**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 1 of 2 residents reviewed for respiratory care, of a total sample of 43 residents, (#111).Findings:Review of the medical record revealed resident #111 was admitted to the facility on [DATE] from the hospital. Her diagnoses included chronic obstructive pulmonary disease, unspecified atrial fibrillation, altered mental status and chronic kidney disease. Review of the quarterly Minimum Data Set assessment with reference date 8/16/25 revealed resident #111's cognition was severely impaired. Resident #111's Order Summary Report showed an active physician's order for oxygen (O2) at 2 liters per minute (LPM) via nasal cannula dated 4/12/25. The medical record further revealed a care plan initiated on 2/29/24 that indicated the resident was to be administered oxygen via nasal cannula as ordered by the physician. The care plan did not indicate resident #111 had any behaviors of refusals nor adjusting the amount of oxygen as ordered. On 8/25/25 at 2:58 PM, resident #111 was sitting up in bed, using O2 administered through a nasal cannula connected to an O2 concentrator. The concentrator's flow rate was set at 3 LPM of O2. The assigned nurse, Licensed Practical Nurse (LPN) D, was standing nearby and verified resident #111's oxygen concentrator was set at 3 LPM. LPN D the concentrator flow rate was correct and should be 3 LPM of O2. A few moments later LPN D verified the physician's order in the medical record was actually for 2 LPM, not 3. The nurse acknowledged she should have verified the physician's order. The Staff Development Coordinator (SDC) who was in the immediate area, stated that the assigned nurse was a new nurse and that this was not her normal unit, she only floated here to take over an assignment from a nurse who called out sick, but she should have checked the orders. A few minutes later, the Director of Nursing (DON) who had been made aware of the situation, said nurses should always verify the orders. On 8/28/25 at 10:37 AM, the SDC said her expectation was for nurses to check and verify the physician's orders for oxygen at least once during the shift. The Facility's Policy for Oxygen Administration revised August 2023 indicated the procedure for setting up the O2 concentrator in section 2. The procedure directed staff to Turn to proper flow rate as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 43 residents, (#89).Findings: Resident #89 was admitted to the facility on [DATE] with diagnoses including nonrheumatic mitral valve insufficiency, heart failure, essential hypertension and personal history of transient ischemic attack and cerebral infarction (stroke). Review of the Minimum Data Set (MDS) significant change assessment with assessment reference date (ARD) of 6/07/25 revealed resident #89's active diagnoses included anemia, heart failure and hypertension. Review of the electronic medical record (EMR) revealed resident #89 had a physician order for Amlodipine Besylate 10 milligrams (mg) to be given one time a day for hypertension. The order included parameters to hold the medication if resident #89's systolic blood pressure was below 110 millimeters of mercury (mmHg), diastolic blood pressure was below 60 mmHg or her heart rate was less than 60 beats per minute (bpm). The record also contained an order for Lisinopril Oral Tablet 20 mg to be given one time a day for hypertension. The order included parameters to hold the medication if resident #89's systolic blood pressure was below 110 mmHg, diastolic blood pressure was below 60 mmHg or her heart rate was less than 60 bpm. Review of the Medication Administration Record (MAR) for July 2025 and August 2025, revealed over a 59-day period in facility, four nurses administered both blood pressure medicine to resident #89 outside of specified parameters and one nurse administered blood pressure medication without consideration of parameters. Documentation showed resident #89 received blood pressure medications 11 times on 6 days. The medications were administered on 7/05/25 with a blood pressure of 123/56, on 7/06/25 with a blood pressure of 100/73, on 7/20/25 with a blood pressure 112/44, on 8/12/25 with a blood pressure of 108/51, on 8/18/25 with a blood pressure of 108/38 and on 8/22/25 with a blood pressure of 101/70. Resident #89 also received blood pressure medications 11 times with a blood pressure listed as not applicable (N/A) on 7/7/25, 7/12/25, 7/21/25, 7/26/25, 7/27/25, 8/04/25, 8/09/25, 8/10/25, 8/18/25, 8/23/25 and 8/24/25. Review of Progress Notes for July 2025 and August 2025 revealed no associated documentation for the above dates to explain why the blood pressure medications were given outside of the physician ordered parameters. On 8/28/25 at 2:01 PM, Registered Nurse (RN) P explained Amlodipine and Lisinopril were medications used to lower blood pressure. She reviewed resident #89's MAR for July 2025 and August 2025 and acknowledged she gave medications outside of the physician ordered parameters. RN P stated she rechecked resident #89's blood pressure before administering medication but was unable to show documentation that this had been done or of any new blood pressure results. She acknowledged that without the additional blood pressure reading, the MAR indicated the medication was administered outside of parameters. RN P explained that administering blood pressure medications to lower blood pressure when blood pressure was already low could cause a resident's heart rate to drop lower and the resident could become unresponsive. On 8/28/25 at 2:37 PM, the Director of Nursing (DON) reviewed the physician orders and MAR for resident #89. She acknowledged resident #89's blood pressure medications were given by nurses outside of physician ordered parameters. The DON stated her expectation was for staff to follow parameters ordered by the physician for medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide routine dental care services to 1 of 2 residents reviewed for dental care, (#101), of a total sample of 43 residents. Findings:Review of the medical record revealed resident #101, a [AGE] year-old female was admitted to the facility from an acute care hospital on 5/30/25 with diagnoses that included bipolar disorder, major depressive disorder recurrent, dysphagia (difficulty swallowing), hypotension (low blood pressure), hypertension (high blood pressure), and abdominal tenderness.The Modified Minimum Data Set admission 5-day Comprehensive Assessment with an Assessment Reference Date of 6/07/25 noted resident #101 scored 15 out of 15 on the Brief Interview for Mental Status which indicated she was cognitively intact and did not reject evaluation or care. Section L (Dental) was modified on 8/28/25 to indicate the resident had, obvious or likely cavity or broken natural teeth.The Care Plan Report included a focus initiated on 6/02/25 for risk for/has oral/dental health problems related to poor dentition and missing teeth. An intervention dated 6/02/25 showed resident #101 was to receive coordination arrangements for dental care, transportation as needed or ordered. The admission Data Set evaluation dated 6/02/25 noted the nurse assessed resident #101 with obvious or likely cavity or broken natural teeth.On 8/26/25 at 2:52 PM, resident #101 relayed she was supposed to see a dentist, but the facility had not made arrangements for her yet. She said, I need to see the dentist for my teeth.On 8/28/25 at 10:27 AM, resident #101 opened her mouth to reveal multiple missing and discolored natural teeth. Upon counting, she identified she had six remaining teeth. The resident pointed to her mouth and said, I only have six left; I need some dentures.In an interview, the 200 Unit Manager explained all referrals for dental services were handled by the Social Services Director.On 8/27/25 at 2:10 PM, the Social Services Director explained she was aware resident #101 needed dental services but because she was in a private pay/Medicaid pending status, there was an issue with who would pay for the services. She said all long-term care residents received an annual evaluation. The Social Services Director stated, it's kind of a weird gap, she explained once the resident's payment source changed, she could be enrolled in the Medicaid dental program.Review of the facility's contracted dental provider's list of residents noted resident #101 was listed however, an annual assessment was not done nor scheduled. The Payor Source read, Med Pending [Medicaid pending].On 8/28/25 at 2:03 PM, the Director of Nursing explained that all residents had access to routine and emergency dental services regardless of their payor source and individual available benefits or the facility's onsite provider were utilized. She said if a resident needed services, the facility was responsible for providing the services, and stated, we will deal with the payment source later.On 8/28/25 at 6:15 PM, the Nursing Home Administrator conveyed the Social Services Director came to her two days prior and let her know she was unaware resident #101 needed services but she was now on their list.Review of the Facility assessment dated [DATE] noted the facility provided person-centered care and services based off their unique care plan. The Medical/Physician services included, Dentist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 2 of 2 residents reviewed for discharge, (#127 and #126); and for 1 of 2 residents reviewed for hemodialysis, (# 100), of a total sample 43 residents.Findings: 1. Resident #127 was admitted to the facility on [DATE] and discharged to the hospital on 7/11/25. His diagnoses included syncope and collapse, cerebral cysts, dementia, anxiety and seizures. A review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment with assessment reference date 7/11/25 revealed resident #127 had a Brief Interview for Mental Status Score of 9/15 which meant his cognition was moderately impaired. On 8/26/25 at 3:56 PM, the Director of Nursing (DON) explained the Change in Condition (CIC) form in resident #127's record dated 7/12/25 at 7:00 AM. According to the CIC form, it indicated the resident was discharged to the hospital on 7/12/25 for low oxygen however, on the census line in resident #127's electronic medical record it showed the resident was discharged the day before, on 7/11/25. The vital signs documented on the CIC form indicated they were from 7/10/25 at 9:26 PM and revealed the blood pressure was 128/76, pulse 68, respirations 18 and oxygen 97% SpO2 (blood oxygen saturation level). There was no indication from documentation in the medical record that resident #127 had a low percentage of oxygen saturation which caused him to be sent to the hospital as the CIC form detailed. The DON said she understood the form was unclear and stated she would try to gather as much information as she could because she was not on duty on 7/11/25. A few minutes later, the DON referred to her own notebook of residents discharged to the hospital, and said resident #127 was discharged on 7/11/25 and was noted to have a low oxygen saturation rate in the 70s and generalized weakness. She said the physician was called, and the resident was given oxygen, and the saturation level went up to 97%. She gave the vital signs that mirrored the vital signs documented in the CIC form. The DON confirmed the date on the CIC form was not accurate and did not provide a true description of what occurred with the resident. She confirmed the nurse should have documented the actual vital signs on the CIC form, written a progress note about the event and documented the findings accurately. SpO2 measures how much oxygen is circulating in your bloodstream for use by your cells. This can be measured with a pulse oximeter which is placed on your finger and gives a percentage of oxygen saturation in your blood. The normal percentage range for oxygen saturation is 90-100%, if it is low, you should call your physician, (retrieved on 9/12/25 from www.clevelandclinic.org). On 8/26/25 at 4:37 PM, in a joint interview with the DON, the Assistant DON (ADON), who was on duty on 7/11/25, the Unit 1 Manager (UM 1), and the Regional Nurse Consultant (RNC); the ADON explained that on 7/11/25 at approximately 8:30 AM he was summoned to resident #127’s room for help because the resident was diaphoretic and unarousable. The ADON said he immediately called a rapid response for help. He recalled he provided oxygen to the resident because “his oxygen was in the 70s and his blood pressure was low maybe 90/60.” The ADON continued that resident #127 ’s status improved, the oxygen level came up, and he became more alert, however, his wife insisted he should go to the hospital, so she called 911. The ADON remembered that the Emergency Medical Technicians arrived and said resident #127 was stable, but his wife asked for him to be transferred. The ADON explained he expected the assigned nurse to document the CIC form completely and accurately in the medical record when changes in condition occurred. The Unit 1 UM confirmed she actually documented the CIC form on 7/12/25 after the event as a late entry, even though she was not present when it happened. The Unit one Manager did not reply as to whether this was facility procedure to have someone document an event that had no actual knowledge of the event other than what they heard from someone else. The UM looked at the ADON, who shrugged and said, “I see.” The UM reviewed the transfer form on which she documented resident #127 was transferred to the hospital on 7/12/25 at 7:00 AM and did not reply as to whether the documentation concerning the transfer was inaccurate. The ADON was unsure who the actual nurse that was responsible to document about resident #127’s CIC when it occurred but thought it might be the Unit 2 UM. A few minutes later, the Unit 2 UM joined the interview and denied she assumed care of the resident and said she did not remember anything about the resident. The Unit 2 UM stated she believed the resident had already left the facility when she came on duty that morning, because she was called in to work due to a call out. The DON and RNC agreed that because of the inaccuracies and lack of documentation it appeared that no nurse was assigned to resident #126, but said it was “impossible.” They said they needed to review the employees' timecards to find out who the actual assigned nurse when the CIC occurred was that should have documented the actual details of the event. On 8/27/25 at 10:50 AM, the Business Office Manager stated that based on her records, resident #127 was admitted on [DATE] at 3:29 PM, and discharged on 7/11/25 at 10:00 AM. On 8/27/25 at 11:25 AM, the Staffing Coordinator provided the names of the nurses who worked on the morning shift of 7/11/25; Licensed Practical Nurse (LPN) Q and LPN R. On 8/27/25 at 11:30 AM, Certified Nursing Assistant (CNA) N confirmed he worked on 7/11/25. He confirmed LPN R was assigned to resident #127 the day he was re-hospitalized . On 8/27/25 at 11:57 AM, the Unit 1 UM recalled she was at the facility on 7/11/25 but was not working on Unit 1. She said she was not involved with the rapid response for resident #127. She explained as the UM she took it upon herself to document the CIC form two days after it happened when the Interdisciplinary Team later realized that both the CIC form and the transfer to hospital form were not completed by the nurse. She acknowledged both forms were inaccurate and did not give a clear description of what transpired. The UM confirmed she should have asked the assigned LPN R to complete the CIC form when she learned it had not been done. Phone calls were made to LPN R resident #127’s assigned nurse, with no reply. On 8/27/25 at 2:56 PM, the ADON said he did not verify documentation was completed because he expected the assigned nurse to document the CIC and transfer form. The ADON acknowledged in hindsight, he should have documented what occurred himself as he was present. He explained he left for vacation the next day and did not return to the facility until 7/21/25. When he came back, he realized the forms had been completed. The ADON said he spoke to the physician about resident #127’s CIC but acknowledged the conversation was not documented. He repeated that the expectation was for the assigned nurse to complete the CIC and hospital transfer form. On 8/27/25 at 3:36 PM, LPN Q in a telephone interview said she remembered a little of what happened that day but was unsure if LPN R was assigned to resident #127. She said she heard an overhead page for a rapid response and assisted LPN R and the ADON. LPN Q explained since it was an emergency, they all were busy and worked together to help the resident. She did not recall the details of who did what and did not remember documenting any of the events. The nurse explained that because it was an emergency, they might have written down the vital signs on a glove or a piece of paper and it could have been lost since they were documented in the medical record. She was unsure who followed up with the paperwork because they were waiting on a nurse to come in that day. LPN Q explained she thought whoever came in should have documented or the assigned nurse. “When it’s your resident, you chart, in this building it’s the assigned nurse who should do the charting.” On 8/27/25 at 4:00 PM, the Nursing Home Administrator, the Medical Director, DON, RNC, and [NAME] President of Operations acknowledged the inaccuracies and incompleteness of resident #127’s medical record and CIC documentation. 2. Resident # 100 was admitted to the facility on [DATE] with diagnoses that included language deficits following cerebral infarction (stroke), encephalopathy (brain disorder) and dependence on renal dialysis. The admission MDS with reference date of 6/02/25 revealed resident #100 had severe cognitive impairment and received hemodialysis. Review of the medical record revealed physician’s orders for resident #14’s dialysis center on Mondays, Wednesdays, and Fridays; dialysis arteriovenous (AV) fistula: Left Arm; and no blood pressure (BP) in the left arm. An AV fistula or dialysis fistula is a connection made between an artery and a vein for hemodialysis access created by a surgeon. It is the most efficient was to access your bloodstream. It takes at least a few months for the fistula to heal in order to utilize for hemodialysis, it can last for several years but should be protected from squeezing of the arm, (retrieved on 9/12/25 from www.clevelandclinic.org). The medical record revealed nurses documented taking the resident’s blood pressure on the left arm when there were specific orders not to use this arm because of the dialysis fistula. A review of the vital signs documented for August 2025 revealed out of a total of 98 times the blood pressure was taken, nurses documented the blood pressure was taken on the left arm 37 times; right arm 28 times; and “other,” 33 times. For the month of July 2025, out of a total of 121 times the blood pressure was taken, nurses documented the blood pressure on the left arm 24 times; on the right arm 58 times, and “other,” 39 times. For June 2025, out of a total of 121 times the blood pressure was taken, nurses documented the blood pressure was taken on the left arm 54 times; the right arm 37 times and “other,” 30 times. On 8/28/25 at 10:05 AM, resident # 100’s assigned nurse, LPN E explained she took the blood pressure on the right arm because of the fistula on the resident’s left arm. The Assistant Director of Nursing (ADON) present at the time, and LPN E verified in the medical record that different nurses documented the blood pressure was taken on the left arm. They both explained it was data entry error, and that the documentation was inaccurate. On 8/28/25 at 12:25 PM, in a joint interview, the ADON and DON acknowledged no weights were listed in the medical record after 6/23/25 for resident #100. The DON stated that the Restorative CNA and Dietician had resident weights, but acknowledged they were not entered in the medical record. On 8/28/25 at 1:45 PM, the DON said she was aware nurses’ documentation was inaccurate in regard to where the blood pressure was taken. She acknowledged it was contraindicated to take the blood pressure on the arm that had the AV fistula and it should be avoided. The facility had no policy on accuracy of documentation of medical records. 3. Resident #126 was admitted to the facility from the community on 6/20/25 with diagnoses including fracture of shaft of right tibia, fracture of left ring finger, paroxysmal atrial fibrillation and major depressive disorder. Review of facility incident reporting dated 7/31/25 revealed documentation from staff who interacted with the resident the night before his change in condition on 7/25/25. Per the incident report the evening shift staff on 7/24/25 noted the resident to be out of breath and sweating. The facility's report detailed that the nurse assessed the resident, obtained vital signs and administered a Covid-19 test. The facility reported the resident’s vital signs were within normal limits, his Covid-19 test was negative, and the resident had no further concerns throughout the night. A review of resident #126’s electronic medical record (EMAR) revealed a physician order to administer the Covid-19 testing as needed with a start date of 6/30/25. Review of the EMAR revealed the test was not documented as administered during the resident’s entire stay at the facility. A review of the residents’ progress notes revealed no documentation of the facility reported shortness of breath or of the Covid-19 test. Further facility incident reporting dated 7/29/25 included steps immediately taken by the facility in response to the incident on 7/25/25 during the day shift. This included resident #126 was dizzy and felt like he had a fever. They reported the resident's vital signs were taken at 8:55 AM, blood pressure of 102/89, pulse 124 beats per minute (bpm), temperature of 97.3 degrees Fahrenheit (F), respirations of 18, oxygen saturation of 91% SpO2. The facility detailed a Covid-19 test was administered which was negative. Review of the resident’s medical record revealed vital signs taken on 7/25/25 at 8:54 AM as blood pressure of 110/88, temperature of 97.5 degrees F, pulse of 92 bpm, respirations of 18, and oxygen saturation of 97% SpO2 on room air. Vital signs documented at 9:42 AM, were blood pressure of 102/89, pulse 124 bpm with new irregular onset, temperature of 97.3 degrees F, oxygen saturation of 91% SpO2 by nasal cannula. No respirations were documented at this time. The medical record revealed no documentation of a Covid-19 test being administered on 7/25/25. Facility submitted incident reporting documentation dated 7/29/25 revealed the changes reported on the CIC evaluation were a functional decline and possible stroke/new neurological signs/symptoms. The reported positive findings included increased confusion, sleepy but easily arousable, decreased mobility, abnormal speech, and a question of right eye droop. The report detailed resident #126's smile was normal; his tongue midline and grasp strength was normal. The resident was noted to have low blood pressure (hypotensive), a high heart rate (tachycardic), diaphoretic (sweaty) and to have mild shortness of breath. The report indicated the physician was notified and gave an order for supplemental oxygen at 3 liters per minute. The document revealed a repeat oxygen saturation was taken, which was 96% SpO2 (normal), the shortness of breath had improved however the resident was still tachycardic and hypotensive. The facility noted the physician gave an order to send the resident to the emergency room for further evaluation and treatment. A review of resident #126's medical record revealed a CIC form dated 7/25/25 at 9:32 AM, which indicated the change in condition symptoms were functional decline and/or mobility and possible stroke/new neurological signs which started on 7/25/25 in the morning. The form listed the most recent vital signs taken after the change in condition to be a blood pressure of 110/88, pulse of 92 bpm, respirations of 18, temperature of 97.5 degrees F and oxygen saturation of 97% SpO2 on room air at 8:54 AM on 7/25/25. The evaluation of body systems section revealed the resident had abrupt increased confusion, difficulty walking, right sided facial drooping, slurred speech, and abnormal vital signs. There was no summary of observations, evaluations or recommendations documented on the form. The form detailed the primary care physician was notified at 9:30 AM on 7/25/25 but no physician recommendations were documented on the form. Further review of the medical record revealed there was no documentation of the initial notification to the physician of the resident’s condition or for the order for supplemental oxygen at 3 liters per minute. The resident medical record showed no documentation of that an oxygen saturation was repeated and read 96% SpO2. The improvement of the resident’s shortness of breath but not his tachycardia and hypotension was not reflected in the resident’s medical record. Additional facility incident reporting dated 7/31/25 included information about staff involved with the change in condition on the morning of 7/25/25. Review of the facility report revealed on the morning of 7/25/25 at approximately 9:15 AM, the assigned nurse responded to concerns over the resident's condition. The facility narrative described the resident was assessed by the nurse who initiated a rapid response after the assessment. The report indicated resident #126 was noted to be sleepy but arousable, hypotensive, tachycardic, diaphoretic and have a functional decline. The facility report detailed the resident had a slight right eye droop, but the rest of the neurological exam was normal. The resident’s vital signs were blood pressure of 110/88, temperature of 97.5 degrees F, respirations of 18, and oxygen saturation of 93% SpO2 on room air. The report described the resident’s oxygen saturation increased to 97% on 3 liters per minute of supplemental oxygen. Review of the resident’s medical record revealed there was no documentation of a rapid response being initiated in contrast to the facility's reporting. The medical record contained no documentation of the resident’s initial oxygen saturation of 93% on room air, nor a repeated oxygen saturation of 97% SpO2 on 3 liters per minute of supplemental oxygen. On 7/25/25 at 8:54 AM, the oxygen saturation was documented in the residents’ medical record by nurses as 97% on room air, not on supplemental oxygen as reported by the facility. On 7/25/25 at 9:42 AM, the oxygen saturation was documented as 91% SpO2 by nasal cannula. On 8/27/25 at 1:20 PM, the facility's incident investigation and incident reporting was reviewed with the DON. She said that through their investigation it was revealed that on 7/24/25 during the night shift the staff reported the resident felt warm and sweaty. The DON continued that staff took vital signs which were within normal limits and administered a Covid-19 test. The DON confirmed the order to administer a Covid-19 test was not documented as administered and the results were not recorded in the resident’s medical record. She confirmed two different dates, 7/24/25 and 7/25/25 were given in the report submitted to the state agency but she stated the test was administered on 7/24/25. The DON stated on the morning of 7/25/25 at approximately 9:00 AM, the resident was noted to be more lethargic and had a decline in function, a rapid response was initiated but she could not give a time. She continued, upon assessment of the resident, it was noted he was hypotensive, tachycardic and had a slight right eye droop, so the physician was notified, who gave an order to apply 3 liters per minute of supplemental oxygen. The DON confirmed the first notification to the physician and the order given for oxygen were not documented in the resident's medical record. She explained that after applying the 3 liters per minute of oxygen staff noticed the resident’s condition did not improve, so a second call was placed to the physician. The physician gave an order to send the resident to the emergency room. The DON stated the time of the call to the physician was 9:30 AM which was documented in the change in condition form. She confirmed there was no documentation that 3 liters per minute of oxygen was ineffective nor was there documentation of the further decline of the resident’s status which led to the second call to the physician. The DON conveyed the resident was sent to the emergency room with emergency medical services (EMS). She was unable to give details of what occurred including a time for when EMS was called, when they arrived or when they left the facility. The DON stated that typically they did not document those types of things. The DON acknowledged there were gaps in the resident's medical record which failed to show a full picture of the resident's change in condition, nor of staff interventions administered during that time. The facility's policy entitled “Physician Order’s” most recently updated 6/28/24 indicated the facility should ensure resident information was complete and accurate. The facility did not have a policy on medical records or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote a dignified existence during dining for cognitively impaired residents in the special-focus dining area and failed to maintain dignity for one resident during transport through facility hallway, (#104), of a total sample of 43 residents.Findings: 1. Resident #123 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia (loss of speech), hemiplegia and hemiparesis (partial paralysis) following cerebral infarction affecting right dominant side, dysphagia (trouble swallowing) and unspecified dementia. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 8/26/25 revealed resident #123 had a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated she had moderate cognitive impairment. The assessment indicated resident #123 required supervision or touching assistance for eating. 2. Resident #76 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, congestive heart failure, chronic kidney disease, anxiety disorder, dysphagia and unspecified dementia. Review of the MDS 5-Day Medicare assessment with ARD of 8/26/25 revealed resident #76 had a BIMS score of 5/15 which indicated she had severe cognitive impairment. The assessment revealed resident #76 required partial to moderate assistance for eating. 3. Resident #9 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, essential hypertension, and atherosclerotic heart disease. Review of the MDS quarterly assessment with ARD of 7/29/25 revealed resident #9 had long-term and short-term memory problems and had severely impaired cognitive skills for daily decision making. The assessment indicated resident #9 required supervision or touching assistance for eating. 4. Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, hemiplegia and essential hypertension. Review of the MDS quarterly assessment with ARD of 6/26/25 revealed resident #11 had a BIMS score of 1/15 which indicated she had severe cognitive impairment. The assessment detailed resident #11 required set up or clean-up assistance for eating. 5. Resident #89 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, type 2 diabetes, acute kidney failure and heart failure. Review of the MDS significant change in status assessment with ARD of 6/27/25 revealed resident #89 had a BIMS score of 00/15 which indicated she had severe cognitive impairment. The assessment described resident #89 required substantial to maximal assistance for eating. On 8/25/25 at 12:35 PM, during meal observation in the special-focus dining area on the 100 unit, 17 residents were observed seated at tables in the area. Staff were observed serving meals to the residents. Meal trays were placed in front of each resident. The plates, cups, bowls and eating utensils remained on the tray and were not removed from the tray at the table. During the observation, it was noted that all residents at one table were not served at the same time. One tray was placed on a table between two residents which allowed resident #123 to remove items from the tray which belonged to resident #76. Resident #9 sat at the same table and began to eat with her fingers without staff intervention. At another table, resident #11 gave a drink from her tray to resident #89 who took the cup, drank a few sips from it and gave it back to resident #11. On 8/27/25 at 12:14 PM, during meal observation in the special focus dining area, resident #9 was observed eating lunch with the silverware still wrapped while Licensed Practical Nurse L assisted setting up a meal tray for resident #76, sitting at the same table. Resident #9 took several bites of the meal using the wrapped silverware. On 8/28/25 at 12:25 PM, 12 residents were observed seated in the special-focus dining area. Each resident had a meal tray in front of them with their meal, dinnerware and eating utensils on the tray. On 8/28/25 at 12:31 PM, the restorative certified nursing assistant (CNA) verified residents were usually served on a tray instead of the items being placed on the table. She explained they tried taking the items off the tray, but explained the residents were cognitively impaired and might get items confused. The CNA was not sure if a placemat would work to delineate each resident's meal but did not recall having used them before. On 8/28/25 at 1:41 PM, the Unit Manager for the 100 Wing stated the dining room was usually monitored by nurses and/or CNAs. She explained that the restorative CNA sometimes came to help as well. The Unit Manager stated she went to the dining room during lunch if there was no meeting. She verified she was in the dining area on 8/25/25 and acknowledged the residents were served on trays instead of placing the items on the table for a more home-like environment. 6. Resident #104 was admitted to the facility on [DATE] with diagnoses including other toxic encephalopathy (brain disorder), type 2 diabetes, congestive heart failure and cardiomyopathy. Review of the MDS quarterly assessment with ARD of 7/18/25 revealed resident #104 had a BIMS score of 4/15 which indicated she had severe cognitive impairment. The assessment detailed resident #104 was dependent on staff for transfer and mobility. On 8/25/25 at 2:53 PM, resident #110 was positioned in a reclined geri-chair. CNA N pulled the reclined geri-chair backwards (with the resident facing backwards) from the day room, down the hallway and entered the shower room. CNA N exited the shower room at 2:58 PM, with resident #110 again in the geri-chair. The CNA continued to pull the reclined geri-chair behind him, backwards down the hallway as they returned to the dayroom. On 8/28/25 at 10:15 AM, resident #110 was again in a reclined geri-chair as CNA O pulled the reclined geri-chair behind them, backwards down the hallway and into the resident's room. At 10:23 AM, CNA O exited the room with resident #110 and pulled the reclined geri-chair backwards down the hallway and entered the dayroom. On 8/28/25 at 10:25 AM, CNA O stated she was assigned to the special-focus dayroom. She acknowledged she was not supposed to pull the Geri-chair backwards when a resident was seated in it. CNA O was unable to explain why she had pulled the resident in the geri-chair backwards if she knew she was not supposed to. On 8/28/25 at 2:31 PM, the Administrator acknowledged residents in the special-focus dining room should have their meals removed from trays. She confirmed resident #104 should not have been pulled backwards down the hall in the reclined geri-chair. She stated her expectation was that staff treated all residents with the same level of dignity. The facility policy and procedure for Resident Dignity and Personal Privacy effective April 2024 indicated the purpose was to provide care for residents in a manner that respected and enhanced each resident's dignity, individuality and right to personal privacy. The document defined dignity as when staff carried out activities that assisted the resident in maintaining and enhancing his or her self-esteem and self-worth. The document specifically indicated that wheelchairs and geri-chairs were to be rolled in a forward direction.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures for medication administration were sustained. Findings:A review of the facility's QAPI plan revised October 2024, stated for their purpose, that it provided guidance for their overall quality improvement program and that the Administrator would ensure that the QAPI plan was reviewed minimally on an annual basis by the QAA committee and conduct at least one distinct performance improvement project annually. Ongoing revisions would be made to the plan, as the need arose, to reflect current practices within the center. The revisions would be made by the QAA committee.Their QAPI plan included the policies and procedures used to Identify and use Data to monitor our performance Establish goals and thresholds for our performance measurement Utilize resident, staff and family input Identify and prioritize problems and opportunities for improvement Systematically analyze underlying causes of systematic problems and adverse events Develop corrective action or performance improvement activitiesThe QAA committee will review data and input monthly to look for potential topics for Performance Improvement Projects (PIPs). The QAA will prioritize topics based on the current needs of the residents. Priority will be given to areas we define as high-risk to residents and staff, high prevalence, or high-volume areas, and areas that are problem prone.The facility had deficiency cited at F755 for pharmacy services and F842 for accuracy of medical records during the previous recertification survey conducted 2/22/24. During the current survey, the facility was found to be in noncompliance with F 755 and F 842. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation.On 8/28/25 at 5:50 PM, the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) explained the facility had two PIPS which they were actively working on, Elopement and the use of Mechanical Lifts. The NHA explained she did not know what to say about the repeat concerns but there were changes in leadership with Unit Managers, the facility did a lot of cleanup and there was high turnover for staff which was their biggest issue. The NHA continued to explain they needed strong competent staff but also needed the leadership team to keep on top of things. The NHA explained she thought the issue would have decreased, or maybe at one time, it just dropped off. The RNC mentioned that the issues identified were not the same, however they all acknowledged that the QAPI process is supposed to outlive the staff and it should have lasted but did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected use of a mobility device, (#5), use of corrective lens, (#24), and limitation in range of motion, (#66), for 3 of 32 residents reviewed for MDS accuracy, out of a total sample of 47 residents. Findings: 1. Review of the medical record revealed resident #5 was admitted to the facility on [DATE] with diagnoses including right lower leg fracture, falls, generalized muscle weakness, and abnormal gait. Review of resident #5's MDS admission assessment with assessment reference date (ARD) of 1/19/24, Section GG - Functional Abilities and Goals, revealed she had functional limitation in range of motion due to impairment of one lower extremity. The document indicated the resident did not use any mobility devices during the 7-day look back period. On 2/22/24 at 4:54 PM, the Licensed Practical Nurse (LPN) MDS Coordinator confirmed resident #5 was admitted to the facility with a cast on her right lower leg and foot. She acknowledged the MDS assessment indicated resident #5 did not use a wheelchair during the look back period. The LPN MDS Coordinator verified the resident now used a wheelchair and propelled herself around the facility, but might not have used the mobility device in the days after admission. On 2/22/24 at approximately 4:58 PM, the Rehab Director stated resident #24 used a wheelchair for mobility from the time of admission. She informed the LPN MDS Coordinator that therapy staff assisted the resident into the wheelchair and took her to the rehab gym for her sessions. The LPN MDS Coordinator confirmed the MDS was inaccurate. 2. Review of the medical record revealed resident #24 was admitted to the facility on [DATE] with diagnoses including dementia, secondary Parkinsonism, and the need for assistance with personal care. The MDS Quarterly assessment with ARD of 2/12/24, Section B - Hearing, Speech, Vision, revealed resident #24 had adequate vision and she could see regular print without corrective lens. On 2/20/24 at 9:59 AM, resident #1 wore large-framed reading glasses as she reviewed paperwork and made notes on a legal pad. On 2/22/24 at 4:40 PM, the LPN MDS Coordinator was informed although corrective lens were not noted on the most recent MDS assessment, resident #24 wore reading glasses. She explained her process was to interview staff and residents and check medical records to obtain information for MDS assessments. However, the LPN MDS Coordinator stated she had never interviewed resident #24. She said, I have not been able to go into her room. I do talk to the staff. I am sure I asked someone. 3. Review of the medical record revealed resident #66 was admitted to the facility on [DATE] with diagnoses including stroke with right side weakness and paralysis, and right hand contracture. A contracture is an abnormal and often permanent shortening of a muscle that results in stiffness or deformity of a joint (retrieved on 2/24/24 from www.medical-dictionary.thefreedictionary.com/contracture). Review of the MDS Quarterly assessment with ARD of 2/06/24, Section GG - Functional Abilities and Goals, revealed the document did not reflect resident #66's right upper extremity contracture. The MDS assessment showed he had no impairment of his upper and lower extremities. On 2/21/24 at 5:15 PM, the Rehab Director verified resident #66 had a right hand contracture and required right elbow and right hand splints to prevent worsening. Review of the facility's policy and procedure for Resident Assessment Instrument (RAI) Process, revised on 3/27/18, revealed the purpose of the RAI was to provide staff with ongoing assessment information necessary to develop care plans and ensure the provision of appropriate care and services. The document read, The facility is expected to use resident observation and communication as the primary source of information when completing the MDS whenever possible. but information would also be obtained from staff on all shifts and the medical record. The procedure indicated the RAI was completed by an interdisciplinary team comprised of staff members who had clinical knowledge of the resident. Each team member would sign the section he/she completed to attest to accuracy of the information, and all were responsible for reviewing the entire MDS assessment for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #34 was admitted to the facility on [DATE]. Her diagnoses included Anxiety, Bipolar Disorder and Depression. Review of the annual MDS assessment dated [DATE] noted the resident scored 7 out 15 for the Brief Interview for Mental Status, which indicated moderately impaired cognition. Review of a PASARR dated 12/18/20 did not note the resident's diagnoses of Bipolar Disorder, Anxiety and Depression. On 2/22/24 at 2:24 PM, the DON explained he determined if a resident needed to have a Level II PASARR. He added the PASARRs were not being completed at the hospital and the Facility did not have a process in place to ensure PASARR Level I and Level II were being completed. 2. Resident #62 was re-admitted to the facility on [DATE] with diagnoses that included pathological hip fracture, stroke, Obsessive-Compulsive Disorder, Major depressive disorder, and mood disorder due to known physiological condition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section A-Identification Information indicated resident #62 had no serious mental illness or intellectual disability and no PASARR was completed. Section B and C of the admission assessment revealed resident #62 had no behaviors toward herself or others during the lookback period. Section I-Active Diagnoses of the assessment also revealed no diagnoses of serious mental illness. Review of the Annual MDS assessment dated [DATE] Section A indicated no serious mental illness and no PASARR was completed. This conflicted with the information submitted in Section I-Active Diagnoses of the assessment with documentation of obsessive-compulsive disorder, mood disorder and depression (other than bipolar) as current diagnoses. Resident #62 had a care plan for resisting care related to refusal of showers, getting changed by staff, cleaning her room and hoarding food and trash in her room. Review of resident #62's Order Summary Report dated 2/22/24 revealed she had orders for Fluvoxamine Maleate once a day and at bedtime for treatment of mood disorder. On 1/03/24 a Change in Condition note for altered mental status indicated resident #62 was observed as verbally aggressive with staff when they attempted to re-direct her for positioning. The document described resident #62 as screaming, spitting, and hallucinating. The physician was notified and recommended an involuntary psychiatric evaluation at the hospital. A nurse's note dated 1/04/24 revealed resident #62 was evaluated by the psychiatric nurse practitioner and physician for hoarding and other behaviors. The nurse documented resident #62 became agitated and acutely psychotic with elevated mood and pressured speech when interviewed by them. A Psychology note on 1/04/24 detailed resident #62 as stable and compliant with medications previously but was seen that day due to multiple behavioral issues. Resident #62 was noted to have questionable mental capacity for decision making including general safety concerns or issues about her health and surroundings. The provider noted resident #62 frequently refused medications, hygiene care, housekeeping and was verbally aggressive. The provider's plan was to continue to educate and continue psychotropic medications as ordered. Diagnoses documented in the note included mood disorder, major depressive disorder, and obsessive-compulsive disorder. Review of resident #62's medical record revealed a level I PASARR dated 3/30/20. The document indicated Section 1 that listed serious mental illnesses was not checked based on documented history. Section 2 of the assessment also had nothing checked, and therefore no level 2 PASARR was warranted. No other level I PASARR or level II PASARR was in resident #62's medical record. On 2/20/24 at 5:13 PM, the Nursing Home Administrator/Risk Manager described an incident on 1/03/24 when staff had attempted to re-direct and educate resident #62 about her hoarding of food and trash and refusal of cleaning and hygiene care. He said resident #62 told the psychiatrist and Advance Practice Registered Nurse that she didn't need to hear their communist comments and to never come back. He said resident #62's behaviors had escalated at that time and her physician felt she needed to be admitted involuntarily to an inpatient psychiatric facility for those behaviors. On 2/21/24 at 5:35 PM, the Social Service Director stated the DON completed the PASARR assessments as he did not have his master's degree in social work. He explained the facility had a psych meeting monthly where they discussed residents who took psychotropic medications and their care. He described the level II PASARR was triggered from a diagnosis of a serious mental illness and from a list of behaviors. The Social Service Director agreed resident #62's diagnoses of obsessive compulsive disorder, major depressive disorder and mood disorder qualified as a serious mental illness. He stated resident #62 did not have a level II PASARR done nor a revised level I with her psychiatric diagnoses. On 2/22/24 at approximately 12:55 PM, the DON stated he was responsible for the level I PASARR screening and requests of level II screening. He acknowledged a level I PASARR was not done for resident #62 when she was diagnosed with serious mental illness after her admission in September of 2020 to the facility. He also acknowledged the MDS annual assessment dated [DATE] with the new mental health diagnoses should have triggered a new level I PASARR screen to be performed. Request was made to the facility for a policy and procedure for level I and level II PASARR screens. The regional nurse confirmed the facility did not have a policy and procedure for PASARR screenings. Based on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) on admission, and/or failed to make referrals for newly evident or possible mental disorders, to evaluate the need for specialized mental health services or alternate placement, for 3 of 3 residents reviewed for PASARRs, out of a total sample of 47 residents, (#24, #62 #34). Findings: The Preadmission Screening and Resident Review (PASARR) is a federal requirement to ensure individuals are not inappropriately placed in nursing homes for long term care. The PASARR process requires Medicaid-certified nursing facilities to evaluate all residents for serious mental illness (SMI) and/or intellectual disability (ID). The Level I screen is a preliminary assessment to determine if there might be SMI or ID. If the Level I screen is positive, then referral for an in-depth Level II screen is required to determine the need for additional services and the appropriate setting, and recommend necessary services to be included in the plan of care (retrieved on 2/26/24 from www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html). 1. Review of the medical record revealed resident #24 was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. Her admission diagnoses included paranoid schizophrenia and mood disorder, and her medical record was updated to reflect new onset diagnoses of delusional disorders (10/28/21), recurrent moderate major depressive disorder (10/28/21), suicidal ideation (1/12/23), mild mixed bipolar disorder (4/27/23), psychosis (11/06/23), and bipolar-type schizoaffective disorder (11/06/23). Review of resident #24's PASARR Level I form dated 8/13/21 revealed the document was completed and signed by a Registered Nurse (RN) screener at the facility. The PASARR form showed the resident had mental illnesses including bipolar disorder and schizophrenia. The findings were based on documented history only, with no behavioral observations or discussions with the resident and/or her representative. The form revealed resident #24 did not typically or possibly have difficulty with interpersonal functioning, concentration, or adaptation to change, nor that she had required inpatient psychiatric hospitalization. Section III of the form indicated resident #24 was admitted to the facility under a Hospital Discharge Exemption and a Level II evaluation must be completed no later than the 40th day of admission. The instructions on the form revealed a physician's signature was required for any resident admitted under a 30-day hospital discharge exemption; however, the area designated for the attending physician's signature was blank. Section IV of the screening form, PASARR Screen Completion, indicated the resident may be admitted to a nursing facility as she had no diagnosis or suspicion of serious mental illness, and a Level II PASARR evaluation was not required. The RN screener did not identify the resident's hospital discharge exemption status as noted in Section III of the form. Review of resident #24's medical record revealed on 10/09/23, a Clinical Psychologist examined resident #24 and noted diagnoses of paranoid schizophrenia and severe manic bipolar disorder with psychotic features. A Certificate of Professional Initiating Involuntary Examination form was completed during the visit, and the document indicated the resident presented with paranoid delusions and hallucinations. She refused her medications, meals, and nursing care, and was agitated, illogical, and disorganized. Resident #24 was determined to pose threat of serious bodily harm to herself or others and was transferred to a psychiatric care facility for treatment. The resident was readmitted to the facility, and on 10/31/23, a Licensed Mental Health Counselor examined her and determined she had unspecified psychosis with substantial likelihood that without care or treatment she would harm herself. The resident was again involuntarily transferred to a psychiatric care facility due to paranoia and visual and auditory hallucinations. Review of a progress note dated 11/09/23 revealed resident #24 was assessed by a Psychiatric Advanced Practice Nurse Practitioner (APRN). The document indicated the resident reported an extensive past psychiatric history of schizophrenia spectrum disorder that was diagnosed in 1983 when she was incarcerated.she started to experience auditory and visual hallucinations. The note revealed resident #24 described a history of multiple medication adjustments during stays in psychiatric hospitals. A Psychology Subsequent Note dated 12/05/23 revealed resident #24's chief complaint was schizophrenia and bipolar disorder and she was illogical due to psychosis. The resident exhibited religious and paranoid delusions, rapid changes in mood, anxiety, and ruminating thoughts and behaviors. The practitioner described the resident's symptoms as occurring daily and causing moderate distress. Review of resident #24's medical record from August 2021 to February 2024 revealed no evidence of PASARR prior to her readmissions from psychiatric inpatient treatments or re-screening due to new behavioral, psychiatric, and mood-related diagnoses and continued symptoms. On 2/20/24 at 3:56 PM, the Social Services Director (SSD) confirmed he was aware resident #24 was involuntarily transferred out of the facility for psychiatric treatment on a few occasions. He acknowledged the resident had a significant psychiatric history, frequently refused necessary medications, and regularly required special approaches by staff as she had difficulty interacting and communicating with people. The SSD confirmed the facility did not refer resident #24 for a Level II PASARR, but she definitely needed one due to her diagnoses and behaviors. On 2/21/24 at 5:57 PM, the Director of Nursing (DON) stated his responsibilities included completion of PASARRs to ensure the facility was the appropriate setting to meet residents' needs. He verified resident #24 was involuntarily transferred out from the facility for treatment of escalating psychiatric symptoms several times in the past year. The DON explained the resident was not compliant with her medication regimen so mental health crises were the expected result. He stated a previous DON completed resident #24's Level I PASARR on admission, but the screening was inaccurate as questions related to her behaviors were not answered correctly. The DON stated the facility did not identify that resident #24 required a revised PASARR as a recent audit of forms focused on the presence of a PASARR for each resident, but not the accuracy of the screening. He explained the facility did not have policies and procedures related to PASARR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary activities of daily (ADL) care related to personal hygiene and incontinence care for 1 of 4 residents reviewed for ADLs, out of a total sample of 47 residents, (#256). Findings: Review of the medical record revealed resident #256 was admitted to the facility on [DATE] with diagnoses including left leg cellulitis (bacterial skin infection), type 2 diabetes, morbid severe obesity, and obstructive and reflux uropathy (a condition in which urine flows backward into the kidneys due to an obstruction). Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 2/11/24 revealed resident #256's speech was clear, she was able to express her ideas and wants, and she had no issues comprehending verbal content. The resident had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. The MDS assessment showed the resident had functional limitation in range of motion related to impairment of both legs, required substantial to maximal assistance for bathing and personal hygiene, and was totally dependent on staff for toileting hygiene and lower body dressing. Resident #256 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of resident #256's medical record revealed a care plan for ADL self-care performance deficit was initiated on 2/04/24. The interventions included extensive assistance of two people for bathing, bed mobility, personal hygiene, and toilet use. A care plan for bowel incontinence, created on 2/04/24, had interventions such as perineal care after each episode and use of disposable briefs. A care plan for impaired skin integrity, initiated on 2/04/24, included the care directive to keep the resident's skin clean and dry and turn and reposition her with care rounds as needed. On 2/19/24 at 12:55 PM, during observation of resident #256's skin, Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) B assisted the resident to roll onto her left side. The fabric pad underneath the resident had a yellow-stained area that measured approximately six inches in diameter. When CNA B removed the resident's incontinence brief, there was a large amount of stool noted in the brief and on her skin. Resident #256 stated she was last changed during the overnight shift. She said, I'm tired of being on my back. I've been on my back since last night. The resident explained her urinary catheter was replaced by the night shift nurse and the urine on the bed had been there since the previous shift. On 2/19/24 at 1:23 PM, CNA B verified she started the day shift at 7:00 AM that morning and did not check the resident's brief during the next six hours, until she was asked to assist LPN A. She explained the resident required assistance from two or three CNAs for bed mobility and toileting hygiene, and all staff had been too busy to assist her. CNA B explained at about 9:00 AM, she washed resident #256's upper body, but did not provide any care for the lower half of her body. On 2/21/24 at 5:53 PM, the Director of Nursing stated CNAs were expected to do rounds at least every two hours to check on assigned residents, provide incontinence care and reposition them if needed, and ensure their skin was clean and dry. Review of the job description for Certified Nursing Assistant, revised on 1/07/17, revealed essential duties and responsibilities included provision of personal care and services. The CNA was to assist with ADLs such as turning, repositioning, toileting, cleanliness, and bathing, and makes routine rounds on each assigned resident and patient in accordance with established procedures. Review of the Facility/Center Assessment Tool dated 10/17/23 revealed facility staff would provide care and services for residents including bathing, incontinence care, and skin care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to physician-ordered dressing changes, for 2 of 3 residents reviewed for non-pressure skin conditions, (#59 & #256), and application of compression stockings to treat edema, for 1 of 2 residents reviewed for edema, (#6), out of a total sample of 47 residents. Findings: Cross Reference F842 1. Resident #59 was re-admitted to the facility from an acute care hospital on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, type II diabetes with foot ulcer, non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity, and diabetes mellitus with mild non-proliferative diabetic retinopathy without edema. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed resident #59 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated moderate cognitive impairment. He presented with frequent changes in mood but did not display any behaviors towards himself or others. He also required partial to moderate assistance for persona care. Skin assessment further revealed that resident #59 had a venous and arterial foot ulcer for which he received wound care. Review of the order summary report from 01/02/24 through 02/22/24 revealed resident #59 had wound treatment orders to be started on 01/12/24 that read cleanse right heel with normal saline, pat dry, apply collagen with silver to wound base, cover with abdominal pad, then rolled gauze, secure with tape once daily. Protect peri wound with skin prep every dressing change. To be completed daily during day shift. Review of the medical record revealed the resident had a care plan for impairment of skin integrity related to right heel arterial ulcer, initiated 10/21/22 and revised on 02/14/24. The goal was for the risk of complications related to skin impairment to be minimized through the review date of 01/25/24. Interventions included to administer medications and perform treatments as ordered, and to identify potential causative factors and eliminate/resolve where possible. On 02/19/24 at 2:50 PM, resident #59 was observed in his room sitting up in bed with eyes open. The resident stated he was legally blind in both eyes. He had a dressing on his right heel that appeared to be clean, dry, and intact dated 02/16/24 with initials of the nurse. Resident #59 stated he was recently hospitalized due to an infection to the wound on his right heel. He said dressing changes were completed by the nurse every two days. On 02/19/24 at 5:17 PM, resident #59's assigned nurse, Registered Nurse (RN) C, was asked to check the dressing on resident #59. She confirmed the date it was last changed was 02/16/24 by the wound nurse. RN C stated the wound nurse completed dressing changes for all residents in the facility and when she was not available, it was the responsibility of the assigned day shift nurse. RN C acknowledged the date of the dressing indicated it was applied three days ago. On 02/19/24 at 5:25 PM, the Wound Nurse explained she was responsible for completing dressing changes for all residents in the facility. She noted when she was not available, it was the responsibility of the resident's assigned nurse. She stated she did not work on the weekends. She stated the resident was being treated for an unstageable vascular wound on his right heel and the wound was healing nicely. She indicated the dressing changes were to be completed daily during the day shift. The Wound Nurse confirmed she had completed resident #59's dressing change on 02/16/24 and review of the Treatment Administration Record (TAR) revealed the same. The record showed that on 02/17/24 and 02/18/2024 dressing changes had been documented as completed by RN G, and wound care on 02/19/24 had not yet been completed. The wound nurse stated she had not completed the dressing change that morning because she was busy and had asked resident #59's assigned nurse, RN C, to complete it. She was not sure why RN C had not completed the dressing change. On 02/21/24 2:04 PM, RN G, confirmed she was the assigned nurse for resident #59 on the weekend of 02/17/24 and 02/18/24. She reported she was very busy and not feeling well during the weekend. She acknowledged she had documented the dressing change with the intention of completing it but got caught up with other tasks. RN G stated she made a mistake and should not have documented the wound care until after it was completed. 2. Review of the medical record revealed resident #256 was admitted to the facility on [DATE] with diagnoses including left leg cellulitis (bacterial skin infection), type 2 diabetes, and open wounds on her toes. The MDS admission assessment with assessment reference date of 2/11/24 revealed resident #256 had no venous or arterial wounds and ulcers on her feet. Review of a Wound Evaluation & Management Summary progress note dated 2/16/24 revealed resident #256 was assessed by a Wound Specialist Physician. The note indicated she had a full thickness diabetic wound on her right heel that measured 4.3 centimeters (cm) x 4.7 cm x 0.2 cm. The wound was described as an open blister with moderate serous exudate, and the wound specialist physician noted he surgically removed dead tissue from the wound during the visit. Review of the Order Summary Report revealed a physician order dated 2/16/24 for a right heel wound treatment. The order instructed nurses to cleanse resident #256's right heel wound with normal saline, pat dry, apply honey alginate to the wound base, cover with an absorbent abdominal pad, and wrap with rolled gauze. The order also included application of a skin protectant around the edges of the wound with every dressing change. The physician order indicated the dressing was to be changed once daily, during the 7:00 AM to 7:00 PM day shift. Review of resident #256's medical record revealed a care plan for impaired skin integrity related to left leg cellulitis, abdominal and groin rashes, a skin tear, and her right heel wound. The care plan, initiated on 2/04/24 and revised on 2/19/24, had a goal to minimize the risk of complications for skin impairments. The interventions included keep skin clean and dry and observe for signs and symptoms of infection. However, the care plan approaches did not reflect ordered treatments such as the daily dressing change for her right heel. On 2/19/24 at 12:46 PM, resident #256 had a white gauze dressing that was dated 2/16 on her right foot. The resident's assigned nurse, Licensed Practical Nurse (LPN) A, confirmed the date on the dressing indicated it was applied three days before. She stated to her knowledge, it should be changed once daily. On 2/19/24 at 1:11 PM, the Wound Nurse reviewed resident #256's physician orders and confirmed her right heel dressing was to be changed once daily, during the day shift. She was informed the resident's dressing was currently dated 2/16/24. The Wound Nurse stated that date meant neither of the assigned nurses on the weekend provided wound care. She acknowledged it was necessary for nurses to complete wound care and dressing changes as ordered to promote healing and prevent worsening of wounds. The Wound Nurse reviewed the resident's care plans and explained she had not yet revised the document to include wound treatments or instructions to float her heels and apply soft boots. On 2/22/24 at 4:44 PM, in a telephone interview, the Wound Specialist Physician was informed nurses had not followed the plan of care related to daily dressing changes for resident #256 over the weekend. He confirmed his expectation was nurses would follow his orders for wound care and treatments. 3. Review of the medical record revealed resident #6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, morbid obesity, left leg cellulitis, and need for assistance with personal care. Resident #6 had a care plan for complications related to edema initiated on 12/06/23. The goal was to decrease the risk of complications associated with edema. The interventions included encourage the resident to keep the affected area elevated; monitor for complications such as redness, discoloration, and breaks in the skin; and provide pressure reduction devices or equipment as ordered. Edema is swelling caused by too much fluid trapped in the body's tissues. It can occur in any part of the body but is more likely in the legs and feet. Edema is often a result of diseases including congestive heart failure. Wearing compression stockings, sleeves or gloves helps by keeping pressure on the limbs to prevent fluid from building up and prevent additional swelling (retrieved on 2/24/24 from www.mayoclinic.org/diseases-conditions/edema/symptoms-causes/syc-20366493). A Podiatry progress note dated 2/15/24 revealed resident #6 had a comprehensive foot exam with findings including poor circulation and swelling. The podiatrist noted the resident's edema was probably due to his legs being in a dependent position throughout the day, and he suggested elevation of the legs as much as possible. In addition, the podiatrist recommended knee-high thromboembolic disease (TED) hose or compression stockings to be worn while awake and removed at bedtime. Review of resident #6's Order Summary Report revealed a physician order dated 2/16/24 for knee high TED hose for gentle compression bilateral lower extremity in the morning. and to be removed at bedtime. A care plan for risk for impaired skin integrity was revised on 2/19/24 to reflect application of the (TED) hose as ordered. On 2/19/24 at 10:39 AM, resident #6 was seated in his wheelchair at the 100 unit nurses' station. He had significant edema to both lower legs and his skin was shiny, taut, and red around and above his ankles. Resident #6 stated he had been waiting for someone to measure his legs for new stockings. On 2/19/24 at 11:37 AM, LPN A stated she was informed during change of shift report at 7:00 AM that resident #6 needed compression stockings. She reviewed the medical record and confirmed the order was entered on 2/16/24 at 10:12 AM. When asked why he did not have the stockings three days after they were ordered, LPN A explained she was waiting for therapy staff to measure the resident's legs to determine the correct size. On 2/19/24 at 11:49 AM, the Rehab Director stated therapy staff did not measure residents for compression stocking size. She explained that was the responsibility of nursing staff and the appropriate size would obtained from central supply. On 2/19/24 at 1:38 PM, the Director of Nursing (DON) recalled on Friday 2/16/24, resident #6 was given compression stockings that were too small. He explained Central Supply staff went out to buy an appropriate size earlier today. The DON was asked why resident #6 was not measured and provided with the correct size compression stockings on the date they were ordered. He stated there was no physician order for measuring the resident's legs and said, It is okay for the nurse to eyeball the resident. The DON was not aware it was a standard of nursing practice to obtain calf and ankle measurements in order to select the appropriate size compression stockings. On 2/19/24 at 1:39 PM, the Central Supply staff was informed resident #6's compression stockings were ordered on Friday 2/16/24. She stated nurses had not informed her he needed the item until this morning. She explained she was in the facility until about 5:30 PM on Friday, and if she had been aware of the resident's need for this item, she would have purchased the compression stockings at a nearby pharmacy, as she did this morning. The Central Supply staff checked the facility's storage area and confirmed there were no regular or extended size compression hose in the facility. Review of the Facility/Center Assessment Tool, dated 10/17/23, revealed the facility would accept and care for residents with conditions including diabetes, skin ulcers, and congestive heart failure. The document indicated staff would provide care and services to promote skin integrity including skin and wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate care and services for splinting to maintain mobility and/or prevent worsening of contractures for 1 of 1 resident reviewed for limited range of motion, out of a total sample of 47 residents, (#66). Findings: Review of the medical record revealed resident #66 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, osteoarthritis, stroke with right side weakness and paralysis, and right hand contracture. The American Stroke Association indicates after a stroke, limb contractures occur when muscles in the arm or leg shorten or contract, due to inactivity or inability to move. The untreated stiff muscles can cause joints to become stuck in an abnormal and possibly painful position called a contracture. Treatments include range of motion exercises, physical therapy, and the use of splints and braces to stretch muscles and maintain full range of motion or prevent permanent muscle shortening (retrieved on 2/24/24 from https://www.stroke.org/en/help-and-support/resource-library/lets-talk-about-stroke/complications-after-stroke). Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 2/06/24 revealed resident #66 did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment indicated he received Restorative Nursing Program (RNP) services for splint or brace assistance on two days in the 7-day look back period. Resident #66 had a care plan created on 3/20/23 and revised on 2/14/24 with focus area of upper extremity splints as tolerated to prevent further contractures and maintain joint mobility. The goals were the resident would maintain his current level of function and not experience complications related to use of splints. Review of an Order Audit Report revealed resident #66 had a physician order dated 2/16/24 that read, Right hand splint and right elbow brace to be donned in AM, doffed in PM or for daily care. On 2/19/24 at 11:26 AM, resident #66 was in a supine position in bed. His arms were bent at the elbows and his hands were noted close to his shoulders. The resident's right hand was closed with the fingers curled towards his palm. A blue brace was noted on the night stand and a blue hand/wrist splint was on top of the dresser across from the foot of his bed. On 2/19/24 at 2:10 PM, resident #66 was in his room with his daughter at his bedside. The orthotic devices remained on the night stand and dresser in the same positions. When asked if her father received RNP services, she stated she was not sure if his splints were applied regularly. The daughter explained she visited almost every day and often saw the devices in the same places she observed them on the previous day. She stated her father used to have a soft pad for his palm to protect the skin from breakdown related to moisture. Resident #66's daughter checked the dresser, night stand, and closet and did not find the padding she described. On 2/20/24 at 9:43 AM, resident #66 was in a supine position in bed with both arms uncovered. The resident did not have his right hand and right elbow splints in place. On 2/20/24 at 12:01 PM, resident #66 sat in a reclining chair in the common area in front of nurses' station. His arms were curled upwards, his hands were closed and rested on his chest. A rolled white washcloth was in his right hand. On 2/20/24 at 4:24 PM, resident #66 was in the 100 unit's dining/activity area. The resident did not have his right hand and right elbow orthotic devices. On 2/20/24 at 4:49 PM, Certified Nursing Assistant (CNA) D stated she was regularly assigned to resident #66 since he was transferred from the other unit a few weeks ago. She confirmed the resident had two splints in his room but explained she did not put them on him as RNP or therapy staff were responsible for that task. On 2/21/24 at 10:13 AM, RNP Aide E stated she was responsible for application of splints and braces. She verified resident #66's splints were to be placed daily, which she usually did at the start of her shift. When RNP Aide E was informed resident #66 was observed without his splints on Monday 2/19/24 and Tuesday 2/20/24, she stated it was very important for him to wear the splints to prevent his contractures from worsening. She was not aware CNAs did not reapply the splints if they removed devices to provide morning care, and she acknowledged she did not go back to check the devices during the shift. On 2/21/24 at 5:15 PM, the Rehab Director stated resident #66 was recently on Occupational Therapy caseload for treatment of his right arm contractures. She explained he was discharged from therapy to RNP services with orders for his right elbow and hand splints. The Rehab Director validated proper use of splints and braces prevented contractures from developing or worsening and promoted maintenance of the gains made in therapy. She was informed after the concern regarding resident #66 not wearing his splints for the previous two days was brought to staff attention, he was observed today, 2/21/24, at 9:59 AM and 2:57 PM with the right hand splint applied. During joint observation of resident #66's room, the Rehab Director was shown the orthotic device that had been on the night stand since 2/19/24. She confirmed it was the resident's elbow brace and stated RNP Aides were trained to alternate application of the resident's elbow and hand splints. On 2/21/24 at 5:43 PM, the Director of Nursing (DON) stated he was responsible for oversight of the RNP. He stated his expectation was RNP staff would apply orthotic devices as ordered and seek clarification of orders from him or the therapy department if necessary. The DON confirmed CNAs should replace splints or braces if they needed to remove them for care, and seek guidance if unfamiliar with a device. Review of the Facility/Center Assessment Tool, dated 10/17/23, revealed the facility would accept residents with common diseases and conditions including disorders of the neurological system to include stroke, and one-sided paralysis or weakness. The document indicated staff would provide general care related to mobility, and specific care such as restorative nursing services, therapy services, the management of splints and braces, and contracture prevention and care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and monitor a notable weight loss trend, and failed to provide meal portions as ordered to promote weight stability and/or weight gain for 1 of 4 residents reviewed for nutrition, out of a total sample of 47 residents, (#66). Findings: Review of the medical record revealed resident #66 was admitted to the facility on [DATE] with diagnoses including mild protein-calorie malnutrition, type 2 diabetes, acute pancreatitis, gastroesophageal reflux disease, iron deficiency anemia, and vitamin deficiency. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 2/06/24 revealed resident #66 required maximal assistance from staff for eating. The MDS assessment, Section K - Swallowing/Nutritional Status, revealed he did not exhibit any signs and symptoms of a swallowing disorder. The resident's height was 5 feet 11 inches and he weighed 154 pounds. The document indicated resident #66 had not lost or gained weight of 5% or more in the last month, or 10% or more in the last six months, and he did not require a mechanically altered or therapeutic diet. Review of the medical record revealed resident #66 had a care plan for decreased nutritional status and dehydration related to advanced age, dementia, and multiple medications, initiated on 5/19/22 and revised on 11/15/23. The goals were the resident would remain free from significant weight changes and tolerate his diet as ordered. The interventions included assist with meals as needed, provide diet as ordered, monitor oral intake, monitor weight as ordered, and evaluation by the dietitian as needed. Review of resident #66's weight record revealed on 7/10/23 he weighed 175 pounds, and one month later on 8/08/23, he weighed 169 pounds, which was a 6-pound or 3.42% weight loss. The following month, on 9/08/23, resident #66 weighed 162 pounds, a 7-pound or 4.14% weight loss. His weight remained stable on 10/10/23 and 11/06/23 at 164 pounds, although it reflected a total loss of 11 pounds or 6.28% over 90 days. On 12/08/23, resident #66 weighed 155 pounds, a 9-pound or 5.48% significant weight loss in 30 days. On 1/05/24, the resident weighed 152# which indicated severe weight loss of over 10% in 180 days and over 13% since July 2023. Review of the Order Summary Report revealed a physician order dated 12/22/23 for fortified foods with meals for weight maintenance and encourage oral intake. Resident #66 had an order dated 1/15/24 for daily House Shake for nutritional support, and an order dated 1/29/24 for a regular diet, regular texture, with large portions for all meals. Review of resident #66's medical record revealed a Nutrition Comprehensive Evaluation dated 11/15/23 that indicated his usual body weight was between 164 and 172 pounds, and he consumed 51% to 76% of his meals. The comprehensive evaluation did not address the resident's weight of 164 pounds which was at the lower limit of his usual body weight, and his less than optimal meal intake percentages. The document did not include interventions related to the unplanned loss of 11 pounds over the previous three months to prevent additional weight loss. Review of a Nutrition Quarterly Note dated 11/20/23 revealed the facility's Certified Dietary Manager (CDM) reviewed resident #66's weights over the same period and noted, Weights stable 30/90 days. A Dietary progress note dated 12/09/23 read, Consult: Per family request, would like double portion with meals. Will honor request and follow as needed. Resident on regular diet. A note dated 12/22/23 indicated resident #66 triggered for significant weight loss of greater than 5% in 30 days, and the dietitian recommended the addition of fortified foods to his meals. According to the abovementioned Order Summary Report, double portions were never ordered, and large portions were ordered seven weeks after the daughter's request, by which time, resident #66 lost another three pounds and was noted to have severe weight loss. A dietary progress note dated 1/15/24 revealed the facility's Registered Nutrition and Dietetics Technician (NDTR) evaluated resident #66 and noted he had a 13.1% weight loss over 180 days and was underweight for his age. The note indicated resident #66 had inadequate energy intake as evidenced by his oral intake and weight loss. The NDTR recommended a daily House Shake that would provide an additional 200 calories and 6 grams of protein, and promote weight stability. On 2/19/24 at 2:10 PM, resident #66's daughter confirmed her father had lost weight while in the facility. She stated during a visit a few months ago, she noticed his ribs were showing prominently and she discovered he lost about ten pounds. She described her father as a big guy and explained the portions of food provided for him were not adequate. The resident's daughter explained she requested larger portions for him to ensure he received enough food. On 2/20/24 at 12:51 PM, Certified Nursing Assistant (CNA) D fed resident #66 in the 100 unit dining area. Review of the resident's meal ticket revealed he was to receive large portions and fortified mashed potatoes. Observation of his tray revealed items including one pork chop, carrots, one scoop of mashed potatoes, a side salad, and one piece of cake. Comparison with other residents' trays in the dining room revealed no difference in resident #66's portion sizes. On 2/20/24 at 12:56 PM, the CDM confirmed resident #66's tray had one pork chop which was a regular portion. She explained a large portion was one and one half servings of protein. She verified the scoop of potatoes and the cake were regular portions, as the term large portion applied only to meats. On 2/21/24 at 3:34 PM, the NDTR validated resident #66 had a significant weight loss of 13.1%. She explained weight loss of over 10% in 180 days or over 5% in 30 days triggered an alert in the system. The NDTR stated the resident ate well and he now received fortified foods and supplements to increase his caloric intake. She confirmed the resident had an order for a regular diet with large portions, which was one and one half portions of all items. The NDTR said, That should be one and a half of everything. He should have received one and a half pork chops and one and a half scoops of potatoes. On 2/22/24 at 9:53 AM, the Director of Nursing (DON) stated the facility conducted a weekly review of weights in the Focus meeting, a type of Risk Management meeting, that was attended by a dietitian or the NDTR. He stated the Nursing department only reviewed weights if they were triggered by the dietitian as 5% in 30 days or 10% in 180 days. When asked to review resident #66's weights, the DON validated there was a weight loss trend. He acknowledged the notable monthly weight losses should definitely have been identified by restorative aides who weighed the resident and the CDM who reviewed the weights when she made monthly notes. The DON stated the dietitian should also have noted the weight loss trend. He stated resident #66 ate well and to his knowledge, did not have any clinical conditions that would have caused the weight loss. He explained it was facility standard for the Nursing department to request weekly weights for residents who had significant weight losses. He was informed resident #66 was never placed on weekly weights even after the 5% and 10% losses triggered alerts. The DON stated if he had been aware, he would have obtained and implemented a physician order for weekly weights. He acknowledged the resident's daughter asked him to arrange large meal portions for her father as she felt the quantity of food provided for him was not enough. On 2/22/24 10:20 AM, the CDM stated the restorative aides obtained residents' weights and she recorded them. She reviewed resident #66's weights from July 2023 to February 2024 and acknowledged she did not notice his weight loss trend. She said, If I had, I would have referred to the dietitian. She confirmed residents who had significant weight loss should be monitored by weekly weights, but this was not initiated for resident #66. The CDM stated she misspoke in the earlier interview, as she knew large portions referred to all foods, not just the meat. On 2/22/24 at 3:05 PM, the NDTR was asked if she addressed weight loss only when triggered as significant or severe. She explained during weekly Focus meetings she also proactively reviewed residents who were at higher risk for weight loss, for example, those who lost five pounds in 30 days even if less than 5% of their weight. The NDTR reviewed resident #66's weight record and acknowledged although he lost five pounds in two consecutive months, August and September, the facility did not implement proactive interventions. She stated she was not on staff during that period, but the previous NDTR probably followed the protocol for losses of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. The NDTR acknowledged in that situation, she would have implemented an appropriate intervention to prevent further weight loss. The facility's policy and procedure for Nutritional Risk Evaluation dated 5/22/18 read, The nutritional evaluation is an approach to screen, define, and treat the resident's nutritional status. The Comprehensive Evaluation was to include diet order, supplement(s), height, weight, usual body weight, recent changes in weight, and estimated intake. The narrative evaluation and plan should address contributing factors for weight loss and interventions to correct or prevent negative outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure transdermal medication patches were removed according to accepted professional nursing standards of practice for 1 of 2 residents observed for mood and behaviors out of a total sample of 47 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified dementia with unspecified severity and other behavioral disturbance, bipolar disorder (diagnosed 03/11/21), and residual schizophrenia (diagnosed 09/02/21). Residual schizophrenia is a subtype of schizophrenia in which the individual has suffered an episode of schizophrenia but there are no longer any delusions, hallucinations, disorganized speech or behavior (retrieved on 02/28/24 from Natural Library of Medicine, https://www.ncbi.nlm.nih.gov). The Minimum Data Set (MDS) Quarterly Assessment with Assessment Review Date (ARD) 01/02/24 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated she had severe cognitive function. The assessment noted she exhibited both physical and verbal behaviors towards others with frequent rejections of care. Review of the Order Summary Report revealed resident #1 had medication orders for Secuado Transdermal Patch 3.8 milligrams (mg) every 24 hrs to be applied once per day for mood disorder, Nudexta 20-10 mg give one capsule by mouth twice a day for pseudobulbar affect, and Depakote Sprinkles 125 mg give four capsules by mouth twice a day related to bipolar disorder and two capsules by mouth in the afternoon for mood disorder. Resident #1 had a care plan for behaviors that included yelling out, and fixation with the over-the-bed light cord due to diagnosis of psychosis, dementia, and multiple sclerosis. Interventions included administering medications as ordered and psych services as needed. A care plan was noted for use of psychotropic medications related to schizophrenia, bipolar disorder, depression, dementia, and history of psychosis. Interventions included evaluating for dose reduction and administering medications as ordered. On 02/19/24 at 9:30 AM, resident #1 was in bed on her back with eyes open and head of bed elevated. There was a transdermal patch, Secuado, stuck to the front top right corner of her gown dated 02/18/24. The patch was not in contact with her skin and there was another similar patch on the floor to the right side of her bed dated 2/8/24. On 02/20/24 at 11:52 AM, the transdermal patch was no longer on her gown. The patch on the ground dated 02/08/24 was still there. On 02/20/24 at 4:41 PM, the resident's assigned nurse, Registered Nurse (RN) C, explained that resident #1 often took off the transdermal patch if it was placed in an area she could reach. RN C stated that normally the patch was placed in an area the resident could not be reach such as upper chest and upper back. On 02/21/24 at 11:14 AM, Registered Nurse (RN) G was observed applying the transdermal patch on resident #1. RN G verified the order and confirmed the transdermal patch was to be applied once per day every 24 hours. RN G informed the resident what she was doing and then chose to place the transdermal patch dated 02/21/24 to the resident's upper chest. RN G then located two other patches that had not been removed dated 02/19/24 and 02/20/24 on resident #1's upper right arm. RN G stated the nurse should have removed the old one before applying the new one. She explained the importance of removing a used transdermal patch was to make sure the resident was not getting more medication than prescribed. RN G was made aware there was a patch on the floor dated 02/08/24 that had not been properly disposed of. She acknowledged it should have been properly disposed to prevent another resident from picking it up. RN G returned to medication cart to document medication patch had been administered and location of the new patch. She stated that nurses were able to see where the previous patch had been placed before putting the new patch on. RN G admitted she had not checked where the old patch had been placed before she entered the resident's room. She noted there was no order to remove the old patch but that it was nursing knowledge that transdermal patches had to be removed before placing a new one to prevent accidental overdosing. On 02/21/24 at 11:33 AM, the 200 Unit Manager stated it was important to remember to put the transdermal patch in an area that had no hair and where a resident with behaviors could not reach it. She explained that before applying a new transdermal patch, it was important to remove the old one to prevent forgetting it and accidentally administering more than the ordered dose. The UM confirmed there was no order for the transdermal patch to be removed before applying the new one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records accurately documented wound care treatments in accordance with professional standards of practice for 2 of 3 residents reviewed for non-pressure related skin conditions, out of a total sample of 47 residents, (#59 and #256). Findings: Cross Reference F684 1. Resident #59 was re-admitted to the facility from an acute care hospital on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, type II diabetes with foot ulcer, non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity, and diabetes mellitus with mild non-proliferative diabetic retinopathy without edema. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed resident #59 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated moderate cognitive impairment. He presented with frequent changes in mood but did not display any behaviors towards himself or others. He also required partial to moderate assistance for personal care. Review of skin assessments noted resident #59 had venous and arterial foot ulcer for which he received wound care. Review of the order summary report from 01/02/24 through 02/22/24 revealed resident #59 had a wound treatment order to be started on 01/12/24 that read, right heel cleanse with normal saline, pat dry, apply collagen with silver to wound base, cover with abdominal pad, then rolled gauze, secure with tape once daily. Protect peri wound with skin prep every dressing change. To be completed daily during day shift. Review of the medical record revealed resident #59 had a care plan for impairment to skin integrity related to right heel arterial ulcer, initiated on 10/21/22 and revised on 02/14/24. The goal was for the risk of complications related to skin impairment to be minimized through the review date of 01/25/24. Interventions included to administer medications and perform treatments as ordered, and to identify potential causative factors and eliminate/resolve where possible. On 02/19/24 at 2:50 PM, resident #59 was observed in his room, sitting up in bed with eyes open. The resident stated he was legally blind in both eyes. He had a dressing on his right heel that appeared to be clean, dry, and intact dated 02/16/24 with the nurse's initials. Resident #59 stated he was recently hospitalized due to an infection to the wound on his right heel. He stated that dressing changes were completed by the nurse every two days. On 02/19/24 at 5:17 PM, the assigned nurse for resident #59, Registered Nurse (RN) C, was asked to check the dressing on resident #59. She confirmed the date it was last changed was 02/16/24 by the Wound Nurse. RN C stated the Wound Nurse was responsible for completing dressing changes for all residents in the facility and when she was not available, it was the responsibility of the assigned day shift nurse to complete. RN C stated she was unsure why resident #59's dressing had not been changed. On 02/19/24 at 5:25 PM, the Wound Nurse stated she was responsible for completing dressing changes for all residents in the facility and when she was not available, it was the responsibility of the resident's assigned nurse. She stated she did not work on the weekends. She explained the resident was being treated for an unstageable vascular wound on his right heel and the wound was healing nicely. She noted dressing changes were to be completed daily during the day shift. She confirmed she had completed resident #59's dressing change on 02/16/24 and review of the Treatment Administration Record (TAR) revealed the same. The record also showed on 02/17/24 and 02/18/2024 dressing change had been documented as completed by RN G, and 02/19/24 had not yet been completed. The Wound Nurse stated she had not completed the dressing change that morning because she was busy and had asked resident #59's assigned nurse, RN C, to complete it. She was not sure why RN C had not completed the dressing change. On 02/21/24 2:04 PM, RN G, confirmed she was the assigned nurse for resident #59 on the weekend of 02/17/24 and 02/18/24. She stated she was very busy and not feeling well on the weekend. She said she had documented the dressing change with the intention of completing it but got caught up with other tasks. RN G noted she made a mistake and should not have documented the wound care until after it was completed. On 02/21/24 at 2:24 PM, the Staffing Development Coordinator (SDC), stated she was actively involved in educating staff about proper documentation. She explained nurses were supposed to accurately and truthfully complete required resident documentation such as Daily Skilled Notes, and Medication and Treatment Administration Records. The SDC said a treatment, procedure, or medication should not be documented first before it had been completed due to possibly forgetting to complete it or resident refusal. She reported she expected nurses and staff to document tasks as they were done or soon after. She added that accurate and precise documentation was important for continuity of care. 2. Review of the medical record revealed resident #256 was admitted to the facility on [DATE] with diagnoses including left leg cellulitis (bacterial skin infection), type 2 diabetes, and open wounds on her toes. Review of the Order Summary Report revealed a physician order dated 2/16/24 for a right heel wound treatment. The order instructed nurses to cleanse resident #256's right heel wound with normal saline, pat dry, apply honey alginate to the wound base, cover with an absorbent abdominal pad, and wrap with rolled gauze. The order also included application of a skin protectant around the edges of the wound with every dressing change. The physician order indicated the dressing was to be changed once daily, during the 7:00 AM to 7:00 PM day shift. On 2/19/24 at 12:46 PM, resident #256 had a white gauze dressing that was dated 2/16 on her right foot. The resident's assigned nurse, Licensed Practical Nurse (LPN) A, confirmed the date on the dressing indicated it was applied three days before. She stated to her knowledge, it should be changed once daily. On 2/19/24 at 1:11 PM, the Wound Nurse reviewed resident #256's physician orders and confirmed her right heel dressing was to be changed once daily, during the day shift. She was informed that the resident's dressing was currently dated 2/16/24. The Wound Nurse stated that date meant neither of the assigned nurses on the weekend provided wound care. Review of resident #256's Treatment Administration Record (TAR) for February 2024 revealed the document reflected the physician order for the resident's right heel wound care and dressing. The TAR was initialed by LPN L on 2/17/24 with a code 13 that indicated resident #256 refused to have her right foot dressing changed. On 2/18/24, Registered Nurse (RN) K initialed the TAR to verify she completed the treatment which conflicted with the date of 2/16/24 observed on the dressing. Review of the Medication Administration Audit Report for the day shifts on 2/17/24 to 2/18/24 revealed LPN L documented resident #256's refusal of wound care at the end of the shift, 2/17/24 at 7:08 PM. The report showed RN K documented completion of the treatment on 2/18/24 at 1:15 PM. Review of nursing progress notes for 2/17/24 revealed no associated documentation regarding resident #256's refusal of care, and no evidence that LPN L attempted to complete the dressing change during the 12-hour day shift. On 2/21/24 at 9:30 AM, resident #256 emphasized she did not refuse wound care or dressing changes over the past weekend. On 2/21/24 at 5:53 PM, the Director of Nursing (DON) confirmed the medical record should be an accurate reflection of a resident's status and the care and services provided by staff. The DON verified nurses were to document a task as completed only after it was done, and his expectation was that nurses would not take shortcuts related to care or documentation. Review of the facility's policy and procedure for Computerized Medical Records, dated 5/19/15, revealed computer-based medical records supported the clinical decision-making process and improved the quality of resident care. The document indicated the medical record was .specifically designed to support users by providing access to complete and accurate clinical and related information concerning a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 2 of 3 residents reviewed for hospitalizations out of a total sample of 47 residents, (#28 and #52). Findings: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses including quadriplegia, intracranial injury with loss of consciousness, thrombocytopenia, encephalopathy, and gastrostomy malfunction. Review of the resident's medical record revealed a nursing progress dated 02/16/24 that noted the resident's gastrostomy tube was displaced. He was transferred to the hospital on 2/17/24 by non-emergency transportation for replacement. As of 02/22/24, the resident remained in the hospital but was expected to return to the facility. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses including calculus of ureter, hydronephrosis with ureteropelvic junction obstruction and functional quadriplegia. Review of resident #52's medical record revealed he was hospitalized on [DATE]. Review of the progress notes revealed resident #52 had complaints of nausea, vomiting, abdominal pain, and discomfort when urinating. Resident became diaphoretic and was transferred to the hospital 1/12/24 by emergency transportation. The resident returned to the facility on 1/29/24. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization. On 2/21/24 at 2:48 PM, the Social Services Director (SSD) stated nurses were responsible for completing the Notification of Transfer or Discharge forms and scanned them into the electronic medical record (EMR). He explained he printed a list from the EMR and submitted it to the Ombudsman's office. The SSD confirmed he had not completed a Notification of Transfer or Discharge form for any resident sent to the hospital in the 2 ½ years he had been the SSD. On 2/21/24 at 3:02 PM, the Director of Nursing (DON) stated the Social Services department was responsible for completing the Notification of Transfer or Discharge forms. He explained he would discuss the process with the clinical team to determine the correct procedure. On 2/22/24 at 10:38 AM, the Regional Nurse Consultant (RNC) stated the facility policy was for nursing to start the Notification of Transfer or Discharge form and Social Services followed up and completed the form as well as notified the Ombudsman's office. The RNC confirmed the forms were not being completed and could not determine how long it had been since the process was followed correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 4 of 4 residents sampled for medication administration, (#3, #41, #77, #204). There were 8 medication errors in 27 opportunities for a medication error rate of 27%. Findings: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, major depressive disorder, and type II diabetes mellitus. On 02/21/24 at 9:21 AM, Registered Nurse (RN) G, was by her medication cart preparing to administer morning diabetic medications. She stated it was her regular process to obtain blood sugars and administer insulin to all diabetic residents on her assignment first before administering all other medications. She stated that resident #41's morning blood sugar was 238 and he had orders for Novolog injection solution 5 units before meals as well as Novolog injection solution per sliding scale give 5 units for blood sugars between 201 and 250 before meals and at bedtime. RN G drew up 10 units of Novolog and prepared the second diabetic medication, Levemir Solution 35 units, which was in a dial pen. She then approached resident #41 who had just finished breakfast, as evidenced by the empty breakfast tray on the bedside table and proceeded to inject both diabetic medications. Record review for resident #41 post medication administration revealed that Novolog, both regular and sliding scale, should be administered before meals starting at 7:30 AM. The Medication Administration Record (MAR) further revealed that RN G had been documenting under Unit Manager's (UM) name that morning. On 02/21/24 at 11:29 AM, a fallow up interview was conducted with RN G and she stated that she was late administering the insulin for resident #41 due to being asked to meet with the Director of Nursing (DON) before starting her shift that morning. She further clarified she did not notice she was not signed into the computer since she was in a rush to get morning medications completed. RN G stated she knew that insulin needed to be administered as ordered so the body has time to absorb it before a meal. On 02/21/24 at 11:37 AM, the Unit Manager (UM) from the 200 unit, confirmed she had not administered the 7:30 AM insulin to resident #41 even though her name was signed off on the MAR. The UM stated she mistakenly forgot to sign off the medication cart computer before RN G started medication rounds that morning. She admitted resident #41 should have had his 7:30 AM insulin before his meal as ordered. 2. Resident #77 was re-admitted to the facility on [DATE] from an acute care hospital. His diagnoses included pancytopenia, gastrointestinal hemorrhage, gastro-esophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease. Pancytopenia is a condition in which there is a lower-than-normal number of red and white blood cells and platelets in the blood. Pancytopenia occurs when there is a problem with the blood-forming stem cells in the bone marrow (retrieved on 02/29/24 from www.cancer.gov). The most common cause of pancytopenia is Megaloblastic anemia, followed by acute myeloid leukemia and aplastic anemia (retrieved on 02/29/24 from www.ncbi.nlm.nih.gov). On 02/21/24 at 9:33 AM, RN F, was ready to administer 10 AM morning medications to resident #77. She had two medication cups and a metered dose inhaler. One medication cup contained two chewable tablets of Calcium Carbonate 500 mg (Tums) and the other contained seven tablets, which did not include Polysaccharide Iron Complex Capsule 150 mg for iron deficiency. RN F counted the medications and confirmed she had two in one cup, seven in the other cup, and one metered dose inhaler. RN F entered resident #77's room and administered seven tablets by mouth. The resident refused the Calcium Carbonate 500 mg. After exiting the resident's room, RN F counted how many medications she had administered as she signed for them on the computer. She stated she administered seven tablets plus an inhaler. RN F then stated she had omitted the Polysaccharide Iron tablet and said she had made a mistake. Resident #77's medical records revealed Calcium Carbonate 500 mg was ordered to be administered by mouth before meals for supplementation starting at 8:00 AM On 02/21/24 at 11:40 AM an interview with UM from the 200 unit and the Regional Nurse Consultant (RNC) revealed they expected medications to be administered as ordered. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic lung disease, bipolar disorder, type 2 diabetes mellitus, and hypertension. Resident #3 had a care plan for altered cardiovascular status related to her elevated cholesterol and hypertension. On 2/19/24 at 12:14 PM, RN H dispensed and administered medications for resident #3 including Amlodipine Besylate tablet 5 milligrams (mg) for hypertension. Review of the Physician Orders on 2/19/24 revealed a physician's order for Amlodipine Besylate 5 mg tablet. The order directed, give 10 mg once a day for hypertension, and to hold for systolic blood pressure less than 110. Review of the Medication Administration Record for February 2024 revealed RN H documented 10 mg of Amlodipine Besylate as given on 2/19/24. On 2/19/24 at 1:09 PM, RN H stated she realized the physician's order was for 10 mg, but explained she decided to only give 25mg because she didn't think resident #3 would take two tablets. She explained she didn't have to call the physician to make them aware of the change in resident #3's dosage because the physicians came in and reviewed the charts for that. RN H then changed her explanation and stated she decided to hold part of resident #3's blood pressure medication because she thought 25mg of the Amlodipine was enough. RN H did not give an explanation as to why she documented 10 mg was given, instead of the 5 mg she actually gave. On 2/19/24 at 1:18 PM, the Director of Nursing (DON) stated the nurse should notify the physician if a resident refused medications or if there was a concern about vital signs. He stated the nurse could not make the decision to hold or change the dosage of a medication if there were not parameters given by the physician. The DON explained it was not in a nurse's scope of practice to change a medication order, without calling the physician for clarification or new orders. On 2/20/24 at 10:43 AM, the Medical Director confirmed nurses should not decide to change medication orders and they should follow what the physician ordered. He agreed it was not in their scope of practice to decide not to give or change a medication and they should notify the physician first. 4. Review of resident #204's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, atrial fibrillation, and obstructive sleep apnea. Review of resident #204's physician orders included Cyanocobalamin 1000 micrograms (mcg) 1 tablet one time a day for supplement, Magnesium Oxide 250 milligrams (mg) 1 tablet one time a day for supplement, Folic Acid 1 mg 1 tablet one time a day for supplement, and Fexofenadine 180 mg one time a day for allergies. On 2/20/24 at 10:53 AM, Licensed Practical Nurse (LPN) I prepared morning medications for resident #204. She pulled the following medications: Potassium 15 milliequivalents 1 tablet, Furosemide 40 mg 1 tablet, Alopurinol 100 mg 1 tablet, Digoxin 125 mcg 1 tablet, Cefdinir 300 mg 1 capsule, Metronidazole 500 mg 1 tablet, Magnesium Oxide 400 mg 1 tablet, Acidophilus with pectin 1 tablet, and Iron 325 mg 1 tablet. LPN I confirmed she had prepared a total of 9 pills for resident #204 which were verified by comparing the actual pills against the medication cards and bottles. LPN I administered the medications to resident #204. Later at 4:26 PM, LPN I looked at the bottle for Magnesium Oxide and stated it was 400 mg. She reviewed resident #204's order, and stated it read 250 mg 1 tablet daily. She said it was her mistake and added she was supposed to inform the physician what she had available, obtain order, and document it. She indicated she was not following the physician's orders. She said she should have held the medication and consulted the physician prior to administering the magnesium oxide tablet for 400 mg. When asked about Cyanocobalamin 1000 micrograms, Folic Acid 1 mg, and Fexofenadine 180 mg which showed documented as given around the same time of the medication administration observation, she stated she did not pull all the medications together and had given those 3 medications before the observation with the surveyor. LPN I immediately changed the details and stated the documentation was an error. She explained she did not have the medications available in the medication cart and confirmed she did not administer Cyanocobalamin, Folic Acid, or Fexofenadine. She acknowledged she should not document medications as administered when they were not. On 2/20/24 at 5:01 PM, the DON stated nurses must follow the physician orders when administering medications. He explained if a medication was unavailable or there was a discrepancy, the nurses must notify the physician, enter any new order, and implement it. He stated the process for over-the-counter supplements was the same. He indicated resident #204's Medication Administration Record needed to reflect the medications were not given with the proper explanation. The DON explained his expectation was nurses followed the physician's orders and documented accurately. Review of the Medication Pass and Med Pass with Medication Cart guidelines not dated revealed purpose was To assure the most complete and accurate implementation of physicians' medication order to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. The document read, Medications are administered in accordance with written orders of the attending physician.

Based on observation, record review, and interview the facilty failed to ensure dishes and eating utensils were sanitized to prevent foodborne illness. Findings: On 2/19/24 at 10:33 AM, Dietary Aide A was observed at the dishmachine, washing the breakfast dishes. The Aide stated the dishmachine was low temperature and utilized a chlorine base chemical for sanitation. A minimum of 50 parts per million (PPM) for the sanitizer level was required. She explained she tested the sanitizer solution with a test strip, when she started washing the dishes, and the sanitizer was at 75 ppm. A rack of dishes came out of the machine and the Dietary Technician used a test strip to determine if the chemical sanitation solution was at the appropriate level. After she swabbed the dishes with the test strip, the test strip remained white in color instead of turning purple indicating none or less than minimum level of sanitizer. The Dietary Technician ran several racks of dishes through the dish machine and each was swabbed with a test strip. The sanitizer solution could not be detected. After several attempts, the Dietary Technician was directed to the container of sanitizer solution that was underneath the dishmachine. It was pointed out the sanitizer solution was not being drawn up the intake line to the dishmachine. Observation of the sanitizer container noted the intake line was floating on top of the sanitizer solution instead of below the sanitizer solution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and and record review, the facility failed to complete, encode and transmit a required Minimum Data Set (MDS) Discharge assessment for 1 of 5 residents reviewed for hospitalization, of a total sample of 42 residents (#28). Findings: Resident #28 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, diastolic congestive heart failure, and dementia. A progress note dated 2/22/22 read, Resident's daughter is concerned about her mother's left lower leg feeling cold because she had a stent put in.As per daughter's request she wants her mother to go to the hospital. As per Dr. [name of physician], we may send resident 911. Resident left via 911. Clinical record review revealed a SNF/NF[Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form dated 2/22/22 that indicated the resident was transferred to the hospital on 2/22/22. Review of the resident's medical record revealed an MDS Entry assessment with Assessment Reference Date (ARD) of 2/09/22, and an MDS admission assessment with ARD of 2/16/22. There was no MDS Discharge assessment to reflect resident #28's discharge from the facility on 2/22/22. On 5/12/22 at 12:04 PM, the 2nd Chair MDS Coordinator stated resident #28 was discharged to the hospital on 2/22/22. She explained an MDS Discharge assessment should be completed for all residents discharged from the facility. She verbalized the assessment would be completed by the Lead MDS/Care Plan Coordinator. During review of resident #28's MDS assessments with the 2nd chair MDS Coordinator, she confirmed an Entry MDS assessment with ARD of 2/09/22, and an MDS admission assessment with ARD of 2/16/22 were completed. She acknowledged no MDS Discharge assessment for this resident could be identified and confirmed it had been missed. On 5/12/22 at 12:10 PM and 2: 28 PM, the Lead MDS/Care Plan Coordinator stated MDS Discharge assessments should be completed, encoded and transmitted within fourteen days of the resident's discharge from the facility. She acknowledged resident #28 was discharged from the facility, and although an MDS Discharge assessment should have been completed for the resident, it was not done. She described the issue as an oversight. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 Version 1.17.1, effective October 2019, provided instructions for MDS staff. Chapter 2 entitled Tracking Records and Discharge Assessments indicated the MDS Discharge assessment - Return Not anticipated or Return Anticipated must be completed when the resident is discharged from the facility and the resident is not expected/[expected] to return to the facility within 30 days. Must be completed within 14 days after the discharge date . The facility's policy Resident Assessment Instrument (RAI) Process revised on 3/27/18 indicated the Resident Care Specialist was responsible for completion of comprehensive assessments for each resident from admission to discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a care plan meeting invitation, and failed to ensure participation of the resident and all required members of the interdisciplinary team (IDT) in the care plan meeting for 1 of 1 resident reviewed for care plans, out of the total sample of 42 residents (#94). Findings: Resident #94 was admitted to the facility on [DATE] with diagnoses including stroke with left sided weakness and end stage renal disease with dialysis. The Minimum Data Set (MDS) admission assessment with assessment reference date of 4/09/22 revealed the resident's Brief Interview for Mental Status score was 13, which indicated he was cognitively intact. The MDS assessment showed that the resident and the family participated in the assessment. On 5/10/22 at 9:35 AM, resident #94 stated he did not remember participating in any care plan meetings since he was admitted to the facility. Review of Progress Notes from 4/08/22 to 4/13/22 revealed a care plan meeting note dated 4/12/22 at 3:15 PM that read, Care plan meeting held with IDT, spoke to neighbor who states he will return home to live with his father upon discharge. There were no progress notes entered by individual members of the IDT and no summary of discussions held in the meeting regarding the resident's plan of care. On 5/12/22 at 11:11 AM, the Lead MDS/Care Plan Coordinator explained the care planning process. She stated all residents had their comprehensive care plans completed within the first 21 days in the facility. The Lead MDS/Care Plan Coordinator explained the facility either hand-delivered care plan invitation meeting letters to residents who were alert and oriented, or mailed the letters to the families of residents who were cognitively impaired. She stated she met with resident #94 on 4/12/22 and he gave her permission to discuss his care plans with his neighbor as his father was not available. The Lead MDS/Care Plan Coordinator reviewed documentation in her office and was unable to find a copy of the care plan meeting invitation letter for resident #94. She provided a Care Plan Attendance Log form dated 4/12/22 which showed signatures for meeting attendees that included herself, the Unit Manager, Therapy Manager, Social Services and Certified Dietary Manager. She confirmed the sections for the resident and family attendance were left blank, and there was no documentation on the form to show resident #94 was informed about his plan of care or that the resident/family was invited. When asked why it was important for the resident to attend his care plan meeting, she stated it was the opportunity for the IDT to explain his care and answer his questions. She confirmed each member of the IDT was expected to be present at the meeting. On 5/12/22 at 11:31 AM, resident #94 reviewed a sample Care Plan Meeting Invitation Letter and reiterated he had never received that letter. He stated he did not attend a care plan meeting with the 5 members of the IDT listed on the attendance log provided by the Lead MDS/Care Plan Coordinator. On 5/12/22 at 12:14 PM, the Lead MDS/Care Plan Coordinator reviewed the resident's electronic medical record and his paper chart and validated there were no copies of the Care Plan Meeting Invitation Letter. She recalled resident #94 was on isolation precautions on the scheduled day of the care plan meeting, so she was the only member of IDT who went to the room. She stated she did not bring the pen or the paperwork to the room and resident #94 was not able to sign for his attendance. The Lead MDS/Care Plan Coordinator did not respond when asked why the care plan meeting was not held by phone, or at a later date when the resident was off isolation precautions. She could not explain why she was able to enter the resident's room, but the other members of the IDT could not do so. Review of the facility's Policies and Procedures Care Plan Conference revised on 2/18/19 revealed staff were responsible for assisting residents to engage in the care planning process. The document indicated a copy of the care plan meeting notification letter would be retained in the medical record. The policy indicated that care plan meeting should be documented in the progress notes and should include a summary of the meeting and attendees including a licensed nurse and the nurse's aid and a member of dietary staff, social service representative and to the extent practicable, the participation of the resident and the resident's representative(s). On 5/12/22 at 2:26 PM, the Lead MDS/Care Plan Coordinator validated the facility's policy required inclusion of residents' direct care aides in the IDT and documentation if the nurses' aide was not available. She stated the facility did not include nurses' aides in care plan meetings. However, the Lead MDS/Care Plan Coordinator confirmed input from nurses' aides was important as they spent more time with residents than any other member of the IDT.