2. On 12/2/24 at 11:00 a.m., an observation and interview were conducted in the 400 hallways with Staff A, Registered Nurse/Unit Manager (RN/UM) during medication administration. An observation was made of Staff A, RN/UM's computer screen, which was showing the Medication Administration Record (MAR) for her assigned residents during the Day (7:00 a.m. to 3:00 p.m.) shift. The MAR showed 15 residents requiring their morning medications and all the residents were shown in red, indicating the medications were late. Staff A, RN/UM agreed medications were late for these residents. Staff A, RN/UM stated she arrived at the facility at her usual time of 8:30 a.m., and was unaware there was a sick call on her side of the facility. Staff A, RN/UM stated this was the reason her medications were late this morning. (Photographic Evidence Obtained) On 12/2/24 at 3:00 p.m., an interview was conducted with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff B, LPN/UM stated medications have a window of one hour before and one hour after the ordered medication time to consider medication on time. Staff B, LPN/UM denied the facility had liberalized medication administration times. On 12/03/24 10:32 a.m., an observation and interview were conducted in the 200 hallways with Staff C, RN, during medication administration. An observation was made of Staff C, RN's computer screen, which was showing the MAR for her assigned residents during the Day shift. The MAR showed with 16 residents requiring their morning medications and all the residents were shown in red, indicating the medications were late. Staff C, RN agreed medications were late for these residents. Staff C, RN stated she normally works the night shift and was having difficulty in locating missing medications, which would normally be in the bottom drawer of the medication cart. Staff B, LPN/UM arrived during the interview and stated he would be assisting Staff C, RN with the remainder of Staff C's medication administration. On 12/3/24 at 10:55 a.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Both the DON and ADON were aware of the late medication administration on 12/2/24 and 12/3/24. The ADON stated Staff C, RN normally works the night shift and may be struggling with the day shifts higher demand of medication administration. The DON stated the pharmacy has a process where automatic renewal should be implemented, and staff can request and/or a par is created by pharmacy to automatically dispense the medication. The DON could not explain why medications were late on 12/3/24. On 12/3/24 at 11:20 a.m., an observation and interview were conducted with Staff B, LPN/UM at med cart 1 pulling medications to assist Staff C, RN. Staff B, LPN/UM stated he was pulling the medications for the residents and Staff C, RN was distributing them to the residents. Staff B, LPN/UM stated the electronic chart was logged in under Staff C, RN's name, but would not state who was documenting in the MAR. On 12/3/24 at 11:30 a.m., an interview was conducted with the DON. The DON stated medication administration should be conducted with one nurse pulling the medication, administering the medication, and documenting the medication. If two nurses are administering from the same cart, an extra computer should be available, or the screen could be split and logged under each nurse individually. On 12/3/24 at 12:20 p.m., an interview was conducted with the ADON. The ADON stated the Medical Director was notified of all the late medication administration for 12/3/24, but the individual physicians for the residents had not. The DON stated the individual physicians will be notified for the late medications for 12/3/24 as well as the late medications from 12/2/24. A review of Resident #3's Medication Administration Audit Report for the month of October 2024 showed medications were administered late on the following dates and times: - 10/7/24: four medications during the 4:00 p.m., 4:30 p.m., and 5:00 p.m. medication passes. - 10/8/24: 19 medications during the 9:00 a.m., 4:30 p.m., 5:00 p.m., and 9:00 p.m. medication passes. - 10/9/24: three medications were scheduled to be administered at 9:00 p.m. and were not administered. - 10/10/24: 10 medications during the 11:30 a.m., 4:00 p.m., 4:30 p.m., 5:00 p.m., and 9:00 p.m. medication passes. - 10/13/24: four medications during the 4:00 p.m., 4:30 p.m., and 5:00 p.m. medication passes. - 10/14/24: 14 medications during the 9:00 a.m. medication pass. - 10/18/24: 19 medications during the 9:00 a.m., 4:00 p.m., 4:30 p.m., 5:00 p.m., and 9:00 p.m. medication passes. - 10/21/24: 15 medications during the 9:00 a.m., 11:00 a.m., and 1:00 p.m. medication passes. - 10/22/24: 16 medications during the 7:00 a.m., 9:00 a.m., and 11:00 a.m. medication passes. A review of Resident #3's Progress Notes for the month of October 2024 did not include notification to the resident's primary physician regarding late administration of medications. (Photographic Evidence Obtained) An interview was conducted with the DON, ADON, and Regional Nurse, on 12/3/24 at 5:10 p.m. regarding the late medications for Residents #2 and #3 for October 2024. There was no explanation provided as to why the medications were administered late on the specific dates. A review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 9/2018 showed the following procedures under the section titled, Medication Administration, to include but not limited to: 3. Medication administration timing parameters include the following: a. Medications to be given on an empty stomach or before meals are not to be scheduled for administration 30 minutes to two hours prior to meals. b. Medications to be given with meals are to be scheduled for administration at the resident's mealtimes. c. Medications to be given after meals or with food are to be scheduled for administration immediately after and up to two hours after meals or with a snack . d. Medications to be given at bedtime are to be scheduled for administration up to one hour prior to the resident's scheduled bedtime. . 5. The person who prepares the dose for administration is the person who administers the dose. . 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtime or in the dining room unless specifically ordered with meal. The policy and procedure also revealed the following under the section titled, Documentation: 1. The individual who administers the medication dose records the administration on the residents MAR immediately following the medication being given. In no case should the individual who administered the medication report off duty without first recording the administration of any medications. A review of the facility's policy titled Physician Notification, effective October 2021, showed the following policy statement: The facility strives to ensure each resident's health is supervised by a qualified attending physician. The attending physician in the facility is ultimately responsible for supervision and management of the care of the resident/patient. A review of this policy's Procedure showed: 1. Licensed Nurses will ensure the physicians are notified of changes or diagnostic results that occur between visits. Changes may include but are not limited to: - Any time a medication is not administered as ordered. Based on observations, interviews and record review, the facility did not ensure timely administration of medications for two Residents (#2 and #3) of two Residents reviewed for receipt of prescribed medications and for two of two medication administration passes observed, resulting in thirty-one residents receiving medications outside of the facility's medication timing parameters. Findings Included: 1. A review of Resident #2's Medication Administration Audit Report for the month of October 2024 indicated the following: On 10/8/24, the following medications were scheduled to be administered at 9:00 a.m. and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg (milligrams), give 200 mg by mouth two times a day for moderate pain: Documented as administered at 10:54 a.m. - Lidocaine External patch 5%, apply to lower back topically one time a day for lower back pain, remove at 2100: Documented as administered at 10:56 a.m. - Allopurinol oral tablet 300 mg, give 1 tablet by mouth one time a day for gout: Documented as administered at 10:54 a.m. - Omeprazole oral capsule delayed release 20 mg, give 40 mg one time a day for GERD (Gastroesophageal reflux disease.): Documented as administered at 10:54 a.m. - Digoxin oral tablet 125 mcg (micrograms), give 1 tablet by mouth one time a day for Afib (Atrial Fibrillation.): Documented as administered at 10:54 a.m. On 10/8/24, the following medications were scheduled to be administered at 1700 hours (5:00 p.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg: Documented as administered at 1936 hours (7:36 p.m.) - Rivaroxaban oral tablet 20 mg, give 20 mg by mouth in the evening for Afib: Documented as administered at 1937 hours (7:37 p.m.) On 10/9/24, the following medications were scheduled to be administered at 2100 hours (9:00 p.m.) and were not documented on the Medication Administration Audit Report as administered: - Xarelto Tablet (Rivaroxaban), give 5 mg by mouth at bedtime for preventative measure. - Rosuvastatin Calcium oral tablet 5 mg, give one tablet by mouth at bedtime for HLD (Hyperlipidemia) - Metoprolol Succinate oral tablet, give 75 mg by mouth at bedtime for HTN (Hypertension). On 10/10/24, the following medications were scheduled to be administered at 1700 hours (5:00 p.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg, give 200 mg by mouth two times a day for moderate pain: Documented as administered at 0015 hours (12:15 a.m.) on 10/11/24. - Rivaroxaban oral tablet 20 mg, give 20 mg by mouth in the evening for Afib: Documented as administered at 0021 hours (12:21 a.m.) on 10/11/24. On 10/10/24, the following medications were scheduled to be administered at 2100 hours (9:00 p.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Metoprolol Succinate 25 mg oral tablet, give 75 mg by mouth at bedtime for HTN: Documented as administered at 0018 hours (12:18 a.m.) on 10/11/24. - Rosuvastatin Calcium oral tablet 5 mg, give one tablet by mouth at bedtime for HLD: Documented as administered at 0016 hours (12:16 a.m.) on 10/11/24. On 10/14/24, the following medications were scheduled to be administered at 0900 hours (9:00 a.m.) and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg, give 200 mg by mouth two times a day for moderate pain: Documented as administered at 11:05 a.m. - Lidocaine External patch 5%, apply to lower back topically one time a day for lower back pain, remove at 2100: Documented as administered at 11:06 a.m. - Allopurinol oral tablet 300 mg, give 1 tablet by mouth one time a day for gout: Documented as administered at 10:34 a.m. - Omeprazole oral capsule delayed release 20 mg, give 40 mg one time a day for GERD: Documented as administered at 11:05 a.m. - Digoxin oral tablet 125 mcg, give 1 tablet by mouth one time a day for Afib: Documented as administered at 10:34 a.m. - Spironolactone oral tablet 25 mg, give 1 tablet by mouth one time a day every Mon, Wed and Fri for HTN: Documented as administered at 10:34 a.m. A review of Resident #2's Progress Notes for the month of October 2024 did not include notification to the resident's primary physician regarding late administration of medication. (Photographic Evidence Obtained)

Based on observation, record review, and interview, the facility failed to have evidence of the provision of a summary of the baseline care plan to the resident and their representative for one (#12) of fourteen sampled residents. Findings included: On 10/17/2024 at 10:30 a.m., Resident #12 was observed in his bed with his eyes closed. An interview was conducted at this time with his spouse. Resident #12's spouse said she had not been able to receive communication about what the plan was for her husband, how long he was going to be at the facility, or what services they were going to provide to him. At approximately 10:40 a.m., Resident #12 was observed to be awake. He stated he wanted to understand the services that were to be provided to him during his stay and why he needed to be at the facility. A review of Resident #12's admission Record reflected an admission of 10/11/2024. Resident #12's diagnosis list included Urinary Tract infection, Nontoxic Multinodular goiter, and occlusion and stenosis of unspecified carotid artery. On 10/18/2024 at approximately 8:45 a.m., the Nursing Home Administrator was requested to provide a copy of Resident #12's Baseline Care Plan. On 10/18/2024 at approximately 10:45 a.m., the Director of Nursing was requested to provide a copy of the Baseline Care Plan for Resident #12 with evidence of the provision of the baseline care plan to the resident and resident's representative. On 10/18/2024 at approximately 11:12 a.m., the Traveling Minimum Data Set (MDS) Coordinator was requested to provide a copy of Resident #12's Baseline Care Plan and the parties who signed the plan. No evidence was provided during the survey to support Resident #12 and his representative had received a summary of the Baseline Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for four (#7, #8, #9, and #11) of fourteen sampled residents. Findings included: 1. On 10/17/2024 at 9:35 a.m., Resident #7 was observed in bed. He was observed curled in a fetal like position, his arm was wrapped in his leg, watching the television. He was observed to have severe contractures, and dry lips. When asked if staff put moisture product on his lips, he shook his head. When asked if he was provided pleasure foods by mouth, he stated sometimes. When asked if he was allowed to have water by mouth, he said, sometimes. He stated he would like water. He said his arm was stuck. When asked if he could use his call bell light. the resident did not answer but turned his head towards the feeding tube pole. An observation was conducted of Resident #7's call bell light laying on the floor at the bottom of the tube feeding pole. Resident #7's breakfast meal tray, untouched, was observed to be positioned on the sink counter. Photographic evidence obtained. A review of Resident #7's admission Record documented an original admission in 08/2023, and a re-admission on [DATE]. A review of Resident #7's diagnosis information included, but not limited to: Muscle wasting and atrophy, muscle weakness, Dysphagia, and Spinal Stenosis. A review of Resident #7's Care Plan on 10/18/2024 reflected no plan of care for contractures. A review of Resident #7's Care Plan reflected a focus: Nutritional: [Resident #7] has a nutritional problem or potential nutritional problem r/t needed for TF (tube feeding) support to assist with wound healing and meeting ntr (nutritional) needs, initiated on 10/17/2024. Interventions included: Provide [Resident #7] with TF using Jevity at 80 ml (milliliter)/h (hour) over 10 h infusion .Also with PO (by mouth) intake during waking hours along with supplement using Medpass 240 ml BID (two times a day) to assist in meeting nutritional needs, initiated 10/17/2024. Resident is NPO (nothing by mouth)-Do not provide food or fluids by mouth. See nurse, initiated 09/19/2024. An interview was conducted on 10/18/2024 at 11:02 a.m. with the Rehabilitation Director, PTA (Physical Therapist Assistant). Regarding Resident#7, he stated the resident was a recent admission, the resident was on case load. When asked if the aids did anything for the resident's contractures, he stated, Not right now. He is super sensitive, and we want to keep his care with us for a while. When asked how the aids provided the resident incontinence care, he stated, Unroll him, the aids have been able to provide him incontinence care; it is work in progress. An interview was conducted on 10/18/2024 at 11:12 a.m. with the Traveling Minimum Data Set (MDS) Coordinator. When asked if Resident #7 had contractures, she stated, I would have to look. She confirmed Resident #7 did not have a Care Plan Focus area for contractures. When asked about Resident #7's feeding status, she stated, He was NPO when he readmitted on [DATE]. The order was discontinued on 09/30/2024. At that point a regular puree diet came into play on 09/30/2024. For meals, he would get the normal 3 meals per day. He would continue to get the peg tube feeding also. She confirmed the Nutrition Care Plan interventions were not current. An observation of Resident #7 was conducted on 10/18/2024 at 11:35 a.m. with the Traveling MDS Coordinator. She confirmed the resident had contractures. Resident was observed to have beads of sweat on his shoulders. Resident#7's call bell light was observed on top of the tube feeding machine. Resident was observed to be unclothed, on a specialized mattress. He said he was hot, burning up. During the observation at 11:37 a.m., Staff A, Personal Care Attendant (PCA) was observed to come in the room with a cup of water. She stated she was going to provide water to the resident. Staff A was asked if Resident #7 could use the push button call bell light. Staff A stated the resident could. She was observed to remove the call light from the top of the tube feeding machine and put it close to the resident's hand. She said the nurse had just put the cord up there a minute ago. For meal assistance: On 10/18/2024 at approximately 8:45 a.m., the NHA was requested to provide a printout of Resident #7's meal consumption for the last 30 days. On 10/18/2024, the list was provided. A review of Resident #7's meal intake documentation from 09/19/2024 thru 10/17/2024, documented from 09/19/2024 through 09/28/2024, the resident was NPO, or Tube fed. The following entries were documented or not documented by staff after 09/28/2024. 09/29 8:00 a.m., Resident consumed 76-100%. 09/29 11:00 a.m., Resident consumed 76-100%. 09/29 evening, No documentation. 09/30 No documentation. 10/01 morning, No documentation. 10/01 noon, No documentation. 10/01 18:03 (6:03 p.m.), Resident consumed 0-25% 10/02 8:00 a.m., Resident consumed 76-100% 10/02 11:30 a.m., Resident consumed 76-100%. 10/02 evening, No documentation. 10/03 morning, No documentation. 10/03 14:20 (2:20 p.m.), Resident consumed 76-100%. 10/03 22:38 (10:38 p.m.), Resident consumed 76-100%. 10/04 morning, No documentation. 10/04 14:35 (2:35 p.m.) Resident consumed 0-25% 10/05 9:35 a.m., Resident consumed 76-100%. 10/05 noon, No documentation. 10/05 evening, No documentation. 10/06 8:00 a.m., Resident consumed 76-100%. 10/06 11:30 a.m., Resident consumed 76-100%. 10/06 18:40. (6:40 p.m.), Resident consumed 76-100%. 10/07 8:00 a.m., Resident consumed 76-100%. 10/07 11:30 a.m., Resident consumed 0-25%. 10/07 22:08 (10:08 p.m.), Resident consumed 0-25%. 10/08, morning and noon, No documentation. 10/08 22:26 (10:26 p.m.). Resident consumed 76-100%. 10/09 morning and noon, No documentation. 10/09 21:40 (9:40 p.m.) resident refused. 10/10 through 10/14, No documentation. 10/15 8:00 a.m. and 11:30 a.m., resident refused. 10/15 20:12 (8:12 p.m.), Resident consumed 0-25%. 10/16 10:28, Resident consumed 0-25%. 10/16 13:32 (1:32 p.m.), Resident consumed 76-100% 10/16 19:28 (7:28 p.m.), Resident consumed 76-100% 10/17 morning, No documentation. 10/17 12:24, Resident consumed 51-75% 10/17 12:27, Resident consumed 26-50% 10/17 evening, No documentation. Days reviewed, 09/29 through 10/17=19 days. Meal opportunities=19 x 3 = 57 meals 23 meals were documented to be offered. 34 meals had no documentation of being offered. A tour of the facility was initiated on 10/17/2024 at 9:32 a.m. The following observations were conducted during the tour. 2. On 10/17/2024 at 10:06 a.m., an observation was conducted of Resident #8, laying in her bed. She confirmed she could use the call bell light, but she could not reach it. Her call bell light cord was observed looped over the bed's right-side rail with the call light button hanging down to the bottom of the side rail. The bed was observed to have padding on the side rail which would prevent access to the call bell light cord. A review of Resident #8's clinical record, the admission Record, reflected a re-admission of 06/10/2024. Her diagnosis list included but not limited to: Cerebral Infarction due to embolism of other cerebral artery, chronic obstructive pulmonary disease, and Dysphagia. A review of Resident #8's Care Plan, listed a focus area, Fall: [Resident #8] has had a fall because of history of falls . Interventions included: Provide environmental adaptions: Call light, frequently used items within reach . initiated 12/11/2022, updated 01/08/2023. 3. In the same room, Resident #9, was observed laying in her bed, eyes open, greeted the surveyor. The call light cord and button were observed on the floor. A review of Resident #9's clinical record, the admission Record, reflected an admission in 06/2023. Her diagnosis list included but not limited to: Hemiplegia and Hemiparesis following cerebral infarction affecting left non dominant side and need for assistance with personal care. A review of Resident #9's Care Plan, listed a focus area, Fall: [Resident #9] had a fall injury because of: Deconditioning, Gait/balance problems, medications, initiated 06/23/2023. Interventions included: Provide environmental adaptions: Call light within reach, initiated 06/29/2023. 4. On 10/17/2024 at 10:24 a.m., Resident #11 was observed in bed with his eyes closed. His call bell light cord and button were observed to be laying on the floor. A review of Resident #11's clinical record, the admission Record, reflected a re-admission of 06/19/2023. Her diagnosis list included but not limited to: Unspecified Dementia, and muscle wasting. A review of Resident #11's Care Plan, listed a focus area, Fall: [Resident #11] is at risk for falls or fall related injuries d/t (due to) her dx (diagnosis) of dementia . Interventions included: Provide environmental adaptions: Call light within reach, initiated 01/04/2021. An interview was conducted on 10/18/2024 at approximately 10:45 a.m. with the Director of Nursing. She confirmed it was her expectation that the call bell light should be placed within reach of the resident, for every resident. She confirmed for a cognitively impaired resident it was important to be within reach. If they need help, they can call for help. Photographic evidence obtained. A review of the facility's Care Plan-Interdisciplinary Plan of Care from Interim to Meeting policy & procedure, effective February 2024, documented the policy: The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but not limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives, and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a timely respiratory assessment and care in accordance with professional standards of practice for one (#2) of three sampled residents related to an assessment of a resident in distress. Findings included: Resident #2 was admitted on [DATE] and discharged on 09/15/2024. Review of the Admissions Record showed the diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD), acute and chronic respiratory failure with hypercapnia, dependent on oxygen, pleural effusion, pulmonary hypertension, Hypertension, and Asthma. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 or cognitively intact. Review of Section GG, Functional Abilities and Goals showed substantial to maximum assistance for bathing. Section O, Special Treatments, Procedures, and Programs showed C1. oxygen therapy. G1. Non-invasive mechanical ventilator was blank (BIPAP/ Bi-level positive airway pressure and CPAP/ Continuous positive airway pressure). Review of the Hospital Records 08/21/2024 to 08/27/2024 showed a progress note dated 08/27/2024 that the patient has had recurrent admissions for this. There is poor compliance at home. Reports no CPAP use with naps and minimal at night as she only wears for short periods as she stated does not sleep well at night. Wean oxygen to keep sats 89 or above and use BIPAP nightly which we will order here. Continue BIPAP at night. Would benefit at home. Discussed importance of home CPAP compliance with sleeping at night and daytime with naps. Review of the physician orders and August and September Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed Resident #2's scheduled 09/15/2024 9:00 a.m. medications were given at 10:01 a.m. per the September MAR by Staff B, RN (Registered Nurse) Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML every 6 hours as needed was given on 09/15/2024 at 10:30 a.m. per the September MAR by Staff B, RN No physician orders for a CPAP machine were found in the physician orders or in the August or September TAR. Review of the nursing progress notes showed On 09/14/2024 at 5:40 p.m., Resident presented with shortness of breath (SOB) and elevated B/P (blood pressure). Physician's office was called to report patient's change in condition and new orders given for Clonidine 0.5mg (milligram) stat by mouth and routine daily and hold for Systolic blood pressure under 140. Blood pressure showed 171/98. On 09/15/2024, at 10:30 a.m., Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) give 1 inhalation by mouth every 6 hours as needed for SOB. On 09/15/2024 at 11:21 a.m., Hospital Transfer Evaluation Summary showed: BP 175/89 - 9/15/2024 10:19 a.m. Position: Lying right arm; Pulse 78 - 9/15/2024 10:30 a.m. Pulse Type: Regular; Respirations 32.0 - 9/15/2024 10:30 a.m.; O2 99.0 % - 9/15/2024 01:53 a.m. Method: Oxygen via Nasal Cannula; Report completed by Staff B, LPN and Report called in by Staff B, LPN; Report called in to: 911. On 09/15/2024, at 11:28 a.m., Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML give 1 inhalation by mouth every 6 hours as needed for SOB was ineffective, resident was sent to hospital, MD (Medical Doctor) notified. On 09/15/2024 at 1:25 p.m. Resident presented with high blood pressure, 175/89 and SOB. Resident was given blood pressure medication and PRN Albuterol solution via nebulizer, and inhaler that was scheduled by mouth. At this time resident was available to take medication by mouth, during the morning. Writer noticed that no medication was successful, that she needed medical attention, and resident was being sent to the hospital for further evaluation and treatment. Spouse was called with no answer back. MD from ER (Emergency Room) called to verify resident's spouse telephone number. Dr. does not have at this time a communication with spouse. No answer to MD telephone calls. On 09/15/2024 at 2:04 p.m. Resident MD was notified that resident was sent to the hospital. Review of the Weights and Vitals Summary showed Blood pressure On 09/09/2024 at 11:51 a.m. was 132/76 On 09/14/2024 at 5:40 p.m. was 171/98 On 09/14/2024 at 6:32 p.m. was 171/98 On 09/15/2024 at 10:19 a.m. was 175/89 Respirations On 09/15/2024 at 1:53 a.m. was 18 On 09/15/2024 at 10:30 a.m. was 32 On 09/15/2024 at 10:40 a.m. was 34 O2 saturation On 09/15/2024 at 1:53 a.m. was 99% On 09/15/2024 at 10:40 a.m. was 95% Review of care plans showed Resident #2 was on oxygen therapy related to COPD, pulmonary hypertension, pleural effusion, asthma revised on 09/09/2024. Interventions included but not limited to administer oxygen as ordered, report changes in respiratory status to physician. Resident #2 had an emphysema/COPD care plan revised on 09/09/2024. Interventions included but not limited to give aerosol or bronchodilators as ordered; Monitor/document any side effects and effectiveness. Give oxygen therapy as ordered by the physician; Monitor for difficulty breathing (dyspnea) on exertion.; monitor for signs and symptoms of respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest, cyanosis, somnolence; monitor/document/report to MD prn any signs / symptoms of respiratory infection. During an interview on 10/17/2024 at 12:10 p.m. Staff A, PCA (Patient Care Assistant) stated, I was passing [Resident #2] her breakfast tray, it was around 7 [a.m.] something. She did not look her usual. Something was off. Staff A stated she walked in the room, she was breathing funny to me. Staff A stated she went to the supervisor, (Staff C, LPN / Weekend supervisor) and told her Resident #2 looked like something was wrong. Staff A stated Staff C brushed me off. Staff C told Staff A, the resident has a UTI. Staff A stated to Staff C, She looks funny can you come check on her? She (Staff C) brushed me off. Staff A stated she finished passing the trays. Staff A went back to check on the resident and she was still the same. Staff A stated it was about 20 minutes later that she checked on Resident #2. Staff A stated, She was still breathing funny, not too good. Her oxygen was on. She was gasping. Staff A stated she went back to Staff C and told her again. Staff A asked Staff C, Can you please check on her, I think something is wrong. She told me, you need to worry about your residents. She is not yours. Worry about your hallway, do what you need to do. Staff A stated, Once that happen, I went and got Staff B, RN (Registered Nurse), she was the nurse that was on my hallway, 200 hallway. Staff A asked Staff B, Can you go check on 18? I told her the same story, something is off. Gasping for air. Staff B went in and told Staff C something was wrong. Staff C had been sitting at the nursing station the whole time. She was still sitting there. Staff A stated, Staff B took charge of the resident. Staff A stated that Staff B told her that the resident needed to be sent out. Staff A, stated, Staff C did not budge until the family got here. Staff A, PCA stated Staff C, LPN made up a story to the family and told them that she had told the other nurse (Staff B) the resident needed to go out. Staff A stated that Staff C did not do anything, she did not leave the desk. Staff B took charge, from another hallway. Staff B told Staff A she would take care of it. Staff A stated she saw the EMS and family in the room. The DON asked Staff A, PCT about what happened the next day and I told them the same thing I told you. Staff A stated, I believe Staff B, RN told the DON. During an interview on 10/18/2024 at 9:57 a.m. with Staff B, Registered Nurse (RN), she stated she was the nurse caring for Resident #2 on 09/15/2024. She stated she performed rounds around 7 a.m. Resident #2 was alert and responding at that time. Staff B stated the resident took her morning medications that morning, but she did not remember the exact time. Staff B stated Resident #2's vital signs were normal. The resident's family was not there when she took the resident's medications in. Staff B stated the family was there when she went back to check on the resident and give her a nebulizer treatment. Staff B stated she was waiting for a change (after the nebulizer treatment), but no change occurred, so she sent the resident to the hospital. Staff B stated the resident was not doing well on her second round. Staff B stated an aide told her the resident was not doing well. Staff B stated she did not remember who the aide was that day. Staff B stated that the resident, was not really gasping for air, not really. Staff B stated the resident needed the nebulizer and then she called the doctor. The doctor said to send the resident to the hospital. Staff B stated the resident was on her oxygen. Staff B stated she assessed the resident the first time (she made rounds), took her vital signs at the time she gave the resident her regular medications (10:01 a.m. based on MAR). Staff B stated before the medications were given, she checked the vitals. Staff B stated the resident was breathing okay when she gave her the medications. Staff B stated the aide told her the resident was not feeling well and Staff B stated she, went back again. Staff B stated, when I made the decision to send to hospital, send her to hospital. Staff B stated that Staff C, LPN (Licensed Practical Nurse / Weekend Supervisor) was sitting at the nursing station when she reported she was sending Resident #2 to the hospital. Staff B stated that Staff C was not at the reception desk (out front). Staff B stated she does not know if the aide spoke with Staff C, LPN or not. Staff B stated Staff A, PCA came and got her. Staff B stated the DON (Director of Nursing) did not talk to her about the incident. Staff B stated we gave a report to the DON that day, we do when we send someone to the hospital. Staff B stated she did not remember the resident's vital signs. Staff B stated the resident was her normal color and not gasping. Staff B stated the resident had COPD or asthma. Staff B stated the resident's family member came in after her morning medications were given. Staff B stated when she went back to give the nebulizer, the family member was there. Staff B stated during the nebulizer treatment two other family members came in. The second family members asked if I was going to send the resident to the hospital, and I said, Yes, going to call 911. Staff B stated she notified the doctor that she was sending the resident to the hospital. Staff B stated she went in to see the resident around 7:30 a.m. and she was in bed. Staff B stated, Do not recall what she looked like, had her a couple of time before, not really changed from prior. Staff B stated when giving the resident her meds, she was ok, gave them in pudding, ok. Staff B stated, She was declined that morning. She had a couple of words, yes or no. Staff B stated, at 7:30 a.m. she was fine, At approximately 9 a.m. I noticed she was in a little distressed, a family member was feeding her, gave her a breathing treatment. Staff B stated, I am a nurse. I know when my resident has a change in condition. She had an increased respiration rate, no sounds. Breathing not well. Staff B stated an aide [Staff A] came and told her So and so does not look good, I went back and gave her a nebulizer. Staff B stated she did not remember if the resident was on the aide's assignment or not. Staff B stated, I made my first rounds and gave the 9 a.m. meds. The aide came and got me and assessed her and she needed a nebulizer treatment. Staff B stated, I don't remember or know if the aide talked to Staff C LPN about the resident, only what I did. Staff B stated Staff C helped with the paperwork. During an interview on 10/17/2024 at 4:28 p.m., Staff C LPN / Weekend Supervisor stated she had never been Resident #2's nurse. Staff C stated, The nurse, cannot remember who it was, reported to me if they are going to send someone out. She was not looking good. Her O2 sats were low. She (Staff B) did not tell me the number. I said, fine, it was a nurse judgment. We started the paperwork; I usually print the paperwork off and help them out. Staff C, stated, I then reported to the DON, we sent her out. When I went to the nursing station, the nurse was already in the process. I don't know who it was, just who had her that day as the nurse. Staff C, stated, I was sitting up front in the reception area; we don't have a receptionist on the weekend. I do know earlier the family came in. I cannot even tell you the time frame. Activities usually comes in about 11 and it was before then. Staff C stated, If the nurse asks me to come in (the room), I will. I cannot recall if I went into the (resident's) room. The nurse came to the reception area and told me she needed to send her out. Only thing I remember is the family came to the reception and said they wanted to send her out. The family met me in the hallway, they were irate. Staff C stated, the family stated, We want her to go out, out now. It went very fast. I jumped up and assisted my nurse, it went so fast. Assisted the nurse by getting the paperwork. The nurse did tell me she was sending her out because she was having problem breathing. EMS came in, I did not let EMS in. Staff C stated she was at the south hall nursing station. Staff C stated, If someone is having problems with breathing or doesn't look right. Normally take the vital, O2 sats. Staff C stated if the resident was in distress, and had no oxygen on, would apply, call the MD and let them know. If the resident had COPD, the protocol would be to give a breathing treatment, if needed. Staff C stated, If having distress, give immediate care. Make sure they are breathing, airway is open. Staff C stated her expectation was for an assessment to be done and documented and if they report to her as the manager. Staff C stated, My nurse should have done an assessment, especially that nurse. She is not a brand-new nurse. If she reports to me not looking good, I assume she has already done the protocol of vitals, oxygen, call MD, pulse ox. I am the last call; I help to send resident out to hospital. Staff C, LPN stated, I don't recall. (anyone asking her about the incident). Staff C stated, When I called the DON, she asks me why. I told her. The next day, I don't remember writing a statement about the day. During an interview on 10/17/2024 at 2:00 p.m. the DON verified that Staff B, RN was assigned to Resident #2 on 09/15/2024. She also verified Staff C, LPN weekend supervisor was the charge nurse that day. During an interview on 10/17/2024 at 3:45 p.m. the DON stated they were unable to locate the admitting chart (chart with the hospital admission paperwork). During an interview on 10/18/2024 at 10:30 a.m. the DON stated Staff C, LPN / weekend supervisor calls when someone goes out on the weekend. The DON stated they had to send the resident out. The DON stated that Staff C told her The aide came and got me and said she (Resident #2) does not look good. The DON stated that Staff C told her, She [Staff C] assessed the resident and went and got Staff B, RN and they went in and assessed the resident together and agreed the resident needed to go out. The DON stated she did not know the time of the incident. The DON stated, I spoke with Staff B the next time she worked, Staff B told me 'When the aide got me, as soon as she got to the room, she knew she was in distress'. The DON stated Staff B got vitals; she did tell me her O2. The DON stated she did not remember what it was. The O2 was low, and they decided to get her out. The DON stated during the first conversation with Staff C, she explained that the family was in the room at the time. Staff C informed me Staff B and her [Staff C] both assessed the resident. DON stated, I don't know if Staff C went in first and then Staff B or what, I know they both assessed the resident. The DON stated she did not speak with the aide. The DON stated she knew now who the aide was, but not then. The DON stated, That is all I know; the resident was in distress and sent her out 911. Good call on the CNA. The DON stated, They review the chart on hospitalizations in the clinical meetings. When someone is transferred out, we have a clinical meeting the next day. If it was Saturday, it would have been discussed on Monday. Neither of the nurses involved were involved in the discussions. The weekly Unit Manager was involved. I remember when we reviewed the chart, they tried to call the husband at the time of the event, but was unable to get a hold of him, per the chart. The DON stated that an event was not documented. The DON stated, I did speak with Staff C and Staff B but did not write it down. The DON stated the family did not complain to her. The DON stated, Staff B and Staff C did not say they (the family) complained to them about her (the resident). The DON stated she had a spouse which came to the care planning meetings and another family member. The DON stated they found during an informal investigation they did the right thing. Her vitals were irregular. The DON stated, Just went by what Staff C and Staff B said, not the aide. The DON stated she would have to go see if they had orders for the CPAP machine and if it had been ordered. The DON stated, she can only go by what was told to her. During an interview on 10/18/2024 at 11:45 a.m. Staff E, Traveling MDS stated that Non-invasive Mechanical Ventilator under section O included BPAP and CPAP machines on this MDS due to the type of payor source. If the resident was Medicare, it would be more specific and include BPAP and / or CPAP. If ordered would be in the physician's orders and signed off on the TAR as performed. Staff E stated you would see on the TAR and check it off that way. Staff E reviewed TAR and verified she did not see an order for a BIPAP or CPAP for August and September 2024. During an interview on 10/18/2024 at 11:00 a.m. the DON stated on 10/18/2024 at 11:00 a.m. the facility had to call the hospital for the medication discharge report for the 08/27/2024 admission. They were unable to locate them in the facility. During an interview on 10/18/2024 at 11:52 a.m. the DON stated a CPAP was ordered on 08/29/2024. The DON stated Resident #2 was the only one admitted around that time, so it must be hers. The spreads sheet did not show it was specifically for that resident. The DON stated she had not looked to see if there was an order written for the CPAP. The DON stated she did not go into the resident's room to see if the equipment arrived. The DON stated it must have been sent back. During an interview on 10/18/2024 at 1:05 p.m. the DON verified the MAR showed the 09/15/2024 meds were given at 10:01 a.m. by the nurse (Staff B) and the nebulizer was given at 10:30 a.m. During an interview on 10/18/2024 at 2:00 p.m. the DON stated, Her expectation was for the nurse to assess the resident, get the resident out 911. The DON stated when we call 911, the nurse available gave EMS report. They send the face sheet, order summary, Do Not Resuscitate order, and transfer orders (with the resident). They follow-up with the hospital afterwards to get the admitting diagnosis. The DON stated someone did the paperwork, someone called the doctor, and someone would take care of the resident. Vital signs and a head-to-toe assessment were done. The nurses called the DON if she was not here. She stated all shifts called her. The next day they did the clinical meeting. Review of the facility's policy, Physician Orders, dated October 2021 showed at the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit. 16. The night shift nurses will verify orders received within the last 24 hours have been transcribed into the electronic record. The nurse will review each hard chart for new orders and compare to the electronic order listing report to ensure each written order has been entered into the electronic medical record. Review of the facility's policy, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, dated February 2024 showed the facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence. Managing risk factors to the extent possible or indicating the limits of such interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the clinical record contained documentation of the services provided for meal consumption for one (#7) of fourteen sampled residents. Findings included: 1. On 10/17/2024 at 9:35 a.m., Resident #7 was observed in bed. He was observed to have severe contractions, curled in a fetal like position. Resident #7 was able to answer questions. When asked if he was provided pleasure foods by mouth, he stated sometimes. When asked if he was allowed to have water by mouth, he said, sometimes. He stated he would like water. Resident #7's breakfast meal tray was observed to be positioned on the sink counter. The meal tray was observed to be untouched. A review of Resident #7's admission Record documented an original admission in 08/2023, and a re-admission on [DATE]. Resident #7's diagnosis information included, but not limited to: Muscle wasting and atrophy, muscle weakness, Dysphagia, and Spinal Stenosis. A review of Resident #7's Care Plan reflected a focus: Nutritional: [Resident #7] has a nutritional problem or potential nutritional problem r/t needed for TF (tube feeding) support to assist with wound healing and meeting ntr (nutritional) needs, initiated on 10/17/2024. Interventions included: Provide (Resident #7 with TF using Jevity at 80 ml (milliliter)/h (hour) over 10 h infusion .Also with PO (by mouth) intake during waking hours along with supplement using Medpass 240 ml BID (two times a day) to assist in meeting nutritional needs, initiated 10/17/2024. Resident is NPO (nothing by mouth)-Do not provide food or fluids by mouth. See nurse, initiated 09/19/2024. On 10/18/2024 at approximately 8:45 a.m., the NHA was requested to provide a printout of Resident #7's meal consumption for the last 30 days. A review of Resident #7's meal intake documentation from 09/19/2024 thru 10/17/2024, documented from 09/19/2024 through 09/28/2024, the resident was NPO, or Tube fed. The following meal consumptions were not documented by staff after 09/28/2024. 09/29, evening, No documentation. 09/30, No documentation. 10/01, morning, No documentation. 10/01, noon, No documentation. 10/02, evening, No documentation. 10/03, morning, No documentation. 10/04, morning, No documentation. 10/05, noon, No documentation. 10/05, evening, No documentation. 10/08, morning and noon, No documentation. 10/09, morning and noon, No documentation. 10/10 through 10/14, No documentation. 10/17, morning, No documentation. 10/17, evening, No documentation. Days reviewed, 09/29 through 10/17=19 days. Meal opportunities=19 x 3 = 57 meals. 34 meals had no documentation of being offered. On 10/18/2024 at approximately 10:45 a.m. an interview was conducted with the Director of Nursing (DON). She stated for Resident #7 we were doing eat and tube feed. She confirmed the aides could feed Resident #7. Yes, the staff are supposed to document what the resident eats for the meal. She confirmed the aides should document a refusal of the meal also. A review of Resident #7's meal documentation was conducted with the DON. She confirmed the documentation for the last 30 days did not consistently document the offering of three meals a day for Resident #7.

Based on observation, and interview, the facility failed to ensure adequate placement of call assistance equipment to call for staff assistance for six (#7, #8, #9, #10, #11, and #13) of fourteen sampled residents. Findings include: A tour of the facility was initiated on 10/17/2024 at 9:32 a.m. The following observations were conducted during the tour. During an observation on 10/17/2024 at 9:35 a.m., Resident #7 was seen in bed with severe contractures of his arms and legs, curled in a fetal like position, and with his arm wrapped in his leg. He was observed watching television. Resident #7 was able to answer questions. When asked if he could use his call bell light. the resident did not answer but turned his head towards the feeding tube pole. An observation was conducted of Resident #7's call bell light laying on the floor at the bottom of the tube feeding pole. Photographic evidence obtained. Resident's call bell light was observed to be a push button type call bell that would require dexterity of the hand to hold and depress the button. On 10/17/2024 at 10:06 a.m., an observation was conducted of Resident #8, laying in her bed. She confirmed she could use the call bell light, but she could not reach it. Her call bell light cord was observed looped over the bed's right-side rail with the call light button hanging down to the bottom of the side rail. The bed was observed to have padding on the side rail which would prevent access to the call bell light cord. In the same room, Resident #9, was observed laying in her bed with her eyes open. She greeted the surveyor. The call light cord and button were observed on the floor. On 10/17/2024 at 10:15 a.m., an observation was conducted of Resident #10, in bed with his hand on his chest. He stated his chest hurt. His call bell light was observed wrapped around the bottom leg of his bed. On 10/17/2024 at approximately 10:17 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She was observed working at a medication cart outside of Resident #10's bedroom. She stated she had just provided Resident #10 with Tylenol. On 10/17/2024 at 10:24 a.m., Resident #11 was observed in bed with his eyes closed. His call bell light cord and button were observed to be laying on the floor. On 10/17/2024 at 10:45 a.m., Resident #13 was observed in bed, eyes closed. Observed his call bell light cord and button on the floor under a plastic hygiene bowl, at the foot of the tube feeding pole. An interview was conducted on 10/18/2024 at approximately 10:45 a.m. with the Director of Nursing. She confirmed it was her expectation that the call bell light should be placed within reach of the resident, for every resident. She confirmed for a cognitively impaired resident it was important to be within reach. If they need help, they can call for help.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to give the opportunity to choose urinal placement and length of the bed frame for one (Resident #104) of one resident sampled. An interview was conducted with Resident #104 on 5/13/2024 at 10:30 a.m. He stated he did not want the urinal on the over the bed table all of the time. He said he was able to smell the urine all the time, even when the urinal was empty. He said he had numerous conversations with personnel in the past. He stated there was not anywhere else for the urinal to be placed without having to call for assistance. He stated, They [the facility] doesn't have a place for the urinal and they don't listen, I have told them numerous times and continue to tell them, I don't like to eat with the urinal next to my tray. He stated he needed a longer bed due to his height, as his feet were always pressing on the footboard. He said the nurse told him nothing could be done and placed a pillow under his feet. On 5/13/2024 at 12:18 p.m. and 5/15/2024 at 8:30 a.m., Resident #104's urinal was on the over bed table with the meal tray and the resident's feet were pressed to the footboard. An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 5/13/2024 at 10:56 a.m. Staff L said nothing could be done with the length of the bed, [the nursing staff] just put a pillow underneath the feet to ensure no breakdown. An interview was conducted with Staff M, Certified Nursing Assistant (CNA) on 5/14/2024 at 1:25 p.m. She said she understood Resident #104 wanted the urinal placed on the over bed table, she was just not sure what the answer was. Staff M confirmed Resident #104's feet were on the footboard normally and again not sure what could be done. An interview was conducted with Staff J, CNA on 5/15/2024 at 2:32 p.m. Staff J confirmed Resident #104 had requested to have the urinal placed elsewhere although there was no other option, so we ended up leaving the urinal on the over bed table. Staff J, CNA stated the resident's bed was probably too short but did not know what to do about, as the nurse knew. An interview was conducted with Staff G, Registered Nurse (RN) on 5/15/2024 at 3:18 p.m. Staff G confirmed Resident #104's urinal on the over the bed tray and there was not really anywhere else to place it and the bed could be longer. A review of the facility grievance log revealed no grievances were filed for Resident #104, during the months of April and May 2024. An interview was conducted with the SSD (Social Service Director) on 5/15/2024 at 12:05 p.m. The SSD confirmed there were no grievances filed for Resident #104. The SSD stated the resident requests should be honored, if possible and care planned. An interview was conducted with the DON (Director of Nursing) on 5/16/2024 at 11:15 a.m. The DON stated she did not know the resident wanted a longer bed and urinal placement changed. The DON said she did not know why the resident's request was not facilitated. Review of Resident #104's admission Record showed the resident was admitted on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, left foot drop, anxiety disorder, neuropathy unspecified, chronic kidney disease and other co-morbidities. Review of Minimum Data Set (MDS), Section C Cognitive Pattern, dated 4/20/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which meant the resident was cognitively intact. A policy for choices or accommodation of need was requested. No policies were produced at the time of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two (Residents #24 and #17) of twenty-six sampled residents. Finding include: During an observation and interview on 05/13/24 at 10:45 a.m., Resident #24 was sitting up in his bed eating peanuts. He said his left hand was contracted. He said he wore a splint on his left hand, but staff had not assisted him with putting it on. He said sometimes he refused to put his splint on because it hurt his hand. Review of an admission Record dated 05/15/2024 showed Resident # 24 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Left Non- Dominant Side, Major Depressive Disorder, Recurrent, Unspecified, Bipolar Disorder, Unspecified. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Further review of the MDS section GG for Functional Abilities and Goals showed section GG0115 coded to indicate Resident # 24 did not have any upper extremity impairment. During an interview on 05/16/2024 at 2:00 p.m. with Staff A, Registered Nurse/ Clinical Reimbursement Specialist, she stated the facility did not have a restorative therapy program at that time to assist with putting splints on residents with contractions. She said [Resident #24] had an upper extremity impairment due to left hemiparesis. Staff A stated, I should have identified this on his MDS assessment. This was a mistake on my part. During an interview on 05/16/2024 at 2:00 p.m. with the Director of Nurses (DON), she stated her expectations were that residents' MDS was coded accurately. Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument, RAI showed If, the resident can perform all arm, hand, and leg motions on the right side, with smooth coordinated movements. They can perform grooming activities (e.g., brush their teeth, comb their hair) with their right upper extremity and are also able to pivot to their wheelchair with the assistance of one person. They are, however, unable to voluntarily move their left side (limited arm, hand, and leg motion), as they have a flaccid left hemiparesis from a prior stroke. Coding: GG0115A would be coded 1, upper-extremity impairment on one side. GG0115B would be coded 1, lower-extremity impairment on one side. Rationale: Impairment due to left hemiparesis affects both upper and lower extremities on one side. Even though this resident has limited ROM that impairs function on the left side, as indicated above, the resident can perform ROM fully on the right side. Even though there is impairment on one side, the facility should always attempt to provide the resident with assistive devices or physical assistance that allows the resident to be as independent as possible. https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual On 5/13/2024 at 11:50 a.m., Resident #17 was observed in the north unit dining room with a bed sheet over the wheelchair. Resident #17 was sitting in the wheelchair, both legs bent and feet were resting on the seat cushion. Resident #17 did not respond to questions. An interview was conducted with Staff M, Certified Nursing Assistant (CNA) on 5/13/2024 at 11:54 a.m. Staff M stated Resident #17 sat like that all of the time. Staff M stated Resident #17 made it very clear if anything was needed. Resident #17 was originally admitted on [DATE] with a recent readmission of 6/7/2023 with diagnoses of Secondary Parkinsonism, psychosis, seizures, recurrent major depressive disorder, epilepsy, Bipolar disorder, Schizoaffective Disorder, Paranoid personality disorder, Hypertension and other co-morbidities. Review of Resident #17's chart showed a Pre-admission Screening and Resident Review (PASRR) Level II dated 6/4/2021. Review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/9/2023 revealed Section A for PASRR not marked, indicating Resident #17 does not have a Level II PASRR, nor were Resident #17's conditions marked. Section E. Behavior revealed Resident #17 had no potential for psychosis (hallucinations, and delusions). During an interview on 5/16/2024 at 9:09 a.m. with Staff A, Registered Nurse/Clinical Reimbursement Director (CRD), She stated she was responsible for completing the MDS. Staff A verified the resident had a PASRR Level II and had one prior to the completion of the MDS and verified that the Level II PASRR section was inaccurately coded. During an interview on 5/16/2024 at 11:30 a.m. the Director of Nursing (DON) stated her expectation on accuracy of the MDS was important. Review of the facility Policy and Procedure titled: Resident Assessment Instrument: MDS Section Completion by Discipline, with an effective date of October 2023 revealed: Overview: The Interdisciplinary Team members participate in the Resident Assessment Instrument to assess each Resident's individual needs and strengths through an approach that assesses problems or conditions and collaboration on appropriate interventions to achieve a Resident's highest level of functioning possible and maintain their sense of individuality. Guidelines: 1. The resident assessment instrument will be coordinated by a registered nurse that signs and certifies the completion of the assessments. 2. Interdisciplinary Team members participating in the MDS completion process are responsible sign the MDS (physical signature or per electronic signature policy), designate their professional title and date the interview or MDS on date data was gathered on, enter the MDS data into the appropriate sections of the MDS software system and complete corresponding care plan updates, revisions, or reviews in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan related to trauma informed care for one (Resident #103) out of 37 sampled residents. Findings included: Review of Resident #103's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to post traumatic stress disorder (PTSD), schizoaffective disorder, bipolar type, major depressive disorder, and adjustment disorder with anxiety. An interview was conducted on 05/13/24 at 3:40 p.m. with Resident #103. She confirmed she had PTSD but declined to give details about the PTSD. She gave permission to ask the staff and review her record related to the details. She said she saw psychiatry and psychology every week. She said they also gave her medication for it and she felt it helped. Review of Resident #103's physician orders showed an order with a start date of 4/5/24, without an end date, for Prazosin HCl Oral Capsule (Prazosin HCl). Give 3 mg by mouth at bedtime for PTSD related nightmares. Review of Resident #103's medical record did not show an assessment for PTSD. Review of Resident #103's Psychosocial History and Assessment dated 3/15/24 showed .12. Trauma Informed Care 1. Has the resident ever been diagnosed with PTSD (Post Traumatic Stress Disorder), had a life altering event or life changing event? No. Review of Resident #103's Care plans did not reveal a care plan related to PTSD. Review of Resident #103's Psych note dated 5/10/2024 showed .She also acknowledges that a book that she likes to read has helped her understand her PTSD and other trauma. She denies any specific new appetite changes and agrees to maintain the current regimen and ongoing plan . An interview was conducted on 05/16/24 at 8:50 a.m. with the Director of Nursing (DON). She said she was not aware Resident #103 had PTSD until last night (5/15/24). She said there should be a care plan in place related to her PTSD. She said the resident did not come in with many diagnoses because she came from the streets. An interview was conducted on 05/16/24 at 9:09 a.m. with Staff A, RN, Clinical Reimbursement Director. She said when the nurses did the admission assessment that triggered the baseline care plan, she confirmed the PTSD diagnosis was documented in Resident #103's chart. The Social Services Director completed a Psychosocial History and Assessment. PTSD should be identified in the assessment and from that assessment a trauma informed care plan should be developed to identify the resident's trigger. She said, it's a cumulative effort with social services, psych physician, and nursing but Resident #103 has been stable since she has been with us. She said, I have not spoken with the psych doctor about her PTSD. She reviewed Resident #103's care plans and confirmed she did not have a trauma informed care plan in place. Review of the facility's Trauma Informed Care, undated, revealed Policy: The facility will provide services for residents who have experienced mental or psychosocial adjustment difficulty, or who have a history of trauma or have diagnosis of post-traumatic stress disorder (PTSD). Purpose: To ensure that residents who are trauma survivors receive culturally sensitive, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Activities of Daily Living ADL grooming was provided for one (Resident # 101) out of eight residents sampled. Findings include: During observations made on 05/13/2024 at 10:30 a.m. and on 05/14/2024 at 3:00 p.m., Resident #101 was observed laying down in his bed with his call light within reach, dressed in his nightgown. He was observed with some missing teeth in his mouth and facial hair. The resident's room was observed well-lit and with a homelike environment. Review of Resident #101's admission Record dated 05/16/2024 showed Resident #101 was admitted on [DATE] with diagnose to included but not limited to respiratory disorder in diseases classified elsewhere, other reduced mobility, and need for assistance with personal care. Review of a Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident 101 was unable to complete the interview. Review of a care plan focusing on Activity of Daily living (ADL) dated 2/27/24 and revised 5/16/24, showed Resident #101 had an ADL self-care Performance Deficit. Review of the care plan interventions showed no interventions related to the resident's hygiene. During an interview on 05/16/2024 at 12:00 p.m., with Staff J, Certified Nursing Assistant (CNA), Staff J said she did not shave Resident # 101 because he did not ask her to shave him. She stated she only provided the resident with shaving assistance when he asked her. During an interview on 05/16/2024 at 3:00 p.m., with the Director of Nursing (DON), she stated her expectation was that staff assisted their resident with personal hygiene care whether the resident asked for assistance or not, especially if the resident was not independent with care. If the resident was refusing care, the CNA should report the resident's refusal to their nurse so that the situation could be addressed. Review of the Certified Nursing Assistant (CNA) Job Description dated 07/01/2019 showed Essential Duties and Responsibilities (To be completed without harming or injuring the resident/patient, co-works, self, or others): Direct care responsibilities: Ensure resident's personal care needs are being met in accordance with the resident's/ patient's wishes. Shaves patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to 1. transportation for coordination of care to their doctors' appointment for four (Residents # 209, #33, #7, and #58) out of 10 residents sampled and 2. application of a medication patch for one (Resident #81) of one sampled resident. Findings include: During an observation on 05/13/2024 at 10:00 a.m., Resident #209 was observed dressed in a nightgown, sitting in her wheelchair in her room. She was observed with soiled bandages on her right and left foot. Resident said she had been up since 9:00 a.m. this morning waiting to go to her appointment for her skin grafts on her feet. She said she had missed a couple of appointments already because transportation did not always show up to pick her up for her appointments. During an observation on 5/13/2024 at 1:00 p.m., Resident #209 was observed sitting in her room in her wheelchair, with signs of distress. She said she was very upset because she had been waiting for a long time to go to her doctor's appointment. She said she was told that transportation had not shown up again to transport her to her appointment. Resident # 209 began to cry as she explained that she felt like the facility was setting her back with her healing because she had not been able to go to her appointments because of transportation. Review of the admission record dated 05/16/2024, showed Resident #209 was admitted on [DATE] with diagnoses to include but not limited to encounter for other specified surgical aftercare, other abnormalities of gait and mobility, chronic kidney disease, unspecified, unspecified abdominal pain. Review of a Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status, (BIMS) score of 15 which indicated Resident #209 was cognitively intact. Review of the Medication Administration Record showed an order dated 5/13/2024 to follow-up with [name of physician] at 10:00 a.m. Further review showed the order was discontinued on 5/13/2024. Additional review of the medication record dated 5/13/2024 showed another order to follow up with [name of physician] at 1:15 p.m. During an interview on 05/13/2024 at 2:00 p.m. with Staff B, Unit Manager, he stated the resident's appointment was rescheduled because the transport did not pick Resident #209 up for her appointment. He said he would reschedule her doctor's appointment and transportation. Staff B said the resident's appointments and transportation were set up through her insurance company. On 5/15/24 at 9:26 a.m., in an interview with the Medical Records Manager, she stated Resident #209 missed her appointment on Monday, 5/13/2024, because she [Medical Records Manager] was unaware of the appointment and stated the appointment notification sheet was never handed to her. She looked through a binder titled Transportation 2023 to demonstrate no sheet was filled out for Resident #209 to go to her May 13th appointment. The Medical Records Manager was unaware of the new re-scheduled appointment for Resident #209 made for May 20th by Staff I, RN/UM. The Medical Records Manager stated Resident #209 would have missed her appointment for May 20th had this conversation not taken place, stating to arrange transportation efficiently, forty-eight-hour notice was needed. The Medical Records Manager stated the appointment notification sheet was never received for the May 20th appointment. During an interview on 05/16/2024 at 11:30 a.m. with the Nurse Practitioner, he stated Resident # 209 was admitted to the facility because of the wounds she had on her right and left foot. He said skin grafts were not always a guarantee for healing. If [Resident #209] did not make it to her appointments it could cause a delay in the healing of her wounds. On 5/14/24 at 12:00 p.m., an observation was made of Resident #33 being escorted past the nurses' station in her wheelchair by Staff F, Personal Care Attendant (PCA). Staff F stated to Staff G, Registered Nurse / Unit Manager (RN/UM) and Staff H, RN, Resident #33 did not get her CT (Computed Tomography) scan at the hospital because the facility did not provide the proper paperwork for Resident #33 to continue with the CT scan as ordered. Staff G, stated the paperwork was there but she would reschedule the CT scan appointment. On 5/15/24 at 9:26 a.m., an interview was conducted with the Medical Records Manager regarding arrangements for transportation. She stated she was responsible for setting up appointments and transportation for all the residents in the facility. The process for setting up appointments started with the nurses who placed the order(s) into the [electronic medical record software] and filled out the Appointment Notification Sheet [photographic evidence obtained] and either hand it to me or slid it under my office door if I am not in my office. The Medical Records Manager scheduled the appointment(s) and then called the resident's individual insurance company to arrange transportation. The Medical Records Manager stated transportation arrangements were not a major concern but if there was, a discussion would be made with the administration. She said, We will try to get insurance companies to cover the transport but sometimes we will have to rearrange appointments if transport is not covered. From there we will ask if the family can cover the cost, or as a last resort, whether the facility will cover the cost of transport. The Medical Records Manager was unaware of the reason Resident #33 missed her CT scan scheduled for yesterday, 5/14/2024, but stated the resident was rescheduled for this Thursday, 5/16/2024. The Medical Records Manager stated the resident missed her MRI (Magnetic Resonance Imaging) appointment scheduled for today, May 15, 2024, because she was unaware of this appointment and had not made any transportation arrangements. The Medical Records Manager stated her process to communicate to the unit managers was as follows I complete the 'Appointment Notification Sheet' and make two copies, one for my binder and I place the second copy at the resident's nurses' station appointment binder. From there, the unit managers agree to look through the binder to see who had an appointment and review and send the copy of the 'Appointment Notification Sheet' with the resident and/or the resident accompanied by the PCA. I will also send an email and/or a text message to the Nursing Home Administrator, the Director of Nursing, the Unit Managers, staffing coordinator and the front desk of residents' appointments. The Medical Records Manager stated there was a morning meeting of the clinical team but she did not attend those meetings. On 5/15/24 at 10:14 a.m., an interview was conducted with the Director of Nursing (DON). She stated the current process for appointments and transportation started in January. The DON stated a sheet was filled out by the Medical Records Manager once an order was printed out for her by the unit managers. From there, the Medical Records Manager would arrange the appointment and transportation and document on the sheet or the actual printed order. The DON presented Resident #209's printed physician orders with notes made by the Medical Records Manager on the printed-out orders. When Resident #209 missed her appointment, calls were made to the transportation company listed on the printed physician orders. According to the DON, Staff I, RN/UM was unable to contact the transportation company from the number left on the printed physician order sheet. We could have easily paid for her way had we known she was in the process of missing her appointment. The DON stated she knew nothing of Resident #33 missing her MRI appointment today and her expectation was for her to be notified immediately to resolve the issue of a resident missing an appointment. The DON stated Staff I, RN/UM should have notified her of the situation but stated Staff I, RN/UM was used to doing things the old way in which the unit managers arranged the appointments. On 5/15/24 at 10:58 a.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding appointments and transportation for the residents. The NHA stated had she known about the issues she would have arranged for another means of transport. She stated If they ask me, I would have paid for transportation, I'll get an Uber or taxi or we would use petty cash. The NHA stated the Medical Records Manager came to the morning meetings held every morning at 8:30 a.m. and informed the team of a resident's appointment(s) and/or we would get an email or text. If a resident missed an appointment, the expectation was the NHA and the physician were to be informed and a grievance should be submitted on behalf of the resident. On 5/15/24 beginning at 11:37 a.m., an interview was conducted with Staff F, Personal Care Attendant (PCA) regarding transportation of residents for their appointments. Staff F stated she was informed of residents' appointments upon starting her shift. Staff F stated transportation was an issue getting to and from the residents' appointments. Staff F stated she was with Resident #33 yesterday when she could not continue with her CT appointment at a local hospital. Staff F stated she went with the resident and arrived at the appointment before 9:00 a.m. She said the hospital radiology department could not continue because they did not have the actual physician orders of what to scan and the reason for the scan. Staff F stated she attempted three times to call the facility unsuccessfully to have the physician orders faxed over to the hospital. The first call to the front desk went unanswered, the second call was answered by the front desk staff but went unanswered when transferred to the nurses' station. The third call went unanswered at the nurses' station. The hospital was willing to wait for the fax but transport arrangements were made by Staff F to return to the facility. Staff F stated, Transport can take hours and I thought I could time the planning for transport back to the facility and the resident could still get her scan without waiting all day. When transport showed up two hours later, we had to go without the scan getting done and the resident did not have anything to eat that day. Staff F continued with the interview and stated, Today, 5/15/2024, [Resident #7] missed his dental appointment because transportation did not show up. According to Staff F Resident #7 had a pick-up time between 9:10-9:40 a.m. and was waiting in the front lobby. At 10:00 a.m., Staff F stated she went to the nurses' station to inform the unit manager the resident had not been picked up. Staff F stated Staff G RN/UM stated, ok. Staff F stated when she followed up with the resident he wanted to wait in the lobby because he thought transportation was slow this morning. Staff F stated she returned to the nurses' station to inform Staff G the resident wanted to wait in the lobby but Staff G informed her transportation was not coming due to a flat tire. On 5/15/24 at 11:56 a.m., an interview was conducted with Staff G, RN/UM regarding transportation for residents to their appointments. Staff G stated orders were put into the [electronic medical record software] and I will make the appointments or really anyone can. I will print two copies of the order and pass one to the Medical Records Director to arrange transportation. I will create a task for the nursing staff to see so they will get the resident ready the day of the appointment. I will put the second copy into the appointment book and then [Medical Record Manager], will put the information for transport including the telephone contact, confirmation number and if an escort is needed. Staff G, RN/UM could not explain why Resident # 33 missed her CT scan yesterday stating, I got her an appointment for tomorrow for the CT and all the paperwork is there. Staff G stated she saw the order for the first time for the MRI yesterday and informed the Medical Record Manager. Staff G said she did not take the original order but the other unit manager did and stated, I did not know she had an appointment today. Staff G said the Assistant Director of Nursing (ADON) informed her of Resident #7 missing his dental appointment due to the transportation's flat tire and a rescheduled appointment was made for May 31, 2024. The resident was informed as well as his family. [photographic evidence obtained] On 5/15/24 at 2:00 p.m., an interview was conducted with Resident #58 who stated she will make her own transportation arrangements herself because she was tired of the long wait times and missing her appointments. She stated, I call my insurance company and make the arrangements and I never have a problem. Resident #58's roommate added she would arrange her own transportation as well because when the facility arranged for her appointment the transportation company refused to take her in her wheelchair with an extra oxygen tank. A review of the facility's policy and procedures entitled, Transportation Services, effective date of February 2021 states the following statement: The facility will assist and/or provide resident/ patient transportation services when needed to ensure that each resident/ patient receives a complete continuum of services. 1. Enter outside appointments on a calendar 2. Obtain transportation preference as applicable from the resident patient, family, or legal representative. 3. Schedule transportation private or ambulance service as soon as the date and time of appointment is known. 4. Communicate date and time for which the transportation has been scheduled to the staff. 5. Assure resident /patient, family, or legal representative is notified of the appointment. 6. Assure resident /patient is up, dressed, and ready for the scheduled appointment. 2. Review of Resident #81's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital. His medical diagnoses included but were not limited to respiratory disorders in disease classified elsewhere, lack of coordination, pneumonia, aphasia, dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. An observation was conducted on 05/13/24 at 10:35 a.m. Resident #81 was observed in bed, his gastrostomy tube was connected to his enteral nutrition, the enteral nutrition pump was turned off, and his head of the bed was elevated. Resident #81 was observed to have a wet, weak cough. The resident said he did not know if his enteral nutrition pump should be on. An interview was conducted with the resident's family member, and he said he came often to visit. He said the resident had a build up of secretions and when he had his patch it brought the secretion's down by 80%. The family member looked at the patch and said the patch needed to be changed. The patch was observed not to be intact with the resident's skin on his neck and the patch was not labeled. The family member said the patch should be changed every 2 days and it should have a date on it. (Photographic evidence obtained) An observation was conducted on 05/13/24 at 3:06 p.m. Resident #81 was observed lying in bed, with his medication patch not intact and not labeled. The resident was alert, had a weak wet cough, and was not in any respiratory distress. An observation was conducted on 5/14/24 at 10:10 a.m. of Resident #81. He was observed in bed, alert, eyes open. There was a large basin with several paper towels on his bed next to him. He was observed to have a buildup of saliva in his mouth as he talked and said the basin was for all the secretion's he had in his mouth. His medication patch was observed not to be intact and was not labeled. Review of Resident #81's physician orders revealed an order with a start date of 2/27/24 and no end date for Levsin Oral tablet 0.125 milligrams (MG), give 1 tablet via PEG-Tube every 8 hours for secretion's. Review of Resident #81's May medication administration record (MAR) revealed no documentation on 5/11/24 at 2:00 p.m. An order dated 4/11/24 with no end date revealed Scopolamine Patch 72 Hour Apply 1 patch transdermal every 72 hours for NAUSEA document the presence of the scopolamine Path every day and remove per schedule. Review of the MAR revealed no documentation on 5/11/24 that the patch was removed or applied as ordered and the last documented removal and applied date was signed off on 5/8/24. The May MAR also revealed Resident #81's patch placement was only documented on 5/2/24, 5/5/24, 5/8/24, and 5/14/24. There was no daily documentation on the presence of the Resident #81's patch. An observation was conducted on 05/15/24 at 8:56 a.m. of Resident #81. He was observed in bed, the head of the bed was elevated, and a basin was on his bed next to him. Staff B, South Unit Manager (UM) was observed in the room at the time of the observation. Staff B went out of Resident #81's room and reviewed Resident #81's MAR and Treatment Administration Record (TAR). He confirmed placement for a scopolamine patch had not come up for him and he was not sure if the resident had one on. He went into the residents room and confirmed the resident had the scopolamine patch on his right neck and it was dated 5/14/24. An interview was conducted on 05/16/24 at 8:53 a.m. with the Director of Nursing (DON). She said the staff called her around 8:0 a.m. to say the Internet was down on 5/11/24 but the staff should have documented medication administration on paper MAR's, but she needed to look into it. She confirmed medication patches should be intact, labeled, and monitored for placement every shift. No additional documentation related to Resident #81's scopolamine patch application was provided by the end of survey. Review of the facility's Transdermal Delivery System (Patches) Policy dated 05/16 revealed the following: Policy To administer medication through the skin by continuous absorption while the patch is in place and maintaining proper placement of the patch and care of the application site. .Procedures .9. Label patch with date and nurse's initials. 10. Apply new patch firmly against skin. Rotate sites in accordance with manufacturer's recommendations. Avoid extremities and hairy body areas. .13. Document placement site on MAR. For patches applied less frequently than daily, check placement and document that patch at least daily

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation and interview was conducted on 5/16/24 at 11:40 a.m. Staff K entered Resident # 97's room and said the resident had a [brand name] tracheostomy tube (6.0 XL) she searched the resident's room and confirmed there was not an extra or an emergency tracheostomy tube in the room. She confirmed there were extra trach (tracheostomy) ties, suction machine, suction kits, and a [brand name] tracheostomy tube (6.0 x l) inner cannula and ambu bags at the bedside. Review of Resident # 97's admission record dated 05/16/2024 showed he was admitted to the facility on [DATE] with diagnose to include but not limited to Acute Respiratory Failure with Hypoxia, Tracheostomy Status, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of a Medication Administration Record for the mouth of May 2024 showed an order dated 03/28/2024 to maintain ambu bag at bedside and replacement trach of equal size and one size down maintained at bedside, every shift for preventative measures. Maintain suction set up at bedside on every shift. An interview was conducted on 5/16/24 at 11:43 a.m. with the Director of Nursing (DON). She said, [Resident # 97's] room was set up with extra trachs. She directed Staff K, LPN to get an extra trach and a size smaller trach to put in the resident's room. Staff K obtained a [brand name] tracheostomy tube (6.0 XL), and a [brand name] tracheostomy tube (5.0 XL), and put it in the resident's room. Review of the facility policy titled, Tracheostomy Care undated, showed 2) Gather the necessary equipment and proceed to the patient's room. Equipment should include. C. Emergency tracheotomy tube replacement, the same size and 1 size smaller. Based on observation, interview, and record review, the facility 1. failed to ensure a physician order was in place for the administration of oxygen for one (Resident #21) out of four residents reviewed for respiratory care, and 2. failed to ensure emergency tracheostomy supplies were readily available for one (Resident #97) out of one resident with a tracheostomy tube. Findings included: 1. An observation was conducted on 05/13/24 at 9:33 a.m. Resident #21 was observed in bed with her eyes closed, an oxygen concentrator was on and set to 1.5 liters per minute (LPM), the oxygen tubing observed to be behind the residents back and not on the resident. An observation was conducted on 05/13/24 at 3:30 p.m. Resident #21 was observed in bed with her eyes open, nasal cannula in her nose, an oxygen concentrator was on and set to 1.5 LPM. The resident said she wore oxygen for her chronic obstructive pulmonary disease (COPD) and she was supposed to be on 6 LPM. She said she had been asking since last week to get oxygen on her wheelchair. She said her wheelchair was in the bathroom. An observation was conducted of the wheelchair in the bathroom without an oxygen tank on her wheelchair. The resident said she was feeling good right now because she had been resting in the bed but when she got out of the bed, she got short of breath. Review of Resident #21's medical record on 05/13/24 at 2:46 p.m. did not reveal an order for oxygen. An interview was conducted on 5/13/24 at 3:32 p.m. with Staff D, Registered Nurse (RN) Supervisor. She confirmed Resident #21 used oxygen, and she thinks the resident was supposed to be on 2 LPM oxygen. She looked at the oxygen concentrator and confirmed the resident was on 1.5 LPM. She said she would have to look at the physician orders to find out how much oxygen the resident was ordered to have. She exited the room and did not review the physician orders. An interview was conducted on 05/13/24 at 4:10 p.m. with Staff D, RN Supervisor, she said she forgot to look up Resident #21's physician orders, but she told the nurse to look it up. The nurse in training assigned to Resident #21 said the resident was supposed to be on 2 LPM oxygen according to the report sheet. Review of the report sheet revealed a handwritten note O2 @ 2L. The note was not written under Resident #21. An observation was conducted on 05/14/24 at 10:14 a.m. Resident #21 was in bed and said someone came in and wanted me to sign paperwork but I was too short of breath. Resident #21's oxygen concentrator was set on 3 LPM via nasal cannula. Resident #21's breathing was observed to be rapid and shallow. An interview was conducted on 5/14/24 at 10:15 a.m. with Staff E, Licensed Practical Nurse (LPN). She confirmed she was Resident #21's nurse and she said Resident #21 was usually on oxygen I think it's 2 liters but I would need to check. I have not experienced her being short of breath today. She normally is not up this early and I know she likes to be left alone when she's tired. Staff E, LPN reviewed Resident #21's physician orders and said, I don't see an order for oxygen, but she has been on oxygen since I started in January of 2024. I don't know what happened to the order. An interview was conducted on 5/14/24 at 10:17 a.m. with Staff B, South Unit Manager. He reviewed Resident #21's physician orders and confirmed he could not find an order for oxygen and said, she used to have oxygen orders for 2 liters PRN [as needed]. On 5/14/24 at 10:20 a.m., Staff E, LPN went into the Resident #21's room and confirmed the oxygen was set to 3 LPM and adjusted the concentrator to 2 LPM. The resident said, please help me I can't breathe Resident #21 was observed to still have shallow rapid breaths. Staff E said she was going to get the machine to check her oxygen and the resident said please hurry. Staff E left the room. Resident #21 was observed to be in the bed eyes closed, saying a healthy baby boy. On 5/14/24 at 10:24 a.m., Staff E entered Resident #21's room and placed the pulse oximeter machine on the resident and confirmed her oxygen saturation was 92%, adjusted her nasal cannula, and confirmed the resident's oxygen saturation went up to 93% and then back down to 92%. Staff E said. I'll call the doctor. She asked the resident if she was having any shortness of breath and the resident said yes. The nurse said are you having any pain? The resident said, yes in my chest. Review of Resident #21's care plan revised on 10/3/23 revealed The resident has Oxygen Therapy r/t [related to] Ineffective gas exchange. dx [diagnosis] with COPD. The goals revealed Will be able to participate in activites [sic] of choice. Will have no s/sx [signs and symptoms] of poor oxygen absorption through the review date. Will have no untreated s/s [signs and symptoms] of SOB [shortness of breath] through next review. The interventions were as follows: o Special Equipment: Oxygen o Administer Oxygen/Nebs as ordered. (Refer to current POS [physician order set]/MAR [medication administration record] for current order) o Give medications as ordered by physician. Monitor/document side effects and effectiveness. o Turn and Reposition resident to facilitate ventilation/perfusion matching: Use upright, high-Fowler's position whenever possible to allow for optimal diaphragm. o Promote lung expansion and improve air exchange by positioning with proper body alignment. o Monitor for changes in or development of signs & symptoms of breathing difficulty and report: SOB, cough (productive or nonproductive), fever, chills, difficulty speaking, bluish skin color, changes in cognition. o Report changes in respiratory status to physician. Change and date respiratory equipment tubing weekly & prn [as needed]. o Keep exterior of respiratory equipment clean. Review of Resident #21's progress note dated 5/14/24 at 3:50 p.m. revealed Resident complained of SOB [shortness of breath] and mild chest pain. Vitals assessed. MD [medical doctor] notified. orders received for STAT CXR [chest x-ray] and lab work. Resident received PRN [as needed] inhaler. Continued on 7-3 [7:00 a.m.-3:00 p.m.] shift without issue, no further complaints of pain or signs of distress. Family at bedside. Review of Resident #21's physician orders revealed an order with a start date of 5/14/24 Stat CXR PA [posterior anterior]and Lateral. An order with a start date of 5/15/24 and an end date of 5/22/24 revealed Zithromax Oral Tablet 500 MG (Azithromycin) Give 1 tablet by mouth one time a day for PNEUMONIA for 7 Days. Review of Resident #21's Chest X-ray 2 view radiology report dated 5/14/24 revealed Conclusion: Left lower lobe infiltrates suspicious for pneumonia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the comprehensive person-centered care plan and physician orders for one (Residents #73) of one sampled resident who required dialysis, which included providing dietary needs (breakfast/snacks). Findings included: During an interview on 5/14/2024 at 8:45 a.m., Resident #73 stated he did not receive breakfast or a snack to take to dialysis. If needed, he had the driver of the transport stop at the convenience store. Resident #73 stated it would be nice if breakfast was provided as I have to leave at 5:45 a.m. and am gone until lunch, that is a long time without food. Review of the admission Record for Resident #73 showed an admission date of 10/3/2022 and a recent admission of 3/16/2024 with diagnoses to include: end stage renal disease; heart failure; diabetes type 1; cachexia; hyperkalemia; protein-calorie malnutrition; muscle wasting and atrophy; and other co-morbidities. Review of Resident #73's physician Order Summary dated 5/16/2024 revealed an order for Resident to have Dialysis on days: [Dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no, order start date of 3/18/2024 and 3/24/2024. Review of Resident #73's Care Plan revealed a focus area of: hemodialysis: The resident has renal failure and is on Hemodialysis Resident to have dialysis on days: [dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no date initiated 1/16/2024 and revised on 4/3/2024. Further review of the care plans showed the resident was at risk for impaired nutrition related to chronic kidney disease stage as of 8/1/2023. Interventions included but not limited to honor food requests and preferences as appropriate initiated 4/5/2023, diet as ordered (refer to POS for current order) initiated 10/4/2022, fluid restrictions 1500 cc/hr revised on 4/3/2024. During an interview on 5/16/2024 at 6:55 a.m. with Staff O, Certified Nursing Assistant (CNA), she said she provided care to Resident #73 on a regular basis. Staff O stated she had not been able to give a bag meal to Resident #73 for a while as the refrigerator was broken. The kitchen staff provided the bags (meals). An interview was conducted on 5/16/2024 at 7:15 a.m. with Staff N, Cook. She stated the kitchen did provide bag meals to residents who needed them. Staff N stated nursing gave dietary a list and they prepared the meals, and passed them out. Staff N stated she not made a bag meal in a long time, as nursing had not provided a list of anyone who was in need of one. An interview was conducted with the Staff G, Registered Nurse/Unit Manager on 5/16/2024 at 8:30 a.m. She stated Resident #73 received his lunch bag from the kitchen, nursing did not have anything to do with it. Review of the facility policy and procedure with the topic: Dialysis Management (Hemodialysis) dated October 2021 revealed: the facility will coordinate care and services for hemodialysis residents. The facility will coordinate routine transportation for the resident. Contractual agreement will include, but may not be limited to, the following: * medical and non-medical emergencies, * development and implementation of resident care plan, * interchange of information useful/necessary for the care of the resident. Guidelines: 1. Obtain a physician's order to include but not limited to: . 6. Manage special dietary regimen and dietary/fluid restrictions as ordered. 7. Verify that travel meal is provided in a thermal bag and has an ice pack . 11. Review and revise care plan/[NAME] as needed.

Based on observation and interview, the facility failed to post the nurse staffing data to ensure the information was readily accessible to all residents and visitors during two of four days of survey. Findings included: On 5/13/2024 at 9:52 a.m., an observation revealed the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care was not posted. On 5/16/2024 at 8:52 a.m. an observation revealed the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care was not posted. During an interview on 5/16/2024 at 11:15 a.m., Staff P, CNA staffing coordinator stated responsibility for posting the staffing numbers. Staff P stated posting the numbers for two days at a time to ensure the weekends are covered. Staff P, stated with the surveyors coming in on Monday the posting was delayed and the same must have happened this morning. Staff P stated posting the information today although it was later in the morning. Review of the facility policy and procedure with the topic: Staffing dated effective April 2015 revealed: policy: each nursing center has sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as required by the federal law, and sufficient staff to meet applicable state law requirements (including minimum staffing ratios). The projected staffing plans are reevaluated on an ongoing basis in response to changes in the facility, resident population, or other circumstances. Staffing is monitored on an ongoing basis through a combination of offsite and onsite facility reviews conducted by facility, consulting and compliance staff. The facility administrator and/or the director of nursing should evaluate staffing on a daily basis. Procedure: Other: 1. Post the daily staffing hours.

Based on interview and record review, the facility did not ensure residents who entered arbitration agreements understood the contract contents for one (Resident #259) of three residents sampled. Findings included: During an interview on 5/14/2024 at 10:04 a.m., the Nursing Home Administrator (NHA) stated there was only one resident who had signed an arbitration agreement. The NHA stated all residents were presented the option to review and sign the arbitration agreements upon admission. The NHA stated the admission Director (AD) was responsible for the arbitration agreements and expectation was that everyone understood what was being signed. Review of the admission Record for Resident #259 showed an admission date of 4/22/2024, with diagnoses to include Schizophrenia; Anxiety Disorder; Other Genetic related Intellectual Disability; Malignant Neoplasm of Bladder; and other co-morbidities. The Responsible Party/Guarantor listed indicated it was not Resident #259. Review of the Arbitration Agreement - Resident Booklet, was signed by Resident #259 and the admission Coordinator (AC) on 4/24/2024. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008 dated 4/22/2024 signed by a physician showed under section U. Mental/Cognitive Status at Transfer - Resident #259 alert, disoriented, but can follow simple instructions. Review of the hospital physician progress note dated 4/21/2024, showed resident was pleasantly confused. Review of the Occupational Therapy Plan of Care dated 4/25/24 revealed Resident #259's Cognition ** orientation person (x 1); Cognition **Memory profound (0-10% ability; dependent, coma/vegetative state, delirium, acute psychosis episode); Cognition **Safety-Judgment Moderately impaired (25-50% intact); Cognition **sequencing moderate (51-70 % ability; frequent direction required in occasional situations). Review of an admission Minimum Data Set (MDS) for Resident #259, dated 4/28/2024, showed Resident #259 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. During an interview on 5/15/2024 at 11:44 a.m., the AD stated the goal was to have residents signed in within 48-72 hours, herself, and the admission Coordinator (AC) both completed sign ins. This included the admission Agreement and Arbitration Agreement. The AC worked part-time at the facility and not at the facility today, 5/15/2024. The AD stated, We utilize the resident's 3008 [Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008] and nurse to nurse to determine if a resident can sign themselves into the center. The AD provided a list of residents who had and had not signed the Arbitration Agreement. The AD continued to state the Arbitration Agreement was optional and the resident did not have to sign to be able to be admitted . The AD stated, I focus on the agreement being optional. The AD stated the AC completed R#259's admission Agreement which included the Arbitration Agreement. The AD confirmed Resident #259 had signed the arbitration agreement with the AC as the facility representative on 4/24/2024. The AD stated R#259's signature was in the form of a line and lower-case cursive letters in the bottom right corner of the agreement. The AD stated the facility would sign the corner of the agreements if the residents were not able. An interview was conducted on 5/13/2024 at 3:57 p.m. Resident #259 's Resident Representative (RR). She said had not had communication with the facility with regards to admission paperwork or anything else. The RR stated there had been very little to almost no communication with the facility. The RR explained Resident #259 had been diagnosed with Intellectual Disability in school age years. The RR stated Resident #259 never was able to learn how to read or write. The RR stated Resident #259 usually would request for her to review documents. Policy and Procedure for Arbitration Agreements was requested on multiple days, one was not provided prior to the survey exit on 5/16/2024.

Based on observation, interview, and record review, the facility failed to ensure the development, revision, and/or implementation of comprehensive care plans was completed for two (Resident #259 and #73) of six sampled residents. The findings include: Review of the admission Record for Resident #73 revealed an admission date of 10/3/2022 and a recent admission of 3/16/2024 with diagnoses to include: end stage renal disease; heart failure; diabetes type 1; cachexia; hyperkalemia; protein-calorie malnutrition; muscle wasting and atrophy; and other co-morbidities. Review of the Minimum Data Set (MDS) from admission dated 3/18/2024, showed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS showed the resident had no identified moods or behaviors and was on hemodialysis. Review of Resident #73's Physician Order Summary dated 5/16/2024, showed an order for a 1500 cc Fluid Restriction Dietary to give 1200cc nursing to give up to 300cc/24hr 7-3 (120cc), 3-11 (120cc), 11-7 (60c) every shift Fluids to be given with medications, no water to be left at bedside order start date of 4/1/2024. Resident to have Dialysis on days: [Dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no order start date of 3/18/2024 and 3/24/2024. Review of Resident #73's Care Plan showed a focus area of: Elopement Risk: Resident is at risk for elopement dated 10/28/2022. Goals and interventions were also listed. Resident #73 had a focus are of: hemodialysis: The resident has renal failure and is on Hemodialysis Resident to have dialysis on days: [dialysis center name]: . catheter site: right chest: . bag meal/snack to go with resident to dialysis yes fluid restriction no date initiated 1/16/2024 and revised on 4/3/2024. Focus area of: Infection: Resident #73 has an infection Respiratory Infection Covid positive date initiated/revised 3/19/2024, with goals and interventions listed. An interview was conducted with Resident #73 on 5/14/2024 at 9:50 a.m Resident #73 stated he did receive a bag meal nor did have an elopement/wandering problem. Resident #73 continued to state he had not been on isolation for some time, he had been free of Covid for a long time. During an interview on 5/16/2024 at 11:35 a.m., Staff A, Registered Nurse (RN), Clinical Reimbursement Director (CRD) confirmed responsibility for updating and developing care plans along with the MDS for each resident. Staff A stated the care plan for Resident #73 should have been reviewed and revised at readmission, and it was not. Staff A, RN stated she would have to investigate the issue. On 5/14/2024 at 9:30 a.m., Resident #259 was observed lying in her bed with the covers over her waste. Resident #259's bed was in the high position, floor mats were not in place and the call light was not within reach. Resident #259 had an Enhanced Barrier Precaution Sign on the door to her room. Review of the admission Record for Resident #259 revealed an admission date of 4/22/2024 with diagnoses to include: history of falling; presence of right artificial hip joint; aftercare following joint replacement surgery; Schizophrenia; Anxiety Disorder; Other Genetic related Intellectual Disability; Malignant Neoplasm of Bladder; Methicillin Resistant Staphylococcus Aureus Infection (MRSA) and other co-morbidities. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008 dated 4/22/2024 signed by a physician revealed Resident #259 had MRSA, Candida auris (C. Auris), Extended Spectrum Beta-Lactamase (ESBL) in the urine, and a history of falls. Review of the Physician Progress note from the hospital dated 4/21/2024 revealed Resident #259 had recent right hip pain and fracture after a fall status post ORIF (open reduction and internal fixation) on 3/30/2024. Review of the MDS from Admission, dated 5/5/2024 revealed Resident #259 had a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. Section J for Falls history showed: Resident #259 did not have any falls in the last 2-6 months prior to admission/entry or reentry and had not fallen with any fracture in the 6 months prior to admission/entry. Review of Resident #259's Treatment Administration Record dated April, 2024 showed a physician order for Contact Precautions for ESBL in the urine until 4/29/2024. Review of Resident #259's Order Summary Report with an active date of 5/16/2024 showed an order for Transmission Based Precautions Enhanced Barrier Precautions dated 4/23/2024. Review of Resident #259's Care Plan reveals a care plan with a focus of Fall: Resident #259 has had a fall because of: deconditioning, gait/balance problem. date initiated 5/7/2024. A focus of: Resident requires Enhanced Barrier Precautions related to: C. Auris date initiated: 5/5/2024. During an interview on 5/16/2024 at 11:35 a.m. Staff A stated the care plan for Resident #259 should have been developed on 4/24/2024 and revised as needed. Staff A, RN confirmed there was no fall care plan on admission nor was there an infection control care plan and there should have been. Review of the facility's policies and procedures with the Topic: Care Plan - Interdisciplinary (IDT) Plan of Care from Interim to Meeting dated effective February 2024. Policy: The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Procedure: . 2. Update to Care Plans: a. Ongoing updates to care plans are added by a member of the ID tea as needed. 3. Dates and documentation on the care plan. a. New, revised, or discontinued problems, goals, or interventions are dated for the date the documentation was made. b. Problems and goals have IDT approaches and interventions to assist the resident in their goal attainment. 5. Comprehensive plan of care a. The comprehensive care plan is developed by members of the IDT and the resident, resident's family, or representative, as appropriate, in conjunction with completion of the admission, annual, significant change in assessment for other comprehensive assessment, and the associated care area assessments.

Based on observations, interviews, and record review, the facility 1) failed to initiate an Enhanced Barrier Precautions (EBP) isolation program for thirteen out of thirteen residents on EBP and, 2) failed to implement an effective infection control program related to facility failure to handle, store, process, and transport all linens and laundry in accordance with infection control practices to produce hygienically clean laundry for 105 out of 105 residents in the facility. Findings included: On 05/15/24 at 11:09 a.m., an interview was conducted with the Director of Nursing (DON) regarding infection control for isolation residents. The DON stated newly arrived residents are screened for any isolation precautions from the transferring facility. The placement of the newly admitted residents depends on their isolation needs and if they can cohabitate with another resident. The DON admitted knowledge of the Center for Disease Controls (CDC) new Enhanced Barrier Precautions (EBP) recommendations announced in February 2024, and stated thirteen residents have been identified in the facility requiring EBP. She stated the residents identified had a potential source of increased risk for infection due to tube feedings via percutaneous endoscopic gastrostomy tubes, wounds, medication via peripherally inserted central catheters, intravenous catheters, and indwelling urethral catheters. The DON stated the facility had not had the opportunity to initiate an Enhanced Barrier Precaution program but stated she will be putting bins out by resident's rooms for gloves and gowns, and proper (EBP) signage was ordered. The DON stated education would be starting in May but was unable to present calendar dates assigned for education for the month of May. The DON stated the Enhanced Barrier Precautions would be difficult to have staff and residents comply. She stated education would be deferred to the new Infection Control Preventionist. On 5/16/24 at 10:30 a.m., a tour of the laundry area was conducted with the Housekeeping /Linen Manager (HM). The facility's entrance to the laundry room was located along an outside perimeter of an open courtyard. An observation was made of three laundry carts of clean folded linen. The cart covers were tattered, threadbare and torn, leaving the clean linen exposed to the elements. [Photographic evidence obtained]. Above the laundry carts on the opposite side of the walkway were five bird's nests with active birds flying overhead. Three large gray garbage bins were observed outside the laundry room in the courtyard. One bin was not labeled, the middle bin was labeled, Clean mops, and the third bin was labeled, Clean microfiber mops. [Photographic evidence obtained]. A wire basket cart on wheels was observed next to the garbage bins with a pile of mops heads and torn clothes. The HM stated the basket was how they dried the rags because the facility did not dry the items in the dryers due to the chemicals utilized. The HM proceeded to demonstrate how the rags were dried. The HM moved the wire basked into the center of the courtyard (so the basket would be in the direct sun). The HM stated the items in the wire basket were dry and moved the cart back to the side of the facility. The items were observed to be moist to the touch and had a musty smell to them. The HM stated the rags are then moved to one of the gray bins for the housekeepers use. The HM opened the unlabeled gray bin, and a strong, pungent musty odor was noted. Another gray bin with a lid on it and a washcloth on top, was between the doors to the clean and soiled rooms, no label was observed on the bin. The HM stated the bin was for clean linen. Behind the open door was another blue bin with the lid upside down and a white cloth hanging from the side, no label observed. The HM stated this bin was for soiled laundry. Directly touching this blue bin was a beige cover to another laundry cart that was holding clean donated clothing. The HM stated this clothing was for any staff member to come out and take to a resident. There was clothing observed on the ground and pushed against the facility at the base of the donated clothing rack. The beige cover did not close, leaving the clothing exposed to the elements, including birds' nests which were visualized to the immediate left of the cart. [Photographic evidence obtained]. The soiled laundry entrance was a receiving area. There were two large linen carts, each covered with a blue canvas, a large gray bin covered with a fitted sheet and a pile of clothes in the corner in between the two linen carts and behind the gray bin uncovered [Photographic evidence obtained]. The Housekeeping/Linen Manager stated clean linen was stored in these areas. Next to the linen cart, directly touching were two large bins of soiled laundry covered with a soiled sheet. The Housekeeping/Linen Manager stated there is no place to store clean laundry, that is why the clean is stored in the soiled room. Two washing machines were active with wastewater emptying behind the machines. The level of the wastewater was high. The HM stated sometimes the wastewater will overflow the basin and he has to take all the bins and carts out to squeegee the water out of the laundry room [Photographic evidence obtained]. Proceeding through plastic strips that represent a barrier to the clean laundry room, the plastic strips were observed to be soiled with an orange sticky substance and brown/black spots along the length of the plastic strips. The dryer/clean laundry area revealed two staff members folding clothes with a fan on the ground to keep the area cool. The staff stated the air conditioning (AC) unit works but will freeze up and drip water in the laundry area, then they must run the fan until the AC unit will work again. In the corner of the laundry area was a clean laundry cart sparsely full of clean linen. The Housekeeping/Linen Manager stated staff would come in and grab linen if they need it for emergencies at nighttime [Photographic evidence obtained]. A review of the facility's policy titled, Barrier Precautions, effective April 2024, revealed the following: Enhanced Barrier Precautions (EBP) states an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) that employ targeted gown and gloves used during high contact resident activities. EBP are used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi drug resistant organisms) to staff hands and clothing. EBP is indicated for residents with any of the following: 1. Infection or colonization with CDC-targeted multi-drug resistant organism when Contact Precautions do not otherwise apply or, 2. Wounds and /or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Procedure 1. Start will be routinely trained in infection control practices to include when to use Standard Precaution, Contact Precautions, Enhanced Barrier Precautions, and Droplet Precautions. 2. A grid is provided (Appendix A) for staff reference which outlines the differences between Contact Precautions and Enhanced Barrier Precautions. 3. Director of Nursing/ Designee will track resident infections and ensure staff is notified of resident -specific precautions. 4. Signage is used, as appropriate. Appendix A [Photographic evidence obtained]. Review of the Infection Control Overview & Policy, undated, revealed the following: Policy Statement: [Vendor Name] promotes the health and safety of all employees, as well as that of the clients and residents we serve. Infections are a significant source of sickness and death for nursing home residents and account for up to half of all nursing home resident transfers to hospitals. Infections result in an estimated 150,000 to 200,000 hospital admissions per year at an estimated cost of up to $2 billion annually when a nursing home resident is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40%. The purpose of this infection control program for [vendor name] and its subsidiaries is to: 1. Investigate, control, and prevent infections in the facility; 2. Communicate the environmental and or dining services procedures that should be applied in the field; 3. To maintain a record of incidents and corrective actions taken related to infections by reporting incidents through the proper facility chain of command; 4. To comply with the Centers for Medicare and Medicaid Services (CMS) guidelines in relation to CMS F880 tag found in CFR 483.80(a)(1)(2)(i)-(iii)(v)-(vi)(e). In addition to this program, it is important that all infection prevention and control practices reflect current Center for Disease Control (CDC) guidelines. Preventing Spread of Infection: preventing the spread of infection is the core of our environmental department, . all employees must be made aware of how they can play a part in preventing the spread of infections including: . * properly store, handle, process, and transport (cover) linens to minimize possible contamination. The first steps to prevent the spread of infection include: . 4. Covering clean linens as they are transported to the units to prevent contamination. Infections and diseases are transmitted in several ways including: . B. Contact with an infected object, person, or surface (touching); . Routes of Disease Transmission Employees can be exposed to or expose residents to disease through: . b. Direct/indirect contact with equipment used to provide care or with health care personnel/visitors/other residents; c. Contact with clothing, uniforms, laboratory coats, or isolation gowns used as PPE may become contaminated with potential pathogens after care of a resident colonized or infected with an infectious agent, (eg.MRSA [methicillin resistant staph aureus], VRE [vancomycin resistant enterococci], and Clostridium difficile [cdiff]). Indirect contact may occur through toilets and bedpans . Review of the policy and procedure for Laundry Operations, dated 3/12/2020, revealed: Descriptions of steps in the laundry process there are 6 steps in the laundry process: 1. Pick up collection of soiled linen 2. Sorting soiled linen 3. Washing (a) wash cycle 4. Drying 5. Folding 6. Delivery . B. Transferring Soiled Linen It is very important to properly transport and store soiled linens to prevent the spread of infection period to do so, all soiled linen and clean linen must be covered during transportation and while being stored on the unit or floors. Additionally, no clean linen may touch floor during transport, if it does, the clean linen is then considered to be soiled. Soiled linen containers must be lined with an impervious (waterproof) liner. Do not allow soiled linens to simply be dropped into a container. At designated times, laundry workers are to collect soiled linens from each soiled linen room using a large bin with lid, marked For Soiled Linen Only. . 2. Sorting Soiled Linen the laundry room must have a process in place to effectively sort soiled linen without cross-contaminating clean linen. For example, soiled linen must never come in contact with clean linen. Soiled linens brought down manually must have a separate delivery entrance and must be placed into the soiled linen bins.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician and document the refusal of laboratory blood tests on two occasions for one (Resident #59) of five residents reviewed for unnecessary medications. Findings included: Review of Resident #59's admission record revealed she was admitted to the facility on [DATE] from the community with diagnoses of Alzheimer's disease, mood affective disorder, major depressive disorder, cognitive communication deficit, and seizures. Review of Resident #59's Change in Condition Evaluation form dated 4/30/22 revealed Resident #59 had a seizure that started the morning of 4/30/22. Review of the mental status evaluation documented on the change in condition form revealed, altered level of consciousness with sudden change in level of consciousness or responsiveness. The physician was notified on 4/30/22 at 8:00 a.m. and recommended labs (blood tests). Review of Resident #59's treatment administration record (TAR) revealed a physician's order dated 4/30/22 at 8:59 a.m., for CBC (complete blood count), CMP (comprehensive metabolic panel), Keppra level one time only for 1 day. The order was signed off as completed on 5/1/22 at 1:52 a.m. Review of the lab company's documentation dated 5/1/22 at 2:31 a.m. revealed patient refused Review of Resident #59's medical record did not indicate the physician was notified of the refused blood tests. Further Physician order review for Resident #59 revealed an order to start on 4/21/22 for Keppra level, Depakote level, CBC, CMP, every night shift every 6 months starting on the 21st for 1 day. Review of the Resident # 59's TAR revealed the physicians order was signed off as completed on 4/21/22. Review of the lab company's documentation dated 4/21/22 revealed Resident #59 refused the blood tests. Review of Resident #59's medical record did not indicate the physician was notified of the refused blood tests. An interview was conducted with the Director of Nursing (DON) on 5/5/22 at 1:52 p.m. she said, I did a building wide sweep on anticoagulants and seizure medications at the end of April to see who needs yearly labs or labs at certain intervals. The DON confirmed Resident #59 refused her labs on 4/21/22 and said, But, she just had her Keppra and Depakote labs taken on 2/28/22 and I just talked to the physician and he said she wouldn't need labs in April if she just had them in February because she's ordered to have them every 6 months . one thing we could have done better is documented the resident refused and the nurse should not have signed it off as completed when it was not. Review of the facility's policy Laboratory Services effective January 1, 2020, revealed Policy: The facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provides by the facility or an outside agency. The laboratory selected to perform the tests will be Medicare approved. Procedure: 1. Assure laboratory tests are completed and results provided to the facility within timeframes normal for appropriate intervention. 2. Provide or obtain laboratory services only when ordered by the physician. 3. Assure Nursing notified the physician promptly of the findings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to appropriately secure medications in the entrance of two resident rooms (Rooms #18 and #305); and failed to ensure appropriate storage of medications in three of three medication carts located on 100 (South Hall), 300 and 400 (North Halls). Findings included: During an observation of room [ROOM NUMBER], on 05/03/2022 at 9:42 a.m., a small oval blue pill was observed at the entrance of the resident room. An immediate interview of Staff A, Licensed Practical Nurse (LPN), revealed the nurse was in the middle of medication administration and confirmed the presence of the unsecured tablet at the entrance of resident room [ROOM NUMBER]. She stated, I can't own it, I don't think it is mine. (PHOTOGRAPHIC EVIDENCE OBTAINED) On 05/03/2022 at 1:15 p.m., during an interview with Staff A, (LPN), she said she informed the Director of Nursing (DON) of the unsecured pill and disposed of the medication in the pill buster. On 05/03/2022 at 3:34 p.m., an interview was conducted with the DON. The DON indicated Staff A informed her of the observations and revealed Staff A performed all her medication checks, and counted her medications earlier in the day. The DON stated, I haven't identified this as a trend, but I will bring it to the Quality Assurance (QA) committee. On 05/03/2022 at 9:59 a.m., an observation was conducted of room [ROOM NUMBER]. During the observation, one round white pill was located at the entrance of the room. An immediate interview was conducted with Staff B, Registered Nurse (RN), assigned to room [ROOM NUMBER]. Staff B, (RN) verified the presence of the unsecured white pill at the entrance of the resident room, and stated, Looks like it was spit out, it has some blurred scoring on it. I have no idea how that got there. An interview was conducted with the DON on 05/04/2022 at 11:37 a.m. She was informed of the observation of an unsecured tablet at the entrance of room [ROOM NUMBER]. The DON indicated she had not known there was another room that had a loose pill in the entrance. The DON stated, There should be no loose pills located anywhere in the facility. She further indicated that when the survey team found the unsecured tablet earlier in the day, she and the Nursing Home Administrator (NHA), held an in-service for staff related to watching for unsecured medications, and ensuring the residents consumed their medications prior to leaving resident rooms. On 05/05/2022 at 9:59 a.m , an observation of the 400 Hall (North) medication cart included eight unsecured tablets. Staff C, Registered Nurse (RN) confirmed the presence of the unsecured tablets. On 05/05/2022 at 10:20 a.m., an observation of the medication cart on 300 Hall (North) included one half of an unsecured blue tablet located in the narcotic box, one loose white capsule located on the side in a small open space in the narcotic drawer, and two loose tablets located in the third and sixth drawer from the top of the medication cart. Staff D Licensed Practical Nurse (LPN) confirmed the presence of the unsecured medications. (Photographic Evidence Obtained.) On 05/05/2022 at 10:40 a.m., an observation of 100 Hall (South) medication cart revealed one unsecured white tablet in the second draw, one unsecured tablet in the 4th draw, and one unsecured yellow capsule sitting on top of the medication box. Staff E, (LPN) confirmed the presence of the unsecured tablets. On 05/05/2022 at 11:33 a.m., an interview was conducted with the DON who was informed of the unsecured tablets located in all three (3) medication carts. During the interview the DON said the nursing staff brought her the unsecured tablets and she directed the staff to destroy the tablets in the pill-buster. She said the nursing staff rip the packages with pills, and the pills had the potential to fall out in the cart and box. She stated, There should be no loose pills in the medications in the carts. She further indicated the facility would immediately initiate audits. A review of the facility policy titled Medication Storage Section 4.1, dated of 09/2018, Pages 01 and Page 02, revealed under Policy Statement: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 1. The pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 15. Medication storage should be kept clean, well lit, organized and free of clutter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement fall risk care plan interventions of floor mats for one (Resident #30) of three residents sampled for falls. Findings included: A review of Resident #30's admission Record revealed the resident was readmitted to the facility at the end of July 2020. A review of Resident #30's quarterly Minimum Date Set (MDS) assessment, dated 8/11/2020 revealed he was unable to complete the Brief Interview for Mental Status (BIMS) interview, had short-term and long-term memory impairment, and was severely impaired for decision making. A review of a significant change MDS dated [DATE] revealed his cognitive status remained unchanged from the 8/11/2020 assessment. A review of Resident #30's Progress Notes, dated 8/15/2020 revealed the resident was found on the floor at 3:30 p.m. by a Certified Nursing Assistant [CNA]. Assessed by nurse for injuries, abrasion observed to back of lower right side of head. No s/s (signs and symptoms), resident assisted off the floor and back into bed. Abrasion treated by nurse and a call placed to physician. Perimeter mattress was put in place and responsible party was notified. A review of Resident #30's care plan, initiated 8/25/2020, revealed a focus related to falls with interventions to include floor mats to the left side of bed while in bed, perimeter mattress, to lock brakes on bed and chair before transferring, and a low platform bed. On 1/11/21 at 7:47 a.m., Resident #30 was observed lying in bed with the bed in the lowest position. No floor mats were observed on either side of the bed and it could not be determined if the perimeter bed was properly placed. An attempt to interview the resident was unsuccessful due to the resident's poor cognitive status. On 1/12/21 at 11:15 a.m., Resident #30 was observed lying in bed in the lowest position with no floor mats in place. On 1/13/21 at 9:47 a.m., the resident was again in the low bed with no floor mats in place and the perimeter bed did not appear to be properly inflated. On 1/14/21 at 8:43 a.m., Resident #30 was lying in bed under the covers without floor mats in place. On 1/14/21 at 9:23 a.m., Staff A, Certified Nursing Assistant (CNA), revealed she has worked at the facility for more than 10 years and that Resident #30 just moved to her assigned rooms less than a week ago. Staff A stated Resident #30 had no known incidents of falls, no fall indicators, and was not care planned for falls. Staff A was advised of the fall interventions in place for Resident #30 and immediately went to address the concern with the nurse. Immediately following the interview with Staff A, Staff B, Licensed Practical Nurse (LPN) was interviewed. She stated she has worked with Resident #30 for a couple months and she was not aware that the resident had interventions for falls. Staff B confirmed that the staff on the entire hall were responsible for reviewing and implementing interventions on the resident's care plan. Staff B stated she was going to review the care plan and ensure that the proper interventions were in place. On 1/14/21 at 9:43 a.m., the Risk Manager (RM) and Administrator revealed that the care plan protocol called for meetings daily with attendance by Unit Managers (UM), RM, MDS Manager, and Administrator. The RM stated she had only been at the facility for a month and she was retroactively reviewing care plans and the in-place interventions. She stated that any time she enters a resident's room she reviews the respective resident's care planned interventions and ensured they were being utilized. The RM stated Resident #30 changed rooms last week and the floor mats did not come with him when they moved rooms. The Risk Manager stated that it was unknown as to why the floor mats did not get put in place when the resident changed rooms. During a follow-up interview on 1/14/21 at 10:59 a.m., the RM stated Resident #30 was moved on 1/8/21 into the current room and the breakdown of mats not being in place occurred at that time. Moving forward, the RM has implemented Room Change Documentation to better inventory assistive and safety devices when changing resident rooms. The facility will be providing education and training on the new system. A review of the facility policy titled Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, effective March 2017, revealed that the facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions . The overall care plan should be oriented towards: 1) Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence. 2) Managing risk factors to the extent possible or indicating the limits of such interventions. 3) Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. 4) Applying current standards of practice in the care planning process. 5) Evaluating treatment of measurable objectives, timetables and outcomes of care. 6) Respecting the resident's right to choose to decline treatment, request treatment or discontinue treatment. 7) Offering alternative treatment's as applicable. 8) Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities. 8) Involving the resident to have a role in care planning even if adjudged incompetent, and the resident's family and/or other resident representatives as appropriate to participate in the development and implementation of his or her person-centered plan of care. 9) Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. 10) Involving the direct care staff with the care planning process relating to the resident's expected outcomes. 11) Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting.