resident is in the hallway and asks for their medications and they are due to be given, she will give it. When Staff C was asked about administering medication in the hallway to Resident #249, the LPN said it that is the resident's choice. During an interview conducted on 10/01/24 at 5:15 PM with Resident #249 who was asked about the nurse administering her the medication in the hallway, how it made her feel, she said I don't want to get anyone in trouble. When asked if requested the medications be given to her while she was in the hallway, the resident refused to answer anymore of the surveyor's questions. 3. An interview was conducted on 10/01/24 at 5:11 PM with Staff C, LPN, who when asked about a tube feeding for a resident, she said she hung the tube feeding one hour early, because they usually get the dinner trays on the floor around 5:00 PM and they have a lot of feeders. She was asked if referring to residents who need dining assistance as feeders is something she normally does, she said 'yes, they all do it. There is a lot of staff that don't speak English to well, so we need to speak to them very clear about which residents need to be fed, so we call them feeders, it is just common sense.' 4. During an observation of lunch being served to the residents in their rooms, on 09/30/24 at 12:40 PM, Staff B, RN/Unit Manager, was overheard by the surveyor calling to staff, Are you ready for a feeder, referring to Resident #201. Staff B then pulled a tray out of the cart containing the lunch trays and stated, she is a feeder, referring to Resident #199. When asked about referring to the residents as 'feeders' and labeling the residents, Staff B replied, If he's a feed, you have to stay in there with him (referring to #201). Staff B further stated that she was not aware of the facility's policy to not label residents in a manner such as referring to a resident as a 'feeder'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's policy, titled, Trauma-Informed and Culturally Competent Care, dated 05/19/23, included the following: Resident Care Planning 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety, and depression). Record review for Resident #70 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included: Malignant Neoplasm of Endometrium, Bipolar Disorder, Psychosis Not Due to a Substance or Known Physiological Condition, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of Section C of the MDS dated [DATE] revealed that Resident #70 had a BIMS score of 15, which indicated that she was cognitively intact. Review of section I revealed Resident #70 diagnosis included: Bipolar Disorder, Psychotic Disorder, Depression, PTSD, and anxiety disorder. Review of Resident #70's Care Plans dated 08/12/24 revealed there was no care plan developed to address PTSD, which would have included implementation of individualized interventions. An interview was conducted on 10/02/24 at 1:31 PM with Staff O, MDS coordinator, who stated she has been working at the facility for 15 years. She stated she uses the information from the resident assessments, notes, and physician orders to put together the resident's MDS and care plans. Staff O acknowledged that for Resident #70's care plan dated 08/22/24, her diagnoses were added including anxiety, psychosis, and depression along with individualized interventions, but the PTSD diagnosis was not used because she felt it was covered under those diagnosis. Staff O was unsure if there was anything under the MDS coding for PTSD. An interview was conducted on 10/02/24 at 4:59 PM with the Social Services Director (SSD), who stated she has been working at the facility for 15 years. She stated the resident's diagnoses are derived from the hospital documentation when the resident is transferred to the facility, and the physician would be the one to diagnose the resident with PTSD. The SSD stated during Resident #70's initial assessment, the resident was not assessed for PTSD and the resident did not show signs of any acute PTSD. She acknowledged not questioning Resident #70 about her PTSD since the resident had no change in mood and did not express any sign of PTSD. Based on observations, interviews and record review, the facility failed to implement care plans for 2 of 5 sampled residents reviewed for smoking, Residents #19, and #8; failed to implement care plans for 1 of 1 sampled resident reviewed with an urinary catheter, Resident #35; failed to implement care plans for 1 of 1 sampled resident reviewed with significant weight loss and receiving tube feedings, Resident #90; and failed to develop care plans for 1 of 1 sampled resident reviewed with a diagnosis of Post Traumatic Stress Disorder (PTSD), Resident #70. The findings included: 1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Fracture of Humerus Right Arm Subsequent Encounter for Fracture with Routine Healing, History of Falling, Anxiety and Muscle Weakness (Generalized). Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 05/09/34 documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating an intact cognitive response. Review of the Nursing Progress Note for Resident #8 dated 08/18/23 documented the following: Resident AAOX3 (Awake, alert, and oriented times 3). Spoke to MD (Medical Doctor) about resident decision not to smoke anymore and asked to discontinue Nicotine patch and Spiriva. OK given verbally by MD. Review of the Nursing Progress Note for Resident #8 dated 09/10/23 documented the following: Resident AAOX3; no distress noted. Administer medications as per order with fluid. Resident started smoking again. Care rendered by staff. All safety measures in place; will continue to monitor. Review of the Nursing Progress Note for Resident #8 dated 12/20/23 documented the following: Pt [patient] complained of pain in lung area after coming back from smoking, pain pills provided to pt as requested. Pt taught to keep HOB [head of bed] elevated for lung expansion and comfort. Thoracic X-ray ordered for pt. Pt left awake, watching television with HOB elevated, all safety and comfort measures maintained. Review of the Smoking Risk Form for Resident #8 dated 12/01/23 documented in part the following: D Frequency: morning, afternoon, and evening E Safety: 6. resident can light own cigarette - yes 8. plan of care is initiated to assure resident is safe while smoking - yes. Review of the Smoking Risk Form for Resident #8 dated 10/01/24 documented in part the following: D Frequency: morning and afternoon E Safety: 6. resident can light own cigarette - yes Resident need for adaptive equipment: 7c. supervision 8. plan of care is initiated to assure resident is safe while smoking - yes. On 09/30/24, review of the Care Plans for Resident #8 dated 12/04/24 with a focus on the resident chooses to smoke with a goal of the resident will remain free from injury was conducted. The interventions included: Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Resident may keep cigarette and smoking items in her possession. Cigarettes and lighter to be kept in a secure location. Smoking in designated area only. On 09/30/24 at 12:19 PM, an observation was made of Resident #8 with cigarettes, lighter in a Styrofoam bowl and vaping device on the overbed table. On 09/30/24 at 12:23 PM, an interview with Resident #8 was conducted who was asked if she was a smoker, she said, 'yes'. When asked if she has smoked since being admitted to the facility, she said, 'yes'. When asked if staff hold her cigarettes and lighter, she said, 'no, she holds them, and they know it.' When asked if staff supervise her while smoking, she said, 'they come in and out, its different staff all of the time.' On 10/01/24 at 10:17 AM, during a side-by-side observation with Staff B, Registered Nurse / Unit Manager (RN UM), she acknowledged the resident should not have the cigarettes, lighter and vape device at the bedside. Staff B took them and informed the resident she could not have those items at the bedside. On 10/01/24 at 10:30 AM, an interview was conducted with Staff B who was asked if residents are assessed for smoking, she said she does not do the smoking assessments, that would be administration. When asked how often the smoking assessments or evaluations are completed, she said she is not sure. When asked if a resident can have cigarettes, lighter and vape device at the bedside, she said no, it needs to be secured. An interview was conducted on 10/03/24 at 2:35 PM with Staff O, MDS coordinator, who stated she has worked at the facility for 15 years. When asked about care plans related to smoking, she stated she would not update smoking care plan unless the status changed regarding smoking. The smoking items, lighter and electronic cigarettes were not secured. 2. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cerebral Infarction, Type 2 Diabetes with Hyperglycemia, and Epilepsy. Review of the Quarterly MDS assessment for Resident #19 dated 08/29/24 revealed in Section C, a BIMS score of 13 indicating an intact cognitive response. Review of the Smoking Risk Form for Resident #19 dated 08/31/23 documented in part the following: D Frequency - evenings E Safety: 6. Can resident light own cigarette - no Resident need for adaptive equipment: 7a. Smoking apron 8. Plan of care is initiated to assure resident is safe while smoking - yes. Review of the Smoking Risk Form for Resident #19 dated 12/05/23 documented in part the following: D Frequency- morning, afternoon, and evenings E Safety: 6. Can resident light own cigarette - yes Resident need for adaptive equipment: 7a. Smoking apron 8. Plan of care is initiated to assure resident is safe while smoking - yes. Review of the Care Plan for Resident #19 dated 09/01/23 with focus on the resident chooses to smoke, documented the resident as: Non-compliant with smoking policy despite education. The goal was for the resident to remain free from smoking related injury. The interventions included: Cigarettes and lighter to be kept in a secure location. Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Smoking apron to be worn when smoking. Smoking in designated area only. Supervised smoking by staff member. An interview was conducted on 09/30/24 at 1:45 PM with Resident #19 who was asked how long she has smoked at the facility, and she said, 'years'. When asked about the covering (smoking apron) on her she said she, 'keeps it on the back of her wheelchair and puts it on herself when she comes out to smoke'. When asked if staff come out to supervise her smoking, she said, 'sometimes staff come out for a few minutes when they come out, but they do not come out every time'. When asked if she can light her own cigarettes, she said, 'sometimes she cannot, but most times she can.' When asked where her cigarettes and lighter are kept, she said, 'the nurse hold her cigarettes and lighter and give them to her when she asks then she will bring them back when she is done smoking.' On 10/02/24 at 1:15 PM, Resident #19 was observed on the smoking patio with smoking apron partially covering her and she lit her own cigarette, and no staff member was present. At approximately 1:22 PM, Staff N, Certified Nursing Assistant (CNA), came to smoking patio to observe the resident. An interview was conducted on 10/02/24 at 1:20 PM with Staff M, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 3-4 months. When asked about Resident #19, she said she was not aware the resident was an unsafe smoker until today. Staff M stated she holds the resident's cigarettes and lighter in the med [medication] cart. Staff M had come down this morning with the resident to smoking area and helped her with the smoking apron and with lighting a cigarette. There was another staff member on the smoking patio, and she was under the impression the staff member was assigned to the smoking patio to observe the residents. When the resident requested cigarettes to smoke around 1:10 PM on 10/02/24, Staff M gave the resident 2 cigarettes and the resident went downstairs, and she assumed the resident would be supervised by another staff member that she thought was assigned to the smoking patio. On 10/02/24 at 1:23 PM, a side-by-side observation with the Administrator was conducted of Resident #19 with smoking apron partially covering her and smoking a cigarette on the smoking patio. There was no risk assessment form since the 12/05/23 date, until after it was brought to their attention. 3. Record review for Resident #35 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Urinary Tract Infection (UTI), Acute Kidney Failure, Type 2 Diabetes Mellitus without Complications, Encounter for Fitting and Adjustment of Urinary Device, and Obstructive and Reflux Uropathy. Review of the MDS for Resident #35 dated 09/02/24 documented in Section C, a BIMS score of14 indicating an intact cognitive response. Review of the Physician's Orders for Resident #35 revealed an order dated 09/30/24 for Catheter / Foley: Catheter care every shift. every shift and as needed. Review of the Physician's Orders for Resident #35 revealed an order dated 09/26/24 for Eliquis Oral Tablet 5 MG (Apixaban) give 1 tablet by mouth two times a day for Atrial Fibrillation (Eliquis is a blood thinner). Review of the Care Plan for Resident #35 dated 09/05/24 and revised on 09/30/24 with a focus on the resident has an Indwelling Catheter r/t (related to) Obstructive Uropathy 16f/10cc documented the following: The goal was for the resident to be/remain free from catheter-related trauma through review date. The interventions included the following: The resident will show no s/sx [signs and symptoms] of Urinary infection through review date; Catheter: The resident has 16f/10cc. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks every shift. Enhanced Barrier Precautions: wear gown and gloves during assistance with dressing, bathing, transferring, hygiene, changing linens, changing briefs & toileting, and catheter care. Monitor and document intake and output as per facility policy. Monitor for s/sx of discomfort on urination and frequency. Monitor / document for pain / discomfort due to catheter. Monitor / record / report to MD [Medical Doctor] for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of progress notes for Resident #35 for 10/02/24 revealed no documentation of the nurse contacting physician to report bleeding or pain during catheter care. On 09/30/24 at 12:55 PM, an observation was made of Resident #35 with an indwelling urinary catheter drainage bag on side of bed covered with privacy cover. An interview was conducted on 10/02/24 at 8:58 AM with Resident #35 who was asked if he recently went to the hospital for pain with his indwelling catheter, he said, 'yes'. He said they changed the catheter in the hospital, and he returned to the facility with the new catheter in place. When asked if the staff have been performing catheter care since he returned, he said, 'yes, they come and put cream on it'. On 10/02/24 at 10:59 AM, an observation was conducted of catheter care for Resident # 35 performed by Staff K, Certified Nursing Assistant (CNA). During the catheter care while washing the tip of the penis around where the catheter was inserted, there was blood observed on the white washcloth. Staff K then proceeded to dry the resident with a dry bath towel, and he screamed out in pain. An interview was conducted on 10/02/24 at 11:19 AM with Staff K who stated she has worked at the facility for 4 months. When asked if she notified the nurse about Resident #35 having pain and bleeding during catheter care, she said 'they already knows this'. An interview was conducted on 10/02/24 at 11:24 AM with Staff L, Registered Nurse (RN), who was assigned to take care of Resident #35 and stated she has worked at the facility for 1 year. When asked about Resident #35 and having any pain or bleeding with catheter care, she said before he had a UTI and went out to the hospital recently and just came back last week. She said sometimes he has pain with catheter care, and he has pain medication, but they only give him pain medication if he asks for it. When asked if the resident has pain with catheter care, she said, 'yes sometimes'. 4. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Progressive Supranuclear Ophthalmoplegia [Steel-[NAME]-[NAME]] (a rare brain disease that affects walking, balance and eye movements and swallowing), Gastrostomy Status, Dysphagia, Crohn's Disease, and Parkinson's Disease. Review of the MDS assessment for Resident #90 dated 09/07/24 documented in Section C a BIMS score of 'could not be conducted due to the resident is rarely/never understood'. Review of the Physician's Orders for Resident #90 revealed an order dated 08/27/24 for Enteral Feed Order two times a day Give Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours [hrs]) Give H20 (water) Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/21/24 Review of the Physician's Orders for Resident #90 revealed an order dated 09/22/24 for Enteral Feed Order one time a day give Osmolite 1.5/1000ml @ @50ml/hour. Give H20 Flush/1000ml @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/26/24 Review of the Physician's Orders for Resident #90 revealed an order dated 09/27/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @31ml/hr. Start at 5pm and run until complete (~16hrs) Total kcal 1500, Total Pro 62.7gm. See additional H20 flush order. Total Kcal 1500,Total Pro 62.7, Total Fluid 1620ml -and was discontinued on 09/30/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/30/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @62ml/hr. Start at 5pm and run until complete *See additional H20 flush order. Total Kcal 1500, Total Pro 62.7, Total Fluid 1620ml. Review of the weights for Resident #90 revealed the following: On 08/27/24 at 10:25 AM, the resident weighed 92.0 Lbs (pounds) via Mechanical Lift. On 08/27/24 at 4:20 PM, the resident weighed 92.0 Lbs via Mechanical Lift. On 08/27/24 at 4:22 PM, the resident weighed 92.0 Lbs via Mechanical Lift. On 08/27/24 at 5:06PM, the resident weighed 92.0 Lbs via Mechanical Lift. On 09/05/24 at 9:54 AM, the resident weighed 82.0 Lbs via Standing. On 09/27/24 at 4:35 PM, the resident weighed 83.0 Lbs via Standing. In summary, this indicated form 08/27/24, to 09/05/27, the resident lost 10 Lbs which is a significant 10.87% Loss. On 10/01/24 at 10:15 AM, Resident #90 was weighed with the Staff J, Restorative Aide, the Director of Nursing and the surveyor present. The resident weighed 77.6 Lbs which indicated the resident has had a weight loss of 14.4 pounds from 08/27/24 to 10/01/24 which was a significant weight loss of 15.65%. Review of the Nutrition Risk Assessment for Resident #90 dated 08/26/24 included the following in part: Continuous feeding - Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours) give H20 Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total feeding - Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm, Free water 1762ml. Estimated Nutritional Needs (Kcal/kg): 42 x 35-40= 1470 - 1680; Protein: 42 x 1.2 - 1.3 = 50-55: MDS Triggers BMI <18.5 or >/= 24.9. Care plan resident will gain 1-21 lbs/month by nrd (next review date). Review of the Care Plan for Resident #90 dated 09/02/24 with a focus on the resident required tube feeding for nutritional support BMI [Body Mass Index] 16. Dx (Diagnosis) dysphagia. The goals were for the resident to tolerate tube feeding without complications such as: aspiration, infection, abdominal pain/distention, dehydration, diarrhea, constipation/fecal impaction, vomiting and the resident will gain at least 1-2 lbs monthly by next review date 12/11/24 . The interventions included: Monitor labs when available - report abnormal data to physician / provider promptly. Monitor tolerance of tube feeding. Monitor weight monthly / weekly. Provide tube feeding as ordered. Provide water flush as order. Review of the Nutrition / Dietary Note for Resident #90 dated 09/05/24 included the following: Resident's care plan meeting today with resident's [spouse], MDS nurse, Therapy director and this RD. Tube feeding regimen reviewed with resident's [spouse]. Resident has been tolerating tube feeding. [The spouse] is in agreement with poc [plan of care] regarding tube feeding at this time. Weight gain desired as [spouse] stated that resident had lost weight prior to admission. Current tube feeding will provide enough calories for gradual weight gain. F/U [follow up] for weekly weight x 3. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/09/24 included the following: Resident's weight on 09/05/24 was 82lbs. Admit weight recorded as 92lbs. Resident is NPO [nothing by mouth] on tube feeding which is providing adequate nutrition / hydrations. F/U with resident's [spouse] who stated she is definitely not 92. [The spouse] stated that she was 78 in the hospital and that he observed her being weighed in this facility on standing scale at 82lbs. 92 lbs may have been an error in recording the weight. Will request reweigh as gradual weight gain is desired. Current estimated needs = 37 x 35-40 = 1295-1480 calories/day, 37 x 1.2 -1.3 = 44-48 gm protein /day, 37 x 30-35 = 1110-1295 ml fluid. F/U for reweigh. Per nursing resident is tolerating tube feeding well. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/26/24 included the following: Resident's tube feeding to be adjusted. Recommend changing to Osmolite 1.5/1000ml @ 62ml/hour via G Tube. Start at 5pm and run until complete (~16 hrs) H2O flush/1000ml @ 31ml/hour via G tube with total of 500ml H20. Start at 5pm and run ~16 hrs. Tube feeding will provide 1500 kcal, 62.7 gm protein, 1262 free H20. Recommend H20 flush 120ml once daily via G tube. Total free water 1382ml Weight 82lbs. Tube feeding provides 40 kcal/kg, 1.6 gm/kg protein, Total free water 37ml/kg. F/U for tolerance/weight/changes. Adjust POC as needed. An interview was conducted on 10/01/24 at 12:12 PM with spouse of Resident #90 who stated the resident's normal body weight was 135 pounds and the last time she was weighed her normal body weight was in March. He said this disease is terrible and now she cannot swallow so she has to be on tube feeding. He said they had some kind of meeting when his wife first arrived at the facility just over a month ago. He expressed his concern over his wife's weight and does not want her to lose any more weight and hopes she can gain weight. He said during that meeting was the only time he talked to the dietician, and they told him they would adjust the tube feeding as they went along. He stated he was never told she had any weight loss since being in the facility, he was under the impression she would have gained weight, but nobody really talks to him or answers question when he asks. He said he comes to the facility just about every day and he sees the tube feeding bottle off and still has about 3 inches of tube feeding left in it and they throw it away and start a new bottle later. He feels she may not be getting all of the tube feeding she is supposed to for this reason. On 10/02/24 at 10:31 AM, an observation was made of Resident #90 sitting up in bed with bottle Osmolite 1.5 tube feeding below the 200 mark out of a 1,000-milliliter capacity bottle. The tube feeding was infusing via pump at 62 milliliters per hour. The tube feeding bottle was labeled with start date of 10/01/24 at 4:00 PM. An interview was conducted on 10/03/24 11:18 AM with the Registered Dietician (RD) who stated she has worked at the facility for 21 years and is full time since June 2024. When asked about residents who receive tube feeding, she said for a resident receiving tube feeding, she would generally not expect to see weight loss. She stated she rounds to spot check resident to make sure the tube feeding orders are followed as ordered. When asked about Resident #90 and weight loss, she said when the resident was admitted , she weighed 92 pound and on 09/05/24 she weighed 82 pounds. When asked if that was a significant weight loss, she said, 'yes it was 10%'. When asked what interventions were put in place, the RD stated that on 09/05/24 she did not change the tube feeding orders because it was meeting the resident needs even though she had a 10% weight loss but after her conversation with the husband on 09/09/24, he reported her weight from the hospital was 78 pounds and she was definitely not 92 pounds, and he had observed her being weighed on the standing scale at 82 pounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide the necessary care and services to ensure residents' abilities in activities of daily living (ADLs) do not diminish including transfer, ambulation and walking for 1 of 1 sampled resident reviewed for rehabilitation services, Resident #80. The findings included: Review of Resident #80's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's diagnoses included Difficulty in Walking, Metabolic Encephalopathy, Diabetes Mellitus, Muscle Weakness, and Acquired Absence of Right Leg Below Knee (BKA). Review of Resident #80's Minimum Data Set (MDS) end-of-skilled-services assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13 indicating the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff for putting on and taking off footwear and needed partial to moderate assistance with transfers and most activities of daily living (ADLs). Review of Resident #80's care plan initiated on 04/04/24 and revised on 06/18/24, documented, [resident name] requires assist with activities of daily living related to Dementia, Right BKA with prosthesis, .interventions included: RLE [right lower extremity] prosthesis to be worn when out of bed for transfers and activity participation . Chair / bed to chair transfer: Partial / moderate assistance required by two (2) Staff . On 10/01/24 at 12:15 PM, observation revealed Resident #80 in bed, and awake. An interview was conducted with the resident who stated that he walked three times wearing the right leg prosthesis, from the gymnasium to the 'birds area' before, but Medicare benefits ended. The resident added that for about a week or 10 days he had not been able to wear his right leg prosthesis because he had a sore behind his right knee (below the knee amputee extremity - BKA). Observation revealed Resident #80 lifted his below the knee amputee (BKA) right leg and showed the sore to the surveyor. Photographic Evidence Obtained. Observation revealed a round open skin area, approximately 0.2 x 0.2 centimeters (cm), with bright redness surrounding skin. The resident stated that he spoke with the nurse and believes the therapist came in and looked at the sore. The resident added the prosthesis is loose, and it hurts when he puts it on, it needs adjustment, and he was waiting on the therapist who was going to check on it and had not heard anything back. On 10/02/24 at 8:58 AM, observation revealed Resident # 80 wheeling himself down the hallway entering his room. Observation revealed the resident had his right leg prosthesis on. An interview was conducted with the resident who stated he had to use the prosthesis to go to eat but it hurts. On 10/02/24 at 9:00 AM, an interview was conducted with the Unit Manager who stated that Resident #80 goes to the dining room to eat. On 10/03/24 at 9:40 AM, an interview was conducted with the Director of Rehabilitation (DOR) who stated Resident #80's spoke with her regarding his prosthesis in the morning of 10/02/24 and she called [name], the prosthesis specialist, and was waiting on a call back from them. The DOR added the resident came to the therapy gym later, spoke with her and told her he felt his prosthesis was digging into his leg. The DOR stated the resident told her he had a sore and asked if he told the nurse and told her he did. The DOR was asked if she notified the nurse and replied she did not tell the nurse. The DOR stated resident was discharge from Physical Therapy (PT) on 07/16/24 and was currently receiving Occupational Therapy (OT) since 07/18/24. The DOR stated that on discharge from PT, Resident #80 was walking 150 feet, was not hurting then and the plan was to receive OT. The DOR was asked if the OT plan was to walk with the resident since he was able to walk on discharge and stated that OT will work with the resident transfer and functional skills. The DOR was asked why the resident was not referred to Restorative Care so he can continue to walk and stated because he could not receive both OT and Restorative Care at the same time. The DOR was apprised that the resident wanted to walk and had not done so for at least a week or two. The DOR was asked to provide Resident #80's PT discharge summary. On 10/03/24 at 10:06 AM, an interview was conducted with Staff X, Occupational Therapist (OT), who stated she had worked with Resident #80 for the most part. The OT stated Resident #80 was very motivated, the resident wanted to walk and did some functional mobility, like walked the resident from bed to the bathroom. Staff X stated the last therapy treatment was on 10/02/24. Staff X was asked if Resident #80 complaint of any issues with his right leg prosthesis and replied that a week ago the resident told her that something did not feel right with the prosthesis. Staff X was asked if she documented or notify the DOR of the resident's prosthesis concerns and replied she did not document it or tell the DOR. Review of Resident #80's PT Discharge summary dated [DATE] documented .Baseline - 04/09/24 -distance on feet: Zero (0) 07/16/24- distance on feet: 150 feet-supervision or touching assistance .patient progress and response to treatment: patient is slowly progression with current treatment interventions and plan of treatment. Patient's condition has potential to improve as a result of skilled rehab and patient's functional performance is progressing as a result of exercises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide care and services to 2 of 2 sampled residents reviewed for skin conditions, Residents #63 and #80, as evidenced by the physician orders not being followed for Resident #36 and an open would not being timely identified for Resident #80. The findings included: 1. Review of Resident #63's clinical record documented an admission on [DATE] and no readmissions. The resident's diagnoses included Chronic Systolic (Congestive) Heart Failure, Malignant Neoplasm of Prostate, and Muscle Weakness. Review of Resident #63's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The assessment documented under Functional Abilities and Goals that the resident needed substantial assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #63's care plan initiated on 09/24/24 and revised on 09/24/24, titled, Alteration in skin integrity - skin tear to left elbow. Interventions that included: .Administer treatments / medications as ordered and monitor for effectiveness . Review of Resident #63's active physician order dated 09/23/24 documented Cleanse skin tear to left elbow with N/S (normal saline) apply Xeroform, and cover with a silicone dressing every day shift. Review of Resident #63's September 2024 Treatment Administration Record (TAR) documented Cleanse skin tear to left elbow with N/S (normal saline) apply Xeroform, and cover with a silicone dressing every day shift, start date 09/24/24. The TAR was initialed as care administered by the nurses on 09/24/24, 09/25/24, 09/26/24, 09/27/24, 09/28/24 and 09/29/24. On 09/30/24 at 10:17 AM, observation revealed Resident #63 in his room sitting in a wheelchair accompanied by his Private Duty Aide (PDA). Further observation revealed the resident had a dressing on his left elbow dated 09/23/24. Resident # 63 was asked what happened to his left elbow and stated he bumps into things. The PDA stated the resident had fragile skin. On 09/30/24 at 10:23 AM, a side-by-side review of Resident #63 physician order for the left elbow was conducted with Staff U, Licensed Practical Nurse (LPN). Staff U stated the dressing to the left elbow skin tear was ordered to be done every day shift. On 09/30/24 at 10:25 AM, an interview was conducted with Staff Q, LPN who stated working in the facility for 2 years on and off and did not know who was responsible to change the resident's wound care dressing. On 09/30/24 at 10:27 AM, an interview was conducted with the Unit Manager (UM) who was apprised of Resident #63's left elbow dressing dated 09/23/24. On 09/30/24 at 10:29 AM, an interview was conducted with the dedicated Wound Care Nurse (WCN) who stated she works Monday through Friday but was off from last Thursday (09/26/24) until today (09/30/24). The WCN stated she was responsible for all resident's wound care including skin tears. The WCN was asked who was responsible to do the residents' wound care on the weekends and replied sometimes the facility designates someone (nurse) to do the wounds or the floor nurse do it. The WCN was asked how she knew about resident's skin tears and replied that residents with new wound, somebody will tell her, the CNA, the Unit Manager, and added she would look at the computer first for new residents and new orders. The WCN stated she was not aware of Resident #63 left elbow skin tear. The WCN was directed to see Resident #63's left elbow dressing date. On 09/30/24 at 10:39 AM, observation revealed the Unit Manager (UM) at Resident's #63 bedside. The UM stated she removed the dressing. A side-by-side observation of Resident #63 left elbow wound was conducted with the UM and the WCN. The wound was bleeding and had an approximately one (1) inch skin flab. The manager was asked to provide the wound measurements. On 10/02/24 at 10:19 AM, an interview was conducted with Staff O, MDS Coordinator, who stated the team is notified during daily morning meeting of resident's skin tears. Staff O stated that on 09/24/24, the resident sustained a left elbow skin tear and a care plan was initiated. On 10/02/24 at 10:30 AM, during an interview, the Unit Manager was asked to submit the notes for the wound care provided on 09/30/24 with the wound description and measurements. The Manger replied she documented the care on the TAR, did not documented the measurements. On 10/02/24 at 2:14 PM, an interview was conducted with Staff M, LPN, who had been working in the facility for three (3) months. Staff M stated her responsibilities included to pass medications, take vital sings, give enemas and change dressings. Staff M was asked if she had done dressing changes to Resident #63 and stated she did one dressing change to the leg in the past. Staff M was asked if she changed the resident's left elbow dressing and stated she did not. Staff M was apprised that she signed off the resident's left elbow treatment in the TAR three times (09/24/24, 09/25/24 and 09/28/24). Staff M stated she did not do the treatment and was under the impression the WCN done it. She added she won't touch the dressing, will leave to the WCN, and will wait to the end of the shift to sign it off. Staff M stated that she signed off at the end of the shift because she was under the impression that the WCN would do it. Staff M was asked if she coordinated, contacted the WCN or looked at the resident's dressing before she signed it off and stated she did not check with the WCN or check the resident's dressing. Staff M stated that when the WCN is not in the facility, they rotate one of the Registered Nurse to do the residents' wound care. On 10/03/24 at 9:43 AM, an interview was conducted with Staff R, RN, who stated he has been working in the facility for eight (8) months and his responsibilities were to give care (helping the residents), safety, administration of medications and assist with dining. Staff R stated he does not know who does the resident's wound care on the weekends. Staff R was asked what his initial on the TAR meant and replied when he signed the TAR, it means that he did the treatment. Staff R was apprised that on 09/30/24, Resident #63's left elbow dressing was dated 09/23/24 and that he signed off the resident's TAR on 09/27/24 as treatment done. Staff R stated he 'clicked it by mistake'. Staff R was asked if he checked with the WCN to see if the treatment was done and replied he did not. 2. Review of Resident #80's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's diagnoses included Difficulty in Walking, Metabolic Encephalopathy, Diabetes Mellitus, Muscle Weakness, and Acquired Absence of Right Leg Below Knee. Review of Resident #80's Minimum Data Set (MDS) end-of-skilled-services assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13 indicating no cognitive impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to put on and take off footwear. Review of Resident #80's care plan initiated on 04/04/24 and revised on 06/18/24 documented (resident name) requires assist with activities of daily living related to Dementia, Right BKA with prosthesis .interventions included: RLE (right lower extremity) prosthesis to be worn when out of bed for transfers and activity participation .Remove before bed, for skin checks and hygiene .Skin inspection: monitor for redness, open areas, scratches, cuts, bruises and immediately report changes to the nurse . Review of Resident #80's care plan initiated on 10/30/23 and revised on 06/18/24 documented (resident's name) is at risk for pressure injury development related to decrease in mobility, diagnosis of PVD (Peripheral Vascular Disease) and DM (Diabetes Mellitus), has right BKA (below knee amputation), interventions included: Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care . Review of Resident #80's care plan initiated on 02/12/24 and revised on 08/12/24 documented (resident's name) has Diabetes Mellitus, interventions include: .check all of body for breaks in skin and treat promptly as ordered by doctor . Review of Resident # 80's nursing progress notes dated 09/30/24 at 6:52 AM documented the resident was medicated for right leg pain. Further review of skilled nursing Flowsheet from 09/20/24 through 09/27/24 documented .skin was also observed; has no skin concerns . Review of nursing progress note dated 09/25/24 documented alert and oriented .received a shower . On 10/01/24 at 12:15 PM, observation revealed Resident #80 in bed uncovered wearing an adult brief. During an interview, Resident #80 stated that he used to walk three times wearing the right leg prosthesis, from the gymnasium to the 'birds area' before, but for about a week or 10 days he had not been able to because he had a sore behind his right knee (below the knee amputee extremity- BKA) where the prosthesis sits in. Observation revealed Resident #80 lifted his below the knee amputee right leg and showed the sore to the surveyor. Photographic Evidence Obtained. Observation revealed a round open skin area, approximately 0.2 x 0.2 centimeters (cm), with bright redness skin surrounding the open sore. The resident stated that he spoke with the nurse and believe the therapist came in and looked at the sore. The resident was unable to provide the staffs' name). The resident added the prosthesis was loose, it hurts when he put it on, stated, needs adjustment, and that he was waiting on the therapist who was going to check on it and had not heard anything back. On 10/02/24 at 8:58 AM, observation revealed Resident #80 wheeling himself down the hallway entering his room. Observation revealed the resident had his right leg prosthesis on. An interview was conducted with the resident at this time who stated he had to use the prosthesis to go to eat but it hurts. The resident was asked if the nurse had seen the open sore and stated no. On 10/02/24 at 9:00 AM, an interview was conducted with the Unit Manager who stated that Resident #80 goes to the dining room to eat. An observation was conducted on 10/02/24 at 9:25 AM of Resident #80 in his wheelchair by his room door speaking with a therapy staff about his prosthesis. Staff U, Licensed Practical Nurse (LPN), was actively preparing medication right next to Resident #80's room. After the therapy staff left, Resident #80 turned to Staff U and stated that she needed to see his leg wound and his prosthesis. Staff U stated she would look at it after she was done with the medications. As the surveyor passed by, Staff U turned to Resident #80 and stated, let me see your leg. On 10/03/24 at 8:50 AM, a side-by-side review of Resident # 80's Weekly Skin Evaluation dated 10/02/24 was conducted with the Unit Manager (UM). The evaluation documented skin observation - no new open areas noted . A joint interview was conducted with the UM and Staff U, LPN, who signed the skin evaluation. Staff U confirmed she checked Resident #80's skin on 10/02/24 and did not see any new open skin, and stated the resident had an ankle and back rash from before. The UM and Staff U were apprised that on 10/01/24, Resident #80 complained of pain behind his right BKA to the surveyor and showed an open skin area where the prosthesis sits. A side-by-side observation of Resident #80's behind the right BKA skin was conducted with the UM and Staff U. Staff U stated, It is open. During the observation, Resident #80 stated the wound was checked by the therapist on 10/02/24 and knew about the open wound. The resident added he did not want the sore to get bad and to have his knee cut off higher. Staff U was asked to measure the open wound and stated the measurements were 0.3 x 0.4 cm. On 10/03/24 at 9:40 AM, an interview was conducted with the Director of Rehabilitation (DOR) who stated Resident #80's spoke with her regarding his prosthesis in the morning of 10/02/24 and she called [Name] (Prosthesis Specialist), and was waiting on a call back from them. The DOR added the resident came to the therapy gym later, he spoke with her and told her he felt his prosthesis was digging into his leg. The DOR stated the resident told her he had a sore and asked if he told the nurse and told her he did. The DOR was asked if she notified the nurse and replied she did not tell the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to act on recommendations for an air mattress for a resident admitted with a Stage 4 pressure for 1 of 1 sampled resident reviewed for pressure ulcers, Resident #200. The findings included: Record review revealed Resident #200 was admitted to the facility on [DATE]. Review of the Nursing Progress note upon admission documented the resident as alert and oriented and that resident was bed-bound. Review of Resident #200's care plan for skin integrity, dated 09/25/24 with a revision date of 09/27/24, documented, Alteration in skin integrity-actual pressure injury present upon admission related to Recent Hospitalization Wound with vac to right knee. Stage 4 to sacrum and Stage 3 to right gluteal. The goals of the care plan were documented as: o Resident will be free of further alteration in skin integrity through next review date. With a target date of 12/24/24. o Stage 4 to sacrum will resolve and show no s/s [signs and symptoms] of infection through next review. With a target date of 12/24/24. o Stage 3 to right gluteal will show s/s of healing and no s/s of infection through next review. With a target date of 12/24/24. Interventions in the care plan included: o Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, and odor-notify physician of significant findings. o Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. o Remind/assist resident to frequently change position when in bed and/or chair. Review of Resident #200's care plan for Pressure Ulcer Development, initiated on 09/25/24, documented, At risk for pressure injury development related to Recent Hospitalization. The goal of the care plan was documented as, Resident will be free of pressure injury development through next review date.09/25/24 with a target date of 12/25/24. Interventions included: o Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. o Remind/assist resident to frequently change position when in bed and/or chair. Review of a Skin and Wound Evaluation, dated 09/26/24, completed by Staff D, Registered Nurse (RN), documented Resident #200 had a Stage 3 pressure injury to the right gluteus that was present on admission [DATE]) with treatment that included an air mattress. A second Skin and wound Evaluation, dated 09/26/24, completed by Staff D, RN, documented Resident #200 had a Stage 4 Pressure injury to the sacrum upon admission [DATE]) with treatment that included an air mattress. During an interview with Resident #200, on 09/30/24 at 1:32 PM, when asked about having any skin issues or impairments, Resident #200 replied, I am supposed to get a new mattress, I got sores on my butt and my doctor wants me on an air mattress. They found them bleeding a little in the hospital (prior to admission). During the interview, Resident #200 was noted to be on a standard mattress. During an observation of Resident #200, on 10/01/24 at 4:08 PM, Resident #200 was noted to be on a standard mattress. During an interview, on 10/01/24 at 10:40 AM, with Staff B (RN/Unit Manager / UM), when asked about the Skin and Wound Evaluations, Staff B confirmed that she did the evaluations and recommended an air mattress. When asked about the air mattress not being provided to the resident, Staff replied, I just forgot to order it. Staff B further stated that the facility had the air mattress on site and that the resident would be getting one prior to returning from a doctor's appointment later this day. During an interview with Resident #200, on 10/02/24 at 7:17 AM, Resident #200 was noted to be on a standard mattress. On 10/02/24 at 12:49 PM, Resident #200 was not in her bed and had left for an appointment, Staff B reported to the surveyor, I just told maintenance, and they should be bringing it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure adequate protection and assistance to residents who smoke with smoking aprons for 1 of 5 sampled residents reviewed for smoking, Resident #19; failed to provide adequate supervision for 5 of 5 sampled residents reviewed and observed for smoking, Residents #19, #8, #249, #46, and #197; failed to secure smoking materials for 1 of 5 sampled residents reviewed for smoking, Resident #8; and failed to ensure the environment remained as free of hazards as possible for 1 of 1 supply room on the second floor. The findings included: Review of the facility's policy, titled, Smoking Policy - Residents, with a revised date of October 2023, included, in part, the following: This facility has established and maintains safe resident smoking practices. 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking in not allowed inside the facility under any circumstances. 3. Electronic cigarettes and smokeless tobacco are permitted in designated areas only. 5. Metal containers with self-closing covers are available in smoking areas. 6. Ashtrays are emptied into designated receptacles. 7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. Current level of tobacco consumption b. Method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etc.) c. Desire to quit smoking d. Ability to smoke safely with or without supervision (per Safe Smoking Evaluation) 8. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation 9. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. 10. Any smoking-related privileges, restrictions and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 11. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 12. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 13. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. 14. Residents are not permitted to give smoking items to other residents. Review of the manufacturer's instructions for the Smoker's Apron with no date included, in part, the following: Application for Instructions: 1) Place the apron over the resident and attach the neck strap to the apron by engaging the hook and loop located on the strap and at the top of the apron. 2) Adjust the strap until the apron reaches the neckline 3) To protect cigarettes and ashes from falling between resident and their wheelchair, wrap the side straps around the wheelchair frame and engage the hook and loop under the apron. Warning: This apron is not a substitute for proper supervision. Patients or residents should always be closely supervised while smoking. 1. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cerebral Infarction, Type 2 Diabetes, and Epilepsy Unspecified Intractable without Status Epilepticus. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #19 dated 08/29/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 13 indicating an intact cognitive response. Review of the Annual MDS assessment for Resident #19 dated 05/29/24 revealed in Section J for tobacco use, is 'yes'. Review of the Smoking Risk Form for Resident #19 dated 12/05/23 documented the resident smokes 2-5 times per day and likes to smoke in the morning, afternoon and evening. She can light her own cigarette and needs adaptive equipment: smoking apron. There were no other Smoking Risk forms completed until surveyor intervention. Review of the Smoking Risk Form for Resident #19 dated 10/01/24 documented the resident smokes 1-2 times per day in the morning and afternoon. She can light her own cigarette. She needs adaptive equipment to include a smoking apron and supervision. Record review for Resident #19 from 12/06/23 to 09/30/24 revealed no Smoking Risk Form. This indicated the resident was not re-evaluated quarterly for safe smoking. Review of the Alteration in Skin Integrity documentation for Resident #19 dated 05/20/24 documented in part the following: Incident description: Resident was observed with a new cigarette burn on her upper left thigh in the healing process. Per resident the cigarette burn happened over a week ago. Immediate action taken: wound was clean and dry, healing observed. The resident was not taken to the hospital. Predisposing Physiological Factors: none of the above. Predisposing Situation Factors: none of the above. People notified: Physician and Family member/responsible family member. Review of the care plan for Resident #19 dated 09/01/23 with a focus on the resident chooses to smoke. Non-compliant with smoking policy despite education. The goal was for the resident to remain free from smoking related injury. The interventions included the following: Cigarettes and lighter to be kept in a secure location. Instruct resident/family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Smoking apron to be worn when smoking. Smoking in designated area only. Supervised smoking by staff member. On 09/30/24 at 1:40 PM, an observation was made of Resident #19 and Resident #249 smoking on the smoking patio. Resident #19 had a smoking apron that was not secured, laying across her and only partially covering her chest and lap. Resident #19's ashes from her cigarette were dropping unto the ground. She was positioned in her wheelchair away from the ashtray on a table and it was out of her reach. When Resident #19 finished with her cigarette, she placed it in the red smoking post. An interview was conducted on 09/30/24 at 1:45 PM with Resident #19 who was asked how long she has smoked at the facility, and she said, 'years'. When asked about the covering on her (smoking apron), she said she keeps it on the back of her wheelchair and puts it on herself when she comes out to smoke. When asked if staff come out to supervise her smoking, she said sometimes staff come out for a few minutes but not every time. When asked if she can light her own cigarettes, she said sometimes she cannot, but most times she can. When asked where her cigarettes and lighter are kept, she said the nurse holds her cigarettes and lighter and gives them to her when she asked for them, then she will bring them back when she is done smoking. On 10/02/24 at 1:15 PM, an observation was made of Resident #19 on the smoking patio with a smoking apron not secured around her neck and was partially covering her chest and lap as she lit her own cigarette. No staff member was present. At approximately 1:22 PM, Staff N, Certified Nursing Assistant (CNA), came to smoking patio to supervise the resident. An interview was conducted on 10/02/24 at 1:20 PM with Staff M, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 3-4 months. When asked about the resident, she said she was not aware the resident was an unsafe smoker until today. The LPN stated she hold the resident's cigarettes and lighter in the med cart. The LPN stated she came down this morning with the resident to smoking area and helped her with the smoking apron and with lighting a cigarette. There was another staff member on the smoking patio, and she was under the impression the staff member was assigned to the smoking patio to observe the residents. She stated when the resident requested cigarettes to smoke around 1:10 PM on 10/02/24, she gave the resident 2 cigarettes and the resident went downstairs, and she assumed she would be supervised by another staff member she thought was assigned to the smoking patio. An interview was conducted on 10/02/24 at 1:23 PM with administrator who did side-by-side observation of resident with smoking apron partially covering her and smoking a cigarette on the smoking patio. 2. Record review for Resident #249 revealed the resident was admitted to the facility on [DATE] with diagnoses including in part the following: Thyrotoxicosis with Diffuse Goiter Without Thyrotoxic Crisis or Storm, Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Unsteadiness on Feet, Muscle Weakness, and Parkinson's Disease Without Dyskinesia. Review of the Social Service Evaluation for Resident #249 dated 09/25/24 documented a BIMS score of 9 indicating moderately impaired cognition. Review of Smoking Risk Form for Resident #249 dated 09/30/24 documented the resident has a cognitive loss, cannot light own cigarette, needs supervision, and other listed as needs assist to light cigarette / stay with. Review of the Care Plan for Resident #249 dated 09/30/24 was a care plan with a focus on the residents' choices to smoke. The goal was for the resident to remain free from smoking related injury. The interventions included: Cigarettes and lighter to be kept in a secure location. Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Needs assist to light cigarette. Smoking in designated area only. Supervised smoking by staff member On 09/30/24 1:40 PM, an observation was conducted of Resident #249 smoking on smoking patio with Resident #19 unsupervised. Resident #249 was using the covered ashtray with the cover off. There were cigarette butts on the patio floor. During an interview conducted on 09/30/24 at 1:40 PM with Resident #249 who was asked how long she has been smoking at the facility, she said since she got here about a week ago. When asked who holds her cigarettes and lighter, she said she usually gets cigarettes from some of the other residents when she comes outside on the smoking patio to smoke. When asked if any staff supervise them or come out to the patio when she is smoking, she said sometimes they come out to see them smoking but they do not stay. 3. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Unspecified Fracture of Humerus, History of Falling, Anxiety and Muscle Weakness (Generalized). Review of the annual MDS assessment for Resident #8 dated 05/09/24 documented in Section J tobacco use, documented 'no'. Review of the MDS assessment for Resident #8 dated 08/09/24 documented in Section C, a Brief interview of Mental Status score of 15, indicating an intact cognitive response. Review of the Smoking Risk Form for Resident #8 dated 12/01/23 documented the resident smokes 2-5 times per day in the morning, afternoon and evening. The Resident can light her won cigarette. No adaptive equipment needed including supervision. Review of the Smoking Risk Form for Resident #8 dated 10/01/24 documented the resident smokes 1-2 times per day in the morning and afternoon. Resident can light her won cigarette. Need for adaptive equipment documented supervision. Record review from 12/02/23 to 09/30/24 for Resident #8 revealed no Smoking Risk Form was completed. Review of the Care Plan for Resident #8 dated 12/04/23 with a focus on the resident chooses to smoke. The goal was for the resident to remain free from smoking related injury. Instruct resident / family on smoking policy. Intervene promptly when smoking in an unsafe manner. Monitor for non-compliance with smoking policy. Smoking in designated area only. Supervised smoking by staff member On 09/30/24 at 12:19 PM, an observation was made of Resident #8 sitting up in bed with electronic cigarette, regular cigarettes and lighter on overbed table. Photographic Evidence Obtained. On 10/01/24 at 10:17 AM, a side-by-side observation was made with Staff B, Registered Nurse / Unit Manager (RN/UM), who acknowledged the resident should not have the cigarettes, lighter and electronic cigarette at the bedside and took them. The RN/UM informed the resident she could not have those items at the bedside. An interview was conducted on 09/30/24 at 12:23 PM with Resident #8 who was asked if she was a smoker, who responded 'yes'. When asked if she has always smoked since being a resident at the facility, she said yes. When asked if staff hold her cigarettes and lighter, she said no, she holds them, and they know it. When asked if staff supervises her while smoking, she said they come in and out, but nobody stays with them. She said it is different staff all of the time. An interview was conducted on 10/01/24 at 10:30 AM with Staff B who was asked if residents are assessed for smoking. She said she does not do the smoking assessments, that would be administration. When asked how often the smoking assessments or evaluations are completed, she said she is not sure. When asked if a resident can have cigarettes, lighter and electric cigarette at the bedside, she said no, it needs to be secured. An interview was conducted on 10/03/24 at 2:35 PM with Staff O, RN / Minimum Data Set Coordinator who stated she has worked at the facility for 15 years. When asked about smoking care plans being updated, she said she would not update smoking care plans for any resident unless the smoking status changed for the resident. 4. Record review revealed Resident #46 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a Quarterly MDS, dated [DATE], revealed Resident #46 had a BIMS score of 15, indicating the resident was cognitively intact. The MDS documented the resident ambulated independently via manual wheelchair and required minimal assistance for bed mobility and transfer. Resident #46's diagnoses at the time of the assessment included Coronary Artery Disease, Hypertension, Peripheral Vascular Disease, Muscle weakness, and History of falling, Resident #46's care plan for smoking, initiated on 07/12/23, documented, Resident chooses to smoke / has been evaluated to be safe and knows to keep smoking materials secure. The goal of the care plan was documented as Resident will remain free from smoking related injury. Date Initiated: 07/12/2023. Revision on: 04/02/2024. Target Date: 12/11/2024. Interventions in the care plan included: o Instruct resident/family on smoking policy o Smoking in designated area only Date Initiated: 07/12/2023. On 09/30/24 at 10:06 AM, two residents, including Resident #46, were observed in the designated smoking area. It was noted that there were no staff members on the patio to provide supervision for the residents. On 09/30/24 at 10:22 AM, the MDS Coordinator arrived at the smoking patio. During an interview, on 09/30/24 at 11:04 PM with the MDS Coordinator, when asked about providing supervision to residents while smoking, the MDS Coordinator replied, Normally there is someone there to supervise them. The Administrator was supposed to go with them this morning. On 09/30/24 at 11:51 AM, Resident #46 was observed going to the smoking patio and smoking independently. It was noted that there were no staff to provide supervision while Resident #46 was smoking. On 10/01/24, at 6:45 AM, Resident #46 was observed going to the smoking patio and smoking independently. It was noted that there were no staff to provide supervision while Resident #46 was smoking. On 10/02/24, at 6:30 AM, Resident #46 was observed on the smoking patio and smoking independently. It was noted that there were no staff to provide supervision while Resident #46 was smoking. 5. Record review revealed Resident #197 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, a Medicare 5-day MDS, dated [DATE], revealed Resident #197 had a BIMS score of 14, indicating an intact cognitively response. The assessment documented that Resident #197 required partial / moderate assist for bed mobility and transfer and ambulated independently with use of a manual wheelchair (w/c). [The resident was observed walking behind w/c on multiple occasions during the survey.] Resident #197's diagnoses at the time of the assessment included: Hypertension, Depression, and Chronic lung disease. Resident #197's care plan for smoking, imitated on 09/20/24 with a revision date of 10/01/24, documented, Resident chooses to smoke. The goal of the care plan was documented as, Resident will remain free from smoking related injury, dated 09/20/24 with a target date of 10/02/24. Interventions of the care plan included: o Cigarettes and lighter to be kept in a secure location o Instruct resident/family on smoking policy o Smoking in designated area only. Review of the Smoking Risk Form, dated 09/12/24, and second form dated 09/30/24, indicated: No cognitive loss, No visual deficit, and No safety concerns. On 09/30/24 10:06 AM, two residents, including Resident #197, were observed in the designated smoking area. It was noted that there were no staff on the patio to provide supervision for the residents. On 09/30/24 at 10:22 AM, the MDS Coordinator arrived at the smoking patio. During an interview, on 09/30/24 at 11:04 PM with the MDS Coordinator, when asked about providing supervision to residents while smoking, the MDS Coordinator replied, Normally there is someone there to supervise them. The Administrator was supposed to go with them this morning. During an interview, on 10/01/24 at 12:46 PM, when asked about smoking without staff supervision, Resident #197 stated that there is normally no supervision. Resident #197 further stated, I keep them (cigarettes) in the pocket of my wheelchair. My daughter will bring me in a pack or two and I keep them with me. The pocket is good for keeping them. On 10/02/24 at 9:12 AM, Resident #197 was observed walking behind a wheelchair to the elevator and did not stop at nurse's station on the second floor for smoking supplies (cigarettes and lighter). On 10/02/24 at 9:15 AM, Resident #197 was observed on the smoking patio smoking independently. On 10/02/24 at 12:52 PM, Resident #197 was observed walking behind a wheelchair to the elevator and did not stop at nurse's station on the second floor for smoking supplies (cigarettes and lighter). On 10/03/24 at 10:00 AM, Resident #197 was observed on the smoking patio with Resident #19. Resident #197 was observed providing a cigarette and lighter to Resident #19 with no staff intervention. 6. On 09/30/24 at 10:00 AM, an observation was made of the supply room on the second floor across from the nursing station The supply room was unlocked, and no staff were present inside. Inside the supply room, there were 19 razors. An interview was conducted on 09/30/24 at 10:05 AM with Staff B, RN/UM, who was asked about the supply room. She said normally it will automatically lock when the door shuts. She acknowledged that the supply room was unlocked and unattended with 19 razor blades.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain physician orders for catheter care, provide catheter care, and report complications associated with catheter care and failed to ensure adequate hand hygiene for 1 of 1 sampled resident observed for urinary catheter care, Resident #35. The findings included: Review of the facility's policy, titled, Catheter Care, Urinary, with a revised date of August 2022, included, in part, the following: The purpose of this procedure is to prevent urinary catheter -associated complications, including urinary tract infections. Complications 1. Observe resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately. a. If the resident indicated that his or her bladder is full or that he or she needs to void (urinate). b. If urine has an unusual appearance (i.e., color, blood, etc.). c. Complains of burning, tenderness, or pain in the urethral area; or d. If signs and symptoms of urinary tract infection or urinary retention occur. Review of the facility's policy, titled, Handwashing/Hand Hygiene, with a published date of 12/29/22 included, in part, the following: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff to use to encourage compliance with hand hygiene policies. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Procedure Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down and folding it into the first glove. 5. Perform hand hygiene. Record review for Resident #35 revealed the resident was originally admitted to the facility on [DATE], transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident's diagnoses included in part the following: Urinary Tract Infection Site not Specified, Acute Kidney Failure, Type 2 Diabetes Mellitus without Complications, Encounter for Fitting and Adjustment of Urinary Device, and Obstructive and Reflux Uropathy Unspecified. Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 09/02/24 documented the resident had a Brief Interview of Mental Status (BIMS) score of 14 indicating an intact cognitive response. Review of the Physician's Orders for Resident #35 from 09/26/24 to 09/29/24 revealed no orders for urinary catheter care. Review of the Physician's orders for Resident #35 revealed an order dated 09/30/24 for Catheter/ Foley: Catheter care every shift. every shift and as needed. Review of the Physician's orders for Resident #35 revealed an order dated 09/26/24 for Eliquis (to prevent a blood clot from forming) Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Atrial Fibrillation. Review of the 3008 form from the hospital dated 09/26/24 documented in Section E, Medical Condition, as Complicated UTI [Urinary Tract Infection]. Section P, Patient Health Status, had Foley catheter checked. The Treatment Administration Record (TAR) for Resident #35 from 09/26/24 to 09/29/24 revealed no documentation of catheter care. Review of the Care Plan for Resident #35 dated 09/05/24 documented a focus on the resident has an Indwelling Catheter r/t [related to] Obstructive Uropathy 16f/10cc. The goals were for the resident to be / remain free from catheter-related trauma and for the resident to show no s/sx [signs/symptoms] of Urinary infection through review date. The interventions included in part the following: Monitor / document for pain / discomfort due to catheter. Monitor / record / report to MD [Medical Doctor] for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating. Review of progress notes for Resident #35 for 10/02/24 revealed no documentation of the nurse contacting physician to report bleeding or pain during catheter care. On 09/30/24 at 12:55 PM, an observation was made of Resident # 35 with an indwelling urinary catheter drainage bag on the side of bed covered with a privacy cover. On 10/02/24 at 10:59 AM, an observation was conducted of catheter care for Resident #35 performed by Staff K, Certified Nursing Assistant (CNA). Staff K gathered supplies, donned appropriate PPE including gown, mask, washed hands and applied and gloves. She adjusted the privacy curtain, touched the bed control to adjust the bed, pulled the covers down, removed brief and said to resident I am going to remove your diaper. The resident asked if the staff was going to put medicine inside, she said no. She added soap to water and washed the resident with soapy washcloth twice moving from tip of penis down tubing away from resident and around meatus of penis. Blood was noted, and the CNA then used a washcloth with just water to wipe tubing and meatus. She removed her gloves, did not perform hand hygiene, and put new gloves on. The resident asked if she was going to put cream on, and she said she was going to dry him. She then proceeded to dry the resident with a dry bath towel, removed her gloves, did not perform hand hygiene, and applied new gloves. She then used wipes to clean the resident's fold under the abdomen and creases on each side of the groin. The resident screamed in pain. She removed her gloves, did no hand hygiene, applied new gloves, and applied cream to abdominal fold and creases next to groin. She then had resident roll side-to-side to remove and replace the pad under the resident. The CNA removed her gloves, did no hand hygiene, had the resident roll side-to-side to place a clean brief on him. She gathered all the garbage into a bag, placed in trash, removed her gloves, did no hand hygiene, applied gloves, pulled the covers over resident, and adjusted the bed. The CNA then removed her gloves and washed her hands. In summary Staff K changed her gloves 5 times during the procedure without performing hand hygiene. When asked how often she checks the drainage bag, she said every 2 hours. An interview was conducted on 10/02/24 at 8:58 AM with Resident #35 who was asked if he recently went to the hospital for pain with his indwelling catheter. He said yes. He said they changed the catheter in the hospital, and he returned to the facility with the new catheter in place. When asked if the staff have been performing catheter care since he returned, he said yes, they come and put cream on it. An interview was conducted on 10/02/24 at 11:19 AM with Staff K, CNA, who stated she has worked at the facility for 4 months. When asked if she notified the nurse about Resident #35 having pain and bleeding during catheter care, she said they already know this. When asked about hand hygiene during glove changes, she said sometimes she uses hand sanitizer, but she could not find any today. An interview was conducted on 10/02/24 at 11:24 AM with Staff L, Registered Nurse (RN), who was assigned to take care of Resident #35 who stated she has worked at the facility for 1 year. When asked about Resident #35 and having any pain or bleeding with catheter care, she said, 'before he had a UTI and went out to the hospital recently and just came back last week'. She said, 'sometimes he has pain with catheter care, and he has pain medication, but they only give him pain medication if he asks for it'. When asked if the resident has pain with catheter care, she said, 'yes sometimes'. When asked how often urinary catheter care is performed, she said, 'every shift'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a resident receiving enteral feeding (tube feeding) received appropriate care and services to prevent complications for 1 of 2 sampled residents reviewed for tube feeding with significant weight loss not addressed in a timely manner, Resident #90; and for 1 of 2 sampled residents reviewed for tube feeding to ensure residents are receiving tube feeding in a manner to prevent complications, Resident #199. The findings included: Review of the facility's policy, titled, Nutrition Support: Enteral Feed, with a date of 11/10/22 included in part the following: Policy: To provide appropriate nutritional care to all patients who require enteral nutrition support. Procedure: Indication for Enteral Nutrition (EN) Enteral feeding is generally indicated for patients who are unable to meet their nutrient requirements orally and have a functioning gastrointestinal tract. Initiation of Enteral Nutrition Patients who are at high nutrition risk or severely malnourished should be advanced to goal as quickly as tolerated over 24-48 hours while monitoring for refeeding syndrome. (efforts to provide >80% of estimated or calculated goal energy and protein within 48-72 hours should be made to achieve the clinical benefit of EN over the first week). Nurses: c) Administer enteral feeding as per order d) Minimize or avoid holding feedings e) Document intake and output as per MD order as applicable. Document if feeding held, reason for holding and rate adjustment. Complete feeding as applicable. f) Ensure head of bed is elevated at least 30 to 45 degrees, unless contraindicated. Dieticians: a) Assess nutritional status and nutritional needs of all patients on enteral nutrition support, as per Evidence Based Nutrition Care Practice Guidelines (Aspen/Academy of Nutrition and Dietetics). The nutrition assessment will include an estimation of calories, protein, and free water provided through the enteral feeding. The RD (Registered Dietician) will compare these to the estimated needs to ensure nutrient needs are met utilizing Aspen method of documentation: actual feeding provided via kg. (When calculating free water, include water provided through formula and through free water flush.) Recommend enteral feeding and fluid flush adjustments as needed to meet the resident's estimate needs adequately. b) Make recommendations as to formula selection, administration, rate, free water flushes, monitoring, and intolerance issues for optimal outcomes. c) The dietician will review the written physician order to ensure that it meets requirement (or use the Enteral Feeding Form/EMR process). Estimating Nutritional Needs Nutritional needs are dependent on the patient's current medical status, presence of inflammation, mechanical ventilation, wounds, weight, age and gender among many other factors. Ideally caloric needs should be estimated using indirect calorimetry. Mifflin-St Jeor (MSJ) can be used in estimating caloric needs. Otherwise, a good starting point for estimating caloric needs can be as follows: For a malnourished, underweight individual (BMI <18.5 to <30): 25-30 kcal/kg/day protein. Review of the facility's policy, titled, Policy Interdisciplinary Management and Prevention of Significant Weight Loss Of Nursing Facility Residents, with a revised date of 11/01/22, included in part the following: Policy: There will be a systemic an interdisciplinary approach to monitoring resident weights in the facility. The facility will develop a standardized process in the management and prevention of unplanned significant weight loss of Nursing Facility residents. Residents who lose weight will be identified and managed in a timely manner. Purpose: The purpose is to provide guidelines for detection of early unplanned weight loss. This includes communication and appropriate action by the interdisciplinary team to maintain acceptable parameters of nutritional status of nursing facility residents. For the purpose of this policy the early unplanned weight loss is defined as 5 pounds in 30 days. Procedure: The nursing staff will: weigh all new admissions and readmissions upon admission and the day after if necessary. Weights ae then taken weekly x 4 weeks (one month) and [NAME] monthly unless the physician order states otherwise. All heights and weights are recorded in the Electronic Medical Records (EMR) per facility policy. Weight discrepancy: a) Reweigh residents with significant weight discrepancies within 24 hours, if needed reweigh the following: Residents weighing ,/+ to 100 pounds - if the weight variance ins +/- >3 pounds weight variance from the previous weight, the resident will be reweighed within 24 hours. As applicable in the EMR, strikeout the incorrect weight. 2. The Clinical Dietician will: If a discrepancy still exists and the change is unplanned or undesirable, place the resident on weekly weights or more often as ordered by physician. The physician will be notified of any weekly or monthly significant weight changes, or as needed. The dietician will be responsible for reviewing all monthly weights. Residents who have a weight loss of >3% or insidious weight change should be seen by the RD by the 9th of each month. Monitor all of the interventions for efficacy and feasibility. Care Plans will be under continuous revisions to meet resident's needs with goal of achieving a desired outcome. A) Calculate percentage of resident's weight loss. B) Monitor appropriateness of the diet prescription. I) Coordinate with the interdisciplinary clinical team/other disciplines (IDT) for a Focus Meeting to discuss significant weight loss and findings J) Modify and/or change current interventions. K) Monitor resident's progress and document weekly or sooner in the medical record until weight status resolve. Significant Weight Loss For the purposes of this policy, the facility considers significant unplanned weight loss a Significant Change which would require IDT Meeting be held to discuss the reason(s) and to review and/or modify the plan of care. Suggested parameters as per Regulatory Standards for evaluating significance of unplanned and undesired weight loss are: 1 month 5% Greater than 5% Appendix CMS Definitions: Avoidable means that the resident did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: evaluate the resident's clinical condition and nutritional risk factors; define and implement interventions that are consistent with resident needs, resident goals and recognized standard of practice; monitor and evaluate the impact of the interventions/ or revise the interventions as appropriate. ' 1. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following Progressive Supranuclear Ophthalmoplegia [Steel-[NAME]-[NAME]] (a rare brain disease that affects walking, balance and eye movements and swallowing), Gastrostomy Status, Dysphagia, Crohn's Disease, and Parkinson's Disease. Review of the Minimum Data Set (MDS) assessment for Resident #90 dated 09/07/24 documented in Section C, a Brief Interview of Mental Status (BIMS) score could not be conducted due to the resident is rarely / never understood. Review of the Physician's Orders for Resident #90 revealed an order dated 08/27/24 for Enteral Feed Order two times a day Give Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours [hrs]) Give H20 (water) Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/21/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/22/24 for Enteral Feed Order one time a day give Osmolite 1.5/1000ml @ @50ml/hour. Give H20 Flush/1000ml @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm and was discontinued on 09/26/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/27/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @31ml/hr. Start at 5pm and run until complete (~16hrs) Total kcal 1500, Total Pro 62.7gm. See additional H20 flush order. Total Kcal 1500, Total Pro 62.7, Total Fluid 1620ml - and was discontinued on 09/30/24. Review of the Physician's Orders for Resident #90 revealed an order dated 09/30/24 for Enteral Feed Order one time a day via Gtube give Osmolite 1.5/1000ml @62ml/hr. give H20 flush/500ml @62ml/hr. Start at 5pm and run until complete *See additional H20 flush order. Total Kcal 1500, Total Pro 62.7, Total Fluid 1620ml. Review of the weights for Resident #90 revealed the following: On 08/27/24 at 10:25 AM, the resident weighed 92.0 # (pounds) via Mechanical Lift. On 09/05/24 at 9:54 AM, the resident weighed 82.0 # via Standing. On 09/27/24 at 4:35 PM, the resident weighed 83.0 # via Standing. In summary, this indicated from 08/27/24 to 09/05/27, the resident lost 10#, which is a significant weight loss of 10.87%. On 10/01/24 at 10:15 AM, Resident #90 was weighed by Staff J, Restorative Aide, with the Director of Nursing and the surveyor present, and the resident weighed 77.6 pounds. If initial weight of 92 pounds is accurate, this would have indicated the resident had a weight loss of 14.4 pounds from 08/27/24 to 10/01/24 and was a significant weight loss of 15.65%. If initial weight was 82 pounds, as noted by the spouse and RD (Registered Dietician), this would have indicated the resident had a weight loss of 4.4 pounds , which is a weight loss of 5.3%. Review of the Nutrition Risk Assessment for Resident #90 dated 08/26/24 included the following in part: Continuous feeding - Osmolite 1.5 (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hours) give H20 Flush (1000ml) @50ml/hour. Start at 4pm and run until complete (~20 hrs). Total feeding - Total fluid 2000ml, Total calories 1500, Total protein 62.7 gm, Free water 1762ml. Estimated Nutritional Needs (Kcal/kg): 42 x 35-40= 1470 - 1680; Protein: 42 x 1.2 - 1.3 = 50-55: MDS Triggers BMI <18.5 or >/= 24.9. Care plan resident will gain 1-21 lbs/month by nrd (next review date). Review of the Nutrition / Dietary Note for Resident #90 dated 09/05/24 included the following: Resident's care plan meeting today with resident's husband, MDS nurse, Therapy director and this RD. Tube feeding regimen reviewed with resident's husband. Resident has been tolerating tube feeding. He is in agreement with poc [plan of care] regarding tube feeding at this time. Weight gain desired as husband stated that the resident has lost weight prior to admission. Current tube feeding will provide enough calories for gradual weight gain. F/U [follow-up] for weekly weight x 3. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/09/24 included the following: Resident's weight on 9/5/24 was 82lbs. Admit weight recorded as 92lbs. Resident is NPO on tube feeding which is providing adequate nutrition / hydrations. F/U with resident's husband who stated she is definitely not 92. He stated that she was 78 in the hospital and that he observed her being weighed in this facility on standing scale at 82lbs. 92 lbs may have been an error in recording the weight. Will request reweigh as gradual weight gain is desired. Current estimated needs = 37 x 35-40 = 1295-1480 calories/day, 37 x 1.2 -1.3 = 44-48 gm protein /day, 37 x 30-35 = 1110-1295 ml fluid. F/U for reweigh. Per nursing resident is tolerating tube feeding well. Adjust poc as needed. Review of the Nutrition / Dietary Note for Resident #90 dated 09/26/24 included the following: Resident's tube feeding to be adjusted. Recommend changing to Osmolite 1.5/1000ml @ 62ml/hour via G Tube. Start at 5pm and run until complete (~16 hrs) H2O flush/1000ml @ 31ml/hour via G tube with total of 500ml H20. Start at 5pm and run ~16 hrs. Tube feeding will provide 1500 kcal, 62.7 gm protein, 1262 free H20. Recommend H20 flush 120ml once daily via G tube. Total free water 1382ml Weight 82lbs. Tube feeding provides 40 kcal/kg, 1.6 gm/kg protein, Total free water 37ml/kg. F/U for tolerance/weight/changes. Adjust POC as needed. On 10/01/24 at 10:00 AM, an observation was made of Resident # 90 lying in bed asleep with no tube feeding hung or infusing. On 09/30/24 11:35 AM, an observation was made of Resident #90 lying in bed with the tube feeding Osmolite 1.5 (formulary type) at 350 mark out of 1,000 milliliter capacity bottle. The tube feeding bottle was labeled with a start date of 09/29/24 at 6:00 PM, infusing at 62 milliliters per hour. On 10/01/24 at 4:23 PM, an observation was made of Resident #90 lying in bed with Osmolyte 1.5 (formulary type) tube feeding connected to the resident with tube feeding just above the 1,000 mark out of a 1,000-milliliter capacity bottle and infusing at 62 milliliters per hour via pump. The tube feeding bottle is labeled with a start date of 10/01/24 at 4:00 PM. On 10/02/24 at 8:45 AM, an observation was made of Resident #90 sitting up in bed with bottle Osmolite 1.5 tube feeding at the 200 mark out of a 1,000-milliliter capacity bottle. The tube feeding was infusing via pump at 62 milliliters per hour. The tube feeding bottle was labeled with start date of 10/01/24 at 4:00 PM. On 10/02/24 at 10:31 AM, an observation was made of Resident #90 sitting up in bed with bottle Osmolite 1.5 tube feeding below the 200 mark out of a 1,000-milliliter capacity bottle. The tube feeding was infusing via pump at 62 milliliters per hour. The tube feeding bottle was labeled with start date of 10/01/24 at 4:00 PM. An interview was conducted on 10/01/24 at 12:12 PM with the husband of Resident # 90 who stated his wife's normal body weight was 135 pounds. The last time she weighed her normal body weight was in March. He said this disease is terrible and now she cannot swallow so she has to be on tube feeding. He said they had some kind of meeting when his wife first arrived at the facility just over a month ago. He expressed his concern over his wife's weight and does not want her to lose any more weight and hopes she can gain weight. He said during that meeting was the only time he talked to the dietician, and they told him they would adjust the tube feeding as they went along. He stated he was never told she had any weight loss since being in the facility. He was under the impression she would have gained weight, but nobody really talks to him or answers question when he asks. He said he comes to the facility just about every day and he sees the tube feeding bottle off and still has about 3 inches of tube feeding left in it and they throw it away and start a new bottle later. He feels she may not be getting all of the tube feeding she is supposed to for this reason. An interview was conducted on 10/01/24 at 10:30 AM with Staff J, Restorative Aide, who stated she has worked at the facility for just over 1 year and has been the Restorative Aide for about 1 year. She said she is the one to do the weights for residents unless she is not scheduled to work, then other staff fill in to do the weights. She said she gets a list of the newly admitted residents and will do admission weights weekly for 4 weeks then monthly unless the dietician instructs her otherwise. She then gives the list of residents with their weights to the dietician once she obtains them and the dietician puts the weights into the resident's medical record. She added sometimes the dietician will asks her to reweigh the residents and she gives the dietician the reweight to enter into the resident's medical record. When asked about the scales she said there is 2 mechanical lifts, one for the second floor and one for the third floor and they have a standing scale that can also accommodate a wheelchair, and that scale is located on the first floor. She said the scales are maintained by maintenance and have just been serviced before she returned from a leave on 08/19/24. When asked about the process for weighing residents with a scale, she said she zeros out the scale the resident is to be weighed on then weighs the resident; if the resident is weighed on the mechanical lift, she will then take the sling used for the resident and weigh it immediately after weighing the resident and subtract the weight of the sling from the weight of the resident and that net weight is what she submits to the dietician. An interview was conducted on 10/03/24 at 11:18 AM with the Registered Dietician (RD) who stated she has worked at the facility for 21 years and has been full time since June 2024. When asked what would constitute a significant weight loss she said, a weight loss of 5% or greater in 1 month, or 7.5% or greater in 3 months, or 10% or greater in 6 months. When asked how often residents are weighed, she said they are weighed on admission by someone from nursing department who will enter the admission weight for the resident. They do not take the weight from the hospital. The resident is weighed on admission, then the Restorative Aide will weigh the resident within next 3 days. Then the resident will be weighed weekly x 4 weeks, then evaluated for what the frequency will be based on any trend and usually will monthly thereafter. When asked about residents who receive tube feedings, she said she would generally not expect to see weight loss. She stated she ensures tube feeding orders are followed by doing rounds to spot check the resident to make sure the tube feeding orders are followed as ordered. When asked about the estimated needs for Resident #90, she said on 08/26/24 according to her calorie and protein the estimated needs of the resident were 1470 -1680 calories per day and 50-55 grams protein per day. When asked what was prescribed for the resident at that time, she said it was 1500 calories per day and 62.7 grams of protein per day (this was on the lower end of the estimated calories per day). When asked about Resident #90's weight, she said the resident weighed 92 pounds on admission to the facility on [DATE]. When asked if she put any interventions in place to address the significant weight loss of 10% in only 9 days, she said no because on 09/09/24 she spoke to the husband who stated his wife was not 92 pounds, she was 82 pounds, and he had witnessed her being weighed on a standing scale. The resident's husband stated his wife had weighed 78 pounds in the hospital and there was no way she could have weighed 92 pounds. She added that on 09/05/24, they had a IDT meeting, and she did not change the tube feeding orders because the tube feeding was meeting the resident needs. When asked if she thought the tube feeding was meeting the resident's needs even when the resident had an unexpected / unanticipated and undesirable significant weight loss of 10 pounds (10%) in less only 9 days, she said even though she had a 10% weight loss after her conversation with the resident's husband he reported her weight from the hospital was 78 pounds and she definitely could not have been 92 pounds because he had observed her being weighed on the standing scale at 82 pounds. The RD then acknowledged the resident's next weight was on 09/21/24 and she was 82 pounds. On 09/27/24 she was 83 pounds, which she acknowledged was a significant weight loss of 9% if you base it on the facility admission weight, but she was basing weight loss on what the husband had informed her was 82 pounds that he saw his wife being weighed on the standing scale. The RD insisted she did not change the tube feeding orders because she felt it was meeting her needs and was actually above her needs. When asked about the witnessed weight on 10/01/24 of 77.6 pounds, she insisted there was no need to adjust the tube feeding because the current tube feeding was above her needs. The RD stated on 10/02/24 she weighed the resident again on the standing scale and she weighed 79.6 pounds which still was a significant weight loss of 13% (12.4 pounds) based on the facility admission weight of 92 pounds but she still did not adjust or change the tube feeding because she was going by what the husband had told her was a weight of 82 pounds he had seen on the standing scale in the facility. She discussed the weight loss and tube feeding with the resident's husband, and he said his wife conveyed to him that she was feeling a little hungry and asked the nurse to start the tube feeding about an hour early. The husband informed her he was going to move his wife to an Assisted Living Facility (ALF), and she needed to be on bolus feeding to be admitted to ALF. The RD said the order for the tube feeding will be the same formulary and was to be 1 carton (355 calories per carton/14.9 grams of protein per carton) and she would receive 5 cartons per day starting in the evening around 4:00 PM on 10/03/24. When asked what the total calories and protein was for the day the resident would be receiving while on the 5 cartons a day, she said it would be 1775 calories per day and 74 grams of protein per day. When asked if the resident had any issue with tolerating the tube feeding, she said the resident has had no issue with tolerating the tube feeding since admission. When asked if she addressed the significant weight loss, she said no. When asked if she updated the care plan for the significant weight loss, she said unfortunately no. 2. Record review revealed Resident #199 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, an admission MDS, dated [DATE], documented Resident #199 had a BIMS score of 04, indicating Resident #199 was severely cognitively impaired. The MDS documented Resident #199 was dependent upon staff for all activities of daily living (ADLs). Resident #199's diagnoses at the time of the assessment included: Anemia, Hypertension, Obstructive uropathy, Non-Alzheimer's dementia, Seizure disorder, Malnutrition, Gastrostomy malfunction, Guillain-Barre syndrome, Metabolic encephalopathy, Dysphagia following cerebral infarction, Speech/Language deficits following cerebral infarction, Sarcoidosis, and Pressure ulcer of sacral region stage 2. Resident #199's orders included: On 09/23/24 with a start date of 09/24/24 for, Enteral Feed Glucerna 1.2/1500ml at 83ml/hr (milliliters per hour). On 09/19/24, Head of Bed (HOB) elevated at 30-45 degrees while tube feed is running. On 10/02/24 at 7:20 AM, Resident #199 was observed in bed with the supplement being provided via an enteral pump. During the observation, Resident #199 was noted to be laying in a nearly supine position. When the concern was brought to the attention of Staff G, LPN, and Staff H, Staff H confirmed that Resident #199 was not positioned properly. Staff G stated, she should be at 45 degrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents with a Post-Traumatic Stress Disorder (PTSD) received trauma-informed care in accordance with professional standards of practice and failed to account for the resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 sampled resident reviewed for PTSD, Resident #70. The findings included: Review of the facility's policy, titled, Trauma-Informed and Culturally Competent Care, dated 05/19/23, included the following purpose: To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Resident Screening 1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. 3. Screening may include information such as: a. Trauma history, including type, severity and duration; b. Depression, trauma-related or dissociative symptoms; f. historical mental health diagnosis Resident Assessment 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Malignant Neoplasm of Endometrium, Bipolar Disorder, Psychosis Not Due to a Substance or Known Physiological Condition, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of section I revealed Resident #70 diagnosis included: Bipolar Disorder, Psychotic Disorder, Depression, Post-Traumatic Stress Disorder (PTSD), and anxiety disorder. Review of the Physician's Orders showed that Resident #70 had an order dated 05/23/24 which included: [NAME] psychology to evaluate and treat as needed. An interview was conducted on 10/02/24 at 1:43 PM with DON. He acknowledged that Resident #70 has not been seen by a psychologist since she was admitted in 05/15/24. An interview was conducted on 10/02/24 at 4:48 PM with Resident #70. She stated she was seeing a psychologist before she was admitted to the facility because of her diagnosis of bipolar disorder and depression. Resident #70 stated she would like to be seen by the psychologist. She does not recall being monitored for any behaviors. An interview was conducted on 10/02/24 at 4:59 PM with the Social Services Director (SSD). She stated the resident's diagnosis are derived from the hospital documentation when the resident is transferred to the facility, and the physician would be the one to diagnose the resident with PTSD. She acknowledged not questioning Resident #70 about her PTSD since the resident had no change in mood and did not express any sign of PTSD. The SSD acknowledged that Resident #70 should have had a psychology evaluation upon admission due to her psychological diagnosis including PTSD. She stated she was unable to find any psychology consultation at all for Resident #70.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to obtain orders for bed rails, failed to develop and implement a care plan for bed rails, and failed to regularly inspect rails for fit and function for 2 of 2 sampled residents reviewed for bed rails, Residents #197 and #199 The findings included: Review of the facility policy, titled, Bed Safety and Bed Rails, with a revision date of August, 2022, documented, in part: Facility Statement: The use of bed rails is prohibited unless the criteria for use of bd rails have been met. Policy Interpretation and Implementation 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping havits and bed environment 6. Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. 7. the maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection result and QAPI committee recommendations are maintained by the administrator and/or safety committee. Use of Bed Rails 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment and informed consent. 4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards b. foam bumpers c. lowering the bed d. use of concave mattresses to reduce rolling off the bed 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails b. The residents' risks from the use of bed rails and how these will be mitigated c. The alternatives that were attempted but failed to meet the residents' needs d. The alternatives that were considered but not attempted and the reasons. 1. Record review revealed Resident #197 was admitted to the facility on [DATE]. Review of the resident's most recent full Minimum Data Set (MDS) assessment, a Medicare 5-day MDS, dated [DATE], dcoumented Resident #197 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment documented Resident #197 required partial / moderate assist for bed mobility and transfer and ambulated independently with use of a manual wheelchair (w/c). The resident was observed walking behind a w/c on multiple occasions during the 4-day survey. Resident #197's diagnoses at the time of the assessment included: Hypertension, Depression, and Chronic Lung Disease. Review of Resident #197's medical records revealed that there were no orders for bedrails and no care plan for the use of the rails. During an interview, on 10/01/24 at 12:50 PM, with Resident #197, it was noted that the resident had bilateral rails in a raised position from the head of the bed to approximately the middle of the bed. When asked about the bed rails, Resident #197 replied, I don't use them, they just put them here. During an interview, on 10/03/24 at 10:51 AM, with the Therapy Director and the Occupational Therapist, when asked about the use of bedrails for Resident #197, the Occupational Therapist replied, he is high-functioning, I see them working with safety orientation and things like that. The Therapy Director stated, we do the bedrail assessments, the nurse does the order for the bedrails, we recommended that he have them. 2. Record review revealed Resident #199 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, an admission MDS, dated [DATE], documented Resident #199 had a BIMS score of 04, indicating that Resident #199 was severely cognitively impaired. The MDS documented Resident #199 was dependent on staff for all activities of daily living (ADLs). Resident #199's diagnoses at the time of the assessment included: Anemia, Hypertension, Obstructive Uropathy, Non-Alzheimer's dementia, Seizure Disorder, Malnutrition, Gastrostomy Malfunction, Guillain-Barre Syndrome, Metabolic Encephalopathy, Dysphagia, Speech / Language deficits, Sarcoidosis, and Pressure Ulcer of sacral region Stage 2. Resident #199 was not interviewable. Review of Resident #199's medical records revealed that there were no orders and no care plan for the use of bedrails. An interview was conducted on 10/01/24 at 10:44 AM with Resident #199's family member. Resident #199 was observed in bed with a supplement being provided via an enteral pump. It was noted the resident had bilateral siderails, from the head of the bed to approximately the middle of the bed. When asked about the benefit of the use of the bed rails for Resident #199, the family member stated the resident would not be able to use them as the resident did not have enough upper body mobility to grab and hold onto the rails. On 10/02/24 at 7:20 AM, Resident #199 was observed in bed with a supplement being provided via an enteral pump. During the observation, it was noted that the resident had bilateral siderails from the head of the bed to approximately the middle of the bed in a raised position. Review of the Siderail / Bedrail Review (assessment), dated 09/15/24, documented: Recommendations - none. Side rails are not indicated at this time. An interview was conducted on 10/03/24 at 10:51 AM with the Therapy Director and the Occupational Therapist (OT). When asked about the use of bedrails for Resident #199, the OT provided documentation of recommendation for the resident to not have rails. The OT stated, the concern would be that the resident could get caught in the rails by involuntary movement. The OT stated Resident #199 did not have upper body mobility to use the rails or be a benefit from the use of the rails. The OT stated the resident was not at risk for falling from the bed due to the limited mobility. 3. An interview ws conducted on 10/03/24 at 8:39 AM with the Maintenance Director, who when asked about monitoring and inspecting bedrails for fit and function, the Maintenance Director replied, every time someone is discharged , we check the rails to make sure they are not loose and that they fit the bed properly. When asked about inspecting the rails for residents that have not been discharged and are long term, the Maintenance Director replied, quarterly. On 10/03/24 at 11:19 AM, the Maintenance Director reported to the surveyor that there were no audits being done and provided a blank spreadsheet that was to be used to conduct audits of the bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to accurately reconcile controlled medications and failed to ensure discontinued controlled medications were removed from the medication cart for 2 of 5 sampled residents reviewed for controlled medications reconciliation, Resident #33 and Resident #41. The findings included: Review of the facility's policy, titled, Controlled Substances, dated November 2022, included the following: The facility complies with all laws, regulations, and other requirements 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. 13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. 14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. 15. The consultant pharmacist or designee routinely monitors controlled substance storage records. Review of the facility's policy, titled, Administering Medications, dated April 2019, included the following: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders 22. The individual administering the medication initials the resident's Medication Administration Records (MAR) on the appropriate line after giving each medication and before administering the next ones. 23 .As required or indicated for a medication, the individual administering the medication records in the resident's medical record. An observation of medication storage and reconciliation of controlled medications was conducted on 10/02/24 at 10:12 AM on the third-floor [NAME] hallway with Staff Q, Licensed Practical Nurse / LPN. 1. Record review for Resident #33 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Unspecified Fracture of Right Femur and Dementia. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated that she was rarely / never understood. Review of the Physician's Orders revealed Resident #33 had an order dated 08/21/23 for Tramadol HCL tablet 50 mg to give 1 tablet by mouth every 6 hours as needed (PRN) for moderate and severe pain. Non-Acute pain. Review of the September Medication Administration Records (MAR) revealed Resident #33 was administered Tramadol 50 mg PRN on the following dates: 09/01/24 at 4:44 PM with a pain level of 5 of 10. 09/04/24 at 3:12 PM with a pain level of 0 of 10. 09/07/24 at 10:50 AM with a pain level of 0 of 10. 09/13/24 at 9:00 AM with a pain level of 5 of 10. 09/16/24 at 8:43 PM with a pain level of 5 of 10. 09/18/24 at 2:58 PM with a pain level of 0 of 10. 09/25/24 at 1:05 PM with a pain level of 0 of 10. 09/25/24 at 8:47 PM with a pain level of 6 of 10. 09/28/24 at 5:40 PM with a pain level of 7 of 10. However, review of the Medication Monitoring / Control Record revealed Resident #33 was administered Tramadol 50 mg PRN on 09/07/24 at 9:00 PM and 09/20/24 at 3:50 PM. 2. Record review for Resident #41 revealed the resident was readmitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus, Immunodeficiency, and End Stage Renal Disease. Review of Section C of the MDS assessment dated [DATE] revealed that Resident #41 had a BIMS score of 07, which indicated that he was severely cognitive impaired. Review of the Physician's Orders showed that Resident #41 had an order dated 04/09/24 for monitor for Pain every shift; and on 04/19/24 an order was added for Tramadol HCL tablet 50 mg to give 1 tablet by mouth every 6 hours as needed (PRN) for pain, with a discontinued date of 09/06/24. Review of the September Medication Administration Records (MAR) revealed Resident #41 was not administered Tramadol 50 mg PRN prior to the discontinued date 09/06/24. In addition, the MAR also revealed on 09/08/24, Resident #41 was monitored for pain reporting a pain level of 0 for every shift. Review of the Medication Monitoring/Control Record revealed Resident #41 was administered Tramadol 50 mg PRN on 09/08/24 at 0100 [AM]. An interview was conducted on 10/03/24 at 2:20 PM with Staff R, Registered Nurse (RN), who stated he has been working at the facility for 7 months. He stated if a resident requests pain medication, such as Tramadol, he would conduct a pain assessment and check physician's orders for pain medication. Staff R stated if there's no order for pain medication, he would contact the doctor for an order and administer the medication. He then will document almost at the same time in the MAR and in the Medication Monitoring/Control Record. An interview was conducted on 10/03/24 at 3:59 PM with the Director of Nursing (DON). He stated that per protocol the nurse will check physician's orders for the controlled medication and document when administered in the MAR and in the Medication Monitoring/Control Record. The DON was asked about a policy for reconciliation of controlled medications and was not sure if a policy existed. He stated the nurses do counts of the controlled medications on every change of shift with the incoming nurse. The DON stated as per protocol the count of the controlled medications in the medication cart drawer is compared to the number in the Medication Monitoring / Control Record, and this is done every shift. When asked if any unit manager/DON randomly conducts periotic reconciliation of controlled medications, he stated, no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to adequately monitor for side effects and behaviors for resident receiving antipsychotic medication and the consultant pharmacist failed to recommend the monitoring for side effects and behaviors for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #70). The findings included: Record review for Resident #70 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Malignant Neoplasm of Endometrium, Bipolar Disorder, Psychosis Not Due to a Substance or Known Physiological Condition, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she was cognitively intact. Review of section I revealed Resident #70 diagnosis included: Bipolar Disorder, Psychotic Disorder, Depression, PTSD, and anxiety disorder. Review of Section N revealed that Resident #70 was on antipsychotic, antidepressant, and anticoagulant. Review of the Physician's Orders revealed that Resident #70 had an order dated 05/16/24 which included: Aripiprazole tablet 2 mg, give 1 tablet by mouth one time a day for psychosis. There was no evidence of a physician's order for monitoring side effects and behaviors for antipsychotic medication such as Aripiprazole. Review of the Care Plan dated 08/12/24 documented Resident #70 uses psychotropic medications to r/t [related to] Bipolar, Psychoses, and Anxiety. Goals included: resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation / impaction or cognitive/behavioral impairment through next review date; and the resident will reduce the use of psychoactive medication through the 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 #70 was monitored for behaviors and side effects for the antipsychotic medication, Aripiprazole. Review of the medication Regimen Reviews performed by the consultant pharmacist since the admission of Resident #70 (May-September 2024) reported no recommendations for monitoring of behaviors or side effects for the antipsychotic medication, Aripiprazole. An interview was conducted on 10/02/24 at 12:47 PM with the consultant Pharmacist. She stated Resident #70 should have been monitored for behaviors and side effects since she is taking an antipsychotic medication. She acknowledged no behavior or side effect monitoring orders from the physician or psychologist for Resident #70. An interview was conducted on 10/02/24 at 1:31 PM with the Staff O, MDS Coordinator. She stated that she was unable to find any psychology notes or orders for monitoring behaviors for Resident #70. However, she acknowledged Resident #70 is on antipsychotic medications and should be monitored for behavior and side effects. An interview was conducted on 10/02/24 at 1:43 PM with Director of Nursing (DON). He stated he was unable to find the order for behavior monitoring for Resident #70's or monitoring for side effects for the antipsychotic medication. He also acknowledged that Resident #70 has not been seen by a psychologist since she was admitted in May 2024. An interview was conducted on 10/02/24 at 4:48 PM with Resident #70. She stated she has never been asked about her behavior or side effects of medications. An interview was conducted on 10/02/24 at 4:59 PM with the Social Services Director (SSD). She acknowledged that Resident #70 should be monitored for behavior due to her medications. She mentioned that she was unable to find any psychology consultation at all for Resident #70. The SSD stated she does not know why Resident #70 was not followed by psychology.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure medications were stored securely for 1 of 4 sampled residents observed for medication administration, Resident #246, and 1 of 25 sampled residents, Resident #8. The findings included: Review of the facility's policy, titled, Medication labeling and Storage, with a published date of 08/06/24, included, in part, the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1. Record review for Resident #246 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. The resident's diagnoses included, in part, the following: Cerebral Infarction Unspecified, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Immunodeficiency, Other Idiopathic Peripheral Autonomic Neuropathy, Other Speech and Language Deficits Following Cerebral Infarction, and Type 2 Diabetes Mellitus with other Specified Complication. Review of the Minimum Data Set (MDS) for Resident #246 dated 09/19/24 documented in Section C a Brief Interview of Mental Status score of 12, indicating moderate cognitive impairment. Review of the Physician's Order for Resident #246 revealed an order dated 09/23/24 for Voltaren Arthritis Pain External Gel 1 % (Diclofenac Sodium (Topical). Apply to right knee topically two times a day for arthritis pain Apply 4 grams. Review of the Physician's Order for Resident #246 revealed an order dated order dated 08/19/24 for Gabapentin Capsule 300 MG give 1 capsule by mouth three times a day for Neuropathic Pain. During an observation of a medication pass conducted on 10/01/24 at 4:30 PM with Staff A, Registered Nurse (RN), for Resident #246, Staff A brought the following medications into the resident's room to be administered: Carvedilol 12.5mg tab, Buspirone hcl 5mg tab, Metformin 1,000mg tab, Elder tonic 15milliliters, Magnesium Oxide 400mg tab, and Diclofenac sodium (Voltaren Arthritis) topical gel 1%. Staff A then placed all of the medications on the resident's overbed table, next to him and went into the resident's bathroom (out of sight of the medications) to wash her hands, she then proceeded to administer the medications to the resident. After Staff A administered the medications, she left the Diclofenac Sodium topical gel 1% on the overbed table, next to the resident, and entered the resident's bathroom a second time leaving the medication out of her sight, while she went into the bathroom to remove gloves and wash her hands. An interview was conducted on 10/01/24 at 4:50 PM with Staff A who stated she has worked at the facility for about 1 month. When asked about leaving the medication at the bedside next to the resident and out of her sight to wash her hands in the resident's bathroom, she said she should not have left the medications unattended. 2. On 09/30/24 at 12:19 PM, an observation was made of Resident #8 lying in bed with the overbed table in front of her. It was noted that on the overbed table was Systene Complete PF eye drops. On 10/01/24 at 10:15 AM, a second observation was made of Resident #8 lying in bed with overbed table in front of her. It was noted that on the overbed table was Systene Complete PF eye drops, still in plain sight. An interview was conducted on 10/01/24 at 10:15 AM with Resident #8 who was asked about the eye drops, she said she uses them every night for her dry eyes. An interview was conducted on 10/01/24 at 10:30 AM with Staff B Registered Nurse / Unit Manager (RN/UM) who was asked about medications (meds) at the bedside, she said residents should not have meds at the bedside. During a side-by-side observation with the RN/UM of Resident #8 with the Systene Complete eye drops on the overbed table, she acknowledged the resident should not have those and they needed a doctor's order. She then informed the resident she could not have the eye drops at the bedside and removed them.

Based on observations, interviews and record review, the facility failed to provide portions of pureed food according to the approved menu, with the potential to affect 14 residents with orders for puree diets, including Residents #4, #40, #48, #199 and #201. The findings included: Review of the approved menu for the lunch being served on 10/02/24 was for 4-ounces of Beef Stew for residents with 'Regular' diet orders and 6-ounces of the beef stew for residents with 'Puree' diet orders. During the kitchen tour, on 10/02/24 at 11:32 AM, accompanied by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager, while plating the lunch meal, Staff F, Cook, placed a scoop of the beef stew that accounted for a serving and plated the remainder of the lunch and passed it off to staff to cover and placed on a tray and in a cart. At the request of the surveyor, Staff F placed a portion of the beef stew in the same manner on the facility's calibrated kitchen scale. The portion of beef stew weighed 4-ounces. At this same time, when a meal of pureed food was called for, Staff F placed a scoop of the pureed beef stew that accounted for a serving and plated the remainder of the lunch and passed it off to staff to cover and place on a tray and in a cart. At the request of the surveyor, Staff F placed a portion of the pureed beef stew in the same manner on the facility's calibrated kitchen scale. The portion of beef stew weighed 4-ounces. It was noted that Staff F used a 4-ounce scoop for both the regular and the pureed portion of the beef stew. At the time of the observation, the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager acknowledged the residents with orders for pureed diet orders were not being served according to the approved menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to prepare pureed vegetables in a manner to preserve their nutritive value, with the potential to affect 14 residents with orders for pureed diets, including sampled Residents #4, #40, #48, #199 and #201. The facility failed to follow the recipe for carrots, with the potential to affect all residents that eat from the approved menu. The findings included: Review of the facility's recipe for Carrots, Diced, (no reference date), documented the following instructions: Procedures: 1. Peel and cut carrots into 1/8 inch slices. Steam about 4 minutes. 2. Add broccoli florets and steam another 7-8 minutes or until vegetables are tender. 3. Add butter. Mix. Add salt and pepper to taste just before serving. Notes: 1. For pureed: Measure desired # of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener if product needs thickening. 2. Puree Level 4: [NAME] texture, no lumps, liquid must not separate from solid, may not be sticky, cannot be drunk from a cup or sucked through a straw. Shows some very slow movement under gravity, but cannot be poured, hold shape of spoon and fall off spoon in a single spoonful. During the kitchen tour, on 10/02/24 at 11:32 AM, accompanied by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager, the pureed carrots that were in a 1/3 sized 6-inch deep hotel pan hot holding unit appeared to be soupy and sloshed about the pan when Staff B stirred the carrots. Additionally, there was a 1/3 sized 6-inch deep hotal pan of diced carrots in the hot holding unit that did not appear to have any other vegetable type or ingredient in it. While Staff B, Cook, was placing a portion of the pureed carrots into a small bowl to place on the plate, the pureed carrots appeared to be soupy and pooled in the bowl. When asked about the preparation of the pureed carrots, Staff B replied, I use frozen carrots and thaw them out and put them in the blender and add water to it so that it will mix better, I reheat them and put them on the line. Staff B did not indicate that there were any other vegetables or ingredients in either pan of carrots. At the time of the observation, the Dietetic Tech / Kitchen Supervisor acknowledged that the amount of water added to the carrots to obtain the consistency that was observed diminished the nutritional value of the carrots.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to prepare pureed vegetables in a form to accomodate the residents' needs, with the potential to affect 14 residents with orders for pureed diets, including Residents #4, #40, #48, #199 and #201. The findings included: Review of the facility's recipe for, Carrots, Diced, (no reference date), documented the following instructions: Puree Level 4: [NAME] texture, no lumps, liquid must not separate from solid, may not be sticky, cannot be drunk from a cup or sucked through a straw. Shows some very slow movement under gravity, but cannot be poured, hold shape of spoon and fall off spoon in a single spoonful. During the kitchen tour, on 10/02/24 at 11:32 AM, accompanied by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager, the pureed carrots that were in a 1/3 sized 6-inch deep hotel pan hot holding unit appeared to be soupy and sloshed about the pan when Staff B, Cook, stirred the carrots. While Staff B, was placing a portion of the pureed carrots into a small bowl to place on the plate, the pureed carrots appeared to be soupy and pooled in the bowl and did not hold the shape and consistency of the other pureed foods that were plated with the carrots. The Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager acknowledged the findings. The Dietitic Teach instructed Staff B to add thickener to the carrots to obtain a thicker consistency.

Based on observation, interview and record review, the facility failed to prepare, store, and served meals in a safe and sanitary manner and in accordance with standards for food safety. The findings included: During the initial kitchen tour, on 09/30/24 at 9:03 AM, accompanied by the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager, the following was observed: 1. Upon entering the kitchen and making an introduction to the staff, the surveyor proceeded to perform hand hygiene at the designated hand washing sink. The surveyor turned on the hot water and waited for the water to get hot. After several minutes, the water did not get to the appropriate temperature for hand hygiene. 2. In the walk in cooler, there was a full sized 6-inch deep hotel pan of par-cooked chicken stored over packages of ready to eat deli meats. The Dietetic Tech and Staff B, Cook, confirmed that the chicken was partially raw. 3. There was a damp towel kept on the handles of the convection oven. When asked about the purpose for having the towels kept in that manner, Staff B stated that it was to remind her that there was food still in the oven. 4. There was an accumulation of residue on the pipes of the fire suppression system over the cooking equipment. 5. Cleaned and sanitized hotel pans were found to be wet nesting on the shelf of the basin used for sanitizing wares in the three compartment sink. 6. There was an accumulation of food residue and debris on the slier blade and in the assembly of the sharpening stones. 7. The temperature of the hot water in the mechanical dishwasher failed to reach the required 120 degrees Fahrenheit (F) necessary to properly clean and sanitize wares. The temperature was observed to be at the approximate 88 to 90 (F) mark. Photographic Evidence Obtained. At the conclusion of the tour, the Dietetic Tech / Kitchen Supervisor and the Regional Dietary Manager acknowledged the findings. The Dietetic Tech/Kitchen Supervisor stated that meals would be served using single use and disposable wares until the dish washer was properly washing and sanitizing the wares. On 09/30/24 at 9:51 AM, the Maintenance Director reported that the hot water heater that supplied hot water to the kitchen had to be shut off due to plumbing issues and that the facility was working on the repairs.

Based on interview and record review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain an environment free of accident hazards. The findings included: Review of the Job Description: Administrator, with no date, included in part the following: Purpose of the Position The primary purpose of the position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities: Administrative Functions 1. Plan, develop, organize, implement, evaluate and direct the facility's programs and activities. 2. Review policies and procedures that govern the operation of the facility. Safety and Sanitation 1. Assure that all facility personnel, residents, visitors, etc., follow established safety regulations, to include fire protection/prevention, smoking regulations, infection control, etc. 2. Assur that the building and grounds are maintained in good repair 3. Review accident/incident reports and establish an effective accident prevention program. Miscellaneous 1. Assure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. 2. Assure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical function status as defined by the comprehensive assessment and care plan 3. Assist the Quality Assurance Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. An interview was conducted on 10/03/24 at 10:15 AM with the Administrator who stated she is also the Risk Manager and has worked at the facility for about 6 years. When asked about the cigarette burn sustained by Resident #19 on 05/20/24, she said she honestly did not remember the incident until she reread the report that was asked for (by the surveyor) on alteration in skin for the resident. She said they had another issue under investigation at that time that she was more focused on. She acknowledged she never went back to review the incident or make sure any interventions were put in place. She said that the Director Of Nursing and several other staff had left the facility in the weeks following the investigation. The Administrator said she was aware residents were coming down to smoke at various times on the smoking patio. She said all but one are safe smokers. She also stated she was not aware that the smoking risks forms / evaluations were not being performed quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure bathrooms located in residents' rooms were adequately equipped with an emergency call system pull cord to allow residents to call for staff assistance, for 6 of 60 rooms reviewed for the residents' call light system on the 2nd (second) and 3rd (third) floors, room [ROOM NUMBER], 222, 232, 304, 307 and 314). The findings included: During the initial tour conducted on 09/30/24 at 10:44 AM of the facility's 3rd floor rooms, it was observed that room [ROOM NUMBER]'s bathroom was missing the pull cord for the emergency call light system. Photographic Evidence Obtained. Further observation at this time of the 3rd floor rooms revealed rooms [ROOM NUMBERS] were also missing the pull cord for the call light system in the residents' bathrooms. During the 2nd floor tour, two resident bathrooms, rooms [ROOM NUMBERS], were observed to be missing the pull cords of the call light system, and in room [ROOM NUMBER], the emergency pull cord was observed to be wrapped around the grabbing bar, making the pull cord not accessible or useable for the resident. On 10/02/24 at 10:15 AM, further observation was conducted of rooms [ROOM NUMBERS] bathrooms. The pull cords were still missing from the emergency call light system. An interview was conducted on 10/02/24 at 10:25 AM with Staff P, Certified Nursing Assistant (CNA). Staff P stated she has worked at the facility since 2008, and is assigned to provide care to the residents in room [ROOM NUMBER]. Staff P stated both residents required assistance for toileting. She stated she would assist the resident to the toilet, stand outside of the bathroom door to provide privacy, but would stay close by to assist the resident once they are done in the bathroom. Staff P stated both residents are vocal and can communicate when they are done in the bathroom. She acknowledged the resident located by the window can wheel herself around the room with her wheelchair. An interview was conducted on 10/03/24 at 4:30 PM with Staff Z, CNA, assigned to provide care to residents in room [ROOM NUMBER]. Staff Z stated she has worked at the facility for 26 years. She stated only one of the residents in room [ROOM NUMBER] can wheel herself to the bathroom and requires slight assistance with toilet transfer. Staff Z was asked if the resident was to have a fall in the bathroom how would the resident call for help. She stated there's a call light in the bathroom the resident can use. When Staff Z was asked to show the surveyor how the resident would use the call light system in the bathroom, she realized that there was no pull cord for the resident to use in case of an emergency. Staff Z was not sure how long the pull cord for the call light had been missing. An environmental tour was conducted on 10/03/24 at 9:00 AM with the Director of Maintenance (DOM) who acknowledged the findings of the bathrooms in resident's rooms not having the pull cords for the emergency call light system.

Based on observations, interviews, and record review, the facility failed to ensure the closet space in residents' rooms had doors or coverings to maintain the residents' clothing clean, protected, and to provide privacy for 30 of 60 total residents' rooms, located on the 3rd floor, that were reviewed for a home-like environment. The findings included: During the initial tour of the facility conducted on 09/30/24 at 9:37 AM, it was observed that all the residents' rooms on the third floor were missing closet doors revealing residents' personal clothing and items. In several of those rooms, observation revealed the resident's clothing whad been thrown on the bottom shelf of the closet in a disorganized manner and visible to residents and visitors. An interview was conducted on 10/02/24 at 9:34 AM with Staff S, Certified Nursing Assistant (CNA). Staff S stated she has worked at the facility for one year and always works on the third floor. Staff S stated since she has been working in the facility, the closets in the residents' rooms have always been without a curtain or a door. An interview was conducted on 10/02/24 at 9:45 AM with Staff T, CNA. Staff T stated she has been working at the facility for about 9 months and has been assigned mainly to the third floor. Staff T acknowledged never seeing the residents' closets with doors. On 10/03/24 at 9:00 AM, an environmental tour was conducted with the Director of Maintenance (DOM) who acknowledged the findings that the residents' closets on the third floor did not have doors or coverings.

Based on interview, record review, and observation, the facility failed to file an abuse report within 2 hours of being made aware of abuse, for 3 of 3 sampled residents, Resident #1, Resident #2, and Resident #3, reviewed for abuse. The findings included: The facility's policy, titled, Identifying Types of Abuse (revised September 2020) documented a section with the heading Policy Interpretation and Implementation, included the following: Under the heading Physical Abuse, the following was documented: 1. Physical Abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. Under the heading Mental and Verbal Abuse, the following was documented: 1. Mental Abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 2. Verbal Abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communications, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. 3. Examples of mental and verbal abuse include but are not limited to: c: yelling or hovering over a resident, with the intent to intimidate. On 05/20/24 at 10:18 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that she was informed that Resident #1 had a laceration to his forehead that was caused by the resident banging his head on a table. The NHA explained the incident occurred on 05/08/24, and she was under the impression that Staff A was telling the truth regarding the matter. The NHA stated she did not report the injury as an injury of unknown origin because she believed the injury was not of unknown origin. The NHA stated she continued to investigate the incident because she realized that the behavior described was not common for Resident #1. The NHA stated that one of her nursing supervisors suggested reviewing the surveillance video to verify the incident. When the NHA reviewed the video, she discovered the abuse of Resident #1, Resident #2, and Resident #3 by Staff A, Certified Nursing Assistant (CNA). The NHA stated she immediately suspended Staff A, who was subsequently terminated. Further interview with the NHA at this time revealed she reported the abuse within 24 hours of the discovery of the abuse, but not within 2 hours of her being aware. The NHA admitted she had forgotten she needed to report within 2 hours of notification of abuse as required. Review of the Federal report filed by the NHA documented the NHA was made aware of the incident on 05/10/24 at 13:16 (1:16 PM). The Federal report was created by the Director of Nursing (DON) on 05/11/24 at 2:26 PM. The Federal report was submitted by the DON on 05/11/24 at 4:45 PM. On 05/20/24 at approximately between 10:30 AM and 11:00 AM, the surveyor reviewed the video surveillance recording of the abuse of Residents #1, #2 and #3, which was perpetrated by Staff A. It was noted in the video that the residents were physically and mentally abused by Staff A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide eating assistance in a dignified manner for 2 of 2 sampled residents observed for in-room dining, Resident #3 and Resident #11. The findings included: 1. Review of Resident #3's clinical record documented an admission on [DATE], with diagnoses that included Parkinson's, Psychosis and Depression. Review of Resident #3's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 of 15 indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #3's care plan, titled, Self-care performance deficit initiated on 08/22/22 documented an intervention that read .requires extensive assist with .meals . On 07/17/23 at 12:38 PM, in-room dining observation was conducted at the facility's 300 rooms unit. Observation revealed Resident #3 sitting upright in bed, with her meal tray to the right side of the bed. Further observation revealed the resident being fed by her private duty Aide (PDA). Observation revealed the PDA was standing, rather than seating, over to the right side while feeding Resident #3. Observation revealed there was a chair in the room to the left side of the resident's bed. Resident #3 was not interviewable. On 07/17/23 at 12:54 PM, an interview was conducted with Resident #3's PDA who stated she gave a can of Ensure and orange juice to the resident because she did not want to eat the meal. During the observation and interview, the PDA did not attempt to move the chair over the resident's right side to continue feeding the resident. 2. Review of Resident #11's clinical record documented an admission on [DATE] and a readmission on [DATE], with diagnoses that included Psychosis and Schizophrenia. Review of Resident #11's MDS significant change assessment dated [DATE] documented a BIMS score of 4 of 15 indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed total assistance from the staff to complete the activities of daily living. Review of Resident #11's care plan, titled, Resident requires assist with activities of daily living related to Dementia, Limited Mobility ., and revised on 04/10/23, documented an intervention that read .assist with meals . On 07/17/23 at 12:47 PM, observation revealed Resident #11was alert and sitting up in bed being fed by Staff L, Certified Nursing Assistant (CNA). Further observation revealed Staff L was standing, next to the resident's left side, while feeding the resident. Further observation revealed a chair across from Resident #11's bed. The resident was not interviewable. On 07/19/23, an attempt was made to interview Staff but she was not available. On 07/20/23 at 9:01 AM, an interview was conducted with Staff M, CNA, who stated that the staff were supposed to seat down while feeding a resident. On 07/20/23 at 9:04 AM, an interview was conducted with Staff N, CNA, who stated that they were supposed to seat down while feeding a resident. On 07/20/23 at 9:06 AM, an interview was conducted with Staff O, Licensed Practical Nurse (LPN), who stated that the staff were supposed to seat down while feeding a resident. Staff O stated that Staff L and Resident #3's PDA were not available for an interview. On 07/20/23 at 1:02 PM, an interview was conducted with the Director of Nursing (DON) regarding the above findings. The DON stated the PDA was not the facility's staff and was allowed to assist Resident #3 with meals and added that the PDA was ultimately responsible for the resident but the facility staff were supposed to do the resident's care. The DON stated the PDA had been in the facility before and knows that she is to seat down while feeding the resident. The DON stated a PDA was like a family member. The DON stated the PDA was a CNA and that the facility educated them on assistance with feeding. The DON was asked to submit a copy of the facility's policy related to assistance with dining / feeding and PDA responsibilities and training. At the end of the survey (07/20/23), the DON had not submitted a copy of the facility's policy related to assistance with dining / feeding and PDA responsibilities and training provided to them. On 07/20/23, 3:40 PM during an interview, the Administrator was apprised of findings related to feeding residents while standing. The Administrator stated that the PDA had to follow the facility's protocols.

Based on interviews, observations and record reviews, the facility failed to appropriately respond to and resolve grievances in a timely manner, for 7 of 7 sampled residents in attendance during a meteting with members of the Resident Council. The findings included: The facility's policy, titled, Grievances/Complaints Filing dated 03/13/23, documented, in part, the following: Policy Statement Residents and their representatives have the right to file grievance, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation 1. Any resident, family member, or appointed resident representative may file a grievance or complaint regarding care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 2. Residents, family, and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. 4. Upon admission, residents are provided with written information on how to file a grievance or complaint . 8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. During a review of the Resident Council Meeting minutes, on 07/18/23 at 10:45 AM, with permission granted by the Resident Council President, the following concerns were noted: June 2023 'Old Business: Meals are running late at times.' May 2023 'Old Business: Meals are running late.' April 2023 'Dietary: Meals are getting later.' The schedule of mealtimes that is posted on the units and at the Main Dining Room documented the following schedule: Breakfast - 7:45AM to 9:00 AM *Cart 1 to the second floor 7:55 AM to 8:00 AM *Cart 2 to the third floor 8:05 AM to 8:10 AM *Cart 3 to the second floor 8:15 AM to 8:20 AM *Cart 4 to the third floor 8:25 AM to 8:30 AM Lunch - 11:45 AM to 1:00 PM *Cart 1 to the third floor 11:55 AM to 12:00 PM *Cart 2 to the second floor 12:05 PM to 12:10 PM *Cart 3 to the third floor 12:15 PM to 12:20 PM *Cart 4 to the second floor 12:25 PM to 12:30 PM Dinner - 4:45 PM to 6:00 PM *Cart 1 to the third floor 4:50 PM to 4:55 PM *Cart 2 to the second floor 5:05 PM to 5:10 PM *Cart 3 to the third floor 5:15 PM to 5:20 PM *Cart 4 to the second floor 5:25 PM to 5:30 PM a. During observations of food carts being sent from the kitchen, on 07/18/23, beginning at 12:14 PM, the following was observed by this surveyor: At 12:14 PM, the first cart left the kitchen to go to the third floor West. At the time that the cart arrived on the unit, staff were already serving vegetable soup in the main dining room to the 14 residents that were seated at the tables. At 12:36 PM, the meal cart for the second floor [NAME] Unit left the kitchen. During an interview with members of the Resident Council, on 07/18/23 at 3:40 PM, when asked about the concerns voiced in prior meetings regarding the meals not being served on time, all of the residents in attendance (7) agreed that the meals being served late was still a problem. Resident #14, with a Brief Interview for Mental Status (BIMS) score of 11 of 15, indicating the resident was moderately cognitively impaired, stated, dinner doesn't come until 6:00 PM Resident #14 further stated, If you eat in the dining room, supper is at 4:30 [PM]. If you eat in your room, it will be around 6:00 (PM). We got our breakfast at 8:30 [AM] this morning. They just say they'll take care of it. Sometimes, the meals will be on the floor and the CNAs don't deliver them and they just sit there. Resident #1, with a BIMS score of 15, indicating the resident was cognitively intact, stated, Breakfast doesn't come until 9:00 AM or 9:30 AM. During observations of breakfast carts being sent from the kitchen to the units, on 07/19/23, beginning at 7:57 AM, the following observations were made: At 7:57 AM, the first cart left the kitchen being taken to the second floor East Unit. At 8:02 AM, a meal cart was observed at the second floor nurse's station with the ADON [Assistant Director Of Nursing] overseeing 3 CNAs [Certified Nursing Assistant] delivering the meals to the residents in their rooms. At 8:19 AM, a meal cart was on the third floor [NAME] and staff began serving to the residents in their rooms. At 8:37 AM, a meal cart arrived to the second floor East Unit. At 9:03 AM, the last meal served to the residents in their rooms on the second floor East Unit. At 9:17 AM, the last meal was served to the residents in their rooms on the third floor East Unit. During an interview, at the conclusion of the breakfast observations, with the Diet Tech, the Diet Tech stated that the meal schedule that was posted in the Main Dining Room and the dining rooms on the units was the time that the meal carts were to leave the kitchen and not the time that the meals are served. b. During observation of lunch, on 07/19/23 at 1:03 PM, the last was meal was served from cart on the second-floor East unit. c. During an observation of the carts leaving the kitchen and being sent to the units, on 07/20/23 beginning at 7:59 AM, the following observations were made: At 7:59 AM, the first cart left the kitchen for second floor [NAME] unit. At 8:11 AM, the second cart left the kitchen for the third floor [NAME] Unit. At 8:50 AM, the last cart left the kitchen for the third floor East Unit. During an interview, on 07/20/23 at 9:02 AM, with the Administrator and Activity Director, the Administrator stated, A new food delivery system will be starting August 2 [2023] that I mentioned at the meeting yesterday (referring to the Resident Council meeting that was scheduled for that 07/19/23), that is one of my QAPIs (PIP) [Quality Assurance and Performance Improvement / Performance Improvement Plan] that we started because they (the residents) were complaining that the food was cold. The pellet system that we had was broken, so they have to warm up the pellets in the oven so they can have hot food. It has been on order for 3 months (referring to the pellet warmer). An interview was conducted on 07/20/23 at 9:26 AM, with the vendor from Aladdin/TempRite (kitchen equipment vendor), the Administrator, the Dietitian, the Dietary Tech and Staff T, Dietary Aide. The vendor confirmed that the new pellet warmer had been ordered in April [2023] and stated, It takes 3 months to get one built. The Administrator stated, the pellet warmer would work for a while and then would stop working and then we would get it repaired and it would stop working again. This has all been going on since the new one has been ordered. We tried different avenues, originally, when they [residents] were complaining the food was cold. We strategized to took care of the cold food. Yesterday, [during Resident Council] they said that the food wasn't cold. When there were specific residents with a concern, we would put their meal on a different cart. The Dietary Tech stated, the first cart leaves the kitchen at 7:45 AM and the last care leaves the kitchen at 9:00 AM. During an interview, on 07/20/23 at 2:37 PM, the Administrator stated, They had the PIP going to heating the pellets up in the oven was a slow process. I read that it happened at times [referring to the concerns voiced during the interview with members of the Resident Council], I wasn't seeing that it was consistent. Yesterday, Resident #1 was the only one that spoke up. They were monitoring the tray line [referring to the Dietary Tech and Staff T] PIP to ensure that they were leaving the floor at the appropriate times to get to the residents. They should be doing random audits for compliance, they did it once a week. They did some breakfast, some lunch and some dinner. The audits showed that they were timely. Staff T would go up to the residents and would go and talk to them during the Food Committee meetings and Resident Council. When asked about following up with the residents to ensure that the meals were delivered timely, the Administrator stated that there was no follow-up with the residents. During an interview, on 07/20/23 at 2:45 PM, with the Dietitian and the Dietary Tech, the Dietary Tech stated that during the audits of the carts leaving the kitchen, all of the carts left the kitchen on time, according to the schedule. When asked if the timing of removing the meals from the carts and delivering to the residents was considered, the Diet Tech stated that it was not part of the audits. When asked about follow-up with the residents that voiced concerns, the Diet Tech stated that there was no follow-up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide fingernail grooming for 2 of 2 sampled residents, Residents #16 and #38. The findings included: Review of the facility's policy, titled, Fingernails/Toenails, Care of published on 05/19/23, documented, in part, the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .proper nail care can aid in the prevention of skin problems around the nail bed .trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .documentation: the following information should be recorded in the resident's medical record: the date and time that nail care was given . 1. Review of Resident #16's clinical record documented an admission on [DATE] and diagnoses that included Sepsis, Cellulitis, Depression, and Chronic Conjunctivitis of Right Eye. Review of Resident #16's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0 of 15 indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed 'from extensive to total assistance from the staff to complete the activities of daily living' (ALDs). Review of Resident #16's care plan, titled, Resident has self-care deficit related to Sepsis, initiated on 07/06/21 and revised on 07/07/23, documented ' .requires extensive assistance with ADLs, dressing, bathing, hygiene, meals .' On 07/17/23 at 10:48 AM, observation revealed Resident #16 lying in bed, eyes were open, non-verbal, and non-interviewable. The resident was observed bringing her left-hand fingernails into her mouth. The fingernails were approximately 1/4 inch past the tips of her fingers. Closer observation revealed dark residue underneath her fingernails. Further observation revealed the resident's right hand had a contracture (hand was closed, unable to open it) and the fingernails were approximately ½ inch long, jagged and digging into the palm's skin. The observation revealed a skin scratch next to the resident's right wrist. The resident was not wearing any arm sleeves to protect the skin from scratches. On 07/18/23 at 8:59 AM, observation revealed Resident #16 lying down in bed, and being fed by Staff E, Certified Nursing Assistant (CNA). Staff E stated the resident did not talk. Further observation revealed the resident continued to have long and jagged fingernails on both hands. On 07/18/23 at 10:25 AM, observation revealed Resident#16 continued to have long and jagged fingernails on both hands. On 07/18/23 at 2:43 PM, an interview was conducted Staff B, CNA, who said she was responsible to clean and file the residents' fingernails. Staff B added she would not cut, but would tell the nurse, if she sees the fingernails were long. On 07/18/23 at 2:55 PM, an interview was conducted with Staff C, CNA who stated she saw that Resident #16's fingernails were long and filed them today. She stated it is common sense that if we see them long, you have to file them. Staff C stated she did the resident's fingernails maybe two weeks ago. On 07/18/23 at 3:42 AM, interview was conducted with Staff O, Licensed Practical Nurse (LPN), who stated that all CNAs were responsible to clean and file the resident's fingernails. A side-by-side review of photographs of Resident #16's fingernails was conducted with Staff O. Photographic Evidence Obtained. 2. Review of Resident #38's clinical record documented an admission on [DATE], a readmission on [DATE] and diagnoses that included Pneumonia, Chronic Pain, Psychosis, Anxiety, Epilepsy, Cerebral Infarction, Legal Blindness, Hemiplegia (paralysis) of the Left side and Diabetes Mellitus, type II. Review of Resident #38's MDS annual assessment dated [DATE] documented a BIMS score of 0 of 15 indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was totally dependent on the staff for completing the activities of daily living including personal hygiene (washing / drying her hands). Review of Resident #38's care plan, titled, .self-care deficit related to diagnoses of Stroke with left Hemiplegia, Diabetes Mellitus, legally blind, initiated on 09/28/21 and revised on 05/29/23, documented an intervention that read requires extensive assistance with .hygiene. On 07/17/23 at 12:07 PM, observation revealed Resident #38 lying in bed. The resident was non-verbal, and non-interviewable. Closer observation revealed the resident's right hand was resting on a soft palm device, with a large yellowish stain on it. Further observation revealed the resident's fingernails were approximately ¼ inch long with dark residual underneath her nails. Further observations revealed the resident's call device was resting next to her linens and around her abdomen area and had yellowish stains on the bell and the cord. On 07/18/23 at 10:25 AM, observation revealed Resident #38 lying in bed. The resident continued to have her right hand resting on a soft palm device, with a large yellowish stain on it. Further observation revealed the resident's fingernails continued to be long and with dark residue underneath her nails. On 07/18/23 at 3:04 PM, an interview was conducted with Staff E, CNA, who stated she works the 3:00 PM to 11:00 PM shift and her duties were to bathe the resident, assist with dinner, toileting, do some activities, cut their fingernails, and wash their hair and shave if needed. A side-by-side observation of Resident #38's fingernails was conducted with Staff E who confirmed that the resident fingernails were long. Further observation revealed the resident did not have the right-hand palm soft device on as previously observed. On 07/18/23 at 3:06 PM, an observation of Resident #38 fingernails was conducted with Staff D, CNA, who confirmed the resident's fingernails were long. Staff D stated that the 3:00 PM to 11:00 PM shifts' CNAs were supposed to check on the residents' fingernails. Staff D added that she did not have time to do the resident's fingernails (Resident #38) but would do it before she leaves her shift today. On 07/18/23 at 3:33 PM, an interview was conducted with Staff F, CNA, who stated her duties were to make rounds with the (outgoing) 7:00 AM to 3:00 PM shift CNA, to check on the residents and made her aware of what needs to be done for the resident. Staff F stated her duties also included: resident's repositioning, check their fingernails and to file them if needed. She added that most of the time the nurses will tell everybody to do the residents' nails. Staff F stated she had 9 residents assigned to her on 07/17/23 including Resident #38 and she did not do the residents' fingernails. Staff F stated she did not notice that Resident #38's fingernails were long and needed to be cleaned and filed. On 07/18/23 at 3:42 AM, interview was conducted with Staff O, LPN, who stated that all CNAs from all shifts were responsible to clean and file the residents' fingernails. On 07/18/23 at 4:07 PM, an interview was conducted with Staff G, LPN, who stated that every shift CNA is supposed to clean and trim the residents' fingernails. On 07/20/23 at 12:35 PM during an interview, the Director of Nursing (DON) was apprised of the above findings. The DON stated that she cleaned Resident #38's call device and added that a new soft palm hand device for the resident was ordered on 07/18/23.

**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 obtain a physician order for the follow-up care and removal of nasal sutures for 1 of 5 sampled residents observed, Resident #42; failed to follow physician's orders for application of bilateral [NAME] sleeves for 2 of 5 sampled residents observed, Resident #16 and Resident #42; failed to ensure that staff changed dressings in accordance with professional standards and per physician's orders for 4 of 5 sampled residents observed, Resident #16, Resident #21 Resident #66 and Resident #205; and failed to identify, document, and follow-up with the status of a resident's visible skin condition on the anterior chest for 1 of 5 sampled residents observed, Resident #205. The findings included: Review of the facility policy and procedure, provided by Director of Nurse (DON) on 07/20/23 at 3:54 PM, titled, Wound Care, published 05/19/23, documented, in part, in the Policy Statement: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident .Documentation: The following information should be provided in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data .7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data. Reporting: .2. Report other information in accordance with facility policy and professional standards of practice. Review of the facility policy and procedure provided by the DON on 07/20/23 at 3:47 PM, titled, Medication and Treatment Orders, published 03/13/23, documented, in part, in the Policy Statement: Orders for medications and treatments will be consistent with 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 .7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, the date and the time of the order. Review of facility's un-dated 'Registered Nurse (RN) job description' on 07/20/23 at 1:45 PM provided by the DON [Director Of Nursing] documented, in part, Purpose of your job position: Duties include: .Document resident care services by charting in resident medical record and department records Assure quality of care by adhering to the Department of Health (DOH) standards of practice and facility standards of care . Review of facility's undated 'Licensed Practical Nurse (LPN) job description' on 07/20/23 at 1:56 PM provided by the DON documented, in part, Purpose of your job position: Overview of Role The licensed practical nurse is a staff nurse who provides direct, primary nursing care to residents and delegates and supervises the care provided by certified nursing assistants Major Responsibilities: Administrative 3. Receives and records physician's orders .11. Administers treatments and other direct care .c. Identifies and promptly communicates adverse drug reactions . 1. Resident #42 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Diabetes Mellitus Type II, Dysphagia, Hemiplegia right dominant side and Epilepsy. He had a Brief Interview Mental Status (BIMS) score of 15, indicating cognitive was intact. During an observation conducted on 07/17/23 at 10:04 AM, Resident #42 was observed with some blue-colored intact sutures in place on the bridge of his nose. The sutures did not appear infected or red. On 07/17/23 at 10:15 AM, an interview was attempted with Resident #42, in which he was asked about the presence of the sutures on the bridge of his nose, but he was unable to provide any more information other than to mention that he vaguely remembered having 'had a fall a little while ago, somewhere'. During a second observation conducted on 07/17/23 at 4:24 PM, Resident #42 was noted to still have some blue-colored intact sutures there in place on the bridge of his nose. During a third observation conducted on 07/18/23 at 10:10 AM, Resident #42 was noted to still have some blue-colored intact sutures there in place on the bridge of his nose. During a fourth observation conducted on 07/18/23 at 4:00 PM, Resident #42 was noted to still have some blue-colored intact sutures there in place on the bridge of his nose. During a fifth observation conducted on 07/19/23 at 12:05 PM, Resident #42 was noted to still have some blue-colored intact sutures there in place on the bridge of his nose. The sutures did not appear infected or red. Photographic Evidence Obtained. Review of Resident #42's hospital's consultation note, dated 04/24/23, documented that Resident #42 tripped and fell at home with his walker and sustained a laceration to his nose with subsequent nasal bone fractures. There was no notation relating to the presence of nasal sutures. Review of the Advanced Registered Nurse Practitioner (ARNP) admission progress dated 05/03/23 had no notation relating to the presence of nasal sutures. Further record review of Resident #42's three (3) weekly skin evaluations, dated 07/02/23, 07/06/23 and 07/13/23, all indicated that Resident #42's skin was intact, at baseline, with no new skin areas noted. Following admission to the facility on [DATE] at 3:43 AM, Staff R, LPN, had previously identified and documented that Resident #42 has multiple bruises to upper and lower body, including face and sclera. Bruises are dark purple, slight greenish and yellowish in color. there was no indication of nasal sutures. On 05/02/23, the care plan documented that Resident #42 has an 'actual potential for skin breakdown related to decreased mobility / daughter stated resident has a behavior of picking at his skin. Approaches: Skin assessment by licensed nurse per facility protocol. Goal: Will minimize risk for skin breakdown through next review date Any noted skin interruptions will resolve without signs and symptoms of infection daily through next review date'. On 07/19/23 at 1:32 PM, an interview was conducted with Staff P, Licensed Practical Nurse (LPN), who, when he was asked the following, responded: When asked, was the resident admitted to the facility with the nasal sutures in place, the nurse stated that he wasn't sure and said that he would have to check. When asked, how long have nasal sutures been in, the nurse stated that he would not know this. When asked, what were they put in place for, Staff P stated that he did not know. When asked, where the physician's orders for care and removal of the nasal suture were located, Staff P stated that he did not know, but that he would check the resident's chart. Staff P acknowledged that the nasal sutures were in place and stated there was no physician's orders in the record for the care and removal of the nasal sutures. On 07/19/23 at 1:52 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the resident was admitted to the facility with the nasal sutures in place but would have to research the record for how long the sutures were in place, why the resident had sutures, and let the surveyor know. The ADON stated she would notify the physician. She acknowledged that the nasal sutures were in place, and stated there was no physicians' orders in the record for the care and removal of the nasal sutures (admitted [DATE]). A side-by-side record review was conducted with Staff P, that revealed it was not documented that on the facility's weekly skin assessment evaluations dated 07/02/23 thru 07/13/23, or in the nursing progress notes dated 07/15/23 through 07/18/23, of the existence of Resident #42's nasal sutures. The nursing progress notes only documented that Resident #42 had a 'nasal bridge incision without dressing, no drainage noted'. There were no interventional follow-up orders for subsequent suture removal. There was a physician order dated 07/12/23 for 'Nose Incision - Monitor for s/s [signs / symptoms] of infection every shift for 3 Days'. There is no order recorded for the care and removal of Resident #42's nasal sutures. On 07/19/23 at 3:25 PM, an interview was conducted with the DON. The DON stated she would have to review the resident's entire chart to see if the resident was admitted with the nasal sutures, why the resident had nasal sutures, if there were physician orders for care and removal of the nasal suture, and if there was a current plan for the nasal sutures. The DON acknowledged the nasal sutures were in place and she further indicated that there were no physicians' orders on file for the care and removal of the nasal sutures. The record revealed that a physician order was not written for nasal suture removal, until after surveyor intervention. 2. Resident #42 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Diabetes Mellitus Type II, Dysphagia, Hemiplegia right dominant side and Epilepsy. The record documented BIMS score of 15 (cognitively intact). Following admission to the facility on [DATE] at 3:43 AM, Staff R, LPN, had identified and documented that Resident #42 has multiple bruises to upper and lower body, including face and sclera. Bruises are dark purple, slight greenish and yellowish in color. The record documented a physician order dated 05/09/23 for Geri sleeves to both arms every shift. On 07/17/23 at 10:04 AM, during an observation, Resident #42 was observed with a dime-sized reddened ecchymotic-like bruise to his uncovered and exposed right outer upper arm approximately two to three (2-3) inches above his right elbow. Observation revealed there were no Geri sleeves in place on the resident's arms as ordered, and no Geri sleeves at resident's bedside. Photographic evidence was obtained. During further observations conducted on 07/17/23 at 4:02 PM, 07/18/23 10:11 AM, 07/18/23 at 4:00 PM, and 07/19/23 at 12:05 PM, Resident #42 was still observed with a dime-sized reddened ecchymotic-like bruise to his uncovered and exposed right outer upper arm approximately two to three (2-3) inches above his right elbow. No Geri sleeves were observed to the arms as ordered for each shift. Photographic Evidence Obtained. On 05/02/23, the care plan documented Resident #42 had an actual-potential for skin breakdown related to decreased mobility / daughter stated resident has a behavior of picking at his skin. Approaches: Skin assessment by licensed nurse per facility protocol .Geri sleeves to arms. Goal: Will minimize risk for skin breakdown through next review date Any noted skin interruptions will resolve without signs and symptoms of infection daily through next review date. On 07/19/23 at 1:31 PM, an interview was conducted with Staff P, Licensed Practical Nurse (LPN), in which he was asked the following questions: Does the resident currently have a dime-sized reddened ecchymotic-like bruise to his uncovered and exposed right outer upper arm approximately two to three (2-3) inches above his right elbow, with no Geri sleeves observed to both arms on the resident. Staff P acknowledged, yes; Is there a physician's order for application of bilateral Geri sleeves every day shift for this resident and the nurse acknowledged, yes; What date was it obtained, and he responded 05/09/23; What are the Geri sleeves ordered for, and the nurse stated to protect the arms from friction, etc. Staff P acknowledged that there was a Geri sleeves order for bilateral arms written for the resident dated 05/09/23. He confirmed that the Geri sleeves were not on the resident as ordered. On 07/19/23 at 2:02 PM, an interview was conducted with the ADON in which she was also asked the above questions. The ADON responded as Staff P to the questions. The ADON also acknowledged that there was a Geri sleeves order for the resident's bilateral arms that was written 05/09/23. She indicated that the resident's Geri sleeves should have been applied as ordered in order to avoid further impairment of skin integrity. On 07/19/23 at 3:29 PM, an interview was conducted with the DON in which she was asked the same above questions. The DON responded as did Staff P and the ADON. When asked what the Geri sleeves were ordered for, the DON stated, for an added layer of protection. The DON further acknowledged that there was a Geri sleeves order for bilateral arms written for Resident #42 dated 05/09/23. She further stated there was no documentation in the record to reflect that the resident's Geri sleeves were applied to his skin as ordered to avoid further impairment of skin integrity. A side-by-side record review was conducted with Staff P and with the ADON in which it was documented there was a physician's order for bilateral Geri sleeves and documented on the Treatment Administration Record (TAR) for Resident #42 dated 05/09/23. The Geri sleeves were not observed applied to the resident during three (3) days of the four (4) day survey. Resident #42's Geri sleeves were not applied, until after surveyor intervention. 3. On 07/17/23 at 10 AM, an observation revealed Resident #205 had a clear Opsite right upper abdominal quadrant dressing in place, which was moistened and discolored in appearance, not clean, not properly covering site and not dated. The dressing was not maintained and not patent with the right lower corner crumpled edges curled, loosened and lifting up and not flattened out to create a solid, secure barrier for the previous Jackson Pratt (JP) drainage site. Photographic Evidence Obtained. On 07/17/23 at 4:18 PM, during a second observation, Resident #205 was observed with the Opsite clear dressing, still not patent with right lower corner crumpled edges curled, loosened and lifting up and not flattened out. On 07/17/23 at 4:25 PM, during an interview, Resident #205 stated he had an appointment scheduled with the general surgeon for tomorrow to see his right upper quadrant dressing site. He added that his friend was unavailable to accompany him to this appointment which had to be changed to a later date this month when his friend will be able to take him to his appointment. On 07/18/23 at 4:26 PM and 07/19/23 at 12:18 PM, during additional observations, Resident #205 was still observed with the Opsite clear dressing still not patent now with the left and right lower corner crumpled edges curled, loosened and lifting up and not flattened out. On 07/19/23 at 1:47 PM, an interview was conducted with Staff P, in which he was asked about the resident's dressing. He stated that he was aware of the current condition of the resident's right quadrant dressing site. He voiced that he didn't do anything about it at the time. During an interview conducted on 07/19/23 at 2:20 PM with the ADON, she was asked if she was aware of current condition of the resident's right quadrant dressing site. She did not comment on the current condition of the dressing site. She stated that she would have to look into this and follow-up. Review of the Baseline care plan of 07/08/23, completed by Staff Q, (RN)/Minimum Data Set (MDS) Coordinator, revealed it only documented Resident #205's current/recent skin integrity issue, as JP [Jackson Pratt] drainage on right side, at the time. Further side-by-side record review with Staff P, and with the ADON, did not reveal there were physician orders obtained for the care, management and follow-up of the resident's right side previous Jackson Pratt (JP) drainage site, now the Opsite right upper quadrant abdominal dressing. Resident #205's right upper abdominal quadrant dressing site was not changed, treated and properly dated, until after surveyor intervention. During an interview conducted on 07/19/23 at 3:10 PM with the DON she was asked if she was aware of current condition of the resident's right quadrant dressing site. Her only comment regarding this was that the name and phone number of a Wound Care Specialist was listed on the resident's profile sheet. There was no other documentation recorded in the resident's file to indicate that this Wound Care Specialist had been contacted or notified on behalf of the resident's skin dressing condition. The DON stated she would have to look into this and follow-up. 4. Resident #205 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included Paroxysmal Atrial Fibrillation, Hypertension, Malignant Neoplasm Bladder, Malignant Neoplasm of Colon and Malignant Neoplasm of Prostate. He had a Brief Interview Mental Status (BIM) score of 10 of 15, indicating moderately cognitive impairment. An observation was conducted on 07/17/23 at 9:55 AM. Resident #205 was observed having a reddened raised dime-sized, misshaped, crusty area to the center of his chest. The area did not appear to be infected. Photographic Evidence Obtained. On 07/17/23 at 10 AM, an interview was conducted with Resident #205. The resident stated he had mentioned to the facility staff about the skin condition on his chest that had been there for some time. He stated that since being in the facility, nothing has been done about it and he is concerned that no doctor has been in to look at it yet. During a second observation conducted on 07/17/23 at 4:18 PM, Resident #205 was still observed with the reddened, crusty dime-sized area to his center chest, as well as the right upper abdominal quadrant dressing site that was still undated, moistened, discolored in appearance, not clean and observed to not have been changed. During additional observations conducted on 07/18/23 at 4:25 PM and 07/19/23 at 12:15 PM, Resident #205 was still observed with the reddened, crusty dime-sized area to his center chest, as well as the right upper abdominal quadrant dressing site still with an undated dressing which was moistened, discolored in appearance, not clean and observed to not been changed. At these times, the resident stated that the area to his chest was now oozing clear liquid, which is getting on his shirts, and was itching, tender and uncomfortable. The wound did not appear to be infected at this On 07/19/23 at 1:47 PM an interview was conducted with Staff P, when asked if he was aware of the reddened, crusty dime-sized area to the resident's center chest, replied, 'no'. During an interview conducted on 07/19/23 at 2:13 PM with the ADON, when asked if she was aware of the reddened, crusty dime-sized area to the resident's center chest, she replied, 'no'. On 07/08/23, review of the Baseline care plan, completed by Staff Q, RN/MDS Coordinator, documented the presence and existence of Resident #205's current skin integrity issues as, 'open area on middle chest'. A side-by-side record review with Staff P and the ADON revealed no evidence that there were physician orders obtained for the care, management and follow-up for Resident #205's anterior chest skin condition. Resident #205's reddened, crusty dime-sized area to his center chest skin area was not treated and dressed until after surveyor intervention. During an interview conducted on 07/19/23 at 3:10 PM with the DON, when asked if she was aware of the reddened, crusty dime-sized area to Resident #205's center chest, stated that the name and phone number of a Wound Care Specialist was listed on the resident's profile sheet. There was no other documentation recorded in the resident's record to indicate that the Wound care Specialist had been contacted or notified on behalf of the resident's skin wound or dressing condition. The DON added that she would have to look into this and follow-up. 4. Review of Resident #16's clinical record documented an admission on [DATE] with diagnoses that included Sepsis, Cellulitis, Depression, and Chronic Conjunctivitis of Right Eye. Review of Resident #16's MDS annual assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0 of 15, indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed from extensive to total assistance from the staff to complete the activities of daily living ALDs). Review of Resident #16's clinical record revealed a lack of a written physician order for a dry dressing for the resident's left elbow. Review of Resident #16's physicians order dated 07/02/21 documented Geri-sleeves to bilateral upper extremities may remove daily and check skin integrity and for daily hygiene care. Review of Resident #16's physicians order dated 10/24/22 documented Geri-sleeves to bilateral upper extremities for protection may remove for skin checks and hygiene. Review of Resident #16's July 2023's MAR (Medication Administration Record) lacked written documentation related to the dry dressing care administration. Review of Resident #16's July 2023's TAR (Treatment Administration Record) lack written documentation of the application of the Geri-sleeves sleeves to the resident's arms from 07/01/23 to 07/18/23 during the day and evening shift. Further review revealed the application of the Geri-sleeves sleeves during the night shift from 07/01/23 to 07/18/23. On 07/17/23 at 10:48 AM, observation revealed Resident #16 in bed, awake and starring at the surveyor, unable to answer questions asked. Further observation revealed the resident had an undated dry dressing on her left elbow and no Geri-sleeves to either arm was noted. On 07/18/23 at 8:59 AM, observation revealed Resident #16 in bed, awake, non-verbal. Further observation revealed the resident continued to have an undated dry dressing on her left elbow and no Geri-sleeves were noted to her arms. Further observation revealed Staff E, CNA, was feeding the resident. Staff E stated the resident did not speak. On 07/18/23 at 10:25 AM, a side-by-side observation of the undated dry dressing on Resident #16's left elbow was conducted with the DON. The DON stated that Staff O, LPN, does rounds with the Wound Care Specialist. The DON stated that Resident #16 did not have a wound. The DON was apprised that the undated dry dressing had been in place since 07/17/23. On 07/20/23 at 12:40 PM, during an interview, the DON stated she did remove Resident #16's dry dressing to her left elbow and noted coagulated blood. The DON added, it was very dry. The DON stated the facility did not have any Geri-sleeves in house until 07/19/23. 5. Review of Resident #21's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's diagnoses included Osteomyelitis of Sacral and Sacrococcygeal Area, Dementia, Sepsis, Dysphagia (difficulty swallowing) Epilepsy, Neuropathy and Closed fracture of Right Lower Leg. Review of Resident #21's MDS admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3 of 15, indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living. Review of Resident #21's physician's orders dated 07/12/23 documented, apply skin prep to scabs on right upper arm daily for 7 days- stop date 07/19/23. Further review revealed a lack of a physician's order for the resident's left upper arm dressing change. Review of Resident #21's July's TAR revealed the lack of written documentation that the resident's received care to the left upper arm. On 07/17/23 at 11:18 AM, observation revealed Resident #21 in bed with an undated dry dressing on her left upper arm above the elbow. Attempted to interview the resident who stated that she was slow. The resident was unable to state the last time her left upper arm dressing was changed. During the interview, observation revealed Staff A, LPN, came into the resident's room. Staff A was asked about Resident #21's undated left upper arm dry dressing and replied she had not worked for the last two days and did not know why the resident had the dressing on her left upper arm. Subsequently, observation revealed Staff A removed the resident's dressing. Further observation revealed the dressing was covering a scab on the Resident #21's left upper arm approximately two inches above the antecubital (elbow) area. During, an interview, Staff A stated she was going to contact the physician because she did not see an order for dressing changes to the left upper arm. On 07/18/23 at 10:22 AM, a side-by-side review of Resident #21's left upper arm's dressing was conducted with the DON. The review revealed a dry dressing dated 07/17/23. The DON was apprised that on 07/17/23 during initial survey observations, it was noted that Resident #21 had an undated dry dressing on her left upper arm and Staff A placed a new dry dressing on 07/17/23. Subsequently, an interview was conducted with Staff H, LPN, who stated she did Resident #21's skin check (today) 07/18/23 and did not pay attention to the dressing on the resident's left upper arm because she thought it was the laboratory staff who placed it when blood was drawn on yesterday (07/17/23). Staff H was asked when she would remove the dressing from the laboratory and replied she would remove it on 07/19/23. On 07/18/23 at 10:40 AM, observation revealed Staff H (LPN) and Staff O (LPN) gathered two skin prep, one silicone super-absorbent dry dressing and non-stick dry dressing. Staff H proceeded to performed hand hygiene and donned gloves, then removed Resident #21's dressing dated 07/17/23. Staff H stated that the resident had a scab on her left upper arm. Observation revealed Staff O wiped the resident's upper arm scab with the skin prep and stated she will leave the scab open to air. During an interview at this time, Staff O stated she knew Resident #21 was getting skin prep to the left arm. Staff O was apprised that the physician order documented skin prep to the right arm, and there was not a physician order for the resident's left arm scab care. On 07/18/23 11:15 AM, a joint interview was conducted with Staff A (LPN) and Staff O (LPN). Staff A confirmed that she saw Resident #21's undated dressing on 07/17/23 and that she cleaned the resident's left upper arm scab with normal saline and placed a call to the physician. Staff A stated she informed the evening nurse to follow up with the physician and had not heard about a new order. 6. Review of Resident #66's clinical record documented an admission on [DATE] with diagnoses that included Chronic Obstructive Disease, Diabetes Mellitus Type II, Hypertension, and Anxiety. Review of Resident #66's MDS quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 of 15, indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed supervision from the staff to complete most activities of daily living except for toilet use and personal hygiene where the resident needed extensive assistance. Review of Resident #66's clinical record lacked documentation of a physician's order for the resident's left upper arm dressing. On 07/17/23 at 11:04 AM, an interview was conducted with Resident #66, who stated she had been in the facility for two months. Observation revealed an undated dry dressing, that was loose and dirty, on the resident's left upper arm, above the elbow. The resident stated that she had the dressing on for a couple of days and probably needed to be changed. Further observation revealed Resident #66 pulling the dressing and the skin was fixed (stuck) to the gauze. The resident stated she hit her skin against the doorknob and got skin breakdown. On 07/17/23 at 11:25 AM, an interview was conducted with Staff A, LPN, who stated she should know the resident by now. A side-by-side review of Resident #66's physician orders was conducted with Staff A, who stated there was not a physician orders for the resident's dry dressing. Subsequently, a side-by-side review of Resident #66's dry dressing was conducted with Staff A, who stated the dressing looked like it needed to be changed and was dirty. On 07/17/23 at 11:31 AM, observation revealed Staff A, LPN, entered Resident #66's room, performed hand hygiene, donned gloves and removed the resident's undated dry dressing on the left upper arm. Continued observation revealed a healing skin tear and the removed gauze had small amount of slight green and brownish drainage. During dressing removal, Resident #66 was guiding, telling Staff A how to pull the dressing from the top to so she will not hurt her. Further observation revealed a new skin tear above the healing skin tear. Staff O stated a non-stick gauze had been placed and the resident's skin ripped off when she pulled the gauze. Observation revealed Staff A left the resident's room to gather wound care supplies. Observation revealed Resident #66's new skin tear was bleeding and the resident was applying pressure with a napkin. At 11:37 AM, Staff A returned to Resident #66's room, donned gloves, brought in non-adherent gauze, soaked the non-adherent gauze with normal saline solution, placed the gauze over the new open skin tear, then with the same non-adherent gauze, cleaned the skin tear, applied a clean non-adherent gauze to the open skin and covered the non-adherent gauze with a dry dressing (kling roll). Staff O stated she would call the doctor. Continued observation revealed Staff A removed her pair of gloves, reached into her uniform pocket with both hands and retrieved a pair of scissors and without disinfecting the scissors, proceeded to cut the dry dressing (kling roll). Continued observation revealed Staff A placed the pair of scissors and her ink pen on top of the resident's linens, and then placed them in her pocket after use. On 07/18/23 at 11:18 AM, during an interview, Staff A was apprised of the concerns regarding her dressing change for Resident #66 on 07/17/23. Staff A confirmed that she left the resident with an open wound that she should have had the dressing supplies with her before she removed the old dressing. Staff A stated her scissors were clean and was apprised that she should disinfect them before and after use. On 07/18/23 at 11:45 AM, during an interview, the DON was apprised of Resident #66 having an undated dressing noted on 07/17/23. The DON was apprised that Staff A ripped off the resident skin above the healing skin tear while removing the dry dressing. The DON was apprised of skin tear observation concerns related to Resident #66's dressing change performed by Staff A. 7. 3) Review of Resident #66's clinical record documented an admission on [DATE] with diagnoses that included Chronic Obstructive Disease, Diabetes Mellitus Type II, Hypertension, and Anxiety. Review of Resident #66's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 of 15 indicating the resident had no cognition impairment. Review of Resident #66's physician orders dated 04/10/23 documented, Accucheck before meals and at bedtime. Review of Resident #66's physician orders dated 05/08/23 documented, Humalog 100 unit per millimeter KwikPen: administered subq (subcutaneously) per sliding scale . Humalog / Lispro is[TRUNCATED]

**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 obtain physicians' orders for oxygen therapy administration for 1 of 1 sampled resident observed for Oxygen use, Resident #42. The findings included: Review of the facility policy and procedure on 07/20/23 at 1:30 PM, titled, Oxygen Administration provided by the Director of Nursing (DON), documented in part, 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 .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 9. The signature and title of the person recording the data . Review of the facility policy and procedure on 07/20/23 at 3:47 PM, titled, Medication and Treatment Orders provided by the DON, published 03/13/23, documented, in part, in the Policy Statement: Orders for medications and treatments will be consistent with 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 .7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, the date and the time of the order. Review of facility undated Registered Nurse (RN) job description on 07/20/23 at 1:45 PM, provided by the DON, documented, in part, Purpose of your job position: Duties include: Medication administration and treatments Assure quality of care by adhering to the Department of Health (DOH) standards of practice and facility standards of care Review of facility undated Licensed Practical Nurse (LPN) job description on 07/20/23 at 1:56 PM provided by the DON documented, in part, Purpose of your job position: Overview of Role The licensed practical nurse is a staff nurse who provides direct, primary nursing care to residents and delegates and supervises the care provided by certified nursing assistants Major Responsibilities: Administrative 3. Receives and records physician's orders .11. Administers treatments and other direct care. a. Prepares and administers medications as prescribed. b. Observes and evaluates resident's responses to medications. c. Identifies and promptly communicates adverse drug reactions. Resident #42 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Diabetes Mellitus Type II, Dysphagia and Hemiplegia following other Cerebrovascular Disease affecting right dominant side and non-tractable Epilepsy. The record documented a Brief Interview Mental Status (BIMS) score of 15 of 15, indicating cognition was intact. During an observation conducted on 07/17/23 10:08 AM, Resident #42 observed resting in bed watching T.V. (television) with the head of the bed elevated and with Oxygen 3 liters infusing for via nasal cannula via oxygen concentrator. During an observation conducted on 07/18/23 10:30 AM, Resident #42 still observed resting in bed with Oxygen 3 liters infusing via nasal cannula via Oxygen concentrator. During an observation conducted on 07/18/23 at 2:50 PM, Resident #42 still observed resting in bed with Oxygen 3 liters infusing via nasal cannula via Oxygen concentrator. On 07/18/23 at 2:54 PM, an interview was conducted with Staff P, Licensed Practical Nurse (LPN), regarding Resident #42's order for oxygen. Staff P acknowledged that Resident #42 did have Oxygen infusing at three (3) liters via nasal cannula through an Oxygen concentrator without a physician's order. Staff P confirmed there should have been an physician order in place for Oxygen administration. On 07/18/23 at 3:16 PM during an interview with the Assistant Director of Nursing (ADON), she acknowledged Resident #42 had Oxygen infusing at three (3) liters via nasal cannula through an Oxygen concentrator, and she confirmed there should have been a physician order for such. A side-by-side record review of the facility's electronic computer system and the paper / hard copy chart was conducted with Staff P and the ADON. It was revealed that there was no physician order found in the records for Oxygen at three (3) liters to infuse via nasal cannula through an Oxygen concentrator for Resident #42. The Oxygen use was not documented in the Baseline care plan or the physicians' orders documentation section for Resident #42 dated 05/03/23. The record revealed there was no Oxygen therapy administration order for Resident #42 for the past two (2) months or more, during the resident's stay. A physician's order for the Oxygen therapy administration to be delivered at two (2) liters via nasal cannula Oxygen concentrator, was not obtained, until after surveyor intervention. On 07/18/23 at 3:40 PM, the DON recognized and acknowledged that a physician's order for the Oxygen therapy administration should have been obtained, and this had not been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to accurately reconcile controlled medications for 3 of 6 sampled residents reviewed for controlled medication administration, Residents #94, #71, and #11. The findings included: 1. On 07/20/23 at 11:57 AM, a side-by-side random review of controlled substance administration was conducted with Staff K, Registered Nurse (RN). The review was done for the medication cart for 3W (3rd floor west) and Resident #11. The medication reviewed was for Tramadol 50 mg tablets, give 1 tablet by mouth twice daily for non-acute pain. A printed copy of the Medication Administration Record (MAR) for July 2023 was provided for Resident #11. The medication was scheduled for 8:00 AM and 8:00 PM. On the Medication Monitoring / Control Record, there were entries from 07/01/23 to 07/19/23 for both the morning and nighttime doses. For 07/20/23, there was an entry for the morning dose. The MAR from 07/01/23 to 07/04/23 and again on 07/19/23, had no entries documented for the 8:00 PM dose times. There were no dosages recorded for 07/06/23, 07/08/23, and from 07/12/23 to 07/15/23. The morning dose was not recorded for 07/07/23. Photographic Evidence Obtained. 2. On 07/20/23 at 1:07 PM, a side-by-side review of controlled substance administration was conducted with Staff I, Licensed Practical Nurse (LPN). The review was done for the medication cart for 3E (3rd floor east) and Resident #71. The medication reviewed was Ativan (Lorazepam) 0.5mg tablets, give 1 tablet by mouth twice daily. Ativan (Lorazepam) is an antianxiety medication. The order for the medication changed on 07/03/23 from a dose of 0.25 mg (1/2 tablet) to a dose of 0.5 mg (1 tablet). A printed copy of the Medication Administration Record (MAR) for July 2023 was provided for Resident #71. The medication was scheduled for 8:00 AM and 8:00 PM. The medication was documented on the Medication Monitoring / Control Record for 07/06/23, where a new log was created for the new medication dose. The MAR for 07/04/23 revealed no 8:00 AM entry for the current dose. On 07/07/23, a dose was document on the MAR for the discontinued dose and the new dose. On 07/06/23, the 8:00 AM does was not captured on the MAR. On 07/14/23, the 8:00 PM does was not captured on the MAR. Photographic Evidence Obtained. On 07/20/23 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON) to discuss the above 2 findings. The Administrator was present. When the discrepancies were presented, the DON explained that the old electronic health record system sometimes had problems of blocking data entry from the nurses. The DON was asked if there were any other ways the nurses documented medication administration. The DON stated that she was not sure. The DON was informed that medication reconciliation of controlled medications is required to ensure these medications are being provided to the residents and not diverted away from the residents. The DON stated she understood the information provided but was unable to supply evidence of the controlled medications being pulled, administered, and documented as ordered. 3. Review of Resident #94's clinical record documented an admission on [DATE] with diagnoses that included Hypertension, Diabetes Mellitus type II, Cerebral Infarction and Toxic Encephalopathy. Review of Resident #94's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 12 of 15, indicating that the resident had moderate cognition impairment. Review of Resident #94's physicians' order dated 05/14/23 documented, Lacosamide 100 mg, give two tablets twice a day. a. Review of Resident #94's Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets), a controlled substance medication, documented that one tablet was removed from the controlled substance box on 05/20/23 at 7:30 PM, 05/21/23 at 9:00 PM, 05/28/23 at 8:00 AM. Review of Resident #94's May 2023's MAR documented Lacosamide 100 mg (2 tablets) was scheduled for 8:00 AM and 8:00 PM. The review revealed that Lacosamide 100 mg (2 tablets) was not documented on the resident's MAR, as being administered on 05/20/23 at 7:30 PM, 05/21/23 at 9:00 PM, 05/28/23 at 8:00 AM. b. Review of Resident #94's Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets) medication, documented that one tablet was removed from the controlled substance box on 06/05/23 at 8:00 PM, 06/08/23 at 8:00 PM, 06/10/23 at 8:00 PM, 06/12/23 at 8:00 PM, 06/14/23 at 8:00 AM, and 06/20/23 at 7:40 PM. Review of Resident #94's June 2023's MAR revealed that Lacosamide 100 mg (2 tablets) was not documented on the resident's MAR as being administered on 06/05/23 at 8:00 PM, 06/08/23 at 8:00 PM, 06/10/23 at 8:00 PM, 06/12/23 at 8:00 PM, 06/14/23 at 8:00 AM, and 06/20/23 at 7:40 PM. c. Review of Resident #94's Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets), a controlled substance medication lacked documentation of the controlled substance being removed from the box on 06/02/23 at 8:00 PM, 06/04/23 at 8:00 AM, 06/04/23 at 8:00 PM, and 06/05/23 at 8:00 PM. Review of Resident #94's June 2023's MAR documented Lacosamide 100 mg (2 tablets) was scheduled for 8:00 AM and 8:00 PM. The review revealed that Lacosamide 100 mg was documented on the resident MAR as being administered on 06/02/23 at 8:00 PM, 06/04/23 at 8:00 AM, 06/04/23 at 8:00 PM, and 06/05/23 at 8:00 PM. d. Review of Resident #94's Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets), a controlled substance medication, documented that one tablet was removed from the controlled substance box on 07/14/23 at 9:30 PM, and 07/15/23 at 5:30 PM. Review of Resident #94's July 2023's MAR documented Lacosamide 100 mg (2 tablets) scheduled for 8:00 AM and 8:00 PM. The resident's MAR documented that Lacosamide has been administered on 07/14/23 at 8:00 PM, the time did not match the time documented on the Medication Control Record (9:30 PM), and on 07/15/23 was not documented on the MAR as administered. On 07/19/23 at 10:10 AM, a side-by-side review of Resident #94's Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets), dated 07/14/23 to 07/18/23, was conducted with Staff O, LPN, and the Consultant Pharmacist (CP). Staff O was asked to submit Resident #94's Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets) dates from 07/05/23 to 07/14/23. During the review, Staff O and the CP were apprised that Resident #94 did not received his Lacosamide 100 mg two tablets as ordered on 07/14/23, 07/15/23, 07/16/23. On 07/19/23 at 11:35 AM, during an interview, Staff O, LPN, stated the nurses were to document in both places, on the Monitoring / Control Record and on the resident's MAR. Staff O confirmed that Resident #94's MARs and control record were not reconciled or matching. Staff O was asked to submit was Resident #94's the Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets) for the month of May and June 2023 and the MARs. The review revealed the lack of Lacosamide 100 mg (2 tablets), a controlled substance medication reconciliation, for Resident's 94's Medication Monitoring / Control Record and the resident's May, June, July 2023's MAR as required. On 07/20/23 at 11:26 AM, an interview was conducted with the Consultant Pharmacist who stated she was looking for the Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets) dates from 07/05/23 to 07/14/23. The CP was apprised of the lack of Resident #94's incorrect controlled substance reconciliation. The CP was apprised that Resident #94 did not received his Lacosamide 100 mg two tablets as ordered on 05/16/23, 05/17/23, 05/18/23, 05/19/23, 05/20/23, 05/21/23, 06/07/23, 07/14/23, 07/15/23, 07/16/23 as per review of the Resident's Medication Monitoring / Control Record. On 07/20/23 at 12:45 PM, during an interview, the DON was asked again to submit Resident #94's Medication Monitoring / Control Record for Lacosamide 100 mg (2 tablets) dates from 07/05/23 to 07/14/23. The DON stated they were looking for it. The DON stated she was aware of the lack of controlled substance reconciliation for Resident #94. On 07/20/23, at the end of the survey at approximately 6:00 PM, Staff O, the DON, or the Consultant Pharmacist had not submitted the Medication Monitoring/Control Record for Lacosamide 100 mg (2 tablets) dates from 07/05/23 to 07/14/23 as requested on 07/19/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' medications were properly supervised and stored, for 2of 6 sampled residents (Resident #21 and #66), as evidenced by medications being left unattended on the residents' bedside table and on top of the 300 west wing medication cart during a Medication Administration Observation. The findings included: Review of the facility's policy, titled, Storage of Medications, published on 03/13/23, documented, the facility stores all drugs .in a safe, secure .manner . 1. Review of Resident #21's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's diagnoses included Osteomyelitis of Sacral and Sacrococcygeal Area, Dementia, Sepsis, Dysphagia (difficulty swallowing), Epilepsy, Neuropathy and Closed fracture of Right Lower Leg. Review of Resident #21's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3 of 15, indicating the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #21's physician orders dated 07/06/23 documented, Pantoprazole 40 milligrams (mg) take 1 packet via PEG (tube feeding) 2 times daily before meals, Ascorbic Acid 500 mg give 1 tablet by mouth twice a day, and Creon DR 12,000 unit capsule give 1 tablet by mouth 3 times a day with meals. [CREON (pancrelipase) is a prescription medicine used to treat people who cannot digest food normally because their pancreas does not make enough enzymes.] Review of Resident #21's July 2023 Medication Administration Record (MAR) documented Pantoprazole Sodium 40 mg 1 packet via PEG 2 times daily before meals scheduled times 8:00 AM, 5:00 PM; Ascorbic Acid 500 mg give 1 tablet by mouth twice a day scheduled times 8:00 AM and 5:00 PM; Creon DR 12,000 unit capsule give 1 tablet by mouth 3 times a day with meals scheduled times 7:30 AM, 11:30 AM and 4:30 PM. On 07/18/23 at 4:31 PM, medication administration observation for Resident #21 performed by Staff J, Licensed Practical Nurse (LPN), was conducted. Staff J stated the resident gets all medications via PEG tube. Observation revealed Staff J poured Ascorbic Acid 500 mg into a pouch and then crushed the medication and poured it back into the medication cup, retrieved a packet of Pantoprazole Delayed Release oral suspension 40 mg. Staff J attempted to open the packet with her hand and was not able to. Staff j then walked away from the medication cart to the treatment cart approximately six feet away from the medication cart. Observation revealed Staff J left the crushed medication on top of the cart unattended. Staff J returned to the medication cart and stated that she was looking for scissors to open the Pantoprazole packet. Staff J was observed securing the medication cart and left the area to go to the nurses station. Continued observation revealed the crushed medication continued to be on top of the medication cart and unattended. At 4:39 PM, continued observation revealed Staff J returned to the medication cart and opened the Pantoprazole packet and poured the beads into a medication cup. Staff J opened the medication cart and poured Creon one capsule 12,000 unit into a medication cup. Staff J proceeded to enter Resident #21's room with the 3 medication cups on a faom tray, placed on the top of the bedside table, wheeled the table to the bathroom and performed hand hygiene. Observation revealed Staff J donned gloves, flushed Resident #21's tube feeding with 30 millimeters (ml) of water, administered the Ascorbic Acid medication via PEG tube, flushed the tube and administered the Pantoprazole beads, flushed the tube then attempted to open the Creon capsule and the capsule dissolved in her gloved hand. Staff J proceeded to remove her soiled gloves, walked to the medication cart and pulled another Creon capsule and poured it into a medication cup. Staff J walked away from the medication cart to the resident's room. Observation revealed Staff J performing hand hygiene in the resident's room. An inquiry was made regarding where the Creon capsule was. Staff J stated she took it out, then walked out of the resident's bathroom to the medication cart. Staff J stated she left the Creon medication on top of the medication cart. The medication was unattended on top of the medication cart. The medication cart was parked in the hallway and residents, staff and visitor walked by the cart. During an interview, Staff J stated that she was not supposed to leave the medication unattended. 2. Review of Resident #66's clinical record documented an admission on [DATE] with diagnoses that included Chronic Obstructive Disease, Diabetes Mellitus Type II, Hypertension, and Anxiety. Review of Resident #66's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 of 15, indicating the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed supervision from the staff to complete most activities of daily living except for toilet use and personal hygiene where the resident needed extensive assistance. Review of Resident #66's physician orders dated 04/10/23 documented, Accucheck before meals and at bedtime. Review of Resident #66's physician orders dated 05/08/23 documented Humalog 100 unit per millimeter KwikPen: administered subq (subcutaneously) per sliding scale . On 07/19/23 at 12:18 PM, a medication administration observation started for Resident #66 performed by Staff K, Registered Nurse (RN). Staff K performed hand hygiene, retrieved a foam tray and gathered the following: Lispro-Insulin KwikPen, Pen needle, a pair of gloves and alcohol pads and walked to the resident's room at 12:27 PM. Observation revealed Staff K proceeded to administer the resident's insulin on her left arm and placed the insulin Pen on top of the foam tray on the bedside table. Further observation revealed Staff K walked away from Resident #6's bedside, went to the bathroom, leaving the insulin Pen and the used pen needle on top of the table unattended. Staff K retrieved a paper towel, come out of the bathroom, wrapped the insulin pen with the paper towel, placed in on top of table again, and walked away from it, leaving the insulin pen unattended, went to the bathroom, and performed hand hygiene. Further observation revealed Resident's #66's roommate had a visitor in the room. Staff K returned to medication cart. A joint interview was conducted with Staff K, RN and Staff D, Certified Nursing Assistant (CNA), who voiced the resident usually eats her breakfast at 11:00 AM and lunch at 2:00 PM. On 07/19/23 at 12:42 PM, an interview was conducted with Staff K, RN who confirmed that she left the insulin pen on top of the table, away from her sight, while she went to wash her hands. Staff K stated she was supposed to keep the insulin pen with her. On 07/20/23 at 11:26 AM, during an interview, the facility's Consultant Pharmacist was apprised of the findings. On 07/20/23 at 12:45 PM, during an interview, the Director of Nursing was apprised of the findings.

Based on observations, interviews, and record review the facility failed to provide a safe, and clean environment for 6 of 6 sampled residents (Resident #52, #17, #49, #55, #23, and #30). The findings include: During an interview with the Administrator on 03/16/22 at 2:30 PM, she was asked for a maintenance policy that provides the process of how maintenance issues are identified, the process of submission of issues to the maintenance department, and how the issues are resolved. She stated, they do not have a policy. She provided a blank copy of maintenance/custodial work request sheet and a blank copy of facility safety committee meeting. 1. On 03/13/22 at 9:55 AM, an observation was made in Resident #52's room. The area around the air conditioning vent had a dark mold like substance and peeling paint; there was dust like debris in the bathtub; the exhaust fan in the bathroom above the bathtub was caked with dust like debris (Photographic evidence obtained). 2. On 03/13/22 at 10:04 AM, an observation was made in Resident #17's room. The area around the air conditioning vent had a dark mold like substance and peeling paint; there was dust like debris in bathtub; and the exhaust fan in the bathroom above the bathtub was caked with dust like debris (Photographic evidence obtained). 3. On 03/13/22 at 10:10 AM, an observation was made in Resident #49's room. The privacy curtain was frayed; the area around the air conditioning vent had a dark mold like substance and peeling paint; there was dust like debris in bathtub; the exhaust fan in the bathroom above the bathtub was caked with dust like debris; and in the corner of the bathroom ceiling was a discolored water mark like brown stain (Photographic evidence obtained). 4. On 03/13/22 at 10:16 AM, an observation was made in Resident #55's room. The exhaust fan in the bathroom was caked with dust like debris (Photographic evidence obtained). 5. On 03/13/22 at 10:23 AM, an observation was made in Resident #23's room. The chair rail behind the resident's bed and all along the entire width of the resident's bed was gouged out down to the bare wood; and there was missing paint from wall behind the bed. (Photographic evidence obtained). 6. On 03/13/22 at 10:42 AM, an observation was made of Resident #30's bathroom. There was dust like debris in the bathtub, and the exhaust fan above the bathtub was caked with dust like debris (Photographic evidence obtained). During the tour and interview, conducted on 03/16/22 at 12:00 PM with Staff J, Laundry/Housekeeping Services, she stated she has been with the facility for 18 years. When asked if a staff member noticed an issue that requires maintenance or housekeeping how does the issue get relayed to the appropriate department, she stated there are maintenance/housekeeping request forms at each nursing station for the staff or resident to fill out and then they leave it in another slot to be picked up by maintenance or housekeeping. Forms are picked up Monday thru Friday. Most issues are taken care of the same day, but some may take a little longer. If a maintenance issue is found to require more than what the maintenance department can do, they call one of their contractors to come out to fix the issue. Staff J stated during the tour that the facility knows it has a problem with the air conditioning system. She also stated that when the maintenance request forms are picked up, they are brought to the maintenance office, once the work is completed the form signed and dated with the completion date and filed. Outstanding orders are held in a pile. During an interview conducted on 03/16/22 at 12:20 PM with Staff D Certified Nursing Assistant (CAN), when asked how she reports a maintenance issue, she stated she fills out a form from the nursing station and puts it back in the slot and then maintenance will pick it up the next day. During an interview conducted on 03/16/22 at 12:28 PM with the Activities Director, when asked how she reports a maintenance issue, she said you fill out a work order form by the nursing station and leave it in the file at the nursing station to be picked up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #35 was readmitted to the facility on [DATE] from the hospital following admission for altered mental status and urinary tract infection. She has a medical history that is significant for a Pressure Ulcer on her Sacrum, Leg Facture, Anemia, Dementia, Stroke, Depression, and Heart Disease. On 01/13/2022, the resident weighed 147 lbs. On 03/01/2022, the resident weighed 140 pounds which is a -4.76 % Loss. A review of her Significant Change Minimum Data Set (MDS) completed on 01/20/22 showed that the interpretation of her Brief Interview for Mental Status (BIMS) score is 5, indicating severly impaired cognition. It also shows that she requires extensive assistance from the staff for her activities of daily living including position changes while in bed, eating, toileting, and personal hygiene. The MDS indicates that Resident #35 is having unintentional weight loss. The section which covers skin conditions indicates that Resident #35 has a stage 4 pressure ulcer which was present on admission from the hospital. A review of Resident #35's physician orders indicates that she is supposed to have daily and as-needed wound care for her pressure ulcer by the nursing staff. The orders also indicate that Resident #35 is supposed to receive supplements for her weight loss including Glucerna 1.2 one carton 3 times per day, Eldertonic Elixir 2 times per day, and Liquid Protein Fortifier 2 times per day along with her regular diet. There are also orders for Vitamin C, Multivitamin, Folic Acid, and Zinc. A Nutrition Assessment was completed by the Dietary Technician on 01/05/22 shows that Resident #35's admission weight was 147 pounds. It shows the resident's nutrient needs as follows: Calorie needs 70x30/35=2100/2450 kcal; Protein needs 70x1.1-1.3=77/91 grams of protein; Fluid needs 70x30=2100cc. The assessment summary states the resident has a history of poor intake of oral supplements and the nutritional risk is inevitably weight loss. It says the resident's body weight of 147 pounds is above the calculated Desirable Body Weight (DBW) of 104 pounds to 127 pounds. The recommendation from the Dietary Technician is to consider restarting 1-ounce Liquid Protein 2 times per day along with Vitamin C, Multivitamin, and Zinc A Significant Change Care Plan was completed by the facility on 01/24/22 related to weight loss suffered by Resident #35. It states that the resident will tolerate her current diet consistency to maintain a weight of +/- 3 pounds monthly. The suggested interventions include providing medications/supplements, providing snacks, dietary consultations as needed, providing diet as ordered, and observing oral intake, weights, and labs. A review of the electronic Medication and Treatment Administration Records reveals that Resident #35 refuses or is not administered her ordered oral supplements almost half of the time during the months of January, February, and March. A dietary note was written on 01/20/22 by the Registered Dietitian which states, Resident's wt. (weight) 147# (pounds). Wt. loss noted. Diet order mech (mechanical) soft, NAS (no added salt), LCS (low concentrated sweets). She is on Glucerna 1.2 1 carton TID (three times per day). Also, on Elder Tonic to help with appetite/intake. Wound noted. Will add back liquid protein 1oz (ounce) BID (two times per day). Continue MVI (multivitamin), Vit (vitamin) C, Zinc. Meds noted. CNA (Certified Nursing Assistant) charting shows good intake at BF (breakfast) and lunch and varied intake at dinner. F/U (follow up) with care plan team and adjust POC (the plan of care) as needed. A dietary note was written on 02/09/22 by the Registered Dietitian which states, Resident's wt. on 2/9 140#. Wt. loss of 28#. She is on Elder Tonic and Glucerna 1.2 TID. CNA charting showed varied intake poor to good. DBW (desired body weight) = 104-127 however rapid weight loss is not desired. Rec (recommend) 3-day calorie count to assess intake. Adjust POC as needed. Please note, the weight loss of 28 pounds talked about in this note is related to her original admission weight of 168 pounds taken on 11/12/21. A dietary note was written on 02/18/22 by the Registered Dietitian which states, Calorie count not available. CNA charting shows resident's intake on 2/10, 2/11, 2/12 was fair to good. 2/10/22 weight 142#. Will continue to observe intake/changes and adjust POC as needed. A dietary note was written on 03/16/22 by the Registered Dietitian which states, Resident's wt. 140#. Wt. stable x1 month after loss after a hospital stay. Diet order NAS, LCS diet. She is also on PO Supp (supplement) Glucerna 1.2 3x/day. MAR (medication administration record) shows intake of supp varies however will cont. (continue) as ordered and encourage intake. Meds noted. F/U for any new labs/wt./changes. Wt. maintenance acceptable as wt. is above DBW range. A review was conducted of wound assessment notes which were written on 01/26/22, 02/03/22, 02/16/22, 02/25/22, and 03/02/22. In each note, Resident #35's sacral wound was measured by the wound care doctor. There is no measurable improvement in the wound size documented during the time these notes were written. An interview was conducted on 03/15/22 at 09:28 AM with Dietary Technician. She stated she works in the facility 5 days per week. She said either herself or the Registered Dietitian completes the resident's dietary assessments- initial, follow up, high-risk residents, and significant change/weight loss. She said the follow-up assessments are done quarterly (every 3 months) or if there is a significant weight loss noted. She said the residents are all weighed on admission, then weekly for the first month, then monthly, but if there is a significant weight loss noted, the residents are changed to weekly weights. She said that a significant weight loss is considered a 10% drop in 6 months or a 5% drop in 1 month. When asked how she and the dietitian are notified of the residents who have significant weight loss, she said they print out the reports (found under the data collection history, underweights) monthly and watch the 6-month trend to calculate any weight loss. If there is any significant weight loss noted, they ask for the resident to be weighed again to make sure it was not a mistake. The Dietitian Technician reported that for any calorie count, nursing will tell the CNAs to record the calories in the resident's chart (found under the data collection history, under meal intake). When asked why it is important for calorie counts to be done accurately, she said it is important to know how much of each meal is being consumed by the residents. When asked how they know if ordered supplements are being consumed by the residents, she said if the residents are refusing the supplements, usually the nursing staff will tell them (dietary) and they will go to the resident to assess why they are refusing the supplement and if they would prefer a different kind of flavor. She said they also address supplements with the resident's quarterly assessments. When asked why a calorie count was not done despite being recommended by the dietitian on 02/09/22, she said she would prefer the dietitian to answer that question. When asked why there has been no follow-up on this resident refusing to consume her supplements, she said she did not know. An interview was conducted with the Registered Dietitian on 03/15/22 at 10:25 AM. She said that any follow-up assessments are completed with significant changes or if the resident is not doing well. When asked how she is notified of a weight loss, she said she prints the monthly weight logs every week for every resident. She said if there is a change noted, she asks for the resident to be re-weighed and she reviews the plan of care and may do a calorie count. She said she may add or change a supplement and check with the resident or family about their preferences and encourage the family to bring outside foods in. The surveyor showed her the concerns about the resident's significant weight loss and non-healing wound and her calorie count that was recommended but not done. Despite these facts, she said that because the resident had gained 2 pounds and was not below her desired body weight, she was not concerned that the calorie count was not done. When asked if she looked at the medication and treatment administration record to see that the resident was not taking the ordered supplements, she confirmed she did not. Based on observations, interviews, and record review, the facility failed to provide nutritional interventions in a timely manner for 3 of 7 sampled residents reviewed for nutrition (Resident #32, #35, and Resident #37). The findings included: 1. Review of the facility's policy titled Weight Assessment/Height and Weight Record maintenance and Reporting dated 11/15/21, showed that the Nursing assigned Restorative team shall be responsible to record heights and weights for our residents to prevent, monitor, and intervene in undesirable weight loss. It further showed that any weight loss of 5 pounds or more should be reported to the Dietary Department. In an observation conducted on 03/13/22 at 12:30 PM, Resident #32 received her lunch tray at 12:40 PM, and staff left the room to assist with other residents. At 1:00 PM, Resident #32 was observed with a tray 100% untouched and no assistance from staff. At 1:15 PM, the tray was still 100% untouched by Resident #32, the room. In an interview conducted on 03/14/22 at 8:43 AM, Staff H, Certified Nursing Assistants (CNA), stated that Resident #32 needs assistance with all her meals at the bedside. Chart review showed that Resident #32 was readmitted to the facility on [DATE] with diagnoses of Diabetes and Anemia. A review of the Minimum Data Set (MDS) dated [DATE] showed that Resident #32 had a Brief Interview of Mental Status (BIMS) score of 08 which is moderate cognitive impaired. Section G for eating showed that Resident #32 needed extensive assistance with one person assist. A review of the electronic charting showed that the following weights were recorded for Resident #32: On 01/07/22 at 205 pounds, on 01/13/22 at 210 pounds, on 01/26/22 at 208 pounds, on 02/14/22 at 193 pounds, and on 03//01/22 at 188 lbs. Further review of the weight binder located in the unit showed the following weights that were recorded for Resident #32: On 02/07/22 Refused, on 02/14/22 at 193 pounds, on 02/23/22 Refused, on 03/01/22 at 187 pounds, and on 03/14/22 at 182 pounds. A review of the Dietary follow-up note dated 01/25/22 showed that Resident #32 is with a current weight of 210 pounds. In this note, the Clinical Dietitian noted that Resident #32 is with varied PO intake and to continue with the current plan of care and follow up for any weight changes. Continued review of the Dietitian's progress notes did not show any follow-up note addressing the 8% weight loss from 01/13/22 to 02/14/22, and no follow-up was noted addressing further weight loss of 10% from 01/13/22 to 03/01/22. The Clinical Dietitian follow-up note dated 03/09/22 showed that Resident #32 had a significant weight loss, and that Resident #32 is on House supplements 3 times a day. A review of the care plan initiated on 10/22/21 showed that some of the interventions in place were to monitor weights and intake of meals and supplements. In an interview conducted on 03/15/22 at 9:20 AM, the facility's Dietitian Technician stated that they monitor all weight loss on a weekly basis and will do a significant weight loss change of 5% or more on all residents. She further reported that she runs the weights on all residents in the smart charting section of the electronic chart and will calculate the % weight loss when needed. If a resident is on nutritional supplements and not eating, she will visit the residents to see why they are not taking the supplements and will change it to a different type of nutritional supplement. When asked as to why she did not address the significant weight loss on Resident #32 in a timely manner she did not know. An interview conducted on 03/15/22 at 10:26 AM with the facility's Registered Dietitian, stated that she prints out the monthly weights on a weekly basis to review any weight losses that are 5% in one month or 10% in 6 months. She stated that some of the interventions in place may be to increase the number of nutritional supplements, conduct a caloric count, or change the nutritional supplements to something more caloric dense. She was asked as to why Resident #32 did not have a follow-up assessment after her significant weight loss from 01/26/22 to 02/14/22 if she reviews all weight losses on a weekly basis. The Clinical Dietitian acknowledged that a follow-up note on Resident #32 should have been done sooner. She also stated that since Resident #32 had a history of weight loss from prior admission she did not address the weight loss. 3). Review of Resident #37's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included Urinary Tract Infection, Anxiety Disorder, Cerebrovascular Accident (CVA), Hemiplegia, Upper and Lower Extremities Contractures and Pulmonary Embolism. Resident 37's quarterly Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of Mental Status score of 6 (six), indicating a severe cognitive impairment. Review of the resident care plan titled Resident BMI (body mass index) 19 initiated on 01/25/22 included in part interventions as to .weigh resident monthly/weekly/prn (as needed) or as ordered by MD (doctor), dietitian to evaluate and follow up at least quarterly . Review of the resident care plan titled Resident has self-care deficits related to a diagnosis of Weakness, COPD ( Chronic Obstructive Pulmonary Disease), CVA (Cerebrovascular Accident) and Upper and Lower Extremities Contractures initiated on 01/25/22 included in part interventions as to .extensive assist for meals . Review of Resident #37's weight history recorded on a Weight Work Sheet located on the third-floor nurses' station documented the following weight readings: Date: 01/22/22- 90 pounds Date: 02/02/22- 93 pounds Date: 02/14/22- 93 pounds Date: 02/19/22- 93 pounds Date: 02/23/22- 93 pounds Date: 03/01/22- 79 pounds Review of Resident #37's electronic clinical record and the Dietary notes, it wasd noted that the records lacked evidence of documentation to address the resident' significant weight loss of 14 pounds in 6 days. Further review of the resident progress notes from 01/27/22 through 03/14/22 revealed the lack of follow up documentation by nursing, the Dietitian, or the Dietary Technician to address the resident's significant weight loss. On 03/14/22 at 9:05 AM, observation revealed Resident #37 in bed, and her breakfast tray with most of the food left on the tray. An interview was conducted with the resident, and she stated she did not want to eat anymore. On 03/14/22 at 9:30 AM, an interview was conducted with Staff B, a Registered Nurse (RN) and stated Resident #37's finished a three-day Calorie Count (a count of everything the resident eat and drink daily) on 03/13/22. On 03/15/22 at 9:01 AM, observation revealed Resident #37 in bed and her breakfast tray revealed the resident ate approximately 75% of her meal. On 03/15/22 at 2:28 PM, an interview was conducted with the facility's Registered Dietitian (RD). The RD stated the resident's initial nutrition history/assessment was initiated on 01/25/22 and completed on 01/27/22. She stated the resident's weight was 90 pounds on admission with a DBW (desirable body weight) between 81-99 pounds. The RD stated she recommended a 2-Cal (calorie and protein dense nutrition/supplement) twice a day, Liquid Protein and Multivitamin. Consequently, side-by-side review of Resident #37's nutrition assessment and weight record was conducted with the RD. The RD was asked if she was aware of the resident's weight loss from 93 pounds on 02/23/22 to 79 pounds on 03/01/22; 14 pounds weight loss in one week. She stated the staff usually tell her on the same day of weight changes. She added that she might had forgotten and that it was her fault. The RD stated that on 03/08/22 or later, on her return to the facility, she saw documentation of Resident #37's weight of 79 pounds done on 03/01/22. She stated she asked for a reweigh. A side-by-side review with the RD of the resident's electronic clinical record- weight readings was conducted. The review revealed the following weight readings: 93 pounds on 02/23/22; 79 pounds on 03/04/22 (three days discrepancy from the paper record) and 85 pounds on 03/10/22. She stated the resident's re-weight was 85 pounds on 03/10/22. The RD was asked why the resident was reweighed 6 days later, and not the same day. The RD stated she might had forgotten to ask for a re-weigh on the same day. On 03/15/22 at 2:39 PM, a joint interview was conducted with the RD and Staff C, a Restorative Aide (RA)/Certified Nursing Assistant (CNA). Staff C-RA/CNA stated she does all residents' weight. Staff C was asked what she would do if she saw a significant weight change. Staff C stated she notifies the Dietitian or someone in the kitchen. Staff C was asked if she was able to see Resident #37's weight change on 03/01/22. She stated she saw the big change and told someone in the kitchen either the Dietary Tech or Food Manager regarding the resident's weight change. Staff C stated she keeps a stack of weights reading (paper charting) for 90 days. Staff C stated she enters the weight readings into the electronic record the same day she takes the weight. The RD stated that on 03/11/22 Resident #37 was started on Megace (appetite stimulant) twice a day and on 03/10/22 and the 2-Cal HN supplement was increased to three times a day. The RD stated they will wait about 7 days to see what happens with her weight and intake. An inquiry was made regarding Resident #37's weight increase of six (6) pounds in six (6) days. The RD stated Resident #37's weight was done via a mechanical lift. She added that the technique, and if the resident moves, the weight reading may be affected. During the joint interview, with the RD, and Staff C-RA/CNA, a request was made to weight the resident on 03/16/22 in the morning in the presence of the surveyor. They both acknowledge the request. On 03/16/22 at 9:15 AM, observation revealed Resident #37 sitting on a Geri chair with the mechanical lift (Hoyer lift) sling underneath of her. An interview was conducted with the resident and she stated they did her weight today and it was 93 pounds. Observation revealed Staff D, CNA at the resident bedside. An interview was conducted with Staff D-CNA and stated she was assigned to care for Resident #37. She stated the resident was provided with a shower today. Subsequently, Staff C-RA/CNA came into the resident room. An interview was conducted with Staff C-RA/CNA and stated the resident was weight already and her weight was 80.2 lbs. During an interview with Resident #37, she was explained regarding retaking her weight and agreed for to be taking again. Observation revealed the mechanical lift sticker documented the lift was calibrated on 01/31/22 and due to be checked on 04/2022. Subsequently, observation revealed Staff C and Staff D weighing Resident #37 via mechanical lift. The lift scale revealed a weight reading of 80.6 pounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and observations, the facility failed to follow infection control practices during the initiation of in-house Hemodialysis using a Central Venous Catheter (CVC) site for 1 of 1 sampled residents reviewed for dialysis (Resident #36). The findings included: A review of the Agreement for Dialysis Services between the facility and the dialysis company showed the following. When a resident is in the skilled nursing facility, their care will be provided according to acceptable standards of medical practice and by the facility policy and procedures. A review of the facility policy titled Handwashing/Hand hygiene revised in April 2020, showed the use of an alcohol-based hand rub for the following situation: before and after handling an invasive device (catheter), before donning sterile gloves, before handling clean or soiled dressing, before moving from contaminated body site to clean body site, after contact with resident's intact skin, after handling used dressing and contaminating equipment. A chart review showed that Resident #36 was admitted on [DATE] with End-Stage Renal Disease and depended on dialysis. In an observation conducted on 03/14/22 at 3:15 PM, Resident #36 was observed in the dialysis room to initiate CVC Hemodialysis by Staff I, Licensed Practical Nurse (LPN). Staff I was observed practicing hand hygiene, taking a clean gauze, and spraying it with ALCAVIS (disinfection solution) spray. She continued to touch her pen and statoscope around her neck and donned a new pair of gloves. She then walked to Resident #36's beside and touched all around the CVC access site. At 3:50 PM, Staff I used hand hygiene, opened the side cabinets, took a clean pad to create a clean surface at the side table. She then pulled a sterile gauze, sprayed it with ALCVIS spray, and continued to place a new pair of gloves. At 4:00 PM, she approached the bedside again and touched the access site. In an observation conducted on 03/14/22 at 4:20 PM, Staff I took a new pair of gloves without practicing handwashing before, touched the computer and drawers, and touched Resident's #32's CVC access site. She repeated that same process practicing handwashing before donning a new pair of gloves, but she touched the cabinets and her cell phone before touching Resident #36's access site. Continued observation of the clean surface on the side table showed that Staff I's cell phone was located near the clean gloves and gauzes during the duration of the dialysis initiation (photographic evidence obtained). In an interview conducted on 03/16/22 at 12:00 PM, with Staff I, she acknowledged all findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's policy titled Controlled Substances dated 08/2019 documented .Accurate accountability of the inventory of all controlled drug is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): date and time of administration (MAR , Accountability record) .initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability record) . 2). Review of Resident #43 clinical record documents an initial admission to the facility on [DATE] with a readmission on [DATE]. The residents' medical diagnoses included in part Closed Fracture of Left Femur, Unspecified Joint Pain, Restless Legs Syndrome. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 3(three) indicating a severe cognitive impairment. Review of the resident physician orders dated 11/27/21 documented Norco (pain medication) 5-325 milligrams (mg) one tablet every six (6) hours as need for pain. On 03/14/22 at 2:38 PM, a side-by-side review of Resident #43's Medication Monitoring/Control Record form for Norco 5-325 mg tablets four times daily as needed for non-acute pain was conducted with Staff B, a Registered Nurse (RN). The Medication Monitoring/Control Record form documented that one tablet of Norco 5-325 mg was removed from the controlled substance locked box on 02/08/22 at 3:00 PM and on 02/25/22 at 9:00 PM. Continued side by side review with Staff B-RN of Resident #43's Medication Monitoring/Control Record form and the February 2022 MAR revealed the tablet of Norco 5-325 mg pulled from the controlled substance box on 02/08/22 at 3:21 PM and on 02/25/22 at 9:00 PM were not documented/reconciled as administered on the residents MAR. During an interview, Staff B stated that once a medication is pulled from the controlled substance box and documented on the control sheet it had to be documented on the MAR. Staff B confirmed that Resident #43's Norco 5-325 mg documented on the resident Medication Monitoring/Control Record form were not documented on the MAR. On 03/14/22 at 3:31 PM, during an interview, the Director for Nursing (DON) was apprised of the controlled substance medication for Resident #43 was not reconciled/documented as administered on the residents MAR. 3). Review of Resident #37's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Urinary Tract Infection, Anxiety Disorder, Cerebrovascular Accident (CVA), Hemiplegia and Pulmonary Embolism. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 6 (six) indicating severe cognitive impairment. Review of the resident physician orders dated 02/22/22 documented Ativan (antianxiety medication) 0.5 mg twice a day as needed for 30 days. On 03/14/22 at 3:30 PM, a side-by-side review of Resident #37's Medication Monitoring/Control Record form for Ativan 0.5 mg one tablet twice daily as needed was conducted with Staff E, a Licensed Practical Nurse (LPN) and Staff A, LPN. The review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on 03/10/22 at 4:30 PM; 03/11/22 at 12 noon; 03/13/22 at 3:00 PM and on 03/14/22 at 12:39 PM. Continued side by side review with Staff E-LPN of Resident #37's March 2022 MAR revealed that Ativan 0.5 mg tablet removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. During an interview, Staff E-LPN stated that once a medication is pulled from the controlled substance box and documented on the control sheet it had to be documented on the MAR. Staff E-LPN confirmed that Resident #37's Ativan 0.5 mg tablets documented on the resident Medication Monitoring/Control Record form were not documented on the MAR. 4). Review of Resident #35's clinical record documents an initial admission to the facility on [DATE] and readmission on [DATE]. The residents' medical diagnoses included in part Fracture of Left femur, Dementia, Coronary Heart Disease and Diabetes Mellitus. Resident's significant change minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 5 (five) indicating a severe cognitive impairment. Review of the resident physician orders dated 01/04/22 documented Tramadol (pain medication) 50 mg one tablet every six hours as needed for pain. On 03/14/22 at 4:29 PM, a side-by-side review of Resident #35's Medication Monitoring/Control Record form for Tramadol 50 mg tablets was conducted with Staff F, LPN. The review revealed that a tablet of Tramadol 50 mg was documented as removed from the controlled substance locked box on 02/15/22 at 9:00 AM and on 03/03/22 at 9:00 AM. Continue side by side review with Staff F-LPN of Resident #35's February 2022 and March 2022 MAR's revealed that Tramadol 50 mg tablet removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. During an interview, Staff F-LPN stated once the medication was removed from the controlled locked box, it had to be documented on the residents MAR. 5). Review of Resident #374's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Pneumothorax and Malnutrition. Review of the resident physician orders dated 02/16/22 documented Percocet (pain medication) 5-325 mg one tablet every six hours as needed for pain. On 03/14/22 at 4:39 PM, a side-by-side review of Resident #374's Medication Monitoring/Control Record form for Percocet 5-325 mg tablets was conducted with Staff F, LPN. The review revealed that a tablet of Percocet 5-325 mg was documented as removed from the controlled substance locked box on 03/09/22 at 12:00 AM. Continue side by side review with Staff F-LPN of Resident #374's March 2022 MAR's revealed that Percocet 5-325 mg tablet removed from the controlled substance locked box was not documented/reconciled as administered on the residents MAR. 6). Review of Resident #32's clinical record documents an initial admission to the facility on [DATE] and a readmission on [DATE]. The residents' medical diagnoses included in part Bacteriuria, Peripheral Vascular Disease, Dermatitis and Tachycardia. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 8 (eight) indicating a moderate cognitive impairment. Review of the resident physician orders dated 12/12/21 documented Percocet (pain medication) 5-325 mg one tablet every four hours as needed for pain. On 03/14/22 4:51 PM, a side-by-side review of Resident #32's Medication Monitoring/Control Record form for Percocet 5-325 mg tablets was conducted with Staff G- LPN. The review revealed that a tablet of Percocet 5-325 mg was documented as removed from the controlled substance locked box on 02/09/22 at 2:00 PM, on 02/26/22 at 9:00 AM and on 03/12/22 at 12 noon. Continued side by side review with Staff G-LPN of Resident #32's February 2022 and March 2022 MAR's revealed the Percocet 5-325 mg tablet removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. During an interview, Staff G stated once a medication was removed from the controlled locked box, it had to be documented on the residents MAR. 7). Review of Resident #6's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Generalized Anxiety Disorder, Hypothyroidism, and Insomnia. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 8 (eight) indicating a moderate cognitive impairment. Review of the resident physician orders dated 02/07/22 documented Ativan 0.5 mg by mouth twice a day as needed for 30 days. On 03/14/22 4:58 PM, a side-by-side review of Resident #6's Medication Monitoring/Control Record form for Ativan (Lorazepam) 0.5 mg tablets twice daily as needed for Anxiety was conducted with Staff G-LPN. The review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on 02/18/22 at 12:00 PM and on 02/26/22 at 9:00 AM. Continued side by side review with Staff G-LPN of Resident #6's February 2022 MAR's revealed that Ativan 0.5 mg tablet documented/removed from the controlled substance locked box were not documented/reconciled as administered on the residents MAR. On 03/15/22 at 3:36 PM, a joint interview was conducted with the facility's Administrator, the Consultant Pharmacist, and the DON. They were apprised of the lack of controlled substance medication reconciliation for 6 of 8 residents record reviewed. Based on interview and record review the facility failed to ensure medications were administered as ordered for 1 of 5 sampled residents reviewed for Unnecessary Medications, Resident #25, as evidenced by the medication frequency was not being followed as ordered by the physician; and failed to ensure controlled substance medications were reconciled appropriately for 6 of 8 sampled residents reviewed during Medication Storage observation involving Resident #6, Resident #32, Resident #35, Resident #37, Resident #43 and Resident #374. The findings included: 1) Review of the facility Oral Medication Administration policy dated April 2018 documents in part, 'Purpose: To administer oral medications in a safe, accurate and effective manner. Procedures: Review and confirm medication orders for each individual resident on the Medication Administration Record prior to administering medications to each resident.' Review of the clinical record for Resident #25 revealed an admission date of 03/15/21 with diagnoses to include cerebral vascular accident with right sided weakness, atrial fibrillation and epilepsy (seizures). Resident #25 requires a feeding tube with feedings infusing for 23 hours daily to meet her nutritional and hydration needs in addition to providing a means to administer medications. Further review of the clinical record revealed Resident #25 was transferred to the hospital on [DATE]. Review of the September 2021 Medication Administration Record (MAR) revealed Resident #25 was receiving Topiramate (seizure medication) 50 milligrams (mg) daily at 8:00 PM. Resident #25 was readmitted to the facility on [DATE]. Review of the physician orders on readmission dated 09/25/21, revealed the Topiramate 50 mg daily was reordered. Review of the September 2021 MAR revealed the Topiramate was not administered on 09/25/21, was administered on 09/26/21 at 8:00 PM and was documented as discontinued on 09/27/21. Further review of the September 2021 MARs revealed a second entry dated 09/27/21 for Topiramate 50 mg tablet, give one tablet by gastrostomy tube daily at 8:00 PM with an indication for use documented as epilepsy. Review of the sign off section of the MAR to the right of the physician order, revealed a dose was administered on 09/27/21 and the dosage frequency was documented as every other day, not daily as ordered, with the next dose administered at 8:00 PM on 09/29/21. Review of the MARs from October 2021 through March 2022, revealed the Topiramate ordered on 09/27/21 to be administered daily, was being administered every other day as evidenced by an asterisk inserted on every other day as per the MAR coding, an asterisk indicates the medication is 'Not Scheduled' for that day. Review of Resident #25's electronic and paper clinical records revealed no physician order changing the Topiramate order frequency from daily to every other day. Further review of the MARs and Treatment Administration Records (TAR) from September 2021 through March 2022, revealed no documentation of any seizure monitoring or assessment. On 03/15/22 at 10:38 AM, an interview was conducted with the facility Pharmacy Consultant and a review of the Pharmacy Consultant monthly reports were reviewed. The Pharmacy Consultant confirmed she had conducted medication reviews of Resident #25's medications on a monthly basis to include 09/29/21, 10/29/21, 11/27/21, 12/22/21, 01/19/22 and 02/10/22. The monthly medication reviews did not include any frequency discrepancy for the Topiramate. On 03/15/22 at 2:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) Staff A in the presence of Charge Nurse Registered Nurse (RN) Staff B, and a request was made to pull up Resident #25's electronic MARs. In reviewing the MARs, it was brought to LPN Staff A's attention the Topiramate which was ordered to be administered daily is being administered every other day. LPN Staff A stated the medication is to be administered every other day as there is an asterisk in the box on every other day indicating the medication is to be administered every other day. LPN Staff A was asked to read the Physician Order to the left of the sign off section of the MAR and stating out loud, LPN Staff A stated 'Topiramate 20 mg one tablet daily' then stated out loud 'Oh, the order is for daily, but it is documented on the MAR as being given every other day.' LPN Staff A then proceeded to review the paper clinical record and came across a hospital Medication Discharge summary dated [DATE] documenting the resident was to continue receiving the Topiramate 20 mg daily. An inquiry was made to LPN Staff A what the process is for reconciling the list of medications upon readmission from a hospital stay, to which she stated they look at the list of medications the resident was taking in the hospital, call the physician to see if he wants to continue with the medications, then they electronically enter the medications into the MAR system which then generates a MAR from the pharmacy. A further inquiry was made who double checks the list of medications inputted electronically into their system, to which LPN Staff A stated the nurse Supervisor on call will review and double check the medication list. LPN Staff A, and now Charge Nurse RN Staff B who got involved in the conversation, proceeded to check the electronic MAR system where the nurse inputted the Topiramate order in September 2021. Charge Nurse RN Staff B and LPN Staff A confirmed the order frequency for the Topiramate was entered as every other day and not daily as ordered. Charge Nurse RN Staff B stated the nurse entered it in wrong, she inputted the wrong frequency, that is where the error is. Charge Nurse RN Staff B stated she will contact the physician about the error and see if he wants blood levels drawn to see if receiving the seizure medication every other day and not daily has affected the effectiveness of the medication. An inquiry was made to Charge Nurse RN Staff B about monitoring residents with a diagnosis of seizures or any assessments conducted to which Charge Nurse RN Staff B stated they monitor residents for seizure activity, however do not document that anywhere, it would not be included on the MAR or TAR. On 03/15/22 at 3:10 PM, an interview was conducted with the facility Pharmacy Consultant and RN Pharmacy Consultant who had just met with LPN Staff A and Charge Nurse RN Staff B and had been apprised of this finding. The Pharmacy Consultant admitted she did not catch this error and would not have caught this error, stating when she does her monthly reviews, she reviews the physician orders and in this case the physician order was correct however the frequency was entered incorrectly on the MAR. The Pharmacy Consultant stated she does not have access to review of the MARs when she does her monthly reviews. The Pharmacy Consultant and RN Pharmacy Consultant stated they checked where the data entry was inputted, and the nurse entered every other day, and it should have been entered as daily. The Pharmacy Consultant reiterated when she reconciles the medications monthly, she goes by the physician orders and does not have access to the MARs, stating again, she would not have caught this error. An inquiry was made to the Pharmacy Consultant, pointing out she is only one person who reviews the medications, however since September 2021 to the current date of March 15, 2022, not one nurse who administered the Topiramate every other day when the order clearly documents daily, did not notice the medication frequency was incorrect on the MAR. The Pharmacy Consultant and RN Pharmacy Consultant could not comment. A record review conducted on 03/16/22 revealed a new Physician Order dated 03/15/22 for Topiramate 50 mg tablet, give one tablet via gastrostomy tube daily. Review of the March 2022 MAR now documented the Topiramate to be administered daily, with no asterisks delineating the frequency of every other day.

**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 with a frequency of as needed, did not exceed the 14 days requirement for 2 of 2 sampled residents (Residents #6 and #37) reviewed during the controlled substance record review at the facility's second and third floor wings. The findings included: Review of the facility's policy titled Medication Orders: Stop Orders dated [DATE] documented the following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated numbers of days .PRN psychotropic medication orders 14 days . 1). Review of Resident #37's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Urinary Tract Infection, Anxiety Disorder, Cerebrovascular Accident (CVA), Hemiplegia and Pulmonary Embolism. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 6 (six) indicating a severe cognitive impairment. Review of Resident #37's clinical record documented a care plan Resident takes an antianxiety medication for anxiety onset date [DATE] and revised on [DATE]. Review of Resident #37's physician orders dated [DATE] documented Ativan (antianxiety/psychotropic medication) 0.5 mg twice a day as needed for 30 days. The review revealed the practitioner/physician order exceeded 14 days as per regulation. On [DATE] at 3:30 PM, a side-by-side review with Staff E, a Licensed Practical Nurse (LPN) and Staff A, LPN of Resident #37's Medication Monitoring/Control Record form for Ativan 0.5 mg one tablet twice daily as needed was conducted. The control record documented 26 tablets of Ativan received on [DATE] from the pharmacy. Continue review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on [DATE] at 4:30 PM; [DATE] at 12 noon; [DATE] at 3:00 PM and on [DATE] at 12:39 PM. The review revealed the practitioner/physician order for Ativan expired on [DATE] as per regulation. On [DATE] at 5:05 PM, during an interview with the Director of Nursing (DON) it was brought to her attention that Resident #37's physician order for Ativan as needed exceeded 14 days. The DON stated the physician ordered for 30 days and it was okay to give the medication within the time frame from [DATE] to [DATE]. The DON was apprised that psychotropic medication (Ativan) ordered on as needed basis is to be renewed every 14 days. She stated that as long as they had a physician order, they were okay to administer Ativan to Resident #37 on [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at 1:16 PM, an interview was conducted with the facility's Consultant Pharmacist (CP). She stated she had not reviewed Resident #37's medication record. A side-by-side review of Resident #37's physician order dated [DATE] for Ativan. The CP stated the order exceeded the 14 days. 2). Review of Resident #6's clinical record documents an initial admission to the facility on [DATE]. The residents' medical diagnoses included in part Generalized Anxiety Disorder, Hypothyroidism, and Insomnia. Resident's quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status score of 8 (eight) indicating a moderate cognitive impairment. Review of Resident #6's clinical record documented a care plan Resident takes an antianxiety medication for anxiety onset date [DATE]. Review of the resident physician orders dated [DATE] documented Ativan 0.5 mg by mouth twice a day as needed for 30 days. The review revealed the practitioner/physician order exceeded the 14 days as per regulation. On [DATE] 4:58 PM, a side-by-side review of Resident #6's Medication Monitoring/Control Record form for Ativan (Lorazepam) 0.5 mg tablets twice daily as needed for Anxiety was conducted with Staff G-LPN. The control record documented 28 tablets of Ativan received on [DATE] from the pharmacy. Continue review revealed a tablet of Ativan 0.5 mg was removed from the controlled substance locked box on [DATE] at 9:00 AM and on [DATE] at 4:50 PM. The review revealed that Resident #6 received Ativan 0.5 mg tablets on [DATE] and on [DATE]. The review revealed the practitioner/physician order for Ativan expired on [DATE] as per regulation. On [DATE] at 1:26 PM, a side-by-side review of Resident #6's practitioner/physician dated order dated [DATE] for Ativan 0.5 mg by mouth twice a day as needed for 30 days was conducted with the facility's Consultant Pharmacist (CP). The CP stated she did a pharmacy review for Resident #6's on [DATE] and did not catch that the resident had and order for Ativan (a psychotropic) that exceeded the 14 days requirement. She added she missed it. The CP stated that she comes to the facility once a month to do residents pharmacy (medications) reviews. She added that she started to sign into the system once a week because the facilities were having problem adhering to the psychotropics 14 days rule. The CP stated that as needed basis psychotropic medication such as Ativan, have to have a 14 days stop date. She stated that on review she made sure those medications had a physician order with a stop date, if not she will make recommendation to stop or provide a stop date. She added if it is passed 14 days her recommendations is to discontinue it right t away. The CP stated she gives all her recommendations to the Director of Nursing (DON). The DON will review them and contact the physician. She added that it is a struggle to have the physician on board writing a 14 days stop date for psychotropic medications. The CP stated it was brought to the Quality Assessment and Performance Improvement committee to review as needed physician orders. On [DATE] at 1:44 PM, an interview was conducted with the DON. She stated that psychiatrist comes in evaluate the resident an order the medication as necessary. The DON stated that it requires a physician note and assessment to continue the psychotropic for more than 14 days.