**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to accurately document the Comprehensive Assessments for 4 of 30 sampled residents (Residents #13, #49, #76, and #26), related to diagnoses, vision, and oxygen use. The Findings included: 1) Record review for Resident #13 revealed that the resident was admitted to the facility on [DATE] with a re-admission on [DATE] with diagnoses of Generalized Anxiety Disorder; Mood Disorder Due To Known Physiological Condition; Major Depressive Disorder; Adjustment Disorder with Anxiety and Dementia. The order summary report showed orders for 3 psychotropic medications, Buspirone HCl 15 milligrams (mg) tablet two times daily for Anxiety, Clonazepam 0.5 mg tablet every 8 hours for anxiety, and Depakote Delayed Release 125 mg, give 3 tablets three times daily for Mood Disorder. Review of Section I of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #13 had diagnoses of Coronary Artery Disease, Hypertension, Non-Alzheimer's Dementia, Anxiety Disorder, and Schizophrenia. Review of Resident #13's psychiatry assessments dating back to re-admission date (06/14/24) revealed diagnoses of Depression, Anxiety Disorder, Schizoaffective Disorder, however, no documentation of Resident #13 being diagnosed with Schizophrenia. During an interview conducted on 05/08/25 at 3:09 PM with Staff O, MDS Registered Nurse (RN), who stated she has worked at the facility for 5 years. She stated the nurses are responsible for entering the physician orders and she is responsible for entering the diagnoses for the residents. Staff O stated that during morning clinical meetings she receives new information for the residents including any new diagnoses and then inputs them into the resident's medical record. Staff O noted that the MDS is then updated with the new diagnosis on the next quarterly or annual MDS for that resident. At this time, a side-by-side record review of Resident #13's MDS and medical diagnoses was conducted with Staff O, who acknowledged that Resident #13 was coded for Schizophrenia in the MDS while there was no medical report (psychiatry notes) or record indicating Resident #13 had such a diagnosis. 2) Resident #49 was admitted on [DATE] with the diagnoses that included Non-Pressure Chronic Ulcer of the Left Lower Leg, Psychotic and Mood Disturbance, Congestive Heart Failure, and Heart Failure. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed no Brief Interview of Mental Status( BIMS) score for Resident #49. Section B for vision revealed Resident #49 had adequate vision. Section O for oxygen revealed a no response. A review of Physician orders dated 10/25/24 revealed Oxygen at 1 to 4 Liters via nasal cannula as needed for oxygen saturation of less than 90 %. Oral and pharyngeal suction every day and evening shifts for Advanced Dementia (unable to clear oral secretions). A review of care plan dated 01/20/25 revealed Resident #49 had impaired vision as evidenced by the following: diagnosis of legal blindness, blurry/hazy/cloudy vision, double vision, side vision deficit, visual loss . An additional review of care plan dated 2/6/25 , originally initiated on 10/20/24 revealed Resident #49 was on respiratory therapy related to shortness of breath. Record review of Resident #49's oxygen saturation results in Point Click Care (PCC) revealed oxygen was delivered via nasal cannula on the following dates: 01/27/25, 02/23/25, 03/05/25, 03/26/25, 4/23/25 and on 05/ 01/25. During the continuing interview with the MDS Coordinator, she was informed that resident #49 had a care plan focus for impaired vision which was contradictory to the MDS assessment of adequate vision, she did not respond. The MDS Coordinator was also informed that Resident #49 has oxygen concentrator, oxygen suction machine, mask and oxygen nasal cannula tubing which was observed being used by resident during the past few days of the survey. Staff MDS Coordinator stated she will update the oxygen assessment in MDS. 3) Resident #76 was admitted on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), Wedge Compression Fracture of Second Lumbar Vertebra , Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia, and Major Depressive Disorder. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed a Brief Interview of Mental Status( BIMS) score of 4 indicating Resident #76 had severely impaired cognition. Section I did not include the diagnosis of PTSD. During an interview conducted on 05/06/25 at 11:11 AM with Staff C, Certified Nursing Assistant (CNA), who when asked if she knew Resident #76's triggers, responded, Resident does not have PTSD triggers. In an interview with Staff S, CNA on 05/06/25 at 4:16 PM who has been working in the facility for 4 months, when asked about Resident #76's triggers, she stated, I think he is afraid to fall. In an interview with Staff D, Licensed Practical Nurse (LPN), on 05/06/25 at 4:18 PM , when asked about triggers for the resident, she responded, I know he does not like cold, and likes to stay in bed. In an interview with Staff T, registered Nurse ( RN), on 05/06/25 at 4:22 PM , who when asked about Resident #76s triggers, responded, I know resident forgets things, and has to be reminded by Staff. He does not want to remember a certain time in his life every year. During an interview conducted with the MDS Coordinator on 5/8/25 at 11:45 AM, when asked where in MDS assessment , Post Traumatic Stress Disorder (PTSD) is documented, she added ,In Section I. She added that in Section D, MDS Staff will also document the mood triggers for any depressive mood or any mental illness. When she was asked about PTSD triggers, she responded, I do not think we have any PTSD triggers. She was informed that Resident #76 did not have a documentation of a PTSD diagnosis under Section I. The MDS Coordinator added that she is not the only MDS Coordinator in the facility. When asked where are the other MDS Coordinators she responded, 'They are not here today. 4) Resident #26 was admitted on [DATE] with diagnoses that included Chronic Cough, Dysphagia, Essential Primary Hypertension and Type 2 Diabetes Mellitus. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed a Brief Interview of Mental Status( BIMS) score of 12 indicating Resident #26 had moderate cognitive impairment. Section B revealed adequate vison, and clear speech. A review of initial care plan dated 10/10/24 and quarterly updated on 01/09/25 revealed that Resident # 26 had impaired communications . The interventions included to anticipate and meet needs per physical and nonverbal indicators of discomfort and distress. During a continuing review of nursing care plan with an initial date of 07/14/24 and reevaluation date of 12/10/24, it revealed a focus on impaired vision as evidenced by visual loss due to Glaucoma, Cataract and Open Angle with Borderline Findings. During an interview conducted with the MDS Coordinator on 5/8/25 at 11:45 AM, she stated she has been working in the facility for 5 years, and when asked about identifying vison, hearing, and speech impairment of residents, responded, when residents have hearing problems, you provide them with reading materials. When residents have visual problems or blind people, you get visual consultations. When the MDS Coordinator was asked where the above impairments are documented, she responded, Under Section B of the MDS assessment. She added that Social Services Staff also document and complete some areas of the MDS assessments, clarifying that both Social Services and MDS Departments have to complete their assigned tasks for the completion of resident's MDS assessment. When asked how often the MDS staff assess and verify the impairments and treatments receive by residents for accuracy of MDS assessments, she responded I do frequent rounds, and I check the Physician orders as often as possible. In an interview conducted on 05/08/25 at 3:22 PM with the Social Services Director, when asked regarding Resident #26's vison, she stated, This resident has adequate vision. She was informed that Resident #26's care plan had a focus for impaired vision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #70 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE] with diagnoses that included in part the following: Cerebral Infarction, Glaucoma, Muscle Weakness (Generalized), Seizures, Other Lack of Coordination, Anxiety Disorder, Contracture Left Elbow, Contracture Left Wrist, and Contracture Left Ankle. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment. Review of facility incident log revealed Resident #70 had an unwitnessed fall on 04/13/25. The Fall Risk Evaluation for Resident #70 completed 09/29/24 documented a score of 12 indicating at risk. The Fall Evaluation Morse for Resident #70 completed 04/14/25 documented a score of 75 indicating a high risk for falling. The Health Status Note for Resident #70 dated 04/13/25 at 2:00 AM documented, during midnight round at 12:53 AM, writer observed resident laying down on the floor. Writer questioned resident regarding the incident and how she found herself lay down by her bedside. Resident stated I am trying to go back to the dining room for the party. Writer oriented resident mentioned that it passed midnight it is bedtime, the dining room is close at this time, she can go back when it open at 0800 AM. Resident insisted that she must go right now, despite multiple tries to orient resident back to reality she is constantly ignoring me and started using profanity. Writer transferred resident back to bed assisted by two nursing assistants. Physical, and neuro assessment performed, no physical injury, no abrasion, no bruises noted, she was able to squeeze my hands when asked to, pupil reacted to light, she was able to move her upper/lower extremities w/o difficulty. Vitals are within normal range. Resident was changed she remains clean and dry and made comfortable in bed. All safety precautions maintained, by keeping the bed low to the ground, wheels are locked, head of bed placed at 45 degrees to facilitate a comfortable breathing pattern. Staff will continue with frequent rounds and continue to educate resident on fall prevention and encouraged resident to continue using the call light for assistance. The Health Status Note for Resident #70 dated 04/13/25 at 11:03 AM documented post fall follow up, resident observed in bed no s/s of pain noted, denies pain or any discomfort, appeared to be stable, consumed up to 80 % of her breakfast. Safety measures maintained and reinforced. Assigned nurse will continue with care. The Health Status Note for Resident #70 dated 04/13/25 at 2:50 PM documented, received resident in bed alert and verbally responsive. S/P fall in progress no C/O pain or discomfort. Resident is able to move all extremities. Routine meds administered as prescribed and well tolerated. Kept clean and dry. Bed is in lowest position. Call light within reach. The incident report for Resident #70 dated 04/13/25 for un-witnessed fall/observed on floor documented the Physician was notified on 04/14/24 at 10:14 AM (more than 24 hours post incident). Review of the Care Plan for Resident #70 dated 05/24/24 with a focus on I am at risk for a fall related to injury. The goal was for the resident to have a reduction in falls and related injuries through next review date. The interventions included in part the following: Floor mats at bedside dated 04/13/25. Review of the Physician's Orders for Resident #70 revealed no orders for floor mats at the bedside. On 05/05/25 at 10:19 AM an observation was made of Resident # 70 lying in bed with 2 floor mats, one behind the bed and the other on the resident's left side of bed. On 05/05/25 at 1:25 PM a second observation was made of Resident #70 lying in bed with only one floor mat next to the bed. During an interview conducted on 05/05/25 at 10:19 AM Resident #70's daughter said her mother had a fall a couple of weeks ago and she is afraid her mother will fall again, this is one of her biggest fears. She came in yesterday (Sunday 05/04/25) and there were no floor mats on side of bed, so she pulled one out from behind the resident's bed and put it on the floor next to the bed by herself. During an interview conducted on 05/06/25 at 2:14 PM with Staff A, Registered Nurse, who stated he has worked at the facility for just over 1 year. When asked if a resident has a care plan intervention for floor mats at bedside when would the resident have the floor mats at the bedside, Staff A RN stated they would just leave the floor mats on the floor next to each side of the bed all the time. During an interview conducted on 05/07/25 at 10:35 AM with the Infection Preventionist (IP) who stated she has worked at the facility since 2020. When asked if a resident has an unwitnessed fall what do they do, who do they notify and where do they document the information. The IP stated they would do neuro checks and notify the physician and the family and the notification of physician and family would be documented in the notes. When asked about floor mats at the bedside, the IP stated they would be placed on each side of the bed while the resident was in bed. Based on observations, interviews, and record review, the facility failed to follow their Fall policy including implementation of fall interventions for 1 of 3 residents reviewed for accidents (Resident #70), and failed to prevent and have an effective response for a resident who eloped for 1 of 1 resident reviewed for elopement (Resident #259). The findings included: Review of the facility's policy titled, Elopements and Wandering Residents, date implemented 11/28/17, included in part the following: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Unannounced drills at least twice yearly to be done across all shifts and as needed depending on the ongoing identified wandering/exit seeking behaviors. The facility may complete an after action review process to help us develop an actionable after action report (AAR). The process will include a roundtable discussion that includes leadership, department leads and critical staff who can identify and document lessons learned and necessary improvements in an official AAR. The AAR, at a minimum, should determine a) what was supposed to happen; b) what occurred; c) what went well; d) what the facility can do differently or improve upon; and e) a plan with timelines for incorporating necessary improvement. Review of the facility's policy titled, Fall Prevention Program with an implemented date of 11/28/17 included in part the following: Fall refers to unintentional change in position coming to rest on the ground, floor, or other lower level. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. When any resident experiences a fall, the facility will: c. Complete an incident report and notify MD and responsible parties. e. Implement immediate intervention within the first 24 hours. H. Monitor staff compliance and resident response. 1. On 05/07/25 around 12:00 PM, the surveyor team was made aware by the Administrator that Resident #259 had left the facility early this morning unauthorized, unaccompanied and an investigation was started. Review of the facility's investigation revealed that on 05/06/25 at 11:00 PM Resident #259 was in bed sleeping. On 05/07/25 at 1:00 AM and 2:00 AM Resident #259 was observed sleeping in bed. At approximately 3:15 AM, the nurse heard an alarm going off and immediately went to see what was happening. The nurse went and checked all residents and found that Resident #259 was not in his bed. The nurse notified all the staff on duty, and everyone began to search inside the facility and then outside of the facility. The search was extended to the back and west side of the facility, and to the neighboring areas. At 3:48 am, the DON/Risk manager was called for notification, and she advised the nurse to call police to assist with the search. At approximately 3:57 am, the police officers were at the facility receiving report and description of the resident. Three minutes later (4:00 am) officers in facility received notification that police officers had located the resident walking down the road on [NAME] Boulevard based on the description provided. At approximately 04:15 am Resident #259 was escorted back to the facility with the police officer unharmed. Full body assessment done with no findings. He was moved to a room closer to the nurse's station and began a safety check every 30 minutes. Resident #259 was asked why he left without notifying staff and he responded, he was taking a walk. The facility also put the following corrective actions in place: Room changed closer to nursing station. [NAME] 30 minutes safety check in process until further notice. Elopement assessment completed as he is now at risk. Wander guard bracelet in place on his person. Elopement information in circulation to raise awareness. Elopement care plan initiated. Will initiate one to one sitter at night until discharge from the facility. An in-service was conducted to all staff regarding responding to alarms. Another BIMS score was done today 5/7/25 at 11:00 AM which showed a score of 14, which indicated he was cognitively intact. Record review for Resident #259 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included: Hydrocephalus, Dementia, Hypertension and presence of Cerebrospinal Fluid Drainage Device. On 05/02/25 a Brief Interview for Mental Status (BIMS) conducted with a score of 14 of 15, which indicated that he had an intact cognitive response. On 05/05/25 an Elopement Risk Assessment/Evaluation was conducted for Resident #259 which revealed he was not at risk for elopement. Review of the Physician's Orders showed that Resident #259 had orders dated 05/02/25 for Levetiracetam 1000 milligrams (mg) tablet give two times daily for Seizures and Nicotine Patch 24 Hour 7 mg/24 hour apply 1 patch transdermal daily for Smoking Cessation for 3 Weeks and remove per schedule, 05/03/25, end date: 05/24/25. During an interview conducted on 5/7/25 at 12:00 PM with Resident #259, who was asked if he had left the facility and he responded that he had gone for a walk and was not told that he could not leave the facility or the property. When he was asked if he returned to the facility with a staff member or own his own, Resident #259 was reluctant to answer and said he did not recall that anyone accompanied him. During an interview conducted on 05/07/25 at 3:30 PM with Staff J, Registered Nurse (RN), who stated she has been working at the facility for less than 3 months, usually works the 11-7 shift, and volunteered today to work the 3-11 shift. She stated she worked last night at the [NAME] wing, assigned to Resident #259. She stated depending on what she is doing, if she is finished with the medication pass, she does her rounds every 2 hours and starts on her documentation. She stated Resident #259 did not have any medications scheduled for administration during the night and the last time she saw him was around 2:00 AM. Staff J also noted she did not see Resident #259 walking in the hallway or passing by the nurses' station during the night. She was at the nurses' station when she heard a beep, beep noise and at first, she thought it was a call light going off; however, no lights appeared to be on. Then, she thought that it might be a resident with a wander-guard who got too close to the emergency exit door. The alarm did not appear to get louder and it was not continuous. She then stated that she went into the hallway and noticed the noise was louder from the back end of the facility (near Resident #259's room) and immediately started to check in the rooms for residents. She called the other nurse that was at the nurses' station for assistance, she looked in Resident #259's room and noticed that the resident was not in the room, or the bathroom. Staff J acknowledged not knowing the code for the emergency exit door to stop the alarm noise. By that time, all the staff were assisting her to look for the resident inside the building and then a few of the staff went outside and searched in the back and front of the facility, basically all around the facility towards the hotel. At this time, Staff J stated that they did not see Resident #259 and the Director of Nursing (DON) was called and she advised to contact the police for assistance in locating the resident. She stated she spoke with the resident when he returned to the facility and he stated, I was just taking a walk. Staff J was asked if she received elopement education and participated in drills to which she replied that she has received training; however, does not recall doing any drills for elopement. Then Staff J was asked if there's a different alarm noise for when there's a wander-guard near the door or when the door is pushed open and she stated did not know. An interview was conducted on 05/07/25 at 3:30 PM with the Administrator near the [NAME] emergency exit door closest to Resident #259's room on the night of the elopement. He stated that if you press lightly on the door it will beep, beep, etc. for 15 seconds, then the light on the top of the door will turn from red to green; if the door is opened, it will then make a continuous beeping sound until the code is entered on the keypad. Only certain staff personnel have the code, usually one of the nurses. During an interview conducted on 05/08/25 at 7:17 AM with Staff K, Certified Nursing Assistant (CNA), who stated she has worked at the facility for over 30 years. She has been working the 11-7 shift for the last 25 years, usually assigned at the [NAME] wing and on that night (05/06-05/07/25) she was assigned to Resident #259. She stated that at the beginning of her shift she makes her rounds and checks on the residents. Staff K confirmed that Resident #259 is able to make his needs known, can walk around independently and does not require any walking device. When she saw Resident #259 at around 11:15 PM, he was trying to get out of bed to go to the bathroom, and she assisted with changing his brief and went back to bed and covered him with the blanket. She returned at 1:00 AM and saw him in bed with the covers on him. Between 2:00 and 2:15 AM, she again saw Resident #259 was in bed half covered and thought maybe he went to the bathroom, she left him half covered because he appeared to be sleeping. Around 3:00 AM, she was assisting another resident when she heard the nurse talking outside of the room by the nurses' station that Resident #259 was not in his room, she went out of the room to see what was going on, and that's when she heard the continuous beeping of the alarm. At this time, she assisted in the search for Resident #259 inside the facility and then outside (front and back of the facility). Staff K stated all staff have the emergency codes printed on their ID badge, code green is for elopement and at night they do not use the overhead speaker. She stated she has participated in the Mock drills in the past; the beep, beep sound means that someone touched the door, if continue to touch the door for 15 seconds the beep, beep will continue, and it will change sound when the door is opened to a continuous loud beeping. Staff K was asked what she would do if she heard the change of sound from beep, beep to continuous beeping, she replied, she would look outside first because it would mean someone opened the door. An interview was conducted on 05/08/25 at 8:54 AM with the DON. She stated she received a few phone calls that night from the nurses including Staff J, RN. The DON stated Staff J was calling to let her know that they were looking for Resident #259 and then the DON advised Staff J to call the police for assistance in locating the resident and then notify the family. Then the DON stated while she was on her way to the facility, the staff called her that the police had found Resident #259. She stated she went to see the resident around 4:25 AM but was sound asleep. She then spoke with the staff who stated they heard the alarm towards the back of the facility on the [NAME] wing and Staff J provided a statement in which she believed that the resident went out using the emergency exit door located in the back of the [NAME] wing. The DON also stated that Staff J stated she immediately responded and searched the rooms and did not see him in his room so she got all other staff members to go on search, started the search in the facility and then went outside. The DON was asked how often and who runs elopement drills, in which she responded that drills are done by maintenance, managers, herself and the social worker; and the drills are done quarterly, and as needed. The DON confirmed that Beep, beep for 15 minutes is a warning that someone is by the door and continuously beeping suggest that the door was pushed open, the alarm continues to beep until the code is entered to stop it. At this point, the DON acknowledged that the nurses should have responded accordingly and more education and drills will be conducted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for urinary catheter care and failed to follow care plan interventions for catheter care, for 1 of 3 sampled residents (Resident #26). The findings included: Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Aphasia, Contracture of the Right Hand, Chronic Kidney Disease, and Neurogenic Bladder. A review of quarterly Minimum Data Set (MDS) assessment, dated 03/17/25, under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of the Nurse Practitioner progress notes dated 04/22/25, revealed Resident #26 had an indwelling urinary catheter draining clear light-yellow urine under genitourinary examination; right hemiplegia, non-ambulatory, and decreased upper and lower extremity strength under neurologic examination; alert, oriented x 2, with poor eye contact, judgement, insight impaired, and flat affect under psychological examination. Review of the quarterly care plan, dated 12/17/24, revealed a focus on an indwelling urinary catheter related to Obstructive Uropathy. The goal included Resident #26 will remain free from catheter -related trauma through review date. The interventions included: catheter urinary drainage; catheter care every shift; secure catheter to leg to prevent migration and abrupt dislodgement every shift. During an observation on 05/06/25 at 10:00 AM, Resident #26's urinary catheter tube was not secured or clipped to resident's leg to prevent tube migration to prevent migration or accidental dislodgement of the urinary catheter. During another observation on 05/07/25 at 9:10 AM, Resident #26's urinary catheter tube was not secured or clipped to resident's leg to prevent tube migration. During an observation on 05/07/25 at 12:13 PM, Staff W, Certified Nursing Assistant (CNA), and Staff X, CNA stated they will perform urinary catheter care for Resident #26. They both performed hand washing, donned on gloves and assembled supplies needed for the urinary catheter care. They did not don on gowns. Staff W, CNA told Resident #26 what she was planning to do and loosened Resident #26's brief and exposed the urinary catheter tube. It was observed that the urinary catheter tube was not secured using a visible blue clip to prevent migration and accidental dislodgement. Both Staff stated that the urinary catheter tube was not secured to Resident #26's leg to prevent moving and accidental dislodgement. After the catheter care and brief changing were completed, they did not secure the catheter tube onto Resident #26's leg. In another observation on 05/08/25 at 9:09 AM, Resident #26's catheter tubing was not secured to the resident's leg. In an interview with the Director of Nursing (DON) on 05/08/25 at 2:00 PM, when asked if Nurses follow the urinary care plan, she responded, Nurses are educated to follow the interventions on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to follow the Physician orders regarding oxygen therapy for 8 of 8 sampled residents (Residents #25, #49, #50, #99, #20, #29, #22, and #44). The facility also failed to correctly document oxygen therapy on Minimum Data Set (MDS) assessment for 3 of 8 sampled residents (Residents #49, #50, and #99). The Findings included: 1) Resident # 25 was admitted to the facility on [DATE] with diagnoses that included Heart Failure, Presence of Cardiac Pacemaker, Acute Kidney Failure, Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. A review of the annual Minimum Data Set (MDS) assessment, dated 03/06/25, under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #25 had good mental cognition. Section O revealed no oxygen therapy . An additional review of records revealed Resident #25 recently received oxygen via nasal cannula on these dates and times: on 04/30/25; on 05/02/25; on 05/05/25 and 05/06/25. A review of Pulmonary progress notes dated 3/19/25 revealed Resident #25's problems included shortness of breath and unspecified cough. Additional notes revealed Resident #25's dependence on supplemental oxygen. During an observation on 05/05/25 at 9:48 AM, Resident #25 was observed sitting opposite an oxygen concentrator with an inspection date of 10/2023. The oxygen tubing connected to the concentrator was not dated, and the concentrator was off. When he was asked if he is currently receiving an oxygen therapy, he responded, I use it while I am in bed. A review of the Physician Orders revealed an order dated 4/22/24 for oxygen at 1 to 4 Liters via nasal cannula as needed to keep oxygen saturation above 93 %. A record review of the nursing care plan did not include goals, plans and interventions for oxygen therapy. 2) Resident #49 was admitted to the facility on [DATE] with diagnoses that included Thyroid Disorder, Cardiomegaly, Dementia, Pneumonia and Heart Failure. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section C, revealed an empty space on a Brief Interview of Mental Status (BIMS), indicating no score for mental cognition. Section O revealed Resident #49 does not receive oxygen therapy. A review of Physician order dated 10/25/24 revealed oxygen at 1 to 4 Liters via nasal cannula as needed for oxygen saturation less than 90 %. An additional review of records revealed Resident #49 received oxygen via nasal cannula on these dates: 05/01/25, 4/23/25, 3/26/25, 3/5/25, 2/23/25. During an observation on 05/05/25 at 09:56 AM, Resident #49 was observed with a nasal cannula infusing at 2 Liters per minute, connected to a concentrator with an inspection date of 10/2023. Closer observation revealed the oxygen tubing was not dated. Additional observation revealed a suction machine on top of the bedside table. The nebulizing tubing and mask connected to another small machine were both undated and not contained. In an Interview with Staff J, RN on 05/07/25 at 3:21 PM who has been working in the facility for less than 3 months, who when asked regarding oxygen therapy care for residents, stated, We provide oxygen therapy with physician's orders. When asked regarding dating oxygen tubing, she responded that it is changed every Sunday during the night shift and as needed. She stated that Staff put the date on the oxygen tubing when it was changed. In an interview with MDS Coordinator on 05/08/25 at 11:57 AM, who when asked if Resident #49 was receiving oxygen therapy per MDS assessment done on 4/20/25, responded, No, Resident #49 was not on oxygen therapy. When asked how she verifies that residents receive oxygen, she responded, I check the doctors' orders. 3) Resident # 50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Degenerative Disease of Basal Ganglia, Cerebral Infarction, Hypertension, Type 2 Diabetes Mellitus, Multiple Fractures of Ribs, Right Side, and Dysphagia. A review of the most recent Minimum Data Set (MDS) assessment, dated 03/12/25, under Section C, revealed no score for Brief Interview of Mental Status (BIMS) indicating unknown mental cognition. Section O revealed a no response to oxygen therapy, indicating Resident #50 does not receive oxygen therapy. A further review of nursing care plan initiated on 7/25/24 and quarterly reviewed on 10/31/24 revealed a focus on oxygen therapy at 2 Liters per minute as needed to maintain oxygen saturation of 92 %. The interventions included changing oxygen tubing every week on Sundays, during night shift. During an observation on 05/05/25 at 9:56 AM, Resident #50 was wearing a nasal cannula on both nares while being fed by a CNA. Further observation revealed the oxygen tubing was not dated. 4) Resident #99 was admitted to the facility on [DATE] with diagnoses that included Traumatic Subdural Hemorrhage with Loss of Consciousness, Spinal Stenosis of the Lumbar Region with Neurogenic Claudication, and Obstructive Sleep Apnea. A review of the recent Minimum Data Set (MDS) assessment dated [DATE], Section O for oxygen therapy revealed a no response, indicating Resident #99 was not receiving oxygen therapy. A record review of Physician order dated 3/23/25 revealed to change oxygen tubing weekly when in use, and label tubing with a date every Sunday. A review of Nursing care plan revealed no focus, goals and interventions for oxygen therapy. A review of May 2025 MAR revealed a check mark, and Nurses initials on 05/04/25, indicating the oxygen tubing was changed, and labeled with a date. During an observation conducted on 05/05/25 at 10:05 AM, it revealed a mask connected to a machine by an undated tube. Further observation revealed the mask was not securely contained but placed on top of the bedside table. An oxygen concentrator with an undated tubing was also observed. During an observation on 05/06/25 at 10:06 AM, there was no oxygen sign at Resident #99's door. In an interview with the MDS Coordinator on 05/08/25 at 12:02 PM, who when asked why some Residents have inaccurate MDS assessment for oxygen therapy, responded, Each MDS Coordinator has different set of residents to assess, so she cannot answer for the assessments performed by other MDS Coordinators. When asked if they conduct MDS review for accuracy of assessments, she responded, I will update all MDS assessments of all residents with oxygen therapy today. 8) During the facility initial tour on 05/05/25 at 9:49 AM, Resident #44 was observed in her room in her Geri chair and not wearing a nasal cannula for oxygen therapy. Further observation revealed that there was no oxygen concentrator and no oxygen tubing in the resident's room. On 05/06/25 at 11:15 AM observed Resident #44 in bed and not wearing a nasal cannula for oxygen therapy as ordered. On 05/07/25 at 2:07 PM observed Resident #44 in bed and not wearing a nasal cannula for oxygen therapy as ordered. Resident #44 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included: Dementia, Type 2 Diabetes Mellitus, Dysphagia, Hypertension and Encephalopathy. Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #44 had a Brief Interview for Mental Status of 00, which indicated that she was rarely understood. The order summary report showed an order for Oxygen at 2 Liters (L) continuous via nasal canula dated 10/17/23. Review of the Care Plan dated 04/20/25 documented a focus that Resident #44 is on Oxygen Therapy via nasal cannula at 2 L via nasal cannula continuously for shortness of breath, with interventions that included change oxygen tubing every week on a Sunday during night shift, check for proper fit of cannula or mask as needed, check rate of Oxygen flow every shift, notify doctor as needed for changes or complications and provide oxygen as ordered. During an interview conducted on 05/08/25 at 2:44 PM with Staff I, Registered Nurse (RN), who stated she has worked at the facility for 2 years. She stated she is not sure if Resident #44 is on Oxygen therapy. Then, a side-by-side review of Resident #44's physician's orders with Staff I revealed that Resident #44 has an order for continuous oxygen 2 L via nasal canula. Then Staff I and this surveyor went to Resident #44's room, and she was asked if the resident was currently receiving oxygen therapy and she replied no. Further observation by Staff I revealed that there was no oxygen concentrator and no oxygen tubing in the room. She then acknowledged that the resident should have the oxygen by the bedside. 5) Record review for Resident #20 revealed the resident was originally admitted to facility on 02/01/19 with most recent readmission on [DATE] with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Morbid (Severe) Obesity Dependence on Supplemental Oxygen, Sleep Apnea, and Respiratory Failure Unspecified. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 10 indicating a moderate cognitive response. Review of the Physicians orders for Resident #20 revealed in part the following: An order dated 08/18/24 Oxygen at 2 liters per minute via nasal canula continuously maintain oxygen saturation at 92%. An order dated 08/18/24 Oxygen: Change O2 tubing every 72 hours when in use. An order dated 08/28/24 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for Shortness of Breath or Wheezing via nebulizer. In summary there was no order to change nebulizer tubing. Review of the Treatment Administration Record for Resident #20 for the month of April 2025 and May 2025 documented the oxygen tubing was changed only on Sundays, not every 72 hours. Review of the Medication Administration Record for Resident #20 documented for the month of April 2025 and May 2025 the resident was wearing oxygen continuously. Review of the Care Plan for Resident #20 with a focus on the resident on Oxygen Therapy via nasal cannula at 2L/M continuously with humidifier due to COPD. Resident #20 is also using a C-PAP machine. The goal was for the resident to have decreased episode of respiratory distress by next review date. The interventions included in part the following: Change O2 tubing every week when in use every night shift every Sunday. Change neb tubing every week every night shift every Sunday. On 05/05/25 at 09:48 AM an observation was made of Resident # 20 sitting up in bed wearing oxygen connected to an oxygen concentrator that had a service label on the concentrator of 09/26/23, the nebulizer tubing was in a plastic bag on nightstand with no date on the nebulizer tubing or on the plastic bag. 6) Record reviewrevealed Resident #22 was admitted [DATE] with diagnoses that included in part the following: Dementia, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, and Major Depressive Disorder Recurrent Moderate. The Minimum Data Set, dated [DATE] documented in Section C that the Brief Interview of Mental Status was not attempted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #22 revealed in part the following: An order dated 03/13/25 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally two times a day for Shortness of Breath and 1 vial inhale orally every 6 hours as needed for Shortness of breath. There was no order to change nebulizer tubing. On 05/05/25 at 9:30 AM an observation was made of Resident #22 sitting up in bed with 2 nebulizer masks in 2 separate plastic bags one dated 04/03/25, the other was dated 04/21/25. 7) Record review for Resident #29 revealed the resident was originally admitted on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Paroxysmal Atrial Fibrillation, Anxiety Disorder, and Vascular Dementia. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 13 indicating a cognitive response. Review of the physician's orders for Resident #29 revealed in part the following: An order dated 08/23/24 O2@ 2L/min PRN to maintain Saturating greater than 92% An order dated 01/14/25 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG\/3ML 1 vial inhale orally every 6 hours for COPD In summary there were no orders to change nebulizer tubing. Record review for Resident #29 revealed no documentation of nebulizer tubing being changed. Review of the Care Plan for Resident #29 dated 08/13/24 with a focus on the resident is at risk for respiratory distress due to history of shortness of breath (SOB)/COPD / Dyspnea/ Hypoxia and the resident uses oxygen therapy as needed. The interventions included in part the following: Change neb tubing every 72 hours when in use on night shift Sunday. Change oxygen tubing weekly or as indicated. On 05/05/25 at 09:20 AM an observation was made of Resident #29 in bed not wearing oxygen, nebulizer mask was in a plastic bag on the nightstand with no date on the nebulizer tubing or the plastic bag it was in. During an interview conducted on 05/06/25 at 2:14 PM with Staff A, Registered Nurse, who stated he has worked at the facility for just over 1 year. When asked about oxygen tubing and nebulizer mask tubing being changed, he said the night shift does that on Sundays. On 05/06/25 at 2:30 PM a side-by-side observation was made with Staff A RN who acknowledged the nebulizer masks for Residents # 29, #22 and #20 were dated over a week ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving and dispensing and administering of all medications as well as drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled to include removing discontinued medications timely for 4 of 9 residents reviewed for controlled medications (Residents #56, #13, #68, and #308). The findings included: Review of the facility's policy titled, Medication Reconciliation with an implemented date of 11/28/17 included in part the following: Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. Verify medications received match the medications orders. Provide pharmacy consultant access to all medication areas and records for completion of pharmacy services activities. Review of the facility's policy titled, Controlled Substance Storage, dated May 2022, included the following: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures: The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR). 1. Record review for Resident #56 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Encephalopathy, Other Abnormalities of Gait and Mobility, and Unspecified Dementia. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment. Review of the Physician's orders for Resident #56 revealed an order dated 03/31/25 for Clonazepam 0.5mg give 1 tablet by mouth every 24 hours as needed for Panic Attack for 7 days and was discontinued on 04/07/25. On 05/07/25 at 2:00 PM a review of the controlled medication Clonazepam 0.5mg for Resident #56 was conducted with Staff A Registered Nurse (RN). The controlled medication form listed Clonazepam 0.5mg 1 tablet orally once a day for 7 days. The medication was still in the med cart. During an interview conducted on 05/07/25 at 2:05 PM with Staff A RN who acknowledged the order for the Clonazepam on the bingo card did not match the order in Resident #56's medical record and the medication was discontinued on 04/07/25. When asked about the process when receiving a controlled medication from the pharmacy. Staff A RN stated he checks the medication label on the bingo card and on the control sheet both match the order in the resident's chart. Staff A RN stated the medication should have been removed from the medication cart. During an interview conducted on 05/07/25 at 2:23 PM with the Director of Nursing who was asked about the medication order of Clonazepam for Resident #56, and she acknowledged the order in the resident's record was for PRN and the label on the medication bingo card and the label on the Medication Monitoring/Control Record both listed the medication at routine. The DON stated the receiving nurse is supposed to verify the label on the medication bingo card and the label on the Medication Monitoring/Control Record should both match the order in the resident's record. The DON also acknowledged the order in the resident's record was discontinued on 04/07/25 and should have been removed from the med cart at that time. 2. Record review for Resident #13 revealed that the resident was admitted to the facility on [DATE] with a re-admission on [DATE] with diagnoses of Generalized Anxiety Disorder; Mood Disorder Due To Known Physiological Condition; Major Depressive Disorder; Adjustment Disorder with Anxiety and Dementia. Review of the Physician's order dated 08/08/24 showed that Resident #13 had an order for Clonazepam (a psychotropic medication) 0.5 milligrams (mg) tablet to be given every 8 hours for anxiety (at 0000 (12:00 AM), 0800, 1600 (4:00 PM).) On 05/07/25 at 5:30 PM, a side-by-side review of Resident #13's Medication Monitoring/Control Record sheet for Clonazepam 0.5 mg tablet was conducted with Staff P, Licensed Practical Nurse (LPN). The review revealed that Clonazepam 0.5 mg medication packet was received by a nurse on 04/25/25 containing a total of 42 tablets. From 04/26/25 to 05/07/25, one (1) tablet of Clonazepam 0.5 mg was removed from the controlled substance box 3 times daily and at the time of the observation, 6 tablets remained in the packet, which matched the amount remaining on the Medication Monitoring/Control Record sheet. According to the Medication Monitoring/Control Record sheet: on 04/27/25 at 12:13 AM, the amount on hand of Clonazepam 0.5 mg was 38 tablets, given 1 tablet, remaining 37 tablets. on 04/27/25 at 0800 AM, the amount on hand was 37 tablets, given 1 tablet, remaining 36 tablets on 04/27/25 at unable to read the time, the amount on hand was 36, given 1 tablet, remaining 35 tablets. on 04/28/25 at 0008 (12:08 AM), the amount on hand of Clonazepam 0.5 mg was 34, given 1 tablet, remaining 33 tablets. No additional documentation was recorded for the discrepancy (the amount on hand should have been 35). on 04/28/25 at 0900, the amount on hand was 33, given 1 tablet, remaining 32 tablets on 04/28/25 at 1625 (4:25 PM), the amount on hand of Clonazepam 0.5 mg was 32 given 1 tablet, remaining 31 tablets. 3. Record review for Resident #68 revealed that the resident was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with Diabetic Nephropathy, Major Depressive Disorder, Metabolic Encephalopathy and Ventricular Tachycardia. Review of the Physician's order dated 08/08/24 showed that Resident #68 had an order for Tramadol (a controlled substance for pain) 50 milligrams (mg) tablet to be given daily for nonacute pain. On 05/07/25 at 5:30 PM, a side-by-side review of Resident #68's Medication Monitoring/Control Record sheet for Tramadol 50 mg tablet was conducted with Staff P, Licensed Practical Nurse (LPN). The review revealed that the medication packet was received by a nurse on 04/10/25 containing a total of 29 tablets and at the time of the observation (05/07/25), 6 tablets remained in the packet, which matched the amount remaining on the Medication Monitoring/Control Record sheet. According to the Medication Monitoring/Control Record sheet Resident #68 was administered Tramadol 50 mg from 04/10/25 to 05/07/25. Continued review of the Medication Monitoring/Control Record sheet revealed the following: on 04/15/25 one (1) tablet of Tramadol 50 mg was removed from the controlled substance box and not recorded as wasted on 04/26/25 the amount on hand of Tramadol 50 mg was 15 tablets, given 1 tablet, remaining 14 tablets on 04/27/25 the amount on hand of Tramadol 50 mg was 14 tablets, given 1 tablet, remaining 13 tablets on 04/28/25 the amount on hand of Tramadol 50 mg was 13 tablets, given 1 tablet, remaining 13 tablets on 04/29/25 the amount on hand of Tramadol 50 mg was 13 tablets, given 1 tablet, remaining 12 tablets on 04/29/25 the amount on hand of Tramadol 50 mg was 12 tablets, given 1 tablet, remaining 11 tablets on 05/06/25 the amount on hand of Tramadol 50 mg was 6 tablets, given 1 tablet, remaining 5 tablets on 05/06/25 the amount on hand of Tramadol 50 mg was 5 tablets, given 1 tablet, remaining 4 tablets. Review of Resident #68's April and May Medication Administration Record (MAR) revealed that the Tramadol 50 mg removed from the controlled substance box on 04/15/25 was not documented on the resident's MAR as being administered. Continued review of the April and May MAR revealed that on 04/29/25 and on 05/06/25 Tramadol 50 mg was documented as administered once, while two Tramadol 50 mg tablets were removed from the controlled substance box on those days. Furthermore, no other documentation was found as to why Resident #68 was administered Tramadol 50 mg twice on those days instead of daily as per physician's order. During an interview conducted on 05/08/25 at 9:20 AM with Staff I, Registered Nurse (RN), who stated she has worked at the facility for 2 years. She stated she first reviews the physician's order, removes the medication from the controlled substance box, administers the medication to the resident and then documents in the MAR and in the Medication Monitoring/Control Record sheet. A side-by-side review of both residents' (Resident #13 and Resident #68) Medication Monitoring/Control Record sheets and MARs was conducted with Staff I, who was unable to explain the discrepancies. During an interview conducted on 05/08/25 at 2:44 PM with the Director of Nursing (DON), who stated pharmacy comes in monthly and conducts audits for all medications including controlled substance drugs. In addition, the DON stated that routine, random audits of the medications, monthly or quarterly, are conducted by the unit managers or herself; however, if a resident or family member has a concern with a medication not being administered, then the audits are conducted daily. The DON was then asked if reconciliation of the controlled substance medications is conducted and she stated the nurses reconcile the controlled drugs every change of shift. The DON also stated the nurses are to sign the Medication Monitoring/Control Record sheet when the medication is removed from the controlled substance box, administer the medication to the resident and then document in the MAR as administered. At this time, a side-by-side review of both residents' (Resident #13 and Resident #68) Medication Monitoring/Control Record sheets and MARs was conducted with the DON. She acknowledged that there are discrepancies with the reconciliation of the controlled substance medications. 4. A record review revealed Resident #308 was admitted to the facility on [DATE] with diagnoses that included Displaced Obliqued Fracture of Base of the Neck of Left Femur, Muscle Weakness, and Other Abnormalities of Gait and Mobility. A review of the most current Minimum Data Set (MDS) assessment, dated 05/02/25, under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #308 had good mental cognition. A review of Physician orders for Resident # 308 revealed an order dated 04/18/25 for Tramadol Hydrochloride 50 mg oral tablet every 6 hours as needed for non-acute pain. A review of the Control Drug Record for Resident #308 for Tramadol 50 mg every 6 hours as needed documented the drug was signed out and given on 04/25/25 at 5:30 AM. A review of Medication Administration Record for Resident #308 for 04/25/25 did not have any documentation for Tramadol 50 mg one tablet being administered on 04/25/25 at 5:30 AM. During an interview conducted on 05/08/25 at 11:16 AM with Staff L, Registered Nurse (RN) who was asked how she verifies that a controlled medication was administered in the MAR, responded, I will see a check mark, the Nurse's initials and the time the medication was given parallel to the medication's name. When asked what marks indicate that the medication was not administered, she stated, I will see a blank box or an x in a designated box parallel to the medication name and the date. When Staff L, RN was shown Resident #308's MAR for Tramadol 50 MG ( milligram), with a start date 0f 04/18/25 revealed an x on 04/25/25 box. When Staff L, RN was asked what it means, she responded, Tramadol was not administered to Resident #308 on that date. During an interview conducted with the DON on 05/08/25 at 11:55 AM who was asked when a controlled drug is being administered, how do Nurses document, responded, The Nurses document on the Controlled Drug Record and in the resident's Medication Administration Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to monitor behaviors and side effects accurately for Residents on Psychotropic medications (Residents #29, #48, #63, and #10), and failed to monitor side effects for a resident on anticoagulant (Resident #29) for 5 of 5 residents sampled for Unnecessary Medications. The findings included: A review of the facility's policy titled Use of Psychotropic Drugs, dated 12/17/2017, showed the following: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The attending Physician will assume leadership in medication management by developing, monitoring, and modifying the medication regime in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice and the resident's Comprehensive Plan of Care. 1. Record review revealed Resident #10 was readmitted to the facility on [DATE] with diagnoses of Psychotic disturbances, Dementia, and Major Depressive Disorder. The Quarterly Minimum Data Set, dated [DATE] revealed that Resident #10 was cognitively severely impaired. A review of the Physician's order showed an order for Remeron Oral Tablet (Mirtazapine), 15 milligrams, at bedtime for depression, which was dated 12/3/24. The Care plan dated 2/5/25 showed to monitor for the following: itching, picking at skin, hypotension, gait disturbance, cognitive impairment, behavioral impairment, decline in appetite, and abnormal involuntary movements. Monitor for the effectiveness of psychotropic drugs such as targeted symptoms/behaviors are controlled and observed for any adverse drug-related symptoms. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show that any of the behaviors or side effects were monitored or recorded by the nursing team regarding Resident #10. A review of the Psychiatrist's note dated 4/25/25 showed that staff to monitor, document, and report worsening symptoms of depressive symptoms: feelings of sadness/depressed mood hopelessness poor concentration loss of interest/lack of pleasure sleep disturbances tiredness and decreased energy change in weight and appetite feelings of worthlessness/guilt In an interview conducted on 5/6/25 at 3:25 PM with Staff E, a Licensed Practical Nurse (LPN), she stated that Resident #10 is monitored for side effects such as seizures, falls, sleepiness, withdrawal, and dizziness. They monitor behaviors and document in the MAR and TAR in the electronic system. In an interview with the Pharmacist on 5/7/25 at 10:45 AM, he stated that the facility staff should monitor behaviors and side effects for residents on psychotropic medication. He could not show this Surveyor that the behaviors or side effects were completed for Resident #10. 2. Record review for Resident #29 revealed the resident was originally admitted on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Atrial Fibrillation, Anxiety Disorder, and Vascular Dementia. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 13 indicating a cognitive response. Review of the Physician's orders for Resident #29 revealed in part the following: An order dated 08/06/24 for Mirtazapine (antidepressant) Oral Tablet 30 MG give 1 tablet orally at bedtime for Depression. An order dated 08/06/24 for Eliquis (anticoagulant) 5 MG Tablet give 1 tablet orally two times a day for AFib. An order dated 04/16/25 Bupropion HCl (antidepressant) Tablet 75 MG give 1 tablet by mouth two times a day related to Depression Record review for Resident #29 including the MAR/TAR for month of May 2025 revealed no monitoring of side effect or behaviors for psychotropic medications and no monitoring of side effects for anticoagulant. Review of the Care Plan for Resident #29 dated 08/13/24 with a focus on the resident is ordered to receive psychotropic medications which increase risk for: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decline in appetite, abnormal involuntary movements. Drug Class: Antidepressant (Bupropion, Mirtazapine). The goal was for the resident to receive the lowest dose possible of the prescribed medication to ensure maximum functional ability both mentally and physically through next review date. The interventions included to monitor the resident for effectiveness of psychotropic drug(s) (i.e. targeted symptoms/behaviors are controlled). Review of the Care Plan for Resident #29 dated 08/13/24 with a focus on the resident is at risk for abnormal bleeding or hemorrhage because of anticoagulant usage (Xarelto). The goal was for the resident to have a reduction of complications associated with anti-platelet/anticoagulant therapy through the next review date. The interventions included to: monitor for and report to nurse any of the following signs of bleeding: bleeding gums, nose bleeds, usual bruising, tarry, black stool or pink/discolored urine. Interview conducted on 05/07/25 at 9:59 AM with the Consultant Pharmacist who was asked if a resident is receiving a psychotropic medication does he check to see if the facility is monitoring for behaviors and side effects, he said yes and he verifies this by running an audit report. The report does not show him the monitoring it will only show the resident and the drugs they are monitoring the behaviors/side effects for. When asked if he checks if the facility monitors for side effects if a resident is receiving anticoagulant, he said he does not and that is up to nursing to monitor. 3. Record review revealed Resident #48 was admitted to the facility on [DATE], a re-admission on [DATE] with diagnoses of Dementia, Type 2 Diabetes Mellitus, Psychosis, Depression, and Anxiety Disorder. Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #48 had a Brief Interview for Mental Status (BIMS) of 05, which indicated that she was severely cognitively impaired. Review of the Physician's Orders showed that Resident #48 had orders dated 04/14/25 for Aripiprazole (an antipsychotic medication) Oral 2 milligrams (mg), to give 1 mg daily for Mood Disorder; and Mirtazapine (a psychotropic medication) 7.5 mg to be given at bedtime for Depression. Review of the Care plan dated 03/28/25 documented a focus that Resident #48 had orders to receive psychotropic medications which increased risk for: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decline in appetite, abnormal involuntary movements. The interventions included administer medications as prescribed by the physician, monitor for effectiveness of psychotropic drug(s) (Targeted symptoms/behaviors are controlled), and observe for any adverse drug-related symptoms. Continued review of the Care Plan documented a focus that Resident #48 had behavior problems on 03/29/25 (combative and getting out of bed without assistance), on 04/02/25 combative and refused medications, 04/04/25 combative during care, threaten staff, 04/07/25 and 04/08/25 combative, 04/09/25 calling out for husband, 04/15/25 combative with periods of confusion, 04/16/25 remains combative. Record review of Resident #48's psychiatry consultations dated 04/02/25 and 04/22/25 recommended for staff to monitor, document, and report worsening symptoms of psychosis, depression and anxiety. Review of the April Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed Resident #48 was not monitored for behavior and no interventions in place. In addition, there was no documentation for monitoring side effects for psychotropic medications. 4. Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Generalized Anxiety Disorder, Major Depressive Disorder, and Psychotic Disorder with Hallucinations. Section C of the MDS revealed Resident #48 had a BIMS of 12, which indicated that she was moderately cognitively impaired. Review of the Physician's Orders showed that Resident #63 had orders dated from 10/18/24 to 02/19/25 for the following psychotropic medications: Memantine 5 mg tablet to be given two times daily for Dementia, Zonisamide 25 mg capsule given at bedtime related to Psychotic Disorder, Donepezil 5 mg tablet given at bedtime for Dementia, and Buspirone 10 mg tablet give three times daily for anxiety. Continued review of the order summary report revealed an order for behaviors - monitor the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care; and to document: 'Y' if monitored and none of the above observed; 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings and interventions. Review of the Care plan dated 03/18/25 documented a focus that Resident #63 had orders to receive psychotropic medications which increased risk for: hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decline in appetite, abnormal involuntary movements. The interventions included administer medications as prescribed by the physician, monitor for effectiveness of psychotropic drug(s) (Targeted symptoms/behaviors are controlled), and observe for any adverse drug-related symptoms. Review of the May MAR and TAR revealed Resident #63 was monitored for behaviors, however, there are only check marks which indicated administered. As per the order to monitor behavior a Y or N were to be documented and progress notes to follow with interventions. In addition, there's no monitoring of the side effects of the psychotropic medications. During an interview conducted on 05/06/25 at 3:44 PM with Staff D, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 18 years. She stated they monitor behaviors and side effects for residents that are taking psychotropic medications. She also stated the documentation is recorded on the computer under the MAR and TAR because they no longer document in the paper charts. Staff D was accompanied by Staff P, LPN, who stated she has worked at the facility for 19 years and she agreed that the documentation is recorded on the computer. An interview was conducted on 05/07/25 at 10:10 AM with the consultant Pharmacist. He stated that if a resident is on a psychotropic medication the resident is to be monitored for behaviors and side effects. A side-by-side review of the monthly behavior report that he runs from the facility revealed that residents are monitored for behaviors of psychotropic medications. He then stated the report lets him know that behavior monitoring is in place; however, he does not know how the facility is doing the monitoring. He also stated that he does not need to see whether the resident is having behaviors because he does his recommendations according to the CMS regulations. 5. Resident #76 was admitted on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), Wedge Compression Fracture of Second Lumbar Vertebra , Type 2 Diabetes Mellitus, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, and Major Depressive Disorder. A review of the most current Minimum Data Set (MDS) assessment, dated 04/21/25, under Section C, revealed a Brief Interview of Mental Status( BIMS) score of 4 indicating Resident #76 had severely impaired cognition. Section I did not include the diagnosis of PTSD. Review of the Physician's Orders for Resident #76 revealed an order dated 09/30/24 for Escitalopram Oxalate Tablet 10 MG, 1 tablet by mouth one time a day for Depression. A review of recent Medication Administration Record (MAR) did not include monitoring for side effects of Escitalopram which might include insomnia and frequent falls. There was no documentation in MAR regarding observation of behaviors related to PTSD triggers. During an interview conducted on 05/06/25 at 11:11 AM with Staff C, Certified Nursing Assistant (CNA), who when asked if she knew Resident #76's triggers, responded, Resident does not have PTSD triggers. When asked about falls, she responded, she does not remember when. In an interview with Staff S, CNA on )05/06/25 4:16 PM who has been working in the facility for 4 months, who when asked about Resident #76's triggers, she stated, I think he is afraid to fall. We asked how many times resident fell, she responded, I do not know. In an interview with Staff T, Registered Nurse (RN) on 05/06/25 4:22 PM , who when asked about Resident #76s triggers, responded, I know resident forgets things, and has to be reminded by Staff. He does not want to remember a certain time in his life every year. When asked if Staff document behaviors and side effects related to antidepressant and other psychotropic medications, she responded' Yes, we do. When asked where Staff document behavior monitoring , she responded, In resident's MAR. During an interview conducted with the Director of Nursing (DON) on 05/08/25 at 1:21 PM, who when asked if Staff monitor behavior of residents on antidepressant, responded, We document them in Medication Administration Record (MAR). When asked if there are correlations with frequent falls and insomnia episodes of Resident #76 with the antidepressive medications, she responded, We have drug evaluations done by the Pharmacy Consultants. We also read Physician progress notes for additional information regarding monitoring for the side effects of medications. If there are falls , we write incident reports. She added that Resident #76 is getting support from the facility Staff and his family. When asked how many times the resident had a fall , she responded, I do not know but Resident #76 had a fall on 1/18/24, 3/19/24, 4/23/24, 5/26/24, 6/9/24, 7/6/24, 11/11/24, 1/24/25, 3/15/25. When asked if they could be related to his medications and the medications' side effects, she responded, Maybe, but physician is aware of what is happening to the resident, and so is the resident's family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication error related to expired insulin, for one of 5 sampled residents (Resident #68). The findings included: Review of facility's policy titled, Insulin Pen Policy, with an implementation date of [DATE], revealed that insulin pens should be disposed of after 28 days or according to the manufacturer's recommendations. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Obstructive Sleep Apnea, Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the Physician's Orders for Resident #68 revealed an order dated [DATE] for Novolog Flex Pen 100 Units (U) per ml (Milliliter) solution per sliding scale: If 0 - 149 = 0 U; 150-200=2 U; 201-250=4 U; 251-300=6 U; 301-350=8 U; 351-400=10 U, subcutaneously before meals for Diabetes Mellitus (DM). During a medication administration observation on [DATE] at 4:43 PM with Staff P, LPN, she stated she obtained a blood sugar of 202 for Resident #68, and she will give 4 units of Novolog insulin based on the sliding scale. She took the flex pen out of the first drawer of Medication Cart 2 on the [NAME] Wing. When Staff P, LPN, showed the Novolog Flex pen to the surveyor, it revealed an opened date of 4/2 and an expiration date of 4/30. When Staff P, LPN was asked regarding the expiration date, she stated the Novolog Flex pen had an expiration date of 4/30. When asked if she will use the insulin to the resident, she stated, Yes, because in this facility, insulin expires in 35 to 45 days. When asked what kinds of insulin expire in 35 to 45 days, she responded, All insulin we use. She proceeded to get the medications ready . The surveyor stopped her and asked again about the expiration date. She looked at the Novolog Flex pen and reread the date written on it, 4/30. When asked if she had given insulin doses to Resident #68 after 4/30, she responded, Yes. When asked if she had another Novolog Flex pen available for this resident, Staff P, LPN left the [NAME] Wing and returned after 10 minutes and told this surveyor that she found an Insulin Flex pen inside the emergency medication cart. She labeled the new Novolog flex pen with the open date and the expiration date before administering the required insulin units to Resident #68. In an interview with the Pharmacist Consultant on [DATE] at 10:08 AM, when asked about the effects of expired short acting insulin for a resident, he responded, There would be no harm, but the medications would be less effective or not as effective. When asked if the administration of expired insulin would contribute to hyperglycemia, he responded, It is possible. When asked about medication cart audits, he responded, I review and perform medication carts audits once a month, and Nurses are instructed to check their medication carts as often as possible. When he was asked about the expiration dates of commonly used insulin flex pens in the facility, he responded, The insulin when opened and kept in room temperature have the following expiration dates: Humulin R will expire in 31 days, Admelog will expire in 28 days, and Novolog will expire in 28 days. Review of the [DATE] Medication Administration Record (MAR) for Resident #68 revealed the resident received Novolog insulin on [DATE] three times; on [DATE] three times: on [DATE] two times; on [DATE] three times; and on [DATE] two times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to secure medications at the bedside for 2 of 30 sampled residents (Residents #19 and #68). The findings included: Review of the facility's policy titled, Medication Storage with an implemented date of 11/28/17 included in part the following: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy offsite and/or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation , moisture control, seclusion, and safekeeping. All drugs and biologicals will be stored in locked compartments under proper temperature controls. During medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage cart. 1 Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included Type 2 Diabetes Mellitus. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS)score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #19 revealed no order for Mupirocin ointment 2% or an order to self-administer medication. On 05/05/25 10:20 AM an observation of Resident #19 in wheelchair in doorway to room, on dresser across from bed was a tube of Mupirocin ointment 2%. On 05/06/25 10:20 AM a second observation was made in Resident #19's room on dresser across from bed was a tube of Mupirocin ointment 2%. During an interview conducted on 05/06/25 at 2:14 PM with Staff A Registered Nurse (RN) who stated he has worked at the facility for just over 1 year. When asked about medications at the bedside, he said no, the residents cannot have medications at the bedside unless they have been assessed to have the meds at the bedside. On 05/06/25 at 2:30 PM a side-by-side observation was made with Staff A RN who acknowledged d the prescription medication Mupirocin ointment 2%. was on Resident #19's dresser in plain sight. Staff A RN immediately removed the medication. 2. During observational room rounds conducted on 05/05/25 at 9:25 AM of Resident #68's room, observed 4 over the counter (OTC) large bottles of Calcimate Plus with Magnesium and Vitamin D-3 800 milligrams (mg) caplets, Magnesium Citrate 200 mg gummies, Probiotic gummies, and High-Metabolite Immunogens 500 mg capsules. The OTC medication bottles were unsecured, in plain sight and accessible to residents, staff members and visitors. Photographic evidence obtained. During a brief interview with Resident #68 on 05/05/25 at 9:25 AM, this surveyor asked Resident #68 about the OTC supplement bottles on her bedside table, the resident replied that her daughter brought them in since she was taking them when she was home. She stated she has not been able to take the supplements yet because she cannot reach them. She was asked if she knew if the doctor had ordered the supplements for her to take daily and she stated no. On 05/05/25 at 1:51 PM, Resident #68 was observed to have the 4 (OTC) large bottles sitting on her bedside table unsecured, in plain sight and accessible to other residents, staff members and visitors. Record review for Resident #68 revealed that the resident was admitted to the facility on [DATE] with diagnoses Type 2 Diabetes Mellitus. Section C of the Minimum Data Set (MDS) revealed that Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that she had an intact cognitive response. The order summary report showed an order for Meropenem (antibiotic medication) Solution Reconstituted 1 gram intravenously every 8 hours for Urinary Tract Infection (UTI) for 7 days starting on 05/01/25. Continued review of the order summary report revealed Resident #68 had no orders for the supplements: Calcimate Plus with Magnesium and Vitamin D-3 800 mg, Magnesium Citrate 200 mg, or High-Metabolite Immunogens 500 mg. In addition, there was no order for self-administration of medications. Review of the Care Plan dated 04/01/25 revealed no focus on Resident #68 to be able to self-administer medications. An interview was conducted on 05/08/25 at 2:44 PM with Staff I, Registered Nurse (RN), who has worked at the facility for 2 years and was the assigned nurse for Resident #68 for the 7-3 shift. She stated that if a resident has medications at the bedside, she is to confiscate them and hold them for the family to pick up. Staff I was not often assigned to the [NAME] wing; however, she was not aware Resident #68 can self-administer her medications and that she had supplements at the bedside table. During an interview conducted on 05/08/25 at 2:56 PM with Resident #68, who stated the nurse came into her room and took all the supplement bottles she had on the table, and she was not sure why. Resident #68 stated she is not getting those supplements at the facility, like Vitamin D-3 and the probiotic, and she needs them since she is currently on an antibiotic.

Based on observations, review and record review, the facility failed to provide food in a form designed to meet individual needs for the Pureed diet observed during 1 of 2 visits to the main kitchen. This has the potential to affect the 20 out of 98 residents on a Pureed diet. The findings included: The International Dysphagia Diet Standardization Initiative, dated January 2019, showed the following: Pureed food should have a smooth texture with no lumps, and it should not be formed or sticky. In an observation conducted on 5/5/25 at 7:55 AM in the central kitchen during the breakfast tray line, the following was noted: A half-size 6-inch deep stainless steel steam table container with pureed pancakes. Staff G, Cook, was getting ready to start the tray line for the breakfast meal. Closer observation showed that the pureed pancakes did not have a smooth consistency and were noted to be lumpy and grainy. This Surveyor tested the pureed food consistency using a spoon, which showed that it was firm and sticky on the spoon. In an interview conducted on 5/5/25 at 8:00 AM with Staff G, she stated that she has a new blender to mix up the food for the Pureed consistency and said she will put it through the blender again for the correct consistency. She then got the new blender from the back of the kitchen. In a phone interview conducted on 5/8/25 at 9:20 AM with Staff H, the Speech Language Pathologist stated that the pureed food consistency should have a uniform texture, smooth and not lumpy. It should resemble the texture of food like pudding, apple sauce, and humus.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of 2 visits to the main kitchen. The findings included: In an observation conducted on 5/5/25 at 7:30 AM during the initial tour of the main kitchen, the following were noted: The Dietary Service Manager was noted to have no facial hairnet protection while walking around the food production area. Staff F, Diet Aide, was noted to have no facial hairnet protection while walking around the food production area. Three rolls of raw ground beef, 5 pounds each, were noted inside the sink with no running water flow. In this observation, Staff G [NAME] stated that the raw ground beef was thawing for lunch today. The reach-in refrigerator was noted to have a metal container of cooked vegetables that was partially opened and exposed. A dirty, used rag was noted in a red bucket with no sanitizing solution. Empty food boxes and dirty used gloves were noted on top of the food production area on top of a clean pot. The reach-in refrigerator was noted to have two plates of a chef salad that were not dated or labeled. In an observation conducted on 5/6/25 at 12:30 PM, the Dietary Service Manager was noted to have no facial hairnet protection while walking around the food production area. In an observation conducted on 5/7/25 at 11:45 AM, the Dietary Service Manager was noted using a facility-calibrated thermometer to measure the temperature of the cooked foods for the lunch tray line. He was observed putting the thermometer inside the different food containers without gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #93 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Muscle Weakness (Generalized), Dysphagia, Expressive Language Disorder, and Adult Failure to Thrive. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status was not attempted due to the resident is rarely/never understood. On 05/05/25 at 10:10 AM observation of Resident #93 receiving tube feeding. There was no Enhanced Barrier Precaution (EBP) sign posted in room or on door. During an interview conducted on 05/05/25 at 10:34 AM with Staff A, Registered Nurse (RN), who stated he has worked at the facility for just over 1 year. When asked about Enhanced Barrier Precautions (EBP) he said he does not have any residents on EBP on his assignment today. When asked what the criteria for someone to have EBP is he said he would have to check on that. The RN never got back to the surveyor. The RN was assigned to care for Resident #75 who a had dialysis access port. During an interview conducted on 05/05/25 at 10:19 AM with Staff B Certified Nursing Assistant (CNA), who stated she has worked at the facility for 18 years. When asked about Enhanced Barrier Precautions (EBP) she said she does not have any residents assigned to her on EBP. When asked if she knew why a resident would have EBP or what the criteria is for EBP, she said she did not know. During an interview conducted on 05/05/25 at 10:25 AM with Staff C, Certified Nursing Assistant, who stated she has worked at the facility for 11 years. When asked about Enhanced Barrier Precautions (EBP) she said she does not have any residents on EBP. When asked what the requirement was for a resident to be on EBP, she said I think if they have falls. During an interview conducted on 05/06/25 at 2:14 PM with Staff A, Registered Nurse (RN), who was asked about Enhanced Barrier Precautions (EBP) and which type of residents would have the EBP or meet criteria for EBP, he said he forgot to check on that. When asked if he has any residents on EBP he said, I don't think so. When asked about if he has any residents receiving dialysis or tube feeding he said yes. Staff A RN said he thinks you need to do hand hygiene, wear gloves and a gown when taking care of those residents. When asked where the gowns are kept, he said they should be in an isolation cart in the hallway. When asked about EBP signs, he said they should be on the front door of the room. On 05/06/25 at 2:30 PM a side-by-side observation was made with Staff A RN who acknowledged there was no EBP sign in the room or on the door for Resident #93 who had a PEG tube. And the EBP signage for Resident #75 (who receives dialysis) was on the closet door and was unable to be seen when the room door was opened all the way as it covered the signage. During an interview conducted on 05/06/25 at 4:51 PM with the Infection Preventionist who stated she has worked at the facility since 2020. When asked about Enhanced Barrier Precautions (EBP) the IP stated EBP is implemented for all resident with any device put there that you were not born with such as a PEG tube , dialysis port, trach, colostomy and any wounds. The IP stated the staff have to wear gown and gloves while performing resident care for those residents, and an order and care plan should be in place. There should be an EBP sign on the resident's closet door. On 05/06/25 at 5:10 PM a side- by-side observation was conducted with the Infection Preventionist (IP) who acknowledged there was no EBP signage on the door or in the room for Resident #93. The IP stated she had overheard the surveyor interview with Staff A RN regarding EBP and immediately educated the staff member. Based on observations, interviews, and record reviews, the facility failed to follow the Enhanced Barrier Precautions (EBP) guidelines for 2 out of 23 residents reviewed (Resident #93 and Resident #26). The findings included: A review of facility policy titled, Catheter Care, implemented on 12/17/17 revealed the procedure for female catheter care is as follows: labia will be separated to expose the urinary meatus; wipe from front to back with moistened towel, with a new moistened cloth, starting at the urinary meatus moving out, then wipe the catheter. 1) Record review for Resident #26 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hemiplegia, Hemiparesis, Muscle Weakness, Aphasia, Type 2 Diabetes Mellitus Dysphagia, and Chronic Kidney Disease. A review of the quarterly Minimum Data Set (MDS) assessment for Resident # 26 dated 03/17/25, under Section C revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A review of Nursing care plan initiated on 12/17/24 revealed a focus on Enhanced Barrier Precautions related to indwelling catheter. The interventions included Staff must wear gown and gloves for high contact care areas which include changing briefs and urinary catheter . During observation conducted on 05/07/25 at 12:08 PM, Staff W, and Staff X, both Certified Nursing Assistants (CNAs) stated We will perform urinary catheter care for Resident #26. Both Staff CNAs gathered supplies after washing their hands, then donned on gloves, but did not don on gowns. Staff W, CNA, loosened Resident #26's brief and exposed the urinary catheter tubing. Resident #26 moaned as soon as the urinary catheter tube was touched and lifted from the perineal area. With gloved hands, Staff W, CNA started wiping the outside part of urinary catheter tube first, before wiping the part closer to the urinary meatus, inner vagina, vaginal folds and the rest of the front perineum. Staff W, CNA, used the same set of gloves during wiping, spraying of the hand-held soap to wet cloth towels, dipping cloth towels into the water basin, and drying both the front and back perineal areas. Staff W, CNA changed her gloves before applying the A and D ointment to the back areas. Staff X, CNA assisted with stabilizing Resident #26 when she was turned to the right side for the cleaning of the back area. When the urinary catheter care was completed, Staff W removed Resident #26's brief and replaced it with a fresh one. In an interview with Staff W, CNA who when asked what EBP means, responded, EBP is when Staff use gloves and gown for residents with tube feeding and urinary catheter. When asked why she did not don on a gown, she responded I forgot. When asked where are the post signage and EBP supplies for Resident #26, she responded, Resident #26's closet door has a EBP post, and the supplies are located on top of Resident #26's bedside table. Staff W, CNA pointed to plastic bags with blue gowns inside Resident #26's room. In an interview with Staff X, CNA, on 05/07/25 at 1:00 PM, who when asked why she did not don on a gown before performing urinary catheter care, responded, I forgot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure residents Do Not Resuscitate (DNR) directives were signed by the resident's Power of Attorney (POA) agent for 1 of 27 sampled residents reviewed for Advances Directives, Resident #67. The findings included: Review of the facility's policy, titled, Resident Rights Regarding Treatment and Advance Directives implemented on 11/28/17, provided by the administrator, did not address the DNR (Do Not Resuscitate) for procedure. Review of Resident #67's clinical record documented an admission on [DATE] with no readmissions. The resident's diagnoses included Adult Failure to Thrive Alzheimer's Disease and Vascular Dementia. Review of Resident #67's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status was not conducted due to the resident is rarely / never understood. The resident had severe cognition impairment and was totally dependent on the staff to complete the activities of daily living (ADLs). Review of Resident #67's care plan, titled, I have advanced directives .My code is DNR initiated on 11/18/22, had an intervention that read facility to discuss and review Advanced Directives with the Resident and/or Responsible Party Review of Resident #67's record profile listed a Power of Attorney (POA) Agent/Responsible Party. Further review of the resident's record documented a physician's DNR order dated 06/29/23. The record included the State of Florida Do Not Resuscitate Order form signed on 10/18/22 by Resident #67's emergency contact who was not listed as the POA. On 02/05/24 at 10:46 AM, observation revealed Resident #67 sitting up at the edge of the bed and fidgeting with the bed linen. An interview with the resident was attempted, who stated she was moving up north and stated she did not have any family. On 02/06/24 at 3:18 PM, an interview was conducted with the facility's Social Services Assistant who stated if the resident was not able to sign a DNR form, the resident's POA or a responsible party would be the one signing the DNR form. The Social Services Assistant stated Resident #67 was severely cognitively impaired. The Social Services Assistant stated that the resident had a POA who was to take care of the DNR form. The Social Services Assistant was apprised that the resident's DNR was not signed by the POA who referred the surveyor to the Director of Social Services. On 02/06/24 at 3:32 PM, an interview was conducted with the Director of Social Services (DSS) who stated that Resident # 67's POA was the person who had to sign the DNR form. The DSS stated she would call the resident's POA today to discuss the DNR and obtain a new form signed by POA. During an interview on 02/07/24 at 9:17 AM, the DSS stated Resident #67's POA was coming on 02/07/24 to sign the DNR form. On 02/07/24 at 9:19 AM during an interview, the administrator was apprised that Resident # 67's DNR was not signed by the POA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #87 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Encounter for Orthopedic Aftercare following Surgical Amputation, Atrial Fibrillation, Presence of Heart Assist Device. Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus. Review of the MDS for Resident #87 dated 01/22/24 revealed in Section C a BIMS score of 15, indicating cognition was intact. Review of the Physician's orders for Resident #87 revealed an order dated 01/25/24 to cleanse the left lower quadrant Ventricular Assist Device (LVAD) site with normal saline, pat dry, and cover with border dressing every night. Review of the record for Resident #87 revealed no care plan for the LVAD (Left Ventricular Assistive Device). On 02/06/24 at 9:00 AM, an observation was made of Resident #87, who was sitting on the edge of his bed. There was a black bag next to the bed with a cord that went under the resident's shirt. An interview was conducted on 02/06/24 at 9:00 AM with Resident #87, who was asked about the black bag with the cord that went under his shirt. He stated he has a LVAD, it runs on 2 battery packs, he has a total of 8 battery packs, and the batteries not being used were kept on the charger at all times. The resident then lifted his shirt to show where the device was connected to his abdomen that had a border dressing with no date. He said he checks it at least once a day every day, proceeded to show the surveyor what he checks, and that he gets a green light. An interview was conducted on 02/06/24 at 9:19 AM with Staff M, Registered Nurse (RN), who was asked if she is familiar with the LVAD, who stated 'yes one of our residents has one'. When asked about a care plan for the LVAD, she said she there should be one. 3. Record review for Resident #557 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included: Sepsis, Urinary Tract Infection, Guillain-Barre Syndrome, Paraplegia, and Obesity. Review of the MDS for Resident #557 dated 02/05/24 revealed in Section C a BIMS score of 15, indicating a cognition was intact. Review of the Physician's orders for Resident #557 revealed an order dated 01/29/24 to change the PICC dressing every 72 hours on Thursdays for hygiene. Review of the Care Plans for Resident #557 revealed no care plan for the PICC line. On 02/05/24 11:44 AM, observation of Resident #557's left arm PICC line that was in place revealed a clean dry intact dressing dated 01/29/24. An interview was conducted on 02/05/24 at 11:44 AM with Resident #557 who stated he is receiving Vancomycin and Rocephin for a Urinary Tract Infection (UTI), and he has a PICC line. An interview was conducted on 02/07/24 at 1:30 PM with Staff N, RN, who was asked how often a PICC line dressing is changed. She said she would have to look in the resident's chart, and was unable to answer the question in general. When asked about Resident #557's PICC line, she said she noticed the dressing needed to be changed based on the date and said it would be changed today. When asked how often the PICC line dressing is changed, she looked in Resident #557's chart and said it is supposed to be changed every 72 hours (3 days) on Thursdays. When asked to clarify if it is every 72 hours or every Thursday, she acknowledged the order was confusing. When asked if there was a care plan for the PICC line, she said there should be one. Based on observation, interviews, record and policy review, the facility failed to develop care plans for 2 of 3 sampled residents reviewed for Peripherally Inserted Central Catheter (PICC) lines, Resident #89 and Resident #557; and failed to develop care plans for residents with a Left Ventricular Assist Device (LVAD) for 1 of 1 sampled resident reviewed for a LVAD, Resident #87. The findings included: The facility's policy, titled, Comprehensive Care Plans, implemented 11/28/17, revealed, in part, The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Record review revealed Resident #89 was admitted to the facility on [DATE]. The resident was readmitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) line to the right upper arm for Osteomyelitis, with other diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Pressure Ulcer of sacral region. Review of the Medicare 5- day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of the resident's care plan revealed no care plan for the PICC line or the antibiotic. On 02/08/24 at 3:03 PM, it was discussed with Staff I, MDS Coordinator, regarding the lack of a care plan for the PICC line and antibiotic. She acknowledged there should have been a care plan for the PICC line and the antibiotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's protocol, titled, Nursing Protocols for Resident with Left Ventricle Assistive Devices (LVAD), with a date of 01/16/24, included: Monitor MAP (Mean Arterial Pressure) every shift with the cuff left in the room (Manual brachial cuff device) Do NOT USE the vital sign auto machine to obtain his MAP. Adequate blood pressure (typically, a MAP between 60mmhg and 90 mmhg) helps maintain sufficient pump flow. Commonly prescribed antihypertensive drugs include vasodilators, beta blockers, angiotensin-converting enzyme (ACE) inhibitors. Always monitor heart rate and blood pressure when giving these medications. Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses that included: Encounter for Orthopedic Aftercare Following Surgical Amputation, Atrial Fibrillation, Presence of Heart Assist Device, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus. The MDS for Resident #87 dated 01/22/24 revealed in Section C, a Brief Interview of Mental Status score of 15, indicating an intact cognitive response. Review of the Physician's orders for Resident #87 revealed an order dated 01/16/24 for full set of vital signs every shift. Review of the Physician's orders for Resident #87 revealed an order dated 02/06/24 to monitor mean arterial pressure (MAP) every shift using manual cuff only (kept at bedside) and record first sound parameters between 100-110 mmhg without doppler 40 mmhg must be subtracted from the reading. Normal flow 60-90 mmhg every shift for monitor and notify MD if lower than 60 mmhg use record LVAD only. Review of the blood pressures for Resident #87 from 02/01/24 to 02/05/24 were documented as: 02/01/24 at 1:15 AM, 127/71 mmhg 02/01/24 at 4:34 PM, 1/1 mmhg (as documented by Staff M, RN) 02/02/24 at 3:04PM, 108/66 mmhg 02/02/24 at 10:37 PM, 115/64 mmhg 02/03/24 at 4:01 AM, 110/62 mmhg 02/03/24 at 3:04 PM, 123/76 mmhg 02/03/24 at 5:30 PM, 120/66 mmhg 02/04/24 at 12:40 AM, 115/75 mmhg 02/04/24 at 2:04 PM, 1/1 mmhg (as documented by Staff M, RN) 02/04/24 at 5:05 PM, 118/70 mmhg 02/05/24 at 12:06 AM, 122/80 mmhg 02/05/24 at 12:40 PM, 1/1 mmhg (as documented by Staff M, RN) 02/05/24 at 6:52 PM, 130/776 mmhg This revealed nursing staff were not accurately documenting the MAP correctly. On 02/06/24 at 9:00 AM, an observation was made of Resident #87 who was sitting on the edge of his bed. There was a black bag next to the bed with a cord that went under the resident's shirt. On the nightstand, there was a charging device with 6 battery-type of boxes in the charging device. An interview was conducted on 02/06/24 at 9:00 AM with Resident #87 who was asked about the black bag with the cord that went under his shirt. He stated he has a LVAD (Left Ventricular Assistive Device). He further stated the device runs on 2 battery packs. He has a total of 8 battery packs, and they are kept on the charger at all times. The resident then lifted his shirt to show where the device was connected to his abdomen that had a border dressing with no date. When asked if the dressing was changed, he said yes, every day. He said he checks it every day at least once a day. An interview was conducted on 02/06/24 at 9:19 AM with Staff M, RN, who was asked if she is familiar with the LVAD. She said yes one of our residents has one. When asked if she does any sort of checks for the device, she said the resident is alert and he checks it. She said she looks at the batteries to make sure they are on the charger and the device gets a green light. When asked if she received any in-service on the LVAD she said yes and she was familiar with the LVAD (prior to the resident being admitted to the facility). When asked about the blood pressure, she stated it has to be done manually with the blood pressure cuff in the resident's room. Staff M stated you don't use a stethoscope, you just look at the needle on the dial and when the needle jumps that is the MAP (Mean Arterial Pressure). When asked where this is documented in the resident's chart, she said it is under the blood pressures, but you cannot just document 1 number (the MAP is only 1 number, not 2 numbers). An interview was conducted on 02/06/24 at 9:40 AM with the Director Of Nursing (DON) who was asked about residents with a LVAD. She stated she made a protocol and in-serviced the nurses. When asked if the staff monitor the LVAD, she said they check the green light and make sure the batteries are being charged. When asked about the blood pressure, she stated they cannot do a regular blood pressure for the resident, and they cannot use an automatic blood pressure machine. She said the resident has a manual blood pressure cuff at the bedside and the nurse will check the blood pressure with the manual cuff and when the needle on the dial first jumps that is the MAP. The nurse will then document this MAP on the resident's chart under blood pressures. She stated the normal MAP is between 60-90. The nurses were not calculating or documenting the MAP as specified by the physician order. Based on record review and interviews, the facility failure to administer antibiotic therapy in a timely manner for 1 of 1 sampled resident, Resident #505, as evidenced by not administering the antibiotic on 09/16/23 for two consecutive doses as ordered; and failed to ensure physician orders were followed for residents with a Left Ventricular Assistive Device (LVAD), as evidenced by lack of accurate monitoring, calulating and documentation of mean arterial pressure (MAP) for 1 of 1 sampled residents, Resident #87. The findings included: 1. Review of Resident #505's clinical record documented an admission on [DATE] with a discharge on [DATE]. The resident's diagnoses included Cellulitis of Left Lower Limb, Fracture of Left Patella with subsequent encounter for Closed Fracture with Routine Healing, and Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity. Review of Resident #505's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident had intact cognition. The assessment documented the resident received an antibiotic 7 days prior to the assessment. Review of Resident #505's care plan, titled, I am on antibiotic therapy (Linezolid) related to (skin and soft tissue) infection initiated on 09/18/23, had an intervention to include administer antibiotic medications as ordered by physician . Review of Resident #505's hospital discharge medication list dated 09/15/23 documented, Linezolid 600 milligram (mg) every 12 hours for 15 doses - last time this was given on 09/15/23 at 10:17 AM . Review of Resident #505's physician orders dated 09/15/23 documented, Linezolid (antibiotic) Oral tablet 600 mg (Linezolid) give 1 tablet by mouth two times a day for skin and soft tissue infection. This physician order was reordered on 09/18/23 as, Linezolid Oral Tablet 600 MG (Linezolid) Give 1 tablet by mouth two times a day for Cellulitis Left Lower extremity for 12 Administrations until finished. Review of Resident #505's September 2023 Medication Administration Record (MAR) documented Linezolid Oral tablet 600 mg (Linezolid) give 1 tablet by mouth two times a day for skin and soft tissue infection start date 09/15/23 at 9:00 PM. Further review of the resident's September MAR documented that Linezolid was administered on 09/15/23 at 9:00 PM and was not administered on 09/16/23 for the 9:00 AM and 9:00 PM doses as scheduled and as per physician order. Review of Resident #505's Staff M, Registered Nurse (RN), note dated 09/16/23 at 3:52 PM documented, Linezolid Oral Tablet 600 MG Give 1 tablet by mouth two times a day for skin and soft tissue infection. Not Given, Pharmacy made aware. The note documented, Show on Shift Report Show on 24 Hour Report. Review of Resident #505's nursing note dated 09/16/23 at 11:51 PM documented, Linezolid Oral Tablet 600 MG Give 1 tablet by mouth two times a day for skin and soft tissue infection. Awaiting on delivery, pharmacy called, NP (Nurse Practitioner) notified. The note documented Show on Shift Report Show on 24 Hour Report. Review of Resident #505's nursing note dated 09/17/23 at 4:29 AM documented, in part, .resident had numerous questions in regard to the antibiotic treatment .resident was informed that an approval from insurance was needed .resident feels her condition is too critical for a delay in sending the medication .pharmacy calls facility stating the antibiotic has a contraindication to one of the resident's current medication. Physician was contacted and stated no changes .pharmacy was recontacted with the doctor's decision, awaiting medication from the pharmacy . On 02/08/24 at 11:38 AM, an interview was conducted with Staff M, RN, who stated medications for new admission are taken from the Pyxis system (an automated medication dispensing system). Staff M stated she recalled Resident #505 and that on 09/16/23, a Saturday, the resident's ordered antibiotic was not in the Pyxis system in either wing. Staff M added she then called the weekend supervisor to make him aware of that, who instructed her to call the pharmacy to get the antibiotic. Staff M stated she did not have the antibiotic to administer to the resident on 09/16/23 for the 9:00 AM dose. Staff M added the medication was not delivered on her shift. On 02/08/24 at 9:17 AM, an interview was conducted with the Director of Nursing (DON) who stated the facility changed the pharmacy provider in 01/2024. The DON was asked if she had heard of any residents not getting their antibiotic therapy as ordered in the last 5 months. The DON stated she had not. The DON was apprised that Resident #505 did not receive the Linezolid antibiotic twice on 09/16/23 after receiving the initial dose upon admission. The DON stated new admissions can come at any time of the day or night. The DON stated if a new resident comes in and needs antibiotic therapy, the nurse can start the initial dose provided it is in house (Emergency kit/ Pyxis system). The DON stated nursing staff had been trained on how to use the Pyxis/Emergency kit. The DON stated that if the antibiotic tablets were not in the Pyxis system, they needed to order before the cut off time and that they could get them at 6:00 PM or on the midnight pharmacy run. The DON added that if they needed the medication right the way, she would contact the Director of Pharmacy and ask for a special run. On 02/08/24 at 1:51 PM, an interview was conducted with the DON who stated she remembered Resident #505 because they bonded. The DON stated she did not know why there was a break on the resident's antibiotic therapy administration on 09/16/23. The DON read nursing note for 09/17/23 at 4:29 AM and stated she did not know why the pharmacy did not communicate the information regarding antibiotic contraindication or insurance approval with her. The DON stated it was not mentioned in the quality meeting about issues with Resident #505 not receiving her antibiotic as ordered. The DON was apprised that the nursing notes for 09/16/23 day and evening shift were checked off to show on the 'shift and 24 report'. The DON stated she was not aware of the payment issue for Resident #505's Linezolid antibiotic and added it was a fluke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide nutritional interventions and assessments in a timely manner for 2 of 5 sampled residents reviewed for nutrition, Resident #15 and Resident #70. The findings included: Review of the facility's policy, titled, Weight Height Monitoring Policy, with a reviewed date of 11/28/23, included: In accordance with the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition suggests otherwise or not aligned with the resident preferences. The facility will obtain heights and measure/monitor weights upon admission, on Day 3 post admission by Restorative, weekly and monthly to assure communication and timely interventions to support or reverse weight gained or lost. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary. 1. Record review revealed Resident #15 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included: Dementia, Anxiety Disorder, Gastroparesis, Myasthenia Gravis, Sjogren syndrome, Systemic Lupus Erythematosus, and Schizoaffective Disorder Review of the Minimum Data Set (MDS) for Resident #15 dated 11/11/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition is intact. In Section K, it was documented the resident's height as 61 inches (5'1) and the weight in pounds as 100, weight loss of 5% or more in the last month or loss of 10% or more in last 6 months was answered yes, not on a physician-prescribed weight-loss regimen. Review of the weights for Resident #15 revealed the following: On 08/16/23, the resident weighed 115.8 pounds. For the month of September 2023, there were no weights. On 10/10/23, the resident weighed 100.0 pounds. This indicated from 08/16/23 to 10/10/23, the resident had a 13.64 % weight loss. On 08/16/23, the resident weighed 115.8 pounds and on 10/10/23, the resident weighed 100.0 pounds which is a -13.64 % weight loss. Review of the Physician's orders for Resident #15 revealed an order dated 11/13/23 for NAS (No Added Salt) diet, Regular texture, Regular / Thin consistency. Review of the Care Plan for Resident #15 dated 04/29/21 with a focus on the resident is at nutritional risk: As evidenced by: Therapeutic diet, mechanically altered texture, h/o [history of] poor appetite PTA, c/o [complaint of] nausea Related to: Disease process / condition, Constipation. The goals were resident desires her laboratory values to be within desired limits (per physician) by the next review date, and she desires her weight to remain +/- 5% current weight through next review date. The interventions included: Weights monthly and as needed. No sig. wt. [significant weight] change seen One inconsistence in wt. seen, reweigh the patient. 25-100% Poor to fair intake. Review of the Nutrition / Dietary Note for Resident #15 dated 05/31/23 revealed: Resident readmit to the facility s/p [status post] hospitalization Diagnoses; Dementia, Gastroparesis, Hypokalemia, HTN [Hypertension], HLD [Hyperlipidemia] Resident refuses for weight checkup. Diet; Reg [Regular] diet, Reg. Text. Reg. thin consistency, PO [oral] Intake : poor Various intake noted in chart 25-76% she refuses to eat meal sometimes, Meds; Ondansetron, Amlodipine, Statin, Colace, Pantoprazole, Losartan, Megace, Tramadol, No recent labs; Recommendation; Boost x 2 daily, She likes ginger ale; snack in between. Request to reweight. Will monitor any change in weight, po intake skin. Will follow as needed. Review of the Weight Change Note for Resident #15 dated 06/02/23, Refused; on 05/08/23, Refused weight. Review of the Standard of Care (SOC) Noted dated 08/09/23 included: Resident with adequate po intake consuming 75% or more of all meals. No significant wt (weight) loss noted at this time. Current wt within desirable range. Review of the Plan of Care Note for Resident #15 dated 08/31/23 included: Dietitian met with care plan team for resident's quarterly review. Contacted POA [power of attorney] regarding resident's current nutritional status. Resident continues to be weighed. POA stated Last known weight at hospital in 123lbs (pounds). Review of the Nutrition Risk Assessments for Resident #15 revealed the last Nutrition Risk / Assessment was completed on 03/06/23. Review of the Notes for Resident #15 revealed no notes related to diet/nutrition or weight loss were documented after 08/31/23. An interview was conducted on 02/05/24 at 1:00 PM with Resident #15 who was asked if she had been trying to lose weight, she said no. When asked about being weighed, she stated she does not like to be weighed. An interview was conducted on 02/06/24 at 11:00 AM with Staff I, MDS Coordinator (MDSC), who acknowledged there were no dietary / nutrition notes or assessments since August of 2023. The MDSC stated she is responsible for the care plan meetings and to make sure the assessments are in the residents' chart. She stated there was a period of time when they were 'with no RD' but did not remember the dates. She acknowledged the RD did not attend the care plan meeting for the resident on 08/31/23. An interview was conducted on 02/07/24 at 2:45 PM with the Registered Dietician (RD) who stated she has worked at the facility for 3 months and 2 weeks full time and is leaving on 02/16/24. She stated she was a covering as the Registered Dietician when the RD would go on vacation or if the dietician had left. The last time the dietician left was maybe 5 months ago around August or September. She mainly would fill in the MDS sections. The RD stated a significant weight loss is 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. The RD stated the restorative aides give her the weights for the resident on a weight sheet, monthly weights are given monthly and weekly weights are given to her weekly. She puts the weights in the chart, and she will print out the last 6 months to see if a resident has any significant weight loss. The RD stated there is no issue with residents being weighed. If a resident has weight loss, she would put interventions in place, such as appetite stimulant, supplements, or weekly weights. Nutritional assessments are done on admission and quarterly, and then annually. When asked about Resident #15, the RD stated if the resident refused her weights, she would simply put a zero in for the weight. The RD acknowledged the resident was not weighed on 10/23/23, 11/14/23, and 12/15/23. She said she would talk to the resident to encourage her to get weighed and she would ask restorative aides to try to reweigh the resident. The RD acknowledged she did not put in any notes for this. She stated the other RD would have identified significant weight loss on 08/16/23 as 16% weight loss in 30 days. The last nutrition assessment completed for Resident #15 was completed on 03/10/23. The RD stated she missed an assessment in November 2023 and the resident had missed an additional nutrition assessment before she started working at the facility. The weight for the resident on 10/10/23 was 100 pounds which was a 13.6# weight loss in 60 days. She stated that for a lot of these weights, she did not have time to address them because she had just started and was trying to get caught up and she missed the significant weight loss in October, and also missed her nutritional assessment as well. She was trying to catch up on the assessments that were not done prior to her starting at the facility and putting a system in place for the weights to be put into the resident's records. The RD acknowledged she did not address the significant weight loss for the resident in October and therefore did not put any interventions in place to address the weight loss. When asked about care plans, she said she would attend the care plan meetings. For the care plan meeting on 12/04/23, she was on vacation for a week and did not attend the 2 care plan meetings scheduled for that week. The RD stated there was no RD covering her for when she was on vacation for the week in December 2023. An interview was conducted on 02/08/24 at 3:30 PM with Resident #15 who was asked if she had been trying to lose weight, she said no, but knows she lost some weight and had put it back on recently. When asked if she refused to be weighed at times, she said she hates to get on the scale so yes, she sometimes refuses. 2. Record review showed Resident #70 was admitted to the facility on [DATE] with diagnoses of protein-calorie malnutrition, colon cancer, and lung cancer. Review of the Physicians' orders, dated 11/03/23, revealed the following: Boost (nutritional supplement) three times a day for weight management, Chocolate flavor Boost 237 milliliters (one bottle). The Significant Change Minimum Data Set (MDS) assessment, dated 12/07/23, revealed Resident #70 has a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. An interview was conducted on 02/05/24 at 9:40 AM with Resident #70 who was noted in bed with the breakfast tray at the bedside out of reach. When asked why he was not eating, he stated that he was waiting for staff to assist him with his breakfast tray. Resident #70 stated that he had lost about 50 pounds and that he has cancer. He then asked the surveyor if any staff was noted at the nurse's station to help him with his breakfast meal. Continued observation at 10:32 AM, an hour and a half later, revealed the meal tray was still at the bedside untouched. At 10:35 AM, Staff A, Licensed Practical Nurse (LPN), went into Resident #70's room and pushed the side table with the breakfast tray closer to Resident #70, so he could reach his meal. In an observation conducted on 02/05/24 at 11:00 AM, Resident #70 had eaten 10% of his oatmeal but did not touch anything else. When asked why he was not eating, he said he was in pain, was tired and that he asked Staff A for Boost when she gave him the pain medication around 10:30 AM. An interview was conducted on 02/05/24 at 11:30 AM with Resident #70, who stated Staff A still needed to bring his Boost supplement and asked the surveyor if they could speak to the nurse regarding his supplement. In an observation conducted on 02/05/24 at 12:35 PM, Resident #70 was noted in the room eating his lunch meal. At 12:55 PM, Resident #70 had eaten 10% of his meal and asked the surveyor if they could bring him another bottle of Boost. Review of the Medication Administration Record (MAR) revealed that on 02/05/24, the Boost was given at 9:00 AM, 1:00 PM, and another one at 5:00 PM. Review of the weight log showed the following weights for Resident #70: 140 pounds dated 11/07/23, 140 pounds dated 11/14/23, no weight recorded on 12/15/23, and no weight recorded on 01/10/24. The nutrition risk assessment dated [DATE] revealed the following: Resident #70 is consuming between 25% to 100% of his meals. He has diagnoses that could cause unavoidable weight and loss of appetite. It further showed that Resident #70 was in hospice and was receiving Boost supplements three times a day. Resident #70 will be followed and monitored with adjustments as needed. In an interview conducted on 02/06/24 at 1:30 PM with Resident #70, he stated that it is easier for him to drink the Boost supplements than to eat the food. When asked by the surveyor if he would drink more than 3 Boost supplements a day if offered, he said yes. Review of the care plans for Resident #70 did not show that any care plan was initiated for nutrition. An interview was conducted on 02/07/24 at 3:07 PM with the facility's Dietitian who stated she did not notice that Resident #70 did not have a care plan for nutrition and that she is in charge of the nutrition care plan for all residents. The facility's Dietitian reported that she should have followed up on Resident #70's nutritional status sooner and acknowledged that the last follow-up note was completed on 12/07/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #557 revealed the resident was originally admitted to the facility on [DATE], with a most recent readmission of 01/29/24 with diagnoses that included: Sepsis, Urinary Tract Infection (UTI), Guillain-Barre Syndrome, Paraplegia, and Obesity. Review of the MDS assessment, dated 02/05/24, for Resident #557 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. Review of the Physician's orders for Resident #557 revealed an order dated 01/29/24 to change PICC (Peripherally Inserted Central Catheter) dressing every 72 hours on Thursdays for hygiene. Review of the Care Plan for Resident #557 revealed there was no PICC care plan implemented. On 02/05/24 11:44 AM, observation of Resident #557 revealed the left arm PICC line was in place with a dressing that was clean, dry, intact and dated 01/29/24. An interview was conducted on 02/05/24 at 11:44 AM with Resident #557 who stated he is receiving Vancomycin and Rocephin for UTI. He said he has a PICC line, and the dressing should be changed today. An interview was conducted on 02/08/24 at 3:00 PM with Staff I, MDS Coordinator (MDSC) who acknowledged there was no care plan implemented for a PICC for Resident #557. Based on observation, interviews, record and policy review, the facility failed to maintain Peripherally Inserted Central Catheter (PICC) lines in a sanitary manner for 3 of 3 sampled residents reviewed for PICC lines, Residents' #67, #89, and #557. The findings included: The facility's policy, titled, PICC/Midline/CVAD Dressing Change implemented 11/28/17, revealed It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing, weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. 1. Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE] with a Peripherally Inserted Central Catheter (PICC) line to the right upper arm for Osteomyelitis. Other documented diagnoses included Chronic Obstructive Pulmonary Disease and Pressure Ulcer of sacral region. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. On 02/05/24 at 8:55 AM, an observation of the resident's PICC line dressing was conducted during the initial screening process. The dressing was labeled with a date of 01/28/24. On 02/06/24, another observation was made of Resident #89's PICC line dressing. It was still labeled 01/28/24 and was bloody. Photographic Evidence Obtained. Review of the resident's Medication Administration Record (MAR) for February 2024 revealed no antibiotic or flushes to the PICC line were scheduled for February 2024. Review of the nursing progress note dated 02/06/24 revealed Picc line removed to right upper arm foul odor and pus noted informed .(Physician's Assistant) PA wound care consult in placed. Interview with the Director of Nurses (DON) on 02/07/24 at 1:19 PM revealed she was unaware there was a problem with Resident #89's PICC line and she would look into it. On 02/07/24, a Health Status note revealed, Resident observed with PICC line still in place. IV [intravenous] antibiotic completed 01/30/2024, flush orders completed on 01/31/2024. PICC site assessed, no pain or swelling, no redness or discoloration and no drainage observed at the site. MD [Medical Doctor] notified order received to discontinue PICC line, CBC [complete blood count], blood culture of site. On 02/07/24 at 4:00 PM, the PICC line concern was discussed with the Director of Nursing (DON). She stated the CBC was completed and the white blood cell count was improved from the last blood test dated 01/29/24. The blood culture will not be ready until 02/12/24. The DON revealed the PICC line should have been discontinued within 2 days after the antibiotic was finished which was 01/30/24. On 02/08/24 at 5:00 PM, the DON revealed that batch orders are put in the computer for PICC lines but for some reason the order for the dressing change was not put in for Resident #89 so her dressing was not changed weekly. 3. Record review of Resident #67's clinical record documented an admission on [DATE] and no readmissions. The resident's diagnoses included Adult Failure To Thrive, Alzheimer's Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, Vascular Dementia, Severe with other Behavioral Disturbance and Urinary Tract Infection. Review of Resident #67's MDS annual assessment dated [DATE] showed a BIMS score was not conducted due to the resident is rarely/never understood. The resident had severe cognition impairment. The assessment documented under Functional Abilities & Goals that the resident was dependent on the staff to complete the activities of daily living (ADLs). Review of Resident #67's MDS annual assessment dated [DATE] showed a BIMS score was not conducted due to the resident is rarely/never understood. The resident had severe cognition impairment and was totally dependent on the staff to complete the ADLs. Review of Resident #67's care plan, for I am on antibiotic therapy .related to Urinary Tract Infection, initiated on 01/26/24, had an intervention to change (Midline) dressing .every 72 hours .monitor (Midline) insertion site every shift for any changes in appearance . Resident #67's physician order dated 01/25/24 documented, Insert Midline .for leukocytosis (infection) for 10 days. Resident #67's physician order dated 01/26/24 documented Change (Midline) dressing 24 hours after initial insertion; then every 72 hour every evening shift every 3 day(s) for hygiene change every 72 hours. Resident #67's physician order dated 01/25/24 documented, Ceftriaxone 1 gram intravenously every 24 hours for Urinary Tract Infection for 7 days. Resident #67's physician order dated 01/29/24 documented, Meropenem 500 milligrams intravenously every 8 hours for Urinary Tract Infection for 7 days. Review of Resident #67's February 2024 Treatment Administration Record (TAR) documented the resident's Midline dressing was changed on 02/04/24 evening. On 02/07/24 at 10:02 AM, a side-by-side review of Resident #67's Midline dressing was conducted with Staff O, Licensed Practical Nurse (LPN). Staff O stated the resident's Midline dressing on the upper right arm was not dated and it was supposed to be changed. Staff O added it was changed but was not dated. On 02/07/24 at 2:45 PM, an interview was conducted with Staff O who stated she worked on 02/04/24 evening shift and did not change Resident #67's Midline dressing that was scheduled for 02/04/24 evening. Subsequently, a side-by-side review of the resident February 2024 TAR was conducted with Staff O. Staff O was apprised that she documented that she did change the resident's dressing when she did not do it. Staff O was asked why she did not do the change as scheduled and did not answer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to address residents' pain in a timely manner for 1 of 1 sampled resident reviewed for Pain, Resident #70. The findings included: Review of the facility's policy, titled, Pain Management, implemented on 11/28/2017, showed the following: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. To help a resident attain or maintain their highest practicable level of well-being and to prevent or manage pain, the facility should recognize when the resident is experiencing pain. Record review showed that Resident #70 was admitted to the facility on [DATE] with diagnoses to include Protein-Calorie Malnutrition, Colon Cancer, and Lung Cancer. Review of the Physicians' orders revealed the following: -On 12/01/23, an order for Morphine Sulfate (pain medication), 15 milligrams, one tablet by mouth every 12 hours for severe pain. - On 11/05/23, an order for Oxycodone (pain medication), 10 milligrams, every 4 hours as needed for pain. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident #70 has a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition is intact. Section J of this MDS showed that Resident #70 is in constant pain. In an interview conducted on 02/05/24 at 9:40 AM, Resident #70 stated that he was in pain and was waiting on his pain medication. He further said that the pain medication was not given to him at the scheduled times, which was twice a day at 9:00 AM and 9:00 PM. In an interview conducted on 02/05/24 at 10:39 AM, Resident #70 stated Staff A, Licensed Practical Nurse (LPN), had just given him his pain medication (Morphine), which was scheduled for 9:00 AM. Review of the Medication Administration Audit Report revealed the following: -On 02/05/24, the Morphine medication that should have been given at 9:00 AM was given at 10:28 AM. -On 02/05/24, the Morphine medication that should have been given at 9:00 PM was given at 11:03 PM. -On 02/01/24, the Morphine medication that should have been given at 9:00 PM was given at 10:23 PM. -On 02/01/24, the Morphine medication that should have been given at 9:00 AM was given at 2:12 PM. -The Morphine medication that should have been given at 9:00 PM was given at 12:12 AM (next day). The care plan initiated on 12/21/23 revealed Resident #70 was at risk for pain and the pain would be reduced by the interventions put in place. Continued reviewing of the care plan showed the nurse would administer and monitor the effectiveness of the routine pain medication. In an observation conducted on 02/06/24 at 8:31 AM, Resident #70 was in bed waiting on his breakfast tray. In this observation, Resident #70 said that he has pain everywhere and that he is waiting on his pain medication (Morphine) that was supposed to be given at 9:00 AM. An interview was conducted on 02/06/24 at 1:21 PM with Staff H, Registered Nurse / RN, who stated Resident #70's pain level is around 6 to 8 levels out of 10. Before giving Resident #70's his pain medication, she would always ask him about his pain level. When asked when the Morphine medication is given for Pain, Staff H said it is given twice daily at 9:00 AM and at 9:00 PM. Interview was conducted with Director of Nursing (DON) regarding the pain on 02/06/24 at 3:20 PM, who stated that regarding pain management, she expects the nursing staff to administer pain medication and assess the pain level as well. When asked about the medications' timing, she said it is usually one hour before and one hour after the scheduled medication time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that dialysis services were consistent with professional standards of practice for 1 of 1 sampled resident reviewed for dialysis (Resident #62), as evidenced by inproper hand hygiene during observation of dialysis services and not providing the correct fluid restriction as per physician orders. The findings included: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses that included End-Stage Renal Disease, Type 2 Diabetes, and dependence on renal dialysis. Review of the physician's orders revealed a diet for regular texture and regular/thin consistency with 1200 fluid restriction diet. Dietary: 240 milliliters (8 ounces) with breakfast, 120 milliliters (4 ounces) with lunch, and 300 milliliters (10 ounces) with dinner. In-house hemodialysis every Monday, Wednesday, and Friday. In an observation conducted on 02/05/24 at 12:30 PM, Resident #62 was in his room with the lunch tray. Closer observation showed a lunch tray with 4 ounces of juice and 8 ounces of milk from the morning breakfast tray at the side table. In this observation, Resident #62 was asked if he was on a fluid restriction, and he said yes. Resident #62 reported that he did not know how much fluid restriction he was on for each meal, but the facility needed to be on top of it. In an observation conducted on 02/06/24 at 8:30 AM, Resident #62 was in the room with the breakfast tray. The meal ticket was noted with the following: regular, No Added Salt (NAS), liberalized protein, No Concentrated Sweets (NCS), double protein, fluid restriction, 4 ounces of milk, and 4 ounces of juice. The meal plate was noted with the following food items: double portion of eggs, toast, cereal, 4 ounces of juice, and 8 ounces of milk (not the 4 ounces of milk as per fluid restriction). In this observation, Staff T, Certified Nursing Assistant (CNA), was observed in the room pouring some of the 8 ounces of milk into Resident #62's cereal. The care plan initiated on 09/20/22 revealed the following: Communicate with the dialysis center on an ongoing basis to maintain continuity of care, and the nurse will ensure that the dialysis access site/ AV (arteriovenous) shunt or graft is checked before and after dialysis treatments. In an observation conducted on 02/07/24 at 7:45 AM, Resident #62 was preparing for the hemodialysis artery fistula connection in the dialysis room. Staff B, the patient care technician, was observed washing his hands and placing on a clean pair of gloves. He then opened the cabinet door to pull out a sanitary disposable pad with the same gloves. He put clean supplies on the clean pad and wiped the access site on Resident #62's left arm. Staff B removed his gloves and placed a new pair without practicing hand hygiene. He then wiped the sweat from his forehead with his arm and part of his gloved hand and continued with the same dirty gloves to connect the dialysis tubing to Resident #62's left arm. During this observation, Staff B did not practice hand hygiene between changing gloves. An interview was conducted on 02/07/24 at 8:40 AM with Staff C, Unit Clerk, who stated that when a resident goes to dialysis, a communication sheet is filled out. The facility fills out the first part before dialysis, the dialysis company fills out the second part of the form, and the nurse fills out the third part when the residents return from dialysis. Staff C reported that all communication sheets are loaded onto the electronic system. Review of the electronic system revealed that the last communication dialysis sheet entered the electronic system was 01/31/24. Further review of the dialysis binder located at the nurse's station showed that on the day of the dialysis treatment dated 02/05/24, the pre-dialysis treatment was completed by the facility nurse, the dialysis center information was completed by the dialysis staff, but the facility staff filled no post dialysis information after the dialysis. In an interview conducted on 02/07/24 at 12:30 PM with Staff B, he acknowledged that he did not practice hand hygiene between glove use when going from a dirty area to a clean area. In an interview conducted on 02/08/24 at 12:51 PM, the facility's Registered Dietitian stated that for any residents on fluid restrictions, she would break down the specific number of fluids that are allocated for breakfast, lunch, dinner, and the nursing staff. The last person on the tray line oversees checking the meal trays to ensure that the correct fluids are provided accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure physician visits were performed as required for 1 of 1 sampled resident reviewed for physician visits, Resident #76. The findings included: Review of the facility's policy, titled, Physician Visits and Physician Delegation, with a reviewed / revised date of 11/28/23, included the following: It is the policy of this facility to ensure the physician takes an active role in supervising the care of the residents. The Medical Record personnel to track due dated of physician visits. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a physician or physician delegate as appropriate by law. At the option of the physician, required visits in SNFs (Skilled Nursing Facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician. Record review revealed Resident #76 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included Osteomyelitis of Vertebra Sacral and Sacrococcygeal Region. Review of the Minimum Data Set (MDS) assessment for Resident #76 dated 12/23/23 revealed in Section C, a Brief Interview of Mental Status score of 15, indicating an intact cognitive response. Review of the Medicine Progress Notes for Resident #76 from 01/03/22 to 01/15/24 revealed the last time the resident was seen by the primary care physician was on 03/03/22. The review also revealed the resident was seen monthly by the ARNP (Advanced Registered Nurse Practitioner) from 04/12/23 to 01/15/24. There was no documentation of physician visits during this time period. Review of additional information provided by the facility noted the resident was seen by the ARNP on 01/05/23 and 02/13/23; and by the PA-C (Physician Assistant) on 04/02/23. There was no evidence of a visit for the month of 03/2023. During an interview conducted on 02/05/24 at 9:43 AM with Resident #76, he stated the doctor does not come in to see him or talk to him, he is only seen by the nurses. During an interview conducted on 02/07/24 at 1:30 PM with the Director of Nursing (DON) who was asked how often the physician visit residents. The DON stated the resident is seen within 72 hours of admission by the physician, then the resident is seen by the Physician's Assistant (PA) or the Advanced Practice Registered Nurse (APRN) every 30 days. When asked how often the physician visits the resident the DON stated the physician comes every other month alternating with the PA or the ARNP. An interview was conducted on 02/08/24 at 12:00 PM with the Director of Therapy / Administrator of PCC, who stated she has been helping the Medical Records department partially for the past few weeks since they no longer have Medical Record personnel. When asked how often a physician visits with a resident, she stated every 30 days for the first 90-day period, then it is every 60 days thereafter. When asked how she keeps track of when the physician visits the resident, she stated there is only 1 physician who comes to the facility, who just came in January (2024), and then he will come again in February 2024. When asked if he sees every resident each time he visits, she said she is not aware of that. When asked who keeps track of how often the physician sees a resident, she said the physician keeps track of his own schedule of which residents he sees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy reviews, the facility failed to initiate care plans with interventions regarding the diagnosis of Trauma/Post Traumatic Stress Disorder (PTSD) in a timely manner for 1 of 1 sampled resident reviewed for Trauma, Resident #86. The findings included: A review of the facility policy, titled, Trauma Informed Care, dated 11/28/2017, revealed that the facility would ensure residents who are trauma survivors receive culturally competent trauma-informed care in accordance with professional standards of practice. Record review revealed Resident #86 was admitted on [DATE] with diagnoses of Trauma/Post Traumatic Stress Disorder (PTSD) and Muscle Weakness. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #86 has a Brief Interview of Mental Status (BIMS) score of 11, indicating intact cognition. In an interview conducted on 02/07/24 at 10:46 AM, Resident #86 stated that someone came to his house in [another country] and shot his wife to death in front of him. He was then taken away and held in a remote place for 16 days by unidentified men. He feels constant guilt after what happened and that he still has nightmares at times. Review of the hospital records dated 11/20/23 revealed Resident #86 has been suffering from PTSD symptoms of being kidnapped from a year ago. The care plan initiated on Resident #86's admission did not show that a care plan with interventions was initiated regarding Trauma/PTSD. In an interview conducted on 02/07/24 at 9:40 AM, the Director of Nursing (DON) stated when Resident #86 was admitted to the facility, the hospital records revealed that he suffered a post-traumatic experience. The DON stated they were not treating PTSD since Resident #86 was in the facility for rehab and not for treatment of PTSD. In an interview conducted on 02/07/24 at 11:22 AM with the Director of Social Services (DSS), the DSS stated when a resident is admitted to the facility with a history of trauma/PTSD, they have to make sure that a mental health professional sees them. A care plan would then be created with interventions in place. When Resident #86 was admitted to the facility, another social worker assessed the resident. The Director of Social Services stated that a psychiatrist and psychology consults were in place, but no care plan for Trauma/PTSD with interventions was ever created. In an interview conducted on 02/07/24 at 11:35 AM with Staff E, Registered Nurse (RN), stated Resident #86 still gets up at night, around 2:00 PM to 3:00 PM, looking for his wife. He then remembers she was killed in front of him. In an interview conducted on 02/07/24 at 12:20 PM, Staff J, Medical Doctor, stated Resident #86 still has symptoms with flashbacks of what happened to him in [another country]. Resident #86 is still afraid that this may happen again and that he will be kidnapped again. Staff J reported Resident #86 would benefit from psychosocial intervention and monitoring symptoms of flashbacks. Record review revealed that a care plan was initiated for a traumatic experience dated 02/07/24, after the surveyor's intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 12% percent, 3 medication errors were identified while observing a total of 25 opportunities, affecting Residents #70 and #77. The findings included: Review of the facility's policy, titled, Medication Administration, with a reviewed date of 11/28/23, included: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer within 60 minutes prior to or after scheduled times unless otherwise ordered by physician. Administer medication as ordered in accordance with manufacturer specifications. Review of the Drug label Information at the following website provided by the Consulting Pharmacist: DailyMed - BUDESONIDE AND FORMOTEROL FUMARATE DIHYDRATE aerosol (nih.gov) included the following: 1. Breathe in (inhale) deeply and slowly through your mouth. Press down firmly and fully on the top of the counter on the BUDESONIDE AND FORMOTEROL FUMARATE DIHYDRATE INHALATION AEROSOL inhaler to release the medicine (see Figures 3 and 4). 2. Continue to breathe in (inhale) and hold your breath for about 10 seconds, or for as long as is comfortable. Before you breathe out (exhale), release your finger from the top of the counter. Keep the BUDESONIDE AND FORMOTEROL FUMARATE DIHYDRATE INHALATION AEROSOL inhaler upright and remove from your mouth. 3. Shake the BUDESONIDE AND FORMOTEROL FUMARATE DIHYDRATE INHALATION AEROSOL inhaler again for 5 seconds and repeat steps 7 to 9. After using your BUDESONIDE AND FORMOTEROL FUMARATE DIHYDRATE INHALATION AEROSOL inhaler 1. After use, close the mouthpiece cover by pushing until it clicks in place. 2. After you finish taking BUDESONIDE AND FORMOTEROL FUMARATE DIHYDRATE INHALATION AEROSOL (2 puffs), rinse your mouth with water. Spit out the water. Do not swallow it. Review of the Drug label Information at the following website provided by the Consulting Pharmacist: DailyMed - VENTOLIN HFA- albuterol sulfate aerosol, metered (nih.gov) included the following: How to use your VENTOLIN HFA inhaler Follow these steps every time you use VENTOLIN HFA. Step 1. Make sure the metal canister fits firmly in the plastic actuator. The counter should show through the window in the actuator. To take the cap off the mouthpiece, squeeze the sides of the cap and pull it straight out. Look inside the mouthpiece for foreign objects and take out any you see. Step 2. Hold the inhaler with the mouthpiece down and shake it well. Step 3. Breathe out through your mouth and push as much air from your lungs as you can. Step 4. Put the mouthpiece in your mouth and close your lips around it. Push the top of the metal canister firmly all the way down while you breathe in deeply and slowly through your mouth. Step 5. After the spray comes out, take your finger off the metal canister. After you have breathed in all the way, take the inhaler out of your mouth, and close your mouth. Step 6. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. 1. Record review revealed Resident #77 was admitted to the facility on [DATE] with diagnoses that included: Acute Bronchitis and Neurocognitive Disorder with Lewy Bodies. Review of the Minimum Data Set for Resident #77 dated 12/19/23 revealed in Section C a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #77 revealed an order dated 09/20/23 for Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for SOB (Shortness of Breath) Rinse mouth with water and spit back into cup after use. Review of the Physician's Orders for Resident #77 revealed an order dated 10/18/23 for Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for Wheezing / Shortness of Breath related to Unspecified Asthma. On 02/05/24 at 8:45 AM, during an observation of medication administration with Staff M, Registered Nurse (RN), for Resident #77, medications were administered that included: Budesonide inhaler 80/4.5mcg 2 puffs. The nurse administered the inhaler upside down, did not shake the inhaler between puffs or have the resident rinse her mouth with water and spit out the water after rinsing. The nurse also administered the Albuterol (Ventolin) inhaler 2 puffs via inhaler with the inhaler upside down. An interview was conducted on 02/05/24 at 8:55 AM with Staff M, RN, who was asked if she administered the inhalers upside down, she stated she did not know the inhalers were upside down when she administered them. When asked if she needed to shake either inhaler between the 2 puffs, she said she was unsure. When asked if the resident needed to rinse her mouth and spit the water out after administration of either inhaler, she said she did not think so. When the nurse looked at the instructions on the bag for the Budesonide inhaler, she acknowledged the instructions included to rinse mouth with water and spit back into cup after use. An interview was conducted on 02/06/24 at 10:15 AM with the Consultant Pharmacist (CP) who stated he has been a pharmacist for 21 years and has worked at the facility for 1 month. When asked about Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG and Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), if they can be administered upside down, he stated there is nothing in the prescribing information about that so he felt it would not really make a difference. When asked what the Drug label Information stated for each of the mentioned inhalers, he stated it does not say. After reviewing the Drug label Information for each of the inhalers with the CP, he acknowledged the manufacturers Drug Label Information for each inhaler said specifically to administer the inhalers in the upright position. When asked if the dosage would be accurate for each inhaler if not administered in an upright position, he stated he would have to reach out to the manufacturers. After reaching out to the manufacturers, he was only able to get in touch with one of the manufacturers which was for the Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG, and they could not say that the dose would be accurate if it was not administered as instructed in the Drug label Information. 2. On 02/06/24 at 9:08 AM, a medication pass was observed with Staff H, RN. Resident #70 was scheduled to receive Midodrine oral tablet 10milligrams (mg) by mouth but the nurse held (did not administer) the medication. The surveyor asked Staff H why she did not administer the Midodrine to Resident #70, who responded 'because his blood pressure was 127/85, which was normal and held it because of nursing judgement'. Staff H was asked if the physician put parameters on the medication and she stated that there were no parameters. She stated if the systolic blood pressure was below 100, she would have given the medication. On 02/06/24 3:24 PM, an interview was conducted with the Director of Nurses (DON). This surveyor explained to the DON that Staff H held Midodrine without an order and did not call the physician when she did this. This was acknowledged by the DON on 02/07/24 at 9:14 AM who confirmed the nurse should not have held the medication without parameters and should have called the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 02/05/24 at 7:23 AM, an observation of the treatment cart noted it to be unattended by nursing staff, and unattended with multiple medications, a pair of bandage scissors, and needles across from room [ROOM NUMBER]. Photographic Evidence Obtained. An interview was conducted on 02/05/24 07:27 AM with Staff K, RN, who stated she has worked at the facility for 5 months and just started her shift today at 7:00 AM. The RN acknowledged the treatment cart was unlocked and said it should always be locked. An interview was conducted on 02/05/24 at 7:28 AM with Staff L RN, who stated she has worked at the facility for 10 months. She stated she worked the 11:00 PM to 7:00 AM shift last night and did not use the treatment cart. She stated mostly it is the wound care nurse who uses the treatment cart. 4. Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses that included: Multiple Fractures of Ribs, Left Side Subsequent Encounter for Fracture with Routine Healing, Rhabdomyolysis, and Injury of Head. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 11/28/23, noted a Brief Interview of Mental Status score of 13, indicating an intact cognitive response. Review of the Physician's orders for Resident #94 revealed no order for Chlorhexidine Gluconate oral rinse 0.12%. Review of the Self Administration of Medication Assessment for Resident #94 dated 11/21/23 documented the resident is not capable of administering medications. On 02/05/24 at 11:05 AM, an observation was made of Resident #94 lying in bed with a bottle of Chlorhexidine Gluconate oral rinse 0.12% on the nightstand. On 02/06/24 at 9:00 AM, an observation was made of Resident #94 lying in bed with a bottle of Chlorhexidine Gluconate oral rinse 0.12% on the nightstand. On 02/07/24 at 11:05 AM, an observation was made of a bottle of Chlorhexidine Gluconate oral rinse 0.12% on the nightstand in the room of Resident #94 (the resident was not in the room at this time). An interview was conducted on 02/05/24 at 11:05 AM with Resident # 94 who stated she got the rinse yesterday and she is supposed to do it twice a day. She does it herself, but she is not sure where the measure cup is to know how much to use. An interview was conducted on 02/07/24 at 11:08 AM with Staff N, RN, who stated she has worked at the facility for almost 1 year. When asked if Resident #94 could have medications at the bedside she stated I don't think so, but I would have to check the resident's chart. Staff N acknowledged the Chlorhexidine Gluconate oral rinse 0.12% at the bedside and removed the medication. Based on record review, observations and interviews, the facility failed to remove expired over-the-counter (OTC) medications from the Central Supply cabinet; failed to remove expired over-the-counter medications from 1 of 3 medication carts observed (medication cart #2-West Wing); failed to secure medications at the beside for Resident #94; and failed to ensure that 1 of 2 treatment cart was locked when unattended (West Wing treatment cart). The findings included: Review of the facility's policy, titled, Medication Storage, implemented on 11/28/17, documented, in part: it is the policy of this facility to ensure all medications housed on our premises will be stored .medication rooms .and to ensure proper .seclusion and safekeeping .all drugs and biologicals will be stored in locked compartments (i.e. medication crats, cabinets, drawers, medication rooms) unused medications: .all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated .medications . 1. On 02/07/24 at 4:01 PM, a side-by-side review of the facility's central supply room was conducted with the Central Supply Clerk. The review revealed two bottles of Pain relief / Acetaminophen 500 milligrams/15 millimeters with an expiration date of 12/23 and one bottle of Saline Nasal Spray with an expiration date of 11/2023. The Central Supply Clerk stated she was responsible to check the medications expiration dates and did not notice those were expired. 2. On 02/08/24 at 11:58 AM, a side-by-side review of the facility's [NAME] Wing medication cart #2 was conducted with Staff M, Registered Nurse (RN). The review revealed a bottle of Vitamin E 180 microgram with an expiration date of 11/2023 and a bottle of Melatonin 1 milligram with a faded expiration date. Staff M stated she had no residents taking Vitamin E at the time of the review. Staff M stated the bottle was labeled as opened on 11/25/23. Further review of the medications cart revealed one round white loose pill at the bottom of the second drawer. During the review, Staff M stated expired medications and loose pill should not be in the cart. During an interview, on 02/08/24 at 3:01 PM, the Director of Nursing was made aware of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide an arbitration agreement that explicitly grants the resident or their representative the right to rescind the contract within 30 calendar days of signing it for 2 of 3 sampled residents reviewed for arbitration, Residents #76 and #3. The findings included: 1. Record review showed Resident #76 was initially admitted to the facility on [DATE]. He was later discharged on 04/21/22 and readmitted again on 05/25/22. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #76 has a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Continued record review showed Resident #76 signed an arbitration agreement on 09/14/21, after September 16, 2019. The arbitration agreement signed by Resident #76 did not show they had the right to rescind the contract within 30 calendar days of signing it. An interview was conducted on 02/08/24 at 8:35 AM with Resident #76, who stated he did not remember signing the arbitration agreement or having staff explain what he was signing. He further stated staff did not tell him he had the right to rescind the agreement within 30 calendar days of signing it. 2. Record review revealed Resident #3 was initially admitted to the facility on [DATE]. He was later discharged on 09/30/23 and readmitted on [DATE]. The MDS assessment dated [DATE] showed that Resident #3 had a BIMS score of 15, indicating intact cognition. Further record review revealed Resident #3 signed an arbitration contract on 04/17/23. It further showed that Resident #3 had seven days (not the required 30 days) to rescind the agreement after signing it. An interview was conducted on 02/08/24 at 11:15 AM with the facility's Director of Nursing, who stated that when residents are discharged after meeting criteria with a return not anticipated, they are considered fully discharged . If they return to the facility later, they are considered newly admitted residents. She further acknowledged that Resident #3 was discharged on 09/30/23 and admitted as a new resident on 01/10/24; and because he was discharged on 09/30/23, the record showed that a return was not anticipated. An interview was conducted on 02/08/24 at 11:29 AM with Staff G, admission Coordinator, who stated the arbitration agreement is part of the admission process. When residents get admitted to the facility, she gives them the admission packet and asks them if they want her to go over the information or let them read it themselves, and she will come back later. She then makes sure that the residents sign all the appropriate sections. Staff G reported that when residents get readmitted again, she will keep/use the admission paperwork that was completed and signed in their prior admissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #76 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included Osteomyelitis of Vertebra Sacral and Sacrococcygeal Region. Review of the Minimum Data Set (MDS) for Resident #76 dated 12/23/23 revealed in section O, hospice while a resident, is documented as 'no'. Review of the banner at the top of the Electronic Medical Record (EMR) for Resident #76 revealed Special instructions: HOSPICE. Review of the care plan for Resident #76, with an initiate date of 09/22/23 and a revised date of 01/09/24, with a focus on: I am on oxygen therapy as needed via nasal cannula. I am under Hospice services, decline is expected. The goal was for the resident to have no s/s (signs/symptoms) of poor oxygen absorption through the review date. The interventions included Change residents position every 2 hours to facilitate lung secretion movement and drainage. An interview was conducted on 02/08/24 at 3:00 PM with Staff I, MDS Coordinator (MDSC), who was asked about the special instructions: Hospice in the banner at the top of Resident #76's EMR. She said the resident is no longer on hospice services. Staff I stated the resident had a significant change MDS completed on 09/22/23 due to no longer receiving hospice services. Staff I stated she does not enter special instruction into the banner at the top of a resident's EMR. When asked about the care plan for Resident #76 that documented the resident is under Hospice services, she acknowledged the care plan was not updated to reflect the resident was no longer on hospice services. An interview was conducted on 02/08/24 at 10:15 AM with the Business Office Manager (BOM) who stated he has worked at the facility since 2007. When asked if he entered any special instructions: Hospice into the banner at the top the Resident #76's EMR, he said 'no he has never done that'. An interview was conducted on 02/08/24 at 10:19 AM with Staff Admissions Coordinator / Director of Activities who stated she has worked at the facility for 2 years and just stepped into the role as Admissions Coordinator today. She stated she had a week and a half with the Admissions Coordinator who no longer works at the facility. When asked if the Admissions Department puts any special instructions: Hospice into the banner at the top of the residents EMR, she said she is not sure, she has not had a resident admitted with hospice, and she would have to ask the Business Office. An interview was conducted on 02/08/24 at 10:27 AM with the Director of Therapy (DOT) / Administrator of PCC (type of EMR program) who stated she has worked at the facility since 2014. When asked about the special instructions: Hospice in the top of the banner in Resident #76's EMR, she said the special instructions would be driven by orders or assessments, it is not something that can manually be edited (entered or deleted). If a resident has an order for hospice that may generate the special instruction on the banner for the resident and when the order is discontinued, the special instruction would automatically be removed. When asked about the special instructions for Resident #76, the DOT/Administrator of PCC acknowledged the resident had the special instruction of hospice but is no longer receiving hospice services since 09/08/23. Based on interviews and record review, the facility failed to maintain communication with hospice, as it relates to the resident's coordinated plan of care and services, to ensure each entity is aware of their responsibilities for 1 of 1 resident reviewed for hospice (Resident #70); and failed to accurately identify a resident's services for 1 of 1 sampled resident reviewed for Hospice services, Resident #76. The findings included: 1. Review of the facility's policy, titled, Coordination of Hospice Services and End of Life Care, implemented on 11/28/2017, revealed the following: The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. The facility and hospice provider will coordinate a care plan and implement interventions per the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative to the extent possible. Record review showed that Resident #70 was admitted to the facility on [DATE] with diagnoses to include Pprotein-Calorie Malnutrition, Colon Cancer, and Lung Cancer. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 has a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Section O of this MDS did not show that Resident #70 was coded on hospice care. Review of the Physician's order revealed an order for hospice consultation, which was dated 11/30/23. There was no order noted to admit Resident #70 to hospice services. The facility care plan initiated on 12/01/23 revealed the following: Resident #70 is with terminal care related to cancer. Uploading notes by hospice staff, weekly visits by hospice staff, and Certified Nursing Assistance visits twice a week. The hospice binder in the nurse's station revealed the following: a hospice visit communication from the Registered Nurse [RN] dated 12/01/23 with no other communication visits since 12/01/23. The hospice binder did not show any hospice care plans or delegation of responsibilities between the hospice and the facility. An interview was conducted on 02/06/24 at 1:21 PM with Staff H, RN, who was asked if Resident #70 was in hospice, and she said yes. She further noted that she communicates with the hospice staff by phone. Staff H reported that the hospice staff come into the facility 2 to 3 times a week, and all communication visit forms are placed in the hospice binder at the nurse's station. Staff H proceeded to show the surveyor the hospice binder on the floor. An interview was conducted on 02/06/24 at 1:40 PM with the facility's Director of Nursing (DON) who stated that a hospice binder islocated in the nursing unit. When the hospice nurse comes into the facility for the weekly visits, communication visit notes are placed inside the binder. An interview was conducted on 02/06/24 at 1:50 PM with Resident #70, who stated the hospice -Certified Nursing Assistant (CNA) comes in to see him once or twice a week, and the hospice nurse comes to see him once every two weeks. Resident #70 stated that they need to be consistent with their visits. An interview was conducted on 02/06/24 at 2:17 PM with Staff I, MDS Coordinator, who stated the hospice staff will place their visits and communication sheets in the hospice binder located in the units. She further said that hospice staff were given access to the facility's electronic system and that all their notes should be uploaded to the electronic system. Staff, I further acknowledged that no hospice care plans or visits were loaded into the electronic system. Review of the progress notes revealed a note dated 12/05/23 that the hospice nurse would see Resident #70 3 times per week. A hospice certification and plan of care provided by the director of nursing, which was after the Surveyor's interventions, revealed the following: a nursing plan of care that meets the patient's needs will be established. An interview was conducted on 02/08/24 at 5:00 PM with the Director of Nursing (DON). The DON was informed of the concern about missing documents regarding the hospice care plan and visit communication forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide influenza and pneumococcal immunizations as required for 5 of 5 sampled residents, reviewed for immunizations, Residents #89, #87 #76, #94, and #557. The findings included: Review of the facility's policy, titled, Influenza Vaccination, with a reviewed date of 10/15/23, included: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. Review of the facility's policy, titled, Pneumococcal Vaccine Series, with a reviewed date of 10/15/23, included: It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine used. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders. 1. Record review for Resident #89 revealed the resident was admitted to the facility on [DATE]. There was no documentation that the Influenza, or the Pneumococcal vaccine was offered, accepted, or declined in the resident's medical record. 2. Record review for Resident #87 revealed the resident was admitted to the facility on [DATE]. There was no documentation that the Influenza vaccine was offered, accepted, or declined in the resident's medical record. 3. Record review for Resident #76 revealed the resident was originally admitted to the facility on [DATE], with the most recent readmission on [DATE]. In the medical record for the resident, under the immunization tab, it was revealed Pneumococcal dose 1 and dose 2 were refused. There was no supporting documentation of a signed declination for the Pneumococcal dose 1 or dose 2. Also, in the medical record under the immunization tab, it revealed the Influenza vaccine was last refused 09/14/21 and there was no documentation of the Influenza vaccine was offered, accepted, or declined in the 2023-2024 influenza season. 4. Record review for Resident #94 revealed the resident was admitted to the facility on [DATE]. There was no documentation that the Influenza or Pneumococcal vaccine was offered, accepted, or declined in the resident's medical record 5. Record review for Resident #557 revealed the resident was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. There was no documentation that the Influenza or Pneumococcal vaccine was offered, accepted, or declined in the resident's medical record An interview was conducted on 02/06/24 at 2:15 PM with the Infection Preventionist (IP) who stated she has been at the facility for 3 years. She stated the Covid vaccine is offered on admission, and when an updated vaccine comes out, they will offer it to residents. She stated the Influenza vaccine is offered annually starting in October to March and on admission during flu season. All residents in the facility have been offered the flu (Influenza vaccine). The Pneumococcal vaccine is offered on admission and when the flu vaccine is offered annually during flu season from October to March as long as the resident is eligible for a pneumococcal vaccine. All acceptance or refusal of all vaccines (Influenza, Pneumococcal and Covid) are uploaded to the resident's chart. An interview was conducted on 02/08/24 at 1:21 PM with the Infection Preventionist (IP) who was asked about the Influenza and Pneumococcal vaccines for Resident #89. The IP acknowledged there was no documentation in the resident's record of the Influenza or Pneumococcal vaccine being offered, accepted, or declined. When asked about the Influenza vaccine for Resident #87, she acknowledged there was no documentation in the resident's chart for the Influenza vaccine being offered, accepted, or declined. When asked about Resident #76, she acknowledged there was no documentation in the resident's record of the refusal of the Pneumococcal vaccine and acknowledged there was no documentation of the influenza vaccine being offered or refused for the 2023-2024 influenza season. When asked about Resident #94, she acknowledged there was no documentation in the resident's record of the Influenza or Pneumococcal vaccine being offered, accepted, or declined. When asked about Resident #557, she acknowledged there was no documentation in the resident's record for the Influenza or the Pneumococcal vaccines being refused. The IP stated she verifies weekly for all residents on Florida Shots to see if they have had any vaccination. She said she does not necessarily routinely document if a resident has had any history of vaccines as identified on Florida shots. She said she is behind in uploading documentation of consents to the resident's charts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer COVID-19 immunization as required for 4 of 5 sampled residents for immunizations, Residents #89, #87, #94 and #557. The findings included: Review of the facility's policy, titled, Covid-19 Vaccination, with a reviewed date of 08/04/23 included: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from Covid-19 (SARS-CoV-2) by education and offering our residents and staff the Covid-19 vaccine. Covid-19 vaccinations will be offered to residents and staff, when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. 1. Record review for Resident #89 revealed the resident was admitted to the facility on [DATE]. There was no documentation of the Covid vaccine being offered, accepted, or declined in the resident's medical record. 2. Record review for Resident #87 revealed the resident was admitted to the facility on [DATE]. There was no documentation of the Covid vaccine being offered, accepted, or declined in the resident's medical record. 3. Record review for Resident #94 revealed the resident was admitted to the facility on [DATE]. There was no documentation of the Covid vaccine being offered, accepted, or declined in the resident's medical record. 4. Record review for Resident #557 revealed the resident was originally admitted to the facility on [DATE] most recently readmitted on [DATE]. There was no documentation of the Covid vaccine being offered, accepted, or declined in the resident's medical record. An interview was conducted on 02/06/24 at 2:15 PM with the Infection Preventionist (IP) who stated she has been at the facility for 3 years. She stated the Covid vaccine is offered on admission, and when an updated vaccine comes out, they will offer to resident. Influenza is offered annually starting in October to March and on admission during flu season. All residents in the facility have been offered the flu (Influenza) vaccine. The Pneumococcal vaccine is offered on admission and when the flu vaccine is offered annually during flu season from October to March as long as the resident is eligible for a pneumococcal vaccine. All acceptance or refusal of all vaccines (Influenza, Pneumococcal and Covid) are uploaded to the resident's chart. An interview was conducted on 02/08/24 at 1:21 PM with the Infection Preventionist (IP) who was asked about the Covid vaccine for Resident #89. The IP acknowledged there was no documentation in the resident's record of the Covid vaccine, being offered, accepted, or declined. When asked about the Covid vaccine for Resident #87, she acknowledged there was no documentation in the resident's chart for the Covid vaccine being offered, accepted, or declined. When asked about Resident #94, she acknowledged there was no documentation in the residents record for the Covid vaccine being offered, accepted, or declined. When asked about Resident #557, she acknowledged there was no documentation in the resident's record for the Covid vaccine being refused. The IP stated she verifies weekly for all residents on Florida Shots to see if they have had any vaccination. She said she does not necessarily routinely document if a resident has had any history of vaccines as identified on Florida shots. She said she is behind in uploading documentation of consents to the resident's charts.

Based on interviews and records review, the facility failed to ensure residents and staff were informed of their rights to file their complaints with the Ombudsman and where to find the Ombudsman posted information, for 1 of 1 sampled resident and staff reviewed for this conncern. The findings included: During an interview with the Resident Council President on 09/14/22 at 2:18 PM, she reported that she never heard about the word Ombudsman. She also informed that she did not know where the Ombudsman information was posted. She said that they meet every month and that she has been the President of the Resident Council for nearly a year, and they never discussed how to file a complaint with the Ombudsman. Review of the Brief Interview for Mental Status (BIMS) score revealed that the Resident Council President obtained a score of 15 of 15, which is an indication of cognitive ability to provide credible information. On 09/15/22 at11:17 AM, while interviewing the Activity Director, she reported that she has been working at this facility since February 2022. She said that she was not aware about the Ombudsman. She informed that she assists the residents in organizing, scheduling their monthly resident council meeting, and keeping, the minutes for them. She also said that she ensured that the residents participate in the meeting. She reported that she will make sure that they discuss the residents' rights during their council meeting. Review of the Resident Council Minutes from February 2022 through August 2022 revealed that the residents' rights related to how to file a complaint with the Ombudsman was not one of the items discussed or documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #357 revealed the resident was admitted on [DATE] with the following diagnoses: End Stage Renal Disease, Unspecified Glaucoma and Type 2 Diabetes Mellitus. Review of Section B of the Minimum Data Set (MDS), dated [DATE], documented that Resident #357's vision was impaired. Review of Section C documented that the resident had a Brief Interview o Mental Status score of 15 which indicated intact cognitive response. Review of Section G revealed functional status of bed mobility and transfer both had self-performance of extensive assistance with support of one person, dressing had a self-performance of limited assistance with support of one person, eating and personal hygiene both had self-performance of supervision with support of one person. Review of the physician's orders showed that Resident #357 had a physician order, dated 08/01/2,2 for NAS/NCS (no added salt / no concentrated sweets) regular texture, thin consistency. Record review for Resident #357 revealed the resident did not have a care plan for impaired vision. On 09/12/22 at 1:50 PM, an observation was made of Resident #357 with an untouched (uneaten) lunch in front of her and the resident's right eye remains shut constantly. The meal ticket on the resident's tray does not indicate what food is on the plate (it is blank). On 09/14/22 at 8:52 AM, an observation was made of Resident #357 receiving her breakfast tray. Staff I, [NAME] Unit secretary, brought the resident her breakfast but did not identify what was on the tray or the location of the food / beverage. During an interview conducted on 09/12/22 at 1:55 PM with Resident #357, when asked if she did not like her lunch or would prefer something else, she stated she does not know what food is on the plate. She stated that she is vision impaired, and nobody tells her what food is on her plate. During an interview conducted on 09/14/22 at 8:55 AM with Staff I [NAME] Unit secretary, when asked if she had provided the breakfast tray to Resident #357, she stated 'yes'. When asked if she was aware of the resident having any visual impairment, she stated 'none that she is aware of'. During an interview conducted on 09/14/22 at 9:00 AM with Resident #357, when asked if Staff I [NAME] Unit secretary, who brought her breakfast tray into her, had identified what was on her tray or the location of the items, she stated 'no'. After informing the resident of what food was on her tray, she stated they did not bring me tea today, and she would need milk for her hot cereal. During an interview conducted on 09/14/22 at 12:45 PM with the Registered Dietician (RD), who has been with the facility for 5 months, when asked if a resident with impaired vision had this indicated on the meal ticket, she stated there is not an option for this to be put on the meal ticket. Based on observations, interviews, and record reviews, the facility failed to develop care plans for 3 of 24 sampled residents reviewed: Resident #102 and Resident #357 related to hemodialysis and impaired vision; and Resident #33 related to revising the dialysis care plan. The findings included: Review of the facility's policy, titled, Comprehensive Care Plans, implemented on 11/28/22, documented the following: it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental need that are identified in the residents' comprehensive assessment. 1. Record review for Resident #102 revealed the resident was admitted on [DATE] with diagnoses of End-Stage Renal Disease (ESRD) and Dependence on Dialysis. A review of the Physician's orders documented an order for In-House Hemodialysis with [name] dialysis centers every Monday, Wednesday, and Friday, dated 04/27/22. A review of the Minimum Data Set (MDS), dated [DATE], documented Resident #102 had a Brief Interview of Mental Status (BIMS) score of 15, which is indicative of intact cognition. In an interview conducted on 09/13/22 at 8:11 AM, Resident #102 stated that she receives dialysis in the facility three times a week. Review of the care plans for Resident #102, that was initiated on 04/28/22, did not show any care plan with goals and interventions initiated for dialysis. In an interview conducted on 09/14/22 at 2:38 PM with the Director of Nursing, she stated that residents on dialysis would have a care plan in place for dialysis. When asked if she knew that Resident #102 did not have a care plan for dialysis, she said no. 3. Record reviewed documented Resident #33 was initially admitted to the facility on [DATE]. The resident's diagnoses included End Stage Renal Disease, Dependence of Renal Dialysis and Type 2 Diabetes Mellitus without Complications. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) 06/28/22, documented the resident's Brief Interview for Mental Status (BIMS) was 13 of 15, indicating the resident was cognitively intact. The Electronic Health Record (EHR) revealed the resident was receiving dialysis in the facility. A review of the dialysis communication note, dated 09/12/22, revealed a shunt location of a right leg catheter. A review of the Medication Administration Record (MAR) revealed the resident was scheduled to receive medications at 9:00 AM at which time he was in dialysis. Review of the care plan for dialysis revealed under interventions / tasks to: Adjust medication to accommodate dialysis, date initiated 08/15/17 and revised on 06/17/21; Encourage me to go for the scheduled dialysis appointments at .Dialysis, date initiated 08/15/17 and revised 06/17/21; and Monitor dialysis catheter dressing every shift to right chest tessio every shift, dated initiated 02/24/21 and revised on 06/17/21. An interview was conducted on 09/14/22 at 2:37 PM with the interim Director of Nurses / Minimum Data Set Coordinator who agreed the care plan was not updated to reflect the current status of Resident #33.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assure that enteral nutrition had been followed by the practitioners' orders for 3 of 4 sampled residents, Residents #14, #66, and #20, reviewed for tube feeding. The findings included: 1. A review of the facility's policy, titled, Enteral Nutrition Support Feeding Accuracy and Hydration Maintenance, revised on 09/14/22, documented the following: it is a policy of this facility to ensure accurate administration and adequate nutrition and hydration of all enteral nutrition support for all residents. Record review documented Resident #14 was readmitted to the facility on [DATE] with diagnoses that included Cerebral Ischemia, Hydrocephalus, Dementia, Gastrostomy Status, and Major Depressive Disorder. The resident had a Brief Interview Mental Status (BIMS) score that indicated the resident was severely impaired. Resident #14's care plan of 06/05/22 documented that Resident #14 is at nutritional risk as evidenced by: Enteral nutrition support via (PEG), history of Abnormal labs, Chewing / Swallowing problem, Nothing by Mouth (NPO), Related to Disease process / condition and resident requires the use of a feeding tube. Related to insufficient caloric intake, dysphagia, and cognition. Interventions include administering nutritional support / tube feeding formula and flushes as ordered (see current physician orders/MAR): Tube feeding, Vitamin supplement, supplement . Provide diet as instructed, and Dietitian to monitor adequacy or tube feeding formula and free-water flushes at least quarterly. On 02/07/22, Resident #14's physician's order documented for: 'two (2) times a day for Dysphagia Jevity 1.5 (tube feeding formula) at 50 milliliters (ml) times 22 hours via PEG (percutaneous endoscopic gastrostomy), total volume = 1100 ml; on at 4:00 PM and off at 2:00 PM'. During an initial observation on 09/12/22 at 11:40 AM, a tube feeding (TF) bottle (Jevity 1.5 kcal) was noted in Resident #14's room, not running. Closer observation showed that the tube bottle was started on 09/12/22 at 7:00 AM at 50 ml an hour. The (TF) in the room showed that it was on the 1500 ml mark out of a 1500 ml bottle; the (TF) timing was off by 4 hours and 40 minutes at the time of this observation. The tube feeding running as per MD order should have been at the 1300 ml mark out of a 1500 ml bottle. During a second observation on 09/12/22 at 2:58 PM, Resident #14 was observed with her (TF) off at this time. The resident's spouse was sitting at the resident's bedside. Resident #14's spouse stated to this surveyor that the resident's (TF) 'was off now for about 2-3 hours until they turn it on again'. Resident #14's spouse was asked very briefly if this was something that would bother /concern him if Resident #14's (TF) was not infusing properly, and he responded by saying, yes. It was noted that only 50 ml had been infused with 1450 cc remaining in the (TF) bottle. The (TF) timing was now off by 6 hours. Photographic Evidence Obtained of Resident #14's 1450 ml (TF) bottle of Jevity 1.5 kcal. During a third observation on 09/13/22 at 9:37 AM, Resident #14 was observed with the same (TF) bottle, dated 09/12/22, still hanging and infusing at 50 ml an hour with only 700 ml infused and 800 ml remaining in the bag. The (TF) bottle, that was hung at 7 AM yesterday at 50 ml an hour, should have been completed at around 5:00 PM yesterday with a new bottle of (TF) being hung at that time. Photographic Evidence Obtained of Resident #14's 800 ml (TF) bottle of Jevity 1.5 kcal During the fourth observation on 09/13/22 at 12:06 PM, Resident #14 was observed sitting up in her Gerichair with the same (TF) bottle, dated 09/12/22, still hanging and infusing at 50 ml with still only 800 ml infused and 700 ml remaining in the bag. Photographic Evidence Obtained of Resident #14's 700 ml (TF) bottle of Jevity 1.5 kcal. During the fifth observation on 09/13/22 at 2:27 PM, Resident #14 was still observed sitting up in her Gerichair with the same (TF) bottle dated 09/12/22, still hanging and infusing at 50 ml with now only 900 ml infused and 600 ml remaining in the bag. Photographic Evidence Obtained of Resident #14's 600 ml (TF) bottle of Jevity 1.5 kcal. An interview was conducted on 09/13/22 at 2:02 PM with Staff G, Licensed Practical Nurse (LPN), regarding the following questions: When was the (TF) hung, and she replied, 09/12/22 at 7:00 AM at 50 ml an hour. What was the order and she replied that the order is for two times a day for Dysphagia Jevity 1.5 @ 50 ml an hour x 22hr via PEG, total vol=1100ml. On 4:00 PM Off 2:00 PM via Percutaneous Endoscopic Gastrostomy tube (PEG). Was it running this morning when you started your shift, and she answered, Yes. Was/has the resident been tolerating the tube feeding well, and she replied, Yes. The nurse also acknowledged that the same (TF) bottle from yesterday at 7:00 AM was still hanging in the resident's room and should not have been. An interview was conducted on 09/13/22 at 2:30 PM with Nichola Fray, LPN, Unit Manager, working in the facility for ten months, regarding Resident #14's (TF) inconsistent infusion volume, and she acknowledged that the (TF) volume should be infused have been greater and that the same (TF) bottle from yesterday at 7 AM was still hanging up in Resident #14's room and it should not have been. An interview was conducted on 09/13/22 at 3:35 PM with the facility's Clinical Dietitian regarding Resident #14's (TF) inconsistent infusion volume. She acknowledged that the (TF) volume infused should have been greater and that the same (TF) bottle from yesterday at 7:00 AM that was still hanging up in Resident #14's room, and it should not have been. The current (TF) bottle was not discarded and a new one started until after the surveyor inquisition / intervention. 2. Record review for Resident #66 documented the resident was readmitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes and Dysphagia. A physician order noted for tube feeding formulary (Glucerna 1.5) to be running at 60 milliliters (ml) an hour times 22 hours starting at 4:00 PM and off at 2:00 PM dated 07/19/22. In an observation conducted on 09/12/22 at 10:30 AM, Resident #66 was noted in bed. The tube feeding was noted with Glucerna 1.5 running at 60 ml an hour, starting at 4:00 AM. Closer observation showed that the feeding was at the 750 ml mark out of a 1000 ml capacity bottle. This showed that only 250 ml was infused in 6.5 hours and not the 390 ml that should have been infused as per the above order. In an observation conducted on 09/12/22 at 12:45 PM, Resident #66 was noted in bed. The tube feeding with Glucerna 1.5 ran at 60 ml an hour, starting at 4:00 AM. Closer observation showed that the feeding was at the 600 ml mark out of a 1000 ml capacity bottle. This showed that only 400 ml was infused in about 9 hours, not the 540 ml that should have been infused as per the above order. In an observation conducted on 09/13/22 at 8:30 AM, Resident #66 was noted in bed. The tube feeding was noted with Glucerna 1.5 running at 60 ml an hour with a start date of 09/13/22 and no start time noted. Closer observation showed that the feeding was at the 800 ml mark out of a 1000 ml capacity bottle. In an observation conducted on 09/14/22 at 7:00 AM, Resident #66 was noted in bed. The tube feeding was noted with Glucerna 1.5 running at 60 ml an hour with a start date of 09/14/22 and no start time noted. Closer observation showed that the feeding was at the 700 ml mark out of a 1000 ml capacity bottle. The tube feeding should have been at the 640 ml mark taking into consideration the 1 hour that was taken off for the morning care. In an interview conducted on 09/14/22 at 7:00 AM, Staff B, Licensed Practical Nurse (LPN), stated that he started the tube feeding bottle around 12:00 AM and stopped it for 1 hour for morning care. He further said that Resident #66 is tolerating her tube feeding well. The care plan, dated 08/10/22, documented to 'administered the tube feeding formula and flushes as ordered by physician orders'. 3. Review of the clinical records documented Resident #20 was admitted to the facility on [DATE] with diagnoses to include Sepsis, Unspecified Organism; and Acute Infections. On the admission of 60/09/22, diagnoses included Secondary Pulmonary Arterial Hypertension (HTN); Cardiovascular And Coagulations Acute On Chronic Diastolic (Congestive) Heart Failure; Cardiovascular And Coagulations; Type 2 Diabetes Mellitus (DM); Chronic Kidney Disease (CKD); Acute Kidney Failure; Dementia, Psychotic Disturbance, Mood Disturbance and Anxiety; Gastrostomy; Acute Respiratory Failure With Hypoxia; Pressure Ulcer Of Right Heel, Unstageable; Pressure Ulcer Of Left Heel, unstageable; Other Abnormalities Of Gait And Mobility; Muscle Weakness (Generalized); Hyperlipidemia, and Urinary Tract Infection. Review of the care plan, dated 06/06/22, showed that the resident was malnourished as evidenced by Nutritional Screening Tool Malnourished, She is NPO (nothing by mouth), Patient has low body weight / BMI, Medical History of DM/HTN, CKD, dyslipidemia, and dementia. Review of the physician's orders, dated 09/01/22, revealed the following: 'Enteral feeding two times a day, Auto flush at 60ml/hr. via peg tube, On at 4pm, Off at 2pm'. This indicated the resident should have been on continuous feeding from 4:00 PM until 2:00 PM or 10 hours: [10 hrs. x 60 ml/hr=600 ml]. The resident's weights were recorded weights as: 09/10/22 at 14:22 (2:22 PM) - 101.0 pounds (lbs) (Manual) 08/11/22 at 9:07 (AM) - 90.0 lbs (Manual) 07/01/22 at 13:00 (1 PM) - 89.8 Lbs (Manual) 06/24/22 at 15:24 (3:24 PM) - 88.4 lbs (Manual) 06/20/22 at 8:54 (AM) - 85.2 lbs (Manual) 06/12/22 at 10:22 (AM) - 87.0 lbs (Manual) 06/03/22 at 21:22 (9:22 PM) - 87.8 lbs Mechanical Lift (Manual) 6/3/2022 at 21:08 (9:08 PM) - 87.8 lbs. Mechanical Lift On 09/12/22 at 1:38 PM, Resident #20 was observed being fed via a G-tube. The feeding bag was observed at 800 ml / cc out of 1000 ml. It was hung at 7 AM and was infusing at 60 cc / hr. The observation revealed there should be approximately 600 ml remaining in the bag (if 1 hour was taken out for care). On 09/13/22 at 11:30 AM, the resident's feeding bag was infusing at 60 ml/hr. The notation on the feeding bag showed that it started at 4:00 AM, At 11:30 AM, there were still approximately 690 cc left in the bag. At 11:00 AM, there should have been 450cc [60 x 7.5 = 450 cc] infused and 550 ml left instead of 690 ml. On 09/14/22 at 10:21 AM, the resident was observed in bed and the tube feeding was read as infusing at a rate of 60 ml/hr. The information written on the feeding bag showed that It was connected at 11:20 PM on 9/13/2022. At 10:21 AM on 9/14/2022 the amount left was 600 ml. There should have been 400 mls [1000-660 = 400 ml] left in the bag rather than 600 ml or at least 540 ml if staff stopped the feeding for 1 hour to provide care. During an interview with the resident's nurse, an LPN on 09/14/22 at 10:30 AM, the nurse reported that she did not know what happened to the feeding. She said that she had not connected the feeding tube nor had she disconnected it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and policy review, the facility failed to provide medication as scheduled on dialysis days for 1 of 2 sampled residents reviewed for dialysis (Resident # 33). The findings included: The facility's policy, titled, Hemodialysis, implemented 11/28/17, revealed Timely medication administration (initiated, held, or discontinued) by the nursing home and/or dialysis facility. Resident #33 was initially admitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (ESRD), Dependence of Renal Dialysis and Type 2 Diabetes Mellitus (DM) without Complications. The resident's Brief Interview for Mental Status (BIMS) was 13 according to the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) 06/28/22, indicating the resident was cognitively intact. The Electronic Health Record (EHR) revealed the resident was receiving dialysis in the facility. On 09/13/22 at 10:36 AM, the Medication Administration Record (MAR) was reviewed for Resident #33, that revealed the resident was scheduled to receive Miralax Powder, Nepro supplement, Renal Vitamin Tablet and Pro-Stat supplement at 9:00 AM daily. On 09/14/22 at 10:53 AM, an interview was conducted with Staff D, Registered Nurse (RN) unit manager. This surveyor asked Staff D at what time Resident #33 leaves his room for dialysis. She stated that he gets to dialysis in the morning. His start time for dialysis is 7:45 AM and he is picked up around 7:30 AM. It usually takes 3-4 hours and he comes back to his room before lunch. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 09/14/22 at 11:01 AM. She stated that the resident gets his medication a little before 7:00 AM and will get the 9:00 AM medications when he returns from dialysis. She stated that she never questioned the timing of the medication on dialysis days. She only works 2 days a week on this hallway. An additional interview was conducted with Staff D regarding timing of medication given on dialysis days. Staff D stated that she was not aware that the nurses were giving 9:00 AM medications late. She stated she will call the physician to change the timing of the 9:00 AM medications on dialysis days if that is what the physician wants to do.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food items that accommodated the preferences of 2 of 3 sampled residents during dining observations, Resident #102, and Resident #46. The findings included: 1. Record review for Resident #102 revealed an admission on [DATE] with diagnoses to include End Stage Renal Disease (ESRD) and dependence on Dialysis. A review of the physician's orders showed an order for In-House hemodialysis with [name] dialysis centers every Monday, Wednesday, and Friday, dated 04/27/22. Review of the Minimum Data Set (MDS), dated [DATE], documented that Resident #102 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. Reivew of the physician orders documented a diet order for regular texture, thin consistency, for diet liberal renal; 1200 cc fluid restriction: 360 milliliters (ml) with breakfast, 240 ml with lunch and dinner dated 05/02/22. In an interview conducted on 09/13/22 at 8:11 AM, Resident #102 stated that she is not getting her hot tea with her breakfast tray every morning. Her favorite meal is breakfast, and she likes extra grits and eggs on her tray. Resident #102 stated tha staff never tells her what food is on the tray or where it is situated since she is blind and cannot see. In this interview, Staff A, Certified Nursing Assistance, brought the breakfast tray into the room. She placed the tray on the side table near Resident #102 and set up the tray for the resident. Resident #102 asked Staff A if she could bring her coffee, and Staff A said, you get coffee every day. Staff A said, you get juice and coffee but no water. Resident #102 requested extra grits, and Staff A went out of the room to get the extra grits. A closer observation of the meal ticket for Resident #102 showed instructions for hot tea but no extra portions for eggs or grits and was dated 09/14/22. The breakfast tray had one serving of eggs, one serving of grits, and no hot tea. Photographic Evidence Obtained. In an interview conducted on 09/13/22 at 8:15 AM, Resident #102's roommate stated that they never gave Resident #102 extra protein or eggs and proceeded to give Resident #102 her portion of eggs. Review of the meal ticket, which was provided by the facility's Clinical Dietitian showed that for Resident #102, the following was noted: for the section under food likes, it had double portions of eggs with hot tea and double protein, which was dated 09/13/22 and 09/14/22. In an interview with the facility's Clinical Dietitian on 09/14/22 at 12:44 PM, she stated that she has been in this facility for the last five months. Food preferences are placed in a food program called Optima. The Food Service Manager will visit the patients and input the choices into the system. She will also collect some of the food preferences. It is then generated on the meal ticket, and the dietary aides can see it on the meal ticket and provide the correct food choices on the tray. The options will show on all three meals with the dislike and likes on the meal tickets. 2. Record review documented that Resident #46 was admitted to the facility on [DATE] with diagnoses to include Anxiety Disorders and Cerebral Infarction. The MDS, dated [DATE], dpcumented a BIMS score of 09, a moderate cognitive impairment. In an observation conducted on 09/14/22 at 8:06 AM, Staff C, Registered Nurse, pulled the breakfast tray for Resident #65 from the meal cart and asked the Director of Social Services to bring the tray to Resident #65. The Director of Social Services was observed giving the tray to Resident #46 instead of Resident #65. A closer observation of the breakfast tray showed eggs, juice, and sausages. The Director of Social Services set up the tray for Resident #46 and asked if she needed anything else. Resident #46 stated that she did not eat the eggs on the breakfast tray and instructed the Director of Social Services to bring her 2 portions of cereal and regular milk. The Social Service Director went out of the room and returned a few minutes later with the 2 portions of cereal and the milk. At 8:10 AM, the Director of Social Services told the surveyor, I gave Resident #46 the wrong tray. A closer observation of the breakfast tray showed eggs, juice, and sausages. In an interview conducted on 09/14/22 at 8:15 AM with Staff C, the Registered Nurse stated that she is aware that the Director of Social Services gave Resident #46 the breakfast tray that was supposed to be for Resident #65. She further stated that she educated the Director of Nursing on the mistake. A review of the meal tickets that the facility's Clinical Dietitian provided showed that Resident #46 had the following: food dislikes showed eggs and juice, and instructions to give corn flakes or frosted flakes (cereals) daily.