**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a physician order for a special study was scheduled and completed in a timely manner for 1 of 3 sampled resident reviewed, Resident #1.The findings included: Review of Resident #1's clinical record revealed an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Dysphagia, Oropharyngeal Phase, Traumatic Hemorrhage of Cerebrum and Gastrostomy Status. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 04 indicating severe cognition impairment and that the resident had a feeding tube. The resident‘s care plan titled Tube Feeding documented, The resident is receiving enteral nutrition r/t (related to) gastrostomy status and Dysphagia initiated on 05/10/25 with interventions to include obtain and review lab (laboratories) / diagnostic work as ordered, report results to MD [physician] and follow up as indicated.Review of Resident #1's clinical record documented a physician order dated 07/29/25 for a MBSS (Modified Barium Swallow Study) to determine the function of the oropharyngeal phase of the swallow function. Further record revealed the lack of the MBSS results on file.Review of the following Speech Therapy (ST) visits documented the following:-Date 08/06/25- .SLP (Speech Language Pathologist) completed pt's (patient's) oral care and proceeded with trials of crushed ice 1/4 to 1/2 teaspoonful boluses. Pt tolerated 17/20 boluses when provided faded verbal prompts to occasionally clear throat.-Date 08/10/25- .SLP provided pt's oral care. Pt tolerated 21 1/2 teaspoonful boluses of ice chips via guided bolus placement with efficient swallow trigger and no overt s/s (sign or symptoms) of aspiration and/or penetration.-Date 08/16/25- .SLP completed oral care and presented pt with trials of crushed ice. Pt tolerated 17 p.o. (orally) boluses of 1/4 teaspoonful of ice. Pt demonstrated no overt s/s of aspiration and/or penetration.-Date 08/20/25- .SLP completed oral care. Facilitation of Frazier free water protocol. Pt tolerated 2 oz of thin liquid water w/o (without) any overt s/s of aspiration and/or penetration.-Date 08/23/25- .ST services targeting conversational intelligibility.Patient is able to converse at 80% of the conversation.Review of Resident #1's Certified Nursing Assistant Plan of Care (POC) task response related to behavior from 07/30/25 to 08/27/25 documented no behaviors reported. On 08/27/25 at 12:32 PM, an interview was conducted with Resident #1 who stated she was in the facility for four (4) months, and she was ready to go home. The resident stated something happened to my stomach, she was crippled and could not walk. The resident added that she couldn't eat, was very hungry, couldn't drink and was very thirsty. The resident was asked if she was getting tube feeding and stated she did not want it because it makes her sick and vomit. The resident stated she was not getting water and was dying of thirsty. Resident #1 stated she asked for ice chips, they don't bother to respond, they are not together, the doctor said she is dehydrated, and they would not give her water. During the interview, observation revealed the resident had a dressing over her trachea area, a basin next to the resident with no vomiting noted, and the resident's tongue was slightly dry. On 08/27/25 at 12:38 PM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN), who stated the last time the Speech Therapist saw Resident #1 she was going to start her on pleasure food. Staff A stated the resident was NPO (nothing by mouth) and could not have ice ships. On 08/27/25 at 1:32 PM, an interview was conducted with the Rehabilitation Director who stated Resident #1 was out of it when she came in to the facility, now she is more alert and asking for water and food, but her swallowing is profound, and the water and food will go to her lungs as per the Speech Language Pathologist (SLP). The Rehabilitation Director stated the resident was currently receiving ST (speech therapy). On 08/27/25 at 3:15 PM, a joint interview with the Rehabilitation Director and Staff B, SLP, was conducted. Staff B stated she was waiting for Resident #1's MBSS [Modified Barium Swallow Study] results, added she spoke to the nurse recently who asked for when they can give her ice ships and told her she was waiting for the test results. Staff B stated she did a thermal / tactile stimulation and did not hear any wet vocal quality, the time of her swallow trigger was very quick, meaning that they progress to ice ships, for trial. Staff B stated she had Resident #1 brush her teeth, the Frazier free water protocol, she cleaned in her checks with a sponge and under her lips and gave her ice chips; the resident tolerated that well. Staff B stated the Frazier free water protocol is a safe way to test that would not cause pneumonia. The Rehabilitation Director was asked how long it takes to scheduled and get an MBSS done and stated the therapy department give the referral to nursing and nursing do the scheduling, added that therapy did not schedule the study. During the joint interview, the Director and Staff B were apprised that the referral for the MBSS was dated 07/29/25. Staff B stated she has inquired about the MBSS results asked the nurse and told her she was going to inquired about it and have not heard back. Staff B stated Resident #1 was receiving ST visits five days a week to do thermal/tactile stimulation, communicating using simple sentences, the resident is confused but much alert, more intelligent speaking. Staff B was asked for the goal of care and stated eventually to get the resident on a diet and added the MBSS results will let her know who she can proceed, be more aggressive with therapy. On 08/27/25 at 5:07 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated whenever the therapy department give her a referral, she calls the doctor for an order then they call to make an appointment either at the hospital or ambulatory. The ADON added that the facility was not doing mobile Swallowing test, it was started back on last month. An inquiry was made regarding Resident #1's MBSS ordered on 07/29/25 that had not been done as of 08/27/25. The ADON responded that she was not sure why it had not been done and added she needed an actual written script and will get it from the doctor tomorrow. The ADON stated the doctor comes to the facility every Monday and Thursday. On 08/28/25 at 9:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a MBSS is ordered and recommend by ST, they will get it done. The DON was asked how long it take to get it done and stated it depends and added Resident #1 had some recent transfer to hospital, pulled out of her trach, her cognition had changed, at those times, she was not at her best to take the test, now she is more aware and cognitively intact. The DON stated the facility was doing the MBSS test at a local Hospital and added, it has been a process to schedule. The DON was asked to submit written documentation regarding attempt to schedule the resident's MBSS and stated there was none. The DON stated the facility has recently contracted with diagnostics, stated Resident #1's MBSS is scheduled for next Tuesday and is on standby to do today if there is a cancellation. Consequently, a side-by-side review with the DON of Resident #1's revealed a transfer to the hospital on [DATE] due to the resident pulling her trach, returned to the facility on [DATE] and an emergency room visit on 08/02/25 due to a fall. The DON was apprised of the delayed on providing Resident #1's MBSS and the resident's begging for ice chips.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain the residents' medical records that are accurately documented in accordance with accepted professional standards and practices for 1 of 3 sampled resident reviewed, Resident #1. The findings included: Review of Resident #1's clinical record revealed an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Traumatic Hemorrhage of Cerebrum, Obstructive and Reflux Uropathy, Unspecified. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 04 indicating severe cognition impairment. Review of Resident #1's clinical record documented a physician order dated 08/06/25 for remove foley catheter.Review of Resident #1's clinical record August 2025 Treatment administration Record (TAR) documented a foley catheter was removed on 08/07/25. On 08/28/25 at 9:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that a Urology Nurse Practitioner (NP) comes to the facility every week to see residents on consultation basis. On 08/28/25 at 11:15 AM, a joint interview was conducted with the facility's Urology Nurse Practitioner (NP) and the Director of Nursing (DON). The NP stated he has been coming to facility for three (3) months, gets a consult from the facility nurses or the in-house NP. The NP was asked if he contacted the resident's family / representative to discuss the plan of care and responded if the patient/resident is alert, he will talk with the resident, will talk to the nurse, and will get a hold a family member if needed. The NP was asked if he get in touch with resident representative, especially those with a BIMS score of 4. The NP replied he never communicated with Resident #1's family / representative, did not talk to the family/representative related to a right kidney mass revealed on ultrasound done on 08/05/25. The NP stated it is important to communicate with the resident's family / representative. A side-by-side review of Resident #1's Urology-NP consult notes was conducted for the following notes:-Service date 06/24/25 documents .sex: female. Genitourinary: External Genitalia: foley catheter; Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.-Service date 07/22/25 documents .sex: female. Genitourinary: External Genitalia: foley catheter; Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.-Service date 07/30/25 documents .sex: female. Genitourinary: External Genitalia: foley catheter; Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.-Service date 08/05/25 documents .sex: female. GU (Genitourinary) + obstructive uropathy.Genitourinary: External Genitalia: Penis: normal, no lesions, no discharge; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. assessment: unspecified urinary incontinence.Current assessment and plan discussed with patient and nursing staff.-Service date 08/13/25 documents .sex: female.foley catheter was removed.patient remains incontinent.GU: + foley catheter.Genitourinary: External Genitalia: Penis: normal, no lesions, no discharge, + foley catheter; Scrotum: normal, no swelling, no tenderness; Testes: descended bilaterally, no masses, no tenderness; Spermatic Cord: no varicocele, no tenderness. Current assessment and plan discussed with patient and nursing staff.During the review, the NP confirmed Resident #1 was a female and that external genitalia male information should have to be removed. The NP was apprised that his note dated 08/13/25 documented + foley catheter when the resident catheter was removed on 08/07/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure it obtained a current physician order for an Intravenous (IV) dressing and IV site; and failed to change the Intravenous (IV) dressing to the right upper chest for 1 of 1 sampled resident observed, Resident #4. The findings included: Review of the facility policy and procedure, titled, Dressing Change for Vascular Access Devices, provided by the Director of Nursing (DON), reviewed 2011, documented in the Policy Statement Purpose: To prevent local and systemic infection related to the IV catheter. Policy: A sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide a microbial barrier, and to provide vascular access device securement .3. Central venous access device and peripheral midline dressings are changed every 7 days and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected .Midline and Central Venous Access Device Dressing Change Procedure: .4. Assess site for: Erythema, Induration, Swelling, Drainage .18. Apply label on dressing with date and nurse's initials 20. Suggested charting: Site assessment, Measured external length of the catheter, Prep used, Type of dressing, Catheter securement (integrity of sutures, other devices) and Resident response. Record review revealed Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Diabetes Mellitus Type II, Hypertension, Dementia, Alzheimer's Disease, Chronic Kidney Disease and Hypertensive Heart Disease with Heart Failure. The record documented a Brief Interview Mental Status (BIMS) score of 00, indicative of (severe impairment). During an observation on 05/14/25 at 10:37 AM, Resident #4 was observed sitting in the wheelchair in the hallway. It was noted the resident had an intravenous (IV) chest dressing dated 04/25/25. Closer observation on 05/14/25 at 2:08 PM, with the Director Of Nursing (DON) revealed the dressing was still dated 04/25/25 that was on the resident's right IV subclavian Opti Flow chest port double lumen dressing (for Hemodialysis which was not required at that time) with the nurse's initials. Photographic Evidence Obtained. Review of the physician orders revealed that 04/25/25 was the last and most recent order for: Change IV dressing to right upper chest every seven (7) days as well as needed (PRN) for soiling and/or dislodgement every evening shift every Monday - order date 04/25/25 14:43 [2:43] PM D/C [discontinue] date 05/06/25 at 15:00 PM. There was no current physician's order for the right upper chest IV dressing as of his re-admission date to the facility on [DATE]. Record review of Resident #4's Hemodialysis care plan, initiated 04/05/25 and revised 04/14/25, indicated Focus: Hemodialysis---the resident has Renal Failure and is on Hemodialysis. Interventions: Dialysis Catheter Site---Observe for signs and symptoms of Bleeding, for gross bleeding at access consider calling 911 .Goal: Will have minimal to no complications . There was no specific care plan reviewed pertaining to Resident #4's right upper chest (IV) dressing. Review of the April 2025 Medication Administration Record (MAR) revealed the resident's right chest IV dressing had been documented as having been changed on each of the following days: 04/05/25, 04/12/25, 04/19/25 and 04/21/25, 04/26/25, with the last documented time that Resident #4's right chest IV dressing was changed was on: 04/28/25, per the nurses' initials on the MARs. Review of the April 2025 Treatment Administration Record (TAR) revealed no documentation pertaining to the resident's right chest IV dressing, per the lack of nurses' initials. Review of the May 2025 MARs revealed the resident's right chest IV dressing was documented as having been changed on 05/03/25 and 05/05/25, per the nurses' initials on the MAR. Review of the May 2025 TARs revealed no documentation pertaining to the resident's right chest IV dressing, per lack of nurses' initials. The date of 04/25/25 was observed on the resident's right IV subclavian Opti Flow chest port double lumen dressing during this current survey. There was no documentation reviewed in the nursing progress notes dated 04/04/25 to 05/11/25 that indicated Resident #4's right upper chest (IV) dressing had been changed during these dates-of-service (DOS). There was no documentation to describe the resident's IV site status or the condition of the resident's skin underneath the outdated dressing. An interview was conducted on 05/14/25 at 2:05 PM with Staff B, Registered Nurse (RN) / South Unit Manager (UM) and the current direct care nurse for Resident #4, who stated she had not changed the IV right port dressing. She acknowledged he IV right port dressing was outdated and should have been changed. A side-by-side record review was conducted with the DON of all of the documentation notated above. The resident's right IV chest port dressing site was not changed since 04/25/25 and documented on the TAR as being done, until after surveyor intervention. The DON acknowledged the findings on 05/14/25 at 4:10 PM that Resident #4's right IV subclavian Opti Flow chest port double lumen dressing should have had a current physician order and should have been changed and documented as per protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 3 wings in the facility, [NAME] wing. The findings included: On 05/28/24 at 9:53 AM, an observation was made in Resident #67's room of an offensive urine-like odor noted in the resident's room. On 05/28/24, a side-by-side observation of Resident #67's room bathroom was conducted with the Housekeeping Manager and District Housekeeping Manager. They both acknowledged the offensive odor. The Housekeeping Manager stated that the Certified Nursing Assistants (CNAs) inform them when the room has odors, they do use deodorizers, and clean the room as necessary. The District Housekeeping Manager stated they were aware of other rooms which are in their focus cleaning list and will add Resident #67's room to the list. On 05/30/24 at 1:00 PM, an observation was made of an overwhelming smell of urine in the hallway between rooms 60 to 62. An interview was on 05/28/24, at 9:55 AM with Staff E, CNA, who stated Resident #67 gets out of bed and walks to the bathroom to urinate and that he also urinates on the floor. Staff E stated that when the resident urinates on the floor, she puts a sheet over because his roommate goes to the bathroom also, and she then calls housekeeping to clean the floor. An interview was conducted on 05/30/24 at 1:10 PM with the District Manager of Housekeeping who stated he has worked for the company for 19 years. When asked about the strong urine like odor in the hallway between rooms [ROOM NUMBERS], he said the residents in the rooms are incontinent, have behavior issues, and are care planned for their behaviors. He acknowledged there was an odor and housekeeping clean the rooms several times a day with cleaners including enzyme cleaners. An interview was conducted on 05/30/24 at 1:15 PM with the Housekeeping Manager who stated she has worked at the facility for 5 years. When asked about the strong odor in the hallway between rooms [ROOM NUMBERS] she said it is an ongoing issue and they clean those resident rooms at least 3 times a day every day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to properly document and thoroughly investigate an injury of unknown origin for 1 of 1 sampled resident reviewed for skin discoloration, Resident #120. The findings included: Review of the facility's policy, titled, Abuse Prevention Program, dated August 2022, included, in part, the following: These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. Injury of Unknown source: An injury should be classified as an injury of unknown source when all of the following criteria are met: No person observed the source of the injury. The resident could not explain the source of the injury. The injury is suspicious because of its extent or location. Procedure: The facility has implemented the following processes: The Administrator is responsible for designating an Abuse Coordinator. The designed shift supervisor is identified as responsible for immediate initiation of the reporting process. The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. Identification: Events of inquiries of unknown origin/source, such as suspicious bruising occurrences, patterns, and trends or other resident injury that may constitute abuse, neglect, or mistreatment are identified and thoroughly investigated, with appropriate reporting as indicated. Investigation: Investigation may include but may not limited to: Resident statements/interviews; Employee statements/interviews; Visitor statements/interviews; Observation of resident(s), staff, environment; Document review i.e. chart reviews, policy review, education programs, appropriate resource review. Record review for Resident #120 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebral Atherosclerosis, Alzheimer's Disease, Generalized Anxiety Disorder, History of Falling, and Chronic Kidney Disease. Review of Section C of the Minimum Data Set (MDS) dated [DATE], revealed Resident #120 had a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. Review of the Physician's Orders showed Resident #120 had an order dated 04/19/24 for admission to Vitas Hospice Healthcare on 03/23/24, with diagnosis of Cerebral Atherosclerosis; Seroquel Oral Tablet 50 mg (Quetiapine Fumarate), give 1 tablet by mouth at bedtime for Psychosis; Tylenol Oral Tablet 325 mg (Acetaminophen), give 2 tablet by mouth every 4 hours as needed for Pain; and Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, give 5 mg by mouth every 4 hours as needed for Pain. Review of the Care Plan dated 05/07/24 documented Resident #120 had Risk for falls or fall-related injury because of Gait/balance problems and a history of falls. The goals were to minimize the risk of falls and have no untreated fall-related injury. Interventions included: Encourage to wear Non-Skid socks / shoes when out of bed; Encourage resident when rising from a lying position, sit on side of bed for a few minutes before transferring / standing; Observe for side effects of drugs including but not limited to gait disturbance, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness and change of mental status; and Report to physician any side effects associated with the residents medication. During an initial tour of the facility conducted on 05/28/24 at 9:23 AM, the surveyor observed Resident #120 in her room in bed. She was awake and alert. Upon further inspection of the resident's face, a blue, purplish-like bruise was noted around her right eye to go to her right forehead and right temple. When this surveyor inquired about the bruise around the eye, Resident #120 appeared confused and stated that she could not recall why she had a bruise. Review of the Nurses Progress Notes dated 04/18/24 to 05/28/24 revealed no documentation of a fall event or report of a bruise for Resident #120. Review of Weekly Skin Assessments dated 04/21/24, 04/28/24, 05/05/24, 05/12/24, 05/19/24, and 05/26/24 documented, No New Areas of Skin Impairment for Resident #120. On 05/30/24 at 2:23 PM, an interview was conducted with Staff N, South Wing Unit Manager and a Registered Nurse (RN), who stated Resident #120 had a fall, but she was not working when the fall happened about a week ago. She acknowledged receiving report from the Vitas Hospice nurse that Resident #120 was doing okay and that the resident reported no pain. She also stated that she had yet to review the report or documentation of the fall event, but this information can be found in the electronic chart. After searching for the event report, Staff N acknowledged that no fall event had been reported and that there were no nurse progress notes for the incident. On 05/30/24 at 3:35 PM, an interview was conducted with the facility's Director of Nursing (DON). She stated that she contacted Vitas Hospice, and Resident #120 had an incident on 05/17/24. The DON stated that she spoke with the floor nurse on duty that night. The floor nurse stated that she heard a noise coming from Resident #120's room. She went to check on the resident and found her sitting on her bed, and appeared to have bumped her head on the nightstand. She called Vitas Hospice and reported the incident to the Hospice team. The DON stated the floor nurse took Resident #120's vital signs, applied ice to the injury, and assessed the resident. She stated she did not document the incident nor file an incident report. The DON also stated that the Vitas Hospice nurse came in on 05/18/24 to assess Resident #120. An interview was conducted on 05/30/24 at 3:46 PM with Staff J, Licensed Practical Nurse (LPN). Staff J stated that on 05/17/24, she was working the 3-11PM shift, and around 10:00 PM, she was at the nurses' station when she heard a noise coming from Resident #120's room. She entered the room and found the resident sitting in bed, leaning to the right. She noticed the resident had a red spot above her right eye and assumed Resident #120 might have hit her head against the nightstand. She assessed the resident, who appeared okay. She stated that Resident #120 has always been confused but was alert and able to respond to her questions. Staff J stated that at 10:15 PM, she called her supervisor and directed Staff J to contact Vitas Hospice. The supervisor did not inquire about the incident report. Staff J acknowledged not documenting the incident in the nurse progress notes 05/17/24. On 05/30/24 at 4:21 PM, the facility's Assistant Director of Nursing (ADON) was interviewed. She stated that on 05/17/24, she worked the 7-3 PM shift. The ADON stated she was aware Staff J had mentioned that she called her, but she did not recall receiving a phone call. In addition, she stated that she went on vacation after her shift on 05/17/24 and returned to the facility on [DATE]. On 05/30/24 at 5:24 PM, an interview was conducted with Staff P, LPN. He stated that on 05/17/24, he was working the 11 PM-7 AM shift. During rounds, he noticed the bump on Resident #120's head and asked Staff J if she had reported it and if an incident report was filed because he would have to follow up. Staff J stated that she reported it to the supervisor, and Staff P was not concerned. There were no nurse progress notes documented from 05/17/24 to 05/18/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to initiate a comprehensive care plan for psychotropic medications with measurable objectives and interventions for 2 of 25 sampled residents, Resident #40 and Resident #63. The findings included: Review of the facility's policy, titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, dated February 2024, included, in part, the following: The facility shall support that 'each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care'. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. 1, Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Intraspinal Abscess and Granuloma, Generalized Anxiety Disorder, Depression, Chronic Pain Syndrome, and Paraplegia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was intact. Review of Section N revealed Resident #40 was on antianxiety, antidepressive, and opioid medications. Review of the Physician's Orders showed Resident #40 had an order dated 09/01/23 for Morphine Sulfate ER Oral Tablet Extended Release 60 MG (Morphine Sulfate), Give 60 mg by mouth every 8 hours for Non-Acute Pain; Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl), Give 60 mg by mouth two times a day for depression; Alprazolam Oral Tablet 0.5 MG (Alprazolam), Give 1 tablet by mouth every 12 hours for Anxiety Hold for sedation (dated 11/10/23); Side Effects Monitoring every shift: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes. Review of the Care Plan dated 04/08/24 noted no measurable objectives and interventions in place for psychotropic medications for Resident #40. Review of the Psych consultation dated 05/06/24 documented the following recommendations: Resident #40 is to continue the Duloxetine 60mg, Alprazolam 0.5mg; and will be monitored for mood or behavioral changes, efficacy, and side effects. On 05/30/24 at 9:55 AM, an interview was conducted with Staff B, Clinical Record Director (CRD). She stated that if a resident were on psychotropic medications, the care plan would include goals and interventions for behavior monitoring as per physician's order. Staff B also acknowledged that Resident #40 is on psychotropic medications and that his care plan did not include measurable objectives, interventions and timeframes for the psychotropic medications. 2. Record review showed Resident #63 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychosis, and falls. Review of the physician's orders revealed an order for Olanzapine (an antipsychotic medication) Oral Tablet 5 milligrams at bedtime for Psychosis dated 01/17/24. Review of the care plan, initiated on 11/02/23, showed the following: The resident uses psychotropic medications related to antianxiety to manage anxiety and will have minimal side effects and no side effects of psychotropic medication. It further showed monitoring of side effects of Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes. An interview was conducted on 05/30/24 at 8:30 AM with Staff B and Staff C (care plan coordinators) who stated that when a resident is placed on antipsychotic medication, they will initiate a care plan with the title of Psychotropic Medication. Under that section of the care plan, there are usually interventions to monitor the side effects of any antipsychotic medication as well. They were asked regarding the anxiety under the care plan section of psychotropic medication. According to Staff B and C, they should have also initiated or updated the care plan under the psychotropic medication to reflect the antipsychotic medication that Resident #63 was on. An interview was conducted on 05/30/24 at 8:47 AM with the facility's Director of Nursing (DON) who was informed of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that residents receive wound care consistent with professional standards of practice for 1 of 1 sampled resident reviewed for wound care, Resident #48. The findings included: Review of the facility's document provided by the Director of Nursing (DON), titled, Clean Dressing Change Competency Checklist, documented, in part, .wash hands and apply gloves .remove dressing and discard, remove gloves, wash hands, apply gloves .clean wound using circular motion starting from the center toward the outside (clean to dirty) .remove gloves, wash hands, don gloves and apply treatment as ordered . Review of Resident #48's clinical record documented an admission on [DATE] and readmission on [DATE]. The resident's diagnoses included Cachexia, Adult Failure to Thrive, Peripheral Vascular Diseases, Pressure Ulcer of Sacral Region and Chronic Pain Syndrome. Review of Resident #48's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 indicating the resident had severe cognition impairment. The resident's MDS assessment coded Discharge with an anticipated return to the facility, dated 03/04/24 documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most of the activities of daily living including personal care. Review of Resident #48's care plan titled The resident has an Actual Wound-Sacral pressure ulcer initiated on 08/22/23 and revised on 04/03/24 documented interventions to include: Air loss mattress .Treatment as ordered . Review of Resident #48's physician order dated 05/08/24 documented Cleanse Sacrococcygeal area with wound cleanser, apply Dakin's Full Strength solution to gauze, secure with adhesive daily and PRN (as needed) for dislodgement every night shift and as needed. On 05/30/24 at 11:10 AM, observation revealed Resident #48 in bed with an Air loss Mattress in placed. The mattress machine was turned Off. A side-by-side review of the machine was conducted with Staff K, Certified Nursing Assistant (CNA) and Staff G, Unit Manager (UM). Staff K stated she did not turn it off. Staff G turned on the mattress machine and stated it was supposed to be On. They both stated they did not know for how long the resident's air loss mattress was turned off. On 05/30/24 at 11:14 AM, wound care observation started for Resident #48 performed by Staff J, Licensed Practical Nurse (LPN) assisted by Staff K. Staff G, UM was present in the room for staff support. Staff J proceeded to gather wound care supplies, the bordered dressing, Dakin's solution full strength, and a wad of gauzes. Staff J performed hand washing, donned a gown and a pair of gloves. At 11:25 AM, Staff J stated the resident had a bowel movement, retrieved a few paper towels and cleaned the resident's bottom. Staff J applied wound cleanser to a gauze, cleaned the resident bottom, then removed the sacrum wound soiled dressing. Staff J applied wound cleanser to another gauze and wiped the resident's bottom again. Further observation revealed Staff J continued to wear the same pair of gloves, applied wound cleanser to a gauze, cleaned the wound surroundings and discarded the gauze, then applied wound cleanser to another gauze, cleaned the wound bed (inside the wound). Further observations revealed Staff J continued to wear the same pair of gloves, soaked another gauze with Dakin's solution and applied it to the wound bed. Staff J wore the same pair of gloves as worn for incontinent care as she did throughout the whole wound care procedure. Staff J, then with the same gloved hand proceeded to repositioned the resident's bed using the bed control. Consequently, an interview was conducted with Staff J, LPN, who stated she was supposed to change gloves before putting the treatment on Resident #48's sacrum wound and she did not. Staff J stated she was nervous having the supervisor in the room. On 05/30/24 at 11:40 AM, in a joint interview with Staff G and the DON, the DON was apprised of Resident #48's wound care observation findings. The DON stated they get nervous.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview, the facility failed to ensure staff followed proper indwelling (foley) catheter care consistent with accepted standards of practice; failed to insert the appropriate catheter size and failed to date the urinary drainage bag as per physician order for 1 of 1 sampled resident reviewed for urinary catheter care review during foley care provided for Resident #48. The findings included: Record review for Resident #48 documented an admission on [DATE] and readmission on [DATE]. The resident's diagnoses included Cachexia, Adult Failure to Thrive, Obstructive and Reflux Uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), Chronic Kidney, Pressure Ulcer of Sacral Region, and Chronic Pain Syndrome. Review of Resident #48's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 indicating the resident had severe cognition impairment. The resident's MDS assessment-coded Discharge with an anticipated return to the facility, dated 03/04/24 documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most of the activities of daily living including personal care. Review of Resident #48's care plan, titled, Indwelling/Other Catheter: The Resident uses a Urinary catheter with risk for infection and/or complications related to: Obstructive Uropathy initiated on 07/24/20, revised on 04/03/24, documented care plan interventions that included: Catheter size 16 French, Change drainage bag routinely and as needed . Review of Resident #48's physician order dated 04/03/24 documented Urinary Catheter: Urinary catheter to drainage bag for Diagnosis of Obstructive Uropathy. Insert urinary catheter size #16F with 10 cc balloon . Review of Resident #48's physician order dated 04/03/24 documented Urinary Catheter: Change urinary catheter bag as needed. Change catheter bag as needed .Label with date. On 05/28/24 at 1:45 PM, a side-by-side observation of Resident #48's Foley (urinary) catheter was conducted with Staff H, Licensed Practical Nurse (LPN). Observation revealed the Foley tubing was not anchored to the resident's thigh and the tubing was across and underneath the resident's bed, Staff H acknowledged this placement. The urinary drainage bag had cloudy urine in it and the bag was not dated. Attempted to interview the resident and he answered only okay to all questions asked. On 05/30/24 at 8:29 AM, observation revealed Resident #48 in bed with his eyes open. Attempted to interview the resident and he stated okay to every question asked. Further observation revealed a drainage bag with approximately 200 cc (cubic centimeter) of cloudy urine. The bag was on a basin out of the privacy pouch on the right side of the resident's bed. The bag was not labeled with a date. On 05/30/24 at 10:46 AM, observations for Resident #48's Foley and pericare were performed by Staff K, Certified Nursing Assistant (CNA). Staff K performed handwashing, donned gown, gloves and retrieved two basins of water. Observation revealed Resident #48 assisting with turning to the side, the Foley catheter was a 18 French with 30 cc balloon, was not anchored to the thigh/leg and was observed being pulled from the penile opening as he was turning. Further observation revealed Staff K lifted the basin with the urinary drainage bag from the floor and placed it on top of the bed. Staff K proceeded to do Foley care. During an interview, Staff K stated that she always placed the basin with the urinary drainage bag on top of the bed while doing the care. Staff K was apprised that the resident's urinary bag cannot be above the bladder level to avoid urinary tract infection. The bag had approximately 100 cc of urine in it. Staff K was asked regarding anchoring the resident's catheter to his thigh and stated that the resident pulls the device. On 05/30/24 at 11:11 AM, a side-by-side observation of Resident #48's Foley catheter tubing was conducted with Staff G, Unit Manager. Staff G was apprised of the resident's Foley tubing not being anchored and the urinary drainage bag placed on the top of the bed during Foley care. Staff G stated that sometimes they do anchor the Foley, if the residents are moving around. Staff G was apprised that Resident #48 was able to move around in the bed and the staff reported that he likes to sit on the floor. Staff G was apprised that the catheter tubing was pulling during the care. Staff G stated that Staff K should not put the urinary drainage bag on top of the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide nutritional interventions in a timely manner for 1 of 3 sampled residents reviewed for nutrition, Resident #63. The findings included: Review of the facility's policy, titled, Nutrition Assessment and Progress Note, dated January 2023, revealed, in part, the following: Initial nutrition assessment will be completed within 14 days of admission, and reassessment is completed quarterly, annually, and with significant change or readmission as needed. Record review showed Resident #63 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychosis, and falls. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #63 has a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. In an observation conducted on 05/30/24 at 9:03 AM, Resident #63 received her breakfast tray. The tray was filled with crispy bacon, cereal, fortified oatmeal, juice, and coffee. Review of Resident #63's recorded weights showed the following: 11/2/23, a weight of 128.4 pounds; 01/02/24, a weight of 124.6 pounds; 03/04/24, a weight of 126.4 pounds; 04/01/24, a weight of 124.2 pounds; and 05/07/24, a weight of 119 pounds. The Nutrition Evaluation Quarterly dated 01/30/24 showed the following: average meal intake above 50%, weight trending down, and Body Mass Index (BMI) at 20.7, which is lower than optimal. On this note, the facility's clinical dietitian recommended fortified cereal for breakfast and Mighty Shake (nutritional supplements) twice a day to stabilize weight and promote weight gain. Further review did not show that a follow-up nutrition quarterly assessment was completed after 01/30/24. A new weight was observed taken using a Hoyer lift on 05/30/24 at 10:50 AM which showed Resident #63 was at 117 pounds. This showed about 5.8% weight loss in a little over a month. No follow up notes or nutritional assessment were noted addressing the weight loss as above. The care plan dated 04/30/24 revealed Resident #63 has a nutritional or potential problem. It showed how to maintain nutritional intake and monitor weight for significant changes. Review of the Certified Nursing Assistants' (CNAs) documentation of the percentage of meals consumed showed that from 05/16/24 to 05/29/24, Resident #63 ate the following: 4 meals between 25% to 50%, 9 meals between 50% to 75%, and 7 meals between 75% to 100%. An interview was conducted on 05/30/24 at 9:27 AM with the facility's clinical dietitian, who said she reviews all the weights for any weight changes daily. The residents not at high nutritional risk will be monitored quarterly, yearly, and as needed. She further said that a quarterly evaluation for Resident #63 was completed on 01/31/24, and the next one should have been done on 04/28/24 but for some reason, it was not triggered by the MDS to be seen Quarterly. The clinical dietitian stated that she recommended fortified cereal and nutritional supplements twice a day for breakfast and added them to the meal tracker. She should have followed up on Resident #63, looking at her weights and any significant changes, whether she drinks her supplements, and if she had any further decline in nutrition. Another interview was conducted on 05/30/24 at 12:00 PM with the clinical dietitian, who reported the quarterly follow-up on Resident #63 never triggered in the electronic system, which was why it was missed. She then said, I will go ahead and do a quarterly assessment on Resident #63.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Record review for Resident #6 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), Morbid (Severe) Obesity with Alveolar Hypoventilation, Chronic Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia, Type 2 Diabetes Mellitus (DM), and Hypertensive Heart Disease with Heart Failure. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #6 had a Brief Interview for Mental Status of 15, indicating cognition was intact. Review of the Physician's Orders showed that Resident #6 had a physician order dated [DATE] that included Bupropion HBr ER Oral Tablet Extended Release 24 Hour Give 150 mg by mouth one time a day for Depression. Observation on [DATE] at 8:16 AM revealed Staff 1 prepared medications for Resident #6 but did not include the Bupropion HBr ER Oral Tablet Extended Release 24 Hour 150 mg medication. Review of the Medication Administration Record (MAR) for Resident #6 revealed that although Staff I did not administer the Bupropion HBr ER 150 mg Tablet medication to Resident #6, Staff I had signed the medication had been administered on [DATE]. Photographic Evidence Obtained. 6. Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses that included: Cerebral Infarction Unspecified, Malignant Neoplasm of Esophagus, Morbid (Severe) Obesity, Chronic Pain, Nausea with Vomiting, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of the Minimum Data Set for Resident #83 dated [DATE] revealed 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 #83 revealed an order dated [DATE] for Zofran Oral Tablet 8 MG (Ondansetron HCl) give 8 mg by mouth every 8 hours as needed for Nausea and Vomiting. Review of the Physician's Orders for Resident #83 revealed an order dated [DATE] for Zofran Oral Tablet (Ondansetron HCl) give 8 mg by mouth every 6 hours for Nausea and Vomiting. Review of the Medication Administration Record for Resident #83 for Zofran Oral Tablet give 8 mg by mouth every 6 hours for Nausea and Vomiting from [DATE] to [DATE] documented the following: On [DATE] at 12:00 PM, code 9 was documented indicating Other/See Nurse Notes On [DATE] at 6:00 PM, code 9 was documented indicating Other/See Nurse Notes On [DATE] at 12:00 PM, there was no documentation On [DATE] at 12:00 PM, code 9 was documented indicating Other/See Nurse Notes Review of the Medication Administration Record for Resident #83 for Zofran Oral Tablet 8 MG give 8 mg by mouth every 8 hours as needed for Nausea and Vomiting from [DATE] to [DATE] documented the following: [DATE], the medication was documented as given at 7:50 AM [DATE], the medication was documented as given at 10:30 PM [DATE], the medication was documented as given at 8:17 AM [DATE], the medication was documented as given at 10:44 AM Review of the Care Plan for Resident #83 dated [DATE] with a focus on the resident has a potential, current, or history of alteration in gastro-intestinal status related to GERD (Gastroesophageal Reflux Disease) and Epigastric Pain. The goals included: Manage Symptoms. Minimize risk of fall. Will have no untreated signs/symptoms (s/sx) of dehydration. The interventions included: Treat per Gastrointestinal symptom protocol. Observe/document/report to MD PRN for but not limited to: Nausea, Diarrhea, Vomiting, Abdominal Cramps, Rash, Fever, Swelling, Pruritus, tolerance to diet, tolerance to fluids, decreased urine output, hypotension, increased heart rate (Tachycardia), abnormal electrolyte levels. Diet as tolerated. (Refer to orders for current orders). Administer medication as ordered (Refer to orders for current orders)and observe for effectiveness. Observe/document for any precipitating factors. Minimize factors which increase the risk of episodes. Review of the Care Plan for Resident #83 dated [DATE] with a focus on the resident receiving Radiation related to Esophagus Cancer. The goal was for the resident to have no untreated s/sx of complications related to radiation therapy side effects through review date. The interventions included: Give medications and treatments as ordered. Observe/document for side effects and effectiveness. Observe nutritional status and intervene as indicated. Increase calories, protein PRN. Provide diet as ordered and encourage the resident to consume meal. Observe/document/report to MD PRN radiation therapy complications or side effects, including Anemia, Anorexia, Bleeding, Abnormal blood counts, Chills, Constipation, Diarrhea, Fatigue, Nausea/vomiting, Flu-like symptoms, Malaise, Hair loss, Stomatitis, Heartburn, Infection Lips dry, cracked, Mood problems, Muscle soreness, weakness, Peripheral neuropathy, Pain, Skin changes, Swallowing problems, Sore throat, Weight changes. Review of the Care Plan for Resident #83 dated [DATE] with a focus on the resident receiving radiation therapy r/t Cancer: Esophageal Cancer. The goals were for the resident's symptoms related to side effects will be improved or resolved by review date. The resident will have no untreated s/sx of complications related to radiation treatment side effects through review date. The interventions included: Give medications and treatments as ordered and observe for side effects, effectiveness. Observe nutritional status and intervene as indicated. Increase calories, protein PRN. Provide diet as ordered and encourage the resident to consume meal. Observe/document/ report to MD PRN radiation treatment complications or side effects, including Anorexia, Chills, Constipation, Diarrhea, Fatigue, Nausea/vomiting, Flu-like symptoms, Malaise, Hair loss, Stomatitis, Heartburn, Infection, Lips dry, cracked, Mood problems, Muscle soreness, weakness, Peripheral neuropathy, Pain , Skin changes (burns, irritation, rashes, redness, itching), Swallowing problems, Sore throat, Weight changes. An interview was conducted on [DATE] at 10:43 AM with Resident #83 who stated he is not getting his nausea medication, he got it today, but they often run out of the medication. He said he was without it for a couple of days before today. He said he gets nausea medications 4 times a day and really needs it since he had chemo and every time he eats he feels nauseous. An interview was conducted on [DATE] at 8:35 AM with Staff H, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 9.5 years. When asked if they ran out of medication, what the process was, Staff H LPN stated they would check if it were in the E-kit, they would get the medication from the e-kit, call pharmacy to reorder the medication. If the resident misses the medication for more than a day, they would notify the physician. When asked how they would document that the resident was not receiving the medication due to it not being available, she said they would 'document it to see notes and document what happened in the nurse progress notes'. An interview was conducted on [DATE] at 8:45 AM with the Staff Development Coordinator (SDC) who stated he has been working at the facility for 10 months. When asked, if they ran out of medication what the process was, the SDC stated they would call pharmacy for an emergency order to obtain med from E-kit or have it delivered to facility and call the MD (Medical Doctor). When asked how they would document the resident was not receiving the medication due to it not being available, the SDC said they would document what happened in the nursing progress notes. When asked if Zofran is in the E-kit, the SDC said it should be. Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 4 of 6 sampled residents reviewed during the controlled substance record review at the facility's west and south wings, for Residents #48, #82, #93 and #117; failed to obtain a physician's order for a psychotropic medication for Resident #93, reviewed for controlled substance use; failed to properly dispose of a controlled substance medication for Resident #117; failed to provide and document a scheduled medication as ordered for sampled Resident #83, as evidenced by it not being available; and failed to administer a scheduled medication to 1 of 3 residents observed for medicaiton administration, Resident #6. The findings included: Review of the facility's policy, titled, Medication Administration General Guidelines, with no revision date, provided by the Director of Nursing (DON) documented under documentation .the resident's MAR (Medication Administration Record) .is initialed by the person administering the medication .when PRN (as needed) medications are administered, the following documentation is provided: date and time of administration, dose, route .signature or initials of person recording the administration . Review of the facility's policy, titled, Medication Orders Controlled Substance Medication Orders, with no revision date, provided by the DON documented .each controlled substance medication order is documented in the resident's medical record with the date, time and signature of the person receiving the prescription 1. Review of Resident #48, clinical record documented an admission on [DATE] and readmission on [DATE], and had diagnoses that included Cachexia, Adult Failure To Thrive, Dementia and Chronic Pain Syndrome. Review of Resident #48's clinical record documented a physician order dated [DATE] for Ativan (Lorazepam) oral tablet 1 mg (milligram) *Controlled Drug* give 1 tablet by mouth every 6 hours as needed for Anxiety. Review of Resident #48's [DATE]'s Medication Administration Record (MAR) documented the resident received Ativan 1 mg on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Further review revealed the lack of a renewed physician order for Ativan 1 mg every 6 hours as needed for anxiety, as the medication order had expired 14 days after the original order of [DATE]. On [DATE] at 12:58 PM, a side-by-side review of Resident #48's Controlled Drug Declining Inventory Sheet was conducted with Staff J, Licensed Practical Nurse (LPN). The review revealed the resident's Controlled Drug Declining Inventory Sheet for Lorazepam 1 mg every 6 hours as needed for agitation was received from the pharmacy on [DATE] and there were 20 tablets left in the controlled substance box. Further review revealed the controlled substance was last removed from the box on [DATE]. During an interview, Staff J stated that any controlled substance removed from the box and administered to the resident, would be documented on the resident's MAR. Review of Resident #48's Controlled Drug Declining Inventory Sheet received from the pharmacy by the facility on [DATE] for Lorazepam 1 mg (30 tablets), give one tablet every 6 hours as needed tablet was conducted. The sheet documented that one tablet of lorazepam 1 mg was removed from the controlled substances box on [DATE], [DATE] and [DATE], (the time of removal was unable to be read). Further review revealed that Lorazepam tablet was not initialed as administered on the resident's MAR on [DATE], [DATE] and [DATE]. The resident's controlled substance was not reconciled as required. On [DATE] at 9:31 AM, a side-by-side review of Resident #48's MAR's documentation and Lorazepam 1 mg Controlled Drug Declining Inventory Sheet for [DATE] was conducted with the DON. The DON acknowledged the lack of the reconciliation for the controlled substance medication for [DATE], [DATE] and [DATE]. 2. Review of Resident #82, clinical record documented an admission on [DATE] with no readmissions, and had diagnoses that included Alzheimer's, Adult Failure To Thrive, Generalized Anxiety and Chronic Pain Syndrome. Review of Resident #82's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS score of 0, indicating severe cognitive impairment. Review of Resident #82's clinical record documented a physician order dated [DATE] for Ativan (Lorazepam) oral tablet give 1 mg via G-tube every 4 hours as needed for Anxiety. On [DATE] at 2:18 PM, a side-by-side review of Resident #82's Controlled Drug Declining Inventory Sheet was conducted with Staff L, LPN. The review revealed the resident's Controlled Drug Declining Inventory Sheet for Lorazepam 1 mg every 4 hours as needed for anxiety was received from the pharmacy on [DATE]. During an interview, Staff L stated that any controlled substance removed from the box and administered to the resident, would be documented on the resident's MAR. Review of Resident #82's [DATE]'s MAR for Lorazepam 1 mg every 4 hours as needed revealed that one tablet was removed from the controlled substances box on [DATE] and was not initialed as administered on the resident April MAR's on [DATE]. The resident's controlled substance medication was not reconciled as required. On [DATE] at 10:18 AM, a side-by-side review of Resident #82's physician orders for Ativan (Lorazepam) 1 mg was conducted with the DON. The DON acknowledged that lorazepam 1 mg removed from the controlled box on [DATE] was not initialed as administered on the resident's MAR as required. The DON stated the controlled substance are to be documented in both places, the controlled sheet and the MAR. 3. Review of Resident #93's clinical record documented an admission on [DATE] with a readmission on [DATE], and had diagnoses that included Cerebral Infarction, Restlessness and Agitation, Anxiety and Bipolar Disorder. Review of Resident #93's MDS quarterly assessment dated [DATE] documented a BIMS score of 14 indicating no cognitive impairment. Review of Resident #93's Controlled Drug Declining Inventory Sheet received by the facility from the pharmacy on [DATE] for Alprazolam 0.25 mg (26 tablets), give one tablet twice a day as needed for agitation, was conducted. The inventory sheet documented that one tablet of Alprazolam 0.25 mg was removed from the controlled substances box on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on [DATE]. Further review revealed that Lorazepam tablet was not initialed as administered on the resident's June, July, August, September, October, [DATE] and [DATE]'s MAR on the above mentioned dates. The resident's controlled substances was not reconciled. The resident's [DATE]'s MAR documented Alprazolam 0.25 mg was initiated as administered on [DATE] at 1437 hours (2:37 PM). The medication was not documented on the resident's controlled drug declining inventory sheet as removed from the box. On [DATE] at 10:26 AM, a side-by-side review of Resident #93's Controlled Drug Declining Inventory Sheet dated [DATE] for Alprazolam was conducted with the DON. The DON stated that they do psychotropic meeting every third Wednesday with the Social Worker, the Psychiatrist and all the Unit Manager. She added she did not know how Resident #93's psychotropic medications got missed. The DON stated the physician order dated [DATE] read Alprazolam 0.25 mg every 12 hours as needed for agitation for 14 days - hold for sedation. The DON acknowledged that the resident received Alprazolam 0.25 mg during the month of June, July, August, September, October, [DATE] and on February and [DATE] without a physician order. During the review, the DON acknowledged that Resident #93's Alprazolam 0.25 mg removed from the controlled box on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], and [DATE] were not initialed as administered on the resident's respective MARs. 4. Review of Resident #117's clinical record documented an admission on [DATE] with no readmissions and had diagnoses that included Traumatic Subarachnoid Hemorrhage, Multiple Fractures and Gastrostomy tube. Review of Resident #117's MDS comprehensive assessment dated [DATE] documented a BIMS score of 9 indicating moderate cognitive impairment. Review of Resident #117's physician order dated [DATE] documented Ativan oral tablet 0.5 mg (Lorazepam) give 0.5 mg via PEG every 12 hours as needed for Anxiety for 14 days. On [DATE] at 1:03 PM, a side-by-side review of Resident #117's Controlled Drug Declining Inventory Sheet was conducted with Staff J, LPN. The review revealed the resident's Controlled Drug Declining Inventory Sheet for Lorazepam 0.5 mg by mouth every 12 hours as needed hold for sedation, was received on [DATE]. Review of Resident #117's Controlled Drug Declining Inventory Sheet received from the pharmacy by the facility on [DATE] for Lorazepam 0.5 mg give one tablet every 12 hours as needed documented that one tablet of lorazepam 0.5 mg was removed from the controlled substances box on [DATE], [DATE], [DATE], and [DATE]. Further review revealed that Lorazepam tablet was not initialed as administered on the resident's March and April's 2024 MARs respectively. The resident's controlled substances was not reconciled. On [DATE] at 9:51 AM, a side-by-side review of Resident #117's March, April and [DATE] MARs documentation and Controlled Drug Declining Inventory Sheet received by the facility on [DATE] for Ativan (Lorazepam) was conducted with the DON. The DON stated the resident had a physician order dated [DATE] for Ativan 0.5 mg via PEG every 12 hours as needed for Anxiety for 14 days. The DON stated she did not see any more order for lorazepam beside the one for [DATE]. The DON acknowledged that Lorazepam 0.5 mg tablets removed from the controlled substances box on [DATE], [DATE], [DATE], and [DATE] were not initialed on the resident's MAR. The DON stated the nurses were supposed to document on the MAR as well as in the controlled sheet. 5. Review of Resident #117's clinical record documented an admission on [DATE] with no readmissions, and had diagnoses that included Traumatic Subarachnoid Hemorrhage, Multiple Fractures and Gastrostomy tube. Review of Resident #117's physician order dated [DATE] documented Ativan oral tablet 0.5 mg (Lorazepam) give 0.5 mg via PEG every 12 hours as needed for Anxiety for 14 days. On [DATE] at 10:07 AM, a side-by-side review of Resident #117's Controlled Drug Declining Inventory Sheet dated [DATE] for Ativan (Lorazepam) 0.5 mg as needed for Anxiety was conducted with the DON. The DON stated that on [DATE] and [DATE], respectively, the nurses wrote on the sheet that a pill fell (unable to read the writing). The DON stated that they need two nurse signature for the controlled substance wasted tablets and that the controlled sheet did not have the two nurses signatures for the [DATE] and [DATE] tablets wasted as required. The disposal of two Lorazepam tablets, a controlled substance medication, was not completed as per the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Intraspinal Abscess and Granuloma, Generalized Anxiety Disorder, Depression, Chronic Pain Syndrome, and Paraplegia. Review of Section C of the MDS dated [DATE] revealed that Resident #40 had a BIMS score of 15 indicating the resident was cognitively intact. Review of Section N revealed Resident #40 was on antianxiety, antidepressive, and opioid medications. Review of the Physician's Orders showed that Resident #40 had an order dated 09/01/23 for: Morphine Sulfate ER Oral Tablet Extended Release 60 mg, give 60 mg by mouth every 8 hours for Non-Acute Pain; Duloxetine HCl Oral Capsule Delayed Release Particles 60 mg, give 60 mg by mouth two times a day for depression; Alprazolam Oral Tablet 0.5 mg, give 1 tablet by mouth every 12 hours for Anxiety Hold for sedation (dated 11/10/23); Side Effects Monitoring every shift: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, Nausea & Vomiting, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes. Review of the Psychiatry consultation dated 05/06/24 documented the following recommendations: Resident #40 is to continue the Duloxetine 60mg, Alprazolam 0.5mg, and will be monitored for mood or behavioral changes, efficacy, and side effects. Review of Tasks, titled, Behavior Monitoring and Interventions from 05/21/24 through 05/27/24, the following was noted: 05/21/24 at 14:59 and 21:30: no behaviors observed. 05/22/24 at 11:45, 14:21, and 21:59: no behaviors observed. 05/23/24 at 4:41 and 22:52: no behaviors observed. 05/24/24 at 00:12 and 22:35: no behaviors observed. 05/25/24 at 15:03, 22:20, and 23:56: no behaviors observed. 05/26/24 at 14:37 and 23:17: no behaviors observed. 05/27/24 at 14:50 and 21:50: no behaviors observed. Based on interviews and record review, the facility failed to adequately monitor residents' behaviors for those residents receiving psychotropic medications for 4 of 25 sampled residents, Residents #63, #40, #99 and #113. The findings included: Review of the facility's policy, titled, Behavior Monitoring Record, dated October 2021, included in part, the following: Procedure 1. Enter the following information into electronic medical record. 2. Describe the specific behavior to be monitored. 3. Code the interventions determined to address the specific behavior. 4. Enter the frequency of the behavior on each shift. 5. Enter the letter code (or # code) of the intervention(s) chosen to address the behavior. 6. Enter the outcome code of the intervention(s). 1. Record review for Resident #63 revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition and Generalized Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #63 dated 04/28/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #63 revealed an order dated 10/23/23 for Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V (Nausea and vomiting), Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes every shift Do not use if any side effects are present or resident appears to be lethargic, drowsy, or sedated. Report changes to practitioner if needed. Review of the Physician's Orders for Resident #63 revealed an order dated 01/17/24 for Olanzapine Oral Tablet 5 MG give 5 mg by mouth at bedtime for Psychosis. Review of Medication Administration Record (MAR) for Resident #63 from 05/21/24 to 05/27/24 for side effect monitoring revealed the following: On 05/21/24, NS (No Symptoms) were documented for the day and evening shift; a check mark was documented for the night shift. On 05/22/24, a check mark was documented for the day and night shift and NS was documented for the evening shift. On 05/23/24, a check mark was documented for the day and night shift and NS was documented for the evening shift. On 05/24/24, NS was documented for the day shift and a check mark was documented for the evening and night shift. On 05/25/24 to 05/27/24, all days had a check mark documented for the day, evening, and night shift. Review of Progress notes and E-MAR (Electronic Medication Administration Record) notes for Resident #63 from 05/21/24 to 05/27/24 revealed no side effects, behaviors, interventions, or outcomes documented. Review of the Task titled: Behavior Monitoring & Interventions for Resident #63 from 05/21/24 to 05/27/24 revealed the following: On 05/21/24, no documentation. On 05/22/24, no documentation. On 05/23/24 at 12:35 PM, documented hitting others, cursing at others, and scratching self with no intervention(s) documented. At 8:32 PM, documented resident not available, and at 11:58 PM documented no behaviors observed. On 05/24/24 at 12:24 PM, documented hitting others and accusing of others with no intervention(s) documented, at 8:39 PM documented resident not available, and at 11:31 PM documented no behaviors observed. On 05/25/24 at 1:03 PM, documented hitting others and accusing of others with no intervention(s) documented, at 10:59 PM documented no behaviors observed. On 05/26/24 at 1:30 PM and 2:59 PM, documented no behaviors observed. At 10:59 PM documented not applicable. On 05/27/24 at 12:04 AM and 11:50 PM, documented no behaviors observed, at 11:55 PM documented hitting others, accusing of others with no intervention(s) documented, and at 9:46 PM documented resident not available. Review of the Care Plan for Resident #63 dated 11/02/23 with a focus on the resident uses psychotropic medications r/t [related to] Antipsychotic medication to manage: Psychosis related to Dementia with behavioral disturbance and Anxiety Disorder. The goals were for the resident to have minimal side effects and to have no side effects of psychotropic medication. The interventions included: Psychotropic Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes. Administer medications as ordered. Observe/document for side effects and effectiveness. 2. Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebrovascular Disease, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance, Schizoaffective Disorder, and Anxiety Disorder. Review of the MDS assessment for Resident #99 dated 04/22/24 revealed in Section C a BIMS score of 2 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #99 revealed an order dated 04/28/23 for Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes every shift Do not use if any side effects are present or resident appears to be lethargic, drowsy, or sedated. Report changes to practitioner if needed. Review of the Physician's Order for Resident #99 revealed an order dated 01/04/24 for End of Life Care Hospice services for diagnosis of: Declining function. Review of the Physician's Orders for Resident #99 revealed an order dated 8/30/23 for Celexa Oral Tablet 20 MG give 20 mg by mouth one time a day for Depression Review of the Physician's Orders for Resident #99 revealed an order dated 01/18/24 for Lorazepam Injection Solution 2 MG/ML use 0.5 mg intravenously every 4 hours as needed for Anxiety Inject 0.5mg (0.25ml) Intravenously q4hrs PRN (use Subcutaneously if IV site not available) [every 4 hours as needed]. Review of the Physician's Orders for Resident #99 revealed an order dated 01/25/24 for Lorazepam Oral Tablet 0.5 MG give 0.5 mg by mouth every 4 hours as needed for Anxiety/agitation. Review of the Physician's Orders for Resident #99 revealed an order dated 01/25/24 for Quetiapine Fumarate Oral Tablet 25 MG give 25 mg by mouth two times a day for Anxiety/Agitation. Review of the Medication Administration Record (MAR) for Resident #99 from 05/21/24 to 05/27/24 for side effect monitoring revealed the following: On 05/21/24, NS was documented for the day shift; a check mark was documented for the evening and night shift. On 05/22/24, NS was documented for the day shift, a check mark was documented for the evening and night shift. On 05/23/24, NS was documented for the day and evening shift and a check mark was documented for the night shift. On 05/24/24, NS was documented for the day and evening shift and a check mark was documented for the night shift. On 05/25/24, NS was documented for the day and evening shift and a check mark was documented for the night shift. On 05/26/24, NS was documented for the day and evening shift and a check mark was documented for the night shift. On 05/27/24, NS was documented for the day and evening shift and a check mark was documented for the night shift. Review of the Task titled: Behavior Monitoring & Interventions for Resident #99 from 05/21/24 to 05/27/24 included the following: On 05/21/24, no documentation. On 05/22/24 at 2:47 PM, documented not applicable. On 05/23/24 at 2:59 PM and 10:35PM, no behaviors observed. On 05/24/24 at 12:22 AM and 9:08 PM, documented no behaviors observed and at 2:43 PM documented not applicable. On 05/25/24 at 2:59 PM, documented no behaviors observed. ON 05/26/24 at 12:04 AM, 2:59 PM, and 10:28 PM, documented no behaviors observed On 05/27/24 at 6:47 AM, 2:21 PM, and 11:39 PM, documented no behaviors observed and at 9:52 PM documented not applicable. Review of the Care Plan for Resident #99 dated 10/17/23 with a focus on the resident is at Risk for falls or fall related injury because of: Cognitive impairment, Psychoactive drug use, frequent wondering, dx with Dementia, Anxiety Disorder, Depression and Schizoaffective Disorder. The goals were for the resident to participate in activities of choice and to minimize the risk of fall. The interventions included: Observe for side effects of drugs including but not limited to; gait disturbance, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness and change of mental status. Review of the Care Plan for Resident #99 dated 02/08/24 with a focus on the resident has a mood problem r/t Schizoaffective Disorder, Dementia, Anxiety, and Depression. The goals were to not harm others and to not harm self. The interventions included: Administer psychotropic medications as ordered Report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician). Speak softly & clearly when communicating. Discuss procedures & mediations prior to administration. Psychiatry Services as needed. Psychological Services An interview was conducted on 05/31/24 at 8:35 AM with Staff H Licensed Practical Nurse (LPN) who stated she has worked at the facility for 9.5 years. When asked about residents receiving psychotropic medications, whether they monitor behaviors, side effects, and interventions, Staff H LPN said yes, they document the side effects on the MAR by indicating a NS for no symptoms and a check mark if the resident is having symptoms. And they would document the side effect, behavior, and any interventions in the progress notes. An interview was conducted on 05/31/24 at 8:45 AM with the Staff Development Coordinator (SDC) who stated he has been working at the facility for 10 months. When asked about residents receiving psychotropic medications, whether they monitor behaviors, side effects, and interventions, the SDC said of course. When asked where these are documented, he said on the MAR and also in the nursing progress notes. A telephone interview was conducted on 05/31/24 at 9:30 AM with the Consultant Pharmacist (CP) who stated that she has been working with the facility since May 2020. When asked if she reviews the medications for residents monthly, she said yes and that includes monitoring side effects and behaviors. The CP said she runs a report for behavior monitoring and none of the residents have behaviors. 3. Record review for Resident #113 revealed the resident was admitted to the facility on [DATE] with diagnosis that included Nontraumatic Compartment Syndrome of Left Lower Extremity, Schizoaffective Disorder, Major Depressive Disorder, Major Depressive Disorder Single Episode In Full Remission, Anxiety Disorder Due to Known Physiological Condition, and Insomnia Due to Other Mental Disorder. Review of the MDS for Resident #113 dated 04/08/24 revealed in Section C a BIMS score of 13 indicating a cognitive response. Review of the Physician's Orders for Resident #113 revealed an order dated 12/15/23 for Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V, Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes every shift Do not use if any side effects are present or resident appears to be lethargic, drowsy, or sedated. Report changes to practitioner if needed. Review of the Medication Administration Record (MAR) from 05/21/24 to 05/27/24 to monitor side effects revealed the following: On 05/21/24, NS was documented for the day shift; a check mark was documented for the evening and night shift. On 05/22/24, NS was documented for the day shift; a check mark was documented for the evening and night shift. 05/23/24, NS was documented for the day and evening shift, and a check mark was documented for the night shift. On 05/24/24, NS was documented for the day and night shift and a check mark was documented for the evening shift. On 05/25/24, NS was documented for the day shift and a check mark was documented for the evening and night shift. On 05/26/24, a check mark was documented for all 3 shifts (Day, evening, and night). On 05/27/24, a check mark was documented for all 3 shifts (Day, evening, and night). Review of the Task Behavior Monitoring and Intervention for Resident #113 reviewed from 05/21/24 to 05/28/24 included the following: On 05/21/24, no documentation On 05/22/24 at 6:59 AM, 2:59 PM and 11:32 PM, documented no behaviors observed On 05/23/24 at 1:21 PM, documented not applicable, at 10:49 PM and 11:40 PM, documented no behaviors observed On 05/24/24 at 10:11 PM, documented no behaviors observed On 05/25/24 at 6:59 AM, 10:59 PM and 11:35 PM, documented no behaviors, observed at 1:13 PM documented hitting others with no intervention(s) documented. On 05/26/24 at 2:59 PM and 11:59 PM, documented not applicable On 05/27/24 at 1:35 PM, documented hitting others with no intervention(s) documented and at 11:45 PM, no behaviors observed. Review of the progress notes and EMAR progress notes for Resident #113 for the month of May 2024 revealed no side effects or interventions for behaviors or side effects of psychotropic medications were documented for the physician ordered medications administered, as follows: a. 04/15/24, for Quetiapine Fumarate Oral Tablet 100 MG give 100 mg by mouth at bedtime for Schizoaffective Disorder. b. 04/15/24, for Quetiapine Fumarate Oral Tablet 100 MG give 1 tablet by mouth one time a day for psychosis. c. 04/15/24, for Citalopram Hydrobromide Oral Tablet 40 MG give 40 mg by mouth one time a day for Depression. d. 04/15/24, for Trazodone HCl Oral Tablet 100 MG give 2 tablet by mouth at bedtime for insomnia. e. 04/17/24, for Alprazolam Oral Tablet 0.25 MG give 1 tablet by mouth two times a day for Anxiety. f. 05/22/24, for Hydroxyzine HCl Oral Tablet 50 MG give 1 tablet by mouth four times a day for Anxiety. Review of the Care Plan for Resident #113 dated 01/04/24 with a focus on the resident is noted with the following disorders that effect behavior: General Anxiety Disorder, Nicotine Dependence, Insomnia, Schizoaffective Disorder, Altered Mental Status, Psychoactive Substance Abuse and Depression. Behaviors include screaming at staff, verbally aggressive and yelling profanities at staff. The goal was for the resident to be informed of the risk/outcomes associated with preference of choice. The interventions included: Administer psychotropic medications as ordered. Report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician). Allow time to communicate effectively. Discuss procedures & mediations prior to administration. Give clear explanation of all care activities prior to and as they occur during each contact. Document episodes of behavior & review to determine the effectiveness of intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to address physician ordered 'As Needed' (PRN) psychotropic medications that had 'no stop date' in a timely manner for 3 of 25 sampled residents, Residents #48, #82, and #99. The findings included: Review of the facility's policy, titled, Use of Anti-Psychotic Medication, dated [DATE], included, in part, the following: To assess, monitor and manage a resident receiving an antipsychotic medication. PRN antipsychotic medications will be discontinued after the 14th day post the initial order. If the prescriber wishes to continue the medication: A face to face evaluation Documentation to include the reason the prn medication is required The benefit to the resident and ways in which the residents condition improved as a result of the prn This documentation must be in the medical record. 1. Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebrovascular Disease, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance, Schizoaffective Disorder, and Anxiety Disorder. Review of the Minimum Data Set (MDS) assessment for Resident #99 dated [DATE] revealed in Section C a Brief Interview of Mental Status (BIMS) score of 2 indicating severe cognitive impairment. Physician order for Resident #99 dated [DATE] dcouemtned for Side Effects Monitoring: Agitation, Blurred Vision, Cardiac or Blood Abnormalities, Confusion, Constipation, Dry Mouth, Difficulty Urinating, Disturbed Gait, Drooling, Drowsiness, Headache, Hypotension, Involuntary movement of mouth, tongue, trunk or extremities, N&V (Nausea and Vomiting), Pacing, Seizure Activity, Stiffness of Neck, Sore Throat, Tremors, Rashes every shift Do not use if any side effects are present or resident appears to be lethargic, drowsy, or sedated. Report changes to practitioner if needed. Review of the Physician's Order for Resident #99 revealed an order dated [DATE] for End of Life Care Hospice services for diagnosis of :Declining function. Review of the Physician's Orders for Resident #99 revealed an order dated [DATE] Lorazepam Injection Solution 2 MG/ML use 0.5 mg intravenously every 4 hours as needed for Anxiety Inject 0.5mg (0.25ml) Intravenously q4hrs PRN (use Subcutaneously if IV site not available (ordered by the Attending Physician). Review of the Physician's Orders for Resident #99 revealed an order dated [DATE] for Lorazepam Oral Tablet 0.5 MG give 0.5 mg by mouth every 4 hours as needed for Anxiety/agitation (ordered by the Attending Physician). Review of Medication Administration Record (MAR) for Resident #99 from [DATE] to [DATE] documented Lorazepam 0.5mg tablet was administered as follows: On [DATE] at 8:20 AM On [DATE] at 9:00 AM and 4:39 PM On [DATE] at 5:00 PM On [DATE] at 4:28 PM On [DATE] at 8:10 AM Review of the 'Note To Attending Physician / Prescriber (Pharmacy Recommendations)' for Resident #99 from [DATE] to [DATE] revealed the following: a. On [DATE] - documented this resident is currently on PRN lorazepam 2mg/ml. Please evaluate current diagnoses, behaviors and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and indicate the duration for the PRN order. The Physician / Prescriber Response documented Pt (Patient/Resident) under hospice. Meds are managed by hospice. and was signed [DATE] by the PMHNP (Psychiatric-Mental Health Nurse Practitioner). b. On [DATE] - documented this resident is currently on PRN lorazepam 0.5mg. Please evaluate current diagnoses, behaviors and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and indicate the duration for the PRN order. The Physician / Prescriber Response documented Pt [Patient/Resident] under hospice. Meds are managed by hospice. and was signed [DATE] by the PMHNP. c. From [DATE] to [DATE], there were no recommendations or Notes To Attending Physician / Prescriber. Review of the Care Plan for Resident #99 dated [DATE] with a focus on the resident is at Risk for falls or fall related injury because of: Cognitive impairment, Psychoactive drug use, frequent wondering, dx with Dementia, Anxiety Disorder, Depression and Schizoaffective Disorder. The goals were for the resident to participate in activities of choice and to minimize the risk of fall. The interventions included: Observe for side effects of drugs including but not limited to; gait disturbance, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness and change of mental status. Review of the Care Plan for Resident #99 dated [DATE] with a focus on the resident has a mood problem r/t [related to] Schizoaffective Disorder, Dementia, Anxiety, and Depression. The goals were to not harm others and to not harm self. The interventions included: Administer psychotropic medications as ordered Report missed or refused medication to physician ( Missed doses can lead to an acute event & should be reported to the physician). Speak softly & clearly when communicating. Discuss procedures & mediations prior to administration. Psychiatry Services as needed. Psychological Services A telephone interview was conducted on [DATE] at 9:30 AM with the Consultant Pharmacist (CP) who stated that she has been working with the facility since [DATE]. When asked about psychotropic medications if they can be ordered PRN (as needed), she said yes it needs to have a stop date and a rationale document for the need for PRN. The CP stated psychotropic medications as needed can only be ordered for 14 days then would have to be reordered. When asked if she reviews the medications for residents monthly, she said yes. When asked when she makes a recommendation to the physician as to the timeframe, she stated she would expect the physician to respond. She did not answer the question asked and said if she does not get a response from the physician, they would make the same recommendation the following month. An interview was conducted on [DATE] at 1:00 PM with the Director of Nursing (DON) who was asked regarding psychotropic medications ordered prn with no stop day, she said she was under the impression if the resident was on hospice services they did not need a stop date. 2. Review of Resident #48's clinical record documented an admission on [DATE] and readmission on [DATE] with diagnoses that included Cachexia, Adult Failure To Thrive, Dementia and Chronic Pain Syndrome. Review of Resident #48's MDS significant change assessment dated [DATE] documented a BIMS score of 7 indicating the resident had severe cognition impairment. The resident's MDS assessment coded Discharge with an anticipated return to the facility, dated [DATE] documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most of the activities of daily living including personal care. Review of Resident #48's clinical record documented a physician order dated [DATE] for Ativan (Lorazepam) oral tablet 1 mg (milligram) *Controlled Drug* give 1 tablet by mouth every 6 hours as needed for Anxiety. The physician order did not have a stop date as required for as needed psychotropics. Review of Resident #48's [DATE]'s Medication Administration Record (MAR) documented the resident received Ativan 1 mg on [DATE], [DATE], [DATE], [DATE] and [DATE]. The physician written prescription of [DATE] for Ativan 1 mg every 6 hours as needed for anxiety expired on [DATE], 14 days after it was ordered. Review of Resident #48's [DATE]'s Medication Administration Record (MAR) documented the resident received Ativan 1 mg on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Further review revealed the lack of a renemal physician order for Ativan 1 mg every 6 hours as needed for anxiety. The physician written prescription had expired on [DATE]. On [DATE] at 9:28 AM, a side-by-side review of Resident #48's physician orders for Ativan (Lorazepam) 1 mg was conducted with the Director of Nursing (DON). The DON stated the last physician order for Lorazepam was written on [DATE]. The DON added that normally the medication would be discontinued because it was as needed, but because the resident was on hospice care, they do not discontinue as needed medication for the residents on hospice care. 3. Review of Resident #82, clinical record documented an admission on [DATE] with no readmissions, with diagnoses that included Alzheimer's, Adult Failure To Thrive, Generalized Anxiety and Chronic Pain Syndrome. Review of Resident #82's MDS admission assessment dated [DATE] documented a BIMS score of 0 indicating severe cognitive impairment. Review of Resident #82's clinical record documented a physician order dated [DATE] for Ativan (Lorazepam) oral tablet give 1 mg via G-tube every 4 hours as needed for Anxiety. The physician order did not have a stop date as required for as needed psychotropics. Review of Resident #82's [DATE]'s MAR documented the resident received Ativan 1 mg on [DATE], [DATE], and [DATE]. Further review revealed the lack of a renewed physician order for Ativan 1 mg every 4 hours as needed for anxiety. The physician written prescription had expired on [DATE]. On [DATE] at 2:18 PM, an interview was conducted with Staff L, LPN, who stated that she was not aware of having a physician order every 14 days for lorazepam as needed and added that when they were down to 4-5 pills, they will call hospice for a new prescription. On [DATE] at 10:18 AM, a side-by-side review of Resident #82's physician orders for Ativan (Lorazepam) 1 mg was conducted with the DON. The DON stated the last physician order for Lorazepam was written on [DATE]. The DON added that normally the medication would be discontinued because it was ordered as needed, but because the resident was on hospice care, they do not discontinue 'as needed' medication for the residents on hospice care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain medications and medication carts in a secure and sanitary manner for 2 of 3 medication carts observed during facility tours and medication administration opportunities; and failed to dispose of expired eyedrops as observed during medication storage tours. The findings included: Review of the facility's policy, titled, Storage of Medication, dated 09/2018, included in part the following: Medications and biologicals are stored properly, following manufacturer or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 1. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. Review of the facility's policy, titled, Medication Administration, General Guidelines, dated 09/2018, included in part the following: Medication Preparation: 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Medication Administration: 17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. 1. A medication administration observation was conducted on [DATE] at 8:16 AM with Staff I for Resident #6. While preparing the prescribed medications, Staff I noted she did not have one of the scheduled medication for Resident #6. She stated that she had ordered the medication from the pharmacy, but it had yet to be delivered. Staff I then proceeded to place the prepared medications in the top drawer and went to the end of the hallway to speak to Staff G, Unit Manager (UM). Staff I left the medication cart unlocked. There were two residents within 5 meters from the medication cart and staff members were observed passing by. During this observation, Staff I was away from the unlocked medication cart for approximately 7 minutes. Upon returning to the medication cart, Staff I realized that she left the cart unlocked, did not address it with the surveyor, and continued to dispense the medications. 2. On [DATE] at 9:50 AM, an observation was made of a medication (med) cart left unattended and unlocked outside of room [ROOM NUMBER]. An interview was conducted on [DATE] at 9:51 AM with the Development Coordinator (SDC) who was asked to check and see if the med cart was unlocked, he opened the top drawer full of medications and acknowledged the med cart was unattended and unlocked. The SDC stated it should not be left unlocked when the nurse steps away. An interview was conducted on [DATE] at 9:53 AM with Staff O, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 2 years. When asked if the med cart in the hallway in front of room [ROOM NUMBER] was assigned to her today, she said yes. She acknowledged she left the med cart unlocked and unattended. She stated she said she did not know how that happened. 3. On [DATE] at 1:33 PM, a side-by-side review of the facility's South wing medication cart was conducted with the Staff Development Coordinator (SDC). The review revealed an over-the-counter Eye drop bottle with an expiration date on 11/2021. During the review, Staff N, Unit Manager (UM) interjected and stated that the staff found the eye drop bottle in the resident's room and it was removed from her, was not sure when it was removed, and was placed in the medication cart. Staff N stated the resident was using it while she had in the room. The expired bottle was given to the SDC for disposal. 4. On [DATE] at 1:40 PM, further side-by-side review of the facility's South wing medication cart with the SDC revealed one loose red round pill in the top drawer of the cart. Consequently, an interview was conducted with the SDC who stated there was not supposed to be any loose pills in the cart and added that he just checked the cart for that and did not see any loose pill prior to the review. 5. On [DATE] at 2:18 PM, a side-by-side review of the facility's South wing-medication cart #2 was conducted with Staff L, LPN. The review revealed one loose white oblong capsule in the second drawer. Staff L stated they should not have any loose pills in the cart. On [DATE] at 10:20 AM, during an interview, the Director of Nursing stated she was informed of the findings.

Based on observations, interviews and record review, the facility failed to follow their menus to meet the nutritional needs of the residents for 1 of 2 observations completed in the main kitchen. This has the potential to affect 40 residents on a regular diet. The cnesus at the time of survey was 124 residents. The findings included: Review of the facility's menu cycle, week 2, 2024 diet menu, showed the following food items on the regular diet: 3 ounces of corn beef, ½ of braised cabbage, ½ cups of boiled new potatoes, dinner roll, and pudding parfait. In an observation conducted on 05/30/24 at 11:30 AM, Staff A, Cook, was observed plating a piece of corn beef on a regular diet plate during the lunch tray line. The surveyor proceeded to request the weight of the corned beef on the plate be taken. Continued observation showed the Food Service Manager (FSD) taking the weight of the corned beef using a facility's food scale. The corned beef measured 1 ounce, which was plated earlier by Staff A on the regular diet. Another piece of corn beef was taken and placed on the food scale, which measured 1 ounce as well. This revealed that the corn beef pieces were not meeting the 3 ounce serving size noted on the menu. During the observation, the Food Service Manager was heard instructing Staff A, You will need to put two pieces of corned beef on each plate for the regular diet. Two pieces of corned beef would have provided 2 ounces of corned beef, which would still not meet the 3 ounces of serving as per the facility's menu. On 05/31/24 at 2:00 PM, in an interview was conducted with the Food Service Manager, and he was infomred of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide food choices and preferences for 3 of 25 sampled residents during dining observations, Resident #28, Resident #64, and Resident #110. The findings included: 1. Record review showed that Resident #28 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. In an interview conducted on 05/28/24 at 10:10 AM with Resident #28, she stated that they often make mistakes on her meal trays and do not give her the correct food items she requested. In an observation conducted on 05/29/24 at 9:00 AM, Resident #28 was in her room with the breakfast tray. The meal ticket on the tray showed the following food items: Two individual hard-boiled eggs Home fried potatoes Bagel with cream cheese A fruit plate. The continued observation showed a breakfast plate with a bagel and cream cheese, a fruit plate, and potatoes but no eggs. In this observation, Resident #28 stated that she did not get any protein served for her breakfast meal and that they could have provided her with other protein choices that she liked. 2. Record review showed that Resident #64 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], revealed Resident #64 had a BIMS score of 15, indicating cognition is intact. In an observation conducted on 05/29/24 at 12:35 PM, Resident #64 was noted with her lunch meal, which consisted of grilled chicken salad, Italian pasta salad, green salad with no dressing, iced tea, and a fruit cup. The meal ticket was noted with a green salad and dressing that needed to be provided. In this observation, Resident #64 stated that she did not eat her green salad because the dressing was not provided with it. 3. Record review revealed Resident #110 was admitted on [DATE]. The Quarterly MDS, dated [DATE], revealed Resident #64 had a BIMS score of 15 indicating cognition is intact. In an observation conducted on 05/29/24 at 12:36 PM, Resident #110 was noted in her room with the lunch tray. Closer observation showed a meal ticket with the following: Regular diet, no pork, grilled chicken sandwich, Italian pasta salad, 4 ounces of ice cream, mighty shake of choice, and fortified pudding. Closer observation of the lunch tray showed that Resident #110 did not receive her fortified pudding or a mighty shake on the tray. In an interview conducted on 05/31/24 at 1:17 PM, the facility's Registered Dietitian (RD) stated that she periodically does tray audits to ensure the meal ticket matches the food items on the meal trays, but she is not in the facility every day. In an interview conducted on 05/31/24 at 1:20 PM with the Food Service Manager (FSM), he stated there is an end person at the end of the tray line who oversees that the food items match the printed meal ticket on the trays. He will also check the meal tickets to ensure the accuracy of the food items. In an interview conducted on 05/31/24 at 1:20 PM with the FSM, he was informed of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide the correct fluid restriction for 1 of 1 sampled resident reviewed for dialysis, Resident #58. The findings included: Record review revealed Resident #58 was admitted on [DATE] with diagnoses of End-Stage Renal Disease (ESRD) and dependence on dialysis. Review of the physician's orders revealed an order for 1200 milliliters (ml) of fluid restriction with a diet of 260 ml at breakfast, 240 ml at lunch, and 120 ml at dinner for a total of 720 ml a day, dated 01/18/24. Further review of orders revealed no water was to be left at the bedside, which was also dated 01/08/24. In an observation conducted on 05/29/24 at 12:58 PM, Resident #58 was in her room with her lunch tray that consisted of the following: 8 ounces of tea and 16 ounces of water noted in a white Styrofoam cup near the lunch tray. The meal ticket for Resident #58 stated the following: Renal diet, with fluid restriction of 720 ml a day and 8 ounces of tea for lunch. In this observation, Resident #58 was provided with 24 ounces of fluids instead of the correct 8 ounces of fluids for the lunch meal. In an observation conducted on 05/29/24 at 3:00 PM, Resident #58 was noted in bed with 16 ounces of water in a white Styrofoam cup on the side table. The surveyor asked Resident #58 if she drank from the cup, and she said, I do not remember. The surveyor asked if she was on a fluid restriction and she did not know. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 had a Brief Interview of Metal Status (BIMS) score of 09, indicating moderate cognitive impairment. The care plan dated 04/10/24 revealed fluid restriction and no water at the bedside. In an interview conducted on 05/31/24 at 7:28 AM with Staff G, Registered Nurse, she stated the Certified Nursing Assistants (CNAs) oversee providing water to all residents. They are supposed to look at the electronic system to make sure the resident is not under any fluid restriction. The nurse assigned to the resident will also tell the CNAs if the resident is on any fluid restriction to be on the safe side. Most CNAs who work in the unit are familiar with residents who are under any fluid restriction. In an interview conducted on 05/31/24 at 11:00 PM with Staff M, Certified Nursing Assistant, she stated that she was aware Resident #58 was on fluid restriction and she was not the one who gave Resident #58 extra water at the bedside.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 observations conducted in the central kitchen. The findings included: The first initial visit to the main kitchen was conducted on 05/28/24 at 7:25 AM. The following concerns were observed: 1. A round garbage can with an opened lid was noted in the food production area. 2. The floor around the food production area and behind the stove was noted with debris and dirt. 3. Another round garbage can with an opened circle created on top of the lid was noted in the food production area. 4. The reach-in refrigerator was noted with a large plastic container with a green lid that was not dated or labeled with the type of food inside. 5. The reach-in refrigerator had an internal thermometer located near the reach-in refrigerator indoors, which had an internal temperature of 51 degrees Fahrenheit (F) and not the recommended 40 degrees and below Fahrenheit for cold food items. 6. The reach-in refrigerator had an internal thermometer located near the back of the refrigerator indoors. Its internal temperature was 55 degrees Fahrenheit, not the recommended 40 degrees and below Fahrenheit for cold food items. 7. The reach-in refrigerator was noted with a metal container that needed to be dated or labeled with the type of food inside. 8. The walk-in refrigerator contained ravioli with a preparation date of 05/18/24 and a used-by date of 05/21/24. 9. The walk-in refrigerator contained a 10-pound package of ground beef that was very soft to the touch. Closer observation revealed that it was placed in the refrigerator on 05/23/24 and used by date on 05/27/24. 10. The walk-in refrigerator was noted with a plastic container labeled beef. Continued observation showed a preparation date of 05/27/24 and a used-by date of 05/27/24. 11. The dry storage area was noted with a box of instant food thickener, graham crackers, and sugar packets located on the floor near the back of the storage room. 12. Continued observation revealed that Staff D, Dietary Aide, was working on the breakfast tray line and plating different food items with his bare hands. He then stopped the work on the tray line and adjusted the glass on his face. He continued plating food on the breakfast trays without washing his hands first. He was told of the findings in an interview conducted on 05/31/24 at 2:00 PM with the Food Service Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 2 of 3 sampled residents, Resident #36 & Resident #43, received the Notice of Medicare Non-Coverage (NOMNC) informing them of their rights to appeal termination of Medicare supported skilled services. The findings included: 1. Record review revealed Resident #36's was admitted to the facility on [DATE] with diagnoses to include: Dementia, Psychotic disturbance, and Benign Prostatic Hyperplasia. Review of the minimum data set (MDS) section C revealed that Resident #36 was rarely understood, so the Brief Interview for Mental Status (BIMS) could not be assessed. record review documented Resident #36's rehabilitation skilled services started on 03/02/23 and ended on 04/02/23. On 03/30/23, the facility issued the notice of Medicare non-coverage (NOMNC) that intended to inform the resident or representative that skilled services would be terminated. Further review of the document showed that the NOMNC was signed by the Social Service Director (SSD) and not by the resident or his authorized representative. The SSD documented on the NOMNC that facility staff spoke with the resident's daughter on 03/30/23 at 3:00 PM to advise of end of Medicare Services. 2. Record review documented Resident #43's skilled services started on 04/01/23 and ended on 04/17/23. The resident had diagnosis to include Dementia. On 04/14/23, the SSD documented that Resident #43 asked her to contact her daughter to explain the NOMNC. Review of the NOMNC showed the facility initiated the discharge from Medicare Part A Services when the benefits days were not exhausted. Further review showed the SSD signed the form as representing Resident #43. Interview on 05/04/23 at 12:43 PM with the Social Worker (SW) revealed that whenever a family member cannot sign, she has been told that she could sign for them. She had signed the NOMNCs for both Residents #36 and #43. The SW also stated she did not send any benefits termination letter to the residents' family members or authorized representatives to confirm that they understood the information conveyed by telephone. The SW said that she sent an email to one of the representatives, but she could not provide the evidence upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for activities that included measurable objectives and timeframes to meet the needs for 1 of 3 sampled residents, Resident #103, reviewed for psychosocial needs. The findings included: Record review documented Resident #103 was admitted to the facility on [DATE] with diagnoses to include Nontraumatic Subdural Hemorrhage and Respiratory Failure. Review of the Minimum Data Set assessment (MDS), section C dated 03/31/23, revealed the Brief Interview for Mental Status (BIMS) score could not be assessed, indicating severe cognitive impairment. On 05/01/23 at 10:44 AM, Resident #103 was observed in bed with no personal sensory stimulation equipment in the room. On 05/02/23 at 11:42 AM, Resident #103 was observed in bed with no activities. There were no sensory stimulation in his personal space. Review of the comprehensive care plans dated 02/10/23 and updated 04/07/23 revealed there was no plan for activities. There were no documented records of ongoing activities. During an interview with the Activity Director (AD) on 05/03/23 at 2:35 PM, she said that she did not have Resident #103 listed as a person requiring 1:1 activity. She also said family visitation is the only type of ongoing activity Resident #103 was having. When questioned about the Resident's plan of care for activities, the AD said that she did not know Resident #103 did not have a plan for activities. She said when the resident was first admitted to the facility, he could not to do anything. She said the resident has a granddaughter who told her that the resident likes light jazz music. The AD said she would implement an activity plan for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to provide adaptive equipment to maintain, restore or improve the functional abilities of 2 of 4 sampled residents, Resident #45 and Resident #103, as evidenced by: no splint for Resident #103, and no weighted utensils and lip plate for Resident #45. The findings included: 1. Review of the Minimum Data Set (MDS) dated [DATE], for Resident #103, under section G (functional Status) and G0110 for ADL (Activities of Daily Living) Assistance documented the resident was totally dependent on staff for all ADLs. Review of the care plan dated 04/17/23 revealed: RANGE OF MOTION: The Resident has a risk or actual limitations in Range of Motion as evidenced by; Requires Splinting Application to left hand (resting hand splint). The Resident: Will have none to minimal pain, discomfort at acceptable level, Limitation will not interfere with daily functions. Will remain free of injuries or complications related to limitations of range of motion. Will minimize the risk of complications related to splint application. Will minimize risk of complications related to fracture, such as contracture formation, embolism and immobility. Splint type: resting hand splint_ Apply to: left hand. Staff will apply the splint at __ am/pm Remove at __am/pm (no times indicated), (Remove for bathing or personal care activities). ·Provide hand hygiene with routine care and prior to application and upon removal of hand splint. The care plan also noted that: If resident removed splint, encourage resident to maintain splint application per recommended duration and inform of the benefits and negative outcomes of removal. Observe fingernails for appropriate length, skin condition to extremity(s), under splint upon splint removal and report areas of concern. The care plan dated 02/10/23 also documented that staff should apply the splint daily on Resident #36 to prevent range of motion (ROM) decline. On 05/01/23 at 10:13 AM, Resident #103's left hand fingers were observed to be contracted. The resident had difficulty opening the hand when asked to do so. Subsequent observations to Resident #36's room revealed the following for Resident #103: 05/01/23 at 1:24 PM, no splint observed. 05/02/23 at 2:14 PM, no splint observed. 05/03/23 at 10:27 AM, left hand fingers observed contracted with no evidence of splints. 05/03/23 at 1:14 PM, no splint observed in place. On 05/03/23 at 10:27 AM, the South Unit Nurse Manager confirmed the resident had a plan of care to wear a splint on the left arm. Review of the completed tasks record for application of the Splint, for the month of April 2023, showed the splint was applied only four times. In the month of May 2023, it showed the splint was applied on 05/01/23 and 05/02/23 during the 11:00 PM to 7:00 AM shift, as evidenced by the documentation time of 22:48 hours (10:48 PM) and 22:55 (10:55 PM) respectively. On 05/03/23 at 1:39 PM, the North Wing Nurse Manager stated they have two CNAs responsible for Restorative Care, as well as all the other certified nursing assistants (CNAs). She said they are supposed to document in the POS when the services are rendered. On 05/03/23 at 1:53 PM, the Unit Manager stated that even though the time to apply the splint is not noted in the plan of care, staff knew they were supposed to render the services during daily during the day. 2. Review of clinical record of Resident #45 documented an admission of 06/04/20 with diagnoses that included Atrial Fibrillation, Muscle Wasting and Atrophy, Dysphagia, Cognitive Communication Deficit, Lack of Coordination, and Convulsions, Review of the current Physician Orders revealed: 04/24/23 - Weighted Utensils and Lip Plate 04/24/23 - No Added Salt Diet 03/16/23 - Patient to continue with use of Inner Lip Plate and Weighted Utensils during meals to Promote Independence. Review of current quarterly MDS dated [DATE] documented: Usually Understood and Understands with Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment; Feeling Down, required supervision and only set up with eating and is on a mechanically altered diet. Review of current care plans dated 02/12/23 documented: Problem: Nutritional Risk d/t [due to] Convulsions and Muscle Wasting Approach: Adaptive Device; Lip Plate & Weighted Utensils. Observation of the lunch meal on 05/01/23 in the Main Kitchen at 11:45 AM noted Resident #45's meal tray ticket documented: Weighted Utensils - Lip Plate - NAS Diet [no added salt]. Observation of the resident's tray noted only a built-up weighted spoon, no weighted knife, and a regular meal plate was provided. The Lip Plate was noted to be heavily stained yellow in color. Further observation noted that 3 of 3 adaptive lip plates were also heavily stained and no new plates were in supply. Interview with the Director of Therapy on 05/01/23 noted the kitchen had an inadequate supply of adaptive eating utensils and scoop plates. Interview with the Director of Skilled Therapy on 05/02/23 revealed that she has reviewed the supply of adaptive eating equipment (silverware, plates, etc.) and new purchases have been made, but there was an insufficient supply of weighted and built-up utensils, lip plates, and divided plates. During the observation of the breakfast meal on 05/03/23 at 9 AM, it was observed the meal tray was served to the room of Resident #45. Review of the resident's Meal Tray Ticket documented: Lip Plate, Weighted Utensils, and No Added Salt Diet. Review of the resident's meal tray noted that only a weighted fork and spoon were provided, and a weighted knife was not included on the tray. Interview with the resident at this time noted some cognitive deficit, however she stated she would like a weighted knife with meals. Continued observation noted that a knife should be included for the resident to be able to independently butter toast, apply jelly to toast and cut the omelet into bite size pieces. It was noted during the observation, the resident had severe hand tremors and gripping issues. It was observed that the resident attempted to open the milk and juice containers without success. The tray was removed without the resident drinking any of the tray beverages (milk, orange juice, water). During the observation, the surveyor requested the Director of Therapy to come to the resident's room to observe the resident issues. The director stated the resident is required to receive weighted fork, knife, and spoon with all meals. The Director also stated there is an adequate supply in the dietary department. The surveyor also inquired why the resident was not assessed and receiving adaptive weighted drinking cups that would be easier for the resident to grasp and control the sever tremors. The Director stated the resident would be screened for additional adaptive eating and drinking equipment and it had been some time since the resident's last adaptive eating equipment screening. On 05/03/23, the Therapy Director submitted an Occupational Therapy Screening form dated 05/03/23 that documented the resident's need and agreement for additional adaptive equipment. The form documented the purchase of Sippy Cups and Two Handled Weighted Mugs that are designed to help residents with weak grasp and unsteady hands. It was further discussed that the screening should be conducted more frequently than quarterly due to the resident's severe tremors and to maintain the resident's independence with eating and drinking. During an observation of the lunch meal on 05/03/23 at 1:00 PM, it was noted the resident received a Sippy Cup until the weighted Sippy Cups were delivered. The resident's juice was noted to be in the Sippy Cup and resident was noted to be drinking without difficulty grasping or spillage. The resident stated she likes the new cup.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview, record review, and observation, the facility failed to provide fingernail care for 2 of 2 sampled residents observed for Activities of Daily Living (ADLs), related to lack of fingernail care for Resident #103, and Resident #315. The findings included: The facility Policy and Procedure, titled, ADL [Activities of Daily Living]: Assistance, effective date July 2022, had 3 steps. Step three listed the ADLs that staff may perform for or with the resident. Item d. listed Nail Care. 1. Record review documented Resident #315 was admitted on [DATE]. The Minimum Data Set (MDS) admission assessment was completed 04/18/23 that documented Resident #315 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating Resident #315 was cognitively intact. In Section G of the MDS, ADLs, under Item J, Personal Hygiene, Resident #315 was identified as needing extensive assistance with a one person assist. Review of the care plan for Resident #315 documented a focus, titled, SKIN INTEGRITY RISK: The resident has an actual impairment to skin integrity r/t [related to] skin tear to left lower leg. The first intervention listed: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. On 05/02/23 at 10:24 AM, during an interview, it was observed that Resident #315 had long fingernails with dirt under the nails. When asked if he would like to have his nails trimmed and cleaned, Resident #315 stated he would like that. On 05/03/23 at 10:06 AM, Resident #315 still had long fingernails with dirt beneath the nails. On 05/04/23 at approximately 11:15 AM, a brief visit with Resident #315 revealed the resident still had untrimmed fingernails with dirt under the nails on the edge of the nail bed. On 05/04/23 11:34 AM, an interview was conducted with Staff G, Licensed Practical Nurse (LPN), who stated the nurse is supposed to do assessments on the resident and should determine if the fingernails and toenails needed to be trimmed. Staff G stated that for diabetics, the nails are not to be trimmed. Staff G clarified that she meant fingernails can be trimmed by the nurses, but diabetics needed a podiatrist to provide toenail care as part of the regular monthly recommended foot check for injuries and infections. On 05/04/23 at 11:45 AM, the Regional Nurse Consultant confirmed the fingernail trimming is the responsibility of the nursing staff and should not require a request from the resident to provide the care. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses that included Nontraumatic subdural Hemorrhage and Respiratory Failure. Review of the MDS, section C, dated 03/31/23, revealed the resident had severe impaired cognition and the BIMS score could not be assessed. Review of the record documented a physician order for oral care, dated 02/24/23, of: Use Peridex Mouth/Throat Solution 0.12 % (Chlorhexidine Gluconate (Mouth-Throat)). Give 15 ml by mouth every day and evening shift for Gingivitis Rinse and spit out. On 05/01/23 at 10:49 AM, Resident #103 was observed in bed with a contracted left hand. Resident #103 could not open his hand when requested to do so. Further investigation of the hand revealed that Resident #103's fingernails were untrimmed containing dark matters at the base of the nails bed. It was observed that no oral hygiene care was completed for the resident. The resident's gums were bleeding. The top incisors teeth were covered in blood. On 05/02/23 at 11:44 AM, Resident #103 had not received oral hygiene care as evidenced by bleeding gum observed. On 05/03/23 at 10:10 AM, Resident #103 was observed in bed, his mouth was unclean with visible glue-like saliva, and his lips were very dry. Review of the medication administration record (MAR) for the month of April 2023 showed that all staff documented oral care was provided daily as ordered. Observation of the bottle containing the treatment for the month of May 2023 indicated that the full bottle of Peridex contained 473 ml of the treatment. Photographic Evidence Obtained. Observation on 05/03/23 of the Peridex bottle being used and dated 04/01/23, showed that the bottle was almost half full. Based on the physician order (POS), staff were to use 30 ml daily, and the bottle should have been empty in 16 days. There was no indication the resident refused treatment on any given day. During oral hygiene observation performed by Staff G on 05/03/23 at 10:26 AM, it was noted that Staff G used three spongy swabs to clean the resident's mouth. She cleaned the resident's mouth with the swabs, but the resident retained the swabs in his teeth from time to time and refused to release them. The nurse was asked why she did not give the ordered 15 ml of the Peridex solution. Staff G answered that she did not want to place the content into the resident's mouth because he had a feeding tube. After surveyor intervention, Staff G retracted and administered the solution as ordered. Before administering the solution, Staff G and the surveyor asked the resident who had great difficulty vocalizing words, if he wanted the solution in a cup. After many attempts trying to understand Resident # 103's answer, it was finally depicted that Resident #103 wanted to shake the medication in his mouth and wash his mouth as ordered. After this cleaning, Resident #103's words became clearer and he said, I have been brushing my teeth for 50 years, I know how to do it. Resident #103 thanked the surveyor for intervening and ensuring that oral care was performed. During an interview with Staff J, Certified Nursing Assistant (CNA) on 05/03/23 at 11:36 AM, who has been working at the facility for two and half years, she said she usually works 11:00 PM - 7:00 PM, and today is the first time she has worked the day shift for this week. She said that she was assigned to care for Resident #103. She stated she has not yet cared for him, and they are supposed to complete their morning assignment by 11:00 AM. Staff J added that it varied from day to day and on whether the residents are manageable or whether there are no other interferences with their assignments. The findings were discussed with the administration staff during the exit meeting on 05/04/23. There was no additional information provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to provide ongoing person-centered activities designed to meet the interest and the psychosocial well-being of 3 of 20 residents, Residents #35, #36 and #103, reviewed for activities. The findings included: 1. Record review for Resident #35 documented diagnoses to include Dementia, unspecified, Major Depressive Disorder, and Schizoaffective Disorder. Review of the care plan dated 03/02/23 documented an outlined activity plan that included: Activities: The resident needs encouragement to pursue activities of choice. Little interest or pleasure in doing things, prefers to stay in room. o Resident will participate in activities of choice/ will accept materials for in room type activities. o Encourage to participate with activities of choice o Prefers/ would benefit from: General Activities Program o Prefers / would benefit from: In Room Activities o Preferred Activity Times: Morning o Preferred Activity Times: Afternoon o Preferred Activity Times: Evening o The resident's preferred activities are: Resident enjoys walking around the facility for exercise, going outside for fresh air, watching television and listening to country music. She also loves dogs and playing cards. o Provide the resident with materials for individual activities upon request. o Provide activities calendar monthly. o The resident prefers the following radio stations: Country music, TV stations: Popular stations. o Observe for psychosocial and mental status changes - document and report as Indicated. During two days of observations, the resident was not observed engaged in any activities: On 05/02/23 at 10:33 AM, Resident #35 was observed in her room alone, and she had no roommate, no television (TV) and no radio. Upon asking, she stated she would be interested in watching TV. On 05/02/23 at 2:12 PM, Resident #35 was observed in her room lying in bed and doing nothing. On 05/03/23 at 1:56 PM Resident #35 was observed in her room sitting on the side of the bed watching the floor and wall. On 05/03/23 at 2:29 PM, during an interview with the Activity Director (AD), she said 'I am going to tell you upfront; I do not document when I see the residents.' The AD further stated she has not done or offered any activities to Resident #35 lately, because of Resident #35's attention span was limited.' The AD stated when Resident #35 listens to music, she settles down and feels relaxed. The AD stated she only has one radio available that she can use, so she could give it to Resident #35. The AD also stated she was not sure whether Resident #35 had any family members. 2. Record review revealed Resident #36 was admitted to the facility on [DATE], with diagnoses that included Dementia and Benign Prostatic Hyperplasia. Review of the Minimum Data Set assessment (MDS), section C, revealed Resident #36 was rarely understood, and had a Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the care plans (CP) for this resident, dated 03/30/23, revealed no plan for activities. On 05/01/23 at 10:42 AM, Resident #36 was observed in bed lying down. The resident had no access to television (TV) for sensory stimulation. There was no TV in the room. On 05/02/23 at 11:42 AM, Resident #36 was observed in bed lying in the same position. There wee no stimuli, and no activities observed. On 05/03/23 at 2:40 PM, the Activity Director (AD) was asked if she had an activity program for Resident #33. The AD said that she did not have Resident #36 listed as a person requiring 1:1 activity. She stated that family visitation is the only type of activity she knows that Resident #36 had. The AD stated when Resident #36 was first admitted to the facility, he could not do anything. She said the resident had a granddaughter who had reported the resident enjoyed light jazz music. There was no plan developed to ensure Resident #36 listened to music and there was no documentation of the resident's activity preference in the CP. The AD further stated she needed guidance and assistance to carry out the responsibility of ensuring the residents receive e required activity. She said the assistant activity position has been eliminated making it difficult for her to efficiently carry out her responsibility. She also stated she did not know that Resident #36 did not have an activity CP. The AD stated she did not know what Resident #33's preferences were for activities. 3. Resident #103 was admitted to the facility on [DATE] with the diagnoses that included Nontraumatic Subdural Hemorrhage; Respiratory Failure, and Cognitive Communication Deficit. Review of the MDS, section C, dated 03/31/23, revealed the resident had severe impaired cognition with a BIMS score that could not be assessed. Review of the CP dated 02/10/23 and 04/07/23 showed there were no plans for activity scheduled for Resident #103. There were no documented records of ongoing activities. On 05/03/23 at 2:35 PM, the Activity Director stated she did not have Resident #103 listed as a person requiring 1:1 activity. She stated she has not provided any ongoing activities for Resident #103.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequate supervision and assistance to prevent smoking accidents, for 1 of 1 sampled resident, Resident #20. The findings included: Review of facility's Policy and Procedure, titled, Smoking/Tobacco Use (Effective October 2021, documented, in part: Employee Expectation: < Monitor residents in the smoking area. < Ensure appropriate adaptive smoking equipment is available and in use for residents as care planned. < Clean smoking apron after each use Procedure: < Initiate and complete admission data Collection and Initial Plan of Care Quarterly Date Collection Form Smoking Safety: < Staff member assigned to the smoking area will monitor the area to conduct walking rounds to observe and intervene for safety issues and to provide oversite and intervention when appropriate. < Provide the smoker with assistance and safety devices indicated. < Donning a smoking apron that is deemed necessary by the IDT. < The assigned staff member should intervene in resident issues that arise. Care Plan: < Review quarterly at a minimum. Review of clinical record of Resident #20 on 05/02-03/23, noted the resident was admitted on [DATE] with diagnoses that included Lack of Coordination, Muscle Weakness, Schizoaffective Disorder, Extrapyramidal and Movement Disorder, Dementia and Psychosis. Review of the current Minimum Data Set assessment (MDS), dated [DATE], documented a Brief Interview for Mental Status of 11, indicating moderate cognitive impairment. The current Care Plan dated 03/02/23 included: < Current Smoker: * Resident to wear apron at all times during smoking * Smoke with Apron * Smoking materials kept by facility staff * Supervised Smoking at all times. The current Smoking Assessment, dated 03/29/23, included: Smokes Cigarettes Can hold independently. Smoking Apron required at all times. Safe to smoke. On 05/01/23 at 9 AM, Resident #20 was observed to be in wheelchair on the smoking patio. The resident had a lite cigarette and was noted to have strong, violent jerking and flailing motions with the 'cigarette hand' while smoking. The ashes were noted falling down on the resident's chest area and lap. Resident #20 had a smoking apron on, but the apron did not cover the lap, as it was pulled all the way to the resident's right side. The designated staff (Staff A) did not make any interaction with the resident to correct the apron issues. Photographic Evidence Obtained. A second observation conducted on 05/02/23 at 9 AM noted the resident was observed again on smoking patio. Staff A, on smoking patio, lit the resident's cigarette and the resident wheeled himself to the outer edge of patio. Staff A did not ensure the resident had donned a smoking apron to cover the resident. Resident #20 was again noted to be violently waving and flailing the cigarette and banging it on his leg, Ashes were noted over resident chest and lap. Photographic Evidence Obtained. The Director of Nursing (DON) was requested to come to the smoking patio to view resident with the surveyor. The DON confirmed that a smoking apron was not applied to Resident #20 per smoking assessment. Interview with Staff A, at time of observation, stated that she gave the resident's apron to the laundry on 05/01/23 for washing and did not get the apron back from laundry. Staff A further stated there are no extra aprons available for smokers who require a smoking apron. On 05/03/23 at 11 AM, Resident #20 again was observed on the smoking patio with a smoking apron only covering the right leg leaving the left leg exposed. Continued observation noted designated staff failed to cover resident's legs and chest with apron. Resident #20 was noted to have severe jerking of arms during smoking resulting in ashes falling to his chest and leg areas. Photographic Evidence Obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to perform catheter care using appropriate professional technique, for 1 of 1 sampled resident, Resident #315. The findings included: The facility used a competency checklist instead of a policy/procedure to ensure perineal care/catheter care is performed correctly. The competency checklist step 5 stated: Cleans top of over bed table and places a barrier on tabletop. Step 9 indicates the staff is to perform hand hygiene. Steps 10 through 12 discuss positioning of the resident and preparing the wash basin with warm water. Step 13 verifies that staff has put on gloves. Step 14 verifies that staff has covered the resident with a bed sheet or bath towel. Step 15 indicated the staff is to place a protective barrier under the resident's buttocks. For a male resident the checklist indicates that the perineal area should be dried using a blotting motion from top to bottom. Resident #315 was admitted to the facility on [DATE] with an indwelling catheter with diagnosis of Obstructive and Reflux Uropathy. Resident #315 had a BIMS (Brief Interview for Mental Status) score of 14 of 15, which indicated the resident was cognitively intact. On 05/02/23 at 10:23 AM, an observation revealed Resident #315 had an indwelling urinary catheter attached to a bedside drainage bag without a device to anchor the tubing to the resident's leg. When questioned about the lack of anchoring device, Resident 315 stated that he thought he had one when he was at the hospital, but he had not had a device since being admitted to the facility. On 05/03/23 at 10:06 AM, an observation of catheter care was conducted with Staff J, Certified Nursing Assistant (CNA), performing the task. Staff J explained to the resident that she was going to provide perineal and catheter care. Staff J washed her hands for 15 seconds, put on clean gloves and proceeded to prepare for the Catheter Care. According to the competency checklist, the clean gloves were to be applied after the supplies were placed and the wash basin of warm water had been placed on the over bed table with a barrier in place. Staff J removed the bagged towels, washcloths, and liquid soap stored in Resident #315's closet. Staff J placed the bag on Resident #315's bed. Staff J placed two paper towels on the top of the overbed table without wiping the table with disinfectant. The paper towels were placed on either end of the table and did not cover the entire surface. Staff J placed the towels, washcloths, and soap on the table next to the paper towel on the left as facing the table. Staff J repositioned Resident #315 in a comfortable position and adjusted the resident's bed to a good working height. Staff J opened the resident's diaper, and did not place a barrier under the resident as per the competency checklist. Staff J failed to cover the resident with a bath blanket or bed sheet as per the competency checklist. Staff J prepared a wash basin with warm water and placed the basin on the overbed table between the clean towels and the paper towel on the right end of the overbed table. Staff J performed perineal care using appropriate technique. Staff J proceeded to wash around the urinary meatus and the catheter tubing away from the meatus as required. Staff J disposed of the dirty water and replaced it with clean water. Staff J removed her gloves and put on clean gloves without washing her hands. Staff J rinsed the perineal surfaces and catheter tubing with the clean water with proper technique. Staff J did not dry the perineal area as per the competency checklist. Staff J placed a new diaper on the resident and repositioned the resident in bed as required. Resident #315 asked Staff J about a leg anchor for the catheter tubing. Staff J told the resident she would ask the nurse to fix the problem. An observation of the drainage tubing revealed an anchoring device attached to the tubing with what appeared to be glue on the back surface. The device was not affixed to Resident #315's leg. On 05/03/23 at approximately 11:15 AM, an interview was conducted with the Director of Nursing (DON). During the interview, the DON disclosed the facility does not have a Policy / Procedure for Catheter Care only a competency checklist. The DON provided the competency checklist which was reviewed at that time. The DON agreed that Staff J did not follow the competency checklist correctly. The DON also agreed that a leg anchor is important to reduce the chance of injury related to tension on the drainage tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation and interview, the facility failed to ensure that it secured the resident's medications for 2 of 5 sampled medications carts observed, the North and South medication carts; failed to secure loose pills in one (1) of five (5) medications carts observed [NAME] medication cart; failed to discard expired wound care dressing in one (1) of three (3) treatment carts, [NAME] wing; and failed to discard expired Sunscreen lotion in Central Supply Room. The findings included: Review of the facility policy and procedure on [DATE] at 2:30 PM, titled, Medication Storage, provided by the Director of Nursing (DON), reviewed 2007, documented, in part, in the Policy Statement: Storage of Medication - Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to the licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: .3. In order to limit access to prescription medications, only licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications (such as medications aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication disposal ., and reordered from the pharmacy , if a current order exists. 1. On [DATE] at 11:30 AM, it was observed, the North wing medication (med) cart which contained twenty-four (24) residents' medications, was unlocked with no nurse in attendance or in view of the cart. The med cart was accessible to residents, staff members and visitors. Photographic Evidence Obtained. An interview was conducted on [DATE] at 11:32 AM with Staff F, Licensed Practical Nurse (LPN), who acknowledged that she had not locked the medication cart on the North wing. 2. On [DATE] at 12:08 PM, during an Accucheck Observation, it was observed that after Staff G, LPN had completed the procedure, she walked back into the resident's room to inform her that she did not need insulin coverage. She did not lock the medication cart #1 on the South wing, which contained twenty-two (22) residents' medications and were accessible to residents, staff members and visitors. Photographic Evidence Obtained. An interview was conducted on [DATE] at 12:10 PM with Staff G, who acknowledged that she had not locked the medication cart on the South wing. 3. On [DATE] at 1:29 PM, a Medication Storage Observation of the [NAME] wing Medication cart was conducted with both Staff H, LPN, and with the Director of Nursing (DON). It was observed that there was a one-half (½) size unidentified, loose white pill located at the bottom of the 7th drawer of the Medication cart. Photographic Evidence Obtained. 4. On [DATE] at 1:51 PM, a Medication Storage Observation was conducted with Staff H and the DON of the [NAME] wing Treatment cart. It was observed that the cart contained Hydrogel Saturated gauze 4 x 4 hydrating wound dressing containing 25mg of Hydrogel with an expiration date of 07/22. Photographic Evidence Obtained. During a brief interview conducted on [DATE] at 1:58 PM with both Staff H and the DON, both acknowledged that the expired Hydrogel Saturated gauze 4 x 4 hydrating wound dressing containing 25mg of Hydrogel should have been discarded. 5. On [DATE] at 2:01 PM, a Medication Storage Observation was conducted with the DON, of the Central Supply closet where it was observed that there was an expired bottle of Good Sense Sunscreen Lotion, which had an expiration date of 11/19. Photographic Evidence Obtained. An interview was conducted on [DATE] at 2:09 PM with the DON, who acknowledged the medication carts should have been kept locked at all times, the loose pill in the medication cart drawer, the expired Hydrogel gauze in the Wound Care Treatment cart and the expired bottle of Good Sense Sun Screen Lotion in the Central Supply room, should all have been promptly discarded. This was not done. The medication carts were not locked, the loose pill, expired Hydrogel gauze and the expired bottle of Good Sense Sun Screen Lotion, were not all discarded, until after surveyor intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide ongoing dental services to 1 of 1 sampled resident, Resident #103. The findings included: Record review revealed Resident #103 was admitted to the facility on [DATE] with diagnoses that included: Nontraumatic Subdural Hemorrhage; Respiratory Failure; and cognitive communication deficit. Review of the Minimum Data Set assessment (MDS), section C dated 03/31/23, revealed the resident had severe impaired cognition. A Brief Interview for Mental Status score could not be determined. On 05/01/23 at 10:45 AM, Resident #103 was observed with noticeable bleeding gum and concerning dental hygiene issue. Further observation conducted on 05/03/23 at 11:19 AM showed evidence of blood in the resident's mouth and blood covered Resident #103's upper incisors. Review of the Medication observation record for the month of April and May 2023 revealed that staff performed daily oral hygiene as recommended by the resident's physician (morning and night). Review of the Nurses' progress notes revealed no documentation of Resident #103's dental issue or bleeding of his gum. Review of the Social Services (SSD) progress notes, dated 03/23/23, documented: SSD spoke with son on 03/21 regarding dad's insurance coverage and possibility of having to pay privately if/when no longer covered by D . SSD called D . today, 03/23 to verify that Pt [patient] is still covered under this plan. They ensured that he is in fact covered and there is no projected date of DC [discharge] as of right now. SSD informed BOM [business office manager] of this info [information] and will continue to monitor and F/U[follow-up] accordingly. There was no indication that staff discussed dental care with the resident's family members. The care plan dated 02/16/23 did not address dental care. The care plan dated 04/17/23 did not address dental care. During an interview with the Director of Social Services on 05/03/23 at 3:19 PM, she said that the family has not requested dental services. She stated that no one reported to her that the resident had bleeding gum. She also stated that the hygienist will be in the facility on the 9th of May and the Dentist will be in the 17th of May. The SSD said that she will make sure that they see the resident to address the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to accommodate individual food preferences for 5 of 5 sampled residents, Residents' #10, #13, #40, #55, and #86. The findings included: 1. Review of clinical record of Resident #10 on 05/03/23, revealed an admission date of 03/30/12 with diagnoses to include DDiabetes Mellitus Type 2 (DM 2), Chronic Kidney Disease, and Left & Right Leg AKA (Above knee amputations). Review of the Minimum Data Set assessment (MDS) of 01/30/23 documented: Sec B: Understood and Understands. Sec C: Brief Interview for Mental Status (BIMS) of 6, indicating severe cognitive impairment. Sec D: Mood - Poor Appetite, Trouble Concentrating, Sec G: Eat = Supervision/Set Up Only Sec K: NO Swallow Disorder Therapeutic Diet. Review of the updated MDS - Annual / Significant Change assessment, dated 05/23/23 noted: Sec C: BIMS Score changed to a 12. Observation and interview conducted with Resident #10 on 05/03/23 at 9:00 AM, noted the resident to be alert, oriented and able to make own decisions. The resident received a Renal Diet tray for the breakfast meal. The resident stated she would not eat the facility food for many of the meals served, stating is just no good. The resident further stated she has been a resident in the facility for over 10 years and has requested Grits, Scrambled Eggs, Butter and coffee for the breakfast meal on a daily basis. The resdient said there have been so many changes in the dietary department that her food preferences are documented on the meal tray cards and are not followed. The resident further stated she would like the breakfast foods (Grits, scrambled eggs, butter, and coffee) and some of her lunch and dinner meals. The resident stated she is served coffee for all meals and must request tea from staff for all meals. She stataed she often has to order food to be delivered from outside restaurants. Further review of the meal tray card noted that 8-ounces of coffee are documented for all 3 meals each day. Following the interview with Resident #10 on 05/03/23, the surveyor requested the Dietary Manager (DM) to visit the resident's preference. The DM recorded that the resident's food and beverages preferences are changed for the resident's meal tray ticket to reflect the resident's preferences. Resident #10 also stated she has Dialysis on Tuesdays, Thursdays, and Saturdays and she leaves the facility at 5:00 AM on these days. She stated she request no foods or fluids to be sent with her to dialysis, and further stated she gets very nauseated during dialysis and can't eat or drink. 2. Review of clinical record for Resident #13 revealed an admisssion of 04/30/21 and a readmission of 02/05/23, with diagnoses to include: COPD (Chronic Obstructive Pulmonary Disese), Depressive Disorder, Anxiety, and Schizoaffective Disorder. The documented diet of 02/05/23 was NAS (No Added Salt). Review of the MDS dated [DATE] documented: Sec C: BIMS=15, indicating no cognitive impairment. Sec G: Supervision with Eating / Set Up Only. Observation of the lunch meal on 05/01/23 at 12:15 PM in the main dining room noted that the Resident #13 was served entrée Swedish Meatballs. Further observation and review of the resident meal ticket noted documentation the resident does not eat beef and requested the entree of Stuffed Shells for the lunch meal. The resident was noted to not eat the meats ball and stated to the surveyor that it was too late to be served the shells. Resident #13 stated that food preference are not being followed on a daily basis. 3. Record Review noted the resident is the responsible party for decisions, the date of admission was 11/11/16 with a readmisssion of 02/0123, and diagnoses that included Pro-Cal Malnutrition, and Morbid Obesity. Review of the MDS of 04/13/23 documented: Sec B: Understood & Understands Sec C: BIMS = 13 (alert and oriented) Sec G: Eat - Supervision / Set Up Only. Observation of Resident #40 in the Main Dining Room on 05/04/23 at 12:00 PM noted the resident was not served an entree and only received Linguini Pasta. Review of Resident's #40 Meal Card documented Peanut Butter Sand [Sandwich] for lunch meal. the resident stated to surveyor at time of observation that food preferences and Meal Ticket are often not followed. 4. Review of clinical record documented an admission of 06/07/19, with diagnoses to include DM2, Protein-Calorie Malnutrition, and Anemia. The physician orders documented: 03/28/22 - CCHO/NAS/Mechanical Soft 03/28/22 - Large Portions. During the observation of the lunch meal in the Main Dining Room on 05/01/23 at 12 PM, it was noted the Resident #55 had a documented meal ticket to receive a Consistent Carbohydrate (CCHO) / No Added Salt / Mechanical Soft Diet, and Fortified Foods. Further observation and review of the resident's Meal Ticket documented: 4-ounce Magic Cup (weight loss) and 8-ounces of Whole Milk. Further observation noted the resident did not receive the Magic Cup or Whole Milk with the meal. The Fortified Food of Mashed Potatoes was also not served. The resident stated to the surveyor that food preferences are not being followed on a regulars basis. The resident stated that he comes to the dining room to be able to choose foods being served to his preferences. Further review of the meal tray ticket for Resident #55 noted no documentation on tray card of large portions and or extra fluids. 5. Review of Record documented: 09/26/22 - CCHO - Consistent Carbohydrate /NAS, Review of MDS of 2/10/23, Quarterly assessment, documented Sec C: BIMS = 14 (alert and oriented) Sec D: Trouble concentrating. Sec G: Supervision/Set Up Receives a Therapeutic Diet. During the observation of the lunch meal in the Main Dining Room on 05/01/23 at 12:45 PM, it was noted the Resident #86 was served the entrée of Swedish meatballs. Further observation noted that the resident was refusing to eat the meatballs. Review of the resident's meal ticket for the lunch meal documented no meatballs and requested the lunch alternate of Stuffed Shells. The resident stated that meal / food preferences are not followed on a regular basis. She stated she likes to come to the dining room for meals to be able to receive food preferences.

Based on observation, interview, and record review, the facility failed to prepare an approved menu in advance and follow an approved menu to ensure the residents' nutritional needs are met for 109 facility residents in the facility, that included potentially 30 of 30 sampled residents. The findings included: 1. During the observation of the lunch meal in the main kitchen on 05/01/23 at 11 AM, the surveyor requested the approved menu for the lunch meal from the cook (Staff B). The cook replied there was not an approved menu for any of the 4-week menu cycle. The cook stated the entree for the lunch meal was Swedish Meatballs and the alternative entree was stuffed shells. The cook also stated the required entree protein serving portion of the meatballs was 3 ounces and Staff B did not know the protein portion of the Stuffed Shells. The surveyor requested the standardized recipe for the preparation of the Swedish Meatballs and Stuffed Shells. The cook stated the entrees were fully prepared frozen and required heating. The cook also stated that meatballs required a gravy to be prepared and added to the meatballs. During the observation of the tray line, the cook stated that 3 meatballs was a standard portion to meet the 3-ounce entree protein portion. A review of the meatball packaging nutrient analysis noted documentation that 3 meatballs provided only a total 12 grams. An interview with the facility's Consultant Dietitian at the time of the tray line observation was held to discuss that a 3-ounce portion of meatballs should provide 21 grams of Protein (1 ounce = 7 grams). The Dietitian stated he was unaware the frozen meatball entree provided on 12 grams instead of the required 21 grams of cooked protein. The Dietitian also stated there was not an approved menu for the cook and facility kitchen staff to follow to ensure that the nutritional needs of the residents were being met. The Dietitian stated there are menu production sheets to follow, however they could not be located. 2. On 05/02/23, the Dietary Manager submitted an approved cycle menu to the surveyor. A review of the approved menu for the lunch meal of 05/02/23 noted a 6-ounce portion of Turkey Noodle Bake to be served to the physician-ordered regular diets, mechanically altered and therapeutic diets. Interview with the Dietary Manager noted that 3 ounces of cooked turkey protein was to be included in each entree serving. The surveyor requested the standardized recipe that was to be utilized in the preparation of the Turkey Noodle Bake. Following the surveyors request, it was noted that a recipe was not available for the preparation of the entree. Further interview with the Dietary Manager at the time of the meal observation revealed that 18 pounds of diced Turkey was purchased and utilized for the preparation of the Turkey Noodle Bake. A calculation of the turkey protein was conducted with the Dietary Manager, and it was noted that 112 servings of the entree provided only 2.5 ounces of Turkey protein per portion. It was further discussed that 3 ounces of Turkey protein was required as per the approved menu.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that potentially affected 109 of the 113 facility residents and included 30 of 30 sampled residents. The findings included: 1. During the initial kitchen/sanitation tour conducted on 05/01/23 at 9:00 AM and accompanied with the Dietary Manager (DM), the following were noted: (a) A chemical test of cleaning cloth buckets noted 1 of 3 did not contain the required level of Quaternary chemical as per regulatory requirement (200 PPM). Photographic Evidence Obtained. (b) The internal cavity and internal door of the convection oven were covered with a black carbon substance and were not being cleaned on a regular basis. The DM stated the oven should have been cleaned over the last weekend. Photographic Evidence Obtained. (c) Observation of the walk-in refrigerator noted that 12 food storage shelves were heavily rust laden. It was discussed with the DM that the shelving was in need of replacement. Photographic Evidence Obtained. (d) Three of 3 food preparation skillets / pans were noted to have a heavily worn interior and Teflon surface was worn. It was discussed with the DM that the Teflon and carbon is coming into contact with foods during each use of the pans. The surveyor requested that the pans be discarded and replaced. Photographic Evidence Obtained. (d) Observation of 3 of 3 Inner Lip Adaptive Eating Plates were heavily stained a yellow color and were being used on a daily basis. Staff were aware of the issue, but no attempts had been made to replace the adaptive plates. It was also noted that Built-Up and Weighted Forks (3) and Spoons (4) were heavily worn, cracked, and in need of replacement. Photographic Evidence Obtained. 2. Observation of lunch meal on 05/02/23 at 11:30 AM noted the dessert of Banana Cream Pie (93 servings) pie had a brown liquid dripping from the bottom and side of each pie serving, and poor appearance. The surveyor requested the Dietary Manager observe the pie servings and agreed with the surveyor's findings. It was discussed that the pie serving could be rancid and has possible be frozen, thawed, and refrozen prior to thawing prior to serving. The surveyor recommended to the Dietary Manager that the pie servings not be served due to the potential of food borne illness. Photographic Evidence Obtained. 3. During the observation of the breakfast meal in the main kitchen on 05/03/23 at 7:30 AM with the Dietary Manager utilizing the facility's calibrated digital thermometer, test temperatures were done. The temperature testing revealed that hot foods were not being held on the steam table at the regulatory required temperature of 135 degrees Fahrenheit (F) or more. The temperatures were recorded as follows: - Pureed Bread (made with milk) held in steamtable = 121 degrees F (25 servings). -Slurry Bread (made with milk) held in steam table at 102 degrees F (20 servings).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the record documented that Resident #89 was re-admitted to the facility on [DATE] with the diagnoses to included: Hyperlipidemia, Hypertension, Protein-Calorie Malnutrition and Schizoaffective Disorder. Review of Section C of the Quarterly Minimum Data Set (MDS), dated [DATE], documented that Resident #89 had a Brief Interview for Mental Status (BIMS) score of 02 of 15, indicating he was severely cognitively impaired. Review of the Care Plan, dated 12/17/21, documented Resident #89 had an actual decline in ability to feed himself. Review of the Certified Nursing Assistant (CNA) Tasks for Eating Self Performance, dated 12/31/21 - 01/19/22, documented Resident #89 mostly required total dependence on staff. During an observation conducted on 01/18/22 at 12:55 PM, Resident #89's roommate received his lunch meal tray. It was noted that Resident #89 was awake and seated in his bed with no lunch meal tray. During an observation conducted on 01/18/22 at 1:15 PM, Resident #89 was still awake and seated in his bed with no lunch meal tray. It was noted that at this time, Resident #89's roommate had finished eating his lunch. During an interview conducted on 01/18/22 at 1:18 PM, Staff C-CNA, was asked why Resident #89 had not yet received a meal tray. Staff C-CNA stated, When you have a feeder, you leave the tray on the cart until you can feed them. During an observation conducted on 01/18/22 at 1:20 PM, the Administrator delivered Resident #89's meal tray to his room. Staff C-CNA entered the room to provide him with feeding assistance. This showed that Resident #89's lunch had not been delivered until 25 minutes after his roommate's lunch was delivered. During an observation conducted on 01/20/22 at 8:38 AM, Staff E-CNA, was in the hallway with Staff D-CNA, passing out breakfast meal trays. Staff E-CNA pointed to Resident #89's room and stated to Staff D-CNA, he's a feeder. Staff D-CNA then entered Resident #89's room to deliver his meal tray and provide him with feeding assistance. During an interview conducted on 01/20/22 at 9:02 AM, Staff E-CNA was asked about referring to residents as feeders. Staff E-CNA acknowledged that residents should not be called feeders. Review of the In-Service, titled, Supervised Dining dated 11/05/21, documented the following objective: During dining, residents are to be assisted, no feeders. Further review showed that Staff E-CNA and Staff C-CNA had not attended this in-service. Review of the In-Service titled, Resident Rights dated 11/12/21, documented the following objective: Serve everyone together. Further review showed that Staff E-CNA and Staff C-CNA had not attended this in-service. Based on observations, interviews and record review, the facility failed to provide eating assistance in a dignified manner for 3 of 3 sampled residents observed for in-room dining, Resident #50, #70 and # 89, as evidenced by providing assistance with meals while standing (Resident #50); as evidenced by not serving all residents in the same room at the same time (Resident #50, #70 and #89); and as evidenced of calling residents feeders during dining (Resident #50, #70 and #89). The findings included: Review of the facility's policy, titled, Dining Program effective January 2021, documented, .the nursing staff assists residents in need of assistance during mealtime .serve all residents at each table at the same time . Review of the facility's policy, titled, Resident Rights effective February 2021, documented, The facility strives to assure that each resident has a dignified existence . 1. Review of Resident #50's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included, in part, Pneumonia, Encephalopathy, Seizures, Hypokalemia and Psychosis. Review of Resident #50's Minimum Data Set (MDS) quarterly assessment, dated 11/06/21, documented a Brief Interview of the Mental Status (BIMS) score of 09/15, indicating that the resident has moderate cognition impairment. The assessment documented under Functional Limitation that the resident needed Extensive Assistance with transfer, dressing and supervision with eating- setup help only . Review of Resident #50's care plan titled, ADL [activities of daily living] Self-care performance deficit initiated on 04/29/20 and revised on 10/20/21, documented an intervention that read Resident is total dependent upon staff for ADLs (Activities of daily living). Review of Resident #50's Admission/readmission data collection, dated 10/20/21, documented the resident needed assistance with eating. On 01/18/22 at 1:32 PM, Resident #50 was observed in bed with the lunch tray in front of him. Further observation revealed Staff W, a Certified Nursing Assistant (CNA), assisting the resident with the lunch while standing over Resident #50. There was no chair noted by the resident's bedside. Subsequently, an interview was conducted with Staff W-CNA and Staff Q-CNA and they both stated that Resident #50 was a feeder. On 01/20/22 at 1:14 PM, observation revealed the meals tray cart delivered to the [NAME] wing. At 1:37 PM, observation revealed Resident #50 in bed and without a meal tray. At 1:37 PM, observation revealed Staff R-CNA, feeding Resident #50's roommate. An interview was conducted with Staff R-CNA. Staff-R-CNA was asked about Resident's #50's meal tray, who stated that she will feed Resident #50 when she is finished with his roommate. She stated she had been feeding his roommate for the last 15 minutes and no one had come to feed Resident #50 and the third resident in the room (Resident #70). Staff R-CNA stated Residents #50 and #70 were 'feeders'. Staff R-CNA was asked if she was supposed to call the resident feeders and stated she did not do it in front of them. On 01/21/22 at 11:37 AM, an interview was conducted with Resident #50 who stated that he was upset that he did not get his lunch at the same time as his roommate got it (meal tray). 2. Review of Resident #70's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included, in part, Peripheral Vascular Disease, Diabetes Mellitus, Protein-Calorie Malnutrition, Muscle wasting, and Contracture of Right Knee and Gangrene. Review of Resident #70 Minimum Data Set (MDS) quarterly assessment, dated 11/02/21, documented a Brief Interview of the Mental Status (BIMS) score of 13/15, indicating that the resident had intact cognition. The assessment documented under Functional Limitation that the resident needed Extensive Assistance with most of his ADL's and limited assistance with eating. Further documentation review revealed the resident had highly impaired vision. Review of Resident #70's care plan, titled, ADL; s Self-care performance deficit initiated on 10/05/19 and revised on 07/23/20, documented an intervention that read the resident needed supervision with eating and was totally dependent on the staff for dressing, personal hygiene, oral care, toilet use and transfers. Review of Resident #70's Nursing quarterly and prn (as needed) data collection, dated 12/16/21, documented the resident needed limited assistance with eating. On 01/18/22 at 1:28 PM, observation revealed Resident #70 in bed with his head under the cover sheet. Further observation revealed Staff W-CNA and Staff Q-CNA in Resident #70's room and feeding his two roommates. An inquiry was made about Resident #70's meal tray and Staff Q-CNA stated the resident ate by mouth and was a 'feeder'. Staff W-CNA also stated Resident #70 was a 'feeder'. Staff Q-CNA stated that Resident #70 was blind and will be fed after one of them is done. Unable to conduct an interview with Resident #70 because he did not speak English. On 01/18/22 at 1:40 PM, observation revealed Staff Q-CNA delivered the meal tray to Resident #70. At 1:41 PM, Staff T, a Licensed Practical Nurse (LPN), came into the resident's room and stated, Is he a feeder. On 01/20/22 at 1:14 PM, observation revealed the delivered of the west wing meals tray cart. At 1:37 PM, observation revealed Resident #70 in bed with his head under the cover sheet. Further observation revealed Staff R-CNA feeding Resident #70's roommate (Resident #50). An interview was conducted Staff R-CNA who stated that she will feed Resident #70 when she is finished with his roommate. She stated she has been feeding the roommate for the last 15 minutes and no one had come to feed Resident #70. On 01/20/22 at 1:43 PM, observation revealed Staff R-CNA delivered Resident #70's tray and proceeded to feed him. Staff R-CNA stated the resident was blind and did not speak English. On 01/20/22 at 2:45 PM, a joint interview was conducted with the Director of Nursing and Staff F, Registered Nurse (RN). They both were apprised of the findings during dining observations. Staff F-RN stated they have to feed all resident in a same room at the same time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to keep call bells within reach for 3 of 45 sampled residents, Resdients #106, #57 and #54. The findings included: 1.Review of the record showed that Resident #106 was admitted to the facility on [DATE] with the following diagnosis: Muscle Wasting and Atrophy in right shoulder, Lack of coordination Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented Resident #106 had a Brief Interview for Mental Status (BIMS), of 09 of 15, indicating the resident had moderate cognitive impairment. Review of Section G of the MDS, dated [DATE], documented Resident #106 required extensive assistance with two-person physical assist for bed mobility. Review of the Care Plan, dated 12/27/21, documented Resident #106 had an Activities of Daily Living (ADL) self-care Performance Deficit, with intervention documented to keep the call bell within reach while in room. During observation on 01/19/22 at 3:24 PM, Resident #106 was lying in bed. The resident's call bell was observed behind the rsident hanging off the right side of bed. When asked if he could reach the call bell, Resident #106 shook his head no and pointed to his right arm, indicating he could not move his arm. During an observation on 01/20/22 at 8:45 AM, Resident #106 was lying in bed. The call bell was observed hanging off the right side of the bed between the chair and bed. When asked if he could reach the call bell, Resident #106 shook his head no and pointed to his right arm, indicating he could not move his arm. During an interview on 01/20/22 at 10:09 AM, Staff J, Certified Nursing Assistant (CNA), and Staff K-CNA were asked about placement of call bells for residents. Staff J-CNA replied, I place it in their good hand, or close to resident. Staff K-CAN agreed. Staff J-CNA and K-CNA were asked how often call bells are checked, both agreed call bells are checked anytime they enter the room. 2. Review of the record showed that Resident #57 was admitted to the facility on [DATE] with diagnoses to include: Hemiplegia and hemiparesis following Cerebrovascular Disease affecting left non-dominant side, Muscle Wasting and Atrophy in Left and Right Shoulders and Muscle Weakness. Review of Section C of the MDS, dated [DATE], documented Resident #57 had a BIMS, of 13 of 15, indicating the rsident was cognitively intact. Review of Section G of the MDS, dated [DATE], documented Resident #57 required extensive assistance with-one-person physical assist for Bed Mobility. Review of the Care Plan, dated 09/22/21, documented Resident #57 had ADL self-care Performance Deficit as evidence by a history of Cerebral Vascular Accident (CVA) with left Hemiplegia/Hemiparesis, Impaired mobility, and functional decline, with an intervention documented to keep call bell within reach while in room. During an observation on 01/18/22 at 10:09 AM, Resident #57 was in bed. The resident's call bell was observed on the floor underneath his wheelchair, next to his bed. Resident #57 stated he could not reach the call bell because he had a stroke and does not have enough strength. 3. Review of the record documented that Resident #54 was re-admitted to the facility on [DATE] with diagnoses that included: Weakness, Difficulty in Walking, Major Depressive Disorder and Unsteadiness on Feet. Review of Section C of the 5-Day Minimum Data Set (MDS) dated [DATE] documented that Resident #54 had a Brief Interview for Mental Status of 13, which indicated that he was cognitively intact. Review of Section G of the 5-Day MDS dated [DATE] documented that Resident #54 required extensive assistance with two person physical assist for bed mobility. Review of the Care Plan dated 09/22/21 documented that Resident #54 had an activities of daily living self-care performance deficit related to weakness and lack of coordination. Interventions were to keep call bell within reach while in room. During an observation conducted on 01/18/22 at 12:53 PM, Resident #54's call light was on the floor underneath his privacy curtain. Resident #54 stated that he wanted help opening his cup of ice cream and stated that he could not reach his call light. He then asked the surveyor to give him his call light. During an observation conducted on 01/20/22 at 8:41 AM, Resident #54's call light was on the floor underneath his bed. Resident #54 stated that he could not reach his call light and Obviously it's not where it's supposed to be. During an interview conducted on 01/20/22 at 3:36 PM, Staff A, Licensed Practical Nurse, stated that call lights were to be placed on the resident's bed within easy reach. He further stated that he checked the placement of call lights every time he went into a resident's room. When asked what it meant for call lights to be within reach, Staff A stated, Within reach would mean in their hands. If they have an emergency, they will need it. If not, they could fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide shower assistance to 1 of 1 sampled resident (Resident #72) as indicated in the plan of care and as desired by the resident. The findings included: On 01/19/22 at 11:03 AM, Resident #72 stated she does not receive her scheduled showers despite her multiple concerns to staff, saying she had discussed this issue with everyone, but was often told the Hoyer lift did not work. Review of section G of the quarterly minimum data set (MDS), dated [DATE], and titled, Functional Status, documented that Resident #72 was totally dependent on staff and required 2+-persons extensive physical assistance for transfer, and 1-person extensive assistance for bed mobility, dressing, and physical assistance in part of her bathing. Review of the Nursing Plan of Care (CP), dated 12/28/21, revealed Resident #72 was incontinent of Bladder and Bowel; was at risk for falls or fall related injury because of Gait/balance problems; and outlined that Resident #72 was at risk or had actual limitations in range of motion as evidence by her need to wear a splint 3 hours per day and as per her tolerance level. It documented Resident #72 was able to sponge bathe herself and could transfer in and out of tub/shower but was unable to wash her back and hair. Review of the Activities of Daily Living (ADL) tasks log revealed Resident #72 was scheduled to receive a shower twice a week, every Wednesday & Saturday, between the hours of 7:00 AM -3:00 PM (day shift). The completed task document showed that the resident only received one shower a week (every Wednesday). There was no documentation or evidence that Resident #72 had refused showers on her other scheduled shower days. An interview with Staff Y, a certified nursing assistant (CNA), on 01/20/22 at 12:46 PM, revealed that she is familiar with Resident #72. Staff Y-CNA said that she usually bathed Resident #72 in bed. She said that at times the resident refused to take a shower. Staff Y-CNA said that Resident #72's shower days were on Sundays and Wednesdays, contrary to ADL shower/tasks log. Staff Y-CNA said Resident #72 occasionally refused her Sunday scheduled shower. Staff Y-CNA said she could not take the resident into the shower in the resident's room because the resident's wheelchair was too big. Staff Y-CNA also said when they tried to shower her in the main shower room, it is too difficult to reach all body parts since the resident cannot stand, so she concluded it is better to give her bed bath. Staff Y-CNA said when they take Resident #72 to the main shower room, water leaks from the Shower room into the resident's room leaving a trail of water on the floor, and it is very difficult. During an interview with the South Unit Manager (SUM), on 01/20/22 at 12:53 PM, she said that they had offered to take Resident #72 to the big shower room as her wheelchair cannot get into her personal shower room, but Resident #72 declined. The S-UM reported that the resident is bathed daily. The S-UM stated that she had observed the resident being bathe daily. The S-UM also said that they would have to get a Hoyer lift with a mesh in order to get Resident #72 to the main shower room and to prevent water spillage on the wheelchair and in the hallways. The S-UM added that she would discuss the matter with the Administrator because there are other residents who could benefit from using a mesh Hoyer lift. Review of the completed ADL Care Task record revealed Resident #72 received daily baths as reported. There was no evidence that she received all scheduled showers as stipulated in the ADL task log. Review of the grievance log, dated 05/12/21, showed that the resident was found in tears with concerns noted to a staff member that they have documented that she had refused to get out of bed to go to the shower when that was not the truth. She said that she wanted to have her showers as scheduled. The issue was then discussed and was, according to the grievance report, resolved. There was no further evidence provided as to how the issue had been resolved. A follow-up interview with Resident #72 on 01/19/22 confirmed that the issue was only resolved for a short while, but it now remains ongoing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure 4 of 6 sampled residents, Resident #31, Resident #34, Resident #61, and Resident #72, or their representatives participated or were involved in their Care Plan development process. The findings included: 1. Review of the electronic census records showed that Resident #31 was admitted to the facility on [DATE]. The assessment, dated 10/29/21, document the resident's Brief Interview of Mental Status (BIMS) as 13 of 15, indicating the resident's cognition was intact. The initial minimum data set (MDS) revealed that Resident #31 was discharged and readmitted to the facility multiple times, with the last reentry on 11/16/21 but the initial MDS was completed on 10/29/21. Section G of the MDS revealed that resident #31 required extensive assistance for most activities of daily living (ADLs) including transfer and bed mobility and he was totally dependent on staff for locomotion on and off Unit. On 01/19/22 at 11:17 AM, Resident #31 stated he had not attended any care plan (CP) meetings about his care. He said that he did not meet with anyone or discussed any care needs with anyone. He also stated his therapy was discontinued and that he would like to have more sessions. Review of the Initial Care Plan (CP) completed on 12/9/21 revealed Resident #31 would receive all services encompassing nursing, activities, dietary and social services. The facility was not able to provide evidence that the resident or his legal representative participated or attended the CP meeting. The signing sheet could not be located. An interview was conducted with the Social Worker (SW) on 01/19/22 at 2:17 PM. The SW could not produce any evidence or confirmation that the resident attended the CP meeting. The SW reported that he has not yet met with Resident #31. The SW said that he was not present when Resident #37's initial CP was developed. During an interview with the Director Of Nursing on 01/19/22 at 2:03 PM, she reported that the minimum data set (MDS) Coordinator was out on sick leave, and that the records could not be immediately accessed. 2. Resident #34 was admitted to the facility on [DATE] and has remained in the facility since admission. His CP was noted to have been revised multiple times. The initial CP was completed on 02/24/21 and the subsequent quarterly reviews were completed on 05/23/21; 09/21/21, and 11/20/21. Review of the last quarterly dietary CP, dated 11/20/21, documented no food preference. On 01/18/22 at 1:56 PM, Resident #34 stated he has not attended or had a CP meeting. He said that he does not recall anyone meeting with him to discuss his care. Resident #34 stated he has had an ongoing issue with his food preference not being followed. During an interview with the Social Worker (SW) on 01/19/22 at 2:14 PM, he stated he is familiar with the resident. The SW remarked that Resident #34 usually sits in the hallway, and he has spoken to him. He also stated Resident #34's CP was due to be updated on 01/28/22. During an interview with the DON on 01/20/22 at 10:09 AM, she stated the CP meetings are usually held with the MDS coordinator, the DON, the Activity Director and the residents and or their representatives. The DON could not, when asked, provide evidence that Resident #34 attended any CP meeting. During an interview with the MDS consultant on 01/21/22 at 10:08 AM, she stated she has been coming to this facility for nearly eleven months. She said that as consultant, she assisted in all spheres, including nursing and MDS. She confirmed she did not work with Resident #34. She was not able to provide any further information regarding Resident # 34 care planning attendance. 3. On 01/19/22 at 10:26 AM, Resident #61 stated that she had not attended or participated in a CP meeting. On 01/19/22 at 2:16 PM, the interim SW said that he has not met with the resident. On 1/19/22 at 2:03 PM, during an interview with the DON, she stated the MDS Coordinator was out on sick leave. she was going to try to access the records. Review of the CP Signing sheet provided on 01/20/22 revealed that the resident signed it, but it was not dated. During a follow-up interview with Resident #61 on 01/21/22 at 11:45 AM, she reported that she was given a CP meeting form to sign yesterday 01/20/22. She said signed it but did not date it because she did not attend the CP meeting. 4. On 01/19/22 at 11:03 AM, Resident #72 stated she has not participated in any CP meeting. She said that she has a power of attorney (POA), and that she too did not participate in any CP meeting. Resident #72 voiced concerns that her shower scheduled was not being followed. On 01/19/22 at 2:14 PM, the interim SW was asked whether he was familiar with Resident #72's care planning and replied that he was not. He said that he recently joined the company and was not present during the resident's care plan development. Review of the CP sign in sheet, dated 12/2/21, revealed that the resident had signed the document as well as the DON, the social worker, and the Activity Director. During an interview with the Resident on 01/21/22 at 11:41 AM, she stated that she did not attend the CP meeting but had received the form on 01/20/22 and had signed it. She reiterated that she did not attend the CP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide toenail grooming for 2 of 6 sampled residents reviewed for Activities of Daily Living (ADL), Residents #95 and #57. The findings included: 1. Review of the record showed that Resident #95 was admitted to the facility on [DATE] with diagnoses that included: Abnormalities of Gait and Mobility and Type 2 Diabetes Mellitus. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented Resident #95 had a Brief Interview for Mental Status (BIMS) of 00, which indicated that the resident was severely cognitively impaired. Review of Section G of the MDS, dated [DATE], documented that Resident #95 required limited assistance with one-person physical assist for personal hygiene. Review of the Physician's Orders (POS) showed that Resident #95 had a physician order dated 12/10/20 for Podiatry services as needed. Review of the care plan, dated 12/21/21, documented that Resident #95 has an Activity of Daily Living (ADL) Self Care Performance Deficit, with intervention that included Personal Hygiene - 1 person assist. During an observation on 01/18/22 at 9:49 AM, Resident #95 was observed lying in bed. The resident said that his toenails were long, and it's been more than one month since they were trimmed. The resident removed the bedsheet and it was observed that his toenails extended past the tips of his toes. The resident was asked if he wanted them trimmed and he said sure. During an interview on 01/21/22 at 9:28 AM, Staff H, Certified Nursing Assistant (CNA), was asked who was responsible for trimming toenails. She stated, They have doctor or something like that, private people cut toenails. Staff-H was then asked what she would do if resident's toenails needed trimming. Staff H-CNA replied, We tell the nurse, verbally. Staff H-CNA stated that toenails are checked every time care is provided, including bathing and showering residents. During an interview on 01/21/22 at 9:50 AM, Staff Z, Registered Nurse (RN), stated normally, they call the doctor to trim toenails. Staff Z-RN said doctors are responsible for coming in and providing toenail care. When asked how often the residents' toenails were checked, he stated there is no time to check, only if we happen to find it, or if the resident reports it to me. When asked what he would do if a resident's toenails needed to be trimmed, he stated that he would inform Staff I, RN/Unit Manager and she would contact the doctor to come. Staff Z-RN then went into Resident #95's room with the surveyor and was asked what he thought of Resident #95 toenails. Staff Z-RN agreed that Resident #95's toenails were long and needed to be seen by the Podiatrist to have them trimmed. He further stated, if they're normal, we can do the toenails, but if it's fungal like than we can't, and he needs the doctor. During an interview on 01/21/22 at 10:02 AM, Staff I-RN stated that Podiatrist comes to the facility every Wednesday. When asked who is responsible for checking toenails, she stated that all staff were responsible and that they would report it to her or the resident's nurse. She stated that any residents that needed their toenails trimmed would have their names placed in the Podiatry Consult book. Staff I-RN reviewed the Podiatry Consult book with the surveyor and stated that Resident #95 was not listed. She then stated that Resident #95 was transferred from the [NAME] Wing and he may have been in the Podiatry Consult book on that Wing. Staff I-RN also stated the Podiatrist writes their notes in the physical chart at the Nursing Station. Staff I-RN reviewed the physical chart for Resident #95 with the surveyor and stated there were no Podiatry notes for Resident #95. Staff I-RN stated she needed to check with Medical Records to see if they had any Podiatry notes for Resident #95. Review of Podiatry Consult Book, dated 06/18/21 to 01/18/22, showed Resident #95 was not listed for a consult. During an observation of the [NAME] Wing Nursing Station 01/21/22 at 10:09 AM, two surveyors were unable to locate a Podiatry Consult book on the [NAME] Wing Station. During an interview on 01/21/22 at 10:11 AM, Staff F, RN/Unit Manager (RN-UM), was asked about the location of the [NAME] Wing Podiatry Consult book. Staff F-RN-UM replied, Podiatry Consult Book? I don't think we have one. On 01/21/22 at 3:30 PM, Staff I-CNA approached the surveyors to inform them that after checking with Medical Records, there were no Podiatry notes for Resident #95. 2. Review of the record showed that Resident #57 was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia and hemiparesis, Muscle Wasting and Atrophy and Muscle Weakness. Review of Section C of the MDS, dated [DATE], documented Resident #57 had a BIMS, of 13 of 15, indicating that the resident was cognitively intact. Review of Section G of the MDS, dated [DATE], documented that Resident #57 required extensive assistance with-two-person physical assist for Personal Hygiene. Review of the Physician's Orders showed that Resident #57 had an order dated 08/05/20 for Podiatry services as needed. Review of the care plan, dated 09/22/21, documented that Resident #57 had an ADL Self Care Performance Deficit with interventions that included: Assist as needed to perform ADL functions including but not limited to Personal Hygiene; Check nail length and trim and clean on bath day and as necessary; and Report any changes to the nurse. During an interview on 01/19/22 at 10:21 AM, Resident#57 stated he informed the physical therapist about his long toenails, and she told him they have the foot doctor, and they would come back for that. During an observation on 01/20/22 at 8:51AM, Resident #57's toenails were thick and past the tips of his toes to the point where they were deformed and curved. During an interview on 01/21/22 at 10:02 AM, Staff I-CNA, reviewed the Podiatry Consult book and stated that Resident #57 was not listed. She then stated that Resident #57 was also transferred from the [NAME] Wing, and he may have been in the Podiatry Consult book on that Wing. Staff I-CNA reviewed the physical chart for Resident #57 with the Surveyor, but she stated there were no Podiatry notes for Resident #57. Staff I stated she needed to check with Medical Records to see if they had any Podiatry notes for Resident #57. Review of Podiatry Consult Book, dated 06/18/21 to 01/18/22, showed Resident#57 was not listed for a consult. During an observation on 01/21/22 at 11:19 AM, Resident #57 toenails were still thick and past the tips of his toes to the point where they were deformed and curved. On 01/21/22 at 3:30 PM, Staff I-CNA approached the surveyors to inform them that after checking with Medical Records, there were no Podiatry notes for Resident #57.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to identify and prevent the development of a right heel pressure ulcer observed during care for 1 of 1 sampled resident, Resident #101, reviewed for pressure ulcer. The findings included: Review of the facility's policy, titled, Standard-Notification of Resident/Patient Change in Condition, with no effective or revision date, documented the facility clinicians will notify the resident / resident representative immediately, if there is a crucial / significant change in the resident's condition .notify the physician if there is a significant change in condition, regardless of the time of day .document the nurses notes, the time of notification . Review of Resident #101's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included, in part, Neuropathy, Dysphagia (Difficulty swallowing), Cognitive Communication Deficit, Hypertension, Diabetes Mellitus, History of Falls, Subluxation(dislocation) of Right Shoulder, and Unsteadiness on Feet. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/14/21, documented that Resident #101 had no cognitive impairment, required expensive assistance from the staff for most of his activities of daily living (ADLs) including bed mobility, transfers, bathing, and toilet use. The assessment documented the resident was at risk of developing pressure ulcers and the resident did not have a pressure ulcer at the time of the assessment. Review of Resident #101's Treatment Administration Record (TAR) for December 2021 documented treatments, dated 12/08/21 and completed on 12/15/21, as to apply skin prep wipe to heels daily very shift for 7 days for preventive measure. Notify MD (doctor) of changes. May continue if needed. Review of the resident's TAR for January 2022 lacked evidence of the administration for pressure ulcer care or preventive measures. Further review revealed no active physician orders for pressure ulcer care or wound healing supplements. Review of Resident #101's Medication Administration Record (MAR) for January 2022 lacked evidence of the administration for pressure ulcer care or preventive measures. Further review revealed no active physician orders for pressure ulcer care or wound healing supplements. Review of the resident's Admission/readmission: Data Collection / Baseline Care Plan Tool, dated 12/08/21, documented the information to complete the assessment tool was provided by the resident's representative, in part as follows: .the resident required a translator to assist with communication; primary language Spanish .the resident was at risk for falls .skin color, temperature and turgor(elasticity) was normal .risk of wound .needed assistance of 2 for transfers and bed mobility . Review of Resident #101's Certified Nursing Assistant's (CNAs) daily tasks included: float heels .monitoring: protective body movements or posture-bracing, guarding, rubbing/massaging a body part/area .skin observations . Review of the resident's CNAs bathing task from 01/08/22 to 01/18/22 documented Resident #101 was total dependence on the CNA for that task. Review of the resident's CNAs Turn and Reposition task from 01/08/22 to 01/18/22 documented Resident #101 was turned and reposition on every shift. Review of the resident's CNAs skin observation task from 01/08/22 to 01/09/22 documented Resident #101 had no scratched, red area, discoloration, skin tear or open area on either shift. Review of the resident's CNAs skin observation task from 01/10/22 to 01/18/22 documented Resident #101 had red area on every shift. Review of Resident #101's Skin Check Weekly and as needed tool, dated 01/05/22 and 01/12/22, documented the resident had no new areas of skin impairment. Review of Resident #101's Skilled Evaluation tool, dated 01/09/22 and 01/10/22, documented under body system baselines that the resident was confused .not able to understand and be understood when speaking .skin warm and dry and color within normal limits .communication was verbal . urinary incontinence .wearing adult brief .was on a turn schedule; .under 'Skin Note', it was noted that the box was left blank, and no documentation was provided. Review of Resident #101's Skilled Evaluation tool, dated 01/11/22, documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care (washing the genitals and anal area) provided; .under 'Skin Note', it was documented that the skin remains intact. Review of Resident #101's Skilled Evaluation tool, dated 01/12/22, documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care provided; .under Skin Note, it was documented wound located to left buttock under treatment as ordered .general / narrative note documented .routine care by staff as ordered Review of Resident #101's Skilled Evaluation tool, dated 01/13/22, documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care provided; .under 'Skin Note', it was documented skin intact Review of Resident #101's Skilled Evaluation tool, dated 01/14/22, 01/15/22, 01/16/22, 01/17/22, 01/18/22 and 01/19/2,2 documented under body system baselines that the resident was alert, oriented to place, person, and time communicated verbally, speech is clear, is able to understand and be understood when speaking .skin warm and dry and color within normal limits .peri care provided; .under Skin Note, it was noted that the box was left blank, and no documentation was provided. Review of Resident #101's care plan, titled, WOUND RISK: The resident is at Risk of developing a wound, initiated on 12/08/2021; and revised on 01/18/2022 with a documented intervention that read, floats heels and Encourage / remind / assist to turn / reposition as needed or requested. On 01/18/22 at 11:42 AM, observation revealed Resident #101 in bed in supine position and leaning over to her right side. An interview was conducted with the resident in Spanish because she stated she did not speak or understand English. When asked if she had any concerns or complaints, the resident stated she was having a very bad pain in her right heel. She was asked if she told the nurse and stated she had not told anyone yet because nobody had asked and that she did not speak English to tell them. Resident #101 allowed the surveyor to look at the right heel. Observation revealed resident's heels were rubbing against the mattress, with no pillows and no heel protectors. The right heel had an approximately quarter size redness with a two centimeters necrotic tissue in the center and skin peeling off around it. The resident stated the staff did not put heel protectors on while she is in bed. During the interview, the resident was asked if she had a bed sore on her heel and stated she did not know that. On 01/18/22 at 1:13 PM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/18/22 at 3:33 PM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/19/22 at 8:45 AM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/19/22 at 2:30 PM, observation revealed Resident #101 in bed lying over her right side with her heels rubbing against the mattress. On 01/19/22 at 4:16 PM, observation revealed Resident #101 in bed leaning over her right side. No heel protectors noted. On 01/19/22 at 4:20 PM, an interview was conducted with Staff L, a Certified Nursing Assistant (CNA). Staff L-CNA stated she works the day shift (7:00 AM to 3:00 PM) and does residents' morning care, assist them with their meals, turns them every 2 hours if needed, changes their adult brief and checks their bottom every 2 hours for any skin opening. Staff L-CNA stated that today (01/19/22), it was the first time she was assigned to take care of Resident #101. Staff L_CNA was asked if the resident had any pressure ulcer and stated she was not able to tell. Staff L-CNA stated she (herself) understood a little Spanish and added that the resident understood a little English. Observation revealed Staff L-CNA asked the resident if she was hungry in English. Resident #101 responded I don't understand in Spanish. On 01/19/22 at 4:35 PM, a side-by-side observation with Staff L-CNA and Staff M-CNA of Resident #101's skin check was conducted. The check revealed a white gauze type dressing on the resident's sacrum area dated 01/19/22. Further review revealed the resident's right heel with necrotic tissue, redness and skin peeling off around it. Staff L-CNA was asked if the resident was supposed to wear heel protectors and she stated that she was not sure. On 01/19/22 at 4:44 PM, a joint interview was conducted with Staff N, a Licensed Practical Nurse (LPN) and Staff F, a Registered Nurse (RN). Staff N-LPN was asked if she checked Resident #101's skin. She stated she did not because she did not have anything schedule related to resident, no skin assessment, no skin care to do. She added she did not have any physician orders related to her skin. She added everything they do was scheduled. Staff F-RN stated Resident #101 did not have any physician orders to do pressure ulcer care. She stated the resident did not have a special mattress. During this interview, Resident #101 right heel wound was shown to Staff N-LPN. Staff N-LPN placed her right hand over her mouth and opened her eyes wide. She stated she was not aware of the resident's right heel wound or of her sacrum dressing, dated 01/19/22. Staff F-RN was apprised that Resident #101's MDS assessment documented that she had a pressure reducing device in bed. Staff F-RN stated the resident did not have a special mattress. On 01/19/22 at 4:58 PM, during the joint interview with Staff F-RN and Staff N-LPN, the Director of Nursing (DON) joined the interview. The DON stated that she was made aware of Resident #101's sacrum wound this morning (01/19/22). She was not informed of the resident's heel condition. The DON stated she communicated with the physician but has not gotten around to enter the orders in the computer. The DON stated she did the sacrum dressing this morning, stated she applied honey to the sacrum wound. Consequently, a side-by-side check of the resident's sacrum area and right heel was conducted with Staff F-RN and the DON. During the check, the resident was asking in Spanish what are you going to do? The DON and Staff F-RN were not able to communicate with the resident in Spanish. Observation revealed the resident looked frightened and stated in Spanish, I am going to fall. They asked the surveyor to translate. There was not a communication board in the resident room. On 01/19/22 at 5:09 PM, during an interview, the DON and Staff F-RN were apprised that Resident #101 complained of pain to the right heel on 01/18/22 during the surveyor's interview and right heel pressure ulcer was noted on 01/18/22. On 01/20/22 at 10:34 AM, an interview via a telephone call was conducted with Resident #101's representative. The representative stated that Resident #101 had been at the facility for over a month, and she was going to stay at the facility. He added the resident needed care that they can't provide. He helped the resident with meals because she can't see, and her appetite was poor which he told the nurses on 01/18/22. He was asked if he has seen the resident's legs being elevated on pillows or having any heel protectors and stated he had not. He stated last night (01/19/22) he was called by the facility to let him know that the resident had an injury / sore on her back and that they started treatment. He was asked if she has had bed sores before and stated that a week ago the resident complained of pain on her buttock. He added they checked her and was told that she did not have anything on her buttock. He added that on 01/19/22, they got her out of bed to a chair and she was complaining of back pain. The resident's representative stated that Resident #101 wears an adult brief a diaper, has Diabetes and Hypertension. He added that she resists to be turned because she can't see, her eyesight was bad and she is afraid that she might fall. He continued to say that the resident presses on her heel when in bed and told him that she keeps her legs bend because of pain. He stated the facility scheduled a meeting for 01/25/22. On 01/20/22 at 11:32 AM, attempt was made to interview Staff O-RN via telephone. A telephone call was made to Staff O-RN, a recorded voice message was activated, and a message was left to call back. On 01/20/22 at 12:15 PM, an interview was conducted with Staff R-CNA who stated she works the evening shift (3:00 PM to 11:00 PM). Staff R-CNA stated she checked on the residents every 2 hours, clean and change their adult brief, bathe them if needed. She stated if the resident's skin breakdown or had discoloration, she will inform the nurse right the way. She stated she had not taken care of Resident #101. On 01/20/2022 at 3:30 PM, an interview was conducted with Staff U-LPN who stated she works the evening shift and that she did not do residents skin checks and added those are done on other shifts. She stated that she did not check Resident #101's skin and was not aware of her skin breakdown / wounds. On 01/21/22 at 7:08 AM, an interview was conducted with Staff V-CNA. She stated she floats to all the facility's wings. She stated she changes the resident's adult brief every 4 hours and will report to the nurse if their skin is red or any changes on their skin color. She stated she did not recall taking care of Resident #101, it was not her assigned area. On 01/21/22 at 7:17 AM, an interview was conducted Staff O-RN. He stated he was a fulltime employee and works the night shift (11:00 PM to 7:00 AM). Staff O-RN stated he had 37 residents assigned to him and his duties were to check on every resident, and to check the Medication Administration Records (MAR) to see if there was an order to be given / administered. He added that he administers, and documents medications and treatments provided such as wound care. He stated he currently had three residents that required wound care on his shift. He stated that he does skin assessment as assigned, and if a CNAs sees skin issues, they will come to him, and he will then assess. He stated he did not speak Spanish but understand few words. He stated Resident #101 knew a few words in English, like thank you. Staff O-RN stated that on (01/19/22) Tuesday night to Wednesday, Staff P-CNA who work the night shift, told him that she saw a wound on Resident #101's back. He added that he then cleaned the wound with normal saline solution and placed a temporary dressing. Staff O-RN stated that when the DON came on Wednesday morning, he reported to her and together they checked the wound in the back. The DON told him she would get a physician order. He was asked if he knew about the resident's right heel pressure ulcer and stated he was not notified by Staff P-CNA about the heel and that he was not aware of a heel pressure ulcer. Staff O-RN was asked regarding his documentation related to the resident's back wound findings and care provided. He replied he did not document what he saw or did for the resident on 01/19/22 and was waiting on the DON. He was asked to describe the wound appearance and stated, 'the sacrum surrounding area looked like there was something there before, skin was black and opened'. He stated at night, they don't want to disturb the residents, but anytime the CNA sees something they report it to him. He stated the wound was avoidable and that it did not happen overnight. On 01/21/22 at 10:37 AM, an interview was conducted with Staff T-LPN. She stated she works the day shift and floats through all wings. An inquiry was made regarding her medicating Resident #101 for pain on 01/18/22 at 12:23 PM. She stated the resident's son told her she was complaining of pain. Staff T-LPN added that the resident was rubbing her right thigh and pointed that the pain was at her thigh. She stated she assessed her right thigh for swelling but did not check her right heel. Staff T-LPN was apprised that Resident #101 had a pressure ulcer on her right heel. She stated she was not aware of the resident's pressure ulcer. Staff T-LPN stated that if a skin assessment popped up in the computer, she would do the whole head to toe assessment and would take the residents socks off. On 01/21/22, multiple calls were placed to Staff P-CNA assigned to Resident #101 on night shift and received no return call by the end of the survey time. On 01/21/22 at 1:28 PM, a telephone interview was conducted with Staff Q-CNA. She stated she took care of Resident #101 on 01/18/22. She stated she saw a bandage on the resident's bottom but did not see anything else. Staff Q-CNA's voice was hoarse and was unable to get more details. On 01/21/22 at 1:35 PM, an interview was conducted with the DON. She stated that Staff O-RN, when she was rounding on 01/19/22 (Wednesday) morning, informed her that Resident #101 had a wound to the sacrum area. The DON added she went into the resident's room, looked at the wound, call the physician, obtained an order for treatment, and provided the care / treatment. The DON stated the sacrum wound had yellow tissue at the base of the wound, no drainage, no odor, and unable to stage the wound, because of the yellow slough. The DON reported the resident right heel wound measurements were 2.0 centimeters (cm) (length) by 2.0 cm (width) and the depth was unable to determine, the wound was classified as a Deep Tissue Injury (DTI). The DON reported Resident #101's sacrum wound measurements as: 3.5 cm (length) by 4.0 cm (width) and the depth unable to determine. The DON was asked if the resident's wound was avoidable and stated she was [AGE] years old who had poor nutrition (meals average intake for most time 50 to 75%), had poor appetite, with confusion at times, and had a medical diagnosis of Diabetes Mellitus, Hypertension and Neuropathy. The DON was asked what Preventive Measures the facility had in place to prevent Resident #101's development of pressure ulcer. The DON stated the following: turning and repositioning; Physical, Occupational and Speech therapy and Med pass (liquid supplement) ordered on 12/10/21. The DON stated the resident was care planned for at risk for developing wounds on 12/08/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to assess 1 of 1 sampled resident, Resident #368, for chest and stomach pain, as evidenced by not following the facility's set protocols; and failed to ensure that care was provided in a timely manner. The findings included: Review of the facility's Pain Management protocol, effective October 2021, revealed the following needed to be completed: 1. Collect data on the intensity of the resident's pain. 2. Identify the current analgesic regimen 3. Analyze the reported pain severity on the current regimen. Review of the electronic clinical record revealed Resident #368 was admitted to the facility on [DATE] with diagnoses that included Adult Failure to Thrive; Unspecified Lack of Coordination; Other Idiopathic Peripheral Autonomic Neuropathy; Chronic Kidney Disease; Type 2 diabetes Mellitus; and Hypertension. The resident was admitted to the Covid unit for observation. Review of the resident's assessment documented the resident tested positive on 01/04/22, was asymptomatic and was placed on contact precautions. Section C of the MDS, dated [DATE], under Cognitive Patterns, revealed Resident #368 obtained a score of 13/15, indicating cognition was intact. He had only missed the current year by 1 year and missed the current month by 6 days. In Section G, it was noted that the resident required extensive assistance for all activities of daily living (ADLs) and he was totally dependent for Bathing requiring 2 persons physical assist. In section I, there was no evidence of a psychiatric disorder recorded. Review of the Physicians' Orders (POS) revealed that on 01/04/22, there was a physician order for 100 mg of Docusate Sodium Tablet ordered to be given by mouth two times a day for constipation. There was also an order for Dulcolax Suppository (Bisacodyl) that read, 'Insert 10 mg of Dulcolax Suppository rectally every 24 hours as needed for Constipation -Administer Daily if no results from MOM (milk of Magnesia). Active since 1/3/2022 at 23:44 PM.' On 01/19/22 at 09:55 AM, Resident #368 stated that he had to dial 911emergency twice, because he had respectively experienced chest pain and severe stomach pain. The resident said that on multiple occasions, he activated his call light, and no one came. His family member present during the interview, confirmed that her father had called her twice asking her to call the facility's main line to request for help for him. She said when no one answered the phone, she left her house and came to the facility after her father activated the National Emergency Number (911), to see what was going on. In a follow-up interveiw with the resident on 01/20/22 at 11:12 AM, he reiterated and expounded on his previous claim and stated that prior to his admission to the facility, he was hospitalized from [DATE] to 01/03/22, and was discharged back to the facility on [DATE]. He said on the night of his arrival to the facility, he had severe chest pain and had activated his call light, and no one responded to the call. After 2 hours, since no one answered, he said, he called 911. Resident #368 said the nurse did not come to his room until after the Paramedics arrived. The resident also added that the nurse never asked him about his pain level instead and was not pleased that he had called 911. Resident #368 further stated that while the paramedics were with him assessing him, he felt better and rescinded his option to go back to the hospital because he did not want to worry his children. Resident #368 said that on January 8, 2022, he had severe stomach pain and no one came to his rescue after he activated the call light. He then called his family member to request her assistance. The daughter tried reaching the office for nearly two hours and no one answered, so he again called 911. When they arrived, they (the paramedics and the nurse) told him that it was wrong for him to call 911. He told them, 'When you feel that you are dying and no one comes to your rescue for nearly 2 hours, isn't it right to call 911.' He added that the facility's action to not answering his call light was 'criminal'. He said that he did not want to create any problems and did not file any complaint, but that no one came to speak to him or see him regarding that matter. He said as of 01/19/21, he has not yet seen a physician. Review of the Medication Administration record (MAR), dated 01/03/22 through 01/06/22, revealed that no medication was administered to the resident for pain. There was no documentation of the resident's pain scale level and no evidence that a new order was received or given by the resident's physician. Review of the Nursing Progress Notes (NPNs), dated 01/04/22 documented that Resident #368 had initiated a 911 call at 3:05:54 AM. The NPNs revealed that the emergency call was made subsequent to the resident experiencing chest pain. Review of the nursing notes revealed the nurse documented the following: 'Resident called out to EMS to be transferred out of the facility back to the hospital. The resident was evaluated and assessed for any arrhythmias or shortness of breath (SOB), none detected. The resident was informed / explained the usage of 911 when there is an emergency. Resident voiced and nodded to understanding. After responders left, Resident placed call to family member to see if he can get discharged from this facility to home or hospital. This writer (the nurse) tried making resident as comfortable as possible and tend to need in a timely manner. Will continue to monitor for any changes. Call bell and bed control within reach.' Another progress note, dated 01/08/22, documented by Staff W, a registered nurse (RN), documented the fact that Resident #368 had complained of stomach pain / constipation. The note showed that stool softener was administered, and the resident was advised to wait about half an hour for the medication to become effective. Before the expiration of the allotted time, the resident called 911 emergency for assistance. The paramedics arrived at the facility and evaluated the resident and determined that his call to emergency was not a valid one and as a result left the facility without transporting him to the hospital. During an interview on 01/20/22 at 11:20 AM with Staff X, a Licensed Practical Nurse (LPN), she said she did not questioned Resident #368 about the extent of his pain. To her knowledge, the resident did not use the call light and when she entered the room, she saw the resident's family member was in the room. She said that the resident wanted to leave the facility. She said that she had not reviewed the chart at that time, when the resident arrived at the facility. She also stated the resident voiced concerns to leave the facility. Staff X-LPN said she was working in the South Wing Unit, and that Resident #368 had complained that no one was there to care for him. She tried to get him a snack, then she gave him a cup of water and a bottle of Resource, which he drank. He did not complain of pain thereafter. Staff X-LPN said that she reported the issue to the South Unit Manager. During an interview with the South Unit Manager (SUM) on 01/20/22 at 10:40 AM, she confirmed that Staff X-LPN, who usually worked at night (11:PM to 7:00 AM shift), informed her the resident had called 911. The SUM said that she had spoken to Resident #368, but she did not document it. She said that she remembered telling the resident to let them know if he needed anything. The SUM stated she did not recall what the resident reported to her. She said that she did not remember the resident complaining to her about his call light not being answered. The SUM said that she is sure that she had a discussion with the resident regarding calling 911, but she did not keep any documentation of it. The SUM also stated when residents complain of chest pain, their protocol is to send the resident out to the hospital after conducting a full assessment. She said that staff should not rely on vital signs because they do not know what is going on internally. The SUM also said that the paramedics did not leave any documents. The only documentation they would have had is if the resident was transferred to the hospital would be a transfer form. The SUM said she would ask the resident if he still had pain, inquire about the last time he had a bowel movement, assess to see if a fleet enema would be necessary since he had complained of stomach pain. After reviewing the medication administration records (MAR), she stated that she has no idea why the other medications ordered for constipation were not administered. Review of the hospital transfer / discharge information, dated 01/03/22, revealed the resident had a bowel movement at 22:06 hours (10:06 PM) and on the 01/04/22 at 12:47 hours (00:47 AM), at 14:50 hours (2:50 PM) and at 21:52 hours (9:52 PM). During an interview with the Director of Nursing (DON) on 01/20/22 at 11:26 AM, she explained the facility's protocol and policy regarding pain assessment. She reported that if the resident complains of pains, they have to notify the residents' physicians and then follow their recommendations. She said the nurses must assess the patient, the assessment would entail asking the resident if they have pain, observed for face grimacing, and whether they are clutching to body parts. The nurse must ask what the pain scale is; where is the pain; what makes it worse or better and has anything helped you in the past for that pain; and then the resident would tell them whether the pain is new or usual and provide pertinent information on how it usually is resolved. The DON stated that when she spoke to the resident on the morning of 01/04/22 at approximately 7:00 AM, the resident confirmed that he had called 911 because he was in a new environment and was anxious and wanted to go back home. the DON stated that they do not keep a log of the incoming and outgoing calls to the facility, so she could not confirm the resident's claim. The DON did confirm that the resident was admitted to the isolation unit for observation. Review of the care plan (CP) documented that Resident #368 had an ADL Self Care Performance Deficit, in which he would be able to help with some ADLs but needed physical help from staff to help complete tasks; and that staff should encourage the resident to participate at highest level and provide assistance required to complete task and document. The following was noted: -BED MOBILITY: Extensive Assist of 2 to turn and/or reposition -TRANSFER: Assist of 1 staff participation with transfers. -LOCOMOTION: Electric Wheel Chair -PERSONAL HYGIENE: Assist of 1 -DRESSING: Assist of 1. -EATING: set up -TOILET USE: Assist of 2 -Toileting: Bathroom -CONSTIPATION: The resident had a potential for constipation r/t Immobility, -Effective Bowel regimen -Maintain Normal Bowel Pattern -Minimize/eliminate constipation; and Observe / report to nurse/MD PRN [as needed] for signs and symptoms of complications related to constipation: Complaints of difficulty passing stools, Abnormal grunting with passing of stools, Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Diaphoresis, Abdomen: tenderness, guarding, and rigidity. -Administer medications as ordered. Refer to POS for current order -Review medications for side effects of constipation. Keep physician informed of any problems. -Review of the Progress notes dated 1/3/2022 to 1/8/2022 revealed Resident #368's physician was not notified regarding complaints of chest and stomach pains. Review of the January 2022 MAR revealed that the resident's pain level was not documented. The order read, 'Monitor pain every shift and record pain number on a 0-10 scale.' From 01/04/22 to 01/08/22, all staff documented a pain level of zero. After review of the policy for Pain Management and further interivew with the DON on 01/20/22 at 11:26 AM, the DON confirmed that staff did not follow the facility's protocol as stipulated in the guidelines. The record showed that stafff did not follow the protocol / policy and this was confirmed by the DON. There was no additional information provided up to the exit meeting on 01/21/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the resident's written plan of care included both the most recent hospice plan of care and a description of the services furnished by the facility for 1of 1 sampled resident, reviewed for Hospice services, Resident #63. The findings included: Review of Hospice Agreement for Nursing Facility Services revealed this agreement for Nursing Facility Services (agreement) is entered into and effective as of 12/16/21, by and between Hospice and Facility for location set forth on Appendix A (Facility). Definitions: Facility Plan of Care means a written care plan established, maintained, and modified (as necessary) by Facility for each Residential Hospice Patient in accordance with applicable laws, rules, and regulations, this Agreement, and Hospice policies and procedures, and which sets forth the Facility Services that Facility has determined to be appropriate for the Residential Hospice Patient, Hospice Plan of Care means a written care plan established, maintained, and modified (as necessary) for each Hospice Patient by the applicable Interdisciplinary Team which includes an assessment of the Hospice Patient's needs, an identification of the Hospice, Services appropriate to meet the needs of the Hospice Patient and his/her family, and details concerning the scope and frequency of such Hospice Services. Facility Obligations: Facility Plan of Care for each Residential Hospice Patient, Facility will develop a Facility Plan of Care which is consistent with his/her Hospice Plan of Care. Facility will furnish Hospice a copy of each residential Hospice Patient's Facility Plan of Care. Agreement signed by Hospice General Manager on 12/20/21 and Facility Nursing Home Administrator on 12/16/21. Record review for Resident #63 revealed the resident was admitted on [DATE] with most recent readmission on [DATE] with diagnoses that included: Encounter for Palliative Care, Schizophrenia, Major Depressive Disorder, Adult Failure to Thrive, and Traumatic Subdural Hemorrhage without loss of Consciousness Sequela. The significant change minimum data set (MDS), dated [DATE], revealed in Section C the brief interview for mental status (BIMS) could not be completed due to the resident is rarely / never understood, Section O revealed while he was a resident, he was on hospice care. There was a physician order, dated 11/01/21, to admit to hospice due to failure to thrive. Review of Resident #63's care plan revealed there was no hospice care plan. Review of the progress note, dated 10/15/21, revealed spoke to resident's brother to discuss pending Hospice admission. The brother stated he is having consents mailed to him by Hospice. Social Service Director (SSD) questioned if he would be able to receive them via email, the brother laughed and said he is disabled and does not have email, then mentioned having an email account attached to his phone. SSD informed him those consents could also be sent that way and he could even sign them from his phone most times. The brother disregarded the recommendation saying he'll wait for the mail. SSD asked if he would be okay with hospice reaching out and seeing if there was anyway of facilitating the process on their end for him. He thanked the SSD and said that would be fine. SSD reached out to Hospice and asked that they please reach out as soon as possible (ASAP). SSD will continue to monitor and follow up as needed. During an interview conducted on 01/20/22 at 4:23 PM with the Assistant Director of Nursing (ADON), when asked if staff communicates with hospice, she stated they talk in person when the hospice nurse comes once a week, and they give report to each other. If any concerns or changes in condition the facility staff call the hospice. During an interview conducted on 01/20/22 at 4:30 PM with Staff F, Registered Nurse (RN), when asked how staff communicate to hospice a change in condition or a concern for a resident who is on hospice, she stated they call hospice or if the hospice nurse is in the facility making a visit, they inform them in person. During an interview conducted on 01/21/22 at 9:21 AM with the Clinical Reimbursement Consultant (CRC). When asked about process for minimum data set (MDS), she stated when someone comes in, they have an admission assessment and then reassessments are done after that. A significant change assessment is done when the resident is admitted to hospice or discharged from hospice. The CRC said that the care plan that would be triggered by significant change due to hospice admission would be the care plan with a focus on terminal care. Review of Resident #63's care plan with the Clinical Reimbursement Consultant revealed there was no terminal care plan now or ever. There was no integration of hospice care on the facility care plan for Resident #63. The CRC then had the Director of Nursing (DON) come in and review Resident #63 record to locate a hospice care plan or a terminal diagnosis care plan and she was unable to find any. The DON and the CRC agreed there should be a hospice care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to develop a communication deficit care plan and interventions for 1 of 1 sampled resident in the [NAME] wing, Resident #101, reviewed for communication. The findings included: Review of Resident #101's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident's diagnoses included, in part, Neuropathy, Dysphagia (Difficulty swallowing), Cognitive Communication Deficit, Hypertension, Diabetes Mellitus, History of Falls, Subluxation(dislocation) of Right Shoulder, and Unsteadiness on Feet. Review of the facility-provided list documented Resident #101 as a non-English speaking resident and only spoke in her foreign language. Review of the resident's Admission/readmission: Data Collection/Baseline Care Plan tool, dated 12/08/21, documented the information to complete the assessment tool was provided by the resident's representative that included: .the resident required a translator to assist with communication; primary language [documented] .the resident was at risk for falls .skin color, temperature and turgor(elasticity) was normal .risk of wound .needed assistance of 2 for transfers and bed mobility . Review of the most recent Minimum Data Set (MDS) admissions assessment, dated 12/14/21, documented that Resident #101 had clear speech, was understood and able to understand other, had no cognitive impairment. The assessment coded that the resident did not need or want an interpreter to communicate with the healthcare staff. The resident's functional status was documented as requiring expensive assistance from the staff for most of his activities of daily living (ADLs) including bed mobility, transfers, bathing, and toilet use. The assessment documented the resident was at risk of developing pressure ulcers and did not have a pressure ulcer at the time of the assessment. Further review revealed the assessment was completed with the participation of a family / significant other. Review of Resident #101's comprehensive care plans did not include a communication care plan. The resident's care plan, titled, PAIN, initiated on 12/09/21 and revised on 01/18/22, included interventions to .Observe / report to Nurse any signs or symptoms of non-verbal pain as .facial expressions- grimaces .protective body movements or postures .rubbing / massaging a body part / area. On 01/18/22, an interview was attempted with the Minimum Data Set- Clinical Reimbursement Specialist (CRS), who completed Resident #101 assessment, but she was not available. On 01/18/22 at 11:42 AM, observation revealed Resident #101 in bed in supine position and leaning over to her right side. An interview was conducted with the resident in [her language] because she stated she did not speak nor understand English. On 01/18/22 at 1:22 PM, observation revealed Staff S, a Certified Nursing Assistant (CNA), delivered Resident #101's lunch tray. She started to reposition the resident and the resident was talking to her in [her language]. Staff S-CNA was asked if she understood what the resident was saying and stated she did not understand / speak her language and left the room. On 01/18/21 at 1:23 PM, observation revealed Staff T, a Licensed Practical Nurse (LPN) came in the room and started to talk to Resident #101 in English. Further observation revealed the resident stated in [in her language], what did you say. Staff T-LPN was not able to communicate in the resident's language and did not have a communication board. Staff T-LPN continued to speak English to the resident and offered coffee. Observation revealed the resident stated No and with a loud speaking tone, the resident told Staff T-LPN, I have told them many times that I don't drink coffee. Observation revealed Resident #101 raised her sheets up and down very fast, irritated, looked at Staff T-LPN and said in in her language, How many times do I have to tell you that I do not drink coffee. Observation revealed Staff T-LPN attempting to said words in the resident's language, but the resident was not able to understand her. Further observation revealed there was no communication board noted in the room. On 01/19/22 at 10:13 AM, observation revealed Resident #101 in bed being assisted with breakfast by the Speech Therapist (ST) and the Occupational Therapist (OT). During an interview, the ST stated the resident is being evaluated because she had a visual deficit. During an interview, the ST stated she spoke a little of the resident's language. On 01/19/22 at 4:20 PM, an interview was conducted with Staff L-CNA. She stated she works day shift (7:00 AM to 3:00 PM) and does the residents' morning care, assists them with their meals, turns them every 2 hours if needed, changes their adult brief and checks their bottom every 2 hours for any skin opening. Staff L-CNA stated that today (01/19/22), it was the first time she was assigned to take care of Resident #101. Staff L-CNA was asked if she spoke the resident's language and stated she (herself) understood it a little and added that the resident understood a little English. Observation revealed Staff L-CNA asked the resident if she was hungry in English. Resident #101 responded I don't understand in her language. Observation revealed Staff L-CNA attempted to say a word in the resident's language and Resident #101 stated in her language that she did not know what she (Staff L-CNA) was saying. Staff L-CNA was asked about a communication board to help with the language communication and stated that they used that sometime, but she did not see one in her room. On 01/19/22 at 4:44 PM, a joint interview was conducted with Staff N-LPN and Staff F, a Registered Nurse (RN). Staff N-LPN stated she used the basic language of Resident #101, but the resident says dolor (pain) and never had complained pain to her. She added that the resident was on scheduled medications for pain. Staff N-LPN stated that if she was thirsty, she said agua (water) and added that they usually found someone who spoke the language. She added they had a therapist and a CNA that spoke the resident's language. Staff N-LPN stated Resident #101 did not have a [language] speaking CNA assigned to her. Observation from 01/18/22 to 01/20/22 revealed Resident #101 did not have a [language] speaking CNA assigned to her. On 01/19/22 at 4:50 PM, a side-by-side check of the resident sacrum area and right heel was conducted with Staff F-RN and the Director Of Nursing (DON). During the check, the resident was asking in [language] what are you going to do. The DON and Staff F-RN were not able to communicate with the resident in her language. Observation revealed the resident looked frightened, resisted to be turned and stated in [language], I am going to fall. They asked the surveyor to translate. Observation revealed the lack of a communication board in the resident room. On 01/19/22 at 5:09 PM, during an interview, the DON and Staff F-RN were informed that Resident #101 was rubbing her stomach area while Staff L-CNA and Staff M-CNA were turning her approximately one hour ago and they did not acknowledge the resident protective body movements and were not able to communicate with the resident, and they did not have a communication board. On 01/20/22 at 10:34 AM, an interview via a telephone call was conducted with Resident #101's representative. The representative stated that Resident #101 had been at the facility for over a month and that she would be staying at the facility. He added the resident needed care that they can't provide. He helped the resident with meals because she can't see, and her appetite was poor which he told the nurses on 01/18/22. He stated he had told the nurses that he was worried that they can't communicate with her because she did not speak English and added she understand very few words in English. He added that Resident #101 gets frustrated and nervous because of the language barrier. On 01/21/22 at 7:17 AM, an interview was conducted Staff O-RN. He stated he was a fulltime employee and works the night shift. Staff O-RN was asked how he communicated with Resident #101 and assessed her pain. He stated that the resident usually sleeps all night and will not be disturbed. On 01/21/22 at 10:37 AM, an interview was conducted with Staff T-LPN. She stated that some residents had a communication book but did not know if Resident #101 had one. On 01/21/22 at 10:56 AM, an interview in the resident's language was conducted with Staff G-RN. He stated he worked in the South wing and spoke fluently [language] and when they need a translator, they will call him. Staff G-RN stated he recalled Resident #101 because she had been admitted to his wing and only spoke her language. Staff G-RN stated he was away for two weeks and was not aware if the facility had a translation service. On 01/21/22, at 2:15 PM during an interview, the DON was asked about the facility's ways to communicate with residents who did not speak English. The DON stated that they had Google translate and staff members that speak other than English like Creole and Spanish. She stated she had not heard any resident complaints regarding language barrier. The DON stated Resident #101 has now a communication package in her room. The DON was apprised of observations during staff members and Resident #101 interaction and the staff were not able to understand the resident and did not offer a communication board or use other ways to understand her. The DON was apprised that the resident was irritated and frustrated because she did not understand what they were saying. On 01/21/22 at 2:34 PM, a side-by-side review of Resident #101 care plan was conducted with the DON. The review revealed the lack of a care plan related to communication due to language barrier. 01/21/22 at 3:30 PM, an interview was conducted with the facility's contracted Clinical Reimbursement Consultant (CRC). She stated she was covering for the facility's CRS. She stated that if a communication barrier was not identified during the assessment, a communication care plan will not be initiated.

Based on observations, interviews, and record review, the facility failed to follow the approved menu and approved portions for 15 residents on pureed diets, which included 10 sampled residents (Resident #50, Resident #83, Resident #89, Resident #49, Resident #24, Resident #105, Resident #31, Resident #96, Resident #70, Resident #57). The census at the time of the survey was 117. The findings included: Review of the approved lunch menu for pureed diets for 01/19/22 documented that the following was to be served: #12 scoop (2.5 ounces) of pureed brown sugar coffee cake and #8 scoop (4 ounces) of pureed oatmeal. During an observation of the breakfast tray line conducted on 01/19/22 at 7:25 AM, accompanied by the Certified Dietary Manager (CDM), it was noted that pureed brown sugar coffee cake had been substituted for pureed bread. When asked about the pureed brown sugar coffee cake, Staff B-Cook, stated, I wasn't sure if I would have enough pureed cake so I substituted with pureed bread. It was further noted that a #16 scoop (2 ounces) was used to plate the pureed bread. This showed that residents on pureed diets were receiving a 2 ounce portion of pureed bread instead of a 2.5 ounce portion. The CDM acknowledged that the approved portion sizes for the pureed diets were not being followed and stated that a #12 scoop should have been used. When asked about the pureed oatmeal, Staff B-Cook stated that grits were to be served instead. When asked why grits were being served instead of the pureed oatmeal, the CDM acknowledged that the approved pureed menu was not followed and stated, I don't know why she did that. I'm packing my sh*t up and leaving. Review of the facility diet census dated 01/19/22 documented that 15 residents were on pureed diets, which included Resident #50, Resident #83, Resident #89, Resident #49, Resident #24, Resident #105, Resident #31, Resident #96, Resident #70, Resident #57.

Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: A. During the initial tour of the kitchen conducted on 01/18/22 at 8:50 AM, accompanied by the Certified Dietary Manager (CDM), the following were noted: 1. A face shield was observed on the floor of dishwashing area. When asked, the CDM was unable to specify if the face shield was used/dirty. 2. A personal phone charging cable was observed on top of the food preparation table in the back area. 3. A sanitation bucket filled with sanitizing solution was stored next to containers of brown sugar and thickener powder. The CDM acknowledged that chemicals should not be stored on the same shelf as food products. 4. The steamer was leaking water onto the floor. The CDM stated that it must have started leaking today. 5. One light bulb in the food preparation area was out. The CDM stated that it must have gone out today. 6. One light bulb in back food preparation area was out. The CDM stated that it must have gone out today. 7. In the dry storage area, one 6.63 pound can of diced beets was dented. 8. The reach-in freezer was observed with plastic garbage (empty Gatorade bottle and plastic lids), yellow residue, and red residue. 9. In the walk-in refrigerator, about 7 boxes of food were stored directly on the floor. The CDM stated that the boxes were delivered yesterday and that he had not had a chance to put them away. 10. The floor underneath the shelving in the walk-in refrigerator was observed with plastic garbage and a moderate amount of brown residue. 11. In the walk-in freezer, about 8 boxes of food were stored directly on the floor. The CDM stated that the boxes were delivered yesterday and that he had not had a chance to put them away. 12. In the walk-in freezer, one bag of sausage patties and one bag of waffles were missing labels identifying the use by dates. B. During an observation of the breakfast tray line conducted on 01/19/22 at 7:25 AM, the following was noted: At the request of the surveyor, the CDM calibrated the facility's digital thermometer to check the temperature of the hardboiled eggs in the hot holding unit. The temperature test revealed that the hardboiled eggs were at 127 degrees Fahrenheit (F). The CDM acknowledged that the hardboiled eggs were not at the regulatory temperature of 135 degrees F or above. He further stated that the hardboiled eggs needed to be removed from the breakfast tray line.