**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to honor the choice of one (#58) out of twenty-three sampled residents related to the preferred use of side rails for mobility and the feeling of safety and failed to assist one (#93) of one sampled resident with planning a discharge to another facility closer to family. Findings included: 1. During an interview on 5/5/25 at 10:59 a.m. Resident #58 reported wanting to have bedrails, getting scared when staff roll the resident over, was told it was a [regulating agency] thing not to have siderails. The resident reported they were told by someone at the facility the regulating agency did not allow side rails. The observation revealed the resident lying on a large-sized mattress and without side rails or enablers. Review of Resident #58's admission Record revealed the resident was admitted to the facility on [DATE]. The record showed diagnoses of malignant neoplasm of endometrium, unspecified type 2 diabetes mellitus with diabetic neuropathy, and unspecified macular degeneration. Review of Resident #58's Order Audit Report showed the resident had received an order dated 5/3/24 for bilateral ¼ rails for bed positioning and mobility 4/5/24. The report showed this order was discontinued on 3/13/25. Review of Resident #58's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 of 15, indicating an intact cognition. Under mobility, the assessment showed no range of motion (ROM) of bilateral upper and lower extremities and required partial/moderate assistance with rolling left and right, sit to lying on bed, and from lying to sitting on side of bed. Review of Resident #58's care plan revealed Resident #58 has an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) Endometrial cancer and was on hospice - 6/12/23. The resident is weak with impaired balance and mobility and required assistance with needs. Further decline is expected r/t disease process. Resident #58 is primarily bedbound by choice. The resolved interventions revealed an intervention initiated on 4/25/24 for SIDE RAILS: ¼ bilateral side rails for positioning/mobility. This intervention was resolved on 3/13/25. The interventions showed the resident received a Bariatric bed on 3/27/25. An interview was conducted on 5/7/25 at 2:39 p.m. with Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member said residents needed to assessed for side/bed rails by therapy. Staff D, LPN reported Resident #58 had a history quarter rails, was able to hold onto bed rail to assist with repositioning, was not able to pull self-up in the bed with the rails, and when staff rolled the resident over, the resident was able to hold on to bedrail to hold self the on side during care. Staff D, LPN reviewed the resident's record and stated for the side rails intervention on 3/13/25, therapy went through the facility and did evaluations to determine if the rails were helping with mobility or keeping independence. Staff D stated therapy discontinued the intervention. An interview was conducted on 5/7/25 at 2:50 p.m. with the Director of Rehabilitation (DOR). The DOR stated the resident was assessed for bed mobility, rolling and repositioning. The DOR stated they looked at different devices such as trapezes and said, If we fail at other interventions, we look into bedrails. The staff member reported therapy went through the facility and audited for other devices to decrease the use of bed rails for safety. The DOR stated they assess if a resident was able to transition to trapeze and bigger beds, and if a resident wanted side rails, therapy would pick them up. He stated if a resident wanted side rails to feel safe, they would try other devices first. The DOR stated Resident #58 was picked up by therapy from 2/26 to 3/26/25 and was working on rolling, bed mobility and that the resident was maximum assist and was not using side rails for bed mobility. The DOR defined bed mobility as grabbing the bar (rail) and rolling. He reported the resident was a substantial to max assist with rolling right to left and could grip and hold the rail but did not know for how long. Review of Resident #58s Physical Therapy Evaluation and Plan of Treatment revealed a certification period of 2/26 to 4/9/25. The resident's baseline on 2/26/25 for rolling towards both sides safely without use of side rails with assist of 1 caregiver to improve functional mobility revealed the resident required a maximum assist to roll towards right side and moderate assist to roll towards left side with use of side rail. The goals for patient and caregiver was to Improve bed mobility/positioning without use of side rails with a fair potential for achieving rehab goals. The reason for referral/current illness revealed the resident was referred to skilled therapy services to address bed mobility/positioning without use of side rails. The assessment summary showed the reason for therapy showed the resident was currently positioned in standard bed with an air mattress. Patient refused to trial trapeze bar to assist with bed mobility. A change in the assessment, dated 2/26/25 at 2:18 p.m. revealed the Patient refused to trial trapeze bar to assist with bed mobility. A treatment encounter note, dated 3/13/25 (the day side rails were discontinued), showed Patient stated she was afraid to perform rolling in bed due side rails being removed. Patient was encouraged and reassured (pronoun) is safe. Certified Nursing Assistant (CNA) educated on performing patient care with another person to assist with bed mobility has patient is a max assist (A) with mobility. A follow up interview was conducted on 5/7/25 at 4:48 p.m. with the DOR who reported visiting the resident and Resident #58 did voice fear. The DOR said, it's back referring to the siderails. Review of the policy, procedure, and information, effective 4/1/23, showed to promote independence and well-being and as well as to not restrict freedom of movement. The facility recognizes that every resident deserves a safe as well as comfortable sleeping environment period to assure safety and optimum bed mobility. This facility will utilize an appropriate resident specific/ centered approach determining the use of side rails/ bed rails. 1. If a side rail does not restrict freedom of what's going on movement or normal access to one's body, it is not considered a restraint. 3. Side rails used for completely immobile residents are not considered restraints and may therefore be used if they provide access to bed controls/call bell. 4. Physical or occupational therapist to assess bed mobility and all residents within 72 hours of admission. If therapist determines that one or two half rails enhance bed mobility and/ or facilitate independent transfers from bed. These rails will be care-planned for resident use. 8. All side rails and use whether or not they are restraints must be carefully assessed for risk of entrapment. The maintenance department upon placement of the side rails will complete a bed system audit to ensure proper placement of the side rails. 9. The maintenance department will also complete a bed system audit anytime you've [NAME] is added or removed from a bed and whenever a mattress has changed, or bolster/ wedge is added or removed. They will be informed of these changes via the maintenance communication log book on each unit, which is checked daily by the maintenance staff. 2. During an interview on 05/05/2025 at 10:11 a.m., Resident #93 stated he was waiting to hear back from the facility about being transferred to another facility so that he can be closer to his family. During an interview on 05/06/2025 at 11:47 a.m., Resident #93's family member and Power of Attorney (POA) stated he had been trying to move Resident #93 to a facility closer to him. The POA said, I live 2 hours away and it is hard for me to be able to see him. He stated he had spoken with the facility and never heard back on what they could do to move Resident #93 to another facility closer to family. Review of Resident #93's admission record revealed an admission date of 11/26/2024 with an initial admission date of 06/28/2024. Resident #93 was admitted to the facility with diagnosis to include Cerebral Infarction Due To Thrombosis Of Bilateral Cerebellar Arteries, Unspecified Cirrhosis Of Liver, Unspecified Severe Protein-Calorie Malnutrition, Muscle Weakness (Generalized), Hypothyroidism, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region. Review of Resident #93's Care Plan dated 11/26/2024 revealed [NAME] is currently in long term care but plans to discharge to an Assisted Living Facility (ALF) when his nephew can find one close to his home. Review of Resident #93's social services quarterly progress note dated 3/4/2025 showed the resident was alert and oriented and able to make his needs known. He does have episodes of confusion and forgetfulness at times, and his mental function varies. He is here for long-term care and plans to discharge to an ALF (Assisted Living Facility) closer to family. During an interview on 05/05/2025 at 2:00 p.m., the Social Services Director (SSD) stated Resident #93's family has been expressing desire to get him to a facility closer to them. The SSD said, I do not know where the family lives. The resident has not mentioned wanting to go to another facility. I didn't know it was mentioned on his care plan. Who would add that to the care plan? During an interview on 05/08/2025 at 2:43 p.m., the Nursing Home Administrator (NHA) stated it was hard finding facilities for residents who are on Medicaid. The NHA asked, Why would the family want to remove a resident from a facility that knows the resident to another facility who will have to get to know the resident all over. It is confusing for the residents when they move facilities. Our residents are like our family. Review of the Resident Handbook revealed, you can discharge from our facility and receive care elsewhere. You have the right to refuse any care or services at our facility. You also have the right to receive care elsewhere. On 05/08/2025 at 5:16 p.m. a policy for discharge preferences was requested. The facility did not have related policy.

Based on observation, interview and record review the facility failed to follow treatment recommendations related to obtaining weights on a weekly basis for one (#93) out of four residents sampled for weight loss. Findings Included: During an observation on 05/05/2025 at 10:11 a.m., Resident #93 was observed laying in bed noted to be thin in appearance. During an observation on 05/07/2025 at 12:10 p.m., Resident #93 was observed in his room with his bedside table in front of him with his lunch tray. On his tray was a plate with spaghetti, green vegetables, a dinner roll, pudding and a piece of pie. In a follow up interview on 12:43 p.m., Resident #93 stated he ate his dinner roll and something else but could not remember what it was. During an interview on 05/07/2025 at 1:41 p.m., Staff E, Certified Nursing Assistant (CNA) stated Resident #93 ate about 25% of his meal. He ate his roll and his pudding. Staff E stated his appetite varies, sometimes it is good and sometimes he does not eat much. Staff C stated they are expected to document meal intake. Review of Resident #93's admission Record revealed an admission date of 11/26/2024 with diagnoses of cerebral infarction due to thrombosis of bilateral cerebellar arteries, unspecified cirrhosis of liver, unspecified severe protein-calorie malnutrition, muscle weakness (generalized), hypothyroidism, unspecified, gastro-esophageal reflux disease without esophagitis, spondylosis without myelopathy or radiculopathy, cervical region. Review of Resident #93's weights revealed on 4/1/2025 he weighed 126.9 Lbs.(pounds). On 3/21/2025 - 126.8 Lbs. On 3/14/2025 - 127.6 Lbs. on 2/11/2025 - 161.6 Lbs. On 1/8/2025 - 164.0 Lbs. On 12/04/2024 -142.6 Lbs. Review of Resident #93's standards of care progress note dated 4/4/25 revealed the resident is here long term. He is receiving a regular dysphagia advanced diet. His current weight is 126.9 Lbs.Registered Dietician (RD) spoke with him, and he agreed to try fortified food, which were added, he is stable x3 weeks. He is not currently on antibiotic therapy or dialysis services. A nutrition note for Resident #93 dated 4/1/25 revealed a weight warning: Value: 126.9 a -7.5% change [ 22.6% , 37.1 ] -10.0% change [ 11.0% , 15.7 ] and it is noted to continue on weekly weights A nutrition note for Resident #93 dated 3/25/25 revealed a weight warning: Triggered due to -5.0% change [Comparison Weight 2/11/2025, 161.6 Lbs., -21.0% , -34.0 Lbs. ]. Diet is Regular diet, Dysphagia Advanced texture, Regular/Thin Liquids consistency. with No: Rice. Right curved built-up utensils at meals. By mouth (PO) intake is 75%+ most meals. Body Mass Index (BMI) is underweight. Spoke with resident who was agreeable to trying out fortified foods for weight loss. RD follow up as needed. An IDT (Interdisciplinary note) dated 3/6/2025 showed a care plan meeting was held with resident at bedside- He continues to feed himself with right built-up utensil- dysphagia advanced diet- no issues or concerns. Weight 161.6 with a BMI of 23.2. No significant changes noted. Md (Medical Doctor). is in agreement with Plan of Care (POC). Floor staff updated on POC. No issues voiced. Will monitor and continue current POC (Plan of Care) A nursing progress note dated 1/17/25 showed weight warning - Triggered due to +5.0% change [Comparison Weight 12/4/2024, 142.6 Lbs., +15.0% , +21.4 Lbs. ]. Resident had no nutritional concerns right now but requested more food and agreeable to fortified foods. Requesting reweigh to confirm weight gain, resident did not desire weekly weights. RD follow up as needed. During an interview on 05/07/2025 10:33 a.m., Registered Dietician (RD) stated he first saw the resident in March 2025. He saw that he had dropped 30 Lbs. in a month and was not sure how. He stated he did a re-weight and confirmed. He puts Resident #93 on weekly weights and spoke with the resident about his diet who was agreeable to adding fortified foods. He stated he spoke to the nurses about their weight policy. He stated he was on his weekly weights, and noted the nurses had not weighed him for the 4th weight record. If he is missing a weight he follows up with the nurses but does not document. I am working on getting better at documenting. The RD confirmed Resident #93 should have a weekly weight effective March 2025. He confirmed there were only three entries since then. During an interview on 05/08/2025 at 10:01 a.m., Staff F, Registered Nurse (RN), stated they have 2 CNA's that do the weights. She stated if a resident needed to be weighed weekly, the Unit Manager would know and relays that to the CNA's. During an interview on 05/08/2025 at 10:03 a.m., Staff G., CNA stated 2 CNA's are assigned to obtain weights for the entire building. She stated they get a list of residents who needed to be weighed from the nurse. During an interview on 05/08/2025 at 10:09 a.m., Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM) stated the RD provides the list of residents that need to be weighed. During an interview on 05/08/2025 at 10:12 a.m., RD, stated 26-50% of a meal is less than half of the meal is consumed. He stated if the resident only ate a roll and a pudding, he would consider that 0-25% of the meal being consumed. During an interview on 05/08/2025 at 1:35 p.m., DON stated 2 CNA's are assigned to doing weights. They are given a list of residents that need to be weighed. She stated they had an issue with keeping up with obtaining weights for residents and they are working on ensuring residents are weighed per orders. Review of the facility's policy dated 02/21/2023 titled Nursing-Weights revealed, Purpose: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates that it is not possible or resident preferences indicate otherwise. Procedure: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility should utilize a systematic approach to optimize our residents nutritional status. This process includes: A. Identifying and assessing each resident's nutritional status and risk factors. B. Evaluating/analyzing the assessment information. C. Developing and consisting consistently implementing pertinent approaches. D. Monitoring the effectiveness of the interventions and revising them as necessary 4. Intervention should be identified, implemented, monitored and modified parentheses as appropriate parentheses, consistent with the residents assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 5. Weight monitoring schedule should be developed upon admission for all residents: A. Weight should be recorded timely. Residents with weight loss monitor weight weekly or per physician order until stable then monthly 8. Documentation A. The physician, resident, or responsible party should be informed of a significant change in weight. B. The physician should be encouraged to document the diagnosis of clinical conditions that may be contributing to the weight loss. The registered dietitian or dietary manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. D. Observations pertinent to the residents weight status should be recorded in the medical record as appropriate.

Based on observations, record reviews, and interviews the facility failed to provide optimal nutrition for one (#78) of one resident sampled for enteral feeding. Findings included: An observation was made on 5/5/25 at 11:25 a.m. of Resident #78 lying in bed, non-verbal, with a bottle of Nepro 1.8 enteral nutrition hanging from the bedside pole with pump. The pump and the tubing showed the resident was not receiving nutrition. The observation showed the 1000 milliliters (mls) bottle contained approximately 350 ml of tan-colored liquid, was dated 5/3/24 at 22:04 (10:04 p.m.), and showed the resident was to receive 60 milliliter/hour (ml/hr) (60mL/hr x 20 hours = 1200 mLs). The bottle label instructed Hang product up to 48 hours after initial connection when clean technique and only one new feeding set are used. Otherwise, hang no longer than 24 hours. Review of Resident #78's physician orders revealed an order for Nepro at 60 ml/hr x 20 hours, down at 10:00 a.m. up at 2:00 p.m. to provide a total of 1200 ml's in a 24-hour period. Review of Resident #78's Nutrition Evaluation Initial, Annual and Significant Change, dated 3/18/25 showed the resident did have an oral diet order of puree texture with thin liquids and tube feedings of Nepro at 60 ml/hr x 20 hours (down at 10:00 a.m. and up at 2:00 p.m.) with 250 ml of water 5 times a day. The evaluation showed the resident received less than 25% of nutrition orally and 100% of total kilocalories (Kcal) via tube feedings in the 7 days prior to the evaluation. Review of Resident #78's late entry Nutrition Note showed- Monthly Enteral Note, created on 5/5/25, effective 4/29/25, showed the resident was ordered dysphagia puree texture, regular/thin liquids, small portions, and were for pleasure per Speech Language Pathologist (SLP). The note showed the resident's oral intake was usually 0-25% and the enteral order of 60 mls of Nepro for 20 hours provided 2160 kcal. Review of the observed nutrition bottle hanging on 5/5/25 at 11:25 a.m. showed the bottle was hung at 10:04 p.m. and according to physician orders when taken down 12 hours later at 10:00 a.m. on 5/4/25 the resident would have received 720 mls of nutrition leaving approximately 280 mls in the bottle. Review of Resident #78's care plan revealed the resident had a nutritional problem or potential nutritional problem. The interventions included instructions for nursing staff to provide tube feeding and water (H2O) flushes as ordered. An interview was conducted on 5/7/25 at 10:22 a.m. with the Registered Dietician (RD). The RD reported Resident #78 was on Nepro at full rate due to not being able to depend on the resident eating (orally). The resident received 2160 calories from Nepro at 60 ml/hr x 20 hours. The RD reviewed photograph of nutrition bottle observed hanging and stated if the bottle was of 300 mls the resident did not receive optimal nutrition on that day. During an interview on 5/8/25 at 11:27 a.m. the Director of Nursing stated liquid nutrition was good for 24 hours and wondered if Resident #78's observed liquid nutrition had been an incorrect date situation. Review of the policy, procedures, and information - Nursing Enteral Tube Feeding via Continuous Pump, revised on 2/21/23 showed The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. The procedure for initiating the feeding instructed staff after attaching the primed feeding pump set to enteral tube and unclamping tube, to hang feeding bag on to pole, connect the infusion pump, set rate, and press start for continuous feeding. The formula label staff would document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. (Photographic evidence was obtained)

Based on record review and interviews, the facility did not ensure there was documented communication of coordination of care with the dialysis center for one (#81) of one resident reviewed. Findings included: A review of Resident #81's admission record revealed an initial admission date of 7/23/24 and a re-admission date of 1/24/25. Further review of the admission record revealed diagnoses to include type 2 diabetes with diabetic polyneuropathy, end stage renal disease, and dependence on renal dialysis. A review of Resident #81's physician orders revealed the following to include: - hemodialysis [dialysis center name and address] chair time 0615 Monday, Wednesday, Friday (M/W/F) every night shift, with a start date of 1/27/25. A review of Resident #81's progress notes from 4/8/25 to 5/8/25 revealed no documentation related to communication with the dialysis center. A nurse's progress note on 5/2/25 revealed the following, [Name of dialysis center] Dialysis [telephone #]. A review of Resident #81's electronic medical record revealed dialysis communication notes dated 3/19/25 - 4/30/25 with no documentation from the dialysis center to the facility. A review of Resident #81's dialysis binder, that goes with the resident from the facility to the dialysis center, revealed communication notes dated 5/3/25 and 5/5/25. The documentation revealed no communication to and from the dialysis center. On 5/6/25 at 2:28 p.m. an interview was conducted with Staff R, Registered Nurse (RN). She confirmed Resident #81 is one of her assigned residents. She said nurses are expected to check the resident's vitals before and after going to dialysis. She said they also check the access site. Staff R, RN said she documents this information in the resident's electronic health record and on the dialysis communication form. She stated, The dialysis center doesn't always fill out the middle part and I don't know why. She said Resident #81 has been okay but has needed some extra dialysis sessions on Saturdays. On 5/6/25 at 2:58 p.m., an interview was conducted with Staff N, Licensed Practical Nurse (LPN)/Unit Manager (UM). She stated, The dialysis center sends over a mass amount of notes about once a month. She said the dialysis center does not fill out the middle part of the communication form. On 5/7/25 at 10:05 a.m., an interview was conducted with Staff D, LPN/UM. She said the dialysis center is good at communicating over the phone if a resident is staying later for treatment or if there's concerns about lab results. She said they are not good about filling out the middle part of the dialysis communication form. Staff D, LPN/UM said staff should be documenting in the residents' progress notes if they communicate with dialysis over the phone. She said the dialysis center sends their notes to the facility every few weeks. On 5/7/25 at 10:18 a.m., an interview was conducted with the Registered Dietitian (RD). He said he emails or calls the dietitian at the dialysis center every month, or more often as concerns appear. He stated, It's really hard to get notes from [dialysis center name] and [dialysis center name]. He confirmed Resident #81 goes to the dialysis center as scheduled and that it is hard to retrieve notes from the center. The RD said he had to reach out to request notes. On 5/7/25 at 10:56 a.m. a follow-up interview was conducted with the RD who stated the dialysis center Resident #81 goes to, Got hacked about a month ago, and there is a back log of notes. On 5/7/25 at 1:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). She said the facility received Resident #81's dialysis treatment notes today, dated 4/2/25 to 4/30/25. She said the dialysis center's system was hacked and they are delayed in sending notes. On 5/7/25 at 5:10 p.m., an interview was conducted with the Director of Nursing (DON). She said if the area on the communication form for the dialysis center is not filled out, staff should be sending it back. The DON said if the communication form from the dialysis center is not filled out, they try to call. She said if something happens while the resident is at dialysis, the center will notify the facility. The DON stated nursing staff are expected to, Document what the facility tells them. She said she started a performance improvement plan (PIP) and audits, in April 2025, to review the dialysis communication forms in morning meetings and determine how they can better monitor the residents. The DON said the PIP and audits were brought to Quality Assurance and Performance Improvement (QAPI). The facility did not have a policy related to communication with dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to execute physician orders as recommended by the Consulting Pharmacist for two residents (#68 and #81) out of five residents sampled for unnecessary medications. Findings included: 1) Review of Resident #68's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses of not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, moderate recurrent major depressive disorder, other bipolar disorder, generalized anxiety disorder, other seizures, gastro-esophageal reflux disease without Esophagitis, and abdominal distension (gaseous). Review of Resident #68's record showed the resident was on Hospital Paid Leave on 3/23/25, returning to the facility on 3/25/25. On 5/5/25 at 11:37 a.m. Resident #68 was observed sitting upright in bed, wearing a nasal cannula delivering 4 liters per minute (lpm) of oxygen. Review of Resident #68's Medication Regimen Recommendations made by the Consultant Pharmacist on 3/12/25 revealed the following: -Currently with active order for Ondansetron (Zofran) as needed (prn) which has not been used in over 30 days. Please evaluate current need and discontinue if appropriate. The physician response was Agree; Will do and signed by the provider on 3/25/25. -Currently receiving Divalproex (Depakote). Unable to locate recent serum level in chart. Recommended 2 weeks after start then every 6 months thereafter. Please consider ordering. The physician response was Agree; Will do and signed by the provider on 3/25/25. Review of Resident #68's April 2025 Medication Administration Record (MAR) showed an order for Ondansetron 4 milligram (mg) - Give one tablet by mouth every 4 hours prn for nausea and vomiting, started on 3/25/25 at 7:51 p.m. The MAR revealed the resident had received the medication fifteen times during the month of April. Review of Resident #68's laboratory results showed a Complete Blood Count (CBC with differential), Comprehensive Metabolic Panel (CMP), and a thyroid-stimulating hormone 3rd generation panel had been completed on 3/5/25. The results revealed the next testing the resident had was a stool culture on 4/30/25. The results did not show the resident had a Depakote level completed after 3/25/25 as ordered by the physician. During an interview on 5/8/25 at 1:41 p.m. the Director of Nursing (DON) reported not knowing why Resident #68's Zofran had not been discontinued, a new order for Zofran was ordered on 3/25/25, and the Depakote level was not ordered or obtained. She stated she searched the orders and results and was unable to locate either. 2) A review of Resident #81's admission record revealed an initial admission date of 7/23/24 and a re-admission date of 1/24/25. The admission record revealed diagnoses to include inflammatory polyneuropathy, unspecified, Type 2 Diabetes with diabetic polyneuropathy, End Stage Renal Disease, dependence on renal dialysis, major depressive disorder, recurrent, moderate, and mood disorder due to known physiological condition with mixed features. A review of Resident #81's physician orders revealed the following: -Sertraline Hydrochloride (HCl) tablet 100 milligrams (mg) give 1 tablet by mouth one time a day for depression related to major depressive disorder, recurrent, moderate. - Oxycodone HCl oral tablet 10 mg (Oxycodone HCl) *controlled drug* give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. - Apixaban oral tablet 2.5 mg (Apixaban) give 1 tablet by mouth two times a day related to acute embolism and thrombosis of deep veins of right upper extremity. -Gabapentin capsule 300 mg give 1 capsule by mouth three times a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Humalog injection solution 100 unit/milliliters (ml) (insulin Lispro) inject subcutaneously three times a day for Diabetes Mellitus (DM). - Sevelamer Carbonate 800 mg tablet give 1 tablet by mouth before meals related to End Stage Renal Disease do not send, supplied by dialysis. - Tresiba subcutaneous solution 100 unit/ml (insulin Degludec) inject 27 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy. - Biscolax suppository 10 mg (Bisacodyl) inset 1 suppository rectally every 24 hours as needed for constipation or no results from Milk of Magnesia (MOM). -Enulose solution 19 grams (gm)/ml (Lactulose) give 30 ml by mouth every 24 hours as needed for no bowel movement (BM) in 3 days for (x) 1 dose. If ineffective by next shift see as needed (prn) Bisacodyl dialysis resident only. -Miralax enema insert 1 applicator rectally as needed for constipation/no results from Bisacodyl suppository if no or poor results from Miralax enema, notify primary care provider (PCP). A review of Resident #81's medication regimen review (MRR) by the consultant pharmacist, dated 3/12/25, revealed the following recommendations: - Currently receiving Gabapentin in dose exceeding maximum recommended dose based on estimated creatinine clearance (CrCl) below 30 ml/minute (min). To decrease risk of central nervous system adverse effects including ataxia, dizziness, and drowsiness consider taper Gabapentin to 600 mg daily at bedtime, if appropriate. - Currently with an active order for Miralax enema which is not recommended for use in residents on dialysis. Please evaluate risk versus benefit of use and discontinue, if appropriate. -The MRR revealed no response was marked for the Gabapentin recommendation, and Agree; Will do, was marked for the Miralax enema recommendation. There was no physician/prescriber signature observed on the MRR, dated 3/12/25. A review of Resident #18's Medication Administration Record (MAR) for March, April, and May 2025 revealed the following orders: - Gabapentin capsule 300 mg give 1 capsule by mouth three times a day related to Type 2 Diabetes Mellitus with diabetic polyneuropathy, with a start date of 2/26/25, was administered as ordered. - Miralax enema insert 1 applicator rectally as needed for constipation/no results from Bisacodyl suppository if no or poor results from Miralax enema, notify primary care provider (PCP), with a start date of 1/27/25, was not administered. On 5/8/25 at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). She said the facility does not have documentation the physician acknowledged the pharmacy recommendations made in March 2025. The DON confirmed the physician did not document whether they considered the pharmacy suggestions or their rationale for not agreeing with the recommendations. A review of the facility's policy titled Pharmacy Services - Drug Regimen Review, dated 4/1/22, revealed the following: . Procedure: 1. The drug regimen of each resident should be reviewed at least monthly by a licensed pharmacist and the pharmacist should report any irregularities to the attending physician, the facility's medical director and the director of nursing and these reports should be acted upon . 5. The attending physician shall document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to administer pain medication as ordered for one resident (#13) out of five residents sampled for pain management. Findings Included: Review of Resident #13's admission record revealed an admission date of 04/03/2024. Resident #13 was admitted to the facility with diagnosis to include other sequelae following unspecified cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, need for assistance with personal care, muscle weakness (generalized), sedative, hypnotic or anxiolytic dependence, uncomplicated, anxiety disorder, unspecified, Opioid dependence, uncomplicated, major depressive disorder, recurrent, moderate. Review of Resident #13's annual Minimum Data Set (MDS), dated [DATE], revealed in Section N- Medications: Anti-Depression, Hypnotic, Anticoagulant, Diuretic, Opioid, and Anticonvulsant. Review of Resident #13's orders revealed: -Norco Oral Tablet 10-325 MG (milligrams) (Hydrocodone Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Moderate/Severe pain -Start Date 02/17/2025. -Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for general discomfort 2 tabs=650 MG not to exceed 3 gm (grams) in 24 hours- Start Date 02/17/2025. Review of Resident #13's Medication Administration Record (MAR), dated February 2025 revealed: -Norco Oral Tablet 10/325 MG was dispensed for a pain level of 0 on 2/8/2025 and 2/23/2025 -for a pain level of 3 on 2/4/2025, and 2/12/2025 -for a pain level of 4 on 2/03/2025, 2/05/2025, 2/09/2025, 2/10/2025, 2/13/2025, 2/17/2025, 2/18/2025, 2/19/2025, 2/21/2025, 2/22/2025, and 2/27/2025. Review of Resident #13's Medication Administration Record (MAR), dated March 2025, revealed: -Norco Oral Tablet 10/325 MG was dispensed for a pain level of 0 on 3/2/2025 and 3/31/2025 -for a pain level of 2 on 03/20/2025 and 3/30/2025 -for a pain level of 3 on 3/4/2025, 3/8/2025, 3/17/2025, 3/22/2025, 3/25/2025, and 3/26/2025 -for a pain level of 4 on 3/3/2025, 3/5/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/18/2025, 3/19/2025, 3/23/2025, 3/24/2025, and 3/27/2025. Review of Resident #13's Medication Administration Record (MAR), dated April 2025, revealed: -Norco Oral Tablet 10/325 was dispensed for a pain level of 0 on 4/25/2025 -for a pain level of 2 on 4/11/2025, 4/12/2025 4/27/2025 -for a pain level of 3 on 4/4/2025 4/10/2025 4/15/2025, 4/20/2025, and 4/30/2025 -for a pain level of 4 on 4/2/2025, 4/5/2025, 4/6/2025, 4/9,2025, 4/14/2025, 4/16/2025, 4/19/2025,4/21/2025, 4/23/2025, 4/24/2025, and 4/28/2025. During an interview on 05/05/2025 at 3:35 p.m., Staff Q, Licensed Practical Nurse (LPN) stated moderate/severe pain is a level of 5 or 6 and above. During an interview on 05/05/2025 at 3:36 p.m., Staff R, Registered Nurse (RN) stated moderate/severe pain would be a pain level of 6/7 or above. During an interview on 05/05/2025 at 3:48 p.m., the Director or Nursing (DON) stated moderated/severe pain would be at a level of 4-10. During a phone interview on 05/06/2025 at 4:40 p.m. the Physician stated a moderate/severe pain level would be 7-10. He stated if the order is scheduled, he would expect for the pain medication to be given as ordered even with a pain level of 0. He stated Resident #13's order is as needed and he would not expect pain medication to be given with a pain level of 0 or 2. He stated he would expect Tylenol to be given for a pain level in the lower range. The facility was asked to provide a policy for unnecessary medication and stated they did not have a policy for unnecessary medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and three errors were identified for one resident (#35) of five residents observed. These errors constituted a 10% medication error rate. Findings included: On 5/6/25 at 9:40 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted for Resident #35. Staff H reported the resident's blood pressure of 135/80 and heart rate of 86 had been obtained approximately four minutes prior to the observation. The staff member dispensed the following medications: - Carvedilol 3.125 milligram (mg) tablet - Sevelamer 800 mg tablet - Hydralazine 50 mg tablet - Amlodipine 5 mg tablet - Folic acid 1000 microgram (mcg) over-the-counter (OTC) tablet - Aspirin low dose enteric-coated 81 mg OTC tablet (order: chewable 81 mg tablet) - acetaminophen 325 mg - 2 OTC tablets The staff member confirmed dispensing 8 tablets prior to entering the resident room. The resident was observed lying in bed and the oral medications were administered. Staff H returned to the medication cart and reported holding the resident's Midodrine due to the blood pressure was too high. Review of Resident #35's May Medication Administration Record (MAR) showed the following errors: -Aspirin 81 (mg) chewable - Give 1 tablet by mouth one time a day related to peripheral vascular disease unspecified. The observation showed the staff member administered an enteric-coated 81 mg tablet of Aspirin. -Midodrine 5 mg - Give 1 tablet by mouth one time a day every Tuesday (Tues), Thursday (Thu), and Saturday (Sat) for hypotension to give in AM (morning) before Dialysis. The order was started on 4/22/25 and did not include blood pressure parameters to hold the medication. -[NAME]-Vite (B complex/C/Folic Acid) - Give 1 tablet by mouth one time a day for nutrition. The staff member documented this medication had been administered, however, it was not observed. Review of Resident #35's Medication Admin Audit Report for the 7 a.m. - 3 p.m. shift on 5/6/25 showed Staff H had administered the following medications at 9:55 a.m.: Carvedilol, Sevelamer, Hydralazine, Amlodipine, Folic Acid, and Aspirin. The following medications were documented as given on 5/6/25 at 9:57 a.m.: Carvedilol, Sevelamer, Hydralazine, Amlodipine, Folic Acid, Aspirin, Acetaminophen and [NAME]-Vite (also administered at 9:57 a.m.). During an interview on 05/08/25 at 11:16 a.m. the Director of Nursing (DON) reviewed Resident #35's MAR. She confirmed the documentation from the nurse. Review of the policy - Administering Medications, revised 2/21/23, showed the following: Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. 3. Medications are administered in accordance with prescriber orders, and current standards of practice. 6. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or suspected of being associated with adverse consequences, the person preparing or administering the medication should contact the prescriber, the resident's Attending Physician, or the facility's Medical Director to discuss the concerns. 20. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/5/25 at 11:49 a.m. Resident #68 was observed sitting upright in bed wearing a nasal cannula delivering 4 liters per minute (lpm) of oxygen. The resident stated there was a dressing on the right hip and something on left hip. The resident granted permission to view and photograph for evidence abdominal pad dressing on right hip, dated 5/3/25. The observation of left hip did not reveal any injury or dressing. Review of Resident #68's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to not elsewhere classified lymphedema, morbid (severe) obesity due to excess calories, intra-abdominal and pelvic swelling mass and lump unspecified site, and other sites of candidiasis. Review of Resident #68's quarterly Minimum Data Set (MDS), target date 3/3/25, revealed the resident scored 15 of 15 for the Brief Interview of Mental Score (BIMS) indicating an intact cognition. A request was made for the facility to provide Resident #68's Non-pressure and Pressure Skin Reports. The facility provided one Non-pressure Wound Report, dated 4/29/25, revealing one left lower leg - lymphedema, one left foot lymphedema wound, one right lower leg - lymphedema, and one right foot - lymphedema. The skin report did not reveal a right hip wound. Review of the medical record revealed a Non-pressure Wound Report, dated 4/8/25 showing a right hip wound measuring 1.0-centimeter (cm) x 0.5 cm x 0.2 cm which was acquired on 3/4/25. Review of a Skin Evaluation, dated 4/9/25 revealed wounds to bilateral lower extremities, right hip, raised areas to trunk, bilateral buttocks, and thighs with a reddened coccyx. Review of Resident #68's May 2025 Treatment Administration Record (TAR), printed on 5/8/25 at 10:56 a.m. did not include treatment orders to place a dressing to the right hip of the resident. An interview was conducted on 5/8/25 at 11:45 a.m. with the Director of Nursing (DON). The DON reported knowing of the resident's right hip wound and thought it was there on the resident's admission. The DON reported Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM) said the wound was like a little blister in between (skin) folds, from the edema, clear liquid leaking out. The DON confirmed there should be documentation related to the right hip blister. A request was made for a policy regarding Skin Evaluations. The facility reported they did not have a policy related to Skin Evaluations. Photographic Evidence was Obtained. Based on observations, interviews and record review, the facility failed to ensure complete and accurate documentation was in the resident's medical record for two (#93 and #68) out of 23 residents sampled. Findings Included: During an interview on 05/06/2025 at 11:47 a.m., Resident #93's Family Member and Power of Attorney (POA) stated he had received a call from the facility on Friday letting him know they were putting an order for Hospice for Resident #93. He stated he was told it was because Resident #93 had recently declined and there was a change in his appetite. The POA stated he tried calling back a few times to speak with someone in regard to the Hospice Order and had not received a call back. Review of Resident #93's admission Record revealed an initial admission date of 06/28/2024 and a readmission admission date of 11/26/2024 . Resident #93 was admitted to the facility with diagnosis to include Cerebral Infarction Due To Thrombosis Of Bilateral Cerebellar Arteries, Unspecified Cirrhosis Of Liver, Unspecified Severe Protein-Calorie Malnutrition, Muscle Weakness (Generalized), Hypothyroidism, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region. Review of Resident #93 Orders revealed on 05/02/2025, Consult Hospice as per family and patient request Review of Resident #93's progress notes revealed there were no progress notes documenting Resident #93, family or POA elected Hospice care. During an interview on 05/05/2025 at 2:00 p.m., the Social Services Director (SSD) stated when residents or families request for a Hospice consult, she gives them brochures for all of the hospice companies they have information for. The SSD sends the referral once the family has chosen the hospice company. She stated Resident #93 asked the Advanced Registered Nurse Practitioner (ARNP) about going on hospice. The ARNP came and verbally told her that Resident #93 was requesting to go on Hospice. The SSD stated this conversation was not documented and there was no note. The SSD stated she had reached out to Resident #93's family in regards to the hospice order, but they are very hard to get a hold of and never returns her calls. She stated she did not document the phone calls attempts. During an interview on 05/08/2025 at 1:37 p.m., Director of Nursing (DON) stated anytime a conversation happens with a resident or family member it should be documented in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #68's Level I PASARR dated 3/19/25, showed the resident had diagnoses of anxiety disorder, bipolar disorder, depressive disorder, and mood disorder. The level I PASARR showed the resident did not have validating documentation to support dementia or a related neurocognitive disorder. The review showed Resident #68 had no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASARR evaluation was not submitted for consideration. Review of Resident #68s admission Record revealed the resident was admitted on [DATE] and 9/2/24. The record included the following diagnoses with onset dates: moderate recurrent major depressive disorder (onset 6/14/24), other bipolar disorder (onset 9/2/24), generalized anxiety disorder (onset 9/2/24), and mood disorder due to known physiological condition with depressive features (onset 6/14/24). Review of Resident #68s quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident received antianxiety and antidepressant medications. Review of Resident #68s psychology providers note, dated 4/28/25 revealed the resident was being seen to follow up after a recent medication change. The note showed the patient had been recently depressed wth some changes in mood but had been under treatment for infections. The resident presented with no change from baseline. Resident is still not at our treatment goals and is being treated for some mood disorders. The assessment showed the resident was not currently responding to therapy and medication combination and the resident's diagnoses of anxiety, depression, and bipolar disorders were unstable. The diagnoses listed included dementia with behavioral disturbances and insomnia. The psychiatric medication instructed to continue Buspar and lorazepam was adjusted to 0.5 mg (milligram) three times a day, continue trazodone for major depressive disorder, discontinue Zonegran, taper Depakote for 7 days, and start Lithium 300 mg twice daily for mood instability. Review of the Psychotherapy note dated 5/7/25, revealed Resident #68 presents with depressed mood, sad affect, reporting interpersonal conflict, negative self-esteem, reduced self-confidence, (and) loss of interest and enjoyment. During an interview on 5/8/25 at 10:48 a.m. the Social Service Director (SSD) stated the resident would trigger for a Level II PASARR with a dementia diagnosis and bipolar diagnoses. Based on interview and record review the facility failed to submit Pre-admission Screening and Annual Resident Review (PASARR) Level II screenings for three (#42, #68, and #42) out of seven residents sampled. Findings Included: 1. Review of Resident #42's admission record revealed an admission date of 11/14/24 with diagnoses to include Major Depressive Disorder, Recurrent, Unspecified, Bipolar Disorder, Unspecified, Anxiety Disorder, and Unspecified, Post-Traumatic Stress Disorder (PTSD). Review of a level I PASARR for Resdient #42 dated 11/15/2024 revealed, Section IV. PASARR Screen Completion: No diagnosis or suspicion of Serious Mental illness or intellectual disability indicated. A level II PASRR evaluation was marked as not required. Review of Resident #42 's medical record revealed Resident #42 was not assessed for PASARR Level II and a recommendation was not submitted. 3. A review of Resident #2's admission record revealed an initial admission date of 4/9/13 and a re-admission date of 9/9/24 with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified mood affective disorder, and disorganized schizophrenia. A review of Resident #2's physician orders revealed orders for divalproex sodium capsule delayed release sprinkle 125 mg (milligrams) give 2 tablet by mouth three times a day related to unspecified mood affective disorder and Risperidone tablet 0.5 mg give 1 tablet by mouth one time a day related to disorganized Schizophrenia. A review of a quarterly note for Resident #2's progress notes, dated 3/14/25 revealed Resident #2 was alert with confusion and forgetfulness he is sometimes understood and sometimes understands staff to anticipate his needs his mental function varies. He has episodes of being verbally aggressive with staff, spitting, cursing and resisting and refusing treatment/care, Shaving, nailcare and medications at times. He hollers staff names for assistance rather than use his call light. He is followed by psych [psychiatry] for Mood disorder, Schizophrenia. we will continue to follow current plan of care. Review of a level I PASARR dated 1/19/2024 revealed the following was marked under section IV, PASARR screen completion: No diagnosis or suspicion of Serious Mental illness or Intellectual Disability indicated. The review showed a Level II PASARR evaluation was not required or submitted for consideration. On 5/8/25 at 10:26 a.m., an interview with the Social Services Director (SSD) was conducted. She said she reviews PASARRs for every resident that is admitted to the facility. She stated she makes sure the PASARR, diagnoses, and medications, All line up. The SSD said if a resident had any new medications then she made sure the new diagnosis was added. She stated, I make sure it's captured on the PASSAR. The SSD sttaed she and the interdisciplinary team (IDT) reviewed Minimum Data Set (MDS) assessments for accuracy. The SSD said she inputs the correct information on the level I PASSAR and depending on what is marked, they get an immediate response to submit for a level II PASARR. The SSD stated if a level II isn't triggered and she suspected the resident might need one submitted, she would email the vendor. A review of the facility's policy titled Social Services - PASARR, dated 4/1/22, revealed the following: Purpose: The facility shall ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. Definitions: An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: (i) Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. This mental disorder is - A) A schizophrenic, mood, paranoid, panic, or severe anxiety disorder, somatformdisorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; (B) Not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined in paragraph (b)(1)(i)(A) of this section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility did not ensure 1.) Continuous Positive Airway Pressure (CPAP) equipment and maintenance was provided for one resident (#12) out of one resident observed and 2.) Signage for oxygen use for five out of 17 rooms in one hallway ([NAME]) out of 4 hallways for four out of four days observed. Findings included: 1.) On 5/05/2025 at 9:19 a.m., an observation and interview were conducted with Resident #12 in her room. Resident #12 was observed with a nasal cannula with settings at three liters per minute administered through an oxygen concentrator. Resident #12 stated she requires CPAP at night but stated her mask currently leaks. Resident #12 stated her mask was very old and in need of a replacement but the facility was unable to provide the mask she likes and one which fits her face. Resident #12 stated she has been in the facility for quite some time and an exchange of her CPAP machine occurred by the facility but obtaining a new mask has not occurred. Resident #12 stated someone came to her room several months ago with a new mask to try but she did not like the fit and requested a replacement for her current mask of which she has not received. Resident #12 stated she thinks the individual who came into her room was the representative for the CPAP machine. On 5/05/2025 at 9:26 a.m., an observation was made of Resident #12's CPAP mask in which there were two to three pieces of clear tape at the bottom of her mask. The resident stated she got the tape from one of the nurses and had placed the tape over the hole to try to minimize the air leak. Resident #12 stated she has had this mask for a long time. Resident #12 allowed the surveyor to look through her supplies for equipment for her CPAP. Upon observation, no extra masks, tubing or filters for her CPAP machine were seen. An observation was made of two commercial sealed cups of sterile water in which the resident stated the nurses will pour the water into her CPAP machine at night. A record review of Resident #12 admission Record showed an original admit date of 10/09/2020, a readmission date of 02/02/2023 with the following diagnoses to include but not limited to, Chronic Obstructive Pulmonary Disease, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Heart failure, Morbid obesity and Chronic rhinitis. A record review of Resident #12's Minimum Data Set (MDS), dated [DATE], Category C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. On 5/06/2025 at 1:51 p.m., an interview was conducted with Staff M, Licensed Practical Nurse (LPN). Staff M. LPN stated the nursing staff is responsible for respiratory equipment every week on Sunday night shift but as far as managing the CPAP machine and supplies the responsibility would be the Respiratory Therapist. On 5/06/2025 at 2:07 p.m., an interview was conducted with Staff N, LPN/Unit Manager (UM). Staff N, LPN/UM stated the nurses are responsible for supplying nasal cannulas, humidifiers, and nebulizers and these supplies are exchanged out weekly, every Sunday by the night shift nursing staff. On 5/06/2025 at 3:17 p.m., an interview was conducted with Staff O, Admissions Coordinator. Staff O stated he would order CPAP machine and supplies for all the new admissions requiring CPAP. Staff O stated he knew of the Resident #12 requesting a new CPAP mask and stated he ordered a new mask several months ago as a trial. Staff O stated Staff P, Respiratory Director requested a new mask for Resident #12 and he simply went on the manufacturer's website to order a mask. Staff O stated he routinely does not order CPAP supplies for any of the long-term residents, only new admissions normally, unless a request is made. On 5/06/2025 at 3:17 p.m., a telephone interview was conducted with Staff P, Respiratory Director. Staff P stated the facility was currently in the process of attempting to fill a vacancy for a respiratory therapist but in the interim of interviews, he was acting as the respiratory therapist for this facility and three other facilities in the area. Staff P stated he is accessible 24/7 for any concerns. Staff P stated he knew of the situation for Resident #12 and stated the mask could possibly be overnighted tonight. Staff P stated he will reach out to the Nursing Home Administrator who has access to a credit card to order the needed CPAP supplies. Staff O stated he will be at the facility this week to maintenance her CPAP machine and fit with a new mask. On 5/06/2025 at 4:02 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the nursing staff are responsible for respiratory supplies and changing the equipment every Sunday during the night shift and as needed. The DON stated respiratory therapy are not in the building but are available by phone for emergency situations. The DON stated currently there are four residents with either CPAP or BiPAP (Bilevel Positive Airway Pressure). The DON stated respiratory therapy will manage these residents' supplies and maintenance. The DON could not state how often respiratory therapy would manage these residents. The DON stated the nursing staff should document the resident's CPAP settings in the medical record on a daily basis. The DON stated a mask was provided for Resident #12 in February. The DON stated she has reached out to Staff O, Admissions Coordinator, to order a mask for her. The DON stated a mask arrived but it was not the same mask the resident currently had. The DON stated the resident told me she was fine with the mask she currently had. The DON stated she placed a note in her medical record on 02/25/2025. On 5/06/2025 at 3:40 a.m., Staff O shared a text message from Staff P of two CPAP masks. The image to the left was the image of the mask he stated he purchased for the resident of which she did not like the fit in comparison to the image on the right which was her current mask. The text was dated 01/31/2025. A record review of Resident #12's medical record progress notes showed a progress note from respiratory therapy dated 02/12/2024: visited with patient, on three liters per minute without SOB( shortness of breath). Changed filter out to CPAP. Patient currently using CPAP-patient compliant. Patient doing well at this time . No further progress note entries were observed. On 5/07/2025 at 8:48 a.m., an interview was conducted with Resident #12 who stated the nursing staff came in last night and cleaned out the filter to my concentrator and CPAP machine. Resident #12 stated she did not know there was a filter in her concentrator and could not recall the last time her concentrator had been cleaned. On 5/07/2025 at 11:55 a.m., an interview was conducted with Staff O, Admissions Coordinator. Staff O stated he would order supplies for CPAP upon admission but as far as long- term residents he does not order supplies unless specifically requested. Staff O reviewed his emails and demonstrated his order placed for Resident 12's CPAP mask but could not find any email order receipts for CPAP tubing. On 5/07/2025 at 11:43 a.m., an interview was conducted with Staff Q, central supply in the main central supply room. Staff Q stated she does not have supplies for CPAP and does not order supplies. Staff Q stated the NHA or Staff O in admissions will order CPAP supplies. On 05/07/25 12:29 p.m., an interview was conducted with the NHA. The NHA stated respiratory therapy would be managing Resident #12's CPAP and the maintenance. The NHA stated she was aware the regional respiratory came in to see the resident a few months ago to assist with finding a mask but the resident was not willing to try a new mask. The NHA stated she was not responsible for ordering supplies but confirmed she ordered a new mask from [on-line shopping network] last night for Resident #12. A record review of Resident #12's current physician orders showed the following: - Clean mask daily every day shift for hygiene - Clean the unit and filter of CPAP machine weekly every night shift every Sunday for hygiene - Clean tubing weekly CPAP every night shift every Sunday for hygiene - Device and settings CPAP AUTO 4 to 20 centimeters of water evening and night shift - Empty water chamber and air dry every AM every day shift - Fill water chamber with distilled water every evening shift - Replace tubing and mask every three months every night shift every three months starting on the 28th for one day for hygiene - Respiratory therapy to evaluate. On 5/08/2025 at 9:58 a.m., an interview was conducted with Staff P, Respirator Director. Staff P stated Resident #12 was fitted today for her CPAP machine and she chose the medium size which was what she currently had. Staff P stated he will put on his calendar to see the resident once a month for her CPAP maintenance and supplies. Staff P stated an Inservice may be in order to the nursing staff for cleaning the CPAP machine, tubing and mask. On 5/08/2025 at 12:46 p.m., an interview was conducted with Staff N, LPN/UM. Staff N stated she was not familiar with how to set up a CPAP machine but would defer to her DON. On 5/08/2025 at 12:48 p.m., an interview was conducted with Staff D, LPN/UM. Staff D stated new admissions will normally come with a CPAP machine and pre-set for settings but if they received a new CPAP machine, she would not know how to set it up and would defer to the DON or the respiratory therapist. On 5/08/2025 at 1:29 p.m., an interview was conducted with the DON. The DON stated she knows how to set up CPAP settings once ordered from the physician. The DON stated she recognized an opportunity for education on CPAP management including setting up the parameters as well as cleaning the tubing, mask and filters was needed. 2.) An observation was made in [NAME] hallway of five rooms out of 17 rooms of residents utilizing oxygen therapy for four days out of four days during survey without oxygen signage posted. On 5/06/2025 at 1:51 p.m., an interview was conducted with Staff M, LPN who confirmed the residents in her assignment were currently receiving oxygen. Staff M stated rooms 201, 210, 214, 215 and 216 had residents with orders for oxygen and were currently on oxygen. An observation was made of no signage outside those room to indicate oxygen was in use. On 5/08/2025 at 3:53 p.m., an interview was conducted with the DON related to oxygen signage. The DON walked to the front of the building entrance to demonstrate a small sign stating, Oxygen in Use. The DON reviewed the facility's policy on oxygen use and stated there should be signs in front of each residents' room requiring oxygen. A review of the facility's policy and procedures titled, Nursing- CPAP/BiPAP Support effective date 04/01/2022 showed the following purpose statement: 1.To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2.To improve arterial oxygenation (PAO2) in residents with respiratory insufficiency, obstructive sleep apnea., or restrictive /obstructive lung disease 3.To promote resident comfort and safety. Preparation: 1.Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. 2.Equipment and supplies: 1.NO SMOKING sign for the resident's room. 2.General Guidelines for Cleaning: 1.General guidelines for cleaning specific cleaning instructions are obtained from the manufacturer supplier of the CPAP device 4.Machine cleaning : wipe machine with warm soapy water and rinse at least once a week and as needed 5.Humidifier (if used): a.Use clean, distilled water only in the humidifier chamber b.Clean humidifier weekly and air dry c.To disinfect, place vinegar water solution 1:3 and clean humidifier. Soak for 30 minutes and rinse thoroughly. 6.Filter cleaning: a.Rinse washable filter under warm water once a week to remove dust and debris Replace this filter at least once a year. b.Replace disposable filters monthly.

Based on observations and interviews, the facility did not follow professional standards for food service safety related to sanitary practices in one of one facility kitchens. Findings included: On 5/5/25 at 9:35 a.m., an initial tour of the kitchen was conducted with the Dietary Manager. An observation of the low temperature dish machine was in use by Staff A, Dietary Aide. An observation of Staff A, Dietary Aide revealed she was wearing gloves and putting soiled items with food debris in the machine. She conducted the testing of the sanitizing solution using the same gloves she had on while putting soiled items to be washed. She used two testing strips and one of them fell in the water of the dish machine, while the other was placed on a clean insulated lid. Staff A, Dietary Aide was not observed removing the testing strip from the insulated lid and the lid was not put back to be cleaned. On 5/5/25 at 9:42 a.m., an observation of the reach-in cooler revealed a brown plastic bag on one of the racks labeled [staff member name]. Observations of the brown plastic bag revealed there were clear, plastic water bottles inside. Further observations of the reach-in cooler revealed a Styrofoam cup, with a lid, next to the plastic bag. The Dietary Manager confirmed it was a staff member's personal items and proceeded to remove them. On 5/5/25 at 10:02 a.m., an observation of the ice machine revealed the ice chute cover had streaks of black residue towards the top of it. Further observation of the ice chute cover revealed the bottom ledge had the same black residue across it. Observations of the inside of the ice scoop holder revealed build-up of a white substance, as well as light brown bio growth/residue. The Dietary Manager said she thinks the maintenance staff cleans the ice machine and is not sure if cleaning the inside falls under the kitchen responsibilities. She said she would confirm with the District Manager. On 5/7/25 at 11:17 a.m., a follow-up tour revealed Staff C, Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON) were observed in the kitchen with no hair restraints. On 5/7/25 at 4:17 p.m., an observation of Staff L, [NAME] completing the hot holding dinner temperatures revealed a stryofoam cup with a brown liquid, with no lid, was on the table next to the steam table. The cup contained a staff member's beverage. On 5/7/25 at 4:48 p.m., interviews were conducted with the dietary manager and District Manager. The Dietary Manager said personal items are supposed to be stored in the breakroom refrigerator, in her office, or there are lockers where staff can store their belongings. The Dietary Manager stated the ice machine gets a deep clean quarterly by the service provider. The District Manager said general maintenance of the ice machine, as well as cleaning, falls under the maintenance staff. He said he thinks the daily cleaning should be under the kitchen's responsibility, however, it could also be nursing or maintenance. He said they need to confirm if the ice machine falls under the responsibility of maintenance. Regarding the observation of the dish machine on 5/5/25, the Dietary Manager confirmed Staff A, Dietary Aide was handling soiled dishes, operating the dish machine, and transferring clean items without changing gloves. She said the testing strip that was observed in the water is, going to be flushed down and would not contaminate the water. On 5/8/25 at 1:19 p.m., a follow-up interview was conducted with the Dietary Manager and District Manager. They said the kitchen staff are responsible for cleaning the outside of the ice machine as well as the scoop and scoop holder. The District Manager said the maintenance staff is responsible for cleaning the ice chute cover. A review of the facility's policy titled Dish Machine Best Practices Guidelines, revealed the following, Placing a sanitization test strip directly on a plate that has just come out of the dish machine, which his considered a sanitized surface, could be viewed as a foreign object. Further review of the policy revealed the following: - Hygiene: The plate is intended to be clean and sanitized, and the test strip, even if used to check the sanitizer, could introduce contaminants back onto the plate if it isn't handled properly. - Unintentional handling: If the strip is left on the plate and is inadvertently moved or touched, it could contaminate other surfaces or food if not properly disposed of. - Proper Procedure: Sanitization test strips are usually designed to be dipped into the sanitizer solution or placed in contact with a surface being tested, such as a warewashing rack, but they shouldn't be left on clean, sanitized surfaces. - Best Practices: Proper Disposal After using the test strip, it should be properly disposed of, not left on a clean plate or surface. A review of the facility's policy titled Outside Food Storage Standard Operating Procedures, revealed the following, Storing food in Dietary coolers by employees, especially without proper labeling, date marking, or temperature control, is a violation of food safety regulations and can pose a risk to residents. Further review of the policy revealed the following, Proper Storage: Food brought into the facility should be stored in designated areas, such as personal refrigerators or community refrigerators, with appropriate labeling and temperature control. A review of the facility's policy titled Ice, revealed the following under policy statement, Ice will be prepared and distributed in a safe and sanitary manner. Further review of the policy under procedures revealed the following: - 3. The exterior of the ice machine will be cleaned weekly. - 4. Ice bins will be cleaned monthly and as needed. - 5. Ice scoops will be cleaned and stored in a separate container that limits expose to dust and moisture retention. (Photographic evidence obtained).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide medically related social services for one of three sampled residents (#2) related to assistance with a room change or assistance with a transfer to another facility as requested. Findings included: On 03/27/2025 at 9:30 AM, Resident #2 was observed lying in bed. Resident #2 said she spoke to the Social Service Director (SSD) in the past about a room change. Resident #2 stated she cannot sleep because her roommate talks all night and keeps the lights on. Resident #2 stated she also talked to the SSD about transferring to a rehab in Jacksonville that specialized in Guillain-Barre Syndrome because the rehab could maybe help her get better. A follow-up interview was conducted on 03/27/2025 at 11:30 AM with Resident #2. Resident #2 stated she talked to the SSD a couple of weeks ago about the room change and was told they did not have any room available. Review of Resident #2's admission Record showed she was admitted to the facility in 2023 and most recently readmitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. Review of a 02/17/2025 Social Service Progress Note electronically signed by the SSD showed Quarterly note-2/14/25, [Resident #2] is alert and oriented and able to make all of her needs known .She has a [family member] that calls daily and visits monthly and has an occasional visit from prior coworkers. [Resident #2] prefers to stay in bed most days. She plans to stay here for long term care but understands she may choose to discharge if she chooses. She also has episodes of feeling tired and feeling down/depressed trouble sleeping and poor appetite at times. She is followed by psychosocial for history of Trauma. We will continue to follow current plan of care. A review of Resident #2's progress notes and assessment forms for February 2025 through March 27, 2025 at 2:58 PM showed no documentation relating to a room change, roommate concerns, or a request to transfer to another facility. During an interview on 03/27/2025 at 12:37 PM, with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the SSD, the SSD stated when Resident #2 requested a room change, they only had a male room available. The SSD stated, When I went back to her room, she decided they [her and her roommate] were getting along, and she did not want a room change. It [the conversation] happened a few days before 2/4/2025, before she went out to the hospital. She declined to move. The SSD stated that a room was available at the time, but the resident did not want that room. The SSD stated, I spoke with her [Resident #2] this morning, and she did not say anything. She has not voiced anything to me since then. The SSD stated Resident #2 had talked to her family member about moving to another facility in Jacksonville. The SSD stated that was about a month ago, and the SSD called the family member at that time but never received a return call. The SSD confirmed Resident #2 told her it was a facility for Guillain-Barre. The SSD was unable to find the facility and did not know the name of the facility. The SSD confirmed she had not documented or followed up on any of the prior conversations with Resident #2 regarding a room change or the request to transfer to another facility prior to the day of the survey. Review of the Social Worker Job Description showed duties and responsibilities included: • Assisting in planning, developing, organizing, implementing, evaluating, and directing the social service programs of the facility. • Assisting in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning, (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required. • Ensuring all charted progress notes are informative and descriptive of the services provided and of the resident's response to the service. • Involving the resident and family in planning objectives and goals for the resident. Review of the Resident Handbook, signed as received by Resident #2 on 09/22/2023, showed: Residents' have the right to move to another care facility at any time, if we cannot meet your needs and you are not satisfied here. You can change room or roommates. Please ask, although there is no guarantee that another room or roommate will be available. Review of the Resident Rights and Responsibilities signed as received by Resident #2 on 0/22/2023, showed the resident has the right to be treated with respect and dignity, including their right to: reside and receive services in the facility with reasonable accommodation of your needs and preferences; share a room with another resident of your choice if you both desire; be notified in writing in advance of room or roommate changes; and refuse to transfer to another room in the facility under certain circumstances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility, 1. failed to ensure allegations of neglect were investigated for one (#8) of two residents reviewed for neglect and 2. failed to have evidence that alleged violations were thoroughly investigated for two (#2 and #7) of five residents sampled for alleged violations. Findings included: On 07/02/24 at 12:30 p.m., an observation and interview was conducted with Resident #8. She was observed in her room laying on her bed. Her Right leg was observed in a cast and was elevated. She stated she was in pain. The resident stated she was involved in a [mechanical lift] accident. She stated she remembered the incident very well. She said two CNAs (Certified Nursing Assistants) were transferring her from the bed to her wheelchair. During the transfer, the [mechanical lift] tipped when she was in mid-air. She stated the staff put her to the ground, but the metal part of the side table caught her ankle. She said, One of the CNAs was standing away from the lift holding on to the wheelchair. One CNA was operating the lift. She stated the side table was very close to the lift and it caught the leg of the lift, causing the lift to tip. The resident stated she broke her ankle. She stated she was frustrated because she could not get out of bed any longer and she probably would not for a very long time. She stated she was struggling with pain and realizing her recovery had been a set back. The resident said, I am a big girl, I think the CNA who was moving me could not do it without help. The resident stated there were two CNAs in the room. She stated when the tray table fell, everything fell over her and the aide had to lower her down. She stated they were calling for help and no one was answering. Review of the admission Record for Resident #8 showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #8 had a BIMS (Brief Interview for Mental Status Score) of 15, which indicated the resident was cognitively intact. Review of section GG - functional abilities showed Resident #8 was dependent, which indicated a helper provided all effort to transfer to and from bed to wheelchair. Review of a progress note dated 06/27/24 at 11:26 p.m., showed Resident #8 returned from [name of hospital] via stretcher . Resident with right fracture of ankle and placed in a cast. Review of an Advanced Registered Nurse Practitioner (ARNP) progress note dated 06/27/24 showed, Resident was seen today in facility after receiving a call the resident was being transferred from bed to wheelchair with [mechanical lift] and 2 Staff members when the [mechanical lift] began to tilt, staff were able to keep her from further tilting. Her right ankle/foot hit the bedside table and multiple staff eased her down to the floor to prevent the [mechanical lift] from tilting further over. She is seen with soft tissue swelling over her right ankle and mild ecchymosis. X-rays of her right ankle were ordered and returned showing, age -indeterminate tib-fib fracture by 2 views. Review of a hospital Discharge summary dated [DATE], showed Resident #8 was discharged with a diagnosis of distal end of fibula, Fracture of distal end of tibia. Review of a CNA task log as of 7/2/24, showed for transferring, the resident required a Mechanical lift with 2- plus assistance. Review of a care plan for Resident #8 with a transfer goal initiated on 04/14/22, showed the resident required a mechanical lift for transfers, with 2 plus assistance. On 07/02/24 at 2:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated she went to see Resident #8 after the fall. She said the resident reported she had an accident with a [mechanical lift]. The NHA said, This resident normally likes to get up. She said she was afraid of transfers. I told her not to let this hold her back. The NHA stated both CNAs walked them through the process. They said the lift legs were open. The CNAs reported during the transfer, the lift started to tilt, and they lowered the resident to the floor. The NHA stated they did not investigate the incident any further because the CNAs were following the right process. She said, I spoke to both CNAs briefly that day. I asked if the [mechanical lift] could accommodate her weight. We ruled that out. The Director of Maintenance confirmed the lift was functioning properly. I believe the CNAs wrote statements. I have to check with the Unit Manager. She was leading the investigation. The NHA stated there were two staff members in the room and she went by that. She stated she would have expected them to write statements. An incident report should have been documented. She stated she was glad there were two staff members in the room. She stated that was her main focus. The NHA said, I don't have any documentation on any interviews. We did not think we had a problem. We did not get to the bottom of how the injury occurred. We did not conclude anything other than there were two staff members in the room. On 07/02/24 at 4:15 p.m., an interview was conducted with the Director of Nursing (DON). She said, Looking back, I feel bad. I think we failed that resident. I should have conducted the investigation myself. I now know better. On 07/02/24 at 5:13 p.m., a follow-up was conducted with the Regional Nurse Consultant (RNC). She stated she did not think the fall should have been reported. She said, Based on our initial investigation, we did not find a reason to report. She stated, a thorough investigation should have been conducted. 2. A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE]. Resident #2 was discharged from the facility to the hospital on 2/4/2024. A review of the facility's reportable incidents log revealed an allegation of neglect was reported for Resident #2 on 2/13/2024. On 7/2/2024 at 3:00 p.m. during an interview with the NHA, she stated an allegation of neglect was reported to her on 2/13/2024, which involved Resident #2 being sent to the hospital on 2/4/2023 and not wishing to return to the facility due to the facility causing pressure injuries. The NHA also stated during the investigation of the allegation of neglect for Resident #2 other alert and oriented residents in the same hallway where Resident #2 resided were interviewed and expressed no concerns with the care they received. The NHA was not able to provide a list of residents who were interviewed and was not able to provide evidence the interviews were conducted with the residents during the investigation. The NHA left the room and attempted to locate the investigation file. The NHA returned to the room at 4:32 p.m. and stated she was not able to locate the investigation file for the allegation of neglect for Resident #2 on 2/13/2024. The NHA also stated the investigation files were transferred between herself and the DON because she also conducted parts of the investigation. The NHA stated the facility interviewed the facility staff as part of the investigation, but was not able to provide a list of staff who were interviewed or evidence of the interviews being conducted at the time. A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE]. A review of the facility's reportable incidents log revealed an allegation of abuse was reported for Resident #7 on 4/24/2023. An interview was conducted on 7/2/2024 at 5:11 p.m. with the NHA regarding the allegation of abuse for Resident #7 on 4/24/2023. The NHA stated an allegation of abuse was reported to her on 4/24/2023 by another staff member involving a verbal argument between Resident #7 and the resident's nurse on 4/24/2023. The NHA also stated during the investigation of the allegation of abuse other alert and oriented residents in the same hallway where Resident #7 resided were interviewed and expressed no concerns related to abuse. The NHA was not able to provide a list of residents who were interviewed and was not able to provide evidence the interviews were conducted with the residents during the investigation. The NHA stated she was not able to locate the investigation file for the allegation of abuse for Resident #7 on 4/24/2023 and was not able to provide evidence of the investigation being conducted. Review of a facility policy titled, Abuse, Neglect, exploitation, Misappropriation, Mistreatment, injury of unknown source and investigations, dated 4/01/22, showed it will be the policy of this facility to honor resident's rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect . Under Investigation, The facility shall conduct their own internal investigation including, but not limited to staff(work history and background screening), resident, and family/resident representative interviews, medical record reviews, 24-hour reports reviews, full body skin exam, etc. The resident/representative and physician should be notified that there is an on-going investigation regarding the alleged incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews, and record review the facility failed to prevent a fall with injury for one (#8) of two residents reviewed for falls. Findings included: On 07/02/24 at 12:30 p.m., an observation and interview was conducted with Resident #8. She was observed in her room laying on her bed. Her Right leg was observed in a cast and was elevated. She stated she was in pain. The resident stated she was involved in a [mechanical lift] accident. She stated she remembered the incident very well. She said two CNAs (Certified Nursing Assistants) were transferring her from the bed to her wheelchair. During the transfer, the [mechanical lift] tipped when she was in mid-air. She stated the staff put her to the ground, but the metal part of the side table caught her ankle. She said, One of the CNAs was standing away from the lift holding on to the wheelchair. One CNA was operating the lift. She stated the side table was very close to the lift and it caught the leg of the lift, causing the lift to tip. The resident stated she broke her ankle. She stated she was frustrated because she could not get out of bed any longer and she probably would not for a very long time. She stated she was struggling with pain and realizing her recovery had been set back. The resident said, I am a big girl, I think the CNA who was moving me could not do it without help. The resident stated there were two CNAs in the room. She stated when the tray table fell, everything fell over her and the aide had to lower her down. She stated they were calling for help and no one was answering. Review of the admission Record for Resident #8 showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of a quarterly MDS dated [DATE], showed Resident #8 had a BIMS (Brief Interview for Mental Status Score) of 15, meaning the resident was cognitively intact. Review of section GG - functional abilities showed Resident #8 was dependent, meaning a helper provided all effort to transfer to and from bed to wheelchair. Review of June 2024 Active Physician Orders for Resident #8 showed an order to send the resident out for imaging to Right foot and ankle on 06/27/24, one time only related to acute pain due to trauma. Review of a Hospital Transfer Form dated 06/27/24 showed Resident #8 was transferred to a local hospital for a possible fracture. Review of a Change in Condition form dated 06/27/24 showed Resident #8 had a fall. The form showed the resident was her own person. Review of Physical Therapy evaluation and plan of treatment dated 06/28/24 -07/27/24 showed the resident was referred by nursing staff to PT (Physical Therapy) services, after sustaining a (R) ankle fracture during a [mechanical lift] transfer from the bed to wheelchair as patient was being lowered into wheelchair by nursing staff. Patient stated her table somehow tilted hitting her (R) ankle. Patient went to the hospital and returned with (R) ankle fracture with a soft cast in place. Review of a progress note dated 06/27/24 showed the resident was in the process of being transferred by 2 staff members via [mechanical lift] from bed to chair when she experienced a fall. In the process of transfer, the [mechanical lift] tilted in a way that was uncomfortable for staff and for safety purposes staff decided to lower resident to the floor . Upon reassessing resident had an abrasion 3 inches long on her lower leg. There were no open areas or further skin tears noted at the time. Review of a progress note dated 06/27/24 at 11:26 p.m., showed Resident #8 returned from [name of hospital] via stretcher . Resident with right fracture of ankle and placed in a cast. Review of an Advanced Registered Nurse Practitioner (ARNP) progress note dated 06/27/24 showed, Resident was seen today in facility after receiving a call the resident was being transferred from bed to wheelchair with [mechanical lift] and 2 Staff members when the [mechanical lift] began to tilt, staff were able to keep her from further tilting. Her right ankle/foot hit the bedside table and multiple staff eased her down to the floor to prevent the [mechanical lift] from tilting further over. She is seen with soft tissue swelling over her right ankle and mild chamois. X-rays of her right ankle were ordered and returned showing, age -indeterminate tib-fib fracture by 2 views. Review of a hospital Discharge summary dated [DATE], showed Resident #8 was discharged with a diagnosis of distal end of fibula, Fracture of distal end of tibia. Review of a CNA task log as of 7/2/24 showed for transferring, the resident required Mechanical lift with 2- plus assistance. Review of a care plan for Resident #8 with a transfer goal initiated on 04/14/22 showed the resident required a mechanical lift for transfers, with 2 plus assistance. An interview was conducted on 07/02/24 at 12:43 p.m. with Staff B, CNA. She stated Staff C, CNA was assigned to the resident but had asked her for help with the transfer. She said, The resident was in bed and was being transferred to her wheelchair. I was the one in control of the [mechanical lift]. [Staff C] was standing behind the chair, guiding her as I was turning the lift. Once she was over the chair, she was leaning a bit and was tipping to her right. The problem started when Staff B went to pull her to the chair, the lift was tipping and I called her, I said '[Staff B], she is about to fall!' We could not pull her. She was heavy. We were calling for help. We were both holding her, and her body was on top of the bedside table. We should have moved that out of the way. We were holding her, she is not particularly small, her feet were in a dangling position. I raised the lift all the way up. We were calling for help. Another resident went and got Staff D, CNA and another staff member, I don't remember her name. They came as we were lowering her down. She was all the way down when they got to the room. The nurse [Staff E, Licensed Practical Nurse (LPN)] came. She was kind of guiding us to position her. She told us to wait for EMS (Emergency Medical Service). It happened so fast we were trying to get her to the floor. We got her down to the floor and called 911. They came and helped lift her up. When we got her to bed, I saw she had an abrasion on the opposite leg, her left I believe. I notified the nurse. Later, the resident reported to Staff B that she had pain to her ankle. Staff B stated they talked about the incident later. Staff C was supposed to have had the resident ready. Her role was to help. Staff C was standing behind the chair the whole time. She was ready to pull her and guide her behind the chair. We used the lift that was in the room. The [mechanical lift] limit was 450 lbs. She stated the resident was already hooked up when she entered the room. She did not remember what sling size she had on. She said, it should have been the new bigger size. They just ordered new ones since the incident. She has one designated for her now. Staff B stated after the incident, the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) asked what had happened. Staff B said, I told them there were two of us in the room. They did not ask about the sling or the lift. They asked if the lift legs were open. I told them they were, but the table was in the way a little bit. They did not ask me to write a statement. No one followed up with me after that. On 07/02/24 at 1:04 p.m., an interview was conducted with the ADON. She said, We were in a meeting when we were told [Resident #8] was on the floor. They were trying to put her in a chair before lunch. The Unit Manager Staff F, Registered Nurse (RN) went to the room and was told there were two CNAs in the room. The resident was on the floor. They said the lift was tilted and they lowered the resident to the floor. We asked if the lift base was open. That's what should have happened. We would want the base to be open to balance the weight. They said she was positioned correctly. At that moment we got the Director of Maintenance to inspect the lift. It had no faults. The ADON stated she could not speak to anything else. She stated she was not present. The ADON stated they concluded they had two staff in the room, and they followed the care plan. The ADON stated she did not confirm the size of the sling. She stated the resident went out and the X-rays came back positive for a fracture. The ADON stated in response they started the in-service about the transfers, use of the [mechanical lift] and demonstrations. The ADON stated they did not conduct any further investigation. She stated they had not educated all CNAs, but they were in the process. On 07/02/24 at 1:28 p.m., an interview was conducted with Staff F, RN. She stated she was made aware by the floor nurse Resident #8 had a fall. Staff F, RN said, there was a malfunction of the equipment at the start. The floor nurse said the lift tilted over during the transfer and they lowered the resident to the ground. Upon investigation, I asked the resident what happened. She said she hit her leg on the bedside table. Staff F stated she removed that particular [mechanical lift] from the room and tagged it so no one could use it. She stated she did not remember the weight limit. She said, That was not a question we asked. We were trying to figure out if the [mechanical lift] was functioning properly. Staff F stated she did not ask the nurse what she meant by the lift was the problem. Staff F said she did not have her write a statement. I asked the two CNAs what happened, and their stories lined up. I did not ask how the injury happened. I did not collect any statements. I did not investigate it further. On 07/02/24 at 2:04 p.m., an interview was conducted with the Director of Maintenance (DOM). He stated after the incident, he inspected the [mechanical lift] that was used to transfer the resident. He stated the [mechanical lift] was fully operational. He said, I would not know the weight limit. All I know was that there was nothing wrong with the lift. That should be something the CNA should now. On 07/02/24 at 2:30 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated she went to see Resident #8 after the fall. She said the resident reported she had an accident with a [mechanical lift]. The NHA said, This resident normally likes to get up. She said she was afraid of transfers. I told her not to let this hold her back. The NHA stated both CNAs walked them through the process. They said the lift legs were open. The CNAs reported during the transfer, the lift started to tilt, and they lowered the resident to the floor. The NHA stated they did not investigate the incident any further because the CNAs were following the right process. She said, I spoke to both CNAs briefly that day. I asked if the [mechanical lift] could accommodate her weight. The DOM confirmed the lift was functioning properly. I believe the CNAs wrote statements. I have to check with the Unit Manager. She was leading the investigation. The NHA stated there were two staff members in the room and she went by that. She stated she would have expected them to write statements. An incident report should have been documented. She stated she was glad there were two staff members in the room. She stated that was her main focus. The NHA said, I don't have any documentation on any interviews. We did not think we had a problem. We did not get to the bottom of how the injury occurred. We did not conclude anything other than there were two staff members in the room. On 07/02/24 at 3:20 p.m. an interview was conducted with the Regional Nurse consultant (RNC). She stated the day the fall happened she was in the building. She remembered them going over the fall and they mentioned there were two staff in the room because she was a 2-person transfer. She said, I asked if the equipment was okay, and they said the DOM inspected the lift and determined there was nothing wrong with it. I understand nothing is documented but we asked those questions. On 07/02/24 at 4:15 p.m., an interview was conducted with the DON. She said, Looking back, I feel bad. I think we failed that resident. I should have conducted the investigation myself. I now know better. On 07/02/24 at 5:13 p.m., a follow -up was conducted with the RNC. She stated she did not think the fall should have been reported. She said, Based on our initial investigation, we did not find a reason to report. She stated a thorough investigation should have been conducted. Review of a facility policy titled, Falls and Fall risk-managing, dated 04/01/22, showed based on previous evaluations and current data the staff should identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Per the MDS (minimum data set) a fall is defined as unintentionally coming to rest on the ground, floor or other lower level but not as a result of an overwhelming external force (e.g. A resident pushes another resident). Fall risk factors include (d). Obstacles in the footpath. Under resident's centered approaches to managing falls and fall risk, (1.) The staff, with the input of the attending physician, should implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk with the history of falls. (7.) In conjunction with the attending physician, staff should identify and implement relevant interventions . to try to minimize serious consequences of falling. Under monitoring subsequent falls and fall risk (1.) The staff should monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. (3.) If the resident continues to fall, staff should reevaluate the situation and whether it is appropriate to continue or change current interventions. (4.) The staff and all physician should document the basis of conclusions that specific irreversible risk factors exist that continue to present a risk or injury due to falls.

Based on observations, interviews, and record review, the facility failed to assess, care plan and identify triggers related to trauma for one (#10) of two residents reviewed. Findings included: On 7/1/24 at 10:10 a.m., an observation of Resident #10 revealed she was lying in bed watching television. An interview with Resident #10 revealed she was upset by an experience she had on 6/21/24. She stated a nurse, who she could not recall her name, and [Staff A, Certified Nursing Assistant (CNA)] were providing catheter care. Resident #10 stated the door was closed. She stated a female resident entered her room and saw Resident #10 exposed from the waist down. Resident #10 stated, I was spread eagle and she saw me. An observation of Resident #10 revealed she was tearful and stated, I felt violated. She stated the nurse assisting Resident #10 escorted the female resident out of the room and closed the door. Resident #10 stated she reported the experience to another nurse, but she could not recall her name, and the Physician Assistant (PA) who followed her for catheter care at the facility. Resident #10 stated the second nurse who she told about the experience stated, The resident is demented and there's not much they can do as the resident is allowed to be in the halls. She stated the Administrator was supposed to see her regarding the experience, however, Resident #10 stated she has not. Further interview and observation of Resident #10 revealed she was tearful while describing an incident at a previous facility. She stated, I was raped by a female staff. She stated the previous facility was aware of the assault and she was sent to the hospital for examination. Resident #10 was visibly upset and crying while communicating about the sexual assault. A review of Resident #10's admission Record revealed an original admission date of 1/17/23 and a readmission date of 11/16/23. Further review of the admission Record revealed no diagnosis related to trauma. A review of Resident #10's active physician orders revealed, Psychiatry as needed, and, Psychology as needed, both dated 11/17/23. A review of Resident #10's psych notes, dated 6/10/24, revealed for abuse and neglect, There is no known history of physical, sexual, emotional abuse, or emotional neglect. Further review of psych notes revealed, Patient denies symptoms of PTSD [Post Traumatic Stress Disorder]. Denies experiencing traumatic events that involved actual or threatened death or serious injury. An initial review of Resident #10's current care plan revealed a focus related to a mood problem which revealed, r/t [related to] feeling tired and poor appetite at times. Interventions related to the mood problem focus revealed, Monitor/record/report to MD prn [as needed] acute episode feelings or sadness, and Monitor/record/report to MD prn mood patterns s/sx [signs and symptoms] of depression. Further review of the current care plan revealed no evidence of a focus associated with Resident #10's trauma history or interventions related to identified triggers. A review of Resident #10's progress notes revealed no notes related to the incident on 6/21/24. A review of a nursing progress note dated 6/21/24 revealed, resident c/o [complaint of] abdominal pain catheter irrigated. A review of the facility's Grievance Logs, dated January 20224 to May 2024, revealed no evidence regarding the resident's grievance/concern on 6/21/24. A review of the facility's matrix revealed the response regarding PTSD/Trauma was blank for Resident #10. On 7/1/24 at 1:02 p.m., an interview was conducted with the Director of Social Services and the Nursing Home Administrator. The Regional Nurse (RN) Consultant was present during the interview. The Director of Social Services initially stated the resident had a care plan for PTSD. She stated, The resident came to us from another facility with a statement that she'd been sexually assaulted. She stated the statement, regarding Resident #10 being sexually assaulted, was in paperwork from the other facility. The Director of Social Services reviewed the current plan and stated, I don't see a trauma care plan. She stated Resident #10 was assessed by her and she received psych services. The Director of Social Services stated she could not recall if Resident #10 was assessed for triggers. She confirmed Resident #10 should have been assessed for trauma. She stated if a resident had a past or current trauma, she assessed the resident, and a care plan was put in place. The Director of Social Services revealed the incident that occurred on 6/21/24 during catheter care with Resident #10 was not reported to her. The Nursing Home Administrator revealed she was not aware Resident #10 had a history of sexual abuse and she stated the incident on 6/21/24 was not reported to her. On 7/1/24 at 2:29 p.m. an interview with the Director of Social Services revealed when a resident was identified with trauma, a care plan was put in place. She stated she reviewed previous trauma assessments for Resident #10, which revealed no documentation of trauma. A review of the facility's policy titled, Social Services - Trauma Informed Care, with a revised date of 4/1/22, revealed the following: Purpose: It is the policy of this facility to provide care and services, which in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Procedure: . 2. The facility should use a multi-pronged approach to identifying a resident's history of trauma . This should include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment and others. Further review of the facility's policy, under procedure, revealed the following, 7. Trauma-specific care plan interventions should recognize the interrelation between trauma and symptoms of trauma .

Based on record reviews and interviews, the facility failed to provide timely and specific notifications to include the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS 10055 to two (Residents #341 and #48) of three sampled residents who were discharged from Medicare Part A services but remained in the facility. Findings included: A review of the SNF Beneficiary Protection Notification Review form completed by the Social Services Director (SSD) for Resident #341 indicated Medicare Part A Skilled Services Episode Start Date 11/03 and a last covered date of 12/02. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident remained in the facility but was not provided the SNF ABN, Form CMS-10055. The SSD completed the SNF Beneficiary Protection Notification Review form for Resident #48 verbally. The last covered day was 01/12. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident remained in the facility but was not provided the SNF ABN, Form CMS-10055. On 02/07/23 at 2:10 p.m., the SSD reported she would only issue the SNF ABN form if the resident was discharged from Medicare Part B only. The policy and procedure provided by the facility Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) issued 04/01/22 revealed the following: If after issuing the NOMNC (Form CMS-10123), the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN (CMS-10055) must be issued to inform the beneficiary of potential liability for the non-covered stay. The SBFABN (CMS-10055) will be issued to the resident no later than 2 days before termination of skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to follow the baseline care plan related to the use of oxygen for one (Resident #242) of thirty-five sampled residents. Findings included: On 02/05/23 at 10:00 a.m., Resident #242 was observed sitting on the side of the bed. An oxygen concentrator was next to the bed with oxygen tubing sitting on the top of the concentrator. The machine was not on. The resident was not using the oxygen at this time. On 02/06/23 at 10:14 a.m., the resident was sitting next to the bed. The oxygen concentrator was next to the bed, but the machine was not on. The resident was not using the oxygen at this time. On 02/07/23 at 10:19 a.m., Resident #242 was observed in her room sitting next to the bed. The oxygen concentrator was next to the bed, but the machine was not on. She was not using the oxygen at this time. She reported she did not know the last time she used the oxygen. She stated, I can't keep up with it. A review of the admission Record revealed Resident #242 was admitted into the facility with a diagnosis that included but was not limited to Chronic Obstructive Pulmonary Disease (COPD). Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired cognition. Section O Special Treatments, Procedures, and Programs indicated the resident used oxygen therapy. A review of the Order Summary Report with active orders as of 02/08/23 revealed the following order: 2 liters of oxygen via nasal cannula continuously for COPD every shift. The base line care plan initiated on 02/01/2023 related to oxygen included but was not limited to the following intervention: Oxygen at 2 liters per minute continuously via nasal cannula. On 02/07/23 at 10:20 a.m., Staff G, Licensed Practical Nurse (LPN), reported Resident #242 used oxygen sometimes. She stated she had not seen her use it this morning. Staff G pulled up the orders for the resident and stated she had an order for oxygen, and it should be continuous. Staff G, LPN, stated the resident had therapy this morning so that was probably why she did not have it on. She had it on before therapy. Staff G, LPN, stated she should have it on and she would put it on her now. Staff G was observed placing the oxygen on the resident. On 02/07/23 at 11:05 a.m., the Director of Nursing (DON) reported the resident had an order for oxygen, but she was noncompliant and was care planned for being noncompliant. On 02/07/23 at 11:35 a.m., the MDS Coordinator reported the greyed out area on the care plan was what the care plan read before she made changes and that was the baseline care plan. The care plan did not indicate the resident was noncompliant with the use of oxygen. On 02/07/23 at 11:39 a.m., the DON stated the expectation was that she should wear the oxygen with the exception of during smoking times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure two (#55 and #36) of two residents sampled for pressure ulcers received wound care per the physician orders. Findings included: 1. An observation and interview was conducted, on 2/5/23 at 2:02 p.m., with Resident #55. The resident confirmed the presence of an infection to the right thigh. The resident reported that wound care was supposed to be every day but a couple of them forgot. The observation of the resident identified a double lumen peripherally inserted central catheter (PICC) located in the right upper extremity. The review of Resident #55's admission Record indicated the resident was admitted on [DATE] with diagnoses that included right femur acute hematogenous osteomyelitis. The admission Minimum Data Set (MDS), 1/24/23, identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition. The MDS revealed the resident had one stage IV pressure ulcer and required pressure ulcer/injury care. Review of the Order Summary Report, active as of 2/8/23, identified the following wound care orders: - Treatment as follows: Right hip. Cleanse with normal saline (n/s), pat dry. Apply calcium alginate and collagen. Cover with clean dry dressing as needed. This order was ordered on 1/19/23. - Treatment as follows: Right hip. Cleanse with normal saline (n/s), pat dry. Apply calcium alginate and collagen. Cover with clean dry dressing every day shift for stage 4 pressure ulcer. This order was ordered on 1/19/23. The February Treatment Administration Record (TAR) for Resident #55 identified that wound care for the stage 4 pressure ulcer was not completed as scheduled on 2/2 or 2/5/23. The TAR did not indicate that as needed wound care to the stage 4 pressure ulcer had been done. Review of Resident #55's care plan included a focus that identified the resident was admitted with right hip chronic stage 4 -recently debrided, right heel - dry not open, right foot - scab not open, 1/23/23 rash left back, and groin - fungal rash. The interventions instructed staff to Administer treatments as ordered and monitor for effectiveness. 2. An observation and interview was conducted at 2:35 p.m. on 2/5/23, with Resident #36. The resident stated that 99% of the time staff changed the dressing to the left foot and the right back side got changed daily and if staff did not come in, the resident let them know. Resident #36 reported a couple of times wound care did not get done and the facility wrote them up. A review of Resident #36's admission Record indicated the resident was originally admitted on [DATE]. The record included diagnoses not limited to Stage 4 pressure ulcer of sacral region, unspecified peripheral vascular disease, Type 2 diabetes mellitus without complications, and morbid (severe) obesity due to excess calories. The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #36 had an intact cognition as evidence by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. The MDS assessment indicated that the resident had 2 - stage 4 pressure ulcers, and Moisture Associated Skin Damage. An observation was made on 2/7/23 at 12:44 p.m., of Resident #36's wound care with Staff Member D, Licensed Practical Nurse (LPN) and Staff Member F, Registered Nurse/Unit Manager (RN/UM). The left lateral foot was observed with black tissue and yellow tissue. As Staff D pulled the dressing off the area, it began to have bright red drainage. The heel wound was observed with a large amount of black tissue. The resident rolled onto left side and Staff D removed a saturated dressing from the sacral area. The disposable pad which the resident was lying on was saturated with a black-brown substance. The bilateral buttock area of the resident was a purplish-red color with a large sacral wound. Staff B applied a super absorbent silicone dressing to the left buttock, Staff F supplied another super absorbent silicone dressing, that was applied to the sacral area, and another foam dressing was removed from the residents closet and then applied to the sacral area. A review of Resident #36's progress notes identified a note, dated 12/20/22 at 10:26 a.m., written by the Social Service Director (SSD). The note indicated the SSD had spoken to the resident and a family member and the resident stated the bandage needed to be changed. The family member pointed out the dressing was dated 12/17/22. The note indicated the nurse changed bandage right away. On 2/7/23 at 3:34 p.m., the SSD confirmed the family member had complained of wound care not being completed in December. She stated she had completed a grievance immediately and turned it into the Director of Nursing. The SSD reported the findings were that wound care had not been provided to Resident #36. On 2/7/23 at 3:47 p.m., the SSD reported a grievance had not been completed as the team decided it was a reportable incident. The Nursing Home Administrator stated, on 2/7/23 at 3:50 p.m., a family member of Resident #36 reported wound care had not been done and the resident had reported notifying the nurse on 12/18/22 but had not reported it to anyone on 12/19/22. The NHA stated the nurse who had worked on 12/18/22 had been contacted and it was confirmed that the wound care had been forgotten. The nurse who had worked on 12/19/22 reported the resident had refused three times due to not having a shower. The NHA stated there should be documentation regarding the resident refusing wound care and she did not know of the resident refusing treatments. A review of Resident #36's December Treatment Administration Record (TAR) identified the following: - Treatment as follows - cleanse left lateral foot ulcer with betadine, apply collagen and alginate, then cover with abdominal pad (ABD), and wrap with kerlix daily and as needed (prn) every day shift for arterial ulcer. This order started on 12/16/22 and was discontinued on 1/17/23. The TAR indicated that wound care was not provided on 12/18, 12/19, and 12/21/22. - Treatment as follows - left ischium. Cleanse with normal saline, pat dry, apply collagen, and cover with silicone dressing daily and prn every evening shift for left ischium pressure wound stage 4. This order was started on 12/7/22 and discontinued on 12/23/22. The TAR identified that wound care had not been provided on 12/18/22. - Treatment as follows: Clean the left inner buttock with normal saline (NS), pad dry, skin prep periwound, apply collagen, and cover with dry dressing daily and prn every day shift for trauma. This order was started on 12/8/22 and was discontinued on 12/23/22. The TAR indicated wound care was not provided on 12/18, 12/19, and 12/21/22. - Treatment as follows: Cleanse left heel with NS, apply skin prep and ABD pad, then [NAME] with kerlix daily every day shift for trauma. This order was started on 12/16/22 and was discontinued on 12/23/22. The TAR identified that wound care was not provided on 12/18, 12/19, and 12/21/22. - Treatment as follows: Cleanse sacrum with Dakins, pat dry, apply silver alginate, with silver, then cover with foam dressing daily and prn, every day shift for Stage 4. This order started on 11/18/22 and was discontinued on 12/23/22. The TAR indicated that wound care had not been provided on 12/18 and 12/19, and 12/21/22. Review of the TAR for Resident #36 did not indicate staff had documented the resident had refused any treatments on 12/18, 12/19, and/or 12/21/22. Review of progress notes for Resident #36 for 12/19/22 and 2/20/22 did not indicate the resident had refused wound care, the notes did indicate that the residents' Mood status is pleasant and Behavioral problems are not noted. The review indicated that there was no progress note on 12/18/22. The care plan for Resident #36 included the focus that indicated the resident had multiple pressure ulcers/surgical/diabetic, vascular, (and) MASD wounds: sacrum stage 4 - admitted with, left ischium stage 4 - admitted with, left lateral plantar foot - arterial - 11/2/22 was diabetic, 8/11/22 bilateral buttock MASD, 11/9/22 - left inner buttock - trauma, 12/1/22 - left heel - trauma, (and) 1/17/23 - abdominal fold. The interventions indicated that on 12/21/22 the resident was seen by wound specialist and multiple treatments adjusted and instructed staff to Administer treatments as ordered and monitor for effectiveness. The Director of Nursing stated, on 2/8/23 at 9:28 a.m., wounds were done by the floor nurses and a wound Advanced Registered Nurse Practitioner (ARNP) came to the facility weekly. She acknowledged the facility did have a problem with one nurse not doing wound care for Resident #36 but was unaware that Resident #55 did not get wound care on 2/2 and 2/5/23. The DON reported the expectation was if a nurse was having an issue (regarding wound care) to reach out to the nursing management team and/or other floor nurses and if there was a reason wound care was not done, the expectation would be there was documentation as to the reason. The DON reviewed the record for Resident #55 and confirmed that there was no reason documented that wound care was not provided. The DON stated when Resident #36's wound care was not done the nurse was suspended and the facilty began its investigation, the nurse had reported going to the resident a few times and (the resident) was not ready, it was shift change, the nurse went to another unit and did not report to the oncoming nurse that it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide pain management services per the physician orders. The facility provided pain medication outside the physician ordered parameters for two (Residents #46 and #30) of two residents reviewed for pain management. Findings included: 1. During an interview on 02/05/23 at 10:25 a.m., Resident #46 stated the facility gave her medications for pain however the pain was always there even after medications were given. A review of Resident #46's medical record showed she had a diagnosis of Paraplegia, unspecified, pain in left leg and other muscle spasms. The care plan showed a focus of Chronic pain due to paraplegia, spinal cord injury and history of meningitis with an intervention to include an intervention to administer analgesia as per orders. A physician order dated 01/18/23 stated, Hydrocodone-Acetaminophen Tablet 5-325- Give tablet by mouth every 8 hours as needed for pain severe (7-10) not to exceed 3 grams. The Medication Administration Record (MAR) for January 2023 and February 2023 revealed the following dates that Hydrocodone was given outside the physician ordered parameters: 01/01/23- pain level was 6 with Hydrocodone administered 01/02/23- pain level was 5 with Hydrocodone administered 01/03/23- pain level was 3 with Hydrocodone administered 01/06/23- pain level was 0 with Hydrocodone administered 01/19/23- pain level was 6 with Hydrocodone administered 01/24/23- pain level was 6 with Hydrocodone administered 01/28/23- pain level was 6 with Hydrocodone administered 01/31/23- pain level was 3 with Hydrocodone administered 02/04/23- pain level was 6 with Hydrocodone administered 02/05/23- pain level was 6 with Hydrocodone administered During an interview on 02/06/23 at 2:25 p.m., the Director of Nursing (DON) confirmed the pain medication was given outside the parameters of the physician order. DON stated the Hydrocodone was not administered per physician order and outside the pain scale parameters. A review of the facility's policy and procedure titled, Administering Medications with no date stated, Medications are administered in accordance with prescriber orders, including any required time frame. 2. Resident #30 reported, on 2/5/23 at 10:40 a.m., pain in left hip, left knee, upper shin, and left ankle that comes and goes. The resident reported a pain level of 9. Staff N, Licensed Practical Nurse (LPN), reported, at 10:43 a.m. on 2/5/23, the resident had previously been medicated for pain. The resident reported Tylenol was not working and Percocet did not work at times. On 2/5/23 at 12:15 p.m., Resident #30 was observed sloped to the right while sitting in a wheelchair, Staff I, Certified Nursing Assistant (CNA), called the resident's name numerous times and Staff N asked for the resident to be put back in bed due to pain. A review of Resident #30's admission Record indicated the resident was admitted on [DATE] with diagnoses that included non-displaced comminuted fracture of shaft of left femur subsequent encounter for closed fracture with routine healing, displaced fracture of lesser tuberosity of left humerus subsequent encounter for fracture with routine healing, repeated falls, and polyneuropathy in diseases classified elsewhere. The Order Summary Report, active as of 2/8/23, included the following physician orders: - Acetaminophen 325 milligram (mg) - Give 2 tablets by mouth every 4 hours as needed for pain, ordered 1/14/23. - Oxycodone-Acetaminophen 5-325 mg - Give 1 tablet by mouth every 4 hours as needed for pain, pain scale 4-6, ordered to start on 1/14/23. - Oxycodone-Acetaminophen 5-325 mg - Give 2 tablet by mouth every 4 hours as needed for pain, pain scale 7-10, ordered to start on 1/14/23. Review of Resident #30's February Medication Administration Record (MAR) identified that 2 tablets of Acetaminophen had not been administered. The MAR indicated staff administered 2 tablets of 5-325 mg Oxycodone-Acetaminophen on 2/1 at 7:47 p.m. for a pain level of 5, on 2/3 at 10:02 a.m. for a pain level of 3, at 5:00 p.m. for a pain level of 5, and on 2/6 at 1:32 a.m. for a pain level of 4. The care plan for Resident #30 indicated the resident had the potential for pain related to (r/t) a fall at home resulting in a left femur fracture with nailing on 12/13/22 and a left humerus fracture without surgical intervention. The interventions indicated that staff were to administer pain med as per orders. The Admission/5-day Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating a moderate loss of cognition. The MDS indicated a pain assessment interview was conducted with the resident who reported occasional pain with the worst pain level of 4.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and three errors were identified for two (Residents #71 and #53) of five residents observed. These errors constituted a 11.11% medication error rate. Findings included: 1. Staff D, Licensed Practical Nurse (LPN) obtained, at 8:45 a.m. on 2/7/23, a blood pressure of 147/83 and a pulse of 70 from Resident #71. On 2/7/23 at 8:50 a.m., Staff D dispensed the following medications for Resident #71: -- Carbamazepine Extended Release 100 milligram (mg) - 6 tablets -- Amlodipine 5 mg tablet -- Aspirin 81 mg Enteric Coated tablet -- Calcium Carbonate 500 mg chewable tablet - Vitamin D3 5000 unit tablet -- Citalopram 10 mg tablet -- Lisinopril 10 mg tablet -- Memantine 10 mg tablet -- Daily Vitamin with multimineral tablet -- Pregabalin 50 mg capsule The staff member confirmed 15 tablets/capsules prior to entering Resident #71's room. An interview, on 2/7/23 at 9:14 a.m., after the administration and upon returning to the medication cart, Staff D confirmed dispensing one Vitamin D3 tablet not the two that was ordered. The staff member confirmed the amount of tablets/capsules would have been 16 if two Vitamin D3 tablets had been dispensed. Review of the Order Summary Report, active as of 2/8/23, for Resident #71 included a physician order: - Cholecalciferol tablet 5000 unit - Give 2 tablets by mouth one time a day for Vitamin D deficiency. 2. On 2/7/23 at 9:17 a.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #53. The staff member dispensed the following medications: - Acetaminophen 325 mg - 2 tablets - Aspirin 81 mg chewable tablet - Sodium Chloride 1 gram - 2 tablets - Metoprolol Succinate 50 mg Extended Release (ER) tablet - Losartan Potassium 50 mg - 2 tablets - Namenda 10 mg tablets Staff Member E confirmed dispensing 9 tablets. The staff member entered the residents' room and administered the medications. Review of Resident #53's Order Summary Report identified the following orders: - Losartan Potassium 50 mg - Give 2 tablet by mouth one time a day for hypertension (HTN). Hold for systolic blood pressure (SBP) <120. - Metoprolol Succinate ER 24 hour 50 mg - Give 1 tablet by mouth one time a day for HTN. Hold for SBP < 120 and /or pulse <60. The review of Resident #53's February Medication Administration Record (MAR) identified that on 2/7/23 Staff E documented NA for the required blood pressure prior to the administration of Losartan and NA for the required blood pressure and pulse for the administration of Metoprolol. On 2/7/23 at approximately 9:50 a.m., Staff E reported, without consulting paperwork and hesitation, that Resident #53's blood pressure was 122/76 and pulse 78. The staff member reported the blood pressure and pulse were obtained at 7:15 a.m. this morning and they had not been documented anywhere but she remembered them. A review of Resident #53's Weights and Vital Summary indicated that Staff E documented at 9:53 a.m. on 2/8/23 a blood pressure of 122/68. The Director of Nursing stated, on 2/8/23 at 9:28 a.m., reported knowledge of the Resident #71's missed Vitamin D during the task of medication administration. She stated her expectation was to follow physician orders and to document (blood pressure and pulse) at the time of administration. The facility policy - Administering Medications, undated, identified that Medications are administered in a safe and timely manner, and as prescribed. The Interpretation and Implementation indicated the following: - Medications are administered in accordance with prescriber orders, including any required time frame. - The following information is checked/verified for each resident prior to administering medications: -- a. Allergies to medications; and -- a. Vital signs, if necessary

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure insulins were removed after expiration date, medications were stored per route and not in same compartment with non-medications in one ([NAME]) of two sampled medication carts, failed to ensure one (Canterbury) of two sampled medication carts were locked while unsupervised, and failed to ensure one ([NAME]/[NAME]) of two medication rooms did not contain expired medications. Findings included: On 2/6/23 at 12:00 p.m., an observation of the [NAME] medication cart was conducted with Staff G, Licensed Practical Nurse (LPN). The observation identified a clear bag containing an Insulin Lispro injection KwikPen. The bag indicated the pen was opened on 1/3/23 and expired on 2/1/23. A pharmacy bag contained 2 vials of Insulin Lispro. The bag identified that the vials were opened on 1/2/23, one of vials was labeled with 1/5. The website, https://www.humalog.com/u100, identified that Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. In the bottom drawer of the medication cart was a compartment that contained an opened bottle of a drug disposal solution, an opened bottle of the medication Valproic Acid, and a box of Lidocaine topical patches. Photographic evidence was obtained. On 2/8/23 at 9:28 a.m., the Director of Nursing stated that external (medications) should be separate from internal (medications). On 2/7/23 at 7:49 a.m., an observation was made of the Canterbury medication cart located in the hallway between rooms [ROOM NUMBERS]. The observation indicated the cart was unlocked and two staff members were at the opposite end of the hallway. The Director of Nursing arrived to the area and confirmed the cart was unlocked and should be locked. Staff D, Licensed Practical Nurse (LPN) came out of room [ROOM NUMBER], at 7:50 a.m. on 2/7/23, and confirmed that the cart was unlocked, I'm so mad at myself. On 2/8/23 at 9:15 a.m., an observation was made of the [NAME]/[NAME] medication room with Staff F, Registered Nurse/Unit Manager (RN/UM). On the top shelf of an upper cabinet was a box of Acetaminophen 650 milligram (mg) suppositories which was opened on 12/27/20 and expired 12/2022. The staff member confirmed findings. Photographic evidence was obtained. The policy - 5.0 Medication Storage, undated, indicated that Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida (FL) Department of Health guidelines. The procedure indicated the following: - A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. - B. Medications for external use will be stored separately from medications for internal use. Ophthalmic, otic and nasal products will be stored separately from other medications for internal use. - C. Medications will be stored in an orderly, organized manner in a clean area. - F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for two (Residents #3 and #78); and 2.) ensure the accuracy of a PASARR Level I for two (Residents #65 and #143) admitted with mental health diagnoses of four residents sampled for PASARR. Findings included: 1. Review of the Face Sheet for Resident #3 revealed admission to the facility on [DATE], with diagnoses that included cirrhosis, benign prostate hypertrophy and hepatitis. Further review revealed additional diagnoses identified after admission to the facility; they included: -schizophrenia, diagnosed 06/09/2015 -major depressive disorder (MDD), diagnosed 07/01/2020 -dementia, diagnosed 10/01/2022 Review of a Psychiatric Note dated 01/06/2023 revealed psychiatric diagnoses and history that included dementia, schizophrenia, MDD and dysphagia. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed in Section I diagnoses that included non-Alzheimer's dementia, depression, and schizophrenia. Section N of the MDS revealed antipsychotic medications had been administered to the resident during the past seven days. Review of the current Care Plan for Resident #3 revealed focus areas that included: -history of being resistive to care/treatment r/t [related to] hx [history] of anxiety, dementia, mood d/o [disorder] and schizophrenia at times. -history of behavioral problems r/t cognitive loss/dementia, depression, mood d/o, med [medication] use, disorganized schizophrenia. -[Resident] has impaired cognitive function or impaired thought process r/t dementia, depression, and mental illness. -on antipsychotic therapy r/t schizophrenia, mood disorder. -[Resident] has a mood problem r/t hx of anxiety, dementia with behavioral disturbances, disorganized schizophrenia, and unspecified mood disorder. Further review of the documents section of the clinical record revealed a PASARR Level I completed 04/10/2013 with history of mental illness checked 'no', and history of mental retardation checked 'no.' No additional PASARR assessments (Level I nor Level II) were evident in the clinical record. During an interview with Staff A, Assistant Director of Nursing (ADON) on 02/06/2023 at 4:13 p.m., she stated it was the responsibility of the Social Services department to ensure PASARRs were complete. On 02/07/2023 at 10:54 a.m., an interview was conducted with Staff B, Social Services Director (SSD) and the Nursing Home Administrator (NHA). The SSD stated she reviewed PASARRs that were completed prior to admission for accuracy and said she did not complete a new PASARR when a resident had a new psychiatric or mental health diagnosis after admission. The SSD reviewed the clinical record for Residents #3 and #78 and confirmed both residents had a new psychiatric diagnoses identified since admission to the facility and completion of the last PASARR Level I. The SSD also reviewed the clinical record for Residents #65 and #143 and confirmed both residents were admitted to the facility with a psychiatric diagnosis that was not reflected on their pre-admission Level I PASARR. Review of a facility-provided policy titled Role of Admissions and Social Services in PASRR dated 4/1/2022 revealed: Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs a by coordinating with the appropriate State-designated authority. IV 2. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II Resident Review upon a significant change in status. 2. A review of the admission Record identified Resident #143 was admitted on [DATE]. The record included the diagnoses of moderate dementia in other diseases classified elsewhere with mood disturbance, uncomplicated alcohol abuse, unspecified persistent mood (affective) disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. A review of Resident #143's Preadmission Screening and Resident Review (PASRR), completed by an acute facility on 1/30/23, did not identify the residents' diagnoses of substance abuse, depressive disorder, psychotic disorder and/or anxiety disorder. The document identified that the findings were based on Documented History and did not indicate findings from behavioral observations and/or medications. The PASRR indicated the resident may be admitted to the facility as a Level II evaluation was not required. Review of the acute facility's History and Physical (H&P) identified that a Care Coordination note, dated 1/31/23 at 1:01 p.m., indicated Resident #143 was also currently in Mitts and roll belt , must be 24 hours (hrs) before patient (pt) can discharge (dc) without having restraints on. The acute facility's H&P identified Resident #143 had a past medical history that included dementia, alcohol abuse, anxiety, and insomnia. The inpatient medications that Resident #143 was ordered included 0.5 milligrams (mg) of Lorazepam three times daily, Quetiapine 100 mg at bedtime, Divalproex Sodium Delayed Release 125 mg three times a day, mirtazapine 15 mg at bedtime, and trazodone 50 mg at bedtime. The Order Summary Report, as of 2/7/23 at 11:31 a.m., included the following medications: - Divalproex Sodium Delayed Release 125 mg three times a day for mood disorder, started 2/4/23; - Lorazepam 0.5 mg three times a day for anxiety, hold for lethargy or sedation, started 2/4/23; - Mirtazapine 15 mg at bedtime for depression, started 2/4/23; - Quetiapine Fumarate 50 mg at bedtime for psychosis, started 2/4/23; - Thiamine 100 mg daily for alcohol abuse, started 2/4/23; - Trazodone 50 mg at bedtime for depression/insomnia, started 2/4/23. Resident #143's care plan identified the following focuses: - is on antipsychotic therapy related to (r/t) psychosis, initiated 2/4/23. - uses psychotropic medications r/t behavior management, initiated 2/4/23. - uses antidepressant medication r/t depression. (resident) also has insomnia and mood disorder, initiated 2/4/23. - uses anti-anxiety medication r/t Anxiety disorder. (resident) has a history of alcohol abuse, initiated 2/4/23. - has dementia with psychosis, failure to thrive. (resident) is confused and mental function varies. At risk for further cognitive loss related to progressive disease process, initiated 2/4/23 and revised 2/7/23. - at risk for falls and for fall related injury secondary to C-Diff, pancolitis, diarrhea. Also has dementia with confusion and forgetfulness, failure to thrive (FTT), severe malnutrition, hypertension (HTN), alcohol abuse, dysphagia, mood disorder, psychosis, depression, and anxiety. Requires extensive assistance with needs and mobility, incontinent of bowel and bladder on admission, initiated 2/4/23. - has behaviors r/t dementia, wanders out of room despite being reminded currently on isolation, frequently undresses self, and easily redirected. An interview was conducted on 2/7/23 at 10:46 a.m. with the Social Service Director (SSD). The SSD reviewed Resident #143's PASRR and confirmed the document should been changed to include psychiatric diagnoses. 3. A review of Resident #78's medical record showed a new diagnosis of Schizophrenia, unspecified and Schizophreniform Disorder dated 12/02/22. A physician order dated 01/25/23 stated, Quetiapine Fumarate Tablet 25 Mg- give 3 tablets by mouth daily for Schizophrenia. The Quarterly Minimum Data Set (MDS) dated [DATE] showed a diagnosis of Schizophrenia under section I of the MDS with an antipsychotic given all seven (7) days during the look back period. A Preadmission Screening and Resident Review (PASARR) dated 10/14/22 was available. No additional PASARR was available after the new diagnosis of Schizophrenia. During an interview on 02/07/23 at 10:45 a.m., Staff B, SSD stated,I didn't know I needed to re-do a PASARR with a new psych diagnosis. 4. Resident #65 was admitted into the facility on [DATE] with admitting diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #65's Preadmission Screening and Resident Review (PASARR) dated 12/29/22 revealed no qualifying mental health diagnosis and that no PASARR Level II was required. Section I of the 5 Day Minimum Data Set (MDS) revealed the resident had the following active diagnoses: non-Alzheimer's dementia, depression, and psychotic disorder. A review of the medical record revealed the resident was not assessed for a PASARR Level II. On 02/07/23 at 10:56 a.m., the Social Services Director (SSD) confirmed the Level I PASARR was inaccurate and should be redone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement an effective infection control program as evidence by not ensuring the appropriate hand hygiene was completed after delivering a meal tray to one (Resident #143) of one resident infected with Clostridioides Difficile (C Diff) on one of four units, failed to designate Contact precautions for one (Resident #55) of 35 sampled residents, and failed to ensure that non-dedicated equipment was cleaned in between two (Residents #7 and #145) of five residents observed during medication administration. Findings included: 1. A review of the admission Record revealed Resident #143 was admitted on [DATE] with a primary diagnosis of Enterocolitis due to Clostridium Difficile not specified as recurrent. The Order Summary Report for the resident included a physician order, dated 2/3/23, for Isolation C Diff every shift for isolation and Isolation maintained for shift, activities, and services brought to room C Diff every shift for Isolation. On 2/5/23 at 12:53 p.m., Staff H, Certified Nursing Assistant (CNA), donned gown, gloves, and a face shield then entered Resident #143's room with a meal tray. The staff member removed gown and eye protection in the hallway outside of the residents' room and crossed the hall to utilize the wall dispenser of hand sanitizer in between rooms [ROOM NUMBERS]. The staff member stated that the hand sanitizer was sticky. Staff H asked Staff Member N, Licensed Practical Nurse (LPN) (as the LPN left room [ROOM NUMBER]) what Resident #143 was on precautions for and Staff N said for C Diff. Staff Member H stated the appropriate hand hygiene was to wash hands. Staff H traveled from outside of rooms [ROOM NUMBERS] to the nursing station at the other end of the hallway and was observed entering a room behind the desk. The Centers of Disease Control and Prevention (CDC) indicated at cdc.gov/cdiff, that washing with soap and water is the best way to prevent the spread from person to person. A CDC informational indicated that C. diff spreads when people touch surfaces that are contaminated with poop from an infected person or when people don't wash their hands with soap and water. The information identified that healthcare professionals can prevent C. diff by: wearing gloves and gowns when treating patients with C. diff and remembering that hand sanitizer doesn't kill C. diff. Review of the facility policy - Hand Hygiene, effective 9/5/2016 and revised 2/5/2021, indicated its purpose was To reduce the spread of germs in the healthcare setting. The process section of the policy identified Hands should be washed with soap and water when they are visibly soiled or before and after eating and with bathroom use. Use of soap and water to perform hand hygiene is recommended when caring for a resident(s) with known or suspected Clostridium difficile, when caring for a resident(s) with known or suspected infectious diarrhea or Norovirus outbreaks. 2. The admission Record for Resident #55 identified an admission date of 1/17/23. The record included diagnoses not limited to acute hematogenous osteomyelitis of right femur and unspecified paraplegia. An observation was conducted, on 2/5/23 at 2:02 p.m., of Resident #55. The resident reported a wound infection to the right thigh. Review of Resident #55's Order Summary Report included a physician order, dated 1/23/23, that indicated Isolation type - Contact every shift for Methicillin-resistant Staphylococcus aureus (MRSA) until 2/19/23. The February Treatment Administration Record (TAR) for the resident identified that staff had documented every shift (minus day shift on 2/2/23) that the resident was on Contact isolation. An observation, on 2/6/23, of the door and area outside of Resident #55's room did not identify that the resident was on contact precautions. Photographic evidence was obtained. Staff O, Licensed Practical Nurse (LPN) confirmed, on 2/6/23 at 2:18 p.m., that Resident #55 was on contact isolation. The staff member confirmed there was no sign on the door or Personal Protective Equipment available outside of the room. Staff O reported just finding the order in the computer and that the resident was on isolation until the 19th. The Director of Nursing (DON) confirmed, on 2/6/23 at 2:24 p.m., that Resident #55 was on contact isolation due to wound until 2/19/23. The DON confirmed that the order did not indicate that contact isolation was for the wound and that it should identify where the MRSA was and that isolation was needed for wound care. An observation with the DON identified that there were no signs on the resident door indicating the necessity for contact precautions. The Centers of Disease Control and Prevention (CDC) guideline - Methicillin-resistant Staphylococcus aureus (MRSA), reviewed January 31, 2019, indicated that to prevent MRSA infections, healthcare personnel: Use Contact Precautions when caring for patients with MRSA (colonized, or carrying, and infected). The instructions indicated that Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. 3. On 2/7/23 at 7:58 a.m., an observation was made with Staff C, Registered Nurse (RN) of the administration of medication with Resident #7. Observed from the hallway of Staff C obtain vital signs with a wrist blood pressure cuff. The staff member returned to the medication cart, laid the cuff on top of the cart without cleaning it and reported vital signs of 115/70, pulse 75, temperature of 97.2, 97% oxygen saturation on room air, and 17 respirations. Staff C dispensed medications and administered the medications to the resident. Staff C moved the medication cart to in front of Resident #145's room. The staff member removed the wrist blood pressure cuff and pulse oximeter from top of the medication cart, that was previously used on Resident #7 and obtained vital signs from Resident #145. Staff C removed a canister of Microkill wipes from the medication cart and used a wipe to clean the oximeter then the wrist cuff. On 2/7/23 at 8:33 a.m., Staff C reported thinking that cleaning of the cuff and pulse oximeter was done after leaving Resident #7's room. The policy - Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy identified that a blood pressure cuff was considered a non-critical item and Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). The Director of Nursing stated, on 2/8/23 at 9:28 a.m., that staff were to clean reusable equipment in between residents with bleach wipes.

Based on observation, interview, and photogenic evidence, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items and did not ensure the dishwasher temperature log was up to date. The failed practice had the potential to effect more than a limited number of Residents. Findings included: 1. An observation on 02/05/23 at 9:15 a.m., during the initial tour of the kitchen, showed the walk in refrigerator contained food items that were not labeled or dated. The following items were noted with photogenic evidence obtained: A bag of lettuce was not labeled or dated A container of white substance was not labeled or dated A container of chopped meat was not labeled or dated. During an interview 02/05/23 at 9:17 a.m., Staff J, [NAME] confirmed the bag of lettuce should have been labeled and dated. Staff J confirmed the container of white substance that was identified as cottage cheese was not labeled or dated and should have been. Staff J also confirmed the chopped meat identified as chopped chicken should have been labeled and dated. Staff J stated all food should be labeled and dated. 2. An observation on 02/05/23 at 9:00 a.m., during the initial tour of the kitchen, showed a dish washer temperature log that was not completed for the evening of 02/04/23. Photogenic evidence was obtained. During an interview on 02/05/23 at 9:10 a.m., Staff J confirmed the dish washer log was not completed for the evening shift of 02/04/23 and should have been. An observation on 02/05/23 at 9:20 a.m., showed Staff K, [NAME] completing the dish washer temperature log for the 02/04/23 evening shift. In an immediate interview on 02/05/23 at 9:20 a.m., Staff K stated he should have completed the dishwasher temperature log last night. Staff K stated the dishwasher temperature log should have been completed on the evening shift but he forgot to complete it at that time. A review of the facility's policy titled, Food Storage: Cold Foods with revision date on 04/2018 stated, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on record review and interview, the facility failed to ensure the arbitration agreement explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it and the agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility for three (Resident #205, Resident #55, and Resident #293) of the sampled three residents. Findings included: Section G of the admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration, shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with the party to the extent that such affiliates joins in the arbitration, and judgement on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The form was signed by Resident #205 on 01/27/23. The form was signed by Resident #55 on 02/07/23. The form was signed by Resident #293 on 01/30/23 The arbitration agreement did not grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement. The arbitration agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. On 02/07/23 at 1:32 p.m., the Admissions Director reported she explained the arbitration agreement to the residents on their level. It was a small blurb in the Admissions Agreement. She explained to them that if there were any issues, they should try to resolve it with the facility first. She also lets the residents know that they could hire an attorney. The residents were signing and acknowledging that they understood the agreement. On 02/08/23 at 9:30 a.m., the Admissions Director stated she had concerns with the arbitration agreement also especially with the Jersey City, New Jersey part. The agreement did not include the residents could rescind the agreement and signing the agreement was voluntary. They were working with the legal team to change it. The legal team sent a new arbitration agreement that they were working on. They were just waiting for legal to approve it.

Based on record review and interviews, the facility failed to ensure the arbitration agreement provided for the selection of a venue that was convenient to both parties for three (Resident #205, Resident #55, and Resident #293) of three sampled residents. Findings included: Section G of the admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration, shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with the party to the extent that such affiliates joins in the arbitration, and judgement on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The form was signed by Resident #205 on 01/27/23. The form was signed by Resident #55 on 02/07/23. The form was signed by Resident #293 on 01/30/23. The arbitration agreement did not provide for the selection of a venue that was convenient to both parties. It indicated that the binding arbitration agreement shall be conducted in Jersey City, New Jersey. On 02/08/23 at 9:30 a.m., the Admissions Director stated she had concerns with the arbitration agreement also especially with the Jersey City, New Jersey part. They were working with the legal team to change it. The legal team sent a new arbitration agreement that they were working on. They were just waiting for legal to approve it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to ensure resident rights for a comfortable and homelike environment by not maintaining comfortable sound levels for residents and maintaining the dignity of one resident (#57) related to 1. one resident (#57) of thirty-one sampled residents yelling and calling out loudly and repetitively during four days (5/24/2021, 5/25/2021, 5/26/2021, and 5/27/2021) of four days observed and, 2. the use of mechanical floor cleaning machines by housekeeping staff in three halls ([NAME], Canterbury, and [NAME]) of four halls while residents were still sleeping for two days (5/24/2021 and 5/25/2021) of four days observed, and 3. a loud floor buffing machine by housekeeping staff in one resident's room (#57) of thirty-one sampled residents room, when the resident has agitation and behaviors related to loud noises during two (5/25/2021 and 5/26/2021) of four days observed. Findings included: 1. On 5/24/2021 at 6:45 a.m., 10:00 a.m., 11:00 a.m., 12:00 p.m., and 1:00 p.m.; 5/25/2021 at 7:00 a.m., 8:00 a.m., 9:00 a.m., 10:00 a.m., 11:00 a.m. 12:00 p.m., and 1:00 p.m.; 5/26/2021 at 7:30 a.m., 8:00 a.m., 9:00 a.m., 10:00 a.m., 11:00 a.m., 12:00 p.m., 1:00 p.m. and 2:00 p.m., while either touring the [NAME] Lane Hall, or while seated in the [NAME] Lane unit station, and while seated in the conference room on the [NAME] Lane Hall, Resident #57 was overheard calling out and yelling repetitively very loudly. Resident #57 could be overheard throughout the entire facility, which included four direct room halls ([NAME], [NAME], Canterbury, and [NAME]). However, he was heard more loudly in and around the [NAME] Hall. From the nurse station, resident #57's room was located all the way down at the end of the hallway, approximately seventy feet away. There were fifteen resident rooms between Resident #57's room and the nurse station. Though Resident #57 was routinely checked on by staff and with continued staff/resident interaction, Resident #57 kept yelling out and grunting out loud in a repetitive manner. While Resident #57 was yelling out loud repetitively, there were several occasions during the 7:00 a.m. to 3:00 p.m. shift, on the dates of 5/24/2021, 5/25/2021, and 5/26/2021, from the nurses' station, other residents on the [NAME] Hall were heard calling out saying, shut up, please stop, and please be quiet. Residents #6, #5, #65, #13 and #8 were interviewed from 5/25/2021 to 5/27/2021 on [NAME] Hall between the hours of 9:30 a.m. to 10:14 a.m. The residents confirmed they hear Resident #57 yelling and screaming throughout the night and sometimes they can't sleep. The residents also revealed that staff do come early to use the floor machine and its loud. None have made any complaints to staff because they did not know that they could and did not want to get Resident #57 in trouble. They would like to be able to sleep at night and early in the a.m. without any loud noises. A review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. A review of the MDS Quarterly assessment, dated 5/12/2021, revealed a BIMS score of 7 out of 15. This score indicated that the resident was lower cognitive functioning but was able to make his needs known. This resident was also the roommate of Resident #57. A review of the medical record for Resident #6 revealed the resident was admitted to the facility on [DATE]. A review of the current Minimum Data Set (MDS) Annual assessment, dated 3/7/2021, revealed a Brief Interview Mental Status (BIMS) score of 14 out of 15. This score indicated that resident had higher cognitive functioning and was able to make her needs known. A review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. A review of the current MDS Quarterly assessment, dated 5/17/2021, revealed a BIMS score of 9 out of 15. This score indicated that the resident had some cognitive deficits but was able to make her needs known. A review of the medical record for Resident #65 revealed the resident was admitted to the facility on [DATE]. A review of the current MDS Annual assessment, dated 5/6/2021, revealed a BIMS score of 11 out of 15. This score indicated that the resident had higher cognitive functioning and was able to make her needs known. A review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. A review of the MDS Quarterly assessment, dated 3/9/2021, revealed a BIMS score of 14 out of 15. This score indicated that the resident had higher cognitive functioning and was able to make her needs known. During an interview with Staff A, Certified Nursing Assistant (CNA) on 5/25/21 at 8:36 a.m., an interview on 5/26/21 at 7:20 a.m. with, Staff B, CNA, Staff C, CNA and an interview on 5/26/21 at 12:09 p.m. with the Care Plan Coordinator it was confirmed that Resident #57 calls out and yells and screams all day and he does this repetitively. They confirmed that once they visit him, he quiets down, but will soon start again. They confirmed that one could hear him throughout the facility but more so in [NAME] Hall. Staff A, B, and C did not know of what else to do but confirmed he was care planned for this behavior and has been seen by the physician and psych services. Review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. Review of the diagnosis. sheet revealed diagnoses to include dementia with behavioral disturbance, schizoaffective disorder bipolar type, anxiety, PVD (peripheral vascular disease), major depression, pseudobulbar affect. Review of the medical record contained an Incapacity Statement signed and dated by the MD (medical doctor) on 10/27 (The year was not readable). However, the Incapacity Statement was dated in the electronic record on 3/20/2020. Review of the current Minimum Data Set (MDS) assessment Medicare 5 day, dated 5/3/2021 revealed, resident did not have a BIMS score, but was coded with Short Term/Long Term memory loss, and with severely impaired decision-making skills. The assessment also indicated Resident #57 exhibits with mood and behaviors to include screaming and disruptive sounds daily. 2. On 5/24/2021 at 6:30 a.m., 5/25/2021 at 7:01 a.m., 5/26/2021 at 7:00 a.m., and 5/27/2021 at 7:08 a.m. Staff I, Housekeeping Floor Tech was observed utilizing a very loud mechanical high speed buffing machine throughout the facility to include [NAME], Canterbury, and [NAME] Halls. He was noted pushing the machine up and down the main hallways of these halls several times and while residents were still in their rooms sleeping. During these observations, there were over twelve resident rooms that were observed with the doors open and with the lights off in the room, while residents were in bed with their eyes closed. Random interviews on 5/25/21 between 9:30 a.m. and 10:14 a.m. with Residents #6, #5, #65, #13, and #8 all revealed they were aware of the housekeeping staff using a loud machine very early in the morning. They further revealed that they have not complained because they did not know they had that right when it comes to how early staff clean the floors. They continued to say that they would like for the noises to decrease during the early times of the morning. 3. On 5/26/2021 at 9:28 a.m. Resident #57's room was approached. Prior to getting to the room Resident #57 was overheard calling out and yelling loudly. Upon reaching the room door, a machine was overheard coming from inside the room. Staff I, Housekeeping Floor Tech was in the room and utilizing a very loud high speed buffing machine to buff the floors in the room. Resident #57 was seated in a specialized chair positioned between his bed and his roommate's bed. The roommate was observed in the room, as well, and was in bed. Staff I continued to buff the floors with this machine in the room for about four minutes. He was observed maneuvering the machine at and around Resident #57 as he was yelling and screaming out loud. Once Staff I was finished in the room he was interviewed. Staff I revealed he generally knocks on the door and goes in to buff the floors. He did not know if there were any residents in the building that are afraid or get agitated with loud noises. He did confirm that Resident #57 was yelling out and he just thought that he just does that. Staff I revealed nobody ever told him or housekeeping of any residents who are afraid of loud noises. On 5/27/2021 at 1:20 p.m. the Director of Nursing (DON) provided the Resident Rights policy and procedure, with an effective date of 11/30/2014, that did not indicate any specific areas for dignity. However, an interview with the DON and the Nursing Home Administrator at this time revealed that resident's dignity should be maintained and free from loud noises, and constant noises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and medical record review, the facility did not ensure a comprehensive person-centered care plan was developed for bed rail/bed enablers and failed to implement interventions for bed positioning and reducing loud noises to prevent agitation for one resident (#57) of thirty-one sampled residents for three days (5/24/2021, 5/25/2021, and 5/26/2021) of four days observed. Findings included: A review the Plans of Care policy and procedure, with a last revision date of 9/25/2017, revealed: Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedure section revealed: Develop and implement an individualized person-centered comprehensive plan of care by interdisciplinary team that includes but not limited to - the attending physician, a registered nurse with responsibility of the resident, a nurse aide with responsibility for the resident, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident and, to extent practicable, the participation of the resident and resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). The policy further revealed; The individualized person centered plan of care may include but is not limited to the following: - Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. - Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths and desired outcomes. On 5/24/2021 at 6:45 a.m., and 8:30 a.m.; 5/25/2021 at 7:38 a.m., 10:45 a.m., and 11:40 a.m.; and 5/26/2021 at 7:20 a.m., 8:30 a.m.; and 10:00 a.m., Resident #57 was observed in his room, lying either flat on his back with his head on a pillow at twenty to thirty degrees, or seated flat in bed and upright at forty-five degrees. Resident #57 had been observed with calling out and repetitive yelling behaviors throughout the day, each day observed. During each observation, the resident was observed in his bed and both bed rails were observed up and locked into position. During each observation, the bed was observed raised to approximately three feet up from the ground level. The bed was never observed in the lowest position. Interviews were attempted several times during the above observations with Resident #57. Resident #57 was not able to respond with relation to his care and services. The observations were as follows: 1. 5/24/2021 at 6:45 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. 2. 5/24/2021 at 8:30 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. 3. 5/25/2021 at 7:38 a.m. the left bed rail was now locked in an upright position, indicating a ½ rail position. The right bed rail was locked in an upright position, indicating a ¼ rail position. The bed was not in the lowest position. 4. 5/25/2021 at 10:45 a.m. the left bed rail was locked in an upright position, indicating a ½ rail position. The right bed rail was locked in an upright position, indicating a ¼ rail position. The bed was not in the lowest position. 5. 5/25/2021 at 11:40 a.m., and 12:20 p.m. the left bed rail was locked in an upright position, indicating a ¼ position. The right bed rail was locked in an upright position, indicating a ¼ position. The bed was not in the lowest position. 6. 5/26/2021 at 7:20 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. 7. 5/26/2021 at 8:30 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. 8. 5/26/2021 at 10:00 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. (Photographic Evidence was Obtained) Resident #57 was not noted with any behaviors of trying to get up and out from bed. The bed was not in the lowest position. Review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include dementia with behavioral disturbance, schizoaffective disorder bipolar type, anxiety, PVD (peripheral vascular disease), major depression, pseudobulbar affect. Review of the medical record contained an Incapacity Statement signed and dated by the MD (medical doctor) on 10/27 (The year was not readable). However, the Incapacity Statement was dated in the electronic record on 3/20/2020. Review of the current Minimum Data Set (MDS) Medicare 5-day assessment, dated 5/3/2021 revealed, a Brief Mental Interview Status (BIMS) with no score. However, it coded Resident #57 with short term/long term memory loss, with severely impaired decision making skills; Mood - Yes to little interest, Yes to trouble sleeping, Yes, Restless 2 - 6 days, Yes short tempered/easily annoyed; Behaviors - Verbal behaviors exhibited 1- 3 days, to include screaming and disruptive sounds daily; Activities of Daily Living ADL - Extensive to total dependence with all ADLs (activities of daily living); B&B (bowel & bladder) - Always incontinent of bladder, Always incontinent of bowels; Bed Rails - Not Used. Review of the MDS assessment significant change, dated 4/26/2021, revealed bed rails - Not Used. Review of the MDS assessment Quarterly, dated 2/3/2021, revealed bed rails - Not Used. Review of the nurse progress notes dated 5/26/2020 through 5/25/2021, did not indicate any notes related to use of bed/side rails. Review of the current care plans, with a next review date of 8/2/2021, did not indicate any problem area or interventions to any problem areas with utilization of bed rails or bed enablers. The current care plan revealed the following areas: - Resident with dementia and behaviors. Confused and rarely understands and is rarely understood. Requires extensive to total care with his needs and mobility. He is totally incontinent of bowel and bladder. Decline expected. Can be aggressive, agitated, combative and resistive to care. Significant decline in function and is currently not propelling self around unit. Interventions to include monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. - Behavior problems r/t (related to) dx (diagnosis) of dementia, schizophrenia, mood anxiety. Hx (history) of wandering/exit seeking. Increase in agitation, yelling, crying, constantly fluctuating mental status. History of attempts to get out the emergency doors and pulling fire alarms. Easily overstimulated, doesn't do well in groups or loud noises. Crying frequently with an intervention in place of anticipate and meet the resident's needs. -Risk for falls and fall related injuries r/t dementia. Has weak and impaired balance and mobility and requires extensive to total care with his needs and mobility. Is totally incontinent of Bowel and Bladder . Can be aggressive, agitated and combative and resistive to care, with interventions in place to include but not limited to: Keep bed in low position, with initial date 7/30/2019. Review of the nurse progress notes dated from 1/1/2021 through to current 5/26/2021 did not reveal any behaviors of falling out of bed, nor any documentation that indicated Resident #57 had falls. On 5/25/2021 at 8:36 a.m. an interview and observation with Resident #57's assigned aide, Staff A, Certified Nursing Assistant (CNA) was conducted. Staff A was observed to go in the room and check on him. Staff A was observed to come back out from the room about two minutes later and she explained that they are to keep them (bed rails) up when in bed. She did not know why the bed rails were used and only knew the bed rails should be up. She did not know if the ¼ rails should be up or the ½ rails should be up when Resident #57 was in bed. She did confirm that both ½ bed rails were up and locked while Resident #57 was in bed at this time. During this interview on 5/25/21 at 8:36 a.m. with Staff A, Certified Nursing Assistant (CNA)., an interview on 5/26/21 at 7:20 a.m. with, Staff B, CNA, Staff C, CNA and an interview on 5/26/21 at 12:09 p.m. with the MDS/Care Plan Coordinator it was confirmed that Resident #57 calls out and yells and screams all day and he does this repetitively. They confirmed that once they visit him, he quiets down, but will soon start again. They confirmed that one could hear him throughout the facility but more so in [NAME] Hall. Staff A, B, and C did not know of what else to do, but confirmed he was care planned for this behavior and has been seen by the physician and psych services. On 5/26/2021 at 8:15 a.m. two CNAs, Staff B, and Staff C were interviewed. Staff C and Staff B confirmed Resident #57's bed rails were up and locked into position. They confirmed one was at the ½ rail position, and the other was at the ¼ rail position. Staff C revealed she does not have Resident #57 on her normal assignment and did not lock the bed rails in position. Staff B revealed Resident #57 is normally on her assignment and she was assigned to care for him today. Staff B confirmed that both bed rails were up but did not know exactly why. She stated, They told me to put them up, so I do. She was not able to explain who they were. On 5/26/2021 at 8:42 a.m. an interview with the floor nurse, Staff D, Agency Licensed Practical Nurse (LPN) to confirm the bed positioning (in lowest position) for Resident #57. She looked and stated, I think it is. The bed surface was observed positioned up at least three feet from off the floor. She added, I'm not sure, I am agency and don't know how the beds should be positioned. At this time Staff A, CNA and Staff B, CNA were in the immediate area and were asked to confirm if Resident #57's bed was in the lowest position. Staff A and B both confirmed that the bed was not in the lowest position and that it should be. They responded that when providing care and services, they do raise the bed so they can reach the resident easier. They both confirmed that at the time Resident #57 was not receiving care and or services. On 5/26/2021 at 12:09 p.m. the MDS/Care Plan Coordinator was interviewed related to Resident #57's bed rail use, and not identified anywhere in the record. The MDS/Care Plan Coordinator revealed the resident's bed rails are supposed to be used as enablers. She did confirm that there are so many types of bed rails in the building and some of them may work as ½ rails. She confirmed that Resident #57's rails can be adjusted to ¼ rails and did not know why staff had those specific rails positioned in a manner that displayed ½ rails on each side. She also confirmed that Resident #57 was and has been extensive assist with two person assist with bed mobility. She also revealed that Resident #57 cannot reposition himself and even if the rails were in a ¼ position, he still would not be able to use them as an enablers. The MDS/Care Plan Coordinator, through review of Resident #57's medical record, confirmed there were no consents, assessments, orders, or care plans related to use of bed rails, or bed enablers. On 5/26/2021 at 1:00 p.m. an interview with the MDS/Care Plan Coordinator confirmed that when Resident #57 was in bed, the bed should be lowered to the lowest position, as per the fall risk care plan interventions. She revealed he has not had a fall recently and does not get out of bed on his own, but the bed was still care planned to be in the lowest position for safety. On 5/26/2021 at 9:28 a.m. Resident #57's room was approached. Prior to getting to the room Resident #57 was overheard calling out and yelling loudly. Upon reaching the room door, a machine was overheard coming from inside the room. Staff I, Housekeeping Floor Technician was in the room and utilizing a very loud high speed buffing machine to buff the floors in the room. Resident #57 was seated in a specialized chair positioned between his bed and his roommate's bed. The roommate was observed in bed. Staff I continued to buff the floors with this machine in the room for about four minutes. He was observed maneuvering the machine at and around Resident #57 as he was yelling and screaming out loud. Once Staff I was finished in the room he revealed that he generally knocks on the door and goes in to buff the floors. He did not know if there were any residents in the building that are afraid or get agitated with loud noises. He did confirm that Resident #57 was yelling out and he just thought that he just does that. Staff I revealed nobody ever told him or housekeeping of any residents who are afraid of loud noises. On 5/26/2021 at 11:00 a.m. an interview with the MDS/Care Plan Coordinator and at 1:00 p.m. with the Nursing Home Administrator, both confirmed Resident #57 yells a lot, and he is care planned with numerous interventions to reduce the yelling, but he continues to do so repetitively. On 5/27/2021 at 1:20 p.m. the Director of Nursing (DON) provided the Resident Rights policy and procedure, with an effective date of 11/30/2014, that did not indicate any specific areas for dignity. However, an interview with the DON and the Nursing Home Administrator at this time revealed that resident's dignity should be maintained and free from loud noises, and constant noises. A review of the policy and procedure titled, Side Rail/Bed Rail, with an effective review date of 4/19/2018, revealed: Policy: The center, will attempt alternative interventions, and document in the medical record, prior to use of side rail/bed rail. The Policy further revealed, Side rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. The procedure section of the policy revealed the following: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/ or resident representative. 3. Obtain consent from the resident/ and or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and [NAME]. 6. Re-Evaluate the use of side rail/bed rail, quarterly, with a change of condition or as needed. 7. Follow the manufacturer's recommendation and specifications for installing and maintaining side rails/ bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 5/26/21 at 12:40 p.m. Resident #26 was observed sitting in a wheelchair with the bedside table across the chair. The resident was eating lunch at the time. The resident had on a pair of slip-on shoes with her feet on the floor. The right foot was observed to have a large open wound, approximately four inches in diameter, exposed to the air with part of the slip-on shoe touching the wound bed. There was no dressing in place. The wound was observed to have a large amount of yellow colored drainage coming from the center of the wound. On 5/26/21 at 12:45 p.m. an interview was conducted with Staff O, LPN. The nurse was asked to observe the wound. She stated the resident should have a dressing in place. She stated she placed a dressing on the wound on each side of the foot the day before and she did not know why there was no dressing in place. The LPN stated the nurse's aide should have let her know if the dressing had come off when the resident was given the morning care. The LPN stated she would be doing wound care as soon as the resident finished the lunch meal. A review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including cerebral vascular disease, cerebral infarction, dementia, and hypertension. The order summary report, as of 5/27/21, revealed active orders for wound care consult; Prostat 30 milliliters twice a day for wound healing; cleanse right dorsal foot with Dakin's solution pat dry and apply Santyl and dry dressing to cover daily and as needed until resolved; Bactrim DS tablet 800/160 milligram one by mouth twice a day for wound infection; Vitamin C tablet 500 milligram one by mouth two times a day for wounds. A review of the pressure ulcer wound rounds notes for Resident #26 revealed the right dorsal foot wound was classified as a pressure wound measuring 2.0 length by 1.7 width by 0.5 depth and unstageable on 5/10/21. On 5/17/21 the wound measured 2.0 length by 1.5 width by 0.5 depth and was a stage IV. On 5/22/21 the wound measured 2.0 length by 1.5 width by 0.5 depth and was a stage IV. On 5/27/21 at 11:00 a.m. a wound care observation was conducted for Resident #26 with Staff O, LPN. Staff O, LPN set up supplies on a foil barrier over bed table in the resident room for the procedure. Supplies set up on the table included: 4 x 4 gauze sponges, normal saline bullets, Q-tip applicator, a tube of Santyl medication, a medicine cup with Santyl ointment in it, scissors, tape, Kerlex gauze, and an elasticized dressing. The LPN was observed to have on a surgical mask and no eye protection as she began to perform the wound care. Staff O, LPN proceeded to perform wound care for Resident #26 as ordered. After the procedure, Staff O, LPN removed the used supplies from the overbed table and returned the tube of Santyl medication to the wound care cart. An interview was conducted with Staff O, LPN after the procedure. Staff O, LPN stated she did not have on eye protection while performing the wound care on Resident #26 and did not think she needed eye protection for wound care. The LPN verified she had taken the tube of Santyl medication into the room and placed it on the barrier. The LPN stated she understood the possible infection control concerns with exposure of the medication tube to the environment and then returning it to the treatment cart. On 5/27/21 at 11:20 a.m. an interview was conducted with the ICP/ADON. The ICP/ADON stated eye protection needs to be worn during all resident care procedures including wound care. The ICP/ADON stated medication tubes are not to be taken into the room for wound care. A review of the policy entitled, Personal Protective Equipment, revised in October 2018 revealed the following: Policy statement: Personal protective equipment appropriate to specific task requirement is available at all times. Policy interpretation and implementation: 1 Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge. 2 Personal protective equipment provided to our personnel includes but is not necessarily limited to: d. eye wear (goggles and/or face shields). 3 Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required of ra task is based on: a) The type of transmission-based precaution b) The fluid or tissue to which there is a potential exposure c) The likelihood of exposure d) The potential volume of material e) The probable route of exposure f) The overall working conditions and job requirements. Based on observations, record reviews, and interviews the facility failed to provide wound care in a sanitary manner that would promote healing for two residents (#61 and #26) out of two residents as evidenced by cleaning and dressing three separate wounds at the same time; not completing hand hygiene between the cleaning and dressing of wounds; leaving wounds uncovered; and not wearing personal protective equipment during wound care. Findings included: 1. The policy titled, Dressing Change, effective 11/30/2014 and revised 12/6/2017, identified that a clean dressing would be applied by a nurse to a wound as ordered to promote healing. A review of the admission Record for Resident #61 was admitted on [DATE], 3/22/19, and 4/23/21. The admission Record identified diagnoses not limited to Type 2 Diabetes Mellitus without complications, acquired absence of right leg above knee, and unspecified peripheral vascular disease. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident scored a 15 out of 15 for his Brief Interview of Mental Status (BIMS) score indicating the resident was cognitively intact. An observation was conducted, on 5/25/21 at 1:42 p.m., with Staff E, Licensed Practical Nurse (LPN) and Staff F, Certified Nursing Assistant (CNA). Staff E gathered the supplies necessary: - bottle of Dakins solution - 3 packages of Calcium Alginate - 2 rolls of gauze - 15 vials of Normal Saline - 12 packages of 4x4 inch gauze - 4 island dressings. Staff E, LPN obtained scissors from the Assistant Director of Nursing (ADON) and cleaned them with a Sani-cloth. She placed the supplies on a piece of wax paper, carried them into Resident #61's room, and placed it on the over-the-bed (obt) table. Staff E washed her hands and donned gloves. The LPN instructed Staff F to stay clean while she assisted the resident to his right side. Staff E removed the left and right ischiums and the sacral area dressings and placed them in a red biohazard bag. As she doffed her gloves, she instructed Staff F to open the gauze packages, and placed the biohazard bag in the trash receptacle near the door. The Staff F, CNA opened the packages and was observed flattening gauze packages with her right hand and Staff E asked her to cut a piece of rolled gauze from the roll and poured Dakins into the other package of rolled gauze. Staff E, LPN poured Dakins over the piece of Kerlix and patted the outside of the three wounds in the rotation of left ischium, sacrum, then right ischium. With the same piece of rolled gauze used to clean the outside of the wounds, Staff E patted the inside of the three wounds in the same rotation: left ischium, sacrum, and right ischium. After finishing the cleaning of the wounds, she used 4x4 gauzes, obtained from Staff F to pat dry all three wounds. Staff E packed the other roll of guaze that had been wettened with Dakins into the left ischium and covered it with an island dressing, placed a 4x4 square of Calcium Alginate onto the sacral wound then covered it with an island dressing, and cut a piece of alginate, place it in the right ischium and after pushing the resident further onto his right side, she covered the wound with an island dressing. Staff E gathered and removed the trash of supplies and placed scissors onto the barrier. Staff E ungloved and washed her hands as Staff F placed the top onto the bottle of Dakins. After donning gloves, Staff E donned gloves and changed the resident's linens then moved the obt to the end of the bed. After sanitizing her hands and donning gloves, Staff E used scissors to cut the rolled gauze from the resident's left foot, ungloved, washed hands, and re-gloved. Staff E stated the wound was closed and sanguineous drainage was observed on the dressing that the staff had removed. The nurse irrigated the wounds on the resident's side of left foot and the left heel with normal saline, placed a piece of Calcium Alginate to the wound bed of the left heel and wrapped the foot with rolled gauze. The nurse removed her gloves, washed hands, donned gloves, and removed gauze from the resident's abdomen. She opened a package of gauze and vial of normal saline to the side of bed and placed a piece of Alginate to the suprapubic area of the abdomen. The nurse gathered the dirty supplies, leaving three packages of gauze and a package of an island dressing. She washed and re-gloved her hands then reached out the door and brought a Sani-cloth into the room, and used it to wipe down the obt, scissors then the bottle of Dakins. She then placed the scissors and bottle of Dakins on the treatment cart that was parked in the hallway outside of the resident's room. Immediately after leaving Resident #61's room, an interview was conducted with Staff E, LPN. The wound care observation was discussed, and the staff member stated that she had Staff F open up all the packages because she did not want to cross-contaminate and had washed her hands before dressing the left ischium, right ischium, and sacrum. The LPN confirmed she probably should not have cleaned and dressed the three wounds at the same time. On 5/27/21 at 11:16 a.m., the Infection Control Preventionist (ICP)/ADON stated that Staff E should have dispensed the Dakins before entering the resident's room (not bringing in the whole bottle) and that the three wounds should have been cleaned and dressed separately. The ICP stated that handwashing should be done after cleaning the wound and putting dressing on. The Pressure Ulcer Wound Rounds and Wound Physician notes indicated the following areas and measurements of Resident #61's wounds: - dated 5/22/21, Stage IV Left Ischium: 9.0 x 6.0 x 3.0 centimeter (cm). - dated 5/17/21, Stage IV Left Ischium: 8.5 x 7.0 x 4.0 cm. - Wound Physician note dated 5/8/21, Stage IV Left Ischium: post-debridement 9.0 x 7.0 x 4.0 cm. No change. - dated 5/22/21, Stage IV Sacrum: 9.0 x 10.0 x 2.0 cm. - dated 5/17/21, Stage IV Sacrum: 8.5 x 9.6 x 0.5 cm. - Wound Physician note dated 5/8/21, Stage IV Sacrum: 9.0 x 9.7 x 0.5 cm. Improving. - dated 5/22/21, Stage III Right Ischium: 9.0 x 4.5 x 0.3 cm. - dated 5/17/21, Stage IV Right Ischium: 7.0 x 6.5 x 0.3 cm. - Wound Physician note dated 5/8/21, Unstageable: post-debridement 7.0 x 6.8 x 0.3 cm. Improving. - dated 5/22/21, Stage IV Left Heel: 4.5 x 4.5 x 0.3 cm. - dated 5/17/21, Stage IV Left Heel: 5.5 x 4.5 x 0.3 cm. - Wound Physician note dated 5/8/21, Stage IV Left Heel: post-debridement 2.0 x 0.4 x 0.3 cm. No change. Resident #61's care plan, initiated on 10/28/20 and revised on 5/6/21, indicated the resident had multiple pressure ulcers, was at risk for further skin issues related to paraplegia secondary to spinal infection. The interventions instructed staff to administer treatments as ordered and monitored for effectiveness.

Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to oxygen and humidification therapy, consistent with professional standards of practice for one resident (#15) of one resident investigated for respiratory care. Findings included: On 5/26/21 at 11:30 a.m. an observation was conducted during tracheostomy care for Resident #15 with Staff O, Licensed Practical Nurse (LPN) who was assisted by Staff L, Registered Nurse (RN) unit manager. Resident #15 was observed seated upright in his bed. The tracheostomy site was open to air and had a dressing around the base of the tracheostomy between the device and the neck. There was an oxygen concentrator and humidifier set up in the room. The equipment was not connected to the resident and was not in operation. There was a nebulizer machine noted on a bedside table with the tubing and mask noted to be inside of a plastic wash bin mixed in with personal items for the resident. The tubing and mask were not properly stored in a clean separate bag. Resident #15 stated he had an infection in his tracheostomy site and was currently being treated with antibiotics for the infection. The resident stated he was unable to perform care for his tracheostomy and required the assistance of the staff for all respiratory care and services. Staff O, LPN prepared a clean table tray for the procedure and set up all the supplies to perform tracheostomy care. Staff O, LPN was noted to have on a surgical mask and no eye protection as she performed the procedure. The tracheostomy care was performed. On 5/26/21 at 12:00 p.m. an interview was conducted with Staff O, LPN and Staff L, RN Unit Manager. Staff L, RN stated Resident #15 was receiving nebulizer treatments as ordered and verified the tubing and mask for the nebulizer machine was not properly stored to reduce the risk of infection to the resident. Staff L, RN removed the tubing and mask from the machine to replace it. Staff L, RN stated the tubing and mask should be cleaned after each use and placed into a clean plastic bag that is dated for proper storage. Staff O, LPN stated she should have had on her goggles as part of the required personal protective equipment (PPE) needed to do the tracheostomy care. She pulled a clean pair of goggles out of her pocket and stated she just forgot to put them on. A review of the medical record for Resident #15 revealed an admission date of 8/31/2018 with diagnoses including tracheostomy, cerebral infarction, acute and chronic respiratory failure, and chronic obstructive pulmonary disease. A review of the current order summary report as of 5/27/21, for Resident #15 indicated active orders as: change inner cannula every day and evening shift and as needed; change tubing, mask, and nasal cannula weekly or as needed; check lung sounds pre nebulizer administration every 4 hours as needed; check pulse and respiration rates post nebulizer administration every 4 hours as needed; humidification via tracheostomy at 28% every shift; oxygen 4 liters via tracheostomy every shift; tracheostomy care twice daily and as needed with dressing change and tracheostomy ties as needed; Ipratropium-Albuterol solution 0.5-2.5 milligrams /3 milliliters one vial via trach every 6 hours as needed for shortness of breath. The comprehensive care plan, initiated 9/13/18 and revised 3/18/21, for Resident #15 revealed the following: Focus area: Resident #15 has oxygen as needed when short of breath. He has tracheostomy and history of respiratory failure and chronic obstructive pulmonary disease. Goal: The resident will have no signs of symptoms of poor oxygen absorption through the review date. Interventions: change oxygen and nebulizer tubing as ordered; give medications as ordered by physician; oxygen settings 4 liters per minute continuously via tracheostomy. Focus area: Resident #15 has a tracheostomy #6 Shiley capped. Goal: The resident will have minimal signs and symptoms of infection through the review date. Interventions: humidification via tracheostomy as ordered; oxygen settings 4 liters per minute as needed via tracheostomy; use universal precautions as appropriate. A review of the May 2021 Medication Administration Record (MAR) for Resident #15 indicated the order for Humidification via tracheostomy at 28% every shift was documented as provided by nursing, and the order for Oxygen 4 liters via tracheostomy every shift was documented as provided by nursing. On 5/27/21 at 11:35 a.m. an interview was conducted with Staff L, RN unit manager. Staff L, RN verified the orders for oxygen and humidification were current for Resident #15. He stated the resident was not currently receiving the oxygen and humidification therapies as ordered. He stated the nurse is responsible for providing respiratory care as ordered by the physician. He stated he would need to get a clarification of the orders to determine if Resident #15 requires the treatments as ordered. A review of the policy entitled, Equipment Change Schedule, effective date of 11/30/2014 and revised date of 8/28/2017, indicated the following: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. Procedure: Nebulizer set-up once, every seven days along with equipment bag labeled with name, date, and room number. A review of the policy entitled, Tracheostomy Care, with an effective date of 11/30/2014 and a revised date of 8/24/2017 indicated the following: Procedure: Follow infection control procedures, as appropriate Aseptically don sterile gloves (gown and goggles as necessary) A review of the policy entitled, Personal Protective Equipment, revised in October 2018 revealed the following: Policy statement: Personal protective equipment appropriate to specific task requirement is available at all times. Policy interpretation and implementation: 1 Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge. 2 Personal protective equipment provided to our personnel includes but is not necessarily limited to: d. eye wear (goggles and/or face shields). 3 Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required of a task is based on: a) The type of transmission-based precaution b) The fluid or tissue to which there is a potential exposure c) The likelihood of exposure d) The potential volume of material e) The probable route of exposure f) The overall working conditions and job requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and medical record review, the facility failed to did not ensure an assessment for bed rails/enablers, a consent was received for use of bed rails/enablers or a physician order was received for bed rails/enablers for one resident (#57) of thirty-one sampled residents. Findings included: On 5/24/2021 at 6:45 a.m., and 8:30 a.m.; 5/25/2021 at 7:38 a.m., 10:45 a.m., and 11:40 a.m.; and 5/26/2021 at 7:20 a.m., 8:30 a.m.; and 10:00 a.m., Resident #57 was observed in his room, lying either flat on his back with his head on a pillow at twenty to thirty degrees, or seated flat in bed and upright at forty-five degrees. Resident #57 had been observed with calling out and repetitive yelling behaviors throughout the day, each day observed. During each observation, the resident was observed in his bed and both bed rails were observed up and locked into position. Resident #57 was observed and interviews were attempted several times with Resident #57 but he was not able to respond with relation to his care and services. The observations were as follows: 1. 5/24/2021 at 6:45 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. 2. 5/24/2021 at 8:30 a.m., the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. 3. 5/25/2021 at 7:38 a.m. the left Bed Rail was now locked in an upright position, indicating a ½ rail position. The right Bed Rail was locked in an upright position, indicating a ¼ rail position. 4. 5/25/2021 at 10:45 a.m. the left bed rail was locked in an upright position, indicating a ½ rail position. The right bed rail was locked in an upright position, indicating a ¼ rail position. 5. 5/25/2021 at 11:40 a.m., and 12:20 p.m. the left bed rail was locked in an upright position, indicating a ¼ position. The right bed rail was locked in an upright position, indicating a ¼ position. 6. 5/26/2021 at 7:20 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. 7. 5/26/2021 at 8:30 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. Resident #57 was not noted with any behaviors of trying to get up and out from bed. 8. 5/26/2021 at 10:00 a.m. the left bed rail was locked in an upright position, indicating a ¼ rail positioning. The right-side bed rail was locked in an upright position, indicating a ½ rail position. (Photographic Evidence was Obtained) Resident #57 was not noted with any behaviors of trying to get up and out from bed. On 5/25/2021 at 8:36 a.m. an interview and observation with Resident #57's assigned aide, Staff A, Certified Nursing Assistant (CNA) was conducted. Staff A was observed to go in the room and check on him. Staff A was observed to come back out from the room about two minutes later and she explained that they are to keep them (bed rails) up when in bed. She did not know why the bed rails were used and only knew the bed rails should be up. She did not know if the ¼ rails should be up or the ½ rails should be up when Resident #57 was in bed. She did confirm that both ½ bed rails were up and locked while Resident #57 was in bed at this time. On 5/26/2021 at 8:15 a.m. two CNAs, Staff B, and Staff C were interviewed. Staff C and Staff B confirmed Resident #57's bed rails were up and locked into position. They confirmed one was at the ½ rail position, and the other was at the ¼ rail position. Staff C revealed she does not have Resident #57 on her normal assignment and did not lock the bed rails in position. Staff B revealed Resident #57 is normally on her assignment and she was assigned to care for him today. Staff B confirmed that both bed rails were up but did not know exactly why. She stated, They told me to put them up, so I do. She was not able to explain who they were. On 5/26/2021 at 8:42 a.m. an interview with Staff D, Licensed Practical Nurse (LPN), who was an Agency nurse confirmed she does not know the residents and whether they should have bed rails in position or not. Review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include but not limited to: dementia with behavioral disturbance, schizoaffective disorder, bi-polar type, anxiety, major depression, and pseudobulbar affect. Review of the medical record contained an Incapacity Statement signed and dated by the physician on 10/27. The year was not readable. However, the Incapacity Statement was dated in the electronic record on 3/20/2020. Review of the current Minimum Data Set (MDS) Medicare 5-day assessment, dated 5/3/2021 revealed, a Brief Mental Interview Status (BIMS) with no score. However, it coded Resident #57 with short term/long term memory loss, with severely impaired decision making skills; Mood - Yes to little interest, Yes to trouble sleeping, Yes, Restless 2 - 6 days, Yes short tempered/easily annoyed; Behaviors - Verbal behaviors exhibited 1- 3 days, to include screaming and disruptive sounds daily; Activities of Daily Living ADL - Extensive to Total dependence with all ADLs; B&B (bowel & bladder) - Not on Toileting program, Always incontinent of bladder, Always incontinent of bowels; Bed Rails - NOT USED. It was determined through observations and review of the medical record that Resident #57 does not ambulate and move on his own. He requires two person assist for transfers and positioning. Review of the MDS assessment significant change, dated 4/26/2021, revealed a Bed Rails - NOT USED. Review of the MDS assessment Quarterly, dated 2/3/2021, revealed Bed Rails - NOT USED. Review of the nurse progress notes dated from 5/26/2020 through to current 5/25/2021, did not indicate any notes related to use of bed/side rails. Review of the current care plans with a next review date of 8/2/2021 did not indicate any problem area or interventions to any problem areas with utilization of Bed Rails or Bed Enablers. On 5/26/2021 at 12:09 p.m. The MDS/Care Plan Coordinator was interviewed related to Resident #57's bed rail use, and not identified anywhere in the record. The Care Plan Coordinator revealed the resident along with no other residents in the building are using bed rails as restraints, and that the rails are supposed to be used as enablers. She did confirm that there are so many types of bed rails in the building and some of them may work as ½ rails. She confirmed that Resident #57's rails can be adjusted to ¼ rails and did not know why staff had those specific rails positioned in a manner that displayed ½ rails on each side. She also confirmed that Resident #57 was and has been extensive assist with two person assist with bed mobility. She also revealed that Resident #57 cannot reposition himself and even if the rails were in a ¼ position, he still would not be able to use them as an enablers. The Care Plan Coordinator also confirmed that per review of the electronic medical record, there were no assessments, no orders, no care plans for the use of either bed rails or bed enablers. She also indicated that the facility was supposed to be going to bed rail/enablers free sometime in near the future. The Care Plan Coordinator, through review of Resident #57's medical record, confirmed there were no consents, assessments, orders, or care plans related to use of bed rails, or bed enablers. A review of the policy and procedure titled, Side Rail/Bed Rail, with an effective review date of 4/19/2018, revealed: Policy: The center, will attempt alternative interventions, and document in the medical record, prior to use of side rail/bed rail. The Policy further revealed, Side rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. The procedure section of the policy revealed the following: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/ or resident representative. 3. Obtain consent from the resident/ and or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and [NAME]. 6. Re-Evaluate the use of side rail/bed rail, quarterly, with a change of condition or as needed. 7. Follow the manufacturer's recommendation and specifications for installing and maintaining side rails/ bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure a repeated pharmacy recommendation was responded to within a timely manner for one resident (#56) of five residents reviewed for unnecessary medications. Findings included: The Policy and Procedure titled, Monthly Drug Regimen Review, effective 4/21/2017 and revised 10/10/2018, indicated that the procedure to ensure the requirement was met for monthly drug regimen review the Executive Director (ED)/Director of Nursing (DON) should implement the following processes which included: - Provide the consultant with responses (Consultant Report - Continuous Print) for consultant comments and recommendations from previous visits. - Discuss the recommendations not responded to and develop to plan for completing. - Download of Pharmacist Consultant Reports: -- Consultant Reports - 1 recommendation per page. ---- Non-Urgent: Report provided to the attending physician for timely response: ------ Day 1-14 provide recommendation(s) to physician(s) for review and response; ------ Day 15-21 the DON/designee will contact the physician(s) with nay outstanding recommendations if no response from physician, notify the Medical Director for further assistance. - If follow up for consultant pharmacist recommendations are not completed within the specified time frame this should be reported to the Medical Director for follow up with attending physician as indicated. An observation was made, on 5/26/21 at 5:45 p.m., of Resident #56 lying in bed and she stated that she was just tired. A review of the admission Record revealed that Resident #56 was admitted on [DATE] and readmitted on [DATE]. The admission Record included diagnoses not limited to unspecified bipolar disorder, unspecified insomnia, and moderate recurrent major depressive disorder. The Order Summary Report, as of 5/27/21, for Resident #56 included an order for Sertraline Hydrochloride (HCl) 25 milligram (mg) tablet orally once a day for depression. The order was dated 5/22/21 and to start on 5/23/21. An Order Recap Report, dated 9/1/20 - 5/21/21, indicated an order for Sertraline HCl 25 mg orally every day related to recurrent moderate Major Depressive Disorder. This order was dated 9/20/20 and discontinued on 5/21/21. A review of the Consultation Report, dated 4/9/21, indicated that Resident #56 had been receiving Sertraline 25 mg daily for depression since 3/17/20 and asked the facility to please attempt a gradual dose reduction (GDR) to Sertraline 25 mg every other day x 30 days while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms. The report indicated this request was a repeated recommendation from 12/1/20 and 2/5/21 and instructed the facility to please respond promptly to assure facility compliance with Federal regulations. The report indicated that a verbal order was received by the Advanced Registered Nurse Practitioner (ARNP) on 5/25/21 to decline the recommendation as the resident was stable at that time. A review of the psychiatry notes indicated the following: - 12/9/20: Major depressive disorder recurrent mild - Continue dose of Sertraline 25 mg every bedtime (QHS). Consider increasing to help manage depression if patient agrees. - 2/1/21: Major depressive disorder recurrent mild - Continue Sertraline 25 mg QHS. Consider increasing to help manage depression if patient agrees. - 3/26/21: Major depressive disorder recurrent mild - Continue Sertraline 25 mg QHS. Consider increasing to help manage depression if patient agrees. - 4/21/21: Major depressive disorder recurrent mild - Continue Sertraline 25 mg QHS. The patient is stable. consider increasing to help manage depression if patient agrees. On 5/26/21 at 3:39 p.m., the Director of Nursing (DON) stated her expectation was that the physicians respond to pharmacy recommendations when they come in to sign paperwork, within two weeks. The DON reported that she could not answer why the 12/1/20 and 2/5/21 recommendations had not been signed. The DON acknowledged that the verbal order from the ARNP on 5/25/21 had not been received until after the team had requested the pharmacy recommendations for Resident #56. The DON stated she was unable to locate a signed copy of the either the 12/1/20 or 2/5/21 recommendations and did not know if the physician had seen them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to maintain drugs and biologicals used in the facility in a safe, secure and orderly manner in three medication carts (Canterbury Hall, [NAME] Hall, and [NAME] Hall) of four medication carts. Findings included: On 5/27/21 at 2:26 p.m. an observation of the medication cart for the Canterbury Hall was conducted. Staff J, Licensed Practical Nurse (LPN) was present during the observation. In the third drawer of the cart a loose round yellow pill, one yellow oblong pill, four loose round white pills, and three oblong loose white pills were observed. In the second drawer three half white pills, and one oval white pill were observed loose. In the top drawer, an unopened multidose vial of Humalog was observed stored in a container with no date indicating when it was removed from the refrigerator. A Lantus Pen was observed stored in a bag, with no open or expiration date documented. An Insulin Aspart Prot-Asp pen was observed with no open or expiration date. Staff J, LPN stated that the cart should not be like this, and that the cart cleaning was usually done by the night shift. Staff J, LPN stated that she would need to dispose of the pens since it was not known when the pens were opened. On 5/27/21 at 2:40 p.m. an observation of the medication cart for the [NAME] Hall was conducted. Staff D, LPN was present during the observation. In the second drawer of the cart one loose round white pill, one and one half white loose oval pills, and one oblong loose white pill were observed. In the top drawer, a Lantus pen was observed stored in a bag with no date as to when it was removed from the refrigerator. Also, an Insulin Lispro Pen was observed stored in a bag, with no open or expiration date documented. A Lantus Solostar pen was observed stored in a bag with no open or expiration date on the pen or bag. An open multidose vial, stored in a container was observed, with no date on the container or the vial. An open vial of Humalog was observed stored in a plastic bag with a handwritten illegible name and date on the bag. In addition, no resident identifying information, date opened or expiration date was observed on the vial. Staff D, LPN stated that she did not know who cleaned the medication carts. Staff D confirmed that the writing on the bag was illegible, but that she believed that the Humalog in the bag with the illegible name and date must belong to (Resident #38). She also stated that she would need to dispose of the pens since it was not known when the pens were opened. On 5/27/21 at 2:55 p.m. an observation of the medication cart for the [NAME] Hall was conducted. Staff K, Registered Nurse (RN) was present during the observation. In the top drawer, a Lantus Solostar pen was observed stored in a bag that was dated with the open date and the expiration date, but the pen was not dated. An Insulin Lispro pen was observed stored in a bag with an expiration date of 5/17/21, with no open or expiration date written on the pen. A Levemir Flex Touch pen was observed stored in a bag, with a pharmacy label, but no open or expiration date on the bag or the pen. Also, two Levemir pens were observed stored in a bag with the resident's name handwritten name on it. One pen was dated but the other had no date. An interview was conducted with Staff K, RN. Staff K, did not answer questions, but did state that she would dispose of the pens. On 5/27/21 at 3:00 p.m. an interview was conducted with the Staff L, RN/Unit Manager related to the observations. He was shown the photographs of the loose pills and the insulins with no expiration dates. He stated he that this should not be this way. 05/27/21 at 3:49 p.m., an interview was conducted with the Consultant Pharmacist. She stated that the expectation was that the medication cart drawers are cleaned routinely, and that an open date is written on insulins when they are removed from the fridge, and it is useful to also have the expiration date on the insulins. A review of the facility policy titled, Medication and Medication Supply Storage and Disposal, effective date 11/30/2014 revealed: Policy: Central storage of medications is required for prescription, prescribed over the counter medications and CAM(Complementary and Alternative Medicine). Will be kept in a locked area, in their original labeled container and may not be removed more than 2 hours prior to the scheduled administration. Meds (medications) will be kept in the medication cart that locks and the keys are only accessible to the licensed personnel distributing medications. Only current medication for individuals living in the residence will be kept in the residence. Procedure: 6. Medications will be stored in an organized manner under proper conditions and in accordance with manufacturer's instructions. 8. The original container for the prescription medications must be labeled with a pharmacy label that includes the following: resident's name, name of the medication, date the prescription was issued, prescribed dosage, and instructions for administration, name, and title of the prescriber. CAM and OTC(over the counter) medications must be identified with the resident's name. Review of the pharmacy guidelines titled, Medication Storage Guidance, dated March 2020 Humalog multidose vial: Unopened store in refrigerator (36-46 degrees F [Fahrenheit]) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store in refrigerator for 28 days Opened store at room temperature for 28 days Lantus multi dose vial: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store in refrigerator for 28 days Opened store at room temperature for 28 days Lantus Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store at room temperature for 28 days Insulin Aspart Pro-Asp Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 14 days Opened store at room temperature for 14 days Insulin Lispro Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 28 days Opened store at room temperature for 28 days Levemir Pen: Unopened store in refrigerator (36-46 degrees F) until expiration date Unopened store at room temperature ( 59 - 86 degrees F) 42 days Opened store at room temperature for 42 days

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to implement their quality assessment and assurance measures for corrective action related to deficient practice identified on the annual survey conducted on [DATE]. Findings of deficient practice were identified during the revisit survey for three (F695, F700, and F761) of the seven citations reviewed for correction. Findings included: 1. A review of the facility plan of correction for the recertification survey ending [DATE] revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F695: The Director of Nursing or designee will perform weekly observational audits for 3 months to verify the facility staff are providing care for tracheostomy patients, following proper procedures and use of personal protective equipment during care and the care of equipment related to respiratory care. Immediate education if required. Audit results will be reviewed by the QA/QAPI (Quality Assurance/Quality Assurance Performance Improvement) committee monthly until such time substantial compliance has been achieved as determined by the committee. During the revisit conducted on [DATE] the facility was found to have failed to provide respiratory care in accordance with professional standards of practice for 1 (Resident #3) of 1 resident sampled for respiratory care related to storage of a nebulizer machine and Resident (#15) related to oxygen nasal cannula and oxygen tubing and the citation was not corrected. On [DATE] at 8:35 am during the initial tour staff member (F), Patient Care Assistant (PCA) was observed handing Resident #3 a nebulizer mask. The nebulizer machine was on, vapor could be seen coming from the front of the mask. Resident #3 held the mask up to her face. Staff member (F), PCA was interviewed at the doorway of the resident's room, and she confirmed that she was not a nurse, she was a PCA (patient care assistant). Staff member (A) R.N.(Registered Nurse) was observed four doors away from the resident at her medication cart. A second observation was conducted at 9:15 a.m., the resident had her oxygen on. She was asked if she usually self-administered her nebulizer treatment and stated that she does. She then opened her top drawer of her nightstand and her nebulizer face mask along with the tubing was laying on top of other articles unbagged. Photographic evidence was taken. At this time staff member (A) came to the resident's doorway and asked if she needed anything, the resident responded that she didn't. Staff member (A) was asked to verify if Resident #3 nebulizer mask was stored in a sanitary manner. She stated that the resident self-administers her treatment. Staff member (A) was asked if the resident was care planned to self-administer, she stated that she didn't know because she was an agency nurse. Staff member (A) was asked if the nebulizer was stored in the resident nightstand appropriately, she reported no, that it should have been cleaned and bagged. The resident was asked if her nebulizer was cleaned before placing it inside her nightstand, she reported that it had not been cleaned. An interview was conducted with the MDS (Minimum Data Set) coordinator regarding Resident #3's plan of care for nebulizer treatments. The MDS coordinator stated that the resident does not self-administer her own nebulizer treatment and a nurse is the only one who should administer the nebulizer treatments. Care Plan review revealed the following: Resident has oxygen therapy related to respiratory illness, COPD (Chronic Obstructive Pulmonary Disease), Lung Cancer. She is easily short of breath. She removes nebs (nebulizers) and oxygen herself. Revision of the plan of care [DATE] with an intervention as follows: [DATE]-Nebs added routinely-every 6 hours. Review of the resident's MAR (medication administration record)/TAR (treatment administration record) revealed: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3-minute inhale orally via nebulizer every 6 hours for SOB (shortness of breath) start date [DATE]. The MAR showed that the resident received a nebulizer treatment on [DATE] at 6:00 am. Review of the facility Policies and Procedures: Dated [DATE], revised [DATE] titled Nebulizer (small volume nebulizer) under the heading procedure showed: Perform hand hygiene Evaluate the resident. Establish baseline respiratory rate, pulse, oxygen saturation and breath sounds. Administer treatment until medication is depleted Disassemble device and rinse the mouthpiece with water and air dry Place entire unit in bag to be maintained in residents' room A review of Resident #15's Medical Record revealed that Resident #15 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, heart failure, and shortness of breath. A review of Resident #15's Physician's orders revealed an order, dated [DATE], for oxygen as needed at 2 liters per minute via nasal cannula for shortness of breath and chronic respiratory failure. Resident #15's Physician's Orders also revealed an order, dated [DATE], for changing oxygen tubing, mask, and/or nasal cannula as needed for hygiene. A review of Resident #15's Care Plan revealed a problem, last revised on [DATE], that Resident #15 had potential for shortness of breath related to having a history of dyspnea and respiratory failure. Interventions included oxygen at 2 liters per minute as needed for shortness of breath and to use universal precautions as appropriate. An observation was conducted on [DATE] at 12:53 PM of Resident #15 resting in bed. An oxygen concentrator was observed next to Resident #15's bed. A plastic bag with an oxygen nasal cannula and oxygen tubing were observed hanging from the oxygen concentrator and sitting on the floor. The nasal cannula inside of the plastic bag was observed to be dated [DATE] and the plastic bag that the nasal cannula was inside was dated [DATE]. An interview was conducted following the observation with Staff B, Registered Nurse (RN) Unit Manager. Staff B, RN stated that residents with oxygen had their tubing, nasal cannulas, and storage bags changed out on a weekly basis. Staff B, RN observed that Resident #15's storage bag was dated on [DATE] and said that the storage bag should have been changed out when the nasal cannula was changed out [DATE]. Staff B, RN stated that storing the newly changed nasal cannula in the old bag would contaminate the nasal cannula. Staff B, RN also stated that the storage bag should not be touching the floor in the resident's room and should be stored in a way so that it was not touching the floor. Staff B, RN removed the storage bag and nasal cannula from Resident #15's room. An interview was conducted on [DATE] at 01:21 PM with Staff G, RN, Assistant Director of Nursing (ADON). Staff G, RN stated that oxygen tubing and storage bags that the tubing was kept in were changed out on a weekly basis. Residents should have orders in their medical record for the changing out of oxygen tubing and other respiratory equipment if they use it. Staff G, RN stated that Resident #15's storage bag should have been changed at the same time that her nasal cannula was because the nasal cannula would become contaminated once it was stored in the old storage bag. An interview was conducted on [DATE] at 04:46 PM with the facility's Director of Nursing (DON). The DON stated that there was an issue previously that nursing staff were not properly changing out or dating respiratory equipment as it should be. Nursing staff were supposed to change out storage bags, nebulizer set ups and oxygen tubing on a weekly basis. The DON stated that she would not expect to see a newly changed nasal cannula stored inside of an older bag and that the bag should be changed at the same time. A review of the facility policy titled Equipment Change Schedule, effective date of [DATE] and revised date of [DATE], revealed the following: - Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. - Procedure: Nebulizer set-up once, every seven days along with equipment bag labeled with name, date, and room number. 2. A review of the facility plan of correction for the recertification survey ending [DATE] revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F700: Conduct audits of newly admitted and current residents utilizing assistive devices/side rails to ensure appropriate use. Any resident identified to not require side rails will have them removed. Facility policy regarding side rail use was reviewed by the Interdisciplinary Team and deemed appropriate. Immediate In-service provided to all interdisciplinary staff and nursing staff on assessments for bed rails/enablers to include policy and procedure by ADON/staff development nurse Assessment of all residents with side rails/enablers for continued use. Facility audit completed for all residents for side rails/enablers. Interdisciplinary Team (IDT) completed therapy referral as indicated for all other residents that could benefit from enablers. Side rails assessments completed for all residents The Director of Nursing or designee will perform weekly audits for 5 residents for 3 months to verify the facility staff is assessing for interventions and the use of any problem areas to include the use of bedrails/enablers. Immediate education if required. Audit results will be reviewed by the QA/QAPI committee monthly until such time substantial compliance has been achieved as determined by the committee. During the revisit conducted on [DATE] the facility was found to have failed to ensure an assessment for bed rails/enablers was conducted and failed to have a consent for the use of bed rails/enablers for one resident (#1) of seven sampled residents and the citation was not corrected. A medical record review was conducted for Resident #1 who was admitted to the facility on [DATE]. Resident is alert and oriented with confusion and forgetfulness but able to make his needs known. Review of the Minimum Data Set, dated [DATE], showed a BIMS (Brief Interview of Mental Status) score of 13, signifying that the resident was cognitively intact. The MDS also showed he had impaired cognition function or impaired thought process related to his diagnosis of Dementia with Behavioral disturbances. Resident #1 was observed with 1/4 bedrails on each side of the bed in the raised position at 8:45 a.m. A second observation was made at 1:15 p.m., the bedrail remained in the raised position. The Resident reported that his rails were always raised. Staff member (B) R.N. was asked to confirm if the resident's side rails were in the raised position. He confirmed that they were and that he was in a specialized bed (Bariatric) which comes with attached rails and if removed there would be a large gap between the mattress of approximately 2 or more inches. Review of the resident's record revealed a Side Rail Evaluation dated [DATE] included, weakness, balance deficit, pain, unable to support trunk in upright position, alert, Recommendations: he has been evaluated by therapy an does not require any side rails or bars. He has no type of device on his bed, be is bedbound by choice - total care. An interview was conducted with the Director of Nursing at 1:22 p.m. She reviewed the side rail evaluation that was conducted on [DATE] and said that a new side rail evaluation should have been completed. Care Plan Review revealed: Resident has ADL (Activities of Daily Living) self-care performance deficit related to weakness with impaired balance and mobility and requires extensive assistance of 1-2 staff with his needs and mobility. Intervention dated [DATE] showed: Side Rails: ¼ side rails used to assist with bed mobility and repositioning. P.O. dated [DATE] Bilateral side rails on bed for bed mobility. Minimum Data Set, dated [DATE] Section P indicates under bed rails (O)- not in use. At 2:30 P.M. an interview with the Minimum Data Set (MDS) Coordinator reports that the bed rail is not a restraint. She was asked if therapy or any IDT (inter disciplinary team) member had evaluated the resident prior to the use of the side rails for risk of entrapment. She confirmed there was no evaluation after the [DATE] side rail assessment. There should have been one completed. The MDS coordinator also confirmed that no consent from the resident was conducted for the use of bed rails. A review of the policy and procedure titled, Side Rail/Bed Rail, with an effective review date of [DATE], revealed: Policy: The center, will attempt alternative interventions, and document in the medical record, prior to use of side rail/bed rail. The Policy further revealed, Side rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. The procedure section of the policy revealed the following: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/ or resident representative. 3. Obtain consent from the resident/ and or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and [NAME]. 6. Re-Evaluate the use of side rail/bed rail, quarterly, with a change of condition or as needed. 7. Follow the manufacturer's recommendation and specifications for installing and maintaining side rails/ bed rails. 3. A review of the facility plan of correction for the recertification survey ending [DATE] revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F761: Review the facility policy regarding medication carts/storage by the Interdisciplinary Team. In-service immediately provided to nurses on appropriate storage and maintaining of drugs and biologicals by ADON (Assistant Director of Nurses)/Staff development nurse. Audit of medication carts. The Director of Nursing or designee will perform weekly audits for 3 months to verify storage and labeling of medication and biologicals. Immediate education if required. Audit results will be reviewed by the QA/QAPI committee monthly until such time substantial compliance has been achieved as determined by the committee. During the revisit conducted on [DATE] the facility was found to have failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards in 3 of 3 medication carts observed and the citation was not corrected. A medication cart inspection was completed on [DATE] at 03:20 PM with Staff C, Registered Nurse (RN). A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. Staff C, RN stated that the container of blood glucose test strips should have a date labeled on them to indicate when they were opened. A manufacturer's box for a Breo Ellipta inhaler and doses were observed in the medication cart. The box had an affixed white label that read Discard after 42 days. The label also had a section which indicated the expiration date, with a hand written date of [DATE] on the provided line. Staff C, RN stated that the medication appeared to be expired and stated that medications were disposed of if they were discovered to be expired. An inspection of the 2nd, 3rd, and 4th drawers of the medication cart revealed a total of 13 loose medications that were not stored inside of any type of container. Staff C, RN addressed that the medication cart should not contain any loose medications and that medications should be stored in the proper container. Staff C, RN stated that she would normally inspect her cart every shift for cleanliness of the medication cart and ensuring that medications had proper labeling. A medication cart inspection was completed on [DATE] at 03:37 PM with Staff D, Agency RN. An inspection of the 2nd drawer of the medication cart revealed a total of 12 loose medications that were not stored inside of any type of container. Staff D, RN addressed that the medication cart should not contain any loose medications and that medications should be stored in the proper container. Staff D, RN also stated that she would expect for the medication carts to be inspected by the nurses working the floor, but also stated that she did not routinely inspect the medication cart for cleanliness. Staff D, RN was not able to state whether the facility had a protocol in place related to inspection of the medications carts by the nursing staff. A medication cart inspection was completed on [DATE] at 03:50 PM with Staff E, Agency Licensed Practical Nurse (LPN). A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. Staff E, LPN stated that the container of blood glucose test strips should have a date labeled on them to indicate when they were opened. A medication bottle containing an open vial of Latanoprost 0.005% eye drops was observed in the medication cart. The medication bottle had an affixed yellow label with a section that read Date Opened:, which did not contain a labeled date. The yellow label also contained a section that read Discard after 42 days. Staff E, LPN stated that medications which contained a label from the pharmacy should be filled out properly to indicate the expiration date of the medication. Staff E, LPN was not able to state when the vial of Latanoprost 0.005% eye drops was opened. An inspection of the 2nd drawer of the medication cart revealed a total of 3 loose medications that were not stored inside of any type of container. Staff E, LPN addressed that the medication cart should not contain any loose medications and that medications should be stored in the proper container. Staff E, LPN also stated that it was her first time with the medication cart and that she did not inspect the medication cart for presence of loose medications or proper labeling of medications in the medication cart. A telephone interview was conducted on [DATE] at 04:28 PM with the facility's Consultant Pharmacist. The Consultant Pharmacist stated that she conducted monthly visits to the facility and conducted spot checks of the medication carts. Nursing staff should be inspecting the medication carts for open dates of medications, expiration dates of medications, and cleanliness of the medication cart itself, which would include loose medications. The Consultant Pharmacist stated that she would recommend that the nursing staff inspect the medication carts at least once a week to correct any potential issues. Nursing staff were also provided with guides to help keep track of the expiration dates of certain medications. An interview was conducted on [DATE] at 04:46 PM with the facility's Director of Nursing (DON). The DON stated that nurses were expected to inspect the medication carts for proper dating of medications, ensuring medications were not expired, and cleanliness of the medication carts. The DON also stated that there was no interval in which nursing staff should be inspecting the medication carts for issues. A review of facility Pharmacy Guidelines: Common Medication Storage, dated [DATE], under General Guidance revealed the following guidelines: - Xalatan Ophthalmic Solution (latanoprost). Store in a refrigerator at 36 to 46 degrees Fahrenheit (F) until ready to use. Date when opened and discard after 6 weeks. Store at room temperature up to 77 degrees F after opening. - Breo Ellipta Inhalation Powder. Store in a dry place away from direct heat or sunlight at 68 degrees F to 77 degrees F with excursions from 59 degrees F to 86 degrees F permitted. Date when opening the foil tray and discard after 6 weeks or when the dose counter reads 0, which ever comes first. During an interview with the Nursing Home Administrator during the Quality Assurance interview on [DATE] she reported that assessments were completed, evaluations, education, and audits. She said that the Director of Nursing and the Assistant Director of Nursing were responsible for reviewing the audits that were completed by the nursing staff for the plan of correction. We have some work ahead of us, the leaders have been here less than 4 months. We will have other disciplines conduct audits sine they would be a set of fresh eyes. Will we continue to develop action plans especially regarding side-rails. Class III