Based on record review and interview, the facility failed to implement their current written policy on resident abuse as it related to annual abuse, neglect, and exploitation training for 2 (Staff B and Staff C) of 6 staff members reviewed. Findings included: During staff record review it was determined that Staff B was hired on 10/2/2001 and last completed abuse training on 9/6/22. It was also determined that Staff C was hired on 10/5/22 and last completed abuse training on 10/5/22, which exceeded the annual training requirement. An interview with the Human Resources Manager on 06/19/2024 at 11:55 a.m. confirmed there was no written evidence that Staff B and C had completed annual abuse training as required. She further confirmed at that time the facility did not have an effective system in place to ensure that annual abuse training was completed as required. The facility abuse policy titled Abuse, Neglect, Exploitation, dated 10/17/22, page 3 of 5, showed under Section II - EMPLOYEE TRAINING - B. Existing staff will receive annual education through planned in -services and as needed. This required component of the policy was not met for 2 of 6 staff members reviewed - B and C. An interview with the Director of Nursing on 6/19/24 at 11:55 a.m. confirmed the facility abuse policy was current and should have been followed as it related to annual staff abuse training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a change in condition was addressed for one resident (#51) of a total sample of 46 residents. Findings included: Review of the admission Record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, unspecified, unspecified atrial fibrillation, dysphagia, and need for assistance with personal care. On 04/10/24 at 8:31 a.m. an interview was conducted with Resident #51. She stated she did not feel well and did not know what was wrong with her. She said, I don't feel well. I feel like crawling out of my skin. The resident stated she has been having this feeling for a long time. She stated she notified the staff and her POA (power of attorney). She stated she was not sure what was being done about it. On 04/09/24 at 12:11 p.m., an interview was conducted with Resident #51's POA. She stated she noticed the resident had declined. She used to be in the front side of the building, they moved about 10 residents. She stated the resident has not been herself since then. She stated the residents on the second floor were long-term residents who were very close and use to the staff. She stated they did not move the staff. The POA stated the resident had different CNAs (certified nursing assistants). She said, She (Resident #51) does not do the things she used to do. I have been telling the nurses that I think she has depression; she needs to be seen. The POA stated the resident has had a change which had been going on for at least three weeks, if not more. She restated the resident had not been herself since the move. The POA stated the resident has had no appetite and she reported feeling like her skin was crawling out. During this interview, Resident #51 stated she reported this to the CNA (Staff Q). During an interview on 04/09/24 at 12:15 p.m. with Staff Q, CNA she stated she noticed a change in the resident. She stated the resident had been eating less. She said, Yes, she told me she is not feeling like herself. I think it was last week. I notified the nurse. An interview on 04/09/24 at 12:22 p.m. was conducted with the Food Service Coordinator (FSC). She confirmed she noticed a change in the resident, but she did not know what it was. She stated it had to do with the move. She is more depressed. She is not her jovial self, she is eating less. She stated she would notify the Director of Nursing (DON) if she noted a change. She stated she had not notified anyone prior to this. The FSC stated she had just mentioned it to Staff S, Registered Nurse (RN). An interview on 04/09/24 12:38 p.m. was conducted with Staff S, RN. He stated Resident #51 sometimes ate and sometimes she did not. He stated sometimes she had expressed some concerns related to wounds. He stated he noticed sometimes she slept too much. He stated he monitors the resident. He stated over the weekend the resident had problems with her blood pressure and he notified the doctor. He stated she had not said anything about her skin crawling. He stated the FSC just notified him. An interview on 04/09/24 at 05:07 p.m. was conducted with Staff E, Licensed Practical Nurse (LPN)/ Unit Manager (UM). She stated if a resident had reported a change, they would do a head-to-toe assessment, ask the resident what they were feeling, assess, complete an SBAR (Situation, Background, Assessment, Recommendation), notify doctor and family and follow -up accordingly. She stated she was not aware this resident had a change. A follow-up interview was conducted on 04/10/24 at 10:04 a.m. with Staff E, LPN/UM. She stated she spoke with the resident. She said, She (Resident #51) did tell me that she has not been feeling herself, and she feels her skin is crawling in her neck. She stated it had been going on for a while. She could not identify how long. Staff E stated the Advanced Registered Nurse Practitioner (ARNP) went to see her this morning. Staff E stated the resident had a change in condition on Saturday related to her blood pressure and they started her on IV (Intravenous). She confirmed there was not much follow up until yesterday. Staff E, LPN/UM stated the resident was agreeable for a psych consult which they had scheduled a consult. Staff E stated staff did not do a note for the skin crawling concern. She said, It could be a medication reaction or a psych issue. I would have expected an SBAR or Change in Condition to be documented and to get orders and follow up with the responsible party and make me aware or the DON. I would be upset if I felt like my skin was crawling. Staff E stated staff should have documented her concerns prior to this and contacted the physician for orders. Review of a facility policy titled, Notification of Changes, dated 10/17/22, showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation was made on 04/08/24 at 1:47 p.m. of Resident room [ROOM NUMBER]. The wall behind the head of the bed had long scrape marks and baseboards that were cracked with several chunks of wood missing. Review of a facility policy titled, Resident Environment Quality, dated 10/17/22, showed it was the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. (Photographic Evidence Obtained) Based on observations, interviews and review of facility policy, the facility failed to ensure four resident rooms (212, 216, 217 and 218) were maintained in a clean and sanitary for one of two floors. Findings included: During a tour of Resident room [ROOM NUMBER] on 04/08/24 at 10:16 a.m., an observation was made of the resident's bathroom with dirt and dust on the floor corners. The floors and bathroom walls were stained with brown and dark matter and the toilet was observed with brown stains around the base. A plastic storage bin under the toilet was observed with dust on the surface. The resident in the window bed stated the cleaning could be better. She stated she had seen a cockroach in the bathroom. She stated the toilet was always dirty. She stated they had a nice housekeeping staff member who was no longer there. She stated it had not been the same. An observation of the resident's drinking cup was made with a small insect on the drinking straw. The resident stated she had observed the insects in her room before. During a tour of Resident room [ROOM NUMBER] on 04/08/24 at 10:30 a.m. the toilet was observed with dust, debris, and particles around the floor corners. The floors were observed with stains and the toilet base with brown matter on the surface. The resident in the door bed stated they did not clean very well, the bathroom was always dirty. During an interview on 04/09/24 at 11:10 a.m. with Staff P, Housekeeping, she stated she cleaned all the rooms. She stated if the floors were stained and if she could not get the stains off, she would notify her supervisor. She stated if there were bugs anywhere, she would notify her supervisor. During a tour of Resident room [ROOM NUMBER] on 04/09/24 at 11:17 a.m., two urinals were observed on the resident's head of bed, hooked to the bedside rail. They were observed with urine, stained and with a foul order. The resident in the window bed stated it was always like that. An interview was conducted on 04/10/24 at 9:06 a.m. with Staff M, Housekeeping, Staff P, Housekeeping, and the Housekeeping Manager (Manager). The Manager stated sometimes they have problems with the caulking around the toilet bases in the bathrooms. She said, There is a rust appearance on the toilets' bases, it is hard to come off. Staff P said, I try to use bleach and brush to get it off. Staff M stated it was the first time she saw the small flying insects. The Manager stated no one said anything about the flying insects. She stated she would call maintenance to come and spray. She stated the facility had a pest control contractor who comes on Wednesdays. She stated the problem with the small flying insects was because the showers don't get used often and it could be the drain issue. On 04/10/24 at 10:09 a.m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN)/ Unit Manager. She stated the small flying insects were all around the building. She stated there should not be flying insects on residents' drinking cups, on themselves or in their spaces. She stated the CNAs (Certified Nursing Assistants), and nurses should replace the residents' urinals daily if needed. Staff E observed photographic evidence and said, Insects on resident's plate, that is gross, I can't imagine about the residents who cannot swish the insects off themselves. Staff E stated maintenance knew. She said, We told them. I am not sure what they have done about it. I spoke to him last week Wednesday. Review of a facility policy titled, Daily Resident Room Cleaning Procedure, dated 1/30/23, showed to (b.) clean the bathroom (see bathroom cleaning policy). [This policy was not provided.] (d.) Utilize bathroom cleaner to disinfect the sink, handrails, toilet, and all other surfaces in the bathroom. (I.) Mop the floor if it is not carpeted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the policy and procedure, the facility failed to ensure an unwitnessed fall that resulted in serious bodily injury (nondisplaced fracture of second cervical vertebra) was reported to the appropriate agencies for one resident (#44) out of the sampled two residents. Findings included: On 04/08/24 at 11:15 a.m. Resident #44 was observed in bed with a cervical collar around her neck. During an attempt to interview her, the resident did not speak. On 04/10/24 at 9:12 a.m. Resident #44 was observed in bed with a cervical collar around her neck. Fall mats were observed on both sides of the bed on the floor. A review of the Transfer/Discharge Report showed Resident #44 was admitted on [DATE] and had diagnoses to include nondisplaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing, bipolar disorder, dementia, psychotic disturbance, mood disturbance, anxiety disorder, contracture of the muscle, history of falling, abnormalities of the gait and mobility, contracture of the right hip, left hip, left hand, left knee, and right knee, depression, other fracture of upper and lower end of left fibula, reduced mobility, and unsteadiness on feet. Section C- Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], showed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe impairment. Section GG- Functional Abilities and Goals showed Resident #44 was dependent for self-care and mobility. A review of the Order Summary Report with active physician orders as of 04/10/24 revealed the following: Air mattress for prevention (08/09/23), and resident to wear cervical collar at all times, may remove for care and reapply every shift for pain (04/05/24). The Incident by Incident Type log provided by the facility showed the resident had an unwitnessed fall on 03/09/24 at 4:40 a.m. (actual time per progress note 3:50 a.m.) and an unwitnessed fall on 04/04/24 at 11:45 p.m. A review of the progress notes from 03/01/24 to 04/10/24 showed the following: 03/09/24 04:27- Resident found on the floor next to the bed at 03:50. 03/09/24 05:10- Situation- Resident was observed lying on her side on the floor next to the bed. Possible and/or actual contributing factors: Pressure reducing mattress too inflated. Assessment and Appearance: vital signs, ortho blood pressure, pain, and/or injuries: within normal limits. The resident complained of pain but unable to state where. Sent to the emergency room for evaluation and further treatment. 03/9/24 09:25- Resident found on floor face down next to bed at 03:50, resident was responsive when asked about pain. No visible cuts or bruises. Certified Nursing Assistant (CNA) assisted writer with getting resident back in bed, resident was lying on sheet that was on her bed which was used to lift from floor back into lowered bed. No visual injuries, 911 call, family member notified, hospice, and doctor notified. Emergency Medical Technician (EMT) arrived around 04:20. Ambulance service transported to local hospital to be evaluated. 03/13/24 14:14 (2:14 p.m.)- Resident was received at 1:45 pm back from a local hospital by ambulance with a diagnosis of cervical compression fracture due to a fall. Using Percocet for as needed (prn) pain every 6 hours. Resident was received with a collar that should only be removed for care and comfort. Results showed compression fracture in cervical vertebra (c2). 03/15/24 20:16 (8:00 p.m.)- She presented to a local hospital on [DATE] for an unwitnessed fall. Per hospital records, computed tomography (CT) of the neck showed acute c2 compression fracture. A neck collar was placed, and she was stable. CT of the cervical spine showed c2 with inferior and anterior osteophyte and vertebral body fracture. Continue cervical collar. The patient was seen today for acute/chronic care management. 03/22/24 13:41(1:41 p.m.)- No gross findings from C1 to C5. Non-diagnostic cervical spine series with non-visualization of the remainder of the inferior cervical spine. Fracture was not excluded. Recommend repeat diagnostic exam to include the inferior cervical spine or CT if unable to obtain appropriate images. 03/22/24 13:56 (1:56 p.m.)- Reviewed cervical spine x-ray. No gross findings from C1 to C5. Non-diagnostic cervical spine series with non-visualization of the remainder of the inferior cervical spine. Fracture was not excluded. Cervical collar in place. 04/05/24 05:43- Resident returned to facility at 05:00 with no new order. 04/05/24 00:01(12:01 a.m.)- Resident found on floor at 11:35 p.m., assessed for injuries, nothing visible observed, and no complaints of pain. 911 called and the resident was sent to a local hospital. 04/05/24 08:30- She was seen for follow up for a fall. She was sent to the hospital and returned with negative findings. Patient was placed on 15-minute checks per facility. Cervical collar in place. She was laying on her side with head of bed elevated. She denied any pain or discomfort. No edema. 04/05/24 09:21- Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: intermittent confusion. Resident was chairbound / incontinent. Vision status: Poor (with or without glasses). Recent hospitalization history in last 30 days: Yes. Gait / balance: Decreased muscular coordination. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Fall Risk Score: 14.0. 04/05/24 14:44 (2:44 p.m.)- Resident was reviewed this morning for being found on floor next to bed. The resident was on an air mattress with bolsters to provide spatial awareness. There was no injury noted. She denies pain at this time. She was unable to state what happened. She was sent out to the emergency room with negative findings. Care plan reviewed. Will place resident on 15-minute checks. Will provide mats at bedside bilaterally. Staff to post outside of door on all shifts. Care plan updated. 04/08/24 11:18- The resident was alert, on an air mattress, and good positioning on bed with 15-minute checks Check to prevent falls. The care plan with a Focus area of falls/injury showed Resident #44 was at risk for falls or injury related to history of transient ischemic attack (TIA) and falls initiated on 11/15/21 and revised on10/19/22. Interventions included the following: Assist to wear non-slick footwear that fits, initiated: 11/15/21. Call bell in reach, initiated: 11/15/21. Ensure adequate lighting for all activities, initiated: 11/15/21. Evaluate risk for falls with Fall Assessment Tool, initiated: 11/15/21. Keep areas free of obstructions to reduce the risk of falls or injury, initiated: 11/15/21. Maintain safety precautions as ordered, initiated: 11/15/21. Medication dose adjustment as ordered, initiated: 11/15/21. The resident uses a high back reclining wheelchair with L board for legs when out of bed, initiated: 10/19/22. Physician follow-up prn, initiated: 11/15/21. Staff to post outside room when charting, initiated: 04/05/24. Transferring - Full body lift assist of 2, initiated: 07/15/22. The care plan showed no new interventions after Resident #44 had an unwitnessed fall and sustained a nondisplaced fracture of the second cervical vertebra on 03/9/24. It was not updated until she had another fall on 04/04/24. An additional Focus Area for Resident #44 revealed: (Resident #44) has an ADL self-care performance deficit r/t (related to) CVA and decreased mobility, revised on 10/19/22. The interventions included: Bed Mobility - (Resident #44) requires total assistance from staff for bed mobility and use of bilateral ¼ rails, Transfer - The resident is totally dependent on (X2) staff with full body lift for transferring. On 04/10/24 at 1:42 p.m. a telephonic interview was conducted with Staff F, Certified Nursing Assistant (CNA). He stated he worked the shift Resident #44 had a fall (3/9/24). It was a regular night and before he left for break, he checked on her and she was asleep. It was a quiet night. When he came from break, Resident #44 was observed on the floor and he went to get the nurse, Staff W, Licensed Practical Nurse (LPN). The resident was talking. Staff W, LPN checked her and they got her back in bed. Staff F, CNA, stated he changed her brief before EMS (Emergency Medical Services) came. She was really contracted. He was still working there (no longer works at the facility) when she returned from the hospital. She had a neck brace and a low bed. He never looked at the mattress. She was really small and didn't notice anything wrong with the mattress at that time. On 04/10/24 at 10:06 a.m. the Regional Nurse Consultant (RNC-1) reported Resident #44's family member presented to the building. He was upset, loud, and stated she was neglected and that caused her to fall. She and Staff E, LPN/Unit Manager met with the family member. They went through her care plan and showed him interventions they had in place. He talked about Resident #44's history with anxiety and was concerned she was having anxiety at night, so they ordered Sertraline. On 04/10/24 at 9:41 a.m. the Director of Nursing (DON) stated Staff F, CNA was the assigned aide for the first fall. Staff had just gone in to check on her and shortly after she was on the floor. Staff W, LPN called 911 and they came to pick her up. She was diagnosed with a nondisplaced C2 cervical fracture. Resident #44 had an air mattress and there were no bolsters on the air mattress at the time of the first fall. After looking at the air mattress, it seemed like it was a hospice air mattress and looked like it was over inflated. They think the air mattress caused her to slide off the bed. The initial air mattress came from hospice. She replaced the air mattress with one of their air mattresses. The DON did not know if hospice was checking the air mattress or not. She looked at the air mattress and could not tell what the air mattress was set on. There were no numbers on the dial for her to see. The numbers were faded. For the air mattresses provided by the facility, they have push buttons. She did not know if the staff were checking the air mattresses. The DON stated she had hospice come pick up the air mattress while Resident #44 was at the hospital and replaced it with one of their air mattresses. Staff X, CNA, was the assigned aide for the second fall (4/4/24). Staff X, CNA reported in her statement that she heard talking and when she went in the room Resident #44 was on the floor. She yelled for the nurse. Staff W, LPN came down and she (Staff X) stayed with the resident while he called 911. Any forward motion such as a sneeze or cough, was determined to cause the second fall. Her body alignment was the issue. They do not use side rails, so bolsters were added to the air mattress after the second fall. When staff are not doing care, someone needs to be posted outside of Resident #44's door when charting. This was added to the care plan as an intervention after the second fall. She talked to her Administration about reporting the incident and because they didn't do anything to cause the accident, the first unwitnessed fall which resulted in a nondisplaced fracture of the second cervical vertebra was not reported. When asked why the second fall was reported and there were no injuries, the DON stated because a family member threatened to call the State Agency. She wanted to make sure she was covered so she reported the second fall. Review of the policy titled, Abuse Prevention and Prohibition, revised on 05/22, revealed the following: 7. Reporting/Response: Report all alleged violations immediately to 1-800-96-ABUSE. In addition, an immediate report must be made to the Survey Agency in Tallahassee. The Elders Justice Act states that the report must not be later than 2 hours after forming the suspicion that resulted in serious bodily injury, or not later than 24 hours if the events that caused the suspicion did not result in serious bodily injury. A one day/five day notification form to be completed and sent to the State Agency in Tallahassee. All necessary corrective actions will be taken depending on the results of the investigation. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences . The facility will also notify the appropriate agencies, based on the nature of the abuse allegation in accordance with State and Federal statute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to develop and implement care plan for two residents (#23 and #670) out of 25 sampled residents. Findings included: 1. An observation was conducted on 4/8/24 at 12:05 p.m. of Resident #23 in the dining room. The resident was asked about her lunch, and she stated she didn't have hearing aids and could not hear. An interview was conducted on 4/8/24 at 2:05 p.m. with Resident #23's family member. He said the resident had hearing aids that had been lost. He was upset Resident #23 was unable to hear him and communicate. Review of the admission Record showed Resident #23 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dysphagia, major depressive disorder, chronic kidney disease, and dementia. Review of an Audiology Testing report, dated 7/6/23, showed Resident #23 had severe-profound sloping hearing loss on the left and right side. Recommendations showed the resident could benefit from amplification in both ears. Review of Resident #23's medical record revealed a progress note, dated 3/11/24, from audiology. The note showed audiology spoke with the nurse and, the nurse had the resident's hearing aid bag and case, but she didn't know where the hearing aids were. An interview was conducted on 4/9/24 at 2:11 p.m. with Staff Q, Certified Nursing Assistant (CNA). She said Resident #23 had hearing issues, but her hearing aids did help her when she had them. She said without them the resident could not hear. Review of Resident #23's active care plan did not show a care plan or interventions in place related to hearing impairment. An observation was made on 4/10/24 at 11:18 a.m. of Resident #23 in the dining room. A staff member was trying to communicate with Resident #23. She placed her mouth about 4 inches from the resident's ear and yelled very loudly trying to get the resident to hear her. The staff member repeated this process three times. An interview was conducted on 4/10/24 at 2:24 p.m. with Staff K, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator. Staff K said she was not aware Resident #23 had a hearing impairment or hearing aids. She said nursing staff should have informed her about the resident's impairment and she would have put in a care plan with interventions. Staff K said she would put a care plan in place with interventions to assist the resident in communicating with staff and family. She confirmed the resident should have already had a care plan related to hearing impairment in place. 2. An interview was conducted on 4/8/24 at 10:13 a.m. with Resident #670. The resident stated she had recently had a fall in the facility. Review of the facility's Accident Log showed Resident #670 had a fall on 3/25/24. Review of progress notes for Resident #670 showed a Health Status Note, dated 3/25/24 at 7:23 p.m. showing: At 6.18pm [sic] CNA assigned to resident observed her sitting on the floor in front of her wheelchair by the bedside and notified writer. Write checked on resident denies pain. Resident slide down from the wheelchair ,ROM [Range of motion] done and assisted back to bed, POA [Power of Attorney] and Physician notified no new order extensive assistance with ADL [Activities of Daily Living] provided will cont [continue] to monitor. Review of admission Record showed Resident #670 was admitted on [DATE] with diagnoses including severe protein-calorie malnutrition, muscle wasting and atrophy, abnormalities of gait and mobility, and unsteadiness on feet. Review of Resident #670's Fall Risk Evaluation, dated 2/20/24, showed the resident had a fall risk score of 13. The evaluation showed, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented in the care plan. Review of Resident #670's Baseline Care Plan, dated 2/20/24, did not indicate the resident was at risk for falls. Review of Resident #670's Comprehensive Care Plan showed a care plan for risk for falls/injury was not put in place until 3/26/24, the day after the resident had a fall. An interview was conducted on 4/9/24 at 3:39 p.m. with Staff E, LPN/Unit Manager (UM). She said a resident that was a fall risk typically had a care plan initiated with interventions to prevent falls, then it is revised, and new interventions added after they had a fall. Staff E reviewed Resident #670's medical record and said she did not see a care plan in place for being at risk for falls prior to her fall. Staff E said she was going to investigate it and provide an update. A follow-up interview was conducted on 4/9/24 at 3:52 p.m. with Staff E, LPN/UM. Staff E said she reviewed Resident #670's care plans since admission looking to see if there was a discontinued fall risk care plan and, Unfortunately she didn't have one. She confirmed Resident #670 should have had a falls risk care plan with interventions in place to prevent falls. An interview was conducted on 4/9/24 at 5:10 p.m. with the Director of Nursing (DON). She said she was made aware of Resident #670's lack of fall risk care plan prior to her fall on 3/25/24. The DON reviewed the resident's care plans, interventions, and baseline care plan. She confirmed there should have been a fall care plan in place and there was not. Review of a facility policy titled, Comprehensive Care Plans, undated, showed the following: Policy: It is the policy of this facility to develop and implement A comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma informed. . 2. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. . Review of a facility policy titled, Hearing and Vision Services, implemented 10/17/22, showed the following: Policy: It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Policy Explanation and Compliance Guidelines: 1. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: a. Obtain history from medical records the family and the resident regarding hearing and vision abilities; b. MDS [Minimum Data Set] and care area assessments; c. Ongoing monitoring of sensory problems; d. Care plan development and implantation, and e. Evaluation. 2. Employees should refer any identified need for hearing or vision services/appliances to the social worker/social services designee. Review of a facility policy titled, Fall Prevention Program, implemented 10/17/22, showed the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 3. The nurse will indicate on the Care Profile the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to provide Activities Of Daily Living (ADLs) for two residents (#122 and #123) of five residents sampled for ADL care related to personal hygiene. Findings included: 1. An observation of Resident #122 on 04/08/24 at 10:09 a.m. revealed the resident sitting up in her bed watching television. The resident was observed to have strands of white facial hair on her chin. Interview with Resident #122 at this time revealed she does not like the hair on her chin and that she would like the facial hair to be gone. An observation of Resident #122 on 04/09/24 at 8:54 a.m. revealed the resident sitting in bed. The resident was observed to still have white strands hair on her chin. An interview with the resident at this time revealed she prefers to have her face clear with no facial hair. The resident reported the staff have helped her get washed up, but no one has asked or offered her assistance with the hair on her chin. Review of Resident #122's admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included muscle wasting and atrophy, unsteadiness on feet, and need for assistance with personal care. Review of the Resident #122's 5-day Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview For Mental Status (BIMS) score of 12 (Moderate Cognitive Impairment). Continued review of the MDS revealed the Resident is dependent with substantial/maximal assist with Shower bath self. Review of the Resident #122's medical record revealed there was no care plan in place to address the resident's need for assistance with ADLs. 2. An observation of Resident #123 on 04/08/24 at 10:09 a.m. revealed the resident sitting up in her bed reading a book. The resident was observed to have strands of white facial hair visible on her chin. An interview with Resident #123 revealed she does not like to have hair on her chin and that she would like the facial hair plucked. An observation on 04/09/24 at 8:57 a.m. of Resident #123 revealed the resident sitting up in her bed reading a book. An interview with the resident at this time revealed the resident does not like hair on her face. She reported that if they gave me a mirror and tweezers I could pluck it myself. Review of Resident #123's admission Record revealed this resident was admitted to the facility on [DATE] with diagnoses that included muscle wasting, and atrophy, need for assistance with personal care, and unsteadiness on feet. Review of a BIMS Evaluation progress note, dated 4/3/24, revealed Resident #123's BIMS score of a 14 (Cognitively intact). Review of the undated therapy dashboard page revealed this page reflected treatment diagnosis that included Z74.1 (OT) Need for assistance with personal care. Review of the Occupational Therapy Treatment Encounter, dated 4/5/24 and maintained by the therapy vendor, revealed the following: Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance, reduced functional activity tolerance, increased need for assistance from others and pain indicating the need for OT to increase (I) w/ADLs. The document revealed the following in the area of hygiene and grooming Hygiene / Grooming = MI (modified independence). Review of the resident's medical record revealed there was no care plan in place that would be available for staff to access to address the resident's need for assistance with ADL's. An interview was conducted on 04/09/24 at 12:55 p.m. with the Director of Rehabilitation. He reported Resident #123 was being seen by Occupational Therapy (OT) and Physical Therapy (PT) and personal care was being addressed by OT. He reported that he was unsure as to what care is provided on the health side. During an interview on 04/09/24 at 9:21 a.m. Staff J, Registered Nurse (RN) revealed staff should take care of the residents' ADLs. She reported that typically if she goes into the resident rooms and sees anything that needs to be done for the resident that she will let the certified nursing assistant (CNA) know. During an interview on 04/09/24 at 12:47 p.m. with the Director of Nursing (DON) she revealed that her expectation was if the resident is independent with their ADLs staff should ask residents if they need assistance with their ADLs, and if the resident refuses assistance staff are to document and let the nurse know. The DON reported if the resident is dependent on staff for assistance with ADLs staff should anticipate the resident's needs and assist them with their ADL needs. The DON reported if the ADL need is facial hair, staff should address it unless the resident refuses. During an interview on 04/09/24 at 2:17 p.m. with Staff K, MDS Coordinator she revealed a care plan should be in place to address the resident's ADL needs. She reported that usually on admission the admitting nurse will put a baseline care plan in place related to the resident's ADL needs, and then the clinical team will review the orders and diagnosis the day after admission. She reported if anything was needed to be added it is added. She reported she was not sure why Residents' #122 and #123 care plans related to ADLs were missed. Review of the facility policy titled, Activities of Daily Living (ADLs), dated 10/17/2022 revealed the following: Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; Under the section titled, Policy Explanation and Compliance Guidelines: revealed the following: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 10/17/2022, revealed the following: 9. Groom and dress residents according to resident preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 04/08/24 at 11:45 a.m. Resident #43 was observed lying in bed with her tube feeding disconnected and hanging on the poll. The feeding was dated 4/7/2024. On 4/9/2024 at 8:30 a.m. Resident #43 was observed lying in bed and appeared to be sleeping. Her tube feeding was connected to the resident and was running at 60 milliliters. On 4/9/2024 at 1:45 p.m. Resident #43 was observed lying in bed with her tube feeding connected at this time. Resident #43 was awake, she stated that she has not been out of bed and that she does not want to get out of bed, she prefers to stay in bed. Review of the admission Record for Resident #43 revealed an admission date of 10/16/2019. The diagnoses included cerebrovascular disease, aphasia, hemiplegia and hemiparesis of right side, chronic obstructive pulmonary disease, dysphagia, gastrostomy, anxiety disorder, hypertension, and bipolar disorder. Review of the Quarterly Minimum Data Set (MDS) for Resident #43, dated 3/13/2024, revealed: Section A - identification information - reentry date of 1/7/2023 with original entry date of 10/16/2019. Review of the active physician orders, dated 4/10/2024, for Resident #43 revealed: Resident #43 is to have nothing by mouth (NPO), enteral feeding order is Jevity 1.2 to run at 60 milliliters every hour for 20 hours, start at 2:00 PM and run/stop at 10:00 AM. Physical therapy, occupational therapy and speech therapy evaluation and treatment as needed. Schedule resident for swallow test (dated 3/26/2024), occupational therapy to evaluate and treat for sitting abilities (dated 4/5/2024). Review of the progress notes for Resident #43, dated 3/26/2024, revealed Resident #43 to have a swallow test. Review of a progress note for Resident #43, dated 4/4/2024, signed by physician revealed, resident was eating well by mouth before last admission. I am trying to do a new evaluation, discussed today with speech therapy, she will need previous evaluation by occupational therapy, she is always in bed, she needs to position in the chair, resident needs to be out of bed for meals. Review of the active care plan Focus for Resident #43, dated 4/10/2024, revealed: Nutrition Focus for altered nutritional status (date of revision 7/6/2023). Interventions included of offer menu selections, adjust food preference as needed, receive adjusted texture, supplements as ordered (date initiated 12/20/2021), potential for complications related to feeding tube (date of revision 12/5/2022). Review of the census report dated 6/5/2023, 7/2/2023 and 11/2/2023 for Resident #43 showed hospital admissions related to the feeding tube malfunction (6/5/2023), related to cellulitis of feeding tube (7/2/2023), and was for evaluation for complaint of abdominal pain (11/2/2023). Review of a therapy screen, dated 4/2/2024, for Resident #43 revealed a physician order in place for speech evaluation for possible oral diet, plan was discussed with Resident #43 and resident agreed with plan. Review of the medical record therapy screen/occupational interaction note, dated 4/4/2024, for Resident #43 revealed communication was done with the primary care physician that the resident needed occupational therapy for positioning. An interview was conducted with Staff E, Licensed Practical Nurse (LPN), Unit Manager (UM), Infection Control (IC) on 4/9/2024 at 2:08 p.m. Staff E revealed the resident is able to remove her oxygen and refuses to get out of bed. The resident was to have a swallow test completed by speech. She verbalized the resident does not want to take oral foods. Staff E was not sure if it was the texture or not. An interview was conducted with Staff E, LPN/UM/IC, and Staff O, Speech Therapy (ST) and Staff L, Director of Rehabilitation on 04/10/24 at 11:15 a.m. It was revealed the order was for 3/26/2024 (swallow test). ST saw the resident on 4/2/2024 and 4/4/2024. OT saw the resident on 4/5/2024 and full service was to begin on 4/10/2024. During the interview Staff E LPN/UM/ IC revealed the delay in follow-up was related to poor communication during morning meeting. On 4/10/2024 at 10:00 a.m. a request was made to review a policy and procedure for morning clinical meeting. The policy and procedure was not provided by the last day of survey (4/10/24). Review of a policy titled, Referral to Therapy, dated 1/18/2023, revealed: Policy: To ensure clinically appropriate care will be provided a Therapy Request Form may be completed for long term care (LTC) patients. Procedure: 1. The therapy request form is completed and provided to the rehabilitation department. A therapy request form or another similar form/process should be completed for any patient that has change in condition or may need therapy services for prevention, compensatory strategies, or caregiver education. 2. This referral is coordinator with other disciplines and/or nursing referral for therapy possibly warranting a therapy evaluation 3. Upon review, the therapist will make the determination if an evaluation is indicated. 4. Once this form is completed, the results will be shared with the interdisciplinary team members. 5. If a therapy evaluation is indicated the therapy order process will be followed. Based on observations, record review and interviews, the facility failed to ensure failed to ensure an order was in place for pressure relieving boots being utilized for one resident (#670) of three residents reviewed for post fall intervention and 2) failed to follow-up on an order for a swallow test for one resident (#43) of a total sample of 46 residents. Findings included: 1. An observation was made on 04/08/24 at 10:08 a.m. of Resident #670 in bed lying down with pressure-relieving boots on both feet. (Photographic Evidence Obtained) The resident stated she cannot get out of the bed because staff are keeping the pressure-relieving boots on her feet. Review of admission Records showed Resident #670 was admitted on [DATE] with diagnoses including severe protein-calorie malnutrition, muscle wasting and atrophy, edema, and unsteadiness on feet. Review of Resident #670's Skin Observation Tool, dated 02/20/24, showed the resident had bilateral purple boots for pressure relief of heels. Review of Resident #670's care plan showed a plan in place for Skin Integrity, Risk for Alteration Impaired Mobility, dated 03/07/24. Interventions included boots bilateral in bed. Another plan was in place for Skin Impairment: Impaired skin integrity related to wounds present, dated 03/12/24. Interventions included heel boots on qs (a sufficient quantity). Review of Resident #670's Visual/Bedside [NAME] Report showed under Resident Care, Staff will float heels with heels up cushion/pillow under calves while in bed. Under the Monitoring/Safety section it documented, Heel protectors while in bed. Review of Resident #670's active physician orders did not show an order in place for pressure-relieving boots. An interview was conducted on 4/10/24 at 1:06 p.m. with Staff V, Registered Nurse (RN). She confirmed she was assigned to care for Resident #670. Staff V said Resident #670 wears pressure-relieving boots to prevent pressure ulcers. She said when she thinks a resident needs the boots, she tells the Unit Manager (UM) and the UM gives her the boots. Staff V said it isn't like medication; you don't need an order for the pressure-relieving boots. She said she thinks Resident #670 had them on anytime she was in bed. An interview was conducted on 04/10/24 at 1:31 p.m. with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). She stated pressure-relieving boots could be used as an intervention on a care plan and a doctor could give orders for them. When asked how long the boots should stay on a resident the Staff E said, I would say could be based on nurses' judgment. As long as they are getting them out of bed appropriately. Staff E stated they would need to get clarification from the doctor to see how long a resident should have the boots on each day. Staff E stated she recently went through all residents that had pressure-relieving boots to make sure they had orders in place. Staff E reviewed Resident #670's record and confirmed the resident had no orders or specific instructions for use of the pressure-relieving boots. Staff E stated she should have put in an order and asked the doctor to specify instructions.

Based on observations, record review and interviews, the facility failed to provide care consistent with professional standards of practice related to oxygen therapy for one resident (#21) of two residents reviewed for oxygen therapy. Findings included: An observation on 04/08/24 at 9:55 a.m. revealed Resident #21 was receiving oxygen via a nasal cannula, the oxygen concentrator was set at two liters per minute. The oxygen tubing was touching the floor and the storage bag was dated 04/01/2024. An observation on 04/08/2024 at 2:00 p.m. revealed Resident #21 in bed and oxygen was in place. An observation on 04/09/2024 at 8:00 a.m. revealed Resident #21 in bed, oral care had been provided and oxygen tubing was removed off the floor, the bag and tubing had been changed and dated 04/08/2024. An observation on 04/10/2024 8:00 a.m. revealed Resident #21 resting in bed receiving oxygen via a nasal cannula at two liters per minute. Review of admission Record for Resident #21 revealed a date of admission as 9/4/2020. The diagnoses included cerebral infarction, shortness of breath, anxiety, pneumonia, and chronic obstructive pulmonary disease. Review of active physician orders as of 04/10/2024 for Resident #21 revealed no orders for oxygen therapy. Review of Medication Administration Record (MAR) dated 03/01/24 - 03/31/24 for Resident #21 revealed no administration of oxygen therapy. Review of the Treatment Administration Record (TAR) dated 03/01/24 - 03/31/24 for Resident #21 revealed no administration of oxygen therapy. Review of the MAR dated 04/01/24 - 04/09/24 for Resident #21 revealed no administration of oxygen therapy. Review of the TAR dated 04/01/24 - 04/09/24 for Resident #21 revealed no administration of oxygen therapy. Review of the active care plan revealed, date initiated 12/30/2023, revised on 06/2023 and printed on 04/10/2024 for Resident #21 revealed no focus, goal or interventions related to oxygen therapy. During an interview on 04/09/2024 at 2:15 p.m. with, she revealed that Resident #21 prefers to remain in bed and confirmed there was no physician order for the observed oxygen use. During an interview on 04/09/2024 at 4:00 p.m. Staff E, Licensed Practical Nurse (LPN), Unit Manager (UM), Infection Control (IC) verified Resident #21 did not have a physician order for oxygen. Review of the policy titled, Oxygen Administration, dated 10/17/2022, revealed: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and compliance Guidelines: 1. Oxygen is administered under the orders of a physician, except in the case of an emergency. 2. Personnel authorized to initiate oxygen therapy include physicians, registered nurses, licensed practical nurses and respiratory. 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.

2. An observation was made on 4/10/24 at 11:06 a.m. on the 200 unit of an unlocked medication cart. The cart was observed to be unlocked with the keys hanging from the open lock while sitting in a resident hall with no staff members in sight. (Photographic Evidence Obtained.) An interview was conducted on 4/10/24 at 11:10 a.m. with Staff V, RN. She confirmed the unlocked medication cart was assigned to her. She said the medication cart should always be locked when the nurse isn't using it. Staff V said she shouldn't have left the keys in her cart; they should be in her pocket. She said sometimes she gets busy and forgets. Based on observation, record review and interview the facility failed to appropriately store and secure medications related to one (1st floor) of two units for medication at the bedside and one (200 hall, cart 1) of four medication carts left unlocked. Findings included: 1. Observation of Resident #120's room on 04/08/24 at 10:28 a.m. revealed there was a white cream in a medicine cup in a tissue box on the resident's over bed table which was located to the right side of the resident's bed. The cup was not labeled with the name of the substance and there was no indication for the direction of the use of the substance. Interview with the resident at this time revealed the resident indicated that is icy hot from last night. Also noted in the tissue box was a bottle of eye drops and a container of Icy Hot. There was no direction for use of the eyedrops or the Icy Hot. Resident #120 said, Those are mine that I paid for because my eyes get dry. Continued observation of Resident #120's room revealed a green substance in a disposable 4 oz (ounce) juice cup with a vinyl glove covered over the top of the cup. The cup was on the resident's nightstand located to the left of the resident's bed. Interview with the resident, at this time, revealed she cannot remember what the substance was and that it had been at the bedside since the night before. She was not sure what the green stuff is. (Photographic Evidence Obtained) Review of Resident #120's electronic record revealed there was no physician order for eyedrops, or mentholated topical creams. Additionally, there was no documentation that would indicate the resident had been assessed to independently store and self-administer her medication. An interview on 04/08/24 at 10:32 a.m. with Staff G, Registered Nurse (RN) revealed she had already administered medication to the resident that morning but had not left any topicals at the bedside. Staff G entered Resident #120's room with the state surveyor present and obtained the bottle of eye drops, white cream and green cream. It was noted at this time, the green cream had a mentholated scent and the white cream did not have a mentholated scent. Staff G reported she was not sure what the creams were and discarded them in the garbage. Staff G gave the resident the eyedrops back after the resident indicated they were hers and that she paid for them. An interview on 04/09/24 at 1:53 p.m. with the Director of Nursing (DON) revealed that residents are allowed to keep medications at the bedside if they have an order for the medication, and are assessed to self-administer medication, and are provided with a Medication Administration Record (MAR) at the bedside. An interview with the DON on 04/09/24 at 4:15 p.m. revealed the resident now has an assessment for self-administrating medication and has physician orders for the eyedrops and Icy Hot medication at the bedside. She reported she was not aware of the topicals that were left at bedside in cups, and the green substance was probably from therapy because nursing has no green topicals. An interview on 04/10/24 at 10:48 a.m. with the DON revealed she found out from therapy the substance that was left in the cup was bio-freeze and she was sure that the other substance was barrier cream. The DON reported no one admitted to leaving any substance at the resident's bedside.

**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 (#6, #120, and #122) of three residents sampled. Findings included: 1. Review of the admission Record for Resident #6 revealed an admission date of 03/21/2024. Resident #6 was noted as her own responsible party. Review of an admission Minimum Data Set (MDS), dated [DATE], showed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 04/10/2024 at 10:45 a.m. an interview was conducted with Resident #6. Resident #6 stated she signed so many forms when she was admitted that she does not remember each one. Upon review of the Arbitration Agreement she signed on 04/05/2024, she stated she remembered signing the Arbitration Agreement. She was not aware the Arbitration Agreement was optional, and she was giving up her right to seek legal action. She stated had she known the Arbitration Agreement was (optional) she wouldn't have signed the Arbitration Agreement. 2. Review of the admission Record for Resident #120 revealed an admission date of 03/22/2024. Resident #120 was noted as her own responsible party. Review of an MDS, dated [DATE], showed Resident #120 had a BIMS score of 14 out of 15, indicating intact cognition. On 04/10/2024 at 10:50 a.m. an interview was conducted with Resident #120. Resident #120 stated when she was asked to sign forms, she was given a tablet where the signature line was only visible. Upon review of the Arbitration Agreement she signed on 04/05/2024, she stated she remembered signing the Arbitration Agreement. She was not aware the Arbitration Agreement was optional, and she was giving up her right to seek legal action. She stated had she known that the Arbitration Agreement was (optional) she would have signed the Arbitration Agreement. 3. Review of the admission Record for Resident #122 revealed an admission date of 03/21/2024. Resident #122 was noted as her own responsible party. Review of an MDS for Resident #122, dated 03/28/2024, showed Resident #122 had a BIMS score of 12 out of 15, indicating intact cognition. On 04/10/2024 at 10:55 a.m. an interview was conducted with Resident #122. Resident #122 reviewed a copy of the Arbitration Agreement she signed on 04/05/2024. Resident #122 stated she did not know what the agreement meant. She was not aware the Arbitration Agreement was optional, and she was giving up her right to seek legal action. She stated had she known the Arbitration Agreement was (optional) she wouldn't have signed the Arbitration Agreement. Review of the facility's Arbitration Agreement revealed the agreement did not show an explicit statement the resident or representative did not have to sign the arbitration agreement. The Arbitration Agreement, page 3 of 4 paragraph 4 read: I hereby agree and acknowledge that I have read this Agreement, have understood it, and have been given the opportunity to see legal counsel regarding this agreement. I hereby acknowledge that I agree and wish to be bound by the provisions of the agreement. On 04/10/2024 at 10:15 a.m. an interview was conducted with the Admissions Coordinator. She stated the Arbitration Agreement is verbally explained to the resident as they are admitted to the facility. Residents are verbally told they have the right to have legal counsel review the Arbitration Agreement. She stated the Arbitration Agreement is optional. She reviewed the form and confirmed the form did not inform the resident that signing the Arbitration Agreement was optional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation was made on 04/8/24 at 1:47 p.m. in Resident room [ROOM NUMBER] of several small flying insects around the resident's room. A small flying insect was observed landing on a resident's face while she was sleeping. The small flying insects were observed in the same room on 4/9/24. Review of a facility policy titled, Resident Environment Quality, dated 10/17/22, showed it was the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. (10.) Maintain an effective pest control program so the facility is free of pests and rodents. (Photographic Evidence Obtained) Based on observations, interviews and review of facility policy, the facility failed to maintain an effective pest control program related to small flying insects observed in three resident rooms (212, 216, and 218) on one of two floors. Findings included: During a tour of Resident room [ROOM NUMBER] on 04/08/24 at 10:16 a.m. an observation was made of small flying insects on the resident's water cup. The resident in the window bed stated the cleaning could be better. She stated she had seen a cockroach in the bathroom. The resident stated she had observed the insects in her room before. On 04/09/24 at 11:10 a.m. an interview was conducted with Staff P, Housekeeping. She stated she cleaned all the rooms. She stated if there were bugs anywhere, she would notify her supervisor. During a tour of Resident room [ROOM NUMBER] on 04/09/24 at 11:17 a.m., two urinals were observed on the resident's head of bed, hooked to the bedside rail. They were observed with urine, stained and with a foul order. An observation was made of small flying insects, approximately 20 of them on the resident's trash can and around surfaces in the room. An observation was made of the small flying insects on the resident's water cup and on his bed. The resident in the window bed stated it was always like that. During a tour of Resident room [ROOM NUMBER] on 04/10/24 at 8:42 a.m. an observation was made of small flying insects on the resident's plate and on their bed. An interview was conducted on 04/10/24 at 9:06 a.m. with Staff M, Housekeeping, Staff P, Housekeeping, and the Housekeeping Manager (Manager). Staff M stated it was the first time she saw the small flying insects. The Manager stated no one had said anything about the flying insects. She stated would call maintenance to come and spray. She stated the facility had a pest control contractor who comes on Wednesdays. She stated the problem with the small flying insects was because the showers don't get used often and it could be the drain issue. On 04/10/24 at 10:09 .m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN)/Unit Manager. She stated the small flying insects were all around the building. She stated there should not be flying insects on residents' drinking cups, on themselves or their spaces. She stated the CNAs (Certified Nursing Assistants), and nurses should replace the residents' urinals daily if needed. Staff E observed the photographic evidence and said, Insects on residents' plate, that is gross. I can't imagine about the residents who cannot swish the insects off themselves. Staff E stated maintenance knew. She said, We told them. I am not sure what they have done about it. I spoke to him last week Wednesday. On 04/10/24 at 3:38 p.m. an interview was conducted with the Director of Facilities. He stated he was made aware of flying insects the previous week. He said, My pest control guys came last week. He said some residents have fruits and flowers which might be causing the flying insects. He stated he could not find any breeding place. He stated if staff observed any pests, they should notify the receptionist to put in a work order. He said, If there is an issue I expect to be notified. Review of the facility's pest log showed no evidence of any insects being reported. The log did not show any work orders or treatments related to pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation was made on 4/9/24 at 12:09 p.m. of the call light being activated in Resident #20's room. The call light remained on until Staff Q, CNA went to the room at 12:27 p.m.,18 minutes after it was activated. The call light was turned off and the CNA immediately exited Resident #20's room. A nurse was observed sitting at the nurses' station during this time. An interview was conducted on 4/9/24 at 12:28 p.m. with Resident #20. He said he needed to be changed because he was soiled. He said he is a quick change he just needed assistance. Resident #20 said the CNA came in and turned the call light off and told him staff were doing something with lunch and she would be back. Resident #20 said it always takes a while for call bells to be answered. Resident #20 reactivated his call light. An observation was made on 4/9/24 at 12:31 p.m. of Staff Q, CNA entering Resident #20's room, turning the light off. The resident was asked what the staff member told him. He said the CNA didn't say a word to him, they just turned the light off and walked back out. An observation was made on 4/9/24 at 12:48 p.m. of Staff R, CNA entering Resident #20's room to pick up his lunch tray. The resident was overheard asking the CNA if he was going to change him. The CNA said, Let me check and see which one [CNA] is down here. The CNA left the room and walked away. An observation was made on 4/9/24 at 12:54 p.m. of Resident #20 yelling out hello repeatedly from his bed. At 12:56 p.m. the Activities Director stopped and asked Resident #20 what he needed. He said, I've been waiting a while and he explained he needed to be changed. The Activities Director walked out of the room to find a CNA. An observation was made on 4/9/24 at 1:00 p.m. of Staff R, CNA returning to Resident #24's room and telling the resident, I can't find her so I will go ahead and change you. As Staff R was getting ready, Staff Q, the resident's assigned CAN, came out of a room from helping a resident eat lunch and said she would assist. Review of the admission Record showed Resident #20 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, contractures, abnormal posture, and need for assistance with personal care. Review of Resident #20's Minimum Data Set (MDS) Section C - Cognitive Patterns, dated 2/27/24, showed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. Section GG, Functional Abilities and Goals, showed he was dependent for toileting hygiene. Section H, Bladder and Bowel, showed the resident was always incontinent of bowel and bladder. An interview was conducted on 4/10/24 at 9:54 a.m. with Staff E, LPN/UM. She said call lights should be answered immediately if staff are able, but at most within two to three minutes. She said during lunch there is one nurse and two CNAs helping residents in the dining room and one nurse and two CNAs helping assisted diners in their room. When asked who was left to answer call lights and assist residents if all available staff are assisting other residents with eating she said, When you put it that way. No one is left to answer call bells. An interview was conducted on 4/10/24 at 3:56 p.m. with the Director of Nursing (DON). She said she expected call lights to be answered in 10 minutes or less. She said any staff member can answer a call light. The DON said she would not expect a CNA to turn off a call light and leave without assisting the resident. She said if a CNA checked on a resident and that resident needed changing, she would expect that CNA to do the work, even if they are not assigned to the resident. The DON said it is not acceptable for a resident to wait 50 minutes to be changed. Based on observations, interviews with residents and facility staff, and review of the facility's records and policies, the facility failed to provide sufficient staff to provide meal assistance on one floor (second floor) of two floors for six (#32, #15, #30, #3, #18 and #54) of 17 dependent residents, and failed to respond to a call light for Resident #20 for two days (04/09/2024 and 04/10/2024) of a three day survey. Findings included: An observation on 04/09/24 of the lunch meal service revealed the residents in the dining room received their trays starting at 11:34 a.m. Resident #32 was the last one to receive her tray in her room at 12:45 p.m., having waited approximately one hour and twenty minutes. During a facility tour on 04/09/24 at 11:43 a.m. an observation was made of staff distributing trays on the facility's second floor dining room. The residents who eat in their rooms were observed waiting for their trays. An observation was made of Staff R, Certified Nursing Assistant (CNA) on 04/09/24 at 12:25 p.m. passing resident lunch trays on the 200 hall. He stated (Resident #15) was a feeder and he would be feeding him shortly. He walked into the resident's room with the tray, dropped off the tray and walked out. Staff R stated he did not assist him with the meal because (Hospice Staff-1) took over. Staff R stated (Hospice Staff-1) was willing to help feed the resident. On 04/09/24 at 12:38 p.m. an interview was conducted with Hospice Staff #1. She stated she did not know this resident ([#15). She stated she did not know how much he normally ate, she said, I'm here to see him for other things. I decided to assist with his meal because he was waiting. On 04/09/24 at 12:27 p.m. Staff R, CNA dropped off a tray for Resident #48. The resident was waiting to be assisted with meal. After approximately 5 minutes, the resident was observed being assisted by Hospice Staff-2. Staff R stated the Hospice staff was willing to feed the resident. On 04/09/24 at 12:28 p.m. Hospice Staff-1 was observed looking for towels. She was observed walking down the halls looking for linen carts. She asked, Where are the staff? Hospice Staff-1 found the towels and a gown and returned to change Resident #15. During this timeframe, Staff T, Licensed Practical Nurse (LPN) was observed on 04/09/24 from 12:11 p.m. to 12:35 p.m. at the nurses' station on the phone. On 04/09/24 at 12:29 p.m. Staff Q, CNA was observed grabbing a tray from the cart. She stated she was going to feed Resident #30. She stated there were two CNAs and one nurse working in this hall. She stated there were about seven residents that needed to be assisted with meals on her assignment. She stated sometimes it takes them a long time to feed all the residents. She stated she did not know if the food was cold. She stated the residents did not say anything about the food being cold. On 04/09/24 at 12:30 p.m. the Director of Nursing (DON) was observed assisting Resident #18 with a meal while standing. She was heard saying to the resident, It's the blind leading the blind. The DON stated she had come to assist with lunch. On 04/09/24 at 12:36 p.m. an observation was made of two residents' meal trays still waiting to be delivered. Resident #32 was one of the recipients. She was observed sitting in her wheelchair in the middle of her room. Resident #32 was not interviewable. She had not had lunch. An immediate interview was conducted with Staff S, Registered Nurse (RN) on 04/09/24 at 12:37 p.m The nurse confirmed Resident #32 was waiting to be assisted. He pulled the tray out, confirmed the meal ticket and put the tray back in the cart. He stated he had about six residents who needed to be assisted with their meal on his assignment. He stated it was tight during meals. He said, There are not enough hands. On 04/09/24 at 12:39 p.m. an interview was conducted with Staff C, CNA. She confirmed Resident #32 was still waiting to be assisted with her meal. She looked inside the meal cart and saw two trays. She said, Yes, they are still waiting to be assisted. The CNAs on this floor had been assisting other residents in the dining room. They just have to wait. On 04/09/24 at 12:41 p.m. Staff R, CNA stated Resident #32 waited over 45 minutes today. Staff R said, Yes, sometimes they wait an hour. There are too many residents that need assistance. There is no way to get everyone in a timely manner. The CNA stated they needed more help, especially during meal service. On 04/09/24 at12:45 p.m. Staff R, CNA was observed grabbing a chair from the nurses' station and proceeded to Resident #32's room. He was observed assisting her with the meal. An observation on 04/10/24 of the breakfast meal service revealed the residents on the second floor received their trays starting at 7:30 a.m. Resident #54 was the last one to receive his tray in his room at 9:01 a.m. having waited 1.5 hours. On 04/10/24 at 8:23 a.m. Resident #3 was observed receiving meal assistance from Staff U, CNA. The resident's roommate, Resident #30, was observed waiting to receive her breakfast meal. On 04/10/23 at 8:24 a.m. Resident #32 was observed sitting on her bed, awake. The resident was waiting for her breakfast meal. On 04/10/24 at 8:26 a.m. an observation was made of Staff C, CNA grabbing a meal tray and going into room [ROOM NUMBER]. She stated both residents were still waiting to be assisted with their breakfast meal. Staff C set a tray by the door bed. She walked back to the cart and grabbed another tray and set it by the window bed. On 04/10/24 08:43 AM an observation was made of Staff C assisting the resident in the door bed with her meal. Her roommate was observed waiting for her breakfast meal. On 04/10/24 at 8:29 a.m. an observation was made of Staff R, CNA assisting Resident #17 with her meal. Her roommate, Resident #18 was observed waiting for her breakfast meal. On 04/10/24 at 8:31 a.m. an interview was conducted with Staff A, CNA. She stated Resident #51 had been assisted with her breakfast, but they still had a few trays left. On 04/10/24 at 8:37 a.m. Staff R, CNA confirmed there were trays left in the cart. He confirmed he had helped one resident so far. He stated it had been approximately 30 minutes since the trays arrived on the unit. On 04/10/24 at 8:39 a.m., an observation was made of Staff R, CNA grab Resident #18's tray and proceeding to assist her. In an interview Staff R stated there were a few more trays left. On 04/10/24 at 8:40 a.m. an observation was made of Staff U, CNA assisting Resident #32. Across the hall, Resident #3 was observed spooning food to her mouth by herself and dropping a substantial amount on the floor and herself. Staff U had been assisting her earlier, but left her to assist another resident. Staff U stated she left her to finish up while she started assisting Resident #32 who had been waiting. An interview was conducted with Staff R, CNA on 04/10/24 at 8:44 a.m. He stated all the independent residents had eaten breakfast or were just finishing up. Staff R stated the first breakfast trays were delivered about 30 minutes earlier. On 04/10/24 at 8:45 a.m. an interview was conducted with Staff U as she walked out of Resident #32's room. She stated she still had Resident #54 and Resident #15 left. She said, They are waiting. There are four CNAs for the second floor. She stated it takes a long time to assist each resident. She said, if everyone would pitch in, it would help. She stated they assisted in the dining room first and then in the resident rooms. Staff U said, It can be a while. I don't want to give it a timeframe, but it takes very long. On 04/10/24 at 8:57 a.m. an interview was conducted with Staff A, CNA. She said, It takes a long time for the residents to receive their meal because we have four CNAs with 20 feeders. She said, It takes more time for the residents to eat so we need more people. That's a lot. Some need more help than others. On 04/10/24 at 9:01 a.m. an observation was made of Staff R, CNA assisting Resident #54 with his breakfast. On 04/10/24 at 9:25 a.m., an interview was conducted with the Food Service General Manager, (FSGM). He stated breakfast was delivered upstairs at 7:30 a.m. and lunch on 04/09/10 was delivered to the dining room at 11:34 a.m. He stated his expectation was that the resident should receive their meal immediately after it is plated, and no more than 30 minutes after the trays go. He stated he was aware there was a problem. He stated he had conducted an audit and identified the test tray on the cart returned to him at 1:35 p.m. He stated the residents should be served and eating within 30 - 45 minutes of the meal being plated. He stated he had attended a Resident Council meeting and the residents complained of trays taking a long time and food temps not being at par. He stated those complaints had lessened. An interview was conducted with Staff E, Licensed Practical Nurse/Unit Manager (LPN/ Unit Manager) on 04/10/24 at 9:45 a.m. She stated they had 17 assisted diners on the second floor and provided the list. She stated the expectation was for the CNAs and nurses to identify who needed to be assisted with dining and provide them the assistance. She stated the trays should not be left in the room until the resident is ready to receive assistance with the meal. Staff E LPN/UM said, We usually have about five to six CNAs. This morning, we had four CNAs and the unit secretary who is also a CNA should help. She stated it should take 30-45 minutes to have everyone fed from the time the trays come up. She said, There were a lot of assisted diners. She said, I can see how there can be short without the additional help. Staff E stated they looked at this issue in the past and decided certain staff should go upstairs and assist. She stated that a staff member who was supposed to help was out of the office and another one was in a meeting. Staff E said, We did not get them to help this week. The residents should not wait that long for their meal. On 04/10/24 at 9:53 a.m. an interview was conducted with the Food Service Coordinator (FSC). She said, We try to get the trays to the resident as quick as possible. There is a little interruptions. She stated they start with the independent people then the assisted residents. She stated the meal trays should be distributed within 10 minutes of receipt. She confirmed an hour, or more was not acceptable wait time. An interview was conducted with the Staffing Coordinator on 04/10/24 at 1:12 p.m She stated residents' acuity did not determine staffing numbers. She said, No, I go by what they tell me. I have a calculation sheet. I split the staff among the whole day. For the CNAs, the ratio is 1-20 and for the nurses the ratio is 1-40. She stated they were running with the new staffing mandate. She said every once in a while, I don't meet it, but it is never two days back to back. She stated this only happened when they had a late call -in and were unsuccessful trying to cover it. She stated they did not use agency staff. She stated if there were staffing shortages, she would always communicate with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). She said, If staff haven't picked up or I have a lot of open shifts I let them know ahead of time. She stated she was a CNA and she assisted if they were short or if we cannot get someone to come in. The Staffing Coordinator said, During meals other staff take turns assisting on the floor, including department heads. She stated they split up between the first and second floors. She stated there was no schedule. She said, We all jump in and pitch. I was not there yesterday for lunch, and was not here to assist with breakfast. She stated there were two staff members who could have assisted, but they were absent. She stated she had been told as long as they hit the numbers, they were okay. The Staffing Coordinator said, I understand we also need to be aware about the quality of care and meeting the residents' needs. On 04/10/24 at 1:40 p.m. an interview was conducted with the NHA, Regional Clinical nurses (RNC)- 1 and RNC- 2. The NHA stated he was notified as of yesterday there were meal assistance concerns. He said, I became aware as of yesterday. They said it is taking a long time, we have someone that is off, therapy should be assisting. It will be a true practice going forward. He stated on 03/11/24 they did not meet the staffing numbers due to call offs. It was not two days in a row. He said in that case they try and replace as best as they can. Leadership should step in and assist. He stated he had not been notified of concerns with residents waiting to be assisted with toileting. He stated he did not know. The NHA said, That is not our practice. Review of an undated facility document titled, Facility Assessment showed on page 15 of 46, B.2. Acuity - care requirements, [name of facility] staffs above state minimum requirements, with the specific focus on adequate CNA staffing to accommodate this greater need for additional assistance with the number of ADL's including daily care, bed mobility, transfers walk in room, toilet use, eating, dressing, and hygiene/grooming. The population at [name of facility] and the staffing levels provided are deemed sufficient based on resident satisfaction, QA/compliance committee data, resident council feedback, resident interviews and observations, clinical outcomes, and functional improvements. Review of a facility policy titled, Serving a Meal, dated 10/17/22, showed (12.) Remember that some residents take a long time to eat. Provide adequate time for the resident to consume the meal and offer to reheat foods as needed. Review of a facility policy titled, Nursing Services and Sufficient Staff, dated 10/17/22, showed it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure residents safety and attain or maintain the highest practicable physical mental and psychosocial well-being of each resident. The facility's census, acuity and diagnosis of the resident population will be considered based on the facility assessment. Under policy explanation and compliance guidelines, (1) the facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with the resident care plans. A. Except when waved licensed nurses and B. Other nursing personnel including but not limited to nurse aides. (5) providing care includes but is not limited to assessing evaluating planning and implementing resident care plans and responding to resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement an effective infection prevention and control program related to: 1) failing to ensure a contact precautions sign was displayed timely for one resident (#24) diagnosed with Clostridioides difficile (C-Diff), 2) failing to ensure proper usage of personal protective equipment (PPE) by staff and volunteers (I, Q, R, V, and Dog Handler), 3) failing to ensure four staff members (Staff Q, B, C, Director of Nursing) performed hand hygiene, and 4) failing to ensure staff provided hand hygiene for 14 residents (#54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33) prior to dining for three days of a three day survey. Findings included: An observation was conducted on 4/8/24 at 10:15 a.m. of Resident #24 in bed with no precaution sign on his door. Throughout the day on 4/8/24 staff were observed entering and exiting the room without donning and doffing PPE. Review of Resident #24's progress notes showed a note from the resident's primary care provider, dated 4/4/24 at 10:38 a.m., revealing the nurse called to notify her Resident #24 had new onset, foul smelling, liquid diarrhea for the past two days. The doctor ordered a stool sample to be collected and tested for C-diff. Review of lab results for Resident #24 showed a positive C-Diff Molecular lab, dated 4/7/24. The lab report showed critical lab results were reported to Staff G, Registered Nurse (RN) on 4/7/24 at 2:30 p.m. Review of the admission Record showed Resident #24 was admitted on [DATE] with diagnoses to include dementia, cognitive communication deficit, and constipation. Review of Resident #24's Minimum Data Set (MDS) Section C, Cognitive Patterns, dated 1/31/24, showed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the progress notes for Resident #24, dated 4/8/24 at 12:48 p.m. from Staff E, Licensed Practical Nurse (LPN)/Unit Manager (UM), revealed labs were reviewed by the resident's PCP and new orders for Vancomycin 125 mg (milligrams) by mouth every 6 hours for 14 days. Review of orders showed an order for Contact Isolation Precautions and an order for Vancomycin HCL Oral Capsule 125 mg every 6 hours for Clostridioides difficile (C-diff), dated 4/8/24 at 12:51 p.m. Review of the active care plan for Resident #24 showed a plan in place for Contact Precautions for C-Diff, dated 4/8/24. Interventions included staff will follow contact precautions. An observation was made on 4/9/24 at 11:54 a.m. of Staff R, Certified Nursing Assistant (CNA) and Staff Q, CNA entering Resident #24's room to deliver lunch trays. The door had a contact precaution sign as well as a PPE door hanger with supplies. Staff Q, CNA exited the room and did not perform hand hygiene before entering another resident room. An observation was made on 4/9/24 at 11:56 a.m. of Staff Q, CNA entering room [ROOM NUMBER] to deliver a lunch tray, which also had a contact precaution sign and PPE door hanger with supplies. The CNA was observed setting up the resident's lunch tray, arranging the position of the tray table and adjusting the bed with no PPE on. An interview was conducted on 4/9/24 at 12:09 p.m. with Staff R, CNA. He said he did not know Resident #24 was on contact precautions when he delivered the lunch tray. He said he is not assigned to that hall and the nurse didn't tell him. Staff R said he did not notice the sign on the door. He confirmed he did not put on PPE. Staff R said normally for a resident on contact precautions he would set the tray on the table right inside the door, put a gown and gloves on, then enter the room, deliver, and set up the tray. An interview was conducted on 4/9/24 at 2:05 p.m. with Staff Q, CNA. She said she currently had two rooms on contact precautions, Resident #24's room related to C-diff and room [ROOM NUMBER] related to MRSA (Methicillin-Resistant Staphylococcus Aureus). She said for rooms on contact precautions staff should put on a gown and gloves all the time no matter what. Staff Q said for food tray delivery some people say staff should wear PPE all the time and some say staff can carry the tray in, set in down, then walk out without PPE on. An observation was made on 4/10/24 at 11:06 a.m. of Staff V, Registered Nurse (RN). Staff V was in the hallway standing at the medication cart with PPE (gown and gloves) on. She then walked away from the cart and was observed caring for a resident. An interview was conducted on 4/10/24 11:10 a.m. with Staff V, RN. She confirmed she had PPE on in the hall and said she should not have. She said she should have taken the PPE of inside the room at the door. An interview was conducted on 4/9/24 at 4:51 p.m. with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). She said when critical labs are called to the facility by the lab, the nurse should get the results and call the doctor for orders. She said if they suspect C-diff for a resident, they put them on prophylactic isolation precautions until the lab results come back. Staff E said she was not aware Resident #24 had loose stools and was being tested and if she would have been notified she would have placed him on precautions. She confirmed Resident #24 should have been on precautions Sunday (4/7/24) when the results came back if not sooner. Regarding food trays being delivered to residents on contact precautions Staff E said one CNA should be inside the room with PPE on and another CNA should pass them the tray at the door. The CNA inside the room would set the tray up for the resident and assist if needed, they would then take off the PPE, exit the room and perform hand hygiene. An interview was conducted on 4/9/24 at 5:03 p.m. with the Director of Nursing (DON). She said if a person is on contact precautions for a wound infection and the infection is covered, she would not expect people to put on all of that [PPE] just to pass a tray. She said if the resident is on contact precautions for C-diff she would expect staff to wear PPE anytime they enter the room. The DON said she was not aware that Resident #24 had tested positive for C-Diff on 4/7/24. She was made aware on 4/8/24. The DON said normally if someone is suspected of having C-Diff they are put on contact precautions until it is ruled out. She said she would have expected the resident to have been on precautions while being tested and definitely after the nurse found out the resident was positive for C-Diff. Review of the Contact Precautions sign the facility posted showed: Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit . Review of the policy titled, Management of C. Difficile Infection, implemented 10/17/22, showed the following: Policy: This facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile infections. Policy Explanation and Compliance Guidelines: 4. Licensed nurses may implement preemptive contact precautions when C. difficile infection is suspected, pending results of testing. Once confirmed, contact precautions shall be implemented in accordance with a physician order and facility policy for transmission-based precautions. 5. General principles related to contact precautions for C. difficile: a. All staff are to wear gloves and a gown upon entry into the resident's room and while providing care for the resident with C. difficile. b. Hand hygiene shall be performed by handwashing with soap and water in accordance with facility policy for hand hygiene. c. Maintain on contact precautions for the duration of the illness, but no less than 48 hours after diarrhea has resolved. d. Encourage/assist residents to wash hands frequently. Bathe daily with soap and water. Review of a policy titled, MDRO [Multidrug resistant organism] Infection, implemented 10/17/22. Policy: This facility implements facility-wide strategies for preventing the spread of infections with multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 3. Infection Control Precautions: a. Staff will use contact precautions in addition to standard precautions when caring for a resident with MDRO infection. b. Signage at entry of the resident's room shall indicate Contact Precautions, and the type of personal protective equipment in required upon entry into the room. On 4/08/24 at 11:41 a.m. an activity was in progress in the main dining room on the second floor. The residents were observed playing tambourines and one resident had a maraca in her hand. At 11:48 a.m., meal trays for lunch were brought to the main dining room. Four staff members were assisting with passing trays. Staff did not offer or assist Residents #54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33 with hand hygiene before the meal. On 4/08/24 at 12:00 p.m. Staff B, CNA was observed seated at a table continuously assisting two residents with their meal at the same time, with the same hand (right), and with no hand hygiene in between. On 4/08/24 at 12:04 p.m., Staff A, CNA whispered something in Staff B's ear. Staff B, CNA, then got up and sanitized her hands using sanitizer from the sanitizing dispenser on the wall in the dining room. She returned to the table and started using a different hand to feed each resident. She then went back to using the same hand (right) to feed each resident with no hand hygiene in between. On 4/09/24 at 11:34 a.m. the meal trays for lunch were brought to the main dining room. The first tray was passed at 11:39 a.m. Staff did not offer or assist Residents #54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33 with hand hygiene before the meal. On 4/09/24 at 11:51 a.m. the Director of Nursing (DON) was observed standing assisting Resident #23 with her meal. Her cell phone rang, she pulled the phone from her pocket, stated I don't know who this person is, and placed the cell phone back in her pocket. She did not sanitize her hands before starting back to assist Resident #23 with her meal. On 4/09/24 at 11:59 a.m. the DON rolled her sleeves up, her cell phone rang, she pulled the cell phone from her pocket again, ignored the call, sat down at the table with Resident #54, picked up the utensil, and proceeded to assist Resident #54 with his meal without performing hand hygiene. On 4/09/24 at 12:06 p.m. Staff C, Staffing Coordinator/CNA was observed seated at a table continuously assisting two residents (Resident #37 & #17) with their meal at the same time, with the same hand (right), with no hand hygiene in between. At 12:11 p.m. she was continuously observed assisting the residents with the same hand. She then stated to Resident #17 last bite and then gave her some of the drink from a cup with two handles. Staff C, Staffing Coordinator/CNA, then stated you ate all your food as she wiped Resident #17's mouth. She then started assisting Resident #37 with the same hand with no hand hygiene in between until she finished her meal. On 4/09/24 at 12:07 p.m. Staff D, CNA stated she assists with meals in the dining room two to three days a week. She stated she did not clean the residents' hands prior to lunch. On 4/09/24 at 12:18 p.m. Staff A, CNA stated she assists with meals in the dining room two to three days per week. Activity staff would usually do hand hygiene. When asked who did hygiene today, she stated the CNAs assist with hand hygiene as well. Staff A, CNA then stated she did not clean the residents' hand prior to lunch today because ADL care was provided right before the residents came to the dining room and their hands were clean. On 4/09/24 at 12:23 p.m. Staff C, Staffing Coordinator/CNA stated she was educated to use different hands when assisting two residents with meals at the same time. When asked if she used different hands today, she stated no, and it was because of the way the residents were positioned at the table. On 4/10/24 at 9:29 a.m. Staff E, Licensed Practical Nurse (LPN)/Unit Manager/Infection Preventionist stated the residents do activities and therapy prior to eating lunch. She expects staff to sanitize or wash their hands before eating. She expects hand hygiene after touching anything. Before touching the resident's tray, there should be hand hygiene. Staff should not use the same hand when assisting two residents with their meals at the same time due to cross contamination. Review of the policy titled, Hand Hygiene, implemented on 10/17/22, revealed the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Review of Resident #121's admission Record revealed she was admitted to the facility on [DATE]. Review of the Resident's 5-day Minimum Data Set (MDS,) dated 3/29/24, revealed a Brief Interview For Mental Status (BIMS) score of 09 (Moderate Cognitive Impairment). Review of Resident #121's physician orders revealed a current order for Doxycycline Hyclate 100 mg every morning and bedtime for MRSA left hip for 28 days, start date 4/8/24, and a physician order for Isolation contact MRSA lt (left) hip wound every shift-4/1/2024. Observations on 4/08/24 at 10:26 a.m. of Resident #121's room revealed an isolation kit hanging on the outside of the door and the room door was open. It was also noted that a sign was posted on the door indicating the room was under Enhanced Barrier Precautions. The sign directed what those who entered the room must do for Enhanced Barrier Precautions. (Photographic Evidence Obtained) Continued observation of Resident #121's room at this time revealed that there were 3 dogs being escorted down the hallway by 3 dog handlers (2 large, 1 small). The group was noted to go in and out of resident rooms on the hallway. During this observation a dog handler with a small dog was noted to enter Resident #121's room without regard to the isolation kit and sign mounted on the door. The dog handler was observed to place the small dog onto Resident #121's lap and Resident #121 hugged, stroked and kissed the dog as the dog licked at the resident. Continued observation on 04/08/24 at 10:27 a.m. revealed the dog handler left Resident #121's room with the dog and entered the room of another resident with the dog, which physically interacted with the second resident. During an interview on 04/08/24 at 10:35 a.m. with Staff G, RN she revealed Resident #121 had a current diagnosis of MRSA in a wound and the resident was on isolation and that visitors should check with the nurse before entering the room. Observations on 4/09/24 at 9:21 a.m. of Resident #121's room revealed Staff I, CNA was noted to walk into the resident room, assisted the resident with organizing her over bed table and nightstand and assist with positioning of resident in the bed. Staff I, CNA was noted to then put on latex gloves then take the resident's meal tray and handed the tray to another staff member. An interview with Staff I at this time revealed that when a resident was on enhanced precautions, and he is performing care that he should be fully gloved up and have on a gown. He reported he should have used a gown and gloves, but that it skipped his mind. During an interview on 4/10/24 at 11:31 a.m. with the Director of Nursing (DON), she reported if a resident is on enhanced precautions and staff is providing close personal care; staff should gown up and be gloved. She reported that all staff are trained on isolation precautions. The DON reported for visitors who need to enter the resident room, the visitor should speak to the nurse before entering the room. Visitors should gown up and use gloves if doing anything hands on with the resident. The DON reported regarding therapy dogs she does not expect the therapy dogs enter the rooms under isolation. She reported therapy dogs would typically go from resident to resident, so it would not be appropriate for the therapy dogs to go into isolation rooms. The DON reported that she can't tell what the process is for this facility related to therapy dogs entering isolation rooms, but all guests should gown up, and speak to the nurse per the sign on the door. She reported the expectation would be that therapy dogs should not go into isolation rooms. She reported in regard to the therapy dog handlers that she does not know how they would know if they should enter an isolated room. She reported that she will need to put something in place. During an interview on 4/10/24 at 11:41 a.m. with the Director of Therapy revealed that therapy dogs come in maybe once a month through Activities, and they do come through the therapy gym. An interview was conducted on 4/10/24 at 11:56 a.m. with the Activities Director. The Activities Director revealed the therapy dogs are a volunteer group from a 3rd party vendor that come in to do visits. She reported the group comes in on a monthly basis and only goes into common areas. She reported, normally the group does not go into resident rooms without facility staff. She reported that she does not expect the group to go into isolation rooms, and the group knows not to go into isolation rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to adhere to their grievance policy for one resident (#26) of 43 sampled residents. Findings included: An interview with Resident #26 on 11/02/21 at 10:40 a.m. revealed the facility was short staffed to the point where he was left to sit in his own bowel movement for 4 hours. He reported this happened two nights ago (Sunday 10/31/21), when they were short staffed and he used his call light and no one responded on the 3:00 p.m. -11:00 p.m. shift. He reported it wasn't until 1:00 a.m. when a temporary staff person came into his room and assisted him. He reported that he reported this to the nurse, who ended up quitting that same day. Review of Resident #26's medical record revealed he was admitted to the facility on [DATE] with a diagnosis that included hemiplegia and hemiparesis following cerebral infraction affecting left dominant side. Review of the resident's Brief Interview For Mental Status (BIMS) dated 8/12/21 revealed a score of 15 (cognitively intact). Review of the facility's Grievance Log from September 1, 2021, to November 2, 2021 revealed no entries related to Resident #26. An interview on 11/02/21 at 1:30 p.m. with Staff F, Social Worker (SW), revealed that she has presented all grievances filed by a resident or on behalf of a resident on the grievance logs provided. She reported that she was not aware of any other grievances. An interview on 11/04/21 at 11:10 a.m. with Staff E, Registered Nurse (RN) revealed that she was familiar with Resident #26 and was typically assigned to him. She reported her first day back on shift was Tuesday and the resident told her that the night prior he had a bowel movement and no one changed him. She reported that at that time the night nurse Staff O, RN was still on the unit and they both went into the room to discuss the issue with the resident. The resident was unable to confirm what he previously reported. She reported that she did not report the resident's complaints to anyone other than the night nurse and that she did not document the resident's concerns. An interview on 11/04/21 at 11:20 a.m. with Staff F, SW revealed that if a resident makes a complaint to anyone a grievance should be written. She reported the nurse who the resident made the complaint too should have written up a grievance form. She reported the grievance forms can be found outside the SW office on both the first and second floor. An interview on 11/04/21 at 11:58 a.m. with Staff F, revealed that she just spoke to Staff E, RN who reported that when the resident made the complaint, she and the night shift nurse went into the resident's room and the resident was clean and dry at that time so the concern was resolved, and did not need to be reported as a grievance. Staff F reported that if someone complains of something and it is addressed right away then it is not considered a grievance. She reported that she was unsure if the resident felt the issue was resolved and reported the Certified Nursing Assistant (CNA) assigned to the resident for the time period in question was not interviewed. An interview on 11/04/21 at 12:02 p.m. with the Director of Case Management, RN, revealed that at the time when the concern was reported the nurses involved checked to make sure the resident was clean, and checked the resident's skin with no concerns noted. She reported that there is no documentation from the nurses that a report was made, no documentation of care provided and no documentation of a skin assessment. Review of the facility policy titled, Grievances, Resident, with a revised date of 11/2016 revealed the following: The facility will do its best to respond to the resident's issue/concern within 24 hours after a thorough investigation is conducted. The resident (or resident representative) will receive notification of the outcome. The grievance/Complaint Report form should be completed by the appropriate department head that initially received the complaint and then forwarded to the Administrator for review and appropriate action. All resident grievances will be recorded on the Grievance/Complaint Log, which will be updated and maintained by the Administrative Assistant to the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to provide for dependent residents appropriate nail care for one resident (#13) of 43 sampled residents. Findings included: Observations on 11/02/21 at 11:54 a.m. of Resident #13 revealed the resident lying in his bed. It was noted that the resident had a contracture to his right hand with his nails elongated approximately half an inch past the top of his finger. Observations on 11/04/21 at 10:48 a.m. revealed the resident lying in bed with his eyes open. The resident was noted with a contracture to his right hand with his nails on the right hand elongated and approximately half an inch past the top of his finger. An interview on 11/04/21 at 10:58 a.m. with Staff H, Licensed Practical Nurse (LPN), revealed that the CNAs do nail care which would include cutting the resident nails whenever necessary. She reported the aides are to check and cut resident nails if needed on the resident's shower days. At this time Staff H checked a white erase board at the nurses station and indicated that the resident's shower days were Mondays and Thursdays on the 3:00 p.m. -11:00 p.m. shift. An observation on 11/04/21 at 11:01 a.m. of the resident's hand with Staff H, LPN present, she confirmed that the resident's nails on his right hand were too long. Staff H, reported that she will have his nails cut right away. Review of the Minimum Data Set (MDS) dated [DATE] indicated the resident has long and short term memory problems, and severely impaired cognitive skills for decision making. For personal hygiene the resident is total dependence of 1 person physical assist and for bathing the resident is total dependence of 1 person physical assist. Review of the facility policy titled Bath, Shower, with a revised date of 5/2015 revealed the following: 8. Give special care to umbilicus, folds of skin, hands and feet. 12. Care of fingernails is part of the bath. Be certain nails are clean. Rinse off skin and dry thoroughly. Review of the facility policy titled Bath, Bed, with a revised date of 5/2015 revealed the following: 10. Give special care to umbilicus, folds of skin, hands and feet. 14. Care of fingernails is part of the bath. Be certain nails are washed. Review of the Minimum Data Set (MDS) dated [DATE] indicated that the resident has long and short term memory problems, and severely impaired cognitive skills for decision making. For personal hygiene the resident is total dependence of 1 person physical assist and for bathing the resident is total dependence of 1 person physical assist. Review of the facility policy titled Bath, Shower with a revised date of 5/2015 revealed the following: 8. Give special care to umbilicus, folds of skin, hands and feet. 12. Care of fingernails is part of the bath. Be certain nails are clean. Rinse off skin and dry thoroughly. Review of the facility policy titled Bath, Bed with a revised date of 5/2015 revealed the following: 10. Give special care to umbilicus, folds of skin, hands and feet. 14. Care of fingernails is part of the bath. Be certain nails are washed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility did not ensure that pharmacy recommendations were followed for one resident (#41) out of 5 residents sampled for unnecessary medications, related to the change in dosage for Aspirin from 325 mg (milligrams) to 81 mg recommended by the consultant pharmacist on 08/03/21. Findings included: Review of Resident #41's consultant pharmacist's medication regimen review (MRR) revealed the resident had a recommendation dated 08/03/21 to reduce the resident's aspirin dosage from 325 mg to 81 mg to avoid increased risk of bleeding. In an interview with the Director of Nursing (DON) on 11/04/21 on 8:55 a.m. she said that she had only been in her position since 10/01/21 and was not the DON when the recommendation was made. She said she didn't realize the recommendations hadn't been done before 11/03/21, so she did them at that time. A review of the admission Record revealed Resident #41 was admitted to the facility on [DATE] for diagnoses that included sepsis, presence of cardiac pacemaker, and embolism and thrombosis of unspecified artery. The resident had a physician order for Aspirin 325 mg to give one time daily related to embolism and thrombosis of unspecified artery dated 10/01/21 and discontinued on 11/03/21. The resident also had a physician order for Aspirin 81 mg to give 1 tablet by mouth one time a day for pain dated 11/03/21. The resident's medication administration record reflected the order set. In an additional interview with the DON on 11/04/21 at 11:00 a.m., she said that she thinks Aspirin will default to a pain diagnosis within the system, and she would have to go back into the electronic system and change it. On 11/05/21 at 12:34 p.m. in a telephone interview with the Consultant Pharmacist for the facility, it was her expectation that pharmacy recommendations to be worked on throughout the month, but the facility would hopefully have them done within 30 days, before she came back to the facility to complete the next monthly review. When asked if she felt recommendations from August 3rd (2021) should be addressed prior to November 3rd, she said that she would absolutely hope so. In a policy titled, Medication Monitoring Medication Regimen Review and Reporting, dated 09/18 under Procedures, #8 read, Recommendations shall be acted upon within 30 calendar days.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed and six errors were identified for five (#21, #20, #85, #25, and #37) of five residents observed. These errors constituted a 20.69% medication error rate. Findings included: 1. On 11/3/21 at 4:32 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) and Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #21. Staff A was observed administering the following medications: - Eliquis 5 milligram (mg) oral tablet - Carvedilol 25 mg oral tablet - Gabapentin 300 mg oral capsule - Timolol Maleate 0.5% eye drops - Novolog 100 unit/milliliter (u/mL) FlexPen 2 units injected. During the oral administration of medication Staff A obtained a blood glucose level of 186 from Resident #21. The observation continued as Staff A removed a Novolog 100 unit/milliliter (u/mL) from the medication cart. The staff member dialed the dosage selector to 2 units and Staff I instructed Staff A to prime the pen by emptying the insulin into the trash. Staff A held the insulin pen with the needle pointing downwards over the carts trash container and the insulin was emptied into the trash. Staff A dialed the dosage selector to 2 units, entered the residents room and injected the insulin into the residents left upper extremity. On 11/3/21 at 4:58 p.m., Staff A and Staff I confirmed that the Novolog FlexPen had been primed over the trash while holding the pen with the needle facing downward. Staff A confirmed that she had primed the Flexpen into the garbage and had primed the pen while holding the pen upside down, with the needle pointing into the trash. According to https://www.novo-pi.com/novolog.pdf, to avoid injecting air and to ensure proper dosing users should turn the dosage to 2 units, while holding the Novolog FlexPen with the needle up, tap the cartridge a few times to make any air bubbles collect at the top, and while keeping the needle pointing upwards press the push button to the dose selector reads 0. The facility policy, Medication Administration - Subcutaneous Insulin, dated 2007, instructed users to Always perform the safety test before each injection. The policy indicated that by performing the safety test ensured that the pen and needle were working properly and removed air bubbles. The procedure instructed users to hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, press the injection button all the way in, and to check if insulin comes out of the needle tip. On 11/3/21 at 5:03 p.m., the Director of Nursing (DON) was informed of the procedure that Staff A and Staff I used to prime the Novolog FlexPen, she did not acknowledge if the pen should be primed while holding the needle up. 2. On 11/3/21 at 4:48 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) and Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #20. Staff A was observed administering the following medications: - Carvedilol 12.5 mg oral tablet - Senna Plus 50 mg/8.6 mg oral tablet. A review of the Physician's orders for Resident #20 revealed the following medication order: - Senna 8.6 mg tablet (Sennosides) - Give 8.6 mg by mouth two times a day for constipation. The review of the Medication Administration Record indicated Staff A had administered the 5:00 p.m. dose of 8.6 mg Senna. The facility policy, Medication Administration - General Guidelines, dated 2007, indicated that Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. The policy instructed staff to: - Prior to administration, review, and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. - Medications are administered in accordance with written orders of the prescriber. - Verify medication is correct three (3) times before administering medication. -- a. when pulling medication package from med cart. -- b. when dose is prepared -- c. before dose is administered. 3. On 11/4/21 at 9:15 a.m., an observation of medication administration with Staff E, Registered Nurse (RN), was conducted with Resident #85. Staff E was observed administering the following medications: - Ascorbic Acid 500 mg - Multi Vitamin with mineral tablet - Vitamin D3 50 microgram (mcg) tablet - Diltiazem 60 mg - 2 tablets - Zinc Sulfate 220 mg capsule - Megestrol 20 mg tablet - Memantine Extended Release (ER) 28 mg capsule Staff E confirmed that 8 oral tablets/capsules had been dispensed, then she crushed the tablets, opened the oral capsules, and mixed the medications in pudding. The observation revealed the resident pushed the vanilla pudding further onto the spoon, which the staff member threw into the trash along with the medication cup. She confirmed that she probably could have used the rim of the medication cup to administer the rest of the pudding. She stated that the resident had probably not received the ordered dosages of the medications. A review of the Medication Administration Record (MAR) for Resident #85 revealed the above observed medications were scheduled to be administered and in addition to: - Donepezil Hydrochloride (HCl) 10 mg tablet orally The observation of medication administration with Staff E and the confirmation by the staff member of the number of dispensed medications indicated Donepezil had not been administered. 4. On 11/4/21 at 9:31 a.m., an observation of medication administration with Staff H, LPN, was conducted with Resident #25. Staff H was observed administering the following medications: - Aspirin Enteric Coated (EC) 81 mg tablet - Active Liquid Protein - Clopidogrel Bisulfate 75 mg tablet - Entresto 24-26 mg tablet - Furosemide 40 mg tablet - Metoprolol Succinate Extended Release (ER) 25 mg tablet - Multi Vitamin with mineral tablet - Trelegy Ellipta 100 microgram (mcg)/62.5 mcg/25 mcg inhaler. A review of the Order Summary Report for Resident #25 indicated that the physician ordered a MultiVitamin tablet one time a day. The order did not identify that staff should administer a Multi Vitamin with minerals. 5. On 11/4/21 at 9:52 a.m., an observation of medication administration with Staff J, LPN, was conducted with Resident #37. Staff J was observed administering the following medications: - Clopidogrel 75 mg tablet - Divaloproex Delayed Release (DR) 250 mg tablet - Ferrous Sulfate 325 mg tablet - Simethicone 80 mg tablet - Misoprostol 200 mcg tablet - Multi Vitamin with mineral tablet - Sulfamethoxazole - trimethoprim (tmp) DS tablet. Staff J confirmed seven tablets had been dispensed. After entering Resident #37's room, Staff J asked the provider, who was standing at bedside, if the facility could get an order for over-the-counter Acidophillus instead of the Florastor ordered as the facility was having an issue with obtaining the medication from the pharmacy. A review of the Medication Administration Record (MAR) indicated that an order for Acidophilus two times a day for Probiotic, started 11/4/21. The MAR identified that Acidophilus was not administered as scheduled on 9 a.m. on 11/4/21 and that a Probiotic capsule (Saccharomyces boulardii) scheduled to be administered at 9 a.m. on 11/4/21 was not administered. The MAR indicated that Resident #37 was not administered the 9 a.m. dosage of 25 mg of Metoprolol Tartrate. The physician order did not include parameters to hold the medication. Staff J documented a blood pressure of 111/55 but did not identify that the physician was notified by the nurse that the Metoprolol was not administered. An interview was conducted at 11:14 a.m. on 11/5/21 with the Director of Nursing (DON). She stated her expectation was that medications be given as ordered. The DON stated she understood that insulin pens should be held upright during priming of the pen, and that doctors (providers) should be notified if a medication was being held due to a blood pressure and if there were no parameters. She reviewed the orders for Resident #37 and confirmed that if the probiotic was available to be given on other days it should have been available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure, six residents (#25, #34, #69, #75, #87 and #99) and a representative for one resident (#40) were invited and/or participated in their plan of care meetings out a total of 43 sampled residents. Findings included: The policy, Resident/Family Participation in Goal Planning, revised 11/2016, indicated, To assure the residents and resident representative's right to participate in planning the resident's care in making informed decisions regarding medical treatment. The procedure identified the following: - 1. A resident has the right to participate in the development and implementation of his or her person-centered plan of care, including requirements that affect both the initial planning process and changes to the plan of care. - 3. Residents and their families or other resident representatives will be given the opportunity to attend an interdisciplinary goal planning conference to participate in resident care planning and medical treatment decision making. - 4. Before the goal planning conference, the Social Worker will invite residents who are able to comprehend their care plan to attend the meetings which are scheduled for them. If a resident chooses not to attend a conference the Social Worker inquires if there are nay care issues the resident wants addressed by staff. - 5. Resident and resident representative attendance at the goal planning conference will be noted in the resident's medical records. Staff F, Social Worker, stated on 11/5/21 at 11:36 p.m. the protocol for care plan meetings was for the family members to attend via phone conference. She stated that alert and oriented residents were invited and brought to the meeting. The Social Worker identified the receptionist sends out invites to families and the invitations are hand delivered to the residents. The staff member indicated that attendees of the meetings are family, resident, and the interdisciplinary team, which included the long-term dietary technician, social services, whatever nurse was available, and activities. 1. Resident #87's admission Record indicated the resident was admitted on [DATE] and diagnoses included Type 2 Diabetes Mellitus without complications and essential hypertension. The admission Record identified the resident as being the resident representative. The annual Minimum Data Set (MDS), dated [DATE], indicated the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of an intact cognition. An interview was conducted, on 11/2/21 at 10:45 a.m., with Resident #87. The resident thought the facility had only one care plan meeting since his admission. The Care Plan Meeting form, dated 10/6 and 10/7/21, indicated that it was the annual meeting and the attendees included Staff F, Social Worker, the Dietary Technician, and a registered nurse. The form indicated that on 10/7/21 a phone conference was conducted with the resident's family member. The meeting form did not indicate the resident had attended the meeting on either date. Staff F confirmed, on 11/5/21 at 1:49 p.m., that Resident #87 was alert and oriented to person, place and time and should have been invited to the care plan meeting. She stated she did not know if an invitation had been given to the resident. The Nursing Home Administrator asked the SW, during the interview, if the receptionist (who sends out care plan invitations) had sent her an email to reschedule the meeting and the SW informed her no. 2. A review of Resident #99's admission Record indicated the resident was admitted on [DATE] and had diagnoses that included unspecified encephalopathy and unspecified dementia without behavioral disturbance. The quarterly MDS, dated [DATE], indicated the resident had a BIMS score of 15, indicating intact cognition. During an interview Resident #99 stated, on 11/2/21 at 11:07 a.m., no not invited (to care plan meeting) they treat us like sick people. A review of the Care Plan Meeting form, dated 10/20/21, indicated the only attendees included Staff F, Social Worker and the Dietary Technician. The review of the clinical notes for Resident #99 indicated that on 10/20/21 the resident's [family member] had attended the care plan meeting on 10/20/21. On 11/5/21 at 12:11 p.m., Staff F, Social Worker stated that Resident #99 was alert and oriented and would be invited. She stated the [family member] of the resident does attend the care plan meetings. Staff F stated she knew the resident had been invited but refused, saying that the [family member] would be attending. The staff member reviewed the care plan meeting form that was used during the meeting and stated it was used as a sign-in sheet and she would make a note of who attended. She reviewed the care plan meeting and confirmed that nursing had not been involved and stated that nursing does attend when they are available. Staff F stated, on 11/5/21 at 1:35 p.m., the receptionist had the invitations that had been sent out and it included a phone number the family was to call to schedule the meeting. She stated she did not speak with Resident #99 regarding the 10/20/21 meeting. She stated the [family member] had attended a care plan meeting that was done after the facility had held their meeting. Staff F reviewed the Care Plan form and identified the check marked areas were for information that may be addressed during the meeting. 3. The electronic medical record indicated Resident #40 was admitted on [DATE] with diagnoses that included metabolic encephalopathy and vascular dementia without behavioral disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], indicated the BIMS assessment was not conducted as the resident was rarely/never understood. On 11/4/21 at 4:42 p.m., the spouse of Resident #40 was sitting at bedside. The spouse stated he had not been invited to a care plan meeting, but they said they were going to implement that. Staff F stated, on 11/5/21 at 12:24 p.m., that since the resident had moved to the long-term care side of the facility and the spouse had not attended any care plan meeting. She stated she was not involved in the skilled residents' care plans. Staff F, Social Worker stated that a care plan meeting had not occurred as planned on 9/8/21 and the Administrator had just spoken with the resident's spouse. She stated that due to her being on vacation the week of 9/8/21 the meeting had not occurred and that another one would have to be scheduled. 4. An interview on 11/03/21 at 1:30 p.m. with a group of five alert and oriented residents (#25, #34, #69, #75, #87) revealed that none of the five residents were invited to their care plan meetings. An interview on 11/05/21 at 11:37 a.m. with Staff F, Social Worker revealed that care plan meetings are currently being done via a phone conference. She reported that alert and oriented residents' invitations are hand delivered to the resident and family/representatives get their invitations mailed to them. She reported the receptionist keeps a binder of those invitations that are sent out and hand delivered. An interview on 11/05/21 at 1:32 p.m. with Staff F, revealed that invitations are not put in the resident's chart. She reported that she knows the receptionist sends out the invitations and the invitations for alert and oriented residents are hand delivered to the resident in the facility, but she had no documentation that would confirm the five alert and oriented residents, who were present at the meeting, received an invitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a safe and homelike environment related to wall baseboard bumpers, handrails, and a resident wall being in disrepair were reported to maintenance staff within a timely manner for repair on one floor (first floor) of two floors . Findings included: An initial tour of the facility on 11/02/2021 at 12:15 p.m. revealed various locations throughout the facility's first-floor hallways with the wall baseboard bumpers, located approximately one foot from the ground, detaching and sticking out from the wall. During these observations handrails were observed throughout the first-floor hallways in disrepair with the internal metal exposed. (Photographic Evidence Obtained) These locations and observations included: 1. The wall bottom bumper located on the right side of room [ROOM NUMBER]. 2. The wall bottom bumper located on the right side of room [ROOM NUMBER] next to room [ROOM NUMBER]. 3. The handrail on the left side of room [ROOM NUMBER]. 4. The wall baseboard bumper on the left side of room [ROOM NUMBER]. 5. The wall baseboard bumper in-between rooms [ROOM NUMBERS]. 6. The endcap connection point of the handrails, located on the corners of the hallways, across from room [ROOM NUMBER] and on the left side of room [ROOM NUMBER]. 7. The endcaps of the handrails, located on the corners of the hallways, across from room [ROOM NUMBER] and on the side of room [ROOM NUMBER] across from room [ROOM NUMBER]. 8. The endcap connection point of the handrail located on the wall corner on the right side of the clean utility room next to room [ROOM NUMBER]. 9. The handrail on the left side of room [ROOM NUMBER]. 10. An observation inside room [ROOM NUMBER] of the A- bed wall, right side of the room, revealed the wall with scratches and grime build-up when A-bed was in the lowest position. An interview on 11/04/21 at 11:05 a.m. with Staff B, Certified Nursing Assistant (CNA) revealed if staff observe any maintenance or environmental disrepairs a work order slip much be filled out and placed into the maintenance work order box. Staff B, CNA stated if any issues or concerns are observed throughout her work assignment, then a work slip should be immediately filled out to, make sure it doesn't get too bad. An interview on 11/05/21 at 9:15 a.m. with the Maintenance Director revealed should staff observed equipment or environmental conditions in disrepair, the first method to report the disrepair is to the receptionist so a work order slip can be completed and input into the online maintenance system. The Maintenance Director stated the work orders are reviewed and anything that are a safety issue are prioritized. Record review of maintenance open and completed work orders dated from 10/01/2021 to 11/05/2021 revealed no work orders for repair related to handrails, wall baseboard bumpers, or the wall in room [ROOM NUMBER]. A tour with the Maintenance Director on 11/05/21 at 9:48 a.m. confirmed the wall bumpers located approximately one foot from the ground and handrails listed above being in disrepair. An observation inside of room [ROOM NUMBER] confirmed the wall by A-bed on the right side of the room with scratches and grime. The Maintenance Director stated the expectation is that anyone who sees equipment in disrepair should be reporting it to ensure it is repaired within a timely manner. Housekeeping is the first line of defense for observing equipment in disrepair, such as the handrails and baseboards, as they are walking the entire facility. The Maintenance Director confirmed that it is the expectation for the wall bumpers, handrails, and walls to be reported to the maintenance department for repair. An interview on 11/05/21 at 1:19 p.m. with the Nursing Home Administrator (NHA) revealed the expectation is that when facility equipment disrepairs are seen, a work order is completed for it to be reported to the maintenance staff for repair. The NHA confirmed that a wall baseboard bumper detaching or sticking out from the wall could result in a resident sustaining a skin tear, or, if the handrails are not fully secured and a resident is using them for mobility it would result in an incident. A review of the Maintenance Procedures, not dated, revealed, . The DOF [Director of Facilities] shall be responsible for managing the Maintenance Service Program (Name of System) in accordance with these policies . The ADOF [Assistant Director of Facilities] shall be responsible for coordinating work on site by (Name of System) and/or building staff, including . properly completing all work orders based on maintenance requests received from residents or originated by staff . requesting DOF to assign work orders to (Name of System) for timely forwarding of work orders to the staff . arranging legal access to all occupied units as necessary for outside contractors or maintenance personnel . inspecting completed work and notifying DOF of any issues or problems . The MS [Maintenance Staff] shall be responsible for . scheduling maintenance work . accomplishing all work in a timely and professional manner and as director by the DOF . maintenance of all tools and equipment, including identification and security measures . SECTION 1.0 Maintenance and Repairs 1.1 REPAIRS . The front desk will then input the request into the (Name of System) system for maintenance personnel assignment. The (Name of System) request should provide enough information to authorize staff and/or vendors . Response by Maintenance: It shall be the goal of maintenance to respond to non-emergency work orders within 48 hours and complete the repair within 5 days of request by a resident. Upon receipt of a properly completely work order the DOF or ADOF shall prioritize and schedule the work. Emergency work orders will be responsible to immediately or within 24 hours. . The DOF and/or Housekeeping Manager . shall be responsible for maintaining all building common areas in a clean and orderly condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to assess two residents (Resident #34 and #73) out of the sampled 58 residents for the self-administration of medications. Findings included: On 02/17/20 at 2:05 p.m., Resident #34 was observed in her room administering her breathing treatment with a nebulizer machine without nurse assistance. On 02/17/20 at 2:08 p.m., Resident #73 was observed in her room administering her breathing treatment with a nebulizer machine without nurse assistance. On 02/17/20 at 2:09 p.m., the Staff C, Licensed Practical Nurse (LPN), confirmed that she was the nurse for both residents. Staff C was down the hall from the residents' room near the nurses' station on the medication cart. Staff C was asked if the residents could self-administer their own medications, and she stated that they were not self-administering their own medication. She stated that she gave them the treatment, and after 10 minutes she goes back to the room to check on them. A record review of the Face Sheet for Resident #34 revealed that she was admitted into the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, asthma, and shortness of breath. A review of the February 2020 Physician Order Sheet revealed the following: Ventolin HFA 90 mcg/actuation aerosol inhaler (2 puffs)- Every four hours as needed for COPD Ipratropium albuterol 0.5 mg-3mg (2.5 mg base)/3 ml nebulization soln (3 ml)- Every 6 hours as needed for shortness of breath Stiolto Respimat 2.5 mcg-2.5 mcg/actuation solution for inhalation (2 puffs)- Every 24 hours for COPD Bupropion HCL XL 150mg 24 hour tablet, extended release (150mg) for COPD Symbicort 160 mcg- 4.5 mcg/actuation HFA aerosol inhaler (1 puff)- two times daily for COPD There was no order for self-administration of medication and no assessment for self-administration of medication. A record review of the Face Sheet for Resident #73 revealed that she was admitted into the facility on [DATE] with a diagnosis that included, but was not limited to, Dementia. A review of the February 2020 Physician Order Sheet revealed the following: Ipratropium albuterol 0.5 mg-3 mg (2.5 mg base)/3 ml nebulization solution (1 vial)-every 6 hours for cough. There was no order for self-administration of medication and no assessment for self-administration of medication. On 02/19/20 at 12:55 p.m., Staff L, Licensed Practical Nurse (LPN), reported that the nurse should stay with residents when giving breathing treatments. On 02/19/20 at 1:42 p.m., the Director of Nursing (DON) reported that the nurse should be in sight when giving nebulizer treatments. The DON confirmed that Resident #34 and Resident #73 did not have an order to self-administer medications. The policy and procedure provided by the facility Self-Administration By Resident, dated 11/17, revealed the following: Policy Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Procedures 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of skill assessment conducted as part of the care plan process. 3. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the accuracy of the code status for one resident (Resident #26) out of the sampled 58 residents. Findings included: The Face Sheet revealed that Resident #26 was admitted into the facility on [DATE] with diagnoses that included but were not limited to Dementia and altered mental status. Section C of the Quarterly Minimum Data Set (MDS) with an effective date of 10/01/19 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A record review of the Face Sheet for Resident #26 under the Advance Directives section revealed that the resident's code status was listed as Full Code and Do Not Resuscitate (DNR). The banner at the top of the resident's electronic medical record indicated that she had a code status of DNR (photographic evidence obtained). The Face Sheet revealed that Resident #26 had a family member listed as the Power of Attorney (POA). A review of the February 2020 Physician Order Sheet revealed the following order: Full Code. The Care Plan had the resident's code status as Full Code under the Advance Directives section. There was a document in Resident #26's medical record that was signed by the POA on 05/10/29 that revealed that she did not want a DNR order. An interview on 02/20/20 at 1:27 p.m. with the POA revealed that she did not want Resident #26 to have a code status of DNR. The POA stated that Resident #26 was too young and in good health to have a code status of DNR. On 02/20/20 at 12:30 p.m., Staff L, Licensed Practical Nurse (LPN), reported that if a resident was coding, she would first look at the physician's orders to determine the resident's code status. She then stated that she would look in the hard chart if the information was conflicting. She stated she would call the doctor to check the resident's code status if the information in the hard chart was conflicting. On 02/20/20 at 2:38 p.m., an interview with the Director of Nursing (DON) revealed that if a resident was coding, she would expect staff to call the code, nurses would respond, and a nurse would bring the crash cart. She stated depending on the code status, they would proceed. The DON stated that she would expect staff to look in the hard chart for the code status first, because it was easily accessible. The surveyor asked the DON to observe Resident #26's electronic record and asked what the resident's code status was. The DON reported that she would think she was DNR by looking at the electronic record. The DON stated that she was not sure what the resident's code status was and that she would have to look in the hard chart. The DON agreed that there was confusion with Resident #26's code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform an Comprehensive Resident Centered Care Plans including a baseline care plan on admission for one of 58 sampled residents (#256). Findings included: 1. Observation on 02/17/20 at 1:10 p.m. Resident #256 was sitting at the dining room table having only eaten a few bites of his lunch. He stated he had eaten a big breakfast and was not very hungry. The resident had multiple discolored areas on both hands and arms. Observation on 02/19/20 at 3:45 p.m. the resident was in the dining room in a wheelchair. He was dressed and groomed for the day in shorts. He was noted to have discolored areas on both hands and arms as well as both knees. Resident #256 was admitted on [DATE]. Record showed diagnoses included but not limited to Cerebral Vascular Accident (CVA) and unsteady gait. A record review showed the chart lacked an admission assessment nor baseline care plan for the 02/15/20 admission. During an interview on 02/19/20 at 9:00 a.m. the Director of Nursing (DON) and the Corporate Director Case Manager reviewed the clinical record and were unable to locate the admission assessment nor the baseline care plan. Record review of the Care Plan Report showed it was performed on 02/19/20, 4 days after the admission. 2 Record review of the facility's policy, Care Plan Summary, revised 11/2017 showed this facility will provide the resident and / or their representative with a written summary of the baseline care plan that includes: the resident's initial goals, a summary of the resident's medications and dietary restrictions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, any updated information based on the details of the comprehensive care plan, as necessary. The care plan summary will be completed within 48 hours after the resident has been admitted to the facility. The care plan summary will be updated with changes to the care plan and provided to the resident and / or their representative per their desired means of communication. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interview, it was determined the facility did not ensure that a care plan was developed related to communication for 1 of 58 residents reviewed (#139). Findings Included: Review of the record for Resident #139 revealed that she was admitted to the facility on [DATE] from the hospital. Diagnoses on the face sheet revealed Displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, History of falling, Other specialized disorders of muscle, Other abnormalities of gait and mobility, Muscle wasting and atrophy, Dysphasia following cerebral infarction, pain, Hyperlipidemia, Anxiety disorder, Age related osteoporosis, Hypertension, Embolism and thrombosis of unspecified artery, Unspecified dementia without behavioral disturbance, Major depressive disorder. Review of the hospital record from the discharge on [DATE] revealed diagnoses which included Expressive Aphasia and Dysarthria secondary to old stroke. Review of the admission nursing assessment (2/19/2020) revealed Speech - yes. Writing messages to express or clarify daily needs - N/A, Signs/ gestures/ sounds - NA. Review of nursing daily skilled progress notes revealed : 1/23/20 Resident is alert when verbally prompted, she is able to communicate her needs although Aphasic. 1/27/20 Alert and communicates in low voice but mostly scribes words on paper. 1/29/20 Alert and oriented. Able to make needs known, patient uses dry erase board for communication. Hard to understand speech. An interview was attempted with Resident #139 on 2/18/20 at 12: 33 p.m. The resident mouthed words, but without sound, and used gestures to indicate that she was not happy with her lunch meal and, when asked if she wanted something else, she nodded. A communication board was observed on the bedside table, under a pile of paper and out of reach of the resident. Resident #139 gestured for the board to be handed to her. Staff D, Unit Manager, came into the room and Resident #139 wrote the words with a marker on the communication board three times before the nurse was able to understand that she wanted frosted flakes and toast with peanut butter instead. The resident appeared frustrated with trying to communicate her needs. Staff D indicated she would tell the CNA and left the room. Resident #139 gestured to the surveyor to place the communication board next to her on the bed, within her reach., Review of a speech therapy note, dated 2/11/20, revealed Moderated to severe Aphasia and Dysarthria noted at current level at this time. Prior living environment: Patient uses verbal expression/letter board to assist with communication due to poor legibility when writing to communicate. An interview was conducted with the day shift nurse, Staff E, who provides care for Resident # 139, on 2/20/20 at 11: 00 a.m. She stated that the resident can only say one syllable words - yes, no, pain. She communicates with her paper and pencil, communication board and a paper she has with letters on it. She stated the resident got frustrated with the communication board so she got her a legal pad and pen and she uses that. She stated If we can't make it out, she uses the letter paper to point to the letters. She stated Resident #139 is very alert and can communicate what she needs one way or another. An interview was conducted with Staff G, the day shift CNA, on 2/20/20 at 11: 00 a.m. She stated she can answer questions with a yes or no and if she says no, she asks her to write it on the communication board or paper. Review of an admission MDS, with assessment reference date of 1/29/20 found the resident had unclear speech, sometimes understood and her ability to express ideas and wants is sometimes understood. Her score on the Brief Interview for Mental Status (BIMS) was 13, which indicated cognitively intact. Under the section for Active Diagnoses, Aphasia was not checked and no additional diagnoses were added. Review of care plans for Resident #139 revealed no care plan related to communication. None of the care plans for Resident #139 indicated the use of a communication board, gestures, pen and paper or letter board for communication. An interview with the DON was conducted on 2/20/20 at 12: 00 p.m. She reviewed the care plans & stated there was no care plan related to communication needs. She reviewed the MDS and stated it did not list the diagnosis of Aphasia. An interview was conducted with two MDS LPNs, Staff A and Staff B, on 2/20/20 at 12:15 p.m. She reviewed the CAA and stated it was triggered for communication but no care plan was developed. On 2/20 at 1: 11 pm, Staff A, MDS nurse, provided a care plan decision note that stated to proceed to the care plan for communication. She stated she did not know why there was no care plan for communication. On 2/20/20 at 1: 30 pm, Staff D Unit Manager, who attends the interdisciplinary care plan meetings for her residents, stated that the lack of a communication care plan was an oversight. She stated that Resident #139 has been here multiple times and that staff know her and how she communicates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure that one resident (Resident #26) out of the sampled 58 residents who was identified as a risk for elopement was assessed appropriately. Findings included: On 02/17/20 at 1:58 p.m., a wanderguard was observed on Resident #26's right wrist. On 02/18/20 at 10:05 a.m., the resident was observed sitting in the hallway near the nurses' station. The wanderguard was observed on Resident #26's right wrist. On 02/20/20 at 1:48 p.m., Staff V, Certified Nursing Assistant (CNA), reported that Resident #26 had had the wanderguard for a while. When asked had Resident #26 ever tried to elope, Staff V stated that she had found Resident #26 downstairs on the first floor a few times and she had to bring her back up to the second floor. On 02/20/20 at 12:30 p.m., Staff L, Licensed Practical Nurse (LPN), reported that she did not see an order for the wanderguard. Staff L was asked where was the elopement book and she stated that she would have to look for it. At 12:35 p.m., Staff L reported that she could not find the book and that she would ask her manager. At 12:39 p.m. Staff L stated that Resident #26 was definitely at risk for elopement. On 02/20/20 at 1:58 p.m., Staff L, LPN, reported that the elopement book was kept downstairs at the reception desk and that they did not keep the book on the units. On 02/20/20 at 2:00 p.m. Staff T, confirmed that Resident #26 was at risk for elopement. Staff T stated that Resident #26 tries to get out of the building and would say that she was looking for her keys and her car. Staff T stated that the wanderguard prevented her from leaving the unit. On 02/20/20 at 2:04 p.m., Staff T was asked if she could find the order or an assessment for the wanderguard. Staff T proceeded to look for the documentation and confirmed that there was not an order for the wanderguard and no assessment. She stated the order was put on hold when the resident went out to the hospital a few months ago and the order was not reactivated. The resident had gone out to the hospital in September reported Staff T. Staff T stated that she was going to get the order now. A record review of the Face Sheet for Resident #26 revealed that she was admitted into the facility on [DATE] with diagnoses that included but were not limited to altered mental status and Dementia. A review of the February 2020 Physician Order Sheet revealed that the resident did not have an order in place for a wanderguard. A review of Section C of the Quarterly Minimum Data Set (MDS) revealed that Resident #26 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of Section P of the MDS revealed that the resident did not have a wanderguard. A review of the Care Plan revealed that there was not a care plan in place for a wanderguard or elopement. An elopement assessment was not found in the medical record. The elopement books were only located at the receptionist desk and not on the units. A review of the elopement book revealed a photo of Resident #26 on an Elopement Risk form. The form indicated that Resident #26 had a wanderguard on her right ankle, an expiration date of 07/2019 for the wanderguard, and her room location as 220B. All of this information was inaccurate. On 02/20/20 at 2:43 p.m., the Director of Nursing (DON) reported that the order for the wanderguard had not been reactivated and she had just found this out. The DON stated that she was told by the unit manager that the order was put on hold and was not reactivated upon return from the hospital. The DON stated that she did not see an assessment for elopement. I don't know why it was not there prior to today, stated the DON. The DON stated that the elopement books should be kept on both units. A review of the policy provided by the facility, Elopement, Risk for or Wandering Resident revealed the following: Policy To provide for the safety of residents who are at risk for elopement or wandering. 1. Assess residents for elopement or wandering risk prior to admission and after any new onset of wandering. 4. When any resident's behavior is witnessed such as attempting to exit the building, trying to exit secured doors, attempting to enter an elevator or continued verbalization of wanting to leave the facility, this behavior must be documented and reported to RN supervisor and passed along and the resident immediately put at risk for elopement. Any resident observed to be aimlessly wandering by staff are also to notify the nurse. If any of these behaviors occur and have not been previously documented or care planned, all interventions used to keep the resident safe must be documented in the nurse's notes and added to the resident's plan of care. The nurse will complete the Elopement Risk Assessment and place resident on Wanderguard Precautions, if applicable. 5. The nurse and care planning team will identify if the resident is at risk for elopement or if the resident is demonstrating aimless or pointless wandering and develop individualized care plans to ensure the resident's safety. 7. When a resident is identified at risk for elopement the Activities Department will be notified to take a photo of the resident which will then be placed at the front desk, nursing and personal care units where only staff is able to view them.

Based on resident interview, staff interview, resident record review and review of policy and procedure, it was determined that the facility did not ensure that a resident who was admitted as continent of bladder and bowel received services and assistance to maintain continence for one (#210) of 58 residents reviewed. Findings included: Review of the record for Resident # 210 revealed that she was admitted from the hospital on 1/30/20. Review of the admission nursing clinical note, dated 1/31/20 revealed that the resident was continent of bowel and bladder. Review of the the nursing admission evaluation, completed on 1/3/120 revealed that the resident was continent of bladder. Bowel continence status was not documented. A Minimum Data Set ( MDS) admission assessment, with a lock date of 2/12/20, indicated a score of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated cognitively intact. The MDS assessment indicated the resident needed the extensive assist of two persons for bed mobility, transfer, dressing and toilet use. Urinary incontinence and bowel incontinence were marked as frequently incontinent. The MDS question for Has a trial of a toileting program been attempted on admission/ entry or reentry or since urinary incontinence was noted in the facility was marked as No. Care plans effective 1/31/20 indicated: Risk of urinary incontinence Goal : will remain continent of urine during daylight hours Interventions: will be cued for increased po fluid intake as tolerated/ within dietary guidelines, will have call light in reach, will have physician follow up prn, Staff will assess for s/s of Uti, dysuria, hematuria, frequency, urgency, concentrated urine, malodorous urine, fever, back pain. Staff will cue to call for assist with toileting as needed to call for assist with toileting as needed, staff will positively reinforce l efforts to participate in interventions to maintain continence. Staff will take to bathroom upon arising, before and after meals, at bedtime, and offer toilet/ bed pan with rounds on 11:00 p.m.-7:00 a.m. shift and as needed, staff will transfer with assist for toileting. Review of CNA task for February 2020 for continence revealed that the resident was coded as frequently incontinent of bladder and bowel. An Occupational Therapy evaluation, dated 2/6/20, revealed that patient will safely perform toileting tasks using standard commode and grab bars with moderate assistance for correct hand foot placement, for safety awareness and for use of compensatory strategies while maintaining good balance. An interview was conducted with Resident #210, on 02/17/20 at 2:32 p.m. Resident #210 stated she was continent but had to use a brief as it took a lot to transfer her and staff were busy during meal times. She stated last week a CNA insisted on helping her transfer to the toilet. She told the CNA she couldn't do it herself but the CNA insisted. During the transfer, the resident said she went crashing down on the toilet She couldn't get up off the toilet and did not want the one aide to help. She told the CNA to get someone to help her. She stated a male therapist came in and told the CNA she should never have done that. He told the CNA that she did not know her patient. She stated he told her that she needed a 3 in 1 commode and would look high and low to get her one. She stated she had not received one and has to use the brief. An interview was conducted with Staff D, Unit Manager, on 2/20/20 at 11:15 a.m. She stated she would have to have the resident evaluated for a 3 in 1 commode. An interview was conducted with Staff G, CNA, on 2/20/20 at 11: 20 a.m. She stated that when Resident #210 was out of bed, she toilets her, but when she was in bed, the resident does not initiate toileting. An interview was conducted with the Director of Nursing, on 2/20/20 at 3: 25 p.m. She stated we do a bowel and bladder protocol in the care plan but she was not sure how it was worded. She stated she would get a copy of the protocol. Review of a policy, provided by the DON, undated and entitled Bowel and Bladder Function Assessment revealed: Policy A nurse will initate the assessment using the Bowel and Bladder Function Assessment Tool on admission, quarterly and when there is a significant change in status. Procedure : 1. Each assessment shall include: Assessment of bowel and bladder function Any past Urology Consults Review of medications Bowel and Bladder diary for three days after admission, Examination by attending physician Observation of toileting behavior Evaluation of responsiveness to promts to voud. 3. The resident, resident representative, interdisciplinary staff, along with the physician will develop and individualized preventative or active treatment plan. 4. The nurse will evaluate the plan periodically for the effectiveness of the plan 5. Complete assessments are kept in the medical record Review of the record for Resident #210 revealed no assessment other than the initial nursing admission assessment and no bowel and bladder diary for three days after admission. The resident was documented as continent on admission. An interview was conducted with Resident # 210 on 2/20/20 at 4: 17 p.m. She stated she now had a 3 in 1 commode as of today and it would be easier for her to be continent. She stated she was continent at home because her bed at home went up and down and she was closer to the bathroom and she had the full use of her right arm. She stated since her gastric bypass, she doesn't get much notice that she has to use the bathroom. She stated by the time the staff answer the call light, transfer her to the bed pan or to the bathroom, she could become incontinent. She stated she feels she will be able to use bathroom better now that toilet seat is not too low. The Resident stated, I only use briefs at night.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Per review of the Consultant Pharmacist Medication Regimen Review for Resident #118 on 12/1/2019-12/23/2019, the Pharmacist wrote, Remeron is recommended to be administered in the evening due to sedation. Consider discontinuing AM dose. The Corporate Director stated on 2/20/2020 at 10:38 a.m., We do not have pharmacy recommendations for November and December for Resident # 118. The Note to Attending Physician Prescriber dated 1/14/2020 revealed: Current Orders: Remeron 7.5mg daily, Sertraline 50mg daily, Trazodone 100mg at bedtime. Pharmacist recommendations These antidepressants may not be necessary and periodic dose reduction are recommended. Consider. D/C Remeron as it is recommended at bedtime (currently 9am). Other. Continue current therapy as benefit outweigh risk of current medication orders. The Physician responded D/C trazodone. Signed and dated 2/12/2020 Review of Electronic Medication Administration Records (eMAR) for December: Resident # 118 received 9:00 a.m. and 9:00 p.m. Remeron 7.5mg tablets 13 out of 13 days. Then continued to receive Remeron 7.5mg tablets at 9:00 a.m. and Remeron 15mg tablets for 8/8 days. Review of January MAR revealed Resident # 118 continued to receive 9:00 a.m. Remeron 7.5mg tablets 24 out of 24 days and 9:00 p.m. Remeron 15mg tablets 2 out of 24 days. Additionally, the eMAR for February 2020 revealed that Resident #118 continued to receive Remeron 7.5mg tablets at 9:00 a.m. 20 out of 20 days, with order date 1/30/2020. The Pharmacist stated during an interview on 02/20/20 at 05:58 p.m. that she Will sometimes make a recommendation and if it is not completed, she will rerecommend if she feels it is something the physician should look at. It is expected that a recommendation should be responded to and followed within 30 days. If the physician decides not to follow the recommendations, there needs to be a written rationale that is signed and dated. Based on observation, interview and record review, the facility failed to ensure the pharmacy recommendations were acted upon for three of six sampled residents (#36, #50 and #118). Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). Record review of the physician orders and Medication Administration Record (MAR) for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day started 08/13/19 and discontinued on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day started 01/24/20 for major depression, an order date of 01/23/20. A physician order dated 01/23/20 showed increase Zoloft (Sertraline) to 150 mg in the a.m. A physician order dated 02/12/20 showed change Sertraline (Zoloft) to 50 mg daily. A review of the Pharmacy Review dated 01/15/20 showed The resident is currently receiving Sertraline 100 mg / day. Sometimes, the decision about whether to continue a medication is clear; for example, someone with a history of multiple, episodes of depression or recurrent seizures may need an antidepressant or anticonvulsant medication indefinitely. Often, however, the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline. Consider Sertraline (Zoloft) 50 mg daily. The physician agreed on 02/12/2020. The medication card showed Sertraline (Zoloft) HCL 100 mg tablet, give one tablet by mouth once a day for depression. There were 15 pills in the medication card. During an interview on 02/20/20 at 11:05 a.m. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) reviewed the February 2020 Physician Order Sheet as well as the pharmacy recommendation regarding Resident #36's Sertraline (Zoloft). They verified that the physician orders showed Sertraline HCL (Zoloft) 50 mg (150 mg) every day as of 01/23/20. The DON stated that the order was not clear. She called the floor and asked the Unit Manager to bring down the resident's actual medication card. Staff T, Registered Nurse (RN) Unit Manager (UM) brought the medication card to the administration office and it showed Sertraline HCL 100 mg, one a day for depression. There were 15 pills left in the medication card. Staff T, RN, UM also brought a physician order dated 02/12/20 that showed change Sertraline to 50 mg daily. Staff T and the surveyor went to the nurses' station. Staff R, LPN was the nurse administering the resident her medications for the day. Staff R, LPN reviewed the order on the electronic MAR and verified it showed Sertraline 50 mg (150 mg) give one tablet. She verified that the medication card showed Sertraline 100 mg daily. She stated that she had been administering one tablet or 100 mg to the resident. When asked if she was following the physician's order, she said, No. Staff T, RN, UM also presented a physician order dated 01/23/20 that showed to increase Zoloft to 150 mg every a.m. The pharmacy recommendation showed the resident was on 100 mg and to decrease by 1/2 and give 50 mg with a physician signature on 2/12/20 was reviewed by the DON, ADON and UM. The DON, ADON and UM reviewed all the orders and signed pharmacy review and agreed there was a medication error and they would call the physician. Review of the Investigation of Possible Medication Error dated 02/20/20 showed the original order was for Zoloft 100 mg daily. On 01/23/20 the physician increased the Zoloft to 150 mg daily. The nurse transcribed the order onto the MAR as follows: Zoloft 50 mg tablet (150 mg) take one tablet by mouth daily at 9 a.m. On 02/12/20 the physician, following the recommendation by the pharmacy, wrote an order to decrease the Zoloft to 50 mg tablet, give 1 tablet daily. The nurse signed the order noting it but failed to put the order in the computer. In addition, neither the order on 01/23/20 or 02/12/20 were faxed to pharmacy. The original dose pack of 100 mg tablets was found in the cart and confirmed by the nurse to be the medication that was being administered. The investigation showed multiple errors made by multiple nurses resulting in the incorrect dosage of a medication being administered for 28 consecutive days. The UM called the prescribing physician to clarify the order for Zoloft. The physician confirmed the order for Zoloft 50 mg daily. The resident was assessed by the attending physician on 02/20/20. 2. Observation on 02/17/20 at 1:06 p.m. Resident #50 was sitting at a dining table. She was trying to stand, and the staff was reminding her to stay seated. She was sitting in a high back chair and was chatting. She was able to feed herself and ate all of her lunch. On 02/18 at 8:50 a.m. she was sleeping in her bed. A fall mat was present beside the bed. At 9:30 a.m. she was noted to be in the dining room drinking juice. Resident #50 was admitted on [DATE]. Record showed diagnoses included but not limited to vascular dementia, altered mental status, psychosis, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 (severe impairment). She required extensive assistance for bed mobility, transfers and toileting. Her medications included an antipsychotic and an antianxiety. Review of physician orders and Medication Administrative Record (MAR) for February 2020 showed the resident was on Ativan 0.5 mg every 6 hours as needed for anxiety since 01/20/20 Review of the Medication Regimen Review (MRR) for 12/01/19 to 12/23/19 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR report that showed Physician chart on rationale, review at psych meeting. Review of the Medication Regimen Review (MRR) for 01/01/2020 to 01/17/20 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR that showed see physician note for rationale. Review of the psychoactive drug and behavior management committee minutes for Resident #50 showed she was reviewed on 12/19/19 no changes, will review next month. on 01/16/20, no changes, will review next month. Record review of the physician's progress note dated 12/05/19 showed Resident #50 had done better in general with less agitation and aggressive behaviors. The plan included to change Risperdal to 1 mg at bedtime and 0.5 mg at 2 p.m. and to continue the Depakote. The note dated 12/19/19 showed the resident continued to exhibit episodes of agitation and irritability. She yelled out for no apparent reason. She had a bad day yesterday. The plan was to increase the Ativan to routine and increase the Risperdal. The note dated 01/09/20 showed the resident had been better in the past month with aid. The staff reported the resident does not do well with the 2 p.m. Risperdal. The plan was to attempt to decrease the Risperdal to find a minimum effective dose. During an interview on 02/19/20 at 3:15 p.m. the Director of Nursing (DON) verified that the physician progress notes did not address or give a rationale as to why Resident #50 needed to continue on Ativan as needed. She stated that the note stated they increased the Ativan in an attempt to decrease the Risperdal. The physician increased the Ativan to include a continuous p.m. dose, it did not address the as needed dose. During an interview on 02/20/20 at 8:50 a.m. Staff S, Licensed Practical Nurse (LPN) stated Resident #50 had behaviors at times. She stated at present there were no pharmacy recommendations. During an interview on 02/20/20 at 2:52 p.m. the DON stated that the pharmacy did not send a pharmacy recommendation for the physician unless it is directly about a medication. If the recommendation was regarding a lab test only, they send multiple residents on the same recommendation. The facility nurses address these types of recommendations with the physician individually. She stated that if the recommendation was not acted on in a month then the recommendation will be addressed again the next month. During an interview on 02/20/20 at 5:48 p.m. the consultant pharmacist stated that the pharmacy recommendations should be acted on within 30 days and if they have not been acted on it should be followed-up on within 30 days. Record review of the facility's policy, Medication Regimen Review and Reporting, dated 09/18 showed Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative. The nursing care center assures that the consultant pharmacist has access to residents and the residents' medical records. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care. Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and / or physician. A record of the consultant pharmacist's observations and recommendations is made available in a easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR completion. The nursing care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record. If there is potential for serious harm and the attending physician does not concur, or refuses to document an explanation, the director of nursing and the consultant pharmacist contact the medical director. If the attending physician is also the medical director, a meeting shall be arranged to discuss issues and come to an agreement in order to ensure that no actual harm occurs.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three (#155, #103, and #130) of seven residents observed. These errors constituted a 14.29% medication error rate. Findings included: On 2/18/20 at 4:20 p.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #155. Staff Member I was observed administering the following medications: - Active Protein 30 milliliters (mL) orally - Novolog 100 unit/mL Flexpen, 10 units subcutaneously Prior to the administration, Staff Member I obtained a blood glucose level, using an Evercare G3 glucometer, of HI. The staff member informed the resident the doctor would need to be notified. A review of Resident #155's February Medication Administration Record (MAR) revealed a sliding scale of units to be administered dependent on the blood glucose level of the resident. The sliding scale identified 10 units of Novolog insulin was to be administered and the physician was to be called. The staff member gathered the Novolog Flexpen from the medication cart and returned to the resident. Staff Member I cleaned the right upper abdominal quadrant of Resident #155 with alcohol, placed a needle on the Flexpen, dialed it to 10 units, and injected the insulin quickly in the abdomen. The staff member did not prime the Flexpen prior to the administration. When asked why she had not primed the pen, the staff member asked, Am I supposed to? Haven't ever heard of priming the pens. The staff member documented a blood glucose level of 401 in Resident #155's medical record and called the physician. On 2/18/20 at 5:16 p.m., an observation of medication administration with Staff Member J, Registered Nurse (RN), was conducted with Resident #103. Staff Member J obtained a blood glucose level of 360 from the resident utilizing a glucometer. Staff Member J was observed administering the following medications: - Novolog Flexpen 100 u/mL - 12 units subcutaneously - Docusate Sodium 100 milligram (mg) softgel orally - Gabapentin 100 mg capsule orally - Lisinopril 40 mg tablet orally - Lorazepam 0.5 mg tablet orally - Memantine 10 mg tablet orally - Xarelto 20 mg tablet orally The staff member was observed removing the Novolog Flexpen from the medication cart and dialed it to 12 units. Staff Member J returned to the resident, raised Resident #103's right arm sleeve, cleaned the area above the elbow with alcohol, applied a needle to the Flexpen, and injected the insulin. Staff Member J did not prime the Flexpen prior to dialing it to 12 units and administering the Novolog. The February Physician Order summary for Resident #103 identified the resident was to be administered 12 units of Novolog via a Flexpen for a blood glucose level of 360. On 2/19/20 at 10:48 a.m., an observation of medication administration with Staff Member K, RN was conducted with Resident #130. Staff Member K was observed administering the following medications: - Risperidone 0.25 mg tablet orally - Multiple Vitamin with mineral tablet orally - Lorazepam 0.5 mg orally - Ensure Plus orally A review of the Medication Administration Record (MAR) for Resident #103 revealed the above medications were scheduled to be administered at 9:00 a.m. The physician orders for Resident #130 identified the medication Risperidone was to administered three times daily at 9:00 a.m., 1:00 p.m., and 5:00 p.m. and Lorazepam was to be administered at 9:00 a.m. and 5:00 p.m. The progress notes did not indicate the physician and/or family was notified of the late administration of the above medications. The electronic medication profile for Resident #103 indicated the medications were 55 minutes overdue. Staff Member K confirmed the medications were late due to some residents were taken to a religious activity without notifying the nurse that did not normally work the shift, and some residents take a little more patience. On 2/18/20 at 6:12 p.m., the Director of Nursing (DON) stated the procedure for insulin administration via a Flexpen was to uncap the pen, clean the tip with alcohol, apply a needle, prime it with two units of insulin, then dial to the correct dosage. She identified staff do receive competency training with insulin pen and syringe training as part of new hire orientation and during the facility's annual competency fair. A review of the observation of the insulin administration for Resident #155 and #103 was discussed with the DON. She confirmed the residents did not receive the correct dosage of insulin due to the nurses not priming the Flexpen prior to the dialing the dosage. According to https://www.novo-pi.com/novolog.pdf, an airshot should occur when using an insulin pen before each injection to avoid injecting air and to ensure the proper dosage. The Novolog instructions indicated users should apply a needle to the pen, turn the dose selector to 2 units and while holding the pen with the needle pointing upwards tap the cartridge to allow air bubbles to collect at the top, and press the buttom all the way until the selector returns to 0 (zero). The policy titled, Medication Administration - Subcutaneous Insulin, dated 5/16, indicated the following instructions for the use of an insulin pen: - apply needle to cartridge. - Always perform the safety test before each dose. Performing the safety test ensures you get an accurate dose by ensuring that the pen and needle work properly and to remove air bubbles. - The illustration indicated the safety test was to select 2 units. - Hold the pen with the needle pointing upwards. - Tap the insulin reservoir so that any air bubbles rise up towards the needle. - Press the injection button all the way in. Check if insulin comes out the needle tip. The policy titled, Medication Administration - General Guidelines, dated 9/18, indicated medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. On 02/20/20 at 3:16 p.m., the DON stated one hour before and after the scheduled time and procedure is to call physician prior to the administration of meds. On 2/20/20 at 5:48 p.m., the Consultant Pharmacist stated most Flexpens need to be primed prior to the administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 58 sampled residents was free from a significant medication error related to one resident receiving an incorrect dosage of Zoloft (#36) and one resident not receiving all their medications on dialysis days (#151). Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). The physician orders and Medication Administration Record for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day starting 08/13/19 and discontinue on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day starting 01/24/20 for major depression, an order date of 01/23/20. No behavior monitoring was evident in the MAR for January or February 2020. A physician order dated 01/23/20 showed increase Zoloft (Sertraline) to 150 mg in the a.m. A physician order dated 02/12/20 showed change Sertraline (Zoloft) to 50 mg daily. A review of the Pharmacy Review dated 01/15/20 showed the resident is currently receiving Sertraline 100 mg / day. Sometimes, the decision about whether to continue a medication is clear; for example, someone with a history of multiple, episodes of depression or recurrent seizures may need an antidepressant or anticonvulsant medication indefinitely. Often, however, the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline. Consider Sertraline (Zoloft) 50 mg daily. The physician agreed on 02/12/2020. The medication card showed Sertraline (Zoloft) HCL 100 mg tablet, give one tablet by mouth once a day for depression. There were 15 pills in the medication card. During an interview on 02/20/20 at 11:05 a.m. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) reviewed the February 2020 Physician Order Sheet as well as the pharmacy recommendation regarding Resident #36's Sertraline (Zoloft). They verified that the physician orders showed Sertraline HCL (Zoloft) 50 mg (150 mg) every day as of 01/23/20. The DON stated that the order was not clear. She called the floor and asked the Unit Manager to bring down the resident's actual medication card. Staff T, Registered Nurse (RN) Unit Manager (UM) brought the medication card to the administration office and it showed Sertraline HCL 100 mg, one a day for depression. There were 15 pills left in the medication card. Staff T, RN, UM also brought a physician add order dated 02/12/20 that showed change Sertraline to 50 mg daily. Staff T and the surveyor went to the nurses' station. Staff R, LPN was the nurse administering the resident her medications for the day. Staff R, LPN reviewed the order on the electronic MAR and verified it showed Sertraline 50 mg (150 mg) give one tablet. She verified that the medication card showed Sertraline 100 mg daily. She stated that she had been administering one tablet or 100 mg to the resident. When asked if she was following the physician's order, she said, No. Staff T, RN, UM also presented a physician order dated 01/23/20 that showed to increase Zoloft to 150 mg every a.m. The pharmacy recommendation showed the resident was on 100 mg and to decrease by 1/2 and give 50 mg with a physician signature on 2/12/20 was also reviewed by the DON, ADON and UM. The DON, ADON and UM reviewed all the orders and signed pharmacy review and agreed there was a medication error and they would call the physician. Review of the Investigation of Possible Medication Error dated 02/20/20 showed the original order was for Zoloft 100 mg daily. On 01/23/20 the physician increased the Zoloft to 150 mg daily. The nurse transcribed the order onto the MAR as follows: Zoloft 50 mg tablet (150 mg) take one tablet by mouth daily at 9 a.m. On 02/12/20 the physician, following the recommendation by the pharmacy, wrote an order to decrease the Zoloft to 50 mg tablet, give 1 tablet daily. The nurse signed the order noting it but failed to put the order in the computer. In addition, neither the order on 01/23/20 or 02/12/20 were faxed to pharmacy, and the original dose pack of 100 mg tablets was found in the cart and confirmed by the nurse to be the medication that was being administered. The investigation showed multiple errors made by multiple nurses resulting in the incorrect dosage of a medication being administered for 28 consecutive days. The UM called the prescribing physician to clarify the order for Zoloft. The physician confirmed the order for Zoloft 50 mg daily. The resident was assessed by the attending physician on 02/20/20. 2. Resident #151 was admitted on [DATE]. Record showed diagnoses included but not limited to End Stage Renal Disease, renal dialysis, Alzheimer's dementia, hypertension, Glaucoma and diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 06 (severe impairment). The resident required extensive to dependence assistance for bed mobility, transfers and toileting. Review of physician orders and Medication Administration Review for January and February of 2020 showed Muro 128 2% eye drops (1 drop) left eye every 6 hours starting 08/13/19 for Glaucoma. The medication was scheduled for 6 a.m. 12 noon, 6 p.m. and midnight. He did not receive the noon dose on Tuesday, Thursday and Saturday due to Resident on LOA or resident not available; he was at dialysis. He had an order for Calcium Acetate 667 mg (2001 mg), give 3 capsules with meals and at bedtime, four times a day starting 08/15/19 for end stage renal disease. His 1:00 p.m. dose was not given on Tuesday, Thursday, or Saturday due to Resident on LOA or resident not available; he was at dialysis. Record review of the dialysis care plan showed the interventions included but not limited to staff will follow instructions provided by dialysis clinic Tuesday, Thursday, and Saturday. Observation on 02/17/20 at 2:52 p.m. Resident #151 was lying in bed watching TV. He stated that he went to dialysis on Tuesday, Thursday and Saturday. He left at 10:00 a.m. and took his lunch and a notebook with him. The facility arranged his transportation. During an interview on 02/19/20 at 11:04 a.m. the Corporate Director of Case Management reviewed Resident #151's physician orders and Medication Administration Record for January and February 2020. She verified there was not an order to hold his medications on his dialysis days nor was there documentation in the progress notes showing the physician was notified of the missed eye drops and Calcium Alginate on Tuesday, Thursday, and Saturdays. She stated that she would expect to see an order regarding what to do with the missed medications on dialysis days. During an interview on 02/19/20 at 1:46 p.m. Corporate Director of Case Management stated that she reviewed the documentation and did not find an order from the physician regarding not taking his medications on dialysis days. She stated that the Unit Manager called the physician regarding the missed medications. During an interview on 02/20/20 at 8:56 a.m. Staff R, Licensed Practical Nurse (LPN) stated that the resident does miss some of his medications when he goes to dialysis. He misses his calcium. She stated that she had not informed the physician he was missing it because it was ordered by the dialysis center and they know he was not getting it because he was at dialysis. She stated that normally she would call the physician and family if a resident was not taking their medications. 3. During an interview on 02/20/20 at 5:48 p.m. the consultant pharmacist stated that a medication error such as giving the wrong dosage or a dialysis resident not receiving the medications on dialysis days should be reported to the physician. For the dialysis resident the physician may want to change the time the medication was scheduled or give an order to skip the medications that day. But the facility should speak with the physician. 4. Record review of the facility's policy, Non-Controlled Medication Orders, dated 12/12 showed medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe. Medication orders include the following specifics: date, name of medication, strength of medication, dose and dosage form, time or frequency of administration. Any dose or order that appears inappropriate, considering the resident's age, condition, allergies or diagnosis, is verified by nursing with the prescriber. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the Physician Order Sheet (POS) / Telephone Order Sheet (TO) if it is a verbal order, and on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). New Orders: the order is transcribed onto the Physician's Order Sheet or Telephone Order Sheet; order is noted by the nurse receiving the order; order is recorded on the MAR or TAR; send the appropriate copy of the telephone order form to the prescriber for signing in a timely manner; transmit the appropriate copy of the order to the pharmacy for dispensing; place the signed copy of the order on the designated page in the resident's medical record. Record review of the facility's policy, Medication Administration, dated 09/18 showed medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Preparation: Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label. Medication Administration: Medication are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Verify medication is correct three (3) times before administering the medication. When pulling medication package from the med cart; when dose is prepared; before dose is administered. Documentation: If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Record review of the facility's policy, Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 09/10 showed the facility utilizes a system to assure that medication usage is evaluated on an ongoing basis. Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and / or prescribers, the pharmacy if needed. Medication Error / Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling dispensing, distributing, administration, education, monitoring and use. Medication errors and adverse drug reactions are considered significant if they: require discontinuing a medication or modifying the dose. Procedure: the interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. When a resident receives a new medication, the medication order is evaluated for the following: dose. In the event of a significant medication error immediate action is taken, as necessary, to protect the resident's safety and welfare. the prescriber is notified promptly of any significant error. Any new prescriber's orders are implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was accurate and complete for one (#138) of 58 sampled records related to falls. Findings included: Observation on 02/17/20 at 12:54 p.m. Resident #138 was out of bed sitting in a broda chair. She had enablers in an up position with a mat in place beside of her bed. The medical record showed she had fallen out of bed. She had an egg-shaped swollen area over her right eye. There was a purplish yellow discolored area from her eye down her right cheek. She was dressed and groomed for the day including her hair being combed. She was drinking a soda. On 02/19/20 at 3:50 p.m. it was noted that she had a discolored area on her right hand also. Record review of the facility's policy, Fall Prevention Program, not dated showed to assure proper follow-up is carried out to reduce the amount of resident falls through assessment and staff awareness and implementation of appropriate interventions. The members of the Interdisciplinary team (Director of Nursing (DON), Assistant Director of Nursing (ADON) Director of Therapy, Social Work, Nurse Manager, Dietary, MDS nurse) will review the Incident Report and causation of fall at (Interdisciplinary Team) IDT meeting and do a root cause analysis to determine cause of fall. Resident #138 was admitted on [DATE]. The record showed diagnoses included but were not limited to dementia without behavioral disturbance, insomnia, depression, altered mental status, history of falls, unsteady gait, weakness, syncope, and Alzheimer's psychosis. Record review of the significant change Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 07 (severe impairment). The resident required extensive assistance for bed mobility, transfers and toileting. The resident had 2 or more falls with no injury. Record review of the nursing progress notes showed inaccurate documentation related to falls. The progress notes dated 12/10/19, 12/27/19, and 02/01/20 showed a fall had occurred but the time of the fall was not documented. The progress note dated 01/10/20 showed the resident had fallen, the note lacked the actual fall date which was 01/09/20 and time. The nursing progress notes lacked documentation for the fall that occurred on 01/16/20. The progress notes reviewed from December 2019 through February 20, 2020 revealed no documentation related to IDT meetings related to the resident's falls. During an interview on 02/18/20 at 6:40 p.m. the Director of Nursing (DON) stated that the facility had morning meetings at which time they discussed each fall including new interventions. She stated that the nurse was to document the falls on a facility report including the details of the fall, possible reason for the fall and interventions. During an interview on 02/19/20 at 8:00 a.m. the Nursing Home Administrator (NHA) and the DON stated the surveyors were not able to look at the facility reports in the electronic record. They stated that the nurses were supposed to document in the nursing notes about the fall including date and time. When asked about the IDT meetings and subsequent documentation of the meetings, they stated that it was kept in a Fall Book. They verified that neither the facility report nor the IDT meeting information was part of the resident's chart. The NHA stated that she had never thought about it, but the documentation could be scanned into the chart. During an interview on 02/20/20 at 11:10 a.m. the NHA and the DON stated that Resident #138 had fallen on 01/16/20. She reviewed the medical record and was unable to locate any documentation related to the 01/16/20 fall in the progress notes. She also verified the discrepancy of the documentation regarding the 01/09/20 related to the fall being documented on the 01/10 instead of 01/09. She stated that the nursing notes should include both date and time as well as a description of each fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. On 02/17/20 at 1:41 p.m., Resident #56 was observed in the bed in his room. The resident was observed to have a yellow wrist band on his left wrist with the words fall risk in big black letters. Resident #56 stated that he had the band on his wrist because he was a fall risk. On 02/19/20 at 12:50 p.m., Resident #56 was observed in bed from the outside of his room door. The yellow fall risk band was visible from the doorway. On 02/19/20 at 12:54 p.m., Staff L, Licensed Practical Nurse (LPN), verified the band on Resident #56. Staff L stated that the band looked like it came from the hospital. On 02/19/20 at 1:46 p.m., the Director of Nursing (DON) reported that the yellow fall risk band came from the hospital and should have been removed. A review of the Face Sheet for Resident #56 revealed that the resident was initially admitted into the facility on [DATE] with a diagnosis that included, but was not limited to, history of falling. A record review revealed that the resident's last discharge was to the hospital on [DATE]. 12. On 02/17/20 at 11:45 a.m., observations were made in the main dining room on the second floor during lunch. Resident #104 was seated at a table with three other residents. Resident #104 was in a geri-chair and the chair was reclined at that time. The three residents were drinking and eating lunch, but Resident #104 did not have a lunch tray at that time. At 11:47 a.m., a staff member took him out of the dining room. When asked why she was removing him from the dining room, she stated because his dentures were coming out. The staff member brought the resident back into the dining room at 11:51 a.m. Resident #104's tray came out at 11:56 a.m. Staff L started assisting the resident with his meal at 12:00 p.m. On 02/18/20 at 11:14 a.m., observations were made in the main dining room on the second floor during lunch. Resident #104, Resident #127, and Resident #406 were seated at the same table. Staff U, Registered Nurse (RN), was distributing drinks in the dining room. Staff U opened a small can drink for Resident #127 and gave him a straw. Staff U opened a small can drink for Resident #406 and gave her a straw. Staff U gave Resident #104 a small can drink, but did not open it. At 11:20 a.m., Staff U pulled up a chair and sat at the table with the residents. Staff U asked Resident #127 if he wanted a drink and assisted him with the drink. Staff U did not open Resident #104's drink, and did not offer him a drink. At 11:35 a.m., staff started passing soup (chicken and rice) and asking residents if they wanted soup. At 11:38 a.m., Staff U gave Resident #127 and Resident #406 soup. At this time, 24 minutes later, Resident #104 had not been offered a drink or soup. Resident #104 was seated at the table in a reclined geri-chair, and was seated where he could see other residents drinking beverages and eating soup. Resident #104 received his lunch tray at 11:46 a.m. At 11:48 a.m., Staff T, LPN, went over to the table and asked him if he was ready to eat. Resident #104 was not offered a drink or meal until 34 minutes after Resident #127 and Resident #406, who were seated at the table with him eating and drinking. On 2/20/2020 at 9:59 a.m., in an interview with the Administrator, she stated that she was shocked that Resident #104 was in the dining room for lunch because he needs more assistance with his meals. The Administrator stated that he needs more assistance with his tray, and his tray was not on the cart because he was usually not in the main dining room for lunch. The Administrator stated, His food comes delayed because he needs more assistance. The Administrator repeatedly stated that she was shocked Resident #104 was in the dining room, because he was normally not in there. The Administrator reported that the delay in Resident #104 receiving his tray was probably due to his tray being on the cart with the trays that were sent to the halls. The Administrator reported that Resident #104 was not supposed to be in the dining room for lunch, due to him needing more assistance. The Administrator reported that the kitchen had to have at least a 24-hour notice if residents want to change from eating in their rooms to the main dining room. A policy was requested from staff related to dignity during dining and was not provided. A record review of the Face Sheet for Resident #104 revealed that he was admitted into the facility on [DATE] with diagnoses that included, but were not limited to, need for cognitive communication deficit, dysphagia, Dementia, and mild cognitive impairment. Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #104 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired. 10. Resident #148 was admitted on [DATE], and re-admitted on [DATE] and 6/28/19. The Face Sheet listed diagnoses including but not limited to senile degeneration of brain and dementia without behavioral disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. On 2/17/20 at 1:05 p.m., Resident #148 was observed wearing a white plastic bracelet and a yellow Fall Risk bracelet on the right wrist. The white bracelet appeared to be old and dirty-looking. The white bracelet had computer-generated scan dots, the name of the resident, and the Medical Records Number (MRN) printed on it. At 2:25 p.m. on 2/19/20, the resident was observed wearing a yellow plastic bracelet with Fall Risk printed on it and the above-mentioned white plastic bracelet. On 2/20/20 at 9:41 a.m., Resident #148 was observed wearing both the plastic white patient identifier bracelet and the yellow Fall Risk bracelets on the right wrist. On 2/19/20 at 2:26 p.m., Staff Member Q, Certified Nursing Assistant (CNA), was asked what the bracelets worn by Resident #148 were. She stated everyone on her assignment had fall risk bands, and the white bracelet was a hospital band and the resident had been wearing it since she started facility employment in November 2019. On 2/19/20 at 2:29 p.m., Staff Member P, Licensed Practical Nurse (LPN), confirmed the MRN 392657 was printed on the white bracelet. The LPN stated some residents have the bracelets on their wheelchairs because they (the residents) are able to remove them; otherwise the residents wear resident identifier bracelets. A review of the Resident #148's medical record, located on the unit, with Staff Member P revealed an acute facilities History and Physical report, dated 10/12/19. The Medical Record Number 392657 was printed in the upper right hand corner of the report. The staff member confirmed the MRN number printed on the report was the same number printed on Resident #148's white bracelet. On 2/20/20 at 2:56 p.m., the Director of Nursing (DON) stated the facility does not use hospital identifier or yellow Fall Risk bracelets. The facility used tubular plastic resident identifier bracelets. The Resident Rights handbook indicated that residents' rights are protected and promoted in the provision of care. The handbook revealed information related to the needs was documented in the residents' medical record for staff review and training on resident rights, confidentiality and abuse are available for all staff. Based on observation and resident and staff interviews it was determined that the facility did not ensure that twelve (#56, #73, #104, #130, #140, #148, #208, #211, #212, #213, #406, and #407) of 58 residents were treated with respect and dignity related to lack of clothing for two residents (#208 and #213); reused non- skid socks for two residents (# 211 and # 212); identifying information in ID bands for two residents (#148 and #56); timely assistance with meals for one resident (#104); providing care and speaking to residents in a rushed manner for five residents (#130, #140, #407, #406, and #73), and staff talking on phones and to each other in patient care areas in a foreign language and during patient care. Findings included: 1. A review of the Face Sheet indicated that Resident #130 was admitted on [DATE] with a diagnosis of Multiple Sclerosis, Mood Disorder due to Major Depressive like episodes, Major Depressive Disorder. Resident #130's most recent comprehensive minimum date set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 13 of 15, indicating cognition intact. Her functional statues related to activities of daily living (ADL) revealed Resident #130 required total assistance with all activities. On 2/17/20 at 10:39 a.m., an initial interview with Resident #130 revealed that the resident was having some problems with the nurses. Upon further questioning, Resident #130 became teary and said when one nurse comes in the room to give her medications, the nurse speaks to her in a rushed manner and while she is in the room, She will do little things to upset me. She did not give any details on, The little things the nurse did. She did not say when this specifically occurred or give a description of the nurse. On 2/17/20 at 2:58 p.m., the surveyor reported Resident #130's concerns to the Nursing Home Administrator (NHA). The Administrator stated that she was unaware of the situation and would check into it. On 2/18/20 at 9:29 a.m., the Administrator informed the surveyor that she spoke with Resident #130. The Administrator concluded it was one of the Certified Nursing Assistants (CNAs) that the resident had the issue with. Per the Administrator, the situation was about being hot/cold and the CNA would be coming in for education about the incident. 2. On 2/18/20 at 5:36 p.m., a family member of Resident #130 stated when her mother sees new faces, she thinks they don't know how to take care of her and that gave her extra anxiety. Resident #130's family member stated she was unsure of what was happening now, and her main concern was no continuity of staff. She stated the staff was competent, but they do not know the residents. Resident #140 was admitted to the facility on [DATE] with diagnosis including Unspecified Dementia, Anxiety Disorder, Unspecified Mood Disorder. Resident #140's most recent MDS dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating cognition intact. On 2/18/20 at 9:06 a.m., the surveyor observed Staff C, License Practical Nurse (LPN), at the nurse's cart and the call light to one of the rooms turned on. Staff C abruptly entered the room and asked the Resident #140 in a curt manner what he wanted. Resident #140 responded, the surveyor was unable hear what the resident said, but heard staff member C tell the resident in a curt manner that he had already received his medication. Resident #140 made another statement, the surveyor was unable to hear what the resident said, and Staff C responded, That's not me, that's this afternoon, and left the room. 3. Resident #407 was admitted on [DATE] with diagnosis including unspecified systolic heart failure, dyspnea, and Type 1 diabetes mellitus without complications. Resident #407's most recent MDS, dated [DATE], documented a BIMS score of 12 of 15 indicating intact cognition. Upon initial interview on 2/17/20 at 9:18 a.m., Resident #407 stated that the nurses were not as nice as they were downstairs. Resident #407 stated the nurse comes into the room rudely saying Get up and walk. Get up and walk. She then held up her arm and stated I am a fall risk while pointing to a yellow fall risk wrist band on her wrist. She stated she had been at the facility for two months, and the only thing she needed to do before going to an ALF was to get her ankle looked at because it was not healing well, and she needed to be able to walk. The surveyor asked Resident #407 if she knew who the nurse was, and she stated I am not sure what her name is, but she has glasses on, and her hair is pulled back today. She gave me my medications today six at a time. She did not have enough patience to take them one at a time, and I have a hard time taking pills. On 2/18/20 at 10:26 a.m., an interview was conducted the Administrator related to the observations and concerns expressed by Residents #140 and #407. The surveyor spoke with Administrator at 2:23 p.m. to follow up with the information reported earlier. The Administrator stated she and the Assistant Director of Nursing (ADON) performed a teachable moment with Staff C. She informed Staff C of the reported concerns and educated Staff C explaining that the residents have the right to take medications as they would like to. 4. Resident #406 was admitted [DATE]. The Face Sheet included diagnoses not limited to unspecified pain, aphasia following cerebral infarction, and apraxia. The quarterly Minimum Data Set, dated [DATE], revealed a Brief Interview of Mental Status score of 2, indicative of severe cognitive impairment. Staff Member C, Licensed Practical Nurse (LPN) was observed, on 2/18/20 at 9:34 a.m. enter Resident #406's room to obtain a blood pressure reading. The staff member placed a blood pressure cuff over the resident's sweatshirt on the left arm. After receiving one blood pressure reading, Staff Member C administered medications to the resident. Staff Member C removed the blood pressure cuff and attempted to remove Resident #406's right arm from the sweatshirt. As Staff Member C held the resident's arm above the residents' head, the resident was exclaiming [NAME], ah ah. The staff member sharply instructed the resident to Flex your arm and pulled the resident's arm from the sleeve as the resident continued to exclaim [NAME], ah ah. The staff member was able to remove Resident #406's arm from the sweatshirt and obtain a blood pressure, then placed the resident's arm back into the sweatshirt. The Nursing Home Administrator was informed, on 2/18/20, of the interaction between Resident #406 and Staff Member C. At 2:23 p.m. on 2/18/20, the Administrator stated a Teachable moment was conducted with Staff Member C. She stated she had interviewed Resident #406, who was unaware of the interaction. The staff member was informed that the residents should not be rushed. On 2/19/20 at 10:27 a.m., Resident #406 was observed sitting in wheelchair in the second-floor hallway outside of room. The resident was not able to inform writer of how long she had resided in the facility. The resident stated no staff had hurt her. The Care Plan for Resident #406 recognized a problem that the resident was at risk for an alteration of communication. The interventions included to allow the resident adequate time to express self; complete word or sentence if the resident was unable to do so and to allow adequate time to express self. The care plan indicated Resident #406 was at risk for pain. The interventions indicated nursing staff would assess for signs or symptoms of pain; facial grimace, guarding, moaning, agitation, anxiety, tearfulness, and/or combativeness. A problem identified within Resident #406's care plan indicated adjustments and instructed all staff to provide a safe, non-threatening environment. 5. On 02/17/20 at 2:10 p.m., Staff C, Licensed Practical Nurse (LPN), was observed going into Resident #73's room. The surveyor was standing outside of the door and overheard Resident #73 state, You don't have to snatch it off like that. Resident #73 was self-administering a nebulizer treatment at that time. A record review of the Face Sheet for Resident #73 revealed that she was admitted into the facility on [DATE] with a diagnosis that included but was not limited to unspecified Dementia without behavioral disturbance. Section C of the Quarterly Minimum Data Set with an effective date of 10/01/19 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderately impaired. A Teachable Moment document dated 02/18/20 was provided by staff and dated 02/18/20 after the concern was brought to the Administrator's attention. The presenter was listed as the Assistant Director of Nursing (ADON) and the Administrator. The topic was kindness and dignity. The content revealed, Teaching regarding taking time with residents, speaking slowly and clearly, and slowing down procedures to match resident's needs. Treating residents with respect in all matters. Staff member apologized to the three residents involved. The form was signed and dated by Staff C. 6. An interview was conducted with Resident #208, on 2/17/20 at 3:01 p.m. He stated that he came to the facility with one pair of shorts and a T-shirt. He stated that someone at the facility gave him a pair of pants. He stated that his family had not brought his clothing in. He had nothing else to wear and needed some assistance. An interview was conducted with Staff H, the rehab social worker, on 2/17/20, regarding Resident #208's lack of clothing concern She stated that she was aware of his concern over clothing. He was alert and oriented and called his family for clothes. She stated there were transportation and time problems with the family getting to the facility with clothes. A subsequent interview was held with Staff H on 2/19/20 at 3: 00 p.m She stated that a nurse, over the weekend, went out and bought him new underwear because he didn't have any, Out of the goodness of her heart. She stated that Resident #208 asked how he was going to pay the nurse the $12 for the underwear and she, Staff H, told him it was a gift from the nurse. On 2/19/20 at 4: 20 p.m., an interview was conducted with the Executive Director, Assistant Director of Nursing (ADON) and Director of Nursing (DON) The Executive Director stated that there is no policy for supplying clothing, but there is a process . She stated that if a resident comes in without clothing, staff go to the laundry and look for clothing that will fit. If the clothes do not fit, the facility will reach out to the family. If the family does not respond, the Activities Department will purchase clothes for the resident. The Executive Director, ADON, and DON were not aware that Resident #208 did not have sufficient clothing. The statements of Staff H were discussed and the Executive Director, ADON, and DON all stated that clothing should have been provided when facility staff were made aware On 2/19/20 at 2: 45 p.m., Resident #208 stated his family had brought clothing to him last night. He stated he is glad he has clean clothes to wear and felt more comfortable leaving his room. 7. During an observation with resident's roommate on 2/18/20 at 9: 45 am, Resident # 213 was observed in his room this morning, seated in a wheelchair in a facility gown. An unidentified CNA came in room and asked him if he wanted a shower. Resident # 213 stated he had no clothes. The CNA looked in his closet and came back and said, Well, you can just wear a clean gown. At 10: 25 am on 2/18/20, Resident #213 was observed in the therapy room on a recumbent bike, dressed in two gowns, one back, one front. His legs were bent while peddling, his gown was pulled up, and his incontinence brief was fully exposed to anyone in the room. 12 residents plus staff were in the room. Two therapy staff were observed going over to talk to him during the 10 minute observation and no one assisted him to cover himself. Review of the record for Resident #213 was admitted on [DATE] at 1:00 p.m. Diagnoses on the face sheet included Unspecified Dementia. Review of an admission Combined Review, dated 2/17/20, revealed that Resident # 213 had memory problems and was not capable of making decisions. An Interview was conducted with the Executive Director, ADON and DON at 4:20 p.m. on 2/19/20. The Surveyor described the scenario of Resident #213, and the Executive Director and ADON all stated that was not acceptable . An interview was conducted with Staff F, the day shift nurse assigned to Resident # 213, on 2/20/20 at 11: 30 a.m. She stated Resident #213 came in with one shirt, one pair of pants, and slippers. She reached out to his wife, but she was not able to bring clothes in. She stated his shirt and pants must have been in the laundry. She said she had obtained some clothing for him from therapy and from laundry and will check his closet again to see if they can get him more clothes. 8. An interview was conducted with Resident #211 on 2/17/20 at 3:25 p.m. She said last week she was given a pair of clean used non-skid socks to wear. She felt like there was something under the bottom of her foot, and she asked the nurse to look at it. The nurse told her that there was nothing under her foot, and it must be in her sock. The nurse helped her take her sock off and they found a man's large toenail in the sock. On 2/19/20 at 3: 00 p.m., a subsequent interview was held with Resident #211. She described the nurse who removed the toenail from the sock and threw it in the trash. The resident stated she was grossed out by it She stated the nurse just walked by. The surveyor found the nurse matching the description and the nurse confirmed she was the correct nurse. She was Staff A, MDS RN. An Interview with Staff A was conducted on 2/19/20 at 3:10 p.m. She confirmed she did work with Resident #211 on Saturday and that the resident complained about something under her foot. She pulled the resident's sock off and it was a hard dried substance that looked like a toenail. She stated they do get used socks from residents from the laundry. She stated, I imagine she was grossed out by it. She stated it was not the resident's toenail. She stated she offered the resident new socks, but the resident declined and put the socks back on. On 2/19/20 at 4:20 p.m., an interview was conducted with the Executive Director, ADON, and DON regarding the sock incident. The Executive Director stated that this was not acceptable and It's an easy fix, we will throw out the used socks and get all new ones. The DON stated that Staff A should never have let Resident #211 put the sock back on and she should have thrown the socks away. 9. On 02/18/20 at 9: 45 a.m., Resident #212 was observed lying in bed uncovered, with legs and underwear briefs visible from the open doorway. He also was observed wearing different color non-skid socks on his feet. Review of the record for Resident # 212 revealed that he was admitted to the facility on [DATE] with diagnoses which included Multiple fractures of Pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, Chronic Kidney Disease (CDK), Muscle weakness, Other abnormalities of gait, History of falling, Pain, fever, Unspecified atrial fibrillation, COPD. A Minimum Data Set (MDS, admission assessment, with an assessment reference date of 2/7/20) revealed that the resident required assistance from staff for dressing and bed mobility. An interview was conducted with a companion of Resident #212, on 2/19/20 at 2:30 p.m. She was observed placing non skid socks on his feet. She stated sometimes the non-skid socks look soiled, and she pulled open the drawer and said Look, most of them don't match, and they are just thrown in the drawer in a heap. An interview was conducted with the Executive Director, ADON, and DON regarding the socks on 2/19/20 at 4:20 p.m. ADON stated she just discovered the issue with the socks being heaped in the drawer and mismatched. The Executive Director stated all the socks will be thrown out and new socks will be provided to the residents. On 2/19/20, a confidential resident council meeting was conducted with nine residents. Four of the nine residents resided on the 2nd floor and stated that Certified Nursing Assistants (CNAs) on the 11:00 p.m. to 7:00 a.m. shift and the 3:00 p.m. to 11:00 p.m. shift talk about residents in the hallway loud enough so they can be overheard. Eight residents in the meeting stated CNAs speak in a foreign language to each other and on their cell phones in front of residents and while providing care to residents. One resident in the confidential meeting stated that a CNA was providing care for her when the CNA's cell phone rang. She stated the CNA removed the cell phone from her pocket, told the resident she would be right back, and left the room. Six of nine residents in the confidential resident meeting stated they have been given used, soiled or torn non-skid socks to wear. Several residents stated they have refused the socks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 02/17/20 at 1:41 p.m., an interview with Resident #56 revealed that during breakfast and lunch they are short staffed. He stated that if you press the light during these mealtimes, you would not get assistance because all staff was in the dining room. Resident #56 reported that if you have a bowel movement, then you would have to wait until they are done in the dining room. A record review of the Face Sheet for Resident #56 revealed that he was admitted into the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS) with effective date of 10/01/18 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. On 02/18/20 at 12:14 p.m., Staff W, Certified Nursing Assistant (CNA), reported that they do not have enough staff. She stated that they are short sometimes. Staff W stated that she had to assist two people in the dining room because they do not have enough staff to assist with meals. Based on observations, record reviews, and interviews, the facility failed to ensure sufficient staffing was maintained to provide necessary care and services to the residents. Findings included: 1. On 2/18/20 at 9:01 a.m., Resident #315 reported insufficient number of staff at night, during mealtimes, and between shifts. The resident identified the need to be assisted to ambulate to the restroom, and sometimes the need to use the restroom was urgent with a capital U. Resident #315 described staff ignoring the call light or stick head in and being informed of having to wait due to staff being busy, I'm busy. On 2/19/20 at 6:46 a.m., Staff Member X, Certified Nursing Assistant (CNA), stated the facility generally replaces staff call-offs, short-staffing happens, and the facility have implemented more agency staff. Staff Member X reported feeling rushed and not being able to get the work done when staffing was short. At 7:05 a.m. on 2/19/20, Staff Member Y, Licensed Practical Nurse, stated the facility was not short on nurses but usually aides on the weekends due to multiple call-offs. On 2/18/20 at 6:29 a.m., the Director of Nursing (DON) stated the facility utilized both agency CNA's and nurses daily. She reported the facility has had staffing overturns and are trying to build back up. The DON stated once the new system (electronic record) came in, and again when she started in October, the facility lost staff, both nurses and aides. The DON said depending on the day, the facility usually did not have more than two agency staff during the day. She said the facility did not usually have agency staff during the weekend, as the regular staff were willing to pick up shifts. She stated agency nurses do not receive a formal orientation, but the offgoing nurse was supposed to acquaint them with the residents and the supervisors are to do a mini-orientation. The DON confirmed there was no competency checkoff list for agency staff. She reported that CNA preceptors acclimate agency aides. On 2/20/20 at 4:08 p.m., the Social Worker/Grievance Coordinator reviewed grievances, listed under Staffing. - 1/8/20: nursing concerns, oral care, nursing not assisting the resident as recommended by the Speech Language Pathologist, and the resident not being cleaned of urine. The issues were addressed with the staff and educated. - 1/8/20: complaint regarding staff. Stated they were rude and not slow enough for her. The aide was removed from the assignment and educated on customer care and allowing for more time. - 1/21/20: a resident stated staff member was rude and not attentive. The nurse removed the staff member (assumed it was an aide) and was educated on customer service. - 1/27/20: grievance included an aide was rude, did not want to help just stood and watched, and was rough. Another aide was rude. Presses call light and staff do not respond. Staff was re-educated on customer service. A review of the 2-week staffing calculations indicated the facility did not meet the state minimal requirements for Certified Nursing Assistants on Sunday 12/1/19, Saturday 12/14 and 12/21/19, Wednesday 12/25/19, Tuesday 12/31/19, and Sunday 1/5, 1/12, 1/26, 2/2, and 2/9/20. On 2/20/20 at 3:30 p.m., the Staffing Coordinator confirmed having an issue with staffing on weekends. She stated when short, the facility tries to ask people (staff) to come in and pickup or to come in early, most of the time staff will only work 4 extra hours, or a 12-hour shift. The Nursing Home Administrator, present during the interview, stated the facility does try to get staff to stay or come in early even it is just for an hour. At 11:10 a.m. on 2/20/20, the Executive Director stated the facility does not have a policy for staffing, but provided the staffing portion of the facility matrix. The facility matrix indicated the facility staffs above state minimum requirements with a specific focus on adequate CNA staffing to accommodate the greater need for additional assistance with Activities of Daily Livings (daily care, bed mobility, transfer, walk-in room, toilet use, and eating). The population of the facility and the staffing levels provided are deemed sufficient based on: resident satisfaction, Quality Assurance/Compliance committee data, resident council feedback, resident interviews and observations, clinical outcomes, and functional improvements. 3. A confidential resident council meeting was held on 2/19/20 at 1: 00 p.m. 02/19/20 1:22 PM Resident Council Meeting 1:00 p.m. on 2/19/20. Nine of nine residents in the meeting expressed issues with sufficient staffing, especially on the 3:00 p.m. to 11:00 p.m. shift. These residents stated call lights are not answered timely when they are short staffed with times for response, ranging from 30 minutes to an hour on this shift. One resident stated I feel left behind when they don't answer my call light. Another resident stated she has had to wait to be assisted to the bathroom when the call light is not answered - sometimes over 30 minutes. All nine residents in the confidential meeting stated there are a lot of agency staff, they don't recognize the staff and the agency staff don't know how to take care of them, the residents have to tell them. They stated the agency staff don't know the residents and the residents don't know their names.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #118's Care Plan dated 5/21/19, Problem: Resident # 118 will not have adverse effects related to the use of Psychoactive Medications through next review. Interventions: (include but are not limited to) Staff will monitor behavior tracking Record. Observer Resident # 118 for change in mood/behavior (sleep pattern, fatigue, appetite, ability to concentrate, participation in activities and crying). Interview with corporate director on 2/20/2020 at 10:38 a.m. We do not have pharmacy recommendations for November and December for Resident #118. The Pharmacist stated during an interview on 02/20/20 at 5:58 pm that all residents on psychotropic medications should be monitored for behaviors. Review of Resident #130's Care Plan dated 6/11/19, revealed Problem: Psychoactive Medication, risk of adverse effects antianxiety and anti-psychotropic. Intervention: (includes but is not limited to) Staff will record behavior on Behavior Tracking Record. Observe Resident # 130 for changes in mood/behavior (sleep pattern, fatigue, appetite, ability to concentrate, participation in activities, crying.) Review of February 2020 Non-PRN Treatment notes for Resident #130 revealed that Resident #130's behavior is to be monitored during medication pass three times per shift. 14 out of 19 days No Behavior was entered. Per review of the resident's progress notes and medical record, there was no documentation of the resident exhibiting any behaviors. Additionally, on the Non-PRN Treatment notes behavior monitoring, there was no corresponding coding for outcomes of the intervention[s] attempted to reduce the behavior[s], the outcome of the intervention[s] used, and any side effects if a medication was used. Resident # 130 had no order for daily behavior monitoring three times daily. The medication and behavior to be monitored was not mentioned. On 2/20/20 at 2:47 p.m. the surveyor asked if she was able to identify the behaviors being monitored or the medication being monitored for side effects on the Non-PRN Treatment notes. The DON stated behavior monitoring in the February Non-PRN Treatment notes was following behavior as stated in care plan. The surveyor asked if there should be separate monitoring logs for anti-anxiety medications and anti-depressant medications. The DON stated, Yes. 4. A record review of the Face Sheet for Resident #104 revealed that he was admitted into the facility on [DATE] with diagnoses that included but were not limited to Dementia and anxiety disorder. Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #104 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of the February 2020 Physician Order Sheet revealed the following order: Ativan 0.5 MG Tablet (1 tablet)- Give one table by mouth as needed every 6 hours for anxiety starting on 01/20/20 A review of the February 2020 Medication revealed that Ativan was administered on 02/05/20 for continuous yelling/screaming. A review of the Consultant Pharmacist's Medication Regimen Review created between 11/01/19 to 11/25/19 revealed the following: Both PRN (as needed) orders need rationale and duration of therapy. A review of the Consultant Pharmacist's Medication Regimen Review created between 12/01/19 to 12/23/19 revealed the following: For therapy greater than 14 days, Ativan PRN needs a rationale and duration for continued therapy. The follow through note indicated physician to chart and monitor through psychotropic meeting. A review of the Consultant Pharmacist's Medication Regimen Review created between 01/01/20 to 01/17/20 revealed the following: Clarify Ativan PRN order. This order needs a duration of therapy with physician documented rationale. For therapy greater than 14 days, Ativan PRN needs a rationale and duration for continued therapy. The follow through note indicated. Order updated 01/20/20. There was no documentation that indicated that the physician had reviewed the recommendations. On 02/19/20 at 1:48 p.m., the Director of Nursing (DON) reported that PRN psychotropic meds should have a stop date. On 02/19/20 at 2:11 p.m., the DON stated that Resident #104 was on a PRN Ativan because he was on hospice. She stated I would have to contact the hospice nurse to see why he had been on the Ativan longer than 14 days. On 02/20/20 at 6:02 p.m., a phone interview with the Consultant Pharmacist revealed that she had an issue with residents being on PRN psychotropic meds for longer than 14 days. She stated that she had talked to the psychiatrist, DON, the physician, and everyone that she needed to. They just have not done it, stated the Consultant Pharmacist. The policy provided by the facility Behavior Management Plans and Suggestions revised on 11/2016 revealed the following: Procedure 2. Behaviors must be quantitatively and objectively documented, persistent, not caused by preventable reasons and are causing the resident to present danger to himself/herself or others or continuously screams, yells or paces which causes impairment in functional capacity. The policy provided by the facility Stop Orders for Acute Conditions revealed the following: Procedures f. PRN psychotropic medications (14 days). Note: PRN antipsychotic medications may only be renewed pursuant to the provider's direct re-evaluation of the resident. Based on observation, interview and record review, the facility failed to ensure the medication regimen was free from unnecessary psychotropic medications for five of six sampled residents. Three residents (#118, #130 and #36) lacked behavior monitoring and two residents (#104 and #50) lacked the rationale for the use of as needed psychotropic medications for over 14 days. Findings included: 1. Observation on 02/17/20 at 11:10 a.m. Resident #36 was lying in bed with the head of the bed elevated. Her call light was within reach. She became upset during the interview and the interview was halted. The surveyor thanked the resident for her time and excused herself. Resident #36 was admitted on [DATE]. Record showed diagnoses included but not limited to depression and Cerebral Vascular Accident (CVA). The physician orders and Medication Administration Record (MAR) for January and February showed: Zoloft (Sertraline) 100 mg tablet (100 mg) tablet every day starting 08/13/19 and discontinue on 01/23/20 for depression Zoloft (Sertraline) 50 mg tablet (150 mg) tablet oral every day starting 01/24/20 for major depression, an order date of 01/23/20. No behavior monitoring was evident in the MAR for January or February 2020. A physician order dated 01/23/20 showed increase Zoloft (Sertraline) to 150 mg in the a.m. A physician order dated 02/12/20 showed change Sertraline (Zoloft) to 50 mg daily. The medication card showed Sertraline (Zoloft) HCL 100 mg tablet, give one tablet by mouth once a day for depression. There were 15 pills in the medication card. Record review of the care plans showed the resident had a behavioral symptom care plan which showed she refused treatment at times. Interventions included but were not limited to monitor behavior episodes and attempt to determine underlying cause. Intervene as needed for safety. Review of the care plan related to anti-depression showed interventions included but not limited to assess and record effectiveness, monitor for sedation and anticholinergic and extrapyramidal symptoms, attempt Gradual Dose Reduction, monitor behaviors and response to medications. The behavior care plan showed interventions included to monitor for effectiveness and side effects of medications, monitor for behavior episodes and determine the underlying cause. During an interview on 02/19/20 at 3:10 p.m. the Director of Nursing (DON) verified that Resident #36 did not have behavior monitoring documented related to receiving an antidepressant. She stated that they do not monitor residents on antidepressant. During an interview on 02/20/20 at 8:56 a.m. Staff R, Licensed Practical Nurse (LPN) stated that Resident #36 was weepy sometimes. She stated that they do not perform behavior monitoring for her. She stated that if they did do behavior monitoring it would be in the blue book and the computer chart. 2. Observation on 02/17/20 at 1:06 p.m. Resident #50 was sitting at a dining table. She was trying to stand, and the staff was reminding her to stay seated. She was sitting in a high back chair and was chatting. She was able to feed herself and ate all of her lunch. On 02/18 at 8:50 a.m. she was sleeping in her bed. A fall mat was present beside the bed. At 9:30 a.m. she was noted to be in the dining room drinking juice. Resident #50 was admitted on [DATE]. Record showed diagnoses included but not limited to vascular dementia, altered mental status, psychosis, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 (severe impairment). She required extensive assistance for bed mobility, transfers and toileting. Her medications included an antipsychotic and an antianxiety. The February 2020 behavior monitoring showed she was anxious on February 2, 6, 13, 16, and 17. Review of physician orders and Medication Administrative Record (MAR) for February 2020 showed the resident was on Ativan 0.5 mg every 6 hours as needed for anxiety since 01/20/20; physical monitors: behaviors, non-drug behavioral intervention, number of incidents and side effects. Review of the Medication Regimen Review (MRR) for 12/01/19 to 12/23/19 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR report that showed Physician chart on rationale, review at psych meeting. Review of the Medication Regimen Review (MRR) for 01/01/2020 to 01/17/20 showed for therapy greater than 14 days, Ativan 0.5 mg every 6 hours prn needs a rationale and duration for continued therapy. There was documentation on the MRR that showed See physician note for rationale. Review of the psychoactive drug and behavior management committee minutes for Resident #50 showed she was reviewed on 12/19/19 No changes, will review next month. On 01/16/20, No changes, will review next month. Record review of the physician's progress note dated 12/05/19 showed the resident had done better in general with less agitation and aggressive behaviors. The plan included to change Risperdal to 1 mg at bedtime and 0.5 mg at 2 p.m. and to continue the Depakote. The note dated 12/19/19 showed the resident continued to exhibit episodes of agitation and irritability. She yelled out for no apparent reason. She had a bad day yesterday. The plan was to increase the Ativan to routine and increase the Risperdal. The note dated 01/09/20 showed the resident had been better in the past month with aid. The staff reported the resident does not do well with the 2 p.m. Risperdal. The plan was to attempt to decrease the Risperdal to find a minimum effective dose. During an interview on 02/19/20 at 3:15 p.m. the Director of Nursing (DON) verified that the physician progress notes did not address or give a rationale as to why Resident #36 needed to continue on Ativan as needed. She stated that the note stated they increased the Ativan in an attempt to decrease the Risperdal. The physician increased the Ativan to include a continuous p.m. dose, it did not address the as needed dose. During an interview on 02/20/20 at 8:50 a.m. Staff S, Licensed Practical Nurse (LPN), stated the resident had behaviors at times. She stated at present there were no pharmacy recommendations. She stated that the behavior monitoring was in blue book and was also in the computer. She stated that they were still using both. During an interview on 02/20/20 at 5:48 p.m. the consultant pharmacist stated that she was not sure if the facility was monitoring behaviors for residents on anti-depressants or not. She was not sure of the facility's policy regarding monitoring behaviors. She stated that we used to not monitor for these types of behaviors, but most facilities are doing behavior monitoring for antidepressants now. The facility has gone to a computer system and was doing some behavior monitoring on both paper and in the computer. She stated that they should be doing a paper or computer monitoring. She stated that she hoped they would get it in one spot. She stated that she would check on the monitoring the next time she was at the facility. She stated that she has spoken with the psych physician, the physicians, the DON, and nurses about the prn psychotropic medications and got, the yeses and have not seen any changes. The physician needs to document the rationale for the need for the prn psychotropic, if they are going to continue the medication. Record review of the facility's policy, Stop Orders for Acute Conditions, dated 11/17 showed new medication orders for acute conditions are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. the following classes of medications will not be automatically refilled after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given or in cases where the automatic discontinuation of a medication may lead to an adverse outcome. PRN psychotropic medications (14 day). NOTE: PRN antipsychotic medications may only be renewed pursuant to the provider's direct re-evaluation of the resident. Prescribers are notified prior to actual discontinuation in situations where termination/ discontinuation may result in treatment failure, clinical deterioration, or other adverse outcomes. When the prescriber gives the order for a medication covered by a stop order policy, the nurse requests a specific duration of therapy for that order. This then overrides the automatic stop order policy with the exception of PRN antipsychotic medications. Record review of the facility's policy, Medication Administration, dated 09/19 showed when prn medications are administered, the following documentation is provided: date and time of administration, dose, route of administration; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time results were noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure medications were stored in an orderly manner in one medication cart (2nd floor #1), and medications with a shortened open life were dated as opened in two medication carts (West 2 and [NAME] 3) out of three medication carts reviewed, and two of two refrigerated narcotic storage boxes were permanently affixed to the refrigerator. Findings included: An observation was conducted, on 2/18/20 at 11:06 a.m., with Staff Member L, Licensed Practical Nurse (LPN) of the 2nd Floor #1 medication cart. The blister packaged medications was divided in the drawers by separators labeled with room numbers and bed letters. In the area designated as 213A were blister packages containing medications prescribed to two different residents, both residing in room [ROOM NUMBER]. The staff member confirmed the area for 213A contained medications for two different residents. On 2/19/20 at 7:20 a.m., an observation of the [NAME] #3 medication cart was conducted with Staff Member M, LPN. The observation identified three opened vials of Lantus 100units/milliliter (u/mL), one opened vial of Humalog 100 u/mL, one opened Lantus insulin pen, and two opened Novolog Flexpens. The insulin vials and pens were undated with an open date. All of the insulin containers were labeled with a yellow sticker with areas to label with the date opened and the date of expiration. The yellow stickers instructed staff to discard after 28 days. The observation indicated an opened foil package of Ipratropium-Albuterol vials. Two vials were observed outside of the foil packaging. According to medline.gov/druginfo for Albuterol and Ipratropium oral inhalations, users were to keep unused vials of nebulizer solution in the foil pouch until ready to use them. An opened bottle of Dorzolamide and Timolol Ophthalmic drops was undated. A green sticker on the bottle of the Ophthalmic drops indicated it should be discarded after 60 days. Photographic evidence was obtained. Staff Member M confirmed the observation findings of the medication cart, [NAME] #3. On 2/19/20 at 7:40 a.m., Staff Member N, Registered Nurse (RN) was observed dating a Lantus insulin pen, 2/19/20. When asked if he had opened the pen, he stated no. Another insulin pen, Humalog, was observed dated 2/19/20, the staff member also confirmed he had dated the pen and had not opened it. Staff Member N confirmed both pens had been already opened and had dated them for today. A review of the [NAME] #2 medication cart with Staff Member N revealed an opened bottle of Latanoprost Ophthalmic solution. The bottle was undated as to when opened or an expiration date. A sticker on the Latanoprost bottle indicated the medication should be discarded after 42 days. An opened bottle of Active Liquid Protein was undated with an open date. The Active Liquid label revealed a 3 month shelf life from date opened. A clear bag contained several foil pouches of Ipratropium/Albuterol inhalation solution. Each of the foil pouches instructed the user not to remove from foil pouch. The clear bag contained 2 vials of the inhalation solution outside of the foil pouches. The bottom drawer of the medication cart contained injectable medication, topical patches, and oral medications stored within the same separated area. On 2/20/20 at 10:23 a.m., a review was conducted of the second floor medication room with Staff Member L, LPN. An observation of the medication refrigerator inside of the room indicated a metal box, unlocked, sitting on a grate-style shelf. The box was attached to the shelf, however the shelf had the ability to be removed from the refrigerator. Staff Member L confirmed the box and shelf could be removed from the refrigerator. The box contained two vials of Lorazepam prescribed to a resident and an emergency kit with four vials of Lorazepam. On 2/20/20 at 10:44 a.m., an observation of the [NAME] medication room was conducted with Staff Member D, LPN/Unit Manager. A plastic narcotic box was attached to a grate-like shelf inside of the refrigerator. The box contained three bottles of Lorazepam prescribed to a resident and a box of four vials of Lorazepam as an emergency drug kit. The Unit Manager confirmed the box and shelf could be removed from the refrigerator. On 2/20/20 at 3:12 p.m., the Director of Nursing (DON) stated the insulin Flex pens should be dated when opened, Anything with a shelf life should be dated. At 5:44 p.m. on 2/02/20, an observation was conducted with the DON of the [NAME] medication storage room. The DON stated the narcotic box should be permanently attached to the inside of the refrigerator. When the narcotic box was shown to be removable, she hung her head and shook it. At 5:48 p.m. on 2/20/20, the Consultant Pharmacist was interviewed via the telephone. The Consultant stated a nurse comes to the facility but was unsure if the medication carts were reviewed during those times. The consultant said the pharmacist does monthly reviews, but does not review all of them. The Consultant stated medications with a short-shelf life should be dated to ensure when the meds should be discarded and the narcotic boxes in the refrigerator should be permanently attached to the inside of the refrigerator. She confirmed two residents' medications should not be stored intermixed together. A policy titled, Medication Storage, dated 09/18, indicated medications were stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The procedure portion of the policy internally administered medications are stored separately from medications used externally and insulin products should be dated on the label when first used.

Based on observations, record reviews, and interviews, the facility failed to use appropriate hand hygiene while assisting two residents (Resident #85 and #12) with their meals, left nebulizer tubing unbagged for one resident (Resident #2), a catheter bag was stored inappropriately for one resident (Resident #127), and failed to ensure two glucometers were cleaned and disinfected in between residents appropriately and according to manufacturer's recommendation. Findings included: 1. On 02/18/20 at 11:41 a.m., observations were made in the main dining room on the second floor. Staff W, Certified Nursing Assistant (CNA), was observed sitting in the middle of Resident #85 and #12 at the table and assisting them with their meals. Continued observations revealed Staff W was assisting both residents with their meals by using her right hand only to assist both residents and was not noted to wash or sanitize her hands in between assisting the residents. Staff W was also observed giving the residents juice from a cup with the right hand only and was not noted to wash or sanitize her hands in between assisting the residents. At 11:45 a.m., Staff T, Licensed Practical Nurse (LPN), came to the table and gave Staff W a small bottle of sanitizer. On 02/18/20 Staff W stated that she did not know the procedure for assisting two residents at the same time. She stated that she had not had training on infection control. She confirmed that she assisted the residents with the same hand without sanitizing in between feedings. Staff W stated that the rules are changed every day. She stated, This person tells you one thing and the next person tells you something else. On 02/20/20 at 1:50 p.m., the Director of Nursing (DON) confirmed that you should be sanitizing in between feeding residents. A policy was requested related to infection control during dining and was not provided. On 02/17/20 at 11:51 a.m., Resident #127's catheter bag was observed on the floor in main dining room on the second floor. On 02/17/20 at 1:17 p.m., Resident #127 was observed sitting in the hallway near the nurses' station with the catheter bag on the floor. On 02/20/20 at 12:56 p.m., the resident was observed in his room and the catheter bag was on the floor. Staff K, Registered Nurse (RN), confirmed the bag on the floor. Staff L, Licensed Practical Nurse (LPN), stated that the bag was clipped on the bottom bar of the wheelchair and should have been on the top bar of the wheelchair. A review of the Care Plan Report revealed that the resident had a care plan in place for an indwelling urinary catheter with a goal date of 04/30/20. Interventions included but were not limited to staff would keep drainage bag off of floor and below bladder level. On 02/19/20 at 1:11 p.m., the Director of Nursing (DON) confirmed that catheter bags should not be on the floor. The policy provided by the facility Catheter Drainage Bag revealed the following: g. Ensure bag is positioned below level of the bladder and does not touch the floor. On 02/17/20 at 10:00 a.m., an observation of Resident #2 revealed a nebulizer mask and tubing were laying on the bed. The resident stated that they did not normally keep it in a bag. On 02/18/20 at 11:12 a.m., the nebulizer mask and tubing were observed on the floor in Resident #2's room. On 02/19/20 at 12:49 p.m., the nebulizer mask and tubing were observed on the bed in Resident #2's room. Staff L verified the nebulizer mask and tubing on the bed. On 02/19/20 1:15 p.m., the DON stated that the mask should be put in the bag and stored up in the drawer or on the table. The policy provided by the facility Nebulizers, undated, revealed the following: At the end of treatment, make sure med container is empty, and place T-piece or mask in clean bag. 2. On 2/18/20 at 4:20 p.m., an observation was conducted with Staff Member I, Licensed Practical Nurse (LPN) during a medication administration. The staff member removed an Evencare G3 glucometer from the medication cart, removed a Clorox Healthcare Bleach wipe from a canister in the bottom drawer. Staff Member I wiped the glucometer front and back with the bleach wipe and then discarded the wipe. The glucometer was visibly wet. The staff member placed another bleach wipe into a plastic cup; another bleach wipe was used to clean a gray plastic tray. When asked how long the glucometer was to stay wet, Staff Member I voiced she did not know. The Clorox bleach wipe container was reviewed and the staff member confirmed the contact time for the wipe was 3 minutes. Staff Member I confirmed the bleach wipe was not in contact with the glucometer for 3 minutes and had not killed, if any, C-diff spores. A review of the Clorox Healthcare Bleach Germicidal Wipes container, indicated the wipes kills C. Difficile spores in 3 minutes in a yellow square on the front panel. The instructions indicated: - wipe surface to be disinfected. - Use enough wipes for treated surface to remain visibly wet for the contact time listed. - Let air dry. The container of Clorox wipes indicated the following contact times to kill pathogens: - Clostridium difficile - 3 minutes - Bacteria - 30 seconds - Viruses - 1 minute - Bloodborne pathogens - 1 minute - TB - 3 minutes - Parvoviruses - 3 minutes - Fungi - 3 minutes On 2/18/20 at 5:16 p.m., Staff Member J, Registered Nurse (RN), was observed to obtain a blood glucose level and administer medications to a resident. When asked how the glucometer was cleaned, the staff member looked at a clipboard on the medication cart, flipped it over, removed a Medline MicroKill wipe from the bottom drawer, and wiped the glucometer. The container of Medline Micro-Kill One Germicidal Alcohol Wipes listed pathogens that did not include Clostridium difficile. To kill pathogens with Micro-Kill One wipes, surfaces were to remain wet for one full minute. The Director of Nursing stated, on 2/18/20 at 6:12 p.m., her expectation for cleaning a glucometer was to clean it before and after each resident. She stated staff were to use the purple top wipe, Germicide (Micro-Kill One), contact time was one minute, and allow it to air dry. The DON stated the germicide kills everything and was the glucometer manufacturer recommendation. At 6:25 p.m. on 2/18/20, the DON provided a container of both a purple topped Micro-Kill One and Clorox Bleach wipes. She confirmed C-diff was not listed on the germicide and the glucometer, if disinfected with Clorox, should be wet for 3 minutes. When asked how the facility dealt with the disinfection of a glucometer used for a resident with C-diff, the DON stated incorrectly using Micro-Kill. The policy titled, Glucometer Disinfection, undated, indicated glucose monitors will be disinfected after each patient's use to prevent the spread of Bloodborne Pathogens per the manufacturer's recommendations. The policy identified the equipment needed was gloves and Medline Micro-Kill+. The procedure portion of the policy instructed staff to clean the meter surface with Medline Micro-Kill disinfecting wipes and allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions of use. The policy titled, Clostridium Difficile, revised 10/1/19, revealed alcohol rubs are not effective as C. difficile is a spore producing organism and bleach is the only effective environmental cleanser to date. According to https://www.medline.com/media/catalog/Docs/MKT/MAN_EvenCare%20G3%20Users%20Guide.pdf, the following products are approved for the cleaning and disinfection of the Evencare G3 glucometers: - Dispatch Hospital Cleaner Disinfectant Towels with Bleach - Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol - Clorox Healthcare Bleach Germicidal and Disinfectant Wipes - Medline Micro-Kill Bleach Germicidal Bleach Wipes

Based on observations, record reviews, and interviews, the facility failed to store, prepare, and distribute, serve food in accordance with professional standards for food service safety and failed to maintain the kitchen in a sanitary condition. Findings included: On 02/17/2020 starting at 9:15 a.m., an initial tour of the kitchen was conducted with the Operations Manager and the Corporate Food Service Director. An excessive amount of dust was observed on the ceiling vent above the ice machine. Black buildup was observed on the ceiling vent in the area between the stove and walk in cooler. The ceiling tiles near the cooking and food prep area were observed to have an excessive amount of food splatter and dust (photographic evidence obtained). Water damage was observed on the ceiling tile right above the food serving area. The Operations Manager reported that the ceilings were cleaned every couple of months. There was a missing vent above the tilt skillet and the third vent was ajar (photographic evidence obtained). The Operations Manager that they had a work order in for the vents. The sanitizer in the three-compartment sink in the dish washing room was tested at 500 parts per million (ppm). The Operations Manager stated he would call state chemical now because the sanitizer should be at 200 ppm. Black buildup was observed near the corner of the three-compartment sink. The tile in the corner was also noted to be cracked, and there was food splattered on the wall (photographic evidence obtained). Paint was peeling on the wall next to the three-compartment sink. The Operations Manager reported that they had a work order in for the wall. Boxes of water were stored on the floor in the hurricane closet. The Corporate Food Service Director stated that the boxes should not be on the floor. A review of the policy provided by the facility Dry Storage Areas, undated, revealed the following: 1. All items must be stored at least 6 inches off the floor. On 02/17/19 at 10:37 a.m., the Corporate Food Service Director reported that they had started replacing ceiling tiles in the kitchen tiles. At 10:46 a.m., he reported that cleaning solutions had fixed the sanitizer in the three-compartment sink. A Work Order for the hood system was created on 12/11/19 and had not been repaired. A Work Order for painting the dish room wall was created on 12/23/19 and had not been repaired. On 02/19/19 at 10:42 a.m., the Operations Manager reported that some things are quicker than others to get fixed. The hood vents had to be customized, but the work order was submitted. On 02/20/20 at 10:00 a.m., the Executive Director reported that they did not have a policy in place for maintenance requests or maintenance of the facility. At 10:37 a.m., the Executive Director reported that all work orders were submitted electronically and that there was a 24 hour turnaround time. On 02/19/19 at 10:35 a.m., the surveyors entered the kitchen for a follow up observation. At 10:40 a.m., wet lids for the trays were observed stacked on top of one another (photographic evidence obtained). This was confirmed by the CDM (Certified Dietary Manager). At 10:44 a.m., the three-compartment sink in the dish room tested at 400 ppm. The Operations Manager stated that they would drain and retest it. He stated that he would get the chemical company back out to fix it. The Operations Manager reported that staff knew that the sanitization was too high and did not report it. He was asked why they were recording 200 ppm on the log every day and he stated that he asked the same question. A dirty fan was observed blowing on clean dishes while staff were washing dishes. Staff reported that they had the fan to keep them cool. Stacks of trays were observed cracked and chipped. Sheet pans were observed very worn with black buildup. At 10:54 a.m., the CDM reported that the trays were just old. At 11:17 a.m., staff was getting ready to put meal trays on a sheet pan for serving. The surveyor observed old dried-up food stuck to the sheet pan. Surveyor asked the staff member what was on the pan and she peeled old food from the pan. Old food was observed on another sheet pan. CDM told staff not to use the sheet pans. The ice machine on the east and west units were observed to have white buildup and rust (photographic evidence obtained). At 11:26, on the care unit, the microwave was observed to have rust in the inside at the top. The CDM reported that it needed to be replaced. A review of the Main Kitchen Cleaning Deep Clean Schedule revealed that ice machine was cleaned by a contracted company and the vents and ceilings were cleaned quarterly. A review of the contact for cleaning the ice machine revealed that the ice machine was cleaned every 6 months. A review of the Dish Room Pot Sink Sanitizing Log revealed that the PPM (parts per million) was 200 everyday from 02/1 through 02/18. A review of the policy provided by the facility Cleaning Dishes Manual Dishwashing, undated, revealed the following: Policy Dishes and cookware will be washed after each meal to assure that all dishes are clean and sanitary. Procedure: Sink 3 Sanitize 1. Measure appropriate amount of sanitizing chemical into appropriate amount of water (following manufacturer's guidelines). 2. Test sanitizing solution in sink using manufacturer's suggested test strips to assure appropriate level. 3. Place dishes in the sanitizing sink. Allow to stand according to manufacturer's guidelines for sanitizer. 4. Allow dishes to air dry. Invert dishes in a single layer to air dry. Check all dishes to be sure they are clean and dry prior to storing.