Based on observation, interview, and policy review the facility failed to ensure dignity was maintained for residents during dining in one dining room (between 400 & 500 halls) out of three dining rooms. Findings included: On 6/17/2025 at 11:45 a.m. an observation of the lunch meal service occurred in the dining room between the 400 and 500 hallways. The dining room was full of multiple residents (a total of 14) and several family members/visitors. Multiple staff members were observed assisting with passing out trays from the tray cart. One of the tables had three residents seated, two residents were served their meals and started eating, while the third resident did not have their meal. Another table had three residents seated, one resident was served their meal, the other two residents did not receive their meals at that time. Staff L, Certified Nursing Assistant (CNA), was observed delivering the tray to one resident who needed assistance. The staff member sat down and proceeded to assist the resident with eating. Staff L, CNA did not remove the food items from the tray and the other two residents at the table were not served their meal at that time. Staff M, CNA, was observed pushing a resident into the dining area. Staff M, CNA was observed approaching a table in the corner of the dining room and loudly stated to another staff member, who was across the dining room, the resident is a feeder and the feeders should be together. This conversation occurred between the staff members who were referring to the residents as feeders loud enough for all residents and visitors to hear. Staff M, CNA left the resident who was just wheeled into the dining room, approached another resident who was at a different table and stated, she is a feeder. At 11:50 a.m. Staff M, CNA proceeded to remove this resident from the table, pushed her to another table, and started to assist this resident with the meal. The table at this time had two residents being assisted and one resident did not have a meal. At 11:54 a.m. a staff member noted the one resident at the table did not have a meal, while the other two residents were being assisted. The staff member removed the resident from the table, and requested staff look for the resident's meal. At 11:56 a.m. the meal was found, and the resident was wheeled back to the table and assisted. During an interview on 6/17/2025 at 1:45 p.m. Staff L, CNA stated all residents at a table should be served at the same time. He stated the food items, drinks etc. should be removed from the tray, and residents should not be called feeders. He stated the dining room was hectic today as there were more staff than usual assisting the residents. During an interview on 6/19/2025 at 11:52 a.m. Staff G, Licensed Practical Nurse (LPN) stated residents should be served one table at a time, the meal should be placed on the table, not left on the tray and certainly residents should not be referred to as feeders. Review of the facility's policy titled Dining Program, dated: 8/3/2017 revealed: Policy Statement: It is the policy of [Facility Name] to enhance the meal experience for all patients/residents who participate in the dining program. Procedure: . 4. When serving patient/resident in the dining room(s), plates, side dishes, glasses/tumblers, etc. will be removed from the tray and placed on the table in front of the patient. 6. Domes, lids, trays, paper/wrapping, etc. will be removed from the table. Paper will be discarded and domes, trays, etc. will be stacked neatly in a designated place. The Nursing Home Administrator stated the facility does not have a policy specific to Dignity and stated they follow the regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#5) of one resident reviewed. Findings included: Review of Resident #5's face sheet, showed an admission date of 6/15/25, with diagnoses to include metabolic encephalopathy, mood disorder, anxiety disorder, difficulty in walking, cognitive communication deficit, left hip osteoarthritis, cognitive impairment, and fall. Review of Resident #5's medical certification for Medicaid long-term care services and patient transfer form (3008), undated Showed the following Section B. Hearing is impaired, Section E. Medical Conditions generalized weakness, urinary tract infection (UTI) and lactic acidosis, Section G. Patient risk alerts is falls, Section O. Vitals Signs dated 6/15/25 at 7:55 A.M., Section P. Patient Health Status the resident is incontinent, Section S. physical function required two assistants to transfer, Section T. Skin Care - resident has a skin tear on the right lower leg. Review of Resident #5's observation detailed list report showed nursing admission assessment dated [DATE] at 5:45 P.M. The assessment showed Resident #5's Morse Fall Risk score was 45 indicating a high risk of falling. There are skin tears on the resident's left upper extremity and right lower extremity. On 6/18/25 at 4:04 P.M. an interview and record review of Resident #5's record was conducted with the Minimum Data Set (MDS) Director. The MDS Director said she used to complete baseline care plans, but recently the facility has transitioned to a process where it is the admitting nurse' responsibility. She said Resident #5 did not have a baseline care plan which should be completed within 72 hours of admission. On 6/18/25 at 4:30 P.M. during an interview the Director of Nursing (DON) said the baseline care plan should be completed by the admitting nurse and some nurses do not understand the process. On 6/19/25 at 8:40 A.M. during an interview with Staff N, Licensed Practical Nurse (LPN), she said approximately two weeks ago they started the process where the resident's admitting nurse is responsible to initiate the baseline care plan. She said, It takes an additional 30-40 minutes to complete. On 6/19/25 at approximately 9:00 A.M., a copy of Resident #5's baseline care plan was requested and was not provided. Review of the facility's policy titled, Care Plans, revised 7/7/23 showed the following - Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan. Definitions: Baseline Care Plans-Must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Procedure -1.) Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT (Interdisciplinary Team), the patient/resident and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to revise an Activity of Daily Living (ADL) care plan to reflect a resident's condition for one resident (#29) out of eight residents reviewed. Finding included: During an interview on 06/16/25 at 11:42 a.m. Resident #29 stated she was getting weaker due to no one at the facility assists her with walking. She stated therapy instructed her to ensure someone is supervising her while walking. During a follow up interview on 06/18/25 at 09:41 a.m. the resident stated loosing endurance since being discharged from therapy as no one was available to supervise except when family visits. Review of the admission Record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses to include: Parkinson's disease without dyskinesia, hypertension, Difficulty in walking, anxiety disorder, and other co-morbidities. Review of Resident #29's Minimum Data Set (MDS) dated [DATE] revealed Resident #29 is cognitively intact. Review of Resident #29's therapy discharge note dated 05/28/25 revealed the resident is able to walk 50-feet with standby assist with a four-wheel walker. During an interview on 06/18/25 at 10:53 a.m., Staff B, CNA stated not having time to complete Range of Motion(ROM) or walking residents around if requested and stated usually the restorative aide completes the task. Staff B stated they don't really need to worry about not getting it done. During an interview on 06/18/25 at 11:58 a.m. Staff M, Restorative CNA stated they had not started in the restorative position, yet. Staff M said currently, assists with residents weights, meals if needed. Staff M, stated not having a specific assignment but assists when requested by a CNA or nurse. The staff member stated the restorative program had not been started and there was no one to oversee the program. During an interview on 06/18/25 at 12:20 p.m. the Director of Rehabilitative Services (DOR) stated Resident #29 was discharged from therapy services on 05/28/25 and was able to walk long distances with just standby assistance with a four-wheel walker. Resident #29 was discharged from therapy with a home exercise program, which usually would mean restorative but the facility does not have restorative at this time as there was no one in nursing to oversee the program. Review of Resident #29's Care Plan dated 8/22/24 revealed: Problem category: Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential Resident #29 is at risk for ADL Decline related to History of head trauma, Lewy body dementia, Parkinson's, adult failure to thrive, weakness, and reduced mobility. Goal dated: 04/07/25 revealed: Patient/ Resident's ADL needs will be met and independence potential maximized within constraints of disease through next review. Approach dated 08/22/24: Provide assistive device as ordered. Set up Resident for ADLs. Assist with toileting PRN. Encourage resident to do as much as possible. Resident needs assistance with transfers. Review of the facility's policy titled Care Plans dated reviewed 07/27/2023 revealed: Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Procedure: . admission Comprehensive Plan of Care 1.The schedule for the care plans will be developed, reviewed, and distributed to the IDT member of the IDT as designated by the administrator. 2. A comprehensive person-centered care plan will be developed by the interdisciplinary team for each patient/resident within seven days after the completion of the comprehensive assessment. * The patient/resident and or the patient/resident's representative will participate to the extent practicable in the care planning process. * An explanation must be included in a patient/resident's medical record if the participation of the patient/resident and their patient/resident representative is determine not practicable for the development of the patient/resident's care plan. 3. The comprehensive person-centered care plan is developed to include measurable gold and time frame to meet a patient/residence medical, nursing and psychological needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following- * the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being * Any services that would otherwise be required but are not provided due and action taken by the facility staff to educate the resident and resident representative, if applicable, regarding alternatives and consequences. *Any specialized services or specialized rehabilitative services the nursing facility will provide because of PASARR recommendations. If a facility disagrees with the * findings of the PASARR, it must indicate its rationale in the patient/resident's medical record. * In consultation with the resident and the resident's representative(s) - * The resident's goals for admission and desired outcomes * The resident's preference and potential for future discharge. Documentation to whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. 4. The care plan will contain 4 main components: Problem, Goal, Approaches and Role or Accountability. * Problems should be written as actual problems or conditions, potential problems, or conditions, at risk for problems or conditions, or may address patient/resident limitations, maintenance level or improvement possibilities, and resident discharge goals. Problem statements to be stated to the extent possible, in functional or behavioral terms (i.e., how is the condition a problem for the patient/resident; how does the condition limit or jeopardize the patient/resident's ability to complete tasks of daily life or affect the patient/resident's well-being). Discharge goals should indicate who made the discharge goal decision and if not the patient/resident, why. *Problems Statement Example: Potential for dehydration due to decreased fluid intake. * The goal is an expected outcome the patient/residents should achieve by implementing specific interventions. Goals are to be established by the interdisciplinary team, with input from the patient/resident, and/or resident representative. All goals should be realistic and attainable considering the patient/ resident's current clinical status. Types of goals may include discharge goals, improvement goals, prevention goals, palliative goals and/or maintenance goals. A well-developed goal will contain the following: * The Goal is a statement of what the patient/resident will accomplish. * The Goal is measurable. * The Goal contains a reasonable timeframe for achievement or reevaluation. * The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal(s), and should include any PASSAR Level II intervention as needed. Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members. When approaches that involve the CNA have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. * Intervention Statement Example: Offer patient/resident fluids every shift in addition to fluids provided with meals. * Upon the completion of a comprehensive care plan for an admission Assessment, each discipline will then sign the care plan on the appropriate discipline signature line of the printed care plan. Document review with patient/resident and/or representative using Care Conference notes. 7. During all care plan meetings other than admission Comprehensive Care Plan that was conducted during a Post admission Care Conference: Review each problem, goal and approach * When a change is necessary, mark through wording to be changed with a single line, sign, and date entry. * When applicable, write a new goal, discontinue approaches and/ or add approaches. * All care plan updates to the problem, goal, or approach should be dated and signed. Care Plan Review and Update: 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/ reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. For [Name of softwareusers, all updates are made electronically. 3. All updates to care plans are to be dated and signed. The Master Care Plan will be electronically updated and printed following the completion of Comprehensive OBRA assessments. 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other needs at any given moment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide meal assistance for one resident (#43) out of two residents sampled. Findings Included: During an interview and observation on 06/16/2025 at 12:20 p.m. Resident #53 was observed scooping mashed potatoes onto a spoon feeding Resident #43. Resident #53 stated I am feeding my [family member] (Resident #43). I feed her and try to eat my food in-between. If I don't feed, her then no one helps her. Review of Resident #43's admission record revealed an admission date of 09/21/2023. Resident #43 was admitted to the facility with diagnosis to include need for assistance with personal care, Muscle weakness (generalized), Mild protein-calorie malnutrition, Other specified joint disorders, right hand, other lack of coordination, Aphasia, Aphasia following cerebral infarction, Dysphagia, oropharyngeal phase. Review of Resident #43's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns a Brief Interview Mental Status (BIMS) of 08 out of 15 showing moderate cognitive impairment. Review of Resident #43's Orders revealed: 04/03/2025 No Added Salt, Mechanical Soft Special Instructions: thin liquids. 05/01/2025 Occupational Therapy (OT) Evaluation and treatment, related to utensils and bowels. Review of Resident #43's Care Plan Dated 09/22/2023 revealed: Problem: Resident #43 has an ADL decline related to Hypertension, Spondylolisthesis, Spinal stenosis, Right hand Contracture and other comorbidities Patient requires assistance in ADLS and presents with incontinence of Bowel and bladder. The approach showed- Assist with feeding at meals, and Physical Therapy (PT)/OT to evaluate and treat as needed. Review of an observation form dated 03/28/2025 Description showed - Interdisciplinary Referral to Rehab Services (Occupational Therapy) for decline in feeding. Review of Resident #43's Progress note dated 03/28/2025 revealed: Psych - Patient noted to have decline in self-feeding, eats 100% with assistance with meals. Will refer to OT services and provide assistance with meals from nursing staff Review of a nutritional note dated 04/03/2025 showed - Hand contractures noted. - Resident needs assistance with meals. Met with family to review weights and nutritional concerns. During an interview on 06/17/2025 at 1:23 p.m., staff C, Certified Nursing Assistant (CNA), stated Resident #43 needs help with scooping the food onto the utensil. She stated recently she has needed more assistance with eating her meals. She said, I assisted Resident #43 on 06/16/2025 after I finished passing the lunch trays for the other residents, normally her family member is here to help, but she left in the beginning of lunch. During an interview on 06/18/2025 at 11:40 a.m., Staff G, Licensed Practical Nurse (LPN) stated she was not too familiar with all of the residents in the 500 unit, but knows they have quite a few residents who need assistance with meals. She stated Resident #43 is a resident who needed assistance with eating during meals. During an interview on 06/18/2025 at 3:50 p.m. the Director of Nursing (DON) stated CNAs, Nurses or the restorative nurse should be helping residents with meal assistance. The DON said, We have a lot of involved families, who are here constantly to help with every meal. It is not an expectation for family to be here, but it is kind of assumed that they will be here during mealtimes. Review of the facility's undated policy titled Assisting with ADLS revealed, Section 1: Introduction, about this course, assisting a person with activities of daily living, or ADLS, is an essential part of your job. Many of those you care for will need some level of assistance with completing personal care period this course discusses how to provide person centered care and promote independence when assisting with ADLS. It also discusses how to help a person with dementia and performing ADLS, .when a person needs help with their ADLS, it is important to provide competent, respectful care. ADLS include eating, bathing, grooming, dressing, toileting, shaving in oral care or denture care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record reviews, the facility failed to provide nephrostomy care and services consistent with professional standards of practice for one resident (#328) out of one sampled resident. Findings included: A review of Resident #328's Face Sheet revealed admissions dated 6/4/2025 to the facility with diagnoses included but not limited to obstructive and reflux uropathy, chronic kidney disease, bladder-neck obstruction, hydronephrosis, neuromuscular dysfunction of bladder, and urinary tract infection. On 6/19/25 at 10:16 A.M. an observation and interview was conducted. Resident #328's nephrostomy insertion site dressing was not intact and dated 6/3/25. Resident #328 said the dressing was last changed before I left the hospital. The urine appears serosanguinous (contains blood). Resident #238 said she asked a nurse to change the dressing and was told there were no orders to change the nephrostomy site dressing. (Photographic Evidence Obtained). A review of Residents #328's Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) summary score was 15, indicating cognitively intact. Review of Resident #328's medical record did not reveal any physician orders related to her nephrostomy tube. On 6/19/25 at 10:51 A.M. during a follow-up interview and observation of Resident #328's nephrostomy site dressing, the Director of Nursing (DON) was unable to describe the care staff provides for the nephrostomy tube every shift. Resident #328 said the doctor said the nephrostomy tube needed to be flushed. The DON said a nurse will contact the urologist for orders and the dressing will get changed today. A review of Resident # 328's progress note dated 6/5/25, written by nursing . R [right] side nephrostomy in place . A review of care plans showed the following: -Problem: Resident #326 requires enhanced barrier precautions related to right nephrostomy and infection. Goal: Resident will exhibit no signs of infection, such as fever, redness, swelling, or drainage from potential sites of infection through next review, the approaches included observe and report any signs and symptoms of worsening infection. [Redness, swelling, increased pain, purulent discharge from incisions, injury, and exit sites of tubes (IV [intravenous] tubing's), drains, or catheters]. -Problem Resident #326 has an infection: urinary tract infection (UTI). Goal: Resident will be free from signs and symptoms of infection by next review date; the approaches include Report signs and symptoms of worsening infection . -Problem Resident has a urinary catheter-Right nephrostomy tube-- related to obstructive uropathy, Goal: Patient/ Resident will not develop any complications associated with catheter usage through the next review. Approaches include, keep catheter tubing free of kinks, keep drainage bag below level of bladder, and provide catheter care per policy. Review of publication titled Nephrostomy Tube Care, medically reviewed by Drugs .com provides the following directions change the bandage around the tube, the bolsters, skin barriers, and tube attachments at least every 7 days. If your bandages, barriers, or devices get dirty or wet, change them right away, and as often as needed. Retrieved on 6/22/2025. Review of facility policy titled Care Plan, revised 7/7/23 revealed .Scope- This policy applies to Case Mix Directors, Social Services, Activities Directors, Dietary Managers, Registered Dieticians, Nursing, Direct Care Staff, and all other members of the Interdisciplinary Team (IDT) that participate in the RAI process admission Comprehensive Plan of Care- A comprehensive person-centered care plan will be developed by the interdisciplinary team for each .resident . 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following- The care plan will contain 4 main components: Problem, Goal, Approaches and Role or Accountability. Problems should be written as actual problems or conditions, potential problems, or conditions, at risk for problems or conditions, or may address patient/resident limitations, maintenance level or improvement possibilities, and resident discharge goals. Problem statements to be stated to the extent possible, in functional or behavioral terms (i.e., how is the condition a problem for the patient/resident; how does the condition limit or jeopardize the patient/resident's ability to complete tasks of daily life.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Twenty-five medication opportunities were observed, and two errors were identified resulting in an error rate of 8.0%. Findings Included: During a medication administration observation on 6/17/25 at 8:41 A.M. for Resident #6, Staff F, Registered Nurse (RN), prepared vitamin B-12 (1 tablet), multiple vitamin with minerals (1 tablet), and Gabapentin 300 mg (milligram) capsule (1 capsule) by crushing the medications and administering with applesauce. Review of the facility's list titled, Oral Dosage Forms that Should Not be Crushed 2016, published by the Institute of Safe Medication Practices (ISMP) showed Gabapentin tablet should not be crushed. On 6/17/25 at 8:48 A.M. during a medication administration observation Staff F, RN prepared and administered the following medications to Resident #53, aspirin 81 mg, calcium carbonate 1500 mg, brimonidine-timolol-one drop in each eye, buspirone 15 mg, vitamin D3 (1 tablet), and nifedipine 30 mg extended-release tablet. Staff F, RN, crushed Resident #53's calcium carbonate, buspirone, vitamin D3, and nifedipine before administering. Review of Resident #53's Medication Administration History, dated 6/1/25-6/18/25, showed, DO NOT CRUSH as special instructions for nifedipine administration. During an interview on 6/17/25 at approximately 9:10 A.M. Staff F, RN, stated she does not know where to find the facility's list of do not crush medications. Review of the facility's list titled, Oral Dosage Forms that Should Not be Crushed 2016, published by the Institute of Safe Medication Practices (ISMP) showed nifedipine tablets should not be crushed During an interview on 6/19/25 at 11:07 A.M. the Director of Nursing (DON) said the nursing staff are expected to follow physician orders, pharmacy instruction and the facility's policy during medication administration. Review of the facility's policy titled, medication administration, reviewed 7/22/24 showed under guidelines a policy statement: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedures: .22. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a patient/resident has difficulty swallowing or is tube-fed, using the following guidelines:-Long-acting or enteric coated dosage forms should generally not be crushed and require a physician's specific order to do so. The physician must record in the medical record that the benefit of crushing the dosage form outweighs any potential risk. -For patients/residents able to swallow, tablets may be crushed together, and along with the contents of opened capsules, may be mixed with the appropriate vehicle (e.g. [such as] applesauce) so that the patient/resident receives the entire dose.

Based on observations and interviews facility failed to ensure medication was stored appropriately on three halls (100, 200, 500) out of five halls related to unlocked medication/treatment carts, unattended medication, dirty medication carts, and controlled drugs not stored in a permanently affixed compartment. Findings included: An observation was conducted on 6/16/25 at 9:35 a.m. of an unlocked treatment cart containing prescription medications on the 500 hall. No staff were observed in sight. An observation was conducted on 6/16/25 at 10:22 a.m. on the 100 unit of an unlocked medication cart left unattended in the hall. There was a resident in the hall and no staff members were present. An observation was conducted on 6/17/25 at 10:16 a.m. of the 500 hall medication storage room with Staff F, Registered Nurse (RN). A metal box in the refrigerator contained an emergency drug kit with a controlled drugs. The metal box was not permanently affixed. Staff A said she did not know why it was not affixed or if it was supposed to be. An observation was conducted on 6/17/25 at 12:09 p.m. of an unlocked and unattended medication cart on the 100 unit. There were no nurses in sight of the cart. An interview was conducted on 6/19/25 at 7:32 p.m. with the Nursing Home Administrator (NHA). The NHA stated the box containing controlled drugs should be attached to the refrigerator and it would be taken care of. The NHA confirmed controlled medication was in the emergency drug kit. 2. On 6/17/25 at 8:32 A.M., during medication administration observation Staff F, Registered Nurse (RN) left intravenous (IV) antibiotics on top of the medication cart while administering medications in a resident's room. Staff F, RN said, I forgot to lock the cart. On 6/17/25 at 8:48 A.M., during a medication administration observation Staff F, RN, left aspirin, vitamin D3, nifedipine, calcium carbonate, Buspar and Combigan on top of the medication cart when she went to get her stethoscope. Staff F, RN said she thought it was okay because the surveyor was standing by the medication cart. On 6/17/25 at 12:59 P.M. during medication administration observation Staff I, RN walked away from an unsecured medication cart. When notified of the observation, Staff I, RN said, Thank you, I always lock the cart. On 6/17/25 at 1:01 P.M. during a medication administration observation Staff I, RN walked away from an unsecured medication cart. When notified of the observation Staff I, RN said, This is the only two times I have done this today. On 6/18/25 at 12:36 P.M., the medication cart at the nurses' station between 100 and 200 hallways was observed unlocked and unattended. Staff K, RN, was notified. She secured the cart and said medication carts should be locked when staff is not using them. On 6/17/25 at 8:12 A.M. the bottom drawer of the 300 Hallway medication cart was observed with a build-up of sticky, gummy red and cream-colored material on the surface to the drawer and around the dividers. On 6/17/25 at 8:32 A.M. the 400/500 Hallway's medication cart was inspected and observed with sticky, gummy red and cream colored build- up in the bottom drawer, and more apparent in the corners and around the dividers. Staff F, RN, said the nurses are responsible for cleaning the drawers. During an interview on 6/19/25 at 11:07 A.M. the Director of Nursing (DON) said medications carts should be locked, and medications should not be left unattended on top of the medication cart. The DON said, If the nurse walks away the cart, it should be locked. Review of facility's policy titled, medication storage in the healthcare centers, revised 11/1/24, Policy Statement: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel. Scope: This policy applies to all licensed nursing staff of [Name of Facility]. Procedure: 2. Only licensed nurses and pharmacy personnel are allowed to access medications .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. Nurses are required to check all medications for deterioration or expiration before administration. Nurses are also required to inspect medication storage facilities, including medication carts routinely. Medication storage areas are to be kept clean, well-lit and free of clutter. Nursing staff who administer medications are responsible for the cleaning and organization of medication carts and medication storage areas. (Photographic Evidence Obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the annual survey conducted 6/19/25 regarding a medication error rate of greater than 5.0% and infection control during medication administration. Findings included: 1. On 6/17/25 during a recertification survey deficient practice was identified during medication administration and F759 was cited with a scope and severity of D. During a medication administration observation on 6/17/25 at 8:41 A.M. for Resident #6, Staff F, Registered Nurse (RN), prepared vitamin B-12 (1 tablet), multiple vitamin with minerals (1 tablet), and Gabapentin 300 mg (milligram) capsule (1 capsule) by crushing the medications and administering with applesauce.Review of the facility's list titled, Oral Dosage Forms that Should Not be Crushed 2016, published by the Institute of Safe Medication Practices (ISMP) showed Gabapentin tablet should not be crushed.On 6/17/25 at 8:48 A.M. during a medication administration observation Staff F, RN prepared and administered the following medications to Resident #53, aspirin 81 mg, calcium carbonate 1500 mg, brimonidine-timolol-one drop in each eye, buspirone 15 mg, vitamin D3 (1 tablet), and nifedipine 30 mg extended-release tablet. Staff F, RN, crushed Resident #53's calcium carbonate, buspirone, vitamin D3, and nifedipine before administering.Review of Resident #53's Medication Administration History, dated 6/1/25-6/18/25, showed, DO NOT CRUSH as special instructions for nifedipine administration.During an interview on 6/17/25 at approximately 9:10 A.M. Staff F, RN, stated she does not know where to find the facility's list of do not crush medications.Review of the facility's list titled, Oral Dosage Forms that Should Not be Crushed 2016, published by the Institute of Safe Medication Practices (ISMP) showed nifedipine tablets should not be crushed.2-During the revisit survey additional medication administration errors were:An observation was conducted on 8/11/25 during medication administration with Staff B, Licensed Practical Nurse (LPN).-At 10:03 a.m. Staff B prepared medication to be administered to Resident #3. The following medications were prepared:1-Tamsulosin 0.4 mg x 12-Olanzapine 5 mg x13-Jardiance 10 mg x 14-Gabapentin 100 mg x 15-Clonazepam 0.5 mg x 16-Methocarbamol 500 mg x 17-Multivitamin x 18-Valproic acid 250 mg/5ml. Give 5 ml.9-Acetaminophen 325 x 110-Eliquis 5 mg x 1Review of admission Records showed Resident #3 was admitted on [DATE] with diagnoses including other paralytic syndrome following cerebral infarction, polyneuropathy, and pain.Review of Resident #3's physician orders showed medications #1-8 were given per orders. For medication #9, Acetaminophen, only one tablet was administered, and the order dated 7/1/25 was Acetaminophen 325 mg. 2 tablets. Once a day at 9:00 a.m. For medication #10, Eliquis, Staff B dispensed the medication and accidentally dropped it on the floor. Staff B disposed of the dropped tablet but did not dispense another Eliquis to be administered. The order dated 6/20/25 was for Eliquis tablet 5 mg. Twice a day at 9:00 a.m. and 9:00 p.m. Further review of physician orders showed the following orders for medications that were scheduled at 9:00 a.m. but were not administered:-Miralax powder; 17 gram/dose. Every 12 hours 9:00 a.m. and 9:00 p.m. Dated 6/25/25.-Voltaren Arthritis Pain gel; 1 %; 2 grams topical. Apply to neck for pain three times a day. 9:00 a.m., 1:00 p.m., and 5:00 p.m. Dated 8/5/253- On 6/17/25 during a recertification survey deficient practice was identified during medication administration and F880 was cited with a scope and severity of E. Finding included:On 6/17 25 at 8:12 a.m. during a medication administration observation for Resident #29, Staff G, Licensed Practical Nurse (LPN) did not perform hand hygiene (HRH) and did not use ABHR (Alcohol- Based Hand Rub) before preparing medications as well as before and after administering the medications.On 6/17/25 at 10:28 a.m. an interview was conducted with Staff G, LPN about the HH during medication administration, she agreed hand hygiene was not done.On 6/17/25 at 8:32 a.m. Staff F, RN was observed preparing intravenous (IV) antibiotics to administer to Resident #278, she dropped the IV tubing on the floor in the resident's room. Staff F, RN picked up the tubing from the floor and while wearing the same pair of gloves, removed the cap covering the drip chamber, spiked the medication bag and primed the tubing. Before administering Staff F, RN, said the IV tubing is safe to use because the caps on both ends of the tubing had not been removed. When asked about the facility's policy Staff F, RN repeated the IV tubing was safe to use because the caps on both ends of the tubing had not been removed and continued to administer the antibiotic.On 6/17/25 at 8:41 a.m. while preparing and administering medications for Resident #6, Staff F, RN did not perform hand hygiene (HH) of any kind before preparing medications as well as before and after administering the medications. During an interview with Staff F, RN confirmed HH was not completed.During an interview on 6/18/24 at 12:38 p.m. Staff K, RN stated if during medication administration the IV tubing dropped to the floor, the expectation was for the tubing to be replaced prior to administering the medication.4-During the revisit survey additional infection control concerns were:An observation was conducted on 8/11/25 during medication administration with Staff A, Licensed Practical Nurse (LPN).-At 9:10 a.m. Staff A prepared medication for a resident. While dispensing Acetaminophen from the bottle, Staff A used her ungloved finger to pull the pills from the bottle.-At 9:20 a.m. Staff A prepared medication and gathered supplies to complete a blood glucose check on a resident. Staff A entered the resident's room, set the glucose monitor on the resident's beds, administered the oral medication, dropped her medical gloves on the floor, picked the gloves up and put them on, proceeded to check the resident's blood glucose level, removed the gloves, pushed resident to dining room, and returned to the medication cart placing the glucose monitor on the cart and proceeded to document on the computer. The glucometer was not cleaned, and no hand hygiene was performed during the entire process.An observation was conducted on 8/11/25 at 10:03 a.m. during medication administration with Staff B, LPN. Staff B prepared medication for a resident, as Staff B poured Valproic acid to be administered to the resident, she poured too much medication into the medication cup. Staff B picked up the medication cup and poured the excess back into the original bottle. Staff B entered the resident's room and assisted the resident by pouring the medication into the resident's mouth. The resident requested more water. Staff B removed the lid to his cup with her hand touching the drinking spout, exited the room and returned to the medication cart to pour water from a pitcher, returned to the room and placed the lid on the cup while placing her hand on the drinking spout. The resident then requested pain medication. Staff B returned to the medication cart, dispensed the pain medication and returned to the room to administer to the resident. Staff B brought her tablet into the room when she returned. The tablet was set on the resident's bedside table while she administered the pain medication. No hand hygiene was performed throughout the entire process. Upon completion of the medication administration, Staff B returned her tablet to the medication cart without cleaning it.An interview was conducted on 8/11/25 at 4:05 p.m. with Staff A, LPN. She stated she had been educated on medication administration and infection control.An interview was conducted on 8/11/25 at 4:15 p.m. with Staff B, LPN. She stated she had gotten really busy and had a lot going on that day, but she had completed education on infection control and hand hygiene.An interview was conducted on 8/11/25 at 6:50 p.m. with the Nursing Home Administration (NHA) regarding the facility's Quality Assurance and Performance Improvement (QAPI) process. The NHA said based on the deficient practice they completed a root cause analysis and determined it was a lack of education, failure of staff following processes, and overall needing to change the culture of the facility which impacted the trajectory of the facility. The NHA said they learned through the process to immediately address concerns and then they went back to determine additional reasoning and addressed that in QAPI. The NHA said medication administration was identified as an issue in the June 2025 survey. He said the biggest area they needed to improve now was not just targeting crushed medications. He said based on observations there was issue with the medication administration process and not just crushed medications. The NHA said moving forward they are going to tailor audits, education, and the process to include all medication types and expand their QAPI to the whole medication administration process from start to finish. The NHA said for infection control they implemented education on contact precautions and hand hygiene. He said audits were completed to identify lapses in the processes. He said they completed education and audits related to hand hygiene with medication pass specific to nurses. He said they had been targeting hand hygiene prior to and during medication administration as well as before and after activities of daily living (ADL) care. The NHA said audits had been dispersed among the management team and the majority of medication administration audits had been completed by the unit managers. The NHA said there will be a re-assignment of individuals completing the auditing process, a root cause analysis will be performed, and they will implement a new process based off the new root cause analysis. Review of a facility policy titled Quality Assurance and Performance Improvement Plan (SNF), reviewed 1/15/24, showed:Quality assurance and performance improvement is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI). Both involve seeking and using information, they differ in key ways:-QA is a process of meeting quality standards and assuring that care and services reach an acceptable level. The process includes the systematic monitoring and evaluation of the various aspects of a project, service, or center/office/agency operations to ensure that standards of quality are being met. Skilled nursing and rehabilitation centers (SNRC's), said quality assurance thresholds to comply with internally developed standards of performance and; also, to comply with all applicable state and federal regulations. QA activities are planned at specific intervals and are ongoing to always assure an acceptable level of performance.-PI (also called quality improvement-QI) it is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. Performance improvement in skilled nursing and rehabilitation centers (SNRC's) aim to improve processes involved in health care delivery, patient safety and quality of life. Performance improvement can make good quality even better.The merger of the two approaches creates Quality Assurance Performance Improvement. QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in healthcare. The activities of QAPI involve members at all levels of the organization to: Identify opportunities for improvement; Address gaps in system or processes; Develop and implement an improvement or corrective plan; and Continuously monitor effectiveness of interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure wound care was done in a timely manner and dressings were dated for three residents (#182, #277, #51) out of four residents reviewed for non-pressure skin conditions. Findings included: An observation and interview was conducted on 6/16/25 at 12:38 p.m. with Resident #182. The resident was observed to have a bandage on his throat area dated 6/11/25. The resident said the bandage covered a stoma (an artificial opening) from having a tracheostomy (trach). He said he had been in the facility for two days and nothing had been done with the dressing. Review of Resident #182's admission Record showed the resident was admitted on [DATE] with diagnoses including gram-negative sepsis and pneumonia due to klebsiella pneumoniae. Review of Resident #182's admission Minimum Data Set (MDS), Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #182's physician orders revealed no orders in place for wound care/dressing changes for the trach site. An order for Clean tracha [sic] with moisten normal saline gauze. Apply dressing. Once A Day, entered on 6/17/25. Review of Resident #182's Medication Administration Record (MAR) showed the trach site bandage was changed on 6/17/25. An interview was conducted on 6/18/25 at 10:45 a.m. with Staff H, Licensed Practical Nurse (LPN). Staff H said Resident #182 had his dressing changed the evening of 6/16/25 for the first time. When asked who should enter wound care orders upon admission, Staff H did not know if the nurse was supposed to enter them or if wound care entered the orders when they saw the resident the first time. Staff H said Resident #182's trach site dressing was changed on 6/16/25 but it was not dated. An interview was conducted on 6/19/25 at 10:48 a.m. with Staff J, Registered Nurse (RN)/Unit Manager (UM). Staff J said for a newly admitted resident the nurse should see if there are wound care orders from the hospital, which was sometimes on the discharge medication list or given verbally in the nurse-to-nurse report from the hospital. Staff J said if there were no wound care orders the admitting nurse should have obtained orders when they called the primary care provider to confirm admission and orders. Staff J said if a resident came in with a bandage, per protocol and education, the nurse should remove it to look for signs and symptoms of infection and put a dry dressing on until orders are received. Staff J reviewed Resident #182's medical record and confirmed there were no wound care orders in place and no wound care was documented until 6/17/25. Staff J said orders should have been placed on 6/14/25 when the resident was admitted . An interview was conducted on 6/18/25 at 12:52 p.m. with Staff K, RN/Wound care. Staff K said Resident #182 had a skin assessment and dressing change late afternoon on 6/16/25. Staff K confirmed the hospital dressing from 6/11/25 remained in place until wound care was provided on 6/16/25. Staff K said the wound care of 6/16/25 was not documented. Staff K stated the admitting nurse should have removed the bandage to assess the area on 6/14/25. As for dating bandages, Staff K, said the facility did not have a policy to date bandages and that was the reason no bandages in the facility were dated. An interview was conducted on 6/19/25 at 9:29 a.m. with the facility's medical director. He said the admitting nurse should have looked at Resident #182's wound and called the doctor for orders if there were not any. He said there was an opportunity there to improve this. He agreed the dressing from the hospital should not have remained in place after two days while in the facility. On 06/16/25 at 11:31 a.m., and 06/17/25 at 8:58 a.m., Resident #51 was observed laying in bed with a dressing on the left side of the back of the neck underneath the left ear. There was no date observed. Resident #51 stated, I'm not sure when they changed the dressings. (Photographic Evidence Obtained). Review of the admission Record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses to include Non-ST elevation (NSTEMI) myocardial infarction (heart attack), hypertension, and congestive heart failure. Resident #51's Clinical admission Assessment marked the resident as Alert & Oriented x 3, communicates verbally, speech is clear, can understand and be understood when speaking. Review of Resident #51's physician orders showed Left posterior ear wound, Cleanse with [brand] wound cleanser, apply skin prep to the peri wound, apply Santyl nickel thick in the wound bed covering edge to edge, and cover with an island border gauze, daily. A review of the Treatment Administration Record (TAR) for June 2025 revealed that treatment was provided on 06/11 - 16/25. During an interview on 06/19/25 at 11:40 a.m. Staff F, RN stated the dressings should be dated and changed if soiled, does not know why it was not. During an interview on 06/18/25 at 4:50 a.m. the Director of Nursing (DON) stated bandages should be clean, dry and dated. She stated this was the expectation and standard of care. During an interview on 06/19/25 at 9:29 a.m. the Medical Director of the facility stated bandages should be dated, and completed as ordered. He stated if a dressing is soiled, the dressing should be changed. Review of the facility's policy titled Documentation of Skin and Wound Care dated reviewed 06/14/2024 revealed: Policy Statement: It is the policy of the Healthcare center to complete documentation that reflects the current resident status as related to skin/wound care. Documentation will provide current and timely documentation on resident's condition related to skin/wound care, accurate information on resident's status as it pertains to skin/wound care, record care rendered and interventions in place and provide a detailed history of the wound assessments that have occurred in the healthcare center. Procedure: *On pressure ulcers, venous insufficiency/stasis ulcers, arterial ischemic ulcers, diabetic wounds and any other chronic or complex wounds (weekly). *Upon admission or re-admission of residents. *On skin tears, rashes, etc. (weekly) in narrative notes kept with the Treatment Assessment Record (ETAR). *Whenever there is an unexpected change in condition of the wound. *As needed, per clinical judgment. 2. Documentation should occur on: admission Documentation: *admission assessment (completed by Admitting Nurse; Skin Integrity Coordinator [SIC], or designee): *admission skin assessment reflects current skin condition, noting wounds, areas of skin compromise, etc. at the time of admission. Wound Manager is to be completed at admission on any noted skin conditions. *Braden Risk Assessment to start risk determination process. Consider adjusting risk according to known clinical condition (including refusals of care). *Baseline admission care plan related to risk for skin breakdown as well as for actual breakdown. *Obtain orders as needed. Orders to be placed on ETAR and initiated per order. Any delay or concern related to orders or products - contact physician or adjunct for clarification/interim order. *This is often completed by the admitting nurse and will be followed up by the SIC (Skin Integrity Coordinator) or designee. SIC may perform these observations. *If SIC does not perform initial assessments, SIC is to review observations and confirm results. Complete skin assessment, Braden, and care plan overview. Clarify/update as needed. *SIC will document a brief overview of admission findings and follow-up in progress notes. Documentation completed by the SIC in wound manager. Daily Documentation of Treatments: *Daily documentation is done by signing the [electronic record] that the dressing was completed. No other documentation is required unless a change is noted then documentation will be completed in wound manager. *Wound measurements are completed when there is significant change in wound status. Weekly Documentation: Weekly Documentation of Treatments will be completed on Wound Manager in the EHR and Focus Observation to include Skin observation. Review of an undated facility's Wound Care Treatment protocol revealed: Dressing Change 5. Label the dressing with the date and your initials. During an observation on 06/16/2025 at 10:53 a.m., Resident #277 was observed dressed in a hospital gown, lying in bed. Resident #277 was observed with a white undated bandage on the top of his right hand, and undated gauze wrapped around his left forearm/elbow area. The bandage on Resident #277's left elbow/forearm was observed to be wet with dark red liquid seeping onto the sheet of his bed. (Photographic Evidence Obtained) During an observation on 06/16/2025 at 11:18 a.m., Resident #277 was observed dressed in a hospital gown, lying in bed. Resident #277 sheets were noted to have several pink and red spots on them. Resident #277's bandage to his left forearm/elbow was noted to be wet with a dark red liquid. Review of Resident #277's admission record revealed an admission date of 06/11/2025. Resident #277 was admitted to the facility with diagnoses to include Parkinson's disease without dyskinesia, Paroxysmal atrial fibrillation, Muscle weakness (generalized), Difficulty in walking, not elsewhere classified, and Unspecified fall, subsequent encounter. Review of Resident #277's 5-Day Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns revealed a Brief Interview Mental Status (BIMS) of 14 out of 15 showing intact cognition. Review of Resident #277's Orders revealed: Bacitracin ointment; 500 unit/gram; amount: 1 application; topical Twice A Day. Cleanse Skin tear to Right Hand with normal saline apply bacitracin cover with dry clean dressing twice a day until healed. Cleanse Skin tear to Right Hand with normal saline apply bacitracin cover with dry clean dressing twice a day until healed. Treatments: Clean left forearm laceration with Normal Saline. Apply Xeroform to area cover with 4 x 4 wrap with rolled gauze once a day on Monday, Wednesday, and Friday. Treatments: Clean left-hand laceration with Normal Saline. Apply Xeroform to are cover with 4 x 4 wrap with rolled gauze once a day on Monday, Wednesday, and Friday. Treatments Non-RX (non prescription): Clean left upper arm with Normal Saline. Apply Xeroform to are cover with 4 x 4 wrap with rolled gauze once a day on Monday, Wednesday, and Friday. Treatments Non-RX: Clean Right elbow with Normal Saline. Apply Xeroform to are cover with 4 x 4 wrap with rolled gauze once a day on Monday, Wednesday, and Friday. Review of Resident #277's Care Plan Dated 05/13/2025 revealed: Resident #277 has skin tears to the right and left upper extremities, left elbow and left forearm, right forearm and right palm related to unwitnessed fall. Approach: Monitor and report signs of localized infection (localized swelling, redness, pain or tenderness, heat at the infected area, purulent drainage, loss of function). Problem: Risk for abnormal bleeding or hemorrhage because of anticoagulation usage: Diagnosis -Paroxysmal atrial fibrillation. Approach: Monitor for and report to the physician signs and symptoms of abnormal bleeding and/ or hemorrhage. Review of Resident #277's Progress Notes revealed there were no progress or nurses notes found related to the resident's bandages being soiled. During an interview on 06/16/2025 at 11:20 a.m., the resident's Physician Assistant stated, I was just about to go check with the nurse to find out what is going on with his bandages and all of this (pointed to the pink and reds spots on Resident #277's sheets). During an interview on 06/16/2025 at 11:26 a.m., Staff E, Licensed Practical Nurse (LPN), stated If you are talking about Resident #277's bandages I saw them and will get to them. He likes to mess with them. We are not allowed to date bandages here. Have you ever heard of this? During an interview on 06/19/2025 at 10:11 a.m., the Medical Director stated he would expect the bandages to be clean and dry. Staff should notify the physician if they have had to change the residents' bandages a few times throughout the shift, and if they are continually saturated. During an interview on 06/19/2025 at 6:20 p.m., Regional Nurse reviewed Resident #277's photographic evidence of bandages from 06/16/2025 and stated she would expect the bandages to be changed upon noticing them being soiled. The Regional Nurse stated if the bandages needed to be changed because they are continually draining, that is soiling the bandages and staff should notify the physician. The nurse stated they have had to change out the bandages.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure pain was controlled for three residents (#185, #379, #182) out of three reviewed for pain management. Findings included: An interview was conducted on 6/18/25 at 2:15 p.m. with Resident #182. The resident said he had been in the facility for four days and did not have any pain medication for the first two days. The resident said pain had gotten to a 10 out of 10 on the pain scale during that time. The resident said he refused tube feedings because they caused stomach cramps and he couldn't handle any more pain. The resident said he was starting to feel better again after having his medication for the last two days. Resident #182 said the pain was so bad on Sunday, 6/15/25 that he almost left the facility. Review of Resident #182's admission Record showed the resident was admitted on [DATE] with diagnoses including gram-negative sepsis, cutaneous abscess of abdominal wall, spondylosis, and pain, unspecified. Review of Resident #182's admission Minimum Data Set (MDS), Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #182's physician orders showed: -Methadone 10 mg (milligram).1 tablet. Every 6 Hours for pain. 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. 6/15/25. -Morphine concentrate 100 mg/5 ml (milliliters) (20 mg/ml); 0.75 ml. Every 4 hours as needed (PRN) for pain. 6/14/25. -Baclofen 10 mg. 1 tablet. Three times a day for pain. 6:00 a.m., 1:00 p.m. and 6:00 p.m. 6/14/25. -Gabapentin 300 mg. 2 tablets. Three times a day as needed for pain. 6/14/25. Review of Resident #182's Medication Administration Record (MAR) revealed: -Baclofen 10 mg was documented as Drug/Item Unavailable on 6/15/25 at 9:00 a.m. and 5:00 p.m. and on 6/16/25 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The resident received the first does of Baclofen on 6/17/25 at 1:00 p.m. -Morphine 0.75 ml PRN was administered for the first time on 6/16/25 at 4:23 p.m. -Methadone 10 mg was documented on 6/15/25 at 11:01 p.m. as 6/16/25 12:00 a.m. does given at 10:00 p.m. due to waiting in pharmacy for code and documented on 6/16/25 at 6:32 p.m. that Drug/Item unavailable. -Gabapentin 300 mg was not documented as given 6/14-6/16/25. Review of Resident #182's progress notes revealed a note dated 6/17/25 at 7:54 a.m. showing, Several attempts and efforts made through the night of 6/16 -17 to encourage resident to receive tube feeding without success has[sic] resident refused feeding through out the night stating he would try again later during the day. Review of a progress note dated 6/17/25 at 10:07 a.m. signed by the Pain Management Nurse Practitioner (NP) showed, Pain/Muscle spasms-Reports pain all over, states medicine took a while to get in and has not been consistently taking it. Review of Resident #182's primary care provider NP notes revealed a note dated 6/16/25 showing, Met with patient and unit manager in patient's room. Patient appears unhappy. He notes he stopped his own tube feeds yesterday due to abdominal discomfort. In addition, he notes pain medications are not being administered as prescribed. Received first dose of methadone this AM He would like to discharge home. Notes he lives by himself. Review of Resident #182's Occupational Therapy Evaluation, dated 6/16/25 at 2:21 p.m. noted patient had pain that interfered/limited functional ability, 8/10 neck and back pain. An interview was conducted on 6/19/25 at 12:35 p.m. with Staff H, Licensed Practical Nurse (LPN). Staff H said she had cared for the resident a couple of shifts over the past few days. She said the resident has a lot of pain all the time. An interview was conducted on 6/19/25 at 1:59 p.m. with Staff O, LPN. Staff O said she cared for Resident #182 on 6/15/25. Staff O said the resident kept turning his tube feed off and she didn't know why. Staff O said she believed it was just behaviors. Staff O said she administered the medications she could, but they were waiting on the resident's medication to come in. Staff O said she remembered the resident's methadone was not in, but she couldn't recall the other specific medications. Staff O said she thought she might have pulled baclofen from the medication dispensing machine for the resident. Staff O said Resident #182 informed her he would sign out of the facility if his pain medications couldn't be administered. Staff O said the resident was upset because the pain medication prescriptions came to the facility with the hospital discharge paperwork. Staff O said she found the resident's admission packet with the prescriptions and faxed them to the pharmacy. She said she was unaware if they had been sent to the pharmacy previously. Staff O said, it wasn't like he was in uncontrolled pain. 2- An interview was conducted on 6/19/25 at 4:43 p.m. with Resident #185. Resident #185 said she had been in the facility three days and had problems with receiving pain medication upon admission. The resident said it took a day and half before pain medication was administered. Resident #185 said with any movement, her pain was a 9-10 on the pain scale. The resident said it was reported to multiple staff members and the nurses continually said, it's on its way. The resident said the only medication administered for pain was over the counter Tylenol and that was not really a pain medication. The resident said when lying completely still, the pain was ok, but it was severe with any movement. Resident #185 said pain medication was now being administered and is effective. Review of the admission Records showed Resident #185 was admitted on [DATE] at 3:10 p.m. with diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic pain, and pain, unspecified. Review of Resident #185's admission MDS, Section C, revealed a BIMS score of 14, indicating she was cognitively intact. Review of Resident #185's physician orders showed: -Acetaminophen 325 mg. 2 tablets. Every 8 hours as needed for mild pain - 6/16/25. -Oxycodone-acetaminophen 5-325 mg. 1 tablet. Every 4 hours as needed for pain - 6/17/25. Review of Resident #185's MAR and physician orders showed: -Oxycodone-Acetaminophen 5-325 mg was administered for the first time on 6/18/25 at 1:33 a.m. -Acetaminophen 325 mg was administered on 6/17/25 at 8:37 a.m. Review of Resident #185's hospital discharge medications from 6/16/25 showed resident should have been on Oxycodone-Acetaminophen 5-325 mg every 4 hours as needed for pain and Tramadol 50 mg every 8 hours as needed for pain. Review of orders showed the Oxycodone-Acetaminophen was not entered into the facility orders until 6/17/25 and the Tramadol order was not entered into facility orders. 3- An interview was conducted on 6/18/25 at 4:01 p.m. with Resident #379. The resident said after admission it took a couple of days for pain medication to arrive and be administered. The resident reported 7-8 out of 10 on the pain scale during that time. Resident #379 said she was told repeatedly her medications weren't here yet. The resident said acetaminophen was administered and didn't do anything to help but, when you are desperate you take it. The resident said the ordered Lyrica wasn't there and for the Morphine that was the problem. Resident #379 was unhappy and said before leaving the hospital she asked multiple times about ensuring the medication would be at the facility because it would mess her up not to have them. The resident said the hospital assured here it wouldn't be an issue. The resident said her pain was reported to multiple staff members, aides and nurses. Review of the admission Record showed Resident #379 was admitted on [DATE] with diagnoses including orthopedic aftercare, spinal stenosis and lumbar region without neurogenic claudication. Review of Resident #379's admission MDS, Section C, revealed a BIMS score of 14, indicating she was cognitively intact. Review of Resident #379's physician orders showed: -Acetaminophen 325 mg. 2 tablets for mild pain 1-3. Every 8 hours as needed. Dated 6/14/25. -Hydrocodone-acetaminophen 5-325 mg. 1 tablet. Every 4 hours as needed for pain. Dated 4/10/23. Discontinued 6/16/25. -Methocarbamol 500 mg. 1 Tablet. Every 6 hours as needed for pain. Dated 6/14/25. -Morphine 15 mg tablet Extended Release (ER). 0.5 tablet. Every 4 hours as needed for moderate to severe pain. Dated 6/14/25. Discontinued 6/16/25. -Pregabalin (Lyrica) 150 mg. 1 capsule. Twice a day 9:00 a.m. and 9:00 p.m. for spondylosis. Dated 6/14/25. -Cyclobenzaprine 10 mg. 1 tablet. Three times a day as needed for spinal stenosis, lumbar region. Dated 6/14/25. -Ibuprofen 800 mg. 1 tablet every 8 hours as needed for pain. Dated 6/14/25. Review of Resident #379's MAR showed: -Acetaminophen 325 mg was administered on 6/15/25 at 8:39 p.m. with a documented pain level of 5/10. -Hydrocodone-acetaminophen 5-325 mg was not administered on 6/14 or 6/15/25 and was discontinued on 6/16/25. -Methocarbamol 500 mg was not administered on 6/14 or 6/15/25. -Morphine 15 mg. ER (extended release) 0.5 tablet was administered for the first time on 6/16/25 at 9:55 a.m. with a documented pain level of 9/10. It was administered again on 6/16/25 at 4:46 p.m. with a documented pain level of 10/10. -Pregabalin (Lyrica) 150 mg was documented as not available on 9/14, 9/15, 9/16, and 9/17/25. -Cyclobenzaprine 10 mg was not administered on 6/14 or 6/15/25. -Ibuprofen was administered on 6/15/25 at 9:18 a.m. Review of Resident #379's hospital discharge medications showed the morphine 15 mg , 0.5 tablet order was not supposed to be extended release. The discharge medications showed pregabalin was last administered on 6/14/25 at 8:11 a.m. and was due to be administered at bedtime on 6/14/25. The Hydrocodone-acetaminophen 5-325 mg was not on the discharge medications; it was an order from a previous admission on [DATE]. An interview was conducted on 6/19/25 at 12:24 p.m. with Staff F, Registered Nurse (RN). Staff F said she cared for Resident #379 on Sunday night. She said the resident was new and she didn't know them. She said the resident did complain of pain of 5 out of 10 on the pain scale. Staff F reviewed Resident #379's medical records and confirmed the resident had an order for Acetaminophen for pain at a level of 1-2 out of 10. Staff F said she gave the resident the Acetaminophen because she didn't know the resident well. She said she told the resident she would find out about any other medication that had been ordered. Staff F said she did not call the pharmacy to get authorization to get any other pain medication from the electronic medication dispensing machine because she didn't hear any other complaints from the resident. Staff F said she realized around midnight the resident's ordered morphine was in the medication cart, so she administered it that Monday morning. An interview was conducted on 6/19/25 at 12:28 p.m. with Staff G, LPN. Staff G said she cared for Resident # 379 the morning of 6/16/25 and the resident had been concerned about pain medication. Staff G said the resident had morphine administered by the previous nurse that morning. Staff G confirmed the resident's Lyrica was not available and the script had been sent to the pharmacy. She said Lyrica was available in the electronic medication dispensing machine, but the resident needed an approved prescription. An interview was conducted on 6/19/25 at 2:16 p.m. with the facility's Pain Management Physician. He said he saw Resident #182 and #379 on Monday. He said Resident #182 did have concerns about not getting pain medication over the weekend. He said when the resident was admitted on Saturday 6/14/25, he had been called, and orders were sent Saturday. He said the biggest issues was pharmacy didn't get it delivered. He said Morphine should be in the facility's emergency drug supply and he could not answer why the nurse did not pull the medication from there and administer it to the resident. He said if a resident says their pain is 10 out of 10, it is a 10 out of 10. The physician said he did not think Resident #182 had uncontrolled pain all weekend, but he did want to get it back under control and on his regimen before he made any changes to the pain medication orders. He said the facility may not have had Resident #182's methadone in the emergency drug supply, but typically if certain medications aren't available, the nurse would call him and ask for a different dose or medication for a one time administration. The pain management physician said he was only called on admission for Resident #182 and was not notified medications were not available or not being administered; he was not aware until he arrived Monday morning 6/16/25. As for Resident #379, the pain management physician said he was called when they arrived at the facility on 6/14/25 and he sent the prescriptions then. He said he wrote a prescription for Morphine 15 mg 1/2 tablet every 4 hours as needed. He said the nurse later told him they couldn't get Morphine 15 mg out of the electronic medication dispensing machine because they did not have extended release and the pharmacy notified the nurse they couldn't give 1/2 tablet because extended release could not be cut. The physician said there had been a transcription error somewhere because his order was not for extended release, it was for immediate release. An interview was conducted on 6/19/25 at 9:23 a.m. with the facility's Medical Director. He said the facility did seem to struggle more on the weekends with getting medications. He said on admission the nurse should do a head-to-toe assessment and call the doctor to confirm orders. He said the facility should have been able to address a resident's pain and if he had been notified there were issues with getting medications they could have put their heads together and used a different medication temporarily. He agreed that going for two days without pain medication was too long. He said there should have been a mechanism in place to address a resident missing medication. He said it would be expected for staff to notify him or the NP if a resident was not getting their medication. He said there was no notification in the on-call system showing anyone was notified of the residents missing their medications over the previous week. An interview was conducted on 6/19/25 at 5:12 p.m. with the Nursing Home Administrator (NHA). He agreed there was an issue with the admission process and receiving medications, specifically weekend admission. The NHA said the facility did have a backup pharmacy and the facility identified that the nurses were not trained on that. He said the facility also used a local commercial pharmacy and had an electronic medication dispensing machine. The NHA said they had identified concerns for residents admitted on Saturday; their medications were not coming until the next business day. He said they are pausing weekend admissions going forward until the clinical leadership and all direct care staff are proficient in the process and audits are completed to ensure residents did not miss significant medications. The NHA said when medication orders were placed by 6:00 p.m. they came in on the night pharmacy run between 9:00 p.m. and 12:00 a.m. He said nurses should get medication out of the electronic medication dispensing machine if the resident is admitted after 6:00 p.m. He was unaware medications were not being administered that were in the electronic medication dispensing machine. The NHA said there was a weekend supervisor from 3:00-11:00 p.m. to ensure medications are taken from the electronic medication dispensing machine if needed. The NHA was unaware there were issues with residents not getting pain medication administered or that there were issues with residents not getting medications for two or more days on weekday admissions. The NHA said medication administration is a priority and this is not acceptable. An interview was conducted on 6/19/25 at 8:20 p.m. with the facility's consultant pharmacist. She was unaware the facility had concerns with getting medication and pain management. She said she would work with the facility to address the issue. Review of a facility policy titled Pain Management, revised 2/7/25, showed a policy statement: It is the policy of [facility name] to provide comprehensive, effective, and appropriate pain management and assessments for all residents. Residents have the right to be fully informed of their total health status, types of care provided, and the risks and/or benefits of the proposed care and treatment options in a language that they can understand. Residents may choose the options that they prefer. Scope: This policy applies to all nurses and consultant pharmacists employed by [facility name]. Procedures: 1. [facility name] will perform audits to determine if the resident's pain is being managed. -every shift nursing will ask the resident about their pain using the pain scale and document the results. -Quarterly pain observations are completed and documented in the resident's clinical record. 2. The physician will select the pain medication based on the type of pain the resident is experiencing. 3. The consultant pharmacist will assess the pain control as well as side effects the resident is experiencing, based on the assessment, the consultant pharmacist will communicate with the physician if changes are needed or recommended. 4. Clinicians may consider prescribing immediate release opioids instead of extended release and long acting opioids.

2. During an interview on 06/16/25 at 11:42 a.m. Resident #29 stated she was getting weaker due to no one at the facility assists her with walking. She stated therapy instructed her to ensure someone was supervising her while walking. During a follow up interview on 06/18/25 at 09:41 a.m. Resident #29 stated having lost endurance since discharging from therapy as no one was available to supervise except when family visits. During an interview on 06/17/25 at 12:13 p.m. Staff V, CNA stated, it is hard sometimes we don't have as many CNAs as needed. Many of the residents are total care and the distance from room to room. Staff V, stated having to cover around corners makes the job tasks even harder to get basic care completed, but certainly at meal times. She stated they did not have time for the extras if asked. During an interview on 06/18/25 at 10:53 a.m., Staff B, CNA stated not having time to complete Range of Motion(ROM) or walking residents around if requested and stated usually the restorative aide completes the task. Staff B stated they don't really need to worry about not getting it done. During an interview on 06/18/25 at 11:58 a.m. Staff M, Restorative CNA stated they had not started in the restorative position, yet. Staff M said currently, assists with residents weights, meals if needed. Staff M, stated not having a specific assignment but assists when requested by a CNA or nurse. The staff member stated the restorative program had not been started and there was no one to oversee the program. During an interview on 06/18/25 at 12:20 p.m. the Director of Rehabilitative Services (DOR) stated Resident #29 was discharged from therapy services on 05/28/25 and was able to walk long distances with just standby assistance with a four-wheel walker. Resident #29 was discharged from therapy with a home exercise program, which usually would mean restorative but the facility does not have restorative at this time as there was no one in nursing to oversee the program. A policy and procedure for staffing was requested and not received. Based on observation, record review and interviews, the facility failed to provide sufficient staffing to ensure residents received assistance with Activities of Daily Living (ADLs) during three days (06/16/25, 06/17/25 and 06/18/25) of four days observed. Findings Included: During an observation on 06/16/2025 at 12:01 p.m., a family member was observed getting coffee cups and coffee from a gray 4-wheeled cart. The family member filled the cups with coffee and began passing coffee, sugar and cream to the residents in the dining room of the 500 hall. During an interview on 06/16/2025 at 12:05 p.m., the Family Member spoke loudly, If there was enough staff to do it, I would not have to. I am here every day helping [Resident #43] with her meals and assisting other residents with coffee. There are not enough staff! The family member stated facility was aware she helped during lunch. The family member said, I am a Registered Nurse (RN). During an observation on 06/16/2025 at 12:20 p.m., Resident #53 was observed scooping mashed potatoes onto a spoon and feeding it to Resident #43. During an interview and observation on 06/16/2025 at 12:20 p.m., Resident #53 stated I am feeding my [family member]. I feed her and try to eat my food in between. If I don't feed her then no one helps her. There are not enough staff here to help her during meals. During an interview on 6/16/2025 at 12:03 p.m., Staff A, Certified Nursing Assistant (CNA) identified a family member who was passing out coffee to residents. Staff A said, I don't like it. But she does it all the time and gets upset if we say anything. During an interview on 06/17/2025 at 12:04 p.m., Staff B, CNA stated We have a lot of residents who need assistance with meals on the 500 hall. Families come in and help those residents who need assistance with their meals. During an interview on 06/17/2025 at 1:23 p.m., Staff C, CNA, stated it can be challenging to get all my work completed. I work every other weekend, and it is harder to get everything done. There are 8-7 residents who need assistance with their meals in this hall. Staff C said, We are lucky that some families come in to help with meal assistance. It is challenging when you have residents who need help eating, having to pass out lunch trays, and answer call lights all at the same time. During an interview on 06/18/2025 at approximately 3:30 p.m. Staff D, Staffing Coordinator/CNA, stated she just transitioned into the position. She said, I staff based of census. Depending on what the census is, I determine how many CNA's you get per shift. There are quite a few residents who need assistance with meals on the 500 unit. She stated she was not aware of any concerns with the 500 unit needing more help during meals. Staff D stated weekends fluctuate; there are usually more call outs during the weekends and she tries to fill the shift by reaching out to as needed staff (PRN) or to staff that was scheduled to be off. She stated if she was not able to find another CNA or Nurse to fill the call out, either herself or one of Nurse Managers comes in to fill in. During an interview on 06/18/2025 at 3:50 p.m. the Director of Nursing (DON) stated she was not aware of any concerns with staff not being able to assist residents with their meals and still completing their other tasks. The DON stated there were 7 or so residents who needed assistance with their meals on the 500 unit. She stated the CNAs, Nurses or the restorative nurse should be helping residents with meal assistance. The DON said, We have a lot of involved families, who are here constantly to help with every meal. She state it was not an expectation for family to be here, but it was kind of assumed they will be here during mealtimes. The DON stated on the weekends they have call outs, but they don't have any issues with getting the shifts covered. She stated they now have a weekend supervisor who can cover the floor as needed. During an interview on 06/18/2025 at 3:50 p.m. the Nursing Home Administrator stated he has not had any concerns with sufficient staffing. He stated his expectation was for there to be enough staff to meet the needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure medications for new admissions were available timely for four residents (#182, #185, #379, #228) out of four sampled for admission orders. Findings included: 1. An interview was conducted on 6/18/25 at 2:15 p.m. with Resident #182. The resident said he had been in the facility for four days and did not have any pain medication for the first two days. The resident said pain had gotten to a 10 out of 10 on the pain scale during that time. The resident said he refused tube feedings because they caused stomach cramps and he couldn't handle any more pain. The resident said he was starting to feel better again after having his medication for the last two days. Resident #182 said the pain was so bad on Sunday, 6/15/25 that he almost left the facility. Review of Resident #182's admission Record showed the resident was admitted on [DATE] with diagnoses including gram-negative sepsis, cutaneous abscess of abdominal wall, spondylosis, and pain, unspecified. Review of Resident #182's admission Minimum Data Set (MDS), Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #182's physician orders showed: -Methadone 10 mg (milligram).1 tablet. Every 6 Hours for pain. 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. 6/15/25. -Morphine concentrate 100 mg/5 ml (milliliters) (20 mg/ml); 0.75 ml. Every 4 hours as needed (PRN) for pain. 6/14/25. -Baclofen 10 mg. 1 tablet. Three times a day for pain. 6:00 a.m., 1:00 p.m. and 6:00 p.m. 6/14/25. -Gabapentin 300 mg. 2 tablets. Three times a day as needed for pain. 6/14/25. Review of Resident #182's Medication Administration Record (MAR) revealed: -Baclofen 10 mg was documented as Drug/Item Unavailable on 6/15/25 at 9:00 a.m. and 5:00 p.m. and on 6/16/25 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The resident received the first does of Baclofen on 6/17/25 at 1:00 p.m. -Morphine 0.75 ml PRN was administered for the first time on 6/16/25 at 4:23 p.m. -Methadone 10 mg was documented on 6/15/25 at 11:01 p.m. as 6/16/25 12:00 a.m. does given at 10:00 p.m. due to waiting in pharmacy for code and documented on 6/16/25 at 6:32 p.m. that Drug/Item unavailable. -Gabapentin 300 mg was not documented as given 6/14-6/16/25. Review of Resident #182's progress notes revealed a note dated 6/17/25 at 7:54 a.m. showing, Several attempts and efforts made through the night of 6/16 -17 to encourage resident to receive tube feeding without success has[sic] resident refused feeding through out the night stating he would try again later during the day. Review of a progress note dated 6/17/25 at 10:07 a.m. signed by the Pain Management Nurse Practitioner (NP) showed, Pain/Muscle spasms-Reports pain all over, states medicine took a while to get in and has not been consistently taking it. Review of Resident #182's primary care provider NP notes revealed a note dated 6/16/25 showing, Met with patient and unit manager in patient's room. Patient appears unhappy. He notes he stopped his own tube feeds yesterday due to abdominal discomfort. In addition, he notes pain medications are not being administered as prescribed. Received first dose of methadone this AM He would like to discharge home. Notes he lives by himself. Review of Resident #182's Occupational Therapy Evaluation, dated 6/16/25 at 2:21 p.m. noted patient had pain that interfered/limited functional ability, 8/10 neck and back pain. An interview was conducted on 6/19/25 at 12:35 p.m. with Staff H, Licensed Practical Nurse (LPN). Staff H said she had cared for the resident a couple of shifts over the past few days. She said the resident has a lot of pain all the time. An interview was conducted on 6/19/25 at 1:59 p.m. with Staff O, LPN. Staff O said she cared for Resident #182 on 6/15/25. Staff O said the resident kept turning his tube feed off and she didn't know why. Staff O said she believed it was just behaviors. Staff O said she administered the medications she could, but they were waiting on the resident's medication to come in. Staff O said she remembered the resident's methadone was not in, but she couldn't recall the other specific medications. Staff O said she thought she might have pulled baclofen from the medication dispensing machine for the resident. Staff O said Resident #182 informed her he would sign out of the facility if his pain medications couldn't be administered. Staff O said the resident was upset because the pain medication prescriptions came to the facility with the hospital discharge paperwork. Staff O said she found the resident's admission packet with the prescriptions and faxed them to the pharmacy. She said she was unaware if they had been sent to the pharmacy previously. Staff O said, it wasn't like he was in uncontrolled pain. 2- An interview was conducted on 6/19/25 at 4:43 p.m. with Resident #185. Resident #185 said she had been in the facility three days and had problems with receiving pain medication upon admission. The resident said it took a day and half before pain medication was administered. Resident #185 said with any movement, her pain was a 9-10 on the pain scale. The resident said it was reported to multiple staff members and the nurses continually said, it's on its way. The resident said the only medication administered for pain was over the counter Tylenol and that was not really a pain medication. The resident said when lying completely still, the pain was ok, but it was severe with any movement. Resident #185 said pain medication was now being administered and is effective. Review of the admission Records showed Resident #185 was admitted on [DATE] at 3:10 p.m. with diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic pain, and pain, unspecified. Review of Resident #185's admission MDS, Section C, revealed a BIMS score of 14, indicating she was cognitively intact. Review of Resident #185's physician orders showed: -Acetaminophen 325 mg. 2 tablets. Every 8 hours as needed for mild pain - 6/16/25. -Oxycodone-acetaminophen 5-325 mg. 1 tablet. Every 4 hours as needed for pain - 6/17/25. Review of Resident #185's MAR and physician orders showed: -Oxycodone-Acetaminophen 5-325 mg was administered for the first time on 6/18/25 at 1:33 a.m. -Acetaminophen 325 mg was administered on 6/17/25 at 8:37 a.m. Review of Resident #185's hospital discharge medications from 6/16/25 showed resident should have been on Oxycodone-Acetaminophen 5-325 mg every 4 hours as needed for pain and Tramadol 50 mg every 8 hours as needed for pain. Review of orders showed the Oxycodone-Acetaminophen was not entered into the facility orders until 6/17/25 and the Tramadol order was not entered into facility orders. 3. An interview was conducted on 6/18/25 at 4:01 p.m. with Resident #379. The resident said after admission it took a couple of days for pain medication to arrive and be administered. The resident reported 7-8 out of 10 on the pain scale during that time. Resident #379 said she was told repeatedly her medications weren't here yet. The resident said acetaminophen was administered and didn't do anything to help but, when you are desperate you take it. The resident said the ordered Lyrica wasn't there and for the Morphine that was the problem. Resident #379 was unhappy and said before leaving the hospital she asked multiple times about ensuring the medication would be at the facility because it would mess her up not to have them. The resident said the hospital assured here it wouldn't be an issue. The resident said her pain was reported to multiple staff members, aides and nurses. Review of the admission Record showed Resident #379 was admitted on [DATE] with diagnoses including orthopedic aftercare, spinal stenosis and lumbar region without neurogenic claudication. Review of Resident #379's admission MDS, Section C, revealed a BIMS score of 14, indicating she was cognitively intact. Review of Resident #379's physician orders showed: -Acetaminophen 325 mg. 2 tablets for mild pain 1-3. Every 8 hours as needed. Dated 6/14/25. -Hydrocodone-acetaminophen 5-325 mg. 1 tablet. Every 4 hours as needed for pain. Dated 4/10/23. Discontinued 6/16/25. -Methocarbamol 500 mg. 1 Tablet. Every 6 hours as needed for pain. Dated 6/14/25. -Morphine 15 mg tablet Extended Release (ER). 0.5 tablet. Every 4 hours as needed for moderate to severe pain. Dated 6/14/25. Discontinued 6/16/25. -Pregabalin (Lyrica) 150 mg. 1 capsule. Twice a day 9:00 a.m. and 9:00 p.m. for spondylosis. Dated 6/14/25. -Cyclobenzaprine 10 mg. 1 tablet. Three times a day as needed for spinal stenosis, lumbar region. Dated 6/14/25. -Ibuprofen 800 mg. 1 tablet every 8 hours as needed for pain. Dated 6/14/25. Review of Resident #379's MAR showed: -Acetaminophen 325 mg was administered on 6/15/25 at 8:39 p.m. with a documented pain level of 5/10. -Hydrocodone-acetaminophen 5-325 mg was not administered on 6/14 or 6/15/25 and was discontinued on 6/16/25. -Methocarbamol 500 mg was not administered on 6/14 or 6/15/25. -Morphine 15 mg. ER (extended release) 0.5 tablet was administered for the first time on 6/16/25 at 9:55 a.m. with a documented pain level of 9/10. It was administered again on 6/16/25 at 4:46 p.m. with a documented pain level of 10/10. -Pregabalin (Lyrica) 150 mg was documented as not available on 9/14, 9/15, 9/16, and 9/17/25. -Cyclobenzaprine 10 mg was not administered on 6/14 or 6/15/25. -Ibuprofen was administered on 6/15/25 at 9:18 a.m. Review of Resident #379's hospital discharge medications showed the morphine 15 mg , 0.5 tablet order was not supposed to be extended release. The discharge medications showed pregabalin was last administered on 6/14/25 at 8:11 a.m. and was due to be administered at bedtime on 6/14/25. The Hydrocodone-acetaminophen 5-325 mg was not on the discharge medications; it was an order from a previous admission on [DATE]. An interview was conducted on 6/19/25 at 12:24 p.m. with Staff F, Registered Nurse (RN). Staff F said she cared for Resident #379 on Sunday night. She said the resident was new and she didn't know them. She said the resident did complain of pain of 5 out of 10 on the pain scale. Staff F reviewed Resident #379's medical records and confirmed the resident had an order for Acetaminophen for pain at a level of 1-2 out of 10. Staff F said she gave the resident the Acetaminophen because she didn't know the resident well. She said she told the resident she would find out about any other medication that had been ordered. Staff F said she did not call the pharmacy to get authorization to get any other pain medication from the electronic medication dispensing machine because she didn't hear any other complaints from the resident. Staff F said she realized around midnight the resident's ordered morphine was in the medication cart, so she administered it that Monday morning. An interview was conducted on 6/19/25 at 12:28 p.m. with Staff G, LPN. Staff G said she cared for Resident # 379 the morning of 6/16/25 and the resident had been concerned about pain medication. Staff G said the resident had morphine administered by the previous nurse that morning. Staff G confirmed the resident's Lyrica was not available and the script had been sent to the pharmacy. She said Lyrica was available in the electronic medication dispensing machine, but the resident needed an approved prescription. An interview was conducted on 6/19/25 at 2:16 p.m. with the facility's Pain Management Physician. He said he saw Resident #182 and #379 on Monday. He said Resident #182 did have concerns about not getting pain medication over the weekend. He said when the resident was admitted on Saturday 6/14/25, he had been called, and orders were sent Saturday. He said the biggest issues was pharmacy didn't get it delivered. He said Morphine should be in the facility's emergency drug supply and he could not answer why the nurse did not pull the medication from there and administer it to the resident. He said if a resident says their pain is 10 out of 10, it is a 10 out of 10. The physician said he did not think Resident #182 had uncontrolled pain all weekend, but he did want to get it back under control and on his regimen before he made any changes to the pain medication orders. He said the facility may not have had Resident #182's methadone in the emergency drug supply, but typically if certain medications aren't available, the nurse would call him and ask for a different dose or medication for a one time administration. The pain management physician said he was only called on admission for Resident #182 and was not notified medications were not available or not being administered; he was not aware until he arrived Monday morning 6/16/25. As for Resident #379, the pain management physician said he was called when they arrived at the facility on 6/14/25 and he sent the prescriptions then. He said he wrote a prescription for Morphine 15 mg 1/2 tablet every 4 hours as needed. He said the nurse later told him they couldn't get Morphine 15 mg out of the electronic medication dispensing machine because they did not have extended release and the pharmacy notified the nurse they couldn't give 1/2 tablet because extended release could not be cut. The physician said there had been a transcription error somewhere because his order was not for extended release, it was for immediate release. An interview was conducted on 6/19/25 at 9:23 a.m. with the facility's Medical Director. He said the facility did seem to struggle more on the weekends with getting medications. He said on admission the nurse should do a head-to-toe assessment and call the doctor to confirm orders. He said the facility should have been able to address a resident's pain and if he had been notified there were issues with getting medications they could have put their heads together and used a different medication temporarily. He agreed that going for two days without pain medication was too long. He said there should have been a mechanism in place to address a resident missing medication. He said it would be expected for staff to notify him or the NP if a resident was not getting their medication. He said there was no notification in the on-call system showing anyone was notified of the residents missing their medications over the previous week. An interview was conducted on 6/19/25 at 5:12 p.m. with the Nursing Home Administrator (NHA). He agreed there was an issue with the admission process and receiving medications, specifically weekend admission. The NHA said the facility did have a backup pharmacy and the facility identified that the nurses were not trained on that. He said the facility also used a local commercial pharmacy and had an electronic medication dispensing machine. The NHA said they had identified concerns for residents admitted on Saturday; their medications were not coming until the next business day. He said they are pausing weekend admissions going forward until the clinical leadership and all direct care staff are proficient in the process and audits are completed to ensure residents did not miss significant medications. The NHA said when medication orders were placed by 6:00 p.m. they came in on the night pharmacy run between 9:00 p.m. and 12:00 a.m. He said nurses should get medication out of the electronic medication dispensing machine if the resident is admitted after 6:00 p.m. He was unaware medications were not being administered that were in the electronic medication dispensing machine. The NHA said there was a weekend supervisor from 3:00-11:00 p.m. to ensure medications are taken from the electronic medication dispensing machine if needed. The NHA was unaware there were issues with residents not getting pain medication administered or that there were issues with residents not getting medications for two or more days on weekday admissions. The NHA said medication administration is a priority and this is not acceptable. An interview was conducted on 6/19/25 at 8:20 p.m. with the facility's consultant pharmacist. She was unaware the facility had concerns with getting medication and pain management. She said she would work with the facility to address the issue. 4. Review of Resident #228's Resident Face Sheet revealed an admission date of 06/10/25 with diagnoses to include ground level fall resulting in a displaced femur fracture and surgical repair on 06/04/25, hypertension, vascular dementia and other co-morbidities. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) for Resident #228 dated 06/10/25 revealed Resident #228 requires a surrogate to make decisions and resident is alert, disoriented, but can follow simple instructions. Review of Resident #228's physician order dated 06/10/25 revealed: lisinopril tablet 20 mg daily and metoprolol succinate tablet extended release 25 mg daily. Review of Resident #228's electric Medication Administration Record (eMAR) dated for June 2025 revealed: lisinopril tablet 20 mg daily and metoprolol succinate tablet extended release 25 mg daily were not given on 06/12/2025 and 06/13/2025. Review of Resident #228's progress notes revealed on 06/12/25 and 06/13/25 comment: lisinopril tablet 20 mg daily- drug not available, pharmacy notified. On 06/12/25 and 06/13/25 comment: metoprolol succinate tablet extended release 25 mg showed- drug not available pharmacy notified. During an interview on 06/19/25 at 02:01 p.m. Resident #228's Durable Power of Attorney (DPOA)/Responsible Party (RP) stated not being aware Resident #228's medications were not available for those two days. During an interview on 06/18/25 at 05:30 p.m. Resident #228's attending physician stated he could not recall being notified of the medications not be available for those two days. During an interview on 06/19/25 at 09:29 a.m. the facility Medical Director stated the medications should be availbe for administration. The facility did not provide a policy and procedure for Pharmacy Services as requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#228, #51 and #29) of three residents sampled. Findings included: Review of the admission Agreement dated 06/13/25 revealed Resident #228 electronically signed all documents personally, and the appointed representative was not present. On page 44 of the electronic admission agreement, it showed the Arbitration Agreement was signed by Resident #228 accepting the terms of Arbitration Agreement. Review of the admission Record for Resident #228 revealed an admission date of 06/10/25 with diagnoses to include ground level fall resulting in a displaced femur fracture and surgical repair on 06/04/25, hypertension, vascular dementia and other co-morbidities. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) for Resident #228 dated 06/10/25 revealed Resident #228 required a healthcare surrogate to make decisions and resident is alert, disoriented, but can follow simple instructions. Review of Resident #228's physician note dated 06/12/25 reveal: Resident #228 was an [AGE] year-old with a history of advanced dementia, Due to her advanced dementia, Resident #228 is unable to provide meaningful information . The resident has a representative appointed for decision making. During an interview on 06/19/25 at 02:01 p.m. with Resident #228's Durable Power of Attorney (DPOA)/Responsible Party (RP) stated having not signed any paperwork for the facility. The DPOA/RP had asked the facility about the paperwork, and they said everything was already taken care of at the hospital. The DPOA/RP stated not being sure Resident #228 was cognitively aware and stated the resident would not be able to sign. Review of the admission Agreement dated 05/26/25 revealed Resident #51 electronically signed all documents personally, and there was no representative appointed. On page 44 of the electronic admission agreement, it showed the Arbitration Agreement was signed by Resident #51 accepting the terms of Arbitration Agreement. Review of the admission Record for Resident #51 revealed an admission date of 05/24/25 with diagnoses to include Non-ST elevation (NSTEMI) myocardial infarction (type of heart attack), hypertension, congestive heart failure and other co-morbidities. During an interview on 06/19/25 at 03:32 p.m. with an alert and oriented Resident #51 and spouse, they both stated not recalling signing any arbitration agreements. Resident #51 stated recalling signing the admission paperwork, but does not recall any conversations regarding arbitration, mediation, jury trials, etc. (and so forth). Review of the admission Agreement dated 02/26/25 revealed Resident #29 electronically appointed a Resident Representative (RP) to sign the agreement on their behalf. The RP was Resident #29's Power of Attorney (POA). On page 44 of the admission agreement, it showed the Arbitration Agreement was signed by Resident #29's RP/POA accepting the terms of the Arbitration Agreement. Review of the admission Record for Resident #29 revealed an admission date of 02/25/25 with diagnoses to include Parkinson's disease, hypertension, congestive heart failure and other co-morbidities. During an interview on 06/18/25 at 02:50 p.m. with Resident #29 and RP/POA both stated not recalling signing any arbitration agreements. They recalled signing admission paperwork, but did not recall any conversations regarding arbitration, nor having the agreement explained. During an interview on 06/18/25 at 03:40 p.m., the Senior Nurse Navigator (SNN) stated being responsible for reviewing the admission agreements with residents or their representatives. The SNN stating the process includes reviewing the arbitration agreement with the resident. The SNN states explaining the agreement and ensures the resident/RP understands what the arbitration is. The SNN informs the resident/RP the agreement can be rescinded in 30 days. Explains if something were to happen in the facility, they are to come to the facility first, to see if they can make it right before seeking legal counsel. The SNN explains the Arbitration is optional and the resident/RP can refuse to sign. The SNN stated if the resident was not cognitively able to sign or speak for themselves, the SNN goes over the agreement with the RP. The SNN stated being able to review the hospital clinical information (physician/nurses notes) including the 3008 to ensure residents are capable of signing the agreement. During an interview on 06/19/25 at 04:30 p.m. the Nursing Home Administrator (NHA) stated the agreement should be explained and only signed by the resident or RP if capable of understanding the agreement. The NHA stated on 06/19/25 at 07:07 p.m. the facility did not have a policy specific to the Arbitration Agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an initial on 06/16/25 at 10:21 a.m. Resident #229's door had an 8 ½ by 11 (letter size) CDC Contact Isolation Precautions sign printed in color showing two large fonts STOP signs in all capital letters and the following Contact Precautions written between the two signs. The next line revealed in all capital letters Everyone Must: Clean their hands, including before entering and when leaving the room.The following line in all capital letters showed: Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. During this tour the PPE cabinet in the hallway outside Resident #229's door revealed only gloves were available and a roll of trash bags at the bottom drawer. On 06/16/25 at 11:30 a.m. Staff W, Occupational Therapist (OT) was observed pushing Resident #229 in a wheelchair down the hallway. Staff W entered the resident's room. Staff W assisted Resident #229 transfer to a chair inside the room, moved the resident's over bed table and drinking cup to be within the resident's reach and exited the room. Staff W did not donn and did not apply hand hygiene prior to or after entering and caring for Resident #229. During an interview on 06/16/25 at 11:35 a.m. Staff W confirmed seeing the sign on the resident's door, and stated the sign meant PPE was only required when assisting the resident with toileting needs, and that was the only time hand hygiene and PPE would be required. On 06/16/25 at 12:11 p.m. Staff V, Certified Nursing Assistant (CNA) was observed removing a meal tray from the food cart, entering room [ROOM NUMBER] and setting up the resident's tray, touched the over bed table and the resident and then exited the room. Staff V walked directly to the food cart, opened and removed another tray for delivery and proceeded to enter another room, without completing any hand hygiene. At 12:18 p.m. Staff V entered room [ROOM NUMBER] which had a Contact Isolation sign on the door. Staff V did not donn PPE prior to entering the room and did not apply hand hygiene. Staff V continued walking down the hall, adjusted long hair into a ponytail at the back of the head. Staff V did not perform hand hygiene and continued passing trays. During an interview on 06/16/25 at 02:30 p.m. Staff V,CNA stated not being aware of the need to complete hand hygiene between tray delivery. Staff V stated not noticing the contact isolation sign on the door in room [ROOM NUMBER]. Staff V stated contact isolation PPE only needed to be worn when caring for resident, and said, I was only delivering the tray. During an interview on 06/17/25 at 02:19 p.m. the Director of Nursing (DON) stated the signs for contact isolation in rooms [ROOM NUMBERS] should have been removed, yesterday morning since the residents in the rooms did not need isolation and everything is ok. The DON said she was not sure why the signs were not removed yesterday. The DON confirmed the signs indicated to the staff and visitors what precautions should be followed to ensure infections are not spread, and if a sign is posted the sign should be followed. On 06/18/25 at 11:52 a.m. Staff P, CNA was observed during meal pass removing a tray from the cart, entering room [ROOM NUMBER], setting the tray up and assisting resident with tray set up, exited the room, returned to the tray cart, selected another tray and entered room [ROOM NUMBER]. No hand hygiene occurred during the observation. During an interview on 06/18/25 at 11:56 a.m. Staff P stated not being aware of the need for hand hygiene between each room. During an interview and observation on 06/16/25 at 11:42 a.m. Resident #29 was observed drinking from a large reusable plastic facility tumbler/cup with a lid and straw. Resident #29 stated the cup is cleaned once or twice per week. During an interview on 06/18/25 at 11:20 a.m. with the Certified Dietary Manager (CDM) stated, the facility's reusable plastic tumbler/cups are sporadically returned to the kitchen for cleaning through the dish machine. The facility does not utilize the reusable straw that came with the tumbler/cup but replaces it with a disposable straw. The CDM was not aware of a specific schedule for the reusable tumbler/cup sanitation. The CDM stated if the staff needed a clean tumbler/cup there were a few in the kitchen for distribution. About 8 reusable tumbler/cups were observed in the kitchen ready for use. There were no other tumbler/cups observed in the kitchen or dish room. During an interview on 06/18/25 at 11:48 a.m. Staff A, CNA stated, they change the straws every shift, and when the tumbler/cup is dirty they can take it to the kitchen. Staff B, CNA stated not having anything to do with the tumbler/cups except to refill them and was not aware of the cleaning process. During an interview on 06/18/25 at 11:53 a.m. Staff X, CNA stated the tumbler/cup is washed in the nourishment room there is a sink there. Staff X stated if need be they send them to the kitchen twice a week, no specific days. During an interview on 06/18/25 at 11:56 a.m. Staff P, CNA stated not aware of any process, was instructed to wash the cups in the nourishment room with hand soap and water. Staff P said, Although, I usually wash in the resident room sink as it seems cleaner with the room being private. During an interview on 06/18/25 at 12:00 p.m. the Registered Dietitian (RD) stated the expectation for the reusable tumblers/cups are to be cleaned at least daily by the kitchen staff in the dish machine. The RD stated not being aware of the cleaning schedule for the tumbler/cups. During an interview on 06/18/25 at 12:05 p.m. the DON stated the tumbler/cups are changed out daily. The DON stated the tumbler/cups don't have a specific time for distribution or know the process for cleaning of the tumbler/cups. During an interview on 06/18/25 at 12:07 p.m. Staff G, Licensed Practical Nurse (LPN) stated we remove the reusable straw and replace it with a disposable, but was not familiar with a specific process for taking the tumbler/cups to the kitchen for cleaning. Review of the facility's policy titled Transmission-Based Isolation Precautions reviewed on 12/11/2023, showed a policy statement, it is the policy of all [Facility Name] to implement and adhere to transmission-based precautions to prevent and protect from exposure and transmission of suspected or confirmed infectious agents within the healthcare setting. Procedures: A. Administrative Responsibilities 1. The Administrator and Director of Health Services of the Healthcare Center are responsible for the implementation of this policy. B. General Principles: 1. Standard Precautions are used in the care of all residents and are never to be discontinued. 2. Promptly initiate isolation precautions for residents with suspected or confirmed communicable diseases to minimize exposure to infectious agents. 5. Personal protective equipment (PPE) is provided for everyone who needs to care for or visit a resident on isolation precautions. 6. Everyone, but not limited to, providers, nurses, environmental services, technicians, are responsible for complying with isolation precautions, donning appropriate PPE, and tactfully calling observed noncompliance to the attention of offenders. 8. Display the appropriate isolation signage on the resident's door frame/door. 11. All residents on isolation are assessed during each shift to determine the need for continued precautions. C. Initiation and Discontinuation of Isolation Precautions 1. Initiation and termination of isolation precaution requires a physician's order for the appropriate type of isolation precautions to be followed. 2. Patients with a known or suspected communicable disease should immediately be placed on appropriate isolation precautions. 4. The appropriate isolation precaution signs should be placed in a readily visible location outside of the resident's room (i.e., resident's door/doorframe). 5. Personal protective equipment (PPE) (e.g., gowns, gloves, masks) should be readily available outside the patient's room and either in a cart outside the patient's room door or in a designated cabinet outside the room door. 6. Discontinuation of isolation precautions requires the order of a physician provider. D. Types of Isolation Precautions 1. Contact Precautions Use contact precautions for residents with known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident, (i.e., hand contact or skin-to-skin contact that occurs when performing resident-care activities that require touching the resident's dry skin) or indirect contact (i.e., touching) with environmental surfaces or items in the resident's environment. B. Personal Protective Equipment (PPE) 1) Gloves * perform hand hygiene prior to donning gloves. * Wear gloves(clean, non-sterile gloves are adequate) upon entry into the room.* Wear gloves when touching the residents intact skin, surfaces and items near the resident. 2) Gowns * Perform hand hygiene prior to dawn and gown. * Done a gown upon entry into the room. * Remove gown before leaving the residence environment and perform hand hygiene. C. Signage 1) Place a contact precaution sign on the residence door/door frame. Resident Transport . 3) ensure that infected or colonized open wounds are covered and contained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental services or equipment. Review of the facility's policy titled Medication Administration: Hand Hygiene dated reviewed 10/14/2024 revealed: Policy Statement: It is the policy of [Facility Name] Pharmacy Services that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. Hand Hygiene: The cleansing of hands by using the organization-approved, alcohol-based hand sanitizer or by washing hands with soap and water. Procedure: 1. During medication administration, use hand hygiene before and after touching a patient, immediately before performing a clean or aseptic procedure, immediately after an exposure risk to body fluids, before moving from a soiled body site, after touching a patient's immediate surroundings, and before and after glove removal. 2. Use an organization- approved, alcohol-based hand sanitizer for hand hygiene, if hands are not visibly soiled or contaminated with bodily fluids. It is faster, more effective, and better tolerated by your hands than washing with soap and water. - To use hand sanitizer, put product on hands and tub hands together, cover all surfaces of hands and fingers until skin feels dry. This should take approximately 20 seconds. 4. Wear gloves during medication administration for IV insertion and removal or when there is contact with blood, mucous membrane, or non-intact skin. Gloves should be worn during eye drop, vaginal, or rectal administration. Glove should be worn while opening capsules during medication preparation or while preparing and administering hazardous agents (NIOSH). Hand hygiene should be performed before donning and after removing gloves. Change gloves and perform hand hygiene during medication administration, if gloves become damaged, visibly soiled with blood or bodily fluids, moving from work on a soiled body site to a clean site, or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient. Based on observations, interviews, record reviews, and review of the Center for Disease Control and Prevention (CC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate and prevent the spread of infection related to use of Personal Protective Equipment (PEP) during care, medication administration and meal service for four (#29, #278, #6, and #229 of 48 sampled residents, and in two halls (300, 100) of five hallways observed. Findings Included: On 6/17 25 at 8:12 a.m. during a medication administration observation for Resident #29, Staff G, Licensed Practical Nurse (LPN) did not perform hand hygiene (HRH) and did not use ABHR (Alcohol- Based Hand Rub) before preparing medications as well as before and after administering the medications. On 6/17/25 at 10:28 a.m. an interview was conducted with Staff G, LPN about the HH during medication administration, she agreed hand hygiene was not done. On 6/17/25 at 8:32 a.m. Staff F, RN was observed preparing intravenous (IV) antibiotics to administer to Resident #278, she dropped the IV tubing on the floor in the resident's room. Staff F, RN picked up the tubing from the floor and while wearing the same pair of gloves, removed the cap covering the drip chamber, spiked the medication bag and primed the tubing. Before administering Staff F, RN, said the IV tubing is safe to use because the caps on both ends of the tubing had not been removed. When asked about the facility's policy Staff F, RN repeated the IV tubing was safe to use because the caps on both ends of the tubing had not been removed and continued to administer the antibiotic. On 6/17/25 at 8:41 a.m. while preparing and administering medications for Resident #6, Staff F, RN did not perform hand hygiene (HH) of any kind before preparing medications as well as before and after administering the medications. During an interview with Staff F, RN confirmed HH was not completed. During an interview on 6/18/24 at 12:38 p.m. Staff K, RN stated if during medication administration the IV tubing dropped to the floor, the expectation was for the tubing to be replaced prior to administering the medication. During an interview on 6/19/25 at 11:07 a.m., the Director of Nursing (DON) said if IV tubing falls on the floor, staff are expected to replace the tubing before administering the medications. She stated staff are expected to perform hand hygiene before preparing medications and when administering medications. Review of the facility's policy titled, Intravenous Antibiotic Therapy, reviewed 7/2/24 showed the following under scope - This policy applies to all nurses within a center serviced by [Facility Name] pharmacy Services. Procedure .7. Aseptic technique shall be maintained and standard precautions observed throughout administration of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement an antibiotic stewardship program including developing a system to monitor use of antibiotic-resistant organisms for one resident (#378) out of two residents reviewed for antibiotic stewardship with potential to impact the entire facility. Findings included: Review of the admission Record revealed Resident #378 was admitted to the facility on [DATE] with diagnoses to include other Staphylococcus as the disease classified elsewhere. Review of the June 2025 Medication Administration Record (MAR) for Resident #378 showed the resident was receiving Vancomycin recon 1.25 grams; IV (intravenous), dated 5/29/25 to 6/18/25. The review of the MAR did not show why the resident was on Vancomycin and it was not specified what type of infection she was being treated for. The MAR did not show a specified diagnosis. The review pf physicin orders for Resident #378 showed there was no order for contact precautions and there was no McGreer's Criteria (a set of standardized definitions used primarily in Long term Care facilities to identify and classify infections for surveillance and antibiotic stewardship purposes) in place. Review of daily progress notes for Resident #378 dates 5/30/25 to 6/17/25 showed, Resident continues IV ABT VANCO (antibiotic vancomycin) to RUE (right Upper extremity) with no adverse reactions to medications. Resident tolerated well with no s/s (signs/symptoms) of infection of IV site and is secure and flushes without difficulty. Resident denies pain or discomfort with no SOB (Shortness of Breath) to note. The progress notes did not show why the resident was on the antibiotic. During an interview on 6/19/25 at 4:56 p.m. the Director Of Nursing (DON) said, The interdisciplinary team conducts a weekly Patient At Risk (PAR) meeting as part of the antibiotic stewardship program, at this meeting we discuss residents on antibiotics. The DON stated after the PAR discussion of who is on antibiotics she documents on a map of the facility, showing which residents have which infections using a color-coded chart. She stated documenting on the chart is what consists of their antibiotic stewardship program. The DON confirmed there was no McGreer's Criteria for monitoring the residents on antibiotics. During an interview on 6/19/25 at 7:04 p.m. the Nursing Home Administrator (NHA) stated there had not been an Infection Control Program or antibiotic monitoring program. The NHA said the facility just started looking at antibiotic stewardship about two weeks ago, but nothing had been done with the data. The NHA stated Resident #378 had not been tracked for her use of antibiotics and the use of McGreer's did not start until 6/16/25. He stated Resident #378 was admitted with an unspecified bacterial infection and a history of Methicillin-resistant Staphylococcus aureus. The NHA confirmed there was no follow up with the physician regarding any type of contact precautions. Review of an undated facility policy titled Antibiotic Stewardship Program, showed: As part of the Infection Prevention and Control Program, [Name of Facility] will implement and maintain an Antibiotic Stewardship Program (ASP). Under the direction of the Medical Director and Director of Health Services (DHS) the ASP is designed to promote appropriate use of antibiotics and improve patient health outcomes. The goal of ASP is to promote appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use.

Based on interviews and record review, the facility failed to complete an investigation for a fracture of unknown origin for one resident (#1) out of thirteen sampled residents. Findings included: Review of admission Records showed Resident #1 was admitted from the hospital on 9/17/24 with diagnoses including urinary tract infection, vascular dementia, gout, muscle weakness, and history of transient ischemic attack, and cerebral infarction without residual deficits. Review of Resident #1's admission Observation, dated 9/17/24, showed an assessment of his musculoskeletal system revealed no contractures, paralysis or flaccidity, extremity weakness, history of joint replacement, weight bearing limitation, requirement of assistive devices, or amputations/prosthetics. The assessment also showed no impairment for functional limitation in range of motion for lower extremities. Review of Resident #1's Physical Therapy (PT) Evaluation, dated 9/17/24, showed a musculoskeletal system assessment of the resident's lower extremity range of motion within functional limits (WFL). Review of Resident #1's Progress Notes revealed a note, dated 9/23/24, showed the following: X-ray to left ordered d/t [due to] c/o [complaints of] pain and discomfort, result received and communicated with doctor, result showed fracture to left head femur, received orders to send patient to hospital, skin assessment completed, no bruises or swelling noted to left hip area, no discomfort reported during assessment when palpating area . patient c/o pain when admitted to this facility from hospital while admitting nurse was assessing patient. Review of imaging results, dated 9/23/24, showed acute fracture of the femoral neck with mild adduction of the femoral head in the acetabular fossa with soft tissue swelling. Review of Resident#1's hospital records showed a computerized tomography (CT) scan of the abdomen/pelvis with contrast was completed on 9/13/24. The results showed no discrete abnormality to explain patient's symptoms. The hospital physical exam on 9/13/24 showed extremities moves all, normal range of motion and musculoskeletal: normal inspection, painless range of motion. An interview was conducted on 10/18/24 at 2:40 p.m. with Staff A, Registered Nurse (RN). He said at the time of Resident #1's fracture he was the interim Director of Nursing (DON), covering for the Risk Manager while she was on orientation, covering for the Nursing Home Administrator (NHA) while he was out of town, and completing his normal nursing duties on a medication cart. He said the resident's x-ray showed Resident #1 had a hip fracture, and he went out to the hospital. He said the resident had not had any falls at the facility. Staff A said no interviews were done and he did not talk to staff; We did not investigate it. He said after the resident went out, he had been told the resident had three falls at his ALF prior to going to the hospital and his subsequent admission to this facility. Staff A said he had not seen the hospital CT results (from his hospital stay prior to admission at this facility) in the resident's record, that showed no fractures, at the time or he would have gone further and investigated the fracture. Review of an article titled Hip Joint, reviewed 1/20/23, explained a hip joint is a connection between the legs and torso. The hip joint is made up of the femur and pelvis. (https://my.clevelandclinic.org/health/body/24675-hip-joint accessed on 10/26/24) Review of an article titled Diagnosing Hip and Pelvic Fractures, undated, showed a CT scan examines a fracture pattern or assess the extend of damage in the hip joint. A CT scan uses x-rays and a computer to create two- and three-dimensional pictures of the hip and pelvic bones, enabling doctors to examine a fracture from many different angles. (https://nyulangone.org/conditions/hip-pelvic-fractures/diagnosis accessed on 10/26/24) Review of a facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation or Property, revised 10/27/2020, did not include any information related to investigating. An interview was conducted on 10/18/24 at 1:30 p.m. with the DON about a policy related to investigating and she said, All I have is what I gave you.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure competent nursing care staff, related to care of one unresponsive Resident (#10), and wound monitoring for two Residents (#1 and #7) was provided out of thirteen resident sampled. Findings included: 1. Review of admission Records showed Resident #10 was admitted on [DATE] with diagnoses including fracture of right femur, subsequent encounter for closed fracture with routine healing. Review of Resident #10's admission Observation, dated [DATE], showed the resident was oriented, generally to person, place and time, understands and had clear comprehension, intact memory and clear, organized thinking. Review of Resident #10's care plan showed she had an Activities of Daily Living (ADL) decline related to a recent hospitalization due to fall with right hip fracture and surgical repair. Interventions included 1-person assist for transfer/toileting. Resident #10 also had a care plan for being a fall risk related to assistance being required for mobility and transfers, pain and pain medication, history of fall with fracture and comorbidities including hypertension and coronary artery disease. Interventions included assist for toileting and transfers as needed and place call light within reach. Review of Resident #10's progress note, dated [DATE] at 3:37 a.m., showed the following note written by Staff G, Licensed Practical Nurse (LPN): Around 3 AM CNA [Certified Nursing Assistant] alerted writer that resident was on the floor. Resident was observed on floor and resident was unable to articulate how she ended up on the floor. Resident responsive, Initiated head to toe assessment, Initiated neuro check. assessed resident's body and head, No bleeding or bruises noted; helped resident into wheelchair and went to grab vital machine, came back resident was unresponsive. Called a code, Initiated call to 911 and writer got RN and other LPN on duty to help initiate CPR. Called emergency contact on file: [family member name] and let him know EMS would be transporting resident to [hospital name]. Called on- call: [Nurse Practitioner name] to let them know resident is unresponsive and is being taken to hospital. An interview was conducted on [DATE] at 10:56 a.m. with a family member of Resident #10. The family member said they would love to know what happened to the resident. They said Resident #10 was admitted to the facility a little over a week before this incident for rehabilitation after a hip replacement. The family member said Resident #10 had not yet stood up or walked on her own after the surgery. They said they were told the resident got out of bed and walked toward the bathroom and that is where staff found her on the floor. The family member said prior to surgery the resident had been completely independent. The family member said a point of contention on the resident's first day at the facility was staff not answering the call bell. The family member said the resident had to go to the bathroom, she turned her call light on, and it took 45 minutes for staff to come help causing the resident to soil herself. They said the resident was so embarrassed she cried. The family member said they spoke to the nurse about their concerns that first day. The family member said Resident #10 told them about having another accident a couple of days later because she was not able to get someone to help her to the bathroom in time. The family member said two days before the accident the resident was excited because the physical therapist was helping her build confidence, and the resident had set a goal to move to a chair on her own by the end of that week. The family member said the resident had been scared to get out of bed on her own. The family member said the day prior to the accident another family member visited the resident. That family member said they had to go get a nurse to help the resident because she pushed her call bell, and no one had come. An interview was conducted on [DATE] at 12:54 p.m. with Staff G, LPN. She confirmed she was the nurse that cared for Resident #10 on the night shift running from [DATE] until the morning of [DATE]. Staff G said this was the first shift she had with the resident and didn't know her well, but she had spoken clearly, was easy to understand and was not mumbling. She said the resident was a little anxious about the hurricane coming. Staff G said early in the shift Resident #10 had requested pain medication due to her hip hurting, and she received medication. Staff G said the Certified Nursing Assistant (CNA) came to the nurses' station around 3:00 a.m. to let her know Resident #10 had fallen. Staff G said she went to the resident's room and called her name. She said the resident was lying on the floor by the bathroom on her left side. Staff G said the resident was mumbling but incomprehensible. Staff G said she asked the resident if staff could pick her up and put her in bed and the resident said no. Staff G said Resident #10 was gasping with her breathing and mumbling. Staff G said she did a quick head-to-toe assessment and didn't see any injuries or bleeding. Staff G said she asked the resident if they could pick her up and put her in the chair and she said yes. Staff G said she and the CNA picked the resident up and put her in the chair. Staff G said she then left the resident and CNA in the room while she got the vital signs machine and when she returned the resident was unresponsive but still breathing. Staff G said she went to get the vital signs machine herself because the resident's room was close to the nurses' station and she could grab it quickly. Staff G said when she found the resident unresponsive, she went to get Staff H, Registered Nurse (RN) from another unit. Staff G said they moved Resident #10 to the bed, and she no longer had a pulse and staff initiated cardiopulmonary resuscitation (CPR). Staff G said CPR continued until emergency medical services (EMS) arrived and took over. An interview was conducted on [DATE] at 4:31 p.m. Staff P, LPN. Staff P said he was assigned to care for the 400/500 unit on the morning Resident #10 was found unresponsive. He said Staff G came to his unit and said she had a resident in a wheelchair that is unresponsive. She informed him she had left the room to get the vital signs machine after the resident had a fall and when she came back Resident #10 was unresponsive. He said he was in the middle of something with a resident, he finished what he was doing and went to the 300 unit. He said it took him probably 2-3 min's to get to Resident #10's room. Staff P said when he arrived in the room with Staff G, the resident was still sitting in the wheelchair; the Certified Nursing assistant (CNA) was present. He said he checked the resident's pulse and her pupils. He said the resident was then transferred to her bed and staff initiated CPR. Staff P said he went and got the crash cart. During CPR he said the automated external defibrillator (AED) was attached to the resident and asked them to stop a few times and he believed it delivered a shock. He said no one documented on the code form during or after the event. Staff P said if he found a resident unresponsive or incomprehensible he would look at the code status and start CPR if needed. Staff P said he would not leave the resident's room without a nurse there. An interview was conducted on [DATE] at 6:05 p.m. with the Director of Nursing (DON). She said if a resident had a fall and was mumbling and gasping, she should have been left on the floor and 911 called. She said her expectation would be for the nurse to stay with the resident and not leave the room to get equipment or go to another unit to get a nurse. The DON reviewed staff statements and confirmed Staff G wrote in her statement she left the unit to go get Staff P. An interview was conducted on [DATE] 1:30 p.m. with the DON. She said the facility did not have a policy and procedure for falls but the staff had competencies to complete. A sample list of these competencies was provided. Review of the documents showed there were competencies related to wound care and skin assessments, but there were no competencies related to resident falls; only fall prevention. 2. Review of Resident #1's entry record, dated [DATE], revealed the resident was admitted on [DATE]. The Minimum Data Set (MDS) records revealed the resident was admitted on [DATE], discharged on [DATE], and re-admitted on [DATE]. Further review of the clinical record revealed the resident was hospitalized from [DATE] to [DATE]. Review of Resident #1's MDS discharge assessment, dated [DATE], revealed the resident had a fall in the last month prior to admission, had a fall in the prior 2-6 months to admission, and did not have a fracture related to a fall in the 6 months prior to admission. The assessment showed the resident's primary medical condition was Medically Complex Conditions. Review of Resident #1's MDS scheduled 5-day assessment, dated [DATE], revealed the resident's primary diagnosis was Fractures and Other Multiple Trauma and secondary diagnoses included hip fracture and non-Alzheimer's dementia. The assessment revealed the resident's fracture history in the 6 months prior to admission was unable to determine. Review of Resident #1's Medication Administration Record (MAR), from [DATE] to [DATE], revealed a physician order instructing staff to obtain a portable left hip x-ray, 2 views, due to (d/t) pain, portable service necessary d/t generalized weakness and pain. The documentation showed the one-time x-ray was completed on [DATE]. Review of the Agency for Healthcare Administration (AHCA) form 5000-3008 revealed the facility had received the resident from an acute care facility, dated [DATE], showed Resident #1's primary diagnosis was hip fracture. The 3008 form revealed the resident had a left (L) hip surgical site and left ankle skin tear. Review of Resident #1's admission Observation Detail List Report, dated [DATE] at 3:06 p.m., and completed on [DATE] at 3:12 p.m. by Staff F, Licensed Practical Nurse (LPN), showed the resident arrived at the facility on a stretcher requiring a manual lift assist from stretcher to new surface. The observation showed extremities were observed for any pain, swelling, weakness, stiffness, warmth, tenderness, loss of sensation, change in color, or impaired function and the resident had no functional limitation in Range of Motion to either upper or lower extremity. The admission observation report showed the resident did not have any abrasions, bruising, burns, dermatitis, skin graft, skin tear, surgical incision (or) ulcer. The staff documented there was no alteration in skin or any skin/ulcer/injury treatments. Review of Resident #1's progress note, dated [DATE] at 7:06 p.m., showed the resident had been re-admitted to the facility status post (s/p) total left hip arthroplasty. The note did not reveal the skin condition of the resident. Review of Resident #1's Restraint-Adaptive Equipment assessment, dated [DATE] at 3:28 a.m., completed by Staff B, LPN, revealed the staff documented the resident did not have a history of hip fracture. Review of a Focused Observation completed by Staff E, LPN on [DATE] at 4:03 a.m., showed the shift charting included mental/neuro, cardiovascular, genitourinary (GU), musculoskeletal, and pain observations. The charting did not include an assessment of Resident #1's skin. Review of Resident #1's Nutrition Assessment, completed on [DATE] at 8:47 p.m., showed the resident was admitted to the facility following a hip fracture (fx). Review of Resident #1's progress note, dated [DATE] at 1:38 p.m., revealed the staff member had assessed the resident's left femur surgical site, the old dressing was removed, no drainage or redness was noted, and 19 staples were noted. The note revealed dressings were noted to the left lower extremity and left heels. Review of Resident #1's skin note written by Staff C, Registered Nurse (RN), dated [DATE], revealed the resident had bruising, skin tear/abrasion, rash/dermatitis, and a left hip surgical incision with 19 staples present. The note showed the resident had a left leg skin tear, scabs on bilateral legs, discoloration both arms, scrotum redness, shift of penis redness, left buttock deep tissue injury (DTI), (and) right buttock open area. Review of Resident #1's progress note, dated [DATE] at 11:50 p.m. written by Staff B, LPN, revealed the resident had arrived to the facility accompanied by 2 transporters and the left femur surgical site was observed with 19 staples, no redness, and no abnormal drainage. The note revealed the resident had shearing to the buttock which was cleaned and dressing applied, an old dressing to left heel was removed and the area was cleaned with an application of a new dressing. Review of Resident #1's re-admit observation report, dated [DATE] at 3:45 a.m., written by Staff B, LPN, showed the resident had an alteration in skin identified as an abrasion to the sacrum/coccyx area with application of non-surgical dressing and application of dressings to feet. The report did not include the resident's left hip surgical incision previously noted ([DATE]). Review of Resident #1's skin note, written by Staff C RN, dated [DATE] at 1:42 p.m. the staff had observed a surgical incision with 15 staples and the skin surrounding the incision was normal color. The observation did not reveal any progress note had been included. Review of a Wound Care vendor note, dated [DATE], showed the provider had been consulted for a Stage III pressure wound to left ischium, Stage III pressure wound to coccyx, arterial wounds to the left heel, digit 1 and 2 of left foot, dorsal proximal of left foot, left lower lateral leg, and post-operative left hip with 15 staples. The vendor recommended cleansing the digits on left foot, left dorsal proximal foot, left lower lateral leg, and left post-operative wound with normal saline/wound cleanser, skin prep peri wound and leave open to air. Review of Resident #1's Focused Observation report, written by Staff D, LPN, dated [DATE] at 5:21 p.m., revealed the resident had no alteration in skin. Review of Resident #1's progress note, dated [DATE], showed staff contacted a provider for an order to remove staples from left hip. The provider notified the staff that the contacted provider did not provide the surgery for the resident and after reviewing the hospital records the correct surgeon was notified. Review of Resident #1's progress note, dated [DATE] at 3:19 p.m. revealed 15 staples were removed from the left hip incision. Review of Resident #1's Medication Administration Record (MAR) did not reveal the staff were monitoring the left hip incision for signs/symptoms of infection. The MAR contained an order dated [DATE] instructing staff to remove staples from left hip and the documentation revealed Staff C had completed the order. During an interview on [DATE] at 1:35 p.m. Staff A, RN reported surgical incisions were monitored, It's usually an order. The staff member reviewed an unsampled resident and reported staff sign off monitoring (of the incisions) on the MAR and per the order the physician was to be notified if any issues. Staff A reported the electronic dashboard tells staff what areas to focus charting on. The staff member stated skin assessments are done weekly on everybody in the building, and the skin was actually looked at if the staff member was doing the assessment. Staff A stated the Wound Care Nurse (Staff C) does skin assessments however if the WCN was not available the day shift nurse was responsible for odd number rooms and the night shift nurse was responsible for the even numbers. An interview was conducted on [DATE] at 4:48 p.m. with the Director of Nursing (DON). The DON stated if there wasn't any orders (for staple/suture removal) staff should reach out (to physician) sooner then later, and to contact them within 10 to 14 days. She stated she would expect the incision to be monitored until after the staples were removed. Review of Resident #1's MAR showed staff were not monitoring the left hip surgical incision from the return of the resident on [DATE] until transfer to hospital on [DATE], then from return on [DATE] until Staff C assessed the area on [DATE]. The facility documentation revealed staff were inconsistent with accurately assessing/observing the resident's skin. 3. Review of Resident #7's Entry Minimum Data Set (MDS) assessment showed the resident was admitted on [DATE]. The admission MDS, dated [DATE] revealed the resident had a history of falls in the last month prior to admission, 2-6 months prior to admission, and had a fracture related to a fall in the 6 months prior to admission. Review of Resident #7's progress note, dated [DATE] at 5:31 p.m., showed the resident was admitted with three (3) different incision related to a right femur fracture. The resident was alert and oriented times 3. Review of Resident #7's late entry progress note, dated [DATE] at 6:58 a.m., revealed the resident had returned from a Orthopedic appointment with new orders which included an advisement not to apply any cream or ointments to legs to allow wounds to heal. Review of the Orthopedic vendor's note, dated [DATE] at 11:40 a.m., revealed Resident #7 was a post-operative hip new patient related to a [DATE] right femur fracture. The note revealed the patient reported experiencing pain which was explained as a normal part of the healing process as the fracture was still healing. The radiograph's showed the rod placement was in good position with no complications and was lined up nicely. Review of the Weekly Skin Check note, dated [DATE] at 4:56 a.m., showed there was no alteration in Resident #7's skin, then continued to document the presence of a right hip surgical incision. The note did not describe the appearance of the surgical incision of the number of staples present. Review of Resident #7's shift charting, dated [DATE] at 3:28 a.m., revealed the skin was warm, dry, normal color, no petechiae, normal turgor, and no alterations in the skin. Review of Resident #7's shift charting, dated [DATE] at 2:41 a.m., revealed the skin was warm, dry, normal color, no petechiae, normal turgor, and no alterations in the skin. Review of Resident #7's progress note, dated [DATE] at 6:34 p.m., showed the resident voiced Some discomfort to right lower extremity to surgical site. The area had some light redness to the stitch's insertion site, warm to touch and some mild and tolerable discomfort. The on-call provider was notified and staff were awaiting a call back. Review of Resident #7's shift charting note, dated [DATE] at 1:20 a.m., revealed the resident's skin was warm, dry, normal color, no petechiae, normal skin turgor, and no alterations in the skin. Review of Resident #7's progress note, dated [DATE] at 2:36 p.m., showed the resident's right lower extremity's post operative site was assessed with slight erythema note to site circa sutures. The note revealed a call was placed to the surgeon and was awaiting a call back related to obtaining an order to remove sutures. Review of a Skin note, dated [DATE] at 3:54 a.m., showed there was no alteration(s) in skin and the area for documentation if a surgical incision was present, the appearance of the incision and number of staples was blank, without documentation. Review of a late entry note, dated [DATE] at 4:08 p.m., (recorded as a late entry on [DATE]), showed the nurse removed sutures from both surgical sites to right lower extremity. The wound was well-approximated, no pain or erythema was noted. Review of the Shift Charting note, dated [DATE] at 2:07 a.m., showed Resident #7's skin was warm, dry, normal color, with no petechiae, normal turgor, and without alterations. Review of the Focused Observation note, dated [DATE] at 11:51 a.m., showed Resident #7's skin was warm, dry, normal color and turgor, without petechiae, and skin intact at this time. Review of the Focused Observation note, dated [DATE] at 1:00 a.m., showed Resident #7's skin was warm, dry, normal color and turgor, without petechiae, and there were no alterations in skin. Review of the Focused Observation note, dated [DATE] at 3:43 p.m., showed the weekly focus observation did not include assessment of Resident #7's skin. Review of Resident #7's Daily Focused Observation, dated [DATE] at 2:54 a.m., revealed the resident's skin was warm, dry, normal color and turgor, without petechiae, and with no skin alterations. Review of Resident #7's Daily Focused Observation, dated [DATE] at 2:00 a.m., revealed the resident's skin was warm, dry, normal color and turgor, without petechiae, and with no skin alterations. Review of Resident #7's Weekly Skin note, dated [DATE] at 8:50 a.m., Staff C, Registered Nurse (RN) documented there was no alteration in skin, a surgical incision was present on the right hip, edges of the incision were well-approximated, sutures were present, and the skin surrounding the incision was of normal color. Review of Resident #7's progress note, dated [DATE] at 9:11 a.m., showed the resident Noted with four sutures to right hip upper incision. Lower incision sutures removed, and incision healed. A call placed to MD for orders to remove sutures. Awaiting return call, son at bedside and is aware. A note on [DATE] at 1:19 p.m. revealed Staff C received orders to remove sutures from right hip incision. Review of the General Administration History, dated 5/1 - [DATE], showed Resident #7's skin was checked by the nurse once a week during the 7 p.m. to 7 a.m. shift. Review of the Treatment Administration History, dated 5/1-[DATE], revealed an order, started and ended on [DATE] to Keep dressing to right hip in place until post-op day 7, remove and leave open to air. A review of the General, Treatment, and Medication Administration History's, dated 5/1 - [DATE], did not show staff had monitored Resident #7's surgical site on a daily basis. Review of the Wound Management section of Resident #7's clinical record did not reveal the resident had either an active or healed surgical incision. Review of Resident #7's care plan revealed the resident was at risk for skin breakdown related to (r/t) assistance needed for mobility and transfers, pain and pain meds, use of antiplatelet medication and comorbidities. Patient (Pt.) admitted with surgical incision to Right (R) hip. An interview was conducted on [DATE] at 4:30 p.m. with the Director of Nursing (DON). The DON stated the facility did have a full-time wound care nurse, confirmed as Staff C. The DON reported Staff C does work full-time but not 100% as the Wound Care Nurse, the staff member has been working at fulfilling floor positions, sometimes has to work the cart. The DON defined an alteration in skin as Alteration is not natural, skin is no longer intact, it's altered, or appearance has changed and confirmed a surgical incision would be considered an alteration until it was resolved. The DON stated the expectation for how staff are to document a skin assessment was for staff to visualize the skin and the facility was doing weekly skin assessments on residents generally done with all care depending on the care and minimally weekly. The DON stated the admitting nurse should document any skin issues, all visualized and sometimes surgeons will give directions not to remove dressings until seen but nurses should document it exists and normally the resident has orders from the hospital to follow up, in event there's no order for surgical follow up staff are to contact the physician or the medical director. The DON reported nurses are to know when to monitor a surgical incision when it's determined they have a site and they should order to monitor the site or reinforce the dressing. Review of the policy - Documentation of Skin and Wound Care, revised [DATE], revealed the following: It is the policy of the healthcare center to complete documentation that reflects the current resident status as related to skin/ wound care. Documentation will provide current and timely documentation when resident's condition related to skin/ wound care, accurate information on resident's status as it pertains to skin/ wound care, record care rendered and interventions in place and provide a detailed history of wound assessments that have occurred in the health care center. The scope of this policy applies to all {Facility Name}providing wound care. Documentation regarding wound observations and care should be completed: - On pressure ulcers, venous insufficiency/ stasis ulcers, arterial ischemic ulcers, diabetic wounds, and any other chronic or complex wounds (weekly). - Upon admission or readmission of residents. - I'm skin tears, rashes, etc. (weekly) in narrative notes kept with the treatment assessment record (ETAR). - Whenever there is an unexpected change in condition of the wound. - As needed, per clinical judgment. The admission skin assessment reflects current skin condition, noting wounds, areas of skin compromise, etc. at the time of admission. Wound Manager is to be completed at admission on any noted skin conditions. The Weekly Documentation off treatments will be completed on wound manager in the EHR and focus observation to include skin observation. At least every seven days a comprehensive nursing assessment is completed by a registered nurse that includes a review of the current plan of care, current wound status (based on assessment and review of all documentation), and the patient/resident's response to the treatment plan. The policy includes necessary documentation as follows: - The anatomical location of existing wound should be documented. - Clean the wound per physician orders. - Assay round for older and document presence of order in the narrative. - Describe the surrounding tissue. Describe using intact, dry, macerated, erythema, edema, hard (indurated), fluctuance, and others should be described in the narrative. - Document any signs or symptoms of infection in the narrative. - Describe how the wound is responding to the current treatment. Describe using new (first assessment of the wound), improving, declining, or stable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure surgical wounds were monitored for signs of infection and surgical sutures were removed per physician orders for two residents (#1 and #7) of three residents sampled for wound care. Findings included: 1. Review of Resident #1's entry record, dated 9/17/24, revealed the resident was admitted on [DATE]. The Minimum Data Set (MDS) records revealed the resident was admitted on [DATE], discharged on 9/23/24, and re-admitted on [DATE]. Further review of the clinical record revealed the resident was hospitalized from [DATE] to 10/11/24. Review of Resident #1's MDS discharge assessment, dated 9/23/24, revealed the resident had a fall in the last month prior to admission, had a fall in the prior 2-6 months to admission, and did not have a fracture related to a fall in the 6 months prior to admission. The assessment showed the resident's primary medical condition was Medically Complex Conditions. Review of Resident #1's MDS scheduled 5-day assessment, dated 9/29/24, revealed the resident's primary diagnosis was Fractures and Other Multiple Trauma and secondary diagnoses included hip fracture and non-Alzheimer's dementia. The assessment revealed the resident's fracture history in the 6 months prior to admission was unable to determine. Review of Resident #1's Medication Administration Record (MAR), from 9/17/24 to 10/17/24, revealed a physician order instructing staff to obtain a portable left hip x-ray, 2 views, due to (d/t) pain, portable service necessary d/t generalized weakness and pain. The documentation showed the one-time x-ray was completed on 9/23/24. Review of the Agency for Healthcare Administration (AHCA) form 5000-3008 revealed the facility had received the resident from an acute care facility, dated 9/27/24, showed Resident #1's primary diagnosis was hip fracture. The 3008 form revealed the resident had a left (L) hip surgical site and left ankle skin tear. Review of Resident #1's admission Observation Detail List Report, dated 9/27/24 at 3:06 p.m., and completed on 9/29/24 at 3:12 p.m. by Staff F, Licensed Practical Nurse (LPN), showed the resident arrived at the facility on a stretcher requiring a manual lift assist from stretcher to new surface. The observation showed extremities were observed for any pain, swelling, weakness, stiffness, warmth, tenderness, loss of sensation, change in color, or impaired function and the resident had no functional limitation in Range of Motion to either upper or lower extremity. The admission observation report showed the resident did not have any abrasions, bruising, burns, dermatitis, skin graft, skin tear, surgical incision (or) ulcer. The staff documented there was no alteration in skin or any skin/ulcer/injury treatments. Review of Resident #1's progress note, dated 9/27/24 at 7:06 p.m., showed the resident had been re-admitted to the facility status post (s/p) total left hip arthroplasty. The note did not reveal the skin condition of the resident. Review of Resident #1's Restraint-Adaptive Equipment assessment, dated 9/28/24 at 3:28 a.m., completed by Staff B, LPN, revealed the staff documented the resident did not have a history of hip fracture. Review of a Focused Observation completed by Staff E, LPN on 9/28/24 at 4:03 a.m., showed the shift charting included mental/neuro, cardiovascular, genitourinary (GU), musculoskeletal, and pain observations. The charting did not include an assessment of Resident #1's skin. Review of Resident #1's Nutrition Assessment, completed on 9/28/24 at 8:47 p.m., showed the resident was admitted to the facility following a hip fracture (fx). Review of Resident #1's progress note, dated 9/29/24 at 1:38 p.m., revealed the staff member had assessed the resident's left femur surgical site, the old dressing was removed, no drainage or redness was noted, and 19 staples were noted. The note revealed dressings were noted to the left lower extremity and left heels. Review of Resident #1's skin note written by Staff C, Registered Nurse (RN), dated 10/2/24, revealed the resident had bruising, skin tear/abrasion, rash/dermatitis, and a left hip surgical incision with 19 staples present. The note showed the resident had a left leg skin tear, scabs on bilateral legs, discoloration both arms, scrotum redness, shift of penis redness, left buttock deep tissue injury (DTI), (and) right buttock open area. Review of Resident #1's progress note, dated 10/11/24 at 11:50 p.m. written by Staff B, LPN, revealed the resident had arrived to the facility accompanied by 2 transporters and the left femur surgical site was observed with 19 staples, no redness, and no abnormal drainage. The note revealed the resident had shearing to the buttock which was cleaned and dressing applied, an old dressing to left heel was removed and the area was cleaned with an application of a new dressing. Review of Resident #1's re-admit observation report, dated 10/12/24 at 3:45 a.m., written by Staff B, LPN, showed the resident had an alteration in skin identified as an abrasion to the sacrum/coccyx area with application of non-surgical dressing and application of dressings to feet. The report did not include the resident's left hip surgical incision previously noted (10/2/24). Review of Resident #1's skin note, written by Staff C RN, dated 10/14/24 at 1:42 p.m. the staff had observed a surgical incision with 15 staples and the skin surrounding the incision was normal color. The observation did not reveal any progress note had been included. Review of a Wound Care vendor note, dated 10/14/24, showed the provider had been consulted for a Stage III pressure wound to left ischium, Stage III pressure wound to coccyx, arterial wounds to the left heel, digit 1 and 2 of left foot, dorsal proximal of left foot, left lower lateral leg, and post-operative left hip with 15 staples. The vendor recommended cleansing the digits on left foot, left dorsal proximal foot, left lower lateral leg, and left post-operative wound with normal saline/wound cleanser, skin prep peri wound and leave open to air. Review of Resident #1's Focused Observation report, written by Staff D, LPN, dated 10/15/24 at 5:21 p.m., revealed the resident had no alteration in skin. Review of Resident #1's progress note, dated 10/16/24, showed staff contacted a provider for an order to remove staples from left hip. The provider notified the staff that the contacted provider did not provide the surgery for the resident and after reviewing the hospital records the correct surgeon was notified. Review of Resident #1's progress note, dated 10/16/24 at 3:19 p.m. revealed 15 staples were removed from the left hip incision. Review of Resident #1's Medication Administration Record (MAR) did not reveal the staff were monitoring the left hip incision for signs/symptoms of infection. The MAR contained an order dated 10/16/24 instructing staff to remove staples from left hip and the documentation revealed Staff C had completed the order. During an interview on 10/18/24 at 1:35 p.m. Staff A, RN reported surgical incisions were monitored, It's usually an order. The staff member reviewed an unsampled resident and reported staff sign off monitoring (of the incisions) on the MAR and per the order the physician was to be notified if any issues. Staff A reported the electronic dashboard tells staff what areas to focus charting on. The staff member stated skin assessments are done weekly on everybody in the building, and the skin was actually looked at if the staff member was doing the assessment. Staff A stated the Wound Care Nurse (Staff C) does skin assessments however if the WCN was not available the day shift nurse was responsible for odd number rooms and the night shift nurse was responsible for the even numbers. An interview was conducted on 10/18/24 at 4:48 p.m. with the Director of Nursing (DON). The DON stated if there wasn't any orders (for staple/suture removal) staff should reach out (to physician) sooner then later, and to contact them within 10 to 14 days. She stated she would expect the incision to be monitored until after the staples were removed. Review of Resident #1's MAR showed staff were not monitoring the left hip surgical incision from the return of the resident on 9/27/24 until transfer to hospital on [DATE], then from return on 10/12/24 until Staff C assessed the area on 10/14/24. The facility documentation revealed staff were inconsistent with accurately assessing/observing the resident's skin. 2. Review of Resident #7's Entry Minimum Data Set (MDS) assessment showed the resident was admitted on [DATE]. The admission MDS, dated [DATE] revealed the resident had a history of falls in the last month prior to admission, 2-6 months prior to admission, and had a fracture related to a fall in the 6 months prior to admission. Review of Resident #7's progress note, dated 5/1/24 at 5:31 p.m., showed the resident was admitted with three (3) different incision related to a right femur fracture. The resident was alert and oriented times 3. Review of Resident #7's late entry progress note, dated 5/15/24 at 6:58 a.m., revealed the resident had returned from a Orthopedic appointment with new orders which included an advisement not to apply any cream or ointments to legs to allow wounds to heal. Review of the Orthopedic vendor's note, dated 5/15/24 at 11:40 a.m., revealed Resident #7 was a post-operative hip new patient related to a 4/27/24 right femur fracture. The note revealed the patient reported experiencing pain which was explained as a normal part of the healing process as the fracture was still healing. The radiograph's showed the rod placement was in good position with no complications and was lined up nicely. Review of the Weekly Skin Check note, dated 5/22/24 at 4:56 a.m., showed there was no alteration in Resident #7's skin, then continued to document the presence of a right hip surgical incision. The note did not describe the appearance of the surgical incision of the number of staples present. Review of Resident #7's shift charting, dated 5/23/24 at 3:28 a.m., revealed the skin was warm, dry, normal color, no petechiae, normal turgor, and no alterations in the skin. Review of Resident #7's shift charting, dated 5/24/24 at 2:41 a.m., revealed the skin was warm, dry, normal color, no petechiae, normal turgor, and no alterations in the skin. Review of Resident #7's progress note, dated 5/25/24 at 6:34 p.m., showed the resident voiced Some discomfort to right lower extremity to surgical site. The area had some light redness to the stitch's insertion site, warm to touch and some mild and tolerable discomfort. The on-call provider was notified and staff were awaiting a call back. Review of Resident #7's shift charting note, dated 5/26/24 at 1:20 a.m., revealed the resident's skin was warm, dry, normal color, no petechiae, normal skin turgor, and no alterations in the skin. Review of Resident #7's progress note, dated 5/27/24 at 2:36 p.m., showed the resident's right lower extremity's post operative site was assessed with slight erythema note to site circa sutures. The note revealed a call was placed to the surgeon and was awaiting a call back related to obtaining an order to remove sutures. Review of a Skin note, dated 5/29/24 at 3:54 a.m., showed there was no alteration(s) in skin and the area for documentation if a surgical incision was present, the appearance of the incision and number of staples was blank, without documentation. Review of a late entry note, dated 5/29/24 at 4:08 p.m., (recorded as a late entry on 6/4/24), showed the nurse removed sutures from both surgical sites to right lower extremity. The wound was well-approximated, no pain or erythema was noted. Review of the Shift Charting note, dated 6/1/24 at 2:07 a.m., showed Resident #7's skin was warm, dry, normal color, with no petechiae, normal turgor, and without alterations. Review of the Focused Observation note, dated 6/1/24 at 11:51 a.m., showed Resident #7's skin was warm, dry, normal color and turgor, without petechiae, and skin intact at this time. Review of the Focused Observation note, dated 6/4/24 at 1:00 a.m., showed Resident #7's skin was warm, dry, normal color and turgor, without petechiae, and there were no alterations in skin. Review of the Focused Observation note, dated 6/4/24 at 3:43 p.m., showed the weekly focus observation did not include assessment of Resident #7's skin. Review of Resident #7's Daily Focused Observation, dated 6/5/24 at 2:54 a.m., revealed the resident's skin was warm, dry, normal color and turgor, without petechiae, and with no skin alterations. Review of Resident #7's Daily Focused Observation, dated 6/8/24 at 2:00 a.m., revealed the resident's skin was warm, dry, normal color and turgor, without petechiae, and with no skin alterations. Review of Resident #7's Weekly Skin note, dated 6/10/24 at 8:50 a.m., Staff C, Registered Nurse (RN) documented there was no alteration in skin, a surgical incision was present on the right hip, edges of the incision were well-approximated, sutures were present, and the skin surrounding the incision was of normal color. Review of Resident #7's progress note, dated 6/10/24 at 9:11 a.m., showed the resident Noted with four sutures to right hip upper incision. Lower incision sutures removed, and incision healed. A call placed to MD for orders to remove sutures. Awaiting return call, son at bedside and is aware. A note on 6/10/24 at 1:19 p.m. revealed Staff C received orders to remove sutures from right hip incision. Review of the General Administration History, dated 5/1 - 5/31/24, showed Resident #7's skin was checked by the nurse once a week during the 7 p.m. to 7 a.m. shift. Review of the Treatment Administration History, dated 5/1-5/31/24, revealed an order, started and ended on 5/4/24 to Keep dressing to right hip in place until post-op day 7, remove and leave open to air. A review of the General, Treatment, and Medication Administration History's, dated 5/1 - 5/31/24, did not show staff had monitored Resident #7's surgical site on a daily basis. Review of the Wound Management section of Resident #7's clinical record did not reveal the resident had either an active or healed surgical incision. Review of Resident #7's care plan revealed the resident was at risk for skin breakdown related to (r/t) assistance needed for mobility and transfers, pain and pain meds, use of antiplatelet medication and comorbidities. Patient (Pt.) admitted with surgical incision to Right (R) hip. An interview was conducted on 10/18/24 at 4:30 p.m. with the Director of Nursing (DON). The DON stated the facility did have a full-time wound care nurse, confirmed as Staff C. The DON reported Staff C does work full-time but not 100% as the Wound Care Nurse, the staff member has been working at fulfilling floor positions, sometimes has to work the cart. The DON defined an alteration in skin as Alteration is not natural, skin is no longer intact, it's altered, or appearance has changed and confirmed a surgical incision would be considered an alteration until it was resolved. The DON stated the expectation for how staff are to document a skin assessment was for staff to visualize the skin and the facility was doing weekly skin assessments on residents generally done with all care depending on the care and minimally weekly. The DON stated the admitting nurse should document any skin issues, all visualized and sometimes surgeons will give directions not to remove dressings until seen but nurses should document it exists and normally the resident has orders from the hospital to follow up, in event there's no order for surgical follow up staff are to contact the physician or the medical director. The DON reported nurses are to know when to monitor a surgical incision when it's determined they have a site and they should order to monitor the site or reinforce the dressing. Review of the policy - Documentation of Skin and Wound Care, revised 6/14/24, revealed the following: It is the policy of the healthcare center to complete documentation that reflects the current resident status as related to skin/ wound care. Documentation will provide current and timely documentation when resident's condition related to skin/ wound care, accurate information on resident's status as it pertains to skin/ wound care, record care rendered and interventions in place and provide a detailed history of wound assessments that have occurred in the health care center. The scope of this policy applies to all {Facility Name}providing wound care. Documentation regarding wound observations and care should be completed: - On pressure ulcers, venous insufficiency/ stasis ulcers, arterial ischemic ulcers, diabetic wounds, and any other chronic or complex wounds (weekly). - Upon admission or readmission of residents. - I'm skin tears, rashes, etc. (weekly) in narrative notes kept with the treatment assessment record (ETAR). - Whenever there is an unexpected change in condition of the wound. - As needed, per clinical judgment. The admission skin assessment reflects current skin condition, noting wounds, areas of skin compromise, etc. at the time of admission. Wound Manager is to be completed at admission on any noted skin conditions. The Weekly Documentation off treatments will be completed on wound manager in the EHR and focus observation to include skin observation. At least every seven days a comprehensive nursing assessment is completed by a registered nurse that includes a review of the current plan of care, current wound status (based on assessment and review of all documentation), and the patient/resident's response to the treatment plan. The policy includes necessary documentation as follows: - The anatomical location of existing wound should be documented. - Clean the wound per physician orders. - Assay round for older and document presence of order in the narrative. - Describe the surrounding tissue. Describe using intact, dry, macerated, erythema, edema, hard (indurated), fluctuance, and others should be described in the narrative. - Document any signs or symptoms of infection in the narrative. - Describe how the wound is responding to the current treatment. Describe using new (first assessment of the wound), improving, declining, or stable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide sufficient nursing staff to meet the needs of three residents (#8, #9, & #13) out of seven sampled residents related to answering call lights timely and provide activities of daily living. Findings included: On 10/17/24 at 10:06 a.m., an interview was conducted with Resident #9. Resident #9 stated, The call bell has not worked since I got here (almost a week). It's been terrible. Finally, the facility provided me with this little bell (a round metal table bell, with the activating lever in the top middle of the bell) after I told them no one was assisting me but still no one comes when I ring it. I'm not sure what I would do if I fell or something. I don't really feel that safe. Although, the therapy is great! That is why I stay. Review of Resident #9's medical record revealed an admission date of 10/15/2024. Review of Resident #9's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008 revealed primary diagnosis of Urinary Tract Infection with other co-morbidities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating cognition was fully intact. Review of Care Plan revealed need for assistance due to impaired mobility. On 10/17/24 at 10:10 a.m., an interview was conducted with Resident #13 and Resident #13's representative. Resident #13 stated not bothering to push the light as no one would come, my representative stays with me and assists me. If my representative wasn't here, I don't know what I would do. Resident #13 and representative stated both have told the Director of Nursing (DON) but nothing changed. Review of Resident #13's medical record revealed an admission date of 10/5/2024, with a primary diagnosis of Left hip hemiarthroplasty (hip replacement) due to a left femur neck fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was fully intact. On 10/17/24 at 10:36 a.m. and 1:10 p.m., an interview was conducted with Resident #8's resident representative in Resident #8's room. The call light available is the normal round control with a red button on top, Resident #8, does not have the ability to press the button on the top of the control. Resident #8's representative has requested a different device that Resident #8 could just place their hand on. Resident #8's representative states no one listens. Resident #8's representative stated the call light stopped working for her. Resident #8's representative stated the facility gave Resident #8 a bell (a round metal table bell, with the activating lever in the top middle of the bell). Although they did not answer prior when the call light did work. Resident #8's representative stated, I would have to go out in the hallway and track people down, so I decided to just change him myself. I have to do this a lot; I don't mind helping but it worries me that he won't get care if I am not here. Review of Resident #8's medical record revealed an admission date of 9/9/2024, with a primary diagnosis of traumatic subdural hemorrhage without loss of consciousness and other co-morbidities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, resident was unable to participate in assessment. On 10/17/24 at 1:05 p.m. the call light to room [ROOM NUMBER] was observed to go on, at 1:25 p.m. a therapist was observed entering the room. Review of the grievance logs from September 2024 to 10/16/2024 showed eleven total grievances under the nursing department during this time. Of those eleven, six were sampled, the concerns were all related to residents in need of assistance and not receiving. A grievance on 9/19/24, revealed a resident was not receiving assistance with hearing aids. Under the section steps taken to investigate: an order was put in place for hearing aid assistance. A grievance on 9/20/24, revealed a resident had to verbally call out for help, no one assists with tray set or elevating resident's head to eat, not brushing resident's teeth, resident had to call grandson for assistance. Another grievance, dated 9/25/24, revealed a resident stated you need to burn this place down, people here they don't care. Today, I needed to call my daughter to ask for help. No-one came to change me until after she got her at 1:45 p.m., this happens all of the time. Review of grievance, dated 10/2/24, revealed: resident was taken to therapy without being changed from her pajamas and without her adult brief being changed and after rehab taken to the beauty salon to get her hair done. Family member continues to state, I changed her. A grievance on 10/15/24 revealed concerns about cold food, activities of daily living care, and oxygen placement. Another grievance placed on 10/15/24, revealed a concern regarding care {State agency name} came into the facility to investigate. An interview was conducted with Staff H, Certified Nursing Assistant (CNA) on 10/17/24 at 1:50 p.m. Staff H, CNA stated not knowing about any different type of bells for call lights and did not know to look for call light function. Staff H stated, The building is huge, and we have difficulty getting to everyone - sometimes the assignment sheets are out but usually you have no idea - we try really hard to get to everyone - but with the layout it is almost impossible. An interview was conducted with Staff J, CNA on 10/17/24 at 2:00 p.m. Staff J, CNA stated, not knowing about call light malfunction or bells. Staff J, CNA stated, Staffing is challenging - I don't want to say anymore - afraid to get fired. An interview was conducted with Staff K, CNA on 10/17/24 at 3:30 p.m. Staff K, CNA stated, not knowing about any bells, I see some in resident rooms but not sure why they are in the rooms. Staff K, CNA stated, The physical layout is hard for us to get around to all the rooms - not enough eyes to accomplish everything. An interview was conducted with Staff L, CNA on 10/17/24 at 3:45 p.m. Staff L, CNA stated, It's hard working with all the residents we are assigned, usually we can't get everything done. An interview was conducted with Staff N, CNA on 10/17/24 at 3:50 p.m. Staff N, CNA stated, not knowing anything about bells and it's hard to get to all your residents assigned with the physical plant. An interview was conducted with Staff M, CNA on 10/17/24 at 4:00 p.m. Staff M, CNA stated not knowing about bells or that the call lights are not working. Staff M, CNA stated the evening shift was really hard due to more residents than during the day, and Getting to everyone especially after dinner is almost impossible. On 10/17/24 at 4:10 PM an observation of call lights was conducted. Resident #9 rang physical ring bell for help two separate times. No staff was observed in the hall. At 4:18 PM Resident #9 rang physical ring bell again, 3 staff members were observed in the hall outside of her room. Observed none of the staff answering her call light. At 4:21 PM an interview with Resident #9 was conducted. She stated she was ringing her physical ring bell, and verified ringing it 2 separate times for help. Resident #9 stated they normally don't answer the ring bell since the call light has stopped working. On 10/18/24 at 10:00 AM an interview with Resident #11 was conducted. She stated she recently fell, she was trying to get up to go to the bathroom. She stated she did not call for help because she is tired of waiting for help and never getting it. She continued to say she always waits for a long time regardless of what time of day, it is all the time. An interview was conducted with the Staffing Coordinator (SC) on 10/18/24 at 10:30 a.m. The SC stated the facility determines staffing based on the census. The SC stated never being instructed to alter staffing for any other reasons. During an interview on 10/18/24 at 2:40 p.m. Staff A, Registered Nurse (RN) explained being the interim Director of Nursing (DON) prior to the current DON arriving. Staff A, RN stated staffing is based on census. During an interview on 10/18/24 at 2:40 p.m. the Director of Nursing (DON) stated staffing is based on the census. Review of the facility's Policy titled Staffing with a revised date of 6/1/2017 showed: Policy: at all times, the center will have as many partners on duty as may be needed to properly safeguard the health, safety and welfare of the residents, and provide unhurried assistance to residents according to each one's individualized plan of care. The minimum staffing pattern observed shall be as follows: *At least one Administrator, on site Manager, or designated responsible staff person at least [AGE] years of age will be on the premises 24 hours per day. *Residents shall not be left unsupervised. A minimum on site staff to resident ratio shall be: . *Staff, such as cooks and maintenance staff who do not receive ongoing direct care training and whose job duties do not routinely involve the oversight or delivery of direct personal care to the residents, will not be counted toward these minimum staffing ratios. *Residents must be supervised consistent with their needs. *An accurate staffing plan that takes into account the specific needs of the residents and monthly work schedules for all partners, including relief workers, showing planned and actual coverage for each day and night, shall be developed and maintained. Any needed changes in the schedule and relief workers used will be indicated on the schedule at the time of the change so the change can be identified. The completed staff schedules shall be maintained for a minimum of one year. sufficient staff time shall be available to assure that each resident: * receives treatments, medications and diets as prescribed.* receives proper care to prevent decubitus ulcers and contractures.* Is kept comfortable and clean.* Is treated with dignity, kindness, consideration, and respect.* Is protected from injury and infection.* Is given prompt, unhurried assistance.* Is given assistance, if needed, with daily hygiene including baths and oral care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to maintain a functioning nurse call system to respond to resident needs during two days (10/17/24, 10/18/24) of two days observed during survey. Findings included: On 10/17/24 at 10:06 a.m., an interview and observation was conducted with Resident #9. Resident #9 stated, The call bell has not worked since I got here (almost a week). It's been terrible. Finally, the facility provided me with this little bell (a round metal table bell, with the activating lever in the top middle of the bell) after I told them no one was assisting me but still no one comes when I ring it. A table bell was observed on the resident's nightstand. On 10/17/24 at 10:36 a.m. and 1:10 p.m., an interview and observation was conducted with Resident #8's resident representative in Resident #8's room. Resident #8's representative stated that the call light stopped working for her. Resident #8's representative stated the facility gave Resident #8 a bell (a round metal table bell, with the activating lever in the top middle of the bell). Although they did not answer prior when the call light did work. A table bell was observed on the resident's nightstand. During an interview on 10/17/24 at 10:30 a.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) stated all the building systems were fully functional. During an interview on 10/17/24 at 11:30 a.m. the DON stated the facility was aware of the call lights not functioning for a few rooms, she did not understand the question being asked earlier regarding the building system's functioning. During an interview on 10/17/24 at 4:00 p.m. with the NHA and DON, the NHA stated a vendor was coming out on Wednesday as the generator is hard on call light systems. The NHA presented a document titled Logbook Documentation dated 10/17/24 at 2:17 p.m., which revealed the following: Nurse Call System Checks - 10/2/24 showed: 100/200 Nurse call - Pass; 400/500 Nurse Call - Fail; 300 Nurse Call Pass. - 10/8/24 showed: 100/200 Nurse call - Pass; 400/500 Nurse Call - Pass; 300 Nurse Call Pass. - 10/14/24 showed: 100/200 Nurse call - NA; 400/500 Nurse Call - Fail; 300 Nurse Call Fail. Comments: rooms [ROOM NUMBERS] 515 are not working. Called IT for service. 320, 321 not working During an interview on 10/17/24 at 4:30 p.m. with the Director of Maintenance (DOM). The DOM stated the facility became aware of two resident rooms call lights not functioning. The DOM stated, an email was sent earlier in the month to the companies IT department, as this is who arranges for repair of the system, although the DOM has not had a reply. The DOM stated on 10/3/24 he became aware rooms [ROOM NUMBERS] were not working. The DOM issued table bells to the Administrator in Training (AIT) for placement in the resident rooms that were not functioning. The DOM stated a complete facility audit (room by room) was not completed. He stated, I did a few rooms every day, a sampling. Usually, this type of audit is only completed monthly, but I have been doing one weekly. But no not all rooms are tested. An interview was conducted with the AIT on 10/17/24 at 4:37 p.m. The AIT confirmed handing out the table bells to the resident rooms that were not functioning. Confirmed explaining the table bells to the resident/resident families and the nurse responsible for those particular rooms. The AIT confirmed not speaking to any other staff members. On 10/17/24 at 4:35 p.m., a resident was heard yelling help from room [ROOM NUMBER]. An unknown nurse was observed standing across the hall from room when this writer and Staff C, Registered Nurse (RN) entered room [ROOM NUMBER]. The unknown resident did not voice any needs when asked and closed eyes. Staff C was asked to press the call light button for the bed and confirmed the call light was not working. The observation did not reveal a hand bell was available for the resident to use. Staff C left the room and informed the unknown nurse that the call light in room [ROOM NUMBER] was not working and it needed to be reported. On 10/17/24 at 4:40 p.m.Staff C confirmed a hand bell was not observed in room [ROOM NUMBER] and the staff member was getting the resident one. An interview was conducted with Staff A, Registered Nurse (RN) on 10/17/24 at 4:45 p.m. Staff A, RN stated, I have been telling administration for weeks now what call lights are not working. The facility ran out of bells, so not everyone has a table bell. I know 502, 504, 518, 513, 515 off the top of my head are not working. I told my staff about the table bells but not other units. An interview was conducted on 10/18/24 at 9:44 a.m. with Staff O, Maintenance Assistant (MA). Staff O, MA stated, not being responsible for the call light audits. Although I was requested to complete some audits yesterday (10/17/24). During a follow-up interview and observation on 10/18/24 at 9:50 a.m. with the DOM. The DOM explained when completing call light room audits, by entering a resident room, pressing the call button, ensuring the wall system is activated, exiting the room and ensuring the light is on above the door. This process is repeated with resident bathroom light. The audit process is in the computer system to be checked on a monthly basis. The DOM changed this to a weekly check. The check occurs of a random sample of rooms in each hall, not all rooms. The DOM entered the facility computer, pulled up the Logbook Documentation for the nurse call system. During this demonstration the DOM pulled up the log book for the week 10/2/24 and changed the document from Fail to Pass. The DOM stated that was an error. The NHA presented a document titled Logbook Documentation, dated 10/17/24 at 4:51 p.m. which revealed the following: Nurse Call System Checks 10/17 2166: 217, 312, 317,318, 319, 320, 321, 322, 502, 504, 508,509,510, 518 - 10/2/24 showed: 100/200 Nurse call - Pass; 400/500 Nurse Call - Pass; 300 Nurse Call Pass. - 10/8/24 showed: 100/200 Nurse call - Pass; 400/500 Nurse Call - Pass; 300 Nurse Call Pass. - 10/14/24 showed: 100/200 Nurse call - Pass; 400/500 Nurse Call - Fail; 300 Nurse Call Fail. - 10/15/24 showed: 100/200 Nurse call - Pass; 400/500 Nurse Call - Fail; 300 Nurse Call Fail. - 10/16/24 showed: 100/200 Nurse call - Pass; 400/500 Nurse Call - Fail; 300 Nurse Call Fail. Comments: rooms [ROOM NUMBERS] 515 are not working. Called IT for service. 320, 321 not working as of 10/14. 508, 509 as of 10/15. 510 as of 10/16. 518, 318, 319, 312, 322, 217, 216 as 10/17. Note: The above was significantly changed from the prior documentation received. During an interview on 10/18/24 at 5:34 p.m. with the Nursing Home Administrator (NHA) and AIT, the NHA stated the vendor was contacted on 10/2/2024 for repair of the call system. The facility was only required to ensure residents had way to notify staff of need for assistance and the facility provided them with table bells, which meets the requirement. The NHA stated, Being quite busy due to the fact two hurricanes had occurred in a short time. We contacted our vendor. The NHA stated on 10/18/24 at 1:30 p.m. the facility did not have a policy and procedure for Equipment Repair and Maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to follow the Person-Centered Comprehensive Care Plan for one resident (#2) out of four sampled residents related to performing weights as ordered and medication administration as ordered. Findings included: Resident #2 was admitted on [DATE] and discharged on 06/16/2023. Record review showed diagnoses, included but were not limited to, urinary tract infection, diabetes hypertension, hypertension with chronic kidney disease with Congestive Heart Failure (CHF), atrial fibrillation (A-fib), hypothyroidism, pulmonary hypertension, and metabolic encephalopathy. Review of the admission Minimum Data Set (MDS), dated [DATE], showed he had Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). He required extensive assistance of two for bed mobility, transfers and toileting. Section J showed he had shortness of breath on exertion. A record review of the care plans showed risk for decreased cardiac output related to CHF, Coronary Artery Disease (CAD), A-fib, and hypertension. Interventions included but were not limited to medications as ordered as of 03/31/23. Nutrition care plan showed he was at nutrition and / or hydration risk as evidenced by impaired skin, diagnosis of metabolic encephalopathy, diabetes, hypertension, and CHF. Interventions included but not limited to weigh and monitor results: on admission weekly times 4, as ordered and as needed as of 03/31/23. A review of the physician orders showed: Torsemide 100 milligrams (mg) 0.5 tablet or 50 mg daily for heart failure as of 05/07/23 to 05/11/23 Torsemide 100 mg bid 0.5 tablet or 50 mg for edema, give 30 minutes prior to Metolazone every Monday, Wednesday, Friday as of 5/21/23 to 05/25/23 Torsemide 100 mg bid 0.5 tablet or 50 mg bid for edema, give 30 minutes prior to Metolazone every Monday, Wednesday, Friday as of 05/25/23 to 05/27/23 at 9 a.m. and 9 p.m. Torsemide 100 mg BID 0.5 tablet or 50 mg for edema, give 30 minutes prior to Metolazone every Monday, Wednesday, Friday as of 05/27/23 to 06/15/23 7 a.m. and 7 p.m. Weights for 3 days upon admission, record on clipboard for Unit Manager (UM) to review on 05/07/23 to 05/09/23 Weekly weights times 4 weeks, record on clipboard for Unit Manager (UM) to review as of 05/08/23 to 05/29/23 Daily weights starting 05/10/23 to 05/28/23 Daily weights in a.m. before breakfast as of 05/25/23 to 06/15/23 Handwritten orders from the nephrologist showed the following: Date 05/11/23 1. Torsemide 50 mg BID 2. Metolazone 10 mg 30 minutes before Torsemide, 3 times a week, Monday, Wednesday, Friday 3. Left arm, no IV, no blood draw A record review of the Medication Administration Record (MAR) for June 2023 shows Torsemide 100 mg 0.5 tablet or 50 mg not given between 05/12/23 and 05/21/23. An Event Report showed on 05/11/23 a medication error occurred. The error was found on 05/20/23. ON 05/11/23 an order was received to increase the Torsemide to 100 mg BID. Order was not transcribed. Torsemide 100 mg daily was discontinued. Resulting in the resident missing dose of Torsemide from 05/12/23 to 05/19/23. The type of error was incorrect transcription. Resident experienced weight gain likely due to decrease in receiving diuretics. Weight gain can also be caused by the resident's overall condition/ comorbidities, Stage III CKD. Interventions included the correct order was entered and Torsemide was administered per physician orders. Audit of all residents written physician orders was completed to ensure no further transcription errors. The nurse responsible was educated. The Medical Records Director was educated on monitoring paper records for notation by the nurse that the order was properly noted. The nurses were educated on the process for order transcription and appropriate documentation A record review of the weights and documented in the resident's medical record were as follows: 05/06/23-234 pounds 05/19/23-245 05/25/23-241 05/26/23-240 05/27/23-241 05/28/23-240 05/29/23-240 05/30/23---239 Additional weights found on the clip board but not documented in the medical record were as follows: 05/15/23-240 05/17/23---241 05/18/23---246 05/22/23---242 05/24/23---242 Both showing weights were not performed daily as per the order. A review of the Progress Notes showed the following : On 05/08/23: the physician wrote the resident had a CHF exacerbation with worsening respiratory failure and was now on a CPAP. He started declining 5 days after he was discharged . He has been confused. He has confusion, weakness, shortness of Breath (SOB) on exertion, gait impairment, lower extremities edema and decreased breath sounds in posterior bases. The plan included monitor for changes, daily weight. On 05/11/23 the physician documented the lower extremities edema was better. He denies SOB and oxygen saturation at room air at 97%. He has SOB on exertion. On 05/19/23 the nurse noted he was alert and oriented. No SOB noted. On 05/20/23 the nurse noted he had a decreased urine output since yesterday. Approximately 250 cc over 12 hours period. He has increased fluid retention in abdomen, legs and arms over the last few weeks, with a noted weight gain. Kidney functions severely compromised per lab results, which has been ongoing since prior to admission. Call was placed to the on-call physician, with orders to monitor output and weight at this time. On 05/20/23 at 6:47 p.m., the resident's wife asked this writer about the orders from the nephrologist when the resident visited on 05/11/23. This writer looked back on uploaded order that stated to give Torsemide 50 mg BID and give 30 minutes apart from Metolazone 10 mg every Monday, Wednesday, Friday. Order was placed to reflect. On 05/21/23, at 4:09 p.m. resident with increased urine output this shift since correction of ordered medications. On 05/24/23 the physician noted resident gained 9 pounds in one week and lower extremities edema was marked. No acute distress at this time, oxygen saturation at 99% on room air. Resident has bilateral Lower extremity edema. Monitor for changes and perform daily weights. On 05/26/23 the physician noted he had lost 4.2 pounds this week. His lower extremity edema was improving. He denies SOB. No acute distress. The oxygen saturation was at 94% on room air. On 05/30/23 physician noted family was at bedside today. He lost 4.8 pounds over the week, and he gained one pound today. His lower extremities are swollen. He denies SOB. No acute distress. Perform daily weights. During an interview on 08/03/23 at 1:17 p.m. with the Director of Nursing (DON) she stated the resident was admitted for short-term rehabilitation. He had been in the hospital for CHF exacerbation. There was a medication error involving the resident. He returned from the nephrologist office with a written order for a change in medication. That order was not transcribed properly. The Torsemide 50 mg was supposed to be twice a day. The resident did not receive the medication from 05/12/23 through 05/19/23. The physician was notified and there were no further orders (except to restart the Torsemide). He had some weight gain. His physician assessed him. The physician was not overly concerned, no negative effect to him, due to all other things going on with the resident. He did return to the hospital on [DATE] but it was unrelated to the medication error, it was due to his declining condition. The DON reviewed the weight orders and verified them. She stated that they should have been performed daily. Based on the orders he should have had daily weights the whole time he was here. She stated that the weights were performed daily between 05/25/23 and 05/30/23 only, prior to that they were not daily. The DON reviewed the MAR for weights and verified there were missing documentation regarding weights. She stated they were documented on a clip board and then inputted into the computer. During interview on 08/03/23 at 1:56 p.m., with the resident's physician and the DON, the physician stated sometimes the sister would weight him. If a weight was not documented in the chart, it was not done. She stated she did not know what happened with the weights. The DON stated the weights were not in the chart. The physician verified she had ordered the weights to be performed. The medication error she was aware of, and a Plan of Correction and education was put into place. It was due to a transcribing problem. She got a call from the nurse regarding the medication error. She stated without the diuretics he would have an increase in swelling, gain weight and his congestion would get worse. He had baseline kidney disease and CHF. She stated after he was given the diuretic, he did improve but it did not improve his kidney functions. She stated she spoke with the family every time she was at the facility. The DON stated he had to have pads on the floor for his leg edema leakage. The DON stated his weight gain of 5 pounds, may not have been noticeable. The physician stated they were trying to balance his diuretics; he was struggling with fluid. The physician stated he was in a very chronic state. She stated they were watching the resident. The physician stated they kept increasing his diuretics (Torsemide). She stated either her or the Nephrologist was changing his diuretics. The kidney function was not getting any better, he was in kidney failure. She stated she and the nephrologist were adjusting the diuretics due to edema and the kidneys not functioning well. He was the same when he was at the facility before (in March). He was 234 pounds on 05/06/23 and in March he was 224 pounds. He left and came back 10 pounds heavier. The physician stated the diuretics were not effective. The medication error caused him to have some weight gain, but it was only part of the chronic problem going on. A record review of the facility's policy, Care Plans, revised 07/27/2023 showed it is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment to the Resident Assessment Instrument (RAI) Manual and the patient / resident choice. 2. A comprehensive person-centered care plan will be developed by the interdisciplinary team for each patient/resident within seven days after the completion of the comprehensive assessment. 3. The comprehensive person-centered care plan is developed to include measurable goals and time frames to meet a patient' / resident medical, nursing, and psychosocial needs, the services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following: the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.