**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/18/24 at 10:59 a.m., Resident #34 was observed sitting in a wheelchair between the bed and the wall next to the bathroom. The resident's call light pad was observed on the other side of the bed. On 11/19/24 at 10:02 a.m., Resident #34 was observed lying in bed. The resident's call light pad was observed lying next to the left hip of the resident's roommate and another call light button was hanging on the top of the roommate's mattress. Neither of the room's call light devices were accessible to Resident #34. On 11/19/24 at 10:12 a.m. the Director of Nursing (DON) observed Resident #34 lying on her left side with her right foot hanging out of bed, facing the bathroom wall. The DON moved the folded floor mat to the left side of bed. She reported Resident #34 was able to use the call light and confirmed the resident's call light pad was on the roommate's bed. On 11/20/24 at 8:46 a.m., an unknown staff member was observed assisting Resident #34 with eating the morning meal while the resident was sitting in wheelchair between the bed and the bathroom wall. On 11/20/24 at 9:00 a.m., Resident #34 was observed sitting in a wheelchair in between the bed and the bathroom wall. The resident's call light pad location was unknown and not seen within the resident's reach. On 11/20/24 at 9:03 a.m., Staff L, Certified Nursing Assistant (CNA) located the resident's call light pad behind the floor mat that was in front of the bedside dresser between the bed and the curtain separating the resident's and roommate's beds. The staff member stated the resident must have dropped it. Staff L stated the staff member who had been assisting the resident with eating should have ensured the call light was within reach of the resident prior to leaving the resident. Review of Resident #34's care plan revealed the resident was at risk for falls related to (r/t) cognitive deficit, history of falls, impaired vision, (and) use of anti-hypertensive medications. The related interventions included but not limited to encourage and remind resident to use call bell to wait for staff assistance with transfers, ambulation, toileting, etcetera (etc.) as tolerated, initiated on 10/4/22. 3. On 11/19/24 at 10:05 am., Resident #24 was observed lying in bed with the head of bed slightly raised. The observation showed the resident's call light button was hanging through the resident's raised bed rail and lying against the bedside dresser. The call light was not within reach of the resident. On 11/19/24 at 10:09 a.m., Resident #24 was observed with the Director of Nursing (DON). The DON viewed the resident's call light and stated it must have fallen and reported the resident was unable to use the call light. Review of resident #24's care plan revealed the resident was at risk for falls related to (R/T) history of falls, unsteady gait/ poor balance, use of anti-hypertensive medications. This focus was initiated and revised on 1/16/23. The interventions showed that nursing staff should Encourage and remind resident to use call bell and to wait for staff assistance with transfers, ambulation, toileting, etcetera (etc.) as indicated. Review of the policy - Call lights, revised 1/2024, showed the standard was the Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. The guideline was Resident's call light is to be within reach and answered promptly by facility personnel. The procedure instructed: 1. Answer call light promptly. All Facility personnel are expected to respond to call lights. 2. Knock on the room door, announce yourself, and be courteous when entering the room. 3. Turn off the call light. 4. Listen to residents' request. DO NOT Make residents feel that you are too busy. (#5 is missing from the policy) 6. Office services before leaving the resident's room. Insure the call light is within reach. 7. If the call light is defective, report to maintenance. 8. Call lights must remain functional and within reach of each resident. Call lights must not be disabled. Call lights shall not be removed from resident's reach unless this is a therapeutic intervention documented in a resident specific behavior management plan set forth by the physician and/ or mental health clinician in response to problematic and/for attention seeking behavior. 9. Respond to the residents' request, if unable to assist, notify the nurse. Return to the resident promptly with a reply. Based on observation, interview, and medical record review, the facility failed to ensure call light cords and buttons were placed within reach for three (#61, #34, and #24) of forty-eight sampled residents. Findings included: 1. On 11/18/2024 at 2:10 p.m., 11/19/2024 at 8:10 a.m., 3:20 p.m., and on 11/20/2024 at 8:02 a.m. and 9:52 a.m., while Resident #61 was visited in her room, she was observed each time lying in bed flat, under the covers and receiving services to include nourishment via a tube feed system, pressure ulcer care via a wound vacuum system, and also was observed utilizing an indwelling urinary catheter. Further observations revealed each visit included the call light button and cord was either placed hanging off the back of the head of the mattress and between the wall out from her reach or lying on the floor out from her reach. An initial interview attempt was made with Resident #61 on 11/18/2024 at 2:10 p.m., she was noted with cognitive deficits. Resident #61 was able to speak related to her daily routines and simple questions related to her care. Resident #61 said that she called staff for help almost every day. She was asked how she called for staff. She said she tried to use the call light and was observed looking for it. She could not find the call light button and revealed there were times the staff did not put it where she could find it. It was observed at that time to be back and behind her pillow/mattress and between the mattress and the wall, hanging down approximately two feet, well away from Resident #61's reach. Resident #61 could not see the call light button and said she would not be able to locate it and use it if it was behind her and hanging down. Resident #61 was noted in a private room and most of the day she had the door closed. Resident #61 revealed there were times when she could not find her call light button and there were times she had to yell out but staff did not hear her. She said she had mentioned to staff to please place the call light within her reach all the time, but this did not happen all the time. She had spoken to her nurses, (no names given or timeframes), but things had not gotten better. Review of the electronic medical record to include nurse progress notes dated from 10/17/2024 to current review date 11/21/2024, did not reveal any documentation to support Resident #61 had behaviors of tossing, or throwing the call light button away from her. There was no documentation to support Resident #61 did not use her call light. Progress note dated 11/19/2024 18:20 (6:20 p.m.) revealed Resident #61 was observed resting in bed and with the call light placed within her reach. This note supported staff are to place the call light within her reach when she was in bed. Review of the current admission Minimum Data Set (MDS) assessment dated [DATE], showed: Cognition or Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment; Mood - none documented as observed during timeframe; Behavior - None documented as observed during timeframe; ADL (Activities of Daily Living) - Shower/Bathing including washing, rinsing, and drying self - Substantial/Maximal assistance; Personal Hygiene-the ability to maintain personal hygiene including combing hair, shaving, apply make up, washing/drying hands - Substantial/Maximal assistance. The MDS assessment Showed Resident #61 required maximum assistance with most of her care and services. Review of the current care plans with next review date 1/18/2025 revealed the following but not limited to areas: 1. Risk for falls related to impaired mobility, cognitive impairment with interventions to include but not limited to: Encourage and remind the resident to use the call bell. On 11/20/2024 at 9:55 a.m., an interview with Staff A, Certified Nursing Assistant (CNA), revealed all residents in the building were to have their call light placed within their reach whether they were in bed, or seated in a chair or wheelchair in their room. Staff A confirmed Resident #61 used the call light at times to get staff assistance. Staff A confirmed at 9:55 a.m., the call light was not placed within Resident #61's reach. Staff A said Resident #61 would toss the call light away, but she had not reported that to any nurses in the past. On 11/20/2024 at 10:03 a.m., an interview with Staff B, Licensed Practical Nurse (LPN), Station 1 Unit Manager, revealed she knew Resident #61 and that she required maximum assistance with all her ADL. She further confirmed Resident #61 used the call light button to get staff assistance. Staff B confirmed all residents were to always have their call light button placed within their reach when they were in their rooms and while in bed. Staff B. revealed she had not been made aware from any staff that Resident #61 threw or tossed the call light button away from her, nor could she find documentation in the electronic record to support that. On 11/21/204 at 7:50 a.m., an interview with Staff C, LPN, who was Resident #61's assigned nurse, revealed all residents were to have their call light buttons placed within their reach when they were in their rooms and in bed. Staff C could not remember a time when Resident #61 threw or tossed her call light button on the floor. Staff C verified the resident often used the call light to call for assistance. Staff C could not show in the medical record that Resident #61 had behaviors of displacing the call light button out of her reach. On 11/21/2024 at 7:56 a.m., an interview with Staff D, CNA revealed she did not know the resident well as she floated around the facility. She confirmed she had the resident on her assignment today and she had seen her already. Staff D confirmed that all residents when in bed and if seated in chairs next to their bed, should have call lights placed within their reach. Staff D was not aware of the resident throwing or tossing the call light button out of her reach. She revealed if that were the case, and for every resident, they would report that behavior to the nurse or Director of Nursing. Staff D revealed she had been trained and inserviced to go in the room and look for things related to comfort and safety, and call light placement is one of those things she looks out for.

Based on observation and interview, the facility failed to ensure a clean and comfortable environment by not maintaining and cleaning one (B Hall) of two community shower rooms. Findings included: On 11/18/2024 at 9:40 a.m., an observation was made of the B Hall community shower room. Upon entering the shower room, it was observed to be cluttered and disorganized. Located on the left-hand side just after entry was a restroom with a toilet and sink. Next to the room with the toilet, there was a shower with a curtain. On the other side of the room there were two sinks. The clutter of the room made it hard to get to the other two sinks. The clutter observed included a privacy curtain, various wheelchair parts, Hoyer lift, bedside commode and a walker. (Photographic evidence obtained). The observation of the shower room also included: 1. The foam mat laying on the top of the shower bed had a dried brown substance on the top. 2. On the shower bed underneath the foam mat and on the mesh part of the bed, there were dried brown and black objects as well as hair. 3. In a corner of the room there was a trash bucket; the lid was sitting on the floor next to the trash bucket; inside the trash bucket there were soiled gloves. The lining of the trash bucket was soiled with a brown substance. 4. The Hoyer lift pad, which was placed on the Hoyer lift, was soiled with a brown substance. 5. The grout in the shower was dirty with a black-brown substance. 6. Next to the entry door of the shower room there was a clump of hair on the wall. 7. The Hoyer lift itself had dirt, dust and a dried brown substance on it. 8. Trash and wheelchair attachments were on the floor. 9. A dirty band aid on the floor of the shower. 10. Hair on the shower floor. 11. Ripped and stained shower curtains. On 11/19/2024 at 9:33 a.m., an observation was made of the B Hall community shower. The observation was the same as the previous day's observation with no cleaning or organizing having been done. An interview was conducted on 11/20/2024 at 3:00 p.m. with Staff H, Director of Environmental Services. The Environmental Services Department includes the Housekeeping Department. He said a housekeeper starts the day at 7:00 a.m. cleaning the front lobby and the offices. The other housekeeping staff work from 9:00 a.m.-5:30 p.m. Staff H, Director of Environmental Services, said the housekeepers were assigned unit halls and were expected to clean the hallways, resident rooms, nurses' stations, and shower rooms. He said the shower rooms were cleaned once per day. Before entering the shower room Staff H, Director of Environmental Services, said he had not seen the current condition of the room. He said housekeeping responsibilities for cleaning the shower rooms include cleaning the floors, walls, toilets and sinks. He said he expected the shower rooms should be cleaned by 10:00 a.m. every day. He said curtains, which include resident rooms and the shower rooms, were checked one unit hall per week and replaced or cleaned if they are dirty. He agreed the curtains in the shower room needed to be changed. He also agreed the shower room did not look clean, appealing or organized. He said in the shower rooms the Certified Nursing Assistants who gave resident showers were responsible for picking up any dirty linen, cleaning up any bodily fluids, cleaning the equipment, and disinfecting the area(s) used while giving resident showers. During an interview on 11/21/2024 at 2:47 p.m., Staff W, CNA said it was the CNA's responsibility in the shower room to clean up after themselves after showering a resident. She said the CNA's were to pick up any dirty linen or towels, clean the shower area, disinfect and clean any equipment that was used during the resident's shower. Staff W said they were really busy and did the best they could to clean everything up as fast as possible. She said if another CNA did not clean up after showering a resident, she would tell the other CNA to clean it up and if it did not get done she could report it to the manager. During an interview on 11/21/2024 at 3:00 p.m. with the Nursing Home Administrator (NHA), he said he was not aware of the issues in the shower room. He said he had not been in the shower rooms lately. The NHA said he would talk to Staff H, Director of Environmental Services and get the shower rooms cleaned and organized. Review of the General Cleaning Policies and Procedures Resident Room - Clean, which was not dated, was provided by the Staff H, Director of Environmental Services, did not reveal specific guidance for cleaning the community shower rooms.

Based on observation, interview, and record review, the facility failed to ensure one (#61) of forty-eight sampled residents, was provided with personal hygiene fingernail care during at least three of four days observed (11/18/2024, 11/19/2024, 11/20/2024). It was observed all ten of the fingernails were found with dark debris and were long, cracked/chipped and leaving sharp edges. Findings included: On 11/18/2024 at 2:10 p.m., Resident #61 was visited while in her room. She was observed residing in a private room and was noted in her bed lying flat with the Head of Bed (HOB) approximately 30 degrees. Resident #61 was further observed with her hands placed on her lap, over the bed linen. All ten fingernails were observed elongated approximately ½ inch to ¾ inches, cracked and chipped with sharp edges. Further, the under nails were observed with build up of dark debris/matter. An interview with Resident #61 revealed she had impaired cognition, but was able to speak with regards to her daily routines and she was able to speak related to her personal hygiene and nail care. Resident #61 confirmed her nails were too long and that they had sharp edges. She did not know what all the debris was, which was packed under her finger nails. She confirmed she did not like her nails long, did not like them chipped and did not like having debris/matter under her fingernails. Resident #61 revealed she had asked staff to clip her fingernails in the past and at least three times since her admission. She could not remember which Certified Nursing Assistant (CNA) she told, but she remembered she had spoken to several of them. Resident #61 revealed that each time she had asked for nail care in the past, the CNA's would just tell her they would get to it, but they never did. Resident #61 revealed she did receive showers during her scheduled shower days, and she did not refuse showers or personal hygiene care. On 11/19/2024 at 8:10 a.m., 3:20 p.m., 11/20/2024 at 8:02 a.m., 9:52 a.m., 2:00 p.m., Resident #61 was visited in her room. She presented both of her hands for observation and it was revealed all ten fingernails were still elongated, cracked, chipped and still with dark debris under her nails. Resident #61 revealed she did ask about nail care during the evening shift on 11/20/2024 but staff never came back to do it. She could not remember what staff member she spoke with. .On 11/20 at 9:55 a.m Staff A, who was Resident #61's assigned CNA, was interviewed with relation to personal hygiene and nail care. Staff A revealed Resident #61 required full staff assistance with personal hygiene including showers/baths and nail care. Staff A, also revealed the resident was provided with a bed bath yesterday and she would typically want bed baths. Staff A revealed she usually would scrub the resident's fingers and finger nails to get debris out but was unaware her finger nails were long, cracked and chipped and with debris under the nails. Staff A went in Resident #61's room and confirmed the nails needed care to include clipping and cleaning. Staff A confirmed that as part of their routine daily assignment, they were to look at the resident's personal hygiene to include fingernails. She revealed staff should recognize if nails needed to be clipped and cleaned. Staff A revealed if a resident was diabetic, usually the nurse would be the one to clip the nails. On 11/20/2024 at 10:03 a.m., an interview with Staff B., who was the Station 1 Unit Manager, revealed Resident #61 was a newer admission and at the facility less than one month. Staff B was aware the resident required maximal assistance with her Activities of Daily Living (ADLs) to include shower/bath and personal hygiene. Staff B explained that she was not aware the resident wanted nail care, but at the very least CNAs should have observed her for the need of nail care and/or cleaning. Review of the current Physician's Order Sheet for the month 11/2024 showed the following but not limited to: a. Weekly skin checks every Tuesday during day shift with an order date of 10/22/2024. Review of the nurse progress notes dated from 10/17/2024 to current 11/20/2024 showed no behaviors of refusing personal hygiene to include nail care. Review of the admission Minimum Data Set (MDS) assessment and dated 10/24/2024, showed Cognition/Brief Interview Mental Status or BIMS score - 5 which indicted severe cognitive impairment; Mood - none documented as observed during the assessment timeframe; Behavior - None documented as observed during the assessment timeframe; ADL - Shower/Bathing including washing, rinsing, and drying self - Substantial/Maximal assistance; Personal Hygiene the ability to maintain personal hygiene including combing hair, shaving, apply make up, washing/drying hands - Substantial/Maximal assistance. Review of the Restorative Nursing Program Initial Evaluation dated 11/11/2024 revealed: Section#1 Assessment/Evaluation diagnosis - Need for Assistance with Personal Care, Weakness. A. Restorative Nursing Program for bed mobility and goal to include: Static and dynamic sitting and standing balance for carryover with ADL tasks to prevent contracture. Review of the current Care Plans with a next review date 1/18/2025 showed the following areas: (a) ADL self care deficit related to activity tolerance ADL needs and participation vary, Limited Mobility with interventions in place to include but not limited to: Extensive Assist for ADL care this may fluctuate with weakness, fatigue and weight bearing status; On 11/21/2024 at 9:47 a.m., the Director of Nursing (DON) was interviewed. She was knowledgeable with regards to Resident #61 and with her daily care and services. The DON revealed the resident had cognition deficits and required maximum assistance with all her Activities of Daily Living (ADL) to include personal hygiene. The DON revealed she was made aware yesterday, 11/20/2024, the resident required finger nail cleaning and trimming and made sure it was completed. The DON revealed it was the expectation of the aide and nurse who were assigned to the resident to look for personal hygiene needs to include nail care, on a daily basis. Review of the ADL Care and Services policy and procedure, with a last revision date of 1/2024 showed the following. The Policy Standard revealed; Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The Guidelines section of this policy revealed; Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Procedure section of this policy revealed; 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, nail care and oral care); 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (#36) of forty-eight sampled residents was offered and assisted to scheduled activities that met his interest. Findings included: On 11/18/2024 at 9:55 a.m., 10:30 a.m., 1:00 p.m., 2:00 p.m.; on 11/19/2024 at 7:30 a.m., 8:20 a.m., 1:00 p.m., 3:00 p.m.; on 11/20/2024 at 8:07 a.m., 10:00 a.m., 11:30 a.m., 12:21 p.m., 1:45 p.m., 2:00 p.m., 3:00 p.m.; and on 11/21/2024 at 8:00 a.m., 10:00 a.m., and 11:45 a.m., Resident #36 was observed in his room, lying flat in his bed with the covers and blanket over him, pulled over, and above his head. When attempting to meet with Resident #36 on 11/18/2024, he did not respond to an interview. During all the dates and times listed above, Resident #36 was observed not up for the day and not dressed. He was also not observed offered or assisted by either his assigned Certified Nursing Assistants (CNAs) or activities staff with the daily scheduled activities. Review of the large posted current month's (11/2024) activities calendar, posted on the wall across from each nurse station, revealed Resident #36 was not offered or assisted with the following posted activities during the 7 a.m. to 3 p.m. shift on 11/18/2024, 11/19/2024, 11/20/2024, and 11/21/2024: 1. On 11/1/24 - Friendly Visits at 9:30 a.m., Movie time at 2:30 p.m. 2. On 11/3/24 - Streaming Religious/Church services at 10:30 a.m., Outdoor visits at 1:00 p.m. 3. On 11/4/24 - Friendly Visits at 9:30 a.m. 4. On 11/5/24 - Friendly Visits at 9:30 a.m., Men's group at 1:30 p.m. 5. On 11/6/24 - Friendly Visits at 9:30 a.m., Therapy Dog visit at 10:30 a.m. 6. On 11/7/24 - Friendly Visits at 9:30 a.m. 7. On 11/8/24 - Friendly Visits at 9:30 a.m., Courtside with Friends, Movie time at 10:30 a.m. 8. On 11/10/24 - Streaming Religious/Church services at 10:30 a.m., Outdoor visits at 1:00 p.m. 9. On 11/11/24 - Friendly Visits at 9:30 a.m., Bible study at 1:30 p.m. 10. On 11/12/24 - Friendly Visits at 9:30 a.m., Musical moment at 10:30 a.m., Men's group at 1:30 p.m. 11. On 11/13/24 - Friendly Visits at 9:30 a.m., Therapy dog visit at 10:30 a.m. 12. On 11/14/24 - Friendly Visits at 9:30 a.m., Ice Cream Social at 2:30 p.m. 13. On 11/15/24 - Friendly Visits at 9:30 a.m., Movie time at 2:30 p.m. 14. On 11/17/24 - Streaming Religious/Church services at 10:30 a.m., Outdoor visits at 1:00 p.m. 15. On 11/18/24 - Friendly Visits at 9:30 a.m., Stretching with friends at 10:30 a.m. 16. On 11/19/24 - Friendly Visits at 9:30 a.m., Men's group at 1:30 p.m. 17. On 11/20/24 - Friendly Visits 9:30 a.m., Therapy dog visit at 10:30 a.m. 18. On 11/21/24 - Friendly Visits at 9:30 a.m., Apple cider social at 2:30 p.m. It was found through review of the medical record, Resident #36 was documented as somewhat interested related to the above listed activities. Further, there was no documentation to support whether he was either offered or assisted to any of them nor was there any documented evidence he refused any of these activities. Review of Resident #36's nurse progress notes and activities notes dated from 6/1/2024 through to 11/21/2024 did not reveal Resident #36 refused to go to activities both group and individual. Review of Resident #36's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the following: Cognition/Brief Interview Mental Status BIMS score - 00 of 15, which indicated Resident #36 was not interviewable and not able to speak related to his daily care and services; Mood - None documented as observed during the assessed timeframe; Behaviors - None documented as observed during the assessed timeframe; Activities/Preference - This section was not completed. Review of Resident #36's Annual MDS assessment dated [DATE], revealed: Activities/Preferences = A. How important is it to you to have books, etc. = Somewhat Important; How important is it to you to listen to music you like = Somewhat Important; How important is it to you to be around animals such as pets = Somewhat Important; How important is it to you to keep up with the news = Somewhat Important; How important is it to you to do things with groups of people = Somewhat Important; How important is it to you to do your favorite activities = Somewhat Important; How important is it to you to go outside to get fresh air when the weather is good = Somewhat Important; How important is it to you to participate in religious service practices = Somewhat Important. Review of Resident #36's Lifestyle & Activity preference evaluation dated 7/15/2022 revealed: Section C; Leisure Preferences = Yes to Entertainment television, music, movies, Yes Catholic activities. Review of the Lifestyle & Activity preference evaluation dated 1/11/2023 revealed: Section C; Leisure Preferences = Yes to Entertainment television, music, movies, Yes Catholic activities. Review of Resident #36's Quarterly Activity Progress notes dated 9/18/2023 revealed; Summary - Resident enjoys a variety of activities including friendly visits from select staff and peers, being read to, listening to music, compassionate touch, listening to the TV. Review of Resident #36's Quarterly Activity Progress notes dated 12/21/2023, revealed; Summary - Resident enjoys watching television and listening to music. Preferably Hispanic program. Review of Resident #36's Quarterly Activity Progress notes dated 3/15/2024, revealed; 1:1 visits provided by staff #3. Notes - Resident enjoys watching television, listening to music, and visiting with select staff members. Resident expresses satisfaction and staff will continue to provide 1:1 visits. Review of Resident #36's most current Lifestyle & Activity preference evaluation dated 6/21/2024, revealed: Section C. Leisure Preferences - Resident enjoys friendly visits and having books read to him. Resident enjoys watching television and listening to music. Review of Resident #36's current Care Plans with next review date 12/16/2024 revealed the following: (a) Resident is receiving palliative care/Hospice services receiving hospice services with diagnosis Cellulitis of perineum. Interventions in place to include but not limited to: Collaborate with hospice team to ensure the resident's spiritual emotional intellectual and physical and social needs are addressed, Assess resident's coping strategies as needed and respect resident wishes. (b) Resident has potential for little or no activity involvement related to visual impairment, impaired cognitive function/impaired balance. Often remains in bed for comfort/preference with interventions in place to include but limited to: 1. Educate the resident on the importance of social interaction and leisure activity time; 2. Encourage participation in activities of potential interest; 3. Invite/encourage the resident's family members to attend activities with the resident as needed/desired; 4. Offer friendly visits to promote independent leisure past times and socialization; 5. Provide resident 1:1 or bedside activities as needed for support and socialization/stimulation; 6. Remind the resident that the resident may leave activities at any time, and is not required to stay for entire activity; 7. Resident requires specific interventions i.e. cueing and reminders to engage in activities of interest; 8. Resident will benefit from small groups to include sensory, listening to music; 9. Resident needs assistance/escort to activity functions. On 11/21/2024 at 9:48 a.m. an interview with the Activities Director revealed she and her staff provide both monthly and daily scheduled activities to residents who want to participate as well as conduct 1:1 room visits with residents who wish to participate. She revealed she knew Resident #36, and he has had some decline lately and has not participated in activities. She could not remember how long he has not participated but did confirm he has not participated. She confirmed her activities assessments indicated the resident felt music, television, small group outings, religious activities and going outside for fresh air were important to him. She could not show documentation that he had been offered any of those types of activities within the past one month (11/2024) but was able to show 1:1 visits were completed. Her documentation could not identify what type of 1:1 activity was conducted, it just was documented 1:1 was completed. The Activities Director confirmed Resident #36 does refuse to do most of the activities offered but could not show documentation in the resident's record to support this. She also revealed his care plan with regards to Activities and participation needs to be updated to show his lack of activities interest. Further interview with the Activities Director revealed she could not support activities staff or direct care staff of offering him to go to any activities with regards to his assessed activities of interest. She could not support Resident #36 attending or offered any of the above listed calendar activities. On 11/21/2024 at 11:00 a.m. an interview was conducted with Staff D, CNA and Staff A, CNA. Both staff members revealed they knew Resident #36 and did not know if he likes certain group or 1:1 room activities. They both confirmed they have had him on their assignments in the past and do not remember if they had ever offered him to get up out from bed to go to any scheduled activities. They also confirmed they did not know what things he is interested in and also did not know if he likes to listen to music in his room or watch special television programs. They confirmed Resident #36 stays in his room and in his bed all day. On 11/21/2024 at 5:30 p.m. the Nursing Home Administrator revealed the facility did not have a specific policy and procedure related to resident activities. He revealed the facility will follow both State and Federal regulations as part of implementation of its activities program. The Nursing Home Administrator provided the Activities Director Job Description for review. The Job Description revealed the Activities Director reports to the Nursing Home Administrator. The overview of the Job Description revealed; The Director of Activities plans individual and group recreation services, both therapeutic and general, supervises recreation assistants and volunteers. The Director of Activities will also be responsible for developing, implementing, and supervising a full scope of recreation services in the nursing home to stimulate customers to have fuller and richer lives. Some of the Responsibilities the Activities Director holds, included but not limited to: (c) Responsible for developing, implementing & supervising all recreational services. (d) Responsible for all necessary documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the admission Record for Resident #763 showed the resident was admitted to the facility on [DATE] and discharged on 06/24/2024. The admitting diagnoses included type 2 diabetes. Review of the Minimum Data Assessment (MDS) dated [DATE] showed Resident #763 had a Brief Interview for Mental Status (BIMS) score of 7 showing the resident had severe cognitive impairment. Review of Resident #763's Care Plan dated 06/03/2024 showed the resident was at risk for adverse effects of hyper/hypo-glycemia related to a diagnosis of diabetes and insulin use. Monitor blood glucose as ordered - notify physician or nurse practitioner if result exceeds parameters and obtain new orders if applicable. Observe as needed any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Review of Resident #763's Medication Discharge Report dated 05/31/2024 and given to the facility from the hospital upon the resident's admission to the facility showed the resident was prescribed insulin isophane-insulin regular (70/30 subcutaneous suspension) 40 units subcutaneous once a day as needed for hypoglycemia in the morning. Review of the Order Summary Report dated 05/31/2024 for Resident #763 showed the resident's physician in the facility ordered 70/30 suspension (insulin isophane and regular) inject 40 units subcutaneously one time a day for diabetes. Review of Resident #763's Medication Administration Record dated 06/01/2024 through 06/30/24 showed the resident was scheduled to receive 70/30 suspension (insulin isophane and regular) 40 units to be injected subcutaneously at 9:00 AM daily. Review of the Medication Audit Report dated 06/01/2024 through 06/24/2024 for Resident #763's insulin administration showed the resident was given insulin late 20 out of 24 instances as follows: Date Time Scheduled Time Administered 06/01/2024 06/01/2024 09:00 AM 06/01/2024 10:55 AM 06/02/2024 06/02/2024 09:00 AM 06/02/2024 10:47 AM 06/03/2024 06/03/2024 09:00 AM 06/03/2024 09:58 AM 06/04/2024 06/04/2024 09:00 AM 06/04/2024 10:57 AM 06/05/2024 06/05/2025 09:00 AM 06/05/2024 11:31 AM 06/06/2024 06/06/2024 09:00 AM 06/06/2024 11:11 AM 06/07/2024 06/07/2024 09:00 AM 06/07/2024 13:05 AM 06/08/2024 06/08/2024 09:00 AM 06/08/2024 11:07 AM 06/09/2024 06/09/2024 09:00 AM 06/09/2024 10:41 AM 06/10/2024 06/10/2024 09:00 AM 06/10/2024 09:19 AM 06/11/2024 06/11/2024 09:00 AM 06/11/2024 13:44 AM 06/12/2024 06/12/2024 09:00 AM 06/12/2024 09:58 AM 06/13/2024 06/13/2024 09:00 AM 06/13/2024 11:09 AM 06/14/2024 06/14/2024 09:00 AM 06/14/2024 10:35 AM 06/15/2024 06/15/2024 09:00 AM 06/15/2024 10:27 AM 06/16/2024 06/16/2024 09:00 AM 06/16/2024 09:24 AM 06/17/2024 06/17/2024 09:00 AM 06/17/2024 10:37 AM 06/18/2024 06/18/2024 09:00 AM 06/18/2024 12:13 AM 06/19/2024 06/19/2024 09:00 AM 06/19/2024 12:20 AM 06/20/2024 06/20/2024 09:00 AM 06/20/2024 10:43 AM 06/21/2024 06/21/2024 09:00 AM 06/21/2024 11:43 AM 06/22/2024 06/22/2024 09:00 AM 06/22/2024 11:33 AM 06/23/2024 06/23/2024 09:00 AM 06/23/2024 14:06 AM 06/24/2024 06/24/2024 09:00 AM 06/24/2024 11:09 AM An interview was conducted on 11/20/2024 at 2:45 PM with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff B said she was unaware Resident #763 had received late medications. An interview was conducted on 11/21/2024 at 2:00 PM with the Director of Nursing (DON). The DON said she did not remember any specifics regarding Resident #763. When presented with the Medication Audit Report dated 06/01/2024 through 06/24/2024 for Resident #763's insulin administration she reviewed the report and agreed the insulin was given to the resident late. The DON said she did not know why the medications were given late and she would have to investigate and return with the results. As of the exit conference on 11/21/2024, the DON did not return with results of her investigation. An interview was conducted on 11/21/2024 at 3:20 PM with the Nursing Home Administrator (NHA). The NHA said he was not aware of any issues regarding Resident #763 and the resident's stay at the facility. 3. Review of Resident #64's admission record showed the resident was admitted on [DATE] with diagnoses not limited to nondisplaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, type 2 diabetes mellitus with hyperglycemia, and generalized muscle weakness. Review of Resident #64's Admission/readmission Nursing Evaluation, effective 8/9/24, showed the resident was admitted from an acute care facility, alert and oriented to person, used a urinary catheter, and had the following skin conditions: - Right antecubital - Coccyx - redness open area - Right trochanter (hip) - Left heel - blister The Braden Scale completed with the admission evaluation showed the resident was rarely moist, bedfast, slightly limited, had adequate nutrition, and friction and shearing was a potential problem. The nursing evaluation showed the resident was at risk for skin breakdown and initiated the interventions of Treatments as ordered, Medications as ordered, Promote use of specialty mattress, cushions, and/or wedges as appropriate, and Monitor for pain and medicate as per orders prior to treatment/turning etc. to enhance comfort. Review of Resident #64's post-admission Skin/Wound note, dated 8/10/24 at 12:51 p.m. showed Resident #64 had a deep tissue injury (DTI) to the left heel, measuring 2.5 x 2.5 centimeters (cm) and a right hip incision from surgery with glue and steri-strips in place. The note indicated there was an old wound to coccyx which was not open and healed. Review of Resident #64's Weekly Skin Check, dated 8/12/24 showed redness to the left toe(s) and redness to the buttock area, no open area noticed. Review of Resident #64's Weekly Skin Check, dated 8/14/24 at 10:00 p.m. revealed Existing blister on the left heel, discoloration on the right heel and back of foot, discoloration groin areas. Barrier cream applied to groin and buttocks to prevent skin breakdown. Review of Resident #64's progress note dated 8/16/24 at 10:58 p.m. showed a Braden scale had been completed with the resident scoring a 15 (of 23) revealing the resident was a low risk for skin impairment. Review of Resident #64's Weekly Skin Check dated 8/21/24 at 10:59 p.m. showed the resident had no new skin issues. Review of Resident #64's progress notes from 8/15/24 to 8/23/24 did not show staff were monitoring or had notified the physician or representative of the existing blister on the left heel or the discoloration on the right heel and back of foot as described in the Weekly skin check dated 8/14/24. The notes did not reveal staff were monitoring the resident's right hip surgical incision for signs or symptoms of infection. Review of Resident #64's progress note, dated 8/23/24 at 10:00 p.m. showed a Braden Scale had been completed and the resident scored 14 (of 23) showing a moderate risk form skin impairment. Review of Resident #64's Weekly Skin check, dated 8/24/24 at 8:49 p.m. revealed the resident had an open blister to both right and left heels. The comments reported open blister under bilateral heels. The progress notes did not show any notes by nursing staff as to the description of the wound bed or peri-wound area of the bilateral open blisters. The note did not show the resident representative, or physician was notified of the open areas. The Weekly skin check also did not report on the surgical incision the resident had been admitted with. Review of Resident #64's progress notes did not show staff were monitoring the open blisters between 8/24 and 8/28/24. Review of Resident #64's progress notes showed on 8/28/24 at 9:44 a.m., Resident was initially evaluated by the wound Dr. this morning due to recent eschar noticed on both heels. After the evaluation the doctor ordered to continue to apply betadine on both heels and leave open to air. Resident heels were left offloaded. The resident was educated about the treatment and understand. Review of Resident #64's Wound Evaluation, dated 8/28/24 at 9:36 a.m. showed an In-house Acquired Left heel unstageable pressure ulcer measuring 3.1 x 2.8 x 0 cm. The documentation showed the wound had been identified on 8/23/24 with no exudate, 100% black eschar, defined wound margins, and a treatment of betadine daily and as needed leaving the area open to air (OTA). The note revealed the resident was notified on 8/28/24 at 7:00 a.m. Review of Resident #64's Wound Evaluation, dated 8/28/24 at 9:19 a.m. showed the resident had an In-House Acquired Right heel unstageable pressure ulcer measuring 4.5 x 4.2 x 0 centimeters (cm). The documentation showed the wound had been identified on 8/23/24 with no exudate, 100% black eschar, defined wound margins, and a treatment was obtained on 8/28/24 for betadine daily and as needed leaving the area OTA. The note revealed the resident was notified on 8/28/24 at 00:00 (12:00 a.m.). Review of Resident #64's August 2024 Medication Administration Record (MAR) did not reveal staff were monitoring the resident's surgical incision, discoloration to right heel or the progression to an open blister , or had monitored the existing blister on the left heel. Review of Resident #64's August 2024 Treatment Administration Record (TAR) revealed staff were not monitoring the resident's surgical incision for signs/symptoms of infection, or for changes in the resident's left heel existing blister as reported on the day of admission. The TAR showed wound care orders had been obtained on 8/27/24 for the application of Betadine on the Right/Left heel and instructed to leave open to air every day shift for eschar. Review of Resident #64's care plan revealed the following: - At risk for skin impairment related to (r/t) anemia, diabetes, fragile skin, (and) weakness/decreased mobility, Pressure area to left heel, right heel (and) redness to coccyx. The focus was initiated on 8/10/24. The interventions included but no limited to Monitor/observe skin while providing routine care. Notify the nurse for any area of concern as indicated, initiated 8/10/24. - At risk for adverse effects for hyper/hypo-glycemia r/t diagnosis of diabetes (and) insulin use, initiated 8/12/24. The interventions included but not limited to Monitor feet for open areas, sores, pressure areas, blisters, edema, or redness. Report to MD indicated, initiated 8/12/24. An interview was conducted with Staff R, Registered Nurse/Wound Care (RN/WCN), on 11/21/24 at 10:15 a.m. Staff R reported she would have expected to be notified of skin issues on Resident #64's right heel prior to the development of eschar. Staff R reported dressing the resident's wounds daily Monday through Friday and floor nurses were responsible for wound care on the weekends. An interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 11/21/24 at 1:34 p.m. The DON stated the resident had come in with one pressure area and had developed one while at the facility and mobile. The facility was going to work up the wounds to see if they were vascular. The DON stated eschar could show up and could deteriorate rapidly. Review of the policy - Prevention of Skin Impairments/Pressure Injury, revised 1/2024, revealed The purpose of this policy is to provide information regarding identification of skin wound risk factors and interventions for specific risk factors. The guideline instructed to Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The risk assessment included: - 1. Assess the resident on admission for existing wound risk factors. - 2. Conduct a comprehensive skin assessment upon a mission, including: - a. Skin integrity- any evidence of existing or developing pressure ulcers or injuries; - b. Areas of impaired circulation due to pressure from positioning or medical devices. - 3. Inspect the skin when performing or assisting with personal care or activities of daily living (ADLs). - a. Identify any signs of developing skin wound (i.e. Non blanchable erythema/rashes). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; - b. Inspect pressure points (sacrum, heels, products, toxics, elbows, ischium, trochanter, etc.). - c. Wash the skin after episodes of incontinence. - d. Reposition resident as indicated on the care plan. The preventions based on the assessment and the resident's clinical condition, choices and identified needs, basic or routine care could include, but is not limited to, interventions to: a. Redistribute pressure (such as repositioning, protecting and/ or offloading heels, etcetera (etc.)); b. Minimize exposure to moisture and keep skin clean, especially a fecal contamination; c. provide appropriate, pressure redistributing, support surface; d. provide non irritating surfaces; and e. maintain or improve nutrition and hydration status, when feasible. Adverse drug reactions related to the residence drug regimen may worsen risk factors for development of, or for non healing pressure ulcers (PU)/ Pressure injuries (PI)s (For example, by causing lethargy or anorexia or creating/ increasing confusion) and should be identified and addressed. These interventions should be incorporated into the plan of care and revised as the condition of the resident indicates. The policy instructed for the Monitoring/Documenting as follows: 1. Evaluate, report, and document potential changes in the skin. 2. Notify the physician and the resident/ resident representative of changes in the skin. 3. Review the interventions and strategies for effectiveness on an ongoing basis. 4. Evaluate open areas (pressure/ surgical areas) per physician orders. Based on record review and interview, the facility did not ensure medications were administered in a timely manner for two (#815, #763) of forty eight residents and failed to ensure wounds were monitored for signs and symptoms of infections and deterioration, and treatment orders were obtained and implemented for one (#64) of two residents sampled for pressure wounds, surgical incisions, and other skin conditions. Findings Included: 1.Review of the admission Record for Resident #815 revealed she was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Heart Failure, Non-St Elevation Myocardial Infarction, Paroxysmal Afibrillation and Pulmonary Hypertension. Review of November 2024 Physician orders for Resident #815 revealed an order dated 11/4/24 for : Enoxaparin Sodium Injection Solution Prefilled Syringe 80 Mg/0.8 ML.(Enoxaparin Sodium) Inject 0.7 ml subcutaneously two times a day for Deep Vein Thrombosis (DVT) prophylaxis for 60 days. Review of the November Medication Administration Record ( MAR) for this medication indicated it was scheduled to be given at 9:00 a.m. and 9:00 p.m. An interview was conducted with Resident #815 on 11/18/24 at 12: 46 p.m. Resident #815 stated she received Lovenox (Brand name of Enoxaparin Sodium ) twice a day every 12 hours and she usually received the morning dose at 8:00 a.m. every day. She stated the nurse Staff S, Registered Nurse (RN) told her the medication was not in the medication cart and the nurse could not find it. Resident #815 stated she did not receive the 11/18/24 9:00 a.m. dose of this medication until 11:15 a.m. Resident #815 was concerned that the late administration of the medication would cause a problem with the next dose of the medication scheduled for 9:00 p.m. A review of a Medication Administration Audit Report for 11/18/24 showed the 9:00 a.m. dose of Enoxaparin Sodium Injection Solution Prefilled Syringe 80 Mg/0.8 ML.(Enoxaparin Sodium) Inject 0.7 ml subcutaneously two times a day for Deep Vein Thrombosis (DVT) prophylaxis for 60 days was administered at 11:15 a.m. on 11/18/24 and the 9:00 p.m. dose was administered at 8: 43 p.m. An interview with the Director of Nursing (DON) was conducted on 11/20/24 at 4: 03 p.m. The DON stated it was Staff S RN's first day on the cart by herself. The DON stated she did not see any communication in Resident # 815's record to the physician regarding the medication being administered late. An interview was conducted with Staff B, Unit Manager Station 1 on 11/20/24 at 4:25 p.m. Staff B stated Staff S did tell her the medication was not in the medication cart. Staff B stated she went and checked the Emergency Drug Kit ( EDK) for the medication however the correct dose was not stocked in the EDK She then called the pharmacy and found out the medication was delivered to the facility on [DATE]. Staff B stated she then went and checked the medication cart herself and found the medication in the cart which was then administered to Resident #815 by Staff S. Staff B stated neither she nor Staff S documented the late administration of the medication in the resident's record on 11/18/24 . She stated she notified the Nurse Practitioner but did not document the notification in the the resident's record. Staff B provided documentation on her phone of the text message that was sent to the Nurse Practitioner on 11/18/24. On 11/20/24, a late entry was recorded in Resident # 18's medical record of the notification to the Nurse Practitioner on 11/18/24. Further interview with the DON and Staff B revealed that the late administration of the 9:00 a.m. dose of Enoxaparin Sodium was not passed on to the 3:00 p.m. to 11:00 pm. nurse who would be administering the 9:00 p.m. dose. Review of a facility policy entitled : Standards and Guidelines : Medication Administration with a revision date of 01/24 revealed : Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescribe's orders, including any required time frame. 6. Medications are administered within one (1) hour before or after their prescribed time , unless otherwise specified ( for example, before and after meal orders, at bedtime). 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering shall document the rationale in the resident's medical record and notify the physician and responsible party if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure a hazarded free room environment, with (brand name) Air Freshener Spray found in one resident room, Resident (#99) out of eight residents sampled. Findings include: During an observation on 11/18/2024 at 10:00 a.m., and 12:41p.m., Resident #99's room was observed with the door open, where other residents were able to enter the room. Her dresser was observed with two air freshener sprays. The bathroom was observed with one additional air freshener spray on the bathroom rail over the toilet. During an interview on 11/19/2024 at 10:00 a.m., with Resident #99. She stated the staff took away her air fresheners today. She stated she has had her sprays on her dresser for about a month but was told by staff today they had to take it away because she is not allowed to have air freshener sprays in her room. Review of an admission Record dated 11/21/2024 showed Resident #99 was admitted to the facility originally on 6/4/2024 and readmitted on [DATE] with diagnoses to include but not limited to Dysarthria Following Cerebral Infractions, Type 2 Diabetes Mellitus Without Complications, Unspecified Asthma, Uncomplicated. Review of Quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. During an interview conducted on 11/21/2024 at 2:00 p.m., with the Nursing Home Administrator, (NHA), the NHA stated when a resident is admitted to the facility, they conduct a 24-hour meeting to discuss the facility's guidelines with the resident. They also conduct a follow-up discussion during the care plan meeting in which they go over the facility do's and don'ts. If a resident has air freshener in the room, they find out if the resident is alert. If the resident is alert the facility would provide the resident with a lock, and they are allowed to have items locked up in their rooms. If they can't use the lock, they would have the discussion with the resident's family to tell them not to bring in air freshener. During an interview conducted on 11/21/2024 at 2:30 p.m., with the Director of Nurses (DON) the DON stated she was not aware that Resident #99 had air freshener spray in her room. She stated the resident orders a lot of items that are delivered to the facility. She stated that Aerosol sprays are not allowed in the facility, so staff should have taken the spray out of the resident room and educated her about the facility process. She stated she will have to do further training with her staff and residents about the use of Aerosol spray. (Photographic Evidence obtained) The facility did not have a policy to provide related to the prohibited use of Aerosol Sprays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure medications were administered at the correct dose for one (Resident #90) out of 26 residents sampled. Findings Included: During an observation on 11/18/2024 at 9:49 a.m. Resident #90 was observed in bed, she was not able to answer questions regarding her care. Review of Resident #90's admission record revealed resident #90 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and depression. Review of Resident 90's admission Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) of 04 out of 15 showing severe cognitive impairment. Review of Section N. Medications revealed Antipsychotic and antidepressant. Review of Resident #90's orders revealed on 11/07/2024 an order for Seroquel Oral Tablet 25 milligrams (MG) (Quetiapine Fumarate) Give 3 tablet by mouth in the evening for agitation and an order for Seroquel Oral Tablet 25 MG Give 25 MG by mouth two times a day for Anxiety. Review of Resident #90's Medication Administration Record (MAR) revealed the following: Seroquel Oral Tablet 25 MG one tablet was given on 11/07/2024 at 5:00 p.m. Seroquel Oral Tablet 25 MG one tablet was given daily 11/08/2024 to 11/20/2024 at 9:00 a.m. and 5:00 p.m. Seroquel Oral Tablet, three 25 MG tablets were given daily 11/07/2024 to 11/20/2024 at 8:00 p.m. Review of Resident #90's Behavior Monitoring revealed on 11/07/2024 0 No Behaviors; 11/08/2024 NA (Not Applicable); 11/09/2024 to 11/14/2024 0 No Behaviors;11/15/2024 NA ;11/16/2024 to 11/20/2024 0 No Behaviors. During an interview on 11/21/2024 at 2:00 p.m., with the Director of Nursing (DON), she stated she called psych about the Seroquel order and psych told her they did not write the order for Seroquel at bedtime and must have been ordered by the attending physician. She stated she would need to reach out to the attending physician for clarification. During a phone interview on 11/21/2024 at 3:13 p.m., the Attending Physician, stated that he remembered Resident #90 and did remember ordering Seroquel 25 MG 3 tabs at bedtime for agitation on 11/07/2024 and he was aware that she was also taking Seroquel 25 mg twice daily. He stated the 75 mg dose was only meant for a short period of time and not an ongoing order. He stated this was not a correct intervention. He stated, It probably should have been ordered for her to have 25 MG dose in the morning and then the 75 MG at bedtime. He stated no one from the facility had called him to clarify the order and that he would bring this up in their next Quality Assurance meeting. On 11/21/2024 at 4:45 p.m., the facility was asked to provide a policy for Unnecessary Medication and provided a policy for Gradual Dose Reduction.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-four medication administration opportunities were observed, and three errors were identified for two (#13 and #11) of four residents observed. These errors constituted an 8.82% medication error rate. Findings included: 1. On 11/19/24 at 8:43 a.m., an observation of medication administration with Staff P, Registered Nurse (RN) was conducted with Resident #13. The staff member dispensed the following medications: - Gabapentin 800 milligram (mg) tablet - Zoloft 100 mg tablet - Megestrol AC Suspension 40 mg/milliliter (mL) - 10 mL - Artificial Tears lubricant eye drops (contained glycerin, hypromellose, and poly glycol) -Buspirone (Buspar) 5 mg tablet Staff P confirmed dispensing 3 oral tablets prior to entering Resident #13's room. The resident refused the liquid Megace reporting refusing all along. The staff member obtained a blood pressure of 98/64, administered oral medications, then placed one drop of Artificial Tears in each eye. The staff member left the room and took the Megace to the unit's medication room and disposed of it in a jug of medication disposer. Staff P dispensed the resident's as needed medication, Oxycodone 5 mg tablet, called the attending physician for instructions regarding the resident's bathyspheres medication, then administered the pain medication. Review of Resident #13's November Medication Administration Record (MAR) revealed the following: - Staff P documented that the 9:00 a.m. scheduled dose of Megace had been administered. - Artificial Tears Ophthalmic Solution 1% (Carboxymethylcellulose Sodium) - Instill 1 drop in left eye four times a day for dry eye. The eye drops were administered in both eyes and the ingredients of the administered drops did not contain Carboxymethylcellulose Sodium. 2. On 11/21/24 at 7:48 a.m. an observation of medication administration with Staff Q, Licensed Practical Nurse (LPN) was conducted with Resident #11. The staff member searched the medication cart reporting having to go to the refrigerator for the resident's Lispro insulin and also had to get the laxative. The staff member went to the medication preparation room and did not obtain the resident's Lispro but did obtain the resident's Humalog 70/30. The staff member dispensed the following medications: - ClearLax polyethylene - in a 5-ounce cup of water - Pantoprazole 40 mg tablet - Tamsulosin 0.4 mg tablet - Lexapro 10 mg tablet - Carvedilol 6.25 mg tablet - Allopurinol 100 mg tablet The staff member confirmed dispensing 5 tablets and the laxative. Staff Q obtained a blood glucose level of 276 from the resident, administered the oral medications followed by the assisting resident with drinking the laxative. Staff Q returned to cart. The resident dialed the resident's Humulin 70/30 pen to 12 units, primed to approximately 6 units then dialed back to 10 units, returning to the resident to inject into the left abdomen at 8:16 a.m. On 11/21/24 at 8:18 a.m., a staff member served Resident #11 the morning meal and the resident was observed feeding himself while sitting in a wheelchair. Staff Q walked to the electronic medication dispenser on the other unit and was unable to obtain the resident's Lispro, stated thinking the facility had a refrigerator kit and would have to check with the unit manager. The staff member searched the refrigerator kit on the unit and was unable to locate the necessary insulin. Staff Q informed Staff O, LPN/Unit Manager of needing to talk to her after Staff O finished assisting a resident with eating. Staff Q notified the Unit Manager at 8:30 a.m. of the situation regarding the insulin. On 11/21/24 at 8:45 a.m., Staff O arrived on the unit and stated the Lispro was in the other kit. Staff O confirmed the insulin was late, I understand. On 11/21/24 at 8:47 a.m. Staff Q reported going to clear off the red and Resident #11 was going to get 6 units of insulin per sliding scale, the staff member primed the insulin Lispro pen, dialed the dosage selector to 6 units and injected into the residents right lower quadrant at 8:51 a.m. Review of Resident #11's Medication Administration Record revealed the Insulin Lispro 100 unit/milliliter solution pen-injector was to be injected per sliding scale subcutaneously with meals for diabetes mellitus at 7:05 a.m. The observation showed Resident #11's insulin Lispro was not available to Staff Q and the medication was administered approximately 30 minutes after the resident had eaten and 1 hour 46 minutes after it was scheduled to be administered. An interview was conducted with the Director of Nursing (DON) on 11/21/24 at 2:03 p.m. The DON was made aware of the observed errors. She stated the procedure (regarding Resident #11) was to notify the physician and the family if the medication was not available. The discussion revealed the medication was available in the other refrigerator and was given late after the resident had eaten breakfast. Review of the policy - Medication Administration, revised 1/2024 revealed medications are ordered in administered safely and as prescribed. - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, at bedtime).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to coordinate dental services for one resident (#18) out of eight residents sampled. Findings include: During an observation on 11/18/24 at 2:05 p.m., Resident #18 was observed sitting up on her bed, fully dressed with no signs of distress. She stated her only concerns were that she had missing teeth, and she really wanted to have a set of dentures so she could chew her food. She stated she did not know what happened to her dentures. During an observation on 11/20/2024 at 11:45 am., Resident #18 was observed sitting up in her wheelchair eating her lunch. She said she was not able to eat her green beans because she did not have any teeth. She stated the facility had not assisted her with dental services. On 11/20/2024 at 2:20 p.m., an interview was conducted with Staff M, Certified Nursing Assistant (CNA). Staff M stated every morning she provided oral care to all her residents. For residents who wore dentures she provided them with denture care. She stated she put Resident #18 dentures in her mouth this morning, so she did not know why Resident #18 did not have her dentures. During the interview with Staff M, Resident #18 interrupted and stated she had not had her dentures in a while, and she really needed them because she was having trouble eating her food. Staff M than stated she did not normally work on the side with Resident #18, and she thought she had put Resident #18 dentures in her mouth. Review of an admission Record date 11/21/2024 showed Resident #18 was admitted to the facility with diagnoses to include but not limited to Chronic Atrial Fibrillation, unspecified, Type 2 Diabetes Mellitus Without Complications, Need for Assistance with Personal Care. Review of a Quarterly Minimum Data Set, (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Review of a Social Service assessment dated [DATE] showed Resident #18 was marked no to indicate she did not have dentures. Review of a [name of dental service] patient note dated 8/30/2024 showed Resident #18 was seen for a Comprehensive Exam and had an impression for upper lower dentures Resident #18 had a care plan for oral/dental health problems related to Alzheimer's Disease, Depression, Diabetes Mellitus (DM), Functional Impairment limiting ability to perform oral hygiene; wears dentures, prefers to remove them at times, date initiated 6/26/2024, revision date 11/21/2024. The care plan goal was for Resident #18 to be free of infection, pain or bleeding in the oral cavity by through review date. Date initiated 6/26/2021, revision on 7/24/2023, Target date 12/18/2024. The care plan interventions include Coordinate arrangement for dental care, transportation as needed/as ordered, ensure dentures are worn, date initiated 6/26/2021, revision on 6/26/2021. During an interview on 11/21/2024 at 2:00 p.m., with Staff F, Care plan Coordinator, she stated when a resident was admitted to the facility, nursing, speech and social services did the resident screening to see if the resident had natural teeth or upper or lower partials. As they build the comprehensive care plan, she gathered the information from the assessments, then she care planned the resident's dental status. Resident #18 had a Quarterly last done on 9/18/2024 and it showed the resident did not have broken or loosely fitting dentures. She stated upon review of the social services and dietary assessment, Resident #18 was marked not to have dentures. Which was not accurate because Resident#18 had a care plan showing she had dental problems and she wore dentures. She stated she updated Resident #18's care plan today, 11/21/2024, to reflect the resident did not have her dentures. She stated staff should have told her as soon as the resident lost her dentures, and she should have been notified when resident had impressions taken and was waiting for her dentures, so a note could have been out in the system. During an interview on 11/21/2024 at 2:30 p.m., with the Social Service Director (SSD). She said the resident had dentures but she lost them because she liked to wrap them up in paper napkins and put them in her purse. She stated the resident was last seen on 8/30/2024 by [name of dental service] and they noted they took impressions for upper and lower dentures. She stated she did not follow up with the dentist about the resident's impressions because she was not aware that Resident #18 had impressions taken. She stated when she went to Resident # 18 room, to look for the resident dentures, she was able to confirm that the resident did not have her dentures. During an interview on 11/21/2024 at 3:00 p.m., with the Director of Nurses, DON. She stated if the CNA(s) notice that their residents had issues with their dentures, such as lost or broken, then the aide should report the issues to their nurse. The nurse would report the issue to the nursing supervisor, who would get the resident added to the dental list. If it was a resident that had issues with their dentures, such as broken or lost, then the nurse would assess the resident to make sure there were no issues with the resident having difficulty in swallowing, chewing, or a decrease in oral intake. She stated Resident #18's aides should have reported the resident's missing dentures to their nurse, so they could have assessed the resident to make sure she had no issues until her dentures came in. Review of the facility policy tilted; Dental Consults Revised dated 1/2024 showed Standard: The facility will facilitate dental services through the service of a Consultant Dentist as indicated. Guidelines: 1. Our facility does not have dental providers on staff, and therefore contracts with external providers to provide dental services to residents as indicated. 2. The facility will contract with an external Dental provider to provide Dental Services to residents as indicated and provide the following: 1. Providing consultation to physicians and providing other services relative to dental matters.

Based on resident meal observation and staff interview, it was determined the facility did not ensure one (Resident #816) of three residents observed during a lunch meal received food presented in an attractive and appealing manner. Findings included: Review of the record for Resident # 816 revealed diagnoses which included Unspecified Alzheimer's disease, Unspecified Dementia, Unspecified Protein-Calorie Malnutrition and Dysphagia Oropharyngeal Phase. Review of the record for Resident # 816 indicated a diet order for Pureed Texture Thin Consistency (Photographic Evidence obtained). An observation of the lunch meal for Resident # 816 was conducted on 11/18/24 at 12:11 p.m. Resident # 816 was observed in her bed and the lunch meal was placed on the overbed table by a CNA (Certified Nursing Assistant) who was observed to remove the lid on the entree and then exit the room. A dinner size plate was located on the tray and was observed to be filled with a soupy consistency of pureed foods running together on the plate (photographic evidence obtained). An interview was conducted with the Dietary Manager on 11/20/24 at 2:15 p.m. She reviewed the photograph of the lunch meal served to Resident # 816 on 11/18/24. The Dietary Manager stated the presentation was not acceptable and said, that was gross. She stated she did not know how the meal got out of the kitchen looking like that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement an effective infection control program related to 1. the use of Personal Protective Equipment (PPE) for one (#88) of one sampled resident for transmission-based precautions, 2. failed to ensure fingernails of staff were kept in a manner that prohibited the growth of microorganisms and allowed for sufficient hand hygiene, and 3. failed to ensure the storage of personal hygiene equipment for one resident (#91) out of ten sampled residents related to oral hygiene. Findings included: 1. On 11/18/24 at 9:14 a.m. an observation was made of a Contact precaution sign posted outside of Resident #88's room. The sign showed STOP - CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. The hallway outside or near the resident's room did not show any PPE was available for staff and/or visitors to don prior to entering the room. During the observation on 11/18/24 at 9:14 a.m., Staff K, Social Work Assistant (SWA) entered the room and stood at the bed of Resident #88's bed without donning any PPE, then Staff J, Licensed Practical Nurse (LPN) entered the room and spoke with the resident. Both staff members left the room and Staff J stated she thought the resident was off precautions since the (PPE) caddy was gone. The staff member read the Contact precaution sign and stated if the sign was still posted staff should dress in PPE. The staff members confirmed the PPE containers were 3-drawer storage unties that were placed in the hallways. Shortly after the observation and interview with Staff K and Staff J, the Infection Preventionist (IP) was seen on B-hall (on other side of the nursing station from Resident #88's room). The IP stated staff got PPE from the shower room and began to walk around the nursing station, stopping at Resident #88's room with the Contact precaution sign posted and stated staff only had to wear PPE when they were providing direct care for the resident. The IP stated staff had to dress in PPE for Resident #88 prior to entering the room. This writer and the IP walked to the shower room at the opposite end of the hall and around the corner. The IP stated PPE was kept in a caddy outside the room for contact precautions and inside the room for Enhanced Barrier Precautions (EBP). The IP stated the PPE kept in the shower room was for restocking the caddies. The IP confirmed there was no PPE available outside of the resident's room. Review of Resident #88's admission Record showed the resident was admitted to the facility with diagnoses included but not limited to type 2 diabetes mellitus without complications, generalized muscle weakness, and need for assistance with personal care. Review of Resident #88's Order Summary Report showed an order for Contact Precautions: Encourage and assist resident to maintain contact precautions for urinary tract infections (UTI) e.coli every shift for UTI e.coli for 7 days, start date 11/11/24 and end date 11/18/24. Photographic evidence was obtained on 11/18/24 at 9:20 a.m. Review of policy - Transmission Based Precautions, revised 2/2024, showed All staff receive training on transmission-based precautions upon hire and at least annually. The procedure for Contact Precautions revealed: a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on a case-by-case basis after considering infections risks to other residents in the room and available alternatives. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens. 2. On 11/18/24 at 11:05 a.m., Staff L, Certified Nursing Assistant (CNA) was observed outside of room [ROOM NUMBER]. The staff member reported looking for someone to assist getting a resident up. The observation revealed Staff L's had unnatural fingernails, painted a blush pink color with white tips and a variegated yellow/pink nail on one observed hand. The nails extended a minimal of approximately ½ past the tip of the fingertip. Staff L confirmed the fingernails were fake. 3. On 11/20/24 at 2:23 p.m., Staff M, CNA, was observed documenting at a wall-mounted kiosk. The staff members nails were square-cut, painted a pink iridescent color extending approximately ¼ past the tip of the fingers. 4. On 11/20/24 at 2:24 p.m., Staff N, Licensed Practical Nurse (LPN) was observed with square tip nails with tips painted a light grass green color extending approximately ½ past the fingertips. The staff member was observed assisting an unknown resident in the hallway, pulling the resident's wheelchair towards a room. 5. On 11/21/24 at 5:09 p.m. the Director of Nursing (DON) was observed with nails colored a pinkish-nude color with the ends extending slightly past the ends of fingertips. The DON reviewed the statement obtained from the facility regarding staff hygiene acknowledging it came from the staff handbook. She stated fingernails (length) should not interfere with care. The DON read further and acknowledged the handbook reported fingernail length no longer than ¼ or fingertip length. She stated it would probably encompass all of us and stated also no artificial nails. The staff handbook, section 5-17 - Employee Dress and Personal Appearance revealed Employees are expected to report to work well-groomed, clean, and dressed according to the requirements of their position. Fingernails should be clean and well-manicured. Fingernails length should not interfere with customer care, job performance, or infection control guidelines (1/4 or fingertip length). Nail polish, if worn, should not be chipped. Review of the Centers of Disease Control and Prevention (CDC) guidelines for Clinical Safety: Hand Hygiene for Healthcare Workers, February 27, 2024, (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) revealed: - Natural nails should not extend past the fingertip. - Do not where artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive care units or operating rooms. Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and hand washing. - Some studies have shown that skin underneath rings contain more germs than fingers without rings. -Further studies should determine if wearing rings increases the spread of deadly germs. 6. On 11/18/24 at 11:31 a.m., an observation was made of Resident #91's bathroom. The observation showed two toothbrushes lying uncovered behind the sink's faucet with multiple tubes of toothpaste, including one opened tube. On 11/21/24 at 9:01 a.m., Resident #91's bathroom was observed with multiple tubes of toothpaste and two toothbrushes laid behind the sink's faucet. Resident #91 reported wearing dentures and staff did not clean them but did put them in. On 11/21/24 at approximately 9:30 a.m., the oral hygiene items in the bathroom of Resident #91 was observed with Staff O, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff O stated toothbrushes should not be stored like that and that's gross. Review of Resident #91's Functional Abilities and Goals comprehensive assessment, dated 9/16/24, shows the resident required set up assistance with oral hygiene and supervision with transferring from bed to chair. Review of Resident #91's care plan showed the following: - That has potential or intellectual or health concerns. Has cognitive impairments and needs assistance to complete oral care task. Has obvious or suspected cavities or broken natural teeth which may lead to complications such as mouth sores, infection, or pain, dated initiated 7/16/24. The interventions instructed staff to Assist with or provide mouth care as needed to ensure task completion. Review activities of daily living (ADL) care plan interventions for degree of assistance needed. Review of the policy - Infection Control Infection Prevention and Control Program, revised 1/2024, reported An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Photographic evidence was obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 11/18/2024 at 11:01 a.m., Resident #39 was observed laying in bed under the covers, dressed in a gown, groomed and sleeping. The resident was receiving nutrition via tube feeding. A verbal attempt was made to wake the resident up by calling her name, however, the resident opened her eyes and immediately closed her eyes. No visitors or staff were observed in the room. On 11/19/2024 at 10:27 a.m., Resident #39 was observed laying in bed under the covers, dressed in her personal clothing, groomed and awake. An attempt at verbal communication with the resident was made by calling out her name, however, the resident continued to stare and did not verbalize a response. No visitors or staff were observed in the room. On 11/21/2024 at 3:30 p.m., Resident #39 was observed laying in bed under the covers, dressed in her personal clothing, groomed and awake. An attempt at verbal communication with the resident was made by calling out her name, however, the resident continued to stare and did not verbalize a response. No visitors or staff were observed in the room. Review of the admission Record showed Resident #39 was admitted to the facility with diagnoses included but not limited to Alzheimer's Disease, gastrostomy, history of falling, need for assistance with personal care, contracture left elbow, contracture left hip, dysphagia, cognitive communication deficit, and contracture right hip. Review of Resident #39's Minimum Data Set (MDS) Quarterly assessment dated [DATE] showed Section C-Cognitive Patterns, Resident #39 had a Brief Interview for Mental Status (BIMS) score of 00 showing severe cognitive impairment. Section GG-Functional Abilities and Goals showed when Resident #39 was seated in a motorized wheelchair/scooter, she had the ability to wheel at least 50 feet and make two turns. Section GG also showed when Resident #39 was seated in a manual wheelchair, she had the ability to wheel at least 150 feet in a corridor or similar space. Review of Resident #39's Care Plan dated 09/24/2024 revealed the resident was dependent on staff for emotional, intellectual, physical, and social stimulation related to cognitive deficits. Resident #39 needed Assist/escort to activity functions as needed. The resident should be invited to scheduled activities. Offer 1:1 bedside/in-room visits/activities if the resident was unable to attend out-of-room events, if the resident chooses. Review of Quarterly Activity Progress note dated 09/25/2024 for Resident #39 showed the following: 1. Assessment Review - activity assessment is complete and appropriate. No changes needed. 2. Activities-related care plan: some elements/interventions were successful: 1:1 visits provided by staff 3. Summary - since the last review the resident has enjoyed these preferred activities: Resident enjoys a variety of activities mainly receiving friendly visits, being read aloud to, hand massages, and listening to music. Resident prefers to stay in bed majority of the time. The positive results included: Resident expresses satisfaction with current routine through facial expressions. Staff will continue to provide 1:1 visits. Review of Resident #39's Activity Participation Report, as completed by the Activities Department staff, showed for the time period 10/23/2024 through 11/20/2024 the section titled Active was checked daily. The other sections were not checked and were titled as follows: Left or In & Out, Passive/Assisted, Present/Observer (difficult to discern response), Therapy Session at time of activity, Visiting with family/other (at time of activity), Resident Not Available, Resident Refused and Not Applicable. Review of Resident #39's Activity Type Report, as completed by the Activities Department staff, showed for the time period 10/23/2024 through 11/20/2024 the section titled Friend/Friendly Visit (e.g. may include by staff, volunteer) was checked daily. All other sections of the report were not checked. The sections not checked included: Memory Stimulation (e.g. reminiscing, photos), Music and Nature/Garden/Science. An interview was conducted on 11/21/2024 at 10:46 a.m. with Staff G, Activities Director (AD) and the Nursing Home Administrator (NHA). Staff G said there were three staff members in the Activities Department, herself and two others. She said friendly visits were done in the morning between 9:30 a.m. and 10:00 a.m. and the visits usually took 15-20 minutes for each resident. She said friendly visits were also completed during any downtime her and her staff might have during the day. Staff G said the resident visits were charted by the activities staff and the charting was usually done at the end of the day. She said the exact times of the visits were sometimes not charted correctly because the facility's electronic medical record automatically records a time and the staff sometimes forgot to change the time when completing their charting. Staff G said the Activities department individually charts what activity they do with the residents. For example, reading, listening to music, etc. were not separately charted because charting as friendly visits encompasses the other activities done on the 1:1 friendly visits. She said the activities staff meet every morning and discuss what types of visits they completed with their assigned residents the day before. Staff G said she did not actually time her staff to ensure they were spending time with their assigned resident, she received the information directly from the staff members. She agreed as a Director of Activities she needed to know exactly how long each staff member was spending with their assigned residents. 7. During an observation on 11/18/2024 at 9:49 a.m. Resident #90 was observed in bed dressed in a night gown, clean in appearance. An attempt to interview Resident #90 was made and she was not able to answer questions regarding her care. Review of Resident 90's admission Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) of 04 out of 15 which indicated severe cognitive impairment. Review of Section O. Special Treatments revealed Hospice care. A review of Resident #90's care plan revealed no focus, goal or interventions related to Resident #90 receiving Hospice Services. During an interview on 11/20/2024 at 11:40 a.m., Staff T, Certified Nursing Assistant (CNA), stated Resident #90 needed assistance with all of her care. She stated Resident #90 liked to try to do everything on her own and goes fast. She stated she thought the resident was being seen by the hospice. She stated she thought the Hospice CNA came in and saw her on Tuesdays. During an interview on 11/20/2024 at 11:40 a.m., Staff U, Licensed Practical Nurse (LPN), stated the paper chart was where they kept the orders for residents on hospice. He stated it could also be found in the resident's profile in [name of computer program]. He stated the Hospice CNAs made their own schedules and did not have set days to come in. He stated the Hospice Nurse came in once a week and would come to the nurse's station to let him know they were seeing the residents. He stated if the nurse had new orders or was changing anything they write it out on an order sheet and gave it to the nurse, who then put the orders into [name of computer program]. During an interview on 11/20/2024 at 1:50 p.m., Staff O, LPN, stated when Hospice notified the facility they were accepting the resident, the nurses add the Hospice order into [name of computer program]. She stated Hospice would do an initial care plan for the residents. She stated the hospice nurse came one or two times a week. Hospice CNAs came in two times a week unless it was requested for more by the family. If staff at the facility had any concerns or if there was a change in condition with the resident, the nurse would notify hospice. She stated Resident #90 was on hospice prior to coming into the facility. She reviewed the orders and was not able to locate the hospice order for Resident #90. She reviewed Resident #90's care plan and stated, the care plan has hospice under nutrition, but it is not clear. She located Hospice's care plan in the document section of Resident #90's chart and stated the facility would not add their own hospice care plan for the resident and would just use the one hospice had. She stated the MDS Director was responsible for doing the care plans for the residents. During an interview on 11/20/2024 at 2:14 p.m., MDS Director, stated Resident #90 was receiving hospice services. She stated the hospice nurses attend the care plan meetings either by phone or in person. She reviewed Resident #90's care plan and stated she saw the hospice under nutrition, but they typically had a care plan for hospice/palliative care that she would add as well. 6. During an observation made on 11/19/24 at 11:46 a.m., and 2:00 p.m., Resident#67 was observed lying down in his bed during an activity. He stated he did not participate in activities because staff did not offer him activities. Review of Quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment Resident #67 had a care plan showing he had potential for little or no activity involvement related to a language barrier, weakness. Date 9/19/2022, Revision on 9/22/2022. The care plan goals were for Resident #67 would increase participation in activities of choice (sic) times per week by review date. Date initiated 9/19/2022, Revision on 7/18/2024, Target date 12/28/2024. The care plan intervention included: Encourage participation in activities of potential interest including (sic). Resident #67 needed assistance/escort to activity functions, the resident needed a variety of activity types and locations to maintain interests. Date initiated 9/19/2022. During an interview on 11/21/2024 at 2:00 p.m., with Staff G, Activity Director. Staff G stated every month they made up packets to hand out to every resident that showed the upcoming activities. She stated on the packet she highlighted what activities she knew each resident would like to attend, so residents could see the activity that would interest them. She stated her and her staff go around to residents' rooms to invite residents to activities every day, but she did not document if a resident refused to participate in activities. She stated Resident #67 always refused activities when they asked him if he would like to participate but she did not document her attempts. She stated she just recently started working in the position and she had not reviewed each resident's care plan to know what their intervention were and to ensure that the resident interventions were followed. Based on observation, record review, and interview, the facility failed to ensure the care plans for eight (#34, #52, #30, #91, #36, #39, #67, and #90) of 48 residents were developed and implemented related to activities, Hospice, and fall devices. Findings included: 1. On 11/18/24 at 10:46 a.m., Resident #34 was observed sitting in a wheelchair between the bed and bathroom wall. The resident was smiling and nodding at this writer, neither of the televisions for the resident or roommate was on or was there radio playing. On 11/19/24 at 9:59 a.m., Resident #34 was observed lying flat in bed, the room did not have a television or radio playing. On 11/20/24 at 9:00 a.m., Resident #34 was observed sitting in wheelchair between the bed and bathroom wall. The observation revealed a Spanish-speaking Activity calendar posted on the wall slightly behind the television which was not turned on. Review of Resident #34's admission Record showed the resident had diagnoses not limited to primary open-angle glaucoma unspecified eye stage unspecified and unqualified visual loss both eyes. Review of Resident #34's care plan revealed the following care areas and related interventions: - Resident has impaired visual function related to (r/t) blindness, initiated 6/11/23. - Resident has a communication problem related to (r/t) language barrier: Spanish-speaking, understands some English, (and) has some hearing impairment. The interventions instructed staff, including Activity staff, to Provide translator if resident needs and or wants one to communicate with the resident, initiated 9/26/24. - Resident is dependent on staff for emotional, intellectual, physical, and social stimulation r/t cognitive deficits (and) physical limitations. The goal showed The resident will increase/tolerate involvement in cognitive stimulation, social activities as desired through review date. The interventions instructed staff to: o Assist with arranging community activities. Arrange transportation. o Assist/escort to activity functions as needed. o Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, (and) meals. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #34 had minimal difficulty with hearing, was usually understood, usually made self understood, and vision was severely impaired, no vision or sees only light, colors or shapes. The comprehensive assessment revealed a daily and activity preferences were discussed with the resident's family member or significant other. The preferences showed that listening to music, doing things with groups of people, doing a favorite activity, going outside for fresh air, and participating in religious services or practices were very important to the resident. Review of Resident #34's Activity documentation showed the resident actively participated in the activity of Friend/Friendly Visit in the resident's room/on unit 20 of 30 opportunities from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any offered activity. Review of Resident #34's Lifestyle and Activity Preferences Evaluation, effective 8/26/24, revealed the resident's religious preference, was Hispanic, vision was impaired and not improved by glasses or contacts, no problem with hearing, had difficulty in finding words, poor reading ability, needed reminder at time of activity, was not bed/room bound, and needed no assistance to/from activity setting. The evaluation showed the resident enjoyed friendly visits by staff, enjoyed crafts in the past, enjoyed church services, enjoyed hand massages, and enjoyed visiting with select staff members. 2. On 11/20/24 at 8:44 a.m., Resident #52 was observed lying in bed, in a room without a roommate. The room did not have a television or radio available for the resident. On 11/21/24 at 8:37 a.m., Resident #52 was lying in bed and wearing a hospital gown. The blinds to the room were closed leaving the room dark with no available television or radio. Review of Resident #52's care plan revealed the following care areas and related interventions: - Has potential for little or no activity involvement related to (r/t): language barrier; Impaired thought process; Dementia. At times chooses to observe activities rather than participate, often chooses to remain in bed. The resident's goal was to increase participation in activities of choice times per week by review date of 2/1/2025. The goal was revised 11/11/24. The interventions instructed activity staff to: o Encourage resident to participate in activities that's tolerated. o Invite/ encourage the residents family members to attend activities with resident as needed/ desired. o Offer friendly visits to promote independent leisure pastimes in socialization. o Remind the resident that the resident may leave activities at any time and is not required to stay for the entire activity. o Resident requires (specific interventions i.e. cueing) to engage in activities of interest, o The resident needs a variety of activity types and locations to maintain interests. The Certified Nursing Assistants (CNA) were instructed the resident needs assistance/ escort to activity functions. - Has a communication problem related to impaired cognition, primary language is Spanish, revised 11/11/24. The goal was for the resident would maintain current level of communication function through the review date of 2/1/25. The interventions included: o provide a program of activities that accommodates the residents communication abilities, initiated 11/11/24. o Provide translator as necessary to communicate with the resident. Review of Resident #52's annual comprehensive assessment, dated 10/15/24 showed the resident did not have a Brief Interview of Mental Status score as the resident was rarely/never understood. The staff assessment of the resident's cognition showed a short-and long-term memory problem, severe impairment for making decisions regarding tasks of daily life, with no acute change in mental status, the behaviors of inattention, disorganized thinking, and altered level of consciousness were not present. The activity preferences were completed with the resident revealing music and religious services were somewhat important. The quarterly Activity Progress note dated 7/27/24 showed the activity assessment was complete and appropriate. The preferred activities were watching television, people watching, listening to music, and visiting with select staff members. Resident expresses satisfaction with current routine and staff will continue to provide 1:1 visits and encouragement for participation in group programs. Review of Resident #52's Activity documentation showed the resident actively participated in the activity of Friend/Friendly Visit 19 of 30 opportunities and one episode of receiving mail from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any activity. 3. On 11/19/24 at 11:05 a.m., Resident #30 was observed lying in bed. The resident acknowledged going to activities sometimes and reported not being informed of daily activities. On 11/21/24 at 12:31 p.m., Resident #30 stated activity staff did not visit daily for 15-20 minutes per day. Review of Resident #30's care plan showed the resident had little or no activity involvement related to physical limitations, chooses to remain in bed at times. Requires much encouragement for group participation. Resident attends outings. The goal for the resident was the resident would express satisfaction with type of activities and level of activity involvement when asked through the review date. The goal was revised on 7/8/24 with a target date of 12/11/24. The interventions instructed activity staff to: - Encourage participation and activities of potential interest. - Encourage resident to participate in activities as tolerated. - Invite/ encourage the resident's family members to attend activities with resident as needed/ desired. - Offer friendly visits to promote independent leisure pastimes and socialization. - Remind the resident that the resident may leave activities at any time and is not required to stay for the entire activity. The CNA's are instructed the resident needs assistance/ escort to activity functions. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status score of 15 of 15, indicating an intact cognition. The annual MDS dated [DATE] revealed the resident's activity preferences of having pets around was very important and reading materials, listening to music, keeping up with the news, doing things with groups of people, doing favorite activities, going outside, and participating in religious services were somewhat important. Review of Resident #30's Activity Documentation showed the resident actively participated in the activity of Friend/Friendly Visit 18 of 30 opportunities, one insistence of an animal/pet visit, and one episode of beauty/grooming from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any activity. 4. On 11/19/24 at 11:05 a.m Resident #91 was observed lying in bed, the resident reported attending activities sometimes. The activity calendar was posted on the wall opposite of where the resident's bed was located and behind the television. The resident and roommate (#30) stated they were not informed of daily activities and were unable to read the calendar from it was located. On 11/21/24 at 12:31 p.m., Resident #91 reported Activity staff did not visit daily for 15-20 minutes and they did not read or talk with her daily. Review of Resident #91's care plan revealed the following care areas with related interventions: - The resident is able to make leisure needs and preferences known in participate in facility activities as desired. Prefers independent leisure activities with encouragement. Resident attends outings, revised 9/30/24. The goal for the resident shows the resident will remain engaged in independent leisure activities and participate in facility activity programming as desired through next review. The resident will express satisfaction with leisure routine through next review. The target date was 1/29/25. The interventions were related to this care area instructed activity in nursing staff to: o assist resident to/ from activities as needed. o Encourage in room leisure time such as TV, phone/ video communication with family/ friends, reading books/magazines, etcetera and allow for resident feedback and suggestions on leisure time activities. o Encourage ongoing family involvement. Invite the residents family to attend special events, activities, (and) meals. o Encourage participation in activities of interest. o Honor residents choice to choose only activities, provide reminders/ cues for participation as needed. - The resident has a psychosocial well-being problem related to self-reporting that (pronoun) not very interested in favorite activities. This area was initiated on 11/11/24. Review of Resident #91's annual comprehensive assessment showed being around animals was very important to the resident and listening to music, doing things with groups of people, going outside to get fresh air, and participating in religious services was somewhat important to the resident. Review of Resident #91's Activity Documentation showed the resident actively participated in the activity of Friend/Friendly Visit in the resident's room/on unit 20 of 30 opportunities, from 10/23 to 11/20/24. The documentation revealed available activity types as animal/pet visits, arts/crafts, audio/visual, beauty/grooming, conversation/social, cooking/baking, exercise/physical/active sport, family/significant other, food as main focus, games/puzzles, knowledge/education, mail, materials/supplies offered/provided, memory stimulation, music, nature/garden/science, and outing away from facility. The documentation did not show the resident had refused any activity. On 11/19/24 at 10:45 a.m., the Activity Room was observed with stacks of boxes and desks around the perimeter of the room. Staff W, Activity Director of sister facility, reported doubting any activities were happening in the Activity Room as it was more of an office and the residents store things in there. An interview was conducted on 11/21/24 at 9:26 a.m., with Staff O, Licensed Practical Nurse/Unit Manager. The staff member stated Resident #34 did not do things like before, two weeks ago the resident went to music and wanted to be brought back within 5 minutes. Staff O reported the resident spoke English, don't let her fool you. The staff member stated Resident #34 did not want to get up (out of bed) and thought it was in the resident's care plan. Staff O reviewed the resident's care plan reporting the issue with not wanting to get out of bed was not part of the care plan. The staff member stated Activity (staff) came around daily and offered activities. An interview was conducted on 11/21/24 at 10:15 a.m., with the Activity Director (AD). The AD stated daily visits were done daily and lasted about 10-15 minutes. During an interview on 11/21/24 at 10:46 a.m. with the AD and Nursing Home Administrator (NHA), the AD reported doing 1:1 activities with music, audiobooks, and singing with Resident #34. She reported playing music yesterday for the resident for 15 minutes. The AD reported activity staff do not speak Spanish but pulled Spanish -speaking staff into the room to speak with the resident. The AD reported Resident #52 was Spanish-speaking and staff performed hand massages and read to the resident every day as the resident did not participate in group activities. The AD reported not reading the activity calendar to residents and said activities were announced through the facility's overhead system (not heard during survey). The NHA stated they had put in a system so the aides brought residents down to activities and were aware of the activities. Resident #91 did not participate in activities and Resident #30 was very specific on activities. Resident #52 liked to have blinds closed in room and the NHA stated the resident would yell out to people in the hallway. 8. On 11/18/2024 at 9:55 a.m. and 2:00 p.m., 11/19/2024 at 7:30 a.m., 3:15 p.m., 11/20/2024 at 8:07 a.m., 10:00 a.m., 11:30 a.m. 12:21 p.m., 1:45 p.m., 2:00 p.m., 3:00 p.m., and on 11/21/2024 at 7:20 a.m., Resident #36 was observed each time in his room, lying flat in a low bed and completely under the bed linen and covers. He was also noted each time with the linen pulled up over his entire head. It was further observed two very large, long and high raised fall floor mats devices on the floor on each side of the bed. The tops of both the fall mats were observed level to the top of the low bed mattress and appeared to be used should the resident roll out from bed. It was also observed Resident #36 had both ¼ side rails up and in position while he was in bed. Photographic evidence obtained. On 11/18/2024 at 9:55 a.m., an interview was attempted with Resident #36. He did not respond to any questions. During the dates and times mentioned above, and while Resident #36 was in his bed, on 11/19/2024 at 7:30 a.m. and 3:15 p.m. the right side fall floor mat was observed folded and positioned behind the divider curtain, which was on Resident #36's roommate's side of the room. It was observed there was bare floor space approximately three feet from the edge of Resident #36's side of the bed and to where the fall floor mat was placed. On 11/20/2024 at 8:07 a.m., the right side raised fall mat for Resident #36 was again observed folded and slid over past the divider curtain, leaving about three feet of bare floor space from the edge of the bed and to the fall mat. On 11/20/2024 at 8:09 a.m., Staff E, a Certified Nursing Assistant (CNA) walked into the room. She revealed the raised fall mats were used for the resident because he sometimes rolled out of bed and onto the floor. She said the side rails were used as enablers and were not restraints. Staff E further revealed she was not sure why the mats were so large other than so he did not roll on to the floor. The bed was in the lowest position but the mats were approximately one to one and a half feet high up off the ground. Staff E said Resident #36 did not get up out of bed on his own and he did not ambulate. Review of the current Physician's Order Sheet dated for the month 11/2024 and 10/2024 did not show any specific order for the use of fall floor mats or any type of special fall/accident devices. Review of the nurse progress notes dated from 6/1/2024 through to 11/21/2024 did not reveal any documented evidence of use of any type of fall floor mats, or any type of special fall/accident devices. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the following; Cognition/Brief Interview Mental Status BIMS score - 00 of 15, which indicated severe cognitive impairment; Mood - None documented as observed during this assessment timeframe; Behaviors - None documented as observed during assessment timeframe. Review of the current Care Plans with a next review date of 12/16/2024, showed the following: 1. Resident has a history of preferring stay in bed on most days. Snacks in bed. Prefers not to be weighed. Refuses showers with interventions to include but not limited to: Acknowledge/commend the resident's progress/improvement in behavior; Administer medications as ordered. Monitor/document for side effects and effectiveness; If reasonable/appropriate, discuss the behaviors with the resident. Explain/reinforce why behavior is inappropriate and/or unacceptable; Monitor behavior episodes and attempt to determine undying cause. Consider location, time of day, person involved, and situations. Document behavior and potential causes. There were no interventions to support the use of any fall floor mats or specialized fall/accident devices. Review of the entire care plan did not reveal any problem areas or interventions related to Resident #36 using fall floor mats or specialized fall/accident devices, while in bed. Further review of the entire medical record, there was no evidence of Resident #36 using these devices while in bed. On 11/21/2024 at 9:30 a.m., an interview with Staff F, Care Plan Coordinator, revealed she did know Resident #36 and his general daily care and routines. She said he was declining and received Hospice services and has had falls in the past. Staff F was asked about the large raised fall mat devices on each side Resident #36's bed. She revealed they were used as safety devices to help when he either placed his le[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 11/18/2024 through 11/21/2024 as evidenced by: 1.) failure to provide a safe, clean, and homelike environment for one (B Hall) of two community shower rooms (F584), 2.) failure to ensure blood glucose levels were checked and insulin was administered timely for two residents (#1 and #2) out of three residents reviewed for insulin administration and failed to administer anti-viral medication for one resident (#3) out of one resident reviewed for flu treatment (F684) and 3.) failure to implement an effective Infection Control program as evidenced by staff members not using personal protective equipment (PPE) for two residents (Resident #3 and Resident in room [ROOM NUMBER]) out of 11 on transmission based precautions (TBP) and two out of six residents observed during medication administration (F880). Findings included: Review of the facility's Quality Assurance/Performance Improvement Plan (QAPI), with a revision date February 23, 2021, revealed: Vision To pioneer healthcare by creating a compassionate, memorable and dignified experience for every person we serve. We strive to treat our patients, their families and our staff with the highest level of dignity and respect by promoting an environment of continuous improvement and service excellence. Mission We at [another healthcare facility name] are committed to the physical, emotional and spiritual well-being of our residents. We strive to provide excellent service for residents of every culture in a supportive, caring, homelike environment and to maintain a high level of dignity and individuality. Values Passion: We are strongly compelled to provide great care to every resident we serve. Respect: We feel deep admiration for others and their abilities, qualities and achievements. Integrity: We do the right thing for the right reasons. Dedication: We are committed to providing great care. The staff will utilize data from industry standards to quantify and benchmark all aspects of performance improvement whenever possible. Any negative trends in data will be addressed utilizing root cause analysis and quality improvement methodologies. The leadership and staff will embrace the evidence-based strategies and utilize PDSA cycles until the desired change is effective and the desired goals are achieved and sustained. Governance and Leadership The governing body and/or administration of the nursing home will develop a culture that involves leadership seeking input from facility staff, residents and their families/representatives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. [Another healthcare facility name] governing body is ultimately responsible for overseeing the QAPI Committee. The owner/CEO has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. A facility-wide training will be conducted to inform everyone in the facility about the QAPI Program. These trainings will be conducted often and in multiple ways through (e.g. in services, department head in services, examples, exercises, etc.) Every caregiver will be made to understand that they are expected to raise quality concerns, that it is safe to do so, and that everyone is encouraged to think about systems. The QAPI approach at [another healthcare facility name] will also be communicated to consultants, contractors and collaborating agencies, to make them understand that they each have a role in the QAPI plan. [another healthcare facility name] will ensure that all residents and families are aware of the facility's QAPI program, and that their views are sought, valued and considered in facility decision-making and process improvements. The QAPI program will be announced and discussed at the resident council meetings, and other resident and family events/venues. Feedback, Data Systems and Monitoring [Another healthcare facility name] will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigation and monitoring events every time they occur, and action plans implemented through the plan, do, study, act (PDSA) cycle of improvement to prevent recurrences. The QAPI team at [another healthcare facility name] will decide what data to monitor routinely. Areas to consider may include, but not be limited to, the following examples: - Clinical care areas (e.g. pressure ulcers, falls, infections) - Medications (e.g., those that require close monitoring, antipsychotics, narcotics) - Complaints/grievances from residents and families - Hospitalizations and other service use - Resident satisfaction - Caregiver satisfaction - Care plans, including ensuring implementation and evaluation of measurable interventions - State survey results and deficiencies - Results from MDS resident assessments - Business and administrative processes (e.g., financial information, caregiver turnover, caregiver competencies and staffing patterns, such as permanent caregiver assignment). Data related to caregivers who call out sick or unable to report to work on short notice, caregiver injuries and compensation claims may also be useful. Targets for performance in the areas that are being monitored will be set by the QAPI team. The target will usually be stated as a percentage. Benchmarks for performance such as Nursing Home Compare (www.medicare.gov/nhcompare), CASPER report, Facility Inhouse Benchmarking, etc. will be used to monitor facility progress. Performance Improvement Projects (PIP) The QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement through the use of a QAPI self-assessment. In addition, the QAPI Steering Committee will implement any PIP topics indicated by date analysis. Quality improvement activities are also developed in collaboration with the support of providers, residents, families and staff. PIPS are implemented in accordance with CMS' protocol for conducting PIPS, including: 1. Measurement of performance using objective quality objective indicators 2. Implementation of system interventions to achieve improvement in quality 3. Evaluation of the effectiveness of the interventions 4. Plan and initiation of activities for increasing or sustaining improvement During an interview on 1/16/2025 at 5:55 p.m., the Nursing Home Administrator (NHA) stated the Quality Assurance (QA) Committee includes himself, the Medical Director, the Director of Nursing (DON), and other department heads. The NHA said he was the Committee Chairperson and the QA Committee meets on the third Thursday of every month, although they have not met this month. The NHA stated a QAPI meeting was conducted on 12/18/2024 to discuss the survey results and plan of correction that was submitted to the State Agency. The NHA stated the facility did not conduct another QAPI meeting in January, even though the third Thursday had past, but then stated, the month is not over yet, we will have one. The NHA stated during the meeting in December, they spent the entire meeting on going over the 2567 and developed action plans based on the situations referenced in the survey. 1.) On 1/16/2025 at 9:58 a.m., the shower room on B hall was observed with a housekeeping employee packing up their supplies, placing a wet floor sign at the door, and about to exit the room. A shower bed was observed in the room. Upon lifting the foam mat sitting on top of the mesh of the shower bed, the back of the foam mat had unidentifiable black spots and various clumps of hair covering almost the entire middle section. The mesh part of the bed was observed with dried brown, black, and white stains on the majority of the mesh. Next to the shower bed was a shower chair. The chair was observed with brown/black substance with hair clumps intermingled on all four shower legs above the wheels. At the joints of the four legs was a pink colored substance above and below the joints. The mesh backing of the shower chair had a buildup of a black substance on all three straps. During an interview on 1/16/2025 at 5:55 p.m., the NHA and DON stated nursing and housekeeping are responsible for cleaning the shower rooms. The NHA and DON reviewed the photos of the shower room on B hall and acknowledged the equipment was dirty. 2.) An observation was conducted during medication administration on 1/16/25 at 12:05 p.m. with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN was preparing to administer medication to Resident #1 and had to go to the dining room to get the resident to check his blood glucose level and administer insulin. Resident #1 said he had already finished eating lunch. He said the nurses often check his blood glucose after meals and not before, they are usually late. Staff A, LPN checked Resident #1's blood glucose and it was observed to be 309. The nurse told the resident she was going to administer 15 units of Humalog insulin. Staff A, LPN was observed priming the Humalog insulin pen and setting it to 15 units. The resident refused the 15 units of insulin, saying his blood glucose level would drop too low if he had that much. The nurse called the doctor and received a one-time order for 10 units of Humalog insulin, which was administered at 12:24 p.m. Review of the admission Record showed Resident #1 was admitted on [DATE] with a diagnosis of type 2 diabetes mellitus (DM) with hypoglycemia. Review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Review of Resident #1's January 2025 physician orders showed the following orders: - Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (units per milliliter) (Insulin Lispro). Inject 15 unit subcutaneously in the morning for DM. Scheduled for 9:00 a.m. Dated 12/8/24. - Insulin Lispro (1 unit dial) 100 unit/ml solution pen-injector. Inject as per sliding scale. Scheduled at 7:05 a.m., 11:30 a.m., and 4:30 p.m. Dated 4/12/24. Review of the Medication Admin Audit Report from 1/2/25 to 1/16/25 showed Resident #1's Humalog was administered late on 7 of 14 opportunities. Resident #1's Insulin Lispro was administered late on 23 of 42 opportunities. An interview was conducted on 1/16/25 at 5:50 p.m. with Staff C, LPN. She said at the time of the interview, all meals had been delivered to residents. Therefore, all blood glucose checks should have been done, because those should be checked prior to eating. An observation and interview was conducted during medication administration on 1/16/25 at 5:57 p.m. with Staff B, LPN. Staff B, LPN was preparing to administer medication to Resident #2. Staff B, LPN was observed entering Resident #2's room to check her blood glucose level. The resident was already eating her dinner at the time. Staff B, LPN confirmed blood glucose levels should be checked prior to meals. Review of the admission Record showed Resident #2 was admitted on [DATE] with a diagnosis of type 2 diabetes mellitus with neuropathy. Review of Resident #2's January 2025 physician orders showed the following orders: - Insulin Lispro (1 unit dial) Subcutaneous solution pen-injector 100 unit/ml. Inject per sliding scale for times a day for DM. Dated 10/28/24. Scheduled times were 6:00 a.m., 12:00 p.m., 2:00 p.m., and 10:00 p.m. The order times changed on 1/10/25 to 6:00 a.m., 12:00 p.m., 5:00 p.m., and 10:00 p.m. - Insulin Glargine Subcutaneous Solution pen-injector 100 unit/ml. Inject 12 units subcutaneously one time a day for DM. Dated 10/28/24. Scheduled at 9:00 a.m. Review of the Medication Admin Audit Report from 1/2/25 to 1/16/25 showed Resident #2's Insulin Lispro was administered late 2 times, early 3 times, and not administered 6 times out of 56 opportunities. Insulin Glargine was administered late 5 out of 14 opportunities. An interview was conducted on 1/16/25 at 6:20 p.m. with the DON. The DON reviewed Resident #1's record and confirmed the resident's blood glucose level should have been checked between 8:00-10:00 a.m. and the Humalog should have been administered then. She said the Humalog was scheduled at 9:00 a.m. for Resident #1. She also said typically when a nurse is running behind, herself or the unit managers jump in to help. The DON said blood glucose levels should be checked before a resident eats their meals and the insulin should be given at mealtime. An observation was conducted on 1/16/25 at 9:25 a.m. of Resident #3's room with a droplet precautions sign hanging on the door. Review of the admission Record showed Resident #3 was admitted on [DATE] with diagnoses including chronic pulmonary edema and dementia. Review of Resident #3's care plan showed a Focus of The resident has infection: flu exposure, initiated 1/11/25. Interventions included droplet precautions, administer anti-viral per MD (medical doctor) orders, and administer treatment per physician orders. Review of Resident #3's January 2025 physician orders showed an order for: - Tamiflu Oral Capsule 75 mg (milligrams). Give 1 capsule by mouth two times a day for exposure to flu for 5 days. Start date 1/13/25. Discontinue date 1/18/25. Review of Resident #3's Medication Administration Record (MAR) for January 2025 showed Tamiflu was not available for the 9:00 a.m. dose on 1/13/25. Tamiflu was signed off as given on 1/13/25 at 9:00 p.m., 1/14/25 at 9:00 a.m. and 9:00 p.m., and 1/15/25 at 9:00 a.m. and 9:00 p.m., and marked not available at 9:00 a.m. on 1/16/25. An interview was conducted on 1/16/25 at 4:55 p.m. with Staff D, Registered Nurse (RN). Staff D, RN said he was assigned to Resident #3. He checked the medication cart and said there was no Tamiflu in the medication cart for Resident #3. An interview was conducted on 1/16/25 at 5:10 p.m. with a representative from the facility's pharmacy. The pharmacy said no Tamiflu was dispensed for Resident #3. An interview was conducted on 1/16/25 at 5:04 p.m. with the DON and Assistant Director of Nursing/Infection Preventionist (ADON/IP). They both reviewed Resident #3's medical record. The DON said she would not expect the Tamiflu to be signed off since it was not given. She said it should have been documented the medication was not administered and the doctor should have been called. The ADON/IP said she did not see any notes in Resident #3's medical record indicating the doctor was notified the Tamiflu was not given or was not available. The DON confirmed there were no notes in the record. Review of a facility policy titled Standards and Guidelines: Medication Administration, with a revision date of 01/2024 revealed the following: Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 3. Medications are administered in accordance with prescriber's orders, including any required time frame. 6. Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, at bedtime). 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering shall document the rationale in the resident's medical record and notify the physician and responsible party if indicated. 3.) An observation was conducted on 1/16/25 at 9:34 a.m. during medication administration with Staff G, LPN. Staff G, LPN was observed completing medication administration for a resident without performing hand hygiene. She began preparing medication for a second resident, entered the second resident's room, and took vital signs. Staff G, LPN exited the room, placing the blood pressure cuff on the medication cart prior to cleaning it. Staff G, LPN put on gloves and cleaned the blood pressure cuff, removed the gloves, and did not perform hand hygiene before continued to prepare and administer medication for the resident. An observation was conducted on 1/16/25 at 11:55 p.m. during medication administration with Staff A, LPN. Staff A, LPN was observed wearing gloves to prepare medication. While dispensing medication, two pills fell onto the medication cart. The nurse picked up the pills and placed them in a medication cup and continued with preparation and administration of medication. The nurse kept the same gloves on to prepare the medication, administer the medication one pill at a time with a spoon, and pick up the resident's water cup for him to drink between each pill. Staff A, LPN removed her gloves but did not perform hand hygiene prior to going to the dining room to get another resident. Staff A, LPN proceeded to gather supplies to check the resident's blood glucose level. The glucometer fell on the floor and Staff A, LPN picked it up and placed it on the medication cart without cleaning it. An observation was conducted on 1/16/25 at 10:08 a.m. while on a tour of C hall. An observation was made of Staff E, Housekeeping (HKG) in Resident #3's room. Resident #3 was in the room and the room door had a Droplet Isolation sign posted, indicating to wear a mask, gown, and gloves at all times and eye protection, if needed. Staff E, HKG was wearing gloves but did not have a mask or gown on while cleaning in Resident #3's room. Staff E, HKG was observed exiting the room while wearing the gloves, pushing the cleaning cart down the hall, picking up a wet floor sign, and re-entering Resident #3's room to continue cleaning. Upon exiting Resident #3's room, Staff E, HKG removed the gloves and exited the room, but no hand hygiene was completed. An interview was conducted with Staff E, HKG on 1/16/25 at 10:15 a.m. Staff E, HKG stated Resident #3's room door had a droplet isolation sign posted and she needed to read the sign to know what PPE to wear. Droplet Isolation would need a gown, gloves and mask. Staff E, HKG stated, I did not, indicating not wearing mask or gown while in Resident #3's room. Staff E, HKG continued to state, I should've washed my hands when I left the room. On 1/16/25 at 10:12 a.m., Staff F, Certified Nursing Assistant (CNA) was observed in room [ROOM NUMBER]. room [ROOM NUMBER] had a Contact Isolation sign posted on the door. The Contact Isolation sign indicated staff must wear gloves and gowns at all times. Staff F, CNA looked around the corner of the privacy curtain, noted the surveyors in the hallway, and closed the curtain. During this time, Staff F, CNA, was observed wearing gloves but no gown. A second person, later identified by the Director of Nursing as a hospice aide, entered room [ROOM NUMBER] with no PPE on. The hospice aide handed a bag of supplies to Staff F, CNA and exited the room without performing hand hygiene. The hospice aide reentered room [ROOM NUMBER] without donning PPE and leaned across the bedside table with her upper body touching the table. Staff F, CNA returned to the door of the room with no gown on, grabbed another pair of gloves, returned to the bedside to pick up a bag of soiled linens, and took the bag to the soiled utility room. The hospice aide remained in the resident room with no gown or gloves on, talking on her cell phone. An interview was conducted on 1/16/25 at 10:25 a.m. with Staff A, LPN. Staff A, LPN said Resident #3 was on Droplet Precautions and room [ROOM NUMBER] was on Contact Precautions. Staff A, LPN also stated Contact Precautions required a gown and gloves whenever going into the room for any reason and Droplet Precautions required gloves, a gown, and a mask when entering the room. An interview was conducted on 1/16/25 at 2:22 p.m. with Staff F, CNA. Staff F, CNA confirmed being assigned to room [ROOM NUMBER], who was on Contact Isolation. Staff F, CNA also stated Contact Isolation required a gown and gloves when entering the room. Staff F, CNA confirmed she took off a gown while in room [ROOM NUMBER], but did not exit the room, and continued to provide care for the resident. An interview was conducted on 1/16/25 at 5:04 p.m. with the DON and ADON/IP. The DON said all staff should be wearing proper PPE when going into a room with a Contact Precaution sign posted. The ADON/IP said, anybody entering a room on Contact Precautions should be wearing the gear. The ADON/IP also said Droplet Precautions required anyone entering the room to wear a blue mask, a gown, gloves, and a face shield. They both stated precautions apply to anyone entering the room, including visitors, contractors, and housekeeping. The ADON/IP said, we educate no gloves in the hallway, and stated they should be removed prior to exiting a room. The DON confirmed the hospice aide should have worn PPE in room [ROOM NUMBER]. The ADON/IP said blood pressure cuffs and glucometers should be sanitized after each use. She explained the glucometer should be wiped with one wipe, then a second wipe should be wrapped around the glucometer and set in a cup for two minutes. She also said if a glucometer falls on the floor it should not be placed on the medication cart prior to cleaning. She said if a pill is dropped on the medication cart, the nurse should dispose of the pill and it should not be picked up and put in the medication cup for administration. The DON said hand hygiene should be done before and after care and should also be done before and after giving medications. She said it does not matter if gloves are worn or not, anytime gloves come off hand hygiene should be done. Review of policy titled Hand Hygiene Infection Control, revised 6/2023, showed: Standard: Hand hygiene is the single most important measure for preventing the spread of infection. Guideline: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: Situations that require hand hygiene include, but are not limited to: - Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). - Before and after entering isolation precaution settings. - Upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, and lifting a resident). - After removing gloves or aprons. Review of policy titled Transmission Based Precautions, revised 2/2024, showed: All staff receive training on transmission-based precautions upon hire and at least annually. The procedure for Contact Precautions revealed: a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on a case-by-case basis after considering infections risks to other residents in the room and available alternatives. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's representative was informed timely of a change in medication, a change in medical condition and a change in treatment orders for two residents (#4 and #1) out of six sampled residents. Findings included: 1. A review of Resident #4's clinical chart revealed an admission date of 07/2019. The clinical record revealed the resident was transferred to the hospital on [DATE]. The diagnosis list included: unspecified dementia, atherosclerotic heart disease of native coronary artery without angina pectoris; Type 2 Diabetes Mellitus with unspecified complications; hypertension; gastro esophageal reflux disease without esophagitis; personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. A review of Resident #4's progress notes revealed the following: 02/11/2023, 14:18 (2:18 p.m.): Late entry, discolored areas noted right heel. Left foot bunion and outer pinky area and left inner ankle skin intact at all areas. Order for skin prep in place. (No documentation of physician notification or family notification.) 02/12/2023, 14:59 (2:59 p.m.): Started on skin prep bilateral feet. Podus boots in place. 02/12/2023, 15:30 (3:30 p.m.): Change in condition: Skin wound or ulcer. The physical assessment documented a skin evaluation, Discoloration; with a summary: skin check done discoloration noted. With the primary care provider feedback: Recommendation: skin prep 02/18/2023, 01:12 (1:12 a.m.): MD (Medical Doctor) notified of minimal swelling with light pink discoloration on the left foot along the side of the existing blister. No new orders given at this time. Will monitor area for any changes and notify physician. 02/18/2023, 03:52 (3:52 a.m.): New order from physician for Keflex 500 mg (milligrams) bid (two times a day) x 7 (seven) days for blister/ skin infection on left foot. Family member notified; medication order placed with pharmacy. 02/21/2023, 11:48: Discontinue multipodus boots, r/t (related to) left foot blister. Resident continues with ABX (antibiotic) with no ill effect. MD in agreement, [family member] called and updated with new order. 03/15/2023, 14:08 (2:08 p.m.): A care plan meeting was attempted with the POA (power of attorney) but got no response. The care plan meeting was held amongst the team. There are no changes with care. Resident eat meals with the assist group. Resident may be discharged with spouse to a facility with memory care or locked unit. Resident will remain a full code. 03/19/2023, 11:04: Change in condition: Skin wound or ulcer. The nursing observations: During skin check nurse noted the open area, started treatment. DON notified. The Primary Care Provider feedback: Recommendations: Continue with present TX (treatment), until assessed by TX nurse and Wound Doctor. (No family notification documented.) 03/27/2023, 20:36 (8:36 p.m.): MD made aware of rapid declining wound to patient's left lateral foot. Family at bedside. Wound appears black in color and redness to exterior of the wound. No drainage or slough. Wound is dry. New order received for doppler, x-ray and labs due dx (diagnosis) of diabetes, and atherosclerosis. Family made aware of orders and treatment that is in place will continue as ordered by MD. 03/28/2023, 16:55 (4:55 p.m.): Change in condition: Skin wound or ulcer. Nursing observations, recommendations are: Send to ER (emergency room) for eval (evaluation) d/t (due to) wound. Primary Care Provider Feedback: Recommendation: OK to send to ER for evaluation. New testing orders: Venous Doppler, X-Ray. 03/28/2023, 17:49 (5:49 p.m.): MD made aware of diagnostics new order made to send patient to ER for vascular calcification per X-Ray and rapid declining foot ulcer to rule out occlusion and osteomyelitis. Patient not responding to recent topical and abt treatment to the foot ulcer. Patient has history of dx, and x-rays also reveal osteoporosis. Family made aware patient discharged to (hospital). Report given to ER nurse. Patient is clean and dry at the time. [family member] states the patient's groin is red. This nurse as well as the floor nurse and paramedics observe perineal area is clean dry and free from redness, irritation, or breakdown at this time. A review of Resident #4's Treatment Administration Record (TAR) for 02/2023, revealed the following treatment orders: Apply skin prep to left inner ankle, bunion and left outer small toe q (every) shift for discolored areas, start date 02/12/2023. The treatment was documented to be provided as ordered. Apply skin prep to right heel every shift for discolored area, start date 02/12/2023. The treatment was documented to be provided as ordered. A phone interview was conducted with Resident #4's family member. He stated on 02/18/2023, he had gone to the facility, and they told him Resident #4 had a wound on his left foot, he had looked at it and it looked like it was healing. He stated, on 02/19/2023, they called me again and told him about the wound. On 02/20/2023, he had gone to the facility and observed Resident #4 with a boot on, and he had spoken to Staff I, Licensed Practical Nurse (LPN) who said she did not know why the boot was on, but she would recommend removing it. On 03/19/2023, he stated he was called, and they told him Resident #4 had a wound on his buttocks. On 03/27/2023, he stated he visited, and he was concerned because the resident was always covered, and always in bed. He stated the resident had no boots on his foot and when he lifted the left foot, he saw all the black on the resident's foot. He stated he was upset and talked to the nurse to find out how it happened. He stated he asked to see the supervisor and was told the blackened area happened yesterday. He stated he also discovered the resident had a wound on his right foot. He stated the supervisor said he would tell the wound nurse. On 04/20/2023 at 3:15 p.m., an interview was conducted with Staff F, Certified Nursing Assistant (CNA). She stated, I assisted a couple of times. I helped the other CNA. When I came in June, he did not have any skin conditions. One time, before he left, I helped with his care; he had something on his left foot. She stated approximately 60% of the side of his foot was black. She stated Resident #4 was a total care resident. She stated, Every day we would get him out of bed. He had a special chair. We used a Hoyer lift. Yes, he had contractures, his legs, and his arm. Yes, we would have to toilet him; change him. On 04/20/2023 at 3:40 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM). She stated for a change in skin or skin impairment, she would expect the CNAs to let the nurse know. She stated We have protocols. We can apply Zinc. They always let me know. I look. Anything stageable, we get a wound consult. If the impairment was not there yesterday and there today, they let us know. We have weekly skin checks. If something is new, we are supposed to notify the doctor, the family and do an assessment. Staff I stated for a wound consult, It is easy. We just put them on the list. She stated the reason for the wound consult is to see what treatment is best for that area. Staff I reviewed Resident #4's clinical chart and confirmed she was not able to find a wound consult visit documented in the clinical chart for 2023. On 04/20/2023 at 1:30 p.m., A review of Resident #4's progress note for 02/11/2023, 14:18 (2:18 p.m.) was conducted with the Director of Nursing (DON). She confirmed the clinical chart had no documentation of the resident's representative being notified about the skin impairment. She also confirmed the chart indicated the doctor was called on 02/12/2023 at 5:30 p.m., which was untimely. The DON indicated the family should be notified immediately. On 04/20/2023 at approximately 4:20 p.m., an interview was conducted with the DON. She stated, for the wound on Resident #4's left foot, It started off as black, scabs, it was a blister. When it started turning black, we ordered the ultrasound. She confirmed the clinical chart had no measurements of the wound. She confirmed on 03/27 and 03/28; the wound covered approximately 60 % of the outer area of the resident's foot. The DON stated, For the wound doctor, he does not see every Stage II wound. The DON confirmed she spoke with the family, and they were under the impression the wound was a pressure wound. She stated they recommended sending the resident out. She stated the resident was transferred to the hospital, and she could tell the family was upset. She stated they called the physician and gave the results. She stated they conducted in-services for family communication. She stated she did not document a grievance form, because she thought there would be something they could do. On 04/20/2023 at 5:05 p.m., the ADON (Assistant Director of Nursing) provided an in-service education record, titled Family & Resident Notification for change in condition, dated 03/29 & ongoing, program length: 15 (fifteen minutes). The Program brief description read: With any change in condition and new orders, family and patient must be notified. Ex (example) (new labs, abt [antibiotic], wounds, etc). Twenty-five nurses had signed the in-service sign in sheet. In addition, attached to the in-service documentation was an agenda for an All Staff Meeting, dated 04/14/2023, which was documented to be conducted by the DON. Verbiage in the agenda included: Notification of family members: make sure when there is a change in condition to notify MD, family and management. Sixty-eight staff had signed the attendance roster. A review of the facility's employee roster documented the facility had 37 Nurses and 59 Certified Nursing Assistants, for a total of ninety-six employees. A review of hospital records for Resident #4, dated 03/28/2023, documented a history of present Illness: This (geriatric) patient . Patient has hypertension and hyperlipidemia. The patient has chronic left and right foot wounds. Patient had bilateral lower extremity ultrasound that showed good flow. On evaluation the patient has a fifth digit infection on the left side with also (sic) and also on the medial aspect of the foot plus on the right side the second toe looks infected.The patient will be on Cefepime and Vancomycin. Further review of the hospital record, a Podiatry Consult, dated 03/29/2023: On examination of lower extremities, the patient has atrophic skin bilaterally with an oval grad 1-2 ulceration on the medial aspect of the 1st metatarsal head of the left foot with a dense eschar which upon removal show a small opening with the droplet of pyrogenic exudate but uncertain if he goes all the way to capsule certainly no bone exposure is seen. There is minimal erythema surrounding the ulcer site which measures about 1 cm in diameter and no other lesions are seen on the left foot. Again, the skin is atrophic, and the pedal pulses were barely palpable to nonpalpable due to nonpitting edema to the area no hair growth patterns of bilateral lower extremities. There is a small excoriation on the lateral fifth metatarsal head on the right foot and an erosion of dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. It is uncertain that there is osteomyelitis at this point. An assessment, dated 03/28/2023, Active Problems: Subacute osteomyelitis of left foot. Grade 2 ulceration is possibly due to arterial insufficiency on the left foot. Grade 1 ulceration dorsal right second toe. Plan: History and physical evaluation of lower extremities. I consulted wound care nursing to suggest a daily dressing bandage for the patient mainly will recommend Santyl collagenase with a dry dressing to be applied on the eschar ulcer on the medial aspect of the first metatarsal of the left foot. Betadine dressing can be applied to the right second toe. Patients will need vascular surgery for evaluation and treatment due to high suspicion of arterial insufficiency. Awaiting possible MRI of the lower extremity. Will follow as needed. An Infectious Disease consult, dated 03/28/2023: Skin: Has ulcer on the medial aspect of the left first metatarsal head. There is some minimal cellulitis present around the ulcer in the left foot. Right foot is also lateral fifth metatarsal head with large necrotic area and a small also behind it on the lateral aspect of right foot. Also, erosion on the dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. Also has right heel ulcer with cellulitis. Left gluteal area has a decubitus ulcer with no purulence. Assessment: Osteomyelitis of the left foot with chronic ulceration on the left metatarsal head area. Chronic ulcer of the left foot on the first metatarsal area medially and x-ray shows possible osteomyelitis. Ulcers of the left fifth metatarsal area necrotic. Some excoriation on the right second toe with cellulitis. Cellulitis of the bilateral feet. Right heel superficial ulceration with cellulitis. Peripheral vascular disease start ultra sound showing unable to visualize the left popliteal artery. Left buttock decubitus ulcer which is stag 2-3/ unstageable. Inpatient consult to Vascular Surgery, dated 03/29/2023. Reason for consultation: Atherosclerosis with bilateral foot ulcers. History: .Unclear duration. Non ambulatory. Severe contracture of left leg at the hip and knee. According to the family, the patient started having blisters of the feet a couple of months ago which progressed to gangrene. Assessment and plan Active Problems: Subacute osteomyelitis of left foot. Arterial duplex images were reviewed. CBC results reviewed .A findings concerning hemodynamically significant arterial occlusive disease with nonpalpable pedal pulses bilaterally. Bilateral lower extremity ulcers with finding concerning for osteomyelitis on the left x-ray. MRI pending. Had a discussion with the family over the phone. Severely limited functional capacity with contracture of the left leg. He is a poor candidate for any revascularization procedures. He cleared from my standpoint for foot debridement. If he does not heel, may end up needing AKA (above the knee amputation). Consider hospice eval if family is agreeable. 2. A review of the medical record revealed Resident #1 had resided at the facility less than a month and had a diagnosis of unspecified dementia. A review of the Hospital After Visit Summary Instruction Medication list revealed the following: Trazodone (psychoactive) 50 mg 1 tablet by mouth at night if needed for sleep dated 02/06/2023. A review of transcribed Physician orders revealed the following: Trazodone HCI Oral Tablet 50 mg give one tablet by mouth every 24 hours as needed for Depression Give at night dated 02/06/2023. A review of the Medication Administration Record (MAR) revealed from 02/06/2023 to 03/03/2023 Resident #1 had received Trazodone one time (02/14/2023) in 25 days for depression. Further review of Physician orders revealed the Trazodone was changed on 03/03/2024 to Trazodone 50 mg give one tablet by mouth one time a day for insomnia. A review of Medication Regimen Review (MRR) dated 02/13/2023 revealed the resident had an order for: Trazodone 50 mg po (every) q hours (hrs.) as needed (PRN) depression Recommendation: Please schedule this order. Rationale: Depression should not be treated PRN Physician/ Prescriber Response: Agree. Please schedule Trazodone to 50 mg at bedtime for insomnia dated 03/02/2023. On 04/20/2023 at 3:25 p.m. an interview was conducted with the Director of Nursing (DON) she confirmed she knew Resident #1. She said when she was admitted to the facility, she had orders for Trazodone. She stated, She did it at the hospital. She was unsure why the order was changed to routine, and why the diagnosis had changed to insomnia. She confirmed the medical record failed to reflect; the resident was having difficulty with sleeping. She stated, I can't see the MD even touching her medications without the family being notified. At 3:59 p.m. the DON said it was the Psychiatrist who had changed the Trazodone orders. On 04/20/2023 at 4:10 p.m. a phone interview was conducted with the facility Psychiatrist related to the change in Resident #1 Trazodone order. The Psychiatrist did not recall the resident at first. The Director of Nursing was present and referenced the Psychiatrist to the MRR change. The Psychiatrist confirmed she did not update the family on the medication change. The DON stated It was not the Psychiatrist responsibility to update the family. It is the facility's responsibility to notify the family of a change. She confirmed the medical record did not reflect the family was notified. A review of the facility's policy and procedures for Change in a Resident's Condition or Status, undated, documented the policy statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical / mental condition and / or status (e.g., changes in level of care, billing/payments, resident's rights, etc.). The policy interpretation and implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): a. Accident or incident involving the resident. b. Discovery of injuries from an unknown source. c. Adverse reaction to medication. d. Significant change in the resident's physical/ emotional/ mental condition. e. Need to alter the resident's medical treatment significantly. f. Refusal of treatment or medications, two or more consecutive times). g. Need to transfer the resident to a hospital/ treatment center. h. Discharge without proper medical authority; and/or i. Specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting). b. Impacts more than one area of the president's health status. c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider including (for example) information prompted by the Interact SBAR communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to change the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/ treatment center. 5. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status. 6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/ her medical care or nursing treatments. 7. The nurse will record in the resident's record information relative to changes in the resident's medical/ mental condition or status. 8. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, photographic evidence, and record review, the facility failed to ensure accurate assessments of skin conditions were conducted to prevent worsening of wounds for one resident (#4) of six sampled residents. Findings included: A phone interview was conducted with Resident #4's family member. He stated on 02/18/2023, he had gone to the facility, and they told him Resident #4 had a wound on his left foot, he had looked at it and it looked like it was healing. He stated, on 02/19/2023, they called me again and told him about the wound. On 02/20/2023, he had gone to the facility and observed Resident #4 with a boot on, and he had spoken to Staff I, Licensed Practical Nurse (LPN) who said she did not know why the boot was on, but she would recommend removing it. On 03/19/2023, he stated he was called, and they told him Resident #4 had a wound on his buttocks. On 03/27/2023, he stated he visited, and he was concerned because the resident was always covered, and always in bed. He stated the resident had no boots on his foot and when he lifted the left foot, he saw all the black on the resident's foot. He stated he was upset and talked to the nurse to find out how it happened. He stated he asked to see the supervisor and was told the blackened area happened yesterday. He stated he also discovered the resident had a wound on his right foot. He stated the supervisor said he would tell the wound nurse. On 04/24/2023 at 2:18 p.m., Resident #4's family member was contacted by phone. He indicated photos that were provided were taken at the nursing home on [DATE], the day before Resident #4 was transferred to the hospital. A review of the photos of Resident #4's left foot, showed blackened skin on the outer side of the left foot extended from the little toe almost to the middle of the foot. A blackened circle area approximately the size of a nickel on the same side was noted. On the inside of the left foot was another blackened circle area with pink open area, approximately the size of a quarter, located at the head of the first metatarsal. The right foot revealed on the top of the second toe was pinkened area with liquid residue present. A review of Resident #4's clinical chart revealed an admission of 07/2019. The clinical record revealed the resident was transferred to the hospital on [DATE]. The diagnosis list included: unspecified dementia, atherosclerotic heart disease of native coronary artery without angina pectoris; Type 2 Diabetes Mellitus with unspecified complications; hypertension; gastro esophageal reflux disease without esophagitis; personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. A review of Resident #4's Minimum Data Set (MDS) Annual Assessment, dated 03/07/2023, documented a score of 99, which revealed the assessment was not able to be completed for the resident. A review of Section G: Functional status, revealed the resident required extensive assistance for his Activities of Daily Living (ADLs), such as dressing, toileting, eating, locomotion, bed mobility, and transfer. A review of Section M: Skin conditions, revealed Resident #4 was at risk of development of pressure ulcers. Section M revealed the resident was identified not to have any unhealed pressure ulcers of Stage 1 or higher. Resident #4 was identified to have no venous or arterial ulcers present, and no indication of having any foot problems, i.e., diabetic foot ulcer or open lesion on the foot. A review of the quarterly MDS, Section M: Skin conditions, dated 12/07/2022, revealed a clinical assessment and formal assessment process was conducted to determine Resident #4's pressure ulcer risk. The assessment revealed Resident #4 was at risk of development of pressure ulcers, and the resident had no venous or arterial ulcers, no open lesions, rashes, skin tears or moisture associated skin damage. A review of Resident #4's Weekly Skin Checks was conducted for 02/04/2023 thru 03/25/2023, which reflected the following: 02/04/2023, the Site and Description boxes were blank; the comment section documented: 0 open area noted. 02/11/2023, the Site and Description boxes were blank; the comment section documented: 0 open area noted. 02/18/2023, the Site and Description boxes were blank; the comment section documented: Discolored areas still noticeable at bilateral feet. 02/25/2023, the Site and Description boxes were blank; the comment section documented: Discoloration still noticeable bilateral feet continue on skin prep. 03/04/2023, the Site and Description boxes were blank; the comment section documented: Discolored areas still noticeable bilateral feet. 03/11/2023, the Site and Description boxes were blank; the comment section documented: skin is clear. 03/19/2023, the Site: Left gluteal fold; Description: Small open area noted left ischium 1.5 x .75 inches. Cleansed with normal saline Medi-honey applied covered with gauze.; the comments section documented: DON notified. 03/25/2023, the Site: Left gluteal fold.; Description: Open area left ischium and discolored areas bilateral feet. The comments section: See Treatment nurse noted. A review of Resident #4's progress notes revealed the following: 02/11/2023, 14:18 (2:18 p.m.): Late entry, discolored areas noted right heel. Left foot bunion and outer pinky area and left inner ankle skin intact at all areas. Order for skin prep in place. (No documentation of physician notification or family notification.) 02/12/2023, 14:59 (2:59 p.m.): Started on skin prep bilateral feet. Podus boots in place. 02/12/2023, 15:30 (3:30 p.m.): Change in condition: Skin wound or ulcer. The physical assessment documented a skin evaluation, Discoloration; with a summary: skin check done discoloration noted. With the primary care provider feedback: Recommendation: skin prep 02/18/2023, 01:12 (1:12 a.m.): MD (Medical Doctor) notified of minimal swelling with light pink discoloration on the left foot along the side of the existing blister. Now new orders given at this time. Will monitor area for any changes and notify physician. 02/18/2023, 03:52 (3:52 a.m.): New order from physician for Keflex 500 mg (milligrams) bid (two times a day) x 7 (seven) days for blister/ skin infection on left foot. Family member notified; medication order placed with pharmacy. 02/21/2023, 11:48 (11:48 a.m.): Discontinue multipodus boots, r/t left foot blister. Resident continues with ABX (antibiotic) with no ill effect. MD in agreement, son called and updated with new order. 03/15/2023, 14:08 (2:08 p.m.): A care plan meeting was attempted with the POA (power of attorney) but got no response. The care plan meeting was held amongst the team. There are no changes with care. Resident eat meals with the assist group. Residents may be discharged with spouse to a facility with memory care or locked unit. Resident will remain a full code. 03/19/2023, 11:04: Change in condition: Skin wound or ulcer. The nursing observations: During skin check nurse noted the open area, started treatment. DON notified. The Primary Care Provider feedback: Recommendations: Continue with present TX (treatment), until assessed by TX nurse and Wound Doctor. (No family notification documented.) 03/21/2023, 13:15 (1:15 p.m.): Nutritional Evaluation: The evaluation indicated no recent lab drawn; the skin condition: Intact Other: Discoloration. 03/27/2023, 20:36 (8:36 p.m.): MD made aware of rapid declining wound to patient's left lateral foot. Family at bedside. Wound appears black in color and redness to exterior of the wound. No drainage or slough. Wound is dry. New order received for doppler, x-ray and labs due dx (diagnosis) of diabetes, and atherosclerosis. Family made aware of orders and treatment that is in place will continue as ordered by MD. 03/28/2023, 16:55 (4:55 p.m.): Change in condition: Skin wound or ulcer. Nursing observations, recommendations are: Send to ER (emergency room) for eval (evaluation) d/t (due to) wound. Primary Care Provider Feedback: Recommendation: OK to send to ER for evaluation. New testing orders: Venous Doppler, X-Ray. 03/28/2023, 17:49 (5:49 p.m.): MD made aware of diagnostics new order made to send patient to ER for vascular calcification per X-Ray and rapid declining foot ulcer to rule out occlusion and osteomyelitis. Patient not responding to recent topical and abt treatment to the foot ulcer. Patient has history of dx, and x-rays also reveal osteoporosis. Family made aware patient discharged to (hospital). Report given to ER nurse. Patient is clean and dry at the time. [family member] states the patient's groin is red. This nurse as well as the floor nurse and paramedics observe perineal area is clean dry and free from redness, irritation, or breakdown at this time. A review of the doppler study, dated 03/28/2023, revealed the following: LT (left) arterial duplex unilat lower extreme (Duplex includes real time 2 D scanning & color Doppler): Impression: Mild to moderate atheromatous change. A review of the Radiology Interpretation, dated 03/28/2023, revealed the following: Left Foot complete: Osteoporosis and changes of chronic osteoarthrosis are noted. No fracture or dislocation can be seen. No acute findings noted. Impression: Osteoporosis and changes of chronic osteoarthrosis. Heel spur noted and degenerative changes seen throughout toes with vascular calcification noted. On 04/20/2023 at 1:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated for skin observations, the CNA will document if they did not see a new area, or if there is a new area. She confirmed the CNAs should document the latter information every day during the appropriate shift. The DON stated if the CNA observes a new area of skin impairment, the CNA tells the nurse, and the nurse conducts the assessment. The DON provided progress notes, dated 02/12/2023, which indicated skin wound ulcer, but no location or size. The DON stated the information should be on the skin assessment. The skin assessment was reviewed for this date, and she confirmed it was blank. The DON said, do not know, what the size of the skin wound ulcer was. On 04/20/2023 at 3:40 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM). She stated for a change in skin or skin impairment, she would expect the CNAs to let the nurse know. She stated We have protocols. We can apply Zinc. They always let me know. I look. Anything stageable, we get a wound consult. If the impairment was not there yesterday and there today, they let us know. We have weekly skin checks. If something is new, we are supposed to notify the doctor, the family and do an assessment. She stated most nurses do not put measurements on their skin checks. She stated, I was there when the DON called the [family member] on 03/27/2023, to let him know we were going to send him out to the ER (emergency room) for a doppler. She stated she had seen the foot and the blackened area on the side of the foot, and they had done two arterial scans and a doppler, on 03/28/2023. A review of hospital records for Resident #4, dated 03/28/2023, documented a history of present Illness: This (geriatric) patient . Patient has hypertension and hyperlipidemia. The patient has chronic left and right foot wounds. Patient had bilateral lower extremity ultrasound that showed good flow. On evaluation the patient has a fifth digit infection on the left side with also (sic) and also on the medial aspect of the foot plus on the right side the second toe looks infected.The patient will be on Cefepime and Vancomycin. A further review of the hospital record indicated an Adult Nutrition Consult was conducted on 03/28/2023, the assessment: Pt (patient) previous NPO (nothing by mouth). Diet progressed by MD after pt seen. Pt non-verbal. No family present. Pt with multiple wounds present. Will order ONS (Oral Nutritional Supplements) to optimize oral intake and provide additional pro/call for wound healing. Interventions: 1. Continue current diet. 2. Recommend SLP (Speech-language pathologist) eval (evaluation) if pt having difficulty chewing/ swallowing. 3. Add Ensure Plus HP (High protein) TID (three times a day), 20 g (grams) pro (protein) per carton. 4. Monitor PO (by mouth) intake, labs/ elytes, BM and weight. A further review of the hospital record, a Podiatry Consult, dated 03/29/2023: On examination of lower extremities, the patient has atrophic skin bilaterally with an oval grad 1-2 ulceration on the medial aspect of the 1st metatarsal head of the left foot with a dense eschar which upon removal show a small opening with the droplet of pyogenic exudate but uncertain if he goes all the way to capsule certainly no bone exposure is seen. There is minimal erythema surrounding the ulcer site which measures about 1 cm in diameter and no other lesions are seen on the left foot. Again, the skin is atrophic, and the pedal pulses were barely palpable to nonpalpable due to nonpitting edema to the area no hair growth patterns of bilateral lower extremities. There is a small excoriation on the lateral fifth metatarsal head on the right foot and an erosion of dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. It is uncertain that there is osteomyelitis at this point. An assessment, dated 03/28/2023, Active Problems: Subacute osteomyelitis of left foot. Grade 2 ulceration is possibly due to arterial insufficiency on the left foot. Grade 1 ulceration dorsal right second toe. Plan: History and physical evaluation of lower extremities. I consulted wound care nursing to suggest a daily dressing bandage for the patient mainly will recommend Santyl collagenase with a dry dressing to be applied on the eschar ulcer on the medial aspect of the first metatarsal of the left foot. Betadine dressing can be applied to the right second toe. Patients will need vascular surgery for evaluation and treatment due to high suspicion of arterial insufficiency. Awaiting possible MRI of the lower extremity. Will follow as needed. An Infectious Disease consult, dated 03/28/2023 revealed the following: Skin: Has ulcer on the medial aspect of the left first metatarsal head. There is some minimal cellulitis present around the ulcer in the left foot. Right foot is also lateral fifth metatarsal head with large necrotic area and a small also behind it on the lateral aspect of right foot. Also, erosion on the dorsum of the distal interphalangeal joint of the right second toe with mild erythema surrounding the area. Also has right heel ulcer with cellulitis. Left gluteal area has a decubitus ulcer with no purulence. Assessment: Osteomyelitis of the left foot with chronic ulceration on the left metatarsal head area. Chronic ulcer of the left foot on the first metatarsal area medially and x-ray shows possible osteomyelitis. Ulcers of the left fifth metatarsal area necrotic. Some excoriation on the right second toe with cellulitis. Cellulitis of the bilateral feet. Right heel superficial ulceration with cellulitis. Peripheral vascular disease starts with ultra sound showing unable to visualize the left popliteal artery. Left buttock decubitus ulcer which is stag 2-3/ unstageable. An Inpatient consult to Vascular Surgery, dated 03/29/2023, revealed the following: Reason for consultation: Atherosclerosis with bilateral foot ulcers. History: .Unclear duration. Non ambulatory. Severe contracture of left leg at the hip and knee. According to the family, the patient started having blisters of the feet a couple of months ago which progressed to gangrene. Assessment and plan Active Problems: Subacute osteomyelitis of left foot. Arterial duplex images were reviewed. CBC results reviewed .A findings concerning hemodynamically significant arterial occlusive disease with nonpalpable pedal pulses bilaterally. Bilateral lower extremity ulcers with finding concerning for osteomyelitis on the left x-ray. MRI pending. Had a discussion with the family over the phone. Severely limited functional capacity with contracture of the left leg. He is a poor candidate for any revascularization procedures. He cleared from my standpoint for foot debridement. If he does not heel, may end up needing AKA (above the knee amputation. Consider hospice eval if family is agreeable. A review of the facility's Prevention of Skin Issues/ Pressure Injuries policy and procedures, undated, documented, the Purpose: The purpose of this procedure is to provide information regarding identification of skin issues/ pressure ulcer/ injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission for existing skin issues/ pressure ulcer/ injury risk factors. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity-any evidence of existing or developing pressure ulcers or injuries. b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. a. Identify any signs of developing skin issues/ pressure injuries (i.e., no blanchable erythema/ rashes). b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). c. Wash the skin after any episodes of incontinence. d. Reposition resident as indicated on the care plan. Moisture 1. Keep the skin clean and free of exposure to urine and fecal matter. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring/ documenting: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 3. Evaluate open areas (pressure / surgical areas) per MD orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the development and implementation of a comprehensive care plan for two residents (#2 and #4) out of six sampled residents. It was determined the facility 1) Lacked evidence related to the development of, care and treatment of actual pressure ulcers and deep tissue injuries for Resident #2; and 2) Failed to implement interventions related to notifying representatives of a change of a condition and the prevention of pressure ulcers for Resident #4. Findings included: 1. On 4/20/2023 medical record review revealed Resident #2 was admitted to the facility on [DATE] for short term rehabilitation services. A review of the Advance Directives revealed the resident had a medical and financial decision maker during the time of his admission. A review of the admission diagnosis sheet revealed diagnoses including but not limited to, hemiparesis, heart Failure, heart disease, anxiety, depression, and history of pulmonary embolism. A review of the 10/2022 Physician's Order Sheet revealed Resident #2 was receiving hospice services. A review of the discharge summary and progress notes, dated 11/2/2022, revealed per Resident #2 and his spouse request, the resident was discharged from the facility and transferred to another Long-Term Care facility. A review of the previous hospitalization Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated with discharge date [DATE], revealed the resident did not have any pressure wounds, and that his skin was clear. A review of the admission Minimum Data Set (MDS) assessment, dated 8/24/2022, revealed the following: Cognition/Brief Interview Mental Status or BIMS score - No score indicated. However, the assessment indicated the resident had Moderately Impaired decision-making skills; Skin Conditions - Checked as at risk for pressure ulcers, did not have any unhealed stageable pressure ulcers during time of admission, did not have any stageable pressure ulcers upon admission, and did not have any deep tissue injuries at time of admission. A review of the Discharge MDS assessment, dated 11/2/2022, revealed the following: Cognition/BIMS score - Not score indicated. However, the assessment indicated the resident had Moderately Impaired decision-making skills; Skin Conditions - Not Checked as at risk for pressure ulcers, checked as having (1) unstageable deep tissue injury. The assessment did not identify any stageable pressure ulcers upon discharge. A review of the Nursing admission Assessment, dated 8/16/2022, revealed; Section O; Skin assessment, not checked for presence of wounds. Indicating skin was clear with no wounds. A review of the following skin assessments/skin sheets revealed the following. 1. Skin check sheet dated 9/3/2022 - no new skin issues. 2. Skin check sheet dated 9/10/2022 - no new skin issues. 3. Skin check sheet dated 9/17/2022 - no new skin issues. 4. Skin check sheet dated 9/24/2022 - no new skin issues. 5. Skin check sheet dated 10/1/2022 - no new skin issues. 6. Change of Condition dated 10/5/2022 - Skin wound or ulcer, and rash, condition of skin just noted, representative and MD (medical doctor) notified 10/25/2022. 7. Skin check sheet dated 10/8/2022 - Right rear skin tear, no new more skin problem. 8. Skin issues in place with treatment. 9. Skin check sheet dated 10/18/2022 - Wound right Outer foot 2.0 x 1.5 x 0.1 cm: Blister right outer foot 2.5 x 2.0, no odor no drainage. 10. Change of Condition dated 10/18/2022 - Other change of condition with notes - Blister and wound in right outer foot, representative and MD notified 10/18/2022. 11. Skin check sheet dated 10/19/2022 - Right lower back Pressure ulcer (in house acquired) Stage III 2 x 3 x 0.1 cm identified on 10/19/2022 with intervention to float heels and reposition x two hours every shift. 12. Skin check sheet dated 10/19/2022 - Right Distal Lateral Foot DTI (deep tissue injury) 2x2, identified on 10/19/2022 with interventions to float heels and reposition x two hours every shift Skin Check sheet dated 10/25/2022 - TX (treatment) in progress to right foot and right lower back. No other issues noted. 13. Wound evaluation dated 10/26/2022 - Right lower back pressure ulcer (in house acquired) Stage III 1.5 x 2.2 x 0.1 cm and identified on 10/19/2022 with interventions to float heels and reposition x two hours every shift 14. Wound evaluation dated 11/2/2022 - Right lower back pressure ulcer (in house acquired) Stage III 1.2 x 1.8, x 0.1 cm. A review of the [company name] Wound Physicians Initial Wound Evaluation and Management Summary, dated 10/19/2022, revealed Resident #2 has multiple wounds. The assessment continued to indicate Resident #2 had wounds identified to include: Unstageable Deep Tissue Injury (DTI) of the Right, Proximal, Lateral Foot; Unstageable DTI of the Right, Distal, Lateral foot; Stage III Pressure wound of the Right lower back. A review of the [company name] Wound Physicians Initial Wound Evaluation and Management Summary, dated 11/2/2022, revealed Resident #2 has multiple wounds. The assessment continued to indicate Resident #2 had identified wounds to include: Unstageable DTI of the Right, Proximal, Lateral foot; Unstageable DTI of the Right, Distal, Lateral foot; Stage III Pressure wound of the Right, Lower back; Unstageable DTI Coccyx. It was determined through review of the assessments, that Resident #2 developed pressure ulcer and deep tissue injuries around 10/5/2022 - 10/19/2022 and continued to be treated through 11/2/2022 upon Resident #2's discharge date . A review of the Physician's Order Sheet, dated for the month of 10/2022, revealed the following: a. Treatment to Left Buttocks as needed with an order date of 10/19/2022. b. Wound care to cleanse DTI of the Right lateral foot with an order date of 10/19/2022. c. Wound care to the Right lower back with an order date of 10/20/2022. d. Wound treatment to Right outer foot with an order date of 10/18/2022. e. Wound treatment to blister on Right outer foot with an order date of 10/18/2022. f. Wound treatment to cleanse DTI of the right, proximal foot with an order date of 10/22/2022. A review of the 10/2022 Medication Administration Record (MAR) revealed all wound orders were documented as completed per the order with no blank spaces that would indicate the treatment was not completed. These orders were verified and also completed with treatment for the first two days of 11/2022, up until the resident discharged out from the facility. A review of the last care plans prior to Resident #2 discharging from the facility, with an initiated date of 8/17/2022, and with a next review of 11/27/2022, revealed the following pertinent problem areas: - admitted as short-term placement and with interventions in place as reviewed. - Impaired cognitive functions and impaired thought process with interventions in pace as reviewed. - Resident needs assist with ADL (activities of daily living) care related to multiple factors including weakness and decreased mobility and status post recent hospitalization with interventions in place as reviewed. - Risk and use of anti-anxiety medications with interventions in place as reviewed. - Resident is receiving palliative care Hospice care with interventions in place as reviewed. - Risk for skin impairment r/t neuropathy, use of ac, weakness, and decreased incontinence with interventions in place. Care plan problem area indicated it was initiated on 8/17/2022 and revised on 10/14/2022. A review of Resident #2's entire care plan did not indicate any problem areas, goals, and interventions to include actual and current wounds. The care plan only identified the resident was at risk for skin impairment. On 4/20/2023 at 2:57 p.m. Staff B, Minimum Data Set (MDS) Coordinator was not available at the facility for in person interview, however, the Nursing Home Administrator (NHA) was able to set up a telephone interview with her. At 3:00 p.m. a telephone interview with Staff B, along with another MDS coordinator Staff A, who was reviewing the electronic record for Staff B, revealed they both knew of and remembered Resident #2. Staff A and Staff B confirmed Resident #2 was admitted to the facility on [DATE] and discharged to another facility per spouse request on 11/2/2022. Staff B explained through medical record review, to include Wound Care Assessments, and Daily and Weekly skin sheets, it appeared the resident developed several wounds. Staff B stated the wounds were: an Unstageable DTI (deep tissue injury) of the Right, proximal, lateral foot; an Unstageable DTI of Right, distal, lateral foot; and a Stage 3 Pressure Wound of the R lower back. Both Staff A and B confirmed the resident had Deep Tissue Injuries and a Stage III Pressure ulcer, which were all developed after his original admission date. Staff A pulled up the wound records on the electronic medical records and confirmed it to Staff B, who was on the telephone. Staff B revealed she did remember Resident #2 developing wounds and he had been assessed, ordered for treatment, and provided with treatment for those said wounds. Staff B and A confirmed when a resident develops an in-house acquired pressure ulcer the care plan team meets and discusses the wounds. Staff B confirmed the wounds should be carried over to the care plans and created as an actual wound problem area with interventions to decrease and reduce the risk of further wounds. Staff B reviewed the last care plans, with a next review date of 11/27/2022, and stated Resident #2 was planned with at risk for skin impairment, rather than having actual skin impairment to include pressure ulcers and deep tissue injuries. Both Staff A and B confirmed the care plan only related to risk for skin impairment and not the actual wounds. Both Staff A and B explained the actual pressure ulcers and deep tissue injuries should have been care planned as an actual problem area with interventions within twenty-four hours of identifying the problem. On 4/20/2023 at 3:30 p.m. an interview with the Director of Nursing confirmed through review of Resident #2's medical record, the resident did develop deep tissue injuries and a pressure ulcer after he was admitted to the facility. She further confirmed though the resident was assessed for, ordered for treatment, and with treatment completed daily, the care planning team did not update and revise, nor develop care plan problem areas with relation to the actual wounds. She confirmed the care plans only had care plan problem areas related to risk for skin impairment. The Director of Nursing stated the care plans should have been updated/developed within a week, but in this case, it did not happen. It was found that the facility did not develop and revise the skin care plan for at least twenty-four days. On 4/20/2023 at 3:45 p.m. the facility's Nursing Home Administrator provided the Care Planning - Interdisciplinary Team policy and procedure, not dated, for review. The policy stated, our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The policy interpretation and implementation section revealed: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician. b. The Registered Nurse who has responsibility for the resident. c. The Dietary Manager/Dietitian. d. The Social Services Worker responsible for the resident. e. Therapists (speech, occupational, recreational, etc.), as applicable. f. The Director of Nursing (as applicable). g. The Charge Nurse responsible for resident care. 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. 2. A review of Resident #4's clinical chart revealed an admission of 07/2019. The clinical record revealed the resident was transferred to the hospital on [DATE]. The diagnosis list included: unspecified dementia, atherosclerotic heart disease of native coronary artery without angina pectoris; Type 2 Diabetes Mellitus with unspecified complications; hypertension; gastro esophageal reflux disease without esophagitis; personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. A review of Resident #4's Weekly Skin Checks reflected the following: 03/19/2023, the Site: Left gluteal fold; Description: Small open area noted left ischium 1.5 x .75 inches. Cleansed with normal saline Medi-honey applied covered with gauze.; the comments section documented: DON (Director of Nursing) notified. 03/25/2023, the Site: Left gluteal fold.; Description: Open area left ischium and discolored areas bilateral feet. The comments section: See Treatment nurse noted. A review of Resident #4's progress notes, dated 03/19/2023, 11:04: Change in condition: Skin wound or ulcer. The nursing observations: During skin check nurse noted the open area, started treatment. DON notified. The Primary Care Provider feedback: Recommendations: Continue with present TX (treatment), until assessed by TX nurse and Wound Doctor. A review of Resident #4's clinical record reflected no evidence the Wound Doctor had reviewed Resident #4's open area on his left ischium from the date of discovery, 03/19/2023 through the date of his discharge on [DATE]. On 04/20/2023 at 12:03 p.m., a request for documentation of Wound Doctor visits for Resident #4 was requested from the Director of Nursing (DON). No documentation was provided by the facility during the survey. A review of Resident #4's Care Plan revealed the following: Focus: Resident #4 is at risk for skin impairment r/t diabetes, incontinence, use of anticoagulant/ antiplatelet medications, weakness/ decreased mobility, initiated 11/01/2022. Goal: The resident will be free from any new skin impairment through the review date, initiated 11/01/2022. Interventions included: Skin checks weekly and as indicated. Report any s/s of skin breakdown to MD/ wound team as indicated, initiated 11/01/2022. Focus: Resident #4 has a stage 2 pressure ulcer to left ischium, initiated 03/21/2023. Goal: The resident's pressure ulcer will show signs of healing as evidenced by decrease in size, improved appearance, and be free from infection by/ through review date, initiated 03/21/2023. Interventions: Administer medications and treatments as ordered by the MD (Medical Doctor), initiated 03/21/2023. Complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress. Monitor for s/s (sign and symptoms) of infection. Report changes to MD as indicated, initiated 03/21/2023. Educate the resident/ family/ caregivers as to causes of skin breakdown; including transfer/ positioning requirements; importance of taking care during ambulating/ mobility, good nutrition, and frequent repositioning, initiated 03/21/2023. Medicate prior to wound treatments if indicated. Notify MD for unrelieved pain, initiated 03/21/2023. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, initiated 03/21/2023. Wound Care MD/ APRN consult as ordered/indicated, initiated 03/21/2023. On 04/20/2023 at 9:05 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She stated she was providing wound care services. She stated the wound doctor comes to the facility on Wednesdays and the treatment nurse rounds with him. She stated he was timely with the uploads of the wound service, usually the same day or the following day. She stated if a new wound were identified, she would tell the house doctor and she would get a consultation order for the wound doctor to see the resident. On 04/20/2023 at 3:22 p.m., an interview was conducted with Staff H, Certified Nursing Assistant (CNA). She stated she did recall Resident #4. She stated she worked with him, but not every day. She stated, I was assigned a little down the hall, sometimes if someone would call off, my assignment would include him. She said, his butt had a little thing on it, redness in the area. The nurse put clear cream on it and then a dressing on it. It was a 4 x 4 soft material. She stated she could not indicate a time, but she said he had the redness, which had treatment from Staff J, (the nurse), and it was looking better before he left. She stated, I saw a pillow for positioning. He was contracted; a Hoyer lift; he was totally cared for. I would cushion him with a pillow; change him every 2-3 hours. On 04/20/2023 at 3:40 p.m., an interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM). She stated for a change in skin or skin impairment, she would expect the CNAs to let the nurse know. She stated We have protocols. We can apply Zinc. They always let me know. I look. Anything stageable, we get a wound consult. If the impairment was not there yesterday and there today, they let us know. We have weekly skin checks. If something is new, we are supposed to notify the doctor, the family and do an assessment. Staff I stated for a wound consult, It is easy. We just put them on the list. She stated the reason for the wound consult is to see what treatment is best for that area. Staff I reviewed Resident #4's clinical chart and confirmed she was not able to find a wound consult visit documented in the clinical chart for 2023. On 04/20/2023 at 1:30 p.m., the DON provided a sheet of paper which documented: Wound consult timeline for [Resident #4] Wound consult placed on 03/26-Sunday. Patient sent out 03/28/2023-Tuesday. Wound MD comes in on Wednesday. A review of Resident #4's hospital records, dated 03/28/2023, indicated an Infectious Disease consult, dated 03/28/2023, which included: Skin: . Left gluteal area has a decubitus ulcer with no purulence. Assessment included: Left buttock decubitus ulcer which is stag 2-3/ unstageable. A review of the facility's Prevention of Skin Issues/ Pressure Injuries policy and procedures, undated, documented, the Purpose: The purpose of this procedure is to provide information regarding identification of skin issues/ pressure ulcer/ injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission for existing skin issues/ pressure ulcer/ injury risk factors. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity-any evidence of existing or developing pressure ulcers or injuries. b. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Inspect the skin when performing or assisting with personal care or ADLs. a. Identify any signs of developing skin issues/ pressure injuries (i.e., non-blanchable erythema/ rashes). b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). c. Wash the skin after any episodes of incontinence. d. Reposition resident as indicated on the care plan. Moisture 1. Keep the skin clean and free of exposure to urine and fecal matter. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring/ documenting: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 3. Evaluate open areas (pressure / surgical areas) per MD orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure comprehensive assessments were accurately documented for one resident (#84) of 50 sampled residents. Findings included: A review of Resident #84's admission Record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and mixed receptive-expressive language disorder. A review of the facility's Minimum Data Set (MDS) Resident Matrix revealed physical restraints were used for Resident #84. A review of Resident #84's active physician's orders as of 1/12/2023, revealed an order, dated 8/25/2022 for an electronic monitoring device to the left ankle. A review of Resident #84's physician's orders did not reveal an order for use of physical restraints. A review of Resident #84's Quarterly MDS assessment, dated 10/6/2022, revealed under Section P: Physical Restraints, a physical restraint, categorized as other was used while in bed on a less than daily basis for Resident #84. The assessment also revealed a wander/elopement alarm was not used. An observation was conducted on 1/9/23 at 12:32 p.m. of Resident #84 propelling himself in his wheelchair in the hallway outside of his room. Resident #84 was not observed to have any physical restraints in use and was observed to have an electronic monitoring bracelet to his left ankle. An interview was conducted on 1/12/2023 at 8:23 a.m. with Staff A, Registered Nurse (RN). Staff A, RN stated Resident #84 did not have any physical restraints in use and did not have any orders for physical restraints. An interview was conducted on 1/12/2023 at 10:20 a.m. with Staff B, MDS RN and Staff C, MDS Licensed Practical Nurse (LPN). Staff B, MDS RN stated Resident #84 did not have any physical restraints in use but did have an electronic monitoring device in use. Staff B, MDS RN reviewed Resident #84's Quarterly MDS assessment and stated the physical restraint for Resident #84 was documented in error and the assessment should have reflected Resident #84's electronic monitoring device use. Resident #84 should not have been coded as using a physical restraint. An interview was conducted on 1/12/2023 at 11:06 a.m. with the facility's Director of Nursing (DON). The DON stated no residents in the facility have physical restraints in use. A resident would need a physician's order and an assessment completed for any use of physical restraints prior to use. The DON stated Resident #84 should not have been coded in the MDS assessment as having a physical restraint in use and should have been coded as having an electronic monitoring device in use. A facility policy related to comprehensive assessments was requested on 1/11/2023 at 3:39 PM but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a care plan related to floor mats for one resident (#15) of fifty sampled residents. Findings included: A review of the admission Record revealed Resident #15 was initially admitted into the facility on [DATE] with diagnoses that included but were not limited to dementia, major depressive disorder, and unspecified abnormalities of gait and mobility. Review of Section C Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], indicated the resident was rarely or never understood. On 01/09/23 at 10:50 a.m., Resident #15 was observed sitting on the side of the bed attempting to get out of the bed. The bed frame was observed resting on the floor. A mattress was observed on the floor to the right of the bed and two stacked floor mats were observed on the left side of the bed (Photographic Evidence Obtained). On 01/11/23 at 4:47 p.m., the resident was observed in bed sleeping with the mattress on the right side of the bed on the floor and two stacked floor mats on the left side of the bed on the floor. A review of the Order Summary Report with active orders as of 01/12/2023 did not reveal an order for fall mats. A review of the active care plans revealed Resident #15 did not have a care plan in place related to fall mats. On 01/12/23 at 11:08 a.m., the Director of Nursing (DON) reported Resident #15 had raised floor mats to keep him on a leveled surface. She stated he doesn't necessarily need an order for the floor mats, but it should be on the care plan. On 01/12/23 at 1:00 p.m., the DON reported they did not have a care plan policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADLs) related to oral care, were provided for one resident (#91) of five residents sampled. Findings included: During facility tours conducted on 01/09/23 at 12:35 p.m., and 01/10/23 at 12:52 p.m., Resident #91 was observed in her room, laying on her bed. Resident #91's tongue was noted with a white substance all over the surface of her tongue and around her lips. Resident #91's lips were noted dry and chapped on the surface. The resident stated she remains in bed all the time and was dependent on staff for care. On 01/11/23 at 1:43 p.m., an interview was conducted with Resident #91. The resident stated she does not receive oral care every day. Resident #91 said, Some staff will just have me rinse my mouth with water and they do not use a toothbrush or toothpaste. Some of them use a sponge and wipe around the inside of my mouth. Resident #91 stated she did not know if she owned a toothbrush and stated she could she ask her family to bring one, and maybe some have toothpaste. Review of the admission Record for Resident #91 showed the resident was admitted to the facility on [DATE] with the diagnoses to include dysphagia and gastrostomy status. A minimum data set (MDS), dated [DATE], showed under Section C1000 Cognitive Skills for Daily Decision Making that the resident is severely impaired and rarely makes daily decisions. Review of a document titled Point of Care Audit Report showed the Certified Nursing Assistant (CNA) task log for Resident #91's oral care performance. The two-month period reviewed, dates 11/5/22 to 1/5/23 showed Resident #91 was not provided oral care 36 scheduled times. The report showed an expectation to provide oral care once daily per shift /three times daily. A care plan for Resident #91 showed a focus initiated on 9/15/22 related to oral/dental health as a problem related to edentulous. The goal indicated the resident will not have any complications related to oral or dental health problems through the next review date. Interventions included to encourage and assist the resident with oral or dental care as tolerated, to monitor document and report as needed any signs or symptoms of oral/dental problems needing attention, to include lips cracked or bleeding, debris in mouth, tongue coated black, white, inflamed, smooth, and any ulcers/lesions in mouth. An ADL focus initiated 8/24/22 showed a self-care deficit related to chronic medical conditions. Interventions included to encourage and assist with all ADL tasks as indicated, including personal and oral hygiene. On 01/11/23 at 1:52 p.m., an interview was conducted with Staff E ,CNA. Staff E stated they are supposed to complete mouth care for the resident three times a day, typically once per shift. She stated she completes oral care for this resident and uses a toothbrush and toothpaste. Staff E stated she tells the resident not to swallow because she is NPO (nothing by mouth). The CNA sated she is still planning on assisting the resident with oral care today. An immediate tour of Resident #91's room was conducted with Staff E. Staff E could not find the supplies needed to provide oral care for Resident #91. Staff E opened every drawer and said, She should have a toothbrush somewhere. I think she should have the oral brushes too. I don't know why she doesn't have any basin. I will get her some. On 01/11/23 at 2:30 p.m., an interview was conducted with Staff D, Registered Nurse (RN). Staff D, RN assessed Resident #91's mouth and stated the resident did not have thrush (fungal infection of the mouth). Staff D said, This is a problem with oral care. The CNAs are not cleaning her up. She should not look like this. Staff D stated he would follow -up and make sure oral swabs are provided and care was given as expected. An interview was conducted on 01/11/23 at 2:36 p.m. with Staff F, Licensed Practical Nurse (LPN) Unit Manager. Staff F stated the expectation is for oral care to be provided at least once per shift or as needed. She stated the task is listed on the CNA Task Log to be completed as scheduled. She stated she would evaluate the resident and address the concern. On 01/12/23 at 9:24 a.m. Resident #91 was observed in her room. The resident stated the night before a CNA had cleaned her mouth. The resident stated she felt much better, and she hoped it would continue. Review of a facility policy titled, Activities of Daily Living, ADL's, revised March 2018, showed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living, ADL's. Residents who are unable to carry out ADLs independently, will receive the services necessary to maintain good nutrition grooming, personal and oral hygiene. (2.) Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene / oral care. (6.) Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. (7.) The resident's response to interventions will be monitored evaluated and revised as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide supervision for smoking and limited access to smoking materials for three residents (#58, #712, and #715) out of ten smokers as evidence by the observation of the three residents smoking unsupervised and the observation of smoking paraphernalia removed from resident rooms. Findings included: 1. An observation was conducted on 1/10/23 at 9:30 a.m., of Resident #58 with Staff H, Registered Nurse (RN). The resident was sitting in the courtyard against the exterior wall of the facility's D-wing. The resident was holding a lit cigarette which had approximately 1 left. An ashtray was not available to the resident in the immediate area. Staff H was the only staff member in the courtyard at the time of the observation and had arrived and then left the courtyard. Staff H did not address the unsupervised smoking with Resident #58. On 1/10/23 at 2:00 p.m. an observation was conducted in the courtyard of three residents (#58, #712, and #715) smoking cigarettes with no staff present in the courtyard. Resident #715 stated the facility kept cigarettes up front. The resident was holding a yellow plastic shopping bag. Resident #58 and #712 were sitting in wheelchairs against the exterior wall of D-wing and not under the covered tables that held metal ashtrays. During the observation, on 1/10/23 at 2:05 p.m., Resident #58 was observed handing an item to Resident #715 and Resident #715 held the item to a cigarette in her mouth. Staff I, Activity Director (AD) arrived to the courtyard with two other residents at 2:05 p.m. on 1/10/23, and she went over and spoke with Resident #58 and #712 then left the area. On 1/10/23 at 2:08 p.m., the AD re-entered the courtyard with a large black box. The AD handed Resident #712 and #715 cigarettes and lit them both with lighter. She was observed passing out cigarettes and lighting them for other residents then handed Resident #58 a cigarette, lit it, and placed cigarettes and lighter into black box. The AD confirmed, on 1/10/23 at 2:47 p.m., that Residents #58, #712, and #715 had been in the courtyard. She stated all smoking material was to be kept with staff, all smoking was supervised, and that no resident was supposed to have smoking material in their rooms. On 1/10/23 at 2:52 p.m., the AD confirmed verbally and visually that she had removed a lighter from Resident #712's room. A moment later, the AD had a yellow plastic bag in her possession and confirmed it contained cigarettes taken from Resident #715's room. The admission Record indicated Resident #58 was initially admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to unspecified chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS), dated [DATE], identified the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition. The Admission/re-admission Nursing Packet, dated 9/5/22, indicated Resident #58 did not use smoking/tobacco/nicotine products. The instructions identified that if the score was 10 or greater, the resident should be considered at RISK, needs supervision when smoking, and The smoking protocol should be initiated immediately and documented on the care plan. A review of this section identified that it had not been completed because the first question regarding if the resident used tobacco/nicotine products was answered no and the staff were instructed to STOP HERE. The Smoking/Nicotine Device evaluation, dated 1/9/23, for Resident #58 identified that Resident #58 used cigarettes, was aware of the Smoking Safety Procedure, and was determined not to need supervision as the additional comments read as: All residents are supervised while smoking. 2. The admission Record identified Resident #712 was admitted on [DATE] with diagnoses not limited to epileptic seizures related to external causes not intractable with status epilepticus and unspecified altered mental status. The Admission/re-admission Nursing Evaluation, dated 12/27/22 indicated that Resident #712 did not smoke. The Cognitive Patterns section of the resident's comprehensive assessment identified a BIMS score of 15 out of 15, indicating an intact cognition. Resident #712's care plan, dated 1/11/23, identified the resident as a smoker and indicated that staff were to provide physical assistance for smoking functions such as lighting, holding, and extinguishing the cigarette/cigar as needed, and to Re-educate resident and/or family on designated smoking times and the designated smoking location. The Smoking/Nicotine Devices evaluation for Resident #712, dated 1/9/23, identified the resident did use cigarettes and the additional comments read as: All residents are supervised while smoking. 3. The admission Record identified Resident #715 was originally admitted on [DATE] and most recently admitted on [DATE]. The record included diagnoses not limited to unspecified sequelae of cerebral infarction, and unspecified intractable epilepsy without status epilepticus. Resident #715's active care plan identified that the resident was at risk for complications related to chronic tobacco use of cigarettes and instructed staff to Educate and remind family/visitors not to give smoking materials directly to the resident and not to leave these materials in resident rooms, to Encourage/remind resident to maintain smoking materials including lighters, matches, etc. at the designated facility location, and Provide physical assistance for smoking functions such as lighting, holding, and extinguishing the cigarette/cigar as needed. The Smoking/Nicotine Devices evaluation, dated 1/9/23, indicated that Resident #715 did use cigarettes and the additional comments read as: All residents are supervised while smoking. A record review of the facility's Smoking Contract Acknowledgement, revealed Resident #58 signed it on 11/15/22 , #712 signed it on 1/9/23, and #715 signed it on 1/9/23. The contract's purpose was To provide residents the privilege of smoking while maintaining their safety and the safety of others. The contract included the following facility policies: -2. All smokers will be assessed upon admission or start of smoking and as their cognitive and/or physical status mandates. -7. Tobacco products will be dispensed one at a time per resident request, with a limit of two cigarettes per supervised break. -8. Absolutely no tobacco paraphernalia and/or tobacco products are to be kept in resident rooms. -13. Smoking paraphernalia for all residents will be secured by staff and labeled with individual resident names. The policy titled, Tobacco Restrictive Policy Acknowledgement, undated Attachment D2, indicated It is the policy of the Facility to discourage any smoking in the facility. However we are also understanding of the fact that as a skilled nursing and rehabilitation facility, some of our residents may choose to smoke. Therefore, the facility will designate an outside smoking area to accommodate the request of those individuals. The purpose of restricting the smoking in the facility is to reduce the effect of smoking to residents who do not smoke, including possible adverse effects on treatment, to reduce the risk of passive smoke, and to, reduce the risk of fire. The policy identified the following: - Staff will dispense the resident's cigarettes, light the cigarette, and stay with the resident until the cigarette is properly extinguished. - All residents smoke with supervision and will do so only in the designated area. - All cigarettes, lighters and any other smoking materials will be kept at the nurses' station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide enteral nutrition in accordance with professional standards for one resident (#459) of two residents sampled for enteral nutrition needs. Findings included: A review of Resident #459's admission Record revealed Resident #459 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). A review of Resident #459's active physician's orders revealed an enteral feed order, dated 1/6/2023, for Glucerna 1.5 at 50 milliliters per hour (ml/hr) with water flush at 30 ml/hr for 20 hours, up at 2:00 PM - down at 10 AM. An observation was conducted on 1/10/2023 at 9:35 a.m. of Resident #459 in the resident's room. Resident #459 was observed resting in bed with the head of the bed elevated and enteral feeding running. An observation of Resident #459's enteral feeding pump revealed Glucerna 1.5 was being administered to Resident #459 at a rate of 55 ml/hr with water flush at 40 ml/hr. The same rate was also labeled on the Glucerna 1.5 solution bottle hanging on the enteral feeding pump pole. An interview was conducted on 1/12/2023 at 9:23 a.m. with Staff A, Registered Nurse (RN). Staff A, RN verified Resident #459's enteral feeding order for Glucerna 1.5 at 50 ml/hr with water flushes at 30 ml/hr. Staff A, RN stated nurses were responsible for ensuring the enteral feeding pump's rate is the same as what is order for the resident and stated Resident #459's pump should not have been set to administer Glucerna 1.5 at 55 ml/hr with water flushes at 40 ml/hr. An interview was conducted on 1/12/2023 at 11:14 a.m. with the facility's Director of Nursing (DON). The DON stated she was notified Resident #459's enteral feeding rate was set to a different setting than what was ordered and she was not sure who adjusted the rate for the feeding. The DON also stated nursing staff should be verifying the rate that is set on the enteral feeding pump and ensuring it is the same rate as what is ordered by the resident's physician. Photographic Evidence Obtained.

Based on observation, record review, and interview the facility failed to ensure the physician order for one resident (#17) out of five residents sampled for unnecessary medications was implemented following the recommendation of the consulting pharmacist. Findings included: The admission Record for Resident #17 indicated an admission date of 1/21/21 and included diagnoses not limited to unspecified sequelae of cerebral infarction, ischemic cardiomyopathy, and moderate recurrent major depressive disorder. An observation of Resident #17 lying in bed was conducted, on 1/9/23 at 12:23 p.m. The Medication Regimen Review (MRR) conducted on 10/29/22, identified a recommendation from the Consultant Pharmacist asking the physician to consider a gradual dose reduction, Alprazolam 0.5 milligram (mg) orally (po) every day (qd) for anxiety (anx). The Physician/Prescriber Response section indicated the physician agreed with the recommendation, was signed, and dated on 11/3/22 or 11/7/22 (date showed as a 3 or 7 written over the other number). The physician's progress note, dated 10/27/22 (2 days prior to the recommendation), indicated the plan was to continue Resident #17's current plan of care. The physician's progress note, dated 11/16/22, indicated the physician did not note a change in the resident's Alprazolam. A review of Resident #17's November 2022 Medication Administration Record (MAR) identified the following: - Xanax Tablet 1 milligram (mg) (Alprazolam) - Give 1 tablet by mouth one time a day for anxiety, start date 6/23/22 and discontinued at 5:50 p.m. on 11/9/22. The order was scheduled for bedtime (HS). - Xanax Tablet 1 mg (Alprazolam) - Give 1 tablet by mouth in the evening for anxiety, start date 11/9/22 at 10:45 p.m. The medication was scheduled to be administered at 10:45 p.m. The November 2022 MAR did not identify that the physician order to reduce Resident #17's Alprazolam to 0.5 mg had been implemented and/or changed. A review of Resident #17's December 2022 MAR identified that the resident continued to receive 1 mg of Xanax (Alprazolam) every evening. The review of Resident #17's progress notes did not identify a reason that the physician order had not been followed. The Director of Nursing stated, on 1/11/23 at 4:59 p.m., that she was not here at the time of the (pharmacy)recommendation so it was just a record review for her. She stated her expectation would be that the order should have been changed per the physician order. The policy titled, Medication Utilization and Prescribing, issued 10/2014 and revised 10/22, identified the guideline as: The facility will comply with the requirements specified in accordance with State and Federal regulations as they pertain to Medications Utilization and Prescribing. The Treatment/Management section of the policy indicated, Based on input from the staff and resident, the physician will adjust medications based on their efficacy, indications and the continued presence of clinically significant risks. The monitoring of medications identified that The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a facility tour on 01/12/23 at 9:10 a.m., an observation was made of room [ROOM NUMBER]. The observation revealed a dead insect on the floor by Bed A's bedside table. Further observation revealed Bed A's privacy curtain was noted stained with brown marks. An observation was made of dark brown matter spattered on the floor by Bed B and on the adjacent wall. The brown matter was splashed on the resident's clothes that were in a bag by the bed. In addition, during this observation Bed B's dresser was noted broken and not closing properly with clothes spilling out. A trash can by the door was noted overflowing with trash and used gloves. The floor was noted with dirt, dust, and papers. (Photographic Evidence Obtained) On 01/12/23 at 10:11 a.m., an interview was conducted with Staff G, Housekeeping / Floor Technician. Staff G reviewed the photographic evidence and said, That looks really bad. I will take care of it now. Staff G stated resident rooms should be cleaned promptly, at least daily and as needed. Staff G stated he did not know why the aide did not at least pick up the mess off the floor and let Housekeeping know. Staff G stated the brown substance on the floor looked like bowel matter. Staff G stated it was unacceptable. Staff G stated he would go to room [ROOM NUMBER] and clean it right away. On 01/12/23 at 1:34 p.m., an interview was conducted with the Director of Maintenance (DOM). The DOM looked at the room appearance and stated the room was not acceptable. It was not clean per their standards. The DOM said, It should have been cleaned right away. The DOM reviewed the photographic evidence and said, It looks like feces, residents should not have feces on the floors and walls. The DOM stated he expected resident rooms to be maintained in a clean and sanitary manner. On 01/12/23 at 1:48 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the resident in room [ROOM NUMBER] Bed B chewed tobacco and spits it on the floor and walls. The NHA reviewed the resident's care plan which had no documented evidence of on-going concerns with spitting tobacco chews or spitting on the floor. The care plan did not show interventions to address the concern. The NHA stated they would put a plan in place, give the resident a spit bottle and/or a trash can to spit in. The NHA stated he would have housekeeping staff go into the room three times a day to maintain a sanitary environment. The NHA reviewed photographic evidence and stated he would have housekeeping take of it. 3. An observation was conducted on 1/12/2023 at 8:23 a.m. in resident room [ROOM NUMBER]. The window side of the room near Bed B contained four unpainted drywall repair areas. Moderate built up areas of hardened drywall compound were observed on the patched areas of the walls. An observation was conducted on 1/12/2023 at 8:30 a.m. in resident room [ROOM NUMBER]. The window side of the room near Bed B contained a large unpainted drywall repair area to the right of the window. Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and homelike environment related to not maintaining the kitchen ceiling in one of one kitchen, repairing of holes in the walls of three resident rooms (#140, #145 and #181), and a stained floor, walls and privacy curtain and broken furniture in one resident room (room [ROOM NUMBER]) out of a total of 64 resident rooms. Findings included: 1. On 01/09/23 at 10:02 a.m., an initial tour of the kitchen was conducted. Three ceiling tiles were observed cracked and chipped in the area near the dish washing machine. In addition, multiple ceiling tiles above the food prep area were observed with an excessive amount of black buildup (Photographic Evidence Obtained). On 01/10/23 at 9:30 a.m., the Nursing Home Administrator reported they have had a Quality Assurance and Performance Improvement (QAPI) in place for building repairs since August 2022 and the kitchen ceiling was on the list. He stated the ceiling tiles were on back order due to the hurricane. The ceiling tiles in the kitchen were cleaned last night, stated the Nursing Home Administrator. On 01/11/23 at 11:08 a.m., the ceiling tiles were observed cleaned and repaired. The Certified Dietary Manager (CDM) confirmed there was a concern with the ceiling tiles, and they could have cleaned the tiles prior to survey. 4. An observation was made on 1/12/23 at 1:50 p.m. of the wall behind the resident's motorized wheelchair in room [ROOM NUMBER]. The drywall behind the chair had previously been patched and left unfinished, and a hole in the drywall was observed behind the wheelchair near the resident's dresser. The resident stated the facility was aware of the issue (with wall) and that it happened when the aides tried to park the wheelchair. During the observation the plastic corner protector next to the resident's bathroom was attached to the wall using green tape. (Photographic Evidence Obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 01/09/23 at 2:40 p.m., an interview was conducted with Resident #98's Responsible Party. The Responsible Party stated the resident had a UTI infection and he was not well. Review of the admission Record for Resident #98 showed the resident was admitted to the facility on [DATE]. Review of physician orders for Resident #98, dated 1/10/23, showed Resident #98 was prescribed Bactrim DS tablet 800-160 mg, give 1 tablet by mouth two times a day for infection for 7 days. Orders initiated on 1/5/23 and with an end date of 1/12/23 showed the resident was being treated for an infection but did not indicate the diagnosis reflecting why the resident was receiving the antibiotic treatment. Review of the Medication Administration Record (MAR) for January 2023 for Resident #98 showed the antibiotic [Bactrim DS tablet 800 - 160 MG), was administered two times a day for an infection for seven days. The MAR did not show the diagnosis. On 01/10/23 at 12:11 p.m., an interview was conducted with Staff D, Registered Nurse (RN) assigned to Resident #98. Staff D stated Resident #98 was taking antibiotic Bactrim. Staff D reviewed the MAR and said, It says infection, I don't know what infection it is specifically, but the doctor usually prescribes it for UTI. Staff D stated he has administered the antibiotics for two days this week. He stated he did not review what the infection was for. Staff D reviewed the physician orders and the MAR and stated he was not sure exactly what the infection was but, he could look at the labs. Staff D reviewed the labs and stated the resident has a UTI according to labs that were obtained on the 1/3/23 with orders to administer antibiotics for 10 days. Staff D stated the doctor's orders should be specific. Staff D said, It should say for UTI. They need to put in the order clearly. It should state the actual diagnosis not just infection. Staff D stated he would confirm with the physician. On 01/10/23 at 12:27 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nurse who received the orders should have put in the diagnosis. The ADON said, It should not just say infection. It should indicate what the infection is. The nurse put it in wrong. The ADON stated she would follow-up. A follow up was conducted on 01/10/23 at 4:51 p.m., with the Director of Nursing (DON). The DON stated the expectation is for the diagnosis to be listed in the orders, the MAR, and the actual medication label. Based on observation, record review, and interview, the facility, 1. failed to ensure blood pressures were monitored adequately for a period of three months for one resident (#40) of five sampled residents, and 2. failed to ensure one resident (#98) receiving antibiotic treatment had a diagnosis listed, to indicate the purpose of the treatment of four residents reviewed for a UTI (urinary tract infection) diagnosis. Findings included: 1. A review of the admission Record revealed Resident #40 was initially admitted into the facility on [DATE] with a diagnosis that included but was not limited to hypertension. A review of the Order Summary Report with active orders as of 11/01/22 indicated the following order: Hydralazine HCL Tablet 25 MG (milligram)- Give 25 mg by mouth four times a day for hypertension, start date 9/25/22. Hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60. A review of the Medication Administration Record (MAR) for November 2022, December 2022, and January 2023 revealed the medication was administered four times a day from 1/1/23 - 1/11/23, 12/1/22 - 12/31/22 and 11/1/22 - 11/30/22. The MARS did not reflect blood pressures were checked per order. A review of the Weights and Vitals Summary, dated 1/11/23, for blood pressures revealed the following blood pressures taken from 11/1/22 to 1/11/23: 01/06/23 - 131/82 01/04/23 - 110/51 12/04/22 - 128/71 11/30/22 - 128/62. The care plan related to hypertension initiated on 09/27/22 included the following intervention: monitor vital signs. On 01/11/23 at 5:15 p.m., the Director of Nursing (DON) confirmed blood pressures were not being checked per orders. She stated the blood pressures should have been checked four times per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to prepare palatable meals for four residents (#13, #17, #32, and #38) out of fifty sampled residents and to ensure the temperature of fried eggs were maintained for one of one test tray. Findings included: 1. Resident #13 stated, on 1/10/23 at 2:39 p.m., that it did not matter what was on the menu, she doesn't get what's on it anyway. The family member of the resident stated she has talked with the Certified Dietary Manager (CDM) (regarding food) and the CDM will shake her head. She stated the facility chops food up so the resident doesn't know what it is, and the resident gets mashed potatoes and gravy every day for lunch and dinner. The admission Record indicated Resident #13 was admitted on [DATE] and 1/7/20. The record identified diagnoses not limited to dysphagia following cerebral infarction and moderate recurrent major depressive disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 14, indicating an intact cognition. 2. Resident #17 was interviewed on 1/9/23 at 12:23 p.m., related to food served at the facility. The resident stated, I hate it, the food is not right. The resident reported getting chicken a lot and that it was fake chicken, described it as round chicken breasts. The resident stated the chicken was overcooked and dry. The resident described the cooking process as taking it out of the oven, putting it on a steam table, and then it continues to cook. Resident #17 reported getting a lot of rice and mash potatoes and that the meat was too salty maybe from the added gravy. The admission Record identified Resident #17 was admitted on [DATE]. The record included diagnoses not limited to unspecified sequelae of cerebral infarction and ischemic cardiomyopathy. The Quarterly MDS, dated [DATE], identified a BIMS score of 15 out of 15, indicating an intact cognition. 3. Resident #32 reported, on 1/9/23 at 10:26 a.m., that They don't cook it right. The resident showed this writer a picture of burnt toast from a previous breakfast. Resident #32 reported getting a mechanical diet and does not know why she was getting chopped food. The resident stated the food was always cold and the food tasted spoiled, especially the real eggs. The admission Record indicated Resident #32 was admitted on [DATE]. The record included diagnoses not limited to morbid (severe) obesity due to excess calories and gastro-esophageal reflux disease without esophagitis. The Quarterly MDS, dated [DATE], identified a BIMS score of 15 out of 15, indicating an intact cognition. The physician Order Summary Report, dated 1/12/23, indicated the resident was ordered a chopped/soft and bite-sized texture regular diet with thin consistency liquids. 4. Resident #38 reported the food (at facility) sucks, and she cannot stand lunch and dinner, and the same seasoning in everything. The resident stated the real egg tastes terrible, spoiled, and rotten. On 1/11/23 at 5:35 p.m., the resident reported the dinner sucks, and she doesn't like the grilled cheese sandwich. The admission Record indicated Resident #38 was originally admitted on [DATE] and recently admitted on [DATE]. The record included diagnoses not limited to oropharyngeal phase dysphagia and unspecified as acute or chronic gastric ulcer without hemorrhage or perforation. The Quarterly MDS, dated [DATE], identified a BIMS score of 14 out of 15, indicating an intact cognition. The physician Order Summary Report, dated 1/12/23, identified the resident's diet as No Added Salt (NAS), Consistent Carbohydrate Diet (CCHO), and fortified foods with a regular texture. On 1/12/23 at 8:08 a.m., a breakfast tray was transported on the last meal cart to B-wing of the facility and then carried to the conference room by the Certified Dietary Manager (CDM). The tray consisted of several pieces of bacon, a hard yolk fried egg, and a cheese danish. The temperature of the fried egg was 108.5 Fahrenheit (F). The CDM stated that it was an ongoing issue with eggs to maintain temperatures and had done a performance plan on it. The observation in the kitchen identified and was confirmed by the CDM that the eggs were cooked prior to the meal service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to honor the rights to a dignified existence by not ensuring that a resident's environment enhanced the quality of life for one resident (#77) of 43 sampled residents. Findings included: Observations of Resident #77's private room on 4/27/21 at 10:49 a.m. revealed that the resident's room was [NAME], with the closet empty and no dresser in the room. During the observation it was noted that there was a large box sitting on an armchair with personal items in it. While interviewing Resident #77, at this time, the resident reported that she had COVID-19 two weeks ago and that the facility moved her to her current room. She reported that all her belongings are in the cardboard box and that nothing was unpacked. An observation of Resident #77's private room on 4/28/21 at 12:25 p.m. revealed that her belongings were still in a cardboard box, and the room was still [NAME]. An interview with the resident confirmed that her belongings are still in the box, and that it didn't matter anymore as she is supposed to leave to go home on Friday. An observation of Resident #77's private room on 4/28/21 at 4:10 p.m. revealed that the resident's room was still [NAME], and her belongings were still stored in a cardboard box on a chair in her room. Review of Resident #77's electronic medical record revealed a Brief Interview for Mental Status (BIMS) score of a 15 (Score of 13-15=Intact cognitive response). Additional review of the electronic medical record under the section of Census revealed that she was transferred from room room number to her current room on 4/14/21. Review of the progress note dated 4/14/21 at 18:00 (6:00 p.m.) documented, Resident is alert and oriented. She is aware that she was tested positive with the rapid COVID test and that she needs to be transferred to another room for isolation precaution . Interview on 4/28/21 at 4:12 p.m. with Staff I, Certified Nursing Assistant (CNA) revealed that the resident was moved from another room to her current room due to her having COVID-19 about two weeks ago. She reported that she is not sure why her belongings are not unpacked as she did not work with her during that time. Interview on 4/28/21 at 4:15 p.m. with Staff J, Registered Nurse (RN) revealed that she was assigned to the resident on this day, but that she is a PRN (as needed) nurse, and that the resident was new to her and was unaware as to why the resident's belongings were in a cardboard box. Interview on 4/28/21 at 4:20 p.m. with Staff H, RN, 3:00 p.m.-11:00 p.m. Supervisor, revealed that she was unsure as to when the resident was moved to her current room and was unsure as to why her belongings were being stored in a cardboard box. In an interview on 4/28/21 at 4:23 p.m. with the Social Service Director and the Admissions Director, the Social Service Director reported that the resident was moved to her current room about two weeks ago, and that she was not sure why the resident's belongings were in a cardboard box. She reported that she believes that she may be discharged soon. The Admissions Director reported that when a resident changes rooms all their belongings should go with the resident, and all belongings should be unpacked for the resident. He reported that Resident #77 moved to her current room on 4/14/21, and by now her belongings should have been unpacked. He was unsure as to why her belongings were not unpacked. Review of the facility policy titled, Resident Rights, with a revised date of December 2016, revealed the following: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: ee. retain and use personal possessions to the maximum extent that space and safety permit; Review of the facility policy titled, Quality of Life- Dignity, with a revised date of February 2020, revealed that 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, feeling of self-worth and self-esteem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to implement the care plan for two residents (#49 and #94) out of forty-three residents sampled in regards to ensuring the resident (#49) was not isolated in her room and ensuring the resident (#94) had bilateral floor mats as ordered. Findings included: 1. A review of the admission Record for Resident #49 revealed the resident was admitted to the facility on [DATE] and 9/25/14. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance, unspecified hand contracture, and aphasia following unspecified cerebrovascular disease. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident did not have a Brief Interview of Mental Status score, indicative of severe cognitive impairment. The MDS identified that Resident #49 exhibited physical behavioral symptoms directed toward others, (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 1 to 3 days of the assessment period. The Functional Status indicated that the resident had a range of motion limitation on one side of an upper extremity and both lower extremities. On 4/28/21 at 10:33 a.m., Resident #49's room door was shut. Upon entry the resident was observed alone and sitting in a wheelchair between her bed and the outside wall. The resident's television was not turned on, but the first bed's television was on, playing cartoons and pointed toward Resident #49. The resident's left arm was bent at the elbow with the hand near her neck, the hand was closed with the middle finger crossing over the pointer finger. Both sides of the resident's wheelchair appeared to be in the locked position. An observation at 10:52 a.m. on 4/28/21 indicated that Resident #49 was alone in her room a wheelchair next to the corner of the Packaged Terminal Air Conditioner (PTAC) unit at the end of the bed. The observation revealed a very tight space of maneuverability between the PTAC unit and the footboard of the bed. During an observation at 10:54 a.m. on 4/28/21 Staff W, Certified Nursing Assistant (CNA) was asked why the resident was in her room with the door shut and she stated that she didn't know who had shut the door. The staff member stated the resident could make the corner between the PTAC unit and bed. Staff W demonstrated by pulling the wheelchair (with resident sitting in it) around the corner of the bed, moving the bed slightly. The staff member placed the brakes of the wheelchair in the unlocked position. An observation at 8:55 a.m. on 4/29/21 revealed Resident #49 in her room alone, lying in the bed next to the window. The privacy curtain between the first bed of the room and the resident was pulled to the end of her bed. The first bed's television was playing cartoons and turned toward the resident, the resident's television was not playing. The care plan for Resident #49 indicated that the resident had a communication problem related to (r/t) rarely or never understood or understands r/t cognition/aphasia, dementia and she will reach out and grab at staff and others, usually when she is hungry, thirsty, or needs to rest. The interventions regarding the resident's communication problem included, ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position, and wheels locked, Avoid isolation, initiated on 12/6/19. During an interview, on 4/30/21 at 1:40 p.m., with the Director of Nursing (DON), the observation of Resident #49 sitting between the wall and bed was described to her. She stated no that shouldn't happen. She confirmed that the privacy curtain being pulled to the end of the bed with the first bed's television playing was not acceptable. 2. A review of the admission Record revealed that Resident #94 was admitted to the facility on [DATE]. The admission Record included diagnoses not limited to other seizures, unspecified anxiety disorder, and unspecified dementia with behavioral disturbance. The admission Minimum Data Set (MDS), dated [DATE], did not indicate a Brief Interview of Mental Status (BIMS) score as the resident was rarely/never understood. A physician order, dated 3/29/21, identified Floormat to bilateral sides of the bed every shift for fall precaution. An observation on 4/29/21 at 10:25 a.m. of Resident #94 in bed indicated the resident had no floor mats in the room. An observation of Resident #94's room was conducted, at 4/29/21 at 11:05 a.m., with the Activity Director (AD) who also identified herself as a Certified Nursing Assistant (CNA). Resident #94 was in bed at this time. The AD confirmed there were no floor mats in the resident's room. The care plan for Resident #94 identified her as a high risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, vision/hearing problems, and tardive dyskinesia. The interventions related to her high risk of falls included, Floor mats on Floor while on bed, initiated 3/31/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide restorative services per physician's orders for two residents (#30 and #49) out of the sampled forty-three residents. Findings included: 1. On 04/27/21 at 12:00 p.m., Resident #30 stated that he wanted to get out of bed to keep his legs strong. He stated that he only had therapy for 30 days and was not doing restorative. Resident #30 stated restorative staff are always doing other duties on the floor. He stated this was not fair to him because he was not ready to give up. On 04/28/21 at 11:03 a.m., Resident #30 reported that he had only seen restorative twice since he had been admitted into the facility. He stated that he wanted to stand to help keep his legs strong. Resident #30 stated he had probably been out of bed four times in the last three weeks, and he use to get up every day. He reported he had a stroke on the left side and does not want to get weaker. A review of the admission Record for Resident #30 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of unspecified sequelae of cerebral infarction and other diagnoses that included but were not limited to morbid obesity, left hand contracture, and muscle weakness. A review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15; indicating he was cognitively intact. Section G Functional Status indicated that the resident was totally dependent for bed mobility and dressing with one-person physical assistance, extensive assistance was needed for transfers with two plus persons physical assistance, and extensive assistance was needed for toilet use and personal hygiene with one-person physical assistance. A physician's note dated 03/25/21 revealed that Resident #30 was discharged from therapy to restorative therapy. The resident had the following active physician's order dated 03/23/21: begin restorative nursing functional maintenance program to maintain current level of function 5 times a week as tolerated. The Medication Administration Record for March and April 2021 did not reflect any documentation related to restorative. The Treatment Administration Record for March and April 2021 did not reflect any documentation related to restorative. The POC (Point of Care) Response History report for Resident #30 revealed that restorative was provided for a total of seven days from 3/31/21 to 4/28/21. On 04/29/21 at 4:15 p.m., Staff N, Registered Nurse (RN), reported that she was in charge of the restorative program. She reported that they had three restorative CNAs (Certified Nursing Assistants), but they do not work every day as restorative aides. She stated, Restorative aides have been working the floor a lot. Staff N stated that staff had been pulled to the floor, so the restorative aides had not been functioning as restorative aides. On 04/30/21 at 1:40 p.m., the Director of Nursing (DON) reported that because of staffing; they had been using the restorative aides on the floor. Nurses should contact the doctor to let them know that the restorative aides were being used on the floor and to see if they could lower the order from 5 days to 3 days. The DON confirmed that restorative services were not being provided as ordered by the physician. 2. A review of the admission Record revealed that Resident #49 was admitted to the facility on [DATE] and 9/25/14. The admission Record included diagnoses not limited to unspecified hand contracture, and unspecified dementia without behavioral disturbance. On 4/28/21 at 10:33 a.m. Resident #49 was observed sitting in a wheelchair, non-verbal, with a left-hand contracture. The resident's middle finger was crossed over the pointer finger. The resident was not wearing a palm guard on her left hand. An observation on 4/29/21 at 3:24 p.m. revealed that the resident was not wearing a palm guard on her left hand. Review of the active physician's orders (as of 4/29/21) indicated a physician's order, dated 4/20/21, for staff to apply palm guard to left hand daily. On in AM (morning), Off in PM (evening). The Certified Nursing Assistant (CNA) Task documentation did not identify whether or not staff had donned or doffed Resident #49's palm guard. The task report indicated staff to apply palm guard to both hands daily, on in a.m., off in p.m. and was completed on the following: - 4/20/21 at 10:08 p.m. - 4/21/21 at 2:59 p.m. and 9:47 p.m. - 4/22/21 at 2:59 p.m. and 10:30 p.m. - 4/23/21 at 10:59 p.m. - 4/24/21 at 1:37 p.m. and 8:57 p.m. - 4/25/21 at 2:59 p.m. and 9:03 p.m. - 4/26/21 at 2:39 p.m. and 8:33 p.m. - 4/27/21 at 2:45 p.m. and 10:59 p.m. - 4/28/21 at 10:20 p.m. -4/29/21 at 2:18 p.m. The Restorative Task Documentation, April 2021, indicated Restorative staff to apply left palm guards daily as tolerated (as tolerated) on in AM, off in PM. Restorative staff to provide hand hygiene before and after palm guards are applied. Restorative staff to provide range of motion to left hand before donn off and off of palm guard. The task indicated that staff had documented the palm guard on 4/1, 4/2, 4/6, 4/7, 4/11, 4/12, 4/14, 4/15, 4/18, and 4/20/21. The documentation indicated that restorative did not apply Resident #49's palm guard daily, 10 out of 20 days. Staff V, Certified Nursing Assistant (CNA) stated, on 4/29/21 at 3:27 p.m., that she thinks Resident #49 has a splint, and that restorative puts it on her. She stated they usually put the guard in the drawer. The staff member was unable to locate the palm guard in the bedside dresser then looked in the clothes dresser at the end of the resident's bed, and in the top drawer the palm guard was observed. She pulled the guard out of the drawer and it appeared to be stained and dirty looking. The care plan for Resident #49 identified she had an Activities of Daily Living (ADL) Self-care performance deficit related to (r/t) confusion, dementia, limited mobility, limited range of motion (ROM), stroke. The interventions for the resident's ADL deficit included: - Floor CNA to apply palm guard daily on in a.m., off in p.m., initiated 4/20/21. - Restorative staff to apply palm guard to left hand daily to prevent skin impairment due to contraction, initiated 11/23/20. The interventions related to Resident #49's care plan focus for alteration in musculoskeletal status r/t contracture of left hand, decreased ROM to extremities did not address the application of the resident's palm guard. On 4/29/21 at 12:02 p.m., Staff E, Restorative CNA, stated the restorative aides have been back and forth on the floor so she hadn't been working restorative the full five days. This week had only been twice. She reported being pulled to the floor almost daily, four to five times tops we have done restorative this month. During an interview on 4/29/21 at 3:55 p.m., Staff N, Restorative Registered Nurse (RN) stated it was the restorative department's responsibility for putting on splints and/or palm guards until last week; then the responsibility of splints/palm guards was switched to floor nursing, specifically the CNAs. She confirmed Resident #49 was one of three or four residents requiring a palm guard. The staff member stated that the resident did wear her palm guard when restorative was doing it. She confirmed the resident wore one palm guard. The Quarterly Minimum Data Set (MDS) dated [DATE], indicated that Resident #49 had a functional limitation of Range in Motion on one side of her upper extremity and both sides of the lower extremities. The Director of Nursing stated, on 4/30/21 at 1:31 p.m., that she was unaware Resident #49 was ordered a palm guard. She stated she believed that was now the responsibility of the floor aides to put it on, and when the observations of the resident not wearing the palm guard was discussed, she stated that it was a communication problem. The policy titled, Restorative Nursing Services, revised July 2017, indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. The Interpretation and Implementation of the policy indicated, Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure weekly weights were obtained following weight loss for two residents (#94 and #27) out of four residents sampled for nutrition. Findings included: 1. Review of the admission Record revealed that Resident #94 was admitted to the facility on [DATE]. The admission Record included diagnoses not limited to gastrostomy status, other seizures, and unspecified dementia with behavioral disturbance. The admission Minimum Data Set (MDS), dated [DATE], identified that the resident had a nasogastric or abdominal feeding tube (percutaneous endoscopic gastrostomy (PEG)) and received more than 51% of her total calories through a tube feeding. The Malnutrition, At Risk of Malnutrition, Morbid Obesity Screening Assessment, effective 3/31/21, indicated that Resident #94 was at risk for malnutrition. The Malnutrition Assessment identified that the most recent weight was 122.4 pounds (#) as of 3/30/21 and a Body Mass Index (BMI) of 20. The initial Nutrition Assessment, dated 4/1/21, indicated the resident weighed 122.4# and had a BMI of 20.4. The Dietitian documented that the resident's current weight was within normal limits (wnl) but low for her age. She noted that the resident was NPO (nothing by mouth) and received all nutrition from tube feed of Jevity 1.5. The assessment noted that staff were requesting the tube feed to continue for 20 hours a day instead of the current bolus. The goals of the Nutrition Assessment were to have no complications related to enteral nutrition, will tolerate enteral nutrition, will not pull on enteral nutrition tubing, have no significant weight changes, and have no skin breakdown. The Dietitian prescribed an intervention for weekly weights (wts) x 4 and to monitor enteral infusion tolerance related to the resident being at risk for inadequate enteral infusion related to bolus interruption as evidence by Registered Nurse stating resident becomes combative when nursing staff tries to administer bolus. A review of the active physician orders, as of 4/29/21, indicated an order, dated 4/13/21, for Weekly weights, nursing to schedule day and time every evening shift every Tuesday (Tue) for weight loss monitoring for 21 days, weekly weights, nursing schedule day and time. A review of the electronic Weight Summary indicated the following weights: - 3/30/21: 122.4# - 4/5/21: 117.6# The difference in the two weights for Resident #94's was -4.8# loss, or a loss of 3.92% body weight in 6 days while obtaining nutrition via a PEG tube. During an interview on 4/30/21 at 11:46 a.m., the Registered Dietitian (RD) stated she completes a monthly assessment of residents who receive tube feedings and then monthly weights unless there was an issue with the tube feed. The RD reported that new admissions are to be weighed weekly. She stated she had noted her concern with Resident #94's bolus when it was changed to continuous feeding and that she had calculated to ensure there would not be a weight loss when changing from bolus to continuous and had noted her concern. If an order was received to weigh weekly her expectation was for the residents to be weighed weekly. When asked if it would be prudent to get weekly weights when changing from bolus to continuous (feeding) she stated absolutely. On 4/30/21 at 12:21 p.m., the RD provided a weight of 124.2# for Resident #94, that staff had obtained, per her previous request, on 4/30/21 but had not given to her. The care plan for Resident #94, initiated on 3/30/21, indicated the resident required tube feeding related to dysphagia and dementia. The plan instructed staff to monitor weight as recommended. 2. A review of the admission Record revealed Resident #27 was admitted to the facility on [DATE] and 9/2/18. The admission Record included diagnoses not limited to dementia in other disease classified elsewhere with behavioral disturbance, and unspecified obstructive and reflux uropathy. Resident #27's Nutrition Assessment, dated 4/19/21, indicated that the resident weighed 164.2# on 4/5/21 with a BMI of 21.0. The assessment identified that the resident had a gradual weight loss of 9.6%/ 9.8# in 6 months. The Dietary Manager suggested weekly weights x 4 weeks. A review of Resident #27's physician orders indicated an order, dated 4/23/21, for weekly weights. A review of the Weight Summary did not indicate any weights were obtained after 4/5/21. On 4/30/21 at 12:21 p.m., the RD provided a weight for Resident #27 of 163.4# that had been obtained by staff on 4/30/21. The weight indicated Resident #27 continued with a gradual weight loss. During an interview, on 4/30/21 at 12:21 p.m., the RD stated that the previous Certified Dietary Manager (CDM) had done a quarterly assessment of Resident #27, recognized a 9% gradual weight loss over 6 months, and wanted to trend weights. She stated her expectation would be that if the order was written on 4/23/21, a weight would have been obtained at that time and that at this time the facility failed to obtain weekly weights for two opportunities. On 4/30/21 at 10:52 a.m., Staff O, Unit Manager (UM) stated that Certified Nursing Assistants (CNAs) do not chart weights, that they give them to the nurses, and the nurses give them to the RD who inputs the weights in the computer. She reported that to prevent discrepancies, restoratives obtained weights but because of restorative aides having to take floor assignments due to staffing issues, all aides were responsible for obtaining weights. Staff O stated that after the weights are obtained the aides give them to the nurse or to her to put in the computer and then she gives a note to the RD that the weight was already in the computer. She stated that when restorative was getting weights, they were done on Sundays but now when a weight is needed the aides are informed, there was no schedule for getting weights. The residents are weighed at least monthly, and the RD would notify that a weight was needed when they are tracking a resident for weight loss. The RD stated, on 4/30/21 at 12:21 p.m., that if a resident had an order to weigh weekly her expectation was to weigh weekly. She stated she gives a list of residents needing weekly weights to the Director of Nursing and she highlights a census to indicate which residents need weekly weights to restorative. She stated her expectation is that the restorative team gets weights and then gives her the list, which she would input them. She has seen other people putting weights in, but her belief was that only the RD should be putting in weights. She stated when the list was given to the restorative department she doesn't really know if they get it done until she reviews them. The RD stated the staff doesn't really have any way to communicate with her except for the morning meeting. She acknowledged that she was aware of the staff not getting weights, had talked to the Director of Nursing (DON), Nursing Home Administrator (NHA), and the Regional Dietitian about the issue. She stated she has talked to the staff scheduler to assure someone was scheduled to get weights and that restorative report that weights are not being done due to restorative staff being assigned to the floor. The DON stated, on 4/30/21 at 1:23 p.m., due to restorative being pulled to floor other staff were able to obtain weights. She stated that weights should be on the aide task or the nurse should be able to tell the aides that weights, monthly or weekly, are needed as they are ordered and should be populated on the Medication and/or Treatment Administration Records. The DON reported that after a resident was admitted they should receive weekly weights then monthly or extend weekly weights if necessary. The policy titled, Weight Assessment and Intervention, revised September 2008, reported that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The policy Interpretation and Implementation section indicated the nursing staff will measure resident weights on admission and weekly for 4 weeks and if no weight concerns are noted at that point, weights would be measured monthly thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy reviews, and interviews the facility failed to ensure respiratory equipment for two residents (#40 and #94) out of thirty residents who received respiratory treatments was stored in a sanitary manner for three of four days. Findings included: During an interview on 4/27/21 at 12:07 p.m., Resident #40 was observed lying in bed with a Continuous Positive Airway Pressure (CPAP) machine sitting on her bedside dresser. On top of the machine was a CPAP uncovered mask. The resident confirmed using the machine nightly. (Photographic Evidence Obtained) On 4/28/21 at 10:20 a.m., Resident #40 was observed sitting in a wheelchair in front of her bedside dresser. On top of the dresser was a CPAP machine with its mask and tubing sitting on top of it. The mask was not in a labeled bag. On 4/29/21 at 10:25 a.m., an observation indicated the Resident #40's CPAP mask was lying uncovered on top of the machine. A review of the admission Record revealed that Resident #40 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated the resident used a BiPAP/CPAP while not a resident and while a resident. Resident #94 was observed lying in bed, on 4/27/21 at 12:23 p.m., with a working oxygen concentrator sitting on the floor in front of the bedside dresser. On the bedside dresser was a suction machine with tubing attached lying uncovered and an oxygen cannula lying against the machine and under a package of peri-care wipes. (Photographic Evidence Obtained) A review of the admission Record revealed that Resident #94 was admitted to the facility on [DATE]. The admission Record included diagnoses not limited to unspecified dementia with behavioral disturbance and unspecified encephalopathy. The active physician orders, as of 4/29/21, included an order for Oxygen (O2) nasal cannula (NC) 2 liters (L) continuously diagnosis (dx) hypoxia, may titrate up to 93% to keep saturation (sat) >93% every shift for hypoxia. This order was started on 4/13/21 and was discontinued on 4/29/21 at 9:29 p.m. On 4/27/21 at 3:18 p.m. Staff U, Licensed Practical Nurse (LPN) confirmed that Resident #94 was supposed to be on continuous oxygen and that she was not wearing the oxygen. The staff member stated she wasn't on oxygen because her family member was here to visit. The oxygen cannula continued to be stored uncovered on top of the bedside dresser and when asked, Staff U stated yes. She then wound up the tubing and stated it was supposed to in a bag. She searched for the storage bag in the bedside dresser and was unable to locate it. When asked if the suction tubing was supposed to be lying on the dresser, she stated she did not suction the resident. On 4/29/21 at 11:05 a.m., an observation was conducted of Resident #94 with the Activity Director (AD), who identified she was also a Certified Nursing Assistant (CNA). Resident #94 was lying sideways in the bed with her head against the top of bed and below the knees were off the bed. She confirmed that Resident #94's oxygen tubing was not being worn and was lying on the floor next to the resident's bed. She also confirmed that Resident #40's CPAP mask should be in a bag, which it was not. On 4/30/21 at 8:20 a.m., the Director of Nursing (DON) stated that resident oxygen equipment should be stored in a plastic bag when not in use. She confirmed Resident #94 was to be on continuous oxygen and that the equipment was not stored appropriately in a bag. The DON reviewed photographs taken of Resident #40's CPAP mask and Resident #94's oxygen cannula and she stated they were not stored appropriately. The facility did not provide a policy regarding the storage of the resident's oxygen equipment by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to monitor side effects of psychotropic medications for two residents (#30 and #25) and failed to monitor behaviors for one resident (#25) out of the sampled five residents reviewed for unnecessary medications. Findings included: 1. A review of the admission Record for Resident #30 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of unspecified sequelae of cerebral infarction. A review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. Section N Medications revealed that the resident received antipsychotics five days a week and antidepressants four days a week. The resident had the following active physician orders: Desvenlafaxine Extended-Release Tablet 24 hour 50 mg (milligram)- Give 1 tablet po (by mouth) one time a day for depression, start date of 1/22/21. Trazodone HCL Tablet- Give 400 mg po at bedtime for sleep for major depressive disorder, start date of 1/25/21. The Medication Administration Record (MAR) for April 2021 indicated that the medications were given daily as ordered. The MAR and Treatment Administration Record (TAR) for April 2021 did not reflect side effect monitoring. The MAR for March 2021 indicated that the medications were given daily as ordered. The MAR and TAR for March 2021 did not reflect side effect monitoring. A review of the progress notes from 03/01/21 to 04/30/21 did not reflect any notes related to side effect monitoring. The care plan for antidepressants initiated on 01/24/21 reflected interventions that included but were not limited to monitor/document side effects and effectiveness. The care plan for psychotropic medications initiated on 01/28/21 reflected interventions that included but were not limited to monitor/document side effects and effectiveness. 2. A record review of the admission Record for Resident #25 revealed that she was admitted into the facility on [DATE] with diagnoses that included but were not limited to dementia without behavioral disturbance, anxiety disorders, altered mental status, and major depressive disorder. A review of Section C Cognitive Patterns of the MDS dated [DATE] revealed that Resident #25 had a BIMS score of 09 out of 15 indicating she was moderately impaired. Section N Medications indicated that the resident received antipsychotics seven days a week and antidepressants seven days a week. A review of the Order Summary Report with active physician orders as of 04/01/21 revealed the following orders: Depakote Tablet Delayed Release 125 MG- Give 125 MG po two times a day for mood disorder, start date of 3/23/21. Donepezil HCL Tablet- Give 1 tablet po for Dementia, start date of 3/3/21. Zoloft Tablet 100 MG- Give 1 tablet po one time a day for major depressive disorder, start date of 3/20/21. The MAR for April 2021 indicated that the medications were given daily as ordered. The MAR and TAR for April 2021 did not reflect side effect and behavior monitoring. The MAR for March 2021 indicated that the medications were given daily as ordered. The MAR and TAR for March 2021 did not reflect side effect and behavior monitoring. A review of the progress notes from 03/01/21 to 04/30/21 did not reflect any notes related to side effect and behavior monitoring. The care plan for antidepressants initiated on 01/25/21 reflected interventions that included but were not limited to monitor/document side effects and effectiveness. On 04/30/21 at 10:31 a.m., the Consultant Pharmacist stated that she would expect to see side effect monitoring if a resident was ordered psychotropic medications. On 04/30/21 at 1:42 p.m., the Director of Nursing (DON) stated that side effect monitoring could be documented on the MAR or TAR. The DON confirmed that side effect monitoring was not documented for Resident #30 and side effect and behavior monitoring was not documented for Resident #25. She stated that side effect and behavior monitoring should be done daily. The policy titled, Behavioral Assessment, Intervention, and Monitoring, provided by the facility and revised 12/2016, revealed the following: Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT [interdisciplinary team] will seek and document any improvements or worsening in the individual's behavior, mood, and function. 4. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications.

Based on observations, record reviews, and interviews the facility failed to ensure that drugs and biologicals were stored in a safe, secure, and orderly manner related to not ensuring medications were inaccessible to residents, unauthorized personnel and/or visitors during two of six observations of medication administration and failed to permanently affix two of two refrigerated narcotic boxes. Findings included: During the task of medication administration on 4/28/21 at 11:32 a.m., after dispensing medications for Resident #43, Staff F, Registered Nurse (RN), walked away from the medication cart to the nursing station, leaving a bottle of Fish Oil, Docusate Sodium, Tylenol (Acetaminophen), Vitamin C, and the blister card of Clopidogrel on top of the cart while it was unattended. On 4/28/21 at 11:49 a.m., Staff F retrieved Resident #11 from near the nursing station and assisted the resident into his room then administered medication to the resident. Staff F left the bottle of Multi-Vitamin with mineral tablets on the medication cart during the administration. After the administration, on 4/28/21 at 12:00 p.m., of Resident #27's medication, two fluid-filled softgels were observed sitting in a medication cup inside of the open trash can attached to the side of the medication cart, which was parked in a resident room hallway. Staff F stated he would normally put the capsules in cellophane and put it somewhere safe. He confirmed the softgels were accessible to others. During an interview on 4/28/21 at 12:32 p.m., with the Director of Nursing (DON), she confirmed that the softgels were accessible. An observation on 4/29/21 at 5:58 p.m., was conducted with Staff H, Registered Nurse / Nursing Supervisor (RN) of Station One Medication Room. A khaki-colored metal box was observed sitting on a grated shelf in the medication refrigerator. The box was easily removed and placed alongside of the room's sink while Staff H unlocked it and exposed the contents. The box contained one brown plastic bag which contained 5 vials of 2 milligram/milliliter (mg/mL) of Lorazepam and one brown plastic bag containing one vial of 2 mg/mL vial of Lorazepam. Staff H confirmed the box was not permanently affixed to the locked refrigerator. On 4/29/21 at 6:25 p.m., the DON and the Interim Nursing Home Administrator confirmed that the refrigerated narcotic box within the Station One Medication room was not permanently affixed to the refrigerator. The DON stated someone could take the box and walk out with it. When asked to see the Station 2 Medication Room's refrigerator, they both reported that the refrigerator was broken so the contents were in the DON's refrigerator. The DON stated she knew that the narcotic box was not permanently affixed to the refrigerator. An observation of the narcotic box from Station 2 indicated that the box was in the refrigerator inside of the DON's office and not permanently affixed and could be easily removed. During an interview, on 4/30/21 at 10:32 a.m., the Consultant Pharmacist stated she could arrange for the narcotic boxes to be permanently affixed to the refrigerators. She stated she was unaware of any statute that required narcotic boxes to be permanently affixed. The policy titled, Storage of Medications, revised April 2007, indicated that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure sufficient staff were available to provide meal assistance for five residents (#20, #52, #54, #55, and #66) during dining services, of 102 residents in the facility, on one of four hallways (the B Hall) for two of two days observed. Findings included: Resident #66 was admitted to the facility with a diagnosis of dementia, according to the face sheet in the admission record. Review of the Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #66 was rarely/never understood, and the Brief Interview for Mental Status (BIMS) could not be conducted, indicating severe cognitive impairment. Section G, Functional Status was reviewed and reflected that Resident #66 required extensive assistance of one staff member for eating. Resident #20 was admitted to the facility with a diagnosis of Alzheimer's disease, according to the face sheet in the admission record. Review of the MDS assessment dated 4/18//21, reflected Resident #20 was rarely/never understood, and the BIMS could not be conducted, indicating severe cognitive impairment. Section G, Functional Status review reflected Resident #20 required extensive assistance of one staff member for eating. Resident #52 was admitted to the facility with a diagnosis of cognitive communication deficit, according to the face sheet in the admission record. Review of the MDS assessment dated [DATE], reflected Resident #52 was rarely/never understood, and the BIMS could not be conducted, indicating severe cognitive impairment. Section G, Functional Status review reflected Resident #52 was totally dependant on staff assistance of one for eating. On 4/28/21 at 12:25 p.m. an observation was conducted during dining services for the lunch meal. Two dining carts were delivered to the B hall. There were four staff members delivering the lunch trays. On 4/28/21 at 12:41 p.m. an observation and interview was conducted on the B hall. Staff C, Certified Nursing Assistant (CNA) was assisting the roommate of Resident #66 with the lunch meal. Staff C, CNA said when she is finished; she will feed Resident #66. Staff C, CNA reported that when she is finished feeding Resident #66 if anyone else hasn't been fed yet, she has to assist them. Further observation on the B hall on 4/28/21 at 12:49 p.m., twenty-four minutes after the dining carts were delivered, revealed Resident #52 did not have a lunch tray. An interview was conducted during the observation, with Staff D, CNA at 12:51 p.m. Staff D, CNA said when she is finished assisting Resident #20 she will assist Resident #52. A review of the face sheet in the admission record for Resident #54 reflected a diagnosis of dementia. Review of the MDS assessment dated [DATE] revealed that a BIMS could not be completed since Resident #54 was rarely/never understood. Review of Section G, Functional Status, reflected Resident #54 was totally dependent on staff assistance of one person for eating. Resident #55 was admitted to the facility with a diagnoses of cachexia and dementia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] revealed that a BIMS could not be completed since Resident #55 was rarely/never understood. Review of Section G, Functional Status, reflected that Resident #55 required extensive assistance of one person for eating. On 4/29/21 at 12:43 p.m. an observation was conducted on the B hall during dining services for the lunch meal. Two dining carts were on the B hall. On 4/29/21 at 12:59 p.m. an observation revealed a staff member was assisting Resident #52 with the lunch meal. Resident #20, her roommate, had the lunch tray sitting in front of her on the bed side table. On 4/29/21 at 1:01 p.m. an observation was conducted. Residents #54, #55, and #66 did not have their lunch trays. On 4/29/21 at 1:11 p.m. an interview was conducted with the Director of Nursing (DON) during the observation on the B hall. The DON said Residents #54 and #66 need assistance, that's why their trays are still in the cart. The DON confirmed Resident #20 just started getting assistance with her lunch meal. Twenty-eight minutes had passed since the dining carts were delivered. The DON also confirmed Resident #54's lunch tray was still in the dining cart. She said staff can only feed one person at a time, and this hall seems to have more assisted diners. When one resident is being assisted, the other tray is kept on the cart to keep it warm. The DON said that a reasonable wait time would be maybe ten minutes. On 4/30/21 at 11:24 a.m. an interview was conducted with the Registered Dietician (RD) Consultant. The RD consultant said it was her understanding that restorative assists with meals. There should be some way to feed both residents in a room at the same time.

Based on interviews, record review, observations, menu review, and policy review the facility did not ensure cultural food choices were available for one resident (#61) of 43 residents sampled. Findings included: Resident #61 was admitted with a diagnosis of sepsis according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment, dated 3/1/21, reflected a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #61 was cognitively intact. On 4/27/21 at 12:27 p.m. an interview was conducted with Resident #61. She said the food is always the same. It's green beans or corn every day, and mashed potatoes or pasta. She prefers Latin American food. No one has ever asked her about her preferences. Resident #61 reported that the alternate is a sandwich. A review of the Resident Profile, Company Name, Dietary Management System, dated 12/22/20 reflected no likes or dislikes were indicated for any of the meals. An observation was conducted on 4/27/21 at 12:37 p.m. during the lunch meal. Resident #61's lunch plate had mixed vegetables, mashed potatoes and gravy, roast beef with gravy, a biscuit, a cup of coffee, and fruit cobbler. On 4/28/21 at 12:31 p.m. an observation was conducted during the lunch meal. Resident #61 had scalloped potatoes, a pork chop, lima beans, a roll, a dessert cup, and coffee. A review of the menu for the week of 4/26/21-5/2/21 reflected the following findings: Sunday 4/26/21 lunch included mashed potatoes and gravy Monday 4/27/21 lunch included buttered noodles Tuesday 4/28/21 lunch included mashed potatoes Wednesday 4/29/21 lunch included scalloped potatoes Thursday 4/30/21 lunch included potatoes and carrots Friday 5/1/21 lunch included a baked potato Saturday 5/2/21 lunch included savory noodles Further review of the dinner menu for the week, reflected that on Sunday 4/26/21 the dinner entree was spaghetti sauce with meat balls and spaghetti noodles. The dinner meal on Wednesday 4/29/21 contained macaroni. The dinner meal Thursday 4/30/21 was chicken [NAME] with fettuccini. Further review of the menu for the week of 4/26/21-5/2/21 reflected no Latin American food options or meals were included, and no alternatives were listed as well. On 4/29/21 at 3:33 p.m. an interview was conducted with the Regional Director of Dietary Services. She said the dietician interviews the residents and asks their likes and dislikes, and it is entered into the system. If they don't like beef for example, they would get chicken. The menus are created through menu management services through Company Name, and sent to us. Then we review them and they are approved. It is a corporate menu. It is reviewed by the RD (registered dietician) and signed off. It is modified by region. For example, Miami has a lot of rice beans and chicken. There is a food committee of residents in every building who look at the menu. If they are on a renal diet they won't get the potatoes they will get noodles. The Regional Director of Dietary Services agreed the potatoes and noodles were not enough variety. On 4/30/21 at 11:24 a.m. an interview was conducted with the RD consultant. She said that she has heard there was a complaint about the variety related to the potatoes and noodles, and no Latino choices. She said she is implementing alternatives that will always be available. She heard the residents want rice and beans. That will always be available. They want salads and fresh produce so we are going to try to implement that ASAP (as soon as possible). We are going to implement a food committee meeting. She has been here about a month and a half, and was not involved in the food committee. The CDM (certified dietary manager) was. As a group they can decide what they want on a particular day. The RD said, I have reached out to my team and asked to review the menu solutions that Company Name provides and see what we can do to increase the happiness of the residents. I was under the impression that the CDM was getting food preferences. The RD consultant said when she sees the residents she will get their likes and dislikes and put them in. She said she would see every resident and document on paper their likes and dislikes. The RD consultant also said the food preferences should be updated at least quarterly. Review of the policy title, Menus, dated 1/15/21, reflected the following: Policy Statement Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Policy Interpretation and Implementation 3. Menu items and available snacks reflect the religious, cultural and ethnic preferences of the residents, whenever reasonable. 4. The dietician reviews and approves all menus. 5. Input from the resident is considered in menu planning. Review of the policy titled, Resident Food Preferences, dated 1/15/21, revealed the following information: Policy Statement Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT). Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation 1. Upon the resident's admission (or within 24 hours after his/her admission) the dietician or nursing staff will identify a resident's food preferences. 2. When possible staff will interview the resident directly to determine current food preferences based on history and life patterns to food and mealtimes. 3. Nursing staff will document the resident's food an eating preferences in the care plan. 8. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. 10. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 11. The facility's Quality Assessment and Performance Improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty- eight medication administration opportunities were observed, and twenty-three errors were identified for four (#43, #11, #27 and #3) of six residents observed. These errors constituted a 60.53% error rate. Findings included: 1. On 4/28/21 at 11:32 a.m., an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #43. The electronic medication profile for Resident #43 was observed to be red-colored, which the staff member stated was due to the medications were late. Staff F was observed dispensing the following medications: - Acetaminophen[[NAME] 325 milligram (mg) - 2 tablets - Vitamin C 500 mg tablet - Clopidogrel 75 mg tablet - Docusate Sodium 100 mg softgel - Fish Oil 1000 mg softgel The staff member searched the medication cart for the Calcium - D3 tablet that was also due at 9:00 a.m. but was unable to locate so he documented on the Medication Administration Record (MAR) that the facility was awaiting the medication from the pharmacy. The staff member crushed the tablets, placed them in a 4 ounce drinking cup, poured water in the cup (approximately 2 ounces) then added a spoonful of pudding into the cup and stirred to dissolve the medications. When offered a drink of water from the cup located on her over-the-bed table, at 11:45 a.m., the resident refused by not opening her mouth. Staff F stated that since she refused the water she did not want her medications either. The staff member threw away the drinking cup with medications into the trash can and documented on the MAR that the resident had been administered Acetaminophen, Vitamin C, Clopidogrel, Docusate, and Fish Oil. A review of the Medication Administration Record (MAR) for Resident #43 revealed the above medications and a Calcium-D3 tablet were scheduled to be administered at 9:00 a.m. 2. On 4/28/21 at 11:49 a.m., an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #11. The electronic medication profile for Resident #11 was observed to be red-colored, which the staff member had previously stated that the red indicated that the medications were late. Staff F was observed administering the following medication with the nutritional supplement of MedPass: - Multi-Vitamin with Mineral tablet. A review of Resident #11's Medication Administration Record (MAR) indicated that the above medication was due at 9 a.m. 3. On 4/28/21 at 12:00 p.m., an observation of medication administration with Staff F, RN, was conducted with Resident #27. The electronic medication profile for the resident was observed to be red, which the staff member had previously identified as being late. Staff F was observed administering the following medications: - Acidophilus Lactobacilli 500 million capsule - Vitamin C 500 mg tablet - Baclofen 10 mg tablet - Fluoxetine Hcl 40mg capsule - Levetiracetam 500mg tablet - Oxybutynin 10mg ER tablet A review of the Medication Administration Record (MAR) for Resident #27 revealed the following observed and unobserved medications were scheduled to be administered at 9:00 a.m.: - Acidophilus Lactobacilli 500 million capsule orally two times a day - Vitamin C 500 mg tablet orally two times a day - Fluoxetine Hcl 40 mg capsule orally one time a day - Levetiracetam 500 mg tablet orally two times a day - Oxybutynin 10 mg Extended Release orally one time a day - Artificial Tears Solution 1.4% drops - one drop in both eyes two times a day - Renacidin solution - instill 30 milliliters (mL) into suprapubic catheter (cath) on Wednesdays. - Ferosul 325 mg tablet - give 2 tablets orally two times a day - Gavilax Powder ([NAME]) - give 17 grams orally one time a day, mix in 8 ounces of fluid. After searching the medication cart and following the medication administration, Staff F documented that the facility was awaiting delivery of the Renacidin, Ferosul, and Gavilax medications, which were not observed as administered. 4. On 4/29/21 at 11:37 a.m., an observation of medication administration with Staff G, RN, was conducted with Resident #3. Staff G was observed administering the following medications: - Bumetanide 1 mg tablet - Carvedilol 25 mg tablet - Ursodiol 300 mg capsule - Reglan 5 mg tablet - Lisinopril 10 mg tablet - Levetiracetam 100 mg/mL- 5 mL - Potassium Chloride 10% - 15 mL The observation revealed that Staff G had poured 7.5 milliliters (mL) of Levetiracetam and when asked how much was poured she identified as 7.5 mL then poured 2.5 mL back into the medication bottle, leaving 5 mL to be administered. A review of Resident #3's MAR indicated that the above medications were to be administered at 9:00 a.m. The electronic medication profile for the resident was observed to be red-colored. Staff G stated the medications are late due to her having to administer medications to 30 residents. At 12:07 p.m. on 4/29/21, a continued observation indicated Staff G administering the resident's insulin after obtaining a blood glucose level of 240. - Admelog SoloStar injectable pen 100 units/mL. - 4 units The staff member removed the insulin pen from the medication cart and reviewed the resident's insulin order to be administered according to a sliding scale. The staff member gathered the pen and needle then re-entered Resident #3's room. She applied the needle to the pen, dialed the pen to 4 units, (which was confirmed), cleaned the right upper quadrant with an alcohol pad, then injected 4 units of Admelog insulin. A review of the resident's MAR indicated the insulin ordered was for Humalog 100 unit/mL which the staff member documented a blood glucose of 240 with the administration of 4 units that was due at 11:00 a.m., one hour and seven minutes prior to the observed administration. On 4/29/21 at 12:16 p.m., Staff G was asked if she had primed the insulin pen. A scenario was given to Staff G as expelling the air from the insulin syringe when drawing from vial, similar to expelling the air from the insulin pen. She voiced understanding and stated, Oh with the 2 units, no I did not, I nervous. During an interview on 4/28/21 at 12:32 p.m., the Director of Nursing (DON) stated Ferosul, Gavilax, and Calcium-D3 were available in the medication cart or the med room. On 4/30/21 at 10:09 a.m., the DON stated if medications are late, staff were to call the doctor and notify the doctor that the medications were late. She stated the staff should notify the physician as soon as they see the medication profile turn red and ask if it was okay to give the medication late. She confirmed that the physicians were not notified prior to the late administration of medications on 4/28/21. At 1:20 p.m., the DON stated that regarding late medications, they should have staggered medication times and staff had one hour before and one hour after the scheduled time to administer and re-confirmed that staff were to contact the physician prior to administration. The DON stated they have work to do. On 4/30/21 at 10:32 a.m., the Consultant Pharmacist was interviewed. When asked if her expectation was that medications be administered according to the professional standard of one hour before and one hour after the scheduled time, she stated she would have to check the policy. The policy titled, Administering Medications, revised April 2019, identified, Medications are administered in a safe and timely manner, and as prescribed. The Interpretation and Implementation of the policy indicated that medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) and if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The pharmacy policy titled, Preparation and General Guidelines, 2006 American Society of Consultant Pharmacists and Med-Pass (Revised January 2018), indicated Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. According to the prescribing information for the Admelog Solostar insulin pen (https://products.sanofi.us/admelog/admelog.pdf) instructed users to Do a safety test. The instructions identified users should always do a safety test before each injection to: check the pen and the needle to make sure they are working properly and to make sure that you get the correct insulin dose. The steps to do a safety test was to select 2 units by turning the dose selector until the dose pointer was at the 2 mark, press the injection button all the way in and make sure insulin comes out of the needle tip, if no insulin appears users may need to repeat the process up to three times. The information indicated users were not to use the pen after testing and changing the needle if no insulin comes from the tip.

Based on observations, record reviews, and interviews, the facility failed to ensure one of one kitchen was maintained in a clean and sanitary manner, one (Station #2) of two refrigerators in the pantry stations was maintained in a clean and sanitary manner, and temperatures were documented daily for the refrigerators and freezers in two pantry stations (Station #1 and Station #2) of two pantry stations. Findings included: On 04/27/21 starting at 9:50 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The white flap inside of the ice machine was observed with black buildup. The inside of the drink nozzle was observed with white buildup. An excessive amount of black buildup was observed above the food preparation area. An excessive amount of dust was observed on two ceiling vents above the food serving area (Photographic Evidence Obtained). The CDM stated that she spoke to maintenance on Friday (4/23/21), and he stated that he had to order replacement tiles for the ceiling. She then stated she spoke with maintenance about the whole ceiling including the vents. The CDM was asked to provide documentation related to the maintenance request and the document was not provided. Following the tour of the kitchen, observations of Pantry Station #1 and Pantry Station #2 were conducted and revealed: The temperature log for the nourishment refrigerator in Pantry Station #1 was observed to be missing temperatures for April 14th, 16th, 17th, 18th, and 20th-25th. The temperature log for the freezer in Pantry Station #1 was observed to be missing temperatures for April 20th-25th. The CDM stated nursing was responsible for taking the temperatures daily. The temperature log for the nourishment refrigerator in Pantry Station #2 was observed to be missing temperatures for April 2nd, 6th, 18th, and 20th. The temperature log for the freezer in Pantry Station #2 was observed missing temperatures for April 2nd, 6th, and 20th. A brown substance was also observed spilled in the refrigerator. The CDM stated that housekeeping was responsible for cleaning the refrigerators. On 04/29/21 at 12:30 p.m., the Regional Director of Culinary Services stated that the dietary staff was responsible for cleaning the ice machine weekly. She stated that staff should clean the drink nozzles daily. All maintenance requests should be submitted through [Name of the electronic maintenance report system] or verbally to maintenance. The Regional Director of Culinary Services stated, The ceiling should never look like that. A review of the Dietary Cleaning Schedule provided by the facility did not reflect the cleaning of the ice machine and the drink nozzles. On 04/29/21 at 3:47 p.m., the Regional Director of Culinary Services confirmed that the ice machine and drink nozzles were not listed on the cleaning schedule. The policy titled, Refrigeration/Freezer Temperature Log, provided by the facility with an effective date of 06/01/04 revealed the following: Policy The Director of Culinary Services will be responsible for implementing and documentation processes on the Refrigerator/Freezer Temperature Log. Process 1. The Director of Culinary Services or designee should ensure that the refrigerator/freezer temperature log is used to record the temperature of all refrigerators and freezers on a daily basis and at routine intervals during all hours of the operation. 4. The Refrigeration/Freezer log should be complete a minimum of twice per day on all refrigeration/freezer equipment.