**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 53 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Chronic atrial fibrillation, and hypertensive chronic kidney disease with stage 1 through 4. Her most recent Minimum Data Set assessment, dated 8/05/24, revealed a Brief Interview for Mental Status exam score of 13 out of 15, which indicated intact cognition. On 8/12/24 at 11:55 AM, resident #1 was lying on her bed with the overbed table across her. A white plastic bin on the table contained personal items, including Hydrocortisone 1% cream. Resident #1 stated she had applied the cream herself for over one year to her private area. On 8/12/24 at 5:21 PM, the East Wing Unit Manager acknowledged two tubes of Hydrocortisone cream, were present on the resident's bed. The East Wing Unit Manager said the resident's husband had been to visit today, and she thought he must have brought the medications in. She explained the resident had an order for cream because she had a rash between her legs. The East Wing Unit Manager acknowledged the nurse should apply the treatment, as the resident was not approved or assessed to have medications at the bedside. On 8/12/24 at 5:27 PM, the Director of Nursing (DON) stated, A resident must be assessed for self-administration [of medications], and if appropriate, then we get physician orders for the resident to perform the treatment. The DON acknowledged those protocols were not in place for resident #1. A review of the facility's policy and procedure for self-administration of Medication program dated 3/2/19 read, It is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident was free from physical restraint for 1 of 1 resident reviewed for restraints, of a total sample of 53 residents, (#65). Findings Resident #65, an [AGE] year-old- female was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was admitted to Hospice Services on 1/17/24. Her diagnoses included convulsions, cerebral atherosclerosis, repeated falls, major depressive disorder, and generalized muscle weakness. Review of the resident's physician orders revealed an order dated 3/12/21 for bilateral upper grab bars to enable positional changes, bed mobility or to determine bed perimeters. The resident's quarterly Minimum Data Set assessment with Assessment Reference Date of 8/02/24 revealed the resident was rarely/never understood and was dependent on staff assistance with activities of daily living, and mobility. A Side Rail Evaluation dated 10/20/22 indicated the recommended type of side rail(s) for resident #65 were left and right upper side rails at all times when the resident was in bed. On 8/12/24 at 12:12 PM, and on 8/13/24 at 9:40 AM, resident #65 was lying in bed with bilateral upper, and bilateral lower bed rails up. On 8/13/24 at 10:48 AM, Registered Nurse (RN) A, confirmed he was the resident's assigned nurse. He stated resident #65 was at risk for falls, and four side rails were implemented approximately four months ago when the resident started on Hospice services. RN A stated the use of the four side rails were implemented because of a request by the resident's family. On 8/14/24 at 9:39 AM, resident # 65 was lying in bed positioned to her left side facing the bathroom. The resident's eyes were open, but there was no response from the resident when spoken to. Bilateral upper and lower side rails were up. On 8/14/24 at 9:59 AM, the [NAME] Wing RN/Unit Manager (UM) stated resident # 65 was on Hospice services, and her bed was provided by Hospice. The UM stated she observed the four side rails on resident #65's bed on 8/13/24. She stated she did not know why the resident had four side rails in place, and recalled she called the Hospice nurse on 8/13/24 to establish the reason for the four side rails. The RN/UM said documentation in the resident's clinical records was for two side rails. On 8/14/24 at 12:18 PM, Certified Nursing Assistant (CNA) C stated that approximately a month ago she noted the resident in bed with four side rails up. The CNA said she was questioning the use of the four side rails, but was told it was a hospice bed, so she did not dig any further. On 8/14/24 at 12:56 PM, the Director of Nursing (DON) stated the [NAME] Wing UM made her aware of the four side rails being used on resident #65's bed. The DON said the bed was a hospice bed, and the [NAME] Wing UM was trying to call Hospice to find out why that bed was sent to the facility. She said four side rails were considered restraints, and if a resident was to have four side rails up, the Interdisciplinary Team (IDT) had to assess, and identify the reason for the four side rails. She stated if use of the side rails falls in the category of restraints, the family would be notified, and asked to sign a consent for the use of the four side rails. The DON stated she knew the hospice bed was delivered for the resident, but she did not know that four side rails were being utilized at the facility. The DON reviewed the resident's clinical records and acknowledged there was no documentation regarding the use of four side rails, or a consent for the use of the four side rails identified. She stated a side rail release consent dated 3/06/20, did not address the use of four side rails. Review of the Side Rails Informed Consent and Release dated 3/06/20 revealed the consent did not address the use of four side rails, and the document read, I understand that the side rails are used as a mobility aid and not as a physical restraint. Documentation on the form revealed verbal consent via telephone was obtained from the family. The DON confirmed no additional consent was obtained when the resident received the bed from Hospice, an assessment for the use of the four side rails was not identified, and there was no documentation in the resident's clinical records regarding the request of the family for the use of four side rails. On 8/14/24 at 1:27 PM, the [NAME] Wing RN/UM stated if family requested four side rails, an assessment for the side rails was required. The RN/UM stated she was aware four side rails were considered restraints, but explained she was not aware resident #65 had four side rails in place until made aware by RN A on 8/13/24. Additional information provided to the field office status post exit from the survey revealed a restraint evaluation was completed for the resident on 8/19/24. The facility's policy Freedom from Physical and Chemical Restraints issued/revised 3/02/19 read, When the use of restraints is indicated, the facility will use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of abuse to State agencies as required for 2 of 5 residents reviewed for abuse, of a total sample of 53 residents, (#110 and #276). Findings: 1. Review of resident #110's medical record revealed she was admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection in the bone), pressure ulcer of the sacrum and bipolar disorder. Review of resident #110's admission Minimum Data Set assessment with Assessment Reference Date of 7/17/24 revealed a Brief Interview for Mental Status score of 15 which indicated intact cognition. The assessment showed resident #110 required substantial assistance with toileting and personal hygiene. The assessment indicated resident #110 did not reject evaluation or care needed to achieve her goals for health and well-being. On 8/13/24 at 10:21 AM, resident #110 stated 2 Certified Nursing Assistants (CNAs) flipped out on her because she had diarrhea, and she had to be cleaned multiple times. She explained she apologized to the CNAs and told them she was taking an antibiotic which caused the diarrhea. With tears in her eyes, resident #110 indicated the CNAs were disrespectful to her and added the way they cleaned her was abuse because they were very rough. She shared she told her assigned nurse, but she could not identify the CNAs. She stated her nurse said she was going to report it to upper management. She recalled the nurse even told her they were handling it but did not tell her how. She stated the CNAs seemed to have a chip on their shoulders. On 8/13/24 at 12:20 PM, Registered Nurse (RN) O stated resident #110 needed a lot of support. She recalled resident #110 expressed concerns regarding the diarrhea while taking antibiotics. She explained the diarrhea was ongoing and, sometimes, she had multiple episodes during a shift. She mentioned resident #110 got discouraged and sad when calling the CNAs often because she needed toileting assistance. RN O indicated resident #110 mentioned some CNAs had different attitudes toward her, rolling their eyes or answering disrespectfully. She indicated she told resident #110 she appreciated she told her because there were residents who could not speak for themselves, so she was not only speaking for herself but helping others. She stated she sometimes would address concerns directly with CNAs, but she did not this time and took it, up the chain of command. She indicated she reported resident #110's abuse allegations to her supervisors but did not recall when exactly. RN O mentioned resident #110 told her CNAs were rude to her, stared at her, or made comments we shouldn't say. RN O recalled resident #110 was crying while sharing this with her, because her feelings were hurt. Review of the Abuse Log for July and August 2024 did not show a report for resident #110. On 8/13/24 at 12:34 PM, the Administrator stated she was not aware of any abuse allegations for resident #110. She indicated her expectation was to be notified by staff when they received any abuse allegation from residents. 2. Review of resident #276's medical record revealed she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, anemia and depression. Review of resident #276's medical record revealed Progress Notes dated 8/05/24 and 8/06/24 which showed she was alert and oriented to person, place and time. On 8/12/24 at 12:54 PM, with her husband at bedside, resident #276 said she was physically abused last Wednesday at approximately 3:00 AM. She explained she was not asked if she could go to the bathroom for an urine sample but was told she had to. Resident #276 shared her assigned nurse was, yanking her hands around and told her, If you do not give me a urine sample, I know how to get it. She indicated the nurse collected the urine sample by inserting a catheter into her urethra without her consent, forced it, and it hurt her. They indicated after the incident they spoke with the Social Services Director. Resident #276 repeated she was grabbed by her arm and was told to get up from the bed by the nurse and was taken to the bathroom for a urine sample. She stated when she could not urinate, the nurse told her she would get the urine sample another way. Review of a Resident Concern/Grievance Form dated 8/07/24 revealed it was filed by resident #276's spouse due to a care concern with the CNA and nurse. The follow-up section of the document included a hand-written statement entered by the Assistant Director of Nursing (ADON) which read, ADON and Unit Manager spoke with resident and spouse about care concern, resident request that she don't [sic] want that nurse and CNA to take care her [sic]. ADON removed CNA and nurse to [sic] that assignment and offer to resident to be move to another room or she wants to start a reportable. Resident verbalized NO she is fine. Just to remove that [sic] staff the [sic] assignment. On 8/12/24 at 2:37 PM, the Social Services Director indicated she was the Grievance Officer, and all grievances were discussed in morning or afternoon meetings. She explained resident #276's husband came to her office last week and reported a care issue concern. She mentioned she did not know the extent as it was assigned to nursing and handled by their ADON. On 8/12/24 at 2:54 PM, the ADON joined the interview with the SSD and confirmed she handled the grievance filed by resident #276's husband on 8/07/24. She read the follow-up section she wrote on the grievance form and said she and the Unit Manager (UM) spoke with the resident and her spouse about a care concern that day. She stated resident #276 did not want the nurse and CNA taking care of her. The ADON stated she removed the CNA and nurse from her assignment and offered resident #276 to move into another room or if she wanted to start a reportable. She indicated resident #276 verbalized no, she was going to be fine if the staff was removed from her assignment. When asked why she offered a reportable to resident #276, the ADON stated resident #276 told them the CNA and the nurse were rough when trying to obtain a urine sample. She recalled resident #276 said she felt hurried to get the specimen. She explained after talking to resident #276, she called the nurse who explained she had to collect the urine sample using a straight catheter because the resident could not urinate, but she asked for permission from the resident. The ADON stated she explained the reportable process to the resident which included contacting law enforcement, and the SSD stated based on this, resident #276 did not want a reportable done. The ADON pointed out to resident #276 the way she said the nurse or CNA was rough with her, they would have to investigate deeper. The ADON stated resident #276 told her the CNA grabbed her by her shoulder, to hurry her to pee. The ADON stated she spoke to the assigned CNA who indicated she was never in the room with the nurse during the urine sample collection. The ADON stated the grievance was discussed during their management meeting. The SSD stated the grievance was closed as resolved because the ADON investigated the concern, and the resident was satisfied with the removal of the staff. The ADON stated the resident and her husband, said no all the time, she mentioned reporting, so she did not report it to the Administrator (NHA). The ADON said she did not know they had to do a reportable until today when the Administrator informed her reporting was required. She stated she thought if the resident or family did not want to proceed, they did not have to do it. On 8/12/24 at 3:09 PM, the Administrator stated she met with resident #276 and her husband that day, before she was discharged home. The NHA indicated resident #276 told her she was treated roughly one-night last week while a nurse tried to collect a urine sample. The Administrator stated they initiated an investigation, contacted Law Enforcement and the Department of Children and Families (DCF). She stated both resident #276 and her husband said they did not want to report this incident, but she explained they had to do it. She stated they provided a description of the staff involved and the nurse was suspended pending investigation. She explained if the allegation was substantiated the staff was reported to Board of Nursing. She indicated the resident's safety was most important, but she was not affected as she was discharged today. The NHA read the grievance filed by resident #276's husband on 8/07/24 and stated she had understood it as a customer service issue. She explained if abuse was suspected staff would call her, but she did not receive a phone call last week while she was out of the facility. She stated the Director of Nursing (DON) told her she was not aware of this until today. She explained she had 2 hours to report allegations of abuse to the physician, the resident's representative, Law Enforcement, DCF and to submit an immediate report to the State Survey Agency. On 8/12/24 at 3:39 PM, Registered Nurse (RN) Q in broken English stated resident #276 had a physician order for a urinalysis and culture and the collection needed to follow a sterile procedure. She indicated she explained the procedure and resident #276 agreed. She stated she asked resident #276 if she could go to the bathroom which she did. She mentioned she tried to collect the urine sample in the bathroom, but resident #276 was unable to urinate so she went back to bed. RN Q stated she told resident #276 to relax once back in bed and she waited a few minutes for resident #276 to calm down. She stated she told resident #276, procedure, catheterize urine and cultivo urinary, me catheterize, I can while showing her the equipment she was going to use. She indicated resident #276 responded yes more than once. RN Q stated she, Did not even touch her much, because the urine came out fast. I almost did not touch her. She recalled during morning report she was sitting at the nurse's station when resident #276's husband was upset after his wife stated she was handled roughly, and was catheterized without her consent. She indicated she tried to explain to him what had happened, but he would not listen. She recalled the ADON called her later that day with questions about this resident. On 8/15/24 at 2:03 PM, the East Wing UM recalled the morning of 8/07/24 resident #276's husband brought up a concern to her assigned nurse and the nurse took him to the nurse's station. The UM stated resident #276's husband mentioned the nurse last night, got a foley (catheter) in his wife and she did not need to do that. The UM stated the husband explained his wife was uncomfortable and asked why she was not taken to the bathroom. She indicated she went to resident #276's room with the ADON to speak with her and her husband. She explained she told them there was a physician order for a urine sample and resident #276 could not urinate so the nurse asked if she could collect a sample with a catheter and resident #276 approved. The UM said the husband clarified what his wife told him, she went to the bathroom, and she could not urinate, and the nurse just collected the sample using the catheter even though resident #276 would have been able to urinate. The UM indicated resident #276, could not really understand the nurse, I think it was miscommunication. She recalled resident #276 's husband requested RN Q not be assigned to his wife again. She stated the ADON and SSD were part of the interview, and one of them asked if they wanted the facility to do, a reportable. The UM said this was done, when there is an allegation of abuse or neglect, when the family thinks they were not taken care of, even if they do not want it, they offer that as an option. Review of the facility's Abuse, Neglect, Exploitation and Injuries of Unknown Origin Policy dated 3/01/17 revealed alleged violations involving abuse, Must be immediately reported to the facility administrator and other officials in accordance with state and federal law. The document indicated the facility would thoroughly investigate and document each alleged violation and ensure all alleged violations involving abuse were reported no later than 2 hours to the administrator and other officials (including the State Survey Agency) in accordance with State Law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 2 of 2 residents reviewed for hospitalizations, of a total sample of 53 residents, (#121 and #123). Findings: 1. Resident #121 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type 2 diabetes, angina, secondary malignant neoplasm of bone, malignant neoplasm of bladder, acute kidney failure and benign prostatic hyperplasia with lower urinary tract symptoms. Review of resident #121's medical record revealed he was scheduled to be discharged home on 6/08/24. Review of progress notes revealed resident #121 was admitted with an indwelling catheter on 6/02/24. The catheter was removed on 6/04/24. On 6/07/24, staff observed a urinal in resident #121's bathroom which contained bloody urine. Resident reported he started to see blood in his urine the day before but did not report it as he was not in pain. Nursing contacted resident #121's physician who ordered the resident be sent to the hospital immediately for evaluation and treatment. The facility provided a copy of the Notification of Transfer or Discharge form for the hospitalization. The form was not signed by resident #121 or his representative. The resident discharged home from the hospital and did not return to the facility. 2. Resident #123 was admitted to the facility on [DATE] with diagnoses including pancreatic cancer, spinal stenosis, chronic obstructive pulmonary disease, congestive heart failure, sleep apnea, and anxiety. Review of resident #123's medical record revealed she was hospitalized on [DATE]. A progress note dated 5/20/24 indicated the resident was noted to be very sleepy with non-reactive pupils and responded only to touch stimulus. The facility received an order for STAT (immediate) labs. Another progress note dated later on 5/20/24 noted the resident to have a blood pressure of 88/60, pulse 57 beats per minute and oxygen saturation level at 93%. The facility received a new order to transfer resident #123 immediately to the hospital for altered mental status and abnormal vital signs. The resident's representatives came in shortly after the transfer and removed her belongings from the facility. The facility provided a copy of the Notification of Transfer or Discharge form for the hospitalization. The form was not signed by resident #123 nor her representative. On 8/15/24 at 1:07 PM, the Social Services Director stated nursing completed the notice of Transfer or Discharge forms for residents who discharged to the hospital. The forms were then given to social services and they sent them to the Ombudsman's office. The Social Services Director clarified she only sent them to the Ombudsman office. She explained she was not responsible for sending the notification to residents or their representatives. On 8/15/24 at 2:50 PM, the Assistant Director of Nursing (ADON) acknowledged her signature was on each of the Notice of Transfer or Discharge forms. She explained nursing completed the forms, sent a copy in the hospital paperwork and gave the form to social services. The Director of Nursing was present and stated she did not know who provided a copy of the form to the resident or resident's representative. The facility was unable to provide proof the resident or resident's representative were notified in writing of the reason for transfer. On 8/15/24 at 2:10 PM, the Executive Director stated she thought social services sent a copy of the Notice of Transfer or Discharge form to the resident's representative if no one was here to sign the form. She explained she was not aware the forms were not being mailed out. The Executive Director clarified the expectation was the resident or resident's representative was provided a copy of the Notice of Transfer or Discharge form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross Reference F695 3. Resident #64 was admitted to the facility on [DATE] with diagnoses that included dysphagia, obstructive sleep apnea, acute respiratory failure, shortness of breath, and encounter for palliative care. On 8/12/24 at 11:47 AM, resident #64 was observed in bed wearing a nasal cannula connected to an O2 concentrator set at 2 liters per minute (LPM). He stated that he used oxygen all the time and was received hospice care. The Quarterly MDS assessment dated [DATE], revealed resident #64 was cognitively intact, was dependent on staff for all activities of daily living (ADLs), had several respiratory diagnoses, and received hospice services. The assessment incorrectly reflected O2 therapy was not provided. A review of resident #64's medical record revealed no physician's order for O2. Review of resident #64's medical record revealed a hospital record dated 4/25/24 showed the resident had a diagnosis of O2 dependence, and used 2 LPM of O2 via nasal cannula. Resident #64 had a care plan for O2 therapy initiated on 6/09/23. Interventions included the use of O2 via nasal cannula at bedtime per resident request as ordered. On 8/15/24 at 11:03 AM, MDS coordinator #1 and MDS coordinator #2, both Licensed Practical Nurses (LPNs) stated they were both responsible for completing the MDS assessments. They confirmed resident #64 had been on O2 since he was admitted to the facility, nor was there an order in the medical record for O2 therapy. They explained it was therefore missed during the last Quarterly MDS assessment. Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for tracheostomy care for 1 of 1 resident, (#86), failed to accurately assess for insulin administration for 1 of 1 resident, (#15), and failed to ensure assessment accurately reflected oxygen (O2) therapy for 2 of 2 residents reviewed for O2 therapy, (#64, and #95), of a total sample of 53 residents. Findings: 1. Resident #86 was admitted to the facility on [DATE] with diagnoses that included nontraumatic brain bleed, respiratory failure, and partial paralysis. Review of the MDS admission modification assessment with an assessment reference date (ARD) of 8/05/24 revealed resident #86 was, rarely or never understood. The assessment indicated the resident did not have tracheostomy care. A review of resident #86's medical record revealed a physician order dated 7/29/24 to obtain oxygen saturation every shift and, as needed, notify the physician. The order continued for staff to cap the tracheostomy, uncuffed as tolerated. Another order dated 8/01/24 read, tracheostomy-provide tracheostomy care every day and as needed. Change tracheostomy ties daily and as needed. On 8/15/24 at 1:35 PM, MDS Coordinator 1 reviewed resident #86's MDS assessment dated [DATE] and acknowledged she incorrectly coded section O for tracheostomy care. She acknowledged the MDS assessment should reflect the resident's status at the time of the assessment. The MDS Coordinator explained the assessment should include a chart review of the orders, all progress notes, and resident observation/interview during the assessment look-back period. 2. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis, pulmonary embolism, and cardiomegaly. A review of the MDS Quarterly assessment with ARD 5/23/24 revealed resident #15 had a Brief Interview for Mental Status (BIMS) score of 0/15, which indicated the resident was severely cognitively impaired. The assessment showed the resident received insulin injections on three days during the last seven days or since admission or reentry if less than seven days. A review of resident #15's medical record revealed no physician orders or medication administration for insulin administration. On 8/15/24 at 1:35 PM, MDS Coordinator 1 reviewed resident #15's MDS and acknowledged she incorrectly coded section N. She again indicated the MDS assessment should reflect a picture of the resident at the time of the assessment. The MDS Coordinator stated the assessment should include a chart review of the orders, all progress notes, and resident observation/interview during the assessment look-back period. Review of the facility's policies and procedures Resident Assessment (RAI) dated 3/02/19 read, It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. 4. Resident # 95 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, asthma, malignant neoplasm bronchus or lung, cough, and dependence on supplemental oxygen. A physician order dated 7/10/24 was for continuous O2 at 3 LPM via nasal cannula for shortness of breath. The resident's admission MDS assessment with ARD of 7/16/24 revealed the resident's cognition was intact with a BIMS score of 15 out of 15. Section O for O2 therapy while a resident was not assessed. On 8/15/24 at 1:33 PM, MDS Coordinator 1 stated MDS assessments were completed by doing a seven day look back of the resident's clinical records, observation of the resident, interview of the resident if the resident's cognition was intact, if not the family would be interviewed, interview of nurses, and Certified Nursing Assistants (CNAs). MDS Coordinator 1 reviewed the resident's admission MDS assessment with ARD of 7/16/24 and confirmed O2 therapy was not assessed. She reviewed the resident's physician orders, which revealed an order dated 7/10/24 for O2 therapy at 3 LPM. The LPN MDS Coordinator confirmed the MDS assessment dated [DATE] was not accurate. On 8/15/24 at 1:35 PM, the Regional MDS Specialist stated the facility did not have a policy regarding accuracy of assessment. She said they followed the guidelines outlined in the RAI Manual. The Centers for Medicare & Medicaid Services Long term Care Facility Resident Assessment Instrument effective October 2019 on page 2-41 read The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 4 residents reviewed for PASARR, of a total sample of 53 residents, (#97). Findings: Resident #97 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, diabetes mellitus, unspecified psychosis, and depression. A review of the Minimum Data Set admission assessment with assessment reference date of 6/12/24 revealed resident #97 had a Brief Interview for Mental Status score of 13, which indicated she was cognitively intact. The document stated her active diagnoses included depression (other than bipolar) and psychotic disorder (other than schizophrenia). Review of resident #97 's electronic medical record revealed the diagnoses of unspecified psychosis with an onset date of 6/05/24 and major depressive disorder also with an onset date of 6/05/24 The record contained a Level I PASARR screening form dated 6/03/24 which did not indicate resident #97 had a mental illness (MI) or suspected MI. The record did not contain a Level II PASARR screening form. On 8/15/24 at 1:05 PM, the Director of Nursing (DON) stated that new admissions from the hospital should have a level l PASARR Screening completed by the hospital before admission to the facility. She explained when psychiatry services made a new diagnosis, the PASARR should be updated. The DON reviewed the Level I PASARR and current diagnoses for resident #97. The DON acknowledged the PASARR did not reflect the resident 's current MI diagnoses of unspecified psychosis and major depressive disorder. The DON stated she did not know why the diagnoses were not listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #42 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, muscle weakness, paraplegia, adjustment disorder with depressed mood and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed resident #42 had a Brief Interview for Mental Status score of 15 out of 15, meaning he was cognitively intact. The assessment indicated he did not exhibit any rejection of care behaviors and was dependent on staff for toileting, personal hygiene, dressing, and mobility. Review of resident #42's physician's orders dated 3/23/23 revealed an order by Occupational Therapy (OT) for a right palm cone to be worn daily as tolerated and removed for meals, activities, and activities of daily living. On 8/12/24 at 11:59 AM, resident #42 was observed in his room sitting up in his wheelchair. His right hand was closed, and he stated he was unable to open the right hand without assistance. Resident stated he was not receiving OT, and did not have a palm cone. A blue palm cone was observed on his nightstand and the resident explained he no longer needed to wear it. Review of the OT evaluation and plan of treatment with a certification period from 3/23/23 to 4/21/23 revealed resident #42 was referred for OT by nursing due to a new onset of weakness, reduced functional endurance, and increased fisting posture in the right hand. The note indicated the new conditions placed the resident's right palm at risk for wounds. Further review of OT treatment notes dated 3/23/23 revealed a short-term goal that resident #42 would tolerate the right palm cone daily for 3 hours without signs or symptoms of adverse effects to reduce risk of skin breakdown in the palm of his hand. The document indicated resident #42 tolerated the palm cone for one hour as of 3/23/23. On 8/15/24 at 10:37 AM, the Director of Rehab (DOR) stated resident #42 was discharged from OT on 4/21/23 with an order for restorative nursing care and to continue with right palm cone to prevent skin break down. He explained the DON oversaw the restorative program, and she was responsible for communicating with the MDS coordinator to create the care plan. The DON would also be responsible for communicating with the west wing UM for the new order. Resident #42 was compliant with wearing the palm cone while receiving OT services, but the DOR said that sometimes resident #42 would refuse to wear it. He explained that it was important for the resident to wear the palm cone to prevent skin breakdown. On 8/15/24 at 10:50 AM, the west wing UM stated that resident #42 did not have a palm cone because his name was not on the list of residents with palm cones. She said that she received a list of residents with palm cones from the DON and it would be placed at the nurse's station. She looked in resident #42's medical record and confirmed there was an order for a palm cone dated 3/23/23. The DON stated that resident #42 refuses medical care sometimes. She was unsure why the DON had not added the resident to the palm cone list. The west wing UM stated that the DON was the person responsible for the restorative program and for communicating with the MDS coordinators. [NAME] wing UM explained that it was important for resident #42 to use the palm cone to prevent skin breakdown. Review of resident #42's medical record revealed that there were no care plans addressing restorative services or palm cone usage. On 8/15/24 at 11:03 AM, MDS coordinator #1 and MDS coordinator #2, both Licensed Practical Nurses (LPNs) stated that they are both responsible for creating care plans. The stated that they were not aware resident #42 had an order for a palm guard and they did not find a care plan for it. MDS coordinator #1 explained that when a resident was recommended for a palm cone or restorative services, therapy would communicate with DON. The DON would then communicate with the MDS office so that a care plan could be created. If the resident was refusing care that would be added to the care plan along with interventions addressing the behavior. On 8/15/24 at 01:24 PM, an interview with the DON revealed that she was aware that resident #42 had an order for the palm cone to the right hand. She stated that she had a conversation with the resident on 8/15/24 and he did not want to wear the palm cone. She confirmed that that there was no documentation that showed resident declined the palm cone since 3/23/23. She confirmed that she oversaw the restorative program and was responsible for communicating with the MDS coordinators to create a plan of care for the palm cone. Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to the collection of an urine specimen for 1 out of 5 residents reviewed for abuse, (#276), and for limited range of motion and contracture care, for 1 of 2 residents reviewed for limited range of motion and positioning, (#42), out of a total sample of 53 residents. Findings: Cross Reference F609 1. Review of resident #276's medical record revealed she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, anemia and depression. Review of resident #276's medical record revealed Progress Notes dated 8/05/24 and 8/06/24 which showed she was alert and oriented to person, place and time. On 8/12/24 at 12:54 PM, resident #276 stated a nurse collected a urine sample using a catheter without her consent, through force, which hurt her. Resident #276 indicated she was taken to the bathroom, but she was unable to urinate at that time. She explained when she could not urinate, the nurse told her she would get the urine sample another way and collected the specimen using a catheter. Review of resident #276's physician orders revealed an order dated 8/05/24 which read, U/A C&S (urinalysis and culture and sensitive). The Treatment Administration Record (TAR) showed this was completed on 8/05/24. There was no evidence of a physician order to collect the U/A via urinary catheterization in the medical record. Urinary catheterization is the aseptic process of inserting a sterile hollow pliable tube into the urethra to facilitate urine drainage . Urinary catheters should be inserted only when medically [necessary] . Document attempts at and inadequacy of alternative methods for bladder elimination prior to insertion of the indwelling catheter . Urinary catheters should be placed only under the direction of a physician order, (Retrieved from https://www.ahrq.gov/ on 8/22/24). On 8/12/24 at 3:39 PM, Registered Nurse (RN) Q in broken English stated resident #276 had a physician order for a urinalysis and culture and it needed to be a sterile procedure. She explained she told the resident the procedure and resident #276 agreed. She stated she first asked resident #276 if she could go to the bathroom and she tried to collect the urine sample in the bathroom, but resident #276 was unable to urinate at that time. She explained the resident returned to her bed and she told her to relax. She waited a few minutes for resident #276, to calm down. She stated she told resident #276, Procedure, catheterize urine and cultivo urinary, me catheterize, I can, while showing her the equipment she was going to use. She indicated resident #276 responded yes more than once. RN Q stated she, Did not even touch her much, because the urine came out fast. I almost did not touch her. She recalled resident #276's husband approached her during morning report at the nurse's station. She stated he was upset and said his wife told him she was handled roughly, and was catheterized without her consent. On 8/15/24 at 2:03 PM, the East Wing Unit Manager (UM) recalled the morning of 8/07/24 resident #276's husband brought up a concern that last night his wife's nurse catheterized his wife without needing to. The UM recalled the husband told her his wife was uncomfortable and he asked why she was not taken to the bathroom for the sample. The UM indicated she went to resident #276's room with the Assistant Director of Nursing (ADON) to speak with them. She explained she told them there was a physician's order for the urine sample and since resident #276 could not urinate, the nurse asked if she could collect the sample with a catheter instead. The UM told her resident #276 had approved of the procedure. The UM indicated resident #276, Could not really understand the nurse, I think it was miscommunication. The UM stated when she reviewed the TAR she noticed there was no documentation of RN Q's collection of the U/A in resident #276's medical record. She confirmed there was no physician order for the alternate collection procedure, which was required for the urinary catheterization. She validated the Lab log showed urine was collected on 8/07/24 for resident #276's and her assigned nurse was RN Q. On 8/15/24 at 5:57 PM, the Director of Nursing (DON) stated she was unaware RN Q did not document she had collected the urine specimen without a new order. She confirmed RN Q did not have an order to collect the urine specimen using a straight catheter. She explained their process for collection of U/A which was collected by the night shift nurses. She confirmed there was no evidence the urine was collected on 8/05/24 as documented in the TAR. She validated there was no evidence the urine sample was sent to the laboratory before 8/07/24. She explained RN Q was required to obtain a new physician's order to collect the urine specimen using a straight catheter and repeated there was no order to recollect the urine sample and no order for straight catheter. She stated the assigned nurse on 8/05/24 should have never signed the U/A completed if not done. She stated RN Q should have verified the orders and notified the physician to obtain a new order. The DON validated RN Q performed the catheterization without a physician's order. Review of the facility's policy and procedures titled Laboratory, Radiology, and Other Diagnostic Services dated 3/02/19 revealed the facility would ensure laboratory, radiology, and other diagnostic services met the needs of the residents with prompt reporting to the ordering provider. Review of the facility's policy and procedures titled Physician Services dated 3/02/19 revealed the facility would provide Physician Services according to State and Federal regulations. The documented read, A physician . must provide orders for the resident's immediate care and needs. It also read, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. Review of the Facility Assessment reviewed by the Quality Assessment and Assurance Committee on 7/31/24 revealed nurses were competent in specialized care including catheterization insertion/care and received education/training/in-services Foley catheter and lab orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview observation and record review, the facility failed to implement accident intervention for 1 of 5 residents reviewed for accidents, of a total sample of 53 residents, (#22) Findings: Resident #22 was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, chronic obstructive pulmonary disease, and schizophrenia. The Minimum Data Set admission assessment with assessment reference date 6/26/24 revealed resident #22 had a Brief Interview Memory score of 6/15, which indicated moderate cognitive impairment. The assessment indicated she required moderate assistance with bed mobility and personal hygiene and maximum assistance for transfers. A review of the Smoking assessment for resident #22 dated 7/02/24 read the resident must wear a smoking apron. On 8/12/24 at 2:14 PM, resident #22 was observed on the smoking patio dressed in a hospital gown, sitting in a wheelchair, smoking a cigarette. She was not wearing a smoking apron. On 8/13/24 at 11:37 AM, resident #22 was observed smoking with Certified Nursing Assistant (CNA) J's supervision. The resident was not wearing a smoking apron and flicked ashes from her cigarette to the ground. CNA J stated she was given the cigarettes and lighters for the residents but was not given an apron for any resident who required them. On 8/15/24 at 9:36 AM, resident #22 was observed dressed in two hospital gowns and assisted to light a cigarette by CNA G. The resident again was not wearing an apron. Resident #22's gown had three cigarette burns on the front. On 8/15/24 at 10:14 AM, the East Wing Unit Manager (UM) validated the cigarette burns on the hospital gown. The UM conducted a skin assessment and stated the resident had no injury. The UM confirmed resident #22 should use an apron when smoking. A review of resident #22's medical record revealed no care plan for potential injury related to smoking for staff to follow. On 8/15/24 at 10:20 AM, the Director of Nursing (DON) stated the resident was a safe smoker with an apron at the last assessment. A review of the facility's policy and procedure dated 1/11/19 read, If the IDT members determine that the resident is an unsafe smoker, the resident may be required to wear a protective smoking vest/apron and have a greater degree of staff supervision while smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a physician's order was obtained prior to the administration of oxygen (O2) therapy for 1 of 1 resident, (#64), and failed to ensure the flow rate for O2 therapy was administered as per physician's order for 1 of 1 resident, (#95) reviewed for O2 therapy, of a total sample of 53 residents. Findings: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses that included dysphagia, obstructive sleep apnea, acute respiratory failure, shortness of breath, and encounter for palliative care. On 8/12/24 at 11:47 AM, resident #64 was observed in bed receiving O2 via nasal cannula at 2 liters per minute (LPM). He stated he used oxygen all the time and received hospice care. A review of resident #64's medical record revealed no physician's order for oxygen. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed that resident #64 was cognitively intact, dependent on staff for all activities of daily living (ADLs), had several respiratory diagnoses, and received hospice services. Oxygen therapy was not documented as being provided. Review of resident #64's medical record revealed a hospital record dated 4/25/24 showed the resident had a diagnosis of oxygen dependence and used 2 LPM of O2 via nasal cannula. On 8/12/24 at 4:46 PM, Registered Nurse (RN G) confirmed resident #64 had been received O2 therapy since being admitted to the facility. She was unable to verify how many LPM of oxygen the resident was on because there were no physician's order for O2 in the medical record. RN G explained when a resident with O2 was admitted to the facility, it was the responsibility of the nurse to obtain an order for O2 therapy. She acknowledged having an order in the medical record would ensure the resident received the correct amount of oxygen. On 8/12/24 at 4:50 PM, the [NAME] wing Unit Manager (UM) stated nurses were responsible for checking the oxygen concentrators in the resident rooms to ensure they were set to the correct amount and matched the physicians' orders. She confirmed resident #64 had no physician's order for oxygen therapy in the medical record. The [NAME] wing UM explained the expectation was for all nurses to obtain physicians' orders and ensure they were entered into the medical record. On 8/15/24 at 1:15 PM, the Director of Nursing (DON) stated the expectation was for nurses to obtain the appropriate physician orders and enter them into the medical record as soon as possible. 2. Resident # 95 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, asthma, malignant neoplasm bronchus or lung, cough, and dependence on supplemental oxygen. A physician order dated 7/10/24 for O2 continuous at 3 liters per minute (LPM) via nasal cannula (N/C) for shortness of breath. A care plan for shortness of breath, cough, stable bilateral Pulmonary nodules, nebulizer treatment and requires continuous Oxygen was initiated on 7/10/24. There were no interventions that addressed the settings of the resident's O2 therapy. On 8/13/24 at 10:16 AM, and at 10:23 AM, resident #95 was sitting up in bed. She confirmed she used O2, and stated she should be on O2 at 2 LPM. Observation of the resident's flow rate showed her O2 therapy via N/C was infusing at 8 LPM. On 8/13/24 at 10:29 AM, Registered Nurse (RN) B stated O2 was considered medication. The resident's physician orders were reviewed with RN B, she stated the resident had a physician order for O2 at 3 LPM continuously. On 8/13/24 at 10:30 AM, an observation of the resident's O2 therapy was conducted in the resident's room with RN B, which showed the O2 via NC was infusing at 8 LPM. This was confirmed by RN B, who at that time adjusted the settings down to 3 LPM. RN B stated that during change of shift she received shift report regarding O2 therapy. She stated she did not check the resident's O2 setting this morning, and verbalized the O2 flow rate should be checked by nurses at the beginning and end of their shifts. On 8/13/24 at 10:36 AM, the [NAME] Wing RN/Unit Manager (UM) stated nurses adjust O2 settings and should ensure O2 was at the right setting. The RN/ UM reviewed the resident #95's physician orders and said the resident's order was for O2 at 3 LPM via N/C continually. On 8/13/24 at 10:44 AM, the Director of Nursing (DON) stated O2 therapy was administered per physician order. She stated her expectation for O2 therapy, was a physician order was in place, and nurses were expected to ensure the O2 therapy was being administered at the right flow rate. The DON said nurses should check O2 settings at the beginning of the shift and periodically throughout their shift to ensure O2 therapy was being infused as ordered by the physician. The facility's policy Oxygen issued date 9/02/2020 read, Oxygen is administered under orders of a physician .The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely assessment, treatment, and management of pain to the extent possible for 1 of 2 sampled residents, (#42), and failed to ensure pain management was provided consistent with professional standards of practice for 1 of 2 sampled residents reviewed for pain management, (#274), of a total sample of 53 residents. Findings: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypertension, paraplegia, adjustment disorder with depressed mood and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed resident #42 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which is cognitively intact. He required total assistance for personal care and mobility. Review of resident #42's progress notes revealed he had reported discomfort in the left ear on 7/01/24 and earwax was observed. The note indicated an order for a consult with an Ear, Nose, and Throat (ENT) physician would be placed. Review of resident #42's physician's orders dated 7/19/24 revealed an order for a consult with an Ear, Nose, and Throat (ENT) physician. On 8/12/24 at 11:59 AM, resident #42 stated he was having pain in the left ear and felt there was wax in there. He stated that he had seen an Audiologist in the past who cleaned his ears but had not seen him again. On 8/14/24 at 10:27 AM, the Director of Social Services stated she was responsible for scheduling appointments with the Audiologist. She indicated resident #42 had last seen an Audiologist on 9/27/22 and was treated for wax buildup. She said she was not aware he was currently having pain in the left ear. On 8/15/24 at 10:50 AM, the [NAME] wing Unit Manager (UM) stated she was made aware of resident #42's ear pain on 7/19/24 and put an order for an ENT consult. The consult with the ENT was scheduled for December 2024. She did not let the Director of Social Services know the resident needed to see an Audiologist as soon as possible because the resident did not continue to complain of discomfort. On 8/15/24 at 1:24 PM, in an interview with the Director of Nursing (DON) it was revealed she had just learned from the [NAME] wing UM that resident #42 was having ear pain. She completed an external assessment of the resident's left ear, and he did not complain of pain when ear was touched. She stated he said he heard buzzing in his left ear. The expectation was to follow up right away with a resident that is reporting pain. The UM should have communicated with the Director of Social Services to schedule a consult with the audiologist. . 2. Review of resident #274's medical record revealed she was admitted to the facility on [DATE] with diagnoses including dementia, glaucoma and neuropathy. Review of resident #274's admission MDS assessment with Assessment Reference Date of 6/26/24 revealed a BIMS score of 11/15 which indicated moderate cognitive impairment. The assessment showed resident #274 required substantial assistance with oral and personal hygiene and she was dependent on staff for toileting, showers, upper and lower body dressing and to put on/off footwear. The assessment indicated she had limited range of motion on her upper extremities and required substantial assistance for all transfers. Resident #274 did not exhibit any behaviors and did not reject evaluation or care needed to achieve her goals for health and well-being. On 8/14/24 at 10:20 AM, during a telephone interview, resident #274's Power of Attorney (POA) and responsible party stated the resident suffered from severe pain that was not properly addressed while she was a resident at the facility. The POA indicated she felt The facility attitude was resident #274 was [AGE] years old and this was the best she can get. She shared resident #274 struggled to participate in therapy sessions because she was limited by the pain. Review of resident #274's physician's orders showed on 6/22/24 Biofreeze 4% gel was ordered for left shoulder pain to be applied twice a day for 14 days. Biofreeze provides cooling relief for sore muscles and joints, simple backaches, arthritis, sprains, strains and bruises . (Retrieved from www.biofreeze.com on 8/22/24). Review of resident #274's Medication Administration Record (MAR) for June 2024 showed Biofreeze was not administered, and code 9 was used for the 9:00 PM dose on 6/25, 6/26, 6/27, 6/29, and 6/30/24. The Chart Codes legend indicated code 9 meant Other / See Nurse Notes. Review of resident #274's MAR for July 2024 showed Biofreeze was not administered, and code 9 was used for the 9:00 PM dose on 7/01, 7/03 and 7/05/24. Review of a comprehensive care plan for potential/actual pain symptoms initiated on 6/20/24 revealed the goal was for the pain to be managed to allow the resident to enjoy quality of life, sleep and participate in activities. An intervention directed nurses to administer medications as per physician orders. Review of a Progress Notes dated on 6/26/24 by the Advanced Practice Registered Nurse revealed resident #274 continued with pain on her left shoulder and was taking the medications prescribed as needed. The plan included to continue Biofreeze twice a day until 7/06/24. The note indicated she was at a high risk for functional impairment without therapy and adequate pain control. Review of a Resident Concern/Grievance Form dated 7/08/24 filed by resident #274's POA revealed she had concerns with diet, pain medications and therapy progress. The follow-up section showed a care plan meeting was scheduled for 7/09/24 and concerns were reviewed and addressed. On 8/14/24 at 5:48 PM, Registered Nurse (RN) O stated resident #274 needed a lot of care and complained of pain, suffered from chronic pain but her pain was addressed. Later on 8/15/24 at 4:48 PM, RN O reviewed the MAR for June and July and validated she entered code 9 five times in June and three times in July. She reviewed the Progress Notes she entered for those days and stated it read, on order. She stated at that time they did not have Biofreeze in the treatment cart. On 8/15/24 at 1:26 PM, the East Wing UM recalled she attended a care plan for resident #274 and the daughter was present. She stated resident #274 complained of pain and she got pain management involved. She stated the Advanced Practice Registered Nurse (APRN) visited residents twice a week and the physician came approximately once monthly. The UM stated the Biofreeze was kept in the treatment carts and all nurses had access to them. She indicated the therapists also had Biofreeze. She indicated she did not know why RN O entered code 9 in the MAR for the Biofreeze. On 8/15/24 at 6:23 PM, the DON stated she was not aware RN O did not find Biofreeze in the treatment cart. She indicated her expectation was nurses followed the physician orders and to let her know when residents did not have the medications they needed. Review of the facility's policy and procedures titled Physician Services dated 3/02/19 revealed the facility would provide Physician Services according to State and Federal regulations. The documented read, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document administered medications in the Medication Administration Record (MAR) for 1 of 6 residents reviewed for choices, of a total sample of 53 residents, (#279). Findings: Review of resident #279's medical record revealed she was admitted to the facility on [DATE] with diagnoses including open wound on the left lower leg, pain, and cellulitis (bacterial skin infection). Review of resident #279's physician orders revealed an order dated 8/09/24 for Bactrim DS 800-160 milligrams every 12 hours for cellulitis for 10 days. Review of resident #279's Medication Administration Record (MAR) revealed code 9 was used for the 9:00 PM dose of Bactrim on 8/09, 8/10, 8/11, and 8/12/24 and on 8/13/24 for the 9:00 AM dose. The MAR showed the 9:00 AM dose of Bactrim was documented as given on 8/10, 8/11, and 8/12/24. The legend showed when code 9 was used it indicated Other / See Nurse Notes. Review of resident #279's medical record revealed a Progress Notes dated 8/10/24 which indicated on oral antibiotic Bactrim, awaiting medication to arrive. On 8/13/24 at 9:57 AM, resident #279 stated she was prescribed an antibiotic for an infection on her legs, but she had not received it for 3 days. On 8/15/24 at 4:38 PM, Registered Nurse (RN) O stated she entered code 9 for the 9:00 PM dose of Bactrim on 8/10, 8/11, and 8/12/24 because the antibiotic was not available. She stated she did not know she could access Bactrim from the automatic medication dispensing machine. RN O validated she did not give resident #279 the night dose of Bactrim for 3 days. On 8/15/24 at 6:15 PM, the Director of Nursing (DON) stated RN P did not give the 9:00 AM dose of Bactrim to resident #279 on 8/10 and 8/11/24 despite documentation showing he administered it. She mentioned he signed a written statement which indicated he documented the medication as administered accidentally instead of documenting not administered because it was not available. She explained she verified the automatic medication dispensing machine and confirmed Bactrim was not available those days therefore the medical record was inaccurate. Review of the Documentation policy and procedure dated 3/02/19 revealed guidelines for timeliness in documentation to ensure accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments were completed within fourteen calendar days of the Assessment Reference Date (ARD) for 4 of 6 residents reviewed for Resident Assessment of a total sample of 50 residents, (#119, #29, #99, #105). Findings: 1. Resident #119 was admitted to the facility on [DATE]. A review of resident #119's medical record revealed the MDS quarterly assessment had an assessment reference date (ARD) of 3/7/23. Review of the history of the quarterly MDS assessment showed it was completed on 5/2/23, locked and accepted on 5/2/23. On 5/4/23 at 12:03 PM, the Licensed Practical Nurse MDS Coordinator C reviewed the resident's medical record and stated her admission/comprehensive MDS assessment was completed and accepted on 12/21/22. The resident's quarterly assessment was due 14 days from the ARD date, 3/7/23. She confirmed the quarterly assessment was not completed and submitted until 5/2/23 and should have been completed on 3/21/23. She acknowledged the assessment was 42 days late. The MDS Coordinator stated she was responsible for ensuring MDS assessments were submitted timely and explained she had just started working at the facility on 5/1/23 and could not explain why the prior MDS nurse did not complete or submit assessments timely. 2. Resident #29 was admitted to the facility on [DATE]. Review of the resident's medical record revealed the resident's quarterly MDS with ARD of 3/06/23 was completed on 5/02/23, 57 days after the ARD. 3. Resident #99 was admitted to the facility on [DATE]. Record review showed his quarterly MDS assessment with ARD of 3/20/23 was completed on 5/02/23, 42 days after the ARD. On 5/04/23 at 10:28 AM, the resident's quarterly MDS assessments were reviewed with Licensed Practical Nurse (LPN) MDS Coordinator C. She stated assessments should be completed within 14 days of the ARD and confirmed the quarterly MDS assessments for residents #29, and #99 were completed late. 4. Resident #105 was admitted to the facility on [DATE]. Record review revealed the resident's quarterly MDS assessment with ARD 4/12/23 was listed as in progress On 5/04/23 at 3:07 PM, the resident's quarterly MDS assessment with ARD of 4/12/23 was reviewed with the MDS Coordinators C and G. LPN MDS Coordinator C stated she completed the assessment on 5/04/23 and was currently waiting for the Registered Nurse's signature to submit the assessment. LPN MDS Coordinator G stated MDS assessments were opened by the facility's Corporate MDS Coordinator, and somehow it was missed that resident #105's quarterly MDS assessment with ARD 4/12/23 was not completed. The assessment was completed 20 days after the ARD. The facility's policies and procedures for Resident Assessment Instrument (RAI) revised 3/2/19 contained the regulatory timeframes for MDS assessments and noted, Quarterly assessments are also done for residents every 3 months, at least every 92 days following a comprehensive assessment .Quarterly Assessments will be transmitted within 14 days of completion date . The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual with effective date of October 1, 2019, revealed that The Quarterly assessment . must be completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type .The MDS completion date must be no later than 14 days after the ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop, implement, review, and provide a copy of a baseline care plan within 48 hours for 2 of 6 newly admitted residents, of a total sample of 50 residents, (#379, #381). Findings: 1. Resident #379, an [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses including osteomyelitis, hereditary and idiopathic neuropathy, implantable cardiac defibrillator, quadriplegia, and cardiomyopathy. Documentation on the resident's admission Evaluation dated 4/26/23 included, Oxygen continuous 4 Liters. The resident's physician's order dated 4/27/23, noted oxygen, continuous at 3 liters per minute via nasal cannula for a medical diagnosis of pulmonary fibrosis. Review of the resident's clinical record revealed a baseline care plan was not developed to address the information needed to provide effective and person-centered care for resident #379. 2. Resident #381, a [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypercapnia, obstructive sleep apnea, and diastolic (congestive) heart failure. The resident's hospital Discharge Summary indicated the resident was instructed to use her CPAP (continuous positive airway pressure) . She finally agreed and will continue to use CPAP during sleep and naps. CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while you sleep. (Retrieved on 5/10/23 from ww.nhlbi.nih.gov) Review of the resident's clinical record revealed a baseline care plan was not developed to address resident #381's respiratory status and need for CPAP therapy. On 5/04/23 at 9:45 AM, the Assistant Director of Nursing (ADON) stated baseline care plans were triggered and started by the admitting nurse. On 5/04/23 at 11:51 AM, the Director of Nursing (DON) stated baseline care plans should address the resident's immediate needs and were imbedded in the admission Evaluation form completed by nursing at admission. The DON explained that baseline care plans should identify the resident's respiratory status and indicate the use of any devices. She said the Paper baseline care plans for residents #379 and resident #381 were used by the Minimum Data Set (MDS) Coordinator in the welcome care plan meetings done following the residents' admission. Section H of resident #379's admission Evaluation with effective date of 4/26/23 at 6:40 PM, and signed date of 4/27/23 was reviewed with the DON. She confirmed the evaluation revealed resident #379 used oxygen continuously. The DON acknowledged resident #381's admission Evaluation form with effective date of 4/24/23 at 8:30 PM, did not identify CPAP for the resident in section H -respiratory or section M-sleep patterns. Resident #379's baseline care plan dated 4/28/23 was reviewed with the DON. Areas were checked off for advance directives, nutrition/hydration, and the document indicated the resident required therapy to achieve her previous level of function. The DON validated the baseline care plan did not address the resident's respiratory status and need for continuous oxygen therapy. A signature, or date was not identified to indicate the baseline care plan was acknowledged, and that a written summary of the baseline care plan was provided to the resident/responsible party. Resident #381's baseline care plan dated 4/28/23 did not identify the need for CPAP therapy. The DON confirmed that resident #381's baseline care plan was not developed within 48 hours of her admission and did not address her need for CPAP. On 5/04/23 at 2:05 PM, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator G stated baseline care plans were initiated by the admitting nurse, then MDS would review the resident's orders and adjust the care plan as needed. LPN MDS Coordinator G verbalized baseline care plan would be discussed with the resident/family/responsible party within three days of the resident's admission. She stated she was not aware that a baseline care plan should be developed and implemented within 48 hours of the resident's admission. LPN MDS Coordinator G acknowledged a signature and date was not on resident #379's baseline care plan to indicate it was reviewed, and that a copy was provided to the resident/responsible party. She confirmed that resident #381's baseline care plan was not developed within 48 hours of the resident's admission. The facility's policy Baseline Care Plan not dated, read, The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission . The baseline care plan must: Be developed within 48 hours of a resident's admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for Continuous Positive Airway Pressure (CPAP) therapy for 1 of 4 residents reviewed for respiratory care and services, out of a total sample of 12 residents, (#381). Findings: Review of the medical record revealed resident #381 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea, primary pulmonary hypertension, and acute respiratory failure. The Minimum Data Set (MDS) admission assessment with assessment reference date of 4/26/23 revealed resident #381 used a non-invasive mechanical ventilator such as a CPAP. The Order Summary Report revealed resident #381 had a physician's order dated 5/02/23 for CPAP therapy at Auto 8 to 18 setting for sleep apnea. A CPAP machine has a motor that blows air through a tube connected to a mask which fits over the nose and/or mouth. The machine maintains mild air pressure to keep airways open during sleep. The device is often prescribed by a physician to treat sleep-related breathing disorders including sleep apnea (retrieved on 6/13/23 from www.nhlbi.nih.gov/health/cpap). Resident #381's comprehensive care plan read, Last Care Plan Review Completed: 5/23/23. Review of the document revealed no care plan focus areas related to respiratory care and services including CPAP therapy. Review of the facility's policy and procedure Comprehensive Care Plans revised on 3/02/19, revealed the facility's goal was to provide appropriate care for residents by utilization of an interdisciplinary plan of care. The document read, The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident.consistent with the medical plan of care. The policy indicated each discipline was responsible for reviewing and revising the care plan to reflect interventions necessary to promote the resident's well-being. On 6/06/23 at 11:58 AM, the Regional Director of Clinical Services (RDCS) was informed that resident #381's medical record showed a diagnosis of sleep apnea and a physician order for CPAP therapy, but there was no associated care plan for CPAP therapy or respiratory issues. The RDCS explained staff should have initiated a care plan for the resident's CPAP use and respiratory issues. On 6/06/23 at 12:11 PM, the MDS Coordinator stated each department was expected to initiate or update appropriate care plans for each resident as indicated. She confirmed the clinical team, specifically the Nursing department, was responsible for ensuring resident #381 had a comprehensive care plan for CPAP therapy. The MDS Coordinator acknowledged she oversaw the care planning process and missed the absence of a care plan for the resident's respiratory diagnoses and CPAP. She explained comprehensive care plans were important as the goals and interventions reflected the resident's essential care needs. Review of the Facility Assessment revised on 3/02/19, revealed facility staff would demonstrate competency in the provision of specialized care and person-centered care to include care planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #93 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, diabetes mellitus, ventricular tachycardia, and hypertension. On 5/1/23 at 10:30 AM, resident #93 was observed in bed. He did not have oxygen applied as the nasal cannula (NC) was draped over the bed rail. The tubing was attached to dirty oxygen concentrator. The side removable filter of the concentrator was covered with a thick layer of gray dust particles. The resident verbalized he did not want to wear his oxygen because the tubing was making his ears sore. The oxygen flow rate was set at 2 liters per minute (LPM). A review of the physician orders dated 11/6/22 noted oxygen at 2 LPM via NC for SOB (shortness of breath)/Sats (saturation) less than 92%, rinse and replace oxygen filters on concentrator q (every) night shift on Saturday and oxygen Sat every shift prn (as needed), and call MD (Medical Doctor) if less than 90%. Resident #93 had a care plan, created 1/6/23, for oxygen therapy related to SOB, included interventions to change equipment as per recommendation or protocol and goal for resident was to maintain use of oxygen without complications. On 5/2/23 at 11:02 AM, resident #93 was observed again in bed and not wearing his oxygen as the NC was draped over the bed rail and the concentrator was running at 2 LPM. The side removable filter of the concentrator was still covered with thick layer of gray dust particles. Again, he voiced he was not wearing oxygen due to his ears being sore from the tubing. He agreed for surveyor to report ear soreness to his nurse. On 5/2/23 at 11:05 AM, assigned Registered Nurse (RN) B was informed that resident #93 wanted foam/cushion on oxygen tubing because his ears were sore. She agreed to put either gauze or foam on the tubing where it was bothering his ears. On 5/3/23 at 10:43 AM, resident #93 was observed lying in bed wearing oxygen tubing that now had cushion taped near the ears. The tubing was connected to a dirty concentrator with thick layer of gray dust particles still present on the removable side filter. The assigned nurse, RN B was present in the room. On 5/3/23 at 1:55 PM, resident #93 wore the NC which was attached to the oxygen concentrator at bedside. The side filter of the machine was unchanged, and RN B acknowledged it was dirty. RN B said, she thought maintenance staff were responsible to clean the oxygen contractor filters and not the nursing staff. She did not know how often the filters should be cleaned and acknowledged she did not notice the dirty filter today or yesterday when assigned to resident #93. On 5/3/23 at 2:15 PM, the Director of Plant Operation validated resident #93's dirty oxygen concentrator filter. He said housekeeping staff were responsible to clean the concentrator and filters but there was no particular cleaning schedule. On 5/3/23 at 2:40 PM, the Manager of Housekeeping and Laundry validated resident #93 had dirty oxygen concentrator with thick layer of gray dust on the side filter. He said, any staff who saw the filter was dirty should have cleaned it. He noted there was no cleaning schedule. On 5/3/23 at 3:15 PM, the Director of Nursing (DON) said, the nursing staff should clean oxygen concentrator filters weekly when they change oxygen tubing. She explained it was not the responsibility of housekeeping or maintenance staff. On 5/3/23 at 3:23 PM, the DON said she provided incorrect information and noted it was the housekeeping staff's responsibility to clean oxygen filters and not the nursing staff. She added, there is no policy regarding who was responsible or how often. Based on observation, interview, and record review, the facility failed to ensure physician orders were obtained and entered correctly in the electronic medical record for Continuous Positive Airway Pressure (CPAP) therapy for 1 of 4 residents reviewed for respiratory care, (#381); failed to ensure Oxygen (O2) therapy was administered per physician orders for 1 of 4 residents reviewed for respiratory care, (#379); and failed to ensure oxygen concentrators were maintained in clean and safe condition for 1 of 4 residents reviewed for respiratory care, of a total sample of 50 residents, (#93). Findings: 1. Resident #381, a [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypercapnia, obstructive sleep apnea, and diastolic (congestive) heart failure. The Hospital Discharge Summary with date of service 4/22/23 read, Patient instructed to use her CPAP at settings of 15/8. She finally agreed and will continue to use CPAP during sleep and naps. CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while you sleep. (Retrieved on 5/10/23 from ww.nhlbi.nih.gov) Review of the resident's physician's orders revealed an order dated 4/25/23 for CPAP one-time only for one day. Progress note dated 5/01/23 read, Resident received in bed watching TV in room with CPAP on .O2:95% on CPAP. On 5/01/23 at 2:16 PM, resident #381 was lying on her back in bed. A CPAP machine was on her bedside table, and the resident stated it was placed on during the nights. On 5/02/23 at 4:47 PM, and at 5:31 PM, the Director of Nursing (DON) recalled that when the resident was admitted to the facility, the CPAP order was faxed over to the company, who delivered the machine with the prescribed settings in place. A review of the resident's current physician's orders with the DON noted an order for CPAP could not be found. The resident's discontinued/completed physician's orders were reviewed, and revealed a one-time order for CPAP dated 4/25/23, scheduled for one day only. The DON stated the order for the resident's CPAP therapy was placed incorrectly, and should have been scheduled for every night, and not for one day. A review of the resident's progress notes revealed a note dated 5/01/23 indicated the CPAP machine was used for the resident. This was confirmed by the DON, who stated she would notify the physician of the transcription error. She stated she spoke with the resident, and the resident told her the CPAP was placed on her at nights. The DON explained that all new admission clinical records were reviewed the following day in the morning clinical meeting, and those admitted over the weekend would be reviewed on Monday. She stated the records were reviewed to ensure they were complete and accurate. She said resident #381's clinical records were reviewed to ensure the CPAP order was in, but the order was not reviewed for accuracy. 2 Resident #379, an [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses including osteomyelitis, hereditary and idiopathic neuropathy, implantable cardiac defibrillator, quadriplegia, and cardiomyopathy. Review of the resident's current physician's orders revealed an order dated 4/27/23 for oxygen (O2) continuous at 3 liters per minute (LPM) via nasal cannula for diagnosis of pulmonary fibrosis. On 5/01/23 at 10:40 AM, and on 5/01/23 at 2:04 PM, resident #379 received O2 via nasal cannula at 4 LPM. On 5/01/23 at 2:20 PM, Licensed Practical Nurse (LPN) A stated resident #379 received O2 therapy via nasal cannula. The LPN reviewed the resident's current physician's orders, and stated the resident had an order for oxygen at 3 LPM. The resident's O2 flow rate was observed with LPN A. She confirmed the O2 was infusing at 4 LPM. LPN A stated O2 was a physician's order and should be checked during medication administration. She stated she did not check the resident's O2 to ensure the O2 was infusing at the ordered flow rate. On 5/01/23 at 3:20 PM, the DON stated that a review of the resident's hospital records revealed the resident received O2 at 4 LPM while in the hospital, and stated the order in place was a transcription error by the nurse and should have been for 4 LPM, instead of 3 LPM. The resident's Baseline care plan dated 4/28/23, did not address the resident's diagnosis and need for O2 therapy. The facility's policy Physician Services issued 3/02/19 read, All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure ongoing communication, coordination and collaboration between the nursing home and the dialysis center for 1 of 1 resident reviewed for dialysis of a total sample of 50, (#8). Findings: Resident #8 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, clostridium difficile, sepsis, dilated cardiomyopathy, human immunodeficiency virus, viral hepatitis, hypovolemic shock and adult failure to thrive. Review of the Minimum Data Set admission assessment with assessment reference date 4/07/23 revealed resident #8 had a Brief Interview for Mental Status score of 14 which indicated she was cognitively intact. She required total assistance for activities of daily living and did not reject care. The document indicated resident #8 had an active diagnosis of end stage renal disease and received dialysis. Review of resident #8's medical record revealed a physician order dated 5/01/23 for hemodialysis at an outside facility on Monday, Wednesday and Friday at 2:00 PM. Hemodialysis is a procedure where a dialysis machine and special filter are used to remove wastes and fluids from the blood to keep a person healthy when the kidneys no longer function properly (retrieved 5/05/23 from the National Kidney Foundation website at www.kidney.org). A care plan initiated 3/30/23 indicated resident #8 had a need for hemodialysis related to renal failure. Interventions included hemodialysis at an outside center on Monday, Wednesday and Friday at 2:00 PM. The care plan did not include any interventions or approaches for communication, coordination and collaboration between the facility and the dialysis center. A review of resident #8's physical chart revealed the chart did not include any Dialysis Communication forms. A review of the Progress Notes from 3/30/23 through 5/03/23 revealed no documentation the facility communicated with the dialysis center regarding pre-treatment and post-treatment weights and vitals signs, access problems, medications given prior to dialysis treatment, medications given during/after treatment, change in condition or special instructions. On 5/03/23 at 1:30 PM, Registered Nurse (RN) D stated resident #8 was on antibiotic therapy for an infection. She confirmed resident #8 received dialysis on Monday, Wednesday and Friday. She stated there was a notebook with dialysis communication forms in it at the nurse station. RN D looked in the notebook and confirmed the communication forms were blank. She acknowledged she did not know where the completed communication forms were located. On 5/03/23 at 1:37 PM, the Assistant Director of Nursing (ADON) stated the dialysis communication forms may have been sent to the medical records department. On 5/03/23 at 4:05 PM, the Health Information Records Tech in the medical records department stated she did not recall receiving any dialysis communication forms for resident #8. She reviewed the forms in her folders but could not locate any dialysis communication forms. The Health Information Records Tech reviewed the electronic medical record (EMR) and confirmed no dialysis communication forms were scanned into resident #8's EMR. On 5/03/23 at 4:34 PM, Licensed Practical Nurse (LPN) A, RN E and LPN F were at the nurse station for resident #8. LPN A, RN E and LPN F did not explain how the facility ensured ongoing communication and collaboration between the facility and dialysis center. LPN A reviewed the medical chart and confirmed there were no communication forms present. LPN A and LPN F looked in the dialysis book and confirmed the communication forms in the notebook were blank. RN E and LPN F searched through the file cabinet at the nurse station and could not locate any documentation to show communication between the facility and the dialysis center. On 5/03/23 at 4:42 PM, the Director of Nursing (DON) stated the facility no longer sent communication forms to the dialysis center because the dialysis center would not complete them. She stated the facility communicated with the dialysis center often but was unable to produce any documentation to show communication between the facility and the dialysis center. On 5/03/23 at 4:56 PM, the DON stated she was on the phone with the Dialysis Center Administrator and the center was going to fax the weight sheets for resident #8's dialysis visits. The DON acknowledged she did not have the pre-treatment and post-treatment weights prior to this date. In a telephone interview on 5/03/23 at 4:58 PM, the Dialysis Center Administrator confirmed the dialysis center did not complete communication forms between them and the facility. She stated she received information from her technicians but had not spoken with the facility. The Dialysis Center Administrator acknowledged she was not aware the resident had an infection or was taking any antibiotics. The facility's Dialysis policy and procedure dated 3/02/19 read, The facility and the Dialysis Center should maintain regular communication and should a change in condition occur before or during the dialysis treatment, the sending facility should communicate the changes in needs to the receiving facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure notification to provider for elevated blood glucose, and failed to ensure orders were received and implemented timely for treatment of elevated blood glucose levels for 1 of 1 resident reviewed for quality of care, of a total sample of 50 residents, (#382). Findings: Resident #382, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, convulsions, Alzheimer's disease, diabetes type II, gastrostomy, and metabolic encephalopathy. Review of resident #382's hospital history and physical dated 4/06/23 revealed the resident's Current Outpatient Medications included Insulin Aspart (Novolog) 20 units three times daily, Lantus, and Januvia 50 milligram. The hospital discharge orders listed Insulin Lantus 20 units daily. Review of the resident's Physician Progress Note documented by the Advanced Practice Registered Nurse (APRN) dated 5/02/23 revealed the resident's past medical history included diabetes. The past medications included insulins Lantus and Humalog. Documentation revealed the APRN assessment indicated the resident had diabetes type II, and the documented plan was to monitor blood glucose levels. Review of resident #382's physician orders revealed an order dated 4/29/23 for Lantus 20 units daily. There were no orders for any additional insulin, or for blood glucose monitoring. On 5/03/23 at 12:16 PM, resident #382's daughter stated the resident had diabetes for over thirty years. She noted before her admission to the facility, she received insulin three times daily. The daughter verbalized that approximately one hour ago, the resident was sweating bullets. She stated Licensed Practical Nurse (LPN) A monitored the resident's blood glucose, and it was over 500. The resident's daughter said the facility did not have an order for insulin for the resident, and she was told they would need to call the physician to obtain an order. On 5/03/23 at 12:21 PM, LPN A was standing at her medication cart. She explained she was monitoring blood glucose, and preparing insulin for other residents. When asked about resident #382's blood glucose, the LPN stated someone was at the desk calling the physician for an insulin order. On 5/03/23 at 12:25 PM, the Director of Nursing (DON) stated she was not aware of the resident's elevated blood glucose. A review of the resident's current physician orders revealed an order for insulin Lantus daily. An order for blood glucose monitoring, or any additional insulin could not be identified. The DON stated when the resident was in the hospital, she required two types of insulin, Lantus, and Novolog, along with oral Januvia. She stated the resident's labs completed on 5/01/23 showed her blood glucose was high, with a result of 213. The lab report indicated blood glucose was considered normal between 70-99. The DON stated the labs were reviewed by the ARNP, and no new orders were placed. On 5/03/23 at 12:45 PM, LPN A stated the Advance Practice Registered Nurse (APRN) gave orders to administer 10 units of regular insulin to the resident and then recheck her blood glucose. On 05/03/23 at 12:59 PM, LPN A recalled when she walked into the resident's room to provide nursing care, the resident was sweaty. She said she removed her blanket, and checked her blood glucose which was high, registering 572 on the glucometer. The LPN stated she reviewed the physician orders for sliding scale protocol to administer insulin to the resident, but an order was not in place. She explained that she tried to get one of the other nurses on the unit to call the physician, but they did not get to call, so she called the physician, and received an order for insulin. LPN A stated a recheck of the resident's blood glucose revealed it was still high at 555. Regular insulin 10 units was administered to the resident at 1:00 PM. On 5/03/23 at 2:33 PM, the DON stated that if a resident's blood glucose was elevated, and there were no orders for insulin, the expectation was the physician would be notified within fifteen to thirty minutes. On 05/03/23 at 2:55 PM, LPN A, noted that when she monitored the resident's blood glucose and the result was 572, and after she reviewed the physician's orders and a sliding scale insulin order was not identified, she called over to the A Wing for assistance but ended up calling the physician herself at approximately 12:27 PM. LPN A could not recall what time she monitored the resident's blood glucose. Both glucometers on the nurses' medication cart was checked, and the history showed the residents blood glucose was monitored at 11:19 AM. Observation revealed the resident's blood glucose was rechecked at 12:56 PM. LPN A confirmed the resident was not treated for her elevated blood glucose in a timely manner. When asked the expectation for monitoring and treatment for elevated blood glucose, the LPN did not have a response. She then verbalized she should have stopped what she was doing and addressed the resident's elevated blood glucose in a timely manner. The resident's blood glucose was 572 at 11:19 AM, and she did not receive insulin until 1:00 PM, one hour and forty-one minutes after her blood glucose was monitored. On 5/04/23 at 10:06 AM, the ARNP stated the facility called her regarding resident #382's elevated blood glucose, and she gave an order for 10 units of regular insulin and for sliding scale protocol. The ARNP stated that when a resident has a diagnosis of diabetes, they were usually placed on blood glucose monitoring. She said somehow it was missed for the resident. She said if the blood glucose was critical/high, the expectation was for the physician/provider to be notified immediately, so orders could be obtained to treat the condition. On 5/04/23 at 11:51 AM, the DON stated it would be a reasonable assumption that blood glucose monitoring should be requested for residents receiving insulin. The facility did not have a policy that addressed blood glucose monitoring/diabetic management. The L.P.N. Competency Skills Checklist dated 12/29/22 indicated LPN A was competent to provide nursing care based on scientific principles and sound theoretical knowledge

Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented effective Performance Improvement Plans (PIPs) to correct and monitor identified deficiencies. Findings: On 6/06/23 at 11:58 AM, the Regional Director of Clinical Services (RDCS) confirmed the facility's QAPI committee implemented PIPs to address noncompliance identified during the facility's recertification survey which ended on 5/04/23. She was informed of a repeat concern related to respiratory care and services for Continuous Positive Airway Pressure (CPAP) therapy with the same resident identified during the recertification survey. The RDCS validated the concern related to use and monitoring of the respiratory device. She explained Unit Managers (UMs) were responsible for auditing residents' medical records to ensure accuracy, but there was no UM on that resident's unit at this time. She acknowledged there was only one resident in the facility who had a CPAP machine and the PIP involved a weekly audit of the resident's physician orders. The RDCS could not explain why the audit had not captured the issue. On 6/06/23 at 12:11 PM, the Minimum Data Set (MDS) Coordinator validated a concern identified regarding lack of a comprehensive care plan for respiratory care and services for the resident who required CPAP therapy. She confirmed there was a deficiency from the recent recertification survey as the resident did not have a baseline care plan for CPAP therapy. The MDS Coordinator acknowledged this resident's comprehensive care plans had since been developed but still did not include care plans for her respiratory care needs including CPAP therapy. On 6/06/23 at 1:38 PM, the facility's Director of Nursing (DON) was informed of a repeat concern regarding a resident who had oxygen administered at the wrong flow rate. She confirmed there was an audit in place and nurses were responsible for ensuring residents received oxygen at the flow rate ordered. The DON was unsure if a member of the QAPI committee regularly checked settings to verify accuracy. On 6/06/23 at 2:43 PM, the RDCS validated a concern identified related to failure to monitor a resident's blood glucose levels as ordered for approximately six months. She confirmed it was a significant finding as the discrepancy had gone unnoticed by all assigned nurses and nurse management staff over that period of time. During review of the QAPI binder with the RDCS, she confirmed the affected resident was listed on an audit form that showed his medical record was reviewed specifically for the plan of care related to diabetes management. The RDCS confirmed the whole house audit of all diabetic residents was conducted as part of a PIP to address noncompliance identified during the facility's recertification survey. The RDCS could not explain why the audit had not captured the issue. On 6/06/23 at 4:33 PM, an interview was conducted with the facility's Administrator, RDCS, and Director of Nursing (DON) to discuss repeat deficient practices identified during the revisit survey. On 6/06/23 at approximately 4:36 PM, the Administrator stated the facility developed and initiated PIPs on 5/05/23 to correct deficiencies identified during the recertification survey. She explained the PIPs were created by all members of the QAPI team in conjunction with the corporate office. The Administrator recalled the QAPI committee met again on 5/31/23 to discuss the facility's plan of correction and audit findings. She stated the committee modified the audit tools, but she was not aware the audit tools had not captured all necessary data to ensure compliance. The Administrator confirmed she led the QAPI committee which was tasked with ensuring success of PIPs. When asked why repeat and/or continued deficient practices were not identified during weekly audits, the Administrator said, Our audit tools were not effective. She stated the revisit survey findings indicated audit tools needed to be reviewed and revised by the QAPI committee. On 6/06/23 at approximately 4:40 PM, the DON stated in response to the concerns identified, the facility would have to conduct another whole house audit of diabetic residents to ensure blood glucose was monitored as ordered. The DON acknowledged the QAPI committee would also have to address the issues of inaccurate transcription of physician orders in the electronic medical record and nursing standards of practice related to reading orders and documentation. On 6/06/23 at approximately 4:43 PM, the RDCS confirmed all areas of deficient practice identified during the revisit survey involved residents who were reviewed during QAPI committee audits. Review of the facility's policy and procedure for Quality Assurance and Performance Improvement revised on 3/02/19 read, The facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The document indicated the facility would develop corrective action plans, implement performance improvement activities, and measure the effectiveness of those actions to ensure desired results were achieved and sustained.

Based on observation, interview and record review, the facility failed to ensure foods were correctly stored in the walk-in cooler and walk-in freezer to prevent contamination, failed to ensure staff members had appropriate hand hygiene/grooming, and failed to ensure the walk-in cooler was in good repair. Findings: 1. On 6/14/21 at 9:20 AM observation of the walk-in freezer with the Certified Dietetic Manager (CDM) revealed bags of vegetables store directly under the evaporator fan. There was ice buildup on the line under the fan that had the potential to drip onto the bags of vegetables. 2. On 6/14/21 at 9:25 AM, Dietary Aide (DA) A was working on clean side of dish machine removing and stacking clean dishes. She had long painted fingernails over 1/2 inch past the tip of her fingers. Her thumbs had punched through barrier gloves. The CDM acknowledged that DA A had long nails and that it was unacceptable for her to have nails that long. 3. On 6/14/21 at 9:30 AM, the outdoor walk-in refrigerator had an empty steam table bucket under the evaporator fan. There was condensation build up on the underside of the fan. The CDM said the soup bucket was there to catch the water that sometimes drips from the line under the fan. Food items stored on the shelf under fan included cooked turkey breast, cooked diced potatoes and cooked corned beef. The door to the walk-in refrigeration did not seal when closed. Light from outside was visible on the top of the door, the handle side of the door, and the bottom left of the door. 4. On 6/15/21 at 3:10 PM, the walk-in cooler door gasket was torn, shredded., and covered in a black-like substance. At 3:30 PM, the Director of Maintenance said that he was aware of the problem with the gasket. He acknowledged that when he cleaned the refrigerator on 5/27/21, the gasket was torn. Review of the work order in the electronic work order log noted the damaged gasket on 5/27/21. The Director of Maintenance confirmed he had not contacted any service company to repair the gasket.