Based on observations and interviews, the facility did not ensure dignity was maintained for residents in one out of two dining rooms related to residents at a single table not being served meals at the same time. Findings included: An observation was conducted on 2/23/25 during lunch in the second-floor dining room. At 12:20 p.m., the first tray cart arrived in the dining room. There were 14 residents in the dining room for lunch: - At a table with two residents, the first resident was served their tray at 12:25 p.m. and the second resident was not served until 12:44 p.m. - At a table with three residents, the first two residents were served their trays at 12:34 p.m. and the third resident was not served until 12:45 p.m. - At a table with two residents, the first resident was served their tray at 12:42 p.m. After a couple of minutes, the resident was overheard asking her table mate if she minded if she went ahead and began eating. The second resident was not served until 12:46 p.m. - At 12:46 p.m., 5 of the 14 residents in the dining room were not served. - At 12:48 p.m., two residents were overheard asking where their food was, and the Certified Nursing Assistant (CNA) said they were on another tray cart coming up soon. An observation was conducted on 2/22/25 at 12:08 p.m. in the dining room of the second floor during meal service: - Staff were observed removing trays from the meal cart, looking around the dining room for the resident whose tray they were holding, and determining if the resident was in the dining room. If the resident was not in the dining room, the staff member proceeded to exit the dining room with the tray. - At a table with two residents, the first resident was served their tray at 12:19 p.m. and the second resident was not served until 12:34 p.m. - At a table of two residents, the first resident was served their tray at 12:19 p.m. and the other resident was not served until 12:26 p.m. - At a table with three residents, two residents were served their trays at 12:20 p.m. The third resident was not served until 12:44 p.m. Meanwhile, the other two residents completed the meal and one exited the dining room. An interview was conducted on 2/23/25 at 12:45 p.m. with Staff L, CNA and Staff N, CNA. Staff L, CNA said the trays arrive in the meal carts by room number and there are three meal carts total. Staff take the tray to the room from the dining room, then come back to the dining room and finish the tray pass. Staff N, CNA said this makes it hard to serve everyone at the table at the same time as one person's tray might arrive on the first cart and the other resident's tray doesn't arrive until the third cart. An interview was conducted on 2/24/25 at 10:15 a.m. with the Food Service Director (FSD). The FSD confirmed the meal carts arrive to the units with resident trays in room number order. The FSD said she was not aware numerous residents dine in the dining room, I was told only about five residents eat in the dining room. The FSD stated, absolutely not should a resident have to watch someone else eat while they wait for their meal. An interview was conducted on 2/25/25 at 5:48 p.m. with the Director of Nursing (DON). The DON stated the expectation is residents are served at the same time. Review of the facility's policy and procedure titled Dignity, not dated, showed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 3. Individual needs and preferences of the resident and identified through the assessment process. 4. Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person or entity associated with this facility. 5. When assisting with care, residents are supported and exercising their rights .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an attempted interview on 2/22/25 at 3:00 p.m., Resident #9 was sitting at the edge of his bed playing with paper. Resident #94 did not acknowledge the State Agency (SA) Surveyor and began to have a conversation with himself. Review of the admission Record showed Resident #94 was admitted to the facility on [DATE] with diagnoses including but not limited to adult failure to thrive and schizophrenia. The Contacts section of the admission Record showed Resident #94 was his own responsible party. Review of the Medical Certifications for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) dated 12/5/24 showed section C - Decision Making Capacity, Resident #94 required a surrogate. Review of the care plan showed Focus: [Resident #94] is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Cognitive deficits. Goals: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions: - All staff to converse with resident while providing care. - Assist with arranging community activities. Arrange transportation. - Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, meals. - Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate. - Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. - Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. Review of the Modification (02) Admission/Medicare - 5 Day Minimum Data Set (MDS) dated [DATE], Section C - Cognitive Patterns, revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete interview. Section C0100 showed no BIMS was conducted resident is rarely/never understood. During an interview on 2/22/25 at 3:04 p.m., Staff A Certified Nursing Assistant (CNA) stated Resident #94 was usually in his own world and the resident does smile at times, but was not coherent very often or for too long. During an interview on 2/22/25 at 3:10 p.m., Staff B Registered Nurse (RN) stated to find out if a resident has capacity to make their decisions, staff would look on the a residents profile page to see if that resident was their own responsible party. Staff B, RN stated Resident # 94 had a POA as he was very confused. Staff B, RN reviewed Resident #94's profile page and stated Resident #94 did not have a POA, but he was very confused. Staff B, RN stated the profile page showed Resident #94 was his own responsible party, but stated he was not. Staff B, RN stated Resident #94 had an emergency contact, so she would call the emergency contact for medical decisions. Staff B, RN stated there was a discrepancy between the Form 3008 and Resident #94's profile page. During an interview on 2/23/25 at 12:27 p.m., Staff C Licensed Practical Nurse (LPN) stated to find residents' emergency contact information, look in the electronic medical record for emergency contact under the profile on the administration record. Staff C, LPN stated the profile page would tell who information can be given to and who to contact for the resident. Staff C LPN stated the admitting nurse would be responsible for entering emergency contact information from the Form 3008 to the profile page for new admissions. During an interview on 2/23/25 at 4:45 p.m., the Social Service Director (SSD) stated the process for advanced directives started with Admissions Department as the admission Department would receive the Form 3008 and enter the information from the 3008 form to create a resident's profile page. The SSD stated to find out if a resident had capacity or not staff could find the information in the electronic medical record on the profile page. The SSD stated Resident #94 should never have been placed as his own responsible party on the profile page because the 3008 form showed he needed a surrogate. The SSD also stated the discrepancy was a mistake and someone should have caught the discrepancy and followed up on it. The SSD stated according to Resident # 94's medical record, he did not have a Power of Attorney (POA), Health Care Surrogate (HCS), or an assigned Guardian at this time and stated the record did not show where a physician declared Resident #94 with capacity either. The SSD stated the original discharge plan was for Resident #94 to go back and live with family. However, it was determined the family would not be able to provide the care for Resident #94 he would need so Resident #94 would now be staying at the facility in long term care. The SSD stated that someone in the facility should have caught that Resident #94 was not his own responsible party. During an interview on 2/24/25 at 10:15 a.m., the Assistant Administrator (AA), formerly the Admissions Director, stated the admitting nurse would be responsible for taking the information off a new resident's Form 3008, reviewing the hospital record, and inputting the information into the resident's electronic medical record. The AA stated the admitting nurse should have reviewed Resident #94's 3008 form and saw the resident required a surrogate. The AA also stated even if the information on the 3008 form was wrong then it should have been fixed. The AD stated even with Resident #94's mental health decline, she was not sure why the 3008 form showed a needing surrogate was not caught. The AA/AD said, I am not disagreeing with you there was a discrepancy between the advance directive information on Resident #94's 3008 form and what was transcribed onto Resident #94 profile page. During an interview on 2/24/25 at 10:30 a.m., Staff D CNA and Concierge stated Resident # 94 was seen talking to himself more and was showing more and more incoherent behaviors lately. During an interview on 2/25/25 at 10:58 a.m., the Director of Nursing (DON) stated the admitting nurse puts in all the information in the chart from the 3008 form, which is considered the facility's starting orders. The DON also stated the process for advanced directives are for the admitting nurse to put the information in the medical record and then the social service department would also review the chart and the 3008 form to ensure all advanced directives are in place. The DON stated if a resident needs a surrogate, it would be the Social Service Department that would act on that and contact the court system to initiate a court appointed guardian. The DON also stated she knew nothing about that process. Review of the facility's policy and procedure titled Resident Rights, not dated, showed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . k. appoint a legal representative of his or her choice, in accordance with state law; . t. privacy and confidentiality; . Review of the facility's policy and procedure titled Advance Directives, not dated, showed: Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation: Definitions: 1. The facility defines the following in accordance with current OBRA (Omnibus Budget Reconciliation Act) definitions and guidelines: . b. Advance Directive - a written instruction, such as living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated (per §489.100). c. Healthcare decision-making capacity - refers to possessing the ability (as defined by State law) to make decisions regarding health care and related treatment choice. Determining Existence of Advance Directive: 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 5. If the resident is incapacitate and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident legal representative. Decision-Making Capacity: 1. Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. 2. The interdisciplinary team conducts ongoing review of the resident's decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity. [NAME] are documented in the care plan and medical record. Based on interviews and record review, the facility failed to honor resident rights to formulate advance directives for two residents (#259 and #94) of 22 residents sampled for advance directives. Findings included: 1. During an interview on 2/26/25 at 9:36 a.m., the court appointed guardian for Resident #259 stated contacting the facility on multiple occasions to inform and ascertain information related to Resident #259, including the resident being intellectually disabled since birth and not able to make decisions. The guardian also stated the hospital had the paperwork from the court and the paperwork was sent with Resident #259 upon admission to the facility. The guardian stated they verbally told the nurses and sent the court documents of the guardianship to the facility. The facility not only had him sign to papers of disenrollment of healthcare coverage, but the facility also had Resident #259 sign vaccination consents and discharge paperwork, all being a violation of the court order. Review of Resident #259's admission Record revealed an admission date of 12/16/24 with a diagnosis of genetic related intellectual disability. Review of Resident 259's, Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 12/16/24 revealed under section C - Decision Making Capacity (Patient), the resident required a surrogate. Section D - Emergency Contact revealed the name and phone number of Resident #259's guardian. Review of Resident 259's Preadmission Screening and Resident Review (PASRR) dated 12/16/24 revealed the resident was receiving services for a Mental Illness (MI) and has a current diagnosis of an Intellectual Disability. Review of Resident #259's Clinical admission nursing note dated 12/17/24 at 1:07 a.m. revealed Resident #259 is only oriented to person and place. Review of Resident #259's Social Service note dated 12/17/24 at 10:24 a.m. revealed, Resident was observed to be alert, disoriented but able to follow instruction. Review of Resident #259's Brief Interview for Mental Status dated 12/17/24 at 12:04 p.m. revealed a score of 9 out of 15, indicating moderate cognitive impairment. Review of Resident #259's Guardianship paperwork, signed and sealed by a Circuit Judge in Highlands County, Florida, dated 7/6/16, revealed Resident #259 lacks capacity to take care of person, property, and estate. The document was uploaded to the facility electronic medical record on 12/24/24. Review of Resident #259's nursing notes dated 12/26/24 at 6:31 p.m. revealed a note created by the Director of Nursing (DON), spoke to resident POA [power of attorney] . Review of Resident #259's Discharge summary dated [DATE] at 11:42 a.m. revealed: Pt [patient] discharged back to group home with group home staff. D/c [discharge] paperwork gone over and all signed by resident and copies made for pt/group home staff. Meds sent home with pt (given to staff). Pt A&O [alert and oriented] and denies and [sic] pain, discomfort or SOB [shortness of breath]. Review of Resident #259's discharge paperwork dated 1/2/25 revealed, Resident #259's signature. Review of Resident #259's vaccination consent form dated 12/17/24 revealed Resident #259's signature and vaccination received on 12/19/24. Review of Resident #259's Disenrollment Request form dated 12/27/24 revealed Resident #259's signature to disenroll from Medicare Advantage and enroll in Medicare. During an interview on 2/24/25 at 4:29 p.m., the Business Office Manager (BOM) stated the facility did not have paperwork stating the resident was not competent and the family brought in the documents after the resident was already asked to disenroll. The BOM stated when learning of the error, they immediately emailed the case manager liaison of the facility, with that particular Medicare Advantage program. The BOM confirmed not notifying the Medicare official website. During an interview on 2/25/25 at 12:56 p.m., the Nursing Home Administrator (NHA) stated the facility should have honored Resident #259's guardianship paperwork that was uploaded to the system on 12/24/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure privacy of residents' personal health information on one unit (East) out of two units in the facility. Findings included: An observation was conducted on 2/22/25 at 10:28 a.m. of a medication cart outside of room [ROOM NUMBER]. The computer screen was unlocked with a resident's medical record displayed. The nurse was in a resident room and people were observed moving through the halls. An observation was conducted on 2/22/25 at 10:44 a.m. of a lab book sitting on the top counter at the nurses' station with a resident's face sheet sticking out of the book. The book was visible to anyone walking past the nurses' station. At the time, four residents were sitting at the nurses' station and no staff were present. An observation was conducted on 2/22/25 at 12:10 p.m. of a second-floor medication cart sitting in a resident hall with the computer screen unlocked and a resident's medical record displayed on the screen. No staff were present and residents were moving through the hall to the dining room for lunch. An observation was conducted on 2/23/25 at 12:50 p.m. of a second-floor medication cart sitting at the nurses' station with the computer screen unlocked and a resident's medical record displayed. The screen was partially covered with a sheet of paper. However, information could be seen and it was logged in to the nurses' account. An observation was conducted on 2/24/25 at 3:20 p.m. of a second-floor medication cart with the computer screen unlocked and a resident's medical record displayed. The nurse walked away from the cart, leaving the screen unlocked, and went to another medication cart. Residents were in the hall near the cart. An interview was conducted on 2/25/25 at 10:12 a.m. with Staff Q, Certified Nursing Assistant (CNA). She said staff are educated to make sure computer screens are locked and papers are turned over so no one can see resident information. An interview was conducted on 2/25/25 at 10:30 a.m. with Staff L, CNA. She said computers should be logged off when staff are not using them. She also said they try not to put papers on the top counter of the nurses' station, papers should be placed on the lower counter behind the nurses' station. An interview was conducted on 2/25/25 at 10:54 a.m. with Staff R, Licensed Practical Nurse (LPN). She said the computer screens on the medication cart should be locked when the nurse is not at the cart and all papers should be turned over. An interview was conducted on 2/25/25 at 5:54 p.m. with the Director of Nursing (DON). She said absolutely staff should be locking computer screens when they are not using them. The DON said papers with resident information should not be on the top counters at the nurses' station. She confirmed computer screens should not just be covered with a piece of paper; they should be locked. Review of a facility policy titled Resident Rights, revised December 2021, showed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 2. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA (Health Insurance Portability and Accountability Act) compliance officer. Photographic Evidence Obtained

Based on observations, interviews, and record review, the facility failed to ensure the prevention of the development of pressure wounds for one resident (#28) out of eight residents sampled. Findings included: On 2/22/2025 at 10:15 a.m., an observation and interview were conducted with Resident #28 and his family member in his room. Resident #28 was in bed and stated he was in a car accident and broke both his legs. Resident #28's family member stated the resident has several new open wounds on his right leg and bottom since he has been in the facility. An observation was made when Resident #28 lifted his right leg to reveal a dressing on the lateral lower area. The dressing had dried light to dark brown drainage and was dated 2/20. Resident #28's family member stated the wounds to his legs were from the brace he was wearing after his accident, but added he no longer wears the brace while he is in bed. An observation was made of two soft boots on the resident's wheelchair seat. The family member stated sometimes the staff will place the soft boots on the resident when he is in bed. On 2/22/2025 at 11:30 a.m., an observation was made of a nursing staff with a wound treatment cart in front of Resident #28's room. On 2/23/2025 at 12:30 p.m., an observation and interview were conducted with Resident #28 in his room. Resident #28 was sitting in his wheelchair with bilateral braces to his lower extremities. Resident #28 had his lunch tray on his bedside table. Resident #28 stated he would like to get back to bed because he had been up since 7:00 in the morning. An observation was made of a seat cushion shaped in a donut on the resident's chair in his room. Resident #28 stated he was not sure why it was there and could not recall if the cushion is supposed to be used while sitting in his wheelchair. On 2/25/2025 at 2:10 p.m., an observation was conducted in Resident #28's room. Resident #28 was in his bed and two soft boots were observed on top of the resident's wheelchair. A review of Resident #28's admission Record showed an admit date of 1/18/2025 with diagnoses of displaced bicondylar fracture of the left tibia subsequent encounter for closed fracture with routine healing, displaced bicondylar fracture of the right tibia subsequent encounter for closed fracture with routine healing, wedge compression fracture of second lumbar vertebra subsequent encounter for fracture with routine healing, unspecified protein-calorie malnutrition, and need for assistance with personal care A review of Resident #28's February 2025 physician orders showed the following: - House supplement two times a day related to unspecified protein-calorie malnutrition ordered 2/19/2025 - Immobilizer to BLE (bilateral lower extremities) when out of bed only every shift ordered 2/15/2025 - Prevalon boot to right and left heel as tolerated when in the bed with lateral lift for foot drop/AFO (ankle foot orthosis) every shift for DTI (deep tissue injury)/Foot drop, ordered 1/21/2025. - Treatment as follows: right outer lower extremity. Cleanse with wound cleanser and then apply xeroform every day shift every Monday, Thursday, and Saturday for skin tear, ordered 2/20/2025 discontinued 2/23/2025. - Treatment as follows: right lower calf cleanse with wound cleanser then pat dry and apply Santyl alginate calcium and dry dressing every day shift for wound care ordered 2/24/2025. - Treatment as follows: right upper calf cleansed with wound cleanser then apply Santyl alginate calcium and dry dressing as every day shift for wound care order 2/24/2025. - Treatment as follows: skin prep to both heels every shift for right heel DTI (deep tissue injury), left red/soft ordered 1/19/2025. - Treatment as follows: zinc oxide to right buttock as needed every day shift for wound care order 2/17/2025. - Wound consult for active wounds right lower extremity ordered 1/19/2025 On 2/25/25 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated nurses should remove a brace or sling for skin assessments. The DON also stated Resident #28 should be on an air mattress, if he's not already, he will be on one. The DON stated anyone can put a work order for an air mattress. The DON was made aware of the dressing dated 2/20 on 2/22/2025's observation for Resident #28 and stated the dressing change should have been addressed daily. On 2/25/2025 at 2:15 p.m., an interview was conducted with Staff W, (Registered Nurse) RN. Staff W, RN stated she is the wound nurse during the weekends and will make wound rounds with the wound physician every Monday and Thursday during wound rounds. Staff W, RN also stated she provided wound care for Resident #28 on 2/22/2025 and agreed the wound dressing was dated 2/20. Staff W, RN stated the resident initially arrived with bilateral lower leg braces, which made it a challenge for potential development of pressure wounds, but stated the resident has an order to now remove the resident's immobilizers while in bed. Staff W, RN stated nurses should be removing the immobilizers to do skin checks and during bathing. Staff W. RN agreed Resident #28 has two areas to his legs from the immobilizer and a pressure area on his sacrum. Staff W, RN stated the resident was not on an air mattress but he should be. Staff W, RN stated Resident #28 may refuse to wear the Prevalon boots ordered but his heels are good. A review of Resident #28 Treatment Administration Record for the month of February 2025 showed Resident #28 as compliant and wearing his bilateral boots with no refusals documented. A review of Resident #28's weekly skin check dated 1/19/2025 showed in Section B - Skin Impairment items (a) bruise and (c)skin tear as checked items. In Section D - New Skin Impairment Interventions items (c) wound care consult and (d) treatment order were checked. A review of Resident #28's Initial Wound Evaluation and Management Summary dated 1/20/2025 showed a focused wound exam (Site 1) to the right calf partial thickness as a trauma injury with wound size (L [length] x W [width] x D [depth]) = 6 x 6.3 10.2 cm [centimeters] with a total surface area of 37.80 cm2 [square centimeters]. A follow up Wound Evaluation and Management Summary dated 1/27/2025 showed the trauma wound to right calf as resolved. A record review of Resident #28's Wound Evaluation and Management Summary dated 2/10/2025 showed a new wound to right buttocks (Site 2) partial thickness with wound size (L x W x D) =1 x 1 x 0.1 cm with a total surface area of 1.00 cm2. Under section Musculoskeletal System, chair with pressure reduction cushion and feet with pressure relieving boot were documented by the wound therapy physician. A record review of Resident #28's Wound Evaluation and Management Summary dated 2/20/2025 showed a new wound to the right calf (Site 3). Site 2 right buttock partial thickness showed the following measurements 1.5 x 2 x 0.1 cm with a total surface area of 3.00 cm2 and wound progress noted as not at goal. Site 3 was described as unstageable (due to necrosis) of the right calf full thickness and measured 2 x 1 x 0.3 cm with a total surface area of 2.00 cm2. Site 3 underwent a surgical excisional debridement procedure by the wound care physician with post procedural orders for wound care treatment. A record review of Resident #28's Weekly Pressure Wound Note dated 2/24/2025 showed the right buttocks pressure measured at 1 x 1 x 0.1 cm Stage II, right lower calf pressure wound measured 2.5. x 1 x 0.3 cm unstageable and right upper calf pressure wound measured at 3.5 x 1 unstageable. All three wounds were documented by the wound care physician as in-house acquired. A review of the facility's policy and procedures titled Pressure Ulcers/Skin Breakdown-Clinical Protocol showed the following: Assessment and Recognition 1. The nursing staff and practitioners will assess and document an individual's significant risk factors for developing pressure ulcers, for example, mobility, recent weight loss, and a history of pressure ulcers. 2. In addition, the nurse should describe and document report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b. Pain assessment. c. Resident's mobility status d. Current treatments include support surfaces; and e. All active diagnosis 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer and characteristics presence of necrotic tissue, status of wound bed, etcetera) of an ulcer. 5. The physician will identify and define any complications related to pressure ulcers. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; (for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. 2. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, and the impact of comorbid conditions on healing and existing wound period. Treatment /Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etcetera), and application of topical agents 2. The physician will help identify medical interventions related to wound management; For example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etcetera. a. The poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcers. b. Beyond trying to maintain a stable weight and providing approximately 1.2 to 1.5 grams per kilogram protein daily, there are no routine pressure ultra specific nutritional measures for those with or at risk for developing the pressure ulcer c. Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight. 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors, For example: a. healing or prevention likely: the resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. b. Healing or prevention possible: healing may be delayed or may occur only partially; Wounds may occur despite appropriate preventative efforts. c. Healing or prevention unlikely: the resident is likely to decline or die because of his or her overall medical instability; Wounds reflect the individual's overall medical instability; An existing wound is unlikely to improve significantly; Additional wounds are likely to occur despite preventative efforts. 4. As needed, the physician will help identify medical and ethical issues influencing wound healing, For example, the impact of end stage heart disease or because the resident or family declines artificial nutrition and hydration. a. Advance directives may limit the scope, intensity, duration, and selection of various wound related or adjunctive treatments such as a choice to forego artificial nutrition and hydration. Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly- healing wounds. 2. The physician will guide the care as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident /patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident /patient or a substitute decision maker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation on 2/22/2025 at 11:52 a.m. revealed a pair of silver colored metal scissors and a razor stored in the bathroom of room [ROOM NUMBER]. An observation on 2/22/2025 at 11:56 a.m. revealed a razor stored in the bathroom of room [ROOM NUMBER]. During an interview on 2/25/2025 at 9:30 a.m., Staff F CNA stated newly admitted residents who were male received a razor in their welcome hygiene basket and male residents could have razors, but female residents were only given razors as needed. During an interview on 2/25/2025 at 9:35 a.m., Staff G CNA stated all razors are stored in the locked supply room and when a resident needs a razor, a razor would be provided to the resident to use. Once the resident is done with the razor it would be taken and disposed of in a sharp's container. During an interview on 2/25/2025 at 9:40 a.m., Staff B Registered Nurse (RN) stated residents are not allowed to have any kind of razors or scissors in their rooms and all razors and scissors should be locked up and residents should have supervision when using. During an interview on 2/25/2025 at 9:45 a.m., Staff H, Activity Director stated there should be no sharps, including razors or scissors of any kind, stored in residents' rooms. During an interview on 2/25/2025 at 9:51 a.m., Staff I CNA stated the staff provided razors when the resident needed it with supervision. The razors in the facility are disposable and one time use, so staff would throw away the razor in the sharps container on the nurse cart. During an interview on 2/25/2025 at 10:13 a.m., the Director of Nursing stated no residents should have razors or scissors in residents' rooms. During an interview on 2/25/2025 at 12:17 p.m., the Administrator stated there was no policy or procedure regarding residents not being allowed to have razors or scissors in their room and stated, we just educate and the staff just know. Photographic Evidence Obtained. Based on observations, interviews, and record reviews, the facility did not ensure the environment was free of possible accident hazards related to smoking materials for one resident (#104) of one resident sampled for smoking and related to razors and scissors in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) of thirty-one resident rooms observed. Findings included: 1. On 2/22/2025 at 12:20 p.m., an observation was made of Resident #104 in his room during the initial tour of the facility. In Resident #104's room there were two packs of cigarettes and three cigarette lighters in view. Resident #104 stated he was in the facility for therapy in hopes to discharge home. On 2/23/2025 at 9:25 a.m., an observation was made of Staff T, Certified Nursing Assistant (CNA) in Resident #104's room, cleaning. Resident #104 was not present in the room. The smoking materials observed the day before in Resident #104's room were no longer present. On 2/23/2025 at 12:49 p.m., an observation and interview were conducted with Resident #104 in the designated smoking area. The staff assigned to the smoking area was not aware Resident #104 had his own smoking paraphernalia. Resident #104 stated he was unaware he could not hold onto his smoking paraphernalia. The staff member explained to Resident #104 he had signed a smoking agreement with the facility and Resident #104 stated he did not receive a smoking agreement. The staff member pulled a sign from the doorway to the smoking patio and presented it to the resident. The staff member told the resident the signage was the contract presented to him. The staff member presented the resident with his smoking agreement he signed on admission. The resident apologized and stated he did not remember signing the smoking policy agreement. On 2/23/2025 at 1:26 p.m., an interview was conducted with Staff T, CNA, who stated she did not observe smoking material in the resident's room when she was cleaning up earlier today. Staff T, CNA stated smoking material should be held in a box in the nurses' station. On 2/23/2025 at 1:35 p.m., an interview was conducted with Staff S, Licensed Practical nurse (LPN). Staff S, LPN stated she did notice smoking paraphernalia in Resident 104's room this morning, but by the time she got back to his room the smoking material was gone. Staff S, LPN could not state who took his smoking paraphernalia out, but stated she thought upper management was making a sweep of all residents' rooms this morning. A review of Resident #104's admission Record showed an admit date of 1/28/2025 with a diagnosis of tobacco use. A review of Resident #104 medical record did not show a smoking evaluation completed by staff for safe smoking. A review of Resident #104's care plan did not show a care plan related to smoking. On 2/24/2025 at 3:20 p.m., an interview was conducted with Staff C, LPN and Staff U, LPN. Both confirmed when a resident arrives new to the facility there is a section in the initial assessment to ask the resident if they smoke. If the resident answers yes, they would have the resident read the smoking policy and have the resident sign the acknowledgment. A review of Resident 104's Minimal Data Set (MDS) assessment dated [DATE], in Section I - Active Diagnoses showed tobacco use. Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of current physician orders for Resident #104 showed an order, dated 1/29/2025, for Nicotine patch 24-hour 14 milligram/24 hour to apply one patch transdermally in the morning for nicotine abuse. On 2/24/2025 at 2:39 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident #104 told the facility he was not a smoker, but acknowledged he signed his smoking policy agreement in January. The DON also stated normally a Smoker Evaluation is done upon admission and quarterly and there is a smoker binder on the first-floor nurses' station of which all smokers are listed along with their evaluation and care plan. The DON stated the book is updated weekly by herself or the Assistant Director of Nursing and all smoking paraphernalia is held in a box for the residents on the first-floor nurses' station. The DON stated she will be calling families too to review the smoking policy. A record review of the facility's policy and procedures titled Smoking Policy - Residents, last revised in August 2022, in showed the following: Policy Statement: This facility has established and maintained safe resident smoking practices. The Policy Interpretation and Implementation: 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate for smoking and non-smoking preferences. . 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. Current level of tobacco consumption b. Method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etcetera) c. Desire to quit smoking, and d. Ability to smoke safely with or without supervision per a completed safe smoking evaluation. 7. The staff consults with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. 8. A resident's ability to smoke safely is reevaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted in the care plan, and all personnel caring for the resident shall be alerted to these issues. 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. . 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etcetera except under direct supervision.

Based on observations, interviews, and record review, the facility did not ensure post-dialysis communication was implemented and documented in the medical records for one resident (#33) of one resident sampled for dialysis. Findings included: A review of Resident #33's admission Record showed an original admit date of 7/6/2022, with a readmission date of 9/21/2024, and a diagnosis of end stage renal disease (ESRD). A review of Resident #33's February 2025 physician orders showed an order dated 2/5/2025 for dialysis weekly on: Monday/Wednesday/Friday at [dialysis center]. A review of Resident #33's dialysis communication records from 1/25/2025 to 2/21/2025 did not show a section for post-dialysis assessment or vital signs upon return to the facility. Upon further record review, no orders to address the resident's central line access for dialysis and/or documentation for post-dialysis assessment or vital signs were revealed. On 2/24/2025 at 12:00 p.m., an interview was conducted with Staff U, Licensed Practical Nurse (LPN) , Staff C, LPN and Staff V, Registered Nurse (RN). All three nursing staff members stated a resident on dialysis should have an order for dialysis and from there a drop-down option is available to assess the hemodialysis site, whether an AV (arteriovenous) fistula or a central catheter used, specifically for dialysis. Staff C, RN stated she checks when a resident returns from dialysis by assessing their port/fistula and vital signs. Staff C, RN also stated nursing staff should assess the dialysis site for any complications such as bleeding. Staff C, RN stated she does not think there is an area on the communication sheet from the dialysis center where she can document this information. Staff U, LPN stated there is an option to assess post-dialysis documentation in the medical record, but stated she does not think the facility utilizes this option. Staff U, LPN demonstrated the drop-down option to her other two nursing staff. At this point, the Director of Nursing (DON) arrived to continue with the interview and stated she was unaware of the option to document in the medical record post-assessment after dialysis. The DON acknowledged the current dialysis communication sheet does not have a section for the nurse to document the resident's assessment post-dialysis. A review of the facility's policy and procedures titled Care of the AV-Fistula-Graft, undated, showed the following: 1. Look for signs of infection: Redness, swelling, pain, warmth to site, drainage, or elevated temperature. Pay special attention to the most recent cannulation sites (where you were stuck last). . 11. Check cannulation (puncture) site carefully for bleeding after dialysis. If bleeding starts again, place pressure over the area for 5-10 minutes. If unable to stop bleeding, call the dialysis center and go to the nearest emergency facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure pharmacy recommendations were completed for two residents (#57 and #5) out of five reviewed for unnecessary medications. Findings included: Review of admission Records showed Resident #57 was admitted on [DATE] with diagnoses including atherosclerotic heart disease. Review of Resident #57's February 2025 physician orders showed an order for Peridex mouth/throat solution 0.12%. Give 15 ml (milliliters) by mouth every 12 hours for gum/teeth pain, dated 11/20/24 and a second order for Peridex mouth/throat solution 0.12%. Give 15 ml by mouth every 12 hours as needed for mouth pain for 2 weeks, dated 2/9/25 to 2/23/25. A review of a Consultant Pharmacist Medication Regimen Review dated 12/16/24 revealed: Peridex 0.12% (Chlorhexidine Gluconate) should not be swallowed. Please add to the order: Swish 15ml for 15-20 seconds, the expectorate- do not swallow A review of a Consultant Pharmacist Medication Regimen Review dated 2/16/25 revealed: Perdix should not be swallowed. Please add to the order. use 15ml to swish for 20-30 sec[onds], then expectorate- do not swallow. Review of orders showed neither of the recommendations were completed. The recommendations were not signed by the physician. An interview was conducted on 2/25/25 2:35 p.m. with the Consultant Pharmacist. He said he does monthly reviews of resident medication and the recommendations go to the Director of Nursing (DON). He said in the past they had issues getting the pharmacy recommendations completed at the facility. He also said if it isn't critical he will give it one month and if the facility doesn't complete the recommendation he will make another recommendation for the same thing. Review of Resident #5's admission Record revealed an admission date of 10/2/23 with diagnoses of brief psychotic disorder, insomnia, moderate major depressive disorder, persistent mood disorder, and anxiety disorder. Review of Resident #5's Consultant Pharmacist Medication Regimen Review dated 12/16/24 showed: Diclofenac [brand name] gel, please add dosage amount to complete this order. Suggest dosing: 1. For upper extremities: Apply 2 grams q [every] 6 hours-not to exceed 8 grams/day to any single joint. 2. For lower extremities: Apply 4 grams q 6 hours- not to exceed 16 grams/day to any single joint. Review of Resident #5's February 2025 physician orders showed: Diclofenac gel, apply to affected areas topically every 6 hours as needed for pain, dated 8/24/24. The recommended dosing was not documented in the order. Review of Resident #5's Consultant Pharmacist Medication Regimen Review dated 1/16/25 showed: 1. Midodrine 10 mg PRN [as needed] frequency, Midodrine is usually given three times daily. Please review Midodrine 10 mg every 1 hour PRN order and consider changing to 10 mg three times daily PRN for SBP<110 [systolic blood pressure]. 2. Calcitonin Nasal solution for COPD [chronic obstructive pulmonary disease] Calcitonin Nasal Solution should only be used in one nostril each day. Suggest clarifying directions to read: one spray in one nostril one time daily, alternate nostrils each day. AIso, please update the diagnoses list and the reason for using the Calcitonin Nasal Spray. [Calcitonin is typically used for osteoporosis]. 3. Mupirocin Ointment 2%; Please check on a stop date for both Mupirocin topical antibiotic orders. Review of Resident #5's February 2025 physician order revealed an order for Midodrine 10 mg, give 1 tablet by mouth every 1 hours as needed for Hypotension related to Other hypotension, administer for systolic b/p (blood pressure) greater 110/60, dated 7/16/24. The recommendation was not addressed. Review of Resident #5's February 2025 physician orders revealed an order for Calcitonin Nasal solution, 1 spray in both nostrils one time a day r/t [related to] Chronic obstructive pulmonary disease w/[with] (acute) exacerbation alternate nostrils daily, dated 10/2/23. The pharmacist recommendations were not addressed. During an interview on 2/25/25 at 5:48 p.m. the DON stated they receive the pharmacy recommendations and tries to complete them, but stated she, must have missed those, I got behind. I try to get them completed within the week. The DON confirmed the recommendations for Resident #5 and #57 should have been completed timely and were not. A policy and procedure for Pharmacy Recommendations was requested on 2/23/25. On 2/25/25 at 6:00 p.m., the DON stated the facility does not have a policy for Pharmacy Recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility did not ensure medications were stored properly on two out of two units in the facility related to unlocked medication carts, unsecured medication, and medication in resident rooms. Findings included: An observation was conducted on 2/22/25 at 10:23 a.m. of a medication cart at the second-floor nurses' station. There were two bottles of medication sitting on top of the cart, one was a stool softener and the other a multivitamin. Both bottles contained medication. No staff were in sight of the medication cart and three residents were sitting within 10 to 15 feet of the cart. An observation was conducted on 2/22/25 at 10:47 a.m. of an unlocked medication cart at the first floor nurses' station. No staff were near the cart. An observation was conducted on 2/22/25 at 11:51 a.m. of an unlocked medication cart on the second floor. No staff were in sight of the medication cart and a resident was sitting approximately 5 feet away from the cart. A nurse walked back up to the cart, grabbed something, and walked away with the cart without locking it. An observation was conducted on 2/22/25 4:11 p.m. of a box of over the counter (OTC) medication sitting in an open bedside drawer in room [ROOM NUMBER]. An interview was conducted on 2/25/25 at 2:35 p.m. with the Consultant Pharmacist. He said he does spot checks on medication carts and medication rooms monthly and he found a medication cart unlocked as well. He said nurses need to keep an eye out for medication in resident rooms that families may have brought in. An observation was conducted on 2/22/25 at 12:46 p.m. in resident room [ROOM NUMBER] b. A resident was lying in the bed with an over the bed table next to the bed. On the table were two medication cups, one was almost full of an orange colored liquid and the other was one fourth full of a dark liquid. An observation was conducted on 2/23/25 at 9:24 a.m. in resident room [ROOM NUMBER] a. A resident was lying in the bed and next to the bed was the over the bed table. On the table was a medication cup one half full of an orange-colored liquid. The resident stated the nurse leaves the medication with them. On 2/23/25 at 10:02 a.m. in resident room [ROOM NUMBER] b, a resident was observed sitting in a recliner and on the table next to the recliner was a bottle of wound cleanser. An interview was conducted on 2/25/25 at 5:49 p.m. with the Director of Nursing (DON). She said she would expect all medication carts to be locked and medications put up. The DON also said medications should not be left in cups at a resident's bedside and residents should not have over the counter medication in their rooms. Review of the facility's policy and procedure titled Medication Storage and Labeling dated 6/2023 showed: . Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: - Secured (locked) locations, accessible only to designated staff; - Clean and sanitary conditions; Photographic Evidence Obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to implement protocols from the facility's antibiotic stewardship program for one resident (#3) out of three residents reviewed for antibiotic use. Findings included: An observation and interview on 2/22/25 at 2:32 p.m. showed Resident #3 lying in bed with an Intravenous Therapy (IV) pole at the bedside. The IV pole contained two empty bags of Vancomycin, both dated 2/22/25. Resident #3 stated she was getting IV antibiotics because she recently had a severe Urinary Tract Infection (UTI) that sent her to the hospital. Resident #3 stated she did not know how long she would be on IV antibiotics but stated she was feeling much better. Review of the admission Record showed Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included but not limited to infection and inflammatory reaction due to other urinary tract infection (UTI) unspecified, urinary catheter initial encounter, infection and inflammatory reaction due to indwelling urethral catheter, and bacterial infection. Review of Resident #3's February 2025 physician orders showed: - A physician order dated 2/18/25, Vancomycin [Hydrochloride Salt] HCl in NaCl Intravenous Solution 750-0.9 [milligrams] MG/250 [milliliters] ML- [percent] % (Vancomycin HCl-Sodium Chloride)- Use 750 MG intravenously two times a day related to urinary tract infection unspecified. There was no end date for the order. - A physician order dated 2/18/25, Cefepime HCl Intravenous Solution 2 [grams] GM/100 ML (Cefepime HCl)- Use 2 gram intravenously every 12 hours related to urinary tract infection unspecified. There was no end date to the order. Review of the care plan showed a Focus: The resident is on antibiotic therapy related to infection (UTI). The Goal showed the resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. During an interview on 2/25/25 at 10:18 a.m. the Director of Nursing (DON) stated she worked with Staff R, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) and acting Infection Preventionist (IP) on infection control in the facility. The DON also stated she was usually on top of all the clinical aspects of infection control in the facility. The DON reviewed Resident # 3's current physician orders and stated all antibiotics should have an end date so appropriate monitoring of antibiotic duration occurred. The DON stated antibiotic monitoring was part of the facility's antibiotic stewardship program and, in Resident #3's case, no end date was added to the order and stated that was a problem. The DON also stated Resident #3 just returned from the hospital with a severe UTI and no one seemed to know how long she was going to need the IV antibiotics. Review of the facility's policy titled Antibiotic Stewardship, revised in December 2016, showed: Policy Statement: Antibiotics will be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and Implementation: . 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name b. Dose c. Frequency of administration d. Duration of treatment; 1. Start and Stop date, or 2. Number of days of therapy. e. Route of administration f. Indications for use.

Based on observation, record review, and interviews, the facility failed to ensure three residents (#41, #167, and #168) out of three residents reviewed for beneficiary notifications were provided with the correct notification prior to changes of skilled services and related changes. Findings included: Review of the Beneficiary Notice-Residents discharged within the Last Six Months form, completed by the facility, revealed 20 residents. Three randomly selected residents were chosen for review. Resident #41 was selected and identified as remained in facility, Resident #167 was selected and identified as remained in facility, and Resident #168 was selected and identified as discharged Home. Review of Resident #41's Skilled Nursing Facility Beneficiary Notification Review form, completed by the facility, showed the following information: - Skilled Services Start Date: 1/5/24. - Last Day of Services Covered: 11/15/24. - Voluntary Discharge from Services. - Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided and signed by Resident #41 on 11/15/24. - Notice of Medicare Non-coverage (NOMNC) was not provided. - Additional information: Resident #41 and Daughter requested to be discharged back to [Name of Assisted Living Facility] Assisted Living. Review of Resident #167's Skilled Nursing Facility Beneficiary Notification Review form, completed by the facility, showed the following information: - Skilled Services Start Date: 11/13/24. - Last Day of Services Covered: 12/8/24. - Voluntary Discharge from Services. - SNF ABN was provided and signed by Resident #167 on 11/15/24. - NOMNC was not provided. Review of Resident #168's Skilled Nursing Facility Beneficiary Notification Review form, completed by the facility, showed the following information: - Skilled Services Start Date: 1/10/25. - Last Day of Services Covered: 2/3/25. - Voluntary Discharge from Services. - SNF ABN was provided and signed by Resident #168 on 2/3/25. - NOMNC was not provided. - Additional Information: Resident expressed his wish to be discharged as soon as he arrived at [Name of Facility]. Resident requested to be discharged . During an interview on 2/25/25 at 3:04 p.m., the Social Services Director (SSD) said the facility quit giving NOMNC forms as of 10/31/24. The SSD also stated he received an email from the Administrator on 10/31/24 advising the use of the new SNF ABN form effective 10/31/24 and to provide all residents with changes in skilled services using this form. The SSD stated, I was told it was just one page now. The SSD stated prior to the direction of the Administrator in October 2024, he used to provide residents that were being discharged from the facility the required NOMNC. An observation on 2/25/25 at 3:06 p.m. revealed an email dated 10/31/24 from the Administrator to the SSD titled new SNF ABN with the form attached to the email. On 2/25/25 at 3:08 p.m., the SSD stated the SNF ABN form was the only notification given to residents when services were terminated or exhausted since 10/31/24. The SSD also stated he used to give the NOMNC form to those residents who were being discharged from the facility but had not since 10/31/24 per the Administrators instruction. The SSD stated there was a mistake on the Beneficiary Notice-Residents discharged within the Last Six Months form as all three residents reviewed were discharged from the facility and did not remain in the facility as identified on the form. The SSD stated since all three residents were all discharged from the facility, a NOMNC form should have been provided to all three residents instead of the SNF ABN. The SSD stated those residents who were identified as remaining in the facility were discharged to the adjoining Assisted Living Facility (ALF) that shared a lobby with the Long-Term Care (LTC) Facility. The SSD stated he assisted residents from both the LTC Facility and ALF and had to remember to treat the LTC and ALF as separate entities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 2/25/25 at 5:48 p.m., the Director of Nursing (DON) stated the expectation is the facility mark the MDS assessments accurately. 3. Review of admission Records showed Resident #56 was admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus with diabetic neuropathy. Review of Resident 56's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 8/13/24. Review of Resident #56's 2/7/25 Quarterly MDS, Section GG, Functional Abilities, showed for chair/bed-to-chair transfer the resident is partial/moderate assistance. An interview was conducted on 2/24/25 at 2:52 p.m. with the Director of Rehab (DOR). He said Resident #56 needed a mechanical list with maximum assistance to get out of bed and has always needed that. 4. Review of admission Records showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition. Review of Resident #39's 1/14/25 Quarterly MDS, Section B, Hearing, Speech, and Vision indicated the resident had adequate vision. Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact. An interview was conducted on 2/22/25 3:08 p.m. with Resident #39. She said she had no idea what she was eating each meal because she could only see shadows and staff do not tell her what she had and where it was. She said she just pokes her finger around it to try and figure out what she had. Resident #39 said it would be nice to know what she is eating each meal. Review of an eye doctor note, dated 10/11/24, showed Resident #39 had highly impaired vision and cataracts in both eyes Review of Resident #39's care plan did not reveal any focus area or interventions related to vision loss. Based on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for four residents (#80, #91, #56, and #39) out of 22 sampled residents. Findings included: 1. Review of the admission Record showed Resident #80 was admitted to the facility on [DATE] with diagnoses that included but not limited to epilepsy unspecified, unspecified dementia without behavioral disturbance, anxiety disorder unspecified, major depression recurrent, moderate, and seizures. Review of a physician order for Resident #80 dated 11/21/24 showed Memantine HCI [hydrochloride] Oral Tablet 10 [milligrams] MG. Give one tablet by mouth two times a day for Alzheimer/Dementia. Review of a Psychiatry Subsequent Note dated 11/19/24 showed Resident #80 presented with major depression recurrent, moderate, unspecified dementia without behavioral disturbance, primary insomnia and other specified persistent mood disorders. The plan of action was to continue Memantine because in general, it helps Dementia related cognitive decline and maintaining of daily living. Review of the Modification (02) of admission /Medicare - 5 Day Minimum Data Set (MDS) dated [DATE] showed Section I - Active Diagnoses (Check all that apply), the diagnosis of Non-Alzheimer's Dementia was not marked. During an interview on 2/24/25 at 10:00 a.m., Staff E MDS, Registered Nurse (RN) stated the diagnosis of Dementia for Resident #80 was not marked because it was overlooked. 2. Review of the admission Record showed Resident #91 was admitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disorder unspecified, major depressive disorder, recurrent, moderate, generalized anxiety disorder, bipolar disorder, current episode, mixed moderate and brief psychotic disorder. Review of Resident #91's physician orders showed the following: - A physician order dated 2/11/25 showed, Olanzapine Oral Tablet 5 MG (Olanzapine) - Give 1 tablet by mouth in the evening related to brief psychotic disorder. - A physician order dated 2/11/25 showed, Alprazolam Oral Tablet 2 MG (Alprazolam) *Controlled Drug*--Give 1 tablet by mouth in the morning related to generalized anxiety disorder. - A physician order dated 12/5/24 showed, Paroxetine HCl Oral Tablet 20 MG (Paroxetine HCl)- Give 2 tablet by mouth in the morning related to major depressive disorder, recurrent, moderate. Review of the Quarterly MDS dated [DATE] showed Section N - Medications (Check all that apply) the antipsychotic and antianxiety medication boxes were not marked. During an interview on 2/24/25 at 10:00 a.m., Staff E MDS, RN stated the antipsychotic and antianxiety medications were not selected on the Quarterly MDS because they were overlooked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) were accurately completed for nine residents (#44, #55, #91, #94, #33, #39, #56, #6, and #5) out of 22 sampled residents. Findings included: 1. Review of the admission Record showed Resident #44 was admitted to the facility on [DATE] with diagnoses that included but not limited to major depressive disorder, recurrent, moderate and muscular dystrophy. Review of a psych note dated 2/6/25 showed Resident #44 presented with major depressive disorder, recurrent, moderate, other specified anxiety disorders, primary insomnia, and muscular dystrophy. Review of the Level I PASRR, dated 1/9/25, showed in Section I, Part A. MI (Mental Illness) or suspected MI (Mental Illness) the diagnosis of Depressive Disorder was not marked. Section I, Part B Intellectual Disability (ID) or suspected ID (check all that apply) Muscular Dystrophy was not marked under Related Condition. 2. Review of the admission Record showed Resident #55 was admitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disorder unspecified, epilepsy unspecified, other seizures, major depressive disorder recurrent, mild, and bipolar disorder, current episode mixed, mild. Review of a psych note dated 12/9/24 revealed under New evaluation, Resident #55 presented with major depressive disorder, recurrent, moderate and bipolar disorder, current episode, mixed and mild. Review of the Level I PASRR, dated 11/8/24, showed in Section I , Part A. MI (Mental Illness) or suspected MI (Mental Illness), the diagnosis of Depressive Disorder was not marked. Section I, Part B. Intellectual Disability (ID) or suspected ID (check all that apply) Epilepsy was not marked under Related Condition. 3. Review of the admission Record showed Resident #91 was admitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disorder unspecified, major depressive disorder, recurrent, moderate, generalized anxiety disorder, bipolar disorder, current episode, mixed moderate, and brief psychotic disorder. Review of a psych note dated 12/5/24 showed Resident #91 present with major depressive disorder, generalized anxiety disorder, primary insomnia, bipolar disorder, current episode mixed, moderate, and a brief psychotic disorder. Review of the Level I PASRR, dated 9/24/24, showed in Section I, Part A. MI (Mental Illness) or suspected (Mental Illness) MI (check all that apply), the diagnoses of Anxiety Disorder, Bipolar Disorder, and Depressive Disorder were not marked. 4. Review of the admission Record showed Resident #94 was admitted to the facility on [DATE] with diagnoses that included but not limited to depression unspecified and schizophrenia unspecified. Review of a psych note dated 2/18/25 showed Resident #94 presented with major depressive disorder, recurrent, mild, other specified persistent mood disorders, and disorganized schizophrenia. Review of the Level I PASRR, dated 12/3/24, showed in Section I, Part A. MI (Mental Illness) or suspected (Mental Illness) MI (check all that apply), the diagnosis of Bipolar Disorder and Schizophrenia were not marked. 6. Review of admission Records showed Resident #39 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including depression, added during her stay on 6/20/23, major depressive disorder, added during her stay on 2/27/24, and generalized anxiety disorder, added during her stay on 2/27/24. Review of Resident #39's PASRR Level I screen, dated 12/22/21, only indicated depressive disorder as a diagnosis. Anxiety was not indicated on the PASRR Level I screen. The facility was unable to provide an updated PASRR Level I screen. 7. Review of admission Records showed Resident #56's was admitted on [DATE] with diagnoses including schizoaffective disorder, post-traumatic stress disorder (PTSD), schizoaffective disorder bipolar type, major depressive disorder, other specified persistent mood disorders, depression, anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of Resident #56's PASRR Level I screen, dated 8/27/24, only indicated depressive disorder, and psychotic disorder as diagnoses. Schizoaffective disorder, bipolar disorder, PTSD, mood disorder, and anxiety disorder was not indicated on the Level I screen. The facility was unable to provide an updated PASRR Level I screen. 8. Review of Resident #6's admission Record revealed an admission date of 10/8/19 with diagnoses of senile degeneration of brain and delusional disorders. Review of Resident #6's psych note dated 11/7/24 showed a diagnosis of anxiety disorder. Review of Resident #6's Level I PASRR, dated 10/4/19, showed in Section I, Part A. MI or suspected MI, Anxiety and Delusional Disorder was not marked. 9. Review of Resident #5's admission Record revealed an admission date of 10/2/23 with diagnoses of brief psychotic disorder, insomnia, moderate major depressive disorder, persistent mood disorder, and anxiety disorder. Review of Resident #5's psych note dated 11/7/24 showed the resident had been a harm to himself or others in the past. Review of Resident #5's Level I PASRR, dated 9/24/24, showed in Section I, Part A. MI or suspected MI, anxiety, persistent mood disorder, and psychotic disorder were not marked; Section II: #4. Is marked no for has the individual exhibited actions or behaviors that may make them a danger to themselves or others. During an interview on 2/25/25 at 10:10 a.m., the Director of Nursing (DON) stated she was responsible for reviewing and ensuring all PASRRs for residents were accurate when a resident was first admitted to the facility. The DON stated she tried to review all PASRRs and make sure the diagnoses were accurate on the PASARR. The DON also stated should a resident get diagnosed with a new diagnosis, the PASRR should be evaluated and updated to reflect the new diagnosis. The DON reviewed the PASRRs for Residents #5, #33, #39, #44, #55, #56, #91, and #94 and confirmed the Level I PASRRs were not correct for these residents. Review of the facility's policy PASRR Completion Policy showed: Policy Statement: The Center will a make sure that all admissions have the appropriate Patient Assessment ad Resident Review (PASRR) completed. Practice Guidelines: 1. Center Administrator will designate either the Admissions Director or Social Worker to make sure that the PASRR and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which night constitute an SMI [Severe Mental Illness] or ID [Intellectual Disability], the PASRR must be completed prior to admission. If the resident is deemed hospital except that must be clearly documented in the transfer documents to admission from the acute care facility. 2. Administrator will also designate a backup in case the designated person is not available. 3. Administrator is accountable for monitoring the process of completing the necessary paperwork for the admission. 4. Business Office Manager (BOM) must have copies of the LOC ad or PASRR in the Business Office resident file. 5. A review of Resident #33's admission Record showed an original admit date of 7/6/22 with a readmission date of 9/21/24. Resident #33's admission Record showed the following diagnoses: major depressive disorder recurrent, moderate and conversion disorder with seizures or convulsions. A review of Resident #33's February 2025 physician orders showed the following orders: - Divalproex Sodium oral capsule delayed release sprinkle 125 milligrams (mg), give two capsules by mouth in the evening for mood disorder, ordered 2/13/25. - Divalproex Sodium oral capsule delayed release sprinkle 125 milligrams, give two capsules by mouth in the morning for mood disorder, ordered 2/13/25. - Levetiracetam oral tablet 500 mg, give one tablet by mouth in the evening related to conversion disorder with seizures or convulsions, ordered 11/4/24. - Levetiracetam oral tablet 500 mg, give one tablet by mouth in the morning related to conversion disorder with seizures or convulsions, ordered 11/4/24. - Escitalopram oxalate oral tablet 10 mg, give one tablet by mouth in the morning for depression, ordered 11/4/24. - A review of Resident #33's Level I PASRR dated 9/13/24 showed under Section I, Part A. Mental Illness or suspected Mental Illness (check all that apply, conversion disorder with seizures or convulsions was not marked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of admission Records showed Resident #4 was admitted on [DATE] with diagnoses including morbid obesity, idiopathic gout, and age-related osteoporosis. Review of Resident #4's care plan showed a focus area of ADL (Activities of Daily Living) self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 7/24/24. An interview was conducted on 2/24/25 at 2:21 p.m. with Staff J, Certified Nursing Assistant (CNA). She stated Resident #4 has always needed a mechanical lift and was definitely not a partial assist. An interview was conducted on 2/24/25 at 2:52 p.m. with the Director of Rehabilitation (DOR). He stated Resident #4 needed a mechanical lift with maximum assistance to get up. 3. Review of admission Records showed Resident #56 was admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus with diabetic neuropathy. Review of Resident 56's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 8/13/24. An interview was conducted on 2/24/25 at 2:52 p.m. with the DOR. He said Resident #56 needed a mechanical list with maximum assistance to get out of bed and has always needed that. 4. Review of admission Records showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition. Review of Resident #39's 1/14/25 Quarterly MDS, Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact. An interview was conducted on 2/22/25 3:08 p.m. with Resident #39. She said she had no idea what she was eating each meal because she could only see shadows and staff do not tell her what she had on her meal tray and where it was. She said she just pokes her finger around it to try and figure out what she had. Resident #39 said it would be nice to know what she is eating each meal. Review of an eye doctor note, dated 10/11/24, showed Resident #39 had highly impaired vision and cataracts in both eyes Review of Resident #39's care plan did not reveal any focus area or interventions related to vision loss. 5. Review of Resident #6's admission Record revealed readmitted on [DATE] with diagnoses of senile degeneration of brain, delusional disorders, hypertension, and other co-morbidities. Review of Resident #6's Hospice Comprehensive Assessment and Plan of Care Update Report dated 1/22/25 showed a start of service date of 10/27/24 and the Hospice interdisciplinary group discussed the resident's hospice care and Resident #6 remains eligible for hospice services. Review of Resident #6's current care plan showed no focus, goal, or interventions for Hospice Care. During an interview on 2/25/25 at 3:00 PM, Staff E MDS Registered Nurse (RN) stated Residents #104, #4, #56, #39, and #6 should have a comprehensive care plan for the services provided to them and a care plan should be developed or an explanation in the record to as why it is not. During an interview on 2/25/25 at 5:48 p.m., the Director of Nursing (DON) stated the expectation is to have a care plan developed and implemented based on the care the resident requires. Review of the facility's policy and procedures titled Care Plans, Comprehensive Person-Centered, not dated, showed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. 6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2. any specialized services to be provided as a result of PASARR recommendations; and 3. which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. Based on observations, interviews, and record review, the facility did not ensure the development and implementation of the comprehensive care plan for five residents (#104, #4, #56, #39, and #6) out of twenty-two residents sampled. Findings included: 1. A review of Resident #104's admission Record showed an admit date of 1/28/25 with a diagnosis of tobacco use. A review of Resident #104's care plans did not show a care plan for tobacco use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility did not ensure care plans were revised for five residents (#13, #10, #6, #65, and #89) out of twenty-two sampled residents. Findings included: 1. Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including dementia, chronic cough, and dysphagia. Review of the Dining Assistance list provided by the Director of Nursing (DON) had Resident #13 listed as cue and assist, prefers bowls. Review of Resident #13's care plan showed a focus area of ADL (Activities of Daily Living) self-care performance deficit with interventions including, Eating: The resident is a feeder, at times feeds self, adaptive device of sippy cup and sided dishes. 2. Review of admission Records showed Resident #10 was admitted on [DATE] with diagnoses including dementia and gastro-esophageal reflux disease. Review of the Dining Assistance list provided by the DON had Resident #10 listed as cue and assist. Review of Resident #10's care plan showed a focus area of ADL self-care performance deficit with interventions including EATING: The resident is able to eat with set up assistance. An additional focus area was risk for malnutrition and altered mental status with interventions included assist with set up at meals, dated 7/12/24, and monitor/document/report PRN (as needed) any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals, dated 8/18/24. An interview was conducted on 2/25/25 at 10:10 a.m. with a hospice aide. She said Resident #10 needs assistance with eating and someone should be with her to cue her. 3. Review of Resident #6's admission Record revealed an admission date of 10/8/19 with diagnoses of senile degeneration of brain, delusional disorders, and hypertension. Review of Resident #6's progress notes dated 12/22/24 showed Resident #6 had a small open area to left side of the coccyx. The physician was contacted and order given for treatment, which was still active as of 2/24/25. Review of Resident #6's current care plan showed no evidence of skin impairment. During an interview on 2/25/25 at 3:00 p.m., Staff E, RN/MDS confirmed Resident #6 had a treatment order for impaired skin and there should be a care plan for this, but there is not one. 4. Review of Resident #65's admission Record revealed an admission date of 9/21/22 with diagnoses of mood disorder due to known physiological condition, moderate major depressive disorder, and delusional disorder. Review of Resident #65's progress notes dated 1/29/25 showed Resident #65 was fighting with staff, yelling at them, calling them names. Review of Resident #65's progress notes dated 2/2/25 showed Resident #65 was standing in the hallway and main dining, yelling and cursing at other residents and staff. Review of Resident #65's current care plan showed the following: Focus dated 8/16/24: Resident #65 is verbally aggressive related to mood disorder and delusions. Resident #65 confabulates, manipulates, and blames staff and residents consistently for verbal abuse and neglect, follows staff around and torments them. Goal dated 1/21/25: Resident #65 will verbalize understanding of need to control verbally abusive behavior through the review date. Resident #65 will demonstrate effective coping skills through the review date. Interventions dated 8/23/24: 2 Certified Nursing Assistants (CNA) at all times while providing care. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation. Monitor behaviors. Document observed behavior and attempted interventions. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. During an interview on 2/25/25 at 3:00 p.m., Staff E, RN/MDS confirmed Resident #65's care plan for behaviors has not been revised with alternate interventions since 8/23/24. 5. Review of Resident #89's admission Record revealed an admission date of 10/2/24 with diagnoses of cerebral infarction due to thrombosis of bilateral cerebellar arteries (stroke), chronic obstructive pulmonary disease (COPD), brief psychotic disorder, moderate major depressive disorder, and anxiety. During an interview on 2/24/25 at 3:30 p.m., Staff X, RN stated Resident #89 had a history of picking at his skin. Review of Resident #89's current care plan showed a Focus area dated 2/5/25, Resident #89 has a psychosocial well-being problem, hallucination, resident reaching for items not there, no other changes were made to the care plan. During an interview on 2/25/25 at 3:00 p.m., Staff E, RN/MDS confirmed Resident #89's care plan for behaviors was not revised with alternate interventions, nor implemented for behaviors. During an interview on 2/25/25 at 5:48 p.m., the Director of Nursing (DON) stated the expectation is for the facility to update the care plans when an incident/behavior/condition of a resident has changed. This permits the staff to try something different. Review of the facility's policy and procedure titled Care Plan, Comprehensive Person-Centered, not dated, revealed the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: l. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. 6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2. any specialized services to be provided as a result of PASARR recommendations; and 3. which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide care treatment and care in accordance with professional standards of practice related to 1.) did not ensure three residents (#13, #10, and #39) were assisted with eating, 2.) did not ensure two residents (#4 and #56) were assessed for transfers and provided wheelchairs, 3.) did not ensure notification of change in condition was completed appropriately for one resident (#29), 4.) did not ensure one resident (#309) was assessed appropriately for pain, and 5.) did not ensure wound care was provided for two residents (#71 and #89) out of twenty-two sampled residents. Findings included: 1. An observation was conducted on 2/22/25 at 12:52 p.m. of Resident #13 lying in bed with the head of the bed elevated and his tray table in front of him. The resident's lunch was on the tray table and he was feeding himself. His food was placed in bowls and he had a regular cup with no lid. The resident had food spilled down the front of his shirt. Resident #13's tray card showed he should have a cup with lid. The resident was observed struggling to hold the regular cup between his hands to drink from it. Both of the resident's hands were contracted. Review of admission Records showed Resident #13 was admitted on [DATE] with diagnoses including dementia, chronic cough, and dysphagia. Review of Resident #13's 12/2/24 Quarterly Minimum Data Set (MDS) assessment, Section C - Cognitive Patterns, revealed the resident is rarely/never understood. Review of Resident #13's orders showed an order for a regular diet, pureed texture, nectar consistency, uses sippy cup, dated 8/17/24. Review of the Dining Assistance list provided by the Director of Nursing (DON) had Resident #13 listed as cue and assist, prefers bowls. Review of Resident #13's care plan showed a Focus area of ADL (activities of daily living) self-care performance deficit with interventions including Eating: The resident is a feeder, at times feeds self, adaptive device of sippy cup and sided dishes. A second observation was conducted on 2/23/25 at 12:39 p.m. of Resident #13 lying in his bed with the head of the bed elevated and his tray table with lunch was in front of him. The resident had a regular cup with no lid and bowls. The resident was eating independently with no staff in sight. He continued to pick up and drop the bowls on his bed. He had food down his shirt and on his face. An interview was conducted on 2/23/25 at 1:12 p.m. with the Director of Rehabilitation (DOR). He said Resident #13 had contractures in both hands and needed a sippy cup and assistance with eating. An interview was conducted on 2/23/25 at 1:33 p.m. with Staff C, Licensed Practical Nurse (LPN). She said Resident #13 fed himself pretty well, but she did not know he needed a sippy cup. She said she checked on him during lunch on 2/22/25 and confirmed he was served a regular cup with no lid. She said she did not know where to get information related to which residents need assistance with eating. An interview was conducted on 2/23/25 at 1:37 p.m. with Staff O, Certified Nursing Assistant (CNA). She said the DON has a list of residents that need queuing or assisting with eating. Staff O, CNA also said she knew Resident #13 had thickened liquids but did not know he needed a sippy cup. An interview was conducted on 2/23/25 at 2:32 p.m. with Staff R, LPN/ MDS. She looked at the nurses' station and said the list of residents who need assistance or special equipment is not in the book it should be in. She said the other problem is the kitchen only has a few sippy cups, not enough for what is needed. An interview was conducted on 2/25/25 at 1:22 p.m. with Staff Q, LPN. She confirmed Resident #13 should not be in his room by himself with his meal tray. An observation as conducted on 2/23/25 at 9:27 a.m. of Resident #10 sitting in bed with her breakfast tray in front of her. She was having a difficult time eating and was very slowly moving the utensil from her plate to her mouth. Review of admission Records showed Resident #10 was admitted on [DATE] with diagnoses including dementia and gastro-esophageal reflux disease. Review of the Dining Assistance list provided by the DON had Resident #10 listed as cue and assist. Review of Resident #10's care plan showed a Focus area of ADL self-care performance deficit with interventions including EATING: The resident is able to eat with set up assistance. An additional Focus area was risk for malnutrition and altered mental status with interventions included assist with set up at meals, dated 7/12/24, and monitor/document/report PRN (as needed) any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals, dated 8/18/24. An interview was conducted on 2/25/25 at 10:10 a.m. with Resident #10's hospice aide. She said Resident #10 needs assistance with eating, and someone should be with her to cue her. She said if the resident is in the dining room eating, she did ok but if she was in her room she needed a staff member to be with her cueing her and keeping her awake. The hospice aide said she came in multiple times and Resident #10 had her breakfast tray in front of her. She said when she came in the day prior, on 2/24/25, the resident was in bed with her tray in front of her and the resident was bent over asleep with food all over. An interview was conducted on 2/25/25 at 1:10 p.m. with Staff Q, LPN. She said Resident #10 needs cueing and assisting with meals and the resident should not be in her room with her tray by herself. An observation as conducted on 2/25/25 at 1:31 p.m. of Resident #10. She was lying in bed with the head of the bed elevated. Her lunch tray was in front of her, and she was attempting to eat. The resident said someone should help her and she couldn't do those with a spoon, referring to her carrots. The resident said no one helped her eat her lunch. An observation and interview was conducted on 2/25/25 at 1:37 p.m. with Staff C, LPN. Staff C, LPN was observed entering Resident #10's room. She said the resident should not be in her room eating on her own. Staff C, LPN said it had been over an hour since the lunch trays were passed to residents. Staff C, LPN asked Resident #10 is she was still hungry and the resident replied yes I could be if the carrots were lined up right and I could eat them. Staff C, LPN was observed assisting the resident with completing her lunch. An interview was conducted on 2/25/25 at 2:00 p.m. with Staff P, CNA. She said she was assigned to Resident #10 and she had gone in and checked on the resident. Staff P, CNA said Resident #10 is set up only for her meals according to her care plan. Staff P, CNA also said it is frustrating because different documents will say different things. An interview was conducted on 2/22/25 3:08 p.m. with Resident #39. She said she had no idea what she was eating for each meal because she could only see shadows and staff did not tell her what she had and where it was. She said she just pokes her finger around it to try and figure out what she had and it would be nice to know what she is eating each meal. Review of admission Records showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition, abnormal weight loss, and need for assistance with personal care. Review of Resident #39's 1/14/25 Quarterly MDS assessment, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13 indicating she was cognitively intact. Review of an eye doctor note dated 10/11/24 showed Resident #39 had highly impaired vision and cataracts in both eyes. Review of Resident #39's care plan did not reveal any Focus area or interventions related to vision loss. An interview was conducted on 2/25/25 at 10:12 a.m. with Staff P, CNA. She said Resident #39 had vision issues and can only see shadows, but staff don't have to help her with meals. An interview was conducted on 2/25/25 at 10:40 a.m. with Staff C, LPN. Staff C, LPN said Resident #39 had glasses and her vision is adequate. When told Resident #39 could only see shadows, Staff C, LPN said she had no idea and would have thought it would have been on the resident's care plan with interventions to help her. 2. An interview was conducted on 2/22/25 at 1:27 p.m. with Resident #4. The resident was observed lying in bed with the head of the bed elevated. Resident #4 said she was not able to get out of bed because she did not have a wheelchair and the mechanical lift hurt when they got her up. The resident said she would like to be able to get up. Review of admission Records showed Resident #4 was admitted on [DATE] with diagnoses including morbid obesity, idiopathic gout, and age-related osteoporosis. Review of Resident #4's MDS assessment dated [DATE], Section C - Cognitive Patterns, showed a BIMS score of 14, indicating the resident was cognitively intact. Review of Resident #4's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 7/24/24. An interview was conducted on 2/24/25 at 2:21 p.m. with Staff J, CNA. She stated Resident #4 would need a mechanical lift and was not a partial assist. Staff J, CNA also said Resident #4 doesn't get up, not that I am aware of. An interview was conducted on 2/24/25 at 2:52 p.m. with the DOR. He stated Resident #4 needed a mechanical lift with maximum assistance to get up and he agreed it would be a problem if a staff member attempted to get the resident up with a partial/moderate assist. The DOR said they had no record of Resident #4 being screened by therapy. The DOR also said residents are typically rescreened at their quarterly and annual review. An interview was conducted on 2/22/25 at 10:40 a.m. with Resident #56. The resident said she lays in bed all day and doesn't get up. She said she had a wheelchair and then it got taken for someone else. She also said the facility had been working on getting her a new wheelchair for a year. Review of admission Records showed Resident #56 was admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus with diabetic neuropathy. Review of Resident #56's Quarterly MDS assessment dated [DATE], Section C - Cognitive Patterns showed a BIMS score of 13, indicating she was cognitively intact. Review of the MDS assessment also there was no therapy screen completed during the quarterly review. Review of Resident 56's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 8/13/24. An interview was conducted on 2/24/25 at 2:52 p.m. with the DOR. He said Resident #56 needed a mechanical list with maximum assistance to get out of bed and has always needed that. The DOR also said Resident #56 had her own wheelchair but someone is borrowing it because she doesn't ever get up. The DOR provided a therapy screen request, dated 11/4/24, showing Resident does not get out of bed. No changes observed. The responses on 11/7/24 from occupational therapy was no change in function and from physical therapy was no change in LOF [level of function] at this time. The DOR said a therapy screen is conducted at the residents quarterly and annual review and he did not know the resident had a quarterly MDS review on 2/8/25. An interview was conducted on 2/24/25 at 2:21 p.m. Staff J, CNA. She said Resident #56 is not a partial/moderate assist. She said the resident can move her arms around and help but cannot do very much. Staff J, CNA said she had never seen Resident #56 out of bed and confirmed Resident #56 did not have a wheelchair. An interview was conducted on 2/24/25 at 3:11 p.m. with Staff L, CNA. She said for the last 5 months or more when she would ask Resident #56 if she wanted to get up she would say no because they took my chair. She said if the resident wanted to get out of bed staff would have found her a chair. A follow-up interview was conducted on 2/24/25 at 3:29 p.m. with Resident #56. She said staff did not ask her if she wanted to get up but it wouldn't have mattered because she hasn't had a wheelchair in a year. 3. An interview was conducted on 2/23/25 at 7:30 p.m. with a family member of Resident #29. The family member said there was an incident of alleged abuse that occurred on 1/24/25 and she was not notified until the next day, over 14 hours after the incident occurred. An interview was conducted on 2/25/25 at 2:19 p.m. with Resident #29's primary care Nurse Practitioner (NP). The NP said she was not notified of the incident with Resident #29 until the next day. She said she would have expected to have been called right away. The NP said Resident #29 was sent out to the hospital the day after the event when the provider was notified. Review of admission Records showed Resident #29 was admitted on [DATE] with diagnoses including Alzheimer's disease. An interview was conducted on 2/25/25 at 4:32 p.m. with Staff AA, Registered Nurse (RN). She said she was assigned to care for Resident #29 on 1/24/25 when the incident of alleged abuse occurred. She said she notified the DON immediately. She also said she did not call the resident's provider or emergency contact because the DON said she was coming to the facility and would take care of notifying the appropriate parties when she arrived. An interview was conducted on 2/25/25 at 5:24 p.m. with the DON. She said she was called immediately on 1/24/25 regarding the incident with Resident #29 and she went to the facility. The DON said she did not call the family until the next day and the NP was not called. She said, honestly I don't know why I didn't call that minute. The DON said she wanted to get more details about what happened. The DON also said she was overwhelmed the night of the incident and she should have called the resident's primary care NP and the family. 5. Review of Resident #89's admission Record revealed an admission date of 10/2/24. During an observation and interview on 2/22/25 at 3:09 p.m., Resident #89's Responsible Party (RP) stated Resident #89 scraped forearm during an incident last week. Resident #89's right forearm was observed with a bandage from the wrist to the elbow. The bandage was not dated. During an observation and interview on 2/23/25 at 1:14 p.m., Resident #89's RP stated a dressing was on the wound yesterday, not sure why there is not one today. The RP raised Resident #89's right sleeve of the sweatshirt and the right forearm was observed with no bandage. The skin impairment had a bright red middle and black scab surrounding the edges. During an observation on 2/24/25 at 10:05 a.m., Resident #89's right forearm was observed without a bandage. The right forearm had an impairment with bright red middle and black scab area surrounding. Four additional open skin areas were noted above the elbow, uncovered. During an interview on 2/24/25 at 11:18 a.m., Staff X, RN stated Resident #89 hurt their arm during an incident at the end of last week and the resident has orders for treatment to the areas. Review of Resident #89's February 2025 order summary showed an order dated 2/20/25 treatment as follows: right antecubital. Cleanse with wound cleanser then apply silicone cream and dry dressing every day for skin tear. Right elbow. cleanse area with wound cleanser then apply silicone cream and dry dressing every day shift for skin tear. Treatment as follows: right elbow. cleanse area with wound cleanser then apply silicone cream and dry dressing every day shift for skin tear. Review of Resident #71's admission Record revealed an admission date of 8/30/24 with diagnoses of multiple sclerosis, stage 4 pressure ulcer, and need for assistance with personal care. During an interview on 2/22/25 at 12:47 p.m., Resident #71 stated the facility does not complete the wound care as ordered by the physician and the facility misses dressing changes. Review of Resident #71's February 2025 order summary showed a physician order dated 1/11/25: Cleanse wound with wound cleanser then apply Mupirocin ointment to wound base then Santyl and cover with calcium alginate, secure with border gauze, twice daily. The order was discontinued on 2/5/25. Review of Resident #71's electronic Treatment Administration Record for January and February 2025 revealed the dressings were not completed on 1/16/25 p.m. shift; 1/21/25 p.m. shift; 1/24/25 a.m. shift; 1/27/25 p.m. shift; 1/28/25 p.m. shift; and 1/31/25 a.m. shift. A total of 6 dressing changes were not completed. During an interview on 2/23/25 at 12:33 p.m., Staff Z, Licensed Practical Nurse (LPN) stated she ran out of time on occasions to complete dressing changes for Resident #71. During an interview on 2/25/25 at 5:48 p.m., the DON stated the expectation is the facility follow the physician orders and dressings should be dated. Review of the facility's policy and procedure titled Wound Care, not dated, revealed the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have PRN (as needed) orders for pain medication to be administered prior to would care . Steps in the Procedure: . 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, date and apply to dressing. Be certain all clean items are on clean field. Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice. Photographic Evidence Obtained 4. On 2/22/25 at 11:24 a.m., an observation and interview were conducted with Resident #309 in his room with his family member at his bedside. The resident had his right arm wrapped in several neutral colored pressure wrappings from his shoulder down to his wrist. A large black brace with a metal joint over the elbow was observed over the pressure wraps from the shoulder to the wrist and a large bulky padding was attached to the black brace under the elbow for support. Under Resident #309's pressure wrappings was a tube extended out from his wrist connected to a portable wound vacuum device, secured under the black brace. The resident and his family member stated he had a fall and he sustained an open comminuted fracture to his right arm and elbow. Resident #309 stated he was having a great deal of pain from the weight of the brace on his shoulder and back pain from a previous back surgery. Resident #309 also stated the facility was slow to address his pain. The resident stated most of the pain was from his back where he had a previous back surgery but his right shoulder ached from the weight of the brace on his arm. The resident also stated he could only sleep in small increments in the bed and would often have to get up and sit in the chair to try and relieve his back and shoulder pain. Resident #309 stated one night a male nurse came in, dropped off medication on his bedside table, and walked away. The resident stated he was not asked why he was out of bed, how he was doing, or if he needed anything. The resident stated a day shift nurse asked him about his night one day and he told her how hard it was to sleep due to his right shoulder and chronic back pain. The resident stated the nurse practitioner came in with the day nurse and a mutual decision was made to have acetaminophen prescribed at nighttime. Resident #309 stated the same night shift nurse came into his room, dropped off medication in a cup, and left before the resident could ask what the medication was. The resident stated he was not given the opportunity to ask for pain medication. Resident #309 stated he had the same day shift nurse the following day and she was able to rectify the situation. Resident #309 stated moving forward he has been given Tylenol every evening and can remove his brace while in bed. Resident #309 stated this has made a big difference for him in a positive way, but he could not understand how something so simple took so long to rectify. Review of Resident #309's admission Record showed an admit date of 2/17/25 with diagnoses of displaced comminuted fracture of shaft of ulna, right arm subsequent encounter for closed fracture with routine healing, unspecified open wound of right upper arm subsequent encounter, and unspecified arthritis unspecified site. A review of Resident #309's February 2025 physician orders showed an order for acetaminophen extra strength tablet 500 milligram, give two tablets by mouth at bedtime for pain, ordered 2/21/25. Resident #309's physician orders did not reveal an order related to pain monitoring. A review of Resident #309's care plan showed a Focus area of Pain initiated 2/18/25 related to arthritis and fracture of the right ulna. The Goal for Resident #309's Focus area for pain revealed the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions include but are not limited to: - Administer analgesia as per orders. Give ½ hour before treatments or care - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Monitor/record/report to nurse any signs or symptoms of non-verbal pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in ROM (range of motion), withdrawal or resistance to care. A review of Resident #309's initial Pain Evaluation dated 2/18/25 revealed the following under Pain Indicators: 3. Staff Evaluation for Pain. Check all that apply: a. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning). 4. Frequency with which Resident complains or shows evidence of pain or possible pain: a. indicators of pain 1 to 2 days. On 2/24/25 at 12:00 p.m., an interview was conducted with Staff U, LPN , Staff C, LPN, and Staff V, RN. All three nursing staff members stated they will ask their residents if they are having any discomfort/pain, especially any new admissions and during their morning rounds if there is any indication the resident was having any discomfort or pain. On 2/24/25 at 12:08 p.m., an interview was conducted with Staff V, RN. Staff V, RN stated the first day she had Resident #309 she asked him how he slept and he stated he did not have a good night's sleep. Staff V, RN also stated the resident had a large bulky post-operative dressing and brace to his right arm. Staff V, RN stated she reviewed his medical records and noted no pain medication was ordered for the resident so she notified the primary physician's nurse practitioner, who was in the facility. She and the nurse practitioner went into the resident's room together and the resident agreed to acetaminophen but preferred to have the medication administered at nighttime. Staff V, RN assumed the medication was ordered by the nurse practitioner until she followed up the next day with Resident #309, who stated he did not have a good night again and confirmed he did not receive acetaminophen. Staff V, RN stated when she reviewed Resident #309's medical record, she noticed the acetaminophen was not ordered and obtained an order for the acetaminophen to be administered at nighttime. On 2/25/25 at 3:21 p.m., an interview was conducted with Staff W, RN/weekend supervisor. Staff W, RN stated she will ask her residents if they are having any pain during her morning rounds and in the medical records, any nurse can add to a resident order to check for pain every shift and added there are batch orders for pain to be considered as well. On 2/25/25 at 5:58 p.m., an interview was conducted with the (DON. The DON stated all residents' pain should be addressed when they are first admitted . Residents with a fracture should be addressed on a day-to-day basis. If the resident stated no pain upon admission, an ongoing assessment should be made of the potential for unforeseen future pain or non-verbal cues for pain, such as facial grimacing. The nursing staff can place a batch order for pain in the resident's medical record to assess for pain every shift. A review of the facility's policy and procedures titled admission Assessment and Follow Up: Role of the Nurse, revised in September 2012, showed the following: Purpose: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. . Steps in the Procedure 7. Conduct an assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalizations, acute illnesses, and overall status prior to admission. b. Relevant medical, social and family history. c. A list of active medical diagnosis and patient problems (such as recurrent falling or impaired mobility), especially those most related to reasons for admission to the facility and those that are affecting function, behavior, cognition, nutrition, hydration, quality of life, likelihood of functional recovery, and ability to participate in activities and to socialize. d. Current medications and treatments. . 9. Conduct supplemental assessments following facility forms and protocols including: a. Activity level b. Pain assessment c. Fall risk assessment d. Neurological assessment e. Skin assessment f. Functional assessment ability to perform ADL's (Activities of Daily Living), and g. Behavioral assessment A review of the facility's policy and procedures titled Pain Assessment and Management, last revised in October 2022, showed the following: Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the residents choices related to pain management. . 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain b. Recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions and h. Modifying approaches as necessary . Steps in the Procedure: . 4. Ask the resident if he or she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptions such as throbbing, aching, hurting, cramping, numbness or tingling. Assessing Pain: 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. 2. Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. 3. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain. 4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 5. During the pain assessment gather the following information as indicated from the resident or legal representative): a. History of pain and its treatment, including pharmacological and non-pharmacological interventions . b. Characteristics of pain: 1. Location of pain 2. Intensity of pain (as measured on a standardized pain scale); 3. Characteristics of pain (aching, burning, crushing, numbness, burning, etcetera); 4. Pattern of pain (constant or intermittent); and 5. Frequency, timing and duration of pain Identifying the Causes of Pain: 1. Residents may experience pain from several different causes simultaneously 2. in addition, common procedures such as moving the resident, physical therapies, or wound care can cause the resident pain. 3. Review the residents clinical record to identify conditions or situations that may predispose the resident to pain, including: A. Musculoskeletal conditions. a. degenerative joint disease b. rheumatoid arthritis c. osteoporosis d. fractures, and e. amputation B. Skin/ wound conditions: a. Pressure, venous or arterial ulcers; and b. surgical incision(s) Defining Goals and Appropriate Interventions: 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the source, type and severity of pain. 2. Pain management interventions shall we address the underlying causes of the resident's pain. 3. For those situations where the cause of the resident's pain has not been or cannot be determined, current standards of practice for managing pain are followed to help determine appropriate options. Monitoring and Modifying Approaches: 1. Monitor the resident's pain and consequences of pain at least each shift for your acute pain or significant changes in levels of chronic pain and at least weekly and stable chronic pain. 2. Monitor the resident by performing a basic assessment with enough detail, and as needed, with standardized assessment tools (for example approved pain scales, etcetera) and relevant criteria for measuring pain management (for example target signs and symptoms.) 3. Monitor the following factor to determine if the resident's pain is being adequately controlled: a. The resident's response to interventions and level of comfort over time; b. The status of the underlying causes of pain, if identified previously; and c. The presence of adverse consequences to treatment Documentation: 1. Document the resident's reported level of pain with adequate detail (for example enough information to gauge the status of pain) and the effectiveness of interventions for pain as necessary and in accordance with the pain [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure food preferences were honored for four residents (#309, #28, #39, and #71) out of twenty-two residents sampled. Findings included: 1. On 2/22/2025 at 11:24 a.m., an observation and interview were conducted with Resident #309 in his room with his family at his bedside. Resident #309 stated he requested hot tea in the morning since his arrival and so far, tea has not been offered to him. Resident #309 stated the facility continued to offer coffee when the resident dislikes coffee. He stated each time they ask him he would request hot tea instead, but no one would bring him a hot tea. The resident denied meeting any representatives from the kitchen regarding his food preferences. The resident stated, at this point, I've given up on getting a hot cup of tea in the morning. On 2/24/2025 at 9:30 a.m., an interview was conducted with the Food Service Director (FSD). The FSD stated her team will conduct a food preference interview with every new admission. On the food preference sheet, options are provided for food preferences and likes and dislikes for foods such as fruits, vegetables, and meats. The FSD stated the usual timeframe to complete the food preferences sheet is within three days but stated it may take a day or two more depending on the number of new admissions. The FSD also stated the food preference sheet responses are placed in the resident's medical record and dated. The kitchen will have a list of the resident's food preference sheet and the original paper will be placed in a binder in her office. Long-term residents will have a reevaluation done every three months prompted by the medical record for review. The FSD stated she did not see a Food Preference Sheet completed for Resident #309 and hot tea is an option for beverages preferences, but stated any staff member could have honored his wishes. 2. On 2/23/2025 at 12:30 p.m., an observation and interview were conducted with Resident #28 in his room. Resident #28 was sitting in his wheelchair with his lunch tray on his bedside table. On the lunch tray there was the remainder of a baked potato skin, a chicken breast, three asparagus stalks, a full cup of a light creamy soup and small remnants of a yellow cake in a cup. Resident #28 stated he could only eat the baked potato and dessert because he could not chew the chicken or the asparagus. Resident #28 also stated he only has three teeth in his mouth so sometimes he can't eat what is served to him because he cannot chew the food. The resident stated at home he would eat food that is softer or ground up and if his chicken was ground up, he could eat it today. On 2/23/2025 at 12:40 p.m., an interview was conducted with Staff U, Licensed Practical Nurse (LPN), who was assigned to Resident #28. Staff U, LPN was unaware of Resident #28's lack of dentation and difficulty in chewing his food. 4. During an interview and observation on 2/22/25 at 12:47 p.m., Resident #71 stated they did not receive condiments on the meal tray. No ketchup, mustard, salt, pepper, and crackers if they have soup. Resident #71 stated not being on a restrictive diet, so they don't understand why they cannot provide the items. No condiments were observed on the resident's meal tray. An observation was made on 2/23/25 at 12:25 p.m. of Resident #71's lunch tray and no condiments were on the meal tray. During an interview on 2/23/25 at 12:45 p.m., Staff L, CNA stated condiments don't come on the trays and if a resident requests something we get the item for them. During an interview on 2/24/25 at 10:15 a.m., the FSD stated condiments are supposed to be on the trays and extras are available in the dining room if anyone requests them. Review of the facility's policy and procedure titled Resident Food Preferences, not dated, revealed: Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation 1. Upon the resident's admission the Dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The Dietitian and nursing staff, assisted by the Physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. 5. The Dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The Physician and Dietitian will communicate the risks and benefits of specialized therapeutic vs. liberalized diets. 6. The resident has the right not to comply with therapeutic diets. 7. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 8. The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. 3. An interview was conducted on 2/22/25 at 3:08 p.m. with Resident #39. She said she would love to have yogurt, fruit, and/or muffins sometimes. She said she asked but never gets them. Review of the admission Record showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition. Review of Resident #39's 1/14/25 Quarterly Minimum Data Set (MDS) assessment, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact. Review of Resident #39's Food Preferences, dated 10/12/24, showed the resident preferred hot tea, oatmeal, bacon, fruit, and yogurt for breakfast options. A follow-up interview was conducted on 2/24/25 at 11:47 a.m. with Resident #39. The resident said she does not get the hot tea she requested for breakfast except occasionally one Certified Nursing Assistant (CNA) will go downstairs and find her some. She reiterated the fact she never gets fruit and yogurt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the protection of a resident's right to remain at the facility by issuing an inaccurate reason on a thirty-day Nursing Home Transfer and Discharge Notice for one resident (#4) out of one resident reviewed for admission, transfer, and discharge. Findings included: On 01/09/2025 at 10:30 a.m., Resident #4 was observed in his room, in bed, working on his laptop. Resident #4 stated the facility was discharging him for non-payment. He stated he did not want to talk about it. On 01/09/2025 at 11:15 a.m., the Nursing Home Administrator (NHA) stated, one resident, Resident #4 had been provided a 30-day discharge notice on 12/05/2024. He stated the reason for the 30-day notice was that the resident was combative. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which meant he was cognitively intact. A review of the medical record showed Resident #4's medical diagnoses included: Cerebral Infarction, unspecified, bed confinement status, and need for assistance with personal care. An interview was conducted on 01/09/2025 at 12:15 p.m. with the Business Office Manager (BOM). The BOM stated Resident #4 did not receive any money at the facility. She stated the resident did not owe any money to the facility. An interview was conducted on 01/09/2025 at 12:25 p.m. with the Social Worker (SW). The SW presented the 30-day notice which had been provided to Resident #4 for review. A review of the notice, dated 12/05/2024 with an effective date of 01/04/2025, revealed the following: -The reason for the notice was check marked, Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay, and Your health has improved sufficiently so that you no longer need the services provided by his facility. -The brief explanation written was, Patient to be discharged to another long-term care facility. -The transfer location was documented to be another nursing facility. -The signature space for the physician to sign the form, reflected the name of a physician with the words telephone order. The SW stated Resident #4 did not want to be transferred to the listed nursing facility, The SW stated the resident wanted to go to a different local nursing facility. The SW stated he did not know what monies Resident #4 owed the facility, what a bill was for, or the amount owed. The SW stated, the other reason for the discharge was that the resident was a little combative with the nurses. The SW stated he had put the name of the physician in the box, and the IDT (Interdisciplinary Team) talked to the physician, but the physician did not sign the form. The SW said, Resident #4 is alert and oriented, we talked to him, he refused to sign the form. An interview was conducted with the NHA on 01/09/2025 at 12:40 p.m. He confirmed the Nursing Home Transfer and Discharge notice was not accurate. He stated the reason Resident #4 was going to be discharged was due to being combative. A review of the comprehensive care plan, review start date 1/2/2025, revealed the following: Focus area: Resident needs discharge planning R/T (related to) : Adjustment to LTC (Long Term Care) placement. Goals: Resident will develop and participate in day-to-day facility routine that includes social out of room activities and daily care preferences. Interventions/Tasks: Resident's discharge plan is to remain in the facility LTC. An interview was conducted on 01/09/2025 at 1:50 a.m. with the Director of Nursing (DON)The DON stated Resident #4 could be combative. She stated, He refuses care a lot of the time. He refuses his medication, he chooses what he wants when he wants it. He is bedbound because he wants to be. She stated, When he refuses care, he will threaten to hit you. She stated she could not say if he actually ever made contact with anyone. The DON stated, He is a very angry man. I do not think they have put anything under behaviors. I was aware he was being given a 30-day notice, but I did not know why. The DON stated Resident #4 was a long-term resident, he required nursing care, and his health had not improved enough for discharge. She stated, He is bedbound and cannot care for himself.

Based on resident record review, staff interview, and policy review, the facility failed to have a complete accurately documented medical record for one (Resident #1) of four residents reviewed. Findings Included: A review of the record for Resident #1 revealed a physician's telephone order dated 5/9/23 to, send to ER [Emergency Room] for eval [evaluation] per resident request. A review of Resident # 1's nursing notes revealed the last documented note was dated 5/9/23 at 6:41 p.m. The nursing note, written by Staff A Licensed Practical Nurse ( LPN) revealed, At this time [Resident # 1] has complaints of pain and discomfort but refused all medications. Lung sounds are diminished along with his bowel sounds, trouble swallowing and speaking. He is refusing to eat on a regular basis, will continue to monitor this shift. There was no documentation in the nurses' notes of the transfer to the hospital per resident request, no documentation of the resident's condition upon transfer and no documentation that the family was notified of the transfer. An interview with the Director of Nursing (DON) on 6/6/23 at 1: 38 p.m., revealed she could not locate an SBAR (Situation, Background, Assessment, Recommendation) form that should have been completed when the resident was sent to the hospital. On 6/6/23 at 2:54 p.m., the DON confirmed there was no nursing note or any other documentation related to the transfer to the hospital. She stated that a transfer form was not completed if a patient requested to go to the hospital. She stated, We notify the physician and send them with a face sheet and a medication list and call report to the hospital, we don't do a transfer form. An interview was conducted with Staff A, the LPN who wrote the last documented nursing note on 5/9/23. She stated Resident #1 requested to be sent out to the hospital that evening. She stated he was adamant about it . He was feeling so sick by that point, I think. He wasn't eating or drinking. Staff A stated she called EMS (Emergency Medical Services) for him. Staff A stated she was an orientee at that time and did not recall who she was orienting with . She stated she did not know why there was no nursing note regarding Resident #1 being sent to the hospital. Staff A stated she could not recall if the family was notified that Resident # 1 was transferred to the hospital. At 5: 28 p.m., DON stated there was no policy for medical records documentation. Review of a policy entitled Transfers, Reducing Acute Care revised 11/8/2021, revealed Policy statement: Transfers to acute care hospitals will be minimized in situations where early intervention would make such transfers avoidable and in situations where the resident's directives specifically request that he or she remain in the facility. Policy Interpretation and Implementation 4. Symptoms or problems that may require physician or practitioner intervention will be documented in a format that will facilitate adequate information when communication occurs. For example: d. Situation: Information about the condition , situation or sign; e Background - Information about the resident, medications, vital signs, recent lab results and changes related to the problem (i.e., mental, functional, respiratory changes, etc. ), including advance directive information. f. Assessment or Appearance - What appears to be going on with the resident; and g. Request _ suggestions or requests for the provider ( i.e., labs, x- ray, acute care transfer, etc.). 5. Should it become necessary to make an emergency transfer or discharge to the hospital or other related in-situation, our facility will implement the following procedures: e. Prepare a transfer form to send with the resident (including Bed Hold). F. Notify the representative (sponsor) or other family members. i. Document disposition and actions in the chart.

Based on observation, resident and staff interview, medical record review, and policy review the facility failed to provide physician ordered wound care services for one (#77) of two residents reviewed for non-pressure related skin conditions. Findings included: During an interview on 01/09/23 at 10:50 AM, Resident #77 stated that he had skin cancer on his leg, and the facility does not take care of the leg dressing daily. An observation on 01/09/23 at 10:50 AM showed Resident # 77 had a dressing that was dated 01/08/22. A review of Resident #77's active physician orders showed a physician order dated 01/04/23 for, Right lower leg- cleanse with normal saline, apply collagen powder, xerform gauze, gauze and tape once daily and PRN (as needed) for dislodge or saturated dressing. A review of the Treatment Administration Record (TAR) for January 2023 showed the same order of right lower leg cleanse with normal saline, apply collagen powder, xerform gauze, gauze and tape once daily and PRN for dislodge or saturated dressing with a start date 01/04/23. The TAR showed the treatment was not completed for the dates of 01/05/23, 01/06/23 and 01/10/23. During an interview on 01/11/23 at 9:25 AM, Staff F, Licensed Practical Nurse (LPN) stated the facility had just hired a new wound nurse, but the protocol was for nurses to complete wound care and dressing changes and then mark the care off in the TAR once completed. During an interview on 01/11/23 12:00 PM, Staff A, Wound Nurse confirmed there was no additional documentation to show wound care treatment was done for Resident # 77's right lower leg on 01/05/23, 01/06/23, and 01/10/23. Staff A, Wound Nurse stated if the treatment was not documented, then it was not done. During an interview on 01/11/23 at 3:30 PM, the Interim Director of Nursing (IDON) stated the expectation would be that all wound care be documented on the TAR. Review of the facility policy titled Wound Care with a revision date of October 2010 stated that the documentation of wound care should include: type of wound care given, date wound care was given, change in resident condition, assessment data, person performing wound care and tolerance of procedure.

Based on observation, record review, interview, and policy review the facility failed to provide care and services related to catheter care for one resident (#25) out of six residents with indwelling catheters. Findings included: A review of admission records revealed Resident #25 had diagnoses to include urinary tract infection, cerebral palsy, and abdominal pain. A review of Resident #25's care plan revealed a care plan for increased risk for urinary tract infection related to presence of indwelling catheter for diagnosis of urinary retention, it noted catheter was changed to suprapubic catheter on 1/25/22. Interventions included change catheter bag monthly and observe/record urine appearance. A review of physician orders revealed the following orders: 1-Cleanse suprapubic site with normal saline, pat dry, apply clotrimazole solution and cover with split 4 x 4 gauze twice daily. Order date 8/28/22. 2-Suprapubic catheter care every shift. Order date 8/28/22. A review of the electronic Treatment Administration Record (eTAR) indicated order 1 was not documented as completed on 23 out of 62 twice daily shifts in December 2022 and order 2 was not documented as completed on 22 out of 62 twice daily shifts. The January 2023 eTAR indicated order 1 was not documented as completed on 7 out of 18 twice daily shifts from 1/1/23 to 1/9/23 and order 2 was not documented as completed on 8 out of 18 twice daily shifts from 1/1/23 to 1/9/23. A phone interview was conducted with the Director of Nursing (DON) on 1/12/23 at 8:31 a.m. She stated catheter care should be documented on the eTAR and would not be documented anywhere else. She confirmed if it isn't documented on the eTAR, there is no way to know that it was done. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 1/12/23 at 8:51 a.m. She stated catheter care is done daily and would be documented on the eTAR. She was observed to check Resident #25's gauze on her suprapubic catheter site. It was observed to be dated 1/9/23. An interview was conducted with Staff H, LPN, Care Team Manager (CTM) on 1/12/23 at 10:34 a.m. Staff H reviewed Resident #25's medical record and confirmed catheter care was not being documented as completed as ordered. A facility policy titled Catheter Care, Urinary, dated September 2012, was reviewed. The policy stated the following: Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections. Documentation The following information should be recorded in the resident's medical record. 1. The date and time that catheter care was given. 2. The name and title of the individual giving the catheter care 3. All assessment data obtained when giving catheter care. 4. Characteristics of urine such as color and order.

Based on observations, interviews, record review, and policy reviews facility failed to ensure one resident (#25) out of thirty-one sampled residents received trauma-informed care in accordance with professional standards of practice and accounted for the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause traumatization. Findings included: A review of Resident #25's Minimum Data Set (MDS,) section I, Active Diagnosis, dated 12/3/22, revealed a diagnosis of Post Traumatic Stress Disorder (PTSD.) A review of admission records indicated Resident #25 was admitted in 2019 with diagnoses to include anxiety, personality changes due to known physiological condition, and persistent mood disorder. A review of Resident #25's care plan revealed no care plans for PTSD or trauma-informed care. On 1/12/23 at 8:28 a.m., an interview was conducted with Staff B, Registered Nurse (RN,) MDS Coordinator, who is currently covering for the Director of Nursing (DON.) When asked if they have care plans for PTSD and Trauma-Informed care she stated, not at this time. She said she didn't think they had any residents with PTSD. When asked who enters the diagnoses into the MDS she stated, I do. When informed of Resident #25 having a PTSD diagnosis in her 12/3/22 MDS she stated, I must have just missed that one. Staff B continued and stated she was surprised Resident #25 had a PTSD diagnosis, but maybe it was related to sexual abuse because she did have issues with exposing herself to men previously. Staff B stated she would add a care plan immediately. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 1/12/23 at 8:51 a.m. She confirmed she was currently assigned to Resident #25. She stated she did not know the resident had a PTSD diagnosis. She said she has had the resident previously and has not seen any behaviors and doesn't know what the PTSD diagnosis was related to. An interview was conducted with Staff J, Certified Nursing Assistant (CNA) on 1/12/23 at 9:00 a.m. She confirmed she was familiar with Resident #25. She stated she did not know she had PTSD and hasn't seen any behaviors but said the resident does refuse baths. An interview was conducted with Staff H, LPN, Care Team Manager (CTM) on 1/12/23 at 10:28 a.m. She stated she was unaware of Resident #25's PTSD diagnosis. She was observed reviewing the resident's medical record. She confirmed PTSD was listed on the resident's MDS. On 1/12/23 at 10:40 a.m., an interview was conducted with Resident #25. She stated she has had trauma in her past but did not elaborate on what it was. The resident stated she was not seeing a therapist but thought talking to someone may help her. Staff H, LPN, CTM was informed of the resident's desire to talk to someone. Psychiatric notes were requested, but the facility was unable to provide any. On 1/12/23 at 11:55 a.m., Staff B, RN, MDS states she spoke to the psychiatrist, and they hadn't seen the resident since 2019. She was trying to reach another provider. No further information was received. A facility policy titled Care Plans, Comprehensive Person Centered, dated December 2016, was reviewed. The policy stated the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The care planning process will b. include an assessment of the resident's strengths and needs, and c. incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: b. describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporate identified problem areas, h. incorporate risk factors associated with identified problems, 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident-centered plan of care related to Dementia Care for one (#21) of one resident reviewed for dementia care out of 21 facility residents with dementia related diagnosis or Alzheimers' disease. Findings included: A record review for Resident #21 revealed admission to the facility in 2020 with diagnoses that included dementia, communication deficit and mood disorder, according to the Face sheet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section I revealed diagnoses that included Non-Alzheimer's Dementia. Review of a behavioral health note dated 10/18/2022 listed a secondary diagnosis of Dementia. Review of the resident's care plan on 01/11/2023 did not reveal a focus area related to Dementia care. During an interview on 01/11/2023 at 01:38 PM with Staff B, Registered Nurse (RN), MDS Coordinator, she stated the Social Services department was responsible for behavioral and Dementia care planning. On 01/11/2023 at 01:58 PM an interview was conducted with the Social Services Director (SSD). The SSD confirmed the Social Services department was responsible for development of a Dementia care plan if the resident had a diagnosis of Dementia. The SSD reviewed the clinical record and confirmed the resident should have a care plan related to dementia, stating, that is on me. He continued, stating he was on his own for several months, and this resident may have fallen through the cracks. During an interview with the Interim Director of Nursing (IDON) on 01/11/2023 at 03:30 PM she confirmed a resident with a diagnosis of Dementia should have a resident-centered care plan related to Dementia. Review of a facility-provided policy titled Dementia - Clinical Protocol dated March 2015 revealed: Treatment/Management: 1. For the individual with a confirmed Dementia, the IDT [interdisciplinary team] will identify a resident-centered care plan to maximize remaining function and quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Clinical record review for Resident #25 revealed she was a long term resident with diagnoses to include cerebral palsy and unspecified pain. A review of the resident's 12/3/22 MDS revealed a brief interview for mental status score of 15, indicating intact cognition. Continued review of the the MDS revealed Resident #25 had three Stage 2 pressure ulcers. The facility Matrix indicated Resident #25 had facility acquired pressure injuries. Interview with Resident #25 on 1/11/23 at 8:55 a.m. revealed she had received wound care, but not every day. A review of Resident #25's orders revealed the following: 1-Cleanse buttock with normal saline, pat dry, apply calcium alginate, cover with bordered gauze dressing daily and PRN (as needed). Order date 12/14/22 end date 1/4/23. 2-Right and left buttock cheek. Cleanse with normal saline, pat dry, apply small honey dressing daily and PRN. Order date 12/21/22 end date 1/4/23 3-Gluteal fold: cleanse with normal saline, pat dry, apply honey gel daily and PRN. Order date 12/21/22 end date 1/4/23 4-Remedy Phytoplex z-guard (zinc oxide) 17%-57% topical paste. Apply to upper back and buttocks BID (twice daily) and PRN. Order date 11/1/22. A review of the eTAR for December 2022 and January 2023 indicated wound care for order 1 was not documented as being completed on 9 out of 21 days between 12/14/22 and 1/4/23, wound care for order 2 was not documented as being completed on 7 out of 14 days between 12/21/22 and 1/4/23, order 3 was not documented as being completed on 6 out of 14 days between 12/21/22 and 1/4/23 and order 4 was not documented as being completed 15 out of 62 opportunities in December of 2022 and 5 out 18 opportunities from 1/1/23 - 1/9/23. 3. A family interview on 1/09/23 at 11:27 AM revealed Resident #35 had pressure ulcers on the buttocks and the pressure ulcers maybe getting worse. A record review revealed physician orders for, Left Buttocks- cleanse with normal saline, apply honey hydrogel sheet with border (medihoney hydrocolloid). Right Buttocks- cleanse with normal saline, apply hydrogel with silver and cover with gauze island dressing. The care plan showed a focus of Skin integrity with a goal of no skin breakdown and an intervention that stated, Head to toe skin assessment weekly and documented. The treatment administration record (TAR) for January 2023 showed no skin assessments were completed. The Nursing progress notes for January 2023 revealed no evidence skin assessments were completed. During an interview on 01/11/23 at 12:00 PM, Staff A, LPN/Wound Care Nurse confirmed there was no additional documentation to prove skin assessments were completed. Staff A, LPN/Wound Care Nurse stated if the care was not documented, then it was not done. During an interview on 01/11/23 at 2:09 PM, Staff B, MDS Coordinator stated skin assessments are expected to be completed weekly and according to the TAR the weekly skin assessment due on 01/06/23 was not completed. Staff B could not provide any additional documentation to prove skin assessments were completed. Staff B stated that she would have expected a skin assessment to be completed for January 2023. During an interview on 01/11/23 at 3:30 PM, the IDON stated the expectation would be that all wound care and assessments be documented on the TAR. Based on record review and interview, the facility failed to provide care and services related to wound care and assessment for three of three (#21, #25, #35) residents reviewed for pressure ulcers out of a total of 10 facility residents with pressure ulcers. Findings included: 1. A record review for Resident #21 revealed admission to the facility on [DATE], with diagnoses that included dementia, communication deficit and mood disorder, according to the Face sheet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had one Stage 3 pressure ulcer and one Stage 4 pressure ulcer. Review of the current physician's orders revealed: -Right Calf - Cleanse with NS [normal saline], apply gentamycin ointment, collagen powder, Calcium Alginate with silver, and cover with ABD [abdominal] pad and secure with a roll of gauze daily, dated 01/04/2023. -Left Calf - Cleanse with NS, apply collagen powder, dry protective dressing and secure with a roll of gauze daily, dated 01/04/2023. Review of the eTAR (electronic Treatment Administration Record) for January 2023 showed no documentation of both wound treatments being provided on 01/05/2023, 01/08/2023, 01/09/2023 or 01/10/2023 (four of the past seven days). Review of the wound assessment dated [DATE] revealed: -Right calf: Pressure Ulcer full thickness stage 4, measuring 22cms (centimeters) by 2.5cms by x3cms deep with purulent drainage. Epithelial tissue 90%; granular tissue 6%; slough 4%. -Left calf: Pressure Ulcer full thickness stage 3, measuring 5cms by 2.5cms by 0cms deep with serous drainage. Epithelial tissue 10%; granular tissue 83%; slough 7%. During an interview on 01/11/2023 at 12:11 PM with Staff A, Licensed Practical Nurse (LPN), Wound Care Nurse, she confirmed all wound care should be documented on the eTAR when completed. The LPN reviewed the clinical record for Resident #21 and confirmed no documentation was present for 01/05/2023, 01/08/2023, 01/09/2023, and 01/10/2023. Staff A, LPN also confirmed no documentation existed elsewhere in the clinical record to validate completion of wound care on 01/05/2023, 01/08/2023, 01/09/2023, or 01/10/2023. The LPN stated if it was not documented, she could not confirm the wound treatment was provided to the resident. On 01/11/23 at 3:30 PM an interview was conducted with the Interim Director of Nursing (IDON), who stated it was her expectation wound care was documented on the eTAR as soon as it was completed. Review of a facility-provided policy titled Wound Care dated October 2010 showed: Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given 2. The date wound care was given 3. The position in which the resident was placed 4. The name and title of the individual performing the wound care 5. Any change in the resident's condition 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound 7. How the resident tolerated the procedure 8. Any problem or complaints made by the resident related to the procedure 9. If the resident refused the treatment and the reason why 10. The signature and title of the person recording the data

Based on observation, staff interview and policy review the facility failed to store food in accordance with professional standards for food service safety as evidenced by failure to discard food items that were expired, unlabeled and undated food items in the kitchen and one of two medication storage rooms, and one dietary staff member not wearing a hair net in the kitchen area. Findings Included: An observation, during the initial kitchen tour on 01/09/23 at 9:25 AM, revealed two (2) low-fat 1% gallons of milk that had an expiration of 12/28/2022. An immediate interview on 01/09/23 at 9:25 AM, Dietary Staff C confirmed the milk was expired and stated, hopefully no one used it. An observation, on 01/09/23 at 9:30 AM, revealed a handful of yellow colored hard tubular food product that was wrapped up with plastic wrap that was not labeled or dated. An immediate interview on 01/09/23 at 9:30 AM, Dietary Staff E stated, what is that and identified the food product as left-over uncooked spaghetti. Dietary Staff stated that should have been labeled and dated. An observation on 01/09/23 at 9:40 AM, revealed a package of brown powder like substance that was opened but wrapped with plastic wrap on the shelf. An immediate interview, on 01/09/23 at 9:40 AM, Dietary Staff E stated, we have been looking everywhere for that cocoa powder. An observation on 01/09/23 at 9:45 AM, revealed a package of hard yellow shells not stored in the original packaging that was sticky to touch on the outside of the package and was not labeled and dated. An immediate interview, on 01/09/23 at 9:45 AM, Dietary Staff E stated, That is sticky why is it sticky? I will throw those taco shells away. Additional observations in the kitchen on 01/10/23 at 12:30 PM, revealed Dietary Staff D was not wearing a hairnet. An immediate interview with Dietary Staff E confirmed that Dietary Staff D was not wearing a hair net but stated that Staff D was usually in compliance with wearing hairnets and this was very rare for Staff D. Staff D stated a hairnet was worn earlier but somehow it must have come off while working in the kitchen. An observation of the medication storage room located on the first floor, on 01/11/23 at 1:16 PM, revealed a frozen pumpkin pie with no name and date. During an interview on 01/11/23 at 1:16 PM, Licensed Practical Nurse (LPN) Staff F confirmed the refrigerator in the medication storage area was designated as a resident refrigerator. LPN Staff F stated that the food in the refrigerator should have been labeled with resident's name and date. LPN Staff F confirmed there was no name or date on the pumpkin pie. An observation of the medication storage room located on the first floor, on 01/11/23 at 1:16 PM, revealed a grocery bag of unlabeled individually wrapped frozen hot pockets. There was a resident name on the outside of the grocery bag but no date indicating a use by date. During an interview on 01/11/23 at 1:16 PM, LPN Staff F, confirmed the observation of the grocery bag with no use by date. Review of the facility policy titled, Food Receiving and Storage revised 11/29/21 stated, Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at al times. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated use by date. 8. Once opened, all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 14. b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. d. Other opened containers must be dated and sealed or covered during storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the binding arbitration agreement explicitly informed the resident or their representative of the right to not sign it for three residents (#12, #41, and #24) of three residents sampled. Findings included: 1. Review of Resident #12's Face Sheet revealed Resident #12 was admitted on [DATE]., with diagnoses that included end stage renal disease, insomnia, and depression. Review of the Minimum Data Set (MDS), provided by the facility and dated 1/12/23, Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was a 15 out of 15, indicating the resident was cognitively intact. Review of the binding arbitration agreement revealed it was signed by the facility representative (Staff G, admission Coordinator) and Resident #12 with no date documented. Further review of the binding arbitration agreement revealed the agreement did not show an explicit statement that the resident or representative did not have to sign the arbitration agreement. 2. Review of Resident #41's Face Sheet revealed Resident #41 was admitted on [DATE] and readmitted on [DATE], with diagnoses to include major depressive disorder, and single episode, unspecified, paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS), provided by the facility and dated 1/12/23, Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was a 15 out of 15, indicating the resident was cognitively intact. Review of the binding arbitration agreement revealed it was signed by the facility representative (Staff G, admission Coordinator) and Resident #41 with no date documented. Further review of the binding arbitration agreement revealed the agreement did not show an explicit statement that the resident or representative did not have to sign the arbitration agreement. 3. Review of Resident #24's Face Sheet revealed Resident # 24 was admitted on [DATE], with diagnoses to include disease of esophagus, unspecified, disease of upper respiratory tract, and a urinary tract infection. Review of the binding arbitration agreement revealed it was signed by the facility representative (Director of Post-Acute) and Resident #24 with no date documented. Further review of the binding arbitration agreement revealed the agreement did not show an explicit statement that the resident or representative did not have to sign the arbitration agreement. On 1/12/2023 at 9:48 a.m., an interview was conducted with Staff G, admission Coordinator. Staff G stated she explains what the arbitration agreement is and they do have an option not to sign the form. She confirmed the binding arbitration agreement did not include a statement giving the resident or their representative the option not to sign the agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to provide Pneumococcal vaccinations for three (Residents #4, #12, and #33) of five residents sampled for Pneumococcal vaccinations, failed to provide influenza vaccinations for three (Residents #12, 33, and 63) of five residents sampled for influenza vaccinations, and failed to provide COVID-19 vaccinations for two (Residents #33 and 63) out of five residents sampled for COVID-19 vaccinations. Findings included: A request was made for pneumococcal, flu, and COVID vaccination consent/refusal and proof of administration for five residents on 1/11/23 to Staff B, Registered Nurse (RN)/Minimum Data Set (MDS Coordinator,) who was covering in the absence of the Director of Nursing (DON.) A record review for Resident #12 indicated he was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal, flu and COVID vaccines with Resident #12's name on it. The form was not filled out or signed. There was no proof the resident received flu or pneumococcal vaccines. The resident was listed on the facility's spreadsheet as having his COVID vaccine. A record review for Resident #4 indicated she was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal, flu and COVID vaccines. The form provided consent by the resident to receive the pneumococcal vaccine, but there was no proof the vaccination was given to the resident. A record review for Resident #33 indicated she was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal and flu vaccines dated 10/11/20. The form consented to the flu vaccine and refused the pneumococcal vaccine. There was no current documentation provided. There was no signed refusal for the COVID-19 vaccinations and the resident was not listed on the facility provided spreadsheet as receiving the vaccine. A record review for Resident #63 indicated she was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal, flu and COVID vaccines, dated 1/26/22. The form provided consent by the resident to receive the flu vaccine and stated she wanted the COVID-19 vaccine. There was no proof the vaccines were given. The resident was not listed as receiving the COVID-19 vaccine on the facility's provided spreadsheet. A Vaccine Consent Form, dated 10/12/22, was checked as stating the resident requested the flu vaccine, but was unsigned. An Authorization for Treatment for pneumococcal, flu and COVID vaccines, also dated 10/12/22, indicated the resident did not want the flu vaccine; the pneumococcal and COVID-19 vaccine sections were not filled out. An interview was conducted with Staff B, RN on 1/12/23 at 10:08 a.m. Staff B stated the documentation provided was the only documentation in the residents records. She stated they have no proof vaccines were received or any more up to date consents or refusals. A facility policy titled Pneumococcal Vaccine, dated December 2012, was reviewed. The policy stated the following: All residents will be offered the Pneumovax (pneumococcal vaccine) to aid in preventing pneumococcal infections. 1. Prior to or upon admission, resident will be assessed for eligibility to receive the Pneumovax, and when indicated, will be offered the vaccine within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 5. Residents/Representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccine. 6. For residents who receive the vaccine, the date of the vaccine, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. A facility policy titled Influenza, Prevention and Control of Seasonal, dated August 2014, was reviewed. The policy stated the following: Vaccination 1. The Infection Preventionist will promote and administer seasonal influenza vaccine. 2. Unless contraindicated, all residents and staff will be offered the vaccine. A facility policy titled COVID-19 Vaccine Education, dated 9/22, was reviewed. The policy stated the following: The purpose of this policy is to maintain compliance with local, state, and federal guidelines relating to COVID-19 vaccination requirements. COVID-19 vaccines are effective at protecting you from getting sick and is an important tool to help us get back to normal.

Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct a citation related to proper storage of medications (F761) as evidenced by failure to secure and store medications properly in one of sixty-two resident rooms, two of six medication carts, and two of two nurses' stations during the revisit survey conducted 01/09/2023 to 01/12/2023. Findings included: 1. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated April 2014, revealed: Policy Statement This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Policy Interpretation and Implementation The primary purpose of the Quality Assurance and Performance Improvement Program (PIP) is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. QAPI Action Steps 18. Planning, conducting, and documenting PIPs 19. Conducting Root Cause Analysis to identify the underlying issues that contribute to recognized problems. 20. Taking systematic action targeted at the root cause of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. 2. During a complaint survey conducted on 11/15/22 the facility received a deficiency (F761) as a result of observations, interviews, and policy reviews, which revealed the facility failed to secure medications for two of six medication carts, one of two treatment carts and one of two medication storage rooms. Review of the facility's plan of correction for the 11/15/22 deficiency revealed the facility would take the following steps in order to obtain substantial compliance for F761 by 12/15/22: 1. Medication cart and treatments carts were locked immediately by Regional Nurse on 11/15/22. Medication was immediately removed from metal cabinet and placed in locked medication room by regional nurse on 11/15/22. Licensed RN and LPN (Staff ., Staff ., and Staff .) was educated on 11/15/22 by regional nurse on Storage Medication Policy which includes locking medication and treatment carts when not in use. On 11/15/22 Regional Nurse completed medication cart audit and any loose medication was disposed of appropriately. 2. Director of Nursing and Regional Nurse conducted a complete audit of all medication rooms, medication refrigerators, medication carts and treatment carts on 11/15/22 to ensure Storage Medication Policy and regulation was met. On 11/15/22, Director of Nursing and Regional Nurse completed audit of resident rooms to ensure no medications were present. On 11/15/22, Director of Nursing and Regional Nurse completed education post audit to nursing team. On 11/16/22, Director of Nursing and Regional Nurse ensured all nurses had keys to the medication room, refrigerator, and treatment carts. 3. By 12/10/22, Director of Nursing and Regional Nurse will provide education to licensed nursing staff on Regulation F761 Label/Store Drugs and Biologicals . related to medication carts, treatment carts, and loose medication in medication carts and resident rooms. Director of Nursing/ Regional Nurse/Unit manager will complete this education during new hire orientation and agency nurse orientation. 4. Director of Nursing or Designee will complete audit and observations of 3 medication carts, 3 treatment carts, 2 medication rooms, and 5 resident rooms weekly for 4 weeks, bi-weekly for 8 weeks, and monthly for 3 months to ensure substantial compliance. The findings will be reported to QAPI until substantial compliance is met. 3. During the revisit survey conducted 1/9/23 to 1/12/23 the following additional medication storage issues were found: An observation was made in the room of Resident #33 on 1/9/23 at 11:00 a.m. where three medication tablets were sitting on a cloth on the bedside table. (Photographic evidence obtained.) The resident stated, they just leave pills and don't take the time to tell her what they are. She stated they do that all the time. On 1/11/23 at 9:47 a.m., the first-floor nurses' station revealed one bottle of Robitussin, one bottle of Ferric X-150, and one bottle of Fiber Gummies sitting on a table in the nurses' station, unsecured with no staff present. (Photographic evidence obtained.) On 1/11/23 at 10:55 a.m., the second-floor medication storage room was observed to have a temperature of 50 degrees Fahrenheit with a second thermometer in the refrigerator indicating the temperature was 48 degrees Fahrenheit. The refrigerator had condensation dripping down the inside due to the temperature inside. All four shelves in the refrigerator contained medication. Staff H, Licensed Practical Nurse (LPN) confirmed the refrigerator was too warm. (Photographic evidence obtained.) A medication cart audit was completed with Staff I, LPN on 1/11/23 at 11:08 a.m., which revealed three loose pills. Staff I stated nurses clean their own carts out, but she hadn't had time to look through her cart yet that day. She said there should not be loose pills in the cart and the pill should be wasted. (Photographic evidence obtained.) On 1/11/23 at 11:58 a.m., the second-floor nurses' station was observed with two prescription inhalers sitting on the desk with no staff at the nurses' station. One inhaler was Fluticas/Salmet (Advair) 250-50mcg prescribed to Resident #62. The second inhaler was Wixela Inhub (Advair) 250/50mcg prescribed to Resident #7. At that time, Staff H, LPN was called over to observe the medication. She confirmed the prescription inhalers should not be out unsecured and didn't know why they were there. (Photographic evidence obtained.) A medication cart audit was completed with Staff F, LPN and Staff H, LPN on 1/11/23 at 12:00 p.m. with findings of 5 ½ loose pills. The bottom drawer of the medication cart had a sticky substance throughout. A liquid medication had spilled and was covering the medication bottle, and a box of gloves. Staff F and Staff H both observed the loose pills and sticky substance in the cart. Staff F, LPN stated she hadn't had a chance to go through her cart yet that day. Staff F stated she had recently received an in-service on medication storage. Staff H, LPN confirmed nurses should clean out their carts and no loose pills should be present. She also stated the liquid medication should be in a bag to prevent spilling in the cart. An interview on 1/11/23 at 12:07 p.m. with the Nursing Home Administrator (NHA) and Staff B, Registered Nurse (RN,) who was filling in for the Director of Nursing (DON) in her absence confirmed medications should not be at the nurses' stations unlocked and unsupervised. They also confirmed medication should never be left in a resident room; the nurse should stay with the resident until the medications are taken. The NHA and Staff B also confirmed no loose medication should be in the medication carts. The NHA said, it is unacceptable. On 1/11/23 at 3:28 p.m., a telephone interview with the DON confirmed no medication should be loose in medication carts, the nurses should be checking their carts daily, no medication should be unlocked and unsupervised at the nurses' station or be left in resident rooms. 4. A meeting was held with the Nursing Home Administrator (NHA) who is also the Quality Assurance Committee Chair on 1/12/23 at 11:45 a.m. The plan of correction, with a correction date of 12/15/22, was reviewed. The NHA stated they completed with 4 weekly audits and were currently doing audits bi-weekly for 8 weeks per the plan of correction. He stated the medication storage issue was discussed at the QAPI meeting held on 12/8/22. He confirmed in-services were completed for staff regarding medication storage. He stated he was brought to the facility to run education and follow through. He stated they have hired new nurses and it was just a need of continuing to educate. He also stated they were trying to stop using agency nurses and felt this would help.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy reviews, the facility failed to secure medications properly for two of six medication carts, one of two treatment carts and one of two medication storage rooms. Findings included: On 11/15/22 at 10:19 a.m., an observation was made of a treatment cart and a medication cart near the first-floor nurses' station. Both carts were unlocked and no staff were nearby. A resident was sitting approximately 4.5 feet from the unlocked medication cart. Addition observations from 10:24 a.m. to 10:35 a.m. on 11/15/22, revealed three nurses walked past the unlocked medication and treatment carts. No staff members stopped to lock the carts. The resident remained sitting near the unlocked medication cart. (Photographic evidence obtained) On 11/15/22 at 10:36 a.m., an interview was conducted with Staff D, Registered Nurse (RN.) She confirmed the medication cart belonged to her. When Staff D was asked about the cart being unlocked, she stated, that's just how it is. She confirmed the cart did not stay unlocked and she was aware it should be locked. She stated, I left it unlocked. Regarding the treatment cart that was unlocked, she stated everybody uses the cart. I don't know where the keys are to that. On 11/15/22 at 10:41 a.m. an observation was made of a door near the first-floor nurses' station. The door had a sign that read Keep this door shut please, however the door was wide open. Upon entering what appeared to be a storage room, a six-foot-tall metal cabinet was just to the left. The cabinet was full of medications. The cabinet nor the room were locked. The door to this room opened to a hall containing resident rooms and the dining room. (Photographic evidence obtained) The Regional Nurse was called to the first floor on 11/15/22 at 10:45 a.m. to discuss the unlocked medication and treatment carts and the unsecured medication in the storage room. At this time the medication cart had been locked and the treatment cart remained unlocked. The Regional Nurse locked the treatment cart. She stated she was unaware of the medications in the metal cabinet in the storage room. She did not know why they were there and not in the medication room. She confirmed the room was not supposed to be used for medication storage. Upon exiting the room at 10:50 a.m. the same medication cart on the 100 hallway was again unlocked with no staff in sight. The Regional Nurse locked the cart and stated she would begin in-services immediately. On 11/15/22 at 10:57 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN). She said the door to the storage room with the metal cabinet full of medications was normally closed, but she was not aware of it ever being locked. She said the storage room was where the over-the-counter medications were kept. On 11/15/22 at 11:02 a.m., an observation made on the second floor revealed an unlocked medication cart on the 200 hallway. No staff were in the hall. On 11/15/22 at 11:08 a.m., an observation was made of a small, round, light blue pill on the floor in room [ROOM NUMBER]. The pill had I 157 imprinted on it. At 11:10 a.m. Staff A, LPN was brought to the room. She stated, I don't know what this is. She said she did not know how it got there because she gave the resident in that room his medication with apple sauce that morning. Staff A put on gloves and picked up the pill; she was unable to identify what the medication was (Photographic evidence obtained) A tour of the second-floor medication storage room was conducted with Staff B, LPN on 11/15/22 at 11:18 a.m. The medication refrigerator had a padlock on the door that was unlocked. Staff B stated, sometimes we can not get to the key. She confirmed the refrigerator often remains unlocked because the nurses' do not have a key. She also said there were issues on the first floor as well because every nurse did not have the correct keys on the key rings for medication storage areas. On 11/15/22 at 12:18 p.m., the medication cart on the first floor 100 hall was again observed unlocked with no staff in the area. It remained unlocked at 12:23 p.m. On 11/15/22 at 1:36 p.m. a medication cart was checked with Staff A, LPN. She stated nurses cleaned their own carts, but it was usually done on the weekends. She said she was not sure when her cart was last cleaned. Two of the drawers had a combined total of nine loose pills in them. (Photographic evidence obtained.) The nurse confirmed that loose pills should not be in the cart, and she did not know they were there. The Regional Nurse came to the cart and witnessed the nine loose pills. She confirmed loose pills should not be in the cart. She disposed of the medication. On 11/15/22 at 1:45 p.m. an additional medication cart was checked with Staff A, LPN. She confirmed the nurses cleaned their own carts as needed. She stated she liked to keep her cart clean and organized. A total of three loose pills were found in her medication cart. She stated she had not checked her cart today (11/15/2022). She confirmed the pills should not be in the cart; they should be removed and disposed of in the medication waste bottle. On 11/15/22 an interview was conducted with the Director of Nursing (DON). She stated the expectation was all medication and treatment carts should be locked when not in sight of the nurse. When asked if there had been any recent staff education on medication storage, she said she now remembered being informed of medication storage issues at the previous survey, but she stated, I forgot. She said there had been recent education on medication administration, but not storage. Regarding keys, she said she knew the first floor only had one key on one of the nurses' key rings. She said the key for the medication refrigerator on the second floor should be in the medication storage room. In regard to the unlocked metal cabinet in the open storage room on the first floor, she said, that is where it has been, and I was told there was a key and it was misplaced. The Regional Nurse joined the interview and stated keys and locks would be made today and she would ensure all medication was secure and keys were provided to the nurses. A facility policy titled Storage of Medications, dated April 2007, was reviewed. The policy stated the following: Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 7. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 10. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of clinical records and policies and procedures, the facility failed to develop a care plan for one (#30) of 32 sampled residents related to respiratory care and behaviors and failed to implement care plan interventions related to smoking for one (#59) of 32 sampled residents. Findings included: 1. On 04/21/21 at 9:41 a.m., Resident #30 was observed lying in the bed flat on his back. The head of the bed was not elevated. The resident was sleeping. An oxygen concentrator was noted in the room running. Resident #30 was noted to have the oxygen tubing with a nasal cannula lying in the bed beside him. A review of the medical record for Resident #30 indicated the resident had a diagnosis of congestive heart failure, hypertension, and obstructive sleep apnea. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of the physician orders indicated the following active orders related to respiratory care: Atrovent administer one vial via nebulizer every six hours for shortness of breath or wheezing; check oxygen saturation every shift; oxygen 2 liters per minute via nasal cannula to keep oxygen saturation above 93%; auto CPAP 5-15 sonometers with heated humidification (dated 4/12/21). A review of the provider progress notes for Resident #30 indicated the following: -a visit dated 4/7/21 noted Resident #30 stated to the provider he was supposed to be assessed for a CPAP machine and the provider plan requisition the hospital for a sleep study. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. -a visit dated 4/12/21 noted Resident #30 reported experiencing sleep apnea that wakes him frequently while sleeping and an infrequent cough that is non-productive. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. Provider plan for automated CPAP at 5-10 sonometers with heated humidity. -a visit dated 4/20/21 noted a follow up for CPAP. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. The resident reported in a discussion to had used the CPAP only once. The resident reported a history of sleep apnea while in the hospital and was told to use a CPAP machine. He stated he had used a CPAP at home. The provider noted a repeat sleep study can wait until discharge and the resident should use an automated CPAP with heated humidification without a study. On 4/22/21 at 1:40 p.m., Resident #30 was observed lying in the bed in his room with oxygen on at 2 liters per nasal cannula via an oxygen concentrator. An interview was conducted with Resident #30 who stated he had not had a test for sleep apnea while at the facility. Resident #30 stated a nurse brought in the sleep apnea machine and put it on him for one night for about four hours, but the machine came apart at the tube and the nurse never came back in to put it back on. He stated he had not had the CPAP on again since that time. Resident #30 stated he does get short of breath and it wakes him up a lot in his sleep. He stated he had a CPAP machine at home before he became sick. He indicated he did wear it at home and would do so if the machine was working. The CPAP machine was noted on the bedside table in a bag. Photographic evidence was obtained. A nebulizer machine was noted on the bedside table with the tubing and mask chamber on the floor under the resident's bed. Photographic evidence was obtained. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/22/21 at 2:30 p.m. The ADON confirmed an order for CPAP dated 4/12/21 for Resident #30. The ADON stated no sleep study had been done and the therapy was ordered by the ARNP after she evaluated the resident. The ADON stated the resident received the machine and it was put on one time by the nurse. She stated the resident did not like the machine and he took it off. She stated the CPAP machine was not fitted for him to her knowledge. The ADON was asked if Resident #30 was refusing to wear the CPAP and if documentation supported the refusal. She indicated refusal was not documented for the CPAP therapy. The ADON confirmed the CPAP therapy for Resident #30 was not being provided by nursing as ordered. A review of the Comprehensive Care Plan for Resident #30 revealed no focus areas associated with respiratory care or behaviors related to refusing care and treatments related to respiratory care. An interview was conducted with Staff J, Registered Nurse, MDS Coordinator on 4/22/21 at 2:46 p.m. Staff J stated if a resident is on oxygen therapy, CPAP therapy, or refuses care related to the therapies prescribed these items should be a focus area on the Comprehensive Care Plan for the resident. She stated she was responsible for the initial care plan. Staff J, RN MDS stated she goes to see each resident and reviews the chart to get the initial care plan information. Staff J, RN MDS indicated all care plan items were reviewed by the care team to make sure the focus areas are accurate. Staff J, RN MDS reviewed the current care plan for Resident #30 and confirmed there were no focus areas associated with respiratory care or refusal of care on the comprehensive care plan. She stated she would make sure the focus areas were updated. A review of the facility policy entitled Comprehensive Care Plan with an effective date of 11/26/16 and a revised date of 5/25/18 indicated the following: Purpose: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan for, and mange resident care as evidenced by documentation from admission through discharge for each resident. Procedure: 2-The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10 (c)(2) and 483.10(c)(3), that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: a-the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40. b-any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6). 2. A review of Resident #59's current active care plan revealed the following: -Resident #59 smokes on a regular basis, (last reviewed 12/31/2020), with interventions to include but not limited to: Encourage him not to have lighters in his room. Inform resident of appropriate areas and redirect as needed. Assess for safety per policy and as needed. Notify Administrator of non-compliance. On 4/20/2021 at 10:30 a.m., an interview with Resident #59 revealed he smokes sometimes and did not remember if there was scheduled times for smoking. He was asked if he keeps his cigarettes and his lighter. The resident pointed to his left front pant pocket referring to the cigarettes and proceeded to pull out the lighter from the same pocket. On 4/20/2021 at 12:45 p.m., Staff A, Licensed Practical Nurse (LPN) was asked if there were any residents on her unit that smoked. She reported that Resident #59 smoked and was unsure when he went out to smoke. Staff A was asked about the safekeeping of cigarettes and lighting devices. Staff A stated that she believed the residents were not allowed to keep lighters and cigarettes and that they should be kept at the nurses' station. She was unsure if Resident #59's cigarettes and lighting device were at the nurses' station at that time. She was asked to check with the resident because he told the surveyor he had his cigarettes and lighter on him. Staff A did not return to speak to the surveyor with any information on this day. On 4/21/2021 at 8:30 a.m., Resident #59 was observed in his room, seated upright in bed and watching television. Resident #59 reported that he smoked sometimes. He reported that he smoked, downstairs, outside in the porch. He was asked where he gets his cigarettes. Resident #59 took his left hand and brought it to his left pant pocket and said, I keep them here. He was asked how he lights his cigarettes and Resident #59 again pointed at his left pant pocket and said, I have a lighter with me. He confirmed that he does not go to nursing to get his cigarettes and/or lighter devices. He said he keeps them on his person at all times. Review of Resident #59's medical record revealed he was admitted to the facility on [DATE] and was at the facility for long term care. Review of the advanced directives revealed Resident #59 was his own decision maker. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognitive impairment. Review of the smoking assessment dated [DATE] revealed a Score of 2 which indicates a minimal risk of resident harm while smoking tobacco products. These Residents are deemed independent and responsible for their actions while smoking at the facility. The narrative section of the smoking assessment noted: safe smoker. On 4/23/2021 at approximately 9:00 a.m., an interview was held with the Director of Nursing (DON) and Nursing Home Administrator (NHA) related to smoking. They both indicated that residents were not allowed to keep any smoking devices, supplies and/or lighting devices. They reported that staff were to keep those supplies at the nurses' station and provide them to the resident upon request. They also revealed that when residents were finished smoking, whether they are safe smokers or not, the supplies were brought back to the nurse to keep in either the nurses' station or medication cart. The NHA believed that Resident #59 stopped smoking and they did not think he had any cigarettes and or lighting devices on him. The DON confirmed Resident #59's current care plans revealed he was a smoker and that he should not have a lighter on his person. On 4/23/2021 at 9:00 a.m., the NHA provided the policy titled Smoking Policy - Residents last reviewed 6/24/2018. The policy revealed This facility shall establish and maintain safe resident smoking practices. The procedure section revealed residents with smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision.

Based on record review, observation, interviews, and policy review the facility did not ensure systems and processes for treatment of a pressure ulcer were implemented related to timely treatment of infection, appropriate disinfection of treatment supplies, maintenance of dressings on a pressure ulcer, adequate cleansing of the pressure ulcer, and appropriate application of the ordered treatment in a manner to prevent the worsening of a pressure ulcer for one resident (#40) of two residents sampled for care and services for pressure ulcers. Findings included: Resident #40 was admitted to the facility with a diagnosis of type II diabetes mellitus, according to the face sheet in the admission record. A review of the history and physical from the hospital, dated 11/4/20, reflected a chief complaint of pressure sore on coccyx. A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 03/03/21, section H, bladder and bowel, revealed Resident #40 was always incontinent of urine and bowel. Review of Section M, skin conditions, reflected a stage 4 pressure ulcer present on admission or readmission. A review of physician's orders in the medical record reflected the following findings: 4/13/21 2 view x-ray of sacrum/coccyx 4/14/21 culture wound to coccyx on 4/15/21 coccyx wound tx (treatment) changed -cleanse with normal saline (NS), pat dry, apply Santyl, calcium alginate and cover with padded dressing. 4/19/21 Place PICC line, may use 1% lidocaine Vancomycin 1 gram IV (intravenous) Q (every) 24 hours for 6 weeks. Pharmacy to dose. Vancomycin, BMP, Sed rate, CRP weekly while on Vancomycin. Indication/dx (diagnosis) MRSA Chest x-ray to be done after PICC inserted for placement. On contact precautions. 4/20/21 Apply triple antibiotic solution (GCP irrigation solution) to coccyx area BID (twice a day) with a dry padded dressing. Draw Vancomycin trough and serum creatinine on Wednesday, 4/21/21 30 minutes before dose is given. Fax results to pharmacy. 4/21/21 Continue previous treatment to coccyx until abt (antibiotic) solution arrives. 4/22/21 clarification order: ok to hold IV until PICC line placed and verified placement. Start Vancomycin 1 gm IV Q 24 Hrs for 6 weeks. Pharmacy to dose vanco. BMP, sed rate, CRP, weekly while on vanco. Need Cxr (chest x-ray) to verify placement. Cxr 1 view PICC line placement check Review of nurses' notes revealed the following: 4/4/21 coccyx wounds cleansed with NS (normal saline), dry, medihoney and calcium alginate applied and padded dressing. No s/s (signs symptoms) of infection noted. 4/13/21 coccyx wound order changed to cleanse with NS, pat dry, apply Santyl, calcium alginate, and cover with padded dressing. Seen by wound dr (doctor). Dr also ordered CRP, CBC, because resident's wound looks worse. Also a 2 view X-ray to sacrum/coccyx. 4/19/21 Culture results for coccyx wounds reviewed. Notified ARNP. New orders to place PICC line. Start Vancomycin 1 gram Q (every) 24 hours x 6 weeks. Pharmacy to dose. BMP, sed rate, CRP weekly labs while on Vanco. Resident placed on isolation for MRSA in wound. Called the IV company. Spoke to tech and confirmed IV nurse to come today to insert Midline. 4/20/21 Resident seen by wound Dr. Tx (treatment) orders to coccyx has changed to apply triple abt (antibiotic) solution -cover with padded dressing. Resident also on antibiotic for wound infection. There were no further notes in the record related to PICC line, iv antibiotic, or new treatment to the coccyx. Review of the wound evaluation and management summary from the wound care consultant reflected the following measurements and assessments: 2/2/21 1.7 x 1 x 1 cm stage 4 pressure wound of the right coccyx etiology: pressure exudate (drainage): light sero-sanguainous granulation tissue: 100% The report indicated the physician debrided the wound to remove biofilm, and ordered leptospermum honey daily for 16 days with a gauze island border dressing. 2/9/21 1.7 x 1 x 1 cm stage 4 pressure wound of the right coccyx exudate: moderate serosanguainous granulation tissue: 100% wound progress: no change The physician continued the previous treatment. 2/16/21 2 x 2.8 x 1 cm exudate: light serosanguainous slough: 5% granulation tissue: 95% wound progress: deteriorated Physician changed the treatment to collagen powder and leptospermum honey once daily for 30 days with a gauze island border dressing. 2/23/21 2 x 2.8 x 1 cm exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change The physician changed the treatment to collagen sheet twice a week for 30 days, with a NPWT (negative pressure wound therapy) pump. 3/2/21 2 x 2.8 x 1 undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change The physician indicated to continue the current treatment. 3/9/21 2 x 2.8 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change Dressing treatment plan: continue collagen sheet twice a week with NPWT 3/16/21 2 x 2.8 x 1 cm Periwound radius: surrounding DTI (deep tissue injury) (purple/maroon) undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change Dressing treatment plan: leptospermum honey, alginate calcium and a foam silicone border dressing twice a day 3/23/21 2 x 4 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: deteriorated Dressing treatment plan: continue treatment twice a day 3/30/21 2 x 4 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change Dressing treatment plan: continue treatment twice a day No assessment from physician or nurse was provided for the week of 4/6/21. 4/13/21 3.7 x 4 .2 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous Thick adherent devitalized necrotic tissue: 20% slough: 20% granulation tissue: 60% wound progress: deteriorated Please draw ESR/CRP and repeat CBC (labs). Patient had elevated WBCs, possibly due to a UTI (urinary tract infection) however wound was also worse and concerns for wound infection. Please obtain 2 view x-ray sacrum/coccyx rule out osteomyelitis, in addition to labs. Santyl was added to the twice daily treatments, and the leptospermum honey was discontinued. 4/20/21 3. 5 x 4 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous Thick adherent devitalized necrotic tissue: 20% slough: 20% granulation tissue: 60% wound progress: improved Dressing treatment plan: triple antibiotic solution twice daily and foam silicone border dressing additional wound detail Patient on IV (intravenous) ABT (antibiotic) for 6 weeks for suspected osteomyelitis Review of the 4/14/21 radiology report for a 2 view x-ray of the sacrum/coccyx revealed the following: conclusion: cannot exclude osteomyelitis, recommend MRI workup. The report was initialed by a nurse who indicated the ARNP (advanced registered nurse practitioner) was notified and ordered a wound culture. Review of the lab report dated 4/15/21 for the culture and sensitivity of wound and abscess reflected moderate MRSA (methicillin resistant staphylococcus aureus), few E. Coli (Escherichia coli), and rare Proteus mirabilis The susceptibility report dated 4/19/21 reflected the MRSA susceptibility to Vancomycin On 4/22/21 at 11:35 AM an observation was conducted during pressure ulcer care with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN reported that the order was changed to GCP (triple antibiotic) Tuesday but the pharmacy doesn't have it. They are supposed to send it today. The doctor said it is ok to continue the current treatment until it arrives. Staff F, LPN donned a gown and gloves after gathering supplies for the treatment; Santyl, normal saline syringes, dressing, calcium alginate, and gauze 4 x 4's. After knocking on the door, Staff F, LPN placed all the supplies on a paper towel on the bed side table. Resident #40 requested a pain pill. Staff F, LPN removed the PPE (personal protective equipment) and performed hand hygiene. When Staff F, LPN returned she said the resident's nurse said she can't have a pain reliever again until 1: 00 PM. Staff F, LPN put on another gown, performed hand hygiene, and put on a pair of gloves. Staff F, LPN informed Resident #40 she could not have the pain pill again until 1:00. Staff F, LPN asked Resident #40 if she could do the treatment or would she rather wait until after 1:00. Resident #40 said it was ok to do the treatment now. Staff F, LPN removed her gloves and washed her hands in the bathroom sink. She put on a new pair of gloves. Then Staff F, LPN assisted Resident #40 to her right side. Resident #40 was clean and groomed and free from any odor. There was not a PICC line observed on either of Resident #40's arms. Staff F, LPN removed the brief tab from Resident #40's left side and pulled the brief down to expose Resident #40's coccyx area. There wasn't a dressing on the wound. Staff F, LPN said no one reported the dressing came off. She changes it every day. The brief appeared to be dry. The wound was on the resident's right coccyx area about a half inch about her anus. It was about a one inch length by a half inch wide and a depth of about an inch. The wound was a stage 4, deep tissue injury. There was a small amount of slough (yellow, necrotic tissue) at about 4:00 on the right side of the wound. No odor was detected. The wound bed was bright red. The surrounding tissue was red and slightly dry and flaky and excoriated (inflamed and irritable). Staff F, LPN removed the gloves and performed hand hygiene. Then she put on a clean pair. Staff F, LPN opened one of the saline syringes and squeezed the contents onto a gauze 4 x 4. Then Staff F, LPN used the saline dampened gauze to dab and pat all around the wound on the periwound (surrounding tissue) completing a circle around the wound. Staff F, LPN used a clean gauze 4 x 4 to pat the periwound dry. Again dabbing all around the wound. Staff F, LPN did not clean the wound or the slough on the right outer edge of the wound. Staff F, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff F, LPN put on a clean pair of gloves and opened the dressing packaging and the calcium alginate. Staff F, LPN removed a pair of scissors and a felt tipped marker from her pocket. Staff F, LPN did not clean the scissors. She used the contaminated scissors to cut a piece of alginate about one inch by half an inch. She placed it back on the package. The surveyor asked if the scissors came from her pocket and Staff F, LPN confirmed they did. She said she cleaned them with bleach before she put them in her pocket. Staff F, LPN then dipped her contaminated gloved right finger into the medication cup with the Santyl in it. She applied the Santyl to the area of slough on the right mid-lower corner of the wound. Then Staff F, LPN placed the calcium alginate on top. Staff F, LPN removed her gloves and washed her hands in the bathroom sink. Then Staff F, LPN put on a clean pair of gloves and used the felt tipped marker to date the dressing. Next, Staff F, LPN covered the wound with the adhesive dressing. Staff F, did not apply any of the calcium alginate to the wound bed. Then Staff F, LPN removed the gloves and disposed of the remaining supplies. Staff F, LPN washed her hands in the sink, and put on clean gloves. Staff F, LPN reapplied the brief tab, and assisted Resident #40 to her back, after placing a foam wedge behind her back. Then Staff F, LPN removed the gown and gloves, and washed her hands in the sink. Staff F, LPN exited the room and used a bleach wipe to clean the scissors and the felt tipped marker. She placed them on a paper towel on top of the treatment cart. At 12:03 PM on 4/22/21, an interview was conducted with Staff F, LPN. The surveyor asked if Staff F, LPN only cleaned the periwound and not the wound bed. Staff F, LPN replied, Is that what you saw me do?The surveyor replied that is correct. Staff F, LPN confirmed she did not clean the inside of the wound. Staff F, LPN said the order says to do Santyl then alginate, it does not say inside the wound. On 4/22/21 at 1:27 PM, an interview was conducted with the resident's nurse, Staff G, LPN. Staff G, LPN said they are waiting for the pharmacy technician to put the PICC line in. The PICC was ordered the day before yesterday. Staff G, LPN said Resident #40 is not getting antibiotics. They are waiting for the PICC. During the interview, the order was reviewed for the PICC and Vancomycin. Staff G, LPN confirmed the PICC and Vancomycin were ordered on 4/19/21. She said the IV nurse is here now putting the PICC line in. On 4/22/21 at 1:57 PM an interview was conducted with the second floor unit manager and risk manager at the facility. She confirmed Resident #40 had MRSA in the wound. The unit manager said 4/19/21 was when they got the final culture. It was reported to the primary (physician). The wound physician was here on the twentieth and was also made aware. The primary ordered Vancomycin IV and a PICC. The unit manager said it is usually four hours to get a PICC line inserted. They travel from out of the area. All of us nurses are responsible for it. It is an IV company. They were contacted via telephone multiple times. The unit manager said she notified the physician this morning (three days later). She said she was sure the other nurses notified the primary also. She is here every day. She is an ARNP (Advanced Registered Nurse Practitioner). The ARNP said it was ok to hold the Vancomycin until the PICC was placed and verified. On 4/22/21 at 2:19 PM an interview was conducted with Staff H, Certified Nursing Assistant (CNA). Staff H, CNA said she changed Resident #40 after breakfast around 10:00, and she changed her a little bit ago again. The dressing fell off because she had a bowel movement (bm). The wound nurse was downstairs. The bm is always going to go in the wound because of where the wound is. So when they change her they clean her real good to make sure it isn't getting in there. On 4/22/21 at 5:07 PM a telephone interview was conducted with the ARNP overseeing Resident #40's care. She said she was notified on the twentieth and the twenty-first that the PICC was not inserted. The ARNP said she asked staff yesterday and was told they were having trouble getting hold of the IV company. Staff reported the IV nurse didn't come and they had called the company every day. The ARNP said she doesn't think that there is going to be a significant outcome. She is monitoring the wound with the wound doctor and treatment nurse. She said it doesn't typically take this long to get a PICC. She said she orders more midlines than PICCs, but the length of treatment is six weeks. I ordered a PICC on her on the 20th. She doesn't have osteomyelitis. She said the PICC is in now and the x-ray was completed. She was waiting for the x-ray result. On 4/22/21 at 5:47 PM an interview was conducted with the DON. She said she was made aware of the delay yesterday. They called the pharmacy and the IV nurse contracted with the pharmacy. You all came Tuesday and so nobody made me aware it was not done. Staff left voice messages and were told the IV nurse would be out the next day. She is contracted with the pharmacy and she is supposed to come out within twenty-four hours. She did not come. When I got the message last night I reached out to the IV nurse line. Nobody answered. I called for the on-call nurse, nobody answered. I called the pharmacy and was told they would reach out to her and get back to me. I told them it was not acceptable. I told the NHA (nursing home administrator) who also reached out to them, and we got a call she would be out today. I let the ARNP know. She usually writes 'may hold antibiotic until PICC is placed'. Resident #40 has a lot of comorbidities. If we saw a fever or altered mental status signs we would send her to the hospital. It is not acceptable and we will address it with the pharmacy to see how we can get better service related to that. The ARNP did a progress note 'may hold vanco until PICC placed'. That was 4/20. We would send her to the hospital if she had a fever or symptoms. That is why we got an order to keep the previous treatment until we get the GCP solution. This is a newer treatment. It's not something we have had before. It seems like there is a problem getting it right away. It takes two to three days to get it. I can call them and see how long it's going to take. That's why we kept the previous treatment, so we have something until it comes in. I think we have used other solutions until the triple antibiotic solution came in. The wound doctor comes every Tuesday so the nurse puts whatever he orders. I will reach out to the pharmacy because I have a lot of concerns. It's kind of left to interpretation on how to clean a wound. If the doctor wants to irrigate it he would write an order. If it says to clean it you would use a 4x4 gauze and a cleaning solution. I would go dirtiest to the cleanest. I would clean the inside, but I would clean it last. You would do the outside then the inside with a different gauze. She should have cleaned the whole area. I would think if something is that bad with tunneling he should order some irrigation and clean it with a syringe. She was nervous. I think it's up to the nurse to clean it in the way she interprets the order. If the staff knew the dressing came off they should have went to the nurse so she could put a dressing on. They probably need to use a different dressing, something that sticks. On 4/23/21 at 10:18 AM a follow up interview was conducted with the ARNP. She said she has seen the wound and she referred the resident to wound care. They are following the wound. If I catch the wound care nurse I go in with her. If I miss her she takes a picture and brings it to me. Yes, they need to pack the wound. Santyl isn't going to work on healthy tissue. It has been taking forever to get the delivery of care over the last couple of weeks. They used to be same day. We expect twelve to twenty-four hours. On 4/23/21 at 12:12 PM a follow up interview was conducted with the DON. She confirmed the scissors need to be cleaned before using them during a clean treatment. On 4/23/21 at 12:42 PM a telephone interview was conducted with the consultant pharmacist. She said she was not notified about the GCP solution. She will call the pharmacy and follow up. She said the pharmacy contracts with a company who inserts the PICCs. The facility can call the pharmacy and the pharmacy contacts the company with the consult. She doesn't hear that as a consultant. This is very concerning. When the surveyor asked what the potential outcome could be related to the delay, she said further infection or spread. Others can get infected also. Usually if they order a treatment it should be at the facility on the next run. She would have to see if that was anything special that would require a special preparation. The PICC line should be as long as it takes for someone to drive there after the order is received. She was not aware of these concerns. The pharmacy manager would be the person who would be notified of the delay with the PICC. On 4/23/21 at 1:48 PM a telephone interview was conducted with the wound care physician. The surveyor asked what the potential outcome of an untreated infection of the wound might be. The physician said, further infection if it is not treated as soon as possible. He said he suspects it is probably chronic osteomyelitis. The antibiotic probably should have been started within twenty-four hours. The IV treatment was more important than the topical. He did the topical as an adjuvant to go along with the IV. The resident didn't have a fever. The order should be to cleanse the wound with normal saline and then dry it. Santyl should be applied with a swab and tongue depressor, and then apply a dressing. He also confirmed the treatment should be applied to the wound bed. A review of the policy, Treatment/Services to Prevent/Heal Pressure Ulcers, revised 5/24/18, reflected the following: Purpose It is the policy of the facility to ensure it identifies and provides needed care and services that a resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: a. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and b. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 5. Interventions will be implemented in the residence plan of care to prevent deterioration and promote healing of the pressure sore. 7. The pressure sore will be evaluated weekly and the nurse will document the size, location, odor if any, drainage if any, and current treatment ordered. A review of the policy, Wound Care, revised 3/5/18, revealed the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Procedure The nurse will follow the physicians orders for treatment using clean technique and following infection control procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review the facility failed to ensure a root cause analysis and meaningful interventions were implemented to prevent accidents for one (#8) of three residents reviewed for falls. Findings included: Resident #8 was admitted to the facility with diagnoses of dementia and history of falling, according to the face sheet in the admission record. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 3, indicating Resident #8 had severe cognitive impairment. Review of the 72 hour charting/report reflected Resident #8 was transferring herself from bed to wheelchair and her leg gave out and fell to her bottom on 4/3/21. A review of the facility documentation for Resident #8 reflected she had fallen on the following dates: 12/11/20 1/9/21 1/16/21 2/28/21 3/3/21 4/3/21 Review of the care plan dated 10/28/20 revealed no new interventions following the 4/3/21 fall had been implemented. A review of the 4/3/21 fall documentation revealed Resident #8 was going from her bed to the wheelchair and fell due to her leg giving out. No apparent injuries noted. She was noted as non compliant with interventions for falls, unable to educate on safety. The documentation revealed no intervention was implemented following the 4/3/21 fall. On 4/22/21 at 2:57 PM, an interview was conducted with Staff I, LPN (Licensed Practical Nurse) MDS coordinator. Staff I, LPN said Yes, we write the new interventions on the care plan. If they have a fall we write them in. When we do the review we write a new intervention. When a resident has a fall, the manager on the floor brings the chart to the morning meeting and the IDT (interdisciplinary team) discusses it, and we update the care plan. Staff I, LPN said the new intervention should be on the care plan. Staff I, LPN reviewed the care plan and confirmed there wasn't an intervention for the 4/3/21 fall. Staff I, LPN said she doesn't necessarily update the care plans. Sometimes she does, but the unit managers or DON (director of nursing) usually update the care plans in the morning meetings. An interview was conducted with the second floor unit manager and risk manager for the facility on 4/22/21 at 3:14 PM. The second floor unit manager said Resident #8 was non-compliant. She said they have done a medication review and referred Resident #8 to therapy who gave her a new walker. Resident #8 won't use the new walker. She gets up unassisted all the time. Therapy put her in a wheelchair. The intervention was to continue the current plan of care since she was non-compliant. She hasn't had a fall in a month. She doesn't walk anymore. She still tries to get up to go to the bathroom all the time by herself. The second floor unit manager also confirmed Resident #8 has dementia. On 4/22/21 at 6:10 PM, an interview was conducted with the DON. The DON confirmed there should be a new intervention after every fall. If they have behaviors, sometimes we continue the previous intervention. We run out of interventions, especially if it's a behavior. There should be some intervention, even if it's continue previous interventions. We talk about it in our morning meeting. Resident #8 was Spanish speaking with dementia. Staff say what she says doesn't always make any since. She was very stubborn. You can ask her to use a walker and she will walk by herself. We tried several things with her. We have changed walkers, and went to a wheel chair. We discuss Resident #8 quite a bit. Review of the policy, Falls and Fall Risk Management, dated 7/29/13, revealed the following: Purpose: To identify possible interventions that address the resident's specific fall risk factors and to minimize the falls the resident incurs and potential complications from the fall. Standard: To prioritize approaches to help manage falls and fall risk and thereby minimize the potential for falls and associated injuries. Process: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to minimize the falls the resident incurs while also trying to minimize complications from falling. 1. The nursing staff and Interdisciplinary team will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once) to try to minimize serious consequences of falling. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the nature or category - root cause analyses of the fall, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. If a resident refuses an intervention the risk and benefits will be reviewed with the resident and/or responsible party. Additional and/or alternative interventions may be implemented at that time. 10. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 11. If irreversible risk factors exist that continue to present a risk for falling or injury to the resident, the Interdisciplinary Team will document the basis of that conclusion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to proper storage of a nebulizer machine and continuous positive airway pressure (CPAP) treatments, consistent with professional standards of practice for one (Resident #30) of one resident investigated for respiratory care. Findings included: A review of the medical record for Resident #30 indicated the resident had a diagnosis of obstructive sleep apnea. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of the physician orders indicated the following active orders: Atrovent administer one vial via nebulizer every six hours for shortness of breath or wheezing; auto CPAP 5-15 sonometers with heated humidification (dated 4/12/21). A review of the provider progress notes for Resident #30 indicated the following: -a visit dated 4/7/21 noted Resident #30 stated to the provider he was supposed to be assessed for a CPAP machine and the provider plan requisition the hospital for a sleep study. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. -a visit dated 4/12/21 noted Resident #30 reported experiencing sleep apnea that wakes him frequently while sleeping and an infrequent cough that is non-productive. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. Provider plan for automated CPAP at 5-10 sonometers with heated humidity. -a visit dated 4/20/21 noted a follow up for CPAP. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. The resident reported in a discussion to had used the CPAP only once. The resident reported a history of sleep apnea while in the hospital and was told to use a CPAP machine. He stated he had used a CPAP at home. The provider noted a repeat sleep study can wait until discharge and the resident should use an automated CPAP with heated humidification without a study. A review of the Medication Administration Record (MAR) for Resident #30 dated April 2021 revealed an order written in for auto CPAP 5-15 sonometers with heated humidification dated to begin on 4/12/21. No nurse documentation was noted indicating the therapy had been provided as ordered on any date in April 2021. On 4/22/21 at 1:40 p.m., Resident #30 was observed lying in the bed in his room with oxygen on at 2 liters per nasal cannula via an oxygen concentrator. An interview was conducted with Resident #30 who stated he had not had a test for sleep apnea while at the facility. Resident #30 stated a nurse brought in the sleep apnea machine and put it on him for one night for about four hours when the machine came apart at the tube, and the nurse never came back in to put it back on. He stated he had not had the CPAP on since that time. Resident #30 stated he does get short of breath and it wakes him up a lot in his sleep. He stated he had a CPAP machine at home before he became sick. He indicated he did wear it at home and would do so if the machine was working. The CPAP machine was noted on the bedside table in a bag. A nebulizer machine was noted on the bedside table with the tubing and mask chamber on the floor under the resident's bed. Photographic evidence was obtained. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/22/21 at 2:30 p.m. The ADON confirmed an order for CPAP dated 4/12/21 for Resident #30. The ADON stated no sleep study had been done and the therapy was ordered by the ARNP after she evaluated the resident. The ADON stated the resident received the machine and it was put on one time by the nurse. She stated the resident did not like the machine and he took it off. She stated the CPAP machine was not fitted for him to her knowledge. The ADON was asked if Resident #30 was refusing to wear the CPAP and if documentation supported the refusal. She indicated refusal was not documented for the CPAP therapy. The ADON confirmed the CPAP therapy for Resident #30 was not being provided by nursing as ordered. An interview was conducted with the Director of Nursing (DON) on 4/22/21 at 3:20 p.m. The DON indicated she was aware of the CPAP order for Resident #30. She stated the ARNP explained a sleep study was not required for the settings ordered and wanted to get the therapy going due to the resident having it at home prior to admission. She indicated she did not know why the resident was not receiving the therapy as ordered. A telephone interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on 4/22/21 at 5:18 p.m. The ARNP stated she was aware Resident #30 had only worn the CPAP machine one time and she planned on speaking to the resident about it. She indicated Resident #30 was having obstructive sleep apnea and did require the CPAP therapy she ordered. A review of the facility policy entitled CPAP/BPAP Support with an effective date of 3/9/15 and a revised date of 8/1/19 indicated the following: Purpose: 1-To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2- To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3-To promote resident comfort and safety. General Guidelines: 1-CPAP and BPAP can be used in conjunction with ventilation to improve oxygenation. 4-CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. Documentation: 1-General assessment (including vital signs, oxygen saturation, respiratory, circulatory, and gastrointestinal status) prior to procedure. 2-Time CPAP was started and duration of the therapy. 3-Mode and settings for the CPAP. 4-Oxygen concentration and flow if used. 5-How the resident tolerated the procedure. 6-Oxygen saturation during therapy. Reporting: 1-Notify the physician if the resident refuses the procedure.

Based on observations and interviews the facility did not ensure appropriately stored refrigerated controlled substances in two of two medication refrigerators in two of two medication storage rooms on two of two nursing units (the first and second floors). Findings included: On 4/20/21 at 10:13 AM an observation was conducted on the second floor in the medication storage room with Staff A, LPN. The medication refrigerator contained a locked controlled substance box on the top shelf that was not secured to the refrigerator. Photographic evidence obtained. During the observation an interview was conducted with Staff A, LPN who said she was not aware it needed to be secured to the refrigerator. On 4/22/21 at 8:46 AM an observation was conducted in the medication room on the first floor with Staff K, RN (registered nurse). The locked controlled substance box was sitting on a shelf in the refrigerator, unsecured. Staff K, RN removed the locked box from the refrigerator and placed it on the counter. She unlocked it and opened it and removed a bottle of lorazepam 2 mg/ml. Staff K, RN closed the box and secured the lock and returned it to a shelf in the refrigerator. In an interview with Staff K, RN, she said she was not aware it needed to be secured to the refrigerator. On 4/22/21 at 5:27 PM an interview was conducted with the Director of Nurses (DON). The DON said she thought if the controlled substance kit was behind two locks it met the regulation requirement. On 4/23/21 at 12:42 PM a telephone interview was conducted with the consultant pharmacist. She said the narcotic boxes in the medication refrigerators have come up before. They have talked about it. We are in the process of changing the E-kits (emergency kits), and they possibly need a different size box to be connected to the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility did not ensure two (#282, #17) of two sampled hospice residents had a record of the benefit of election for hospice and a hospice plan of care or indication of hospice personnel involved in hospice care and working in collaboration with the facility. Findings included: During multiple facility tours throughout the survey, Resident #282, a hospice resident was observed laying in bed, appeared to be resting. A review of Resident # 282's clinical record revealed an admission date of 03/30/21 with diagnoses to include: unspecified systolic (heart failure), acute encephalopathy, Gastro-esophageal reflux disease, unspecified dementia, essential hypertension, hypothyroidism, hyperlipidemia, heart disease, unspecified atrial fibrillation, dehydration, history of dementia and hypothyroid. Continued review of the record revealed no hospice physician consult order, no benefit of election, no plan of care for hospice or indication of hospice personnel involved in hospice care and no hospice contact information. A review of an admission MDS (minimum data set) dated 04/6/21 revealed under section C: a BIMS (Brief interview for mental status) of 14 indicating cognitive intact status. Section O, special treatments, procedures, and programs revealed Resident #282 was on hospice care prior to admission and while a resident. During multiple facility tours, Resident #17 was observed self propelling in the hallways. Resident #17 was noted spending most of her days outside the nurses' station. Clinical record review revealed Resident #17 was admitted to the facility on [DATE] with a diagnoses to include a history of atrial fibrillation, chronic hyponatremia, severe anemia, hypertension, cerebral atherosclerosis, and vascular dementia. A quarterly MDS (minimum data set) dated 02/8/21 revealed a BIMS (Brief interview for mental status) of 11, indicating moderate impairment. Section O, special treatments, procedures, and programs indicate resident #17 was admitted to Hospice care while a resident at the facility. Following record review, Resident #17's chart did not include a hospice physician consult order, benefit of election, plan of care or indication of hospice personnel involved in hospice care or contact information. On 04/22/21 at 09:37 a.m., Staff K, RN (registered nurse) was asked how she would know what care to provide a resident who was on hospice. Staff K, RN stated that a hospice assessment should be in the resident's chart to include a plan of care. Staff K, RN looked through Resident #282 and #17's medical record and could not find a plan of care. A follow-up interview was conducted with the ADON (Assistant Director of nursing) on 04/22/21 at 09:53 a.m. ADON stated that the plan of care should be in the resident's medical record but if it is not, we will get it. ADON looked through Resident #282 and #17's medical record and could not find the hospice physician consult order nor the plan of care. ADON confirmed that these documents should be available to facilitate appropriate care. On 04/22/21 at 4:35 p.m., ADON was asked how the nurses would know what treatment areas they were working on with hospice residents. ADON reiterated that the nurses should review the plan of care. ADON confirmed that it should be in the medical record. When asked how she ensures communication with the Hospice agency, ADON stated that they call them if needed. ADON was asked how she would know when to expect the Hospice agency without a plan of care. ADON stated, We know the frequency because these residents have been here for a very long time. On 04/22/21 at 11:42 a.m., ADON and NHA (nursing home administrator) confirmed that the paperwork was not in the medical record, but it was now. NHA stated that Resident #282 came from the hospital and they did not request the paperwork at the time. Resident #17 had been here for a very long time. When asked if she was aware that she was supposed to have the election statement, consents, and plan of care in the facility to collaborate care, NHA stated, Yes, we do now. An interview was conducted with ARNP (advanced registered nurse practitioner) on 04/22/21 at 04:40 p.m. When asked what the expectation would be regarding access to a hospice plan of care, ARNP stated that she expects the plan of care to be on file at the facility. ARNP said, We review them to establish continuum of care. On 04/23/21 at 12:14 p.m., an interview was conducted with DON (director of nursing) she was asked what the expectation would be regarding to having hospice plans of care available here at the facility. DON sated that there was a tab in the resident's medical record that should hold these documents. DON stated that they have some Hospice agency's that are not good about making sure we have the information, but that they will put the plan in place to ensure consistency. The DON stated that it was brought to her attention yesterday that Resident #282 and Resident #17 did not have a hospice plan of care in their records and that was why we initiated a plan to correct. Further review following interview confirmed that the hospice election statements were now present in the charts as well for Resident #282 and #17. Resident #282 entered the hospice agreement on 09/22/20 and Resident #17 entered the agreement on 08/05/20. A review of the facility's policy titled, Hospice Services with a revision date of 05/30/18, under purpose revealed: It is the policy of the facility to provide collaborative care with hospice providers to ensure that our resident's end of life preferences and choices are honored. Under (2.) When hospice care is furnished on the facility through an agreement, the following requirements will be met: (iii) The services the LTC (long term care facility) will continue to provide based on each resident's plan of care. (iv.) A communication process, including how the communication will be documented between the LTC facility and the hospice provider to ensure that the needs of the resident are addressed and met 24 hours per day. Section 5. (d) The designated interdisciplinary team member is responsible for obtaining the following information from hospice including: (i) the most comprehensive plan of care specific to each patient, (ii) Hospice election form (iii) physician certification and recertification of the terminal illness. A review of an agreement titled [Hospice Company Name], Agreement for Nursing Facility, inpatient and Inpatient respite services, entered as of 02/01/21 and is effective as of 04/01/21 by and between [Hospice Agency] and [Facility] page 5, under delineation of roles; 2.1.4 In the provision of care to Hospice patients, the facility shall be responsible for providing services as contained in the hospice plan of care, and communicating to designated . personnel any changes in condition. 2.1.5 medical records documentation, Facility shall permit the inclusion of . care plans and other appropriate documentation in the hospice patient's facility medical record to ensure documentation of services is completed as applicable for hospice patients. 2.1.7, Plan of care, . shall establish, modify, and provide the Facility a copy of a hospice plan of care for each hospice patient admitted to facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 4/21/21 at 9:47 AM, an observation was conducted in resident room [ROOM NUMBER]A. The over the bed table had thick dried yellow-brown matter on the base. There were faded brown splatters on the wall across from the left side of the bed. On 4/23/21 at 9:19 AM, another observation was conducted in room [ROOM NUMBER]A. The base of the over the bed table still had the thick dried yellow-brown matter on it. The wall across from the left side of the bed also still had the splatters on it. Staff L, CNA (certified nursing assistant) was present during the observation. An interview was conducted with Staff L, CNA. She said housekeeping cleans the rooms once a day and comes back around a second time later. CNAs only clean the tops of the bedside tables after meals and as needed. On 4/23/21 at 10:28 AM, an interview was conducted with the Environmental Services Director. Photographic evidence was shared with her during the interview. She said every resident room was cleaned daily. She confirmed that part of their duties included cleaning walls and bases on tables. She confirmed housekeeping services should have cleaned the table base and wall. Review of the policy, Infection Control-Cleaning and Disinfection/Non-Critical Care and Shared Equipment, revised 5/30/18, revealed the following information: Purpose: What is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with state and federal regulations, and national guard lines. Procedure: 1. Cleaning and disinfection of the facility including resident rooms is completed in accordance with environmental services policies and procedures. 4. Environmental services staff is to focus on cleaning and disinfection of high touch surfaces such as TV remotes, call buttons, over-bed tables, etc. Photographic evidence was obtained. Based on observations, staff interviews, and facility file review, the facility did not ensure a safe, clean, comfortable, and homelike environment during four of four days observed (4/20/2021, 4/21/2021, 4/22/2021, and 4/23/2021) as evidenced by: 1) one of one smoking area observed with cigarette butts on the ground and cigarette butts in a trash can that was not fire rated, 2) seating equipment in disrepair in one (first floor) of two dining rooms, and 3) Twelve (203, 204, 206, 210, 211, 213, 216, 219, 222, 227, 230, 231) of 62 resident rooms with soiled floors, cracked and chipped tiles, unbagged plungers, and walls in disrepair. Findings included: 1. During facility-wide tours on 4/20/2021 at 10:30 a.m., 4/21/2021 at 7:30 a.m., 1:00 p.m., 4/22/2021 at 7:45 a.m. and 2:00 p.m. and 4/23/2021 at 9:00 a.m. the following was observed: The first floor dining room was observed with a door that led from the dining room into a screened in porch. The porch was identified as a smoking area for residents. The porch included two white painted metal tables with peeling paint and heavy rust. The rust was observed in large spots on the top of the table surface and down the table legs. Smoking ashtrays were placed on these two tables. Two of the three fabric and plastic chairs were observed heavily torn and ripped in the seat area. One small red cigarette trash receptacle was placed in the back and behind two chairs making it difficult to access. A large silver tin/metal trash can was observed with a lid that was only coving approximately ¼ of the top, leaving the inside of the trash can exposed. Further observations revealed over fifty cigarette butts lying on top of the plastic liner in the bottom of the trash can. The lid to the trash can had a sheet of paper on it with the following typed in bold: Trash Only, No Cigarette Butts. This trash can with cigarette butts in it was observed on all four days of the survey. The screened in porch led to an outside courtyard with grass, chairs, tables and a table umbrella. This area was fenced in and noted as an area where residents frequent and also smoke. There were observations of residents smoking in this area on all four days of the survey. In the courtyard area there were chairs and a bench in a grassy and landscaped area which was heavily littered with cigarette butts. There were cigarette butts strewn on the ground over a ten foot by ten foot space. No fire rated trash cans or ash trays were observed in this direct area. Random observations revealed three residents flicked cigarette butts into the grass and landscaped area after they were done smoking. There were no smoking aides/staff in this area during all times/days observed. 2. The first floor dining room was observed during three meal observations on three days of the survey to include 4/20/2021, 4/21/2021, and 4/22/2021. During times observed, there were approximately fifteen residents being assisted with their breakfast and or lunch meal. All residents were seated in a manner to promote social distancing. Some residents were seated in their wheelchairs and others utilized chair furniture in the room. Further observations revealed five of the nine chairs in the first floor dining room had cracks and tears in the plastic seat area, leaving the surface non cleanable. Residents were observed seated in these chairs while in the dining room. 3. During all four days of survey (4/20/2021, 4/21/2021, 4/22/2021, and 4/23/2021) the following was observed: a. Resident room [ROOM NUMBER] was observed with the main floor tiles cracked and chipped, leaving non cleanable surfaces and trip hazards. There were four to six tiles damaged. Also, the bathroom had an unbagged toilet plunger placed near the wall next to the toilet. b. Resident room [ROOM NUMBER] (a) bed was observed with dark gray non skid strips on the floor on either side of the bed. The strips were peeling and ripped up, leaving a potential trip hazard and non cleanable surfaces. Also, the bathroom walls were peeling and in disrepair. c. Resident room [ROOM NUMBER] had a black sticky substance and stains on the main floor at the door way and in between both beds. The sticky substance was present on all four days of the survey. d. Resident room [ROOM NUMBER] (b) had gray colored non skid strips on the floor at bed side. The strips were torn and ripped leaving non-cleanable surfaces. e. Resident room [ROOM NUMBER] (a) had heavy scraped walls and material peeling off the wall near the bed. The walls in the bathroom were observed in disrepair with heavy scratches and the plastic baseboards in the bathroom and main room were not secured and peeling away from the wall, leaving a non cleanable surface. f. Resident room [ROOM NUMBER] bathroom was observed with an unbagged toilet plunger. g. Resident room [ROOM NUMBER] had a sticky floor that was soiled with a black substance on all four days of the survey. h. Resident room [ROOM NUMBER] had a sticky floor that was soiled with a black on all four days of the survey. Interview with a passing nurse stated, oh that floor is like that all the time. It's from the wheelchairs. i. Resident room [ROOM NUMBER] main floor tiles throughout the entire room were observed sticky with black substance and stained during all four days observed. j. Resident room [ROOM NUMBER] bathroom observed with an unbagged toilet plunger. k. Resident room [ROOM NUMBER] (a) floor tiles between bed wall and roommate's bed was observed soiled with a black sticky substance on all four days observed. On 4/23/2021 at 10:15 a.m. an interview with the Maintenance Director, who was also the Housekeeping Director revealed that it was the responsibility of the housekeeping staff to clean rooms appropriately. The Maintenance/Housekeeping Director reported that meant they clean and disinfect all high touch surfaces in rooms and other resident and employee spaces. She further revealed that staff were to change trash from resident bathrooms, wipe space/equipment, and sweep and mop in both resident bathrooms and rooms on a daily basis. She was aware that there were floors and walls in disrepair and that they do their best to make repairs, but it's always ongoing. She also revealed that when it comes to the main dining rooms, all equipment, tables, and chairs were to be wiped and disinfected and staff were to sweep and mop after each meal and in between if need be. She was unaware of the chairs that were in disrepair and stated her staff should tell her things like that when they see it. The Maintenance Director/Housekeeping Director also explained that it was maintenance and housekeeping's responsibility to clean and maintain the grounds where residents smoke to include the screened in smoking porch and the outer courtyard where residents frequent and smoke. She revealed that they should be ensuring the areas were clean and free from cigarette butts and picking up cigarette butts on a daily basis. She did not have a cleaning schedule document to include the smoking areas and did not have documentation to show how it was cleaned and when. She did confirm all the cigarette butts that were present on the grass in the courtyard. She also confirmed the tables and chairs in the smoking porch were in disrepair, with paint chipped off and leaving large areas of rust. She also confirmed one fabric chair in the smoking porch was ripped and torn, leaving a non-cleanable surface. A review of the policy and procedure titled Environment with an effective date of 11/26/2016 revealed: Policy: It is the policy of the facility to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible, according to state and federal regulations. Procedure: #3 The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Procedure: #7 revealed; The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior.