**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide access to activities for one resident (#74) out of one resident sampled for activities. Findings included: On 11/13/2023 at 8:25 AM, Resident #74 was observed sleeping in bed. Floor mats were observed on each side of the bed. On 11/13/2023 at 11:45 AM, Resident #74 was observed in bed. The roommates television (TV) was on. On 11/13/2023 at 2:30 PM, Resident #74 was observed in bed. The resident was observed with the head of the bed slightly raised, utilizing the left hand, and tapping on the overbed table. Resident #74's TV was not on, but the roommate's TV could be heard. On 11/14/2023 at 9:05 AM, Resident #74 was observed in bed, with the head of the bed at a 90-degree angle, being assisted with breakfast. Resident #74 stated breakfast was good. Resident was utilizing left hand to tap on the over bed table. On 11/15/2023 at 3:30 PM, Resident #74 was observed in bed with the head of the bed raised. Resident #74's TV was on, and was facing bed A, not toward the resident. An interview was conducted with Resident #74's family member on 11/14/2023 at 10:30 AM. The family member stated she insisted the facility get Resident #74 up for lunch. She stated she took the resident to the dining room across from the nurses' station, and was told the area was not really a dining room, so she could not assist the resident to eat in the area. She stated, I was very perplexed as other residents are permitted to eat in the room. I was told [Resident #74] would be getting up for lunch and going to the dining room on the other side of the facility, which was fine with me. The facility got [Resident #74] up for one or two days and then stopped. I had to insist they get [Resident #74] up so we can go outside. The facility told me [Resident #74] was only permitted to be up for two hours due to her wound, of course I don't want anything to impede healing. The rest of the time [Resident #74] just lays in the bed looking at the walls. [Resident #74] has a TV but needs to get out of the room or have something in the room to do. Every time I come [Resident #74] says, 'bored'. [Resident #74] has started a habit of tapping on the over bed table. I think [Resident #74[ started this behavior due to boredom and anxiety, with nothing to do. The only activities offered are the ones I offer her. No one from activities comes to the room to offer something different to do. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 11/15/23 at 9:50 AM. Staff B, LPN stated Resident #74 does not get up for breakfast and does not normally get up for lunch until recently, as the family member comes to assist the resident. An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 11/15/23 at 10:00 AM. Staff A, CNA stated regularly working with Resident #74. Staff A, CNA stated the resident is assisted to eat in her bed for breakfast and only recently gets up for lunch. She stated, I don't see anyone doing anything with Resident #74, only the [family member]. I only provide care not activities. An interview was conducted with Staff G, Registered Nurse (RN) on 11/15/23 at 3:45 PM. Staff G, RN stated Resident #74 does not get up for dinner. An interview was conducted with Staff R, CNA on 11/15/23 at 4:05 PM. Staff R, CNA stated Resident #74 does not get up for dinner. An interview was conducted with the Activity Director (AD) on 11/16/2023 at 8:11 AM. The AD stated the activities department goes room to room and asks residents if they would like to attend the activities for the day. She stated they try to go back and bring the residents to the group activities. The AD stated the facility does complete 1:1 visits with some of the residents who cannot get out of their rooms. The AD stated Resident #74 was not one of those residents. The AD stated residents on the rehabilitation side do not usually want to go to activities and they do not really have to provide much support to the rehabilitation side. An interview was conducted with the Registered Dietitian (RD) and the Nursing Home Administrator (NHA) on 11/16/2023 at 9:35 AM. The NHA stated Resident #74 was admitted with numerous wounds and poor nutritional status with protein deficiency. They stated they had been working with the family member on providing a dining experience that would reduce the distractions for the resident, and permit Resident #74 to focus on eating. They stated they had assigned Resident #74 to sit in a smaller dining room to accomplish this goal for the last two weeks. They stated, the staff know to get Resident #74 up for lunch and dinner and to take Resident #74 to the smaller dining room on the other side of the building. They stated they verbally told the nurse on floor, the Unit Manager (UM), the evening supervisor, and the weekend supervisor. A review of Resident #74's admission Record showed Resident #74 was admitted on [DATE] with the following diagnoses: Pressure Ulcer of sacral region, stage 4; atrial fibrillation; necrotizing fasciitis; dementia, anxiety plus other co-morbidities. A review of Resident #74's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 6 out of 15, indicating severe cognitive impairment. Section G: Functional Abilities revealed the resident was dependent on the facility staff for bed mobility, toileting, showering, eating, and dressing. A review of Resident #74's PG Life Enrichment Assessment - V 2, dated 9/30/2023, revealed the following: 4. Daily routine-prefers to spend free time in room, prefers to participate in leisure activities mostly in morning, and preferred activity setting in own room. 5. Leisure interest-several interests marked very important included computer/games, clothes/fashion, crafts, exercise, music, gardening/plants, snacking, pet therapy, spiritual and family/visitors. Interests marked somewhat important included reading, TV, talking/conversation, and group activities. A review of Resident #74's Care Plan, dated 10/17/2023, revealed the following: Focus: Resident #74 prefers being involved in self-directed activities, no interest in group activities. Listen to Music, spend time outside weather permitting, spend time with visitors, watching/listening to TV. Goal: Resident #74 will show no signs and symptoms of social isolation/sadness through next review. As evidenced by: no longer engages in self-directed activities of expressed interest, increased refusal for care or therapy, not engaging with visitors and staff. Interventions: Address Resident by preferred name, encourage Resident #74 to be active daily, give pastoral visits for opportunities for Resident #74 to exercise her spirituality, invite and escort to activities as resident elects/chooses of choice, provide daily meet and greet visits and give Resident the daily chronicle with the activities for the day listed, and provide materials needed for in-room activities as needed. A review of the policy titled Live Enrichment Manual, dated 11/22, revealed the following: -Life enrichment programming can enhance quality of life for guests/residents by integrating meaningful and enjoyable activities into daily experiences. Facility team members plans, coordinates, encourages, and supports a variety of recreational and therapeutic activities for all guests/residents based on individually identified needs, interests, culture, and background. -Life enrichment programs are developed and implemented to meet the individualized physical, mental, spiritual, and psychosocial/emotional needs of the guest/resident as well as promoting self-expression and choice. Activities refer to an endeavor, other than routine activities of daily living, in which a guest/resident participates in activities that enhances his/her sense of well-being and that promotes or enhances physical, cognitive, and emotional health. -Guest/residents are encouraged, but not required, to attend and participate in recreational and therapeutic activities in a group setting, one-on-one, or self-directed activities. . Procedure: 3. Share with guest/resident and family the center schedule of life enrichment activities and assist in identifying areas programs of interest *If there are no scheduled programs of interest to the guest/resident, discuss plan to schedule desired activities. 10. Assist and support other life enrichment programs as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/13/2023 at 7:30 a.m. Resident #62 was observed sitting at his bedside getting ready for breakfast. He stated that he was concerned regarding his refrigerator being taken away without notice, and he wanted to have it back in his room. On 11/13/2023 at 11:00 a.m. review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses to include Type II Diabetes Mellitus, obesity, adult failure to thrive, hypertension and insomnia. Review of the admission Minimum Data Set, October 2022, revealed in Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. An interview with Resident #62 on 11/15/2023 at 11:45 a.m. confirmed he had a refrigerator, and it was removed several months ago. He stated the Nursing Home Administrator (NHA) was removing all the refrigerators because residents were not following the facility policy to keep them clean. Resident # 62 stated he asked the NHA to look at his refrigerator and she stated to him she wished hers was as clean at her home. Resident #62 stated at no time was he informed he did not follow facility policy for the care of the refrigerator. Resident #62 stated he keeps his extra milk from dietary in the refrigerator, he keeps his soda his family brings to him in the refrigerator as well. He stated using the refrigerators on the nursing unit is an inconvenience and he has to get someone to unlock the door to the nourishment room. Review of the care plan, dated 11/2/2022, revealed the following: Focus: Resident will remain in long term care at the facility, and the goal will be to adjust to facility living without difficulties, and the intervention will be to provide services in an effort to enhance well-being. Focus: Resident prefers self-directed activities with a goal of being involved in activities of his choosing, and an intervention of in room activities of his choice. Focus: Resident is at risk for malnutrition related to adult failure to thrive, a goal of no weight loss and with an intervention of honoring preferences and diet as ordered. Review of a progress note dated 7/18/2023, and signed by the facility psychiatric service provider, revealed, [Resident #62] is being seen for depression and insomnia follow-up. Resident is in good spirits he reports his appetite is fair and that depends on the food. He admits that he orders take out with other residents. During an interview on 11/16/2023 at 9:50 a.m., with the Nursing Home Administrator (NHA) and the Dietician, the NHA stated a meeting was held with the resident regarding his request for a refrigerator in his room. The meeting was held with the resident and his family member. The NHA stated the resident's family member stated she does not feel Resident #62 is capable of following the facility policy to maintain the refrigerator and she is not able to help Resident #62 maintain the refrigerator. The NHA stated facility notes went out to the residents with refrigerators on August 21, 2023, regarding the removal of refrigerators, and on August 26, 2023, regarding storage of any refrigerators. Review of a progress note dated 5/31/2023, by the NHA revealed the meeting with the resident and family member acknowledged and agreed to the facility terms to have a personal refrigerator within the resident's room. Resident #62 and family member agreed to clean the refrigerator, temperature check the refrigerator, and keep the refrigerator in good repair for the resident's and facility's safety. There were no further progress notes related to denial of Resident #62 having a refrigerator in his room and no notes related to him not following facility policy for maintaining the refrigerator. During an interview with Resident # 62 on 11/16/2023 at 11:45 a.m. the resident stated the NHA told him the refrigerator had to be removed as there were other residents that did not keep their refrigerators clean and so all of the refrigerators in the facility had to be removed. He stated he was not given any letter regarding the removal. He stated that his family members help him with whatever he needs, and they bring him any items that he needs. He stated that his family members visit him weekly. He stated that when the NHA came to see him about the refrigerator and told him it was because residents are not keeping the refrigerators as per facility policy, he asked her to look at his and he stated that she told him she wished hers at home was as clean as his was. Resident #62 stated that he has not received any written notices and that no one spoke with a family member as far as he knows regarding care of the refrigerator. Interview with Staff K, Certified Nursing Assistant/Unit Clerk/Transport Driver (CNA/UC/TD) stated Resident #62's family members visit several times a week and they come in the evenings as they work during the day. Review of a facility memo, dated August 21, 2023, revealed the following: As of today, Palm Garden of [NAME] will no longer permit use of personal refrigerators in resident/guest rooms due to health and safety concerns. All personal refrigerators need to be removed by the end of day on August 24, 2023. If you are unable to arrange for the removal, the facility will place the refrigerator in resident/guest storage for a short period of time while arrangements are made for picking up the personal item. Please call [phone number] if you have any questions. The facility has nourishment rooms on each unit for storage of food items. We ask that your personal items be labeled for identification purposes. Review of the policy titled, Culinary Services - Resident Personal Food, December 2018, revealed the following: Policy: All residents have the right for family members and visitors to provide preferred or requested foods and fluids from outside of the facility, except where the health and safety of the individual or other residents would be endangered. Items brought into the facility will be stored under sanitary conditions. Procedure: Personal refrigerators will be allowed in resident rooms at the discretion of the Executive Director. Resident or designee will be responsible for monitoring and maintaining the refrigerator in accordance with standards of food safety. Review of the policy titled, Resident [NAME] of Rights - A Guide To Your Rights As A Resident, revised July 2021, revealed the following: B. Notes of Rights and Services: The center must inform the resident, both orally and in writing, in a language that the resident understands of his or her rights and all the rules and regulations governing resident conduct and responsibilities during the stay in the center. The center must also provide the resident with notice (if any) of the state plan developed under section 1919 (e)6 of the act such notification must be made prior to or upon admission, and as appropriate during the resident stay, and when the centers rules change. The resident has the right to be informed of his/her rights and of all rules and regulations governing resident conduct and responsibilities during his/her stay in the center, anytime state or federal laws relating to the residents right or center rules change during the resident stay in the center he/she must be promptly informed of those changes N. Personal Property: The right to retain and use personal possessions including some furnishings, and appropriate clothing as space permits, unless to do so would infringe upon the rights or health and safety of other residents. The center shall exercise reasonable care for the protection of the resident's property from loss or theft. Based on observations, interviews, and record reviews, the facility failed to allow two residents (#64 and #62) out of 40 sampled residents to exercise their autonomy related to the individual preference of having a personal refrigerator in their room. Findings included: 1) The review of Resident #64's admission Record identified the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to cervical spina bifida with hydrocephalus, moderate protein-calorie malnutrition, and unspecified paraplegia. On 11/14/23 at 9:24 a.m., Resident #64 reported having a personal refrigerator and the facility had removed it about 3-4 weeks before his birthday in June. The resident stated the facility informed him the removal was due to health and safety. The resident reported being able to maintain the refrigerator and it had contained cans of soda. Resident #64 reported it was a new refrigerator bought by a family member. During the interview, a refrigerator was not observed in the resident's room. On 11/15/23 at 3:25 p.m., Resident #64 stopped writer in hallway and again reported the facility had removed a personal refrigerator from his room. The resident reported being informed of the removal right before they took it, it had a 6 pack of cola in it, and he could clean it by himself. The resident stated the Nursing Home Administrator (NHA) informed him the refrigerator was in storage. An observation, on 11/16/23 at 1:36 p.m., identified Resident #64 propelling self in wheelchair in the hallway and was able to maintain control of it using both hands. Review of Resident #64's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. The MDS revealed the resident required extensive assistance from one person for bed mobility, dressing, and toileting, was independent with locomotion on and off unit, and required limited assistance from one person for personal hygiene. On 11/15/23 at 1:52 p.m., Staff N, Certified Nursing Assistant (CNA), stated Resident #64 had a refrigerator and about 2-3 months ago they (management) came around and took them all out saying it was because of health and safety issues. The Executive Director (ED) provided, on 11/16/23, a copy of a handwritten list of thirteen resident names, which included Resident #64's. The list was dated June 2023, Resident #64's name had a X next to name with Sat - Birthday. Resident #64 was the only name with a X next to it, others had notations with bullet points in front of the name. A handwritten list of refrigerators, dated July 2023, did not include Resident #64's name and included 11 other resident names. The resident names had x after the name, with no indication of what x meant. A handwritten list of Refrigerators, dated 8/15/23, included 10 resident names - 3 with ok, 1 identified I did, 6 noted no. Additional information listed was two additional resident names, one of which was Resident #64's, dated 8/21/23, both of the names were followed by no. The list for August 2023 did not identify what no, ok, or I did meant. The lists provided by the ED did not identify the staff member or members who had noted the refrigerators, revealing multiple staff had been involved. On 11/16/23 at 3:15 p.m., the ED stated residents were assessed on their ability to clean the personal refrigerators and maintain temperature logs, and as a team the personal refrigerators were determined to be a safety issue as well. The ED reported residents were notified by memo and representatives received a robo-call to inform them of the removal. On 11/16/23 at 3:34 p.m., the ED stated Resident #64's refrigerator had not been managed appropriately and no resident and/or representative had been able to maintain the personal refrigerators so all had to be removed. The NHA stated during a resident council meeting the residents were notified that they or their representatives would have to maintain the refrigerators. She reported there were nutrition refrigerators on the units that residents could use. The NHA was unable to provide documentation that determined Resident #64 had not maintained his personal refrigerator. She reported she had the documentation in sooooo many areas, not knowing she would have to have access to it, and sent the Director of Nursing (DON) to the unit to look for the documentation. The NHA stated the Ombudsman was notified of the refrigerators removal and did not have an issue with the decision. A review of the Resident Council meeting notes from May 2023 identified the council was informed on 5/10/23 that all residents having refrigerators in their rooms must be able to maintain/clean them and no coffee machines were allowed in resident rooms. The meeting notes, from 5/10/23, revealed Resident #64 had not attended the meeting. The review of Resident #64's progress notes did not reveal the resident was notified of the need to maintain or had been educated on maintaining the personal refrigerator in accordance with the standards of food safety. A letter provided by the ED and addressed to Resident #64, dated October 26, 2023, identified the facility was storing the residents refrigerator and it needed to be removed from our center to a permanent location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to inform the resident/resident representative of a change in status and change in medication for two residents (#99 and #314) of two residents sampled for change of status. Findings included: 1) Review of the admission Record revealed Resident #99 was admitted to the facility on [DATE], with diagnoses to include surgical aftercare following surgery on the digestive system, difficulty in walking, malignant neoplasm of the pancreas, and other co-morbidities. An admission Minimum Data Set (MDS), dated [DATE], for Resident #99 showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 11/13/2023 at 8:18 AM, Resident #99 stated, My discharge medication list from the hospital and my surgeon showed Lovenox to be given to prevent thrombosis, which I have had in the past. I received two injections from here, then the nurses stopped administering. I wasn't receiving the medication. I kept asking the nurses for it. I know how important this medication is to prevent me from having a stroke. I did not hear anything from them, they just said I was being difficult. I even showed them the discharge paperwork the hospital had given to me. The paperwork clearly indicates continue the Lovenox. I had to get my family involved. When my family checked, they were told, the Advanced Practice Registered Nurse (APRN) from the facility discontinued the Lovenox. No one discussed this change with me or my surgeon. My surgeon called and the medication was restarted. This should not have occurred without my knowledge or my surgeons. Review of the Medication Administration Record (MAR) for the month of October 2023, showed Resident #99 received Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG (milligram)/0.4 ml (milliliter) (Enoxaparin Sodium) generic for Lovenox, inject 0.4 ml subcutaneously in the evening for prophylaxis, on 10/14/2023 and 10/15/2023. The order was discontinued on 10/16/2023 at 1636. An order was started on 10/18/2023 for Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4 ml (Enoxaparin Sodium) generic for Lovenox, inject 0.4 ml subcutaneously in the evening for Deep Vein Thrombosis (DVT) upper extremity and was given for the remainder of Resident #99's stay. 2) Review of the admission Record revealed Resident #314 was admitted to the facility on [DATE], with diagnoses to include Rhabdomyolysis (skeletal muscle breaks down rapidly), centrilobular emphysema, history of falls and other co-morbidities. On the admission Record under contacts the resident is listed as responsible party. Resident #314's Clinical admission Assessment marked the resident as alert & oriented x 3, communicated verbally, speech is clear, can understand and be understood when speaking. During an interview on 11/13/23 8:13 AM, with Resident #314 and a family member, who is his health care surrogate and primary care giver, the family member stated, I guess he fell the other day; they did not call me when the fall occurred. They told me when I got here today. Review of Resident #314's Progress Notes with an effective date of 11/12/2023, 7:41 AM showed the following: Resident was observed on the ground by the CNA. CNA reported the incident to the nurse. Comprehensive assessment completed and no abnormal findings and will continue to monitor for any pertinent changes. Review of Resident #314's Therapy Screen Form - V4 with an effective date of 11/12/2023 at 5:06 PM. showed the following: Resident #314 was referred to therapy due to a fall on 11/12/2023. A Physical Therapy Assistant denied completing the screen as Resident #314 was already being seen by physical and occupational therapy. An interview was conducted with the Director of Nurses (DON) on 11/15/2023 at 3:51 PM. The DON stated he was not aware of Resident #314's fall and would have to ask the Unit Manager. The DON stated the expectation for notification of changes would be shortly after the incident or changes to the medications. Review of a facility policy titled, Nursing - Change in Residents Condition or Status, effective date: October 2014, showed the following: Policy: The facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Procedure: . 3. Unless otherwise instructed by the resident, the nurse supervisor/charge nurse/designee will notify the resident's family or representative when: * The resident is involved in any accident or incident that may or may not have resulted in an injury, including injuries of an unknown source; *There is a significant change in the resident's physical, mental, or psychosocial status; . 4. Regardless of the resident's current mental or physical condition, the nursing supervisor/charge nurse will inform the resident of any changes in his/her medical care or nursing treatments. 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide treatment and care according to physician orders for non-pressure related skin conditions for two residents (#314 and #316) of two residents sampled for skin conditions. Findings included: 1) On 11/13/23 at 08:13 AM, Resident #314 was observed laying in the bed, sheet up to waist with arms on top of the sheet. Resident had a soiled dressing, with dried blood visible to his left forearm dated 11/12/2023. Directly above the left forearm was a soiled folded gauze with medical tape wrapped around the arm, undated. A soiled dressing to left elbow, the dressing was peeling off and undated. The dressing to the right elbow was soiled with red and brown bloody drainage and starting to peel off the skin dated 11/12/2023. (Photographic Evidence Obtained). During an interview on 11/13/23 at 12:00 PM, the family member of Resident #314 stated the resident had several skin areas that needed bandages, the ones you can see on his arms and on both of his legs. The family member stated the bandages on his legs look just as bad as the ones on his arms. The family member stated you should have seen the bandages yesterday, all the bandages were so saturated the bed was wet from the leakage. The family member stated, I kept asking for someone to come and change them. I could not get anyone to come change the bandages until I stood in front of them. Resident #314 confirmed this was an issue. Review of the admission Record revealed Resident #314 was admitted to the facility on [DATE], with diagnoses to include Rhabdomyolysis (skeletal muscle breaks down rapidly), centrilobular emphysema, history of falls and other co-morbidities. On the admission Record under contacts the resident was listed as responsible party. Resident #314's Clinical admission Assessment marked the resident as alert & oriented x 3, communicated verbally, speech is clear, can understand and be understood when speaking. Review of Resident #314's N Adv - Clinical admission evaluation, dated 11/10/2023 at 7:53 PM, revealed the resident was admitted with skin impairments to the right and left anterior elbow, the right lower leg, and right knee. Review of Resident #314's hospital history and physical revealed the resident had dressings on in the hospital and an order to change dressings daily. Review of Resident #314's Physician Order Summary Report showed no orders for treatments to the left elbow, left wrist, right elbow, and right knee until 11/13/2023 at 2:44 PM. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:44 PM Cleanse Left elbow with normal saline, pat dry, apply Xeroform, cover with abdominal pad then wrap with Kerlix every two days and as needed (PRN) if soilage or dislodgment. Order was discontinued on 11/15/2023. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was provided on 11/14/2023. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:44 PM Cleanse Left wrist with normal saline, pat dry, apply Xeroform, cover with abdominal pad then wrap with Kerlix every two days and PRN if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was provided on 11/14/2023 and 11/16/2023. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:40 PM Cleanse Right elbow with normal saline, pat dry, apply Xeroform, cover with abdominal pad then wrap with Kerlix every two days and PRN if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was provided on 11/14/2023, 11/15/2023 and 11/16/2023. Review of Resident #314's Physician Order Summary Report showed an order dated 11/13/2023 at 2:44 PM Cleanse Right knee with normal saline, pat dry, apply Xeroform, cover with bordered gauze island dressing every two days and PRN if soilage or dislodgment. As needed for skin tear. Order discontinued on 11/15/2023. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was not provided. During an interview on 11/13/2023 at 3:00 PM, Staff B, Licensed Practical Nurse (LPN) confirmed the resident did not have orders for treatments until 11/13/2023. Staff B, LPN stated orders should have been requested at the time of admission. 2) On 11/13/23 at 08:18 AM, Resident #316 was observed, dressed, and lying on top of the bed. Resident's left foot was observed with a bandage that was not secured to itself or the resident. The bandage was barely covering the resident's recent surgical incision (amputation of the toes). The bandage was loosely wrapped from the top of the foot to the heel and around the ankle. The bandage had no visualized drainage or discoloration. The incision site had no discoloration, ointments, or cream observed. (Photographic Evidence Obtained). During an interview on 11/13/23 at 8:18 AM, Resident #316 stated she had requested all weekend for the nurses to fix the bandage as it was falling off. No one would listen or help. The resident stated knowledge of the treatment needed, and said there should be an orange medicine applied to the incision and this not being done. Resident #316 stated the physician had said to keep the incision clean and not to put pressure on it. Review of the admission Record revealed Resident #316 was admitted to the facility on [DATE], with diagnoses to include dehiscence of amputation stump; left foot amputation partial, open wound to the left foot, Peripheral Vascular Disease, muscle weakness, dysphagia, cognition, need for assistance, hypertension, and other co-morbidities. On the admission Record under contacts the resident was listed as responsible party. Review of Resident #316's Brief Interview for Mental Status (BIMS) reveals a score of 13 out of 15, indicating the resident is cognitively intact. Review of Resident #316's Physician Order Summary Report showed an order dated 10/30/2023. Cleanse left lower extremity with normal saline, pat dry, apply Betadine then wrap with Kerlix daily and as needed (PRN) if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was document completed from November 1st to 15th. Review of Resident #316's Physician Order Summary Report showed an order dated 10/30/2023. Cleanse left foot with normal saline, pat dry, apply Betadine then wrap with Kerlix daily and as needed (PRN) if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was document completed from November 1st to 15th. Review of Resident #316's Physician Order Summary Report showed an order dated 10/30/2023. Cleanse left heel with normal saline, pat dry, apply Betadine then wrap with Kerlix daily and as needed (PRN) if soilage or dislodgment. A review of the Treatment Administration Record (TAR) for November 2023 revealed treatment was document completed from November 1st to 15th. During an interview on 11/16/2023 at 8:00 AM with Staff H, LPN, a review of the photographs of Resident #314's left and right arms was conducted. Staff H, LPN stated a recollection of 11/13/2023 when a family member requested dressing changes, and confirmed the dressings should have been changed when soiled and dated when completed. Reviewed the photographs of Resident #316's bandage on 11/13/2023. Staff H, LPN stated a recollection of that dressing as well and confirmed the bandage should have been changed, secured with tape and dated. Staff H, LPN stated the bandage did not appear to have the Betadine applied but Staff H, LPN was not here and could not confirm. During an interview on 11/16/23 at 1:26 PM with the Director of Nursing (DON) a review of the photographs for Resident #314 and #316's bandages was conducted. The DON stated the bandages should have been changed. The DON stated the expectation is for the physician's order to be followed and the bandages should be dated when placed. Review of the Policy and Procedure titled, NURSING PROCEDURE MANUAL Clean Dressing Change (Wound/Surgical Site), dated 07/2023 showed: Purpose: * To prevent contamination of the wound. * To protect adjacent skin surfaces from irritation due to wound drainage. *To promote wound healing. Procedure: 1. Verify physician's order for dressing change and pain medication. 4. Identify a guest/resident, explain procedure, and provide privacy. 8. Observe the amount, color, and odor of drainage and condition of wound bed or incision. 18. Document date, time dressing changed, and initials on a piece of tape and place on dressing. 23. Document the following in the electronic medical record: Date and time of dressing change; Amount of drainage, color, and odor; Any unusual appearance of wound or peri-wound area; Complaints of pain or discomfort; Guest/resident response to procedure

Based on observations, interviews, and record review the facility failed to ensure the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed and nine errors were identified for two residents (#211 and #25) of four residents observed. These errors constituted a 24.32% medication error rate. Findings included: 1) On 11/15/23 at 7:46 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #211. The staff member dispensed the following medications: - Levofloxacin 500 milligram (mg) tablet - Lisinopril 10 mg tablet - Mucinex DM 600 mg Guaifenesin/30 mg Dextromethopran over-the-counter (otc) tablet - Aspirin 81 mg chewable otc tablet - Nifedipine Extended Release (ER) XL 60 mg tablet - Polyethylene glycol 3350 - 17 grams (gm), mixed with 4 ounce (oz) of water - Vitamin D 25 microgram (mcg) - 2 otc tablets Staff D confirmed 7 tablets and one liquid medication. The staff member administered oral medications and identified the resident was to receive short and long-acting insulin. Staff D obtained a blood glucose level of 91 from the resident. The staff member stated and documented the dosage of Insulin Lispro (short-acting) would not be administered due to glucose level of 91. An unknown Certified Nursing Assistant (CNA) informed Staff D the breakfast trays were on the unit and the nurse left the area, returning with a breakfast tray placing it in front of the resident, and reported being told by a doctor to ensure a resident ate before administering insulin. Staff D returned to the medication cart, dialed a Insulin Glargine pen to 2 units, pressing the dosage selector to it reached zero, then applied a needle to the pen, dialed it to 25 units, entered the resident room and injected the insulin into the right upper arm of Resident #211. A review of Resident #211's physician orders included the following: - Guaifenesin ER 12 hour 600 mg tablet - Give one tablet by mouth two times a day for indigestion for 14 days, dated 11/10/23. - Insulin Lispro 100 unit/milliliter (mL) - Give 6 unit sublingually three times a day for Diabetes Mellitus (DM). - Insulin Glargine 100 unit/3 mL - Inject 25 unit subcutaneously two times a day for DM. The review of Resident #211's physician orders did not identify the resident was to receive Mucinex DM that is a combination medication containing 600 mg of Guaifenesin and 30 mg of Dextromethopran and the morning dose of Insulin Lispro did not include parameters to hold. The manufacturer instructions for Lantus (Insulin Glargine), located at https://products.sanofi.us/Lantus/Lantus.html., included the following education for insulin pen users: Step 2. Attach the needle Do not re-use needles. Always use a new sterile needle for each injection. This helps prevent contamination and potential needle blocks. A. Wipe the Rubber Seal with alcohol. B. Remove the protective seal from a new needle. C. Line up the needle with the pen, and keep it straight as you attach it (screw or push on, depending on the needle type). - If the needle is not kept straight while you attach it, it can damage the rubber seal and cause leakage, or break the needle. Step 3. Perform a Safety test. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: - ensuring that pen and needle work properly - removing air bubbles A. Select a dose of 2 units by turning the dosage selector. B. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards. D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle tip. - You may have to perform the safety test several times before insulin is seen. - If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. - If still no insulin comes out, the needle may be blocked. Change the needle and try again. - If no insulin comes out after changing the needle, your SoloStar may be damaged. Do not use this SoloStar. 2) On 11/15/23 at 9:20 a.m., an observation of medication administration with Staff P, Licensed Practical Nurse (LPN), was conducted with Resident #25. Staff P obtained a blood pressure of 105/78 from the resident and dispensed the following medications: - Thiamine Vitamin B1 100 milligram (mg) over-the-counter (otc) tablet - Cetirizine 10 mg otc tablet - Artificial tears eye drops - Creon Delayed Release (DR) 6000 unit capsule - Dicyclomine 10 mg capsule - Folic Acid 400 microgram (mcg) otc tablet - Gabapentin 300 mg capsule - Mesalamine ER 500 mg capsule - Senna 8.6 mg otc tablet - Vitamin D3 125 mcg otc tablet - Klor-Con 10 milliequivalents (meq) tablet - Polyethylene glycol 17 gram (gm) - mixed with 4 ounces (oz) of water - Aspercreme with 4% Lidocaine Max Strength topical patch Staff P confirmed dispensing 10 tablets/capsules, acknowledging the resident was scheduled to receive Lactulose but it had to be re-ordered, and was holding Amlodipine due to the blood pressure parameters. The staff member crushed tablets together and added to applesauce. The staff member administered the medications and placed the topical patch to the lower- mid back of the resident. The physician orders for Resident #25 included an order reading May crush medications unless contraindicated, the orders were further reviewed and the following issues were observed: - Lidocaine 5% patch - apply topically daily, apply in a.m. and remove at bedtime (hs) for chronic pain. Staff P applied a topical patch of Aspercreme with 4% Lidocaine. - Amlodipine Besylate 5 mg tablet by mouth in the morning for hypertension (HTN). The order did not include blood pressure parameters to hold. - Lactulose solution 10 gm/15 milliliter (mL) - give 15 mL by mouth one time a day for constipation. The medication was not administered due to unavailability of it for the resident and the medication profile was colored red revealing the medication was late. The Medication Administration Record (MAR) identified the medication was scheduled for 8:00 a.m. - Thiamine B1 was scheduled for 8:00 a.m., medication profile colored red revealing the medication was late. - Creon DR 6000 unit capsule - observation identified the breakfast trays on the unit have been removed from resident rooms. No meal tray was observed in Resident #25's room. According to creoninfo.com, Creon needs to be taken with every meal and snack to work as expected. The digestive enzymes in Creon need to mix with food and enter the stomach and the small intestine at the same time. - Klor-Con 10 milliequivalent (meq) tablet - crushed with other oral medications. Physician order - Potassium Chloride Extended Release 10 meq - Give 1 tablet by mouth in the morning for hypokalemia. Do Not Crush. The website, mayoclinic.org identified Potassium Supplement, Do not crush or chew the capsule. Swallow the capsule whole with a full (8-ounce) glass of water. Some capsules may be opened and the contents sprinkled on applesauce or other soft food. On 11/5/23 at 9:48 a.m., Staff P confirmed crushing Potassium, We need to change that. A request was made to the Director of Nursing (DON), on 11/15/23 at 4:46 p.m. for a Do Not Crush medication list. The DON reported This is about the potassium. On 11/15/23 at 5:25 p.m., the DON stated the facility does not have a Do Not Crush medication list. An interview was conducted on 11/16/23 at 11:22 a.m. with the Consultant Pharmacist. The issues observed during medication administration were reviewed and discussed with the consultant. In regards to Staff D not applying a needle when priming the Insulin Glargine pen for Resident #211, he stated How did it get out? and the facility should have followed the orders for Insulin Lispro. The pharmacist reported Klor-Con was extended release and should not be crushed, Creon Dr should be administered with meals, there was no reason for Thiamine and Lactulose to scheduled at a different time than the other observed medications, and Mucinex DM was not the same as Guaifenesin ER as it contained the additional medication Dextromethopran. The consultant agreed with the findings and stated it looked like the facilty would need extensive education with medication administration. During an interview on 11/16/23 at 2:50 p.m., the Director of Nursing (DON) stated he had spoken with the Consultant Pharmacist regarding the findings during medication administration and did not have any questions. The policy - Medication Administration, dated 7/2023, included the following instructions: - Compare the medication with the Medication Administration Record (MAR). - Verify physician's order to crush medication. - Verify medication can be crushed. Examples of medication that should not be crushed includes, but are not limited to: enteric coated tablets, sustained or extended-release tablets, effervescent tablets, (and) sublingual or buccal tablets. The policy regarding Insulin Injection did not instruct the use of an insulin pen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to resolve grievances related to dietary concerns in a timely manner for two residents (#4 and #85) out of the two sampled residents for grievances. Findings included: 1. On 11/14/23 at 10:12 a.m., Resident #4 reported he was the Resident Council President. He stated the number one concern in the facility was food. The food was cold, did not taste good, and was always late. He reported these concerns have been voiced over and over during the Resident Council Meetings and nothing changes. The response from staff related to the food concerns was always something about the budget. If they are served hotdogs, then they probably won't get mustard and ketchup. Administration took away cokes and they are only served ginger ale and diet ginger ale. They were told this was for nutritional reasons. The administration took away vending machines for residents. They have one in the staff break room but if they want something they have to ask a staff member to get it. Resident #4 stated, For some of them, food is the only thing they have to look forward to. He stated the concerns have been discussed with the Administration and they always say they will look into it. A review of the admission Record for Resident #4 showed he was initially admitted to the facility on [DATE] with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Review of the Food Committee Meeting Minutes, dated 05/10/23, revealed there would be cutbacks on certain drinks due to cost. There were eighteen residents in attendance. Review of the Resident Council Meeting Minutes, dated 08/09/23, revealed during food council, the council voiced concerns regarding dissatisfaction about the meals. There were ten residents in attendance. There was new business discussed about the facility providing a survey for food times likes/dislikes, dinner starts promptly at 4:45 p.m., and the menu for the week including alternatives would be at the nurses' station. Review of the Food Committee Meeting Minutes, dated 08/09/23, showed the council voiced concerns regarding dissatisfaction with meals. The facility would provide a survey for food items likes and dislikes. Menus for the week, including alternatives, will be at the nurses' station. Review of the Food Committee Notes, dated 11/09/23, indicated guests requested to get regular sodas back. Soda will be ordered as available through the vendor. A review of the Grievance/Complaint Log from July 2023 to November 2023 did not show any grievances for the dietary concerns voiced by the resident council. On 11/16/23 at 11:11 a.m., the Life Enrichment Manager reported she assisted with putting together the Resident Council Meetings. She stated the residents complained mostly about food. She stated, One time the whole meeting was about food. She stated, the residents complained about running out of syrup and other small items that they should not have run out of, and the residents were upset about not being able to have sodas. The Life Enrichment Manager stated anytime they have a concern, she writes a grievance and puts it on the grievance log. On 11/15/23 at 11:15 a.m., the Registered Dietitian (RD) stated they only have ginger ale or diet ginger ale available, and she was not sure why they stopped ordering cokes. On 11/16/23 at 12:26 p.m., an interview with the Administrator and the RD was conducted. The Administrator reported about fifty residents completed surveys related to food to get an idea of what were the concerns the residents had. On 11/16/23 at 10:12 a.m., the Administrator reported she attended the Food Committee Meetings. At the time a new menu was rolling out and she wanted to see if any additional concerns would come up. The residents spoke about preferences through the dietitian and the Certified Dietary Manager (CDM). The Administrator stated they have not found a particular pattern for any specific items. The residents are aware that alternatives are available. The Administrator stated soda was removed, but they have ginger ale and diet ginger ale. They are readdressing the concern with the sodas. Some of the residents have family members bringing sodas to them. On 11/16/23 at 11:19 a.m., the Social Services Director (SSD) stated a grievance was usually resolved within three days after she receives it. She confirmed she did not see any grievances from the Resident Council and the Grievance/Complaint Log. 2) On 11/13/23 at 9:39 a.m., Resident #85 reported, Food is terrible, chicken looked like it was dragged across the floor, the food tastes terrible. The resident stated the kitchen was not very efficient and reported telling the kitchen manager if working in a public restaurant Would be closed in a week. A review of Resident #85's Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. Review of a grievance filed by Resident #85 on 11/7/23 included the following concerns voiced by the resident: - Chicken looks like its been drug on floor; - Quality of food is not good; - Chicken still pink on plate; - Chicken rib cage on plate; - Quiche is burnt and terrible; - Oatmeal is like clay, too thick. The grievance revealed the resident desired Manager to be more efficient and pay attention to what goes on and for efficiency and quality. The steps taken to investigate the grievance included the resident showing photos of food that the investigator identified as Most of the meals were dated months to even a year ago. The food in the pictures also looked fully cooked. The investigators findings revealed Resident #85 had been spoken with and Tried my best to resolve his concerns and explained to him that we temp and document our food before serving it. I followed up to the cook that cooked the quiche on the 23 rd of October. That cook has been spoken with on numerous occasions about food quality and preparation. The corrective action revealed the investigator had Verbally expressed the concerns and needs of how the food is to be cooked and prepared. Also will follow up with a written in-service on food temps. The grievance identified the resident was notified and the response was Satisfied/understood on 11/7/23. On 11/15/23 at 3:31 p.m., Resident #85 reported sending a note on his food tray two days ago (11/13/23) then the Certified Dietary Manager (CDM) came to speak with him. The resident reported sending a note yesterday and the CDM came to speak with him again. Resident #85 stated after filing a grievance last week the Certified Dietary Manager (CDM) spoke with him 2 days ago. The resident reported after speaking with the CDM felt the grievance had been taking care (7 days after the grievance was resolved) of satisfactorily and would continue to send notes. The policy provided by the facility Grievance Policy and Procedures, undated, revealed the following: This facility will assist residents and their representatives in filing grievances when such requests are made and/or complaints are voiced. The facility will promptly and responsibly investigate these grievances to initiate timely resolution and determine if the facility has areas that need corrections to achieve our desire or providing quality care and a safe environment. Procedure 5. The Social Service Director will make every attempt to resolve the grievance in a timely manner and will keep the resident and their representative aware of the progress towards resolution. 6. The Social Service Director will keep a summary log of all grievances, which will be brought to the monthly QAPI meeting for review and further action, if necessary. The log will be signed by the Medical Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to reassess the need for an appropriate use of bed rails for one resident (#80) of three residents sampled for bed rails. Findings included: On 11/15/23 at 4:09 p.m. Resident #80 stated the facility just came in and took the rails off the bed. The resident reported using the rail/enabler to assist with getting into bed and moving up in the bed. The resident stated he knew what a trapeze was and had not been assessed for one. The observation revealed Resident #80 had a left upper arm contracture which was held in front of the chest. An observation of the resident bed revealed no assistance devices were attached to the bed. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #80 had a Brief Interview of Mental Status score of 13, indicative of an intact cognition. Section GG of the MDS identified the resident had Range of Motion limitations on one side of the upper and lower extremities. The MDS revealed the resident required substantial/maximal assistance with toileting hygiene, bathing, and lower body dressing, and required partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The assessment identified the resident was independent with rolling left to right, sit to lying, and lying to sitting on side of bed. Review of Resident #80's admission Record revealed the resident was admitted on [DATE] and was the responsible party. The record included the diagnoses of unspecified encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, generalized muscle weakness, other abnormalities of gait and mobility, and Type 2 Diabetes Mellitus without complications. The clinical record for Resident #80 included an Adaptive Rails Informed Consent and Release form signed by Resident #80 on 4/7/23. The consent revealed the resident had been informed of the benefits and risks associated with the use of adaptive rails, including possible entrapment and accidental skin bruising, cuts, or scrapes. The consent identified the benefits to using the adaptive rails were: 1. Improved mobility in bed: I will be able to reposition myself or assist my caregivers to reposition me. 2. Improved mobility getting in and out of bed. I will be able to transfer myself into and out of bed or to assist my caregivers with transferring me into and out of bed. I understand that the adaptive rails are to be used as a mobility aid and not as a physical restraint. I can withdraw this consent at any time. If I become unable to use the adaptive rails, the adaptive rails will be removed from my bed, so they are not an unintended physical restraint or possible entrapment hazard. Included with the consent was a description of adaptive rails approved by the center: quarter-length adaptive rail and an adaptive transfer bar. A review of Resident #80's care plan identified the resident was at risk for falls related to impaired mobility, balance, status post (s/p) Cardiovascular accident (CVA) with left (lt) hemiplegia (hemi), atrial fibilation (Afib), hypertension (HTN), Diabetes Mellitus (DM), (and) need for assistance with transfer. The interventions included but not limited to Keep adaptive equipment within reach. The care plan identified the resident had the need for setup to complete assistance from staff with Activities of Daily Living (ADL) self-care and/or mobility deficit with potential for further decline due to diagnosis. The interventions instructed staff to encourage and assist to turn and reposition, shifting weight to enhance circulation. During an interview on 11/13/23 at 1:34 p.m., Staff O, Licensed Practical Nurse (LPN) reported a couple of months ago the facility removed side rails and enablers due to the new state law. The staff member stated if residents insisted on having side rails they have to be evaluated for them. An interview on 11/15/23 at 12:24 p.m., was conducted with Staff O, LPN. The staff member reported side rails were taken out in stages and if a resident or family requested side rails or if she felt the resident needed them for safety, a therapy request would be initiated who would assess for a trapeze and if the resident continued to want rails, she would have to ask again for them and have a consent signed. Review of Resident #80's Adaptive Rail Screen revealed it was completed on 4/11/23. The screening identified the use of adaptive rail(s) were being considered due to Resident requested for safety/security and the resident had requested rails states it provides a sense of security. The screening revealed adaptive rails will assist the resident in turning side to side/holding self to one side or up and down in bed, pulling self from laying to a sitting position, will assist the resident in improving balance or trunk control, assist in supporting self, and assist the resident in entering/exiting (the) bed or transferring more easily. The documentation revealed the use of adaptive rails would not create a possible accidental hazard or barrier to the resident or have any negative physical or psychosocial outcomes, and no prior interventions such as a low bed, restorative care, frequent staff monitoring, assisted toileting, or reminders to use call bell had been implemented. The recommendation identified adaptive rails on both sides were recommended due to resident request and the risks, benefits and alternatives had been discussed with the resident. The therapy screens for Resident #80 included: - 6/8/23 Quarterly evaluation identified Physical therapy (PT) was indicated without occupational therapy (OT). The evaluation did not reveal the resident was screened for the discontinuation of adaptive rails or the evaluation of alternatives. - 6/23/23 Referral evaluation indicated no PT, OT, or speech therapy (ST) was indicated. Patient (Pt) currently on caseload for PT. - 7/31/23 Referral evaluation identified PT was indicated as resident had decline in lower extremity (LE) strength and was no longer ambulatory. The screening did not address the discontinuation of adaptive rails or the evaluation of alternatives. - 9/8/23 Quarterly speech therapy evaluation revealed no change or concerns and speech therapy was not indicated at that time. - 9/12/23 Quarterly evaluation for PT and OT revealed neither was indicated at that time. The screening did not address the discontinuation of adaptive rails or the evaluation of alternatives. The evaluation did identify the resident was recently discharged from PT services. - 9/19/23 Referral for speech therapy to assess swallowing function. - 10/24/23 Referral to OT for assessment of left hand contracture development. Review of Resident #80's PT Discharge Summary for the date of services of 6/16/23 through 7/10/23 identified the short-term goal of Patient will safely perform bed mobility task with standby assistance without use of side rails and 5% verbal cues for safety awareness, for proper sequencing, for task segmentation, for correct hand/foot placement, and for initiation/termination of tasks in order to decrease risk for skin breakdown, participate in EOB activities, get in/out of bed, participate in activities of daily living, enhance safe functional mobility, and reduce risk for falls. The summary identified the resident's baseline on 6/16/23 for this goal was contact guard assist (CGA) and was unchanged at the time of discharge on [DATE]. A long-term goal for the resident was Patient will safely perform bed mobility tasks with Supervised (A) without use of side rails and 5% verbal cues for safety awareness, for proper sequencing, for task segmentation, for correct hand/foot placement, and for initiation/termination of tasks in order to decrease risk for skin breakdown, participate in EOB activities, get in/out of bed, participate in activities of daily living, enhance safe functional mobility, and reduce risk for falls. The summary identified the resident's baseline (6/16/23) and discharge (7/10/23) was contact guard assist (CGA) for bed mobility. The summary revealed the patient demonstrated fair progress and had plateau' d and the recommendation to continue with restorative nursing program (RNP). A review of the facility admission Agreement identified The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility provided a letter dated 2/7/23 (2 months prior to Resident #80's admission) sent to families and residents. The letter identified the facility would be working to eliminate the use of all adaptive rails/mobility bars unless they are proven to be medically necessary for each individual guest/resident. The letter revealed as part of an ongoing performance improvement program each individual guest/resident would be assessed for the use of adaptive rails/mobility bars with the input from the interdisciplinary team and all recommendations would be reviewed with the individual guest/resident and/or responsible party. A facility letter, dated 5/30/23, revealed the facility was working towards eliminating the use of all adaptive rails/mobility bars unless proven medically necessary. The assessment for the use of rails/bars would include input from the interdisciplinary team (IDT) and the recommendations would be reviewed with the individual guest/resident and/or responsible party. The continued use would be routinely monitored and the IDT would make recommendations if a guest's/resident's circumstances changed. The facility plan for removal of adaptive rails, dated 6/18/23, identified Adaptive rails to only be utilized when the center has tried alternatives, IDT (includes therapy) assessment recommends one or tow for mobility and transfer and physician's order has been obtained, family/resident consents, and is care planned. - 1. letter to sent to all families/residents two weeks prior to removal explaining regulation and new protocols. - 2. center will obtain and have a par level of concave/perimeter mattresses, fall mats, motion sensor lights, and night lights, identify facility bed frames that are able to extend to wider beds with wider mattresses available. - 3. all adaptive rails and bed rails will be removed from all beds and stored in an inaccessible storage area for anyone but maintenance/environmental services to ensure that none make it back to the floor without the process being followed. - 4. Alternatives to adaptive rails will be attempted and documented. Should multiple alternatives fail, an adaptive rail review will be performed, and a therapy referral will be made. Therapy interventions, i.c. slide boards will be utilized. Should the therapy alternatives fail, the IDT will discuss and if need be, the possible use of one or two adaptive rails for transfers, the IDT recommendations will be discussed physician and resident/family. Should a recommendation be made for one or two adaptive rails and physician and family/resident agree, a consent would be obtained, scanned into the medical record, and care planned. The adaptive rail review will be performed quarterly and as needed with change of condition (COC). During an interview on 11/16/23 at 2:56 p.m., the Director of Nursing (DON) reported the facility looked at adaptive rails in June and removed them. He stated when someone requests an adaptive rail the facility asks for an alterative such as a scoop mattresses, trapeze, or furniture placement, therapy would screen them, nursing would meet, a side rail evaluation, physician order, consent and the rails would be added to the care plan. The DON stated the facility looked at the rails, explained to residents, sent out letters to residents and family members, and met in resident council in June or July. The facility also held a team talk with staff. He reported all residents were informed the facility was to try something different and all residents were screened. The policy - Siderails/Adaptive Rails Guideline, revised January 2023, identified It is the standard of the center to attempt to use alternatives prior to installing an adaptive rail (bed mobility assistive device). If an adaptive rail(s) is used the center will ensure correct installation, use and maintenance of the adaptive rail. The center only utilizes adaptive rails to aid with bed mobility. The center only utilizes adaptive rails based on individual guest/resident assessment - no full side rails, half rails or quarter rails will be installed. 1. Adaptive rails are used to assist with mobility and transfer of guests/residents. 2. Prior to the use of adaptive rails, alternatives will be attempted and documented. 3. Alternatives to be considered prior to installing adaptive rail include but are not limited to - a. Low bed - b. Concave mattress - c. Furniture placement - d. mechanical lift - e. therapy recommended bed mobility devices such as slide boards - f. One adaptive rail instead of two for guests/residents with limitations related to medical conditions on a specific side of their body. - g. fall mats - h. Overbed trapezes - i. motion sensor lights - j. night lights - k. Other resident specific interventions with supporting documentation. 11. If guest/resident condition improves and adaptive side rail use is no longer indicated the adaptive rails will be reviewed by the interdisciplinary team and discontinued after reviewing with guest/resident and/or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure medications were stored in a safe manner in regards to 1) leaving one of two treatment carts unlocked while unattended (C-wing), 2) unopened eye drops requiring refrigeration stored in one (100-hall team #2) out of six medication carts, 3) one (C-wing team #3) out of six medication carts held medication tablets in a medication cup and a loose tablet, 4) three (C-wing, A-wing team #2, C-wing team #1) out of six medications carts left unlocked while unattended, 5) medications left on top of two unattended medication carts (100 team #2 and A-wing) out of 6 carts, 6) allowing a visitor unattended access to an unlocked medication cart (A-wing team #2 and C-wing team #1) out of six carts, and 7) allowed one resident (#85) to have a prescribed Albuterol inhaler at bedside. Findings included: 1. On 11/13/23 at 7:27 a.m., an observation was made of an unlocked treatment cart parked inside the C-wing nursing station. The observation identified a intravenous (IV) bag of normal saline with IV supplies on top of the treatment cart. The cart contained wound care supplies including creams/ointments. An unknown housekeeper was observed in the office next to the unlocked treatment cart. Staff B, Licensed Practical Nurse (LPN), arrived to the station and stated the cart should be locked at all times. The staff member locked the treatment cart leaving the IV bag and supplies sitting on top of the cart. The nursing station did not have a door prohibiting entrance into the area behind the desk. (Photographic evidence was obtained) 2. On 11/15/23 at 7:18 a.m., the review of the 100-hall, team #2 medication cart was conducted with Staff Q, LPN, identified an unopened bottle of Latanoprost ophthalmic drops. The bottle was labeled to refrigerate. The staff member walked away from the open medication cart to the nursing station while writer was inspecting the cart and the bottle of Latanoprost was sitting on top of it, which was parked across from the station. Staff Q was observed speaking with Staff P, LPN, behind the nursing station and not looking in direction of the medication cart. The staff member returned to cart and agreed this writer was not authorized to have unattended access to the medication cart, I guess not. The staff member confirmed the bottle of Latanoprost was unopened, should be refrigerated, and stated the medication had not been delivered from pharmacy during the shift of 11 p.m. to 7 a.m. (Photographic evidence was obtained) 3. On 11/15/23 at 7:37 a.m., an observation was conducted with Staff B, LPN, of team #3 medication cart. The staff member opened the top drawer of the cart and removed a medication cup with 3 tablets, 2 white and 1 blue, in it. Staff B identified one of the tablets as an antidepressant. The staff member stated the tablets were not morning medications, had taken over the cart so did not know the resident they were prescribed. One round white tablet was found in the bottom of the second drawer which Staff B identified as an antihypertensive. 4. During an observation of medication administration for Resident #211 on C-wing, on 11/15/23 at 7:46 a.m., the medication cart was parked slightly to the side of a resident's door and in the hallway allowing people to pass in between the door and cart. Staff D, Registered Nurse (RN), left the cart unlocked and out of vision when administering medications to a resident. 5. During an observation of medication administration, on 11/15/23 at 9:20 a.m., of Resident #25, medication blister-packaging cards were left on top of an unlocked med cart. The nurse was observed standing behind the resident's privacy curtain administering the medication. On 11/15/23 at 9:39 a.m., the Director of Nursing (DON) walked in between the cart and rooms door, leaving medications on top of it and unlocked. Immediately following the medication administration, on 11/15/23 at 9:48 a.m., Staff P confirmed 5 blister-packaging medication cards containing tablets/capsules were left on top of the cart and the cart was unlocked. (Photographic evidence was obtained) 6. An observation was conducted with Staff O, LPN, on 11/16/23 at 1:36 p.m. of C-wing team #1 medication cart. The medication cart was parked between room [ROOM NUMBER] and 203, approximately halfway down the hallway and around the corner from the nursing station. Staff O unlocked the cart and as this writer opened the top drawer of the cart the staff member walked away standing at the nursing station then disappeared from sight. The observation identified the Director of Education (DOE) was seen standing at the nursing station and after a few minutes the DOE arrived to the cart and confirmed Staff O should not have unlocked the cart and walked away. The DOE went to the nursing station and returned with the staff member. Staff O confirmed being responsible for the medication cart and was watching from afar. (Photographic evidence was obtained) 7. An observation was made, on 11/13/23 at 9:38 a.m., of a handheld red/gray inhaler in a manufacturer box on Resident #85's over-bed table. The inhaler was dated 9/22. Resident #85 reported, on 11/13/23 at 9:59 a.m., of using the inhaler twice a day, 2 puffs in the morning and 2 at night, They trust me with it. An interview was conducted on 11/14/23 at 8:30 a.m., with the Director of Nursing (DON). The DON reported no resident in the facility was self-administering medications and stated hope that doesn't mean you found meds at bedside. During an observation and interview on 11/15/23 at 12:24 p.m. with Staff O, LPN, and Resident #85. The resident stated to the staff member that he was not upset that she had taken the inhaler but he was able to take it (administer) it by himself. The staff member reported she had taken the inhaler from the resident today after informing him that it would be easier to reorder it. During an interview, on 11/16/23 at 2:53 p.m., the DON did not ask any questions or commented on findings. The policy - Storage and Expiration Dating of Medications, Biologicals, last revised 7/21/22, revealed, This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. The policy included the following: - Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. - Store all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. - Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. - Facility should ensure that medications of biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. - Facilities should store bedside medications or biologicals in a locked compartment within the resident's room.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program as evidenced by small gnat like flies observed in the kitchen at the hand washing station, inside the dry storage area, inside the freezer, the dish cleaning area, around a cart outside of the freezer, and flies were observed over the tray/cook line for two days (11/13/23 and 11/15/23) out of four days of survey. Findings included: On 11/13/2023 at 7:20 a.m. during the initial kitchen tour the trash can at the hand washing station was observed to be overflowing with trash and the entire area had gnat like flies flying around. In addition, inside the dry storage area dead gnat like flies were observed on several plates. An observation of the inside of the freezer revealed dead gnat like flies in the corner on the floor behind milk crates. Outside of the freezer gnat like flies were observed flying around a cart that had several containers with tops that appeared dirty and smeared with a brown pasty substance. Also observed during this time was the dish cleaning area which had a stack of dirty dishes on the shelf with gnat like flies flying around. The catch tray/drain pan under the dishwasher had old food present and observed gnat like flies in this area (Photographic Evidence Obtained) During an interview on 11/13/2023 at 7:20 a.m. the Assistant Certified Dietary Manager (ACDM) stated the dishes from the night before are cleaned up by the staff that come in the next morning, they also clean the catch tray/drain pan. On 11/13/2023 at 9:30 a.m. a second tour of the kitchen was conducted, and the trash can in the hand washing area was observed to not have a trash bag and was full of gnat like flies when opened. A staff member was cleaning a food cart lying on its side in the middle of the kitchen and gnat like flies could be seen flying around the area. During an interview on 11/13/2023 at 9 30 a.m. the Certified Dietary Manager (CDM) stated the cart was being cleaned as a plate had broken inside. The CDM stated he pours bleach down the drains for the gnat like flies weekly. He stated he put a work order in the Electronic work order system two weeks ago. The food buildup was observed in the drain pain under the dish machine, and gnat like flies were observed flying throughout the kitchen area. On 11/15/2023 at 11:45 a.m. an observation of the tray/cook line for lunch revealed gnat like flies in the kitchen area and larger flies over the tray/cook line during the food service. During an interview on 11/16/2023 at 9:50 a.m. with the Nursing Home Administrator (NHA) and Dietician photographic evidence was shared regarding the gnat like flies observed in the kitchen. The NHA stated a bug zapper was installed in the kitchen. A request was made to have a copy of the work order for the bug zapper. On 11/16/2023 at approximately 1:00 p.m. an observation of the kitchen revealed no bug zapper was seen. Interview with the ACDM at this time confirmed he was not aware of a bug zapper. Review of the pest control company's service report revealed: 1. Dated 10/10/2023 - revealed the areas serviced for pests were exterior, courtyards, dumpster areas, rodent bait stations, Rm #161, and nurse's station. No kitchen areas were serviced. 2. Dated 10/17/2023 - revealed areas serviced for pests included dietary kitchen, dry storage, juice station, tray line/cook line, and dish room. 3. Dated 11/3/2023 - revealed the areas serviced for pests were exterior, court yards, dumpster area, rodent bait stations and maintenance building. No kitchen areas were serviced. 4. Dated 11/14/2023 - revealed areas serviced for pests included dry storage, kitchen, tray line/cook line, and the dish washing room. Review of the policy titled, Maintenance-Pest (Insect) Control, revised October 11, 2022, revealed: Policy: The facility will maintain an ongoing pest control program. Pest control services are provided by a licensed pest exterminator on a no less than monthly basis and as needed. The contracted Pest Control Services will include both interior and exterior pest control. Procedure: 1. Food items in resident rooms should be kept in air-tight containers. 2. Garbage and trash are to be removed from the facility daily. 3. Staff will report any evidence of insects in resident's rooms or common areas to the maintenance/housekeeping staff. During regular hours, the report can be logged into the maintenance request log and/or the log provided by the pest control company, if applicable. 4. Live insects in resident rooms or care areas should be reported as soon as possible to the maintenance or housekeeping supervisor and the administrator. 5. Maintenance/housekeeping will investigate any reports of insects and will ensure adequate control measures are provided. Maintenance/housekeeping will notify the licensed pest exterminator. 6. Residents will be removed from the area where live insects are noted until control measures are provided. Only pest control measures that are approved by the licensed pest exterminator will be used. 7. If insects are detected on a resident, the resident will be assessed by nursing staff and the resident's physician will be notified of any insect bites. The Director of Nursing and resident's family will also be notified. A work order for the bug zapper was not provided to the survey team as of the survey teams exit on 11/16/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure one resident (#30) was assessed for self-administration of a medication and that the medication was not stored at bedside out of five residents sampled for unnecessary medications. Findings included: An observation was made at 3:18 p.m. on 9/22/21 of a box labeled, Fluticasone Propionate Nasal Spray on the over-bed-table of Resident #30. (Photographic Evidence Obtained) The resident stated that she had brought the nasal spray from home and used it every couple of days. She reported that staff were aware she had it and that she did not try to hide it. A review of Resident #30's September 2021 physician orders indicated that the resident did not have an order for the Fluticasone and the facility had not assessed the resident for self-administration of the medication. On 9/22/21 at 4:01 p.m., the Director of Nursing (DON) stated Resident #30 was not allowed to self-administer medications. An observation was conducted with the DON, who viewed the box of Fluticasone on the resident's table and stated that she would take care of it. A review of the admission Record for Resident #30 showed the resident was admitted to the facility on [DATE] with diagnoses to include cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery, chronic atrial fibrillation, anxiety disorder and encephalopathy. The policy titled, Self-Administration of Medications, effective 12/1/07 and revised 5/10/10 and 11/28/16, indicated: - 3. To ensure safe and appropriate Self-Administration, Facility should educate residents to ensure that a resident is able to: .correctly store his/her medications in a locked compartment .5. Facilty should ensure that orders for Self-Administration list the specific medication(s) the resident may Self-Administer. The policy: Storage and Expiration Dating of Medications, Biological's, Syringes, and Needles, effective 12/1/07 and later revised on 10/28/19, identified the following: - Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. - When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle. - Bedside Medication Storage: Facility should not administer/provide bedside mediations or biological's without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. Facility should store bedside medications or biological's in a locked compartment within the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with the resident, interview with facility staff, and review of facility documents, the facility failed to provide one resident with impaired vision, (Resident #56) with assistance at meals, leisure activities to meet his needs of a total sample of 21 residents reviewed for accommodation of needs. Findings included: A review of the admission Record for Resident #56 showed the resident was admitted to the facility on [DATE] with diagnoses that included gastrointestinal hemorrhage, a wedge compression fracture of the spine, macular degeneration and glaucoma. On 09/20/21 beginning at 11:52 a.m. Resident #56 was observed sitting in his wheelchair next to his bed with the over bed table in front of him. His television was on. When the surveyor knocked on his door and called out to him, the resident looked at the door, toward the sound, but it didn't appear that he was looking at the surveyor. The resident was observed to be holding his call bell and to the cord to the receiver of the phone tightly. When asked why, he reported that he had to hold on to them as that was the only way he could contact anyone. He reported that when anyone came in to do anything for him, they would never leave the call bell or the phone in the same place, and then he couldn't find them. He confirmed he was vision impaired and he confirmed that he usually had to tell staff he could not see well. The resident was not wearing glasses during the interview. At lunch on 09/20/2021, at approximately 12:50 p.m., the resident was observed in his room, in his wheelchair next to his bed with his lunch tray on his table in front of him. He was observed to be alone in the room. He was observed without his glasses on. When asked if he had been told what he was served, he said no, he had to taste what was on his plate to know. During the interview the resident was holding a cup of ice cream in one hand and a straw in the other. He was poking the ice cream and then sucking the melted bits of ice cream through the straw. He had been served a chopped salmon burger with soft mixed vegetables and sweet potato fries. By the end of the meal he had eaten about half of the meal. On 09/21/2021 at approximately 8:30 a.m., Resident #56 was observed sitting up in bed, with his over the bed table across his waist and his breakfast tray on the table. He had both a fork and a spoon in his bowl of oatmeal, but was using the fork to eat the oatmeal. On 09/22/2021 at 12:45 p.m. the resident was observed to be sitting in his wheelchair at a table in the day room. His lunch tray was on the table in front of him. He was holding an ice cream cup but did not have a spoon. His bag of silverware was unopened, on his tray, with the open end pointing away from him. When asked if he was going to eat, he replied that it might be difficult for him to do that with his vision difficulty. When asked if anyone had told him what he was having, he said no and asked if the surveyor would. He asked for his meat to be cut up and a facility nurse was stopped in the hall and asked to assist. During all of the observations and interviews with the resident, he had not been wearing glasses and there were no glasses observed on his over bed table or side table. During the observations and interviews with the resident while he was in his room, the television was on. On 09/23/2021 at 8:55 a.m., Staff S, Life Enrichment Aide was delivering the Daily Chronicle (detailing activities for the day at the facility), which the resident received. When asked if he was satisfied with listening to the television, he confirmed yes he liked the news. When asked if he was interested in any puzzles or books, Resident #54 reported no, explaining he had impaired vision. He confirmed that he was not able to read the Daily Chronicle. A review of the physician's note, dated 08/13/2021, included in the assessment, blindness. A review was conducted of the Minimum Data Set (MDS) admission assessment dated [DATE]. Section B for Hearing, Speech and Vision identified Resident #56's vision as adequate with corrective lenses. His Brief Interview for Mental Status score was coded as a 10, indicating his cognition was moderately impaired. His diagnoses of cataracts, glaucoma, or macular degeneration was identified. An interview was conducted with the Staff M, Licensed Practical Nurse (LPN)/MDS on 09/23/2021 at 3:00 p.m. to confirm the above information about Resident #56. She agreed to visit Resident #56 to observe and speak with him about his vision. At 3:50 p.m. after an interview with the resident, Staff M reported the resident confirmed he had glasses, but didn't know where they were. She reported the resident confirmed that even with his glasses, his vision was still impaired. On 08/04/2021 a Life Enrichment Evaluation was conducted with Resident #56. It identified the resident as having adequate vision, being oriented x 3, and preferring to spend his free time in his room with leisure activities conducted in the afternoon. Activities that were very important to him included clothing/fashion, sports, music, television, conversation, snacking, keeping up with the news and family or visitors. A note written by Life Enrichment staff dated 08/04/2021 indicated he enjoyed doing crossword puzzles and he enjoyed being outside. A nutrition assessment, dated 08/05/2021, by the Registered Dietitian (RD) was reviewed, which documented the resident's height as 65 and his weight as 130 lbs (pounds). The assessment identified his intake at meals as good. The RD referenced intake records which documented his intake at more than 50% of most meals. However, due to his increased needs, recommendations had been made for fortified foods at meals, and vitamin, mineral and protein supplements. Within one month, according to the RD's follow up note dated 09/03/2021, the resident's weight had dropped to 122 lbs, a loss of 6.2% in one month. An interview was conducted with the Staff L, LPN/nurse supervisor on 09/232021 beginning at 12:30 p.m. She agreed to visit Resident #56 with the surveyor, but commented that she didn't know him very well. Staff L asked the resident about his vision and the resident replied that it had deteriorated since he had been in the facility. The resident denied having glaucoma but confirmed he had macular degeneration. In an interview with his aide, Staff N, Certified Nursing Assistant (CNA), on 09/23/2021 beginning at 5:00 p.m., she confirmed that she usually worked on Resident #56's hall on both the day and evening shifts. She reported that she was aware he had impaired vision, but staff tried to maintain his independence by telling him where his food was on his plate and where his drinks and dessert were located. She said that she never saw him wear glasses. She said the manager just told the staff that his glasses were missing, and she looked in all of his drawers and even the pockets in all of his clothes for them, but did not find them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and facility staff interviews, and review of facility documents, the facility failed to revise a care plan to meet the needs related to accommodating needs, specifically for impaired vision for one resident (#56) of 21 residents reviewed. Findings included: Review of the admission Record for Resident #56 showed the resident was admitted to the facility on [DATE] with diagnoses that included gastrointestinal hemorrhage, a wedge compression fracture of the spine, macular degeneration and glaucoma. On 09/20/21 beginning at 11:52 a.m. Resident #56 was observed sitting in his wheelchair next to his bed with the over bed table in front of him. His television was on. When the surveyor knocked on his door and called out to him, the resident looked at the door, toward the sound, but it didn't appear that he was looking at the surveyor. The resident was observed to be holding his call bell and to the cord to the receiver of the phone tightly. When asked why, he reported that he had to hold on to them as that was the only way he could contact anyone. He reported that when anyone came in to do anything for him, they would never leave the call bell or the phone in the same place, and then he couldn't find them. He confirmed he was vision impaired and he confirmed that he usually had to tell staff he could not see well. The resident was not wearing glasses during the interview. At lunch on 09/20/2021, at approximately 12:50 p.m., the resident was observed in his room, in his wheelchair next to his bed with his lunch tray on his table in front of him. He was observed to be alone in the room. He was observed without his glasses on. When asked if he had been told what he was served, he said no, he had to taste what was on his plate to know. During the interview the resident was holding a cup of ice cream in one hand and a straw in the other. He was poking the ice cream and then sucking the melted bits of ice cream through the straw. He had been served a chopped salmon burger with soft mixed vegetables and sweet potato fries. By the end of the meal he had eaten about half of the meal. On 09/23/2021 during a visit with the resident, beginning at 8:55 a.m., Staff S, Life Enrichment Staff was observed delivering the Daily Chronicle (detailing activities for the day in the facility) to the residents. She agreed to step into the resident's room and talk with the surveyor and the resident. She reported that she knew him a little from delivering the chronicle. She asked him if he wanted any activities - something to do? He agreed the television was enough but he would like some music also. She asked if he wanted the TV on now and he agreed and asked for a specific news channel. I asked the resident if he wanted puzzles, referring to the Life Enrichment care plan. Resident #54 reported no, explaining he had impaired vision. He confirmed that he was not able to read the Daily Chronicle. Care plans were developed based on the Minimum Data Set (MDS) assessment dated [DATE]. The resident was identified as having adequate vision when wearing corrective lenses. The care plan, initiated on 8/4/21 and revised on 8/10/21, referred to the diagnoses of Glaucoma and Macular Degeneration. Interventions included orienting him to his surroundings as necessary and placing items in easy reach and orienting him to their placement. A care plan was developed for the resident's risk for falls, initiated on 8/4/21 and revised on 8/30/21, related to his poor vision. Interventions included placing items used in easy reach, such as his water, telephone and his call light. The resident was assessed by activity staff, which was reflected in a care plan, initiated on 8/10/21, as being independent in his decision making regarding his leisure time. It was documented that he preferred to engage in independent activity in his room daily, by watching television, and doing word puzzles. An interview was conducted with the Staff L, LPN/nurse supervisor on 09/23/2021 beginning at 12:30 p.m. She agreed to visit Resident #56 with the surveyor but commented that she didn't know him very well. Staff L asked the resident about his vision and the resident replied that it had deteriorated since he had been in the facility. The resident denied having glaucoma but confirmed he had macular degeneration. An interview was conducted with the Staff M, Licensed Practical Nurse (LPN)/MDS on 09/23/2021 at 3:00 p.m. to confirm the above information about Resident #56. She agreed to visit Resident #56 to observe and speak with him about his vision. At 3:50 p.m. after an interview with the resident, Staff M reported the resident confirmed he had glasses, but didn't know where they were. She reported the resident confirmed that even with his glasses, his vision was still impaired. She agreed the assessment did not fully capture Resident 56's status related to his impaired vision and increased needs. In an interview with his aide, Staff N, Certified Nursing Assistant (CNA), on 09/23/2021 beginning at 5:00 p.m., she confirmed that she usually worked on Resident #56's hall on both the day and evening shifts. She reported that she was aware he had impaired vision, but staff tried to maintain his independence by telling him where his food was on his plate and where his drinks and dessert were located. She said that she never saw him wear glasses. She said the manager just told the staff that his glasses were missing, and she looked in all of his drawers and even the pockets in all of his clothes for them but did not find them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure treatment and care was provided related to the appropriate application of a splint for one resident (#81) of 48 sampled residents. Findings included: Review of Resident #81's admission Record revealed this resident was admitted to the facility on [DATE] with a diagnosis primary diagnosis of Infection and inflammatory reaction due to internal right hip prosthesis. A review of the Minimum Data Set Assessment, dated 6/28/21, indicated Resident #81 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Review of the physician orders for September 2021 revealed, Patient to wear right ankle brace in bed as tolerated every day and night shift, with a start date of 7/15/21. Review of the electronic Therapy Page revealed Precautions: (PT) [patient] Fall risk, R [right] THA [total hip arthroplasty] revision (6/15/21), RLE (right lower extremity) WBAT [weight bearing as tolerated], brace for RLE while in bed to maintain neutral hip position. Review of the care plan, dated 6/22/21, revealed that Resident #81 required extensive to total assistance to complete his self-care tasks, due to the diagnosis of osteomyelitis. Interventions included: Patient to wear right ankle brace in bed, as tolerated. Review of the paper chart revealed: Splint/positioning instructions: When in bed 8-10 hrs (hours) as tolerated. This document indicated the following: -Make sure R (right) leg is in normal position when placing on the patient. -Make sure kick stand is visible to maintain R leg in neutral position. -Complete daily skin checks for redness or breakdown. Continued review of this document revealed that on the reverse side of the document were three pictures showing the correct positioning of the splint. The document indicated that it was completed by Staff K, Physical Therapist (PT). Observations on 9/20/21 at 1:27 p.m. of Resident #81 revealed the resident lying in his bed with his eyes closed. A foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. Observations on 9/21/21 at 11:38 a.m. of the resident lying in bed revealed he had a boot on his right foot. Interview with the resident at this time, revealed the boot was supposed to help keep his toes point straight up to the ceiling but that it is not on right and something is wrong. He reported that staff put on the boot each morning after providing care. Closer observation of the resident's foot revealed the boot was in place and the foot was resting on a pillow and leaning sideways to his right side with toes pointing to the window. Observation on 9/22/21 at 11:06 a.m. revealed the resident lying flat on his back in bed asleep, with both of his feet exposed. The resident's right foot was noted to be lying flat on its right side and the foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. On 9/22/21 at 12:25 p.m. an observation of Resident #81 revealed the resident was seated up in bed with his midday meal tray. Continued observation of the resident at this time revealed that his right foot was lying flat on its right side, pointed towards the window next to his bed and no splint in place. Observation of Resident #81 on 9/22/21 at 1:35 p.m. revealed him lying on his back in bed with his right foot lying flat on the right side pointing towards the window and no splint in place. Observation of Resident #81 on 9/22/21 at 3:44 p.m. revealed the resident lying on his back in his bed, with his right foot noted to be lying flat and pointing to the right side towards the window. On 9/22/21 at 3:54 p.m. a review was conducted of the Treatment Administration Record (TAR) for the month of September 2021. Staff were to document the application of the right foot brace on days and at night. Closer observation of the TAR revealed that a check mark was in place for the days on 9/22/21. An interview on 9/23/21 at 2:01 p.m. with Staff W, Physical Therapy Assistant (PTA), revealed the resident was currently on caseload for strengthening. He reported that he put the splint on this morning, and the resident will let staff know when he wants it off. He reported the resident will refuse to have the splint on at times. Staff W reported the resident was on a splint program for his right hip, as tolerated. He reported that both staff and the resident had been educated on the use of the splint and the importance of using the kick stand to keep the resident's leg and hip aligned. An interview on 9/23/21 at 2:15 p.m. with Staff X, Registered Nurse (RN) revealed that she was currently assigned to Resident #81 did not know much about him. She reported she was unaware the resident had a splint or when/how the splint was to be used. She reported at this time she had not signed off for any splint use. An interview on 9/23/21 at 2:20 p.m. with Staff Y, Certified Nursing Assistant (CNA) revealed she was currently assigned to this resident and that she was very familiar with him. She reported he does use a foot splint and that she takes it off when he requests and that she just took it off. Staff Y was asked to demonstrate how the splint goes on without putting it on the resident. She demonstrated how the foot splint goes on and how it closes using the attached [hook and loop fastener]. When asked about the stand on the back of the boot she responded, Oh that is nothing, I don't know what it is there for. When asked if there was any direction that staff are to follow to make sure that the boot was on correctly, she responded, No. An interview on 9/23/21 at 2:30 p.m. with Staff K, Physical Therapist (PT) revealed the resident was on PT caseload and currently has a foot brace for his right foot to be on as tolerated when in bed. She reported that staff are to use the kickstand to enable the foot to stay straight up which helps to align the resident's hip. Observation was conducted on 9/23/21 at 2:58 p.m. of Staff Y, CNA, with the permission of the resident. Staff Y applied the splint to the resident's right foot. The staff put the boot on but did not utilize the kick stand and left the foot leaning to the right side. At this time Resident #81 intervened and was able to explain to the CNA how to place the splint and utilize the kick stand. The PT also intervened and provided further direction to the CNA to ensure the boot was on correctly utilizing the kick stand. During an interview with the PT at this time she reported the therapy department in-services staff on the application and use of splints, however with the constant turn-over and change in staff they are unable to train every person who may come in contact with the resident as there was no consistency in staff. A request was made for the facility policy on splint use, but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation of the resident (#140) at meals, and review of the resident's medical record and facility documents, the facility failed to ensure one (#140) of one resident reviewed for dialysis services received care and services to meet her needs. Findings included: On 09/20/2021 at 1:55 p.m., an interview was conducted with Resident #140. She was sitting in a recliner in her room with the television on. She confirmed that she went to her dialysis sessions three times a week, leaving the facility about 10:30 a.m. and returning by 4:30 p.m. She confirmed she had a catheter in her upper left chest which the facility nurses did not touch at all, she was knowledgeable about her diet and fluid intake, she knew her weight had remained pretty stable and she reported that the dialysis facility drew her labs. She confirmed that she was given a lunch to take with her but since she slept the whole day, she hadn't been eating the packed lunch. She said that since she ate breakfast before she left the facility and had dinner shortly after she returned from dialysis, not eating the lunch had worked out for her. On 09/22/2021 at 10:35 a.m. the resident was observed in her bed with her breakfast tray on her over bed table across her waist. She was sitting up in bed and the television was on. She reported that she had eaten two bowls of oatmeal, half of a slice of toast with jelly and had drank coffee. An unopened 8 ounce carton of milk was also on the breakfast tray but she said she didn't drink milk as it caused her distress. She said she would have liked to have received protein at the meal as she had been told by her doctor at dialysis the day before that her protein was low and she needed to eat more protein. The admission Record showed the resident had been admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis. A review was conducted of the resident's medical record which revealed communication forms from the resident's dialysis center for two of the three days that the resident had received dialysis and then returned to the facility. The Registered Dietitian (RD) completed a nutrition assessment of the resident on 09/16/2021 which documented the resident's height, weight and Body Mass Index (65, 196 lbs. [pounds] or 89 kg [kilograms], 34.3). The resident's diet order was for a Renal diet with thin liquids. Diagnoses were documented as hypertension, cerebral vascular accident, and diabetes. Her blood glucose values had been normal, her skin was intact and she had limited activity. The RD had determined she had increased needs for protein due to the renal failure with dialysis. She documented that she had educated the resident on consuming an adequate intake of protein due to the dialysis expenditure. The RD's plan was to communicate with the Dietitian at the dialysis center to help manage the resident's dietary needs, which would include obtaining the resident's weights from the dialysis center for the most accurate weight trend. There were no labs referred to in the nutrition assessment, no indication an attempt had been made to contact the dialysis dietitian and no reference to the communication forms from the dialysis center. Two dialysis communication forms were located in the resident's medical record, which the Nurse Manager indicated was where the communication forms were filed. The two forms were dated 09/16/21 and 09/18/2021. Both communication forms documented blood pressure that was high. The resident's pre weights were 106.7 kg and 106.1 kg respectively and post weights were 103 kg and 103.9 kg. These documented weights were very different from the weight that was documented for the resident at admission, which was 196 lbs. or 89 kg. The dialysis center was weighing the resident pre dialysis at 235 lbs. and post dialysis at 228 lbs. On 09/22/2021 at 10:30 a.m. the RD confirmed that she had seen and assessed Resident #140. She confirmed that she had not seen any labs in the chart and when she asked the resident when she had her labs drawn at the dialysis facility, the resident reported that she did not know. She confirmed the facility sent a lunch with her and she assumed the resident ate the lunch. The observation that was made of the resident's breakfast on 09/22/2021 was discussed with the RD. The RD reported the resident had requested the two bowls of hot cereal and had reported that she didn't eat eggs. She reported the resident liked milk on cold cereal but then had to admit the resident had not requested cold cereal. The RD provided the resident's documented food preferences which included the dislike of eggs, but there was nothing about the distress the resident felt when she drank milk. The RD confirmed that even though part of the plan was to increase protein in the resident's meals, that had not occurred. The RD confirmed that she had not contacted the Dialysis Center to obtain the resident's dry weight or recent lab reports.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Staff F, Licensed Practical Nurse (LPN) was observed, on 9/21/21 at 11:31 a.m., dispensing and administering a total of five medications for Resident #90, four of which were to be administered at 9:00 a.m. and did not include one oral medication, Folic Acid, that the staff could not locate. Immediately prior to the observation, Staff I, Registered Nurse (RN) was observed speaking with Staff F in the hallway outside of Resident #90's room. Staff I stated she was helping the LPN due to him being backed up. On 9/21/21 at 12:10 p.m., Staff F completed the administration of Resident #90's medications and reported that the reason for late medications was that he had not arrived to the facility until 9:30 a.m., doing them a favor, normally works 3-11 p.m. shift on the other unit (A-wing), that prior to his arrival staff had administered medications to one person on the assignment, and that Staff I had assisted him for one room prior to the observation. A review of the facility floor plan indicated that the hallway which Staff F had been observed contained nine (9) resident rooms and those rooms contained eight (8) residents as of 9/21/21 at 4:14 p.m. On 9/22/21 at 12:09 p.m., Staff Member G, Licensed Practical Nurse (LPN), stated that she was an agency nurse who had started working at the facility last week. She stated medications were late because she received her assignment late. Resident #58 was observed with his lunch tray on an over-the-bed table in front of the resident. Staff G, LPN, was observed dispensing, at 12:31 p.m. on 9/22/21, Resident #58's oral medications. The staff member administered the residents oral medication and residents subcutaneous dose of insulin at 12:57 p.m. on 9/22/21. A review of Resident #58's MAR indicated 15 oral medications, including an inhaler, that Staff G administered which were due at 9:00 a.m., and a subcutaneous injection of Novolog which was due before meals. The policy, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), effective December 2020 and revised January 2021, indicated that Maintaining appropriate staffing in healthcare facilities is essential to providing a safe work environment for healthcare personnel (HCP) and safe patient care. As the COVID-19 pandemic progresses, staffing shortages will likely occur due to HCP exposures, illness, or need to care for family members at home. The facilities plan and process to mitigate staff shortages for safety and quality of care provided to the residents of the facility included Schedules may be adjusted to meet the needs of the residents and Agency employees will receive adequate orientation, training, and verification of competency. During an interview, at 2:12 p.m. on 9/22/21, the Director of Nursing (DON) confirmed that the facility had a problem with late medications and were going to move schedule medication administration times to a patient-centered liberalized times: day, afternoon, evening and bedtime, but it was going to take 2 months. Based on observations, record review and interview the facility failed to provide sufficient and competent nursing staff to meet the resident needs according to the care plan and the facility assessment regarding two (#4, #81) of 48 sampled residents, and on 1 of 2 (C-Wing) patient wings related to timely and appropriate response to call light; staff being available for change of shift report on one (100) of two wings and timely administration of medication for two (#90, #58) of five residents observed. Findings included: 1. Interview of a group six of alert and oriented residents who wished to remain anonymous on 9/21/21 at 1:33 PM revealed that staff do not respond timely to the call bell. The residents reported that the call lights will be on and staff are noted to walk past the rooms never responding to the call light. The group reported that if staff do come to the room timely, they will just turn off the call lights, and say they will be back, or say that they are not the resident's CNA or that they are going on break and will get some help, but they never return and no-one else comes. All residents reported that they typically wait for 30 minutes or more for a response for call lights. Continued interview with the group revealed that they knew how long they waited because all of them have a clock on the wall across from their bed. The group reported that sometimes there are no staff around at night and they wonder where everyone went. 2. Observation on 9/22/21 at 11:06 AM of Resident #4's room from the hallway revealed that the call light was illuminating above the room door. Interview with Resident #4 at this time revealed that he was ready to get up so that he would be ready for lunch in the dining room. Continued observation of the call light from the hallway reveled two staff walk by. Observation on 9/22/21 at 11:08 AM, the same 2 staff walk by again and stop and go into room. Staff AA, Certified Nursing Assistant (CNA) noted to turn off the light and could over hear the resident tell her that he was ready to get up. Staff was overheard telling the resident that she will tell his aide, and then she left the room. Review of the assignment posted on the wall indicated that Staff BB, CNA was assigned to Resident #4's room. Observations on 9/22/21 at 11:25 AM while seated at the nursing station with clear view of Resident #4's room revealed that no nursing staff has gone into his room yet. Observations on 9/22/21 at 11:38 AM while seated at the nursing station with clear view of Resident #4's room room revealed that nursing staff had still not gone into his room. Observations on 9/22/21 at 11:47 AM while still seated at the nursing station with clear view of Resident 4's room revealed that no nursing staff have gone into his room to address his needs. Interview with Resident #4 on 9/22/21 at 11:53 AM revealed that he is still waiting to get up for lunch in the dining room, and that he has only seen his aide once before now. While in Resident #4's room on 9/22/21 at 11:55 AM Staff T CNA came into the resident's room to take him to the dining room for lunch and asked the resident why aren't you ready yet, left the room for a moment and came back and said I think his aide went to lunch, but I will get someone to help me get you up. She reported that Resident #4 eats in the dining room and is usually up, dressed and ready for the dining room before 11:30 AM. Interview with the DON on 9/22/21 at 12:09 PM while walking to the resident's room revealed that the expectation is for those residents who go to the dining room and need assistance, to be assisted and ready before lunch. At this time the DON and this surveyor both entered Resident #4's room and the resident explained that he wanted to get up for lunch. At this time meal trays for the resident rooms were being passed and it was noted that none of them were for Resident #4. Review of Resident #4's record revealed that he was admitted to the facility on [DATE] and had diagnoses that include: Non-traumatic intracerebral Hemorrhage; Muscle wasting and atrophy to left forearm, left thigh, left lower leg, left shoulder, left upper arm, and left hand. Review of Resident #4's Annual Minimum Data Set (MDS) dated [DATE] revealed that this resident has a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) and required extensive assistance of one person to complete the tasks of dressing, toilet use, and personal hygiene. 3. Review of Resident #81's record revealed that this resident was admitted to the facility on [DATE] with the primary diagnosis of Infection and inflammatory reaction due to internal right hip prosthesis and has a Brief Interview of Mental Status dated 6/28/21 with a score of 15 (Cognitively intact). Observations on 9/20/21 at 1:27 PM of Resident #81 revealed the resident lying in his bed with his eyes closed. A foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. Observations on 9/21/21 at 11:38 AM of the resident lying in bed revealed that he had a boot on his right foot. Interview with the resident at this time, revealed that this boot is supposed to help keep his toes pointed straight up to the ceiling but that it is not on right and something is wrong. He reported that staff put on the boot each morning after providing care. Closer observation of the residents foot revealed that the boot was in place and the foot resting on a pillow and leaning sideways to his right side with toes pointing to the window. Observations on 9/22/21 at 11:06 AM revealed the resident lying flat on his back in bed asleep, with both his feet exposed. The residents right foot was noted to be lying flat on its right side and the foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. On 9/22/21 at 12:25 PM an observation of Resident #81 revealed him seated up in bed with his midday meal tray. Continued observation of the resident at this time revealed that his right foot was lying flat on its right side, pointed towards the window next to his bed and no splint in place. Observations of Resident #81 on 9/22/21 at 1:35 PM revealed him lying on his back in bed with his right foot lying flat on the right side pointing towards the window and no splint in place. Observations of Resident #81 on 9/22/21 at 3:44 PM revealed the resident lying on his back on his bed, with his right foot noted to be lying flat pointing to the right side towards the window located next to his bed. On 9/22/21 at 3:54 PM a review was conducted of the Treatment Administration Record (TAR) for the month of September 2021. Staff are to document the application of the right foot brace on days and at night. Closer observation of TAR revealed that a check mark was in place for days on 9/22/21. Interview on 9/23/21 at 2:01 PM with Staff W, Physical Therapy Assistant (PTA), revealed that the resident is currently on caseload for strengthening. He reported that he put the splint on this morning, and the resident will let staff know when he wants it off. He reported that the resident will refuse to have the splint on at times. Staff W reported that the resident is on splint program for his right hip, as tolerated. He reported that both Staff and resident have been educated on the use of the splint and the importance of using the kick stand to keep the residents leg and hip aligned. Interview on 9/23/21 at 2:15 PM with Staff X, Registered Nurse (RN) revealed that she is assigned to this resident today and does not know much about him. She reported that she is unaware that the resident has a splint or when/how the splint is to be used. She reported that at this time she has not signed off for any splint use. Interview on 9/23/21 at 2:20 PM with Staff Y, Certified Nursing Assistant (CNA) revealed that she is assigned to this resident today and that she is very familiar with him. She reported that he does use a foot splint and that she takes it off when he requests and that she just took it off. The aide was asked to demonstrate how the splint goes on without putting it on the resident. At this time she demonstrated how the foot splint goes on and how it closes using the attached Velcro. When asked about the stand on the back of the boot she responded oh that is nothing, I don't know what it is there for. When asked if there is any direction that staff are to follow to make sure that the boot is on correctly she responded No. Interview on 9/23/21 at 2:30 PM with Staff K, Physical Therapist (PT) revealed that the resident is on PT caseload and currently has a foot brace for his right foot to be on as tolerated when in bed. She reported that staff are to use the kickstand to enable the foot to stay straight up which helps to align the resident hip. Observation on 9/23/21 at 2:58 PM of Staff Y, CNA with permission of the resident she applied the splint to the residents right foot. The staff put the boot on but did not utilize the kick stand and left the foot leaning to the right side. At this time Resident #81 intervened and was able to explain to the CNA how to place the splint and utilize the kick stand. The PT also intervened and provided further direction to the CNA to ensure that the boot was on correctly utilizing the kick stand. During an Interview with the PT at this time she reported that the therapy department in-services staff on the application and use of splints, however with the constant turn-over and change in staff they are unable to train every person who may come in contact with the resident as there is no consistency in staff. Review of the paper chart revealed splint/positioning instructions: When in bed 8-10 hrs as tolerated. This document indicated the following: -Make sure R leg is in normal position when placing on the patient. -Make sure kick stand is visible to maintain R leg in neutral position. -Complete daily skin checks for redness or breakdown. Continued review of this document revealed that on the reverse side of he document were 3 pictures showing the correct positioning of the splint. The document indicated that it was completed by Staff K, Physical Therapist (PT) Review of the physician orders revealed Patient to wear right ankle brace in bed as tolerated every day and night shift with a start date of 7/15/21. Review of the electronic Therapy Page revealed Precautions: (PT) Fall risk, R (right) THA (total hip replacement) revision (6/15/21), RLE WBAT (right lower extremity weight bearing as tolerated), brace for RLE while in bed to maintain neutral hip position. Review of the care plan dated 6/22/21 revealed that Resident #81 required extensive to total assistance to complete his self care tasks, due to the diagnosis of osteomyelitis. Interventions include -Patient to wear right ankle brace in bed, as tolerated 4. On 09/21/2021 beginning at 2:45 p.m., an observation began of the 100 wing for sufficient staff. Initially only two aides were observed, both in and near to the day room. One aide was providing one on one care to a male resident and the second was talking with that aide. No other aides were observed on the unit. At 2:49 p.m. while walking the halls to observe for the aides, at the end of the high numbered rooms, a resident called out for help. When the surveyors approached the resident she asked for help, that she was wet and needed to be changed. The surveyors asked her to put her call bell on and someone would come to assist. The surveyors walked up the hall, continuing to look for aides and finally when they reached the nursing station without observing any aides, they asked they nurses where their staff were. One of the three nurses at the station reported that they were down the halls. The nurse walked down the low numbered hall and found no aide. She walked down the middle hall and found one aide in the last room providing care. And when she walked down the third hall, where the resident had turned on her light, she found one other aide providing care. Further observation revealed both aides were providing care by themselves to the residents and the two aides were from the Day Shift. By then it was 3:00 p.m. and upon returning to the nurses station, the nurse was able to name four aides who were working onto the unit. At 3:15 p.m. the resident's call bell that the Surveyor had been speaking with was answered by the Day shift aide who had been across the hall providing care. On 09/22/2021 at 3:10 p.m. a call light was noted at the end of the middle hall on the 100 wing. The surveyor asked the resident if she needed help and the resident reported that she needed her diaper changed adding would you do it for me? The surveyor explained that she would get someone to help her. As the surveyor walked back up the hall to the nurses station an aide (Aide R) passed her on the way to the resident's room. The surveyor watched the aide go into the room and within one minute left the room having turned off the light. The aide walked up the hall and entered a room where another aide was providing care to the resident. The surveyor saw that aide leave that room and continue toward the nursing station and turn to walk down the low numbered hall. The surveyor saw the aide enter the room, speak with another aide and then leave the hall. The aide then left the wing. It was 3:20 p.m. by then. The DON had walked down the hall toward the room where the light had been on but stopped to talk with another resident who was in the hall. The resident at the end of the hall who had turned her light on put her light on again. The DON had not turned around to see the light and walked away from the light toward the nursing station. The surveyor joined the DON half way down the hall and asked her to answer the light with the surveyor. The resident asked the DON the same question and the DON agreed to find someone to help. While walking back to the nursing station the surveyor reported what she had seen take place with the aide who had turned off the resident's light, visited with other aides then left the floor. In an interview with the Director of Nurses on 09/22/2021 beginning at 3:30 p.m. , when asked why the evening shift started at 2:45 p.m. and the day shift ended at 3:15 p.m. she replied that there was a purpose in that. When asked to elaborate on the purpose, she explained that there was a 30 minute overlap of the staff so they could endorse any relevant information for each resident to the oncoming staff. She explained that the aides should be conducting walking rounds to observe residents and let the oncoming shift know of any changes in the status of each resident. On both 09/21/21 and 09/22/21 from 2:45 p.m. until 3:15 p.m., endorsing resident care information from one shift to the other was not observed by two surveyors on the A wing. On 09/21/2021 at approximately 3:00 p.m. only two aides were observed near to the nursing station and two aides had been identified as providing care to residents in their rooms. On 09/22/2021, at approximately 3:10 p.m. one aide was observed to answer a call light, but turn it off, speak with an aide in a room, find another aide to speak with and then leave the unit. Neither aide was observed to walk down the hall to the resident's room to provide care, until the DON requested that the care be provided. During the interview with the DON on 09/22/2021 which began at 3:30 p.m. , it was noted and a comment made to the DON that the assignment was just being posted on the board in the hall. The DON was asked how aides were to endorse to the oncoming shift, when the assignment was being posted after the Day shift left? The DON reported that the aides have permanent assignments. In an interview with the Aide T who was writing the assignment on the board, on 09/22/2021 at 3:35 p.m., it was revealed that some aides have permanent assignments but with all the agency and call offs, assignments have to change. The Facility Assessment (03/05/2021) was reviewed for their staffing plan related to nurses and aides. (Refer to Section III Facility Resources Needed to Provide Competent Support and Care for Resident Population Every Day and During Emergencies). A chart for Staffing in a 24 hour day listed the Total Number Needed or Average or Range as 18 for Registered and Licensed Nurses. The chart listed 36 for the certified aides. (The chart did not clarify what the number was - whether the number was the total number or average. A note at the end of the section indicated that The Facility adheres to F.S. 400.23 (3) (a) which describes minimum staffing requirements in skilled nursing facilities in the state of Florida.) When this information was compared to numbers listed on the form Calculating Staffing for Long Term Care Facilities, provided for nurse and aide staffing for the period of 08/29/2021 through 09/11/2021, it was noted that the Minimum per shift of licensed nursing hours was only 17, not 18, on every day. There were six days when the total number of aides was below the 36 total number needed or average as listed in the Facility Assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure target behaviors, side effects, and outcomes were monitored and documented for two (#6 and #30) out of five residents sampled for unnecessary medications. Findings included: 1. On 9/20/21 at 1:05 p.m., Resident #6 was observed lying in bed, quiet and eyes closed. The resident was very thin with muscle-wasting, wearing a nasal cannula delivering 3 liters of oxygen per minute. On 9/21/21 at 8:51 a.m., the resident was observed lying in bed, wearing a nasal cannula delivering oxygen, mouth open, eyes closed, and with neck hyperextension on pillows. Resident #6 was admitted , per the admission Record, on 1/11/21 and readmitted on [DATE]. The medical record included diagnoses not limited to dementia in other diseases classified elsewhere without behavioral disturbance, unspecified mood disorder due to known physiological condition, and unspecified schizoaffective disorder. A review of the physician orders for September 2021 for Resident #6 included the following: - Citalopram Hydrobromide tablet 20 milligram (mg) - Give one (1) tablet by mouth one time a day for depression, ordered 3/9/21. - Mirtazapine tablet 7.5 mg - Give 2 tablet by mouth at bedtime for depression. 2 tabs = 15 mg, ordered 8/26/21. Mirtazapine 15 mg ordered on 3/9/21 and scheduled for 9:00 a.m., the administration time was changed to 9:00 p.m. on 8/23/21. - Risperdal tablet 1 mg - Give 0.5 mg by mouth at bedtime for schizoaffective disorder, ordered 8/25/21. - Risperidone tablet 0.5 mg - Give 1 tablet by mouth in the morning for schizoaffective disorder. Behavior (BEH): 0) no, 1) fear, 2) anger, 3) scream, 4) danger/self/others, 5) delusions/hallucinations ([NAME]/[NAME]), 6) sad, 7)other description (desc). Interventions (INT): 1) Music, 2) Reminisce, 3) exercise (ex), 4) 1:1, 5) quiet, 6) as needed (prn). Outcome: I) Improved, S) Same, W) Worse. Side Effects (SE): 0) None, 1) Extrapyramidal Symptoms, 2) Tardive Dyskinesia, 3) Hypotension, $) Behavior (beh), 5) Drowsy, 6) Dizzy. This order was ordered on 6/9/21 for the diagnosis of psychotic disorder then changed on 8/17/21 for diagnosis of schizoaffective disorder. The above physician orders were discontinued on 9/22/21 related to the passing of Resident #6. The review of Resident #6's August and September 2021 Medication Administration Records (MAR) indicated that the physician order for the resident's Risperidone did not include areas for the staff to document the monitoring of behaviors, interventions, outcome and side effects. The MAR did not include monitoring for the antidepressant medications of Citalopram or Mirtazapine administered to the resident, the target behaviors the psychotropic medications were used to treat, or the time in which staff should be monitoring. The physician note, dated 9/21/21 at 12:12 p.m., indicated that Resident #6 had worsening pneumonia, with a Past Medical History (PMH) which included dementia. The note identified the resident was alert, very confused, and worsening dementia. The note did not identify behaviors related to the use of psychotropic medications. The facility was asked for Psychiatry notes for Resident #6 and the following notes were provided: - Psychiatry note, dated 6/5/21, indicated that services were reconsulted to assess meds for possible dose reduction of psychotropics. Patient (Pt) has done well recently with no agitation or disruptive behaviors - she is cognitively impaired and has difficulty communicating. The plan was to attempt a dose reduction of Risperdal and consider a decrease in Remeron (Mirtazapine). - Psychiatry note, dated 7/6/21, identified that the patient was able to tolerate a decreased dose of Risperdal and remained disoriented and disorganized. 2. On 9/20/21 at 10:49 a.m., Resident #30 was interviewed while she sat in a wheelchair in the resident's room. The resident was observed, on 9/22/21 at 11:37 a.m. sitting in wheelchair applying body lotion. The admission Record for Resident #30 identified that the resident was admitted on [DATE] and diagnoses included unspecified encephalopathy, unspecified anxiety disorder, and cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery. A review of the September 2021 physician orders for Resident #30 included the following psychotropic medications: - Alprazolam tablet 0.5 milligram (mg) - Give 1 tablet by mouth every 8 hours as needed for anxiety until 9/26/21 x 14 days from 9/12/21. Revised 9/21/21. - Lexapro tablet 10 mg (Escitalopram Oxalate) - Give 10 mg by mouth at bedtime for depression. Revised 9/18/21. - Trazodone Hydrochloride (HCl) tablet 50 mg - Give 2 tablet by mouth at bedtime for insomnia. 2 tabs = 100 mg. Revised 9/21/21. A review of the September 2021 MAR did not indicate behaviors for the use of psychotropic medications were monitored. The active physician orders, dated 9/23/21 at 12:57 a.m., did not include orders for the monitoring of behaviors, side effects, outcomes, and non-pharmaceutical interventions related to the use of psychotropic medications. A request was made to the Director of Nursing (DON), on 9/22/21 at 6:57 p.m., for portions of Resident #30's clinical record which included the September 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR). The facility did not provide the September MAR or TAR but did provide other requested documentation. The review of Resident #30's August 2021 MAR revealed the following: - Lexapro 5 mg - Give 5 mg by mouth one time a day for anxiety, ordered 8/27/21 and discontinued on 9/18/21. The MAR did not indicate staff were documenting behaviors, non-pharmaceutical interventions, outcomes, or side effects related to use of Lexapro. - Trazodone 50 mg - Give 2 tablet by mouth at bedtime for Insomnia. 2 tabs = 100 mg, ordered 4/2/21. The MAR did not indicate staff were documenting behaviors, non-pharmaceutical interventions, outcomes, or side effects related to use of Trazodone. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 day, ordered 7/30/21. --- a): The MAR did not indicate that staff had monitored for a target behavior or the resident had exhibited behaviors, interventions, outcomes or side effects related to the use of an as needed psychotropic medication. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as needed from anxiety. Behavior (BEH) 0) No, 1) Fear, 2) Anger, 3) Scream, 4) Danger/Self/Others, 5) Delusions/Hallucinations ([NAME]/Hall), 6) Sad, 7) Other describe (desc). Interventions (INT): 1) Music, 2) Reminisce, 3) Exercise (ex), 4) 1:1, 5) Quiet, 6) as needed (prn). Outcome (OC): I) Improved (Imp), S) Same, W) Worse. Side Effects (SE): 0) none, 1) Extrapyramidal Symptoms (EPS), 2) Tardive Dyskinesia (Tard Dys), 3) Hypotension, 4) Behavior (beh), 5) Drowsy, 6) Dizzy. ordered 8/15 and discontinued 8/18/21. --- a): The MAR indicated that the staff had documented Not applicable (NA) on 8/15 and 8/16 for behaviors exhibited by the resident and did not indicate the medication had been monitored every shift. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as ended by Anxiety x 14 days from 8/15 until 8/28/21. Behavior (BEH) 0) No, 1) Fear, 2) Anger, 3) Scream, 4) Danger/Self/Others, 5) Delusions/Hallucinations ([NAME]/Hall), 6) Sad, 7) Other describe (desc). Interventions (INT): 1) Music, 2) Reminisce, 3) Exercise (ex), 4) 1:1, 5) Quiet, 6) as needed (prn). Outcome (OC): I) Improved (Imp), S) Same, W) Worse. Side Effects (SE): 0) none, 1) Extrapyramidal Symptoms (EPS), 2) Tardive Dyskinesia (Tard Dys), 3) Hypotension, 4) Behavior (beh), 5) Drowsy, 6) Dizzy. ---a): The MAR indicated that staff had documented n on 8/18 for behavior, interventions, and Side effects and that administration was effective at 10:47 a.m., 0 on 8/20 for behavior, interventions, Outcomes, and Side effects and that the medication was effective on 8/19 at 11:08 a.m. and 8/20 at 6:39 p.m., Staff documented Not applicable (NA) on 8/21 - 8/26/21 for behavior, interventions, Outcomes, and Side effects while the medication had been administered with an effective outcome. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as needed for anxiety, ordered 8/29/21 and discontinued 8/31/21. ---a): The MAR did not include an area for staff to document behaviors, interventions, outcomes or side effects. The review of Resident #30's care plan identified the resident had a diagnosis of depression and had the potential for adverse consequences of antidepressant medication, initiated and revised on 4/2/21. The interventions included: Monitor for effectiveness of medication, monitor for side effects of medication i.e.: nausea, gastrointestinal problems, dizziness, fatigue, dry mouth, weight gain, and insomnia, and monitor for signs and symptoms of depression and notify MD (doctor) prn (as needed). The care plan identified that the resident had a diagnosis of anxiety and had potential for adverse consequences related to use of Antianxiety and staff were instructed to monitor for effectiveness of medication and monitor for side effects of antianxiety medication i.e.: drowsiness, dizziness, weakness, dry mouth, diarrhea, nausea, constipation, blurred vision, and report to MD prn. A review of Daily Skilled Services notes, dated 9/12 - 9/20/21 indicated that staff had documented no changes to mood and behavior noted. The progress notes indicated that an order was added, 9/20/21, for Lexapro 10 mg, on 9/23/21 and the resident was placed on a three-day voiding trial, then on 9/23/21 related to speaking to the resident regarding medications found at bedside. The physician progress note, dated 9/14/21 at 6:49 p.m., did not identify a past medical history (PMH) of depression and the resident was alert/awake/oriented x3. The Psychiatric Consultation, dated 8/27/21, indicated the resident was diagnosed with depressive disorder. The consultation indicated the resident reported taking Xanax to prevent crying and admitted to sadness, and also reported taking Trazodone for insomnia with no behavioral issues reported. The psychiatric note, dated 9/18/21, indicated the resident did not note any difference in mood and denied side effects. The note indicated the resident continued to cry for no reason and relies on Xanax as needed to calm down. The note indicated the plan was to increase Lexapro to 10 mg at bedtime. The Director of Nursing (DON) was interviewed at 10:04 a.m. on 9/23/21. She stated that staff were monitoring behaviors and indicated the psych notes should be reviewed. A review of Resident #30's September MAR was completed with the DON. She confirmed that different psychotropic medications exhibit different side effects and the resident's MAR did not include any monitoring of target behaviors related to the continued use of Xanax and two antidepressants. She stated the facility did not separate monitoring of different classes of psychotropic medications. Staff T, Certified Nursing Assistant (CNA), stated, at 11:58 a.m. on 9/23/21, she was not caring for Resident #30 but did know her. She stated Resident #30 was real sweet, an able to tell them what she needs and did not have any behaviors and doesn't cry. During an interview with the Pharmacy Clinical Case Manager, at 12:59 p.m. on 9/23/21, he stated that staff should be documenting behaviors every shift and does not think it was necessary to separate the monitoring for different classes of psychotropic medications if they are used to treat the same behavior. The policy and procedures: Pharmacy Services - Drug Regimen Free from Unnecessary Drugs, issued and revised on 2/1/20, indicated the intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and prn orders for psychotropic medications are only used when the medication is necessary and prn use is limited. The procedure indicated that each resident's drug regiment must be free from unnecessary drugs. An unnecessary drug is any drug when used: c. Without adequate monitoring; or d. without adequate indications for its use.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed, and twenty-three errors were identified for three (#66, #90, and #58) of five observed residents. These errors constituted a 63.8% medication error rate. Findings included: 1. On 9/21/21 at 8:23 a.m., an observation of medication administration with Staff Member C, Licensed Practical Nurse (LPN), was conducted with Resident #66. Staff C was observed administering the following medications: - Levetiracetam 1000 milligram (mg) tablet orally. - Metoprolol Tartrate 25 mg tablet orally. - Potassium Chloride (Cl) Extended Release (ER) 10 milliequivalent (meq) caplet orally. - Sodium Chloride (Cl) 1 gram (gm) tablet orally. The observation indicated that the pharmacy label of the blister-packaged Metoprolol indicated the medication was to be administered if vital signs were within parameters. The staff member stated that the Metoprolol doesn't have any parameters, nothing pops up (on the electronic Medication Administration Record (MAR)). Staff C crushed all the medications together and placed the items in applesauce. Staff C reported, on 9/21/21 at 8:39 a.m., that the resident would not take the Potassium without crushing it and that the resident did have liquid Potassium awhile ago but did not like the taste. A review of Resident #66's physician orders revealed the following: - Obtain vital signs every shift, ordered 11/18/20. - Metoprolol Tartrate Tablet 25 mg - Give 1 tablet by mouth every 12 hours for Hypertension (HTN). Hold for Systolic Blood Pressure (SBP) less than 110 or Heart Rate (HR) less than 60, ordered 11/18/20. - May crush medications unless contraindicated, ordered 11/17/20. The review of a Daily Skilled Services note, completed by Staff C and effective at 7:34 a.m. on 9/21/21, indicated the Most Recent Blood Pressure was 120/76 obtained at 11:58 p.m. on 9/20/21 from the left arm of Resident #66 while lying down. The Most Recent Pulse of 62 with a regular rate was also obtained at 11:58 p.m. on 9/20/21. The review of the Weights and Vital Summary indicated the following: - Blood pressure: 120/76 at 11:58 p.m. on 9/20/21 and the next recorded blood pressure of 135/91 was documented at 8:09 p.m. on 9/21/21. - Pulse: 62 beats per minute (bpm) at 11:58 p.m. on 9/20/21 and the next pulse of 75 was documented at 8:09 p.m. at 9/21/21. An interview was conducted with the Pharmacy Clinical Case Manager (CM), at 12:59 p.m. on 9/23/21. The CM stated that Potassium Chloride ER should not be crushed and in regards to obtaining a blood pressure and pulse, staff should obtain vital signs prior to the administration of the medication, and not use the ones obtained from the night before. 2. On 9/21/21 at 11:31 a.m., an observation was made of Staff Member F, Licensed Practical Nurse (LPN), standing at a medication cart on the C-wing speaking with Staff Member I, Registered Nurse/Infection Control Preventionist (RN/ICP), the electronic Medication Administration Record identified the resident profiles colored red. Staff I stated she was helping Staff F due to being backed up, prior to the medication observation Staff I left the area. Staff F was observed administering the following medications to Resident #90: - Carvedilol 6.25 mg tablet orally - Misoprostol 200 microgram (mcg) tablet orally. - Sucralfate 1 gram (gm) tablet orally. - Lisinopril 40 mg tablet orally. - Enoxaparin Sodium 40mg/0.4 milliliter (mL) injection. The staff member confirmed he was administering 4 oral tablets. The staff member identified that the resident was to receive Folic Acid but after searching the medications received from pharmacy and over-the-counter medications he stated he was not able to locate it. He obtained blood glucose level from the resident during the administration and at 12:08 p.m., the nurse reviewed the insulin order and stated that the resident did not need to have insulin coverage. Immediately following the observation Staff Member F stated that the profile was red due to late medications and when medications were late he does look for someone to help. The staff member stated he did not get to the facility till 9:30 a.m., doing them a favor, normally works the 3-11 shift on the other unit, (A-wing) and that prior to his arrival staff had administered medications to one person on the assignment and that Staff I had begun to assist him one room ago. A review of the Medication Administration Record (MAR) for Resident #90 revealed the above medications were scheduled to be administered at 9:00 a.m. including Folic Acid 1 mg tablet orally. On 9/21/21 at 12:05 p.m., a review of the resident's MAR indicated that Staff F had documented that the Folic Acid prescribed to the resident had been administered. A further review of Resident #90's clinical record identified that a physician order had been obtained, on 9/22/21 at 12:54 p.m. ok to give all meds that were late for 9 a.m. 9/21/21. 3. On 9/22/21 at 12:09 p.m., Staff Member G, Licensed Practical Nurse (LPN), stated she was picking up shifts at this facility in the last week and that the medications were late because she was going to be on this unit or another but another nurse had not shown up then one came in so she was able to be on this hall. Resident #58 confirmed, on 9/22/21 at 12:22 p.m., with Staff Member G that he wanted to take his medications, a lunch tray was sitting on the over-the-bed table in front of the resident. The staff member retrieved over-the-counter medications from the medication room then began dispensing the following medications at 12:31 p.m.: - Breo Ellipta 100-25 mcg inhaler - Colace 100 mg tablet - Carvedilol 12.5 mg tablet - Desveniafaxine ER 25 mg tablet - Clopidogrel 75 mg tablet - Divaloproex DR 250 mg tablet - Eliquis 5 mg tablet - Gabapentin 400 mg capsule - Folic Acid 1 mg tablet - Isosorbide Mononitrate ER 30 mg tablet - Furosemide 40 mg tablet - Januvia 25 mg tablet - Pantoprazole DR 20 mg tablet - Potassium Cl ER 20 meq tablet - Tamsulosin Hydrochloride (HCl) 0.4 mg tablet - Novolog 100 unit/mL Flexpen 2 units The residents meal tray was removed from his room at 12:45 p.m., and at 12:56 p.m. Staff G obtained a blood glucose level of 173 from the resident. She handed the medication cup of oral medications to the resident, then the inhaler was administered and the staff member returned to the medication cart. She confirmed the amount of insulin needed, removed the Flexpen, applied a needle, and while holding the pen horizontally she dialed the dose selector to 2 units, returned to the residents room, and administered the 2 units in the residents right upper extremity. Immediately following the observation, Staff G stated she does not prime the Flexpen if she was able to see insulin coming from the needle after she selected 2 units. A review of the Medication Administration Record indicated that the above oral medications were due at 9:00 a.m. and the Novolog insulin was ordered before meals. The progress notes written by staff members on 9/22/21 did not indicate that the physician was notified that the residents' oral medication was administered 2.5 hours outside of the allowable time frame for administration and that the residents insulin was given after the resident had eaten lunch. During an interview with the Director of Nursing (DON), on 9/22/21 at 2:12 p.m., she stated that she was aware of Staff F's late medications and that a physician order was obtained, after the meds were given, that it was okay that the medications were late. She stated her expectation in regards to late meds was that the nurses were to administer the medications then to let the physician know that they were late, because staff wouldn't know they were late until they were late. She reported that the facility was aware they had a problem with late medications and was moving towards patient-centered liberalized medication administration times, such as day, afternoon, evening, and bedtime but that it was going to take 2 months. She stated the procedure for administration of insulin with a Novolog pen was to prime with 2 units, she reiterated to waste 2 units. The DON was asked to supply the facility's policy for medication administration. On 9/23/21 at 12:59 p.m., the Pharmacy Case Manager stated that the procedure for late medications depended on their policy but the window for scheduled 9 a.m. medications was between 8 a.m. and 10 a.m. and that the facility picked the scheduled time for medications. The Pharmacy policy (that the facility provided), General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10 and 1/1/13, indicated that, Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. The policy instructed staff in the following: - Facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Appendix 16: Common Oral Dosage Forms that Should Not Be Crushed and /or facility policy; - Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule; - Administer medications within timeframes specified by facility policy; Appendix 16: Common Oral Dosage Forms that Should Not Be Crushed, a Pharmacy policy copyrighted 2020, indicated that Potassium Chloride ER should not be crushed. The facility Clinical Competency regarding Insulin Injection, dated May 2017, identified, in section: Subcutaneous Insulin-Pen Device, that staff: - performs safety test prior to each injection, selects dose of units by turning dosage selector; - Takes off outer needle cap and keeps it to remove used needle following injection; - Takes off inner cap and discards it, holds pen with needle pointing upwards; - Taps insulin reservoir to move air bubbles put toward needle, presses injection button all the way in; - Checks if insulin comes out of the needle tip, repeats test until insulin is seen.

Based on observations, record reviews, and interviews the facility failed to ensure medications stored in three (A-Wing 3, C-Wing 1, and C-Wing 2) out of the six facility medication carts were stored appropriately as evidenced by narcotic medications not accounted for when administered and medications were not dated when opened when medications had a shortened shelf life. Findings included: Staff F, Licensed Practical Nurse (LPN) was observed, at 5:52 p.m. on 9/22/21, at the A-Wing nursing station. After reviewing the A-Wing Medication Cart 3 with Staff F. A full review of the controlled medications was made with Staff F and it was found that multiple narcotics had not been signed out when he had administered them. Four Controlled Medication Utilization Records for different residents were identified as not having the medications reconciled against the number of tablets/capsules available on the blister packages. (Photographic Evidence Obtained) Staff F stated he knew that the record should be signed off when the medication was administered but did not have time because the assignment had residents with multiple needs. An observation was conducted of the C-Wing Cart 1, on 9/22/21 6:19 p.m., with Staff U, Registered Nurse (RN). The observation revealed an Insulin Determine FlexTouch pen lying in a plastic basket, labeled with a resident name and without an open date. Staff U confirmed that the pen was not in a container and was undated. The RN stated, she was going to get her a bag for the pen and dated the pen 9/22/21. The observation revealed a Combivent Respimat inhaler that was not dated with an open date, which Staff U confirmed. Located in the same medication cart was another Combivent Respimat inhaler with a sticker that indicated it would need to be discarded 90 days after opening. (Photographic Evidence Obtained) On 9/23/21 at 12:59 p.m., the Pharmacy Clinical Case Manager (CC) stated that Combivent Respimat inhalers expire in 90 days after opening. An observation was made, 9/22/21 at 6:48 p.m., of the C-Wing Medication Cart 2 with Staff H, RN. The observation identified an opened, undated bottle of Fumigant eye drops, an opened, undated bottle of Brigandine eye drops, and a Novolog FlexTouch insulin pen undated as to when it was opened or when it would expire. The Staff H, RN and Staff I, RN, confirmed the findings. The staff members stated the resident who was prescribed the Novolog insulin pen had been discharged today. (Photographic Evidence Obtained) The Pharmacy CC stated, during an interview on 9/23/21 at 12:59 p.m., that both Fumigant and Brigandine eye drops expire 28 days after opening and should be dated when opened. The Pharmacy guidance, Medication Storage, identified the following: - Ophthalmic Products: Date when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations or facility policy. - Combivent Respimat Inhalation Spray: After initial assembly, the inhaler should be discarded after 3 months or when the locking mechanism is engaged, whichever comes first. - Novolog cartridge or pen: Room Temperature unopened- 28 days or Room Temperature opened- 28 days. The policy: Storage and Expiration Dating of Medications, Biological's, Syringes, and Needles, effective 12/1/07 and later revised on 10/28/19, identified the following: - Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. - When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle. - Bedside Medication Storage: Facility should not administer/provide bedside mediations or biological's without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. Facility should store bedside medications or biological's in a locked compartment within the resident's room.

Based on observation of dietary staff, interview with dietary staff, and review of dietary documents, the facility failed to ensure the kitchen equipment was maintained in a clean manner, items stored in the walk in refrigerator were dated and discarded when indicated by the date, the temperature and sanitation logs for the dish machine were accurately completed, and a floor drain was kept clean. Findings included: On 09/20/2021 at 10:00 a.m. a tour of the facility's main kitchen began. Staff J, Dietary Aide was standing at the dirty side of the dish machine and was observed to push a rack of dirty items into the dish machine. She was not able to answer questions about the dish machine so the Dietary Manager stepped in to answer. The temperatures of the dish machine met the standard per the manufacturer's guidelines, but the sanitizer strip did not change color to indicate the correct amount of sanitizer. The Dietary Manager checked the bucket of sanitizer and realized that the tubing was not in the sanitizer which did not allow the sanitizer to flow into the machine. The monitoring log for the dish machine was reviewed at that time and noted for having the three shifts for the day of temperature and sanitizer already documented. The Dietary Manager confirmed that someone must have just written in similar values to the other days and that it was incorrect to document the values prior to actually checking them. In addition at this time, the walk-in refrigerator located across from the range and oven was toured, and two gallon jugs both half full of mayonnaise were observed on a shelf in the refrigerator. Neither jug was labeled with the date that it had been opened. The manufacturer's date of production was not able to be determined as the date was encoded. A quarter steam table pan was observed toward the back of a shelf in the refrigerator topped with clear wrap which had the description of sloppy joe and the date of 09/07 scribbled on it in black marker. The Dietary Manager agreed that both jugs of mayonnaise should have been dated when opened and the sloppy joe should have been discarded after three days. In addition, the can opener attached to the cook's preparation table was noted to have a dark sticky substance on the pincer. The Dietary Manager reported that it had not yet been used that morning. An observation of the floor drain located between the ice machine and the reach-in freezer was noted to have standing water along the edges between the tile floor and the metal drain cover. The surface of the drain cover was slick when rubbed with the toe of a shoe. The inside drain was white and noted to be soiled with a black material.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and admission agreement review, the facility failed to provide admission information related to facility rules, rates, and resident rights at or after admission for one (Resident #89) of four residents reviewed. Findings include: Record review of admission Record revealed Resident #89 was admitted on [DATE], according to the admission record. During initial tour of facility on 01/13/20 at 11:25 a.m., an interview with Resident #89 and her son (the Power of Attorney (POA)) revealed that neither parties had signed an admission policy or received admission package information. A follow-up interview on 01/13/20 at 1:28 p.m. with Resident #89 and POA found that they requested on various occasions to meet with someone to discuss the facility rules, facility rates and the Resident's coverage. The POA spoke with both nurses and the receptionist about setting up a meeting but, nothing came of it. The POA said they are not sure of what they can and cannot do in the facility. On one occasion the POA brought in cake for the Resident and left it overnight in the room. The next day he was told by a nurse that this was not allowed because it can attract ants. The POA said that he would have known this had they been provided with the facility rules. Record review of the facility's admission Agreement under General Information heading, located in the admission Package, found, This is a legal document creating rights, responsibilities and obligations for each person or party signing this agreement. Please read this agreement carefully before you sign it. If you do not understand any provision of this agreement, please obtain clarification before you sign. If you choose, you may have your legal counsel or other advisor review this agreement before you sign. Record review of the admission Package revealed information related to, 1) Guest Rules and Regulations. 2) Room Type and Rates 3) Welcome Information Booklet 4) Patient (Guest) and Resident State Rights. Record review of the admission Policy, undated, revealed, The Admissions Team will follow facility policies regarding admissions. On 01/14/20 at 8:45 a.m., during an interview, Resident #89 stated, you can check anything you want but I don't think we got one. My son would have had it. Observation revealed there wasn't an admission packet in room. An interview was completed on 01/14/20 at 1:57 p.m. with the Director of Guest Services (DGS). DGS stated that they provide residents with a packet they take with them, which includes the information welcome booklet, resident rights, copy of the ombudsmen pamphlet, pet policy, all the different practitioners, and dentists. This package also includes a rate sheet. DGS stated the admission agreement does require a signature and that residents have a right to a copy if they wish. DGS stated that facility does keep a hard copy of the signed admission agreement which is also scanned into their Point Click Care system. DGS acknowledged that they did not have a signed copy of the admission agreement from the Resident or POA. DGS acknowledged that they did not know about the request for a meeting from the Resident's POA. DGS acknowledged that the date to have the paperwork signed was on 12/30/19 during the Partners in Care Meeting with the Resident's POA present. The Partners in Care (PIC) Meeting consists of the interdisciplinary team that will discuss the discharge plan, go over medication, meet and greet the family members, and orient the Resident to the department. Facility staff that usually attends the PIC meeting will be a member of Quality Assurance, a Unit Manager, a social worker, and a member of dietary. Record review of the Partners in Care Meeting documentation, signed and dated on 12/30/19, revealed, code status verified- son @ bedside. Photo evidence of documentation included. Interview on 01/14/20 at 2:32 p.m. with the Unit Manager Staff H, Registered Nurse (RN), said that they document anything that occurs in the PIC meeting onto the PIC documentation. They discuss information related to discharge and introduce the Resident to the various staff members. Staff H revealed that they don't do anything with the admission package during the PIC meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the admission Record for Resident #89 revealed the Resident was admitted on [DATE] from an acute care hospital. During an observation on [DATE] at 11:25 a.m. with Resident #89 and her son, who was her designated Power of Attorney (POA), the SSD (Social Services Director) entered the resident's room. She provided Resident #89 a goldenrod Florida Do Not Resuscitate Order (DNRO). Resident #89 signed the document. An interview was conducted on [DATE] at 1:05 p.m. with Resident #89 and her DPOA. Resident #89 said she desired to have a DNR order. Phone interview with POA on [DATE] at 4:07 p.m. revealed that the POA will sign the Resident's name if needed and they will write POA next to the signature. Record review of the Advance Directives- Code Status Quick View Guide, revealed the following: 1) Two Nurses will witness and document physician's order for DNR: Resident/Designated Health Care Decision Maker will sign the yellow Florida DNR form (this form is for transport communication for EMT's, Medics and ER staff only). Health Care Decision Maker may sign in person, via fax or scanned in email. Form will be faxed to physician for signature by Social Services. Copy of DNR order in hard chart in the Advanced Directives section. 2) The Code Status order entered in to PCC (Point Click Care) is the primary source for validating a resident's code status. In the event a resident becomes unresponsive and without pulse or respirations. Check the Order in PCC. Record review of physician orders in the electronic medical record revealed an active CPR; full code status, dated [DATE] and an active DNR status dated [DATE]. Record review of Progress Notes, dated [DATE], revealed, Resident alert and oriented able to make needs know. This nurse along with another nurse witness addressed code status. Resident states she wishes to be DNR. Son (POA) confirmed. MD will be called for order. This nurse along with another nurse called MD to obtain orders for resident to be DNR. Doctor gave orders. Record review of Partners in Care Meeting, dated [DATE], revealed, code status verified- son at bedside, Resident wants DNR status. *Photographic evidence was obtained. Record review of Progress Notes, dated [DATE] at 10:37 a.m., revealed, two nurses addressed DNR code status on 12-30-19 she wants to be a DNR. Asked resident to sign on 12-30-19. She states she cannot, readdressed the situation today but she, again, says, yes, she wants to be DNR but we have to wait for son to come in this afternoon so she can attempt to sign the DNR. Based on record review, observations, policy review, and interviews, the facility did not ensure the advance directive status, related to a DNRO (do not resuscitate order), was clearly identified in the medical record for two (#80 and #89), of eight residents reviewed. Findings included: 1. Resident #80 was admitted to the facility on [DATE] with a diagnosis of dementia, according to the facesheet in the admission record. During the record review for Resident #80, a telephone order, dated [DATE], was discovered under the Advance Directive tab in the medical record at the nurse's station. The order summary indicated Resident #80 was a full code. However, further review of the record revealed a yellow Florida Do Not Resuscitate Order, dated [DATE], and signed by the resident and her physician. It was located directly behind the telephone order. Upon review of the electronic physician's orders, an order, dated [DATE], indicated Resident #80 was a DNR. Further review of the same electronic orders, reflected an order, dated [DATE], Resident #80 was a full code. Both orders were marked Active. *Photographic evidence was obtained. The advance directives care plan, dated [DATE], was also reviewed, and revealed the following: Resident #80 does not have advanced directives: She is a DNR code status. A review of the form, Acknowledgement of Advance Directives, dated [DATE], and signed by Resident #80, revealed Resident #80 had a Florida DNRO, and the resident's husband was to bring it in. Review of the Quarterly Advance Directive Review, dated [DATE], reflected the Florida DNRO was provided on [DATE], and was signed by Resident #80's husband on [DATE]. Review of progress notes in the medical record, dated [DATE], revealed a nurse's note that indicated Resident voices desire to be a DNR, husband is aware of her wishes. Witnessed with Unit Manager. A subsequent note indicated Resident #80 signed her DNR forms and made her wishes known that she does not wish to be resuscitated if her heart was to stop. Husband is also aware of resident's wishes. The physician gave orders for DNR, and signed the DNR form. On [DATE] at 3:01 p.m. an interview was conducted with the SSD (social services director) and SSA (social services assistant). The SSD said two nurses go in as soon as they can, the day of admission, and they establish if the resident is DNR or full code. If the resident is DNR, the nurses write the order. Social services follows up on the the Florida DNRO. When the Florida DNRO is signed, social services puts it in the doctor's book. Social services follows up checking on the Florida DNRO, to make sure the physician has signed it. The SSD said that happens as soon as social services is in the building. If the resident came on a Friday or weekend, then social services would address it Monday. She also confirmed a care plan should be initiated for CPR or DNR. The SSA said social services creates the care plan. The SSD said they have to make sure everything is in place before they create it. They don't put the care plan in there until they know it is correct. Social services puts in the care plan when they know everything is complete. The nurses are inserviced to know to look for that order in the chart, the hard chart. The chart they have access to on the floor. The residents are a full code if they're not a DNR. The order will either say CPR or DNR. The nurses wouldn't do anything until they pulled that chart and verified the order. It is actually a telephone order. The nurses take the order, put it on the chart, and then a copy of the order is placed in the physician's book for him to sign. She said she doesn't know how that piece (the electronic record) is handled. That is definitely a nursing question. Two nurses have to verify the DNR order. The paper isn't necessarily on the chart until the doctor signs it. The SSA said the yellow form is for transport. The SSD said that DNR order is effective once the physician is notified, after the two nurses verified that is the patient's wish. The policy review, Advance Directive and Code Status, dated [DATE], revealed the following information: Advanced Directive Code Status Guidelines: The center will perform CPR on residents that do not have physician's orders for Do Not Resuscitate DNR. However, the Center will support the right of every resident to make decisions, including the right to accept or decline cardiopulmonary resuscitation in the event of cardiac arrest. Procedure 1. Upon admission the nurse completing the admission assessment will ascertain the resident's wishes related to code status (CPR or DNR) with a second nurse witness. If the resident is incapacitated or is unable to communicate their wishes regarding code status, reasonable efforts will be made to contact the designated responsible party or surrogate medical decision maker to ascertain the resident's desired code status. The code status for the resident will remain CPR until contact is made to determine the resident/responsible party's wishes. 2. Two nurses will witness and will document the resident/responsible party's code status wishes in the electronic health record (EHR). 3. The nurse will contact the resident's attending physician/extender, to notify the attending physician/extender of the resident/responsible party's wishes related to code status and an order for CPR or DNR will be obtained, and immediately entered into the EHR. In the event of a DNR order received via telephone, two nurses shall witness a verbal telephone order by each nurse making a progress note in the EHR documenting the verbal/telephone order by each nurse making a progress note in the EHR documenting the verbal/telephone order for DNR, and place copy of order in advance directive section of the chart. 4. The code status order will be documented in the EHR and will serve as the primary source of validation of code status should a resident be found unresponsive. 5. The state of Florida DNR form (DH 1896) found in FL statute 401.45, we use to communicate a resident's DNR code status wishes to 911/ emergency medical services (EMS) should the resident be found unresponsive. If executed, the state of Florida DNR form (DH 1896) will be scanned into the EHR under miscellaneous section. 6. If the resident/responsible party wish to choose a DNR code status, the resident/responsible party will sign and date the state of Florida DNR form DH 1896. This can be signed and dated in person, via fax, or scanned in email, for a resident representative not present. 7. After signatures have been obtained from the resident/responsible party, the resident's attending physician will sign and date the state of Florida DNR order form (DH 1896), either in person at the time of the order, in person at their next visit to that record, or via fax/scanned and email. 8. If a resident was found unresponsive the EHR must be accessed to determine the code status order. For any resident without a physicians order for DNR, or without documented wishes to withhold CPR, EMS 911 must be called, the attending physician notified, and emergency basic life support CPR must begin. On [DATE] at 3:46 p.m. an interview was conducted with Staff L, RN. She said there was a system in here, (she pointed to the computer screen) where staff check the physicians orders, and see the code status. If its not there, you go and get the chart. Its supposed be there. The moment the resident comes in for admission, they have to find out if it's yes or no (for CPR). On [DATE] at 3:50 p.m. an interview was conducted with Staff C, LPN. She said the code status is on the computer. Staff C, LPN said when you go in to the resident's name, it is listed right here (pointed to 'code status' on the ribbon beneath a resident's name), and if it's not there, you have to go into the chart. Staff C, LPN verified she was referring to the paper record. Staff C, LPN said, If there's a yellow DNR in the chart, then the resident is a DNR. If not, they're a full code. Staff C, LPN said there is a policy that a status is printed out and put in the chart under advance directives, that says whether the resident is a DNR or full code. She pulled up Resident #80 on the computer and said, she doesn't have a code status. No code status on her. She said she would have to log out and go back in to see physicians orders. She logged out, then logged back in to the orders. Staff C, LPN said, Here it says Resident #80 is a full code. Staff C, LPN indicated they would have to check that in the chart also. The surveyor pointed to the order on the computer screen Patient is a DNR, and asked what it read. Staff C, LPN said, It says DNR. We would have to check the chart. It looks like they didn't take the order out. One is dated [DATE]th, the full code, and the second one, the DNR, is dated December twenty-seventh. Staff C, LPN said she would go check the chart. Staff C, LPN and the surveyor went to the paper chart behind nurses' station, down the hallway. Staff C, LPN opened the chart and turned to the advance directives tab, and found the yellow DNRO. Staff C, LPN said, It's right here, dated December twenty-third. The page in front of the yellow Florida DNRO was a physician's order which indicated resident is a full code. Staff C, LPN said, This is the old one, dated December seventh. Obviously, the updated one is current. So we also need an order to put in the chart. On [DATE] at 4:01 p.m. in an interview with Staff D, RN, she said, We look in the system to see the code status. If we find that it is not in the system, we go to the chart and see if the code status is in the chart. We are looking for the advance directives. It is supposed to have the status if it isn't in the system. We make sure we are dealing with the right chart, the right patient. Open it up to advanced directives and look for the code status. When we have a new admission, if the patient is alert, two nurses go in to verify whether the patient wants to be resuscitated or not. Then we call the doctor and let him know. Then we write an order and put it in the system. We have to write a note describing what the patient wants. Then we call the doctor and put it in the system. On [DATE] at 4:08 p.m. an interview was conducted with Staff E, RN. Staff E, RN said she can pull it up on the computer. If it's not there, she can pull the chart. The code status is under the photo on the computer. Staff E, RN said it is also under physician's orders. She can look at the orders in the computer, or she can look in the chart. There is a DNR or advance directive in the chart. Two nurses go in and ask the patient what their wishes are. We call the doctor and tell them what the patient wants. We put a progress note in; both nurses, that says what the patients wishes are. We put it in the orders in the computer. We also print out the phone order and put it in the chart. On [DATE] at 4:17 p.m. an interview was conducted with the ADCS (assistant director of clinical services). The ADCS said, Usually we have two nurses that go in. If the resident is alert and oriented, and they don't have a surrogate, then we explain what the advance directive is; the code status. They have to be alert and oriented. Then you call the physician and tell them their wishes are full code or DNR, and obtain a telephone order. Then, they come in a sign the paper for DNR process. It's entered into PCC (the electronic medical record) and a copy goes into the chart. The nurses check the orders. They can start in PCC. The chart is always available. You want to grab that chart and verify. It has happened. We had a resident who was full code one day, and was DNR the next day. We pull the orders as they change, and we actually verify them with another nurse. We remove all those orders from the chart if they changed their resuscitative status. The surveyor asked if there was an order for full code and DNR how the nurse would determine which one was correct. The ADCS said, I would check the date and time. Normally it would go with the last order. I would call the physician and family and verify the order. On [DATE] at 4:28 p.m. an interview was conducted with the DON (Director of Nursing). She said, The patient comes in with a yellow sheet. That would be a DNR depending on who signed it. Two nurses will go in and verify that the patient wants to be a DNR. They will write a note, stating they witnessed it, call the physician and get the order. Put the order under the advanced directives tab. They put a copy in the physician's book so they can sign it. Physicians come in once a week, twice a week. If the patient is critical we will fax it to the physician. There is no actual timeframe. They will look in the EMAR (electronic medication administration record). It will say the code status on the EMAR and the orders. If there's nothing under the orders, then they will go to the chart, the hard copy on the rack. Normally we bring that to a code anyway. They are going to go under advanced directives to see if there's an order for it. If there is nothing there, they will initiate CPR. They can look at the latest progress note also. It would be the last date on there. If the full code was 1/1 and the order on 1/2 is DNR, it would be a DNR. It would be the last date. The surveyor informed her the first page under the advanced directives tab in Resident #80's chart contained an order indicating Resident #80 was a full code. The DON said, I would have to look at the chart and see how it was placed in there. We would look at the last date. The DON said best practice is to remove the full code when they enter the DNR.

Based on observation, interview and record review, the facility failed to ensure residents with pressure wounds received care and treatment to promote healing, prevent infection and prevent new wounds from developing for one resident (#7) of two sampled residents. Findings Included: During observation of wound care for Resident #7, on 1/16/2020 at 9:36 a.m., the ARNP was present during the observation and staff member I, LPN removing bleach wipes with bare hands and placing a bleach wipe into each cup times two. One large ampoule of normal saline, three - 4 x 4 gauze pads, one pad of skin prep, scissors and one wound vac kit. Staff member I, LPN cleaned off the bedside table using a bleach wipe with her bare hand while keeping her barrier with supplies in her left hand then placed the supplies on the table. After placing the barrier and supplies on the bedside table the staff member went to wash her hands. Resident #7 was lying on his back on an air mattress. Staff member I, LPN was asked if she would obtain assistance with the dressing change. Staff member I, LPN stated she usually completes it herself since the aides are busy. Resident #7 was lying on a chux pad with the brief opened. Staff member I, LPN, donned gloves and removed the odorous dressing and discarded the tubing and dressing in the clear plastic trash bag. The ARNP asked Staff member I, LPN if she was going to get assistance with the wound care. Staff member I, LPN stated the aides were busy. Staff member I, LPN used the same gloves to clean the circular wound with normal saline using her left hand to hold the resident toward his side and the right hand to clean the wound x 2. The resident was laid on his back with the chux pad under the cleaned wound. Staff member I, LPN cut the sponge with the same gloves and barely lifted the resident's left side off the bed and applied the sponge to the wound and laid the resident back onto the chux pad to pick up the tape, applied the tape, then the suction tubing and turned on the wound vac to 125 psi with the same gloves used to clean the wound. Staff member I, LPN then doffed gloves and added one new glove to wipe scissors at the bedside, doffed the glove then washed her hands and walked in to the hallway. Staff member I, LPN then picked up the trash, scissors and tied the trash and shoved the clear plastic bag into the right side of the treatment cart. Staff member I, LPN then used a bleach wipe without gloves to clean the scissors. She used her right hand to throw the dirty wipe into the trash and used the mouse with the right hand to document on the computer. Staff member I, LPN confirmed, directly after the observation, she did not perform hand hygiene, change gloves between clean and dirty and laid the resident back down on the chux pad after cleaning the wound. The nurse stated she did not always wear gloves using the bleach wipes. Review of the physician orders reflected to clean the left buttocks with normal saline, skin prep periwound, apply wound vac every Tuesday, Thursday and Saturday and as needed at 125 PSI every day shift for pressure wound dated 12/10/19. Review of the facility matrix reflected a stage IV in house acquired wound. Review of the wound care progress notes dated 1/7/20 reflected a resident with a wound of left buttock measuring 2 x 1.9 x 1.3 cm with inflammatory stage and unable to progress to healing stage due to presence of a biofilm. No change in wound care. Review of the wound specialist progress notes dated 12/31/19 reflected the wound on the left buttock measured 2 x 1.9 x 1.3 cm with 10% muscle, 80% granulation tissue and 10% slough. The wound was in an inflammatory stage and unable to progress to a healing phase because of the presence of biofilm. Pertinent medications Zosyn IV 4.5 gram three times a day. Review of the care plan reflected Resident # 7 required extensive to total assist to complete activities of daily living. Focus area for skin breakdown as the resident is frequently incontinent. Inconsistent with toileting needs and requires assistance with mobility. On 5/29/19 a wound opened to the left gluteal fold requiring antibiotics, on 7/20/19, for a wound infection, 7/30/19 referred to wound clinic, 8/16/19 antibiotics for a wound infection, 9/5/19 to 9/11/19 hospital stay, 11/7/19 antibiotics for wound infection. Interventions included encourage and assist to reposition, dated 4/16/19, monitor skin during care assistance, dated 4/16/19, and wound vac as ordered, dated 9/13/19. Review of the Minimum Data Set (MDS) reflected the resident's brief interview for mental status (BIMS) of 7 meaning severe cognitive impact, dated 11/20/19. Section G bed mobility reflected total assistance of two plus persons. During an interview, on 1/16/20, at 12:12 p.m. with Director of Nursing (DON) she confirmed the staff should be performing hand hygiene prior to donning or doffing gloves and after cleaning a wound. Review of the policy and procedure for hand hygiene, revised on 8/19, 2 pages reflected: the purpose of this procedure is to provide guidelines to employees for proper and appropriate hand hygiene techniques that will aid in the prevention of transmission of infections. 7. After contact with blood, body fluids, secretions, excretions, mucous membranes or broken skin. Review of the policy and procedure for wound care, effective date of 10/14, 3 pages reflected: 12. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 13. Put on exam glove. Loosen tape and remove dressing. 14. Pull glove over dressing and discard into appropriate receptacle. Wash hands. 15. Put on disposable gloves.

Based on observation, interview and record review, the facility failed to ensure one Resident #13 was free from a significant medication error related to medication administration of an insulin flex pen with another resident's name on the label. The facility failed to identify the error and was stopped prior to administration of the insulin for one of one sampled residents receiving insulin. Findings Included: During observation of sliding scale insulin administration on 1/15/20 at 4:22 p.m. with staff member L, RN, she verified the order of Insulin Aspart solution pen-injector 100 unit/ML and stated Resident #13 will receive 2 units of insulin. Staff member L, RN went into the top drawer of the medication cart and looked for the resident's pen by name. She pulled out a pen from the top right side of the drawer and stated she had a lot of residents on insulin. The computer screen was on the page that reflected the sliding scale from 151 to 200. Staff member L, RN looked at the insulin pen which reflected Novolog with a small pharmacy label. The clear plastic bag contained a faded label. Staff member L, RN attached the new needle and dialed in 2 units. Staff member L, RN turned around to walk toward Resident #13 and asked the resident where she would like the injection. The surveyor asked Staff member L, RN to look at the insulin pen to observe the small pharmacy label on the pen to verify the resident's name. The Name on the insulin pen belonged to Resident #48. Staff member L, RN was asked to verify Resident #13's name on the insulin pen and the nurse stated that was the incorrect resident. Staff member L, RN immediately removed the needle on the syringe and verified the plastic bag label also belonged to Resident #48. Staff member L, RN looked through the insulin pens and could not find Resident #13's sliding scale insulin and stated that it must have been finished and walked to the medication room and retrieved a new pen from the refrigerator. Staff member L, RN stated thank you for rechecking the name and confirmed the new pen was labeled on the clear plastic bag and on the Novolog pen Resident #13's name. She attached the new needle and set the dial to 2 units without priming the pen and turned again to Resident #13 and asked her where she would like the injection while walking toward the resident. Resident #13 stated anywhere but the bellybutton while laughing. An interview on 1/15/20 at 5:24 p.m. was conducted with the Risk Manager. She confirmed the insulin error would be considered a near miss and significant error. She confirmed the nurse should be priming the insulin pen prior to using it and had been trained on this process and the five rights prior to administering medications and would start an immediate in service. During a phone interview with the pharmacist on 1/16/20 at 11:37 a.m. she confirmed that anyone receiving insulin should get the right order and the nurse should prime the insulin with 2 units the first time using the pen. During and interview on 1/16/20 at 11:50 a.m. with DON she confirmed the in-service was completed on the use of the insulin pen and priming. The DON confirmed the staff are educated on hire and annually. The DON stated she was not aware the wrong resident almost received the wrong insulin pen and confirmed the nurse should have verified the resident and five rights prior to giving the insulin. The DON stated they do not train on priming the insulin pen from the package insert since they do not receive the manufacturer's instructions from the pharmacy but do receive guidance on insulin products from the pharmacy. Review of the clinical competency for insulin injections was completed for staff member L, RN on 1/16/20 and 12/9/19. Review of the pharmacy guidance for using insulin products reflected two pages dated 3/2019 in section 3. Preparation of product subsection g. To minimize air bubbles in the pen-like devices prime the pen prior to each and every injection by pushing 2 units in to the air until a drop of insulin is seen at the top of the needle. If this does not happen after 2 to 6 attempts (refer to prescribing information), change needles.

4. Resident #44 was admitted to the facility with diagnoses of obstructive uropathy and urine retention, as reflected by the facesheet in the admission record. A review of the 11/16/19 MDS assessment indicated Resident #44 had an indwelling catheter. Section H, bowel and bladder, also reflected Resident #44 was always incontinent of bowel. Section C, cognition, reflected a BIMS score of 13, indicating Resident #44 was cognitively intact. Section G, functional status revealed Resident #44 required extensive assistance of one person for bed mobility. An observation was conducted on 1/13/20 at 2:44 p.m. Resident #44 was in her bed. The catheter bag was on the resident's right side of the bed hanging from the bed frame. It was resting on the floor in a privacy bag. The urine was yellow and cloudy. On 1/14/20 at 9:30 a.m., an interview was conducted with Resident #44's family member. She said Resident #44 was supposed to be checked for a UTI (urinary tract infection) because she has been a little loopy lately. She also said Resident #44 had been to the hospital in September with a really bad UTI. On 1/15/20 at 4:48 p.m. another observation was conducted. Resident #44 was lying on her back in her bed, with her eyes closed. The catheter bag was on the right side of the bed sitting on the floor. At 4:56 p.m. on 1/15/20 Staff F, LPN confirmed the catheter bag was on the floor. Staff F, LPN put on a pair of gloves, and removed the bag from the floor and placed it on the bed frame. She asked Resident #44 if she had caused it to fall. Resident #44 said she had an X-ray of the hip earlier and it might have gotten knocked off then. A urinary analysis sample dated 1/15/20 showed the sample was cloudy, positive for nitrites, with 1+ bacteria, 21-50 wbcs (white blood cells), and 21-50 rbcs (red blood cells), indicating a UTI was likely. On 1/16/20 at 12:01 p.m. in an interview with the DON, she said the catheter bag had to be maintained off the floor. A review of the policy, Nursing-Catheter Care, including Drainage Bag Care/Maintenance, dated October 2014, reflected the following information: Purpose To provide safe and proper care of the resident with an indwelling urinary catheter To minimize the risk of bladder infection To maintain skin integrity Procedure 8. Position the drainage bag below the level of the resident's bladder. Secure to the bed or wheel chair in such a manner that neither the bag nor the spigot touches the floor. coil excess tubing on bed verifying that there are no obstructions or kinks in tubing. The following information was found on the CDC (Centers for Disease Control) website at https://wonder.cdc.gov/hai/pdfs/cautiguideline2009final.pdf: 111. Proper Techniques for Urinary Catheter Maintenance 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Based on observations, interviews, record review, policy review, and CDC guidelines, the facility failed to ensure appropriate hand hygiene and glove use was utilized during medication administration for one (#91) of eight residents observed during medication administration, and the facility failed to ensure a nebulizer and bagged mask was kept off the floor for one (#57) of eight residents observed during medication administration, and for touching medications with bare hands during administration, and failing to clean the blood pressure cuff after use, and for failing to clean the blood pressure cuff prior to use for one (#16) of eight residents observed during medication administration, and failure to ensure a urinary catheter was maintained off the floor for one (#44) of two residents reviewed for appropriate catheter care. Findings Included: 1. During Medication observation for Resident #91 on 1/14/20 at 4:06 p.m., staff member J, LPN removed one ampoule of refresh plus on the barrier, then donned a glove to remove one sucralate tab one gram and place into the medication cup, doffed the glove and preceded into Resident #91's room. She placed the barrier on the bedside table and donned gloves without hand hygiene. The LPN applied two drops into the left eye, doffed gloves and washed hands. She donned gloves and placed two eye drops of refresh plus into the right eye. Doffed gloves and washed hands. 2. During medication administration for Resident #57 on 1/15/20 at 9:27 a.m. staff member K, LPN was observed removing a blood pressure cuff from her pocket and using it to obtain the resident's blood pressure of 127/62 with a pulse of 81 then placing the cuff on top of the medication cart in a small bag without cleaning the blood pressure cuff. The nurse stated that she uses her own blood pressure cuff since she has to check blood pressures and the aides are busy when she is ready to dispense blood pressure medications. Staff member K, LPN was observed putting one tramadol 50 mg, one simethicone 80 mg, one colace 100 mg, one xanax 0.25 mg,one mucinex DM, one Verapamil 360 mg tab and one eliquis 2.5 mg tab into a medicine cup. Staff member K, LPN then spilled the medications on to the medication cart and used her left hand to scoop up the medication to place in the med cup and a spoon to place another medication from the medication cart into the medicine cup. Staff member K, LPN was moving quickly and had to be asked to verify the quantity of medication after spilling them on the medication cart. After providing Resident #57 her oral medication she found the nebulizer machine on the floor between Resident #57's chair under the curtain on Resident #16's side and started Resident #57's treatment with the nebulizer on the floor. Staff member K, LPN went to the medication cart and checked off Resident #57's medication and went back in the room to get Resident #16's blood pressure with the same blood pressure cuff that had not been cleaned. During an interview on 1/15/20 at 5:24 p.m. the Risk Manager confirmed the nebulizer and mask should not be on the floor, and the nurse should have cleaned the blood pressure cuff in between use as well as the facility really does not like the staff using personal equipment on the residents. During an interview on 1/16/20 at 12:12 p.m. with the DON, she confirmed gloves should be changed with hand hygiene performed before and after and when using blood pressure cuffs, they should be cleaned in between use. 3. Review of the policy and procedure for hand hygiene revised on 8/19, 2 pages reflected: the purpose of this procedure is to provide guidelines to employees for proper and appropriate hand hygiene techniques that will aid in the prevention of transmission of infections. 4. Before preparing or handling medications. Review of the cleaning and disinfection of Resident care items and equipment policy revised October 2018, two pages reflected: Resident - care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 1.c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) non-critical resident care items include blood pressure cuffs.