**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to honor the resident's right to a dignified existence and self-determination by failing to serve identifiable foods for two (#67 and #38) of two residents sampled for pureed diets. Finding included: 1. Resident #67 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Alzheimer's disease, severe protein-calorie malnutrition, dysphagia, and adult failure to thrive. An observation on 04/07/2025 at 12:48 p.m. revealed Resident #67 being assisted by an unidentified staff to eat her pureed diet. Resident #67's meal ticket was lying on her tray. The meal ticket did not show the food items she was eating. During the observation and interview the staff member assisting her to eat stated they did not know what the pureed items were. They stated it may have been spaghetti or pasta and peas. Review of the menu for the day showed on 04/07/2025 for lunch the residents received spaghetti sauce with meatballs, spaghetti noodles, tossed salad with dressing, bread sticks, mandarin oranges, 2% milk and coffee/tea. An observation and interview on 04/10/2025 at 8:19 a.m. showed Resident #67 being assisted with her puree breakfast at bedside by Staff I, Certified Nursing Assistant (CNA). Staff M, CNA was assisting her roommate. An observation of Resident #67's tray on her overbed table revealed a pureed meal on the plate. The meal ticket did not show the food items she was eating. The plate showed a mound of uniform texture yellow portion, and the other two portions were eaten. Staff I, CNA and Staff M, CNA stated sometimes they do not know what they are feeding the residents. Staff M, CNA stated, Better for us, better for them. Staff I stated, If it looks like bread, we can tell if it is pancakes or waffles only if there is syrup on the tray, otherwise it is bread. They both stated they would want to know what they were feeding the residents. Staff I, CNA stated, What if a family member asked us what they were eating, we don't know. They stated they should put it on the meal ticket. When asked about food allergies, the staff member said, Good question. During a follow -up interview on 04/10/2025 at 8:45 a.m. with the Certified Dietary Manager (CDM) and Staff I, CNA, they both verified the unidentified food items Resident #67 had been served were pureed eggs, muffin and sausage. They confirmed the meal ticket did not include this information. Review of the menu for the day showed on 04/10/2025 for breakfast the residents received orange juice, cheese omelet, cereal of choice, muffin, 2% milk, coffee/tea. During an interview on 04/09/2025 at 2:27 p.m. The CDM stated the CNA should be telling the resident what the meal consists of. The CDM stated, The puree diet is also what is on the menu, the menu reflects what we pureed. The CDM stated the CNA should be referencing the meal ticket to ensure the resident was getting the proper diet. 2. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD), hypertension, dysphagia, and anemia. Review of the Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13, meaning cognitively intact. Review of the physician orders showed NAS (No Added Salt) diet, Pureed texture, Thin consistency. During an interview on 04/07/2025 at 11:18 a.m. Resident #38 stated he eats mashed potatoes and oatmeal every day. He stated he wanted something else, but they don't offer him other foods. During an interview and observation on 04/10/2025 at 8:16 a.m. Resident #38 was observed eating his oatmeal. An observation was made of a pureed meal on his tray placed on his overbed table. The plate showed three mounds, one was uniform texture yellow portion, one was light brown uniform texture portion, and one lumpy darker brown portion, a bowl of oatmeal, and fluids. Resident #38 stated he was eating his oatmeal only. Resident #38 stated, I don't know what it is. Not eating it. It doesn't look good. Eating my oatmeal only. During an interview and observation on 04/10/2025 at 8:30 a.m. The CDM stated the residents with pureed diet were served eggs, muffin and hot cereal. It was confirmed an observation was made of oatmeal in a bowl on the side of Resident #38's tray. The CDM was observed looking into the pureed containers in the kitchen and she stated she did not know what the residents had been served. The CDM went to Resident #38's room and observed his tray. The CDM stated it was eggs, a muffin and sausage. Review of the menu for the day revealed sausage was not on the menu. 3. Review of the facility policy, Nutritional Management, dated 9/1/2023 showed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance guidelines: 2. Identification / assessment: B. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. 4. Care plan implementation: B. Interventions will be individualized to address the specific needs of the resident. Examples include but are not limited to: i. Diet liberalization unless the resident's medical condition warrants a therapeutic diet 5. Monitoring / revision: i. Interviewing the resident and / or resident representative to determine if their personal goals and preferences are being met. ii. Directly observing the resident. iii. Interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestions for changes if necessary. Review of an undated facility policy titled, Pureed Food Preparation, showed facility will prepare pureed foods in a manner that sustains nutritional value and taste. The foods will be pureed to assure the desired consistency. Review of the facility policy, Resident Rights, dated 9/1/2023 showed the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. 2. Planning and Implementing care. The resident has the right to be informed of, and participate in, his or her treatment. 4. Respect and dignity. c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. 5. Self-determination. The resident has the right, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. (Photographic Evidence Obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders, assess the residents or develop care plans for two (#38 and #89) of two residents related to self-medicating for nebulizer treatments. Findings included: 1. An observation on 04/07/2025 at 10:25 a.m revealed Resident #38 sitting in his room in his bed. The head of the bed was elevated. His un-bagged nebulizer mask was laying on the overbed table. The nebulizer machine was off. He stated the nurse brought in medicine for his machine and left. Resident #38 stated he took it off after it was finished. He stated the nurse did not stay with him. An observation on 04/07/2025 at 11:26 a.m revealed Resident #38's un-bagged nebulizer was still laying on the overbed table. An observation on 04/08/25 at 8:58 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. The nebulizer mask was in a plastic bag on the overbed table. An observation on 04/09/2025 at 10:30 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. His nebulizer mask was sitting on top of a plastic bag. The nebulizer machine was off. Photographic evidence obtained. During an interview on 04/09/2025 at 10:46 a.m. with Staff P, Licensed Practical Nurse (LPN), she stated she entered the room and put the nebulizer mask in the plastic bag. Staff P stated, No, I did not stay with [Resident #38] the whole time he was on his nebulizer. Staff P stated she brought his (oral) medications in including his nebulizer medication. She stated she brought in his roommate's medications and gave another resident (in another room) their medication. Staff P stated she just came in and put the nebulizer mask back in the bag as it was laying on the plastic bag. She stated she was not in the room the whole time he was on the nebulizer; she just came back. Resident #38 stated he did his own nebulizer treatments and turned the machine off. During an interview on 04/09/2025 at 11:38 a.m., the Director of Nursing (DON) stated they did not have anyone that was self-medicating. She stated the process for nebulizer treatments was for the nurse to check the lung sounds, put the medications in the nebulizer cup, put the mask on the resident's face, stay with the resident, when the resident was finished, take the mask off, check the lung sounds, rinse the mask and put it back in the plastic bag. If the resident was giving his own nebulizer treatments, he should have an order to self-medicate, assessment for self-medications and care planned for such. The DON stated they did not have an order for self-medication for Resident #38 nor had anyone assessed him. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD), hypertension, dysphagia, and anemia. Review of the Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Section GG Functional Abilities showed dependence on eating, maximum assistance needed for toileting and bathing. Section J, Health Conditions showed shortness of breath when lying flat. Section O, Special Treatments, Procedures, and Programs showed oxygen therapy. Review of the active physician orders as of 04/10/2025 showed: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) every 8 hours as needed for Shortness of Breath (SOB) Review of the physician orders showed none regarding self-medicating of nebulizer treatments. Review of the Medication Administration Record for April 2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML every 8 hours as needed for SOB was administered 2 to 3 times a day. Review of the assessments showed no documentation regarding assessing Resident #38 for self-medicating of nebulizer treatments. Review of the care plans for Resident #38 showed At risk for impaired respiratory status related to COPD, bronchitis as of 03/20/2025. Interventions included but not limited to administer medications as per order, administer oxygen as per order, and administer respiratory treatment as directed. Monitor lung sounds as ordered. Check lung status including lung sounds as indicated, all initiated as of 03/20/2025. 2. An observation and interview on 04/07/2025 at 10:35 a.m., revealed Resident #89 lying in bed, with the head elevated. His un-bagged nebulizer pipe was laying on the nightstand. The nebulizer machine was off. Resident #89 stated the nurse brought in the medicine, set up the pipe, turned on the machine, and left the room. Resident #89 stated when the medicine was finished, he placed the pipe on the nightstand and turned off the machine. Resident #89 stated the nurse did not stay in the room. Observation on 04/07/2025 at 12:26 p.m. revealed Resident #89's un-bagged nebulizer was still laying on the nightstand. Review of Resident #89's admission Record showed an admission date of 01/180/2025, with diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD) and Respiratory conditions due to other specified external agents. Review of the Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Section GG Functional Abilities showed set up assistance with eating, maximum assistance needed for toileting and bathing. Section J, Health Conditions showed shortness of breath when lying flat. Section O, Special Treatments, Procedures, and Programs showed oxygen therapy. Review of the physician orders summary report dated as of 04/09/2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) every 6 hours for Cough. Review of the physician orders showed no order regarding self-medicating of nebulizer treatments. Review of the Medication Administration Record for March and April 2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML inhale orally four times a day for COPD related to Sleep Apnea, with a start date of 1/19/25 and discharge date of 4/8/25. Documentation showed medication given. Review of the progress notes showed no documentation regarding self-medication of nebulizer treatment. Review of the assessments showed no documentation regarding assessing Resident #89 for self-medicating of nebulizer treatments Review of the care plans for Resident #89 showed the focus: The resident has altered respiratory status related to Sleep Apnea. CPAP (Continuous Positive Airway Pressure), date initiated 1/21/2025. Interventions included but not limited to administer medications as per order, Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger; Monitor for signs and symptoms of respiratory distress and report to MD (Medical Doctor) as needed: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey; all dated as initiated 1/21/25. Review of the facility's policies and procedures titled Nebulizer Therapy with a revised date of 3/1/2025 revealed: Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. If the nebulizer will supply oxygen to the patient, refer to policy Oxygen Concentrator. Policy Explanation and Compliance Guidelines: Care of the Resident 1. Verify practitioner's order. 2. Gather appropriate equipment and ordered medication. 3. Knock to gain permission to enter room and explain the procedure to the resident. 4. Perform hand hygiene. 5. Don gloves and other personal protective equipment (PPE) as needed to comply with standard or transmission-based precautions. 6. Obtain resident's vital signs, and perform respiratory assessment to establish a baseline. 7. Correctly assemble the tubing, nebulizer cup, and mouthpiece (or mask) per manufacturer's specifications and ensure connections are secured tightly. 8. Place ordered medication into nebulizer cup. Premixed solutions may be used if available in the correct dosage. 9. Assist resident into a comfortable position. If possible, place resident an upright position to encourage full lung expansion and promote aerosol dispersion. 10. Connect the nebulizer to a power source. 11. Instruct resident on how to use the nebulizer appropriately. 12. Turn the machine on. 13. Keep nebulizer vertical during treatment. 14. Observe resident during the procedure for any change in condition. 15. When medication delivery is complete, turn the machine off. Treatment may be considered complete with the onset of nebulizer sputtering. 16. Disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry. Review of the facility's policies and procedures titled Resident Self-Administration of Medication dated 9/1/2023 revealed: Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines: 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. resident's physical capacity to: swallow without difficulty, open medication bottles, administer injections; c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for, d. The resident's capability to follow directions and tell time to know when medications need to be taken; e. resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff. f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs. g. The resident's ability to ensure that medication is stored safely and securely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 5. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR. 13. The care plan must reflect resident self-administration and storage arrangements for such medications. Photographic Evidence Obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide notification to the resident representative for one of six residents (Resident #106) sampled for accidents out of a total sample of 52 residents. Findings Included: Review of Resident #106's admission Record showed an admission date of 07/11/2024, discharge date of 07/16/2024 to an acute care hospital, and diagnoses to include urinary tract infection, osteoporosis, leukemia, hypertension, rheumatoid arthritis, muscle wasting and atrophy, difficulty walking, and repeated falls. Resident #106 had three family members listed as emergency contacts on the admission Record. Review of the Change in Condition Evaluation dated 07/15/2024 at 2:43 a.m. showed Resident #106 fell on [DATE] at 2:20 a.m. Section 3. Resident/Representative Notification was blank. Review of the progress notes showed no documentation the family was called post fall on 07/15/2024. Review of the Situation, Background, Assessment, Recommendations (SBAR) dated 07/16/2024 showed Resident #106 was sent to the ER for treatment on 07/16/2024 at 12:20 a.m. The family was notified on 07/16/2024 at 7:00 a.m. about the 07/15/2024 at 2:20 a.m. fall and being sent to the ER. During an interview on 04/09/2025 at 2:26 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) it was confirmed Resident #106 fell on 7/15/24 at 2:20 a.m. The resident was assessed for the pain and neuro-checks were conducted. The resident stated she was getting ready for the day, and was reminded what time it was. The resident had no pain at the time of the fall and no injuries at that time were noted. The DON confirmed there was no documentation that the family was informed of the fall on 7/15/2024 at 2 a.m. She stated there was documentation the family was informed she was going to the hospital on [DATE] after the resident expressed an increase in pain and x-rays revealed a left hip fracture. The DON stated the family should have been informed about the fall on 7/15/2024.

Based on observations, record reviews, and interviews, the facility failed to revise the care plans and related interventions accurately for one residents (#93) of fifty-two sampled residents related to indwelling urinary catheter. Findings included: Review of Resident #93's care plan revealed the following focuses and relevant interventions: - Enhanced Barrier Precautions related to (r/t) indwelling urinary catheter (and) wound. The focus was initiated on 1/27/25 and revised on 4/7/25. - Has a[n] [indwelling] Catheter. Diagnosis (DX) wounds. The focus was initiated on 1/15/25 and revised on 4/9/25. The goal was for the resident to remain free from catheter-related trauma through review date. On 4/7/25 at 11:28 a.m., Resident #93 was observed lying in bed. No urinary catheter was observed. During an interview on 4/8/25 at 5:43 p.m., Resident #93 reported not having a urinary catheter and stated it came out on its own about 3 weeks ago. The nurse at the time was going to put it back but needed a 16 French (fr) sized catheter, but only had a 14 fr available and did not have an order for the catheter, so they left it out. An observation was made at the time of interview and confirmed the resident did not have a urinary catheter. During an interview on 4/9/25 at 1:40 p.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the DON stated Resident #93 did have an indwelling catheter when admitted , but had it removed. The DON reviewed documentation for Resident #93, reporting there was a progress note from 3/18/25 related to the removal of the resident's catheter. The note reported the catheter was found on the bed, balloon was deflated, and 30 cubic centimeters (cc) of water out. The resident's physician was notified and ordered to leave the catheter out and see how well the resident did without the catheter. During an interview on 4/9/25 at 2:45 p.m. with the Minimum Data Set (MDS) Lead and Regional MDS Coordinator (Reg MDS), the Reg MDS stated the resident had a care plan for the catheter but no order for it. The MDS Lead reported the resident had a catheter and confirmed, when she saw the resident on 4/7/25, the resident had a urinary catheter. The Reg MDS left the interview to determine whether the resident had a urinary catheter, returned, and confirmed the resident did not have a catheter. A continued interview was conducted on 4/9/25 at 3:09 p.m. with the MDS Lead, who stated the resident's catheter was discontinued yesterday and she did not have the physician order at that time. Review of the facility policy titled Comprehensive Care Plans implemented on 9/1/23 revealed under Policy, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, and includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy revealed the following under Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assess, document and/or treat a surgical wound for one (#96) of one resident sampled for skin conditions. Findings included: On 4/7/25 at 5:10 p.m., Resident #96 was observed with a blue cast on his right arm and a mesh pad covering a black area approximately 2 centimeters (cm) x 3 cm on his interior left ankle. The mesh was lifted off the skin in one corner. The resident stated the doctor did not want it to come off and it had been there for about a month. Review of Resident #96's admission Record revealed the resident had been admitted on [DATE] and included diagnoses not limited to unspecified fracture of right femur subsequent encounter for closed fracture with routine healing, stress fracture right ankle subsequent encounter for fracture with routine healing, and multiple sites muscle wasting and atrophy not elsewhere classified. Review of Resident #96's Admission/readmission Nursing Evaluation, effective 2/7/25, showed the resident was admitted for a right ankle/femur fracture, chronic obstructive pulmonary disease (COPD), hypertension (HTN), and left ankle Open Reduction and Internal Fixation (ORIF). The skin integrity revealed abrasions on top of his scalp, [Brand Name] drain removal site to abdomen, right inner ankle surgical site, and left inner ankle surgical site. Review of Resident #96's Order Summary Report did not show orders had been received from the surgeon or facility physician regarding the care of the resident's left ankle mesh covered surgical site. Review of Weekly Skin Checks revealed the following: - 2/14/25 showed the resident had surgical incisions to abdomen and right leg. There was no mention of the left ankle surgical site. - On 2/19/25 the facility documented the resident had no new and/or existing area of skin impairment, did have a [Brand Name] drain surgical site AB([NAME]), and no resolved skin impairment. No mention of left ankle surgical site. - On 2/26/25 the facility documented the resident's skin was clear with no impairment, no existing skin impairment, and no resolved skin impairment. - On 3/5/25 staff revealed the resident had an existing skin impairment, a surgical incision to the abdomen and right leg. The assessment showed the resident did not have any resolved skin impairments. - On 3/14/25 staff documented the resident had an abdomen surgical incision with no resolved skin impairments. - On 3/28/25 the assessment revealed the resident's skin was clear with no impairment. - On 4/2/25 the Director of Nursing (DON) documented the resident's skin was clear with no impairment. On 4/9/25 at 4:30 p.m., Staff H, Licensed Practical Nurse (LPN) stated it was her first time working Resident #96's hall. Staff H observed the mesh pad on the resident's left ankle and spoke with the resident and visitor. During an interview and observation of Resident #96 on 4/9/25 at 4:42 p.m., the DON reported the resident had several fractures prior to admission, confirmed knowledge of the left ankle mesh pad and the wound specialist had not recommended anything further for the ankle. She stated she had not seen the area recently (did weekly skin check week prior). She reported the last wound specialist evaluation was on 3/6/25 (month prior). The DON stated the expectation would be for nurses to address the issue. She observed the mesh pad attached to the left ankle and confirmed something should have been done about it, nurses at least should be monitoring the area. The resident informed DON the mesh pad was a surgical site where screws had been placed. Review of Resident #96's March and April Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show staff were monitoring the surgical site on the left ankle. Review of Resident #96's care plan revealed the following focuses and interventions: - Has potential/actual impairment to skin integrity related to (r/t) decreased mobility, fragile skin, (and) incontinence. Right leg - closed surgical = resolved, Abdomen - closed surgical = resolved. The interventions include instructions for staff to Monitor/ document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/ symptoms (s/sx) of infection, maceration etcetera (etc) to MD. Review of Resident #96's physician orders, MAR, TAR, and care plan did not include follow up instructions on how staff were to care for the surgical site to left ankle. Review of the policy - Documentation in Medical Record, implemented 3/2024, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and including enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the residence medical record in accordance with state law and facility policy. 3. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/ or responses to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation staff interview and record review, the facility failed to ensure a contracture management program to include wearing of splints/orthotics was implemented for one (#7) of fifty - two sampled residents during three of three days observed (4/7/2025, 4/8/2025, and 4/9/2025). Findings included: On 4/7/2025 from10:30 a.m. to 12:30 p.m. Resident #7 was observed in her room lying in bed with both of her upper extremities noted to be contracted. Both of her hands and fingers were in a closed position. Resident #7 was not observed wearing either splints or orthotics. There were no splints or orthotics visible in the room during the multiple visits. Resident #7 was not able to answer any questions related to her medical care and services as she was observed with cognitive deficits. On 4/7/25 at 1:00 p.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C confirmed she had Resident #7 on her assignment for the day and that she did not know the resident well. Staff C was able to observe Resident #7 while positioned in bed and confirmed she had contracted upper extremities on both sides. Staff C was not sure if the resident had splints or orthotics to wear, and she was also not sure if Resident #7 was being seen by Restorative Nursing for contracture management. Staff C confirmed she did not see any orthotics or splints in the room for the resident to use. During multiple observation conducted on 4/8/2025 from 7:50 a.m. through 2:58 p.m., Resident #7 was again observed in her room and lying in bed. Resident #7 was observed without any splints/orthotics on either of her upper extremities. During multiple observation conducted on 4/9/2025 from 8:00 a.m. through 3:00 p.m. Resident #7 was observed in her room and lying in bed with both hands and upper extremities without any splints or orthotics. On 4/9/2025 at 10:00 a.m. an interview was conducted with Staff F, Occupational Therapist (OT). Staff F revealed the Rehabilitation Director was not available today for interview, but she (Staff F) would try to answer any questions. Staff F revealed she knew of Resident #7 very little, but did confirm she had contractures. Staff F needed to refer to the electronic medical record to see if OT had her on case load. Staff F revealed Resident was discharged from OT on 1/10/2025, following plateauing with goals. Staff F continued to say Resident #7 was referred to Restorative Nursing for contracture management to include utilization of splints/orthotics on her Right elbow, Right hand and Left palm. Staff F was not able to say what the outcome was with regards to Restorative Nursing and her current contracture management. On 4/9/2025 at 12:10 p.m. an interview with Staff G, Certified Nursing Assistant (CNA) assigned to Resident #7 during the 7a.m. - 3 p.m. shift, revealed she had only been working the unit for about one week now and did not know all the residents on the hallway to include Resident #7. Staff G stated Resident #7 was totally dependent on staff with most of her ADLs. (activities of Daily Living). Staff G confirmed Resident #7 does have limited range of motion with all her extremities and knew Resident #7 had any contractures on her upper extremities. Staff G explained as far as she knew, Resident #7 did not wear any splints/orthotics. She confirmed there were no orthotics or splints in the room, as she would have seen them. Staff G confirmed there was no documentation in the CNA's task sheet from the care plan indicating if Resident #7 utilizes splints/orthotics. On 4/9/2025 at 12:20 p.m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN) who normally had Resident #7 in her assignment. Staff E revealed she knew Resident #7 had limited Range of Motion (ROM) with upper extremity contractures. She did not know if the resident was ordered, and care planned for the use of splints/orthotics for the contractures. Staff E reviewed the care plan's document used by staff with instructions specific to a resident's care needs and confirmed there was no documentation to support the resident was to wear splints or orthotics on either of her extremities. Staff E then reviewed the electronic medical record to include the current order sheet and current care plans and found documentation indicating the resident was supposed to wear a Right elbow extension splint, a Right resting hand splint, and a Left palm guard for 6 hours per day, 5 days a week and supplied and removed by nursing staff. She confirmed the original order date was 2/20/2025. On 4/10/2025 at 10:15 a.m. an interview was obtained Staff D, Registered Nurse (RN)/Unit Manager (UM). Staff D revealed she was not aware Resident #7 was not offered or donned with splints/orthotics on her upper extremities the past few days. Staff D revealed it was brought to her attention by Staff E, LPN, the previous afternoon on 4/9/2025. Staff D revealed she was the Unit Manager and should be monitoring her nursing staff to ensure care plan interventions and orders were being followed, especially for those who are on contracture management requiring use of splints/orthotics. Staff D, RN was not sure who's initial responsibility was to don and doff the splints/orthotics on a daily basis. Review of Resident #7's electronic medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 2/2/2025 with diagnoses to include but not limited to: Dysphagia, Contracture Right wrist, Contracture L (left) wrist, Contractures unspecified joint, Chronic pain, Anxiety, Dementia. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status or BIMS score of 00 of 15. Under ADL, it showed, Impairment both sides upper and lower extremities, with substantial assistance to dependent on staff for most ADLs. Review of the current Physician's Order Sheet (POS) for the month 4/2025, revealed the following but not limited to orders: a. Patient will wear R (Right) elbow extension splint, R resting hand splint, and L palm guard for 6 hours per day 5 days a week a supplied and removed by nursing staff. Order date 2/20/2025). b. Skilled Occupational therapy three to four times per week for sixty days which may include therapeutic exercise and activities, neuromuscular reeducation, orthotics management, manual therapy, and w/c management. (order date 1/30/2025). Review of the Occupational Therapy Evaluation and Pan of Treatment with a certification period 1/29/2025 - 3/27/2025 revealed primary diagnoses to included: Muscle wasting and atrophy, Contractures unspecified joints, Lack of coordination. The Plan of Treatment revealed approaches to include but not limited to: Initial encounter, Orthotic management and training, each 15 minutes with a frequency of 3 to 4 times a week for 60 days, on a daily basis. The New Goal section revealed the Patient will safely wear least restrictive splinting/orthotic devices 4 hours on / 4 hours off without swelling/edema and complaints of discomfort in order to maintain joint mobility and improve PROM (Passive Range of Motion) for adequate hygiene. The recommendation section of the assessment summary revealed; Orthotics - Splint/Orthotic Recommendations: It is recommended the patient wear appropriate orthotics. Further assessment will follow in order to obtain or fabricate orthotics for both wrists and Right elbow. The Clinical Impression section of the summary revealed; Patient presents with severe limitations in joint mobility and muscle strength in all extremities as well as pain, deficits in cognition, and poor balance and sitting tolerance. She has pressure wounds and increasing contractures and is in need of proper positioning. Review of the Occupational Therapy Discharge summary dated [DATE] revealed patient discharged to reside in the Long-Term Care facility. Review of the Restorative Nursing Program for ROM dated 2/19/2025 revealed; Program type - Passive Range of Motion; Program goals - Increase joint motion to max. range, Improve circulation. Joint exercises to include: Shoulders - In front of body, out to side of body, palm neutral; Arm circles in front of body and out in front of body. Precautions included R upper extremity shoulder, elbow, wrist, and digit contractures. Left upper extremity digits 3, 4, 5, contractures. Patient is aphasic, confuses easily. Review of the nurse progress notes dated from 12/1/2024 through to 4/9/2025 did not include any documented evidence of the resident receiving any assistance with upper extremity splint/orthotics. Nor was there any documentation to support Resident #7 ever refused wearing said splint/orthotics. Review of the current care plans with next review date 5/5/2025 revealed the following but not limited to: 1. ADL Resident has a self-care deficit with need for staff assistance with ADL completion on daily basis: Dx. contractures, weakness, impaired mobility, impaired cognition, Right elbow extension splint, Right resting hand splint and left palm guard. Followed by MD order, with interventions in place to include but not limited to: Patient will wear R elbow extension splint, Right resting hand splint, and Left palm guard for 6 hours per day 5 days a week as applied and removed by nursing staff. 2. Resident has limited physical mobility r/t weakness bilateral upper extremity and bilateral lower extremities with interventions in place to include but not limited to: Resident is totally dependent on 1 staff for locomotion using wheelchair, Monitoring/documenting/report PRN any signs/symptoms of immobility forming or worsening, thrombosis formation, Provide gentle range of motion as tolerated with daily care. 3. Alteration in musculoskeletal status r/t contracture to L ankle, Right ankle, R wrist, and R elbow, with interventions in place to include but not limited to: Anticipate needs, Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders and or PT treatment plan, Monitor/document/report PRN signs and symptoms or complications related to arthritis; Joint stiffness, usually worse on waking; Swelling; Decline in mobility, Delcine in self-care ability, Contracture formation/joint shape changes, clicking with joint movement, pain after exercise or weight bearing. Review of a facility's Restorative Nursing Program policy and procedure with an implementation date of 9/2023 for review showed it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The definition section of the policy revealed; Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The policy Explanation and Compliance Guidelines revealed but were not limited to: 3 . Nursing personnel are trained on basic or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: d. Promoting independence in ADLs, performing tasks for residents only as needed to ensure completion of tasks. e. Assisting residents in adjustment to their disabilities and use of any assistive devices. f. Assisting residents with range of motion exercise, performing passive range of motion for residents who lack active range of motion ability. 4. All residents will receive maintenance nursing services as described above, as needed, by certified nursing assistants. 6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include, but not limited to: a. Passive or active range of motion. b. Splint or brace assistance. 13 . The Restorative nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly and document accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure physician orders were in place for one (Resident #19) of two residents sampled for a Foley catheter. Findings included: A review of admission record revealed Resident #19 was readmitted on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of bladder, quadriplegia, resistance to multiple antibiotics, carrier of other enterobacterales and other co-morbidities. A review of Resident #19's care plan revealed the following: Focus: Resident #19 Urinary catheter r/t (related to) Neuromuscular Dysfunction of Bladder Date Initiated: 04/04/2024 Revision on: 02/22/2025. Interventions included: Change catheter as needed Date Initiated: 04/13/2024; Foley Catheter as ordered Date Initiated: 04/13/2024 Revision on: 04/07/2025; Observe/document for pain/discomfort due to catheter Date Initiated: 04/04/2024; Observe/record/report to MD for s/sx (signs/symptoms) (Urinary Track Infection) UTI - pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns Date Initiated: 04/04/2024; Provide catheter care Date Initiated: 04/04/2024 Revision on: 04/07/2025; Provide privacy bag to drainage bag per facility protocol Date Initiated: 04/04/2024 Revision on: 04/07/2025 . A review of physician orders revealed the following: 1-Catheter care every shift and as needed. order date 4/11/2024 2- Monitor catheter for patency and drainage every shift. Order date 4/11/2024 3- Catheter-Bag change as Needed. Order date 4/11/2024 4- Foley Catheter 30 F 30 cc balloon No directions specified for order. Order date 9/1/2024. No diagnosis was found in the physician orders or notes for the Foley catheter. Review of the Medication and Treatment Records for March and April of 2025 revealed no order to change the catheter, or size of balloon and Foley catheter. During an interview on 4/9/2025 at 1:40 p.m. the Director of Nursing (DON) stated the expectation for Foley catheter orders would include: balloon and Foley size, catheter care, and to change the catheter for blockage or leakage, as needed. The DON confirmed not seeing an order for Resident #19's catheter. The DON stated knowing the catheter was changed about two weeks ago, but was unable to provide documentation. The DON stated the resident has a diagnosis of neuromuscular bladder, although not everyone with this diagnosis needs a catheter. The DON stated Resident #19 had multiple wounds and the catheter could be for the benefit of wound healing. The DON confirmed the physician order did not have a diagnosis, Foley or balloon size. Review of the facility's policies and procedures titled Catheter Care, dated 9/1/2023, revealed: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to identify, implement, monitor, and modify interventions for one (Resident #33) out of 52 related to coughing during meals. Findings Included: During an observation on 04/07/2025 at 12:18 p.m., Resident #33 was observed sitting in the dining room with a plate of spaghetti, meatballs and garlic toast. Resident #33's eyes became watery and was observed coughing after taking a bite of food. Resident #33 continued to cough for a few seconds when staff approached Resident #33 raised her hands and removed the plate of spaghetti and toast. During an interview on 04/07/2025 at 1:19 p.m., Resident #33's Family Member (FM) stated that she had had an issue with the facility not assisting the resident with eating. She stated the resident had had issues with chewing her food and was supposed to be on a pureed diet. She stated the last time the resident went to the hospital and came back to the facility, she brought up that the resident needed assistance with eating and was told by the facility they did not have any documentation from the hospital for assisting her with food and never addressed her concern. Review of Resident #33's admission record revealed an admission date of 03/20/2025 with an initial admission date of 10/11/2021. Resident #33 was admitted to the facility with diagnosis to include Metabolic Encephalopathy, Unspecified Protein-Calorie Malnutrition, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Acute Respiratory Failure with Hypoxia, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety. Review of Resident #33's Minimum Data Set (MDS) dated [DATE] revealed, Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) score of 05 out of 15 which indicated severe cognitive impairment. Review of Section. K. Swallowing/Nutritional Status revealed Nutritional Approaches Mechanically altered diet-require change in texture of food or liquids and Therapeutic diet. Review of Resident #36's Physician Orders revealed: 01/09/2025-Regular diet, Regular texture, Thin consistency two handle cup with concave lid for Speech Therapy (ST) Swallowing precautions in place 02/03/2025-Regular diet, Pureed texture, Nectar Thin consistency 02/07/2025-Regular diet, Mechanical Soft texture, Thin consistency, Two Handled Cup with lid 03/24/2025- CCHO diet, Mechanical Soft texture, Thin consistency no dry foods for moist 04/07/2025- Regular diet, Pureed texture, Thin consistency, Two Handled Cup 4/8/2025-Regular diet, Mechanical Soft texture, Thin consistency for Two Handled Cup Diet Review of the facility's Menu Titled: Agora/Fall Winter 2024-25, Week 4, Monday, Mechanical, Lunch revealed: 3 oz Spaghetti Sauce w/ Meatballs 4 oz of spaghetti noodles 4 oz tossed salad w/ dressing, 2 oz Bread sticks. Review of Resident #36's Care Plan dated 03/20/2025 revealed: Focus: The resident has a nutritional problem or potential nutritional problem r/t fluid restriction, impaired skin, abnormal labs, mechanically altered diet, dx (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) of protein calorie malnutrition, COPD,, heart failure, HD, dementia, depression, atrial fibrillation, HTN. Interventions/Task: Mechanically altered diet and/or thickened liquids, Provide and serve supplements as ordered, Provide, serve diet as ordered, monitor intake and record every meal. Review of Resident #36's Progress Notes showed showed 04/08/2025: Resident observed in dining room with saltine crackers on her plate. The item was not provided by Dietary and had not yet been consumed, Resident #33 asked another resident at the table for crackers and the resident obliged. Item was removed from plate prior to consumption. Resident is non-compliant with her diet. The responsible party informed via telephone and educated on residents diet. 4/7/2025 12:16 p.m. Nurses Notes Note Text: coughing noted with meals, diet downgraded per MD orders. Speech to consult. 3/31/2025 17:19 (5:19 p.m.) Nurses Note Note Text: Attempted to leave voicemail for the resident's [family member] to update her on the resident's follow-up modified barium swallow scheduled for tomorrow. Unfortunately, her voicemail box is full. 3/31/2025 17:32 (5:32 p.m.) Nurses Note Note Text: The [family member] called back and was updated on [the resident's] appointment. She also requested that per the hospital, the resident be an assisted [with meals]. I did explain that no notes were seen stating that from the hospital 3/20/2025 19:02 (7:02 p.m.) Admit/Readmit Note Text: Resident readmit at 17:00 (5:00 p.m.). Resident arrived via stretcher, admitting dx (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) (diagnosis) Hypoxia. Discharge reports show Diet change to level 5 mince, moist, and bite size foods. POA stated, resident needs assistance during meals. Concentrator set up, bed in low position, and call light within reach. Medication and MD orders reviewed. 3/18/2025 00:18 (12:18 a.m.) Alert Note Note Text: resident is alert to person, place, and situation; is noted to be non-compliant with diet. 2/6/2025 16:49 (4:49 p.m.) Nurses Note Note Text: Resident sitting on her bed eating pork skins and coughing in between each bite. Educated resident that her diet has downgraded to puree. 2/3/2025 18:01 (6:01 p.m.) Nurses Note Note Text: Resident coughing during meal. Speech therapist was present and downgraded resident to puree. Resident was unable to eat on her own. CNA present had to assist resident during meal. Review of Speech Therapy Notes Revealed: 01/18/2025: Safe Swallowing Strategies 01/20/2025: Oral Intake: Swallowing Abilities = Min/Close Supervision; Current Diet: Regular Textures; Current Liquids= Thin Liquids 02/03/2025: Oral Intake: Swallowing Abilities=Mod; Current Diet=Puree Consistencies; Current Liquids=Thin Liquids 02/07/2025: Oral Intake; Wallowing Abilities=Mild; Current Diet: Mechanical Soft Textures, Mechanical Soft/Ground textures; Current Liquids=Thin Liquids 02/11/2025: Oral Intake: Swallowing Abilities=Min/Close Supervision; Current Diet=Mechanical Soft Textures, Mechanical Soft/Ground Textures; Current Liquids=Thin Liquids 04/08/2025: Initial Assessment/Current Level of Function & Underlying Impairments: Prior Level of Function: Intake/Diet Level=mechanical soft, thin, liquids, successive swallows; swallowing abilities=mild; Medical Factors: Precautions/ Contraindications: Aspiration-Mech Soft Solids; Intake/Diet Level: Puree Consistencies, thin liquids, successive swallows; intake method= All oral Clinical Bed side Assessment: Swallowing abilities mild; Assessment Summary: Clinical Impressions: Pt presents w/mild-moderate oral phase dysphagia, exhibiting prolonged mastication w/ reduced mastication efficiency, reduced lingual coordination for bolus manipulation/propulsion, and intermittent oral residue w/solids. Pt able to safely consume thin liquids (via cup) w/o overt, s/s of aspiration. SLP recommending diet texture modification back to baseline diet of mech . soft solids w/ thin liquids, but at this time pt appears to remain at baseline level of function. Evaluation Only. Further testing: Further exam/consult not indicated d/t = other (Pt at baseline level of function). During an interview on 04/09/2025 12:44 p.m., Regional Director of Therapy stated the facility currently did not have a full-time speech therapist. They did not get the results of the swallow study because the resident was out of the facility and went to the appointment while she was discharged from the facility. He stated Resident #33 was only seen by speech in February on the 6th for an evaluation and had not seen the resident after that so the speech therapist would not have anything else to add about the resident. He stated the Speech Therapist who saw Resident #33 on 04/08/2025 was new and would not know much about Resident #33. During an interview on 04/09/2025 at 1:06 p.m., Certified Dietary Manager (CDM) stated Resident #33 had been a resident for a long time and was on a mechanically soft diet with gravy to keep her food moist. She stated Resident #33 had had a choking incident before and she thought that was why she had a hard time eating now. She stated when the resident ate her food, she had noticed Resident #33 chewed and stopped and then swallowed. She thought she might have a swallowing issue. Residents on mechanically altered diets were supposed to get a bread stick instead of garlic bread, but they did not receive garlic sticks so she served all residents the garlic bread. During an interview on 04/09/2025 at 2:12 p.m., the Registered Dietician (RD) stated Mechanical soft diet was where the food was chopped up. Residents on a mechanically soft diet should not be given anything that could cause them to choke. You want to be sure there is no crust or something too hard. During an interview on 04/09/2025 at 2:28 p.m., Staff N, Speech Therapist, stated she started seeing Resident #33 in February because she was having a hard time with her diet. She stated she first saw Resident#33 when she had a choking incident in the dining room she was unsure of the date but knew it was in February. She stated she was there for this incident so she downgraded her diet at that time to a puree diet, Resident #33 did not like the pureed food so she would go and get snacks from the vending machine. She stated she evaluated and observed Resident #33 eating chips, and she was okay with those, so she upgraded her diet back to Mechanical soft diet because she did well with eating the chips. Resident #33 should be supervised while she is eating. Typically, she would review the swallow study she was not aware Resident #33 had an order for a swallow study or that it had been completed because the last she knew, Resident #33 was in the hospital. The provider was the one who would have ordered the swallow study. She stated she could recommend one, but she had not recommended one for Resident #33. She stated breads were not typically recommended for residents with a mechanically soft diet. During an interview on 04/09/2025 at 2:36 p.m., Staff O, Speech Therapist, stated she did not typically work at this facility and covered a different area, but the facility called and asked for her to come in and see Resident #33 on 04/08/2025 because she had a choking event on Monday (04/07/2025). They wanted to make sure she was on an appropriate diet. She did a bedside swallow evaluation. She checked to see if Resident #33 was aspirating while eating. She gave her different textures and water to drink and made sure she was chewing well enough. After evaluating Resident #33 she felt she was okay to be upgraded back to a Mechanically soft diet. She felt like pureed was way too restrictive. She stated residents on a Mechanically soft diet really should not have anything with a crust. During an interview on 04/10/2025 at 12:10 p.m., the Director of Nursing (DON) stated the resident had had issues with eating on and off. She started coughing while eating so they put her on a puree diet. Resident #33 did not like the pureed food, so they had speech come see her. She had another episode and speech evaluated her again. She stated medical records was responsible for requesting the records after appointments. She confirmed their swallow study results were not in Resident #33's chart. Once results were received, the unit manager, Assistant Director of Nursing (ADON), or the DON made sure it was reviewed by the physician. During an interview on 04/10/2025 at 3:45 p.m., Staff D, Registered Nurse, Unit Manager stated Resident #33 coughed during eating. Resident #33 was non-compliant and when they switched to puree she would not eat it. She did go to the vending machine to get food and she had a friend who gave her food. The hospital changed her to a minced grade 5 diet which was the same as the mechanical soft diet. She spoke with someone at the hospital and confirmed what a minced diet was and they told her that Resident #33's food had to be moist. When they found Resident #33 eating foods she was not supposed to, they provided education to the resident on why she should not be eating those foods. They had told her friend to not share foods with Resident #33 as well. They moved the vending machine from the dining room to a more closed area to make sure Resident #33 did not have full access it. She had not seen her with any other foods she was not supposed to have. The CNA's were aware that she had food limits. She was always in the dining room for meals for supervision. During an interview on 04/10/2025 at 2:03 p.m., the Medical Physician stated she was not aware Resident #33 had any incidents while eating this week. Resident #33 had been evaluated by speech therapy in the past. When Resident #33 went to the hospital they had speech therapy evaluate her and there were no new diet recommendations. Usually if Resident #33 had an issue with eating it was short lived. Resident #33 was on a Mechanically soft diet, meaning her food should be chopped up very finely especially any meats. She did not believe garlic toast was on a Mechanical soft diet. Resident #33 has been known to not be compliant with her diet. She would expect staff to take the unapproved food items from Resident #33 and to be sure items were removed from her room. She expected staff to supervise Resident #33 a little closer. She reviewed Resident #33's hospital discharge record and stated they recommended speech and language/ cognitive therapy on 03/20/2025. The nurse and the unit manager review the hospital orders. There is a nurse practitioner who also sees the residents and she would have addressed these orders as well. Review of the facilities policy titled serving a meal dated 9/20/23 revealed, Policy It is the policy of this facility to serve meals that meet the nutritional needs of residents. Policy Explanation and Compliance Guidelines Diet should be served in accordance with the physician's order. Resident should be encouraged to eat in the dining room, however, requests to remain in the room should be honored. Review of the facilities undated policy titled Therapeutic Diets revealed, Policy Therapeutic diets are prepared and served as ordered by the attending physicians.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure oxygen therapy was provided in accordance with professional standards of practice for two residents (#38 and #26) of four residents sampled and failed to ensure respiratory equipment was stored appropriately for two residents (#14 and #89) of four sampled residents. Findings included: 1. An observation was conducted on 4/7/2025 at 10:25 a.m. of Resident #38 sitting in bed with an oxygen nasal cannula in place in his nose. The oxygen concentrator set to 3.5 liters/minute. An observation was conducted on 4/8/2025 at 8:58 a.m. of Resident #38 sitting in bed with an oxygen nasal cannula in place in his nose. The oxygen concentrator set to 3.5 liters/minute. An observation was conducted on 4/9/2025 at 10:30 a.m. of Resident #38 sitting in bed with an oxygen nasal cannula in place in his nose. The oxygen concentrator set to 1.5 liters/minute. A review of Resident #38's medical record revealed he was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD), hypertension, and anemia. Review of Resident #38's April 2025 physician orders showed an order dated 7/25/2024 for oxygen at 2 liters per minute continuous via nasal cannula (O2@2lpm continuous via N/C) every shift for COPD. Review of Resident #38's Medication Administration Record for April 2025 showed O2@2lpm continuous via N/C was not documented as observed on 4/2/2025 at night, 4/4/2025 on evening shift, 4/7/2025 on night shift, or 4/8/2025 on evening shift. On 4/8/2025 on both day shift and evening shift showed the oxygen was observed. On 4/9/2025 on all three shifts showed the oxygen was observed. Review of Resident #38's care plans showed the resident was at risk for impaired respiratory status related to COPD and bronchitis as of 3/20/2025. Interventions included but not limited to administer medications as per order, administer oxygen as per order, and administer respiratory treatment as directed. Monitor lung sounds as ordered. Check lung status including lung sounds as indicated, all initiated as of 3/20/2025. Review of Resident #38's Minimum Data Set (MDS) assessment dated [DATE] showed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Section J - Health Conditions showed shortness of breath when lying flat. Section O - Special Treatments, Procedures, and Programs showed the resident received oxygen therapy. During an interview on 4/9/2025 at 10:46 a.m. with Staff P, Licensed Practical Nurse (LPN), she verified Resident #38's oxygen was set at 1.5 liters instead of 2 liters per minute as per the physician orders. Staff P, LPN stated the oxygen setting was supposed to match the physician orders. During an interview on 4/9/2025 at 11:38 a.m., the Director of Nursing (DON) stated staff should be following the physician order for the number of liters of oxygen Resident #38 was to receive. If the order was for 2 liters, the oxygen concentrator should be on 2 liters not 1.5 liters. An observation was conducted on 4/7/2025 at 10:06 a.m. of Resident #26 lying in bed sleeping with an oxygen nasal cannula in place in her nose. Her oxygen concentrator was set at 1.5 liters per minute. An observation was conducted on 4/7/2025 at 4:52 p.m. of Resident #26 lying in bed sleeping with an oxygen nasal cannula in place in her nose. Her oxygen concentrator was set at 1.5 liters per minute. An observation was conducted on 4/8/2025 at 8:55 a.m. of Resident #26 lying in bed sleeping with an oxygen nasal cannula in place in her nose. Her oxygen concentrator was set at 1.5 liters per minute. An observation was conducted on 4/9/2025 at 10:26 a.m. of Resident #26's oxygen concentrator, which was set at 2 liters per minute. Staff P, LPN was in the room at the time of the observation and stated the oxygen settings should match the physician orders. A review of Resident #26's medical record revealed the resident was admitted on [DATE]. Review of Resident #26's physician orders showed O2@2lpm via N/C (oxygen at 2 liters per minute via nasal cannula) to be monitored every shift, as of 11/14/2024. Review of Resident #26's MDS assessment dated [DATE] showed under Section O - Special Treatments, Procedures, and Programs showed the resident received oxygen therapy. Review of the Treatment Administration Record (TAR) for April 2025 showed O2@2lpm via N/C to be monitored every shift was not monitored on the following dates: 4/2/2025 on day shift; 4/3/2025 on day shift; 4/4/2025 on evening shift; 4/7/2025 on evening shift; and 4/8/2025 on evening shift. The TAR also showed on 4/7/2025 on both day and night shift, the oxygen was observed. On 4/8/2025 on both day and night shift showed the oxygen was observed. Review of Resident #26's care plans showed the resident had an oxygen therapy care plan initiated 1/14/2025. Interventions included but not limited to oxygen: O2 as ordered, as of 1/14/2025. During an interview on 04/10/2025 at 3:57 p.m., the DON stated the care plans and physician orders for Resident's #26 and #38 should be followed related to oxygen therapy. She verified both were not being followed. 2. An observation was conducted on 4/7/2025 at 10:23 a.m. of Resident #14 lying in the bed. A nebulizer machine was observed on the bedside table with a nebulizer mask sitting on the nightstand in front of the machine, unbagged. An observation was conducted on 4/7/2025 at 10:35 a.m. of Resident #89 lying in the bed. A nebulizer machine was observed on the bedside table with a nebulizer mask sitting on the nightstand in front of the machine, unbagged. During an interview on 4/9/2025 at 12:52 p.m., Staff V, LPN verified Resident #89 has an order for nebulizer treatments. Staff V, LPN stated any oxygen tubing/pipe/mask should be placed in a bag when not in use. During an interview on 4/9/2025 at 12:56 p.m., Staff U, LPN verified Resident #14 has an order for nebulizer treatments. Staff U, LPN stated the nurse should place the mask or pipe into a bag when the treatment is completed. Review of the facility's policies and procedures titled Nebulizer Therapy with a revised date of 3/1/2025 revealed: Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: Care of the Resident . 15. When medication delivery is complete, turn the machine off. Treatment may be considered complete with the onset of nebulizer sputtering. 16. Disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry. Review of the facility's policies and procedures titled Oxygen Administration dated 3/2024 revealed: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, . 7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. 8. Storage of oxygen shall be in accordance with the facility's Oxygen Safety Policy. Photographic Evidence Obtained

Based on observation, interview, and record review the facility failed to provide behavioral health care services to one (#36) of three residents reviewed for mood and behaviors. Findings Included: During an observation on 04/07/2025 at 10:45 a.m., Resident #36 was heard from the nurse's station yelling out. During an observation on 04/08/2025 at 9:23 a.m., Resident #36 was observed hitting her leg and yelling out. Resident #36 was unable to answer any questions regarding her care. Review of Resident #36's admission record revealed she was originally admitted in 2018, most recently admitted in June of 2024, and had diagnoses to include Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Adjustment Disorder with Mixed Disturbance of Emotions And Conduct, Other Specified Persistent Mood Disorders, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Dysarthria following Cerebral Infarction, Aphasia, and Dysphagia, Oropharyngeal Phase. Review of Resident #36's Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/02/2025 and an Annual MDS with an ARD of 4/04/2025 revealed a Brief Interview for Mental Status (BIMS) was not conducted. The resident had short term and long term memory impairment, severely impaired decision making skills, no signs or symptoms of delirium, no behaviors, no mood problems, received no psychotropic medications and had not received any therapy services to include psychological therapy. Review of Resident #36's care plan revealed: Focus: Behaviors (initiated on 8/25/2019 and most recently revised on 11/7/2023): Resident #36 has a behavior problem r/t [related to] her diagnosis of Depression, Dementia, Anxiety. She is often Screaming and banging on things, yelling. She is easily agitated at times. She is at risk for further decline due to her HX [history]. She lowers the head of bed while administering nutrition. Refuses to allow staff to administer tube feed at times. Hits on her leg or buttocks at times as she yells. Removes/unplugs tube feed at times. Was noted to be hitting hands/banging bed frame with her hands. Goal: Resident will have fewer episodes of screaming and banging weekly by review date (initiated 8/25/2019, revised on 5/12/2022, target date 5/8/2025). Interventions/Tasks Included: Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. This intervention was initiated on 8/25/2019 and had no revision date). Review of Resident #36's physician orders revealed no orders for monitoring behaviors. Review of Resident #36's Treatment Administration Record (TAR) revealed no documentation of behaviors exhibited by Resident #36. Review of Resident #36's progress/nurse notes revealed no documentation of behaviors exhibited by Resident #36. During an interview on 04/08/2025 at 1:24 p.m. Staff L, Certified Nurse's Assistant (CNA), stated Resident #36 needed total care. Staff L, CNA said the resident calls out typically when she is in pain or when she is soiled. When the resident begins to call out, she checks on the resident and speaks with the nurse to confirm if she has had any pain medication. During an interview on 04/08/2025 at 1:30 p.m., Staff E, Licensed Practical Nurse (LPN), stated Resident #36 calls out and hits her legs often. She was not sure if she was supposed to monitor or document Resident #36's behaviors. She did not see orders or anything on the TAR indicating Resident #36 behaviors should be documented. During an interview on 04/10/2025 at 12:10 p.m., the Director of Nursing (DON), stated Resident #36 was nonverbal and makes noises to communicate. If she wants something she will tap her leg or make a noise. Nurses document behaviors in their progress notes. Most of her behaviors are a form of communication. She would consider Resident #36 yelling out and hitting herself as a form of communication. Review of the facility's policy titled Behavioral Health Services dated 01/2025 revealed: Policy: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to reconcile, obtain, and provide medications as ordered, for two residents (#105 and #53) of five residents sampled for admissions/readmissions. Findings included: 1. Review of Resident #105's admission Record showed the resident was admitted on [DATE]. The primary admitting diagnosis was other seizures, with other diagnoses of unspecified benign neoplasm of brain, epileptic seizures related to external causes not intractable without status epilepticus, myasthenia gravis without (acute) exacerbation, and chronic pain syndrome. Review of Resident #105's Admission/readmission Nursing Evaluation, dated 11/19/24 at 4:08 a.m., revealed the resident's medications and physician orders had been reviewed and the resident had arrived via stretcher from a hospital for seizure activity and pain history (hx) left shoulder Arthropathy. The evaluation did not reveal an order had been received from the physician to administer medications when they became available. Review of Resident #105's discharge medications, dated 11/19/24 at 9:53 a.m. from the acute care facility, the following scheduled medications were ordered with the times the next dose was due: - Butalbital-acetaminophen-caffeine 50-325-40 milligram (mg) - Take 1 tablet by mouth in the morning and 1 tablet before bedtime. Next dose: 11/9/24 at 9:00 p.m. - Carvedilol 6.25 mg - Take 1 tablet by mouth in the morning and 1 tablet in the evening. Take with meals. Next dose: 11/19/24 at 7 p.m. - Clotrimazole-betamethasone - apply 1 application topically in the morning and 1 application before bedtime. Next dose 11/19/24 at 9:00 p.m. - Doxepin 100mg - Take 1 capsule (100 mg) by mouth every night. Next dose 11/19/24 at 9:00 p.m. - Gabapentin 300 mg - Take 1 capsule by mouth in the morning and 1 capsule at noon, and 1 capsule before bedtime. Next dose: 11/19/24 at 9 p.m. - Glucosamine 200 mg - Take 1 tablet by mouth in the morning and 1 tablet before bedtime. Next dose: 11/19/24 at 9 p.m. - Lamotrigine 100 mg - Take 1 tablet by mouth in the morning and 1 tablet before bedtime. Next dose: 11/19/24 at 9:00 p.m. - Magnesium oral (PO) - Take 1 tablet by mouth one time a day. Strength per over-the-counter product labeling. Next dose: 11/20/24 at 9 a.m. - Melatonin PO - Take 1 tablet by mouth every night. Strength per over-the-counter product labeling. Next dose: 11/19/24 at 9 p.m. - Olmesartan-hydrochlorothiazide (Benicar HCT) 40-12.5 mg - Take 1 tablet by mouth each day. Next dose 11/20/24 at 9:00 a.m. - Potassium gluconate 595 mg - Take 1 tablet by mouth one time a day. Next dose: 11/20/24 at 9:00 a.m. - Quetiapine (Seroquel) 300 mg - Take 1 tablet by mouth every night. Next dose: 11/19/24 at 9 p.m. - Rexulti 1 mg - Take one tablet by mouth one time a day. Next dose 11/20/24 at 9:00 a.m. - Tizanidine 4 mg - Take 1 capsule by mouth in the morning and 1 capsule at noon and 1 capsule before bedtime. Next dose: 11/19/24 at 9 p.m. - Trazodone 150 mg - Take 1 tablet by mouth every night. Next dose 11/19/24 at 9:00 p.m. - Vitamin C (PO) - Take 1 tablet by mouth one time each day. Next dose: 11/20/24 at 9:00 a.m. Review of the pharmacy Delivery & Cut-off Times showed Monday - Friday new order cut off times were 11:00 a.m. with a departure time (from pharmacy) of 2:00 p.m. and 8:00 p.m., for new admissions the cutoff time was 10:00 p.m. with a departure time of 2:00 a.m. The information revealed if a refill was needed immediately, please contact pharmacy and if something was faxed after cutoff and needed to be received staff were to call the pharmacy immediately. Review of Resident #105's progress notes showed medication orders for Carvedilol, Doxepin, Glucosamine, Oxycodone, Potassium Gluconate, Quetiapine Fumarate, Rexulti, Tizanidine, and Trazodone had been entered on 11/19/24 at 3:46 p.m. The notes showed possible interactions between medications with the following orders (for) Butalbital-acetaminophen-Caffeine, Clonidine, and Benicar. Review of Resident #105's November Medication Administration Record (MAR) revealed the following: - Butalbital-acetaminophen-caffeine 50-325-40 milligram (mg) - Give 1 tablet by mouth three times a day for chronic pain syndrome. Started on 11/19/24 at 9:00 p.m., scheduled for 9:00 a.m., 12:00 noon, and 9:00 p.m. The MAR showed the resident did not receive the dose scheduled for 11/19 at 9:00 p.m. and doses scheduled on 11/20 at 9:00 a.m. and 12:00 noon, missing 3 doses. - Carvedilol 6.25 mg - Give 1 tablet by mouth one time a day for transient ischemic attack (TIA). Started on 11/20 and scheduled for 9:00 a.m. The MAR showed the resident did not receive the scheduled dose on 11/20/24, missing one dose. - Clotrimazole-betamethasone External cream 1-0.05% - Apply to affected area topically two times a day for rash. Started on 11/19/24 at 9:00 p.m. and scheduled for 9:00 a.m. and 9:00 p.m. The MAR showed the resident did not receive on 11/19 at 9:00 p.m. or on 11/20 at 9:00 a.m., missing 2 doses. - Doxepin 100mg - Give 1 capsule by mouth one time a day for prophylactic. Started on 11/20 at 9:00 p.m. Per the discharge medication list the resident was to receive a dose on 11/19 at 9:00 p.m. - Gabapentin 300 mg - Give 1 capsule three times a day for neuropathy. Started on 11/19/24 at 9:00 p.m. and scheduled for 8:00 a.m., 12:00 noon, and 9:00 p.m. The MAR showed the resident did not receive the scheduled dose for 11/19 at 9:00 p.m. or the 8:00 a.m. dose on 11/20/24, missing two doses. - Glucosamine 200 mg - Give 1 tablet by mouth two times a day for seizures. Started on 11/19/24 at 9:00 p.m. and scheduled for 9:00 a.m. and 9:00 p.m. The MAR showed the resident did not receive the 9:00 p.m. dose on 11/19 or the 9:00 a.m. dose on 11/20, missing 2 doses. - Lamotrigine 100 mg - Give 100mg by mouth two times a day for seizures. Started on 11/19 at 9:00 p.m. and scheduled for 9:00 a.m. and 9:00 p.m. The MAR showed the resident did not receive the 9:00 p.m. dose on 11/19 or the 9:00 a.m. dose on 11/20, missing 2 doses. - Magnesium 400 mg - Give 1 tablet by mouth one time a day for supplement. Started on 11/20 at 9:00 a.m. The MAR showed the resident did not receive the 11/20 dose, missing one dose. - Melatonin 3 mg - Give 1 tablet by mouth one time a day for insomnia. Started on 11/20/24. Per the discharge medication list the resident was to receive a dose on 11/19 at 9:00 p.m. - Olmesartan-Hydrochlorothiazide (Benicar HCT) 40-12.5 mg - Give 1 tablet by mouth one time a day for hypertension. The order started on 11/20/24 at 9:00 a.m. The MAR showed the resident did not receive on 11/20 and staff documented on 11/21 Awaiting arrival from pharmacy. The resident missed two doses. - Potassium gluconate 595 mg - Give 1 tablet by mouth one time a day for supplement. Started on 11/20/24 and scheduled 11/20 at 9:00 a.m. The MAR showed the resident did not receive on 11/20 and staff documented on 11/21 Awaiting arrival from pharmacy. The resident missed two doses. - Quetiapine (Seroquel) 300 mg - Give 1 tablet by mouth one time a day for depression. Started on 11/20 at 9:00 a.m. The MAR showed the resident did not receive a dose on 11/20, missing one dose. - Rexulti 1 mg - Give 1 tablet by mouth one time a day for seizures. Started on 11/20/24 at 9:00 a.m. The MAR showed the resident did not receive a dose on 11/20. - Tizanidine 4 mg - Give 1 tablet by mouth three times a day for muscle spasms. Started on 11/19/24 at 9:00 p.m. and scheduled for 9:00 a.m., 1:00 p.m., and 9:00 p.m. The MAR showed the resident did not receive the 9:00 p.m. dose on 11/19 or the 9:00 a.m. dose on 11/20, missing two doses. The resident also did not receive the 1:00 p.m. dose on 11/21, and 11/27. - Trazodone 150 mg - Give 1 tablet by mouth one time a day for depression. Started on 11/20 at 9:00 p.m. The MAR showed the resident did not receive the dose on 11/20, missing one dose. - Ascorbic Acid (Vitamin C) - Give 1 tablet by mouth one time a day for supplement. Started on 11/20 at 9:00 a.m. The MAR showed the resident did not receive the dose on 11/20, missing one dose. During an interview on 4/9/25 at 10:25 a.m. the Director of Nursing stated the policy (regarding missing medications) was to get an order to hold or call the pharmacy to see how quickly it can arrive, or to get an order to administer (medications) when it arrives. She stated the facility could get over-the-counter (OTC) from a local drug store and staff should retrieve from central supply or the electronic dispenser if the medication was not available on the cart. An interview was conducted on 4/10/25 at 3:57 p.m. with the DON. The DON stated physicians would need to be notified if the medication was not available and should have documentation related to why the medication was not given and the physician was notified in either a nursing note or a medication administration note. She described the process for new admissions was medications were ordered upon admission, in morning meeting the team reviews orders to ensure they were transcribed correctly, the orders goes straight to pharmacy (when ordered) and if they are put in on time (scheduled cut of time) they would arrive on the next (pharmacy) drop. Review of the list of medications available in the electronic dispenser revealed the following medications were stocked (on 4/8/25): - Carvedilol 3.125 mg tablets - Gabapentin 300 mg capsules - Quetiapine 25 mg tablets Review of the list of House Stock medications, provided by the facility, revealed the facility did not stock over-the-counter Vitamin C, Magnesium or the sleep aid Melatonin. 2. Review of Resident #53's admission Record revealed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record showed the resident's primary diagnosis was unspecified chronic obstructive pulmonary disease, unspecified diabetes mellitus due to underlying condition with diabetic neuropathy, type 1 diabetes mellitus, unspecified respiratory failure with hypercapnia, unspecified heart failure, essential (primary) hypertension, and unspecified systolic (congestive) heart failure. Review of Resident #53's Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form showed the resident was transferred on 4/5/25 at 3:06 p.m. to an acute care facility without a listed reason for the transfer. On 4/9/25 at 9:11 a.m. an observation was conducted with Staff E, LPN of medication administration for Resident #53. The staff member reported not knowing how long the resident had been in the hospital but was coming back when the staff member was leaving on 4/8/25 at approximately 4:30 p.m. The observation revealed the staff member writing numerous medications on the report sheet. Staff E administered Baclofen, Gabapentin, Venlafaxine, Cetirizine, Sucralafate, metoprolol Tartrate, ferrous and Spiriva inhaler. The staff member confirmed dispensing 8 oral medications, one liquid, and one inhaler. The resident complained of hurting so bad and asked the staff member for Zofran, Staff E looked in cart for the requested medication and stated it would have to be re-ordered. The staff member informed Staff D, Registered Nurse/Unit Manager (RN/UM) of missing all these showing the report sheet. Review of the pharmacy Delivery & Cut-off Times showed Monday - Friday new order cut off times were 11:00 a.m. with a departure time (from pharmacy) of 2:00 p.m. and 8:00 p.m., for new admissions the cutoff time was 10:00 p.m. with a departure time of 2:00 a.m. The information revealed if a refill was needed immediately, please contact pharmacy and if something was faxed after cutoff and needed to be received staff were to call the pharmacy immediately. Based on the interview with Staff E, Resident #53's revealed the resident was re-admitted prior to the last cutoff time of 10:00 p.m. and medications would have left the pharmacy at 2:00 a.m. and if a refill was needed immediately staff were to contact the pharmacy. Review of Resident #53's April Medication Administration Record (MAR) revealed Staff E had documented the following medications were not administered: - Aldactone (Spironolactone) 25 mg - Give 1 tablet by mouth one time a day for Hold for systolic blood pressure (SBP) <100 related to unspecified heart failure. - Azithromycin 250 mg - Give 1 tablet by mouth one time a day for infections for 3 days. This order was new with a start date of 4/9/25. - Empagliflozin 10 mg - Give 1 tablet by mouth one time a day related to Type 1 diabetes mellitus without complications. - Lamotrigine 200 mg - Give 1 tablet by mouth one time a day for mood disorder (d/o). - Lisinopril 10 mg - Give 1 tablet by mouth one time a day related to essential (primary) hypertension. - Potassium Chloride Extended Release (ER) 20 milliequivalent's (meq) - Give 1 tablet by mouth one time a day for congested heart failure (CHF). - Prednisone 20 mg - Give 2 tablets by mouth one time a day for pain for 2 days. This order was new with a start date of 4/9/25. - Spironolactone 50 mg - Give 1 tablet by mouth one time a day for CHF. - Zofran 4 mg - Give 4 mg by mouth every 6 hours as needed for nausea (and) vomiting. The order started on 1/13/25. Review of Resident #53's progress notes showed Staff E had documented the medications: Azithromycin, Empagliflozin, Potassium chloride, Lisinopril, Lamotrigine, Aldactone, Spirolactone, and Prednisone were on order. The notes did not show the pharmacy or physician was notified of the medications not being available. Review of the electronic medication dispenser list, dated 4/8/25 at 9:49 a.m. showed the facility had the following medications available: - Azithromycin 250 mg tablets - 13 tablets available. - Lisinopril 5 mg tablets - 12 tablets available. - Potassium chloride ER 10 meq tablets - 14 tablets were available - Prednisone 5 mg tablets - 20 tablets available. - Ondansetron (Zofran) oral disintegrating tablet (ODT) 4 mg tablets - 5 tablets were available. During an interview on 4/9/25 at 10:02 a.m. Staff E, Licensed Practical Nurse (LPN) reported the policy for missing medications was to call the pharmacy and the physician. The staff member reported having to call the pharmacy as some of the medications said they were on order. Review of the policy - Medication Administration, reviewed and revised 9/1/23, showed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy showed If any medication is not available, or the possibility of late administration, the nurse will contact the Attending Physician. Review of the policy - Pharmacy Services, reviewed/revised 1/2025, revealed the following: It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The compliance guidelines included: 1. The facility will provide pharmaceutical services to include procedures that usher they're accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements and reflect current standards of practice. Review of the policy - Medication Reconciliation, reviewed/revised 1/2025, revealed the following: This facility reconciles medication frequently throughout a resident state to ensure that the resident is free of any significant medication errors, and that the facilities medication error rate is less than 5%. 3. Pre admission Processes: a. Obtain current medication list from referral source (i.e. Hospital, home health, Hospice, or primary care provider). b. Obtain current medication/ admission orders. c. Verify resident identifiers. d. Forward to nursing unit accepting the resident. 4. admission processes: a. Verify resident identifiers on the information received. b. Compare orders to hospital records, etcetera. Obtain clarification orders as needed. c. Transcribe orders in accordance with procedures for admission orders. d. Order medications from pharmacy in accordance with facility procedures for ordering medications.

Based on observations, interviews and record review, the facility did not ensure physician orders for medications with parameters were followed for two (#29 and #11) out of two residents reviewed. Findings included: 1. On 6/03/2025 at 10:05 a.m. an observation and interview was conducted with Staff A, Licensed Practical Nurse (LPN) during medication administration for Resident #29. Staff A, LPN stated she will make a call to the physician to inform the physician of the late administration of medication for the resident. Staff A, LPN took Resident #29's blood pressure and obtained a result of 111/68 millimeters of mercury (mmHg). Staff A pulled Lisinopril 2.5 milligrams (mg) from the medication cart and administered the medication. A record review of Resident #29's admission Record showed an admission date of 6/14/2019 with diagnoses to include but not limited to essential hypertension. A record review of Resident #29's physician orders showed an order dated 5/25/2025 for Lisinopril 2.5 mg to give one tablet by mouth one time a day for hypertension, hold if systolic blood pressure (sbp) less than 110 mmHg. A record review of Resident #29's Medication Administration Record (MAR) for the month of June 2025 showed Lisinopril was given each day for the month of June but no vital signs to correlate with administration parameters. A record review was conducted of Resident #29's Weights and Vitals Summary. An entry for June 3, 2025, showed two blood pressures: 111/68 mmHg at 10:38 a.m. and 134/83 mmHg at 11:37 a.m. The review of Resident #29's Weight and Vitals Summary showed on 5/26/2025 at 11:30 a.m., an entry of 101/59 mmHg; there were no entries for 5/272025 and 5/28/2025. On 5/29/2025 at 19:10 (7:10 p.m.) an entry of 103/55 mmHg was entered. On 5/30/2025 at 11:50 a.m., an entry of 109/60 mmHg was entered and on 6/02/2025 no entry was entered for a blood pressure. A record review of Resident #29's May and June 2025 MARs showed Lisinopril 2.5 mg was administered on 5/26, 5/27, 5/28, 5/29, 5/30 and 6/02/2025 outside the physician ordered parameters and/or with no vital signs obtained. On 6/03/2025 at 2:31 p.m., an interview was conducted with Staff A, LPN. Staff A, LPN stated she recorded the entry of 134/83 mmHg for today because she forgot the earlier blood pressure she had obtained on Resident #29. Staff A, LPN stated there are three ways to enter a blood pressure into the medical record. Staff A, LPN demonstrated vital signs in the electronic chart can be entered through the 1.) the home page, 2.) the MAR, or 3.) the Vital Sign tab. Staff A, LPN agreed there were no recorded vital signs for 5/27-5/28 and 6/2/2025. Staff A, LPN looked at Resident #29's orders and agreed there were no parameters to hold Lisinopril if SBP <110 mmHg. A record review of Resident #29's electronic chart for the nursing progress notes did not show any entries from 5/26/2025 to current to state a physician was notified of blood pressure parameters not met and/or the medication (Lisinopril) was held as per physician orders. A review of Resident #29's care plan showed a focus area of hypertension related to lifestyle choices initiated on 11/06/2023 with a revision date of 5/22/2024 with interventions to include but not limited to: Give anti- hypertensive medications as ordered. Monitor of side effects such as orthostatic hypotension and increased heart rate and effectiveness, effective11/06/2023. 2. A record review of Resident #11's admission Record showed an admit date of 02/27/2025 with a diagnosis to include but not limited to hypotension, unspecified. A record review of Resident #11's physician orders showed an order dated 5/25/2025 for Midodrine HCL oral tablet five mg to give by mouth three times a day for hypotension old for systolic blood pressure>130. A record review of Resident #11's MAR for the month of June showed the resident received Midodrine on 6/02/2025 at 13:00 (1:00 a.m.) and 17:00 (5:00 p.m.) outside the ordered parameter per physician orders. A record review of Resident #11's MAR for the month of May showed the resident received Midodrine on 5/23/2025 at 17:00 (5:00 p.m.); 5/25/2025 at 17:00 (5:00 p.m.); 5/28/2025 at 13:00(1:00 p.m.); 5/29/2025 at 9:00 a.m. and at 17:00 (5:00 p.m.) and 5/31/2025 at 13: (1:00 p.m.) outside the ordered parameter per physician orders. A review of both the MAR and the tab for vital signs did not show an entry for 5/25/2025 for morning shift/9:00 a.m. and the Midodrine was held. A record review of Resident #11's electronic chart for the nursing progress notes did not show any entries from 5/21/2025 to current to state a physician was notified of blood pressure parameters not met and/or the medication (Midodrine) was held as per physician orders. A review of Resident #11's care plan showed a focus area of hypotension initiated on 4/05/2025 with interventions to include but not limited to: give medications as ordered, monitor for side effects and effectiveness. On 6/04/2025 at 11:10 a.m., an interview was conducted with Staff B, Registered Nurse/Unit Manager (RN/UM). Staff B, RN/UM stated if a resident has a parameter for medication, the nurse should check the blood pressure, vital signs etc. If the results are out of the parameters, the nurse should hold the medication, inform the ordering physician (to see if there may be a pattern) and make a notation in the MAR/progress notes. On 6/04/2025 at 11:12 a.m., an interview was conducted with Staff C, LPN/UM. Staff C, LPN/UM stated the nurse should check the blood pressure, check the order, hold the medication if outside the ordered parameters, and inform the MD medication was held. On 6/04/2025 at 11:26 a.m., an interview was conducted with Staff D, LPN/UM. Staff D, LPN/UM stated if a medication was out of ordered parameters, he would hold the medication and inform the ordering physician and write a note in the MAR/progress notes indicating the medication was held. On 6/04/2025 at 1:51 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) during review of their Quality Assurance and Performance Improvement from previous survey. The NHA and the DON stated during their analysis they did recognize a concern for parameter monitoring during medication administration. The DON stated education had been provided but stated further education and more frequent auditing will have to be initiated. A record review of the facility's policy titled, Medication Administration revised on 01/2025 showed a policy statement: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination of infections. Under section Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. 18. Sign MAR after administration. For those medications requiring vital signs, record the vital signs onto the MAR.

Based on observation, record review, and interview the facility failed to maintain accurately documented medical records for vital signs, medication, and indwelling catheters for two (#98, #93) of 52 total sampled residents. Findings included: 1. On 4/8/25 at 4:06 p.m., Resident #98 was observed with Staff Q, Licensed Practical Nurse (LPN) during the administration of medication. Review of Resident #98's April 2025 Medication Administration Record (MAR) showed a physician order for staff to monitor vital signs every shift. Review of the MAR documentation showed: - Identical vital signs on 4/1/25 evening and night shift of 132/72 blood pressure (bp), 97.3 temperature (temp), 72 pulse, 17 respiratory rate (resp), and 98% oxygen saturation rate (O2 sats). - Identical vital signs on 4/2/25 night shift and 4/3/25 evening and night shift of 122/88 bp, 97.6 temp, 77 pulse, 18 resp, and 97% O2 sats. - Identical vital signs on 4/4/25 day, evening, and night shift and 4/5/25 evening shift of 118/68 bp, 97.1 temp, 65 pulse, 19 resp, and 96% O2 sats. - Identical vital signs on 4/5/25 night shift and 4/6/25 evening shift of 116/70 bp, 98.1 temp, 74 pulse, 17 resp, and 97% O2 sats. - Identical vital signs on 4/7/25 evening and night shift of 100/78 bp, 97.8 temp, 74 pulse, 17 resp, 97% O2 sats. - Identical vital signs on 4/8/25 evening and night shift of 148/73 bp, 98 temp, 73 pulse, 18 resp, 96% O2 sats. - Staff failed to document vital signs on the day shift on 4/1, 4/2, 4/3, 4/5, 4/6, and 4/7/25, on the evening shift on 4/2/25, and night shift on 4/6/25. Review of Resident #98's MAR showed an order (to start 4/2/25 at 5:00 PM and discontinued on 4/9/25 at 5:26 PM) for Midodrine 2.5 mg - Give 1 tablet by mouth three times a day for dizziness/low bp, hold for systolic bp greater than (>) 140. The MAR did not include documentation of bp's at the time of administration and showed the medication was administered three times a day, except for the scheduled time of 5:00 PM on 4/2/25, and 1:00 p.m. on 4/5/25 and 4/6/25. 2. On 4/8/25 at 5:43 PM, Resident #93 was observed lying in bed. The resident reported her urinary catheter came out about 3 weeks ago. The resident said the nurse was going to put it back in but needed a 16 french (fr) and only had a 14 fr. Review of the nursing note, dated 3/18/25 at 3:01 PM showed Resident #93's Foley catheter was found on bed, balloon deflated and 30 cubic centimeter (cc) of water out of balloon. Notified MD [ Medical Doctor], orders to leave foley catheter out, and see how well resident does with foley catheter out. Review of the physician note, dated 3/19/25 showed Resident #98 was resting in bed, in no acute distress, and included Foley catheter draining with no problem. Review of the Physician Assistant note, effective 3/21/25 at 1:00 a.m. revealed Resident #93 did not have a Foley catheter and was making urine. Review of the skin/wound note, effective 3/23/25 at 1:20 p.m. revealed Resident #93 was incontinent of Bladder and Foley has been discontinued. Review of a physician encounter note effective 3/26/25 at 1:00 a.m. showed Resident #93 complained of mild dysuria after Foley cath was removed. Review of the Certified Nursing Assistant (CNA) documentation revealed Resident #93's urinary continence was not rated due to Indwelling Catheter was last documented one time on 3/27/25 at 2:38 a.m. and from 3/27 to 4/10/25 the resident was incontinent of urine. Review of Resident #93's March 2025 MAR and Treatment Administration Record (TAR) showed nursing staff had completed Foley Cath Care with soap and water every (q) shift and as needed (PRN) every shift for maintenance for a total of 37 out of 41 opportunities from the evening shift on 3/18/25 when the catheter was found in the resident's bed through the night shift on 3/31/25. Staff documented a Privacy bag for drainage bag at all times while in bed, while walking, or in wheelchair every shift for privacy for a total of 37 out of 41 opportunities from the evening shift on 3/18/25 when the catheter was found in the resident's bed through the night shift on 3/31/25. Review of Resident #93's April 2025 MAR and TAR revealed staff continued to document the resident received Foley Cath Care with soap and water every (q) shift and as needed (PRN) every shift for maintenance every day, evening, and night shift from 4/1/25 through the night shift on 4/7/25. The order was discontinued at 5:50 a.m. on 4/8/25. The MAR revealed staff had documented the presence of a Privacy bag for drainage bag at all times while in bed, while walking, or in wheelchair every shift for privacy from 4/1/25 through the evening shift on 4/7/25. The order was discontinued on 4/8/25 at 5:52 a.m. Review of the policy - Documentation in Medical Record, implemented 3/2024, revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 3. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. During an interview on 4/9/25 at 1:40 PM the Director of Nursing (DON) stated Resident #93 was admitted with a Foley catheter, the Foley came out on 3/18/25, and was not put back in. The DON stated she did not know why staff documented catheter care was provided (after it was removed) and reported this would not be correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to maintain a safe, clean, and comfortable homelike environment in 16 out of 52 resident rooms and in three Wings/Common areas (100, 400 and 600) of six Wings toured. Findings included: On 4/8/2025 at 12:40 p.m., 4/9/2025 at 09:50 a.m., and on 4/10/2025 at 10:10 a.m. the following was observed: Resident room [ROOM NUMBER] was observed with bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed with unfinished walls near the TV and bio growth on the ceiling at the fire sprinkler head. Resident room [ROOM NUMBER] was observed without a call light pulling string in the bathroom. Resident room [ROOM NUMBER] was observed with broken drawers. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with no call light system in the bathroom. Resident room [ROOM NUMBER] was observed with a broken toilet. Resident room [ROOM NUMBER] was observed with pest feces in the shower. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat, unpainted walls near the TV and baseboards missing near the air conditioner. Resident room [ROOM NUMBER] was observed with brown, rough surfaces in the bathroom walls and over the toilet seat. Resident room [ROOM NUMBER] was observed with no paint on the walls near the TV and no light in the bathroom. Resident room [ROOM NUMBER] was observed with a brown, rough surface over the toilet seat, and no call light in the bathroom. Resident common areas in the 100 Wing were observed with bio growth on the ceiling near the nurses station in the sitting area. The common area in the 400 Wing was observed with bio growth on the ceiling near the nurses station and the ceiling tiles hanging loose in the sitting area. The 600 Wing hallway was observed with bio growth in the light at the end of the hallway and also near the sprinkler head in the same area. On 4/10/25 at 11:08 a.m. an interview was conducted with the Director of Maintenance (DOM). The DOM stated he walked the facility daily and if he saw an issue, he resolves it immediately or enters it into the electronic maintenance work order system. He stated the staff also enters issues into the electronic maintenance work order system, and he reviews the system for additions on a daily basis if not at least weekly. The DOM said, I do not do a comprehensive survey and submit it to the Nursing Home Administrator (NHA). The DOM stated he tries to get issues fixed immediately and if he can't get it accomplished, he has his assistant who fixes it and keeps a log with emails correspondence. The DOM stated he does not have a written policy regarding daily, weekly, monthly or annual maintenance. He stated it is directed through the electronic maintenance work order system. The DOM stated he did not have a bio growth policy. He stated if he suspected bio growth, he would clean the area and watch it. Review of an undated facility document titled, Patch and paint revealed twenty-two resident room walls were patched without paint. Review of an undated facility document titled, electronic maintenance work order system task manager, did not show a task manager for maintenance of walls, floorboards or resident equipment was in place. Review of an undated facility document titled, Work Orders showed no orders addressing the walls or floorboards or bio growth or the falling ceiling. Review of a facility policy titled, Routine Cleaning and Disinfection policy, dated 9/2023 Reviewed by Clinical Services, showed it is the policy of this facility to ensure the provision of routine cleaning and disinfection to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Cleaning refers to the removal of visible soil from objects and surfaces, transmission-based precautions refers to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for 3 of 5 months reviewed and two (#19 and #69) of 52 total residents sampled. Findings included: 1. Review of the Resident Council Minutes dated November 18, 2024 showed: New Business: Current Situation Weekend Call lights long response time 11-7 and Customer Service. Review of Resident Council Minutes dated 2/12/205 showed: New Business: Current Situation To long to answer call lights 11-7. Review of Resident Council Minutes dated 3/13/2025 showed: New Business: Current Situation call lights. During the Resident Council Meeting on 4/8/25 at 2:30 p.m., Resident Council stated call lights and staff assistance continue to be a problem, especially on evenings and weekends. A review of the Grievance Logs from November 2024 to March 2025, revealed an absence of grievance issue concern on behalf of the Resident Council. An interview was conducted on 4/8/25 at 3:49 p.m. with the Activity Director (AD). The AD stated the residents request for her to assist with the council minutes. Part of these duties was reviewing the residents concerns with the Social Service Director (SSD) who was also the Grievance Coordinator. The AD stated Resident Council has had multiple call light recurrences of residents not receiving assistance, the SSD writes the grievance and I let Resident Council know the issue is resolved. During an interview on 4/8/25 at 4:46 p.m. and follow up interview on 4/9/25 at 11:55 a.m. with the SSD the grievance process was reviewed. The SSD stated once the grievance was received, it was logged in by social services. The SSD said I take the grievance to our morning meeting for discussion, at which all managers, including the Administrator, were in attendance. We decide who would be responsible for investigating the grievance and that manager takes the grievance to complete the investigation, determine resolution and follow up with the resident/responsible party. Once completed, the grievance form was returned to social services. The SSD stated we like this process to occur within three to five days. The SSD reported noticing an issue with call lights and customer service, especially for nights and weekends stating, we should definitely do better with this. The SSD confirmed not seeing any grievances from Resident Council recorded on the log. 2. Review of a grievance dated 3/10/25 for Resident #69, revealed the grievance was filed by the resident related to not receiving staff assistance. The investigative section of the report showed Nurse Aide in dining room for lunch. The notification of the representative section was blank. During an interview on 4/8/25 at 2:29 p.m. during the Resident council meeting Resident #69 stated she continued to have difficulty in receiving staff assistance. Review of Resident #69's Cognitive Pattern assessment dated [DATE] showed the resident was cognitively intact with a score on the Brief Interview for Mental Status (BIMS) of 15 out of 15. 3. Review of a grievance dated 2/6/25 for Resident #19, revealed the grievance was filed by the Resident, related to not receiving staff assistance and maintenance of an air mattress. The investigative section of the report showed Maintenance changed mattress, nothing was noted regarding staff assistance. The date resolved section was blank. During an interview on 4/7/25 at 10:14 a.m., Resident #19 stated continued difficulty in receiving staff assistance. Review of the admission Record for Resident #19 showed an original admission date in April of 2024 and a readmission date on 2/27/25. The admission Record included diagnoses of multiple sclerosis, depression, diabetes mellitus, and quadriplegia. Review of Resident #19's Cognitive Pattern assessment dated [DATE] showed the resident was cognitively intact with a score on the Brief Interview for Mental Status (BIMS) of 15 out of 15. An interview on 4/9/25 at 12:20 p.m. was conducted with the Nursing Home Administrator (NHA). The NHA stated grievances were brought to morning meeting for discussion and the appropriate department manager followed through with the grievance and the SSD ensured completion. The NHA stated the facility noted a call light response issue about four months ago. The facility decided to add a Certified Nursing Assistant (CNA) to the 3 p.m. to 11 p.m. shift to assist with new admissions, labeling clothing, and assisting with call lights. The NHA was not aware of further issues. Review of the facility's policies and procedures titled Resident and Family Grievances, with a revision date of 4/29/2024 revealed: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines: . 2. The Grievance Officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; coordinating any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay. 7. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Officer. b. Written complaint to a staff member or Grievance Officer. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. e. Via the company toll free Compliance Line (if applicable). 10. Procedure: a. The staff member receiving the grievance Will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. i. Take any immediate actions needed to prevent further potential violations of any resident right. ii. Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. b. Forward the grievance form to the Grievance Officer as soon as practicable. c. Grievance Officer will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Officer. Prompt efforts include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance. iii. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know. d. The Grievance Officer, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. e. The facility will take appropriate action in accordance with State law if an alleged violation of resident's rights is confirmed by the facility or an outside entity, such as State Survey Agency, Quality Improvement Organization, or local law enforcement agency. f. If resident observes his/her rights and requests a written response it will contain the following: i. The date the grievance was received. ii. The steps taken to investigate the grievance. iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s). iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued. g. For investigations regarding allegations of neglect, abuse, Injuries of unknown source, and/or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and other officials in accordance with State law, within five working days of the incident. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 12. The facility will make prompt efforts to resolve grievances. 13. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 14. The facility will make prompt efforts to resolve grievances. 16. If the Resident/Responsible Party or concerned parties' express dissatisfaction with resolution the following may be indicated: a. Setting up a Special Care Meeting b. Appointing an On Going Partner c. Notify the Attending Physician and Medical Director when appropriate. 17. All Grievances should be documented on the Grievance Log and maintained per retention policy. 18. Trended issues should be addressed in center Quality Assurance/Risk Management meeting by the Grievance Officer and discussed with the Center Clinical Risk Manager. 19. The center's appointed Grievance Officer shall receive formal and documented in-servicing on how to conduct an appropriate center investigation for timely grievance resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate Pre-admisson Screening and Resident Review (PASRR) screenings for eight residents (#2, # 67, #64, #83, #57, #26, #20, and #81) out of 52 residents sampled. Findings included: 1. Review of Resident #2's admission record revealed an admission date of 03/16/2024, with diagnoses to include Other Bipolar Disorder, Major Depressive Disorder, Single Episode, Unspecified. Review of Resident #2's Level I PASRR, dated 03/15/2025, showed the Level I PASRR was missing diagnoses including Bipolar Disorder and Major Depressive Disorder. A rescreen was not perfomred by the facility to include these diagnosis and assess if a Level II screen wuld be needed. 7. Review of the admission Record showed Resident #83 was admitted on [DATE] with diagnoses of, encephalopathy, hypertension, depression, dementia and other comorbidities. Review of Resident #83's PASRR Level I Assessment, dated 1/22/2024, did not reveal a qualifying mental health diagnosis marked in section I A. nor was the diagnosis of Dementia. No Level II PASRR was completed due to the qualifying diagnoses. 8. Review of the admission Record showed Resident #20 was admitted on [DATE] with diagnoses of osteomyelitis of vertebra, low back pain, cocaine abuse, hypo-osmolality and hyponatremia anxiety disorder, depression, and other comorbidities. Review of Resident #20's PASRR Level I Assessment, dated 06/05/2021 did not reveal a qualifying mental health diagnosis marked in section I A. nor was the characteristics of behaviors completed. No Level II PASRR was completed due to the qualifying diagnoses. During an interview on 04/10/25 at 11:48 AM, with the Nursing Home Administrator and the Director of Nursing (DON), the DON stated the hospital is to complete the PASRR prior to admission to the facility. Once admitted the Interdisciplinary Team (IDT) reviews the documentation from the hospital to include the PASRR, and determine if the information is correct. If the information is not correct then a new PASRR will be completed by the facility. The DON confirmed if a resident has a diagnosis of a mental illness or serious mental illness the diagnosis should be indicated in section IA of the PASRR, as well as if the resident has dementia. The DON stated the form should be completed accurately to reflect the resident's conditions. The expectation would be that a new PASRR would be completed to reflect the diagnosis and characteristics of the resident. Review of the facility's policies and procedures titled Resident Assessment - Coordination with PASRR Program dated 9/1/2023 revealed: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I initial pre-screening that is completed prior to admission i. Negative Level I Screen -- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level Il evaluation prior to admission. b. PASARR Level Il -a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the Individual, and recommends any specialized services and/or rehabilitative services the Individual needs. 2. The facility will only admit individuals with a mental disorder or Intellectual disability who the State mental health or Intellectual disability authority has determined as appropriate for admission. 3. A record of the pre-screening shall be maintained In the resident's medical record. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level Il determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 8. Any level Il resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or Intellectual disability authority for a level Il resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment. 2. Review of Resident #81's admission Record showed the resident was admitted on [DATE], 9/3/24, and 2/10/25. The record revealed the resident's primary diagnosis with an onset date of 8/15/24 was unspecified Alzheimer's disease, other diagnoses included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 2/10/25), unspecified anxiety disorder (onset 11/22/24), mood disorder due to known physiological condition with mixed features (onset 11/19/24), and unspecified depression (onset 9/18/24). Review of Resident #81's care plan revealed the resident had a behavior problem related to (r/t) combative toward staff both physical and verbally, exit seeking, wander in resident's room(s), bit a couple of staff members (and) resident slapped another resident. The focus was initiated on 9/26/24 with a goal of fewer episodes of behaviors (target date 6/16/25). Review of Resident #81's Preadmission Screening and Resident Review (PASRR) Level 1 screening, dated 8/13/24, did not show the resident had any Mental Illness (MI) or suspected Mental Illness (SMI) and had no history of receiving services for MI. The decision-making section did not show the resident had exhibited actions or behaviors that may make them a danger to themselves or others and did not have a primary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). The PASRR did show the resident did have a secondary diagnosis of dementia, related neurocognitive disorder, and the primary diagnosis of a SMI or Intellectual disability. The screening showed the resident did not have a diagnosis or suspicion of SMI or ID and a Level II PASRR was not required. Review of Resident #81's PASRR was not updated to include mental illness diagnoses documented after the screening was completed and did not show the resident's primary diagnosis was unspecified Alzheimer's disease. 3. Review of Resident #57's admission Record revealed the resident was admitted on [DATE] and 3/29/24. The record revealed the resident had a secondary diagnoses of unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 3/29/24), and unspecified cerebral palsy (11/2/23). Review of Resident #57's Preadmission Screening and Resident Review (PASRR) Level 1 screening, dated 12/6/23 and completed by the facility's Director of Nursing (DON), showed the resident had diagnoses of anxiety, depression, and schizoaffective disorders. The screening did not reveal the resident had the Intellectual Disability (ID) related condition of Cerebral Palsy. Review of Resident #57's PASRR revealed the facility did not update accurately related to not including the diagnosis of Cerebral Palsy in the resident's screening. 4. Review of Resident #64's admission Record revealed the resident was admitted on [DATE] and 4/2/25. The record revealed diagnoses not limited to unspecified depression (onset 2/25/25), and unspecified anxiety disorder (onset 2/25/25). Review of Resident #64's Preadmission Screening and Resident Review (PASRR) Level 1 screening, dated 2/21/25 completed at an acute care facility prior to the resident's admission. 5. Resident #67 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Alzheimer's disease, unspecified; mood disorder due to known physiological condition with mixed features. major depression, disorder single episode, unspecified, sever protein-calorie malnutrition, dysphagia, and adult failure to thrive. Review of the 01/04/2025 in Section I PASRR Screen Decision-Making A. Depressive Disorder. Mood disorder was not addressed on the PASRR. 6. Resident #26 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to polyneuropathy, acute kidney failure, nontraumatic subdural hemorrhage, chronic kidney disease, anxiety disorder, unspecified, muscle weakness, other seizures, Hypertension, anemia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], showed a Brief Interview of Mental Statu (BIMS) score of 05 or severe cognitive impairment. Section O, Special Treatments, Procedures, and Programs showed on oxygen therapy. Review of the PASRR, dated 11/05/2016, showed Screen Decision Making A. SMI or suspected SMI was blank.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/7/2025 at 10:30 a.m. through to at least 10:50 a.m., and 11:50 a.m. though to at least 12:30 p.m., Resident #7 was observed in her room and lying in bed with the head of the bed raised at approximately forty degrees. Resident #7 appeared with both of her upper extremities contracted. Both of her hands and fingers were in a closed position. Resident #7 was not observed wearing either splints or orthotics. There were no splints or orthotics visible in the room during the multiple visits. On 4/7/2025 at 1:00 p.m., an interview with Staff C, Certified Nursing Assistant (CNA) confirmed she had Resident #7 on her assignment for the day and that she did not know the resident well. Staff C confirmed the resident had contracted upper extremities on both sides. Staff C was not sure if the resident had splints or orthotics. On 4/8/2025 at 7:50 a.m. through to 8:10 a.m., 12:15 p.m., 1:55 p.m., and 2:58 p.m., Resident #7 was again observed in her room and lying in bed under the bed linen, with a sheet pulled up to her waistline. She was observed with her eyes closed and with both of her arms and hands folded and positioned on top of her stomach area. Resident #7 was observed during specified times without any splints/orthotics on either of her upper extremities. Both of her hands and fingers were noted in a half closed position. There were no splints/orthotics visible within the resident's room. On 4/9/2025 at 8:00 a.m., 8:55 a.m., 9:24 a.m., 9:56 a.m., 11:54 a.m., 1:00 p.m., and 3:00 p.m. Resident #7 was observed in her room and lying in bed with the HOB raised approximately forty-five degrees. The call light was observed on the bed placed within her reach, with both extremities exposed and with one positioned on her stomach, and the other to her side on the bed. Both hands and fingers appeared in a closed position. Both hands and upper extremities were without any splints or orthotics. There were no splints/orthotics visible in the room. On 4/9/2025 at 10:00 a.m., an interview with Staff F, Occupational Therapist (OT) revealed the Rehabilitation Director was not available today for interview, but she (Staff F) would try to answer any questions. Staff F revealed she knew of Resident #7 very little, but did confirm she had contractures. Staff F revealed the resident was discharged from Occupational Therapy on 1/10/2025. Staff F continued to say Resident #7 was referred to Restorative Nursing for contracture management to include utilization of splints/orthotics on her right elbow, right hand and left palm. Since Staff F was not able to say what the outcome was related to Restorative Nursing and her current contracture management. On 4/9/2025 at 12:10 p.m., an interview with Staff G, Certified Nursing Assistant (CNA), who was assigned to Resident #7 during the 7- 3 shift, revealed she had only been working the unit for about one week and did not know all the residents on the hallway to include Resident #7. She said Resident #7 was basically totally dependent on staff with most of her Activities of Daily Living (ADL). She explained as far as she knew, Resident #7 did not wear splints/orthotics. She confirmed there were no orthotics or splints in the room. On 4/9/2025 at 12:20 p.m., an interview with Staff E, Licensed Practical Nurse (LPN) , revealed she normally had the same floor hall on her routine 7-3 assignment. Staff E said Resident #7 had limited Range of Motion with upper extremity contractures. She did not know if the resident was ordered and care planned for the use of splints/orthotics for the contractures. Staff E reviewed the care plan [brand name for a summary of patient care information] on her computer and confirmed there was no documentation to support the resident was to wear splints or orthotics on either of her extremities. She reviewed the electronic medical record and found documentation indicating the resident was supposed to wear a right elbow extension splint, a right resting hand splint, and a left palm guard for 6 hours per day, 5 days a week and supplied and removed by nursing staff. She also confirmed the original order date was 2/20/2025. On 4/10/2025 at 10:15 a.m., an interview was conducted with Staff D, the 100, 200, 300 Unit Manager. She revealed she was not aware Resident #7 was not offered or donned with splints/orthotics on her upper extremities the past few days. Staff D revealed it was brought to her attention by [Staff E] yesterday afternoon on 4/9/2025. Staff D revealed she, as the Unit Manager, should have been monitoring her nursing staff to ensure care plan interventions and orders were followed; especially for those who were on contracture management, and who required use of splints/orthotics. Staff D was not sure who was responsible for donning and doffing splints/orthotics on a daily basis, but thought it was Restorative Nursing. Staff D said she had seen Resident #7 in the past wearing splints/orthotics on her left palm and right hand/arm. She could not say if Resident #7 ever had any behaviors of refusing to wear the splints/orthotics, and if she had, the nursing staff would have to report that to her so she could document the behaviors and have the Interdisciplinary Care Plan team develop a care plan problem area to identify that. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; Cognition/Brief Interview for Mental Status or BIMS score - 00 of 15, which indicated severe cognitive impairment. Behaviors - Physical bx.(behaviors) symptoms directed towards others 1 - 3 days during the 7 day assessment period; ADL - Impairment both sides upper and lower extremities, Substantial assistance to dependent on staff for most ADLs. Review of the current Physician's Order Sheet (POS) for the month 4/2025, revealed the following but not limited to orders: c. Patient will wear R elbow extension splint, R resting hand splint, and L palm guard for 6 hours per day 5 days a week a supplied and removed by nursing staff. Order date 2/20/2025). Review of the nurse progress notes dated from 12/1/2024 through to 4/9/2025 did not include any documented evidence of the resident receiving any assistance with upper extremity splint/orthotics. Nor was there documentation to support Resident #7 ever refused wearing said splint/orthotics. Review of the current care plans with next review date 5/5/2025 revealed the following but not limited to: 1. ADL Resident has a self care deficit with need for staff assistance with ADL completion on daily basis: Dx. contractures, weakness, impaired mobility, impaired cognition, Right elbow extension splint, Right resting hand splint and left palm guard. Followed by MD order, with interventions in place to include but not limited to: Patient will wear R elbow extension splint, Right resting hand splint, and Left palm guard for 6 hours per day 5 days a week as applied and removed by nursing staff. 2. Resident has limited physical mobility r/t weakness bilateral upper extremity and bilateral lower extremities with interventions in place to include but not limited to: Resident is totally dependent on 1 staff for locomotion using wheelchair, Monitoring/documenting/report PRN any signs/symptoms of immobility forming or worsening, thrombosis formation, Provide gentle range of motion as tolerated with daily care. 3. Alteration in musculoskeletal status r/t contracture to L ankle, Right ankle, R wrist, and R elbow, with interventions in place to include but not limited to: Anticipate needs, Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders and or PT treatment plan, Monitor/document/report PRN signs and symptoms or complications related to arthritis; Joint stiffness, usually worse on waking; Swelling; Decline in mobility, Decline in self care ability, Contracture formation/joint shape changes, clicking with joint movement, pain after exercise or weight bearing. Based on observation, interview and record review, the facility failed to follow the comprehensive person-centered care plans for three (#26, #38, and #7) of 52 sampled residents. Findings included: 1. An observation on 04/07/2025 at 10:25 a.m revealed Resident #38 sitting in his room in his bed. The head of the bed was elevated. His un-bagged nebulizer mask was laying on the overbed table. The nebulizer machine was off. He stated the nurse brought in medicine for his machine and left. Resident #38 stated he took it off after it was finished. He stated the nurse did not stay with him. An observation on 04/07/2025 at 11:26 a.m revealed Resident #38's un-bagged nebulizer was still laying on the overbed table. An observation on 04/08/25 at 8:58 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. The nebulizer mask was in a plastic bag on the overbed table. The oxygen concentrator was set at 3.5 liters per minute. An observation on 04/09/2025 at 10:30 a.m., revealed Resident #38 was sitting in bed with the head of the bed elevated. His nebulizer mask was sitting on top of a plastic bag. The nebulizer machine was off. His oxygen concentrator was set at 1.5 liters per minute. During an interview on 04/09/2025 at 10:46 a.m. with Staff P, Licensed Practical Nurse (LPN) she verified Resident #38's oxygen was set at 1.5 liters instead of 2 liters per minute as per the physician orders. Staff P, stated the oxygen setting was supposed to match the physician orders. She stated she entered the room and put the nebulizer mask in the plastic bag. Staff P stated, No, I did not stay with [Resident #38] the whole time he was on his nebulizer. Staff P stated she brought his (oral) medications in including his nebulizer medication. She stated she brought in his roommate's medications and gave another resident (in another room) their medication. Staff P stated she just came in and put the nebulizer mask back in the bag as it was laying on the plastic bag. She stated she was not in the room the whole time he was on the nebulizer; she just came back. Resident #38 stated he did his own nebulizer treatments and turned the machine off. During an interview on 04/09/2025 at 11:38 a.m., the Director of Nursing (DON) stated they did not have anyone that was self-medicating. She stated the process for nebulizer treatments was for the nurse to check the lung sounds, put the medications in the nebulizer cup, put the mask on the resident's face, stay with the resident, when the resident was finished, take the mask off, check the lung sounds, rinse the mask and put it back in the plastic bag. If the resident was giving his own nebulizer treatments, he should have an order to self-medicate, assessment for self-medications and care planned for such. The DON stated they did not have an order for self-medication for Resident #38 nor had anyone assessed him. The DON stated they should be following the physician order for the number of liters of oxygen Resident #38 was to receive. If the order was for 2 liters the oxygen concentrator should be on 2 liters not 1.5 liters. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Section GG Functional Abilities showed dependence on eating, maximum assistance needed for toileting and bathing. Section J, Health Conditions showed shortness of breath when lying flat. Section O, Special Treatments, Procedures, and Programs showed oxygen therapy. Review of the active physician orders as of 04/10/2025 showed, Oxygen at 2 liters per minute continuous via nasal cannula (O2@2 lpm (liters per minute) continuous via N/C) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter) every 8 hours as needed for Shortness of Breath (SOB) Review of the physician orders showed none regarding self-medicating of nebulizer treatments. Review of the Medication Administration Record for April 2025 showed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML every 8 hours as needed for SOB was administered 2 to 3 times a day. Review of the assessments showed no documentation regarding assessing Resident #38 for self-medicating of nebulizer treatments. Review of the care plans for Resident #38 showed, At risk for impaired respiratory status related to COPD, bronchitis as of 03/20/2025. Interventions included but not limited to administer medications as per order, administer oxygen as per order, and administer respiratory treatment as directed. Monitor lung sounds as ordered. Check lung status including lung sounds as indicated, all initiated as of 03/20/2025. . 2. Observation on 04/07/2025 at 10:06 a.m. showed Resident #26 was lying in bed sleeping. Her gastrostomy tube feeding was infusing at 70 cc per hour. Her oxygen concentrator was set at 1.5 liters per minute. She had her nasal cannula in place. An observation on 04/07/25 at 4:52 p.m. showed Resident #26 was lying in bed asleep. Her oxygen concentrator was set at 1.5 liters per minute. An observation on 04/08/2025 at 8:55 a.m. showed Resident #26 was lying in bed sleeping. Her oxygen concentrator was set at 1.5 liters per minute. An observation on 04/09/2025 at 10:26 a.m. showed Resident #26's oxygen concentrator was set at 2 liters per minute. Staff P, Licensed Practical Nurse (LPN) verified her oxygen was not at 2 Liters per minutes as per her orders. Staff P LPN stated the oxygen should match the physician orders. Resident #26 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to polyneuropathy, acute kidney failure, nontraumatic subdural hemorrhage, chronic kidney disease, anxiety disorder, unspecified, muscle weakness, other seizures, Hypertension, anemia, and unspecified dementia. Review of the MDS dated [DATE] showed a BIMS score of 05 or severe impairment. Section O, Special Treatments, Procedures, and Programs showed on oxygen therapy. The resident had an oxygen therapy care plan initiated on 01/14/2025. Interventions included but not limited to oxygen: O2 as ordered as of 01/14/2025. Review of the physician orders showed O2@2 lpm via N/C or (oxygen at 2 liters per minute via nasal cannula) as of 11/14/2024. Review of the Treatment Administration Record (TAR) for April 2025 showed O2@2 lpm via N/C to be monitored every shift. The following lacked documentation it was monitored: 04/02/25 on day shift; 04/03/2025 on day shift; 04/04/2025 on evening shift; and 04/08/2025 on evening shift. During an interview on 04/10/2025 at 3:57 p.m. the DON stated the care plans and physician orders for Resident's #26 and #38 should have been followed related to oxygen therapy. She verified both had not been followed.

Based on observation, interview, and record review, the facility failed to provide grooming assistance of shaving facial hair for four (#5, #14, #33, #46) of six residents sampled for activities of daily living (ADL). Findings included: 1. On 04/08/25 at 02:35 PM, Resident #5 was observed in Resident Council meeting with several white hairs about ¼ inch in length on her chin. During an interview on 04/08/25 at 05:07 PM, Resident #5 stated she did not like the facial hair and hoped the facility would assist in removal. The resident stated they don't ask me. Review of the Certified Nursing Assistant (CNA) ADL task report for Resident #5 for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. Review of Resident #5's care plan dated 1/25/25 revealed Resident #5 required supervision or touching assistance with personal and oral hygiene and partial moderate assistance on bathing/showering. 2. On 04/07/25 at 10:20 AM, Resident #14 was sleeping in bed with two patches of approximately ½ inch gray hair patches on each side of her chin. During an interview on 04/07/25 at 02:00 PM, the Resident Representative (RR) for Resident #14 stated the resident would not want to have whiskers; what lady wants to have whiskers? The RR said she wished the facility would take care of this. On 04/08/25 at 12:25 PM, Resident #14 was sitting up in the wheelchair with her lunch meal and still had the two patches of approximately ½ inch gray hair on each side of her chin. Review of the CNA ADL task report for Resident #14 for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. Review of Resident #14's care plan dated 2/12/25 revealed Resident #14 required maximum assistance with oral hygiene and was dependent on bathing/showering. The resident had no care plan for any behaviors/rejection of care. 3. During an observation on 04/07/2025 at 10:16 a.m., Resident #33 was observed to have small patches of white hair protruding from her chin. During an observation on 04/08/2025 at 12:19 p.m., Resident #33 was observed having the same small patches of white hair protruding from her chin. Review of Resident #33's active care plans revealed no care plans for rejection of ADL care. Review of Resident #33's ADL care plan dated 3/21/2025 revealed the resident required partial/moderate assistance with bathing/showering; provide sponge bath when a full bath/shower cannot be tolerated. Review of Resident #33's CNA ADL task report for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. 4. During an observation on 04/07/2025 at 12:19 p.m., Resident #46 was observed to have a white patch of hair protruding from her chin. During an observation on 04/08/2025 at 9:23 a.m., Resident #46 was observed with a patch of white hair protruding from her chin. Review of Resident #46's CNA ADL task report for the month of April 2025 revealed documentation did not reflect any instances of this resident refusing care and showed ADL care was provided. Review of Resident #46's care plan initiated 8/19/22 revealed Resident #46's facial hair will be removed as desired, requires assistance of 1 with oral and personal hygiene and was dependent on staff for bathing/showering. The care plan did show behaviors of refusing showers, but did not document refusal of personal grooming. During an interview on 04/08/25 at 3:03 PM Staff W, CNA stated if a female resident has facial hair, we (staff) should shave them. During an interview on 04/08/25 at 4:10 PM Staff Y, CNA stated facial grooming was completed daily during morning care, and during bath/shower days. This included, male and female residents. Staff Y, CNA stated females should not have facial hair. We should shave them. During an interview on 04/08/25 at 4:53 PM Staff R, Licensed Practical Nurse (LPN) stated that ADL care was completed at least in the morning. ADL care included facial grooming. Female residents should not have whiskers. Staff R, LPN was not aware of any female residents who refused facial grooming. During an interview on 04/08/25 at 4:55 PM Staff AA, LPN Unit Manager stated ladies facial grooming should be included with ADL care. Staff AA, LPN did not know of any female residents who wanted facial hair and was unaware of any residents refusing to have facial hair removed. During an interview on 04/08/25 at 5:00 PM the Director of Nursing (DON) stated ADL care was all encompassing of general hygiene to include facial grooming (for both males and females). The DON reported if the resident does not want to have facial hair, it should be shaved. The DON said the resident's preference should be care planned and if the resident has behavior of refusing care, this should be care planned. The DON stated the expectation would be for resident's preferences to be followed. Review of the facility's policies and procedures titled Grooming a Resident's Facial Hair with a revision date of 7/1/2024 revealed: Policy: It is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. Policy Explanation and Compliance Guidelines: 5. When the facial hair is covered with shaving cream and softened, begin shaving. Shave in the direction that the hair grows. Hold the skin taut and smooth by pulling the skin upward with one hand and shaving with a downward stroke with your other hand. Use short, even strokes. Be particularly careful with the neck, chin, and upper lip. Use upward strokes for the neck, downward and slightly diagonal strokes for the chin, and very short downward strokes above the lip. 8. Allow the resident to look in a mirror to make sure they are satisfied with their appearance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Forty-one medication administration opportunities were observed, and fourteen errors were identified for four residents (#40, #98, #93, and #53) of six residents observed. These errors constituted a 34.15% medication error rate. Findings included: 1. On [DATE] at 8:24 a.m. an observation of medication administration with Staff P, Licensed Practical Nurse (LPN) was conducted with Resident #40. The staff member searched medication cart for a bottle of Calcium 500 milligram(mg) tablets. Staff P went to the central supply office cupboard and retrieved an over-the counter bottle before revealing the bottle was Calcium with Vitamin D and not the medication the resident was ordered. The staff member proceeded to dispense the following: - Carvedilol 3.125 mg tablet - Furosemide 40 mg tablet - Jardiance 10 mg tablet - Lisinopril 40 mg tablet Staff P confirmed dispensing four (4) tablets prior to administering the medications to Resident #40. The staff member informed the resident of owing him one calcium (tablet). Review of Resident #40's April Medication Administration Record (MAR) showed an order dated [DATE] for Calcium Oral Tablet - Give 500 mg by mouth one time a day for supplement. The MAR revealed the resident had received 500 mgs of Calcium per the physician order daily from 4/1 - [DATE]. The Director of Nursing (DON) had documented 5 on [DATE], which according to the legend Hold/See progress note. The MAR revealed the order for 500 mgs of Calcium had been discontinued on [DATE] at 9:33 a.m. and a different order was written for one tablet of Calcium 600/Vitamin D 10 microgram (mcg) to be administered one time a day for vitamin (vit) deficiency (def). The order for Calcium with Vitamin D was to start on [DATE] at 10 a.m. Review of a progress note written on [DATE] at 9:35 a.m. (1 hour 11 minutes after observation) showed the order for 500 mg of Calcium had been updated per the physician had changed the order to Calcium 600/Vit D 10 mcg. 2. On [DATE] at 4:06 p.m. an observation of medication administration with Staff Q, Licensed Practical Nurse (LPN) was conducted with Resident #98. The staff member removed the resident's glucometer and a blood pressure machine from the medication cart. The glucometer was used to obtain the resident's blood glucose level of 414 and a blood pressure of 143/78 was obtained. Staff Q removed from the top drawer of the medication cart a clear plastic bag containing a box, which the staff member removed a vial of Insulin Lispro. The plastic bag revealed the vial had been opened on 3/5 and a handwritten date revealing the insulin had expired on [DATE]. The staff member stated the insulin was good for one month and should still be good then looked at the date and confirmed it had expired on [DATE]. Staff Q searched medication cart and was unable to locate another Insulin Lispro vial or pen for Resident #98. The staff member observed the unit's medication refrigerator and reported the resident did not have any extra Humalog. The staff member returned to the medication cart and dispensed one 2.5 milligram (mg) tablet of Midodrine into a medication cup and handed it to the resident. The Midodrine blister card label had parameters to hold for systolic >140. The staff member was asked to stop, take cup back from resident, and review the physician order. Staff Q read the order aloud and stated she should not give the Midodrine but was going to contact the physician and verify the order as she felt it was wrong due to the medication was for low blood pressure. As the pharmacy delivery was standing at the nursing station during the observation with Staff Q, she stated she was going to check and see if Resident #98's Humalog was included in the delivery (which it was not). The staff member returned to the unit's medication refrigerator and removed an Insulin Lispro Kwikpen from the Emergency Drug Kit (EDK), labeling it with the resident's name and the date it was opened. The staff member returned to the resident's room, placed needle on pen, dialing the dosage selector to 16 units, saying one unit was used to prime the pen because it was new. Staff Q stood in front of the resident's trash can, pointed the needle end of the pen downwards and pushed the dosage selector, dialed the pen to 15 units and injected the resident in the right lower abdominal quadrant. The staff member called physician who confirmed the Midodrine order was correct, and it was to be held for a blood pressure greater than 140. An interview was conducted with Staff Q on [DATE] at 5:08 p.m. The staff member stated she was not going to administer the Midodrine because she was thinking about it. Then after discussing the observation, the staff member admitted that she was going to administer the Midodrine prior to being asked to stop. The staff member reported she had been educated to prime the insulin pens with one unit to get rid of the air bubble. She confirmed by holding the pen with the needle downwards the air bubble would have been toward the top of insulin cartridge and the air bubble would not have been removed. Review of Resident #98's April Medication Administration Record (MAR) revealed an order for Midodrine 2.5 mg - Give 1 tablet by mouth three times a day for dizziness/low blood pressure (BP), hold for systolic BP greater than (>) 140. Review of policy/procedure - Insulin Pens, implemented 9/2023 revealed it was the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self administration of insulin therapy upon discharge. The compliance guidelines described Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The procedure revealed staff to prime the insulin pen by - Dial 2 units by turning the dose selector clockwise. - With the needle pointing up, push the plunger, and watch to see at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. 3. On [DATE] at 5:37 p.m. an observation of medication administration with Staff R, Licensed Practical Nurse (LPN) was conducted with Resident #93. The staff member dispensed the following: - Magnesium Oxide 400 milligram (mg) over the counter (OTC) tablet Staff R confirmed the resident was to receive a tablet of Citalopram but it hadn't arrived so she had documented a progress note. The staff member confirmed one tablet had been dispensed. Review of Resident #93's April Medication Administration Record (MAR) revealed the resident was to receive Celexa (Citalopram Hydrobromide) 10 milligram (mg) tablet - give 1 tablet by mouth in the evening for depression (start date [DATE]). The record showed Staff R had documented 9 (per legend = other/see progress notes). 4. On [DATE] at 9:11 a.m. an observation of medication administration with Staff E, Licensed Practical Nurse (LPN) was conducted with Resident #53. The staff member dispensed the following medications: - Baclofen 10 milligram (mg) tablet - Gabapentin 600 mg tablet - Venlafaxine Extended Release (ER) 75 mg - 3 capsules - Cetirizine 10 mg over the counter (OTC) tablet - Sucralfate 1 gram(gm)/10 milliliter (mL) oral suspension - 10 mL's - Ferrous sulfate 325 mg OTC tablet - Spiriva Respimat 2.5 mg actuation inhalation The staff member searched the bottom drawer of medication cart for additional medications before writing Lamotrigine, Lisinopril, potassium, Prednisone, Spirolactone, Aldactone, and Jardiance on report sheet. Staff E asked resident about taking Miralax or Lactulose, which the resident refused both and the staff member stated the resident had also refused the inhaler Anoro. The resident complained of pain and the staff member stated the resident's hydrocodone 10-325 mg tablets were not available. Staff E confirmed dispensing 8 oral medications, one liquid, and one inhaler. The resident asked the staff member for Zofran, which after looking in locked narcotic box in drawer of medication cart, Staff E reported it was not available and reordered it. Staff E reported to Staff D, Registered Nurse/Unit Manager (RN/UM) the resident did not have all these showing her the medications written on the report. Staff D stated the resident had just returned from the hospital, providing a blister card of hydrocodone/acetaminophen 10-325 mg tablets, reporting the hospital had changed it but physician had okayed for the resident to receive prior ordered narcotic. Review of Resident #53's MAR revealed Staff E had documented 9 - other/see progress notes on [DATE] during the time of the observation for the following medications: - Aldactone (Spironolactone) 25mg - one time a day - Azithromycin 250 mg - one time a day for infection for 3 days - Empagliflozin 10 mg - one time a day for Type 1 Diabetes Mellitus - Lamotrigine 200 mg tablet - one time a day - Lisinopril 10 mg - one time a day - Potassium Chloride ER 20 meq - Prednisone 20 mg - give 2 tablets for pain for 2 days - Spironolactone 50 mg The MAR showed Staff E had administered one 100 mg capsule of Colace, which was not observed or accounted for during the confirmation of the number of oral medications. Review of a list of medications available in the electronic dispenser, as of [DATE] at 9:49 a.m., the following medications were available: - Azithromycin 250 mg - 13 tablets were on hand - Lisinopril 5 mg - 12 tablets were on hand - Potassium Chloride ER 10 meq - 14 tablets were on hand - Prednisone 5mg - 20 tablets were on hand Review of Resident #53's progress notes showed the resident had been transferred to hospital on [DATE] at 8:00 a.m. during shift change. The progress notes revealed on [DATE] the resident continued to be hospitalized . The notes did not reveal staff had documented when the resident had returned from the hospital or had assessed the resident upon return. The MAR revealed empty spaces and hospitalization codes from [DATE] until the scheduled dose of Insulin Aspart at 4:00 p.m. on [DATE] when the resident had received 6 units for a blood sugar of 202. During an interview on [DATE] at 10:02 a.m. Staff E stated she did not know how long Resident #53 had been in hospital, but she was coming in when the staff member was leaving ([DATE] at approximately 4:30 p.m.). The staff member stated the policy for missing (unavailable) medications were to call the pharmacy and the physician. She stated some of the medications said they were on order. Review of the pharmacy Delivery & Cut-off Times showed Monday - Friday new order cut off times were 11:00 a.m. with a departure time of 2:00 p.m. and 8:00 p.m. with a departure time of 2:00 a.m., for new admissions the cutoff time was 10:00 p.m. with a departure time of 2:00 a.m. The information revealed if a refill was needed immediately, please contact pharmacy and if something was faxed after cutoff and needed to be received staff with to call the pharmacy immediately. During an interview on [DATE] at 10:25 a.m. the Director of Nursing (DON) stated the procedure for unavailable medications was to either get an order to hold the medication, to call pharmacy to see how quickly it could arrive, or an order to administer it when it arrived, regarding over-the-counter medications, the facility can get them from local drug store. The DON reported staff should retrieve medications from central supply or the electronic dispenser if the medication was not available on the cart. She reported an order can be changed per the physician discretion, if the doctor felt it more beneficial to the resident the order can be changed. In regards to Resident #40, the DON stated the medical director was here, assessed the resident, and felt changing the medication to Calcium with Vitamin D was appropriate, however Calcium 500 mg tablets should have been available. She stated typically medications should be re-ordered within a week, for a re-admission (Resident #53) the hospital will give orders, staff reconcile them, and if the medications were held in the medication room, staff were to return them to the cart, if they had been sent back they would arrive on the next delivery. The DON stated medications for Resident #53 probably missed the cutoff time but would have arrived on this morning's run. Reviewed list of medications available in electronic dispenser with the DON, who was surprised Citalopram (Resident #93) was not available but felt it was strange it wasn't available one day, administered for 4 days, then not available on the 5th day. An interview was conducted with the DON on [DATE] at 3:57 p.m. The DON reported physicians would need to be notified when the medication was not available. Review of the policy - Medication Administration, reviewed/revised [DATE], revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. - 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. - 12. Identify expiration date. If expired, notify nurse manager. - 14. Administer medication as ordered in accordance with manufacturer specifications. - 15. If any medication is not available, or the possibility of late administration, the nurse will contact the attending physician. - 18. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. Review of the policy - Medication Reconciliation, reviewed/revised 1/2025, revealed this facility reconciles medication frequently throughout a resident state to ensure that the resident is free of any significant medication errors, and that the facilities medication error rate is less than 5%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective resident call system in four resident rooms (#204, #207, #403, and #609) of sixty four resident rooms in the facility Findings included: On [DATE] at 12:40 p.m. and [DATE] at 9:50 a.m., the following observations were made. a. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. b. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. c. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. d. The bathroom in resident room [ROOM NUMBER] was observed with no call light pull string. During an interview with the Nursing Home Administrator (NHA) on [DATE] at 2:53 p.m., the NHA stated he was notified of the broken call light pull strings in room [ROOM NUMBER], #207, #403, and #609. On [DATE] at 11:08 a.m., an interview was conducted with the Director of Maintenance (DOM). The DOM said he walks the facility daily and if he sees an issue he resolves it immediately or enters it into the electronic maintenance work order system. The staff also enters issues into the electronic maintenance work order system and he reviews the system for additions on a daily basis, if not at least weekly. The DOM said, I do not do a comprehensive survey and submit it to the Administrator. The DOM stated he tries to get issues fixed immediately and if he can't get it accomplished he has his assistant, who fixes it and keeps a log with emails. The DOM stated he does not have a written policy regarding daily, weekly, monthly, or annual maintenance and it's directed through the electronic maintenance work order system. Review of an undated facility document titled electronic maintenance work order system weekly tasks schedule showed to conduct a test of the nurse call system. A review of the electronic maintenance work order system report revealed Conduct a test of the nurse call system was listed under the section titled Tasks due this week. Review of a facility document titled Work Orders, dated [DATE] to [DATE] showed there were no work orders placed for call light parts to address call light concerns in rooms #204, #207, #403, or #609. Review of a facility policy titled Call Lights: Accessibility and Timely Response dated 9/2023 showed under Policy, the purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. The policy also revealed the following under Policy Explanation and Compliance Guidelines: . 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 7. The call system must be accessible to the residents at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied.

Based on interview, observation, and record review, the facility failed to maintain an effective pest control management system in nine rooms (100, 103, 108, 106, 207, 210, 303, 410, and 604) out of 52 rooms toured, and for one resident (#78) of one resident sampled. Findings included: On 4/9/2025 at 12:45 p.m. and on 04/10/2025 at 10:10 a.m., observations were made of live crawling bugs and what appeared to be insect feces in resident rooms and common areas. The rooms included rooms 100, 103, 108, 106, 207, 210, 303, 410, and 604, and common areas of the 400 Wing. On 4/7/2025 at 11:00 a.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She stated she had seen pests throughout the entire facility. On 4/10/2025 at 11:08 a.m., an interview was conducted with the Director of Maintenance (DOM). The DOM said, he walked the facility daily and if he saw an issue he resolved it immediately or entered it into the electronic maintenance work order system. The staff also entered issues into an electronic maintenance work order system, and he reviewed the system for additions on a daily basis if not at least weekly. The DOM said, I do not do a comprehensive survey and submit it to the Nursing Home Administrator (NHA). The DOM stated he tried to get issues fixed immediately and if he could not get it accomplished, he had his assistant who fixes it and keeps a log with emails. The DOM stated that he does not have a written policy regarding daily, weekly, monthly or annual maintenance, and it's directed through the electronic maintenance work order system. The DOM stated that the pest control schedule is for two times a month and if he sees a repetitive cycle, he will defer to the contractor. The DOM also stated that he has a background in Pest Control. On 4/7/2025 at 10:12 a.m. an interview was conducted with Resident #78. The resident stated that she has had multiple sightings of roaches and ants throughout her room and pointed out what appeared to be pest droppings under her nightstand. Review of a facility document titled the Pest Control Service Agreement dated, 2/12/2024 showed the Service Agreement states, during the term of this Agreement, (names pest control company), will provide the pest management services, described in a Service Specifications attached hereto and incorporated herein as Exhibit A-Client Proposal & Specifications (the Service Specifications). Covered pests: Mice, Rats, Ants and Roaches. Common areas, kitchen and exterior perimeters are included in the program. Initial service includes installation of equipment, logbook, map creation, inspection and spot treatments as needed. Schedule of one time and biweekly maintenance noted in agreement. Review of a facility document titled, pest log, for wings 100, 200 and 300 showed roaches were noted on: 12/3/2024, 12/30/2024, 12/31/2024, 1/3/2025, 1/11/2025, 2/22/2025, 3/20/025, 3/20/2025, 3/11/2025, 3/11/2025, and 4/2/2025. Ants were noted on: 2/8/2025, 2/8/2025, 2/8/2025, 3/14/2025. Flies were noted on 2/4/2025 and spiders were noted on 4/2/2025. Review of a facility document titled pest log for wings 400, 500 and 600 showed roaches were noted on 9/24/2024, 10/27/2024, 12/23/2024, 12/30/2024, 1/14/2025, 2/5/2025, 2/24/2025, 4/2/2025, and 4/9/2025. Ants were noted on: 11/23/2024, 12/13/2024. Fleas were noted on: 2/5/2024. Pests were identified by a resident on: 3/7/2025. Review of a facility document titled, Pest Control Program Policy, dated 9/2023, reviewed by the administration stated it is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition of Effective pest control program is defined as measure to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). Policy explanation and compliance guidelines: 1. Facility will maintain written agreement with a qualified outside pest service. 2. Facility will ensure appropriate chemicals are used. 3. Facility will maintain a report system of issues that may arise 4. Facility will utilize a variety of methods in controlling pests. 5. Facility will ensure that the outside pest service also treats the exterior perimeter. Photographic Evidence Obtained.

Based on record review and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) staffing data for the first quarter in the Fiscal Year 2025. Findings Included: Review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing data report Certification and Survey Provider Enhanced Reports (CASPER Report 1705D) revealed there was no facility staffing data submitted for the period of October 1 to December 31 (FY Quarter 1 2025). During an interview on 04/10/2025 at 10:05 a.m., the Nursing Home Administrator (NHA) stated he had nothing to do with PBJ and was not aware they had triggered for not reporting PBJ data for Quarter 1. He stated they used a third party company who submitted their PBJ staffing hours. He stated he could pull the [NAME] report to view the hours but rarely looks at it. The facility did not have a policy or procedure on the expectaions of reporting PBJ staffing hours.

Based on interviews and records reviewed, the facility failed to developed and implemented action plans to correct identified quality deficiencies; measure the success of actions implemented and track performance to ensure improvements are realized and sustained, track medical errors and adverse events, analyze their causes, and implement preventive actions and mechanisms, conduct at least one Performance Improvement Plan (PIP) annually that focuses on high-risk or problem prone areas, identified by the facility, through data collection and analysis, and did not ensure the QAA Committee regularly reviews and analyzes data collected under the QAPI program and resulting from drug regimen reviews, and act on the data to make improvements. The Findings Included; Record review of the facility's policies and procedures titled Quality Assurance and Performance Improvement dated 9/2023 revealed: Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. 2. The QAA Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services; ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, owner, a board member or other individual in a leadership role; and iv. The Infection Preventionist. b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. c. Develop and implement appropriate plans of action to correct identified quality deficiencies. d. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. e. The QAA committee must sign to verify approval of all plans of correction written. 3. The QAPI plan will address the following elements: a. Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions. b. Policies and procedures for feedback, data collection systems, and monitoring. c. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: i. Tracking and measuring performance. ii. Establishing goals and thresholds for performance improvements. iii. Identifying and prioritizing quality deficiencies. iv. Systematically analyzing underlying causes of systemic quality deficiencies. v. Developing and implementing corrective action or performance improvement activities. vi. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. d. A prioritization of program activities that focus on resident safety, health outcomes, autonomy, choice and quality of care, as well as, high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves. The facility must also consider the incidence, prevalence, and severity of problems or potential problems identified. e. A commitment to quality assessment and performance improvement by the governing body and/or executive leaders. f. Process to ensure care and services delivered meet accepted standards of quality. 4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: a. The written QAPI plan. b. Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events. c. Data collection and analysis at regular intervals. d. Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. 5. The plan and supporting documentation will be presented to the State Survey Agency or Federal surveyor at each annual recertification survey and upon request. 6. The plan and supporting documentation will be presented to Centers for Medicare & Medicaid Services (CMS) upon request. Program Development Guidelines: 1. Program Design and Scope - a. The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. b. At a minimum, the QAPI program will: i. Address all systems of care and management practices. ii. Include clinical care, quality of life, and resident choice. iii. Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a Skilled Nursing Facility (SNF) or Nursing Facility (NF). iv. Reflect the complexities, unique care, and services the facility provides. 2. Governance and Leadership - a. The governing body and/or executive leadership is responsible and accountable for the QAPI program. b. Governing oversight responsibilities include, but are not limited to the following: i. Approving the QAPI plan annually, and as needed. ii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities. iii. Ensuring the program is sustained during transitions in leadership and staffing. iv. Ensuring the program is adequately resourced, including ensuring staff time, equipment, and technical training as needed. v. Ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. vi. Ensuring that corrective actions address gaps in systems, and are evaluated for effectiveness. vii. Setting clear expectations around safety, quality, rights, choice, and respect. c. The QAA Committee shall communicate its activities and the progress of its subcommittee activities to the governing body (if leadership role is greater than the administrator) at least quarterly, with a formal meeting no less than annually. d. The QAA Committee shall submit supporting documentation of ongoing QAPI activities to the Governing Body upon request. e. QAPI training that outlines and informs staff of the elements ofQAPI and goals of the facility will be mandatory for all staff. 3. Program Feedback, Data Systems, and Monitoring - a. The facility maintains procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. b. The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate. Data sources may include, but are not limited to: The facility assessment. ii. Paper and electronic medical records. iii. Grievance logs. vi. Medical record audits and drug regimen reviews. v. Skilled care claims. vi. Clinical logs such as for falls, pressure injuries, and weights. vii. Staffing trends. viii. Incident and accident reports. including reports of adverse events or abuse, neglect, or exploitation. ix. Minimum Data Set (MDS). x. Quality measures. xi. Survey outcomes. xii. Staff. resident and family satisfaction surveys. xiii. Suggestions. c. Data is collected from all departments and is used to develop and monitor performance indicators. i. Facility staff are responsible for following departmental procedures for data collection. ii. Department heads are responsible for ensuring data is collected appropriately and performance metrics are monitored in accordance with facility policy. iii. Sample data collection forms are maintained with the written QAPI plan. 4. Program Activities - a. All identified problems will be addressed and prioritized, whether by frequency of data collection/ monitoring or by the establishment of sub-committees. Considerations include, but are not limited to: i. High-risk, high-volume, or problem-prone areas. ii. Incidence, prevalence, and severity of problems in those areas. iii. Measures affecting resident health, safety, autonomy, choice, health equity, and quality of care. iv. Certain classes of medications, such as antipsychotics, which could identify trends. b. Medical errors and adverse events are routinely tracked. i. Facility staff monitor residents for medical errors and adverse events in accordance with established procedures for the type of adverse event. ii. An investigation will be conducted on each identified medical error or adverse event to analyze causes. iii. Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education. iv. Monitoring will be conducted to ensure desired outcomes are achieved and sustained. c. The facility conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. Additional projects may be conducted as needed, and may be clinical or non-clinical in nature. i. The number and frequency of improvement activities conducted shall reflect the scope and complexity of the facility's services as reflected in the facility assessment. ii.PIPS shall be designed to achieve and sustain performance improvement over time and to have an expected favorable outcome. iii. The QAA Committee shall select additional members to participate in various subcommittees based upon the PIP topic and participant expertise. iv. Each sub-committee shall be guided by a QAA Committee member who will facilitate coordination of the PIP and ensure each sub-committee is adequately resourced. v. Upon conclusion of the PIP, the sub-committee shall provide the QAA Committee with a report, which contains a summary and analysis of activities and recommendations for improvement. 5. Program Systematic Analysis and Systemic Action - a. The facility takes actions aimed at performance improvement as documented in QAA Committee meeting minutes and action plans. Performance/success of the actions will be monitored and documented in subsequent QAA Committee or sub-committee meetings. b. To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA Committee meetings in accordance with the QAPI plan, but no less than annually. During an interview on 04/10/25 at 03:24 PM the Nursing Home Administrator stated the facility had a QAPI/QAA program that met at least once a month; on the last Tuesday of every month. The participants included the Director of Nursing (DON), The Medical Director, and other Interdisciplinary Team members. Participants included all department heads including the Maintenance Director and the Housekeeping Director. The NHA stated he was not able to show signature pages or any other documentation related to the meetings as the QAPI/QAA book is missing, and does not know where the book is currently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to implement an effective infection control program related to 1.) initiating contact precautions for one resident (#154) of one resident suspected and treated for a highly contagious condition, 2.) failed to clean shared equipment appropriately and store it in a sanitary manner, and 3.) failed to promote good hand hygiene by limiting the length of fingernails of direct care staff. Findings included: 1. Review of Resident #154's admission Record revealed the resident was admitted on [DATE]. The record revealed diagnoses of diverticulosis of large intestine without perforation or abscess without bleeding. Review of Resident #154's Medication Administration Record on 4/7/25 at 3:30 p.m. revealed the following: - Saccharomyces boulardii - 2 capsules by mouth two times a day for gastrointestinal (GI) support for 14 days, started on 4/2/25. - Flagyl 500 milligram (mg) - Give 500 mg by mouth three times a day for possible C-diff (Clostridioides difficile) for 10 days, started on 3/31/25. On 4/7/25 at 3:56 p.m., the door and immediate area to Resident #154's room did not reveal signage indicating the resident was under transmission-based precautions. Personal Protective Equipment (PPE) was not observed outside of the resident's room. Review of the Resident Matrix, printed by the facility on 4/7/25, did not show any resident in the facility was on transmission-based precautions. Review of Resident #154's Order Summary Report dated 4/10/25 did not reveal physician orders for any type of precautions. The review revealed staff were to check stool for C-diff one time only for multiple loose stools until 3/31/25 23:59 [11:59 p.m.]), which was documented as completed on 3/31/25. Review of a provider note, dated 4/2/25 at 1:00 a.m. showed the resident was to receive Flagyl 500 mg three times a day for possible C-diff for 10 days from 3/31/25 to 4/10/25. The note revealed on 3/28/25, the resident reported some loose stools this morning and noted it was going on for 3-4 days. On 3/31/25, the provider noted the resident reported continuing loose stools and thought she had 2-3 loose stools the previous night. On 4/2/25, the resident reported having 5 episodes of diarrhea that day and 4 the previous day and the C-diff stool study was pending. Review of Resident #154's progress notes showed a stool sample was collected on 4/1/25. Review of Resident #154's laboratory results did not reveal any results or pending results for the resident's completed stool collection. During an interview on 4/10/25 at 9:38 a.m., the Director of Nursing (DON) stated until they get the culture back, they treat prophylactically and do not use precautions until it's determined by the culture, stating it's the facility policy. Review of Resident #154's Certified Nursing Assistant (CNA) Task documentation for bowel elimination revealed three available questions - bowel continence, size of bowel movement (BM), and consistency of BM. Staff documented the resident was incontinent of bowel when appropriate from 3/26/25 to 4/10/25 with one incident of continence on 4/10/25. Review of Resident #154's care plan showed the resident was on antibiotic therapy related to (r/t) infection C-diff, initiated on 3/28/25 and instructed staff to report pertinent lab results to the physician. During an interview on 4/10/25 at 10:09 a.m., Staff S, CNA stated Resident #154 was having semi-formed stools, not runny today, but in the past stools have been runny. Staff S, CNA reported the resident has not been on any type of precautions and asked about it when the resident was having loose stools but did not get any further information. The staff member stated staff are notified of precautions usually by signage, the PPE caddy hanging from the door, and the nurse. During an interview with the DON on 4/10/25 at 3:01 p.m. regarding infection control, the DON stated the determination of needed isolations was based on the strand of the organism and determined the strand usually by culturing. If a culture isn't obtained, sometimes the doctor will order an antibiotic prophylactically depending on symptoms, McGeer's criteria, and how the doctor orders them. The DON stated staff are to handwash when hands were visually soiled and every other time between alcohol-based hand rub, if C-diff staff have to wash hands. She stated if Resident #154 was not on isolation, the negative outcome would be staff could contract and spread it. She reported some of the resident's lab results came back but the stool results were pending. In morning meeting lab results are reviewed. Floor nurses, the DON, and Unit Managers can obtain lab results. Review of the policy titled Transmission-Based (Isolation) Precautions, implemented 9/2023, revealed under Policy, it is the policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. The policy defined contact precautions as: Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. The policy revealed the following under Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the Centers of Disease Control and Prevention (CDC), for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. 4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care. 6. High touch objects and environmental surfaces (e.g., bed rails, over bed table, bedside commode, lavatory surfaces in resident bathrooms) should be cleaned and disinfected with an EPA (Environmental Protection Agency) registered disinfectant for healthcare use at least daily invisibly soiled. 7. Visitors coming in to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident. 9. Initiation of transmission-based precautions (isolation precautions) - a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission-based precautions/isolation empirically while awaiting confirmation. b. An order for transmission-based precautions/ isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. c. The order for transmission-based precautions/ isolation will specify the type of precaution and reason for the transmission-based precaution. The duration will depend upon the infectious agent or organism involved. 10. Contact precautions - a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the residence environment. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the residence environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., . C difficile, noroviruses and other intestinal tract pathogens, .). e. Residents experiencing with wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions even before a specific organism has been identified. 12. Discontinuation of transmission-based precautions (Isolation Precautions)- a. Transmission-based precautions remain in effect for limited periods (i.e., while the risk of transmission of the infectious agent persists or the duration of the illness). b. Empirically initiated transmission-based precautions may be adjusted are discontinued when an additional clinical information becomes available (e.g., confirmatory laboratory results). 2. On 4/8/25 at 4:06 p.m., Staff Q, Licensed Practical Nurse (LPN) was observed during medication administration for Resident #98. The staff member removed the resident's individual glucometer from the medication cart. After obtaining a blood glucose level reading, the staff member opened a container of disinfectant wipes, which she brought into the room, and placed on the resident's over-bed table (obt), wiped the glucometer, and placed the meter directly on the resident's obt without a barrier. Staff Q, LPN placed a blood pressure cuff on the resident's right arm, obtained blood pressure of 143/78, wiped the cuff and monitor with a disinfectant wipe, and placed both on the resident's obt without a barrier. Staff Q, LPN removed the container of wipes and placed it in the bottom drawer of the cart. The staff member removed a clear bag containing a temporal thermometer and pulse oximeter, placing the thermometer against the resident's temple before placing it back into the bag and placing it in the bottom drawer. Immediately following the medication observation, Staff Q, LPN stated disinfection was done to get rid of stuff, she confirmed the cuff was contaminated and not cleaning the thermometer. Review of the policy titled Routine Cleaning and Disinfection, implemented 9/2023, revealed under Policy, it was the policy of the facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment, and to prevent the development and transmission of infections to the extent possible. 3. On 4/8/25 at 4:06 p.m. Staff Q, LPN was observed with square-cut fingernails painted a light purple color on 8 of 10 fingers extending one half to three quarters of an inch past the end of the fingertips. The staff member confirmed the fingernails were acrylic and the nails on bilateral pointer fingers had broken off. The staff member was observed having difficulty removing the green tags on the emergency drug kit and opening a container of disinfectant wipes. On 4/8/25 at 5:18 p.m., Staff R, LPN was observed during medication administration. The staff member had square-cut fingernails, painted pink with black stripes, on eight of the ten fingers extending approximately one quarter of an inch past the end of each finger. On 4/9/25 at 4:48 p.m., the Director of Nursing was observed with almond-shaped fingernails painted with white tips extending approximately one quarter of an inch past the fingertips. An interview was conducted with the DON on 4/10/25 at 10:20 a.m. The DON stated anyone providing care should have clean, short fingernails, including the DON. A request was made to the facility on 4/10/25 for the Dress Code policy. The policy was not provided. Review of the Centers of Disease Control and Prevention (CDC) guidance - Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, directed the guidance to Protect yourself and your patients from deadly germs by cleaning your hands. The recommendations for treating a patient with confirmed or suspected C. difficile infection showed C. diff is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are an inactive form of the germ and have a protective coating allowing them to live on surfaces for months. When entering the room of a patient with C. difficile, the priority should be to ensure glove use (in addition to a gown) and proper technique when removing gloves to minimize the risk of self-contamination. Current evidence demonstrates that C. difficile spores may not be fully removed from hands, regardless of the method used to clean hands. This further emphasizes the need for appropriate use of gloves for the care of patients with CDI. The CDC recommendations for maintaining fingernail and jewelry safety revealed the following: - Natural nails should not extend past the fingertip. - Do not wear artificial fingernails or extensions when having direct contact with high-risk patients like those at intensive-care units or operating rooms. - Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing.

Based on observations, record reviews, and interviews the facility failed to establish an effective antibiotic stewardship program related to the antibiotic use protocols and monitoring the use of antibiotics. Findings included: Review of February 2025's Infection Control Log, 2/1 to 2/28/25, showed the facility had a total of 7 infections effecting 7 residents for the month. The log revealed the facility had 3 Urinary Tract Infections (UTIs), one mouth, one eye, one acute kidney injury, and one leg cellulitis infections. Five of the infections listed did not include an onset date, two of the UTIs were cultured with no information related to culturing for three of the infections (yes or no), two of the three UTIs had organisms listed, five of the list did not show whether the infection required isolation or not or if they were Healthcare-Associated Infections (HAI). Six of the seven infections did not show a resolution date. The section of the log used to document the total number of infections (skin, eye, UTI with catheter, Urinary Tract, Upper Respiratory, Lower Respiratory, Gastrointestinal, other) was not completed and did not reveal a date the information was reported to the Infection Control/Performance Improvement Committee. Review of February 2025 Monthly Resident Infection Analysis showed one of the two facility units had 2 nosocomial (originated in hospital) and the other unit had four nosocomial infections for a total of six infections. The analysis did not show any infections were community-acquired or if there were any residents with repeat infections in the last 30 days. The number of infections by type listed one E.coli, one Cellulitis, and one other. The analysis did not show infections by site or if any sites required isolation precautions. The Infection Preventionist signed the form on 3/2/25 however there was no Director of Nursing signature. Review of March 2025 Infection Control Log, 3/1 to 3/31/25, revealed the facility had 10 UTIs, one skin rash, one case of shingles, one upper respiratory infection (URI), 2 cases of bronchitis, one case of pneumonia, a total of sixteen infections. The incomplete log did not include admit date s for thirteen of the residents listed, only four infections had onset dates listed. The log showed four of the ten UTIs had been cultured, and no x-rays had been completed to diagnosis the four respiratory infections. The URI infection was listed with the organism of Respiratory Syncytial virus (RSV), which showed the effected had been isolated but did not reveal if the infection was HAI or community acquired. The log showed information for four of the sixteen infections had required isolation or not, no information related to HAI, if any infection had been recultured or the date any of the sixteen infections had resolved. Nine of the sixteen infections had the name of the ordered antibiotic listed. The log did not break down any infections per site or the date the information had been reported to the Infection Control/Performance Improvement Committee. An interview was conducted on 4/10/25 at 10:20 a.m. with the Director of Nursing (DON) as the Infection Preventionist, (IP) was unavailable. The DON reported for a newly ordered antibiotic the facility would request a culture to support the antibiotic, contact the physician to ensure it was the correct antibiotic also, use the culture to ensure the antibiotic was appropriate, if appropriate to continue or change. The facility used McGeer criteria which is documented in a book not in the electronic record. The facility does an infection line listing and maps infections monthly. The IP presents info to the Quality Assurance committee, there were no trends for March. A continued interview was conducted on 4/10/25 at 3:01 p.m. with the DON. The DON stated the IP had the position for 6 months and both her and the IP had completed Centers for Disease Control and Prevention (CDC) training. The DON stated isolation was determined by the strand of organism, the facility does not get a culture for all of infections, sometimes the doctor will order an antibiotic prophylactically. The facility determined appropriateness by symptoms, McGeer's criteria and how the doctor orders them. The DON confirmed ordering doesn't follow the antibiotic stewardship. The DON stated the Medical Director doesn't usually order antibiotics unnecessarily and neither of the two in-house physicians order antibiotics prophylactically. The DON was asked for the facility's antibiotic utilization rate and she reviewed the Monthly Resident Infection log and stated both units had a total of 9 infections, after pausing a few minutes the DON reported each (two) units had 9 infections. The DON reviewed March Infection Control Log that showed multiple UTIs had not been cultured, she stated at that point without cultures the doctors were treating prophylactically. When a resident is admitted or re-admitted the culture should be requested from the hospital to determine if the antibiotic is appropriate. She stated the incident of shingles was to be reported but did not know if it was and it would be reported to the Centers for Disease Control (CDC). The DON reported when a resident comes from the hospital, the facility would request culture results, would reconcile it with the physician and the doctor confirms if the antibiotic is appropriate. The charts are reviewed during morning meetings which included the IP. The IP reaches out to the physician to ask if the antibiotic is appropriate. The DON confirmed the IP had not been doing McGeer criteria during her tenure, the last McGeer criteria completed was in September 2024. The DON stated there was no evidence that the IP followed up on antibiotics, as there was no documentation with the physicians or QA to review. Review of the policy - Antibiotic Stewardship Program, implemented 9/1/23, revealed the following: It is the policy of this facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 1. The infection preventionist, with oversight from the director of nursing, serves as the leader of the antibiotic stewardship program and receives support from the administrator and other governing officials of the facility. a. Infection Preventionist - coordinates all antibiotic stewardship activities comma maintains documentation comma and serves as a resource for all clinical staff. b. Director of Nursing - serves as backup coordinator for antibiotic stewardship activities, provides support and oversight, and ensures accurate advice adequate resources for carrying out the program. c. Administrator - provides adequate resources for carrying out the program and ensures review of the antibiotic use and resistance data at QAPI meetings. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Laboratory testing shall be in accordance with current standards of practice. ii. The facility uses the (CDC NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. iii. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. b. Monitoring antibiotic use: i. Monitor response to antibiotics common in laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic or any antibiotic regimen review as requested by the QAA committee. v. Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure). vi. Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy). 5. Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotics timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. 11. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: a. Action plans and/ or work plans associated with the program. b. Assessment forms. c. Antibiotic use protocols/ algorithms. d. Data collection forms for antibiotic use, process, and outcome measures. e. Antibiotic stewardship meeting minutes. f. Feedback reports. g. Records related to education of physician ,staff, residents, and families. h. Annual report. 12. Data obtained from antibiotic stewardship monitoring activities as discussed in the facilities QAPI meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure one resident (#28) was assessed and determined to be clinically appropriate and safe to self-administer medications of two residents sampled for self-administration of medications. Findings included: An observation on 07/10/23 at 10:44 a.m., showed four pills in a medication cup placed on Resident #28's bedside table. (Photographic Evidence Obtained) During an interview on 07/10/23 at 10:46 a.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #28 did not have the ability to self-administer medications. Staff A, LPN identified the four pills as Norvasc, Lisinopril, Zoloft, and Namenda. Staff A, LPN stated the facility protocol for medication administration was for the nurse to watch a resident take their medications before walking away. Staff A, LPN stated she did not normally leave pills at bedside for residents to self-administer medication, but she had gotten sidetracked by another resident this morning and left Resident #28's pills at bedside and Resident #28 must have fallen back asleep again before taking the morning medications. During an interview on 07/10/23 at 10:47 a.m., Resident #28 stated he would have taken his medication, but he fell back asleep before he could take them. A review of Resident #28's admission Record showed Resident #28 had diagnoses of Type 2 diabetes mellitus, essential (primary) hypertension and dementia in other diseases classified elsewhere, mild, without behavioral disturbance. Review of the July 2023 physician orders showed the physician orders as followed: - Amlodipine Besylate Tablet 10 milligrams (MG) [brand name Norvasc] give one tablet by mouth one time a day for hypertension. - Lisinopril Tablet 30 MG give one tablet by mouth one time a day for hypertension. - Memantine Tablet 10 MG [brand name Namenda] give one tablet by mouth one time a day for dementia. - Zoloft Oral Tablet 50 MG give one tablet by mouth one time a day for depression. The July 2023 physician orders did not include a physician order for self-administering of medications. Further record review showed Resident #28 did not have a care plan for self-administering medications and was never assessed for self-administering medications. The Minimum Data Set (MDS), dated [DATE], showed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 09 that showed cognitive function of mildly impaired. A Physicians Evaluations of Resident's Capacity To Make form, dated 06/12/23, showed Resident #28 was Incapacitated to make health care decisions. A review of the facility's policy titled, Resident Self-Administration of Medication, dated 06/01/23, showed, A resident may only self-administer medications after the facility's interdisciplinary team had determined which medication may be self-administered safely. Each resident is evaluated to self-administer medications during the routine assessment by the facility's interdisciplinary team. The care plan must reflect resident self-administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and resident record review, the facility failed to ensure reasonable accommodations were made for one resident (#74) related to not providing an appropriate length mattress to ensure the resident's feet did not touch the footboard of six residents sampled. Findings included: During an observation and interview conducted on 7/10/23 at 9:55 a.m. Resident #74 said his feet frequently touch the footboard. Resident #74 stated staff need to reposition me although even with the knees raised, I slide right back down. I am 6'7; they don't have a bed for my height. When I requested a longer mattress, I was given this bed and was told this is the longest they have, it will have to do. On 7/10/23 at 12:20 p.m. Resident #74 was observed in his bed sitting up and eating his lunch. His feet were touching the footboard and his heels were not supported by the mattress as there was a gap of approximately 7 ½ inches. (Photographic Evidence Obtained) During an interview with Resident #74 on 7/10/23 at 12:25 p.m., the resident verbalized he has gotten used to his feet pressing on the footboard and he gets tired of having to bother the staff to move him up constantly. I am not able to move myself up in the bed. Resident #74 stated he has told several staff members, nurses, maintenance staff and CNAs (certified nursing assistants). They all continue to say there is nothing more that can be done. During an interview on 7/11/23 at 9:54 a.m., Staff K, Certified Nursing Assistant (CNA) stated Resident #74 does have to be moved up in the bed frequently, so his feet do not rest on the footboard. Staff K, CNA confirmed there was a gap, and his feet were not supported by the mattress even after they pull him up in the bed. During an interview on 7/12/23 at 12:06 p.m., Staff M, CNA stated she had noticed the gap in the length of Resident #74's bed. She continued to state, she found a cushion intended to prevent such a gap. Resident #74 told me the cushion won't fit, it just falls on the floor. Of course I tried to place the cushion between the mattress and the footboard, he was right the cushion just fell to the floor. During an interview and observation on 7/12/23 at 12:18 p.m., Staff P, Licensed Practical Nurse (LPN), validated Resident #74's feet were on the foot board of the bed and heels were not supported by the mattress. Staff P, LPN stated she would speak with Director of Nursing (DON) about different options for the situation, as this is not optimal. During an interview and observation on 7/12/23 at 12:20 p.m. the DON validated Resident #74's feet were hitting the foot board and a gap between the mattress and footboard existed. The DON stated she would have to get with maintenance and the Administrator regarding what could be done. Review of the admission Record for Resident #74 revealed he was admitted to the facility on [DATE] and his diagnoses included metabolic encephalopathy, chronic pulmonary edema, chronic obstructive pulmonary disease (COPD), obesity, weakness generalized, chronic respiratory failure with hypoxia, abnormalities of gait and mobility, lack of coordination, chronic diastolic (congestive) heart failure (CHF), functional quadriplegia, and other idiopathic peripheral autonomic neuropathy. A review of the admission Minimum Data Set (MDS) assessment, dated 6/19/23, revealed in Section C Cognitive Patterns a score of 13/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Section G Functional Status indicated Resident #74 needed extensive assist of two person for bed mobility. A review of Resident #74's care plan, initiated on 6/14/23, revealed a Focus area of: Activities of Daily Living (ADL) Care Plan Resident #74 has self-care performance deficit related to his COPD, Brain Damage, CHF and mobility. Interventions added to this care plan on 6/29/23 were: Bed Mobility: The resident is totally dependent times two staff for repositioning and turning in bed. Review of the facility's policy for Accommodation of Needs, dated 10/2022, showed: Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered.

Based on record review and interview the facility failed to transmit two comprehensive assessments for one resident (#96) out of two residents sampled for the task of Resident Assessments. Findings included: A review of Resident #96's Minimum Data Set (MDS) information identified a Modification of Entry assessment, dated 2/10/23, was Export Ready, the status of the original Entry assessment was modified and the Modification of admission assessment, dated 2/16/23, was Export Ready. The original admission assessment status was modified. The Discharge Return Not Anticipated assessment, dated 2/28/23 was accepted. On 7/13/23 at 11:26 a.m., during an interview Staff C, MDS Licensed Practical Nurse (LPN) stated they had some issues and couldn't transmit (at that time). The staff member stated both modifications should have been sent and Resident #96's assessments were missed. The policy titled, MDS 3.0 Completion and Transmission, dated 4/5/23, showed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy guidelines showed an entry assessment was to be completed and submitted with every entry into the facility no later than the entry date + 7 calendar days. The admission assessment must be completed within 14 days of admission, with the day of admission as day 1. The modification information must be corrected with 14 days after identifying the errors. According to the Transmission Requirements: All assessments shall be transmitted to the designated CMS system (QIES ASAP) with 14 days of completion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two residents (Resident #74 and #77) of fourteen sampled residents. Findings included: 1. Review of the admission Record showed Resident #74 was admitted on [DATE] with diagnoses of metabolic encephalopathy, obstructive sleep apnea, chronic pulmonary edema, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure and history of COVID-19 (coronavirus disease of 2019). An observation on 7/10/23 at 10:00 a.m. revealed Resident #74 with a non-invasive mechanical ventilator (BiPAP [bilevel positive airway pressure]/CPAP[continuous positive airway pressure]) at his bedside. During an interview on 7/11/22 at 3:00 p.m., Resident #74 stated he has had the BiPAP since his hospital stay. Resident #74 stated he had significant breathing problems that included having a tracheostomy (surgical opening created in the neck into the trachea [windpipe] to allow air to fill the lungs. After creating the opening a tube is placed in the hole which creates the airway and being on a continuous ventilator). He stated he has improved and was able to have the tracheotomy removed before discharging from the hospital, now he only must wear the BiPAP at night. Review of Resident #74's physician orders, dated 6/14/23, revealed an order for BiPAP to be applied every evening. Review of Resident #74's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/19/23 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which revealed the resident was cognitively intact. Further review of the MDS revealed no documentation that Resident #74 had a BiPAP, during admission, or prior to admission. During an interview on 7/13/23 at 11:10 a.m., with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated she was responsible for completing the section of the MDS that would indicate a Non-Invasive Mechanical Ventilator (BiPAP/CPAP). Staff C, LPN verified the resident had an order for a BiPAP here and had one prior to admission and verified the assessments for non-invasive mechanical ventilator (BiPAP/CPAP) were inaccurately coded. During an interview on 7/13/23 at 9:30 a.m. the Director of Nursing (DON) stated the accuracy of the MDS was important. 2. An observation on 07/10/23 at 10:32 a.m. showed Resident #77 was being administered oxygen via a nasal cannula at 2 liters per minute (lpm). During an interview on 07/10/23 at 10:32 a.m., Resident #77 stated she was to be administered oxygen continuously. A review of Resident #77's admission Record showed a diagnosis of sleep apnea, unspecified. A review of the July 2023 Medication Administration Record showed two physician orders for oxygen. The first physician order, dated 05/26/23, documented, O2 [oxygen] at 2 lpm via nasal cannula continuous for sleep apnea. The second physician order, dated 06/13/23, documented, O2 [oxygen] at 3 lpm via nasal cannula every shift. The care plan, initiated on 4/10/23, showed Resident #77 was At risk for impaired respiratory status and showed interventions to include, Administer oxygen per order. A review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/07/23, showed Resident #77 did not use oxygen. During an interview on 07/13/23 at 11:05 a.m., Staff C, LPN MDS stated Resident #77's Quarterly MDS, dated [DATE], the oxygen use was marked No, which was wrong. Staff D, Registered Nurse (RN) MDS also stated, at this time, that oxygen use on Resident #77's Quarterly MDS was marked in error and should have been marked yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review and failed to correct the document for three residents (#10, #105, and #36) out of forty-seven residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: 1. A review of Resident #10's admission Record indicated an original admission date of 4/2/18 and a recent re-admission date of 3/23/23. The census list for the resident identified additional admission dates of 9/28/18 and 12/14/19. A Preadmission Screening and Resident Review, Level I Screen for Resident #10, dated 4/2/18, indicated N/A in sections A. Mental Illness (MI) or suspected MI and B. Intellectual Disability (ID) or suspected ID. Section II: Other indications for PASRR (PASARR) Screen Decision-Making identified the resident had no indications. Section IV indicated the resident may be admitted to a Nursing Facility (NF) as no diagnosis or suspicion of serious MI (SMI) or ID was identified and a Level II evaluation was not required. The Diagnosis Report for Resident #10 identified the following diagnoses: - unspecified major depressive disorder, single episode - present on admission, onset date 4/2/18 and resolved on 10/1/19. - unspecified mood (affective) disorder - present on admission, onset date 11/20/18. - unspecified anxiety disorder - present on admission, onset date 11/20/18. - schizoaffective disorder bipolar type - present on admission, onset date 9/15/19. - adjustment disorder with anxiety - during stay, onset date 10/1/19. - unspecified recurrent major depressive disorder - during stay, onset date 10/1/19. - other bipolar disorder - during stay, onset date 10/1/19. The comprehensive assessment for Resident #10, dated 6/26/23, identified the resident had active psychiatric/mood disorders of anxiety disorder, depression (other than bipolar), bipolar disorder, schizophrenia, and unspecified mood (affective) disorder. A psychiatry note, dated 6/14/23, included the chief complaints as depression, anxiety, and insomnia. The reason for the encounter was reported to me that patient is unstable requiring psychiatric assessment. The assessment and plan read patient (pt) is unstable but requires no med (medication) changes and the provider felt symptoms were occurring due to exacerbation of underlying depressed disorder. 2. Resident #105's admission Record identified an admission date of 6/1/23. The admission Record for the resident included the diagnosis of schizophreniform disorder due to history and with an onset date of 6/28/23. The Diagnosis Report identified the resident had a history of schizophreniform disorder with an onset date of 6/28/23. The PASARR, dated 4/21/23, and completed at an acute care facility identified that Resident #105 had a documented history of depressive disorder. A review of Resident #105's comprehensive assessment, dated 6/7/23, did not identify that the resident had any psychiatric/mood disorders. A psychiatry evaluation note, dated 6/7/23, identified Resident #105 had chief complaints of depression and schizophrenia. Per the evaluation, the resident was receiving the antidepressant, Escitalopram daily for depression and the antipsychotic medication, Olanzapine twice daily for psychotic disorder. The assessment and plan indicated a gradual dose reduction was considered but based on history, the patient would be unable to tolerate the reduction and would likely become unstable, therefore the provider felt the resident was on the minimal effective doses of the psychotropic medications. 3. A review of Resident #36's admission Record indicated the resident was admitted on [DATE] and 4/28/23. The admission Record included the following diagnoses: - schizoaffective disorder - bipolar type, was present on admission with an onset date of 10/11/21. - schizoaffective disorder - depressive type, history of with an onset date of 5/31/23. The modified 5-day comprehensive assessment, dated 5/4/23, identified Resident #36 had an active diagnosis of schizophrenia. Resident #36's PASARR which was completed at an acute care facility and dated 10/11/21, did not have a documented history of any mental illness or intellectual disability. The resident's PASARR indicated a Level II PASARR evaluation was not required. The amended Cognitive Assessment note, dated 5/5/23, identified the chief complaint of Resident #36 was depression, anxiety, schizoaffective disorder, and pseudobulbar affect. The note indicated the facility was requiring a detailed cognitive assessment as the resident was exhibiting behaviors related to memory problems. The note included the diagnoses of moderate recurrent major depressive disorder, generalized anxiety disorder, depressive type schizoaffective disorder, and pseudobulbar affect and appeared to have major cognitive disorder of mixed etiology. The psychiatry note, dated 6/14/23, indicated Resident #36's chief complaint was depression, anxiety, schizoaffective disorder, and pseudobulbar affect. The plan of action indicated the provider decided to continue the antipsychotic medications of Aripiprazole (Abilify), Geodon, and Fluphenazine for schizoaffective disorder, the anticonvulsant Depakote for mood disorder, and the antidepressant Venlafaxine. On 7/13/23 at 7:41 a.m., the Social Service Director (SSD) stated that either the SSD and/or Director of Nursing (DON) review the PASARRs. The SSD reported they normally do not do the PASARR due to being a Licensed Practical Nurse and not a licensed Social Worker, so the DON and/or Assistant DON deal with them. The DON stated, on 7/13/23 at 9:54 a.m., there was not a Performance Improvement Plan (PIP) (for PASARRs) and have discussed doing an audit but haven't started. The DON reported when the PASARR waiver ended the facility identified they were old or diagnoses had been added but the facility did not have a process. The DON reviewed the PASARR for Resident #10 and concluded the resident did have psychiatric diagnoses and that N/A was not appropriate. The DON stated Resident #105's PASARR was incorrect, it listed depression but should have listed schizoaffective (disorder), and that Resident #36 did have diagnoses that should have been included on the PASARR. The policy titled, Resident Assessment - Coordination with PASARR Program, dated 9/7/22, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The guidelines indicated that all applicants to the facility would be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A Negative Level I Screen permits admission and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later or a Positive Level I indicates that a Level II evaluation is necessary prior to admission. A PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. The policy identified that any resident who exhibited a newly evident or possible serious mental disorder, intellectual disability, or a related condition would be promptly referred to the state mental health or intellectual disability authority for a level II resident review. The examples given included, a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis), and a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure two residents (#93 and #461) of three residents sampled for skin impairments received wound care in accordance with professional standards related to changing dressings as ordered and documented and failed to assess and document skin conditions. Findings included: 1. An observation was conducted on 7/10/23 at 12:27 p.m. of Resident #93 lying in bed, the resident stated the bed sheets were piled. The observation identified an area of rolled gauze, dated 6/27/23, on the right upper arm and a white bordered dressing, dated 7/1/23, on the left knee. On 7/10/23 at 12:39 p.m., Staff P, Licensed Practical Nurse (LPN) observed Resident #93's dressings. Staff P reported not seeing the right upper arm rolled gauze earlier, another nurse was taking care of wounds, and maybe that nurse had dated (6/27/23) it wrong. Staff P removed the resident's sock from the left heel and stated the dressing was dated 7/1/23. The observation identified the left heel of the resident had eschar attached to the wound bed. Staff P, LPN removed the dressing to Resident #93's left knee and confirmed the white dressing was dated 7/1/23. The dressing was soiled with dried red and tan colored drainage. The admission Record for Resident #93 identified the resident was originally admitted on [DATE]. The admission Record included diagnoses not limited to unspecified chronic obstructive pulmonary disease, adult failure to thrive, unspecified bipolar disorder, and unspecified malignant neoplasm of pancreatic duct. A review of Resident #93's Order Summary Report, dated 7/13/23, included a treatment order, dated 5/28/23, as Cleanse left heel with normal saline (NS), pat dry, apply skin prep (to) peri-wound, apply (Collagenase) ointment to wound bed followed by calcium alginate, and cover with dry dressing every evening shift for wound care. A review of Resident #93's June and July 2023 Treatment Administration Records (TARs) included the following treatment orders and documentation: - Cleanse skin tears to right upper arm, left (outer) knee, and left elbow with NS, pat dry, apply Triple Antibiotic Ointment (TAO), and cover with dry dressing daily till resolved every evening shift for skin tears, dated and discontinued on 6/27/23. The TARs did not indicate this dressing had been applied. - Cleanse skin tears to right upper arm and left elbow with normal saline, pat dry, apply (petrolatum gauze), cover with abdominal (abd) pad, and wrap with (rolled gauze) daily till resolved, every evening shift for skin tear. Dated 6/28 and discontinued 7/5/23. The June 2023 TAR indicated the dressing had been applied on 6/28 and 6/29. The printed TAR did not include documentation from 6/30/23. The July 2023 TAR indicated the dressing had been applied 7/1, 7/2, and 7/4. The order had been discontinued on 7/5/23. - Treatment as indicated - Cleanse left heel with NS, pat dry, apply skin prep (to) periwound, apply (Collagenase) ointment to wound bed (followed) by calcium alginate, and cover with (dry) dressing every evening shift for wound care. The July 2023 TAR indicated the resident's dressing had been changed on 7/1, 7/2, 7/4, 7/5, 7/8, and 7/9, despite the dressing being dated 7/1/23. The TAR indicated the dressing had been refused to be changed on 7/3, 7/6, and 7/7/23. - Cleanse skin tear area bilateral knees with NS, apply dry dressing daily every day shift for wound care and (monitoring). The July TAR indicated that the dressing had been changed on 7/1 and 7/2/23, despite being dated 7/1/23 and staff had not documented the dressing change had been refused on 7/3, 7/4, or 7/5/23. The active care plan for Resident #93 revealed the resident had altered skin integrity non-pressure location: left heel and sacrum wound with an intervention that included: Treatment per order. The care plan identified the resident had a skin tear to left outer knee and left arm and instructed staff that if skin tear occurs, treat per facility protocol and notify MD (medical doctor), family. On 7/12/23 at 2:22 p.m. the Director of Nursing (DON) reported being unaware of the observation of Resident #93's dressings. The DON reviewed documentation and confirmed it was concerning of a dressing that was nine days old. After reviewing the July 2023 TAR the DON confirmed that staff were documenting wound care was being done. 2. A review of Resident #461's admission Record indicated the resident was admitted on [DATE]. The diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, diabetes mellitus due to underlying condition with hyperglycemia, paroxysmal atrial fibrillation, and essential (primary) hypertension. The Wound Care Services note from the transferring acute facility, dated 12/26/22, identified Resident #461's wounds as follows: - right great toe, distal tip with unstable eschar surrounded by red moist tissue. Protocol was initiated: cleanse (with) NS, apply (petrolatum) gauze to wound area and cover with silicone border foam dressing. - right plantar distal 3rd toe, diabetic ulcer superficial 100% red, protocol initiated: cleanse (with) NS, apply (petrolatum) to wound area and covered (with) silicone border foam dressing. The Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 3008), dated 1/2/23, the facility had received from the acute facility identified in Section T Skin Care - Stage Assessment, right big toe wound, left big toe starting to be necrotic. The Admission/readmission Nursing Evaluation, dated 1/2/23, indicated Resident #461 was admitted with discoloration to the right and left toes without any additional skin impairments. The Head to Toe Weekly Skin Check, effective 1/9/23, identified Resident #461 had an existing skin impairment of a skin tear to the right forearm and did not have any resolved skin impairment. The skin check did not identify discoloration to the right and/or left toes. The Advanced Practitioner Registered Nurse (APRN) notes,, dated 1/3, 1/16, and 1/19/23, indicated Resident #461 did not have any rash, lesions, or petechiae (small red or purple spot caused by bleeding into the skin). The assessment identified the resident did have right third and great toe necrosis, with skin care as indicated. The Wound Care Specialist noted on 1/4/23, identified right knee and a left hand trauma wounds that were present on admission. The measurement of the right knee was 1.8 x 2.8 x 0.3 centimeters with 100% granulation tissue. The specialist ordered the wound to be cleaned with wound cleanser, petrolatum to be applied and the dressing changed three times a week and the left hand to be cleansed with wound cleanser three times a week. The note indicated the treatment was discussed with the nurse (unidentified) and the plan was for petrolatum gauze. The Wound Care Specialist noted on 1/11/23 that both the Right knee and Left hand was resolved and that skin prep was to be applied daily for one week as resolved wounds do not achieve their original tensile strength (measurement of the wounds load capacity per unit area). It is possible for wounds to recur. A review of Resident #461's care plan included a focus that identified the resident has potential/actual impairment to skin integrity related to (r/t) resolved right knee and left hand, initiated on 1/3/23 and revised on 2/1/23. The nutrition care plan indicated the resident was at risk for altered nutrition status secondary to diagnosis (dx) dementia, diabetes mellitus (DM), heart disease, GERD, wounds, (and) receives therapeutic diet. The review of Resident #461's January Medication and Treatment Administration Records (MAR/TAR) did not include wound care orders for the necrotic toes, the skin tear to the right forearm noted on the 1/9/23 Weekly Skin Check, the right knee, and/or left hand skin tears. A nursing note, dated 1/22/23 at 12:43 p.m., identified Resident #461 was found to have open area to left great toe, wound was cleaned and dressed. A nursing note, dated 1/22/23 at 4:28 p.m. revealed Resident #461's family member checked the resident's skin prior to discharging home and noted sock was dried to right toe. [Staff H, Licensed Practical Nurse (LPN)] was called to look at top of the resident's right great toe, looked like his toe had been bleeding and dried up. The staff member noted that wound cleanser was used to clean it and applied (Collagenase) and wrapped with rolled gauze. On 7/12/23 at 2:07 p.m., the DON stated the expectation would be to monitor the toes and dependent on how they looked and condition; to be doing wound care if necessary and per wound physician orders. The DON stated the expectation would be that someone else observe the wound as a second opinion within 24 hours and the Unit Manager would have been aware of the toes after admission. The DON reported if a resident had a skin condition, staff would let the attending physician know and it would be up to their discretion if the wound care specialist would be consulted. The DON stated at the time of Resident #461's admission the Unit Manager or the DON was getting the Wound Care specialist notes and that orders would be written in the electronic record or the Unit Manager would take a verbal order and put it in the record. The DON reviewed Resident #461's record and confirmed there were no orders for wound care and there was no description of the right knee and/or left hand trauma wounds at the time of admission or elsewhere. The Skin Evaluation policy, implemented 8/22/22, revealed, It is our policy to perform a full body skin evaluation as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body identified pressure injury. The explanation documented the staff should begin head to toe, thoroughly examining the resident's skin for condition, remove any special garments or devices if not contraindicated or ordered to remain in place, remove any dressings and note findings, and note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. The Wound Treatment Management policy, implemented 8/25/22, revealed, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The guidelines revealed: - Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. - In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. - Treatments will be documented on the Treatment Administration Record.

Based on observation, record review and interview the facility failed to ensure two oxygen administration orders were clarified for one resident (#77) of two residents reviewed for respiratory care. Findings included: An observation on 07/10/23 at 10:32 a.m., showed Resident #77 was being administered oxygen via a nasal cannula at 2 liters per minute (lpm). During an interview on 07/10/23 at 10:32 a.m., Resident #77 stated she was to be administered three liters of oxygen continuously. A review of Resident #77's admission Record showed a diagnosis of sleep apnea, unspecified. A review of the July 2023 Medication Administration Record showed two physician orders for oxygen. The first physician order, dated 05/26/23, documented, O2 [oxygen] at 2 lpm via nasal cannula continuous for sleep apnea. The second physician order, dated 06/13/23, documented, O2 [oxygen] at 3 lpm via nasal cannula every shift. The care plan, initiated on 4/10/23, showed Resident #77 was At risk for impaired respiratory status and showed interventions to include, Administer oxygen per order. During an interview on 07/12/23 at 2:31 p.m., the Director of Nursing (DON) confirmed there were two separate physician orders for Resident #77. The DON confirmed that both oxygen administration orders had different liters per minute ordered, contradicting each other. The DON stated those two oxygen administration orders will need to be clarified with the doctor to determine which oxygen flow rate was correct. A review of the facility's policy titled, Oxygen Administration, revised date 02/2023, showed, 1. Oxygen is administered under orders of a physician.

Based on observation, record review and interview the facility failed to ensure continuous communication with the dialysis center for one resident (#31) out of two residents reviewed for dialysis services. Findings included: During an interview on 07/10/23 at 10:09 a.m., Resident #31 stated he received dialysis services three days a week. A review of Resident #31's admission Record showed an admission date of 12/1/22 and diagnoses to include chronic kidney disease without heart failure, with Stage 5 chronic kidney disease, or end stage renal disease. A review of the July 2023 physician orders showed a physician order, dated 12/04/22, showed, Dialysis: May go to Dialysis on: Monday, Wednesday, Friday. A second physician order, dated 12/04/22, showed, Complete Dialysis communication form and send with Resident to dialysis center. A third physician order, dated 12/04/22, showed, Complete post communication dialysis form on return. A review of the care plan showed Resident #31 had a care plan focus, initiated on 12/5/22 and revised on 12/15/22, of Dialysis Care Plan: Renal failure with dialysis and interventions included: Review Dialysis communication forms. There was one Dialysis Communication Form found scanned in Resident #31's electronic medical record and dated 06/26/23. An observation on 07/11/23 at 5:35 p.m., revealed no dialysis communication book was available for Resident #31. During an interview on 07/11/23 at 5:40 p.m., Staff B, Licensed Practical Nurse (LPN) stated Resident #31 had a dialysis communication book but could not find it. Staff B, LPN found Resident #31's dialysis communication book and stated, Resident #31 had it in his room. Staff B, LPN stated, To be honest the dialysis communication book is rarely used. Staff B, LPN stated she usually just obtains Resident #31's vital and status information on post dialysis from the transportation people. Staff B, LPN stated, the last Assistant Director of Nursing (ADON) trained me and said nurses didn't have to use the dialysis communication book any longer, as nurses just needed to document everything in the computer. A review of Resident #31's dialysis communication book, on 07/11/23 at 5:45 p.m., showed three pre-communication forms for the dates of 07/05/23, 07/07/23 and 07/10/23. There were no dialysis communication forms present in Resident #31's dialysis communication book. (Photographic Evidence Obtained) Review of Post Dialysis communication forms showed no communication between the dialysis center and the facility. The Post Dialysis Communication forms are assessments completed by the nurse at the facility of Resident #31's status upon return to the facility after dialysis services. The following Post Dialysis Communication forms were as followed: 07/10/23- No received information regarding treatment from dialysis 07/05/23- No received information regarding treatment from dialysis 06/28/23- No received information regarding treatment from dialysis 06/19/23- No received information regarding treatment from dialysis 06/14/23- No received information regarding treatment from dialysis 06/13/23- No received information regarding treatment from dialysis 06/07/23- No received information regarding treatment from dialysis During an interview on 07/12/23 at 2:27 p.m., the Director of Nursing (DON) stated if the nurse did not receive communication from the dialysis center, I would expect the nurse to call to get a report on the resident, if no written communication was returned with the resident. The DON stated it was expected to be a two way communication between facility and dialysis center. A review of the facility's policy titled, Coordination of Hemodialysis Service, revised date 07/02/23, showed, The Dialysis Communication form will be initiated by the facility for any resident going to ESRD [End Stage Renal Disease] center for Hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. The ESRD facility is to review the Dialysis Communication form and either Complete the communication from and return with the resident or provide treatment information to the facility. Upon the resident's return to the facility, nursing will review the Dialysis Communication Form and information completed by the dialysis center or the information sent by the dialysis center; communicate with the resident's physician or other ancillary departments as needed, implement interventions as appropriate. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's Clinical record.

Based on record review and interviews the facility failed to ensure staff administered medication with adequate indication for use and monitored the administration and effectiveness of this medication for one resident (#21) out of 28 sampled residents; and administered antihypertensive medication outside physician ordered parameters twelve out of thirteen administrations reviewed for one (#45) out of five residents observed during the task of medication administration. Findings included: 1. A review of Resident #21's admission Record showed diagnoses of insomnia unspecified, anxiety disorder, unspecified dementia with behavioral disturbance and disorganized schizophrenia. A review of medical record revealed a nursing progress note, dated 06/05/23, and showed, resident was very upset all evening, claiming devil was in my belly resident wouldn't take melatonin for sleep, (gave her pudding with melatonin in it to calm her). A review of Resident #21's June 2023 Medication Administration Record (MAR) showed no physician order for Melatonin. The June 2023 MAR showed no Melatonin was provided to Resident #21 during the month of June 2023. The active care plan was reviewed and was silent of a focus for insomnia. During an interview on 07/12/23 at 10:40 a.m., the Nursing Home Administrator (NHA), Regional Clinical Nurse Consultant (RCNC) and the Director of Nursing (DON) reviewed the 06/05/23 progress note. The NHA, RCNC and DON were not aware of the progress note and stated they would be looking into this information more. During an interview on 07/12/23 at 11:23 a.m., Resident #21's Psychiatric Nurse Practitioner (PNP) stated she was not aware of Resident #21 having any insomnia issues lately. The PNP stated Resident #21 does have intermittent hallucinations. The PNP stated she assessed Resident #21 once a month and as needed. The PNP stated she expected facility staff to notify the PNP when Resident #21 had hallucinations. The PNP stated that Melatonin should only be given when prescribed by a physician and it was not in the normal scope of practice to administer Melatonin to calm a resident down. During an interview on 07/12/23 at 11:45 a.m., Staff B, Licensed Practical Nurse (LPN) stated Resident #21 was on her regular caseload. Staff B, LPN stated lately Resident #21 had been very irate and thrashing her legs around. Staff B, LPN stated Resident #21 was going downhill because Resident #21 used to be very easy to get along with, however, lately Resident #21 had been talking a lot to herself and agitated. Staff B, LPN stated she had been administering Melatonin to Resident #21 intermittently for a couple months and stated yes, she texted the doctor, to ask if she could administer Melatonin to Resident #21. Staff B, LPN stated the doctor texted back on 04/25/23 that Staff B, LPN could administer Resident #21 Melatonin 5 mg (milligrams) once a day at bedtime (qhs). Staff B, LPN shared the text message on her personal cell phone with the survey team where it was confirmed Resident #21's doctor (phone number verified) texted an order showing, Yes, give Melatonin 5 mg qhs. Staff B, LPN stated the next step would have been to administer Resident #21 the Melatonin. Staff B, LPN was asked if she transcribed the physician order into Resident #21's medical record and she responded, If it's not there, I didn't do it. Staff B, LPN was unable to describe the process of entering a physician order into a medical record when asked. Staff B, LPN stated when she provided any resident with medication she always signed them off the Medication Administration Record (MAR). Staff B, LPN reviewed the June 2023 MAR and could not find Melatonin on Resident #21's MAR. Staff B, LPN stated, I only give it to her when I think she needs it. I don't wake her up to give her Melatonin. Staff B, LPN stated she had administered Resident #21 Melatonin intermittently since getting permission from the physician to do so on 04/25/23. During an interview on 07/12/23 at 12:10 p.m., Resident #21's Primary Care Physician (PCP) stated Resident #21 had a few restless nights and remembered sending a text to Staff B, LPN on 04/25/23 instructing Staff B, LPN to give Resident #21 Melatonin 5 MG by mouth qhs. Resident 21's PCP stated that it was his expectation the nurse would have transmitted the order to Resident #21's medical record and on the Medical Administration Record (MAR). Resident #21's PCP stated the appropriate use for Melatonin was not for calming down a resident with psychological or anxiety symptoms but to aide in sleeping when a resident had insomnia. During an interview on 07/12/23 at 12:55 p.m., the RCNC and the DON stated nurses could receive physician orders by phone calls to the doctor's cell phone or on-call service. The RCNC stated some doctors do prefer texting but the facility had no agency phones so staff would have to use personal phones to text with a doctor. The RCNC stated staff, when texting a doctor, should transcribe the physician order into the medical record immediately. The DON stated Staff B, LPN did not transcribe the physician order to Resident #21's medical record per facility policy so therefore the medication did not go onto the MAR to administer. The RCNC stated all nurses are trained to not administer medications unless the medication was signed off on the MAR, however Staff B, LPN did not follow the facility policy in this situation. The DON confirmed the appropriate use of Melatonin should not be used to calm a resident down but used to assist with restlessness and insomnia symptoms. A review of the facility's policy titled, Medication Orders, dated 08/25/22, showed, 2. Verbal orders should be received by a licensed nurse, or pharmacist, and confirmed in writing by the physician, on the next visit to the facility. 4. Documentation of Medication Orders: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). b. Clarify the order. c. Enter the order on the medication order and receipt record. d. If using electronic medication records, input the medication order according to the electronic health record instructions and facility policy. e. Call or fax the medication order to the provider pharmacy. f. Transcribe newly prescribed medications on the MAR or treatment record to ensure the order is in the electronic MAR. g. When a new order changes the dosage of a previously prescribed medication discontinued software instructions and retype the new order. h. Enter the new order on the MAR or ensure the new order is in the electronic MAR. i. Notify the resident's sponsor/family of new medication order. 2. On 7/11/23 at 8:24 a.m., an observation was conducted with Staff H, LPN of Resident #45's medication administration. Staff H placed a blood pressure cuff on the resident's upper right arm, took it off placed it on the right forearm, and obtained a blood pressure of 118/75. Staff H dispensed a tablet of 25 milligram (mg) Atenolol, 10 mg tablet of Baclofen, and a 100 mg gel cap of Docusate sodium. Staff H placed the medication cup into the top drawer, re-entered the room and obtained a pain level of 9 out of 10 in the back and legs of the resident. Staff H dispensed one tablet of Oxycodone/Acetaminophen 5-325 mg and returned to the room to administer the four tablets. The Order Summary Report included the physician order: Atenolol 25 mg tablet - Give one tablet by mouth one time a day for hypertension, hold if systolic blood pressure less than 140 and diastolic blood pressure less than 90. A review of Resident #45's July Medication Administration Record (MAR) indicated that the resident had been administered Atenolol when staff documented blood pressures outside parameters to hold as follows: 7/1- 133/78, 7/2- 128/73, 7/3- 136/74, 7/5- 129/78, 7/6- 137/77, 7/7-130/75, 7/8- 127/69, 7/9- 123/74, 7/10- 129/70, 7/11- 118/75, 7/12- 134/81, and 7/13/23- 129/78, a total of twelve times out of 13 administrations. An interview on 7/13/23 at 1:51 p.m. was conducted with the DON. The DON reviewed Resident #45's Atenolol administration record, and stated, I see what you mean. (regarding parameters). The policy - Medication Administration, implemented on 3/24/23, identified that Medications are administered by licensed nurses, or to her staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The explanation and guidelines instructed staff to Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and three errors were identified for two residents (#45 and #70) of five residents observed. These errors constituted a 10% medication error rate. Findings included: 1. On 7/11/23 at 8:24 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #45. Staff H placed an electronic blood pressure cuff on the upper portion of the resident's right arm, then removed it, placing it on the lower right forearm and obtained a blood pressure of 118/75 and a pulse of 80. Staff H returned to the medication cart and dispensed the following medications: - Atenolol 25 milligram (mg) tablet - Baclofen 10 mg tablet - Docusate Sodium 100 mg gelcap - Oxycodone/Acetaminophen 5-325 mg tablet Staff H confirmed a total of 4 tablets were dispensed, re-entered the resident's room and administered the medications. The Order Summary Report, dated 7/13/23, included the following physician order: - Atenolol 25 mg tablet - Give 1 tablet by mouth one time a day for hypertension (HTN). Hold if systolic blood pressure (SBP) less than 140 and diastolic blood pressure (DBP) less than 90. This order was started on 11/9/22. The July 2023 Medication Administration Record (MAR) identified Staff H had administered the antihypertensive medication to the resident despite the ordered parameters. 2. On 7/11/23 at 9:31 a.m., an observation of medication administration with Staff A, LPN was conducted with Resident #70. Staff A dispensed the following medications: - Metformin 500 mg tablet - Carvedilol 3.125 mg tablet - Glimepiride 2 mg tablet - Jardiance 10 mg tablet - Potassium Chloride 10 milliequivalent (meq) Extended Release capsule - Entresto 24-26 mg tablet - Isosorbide Mononitrate Extended Release 30 mg tablet - Metoprolol Tartrate 25 mg tablet Staff A, LPN confirmed the dispensing of 8 tablets and stated the pharmacy would have to be called for the resident's Bumex. The resident removed the Potassium capsule which Staff A stated that sometimes will take it and offered to call the physician to get a liquid order for it. Staff A left the room and obtained 2 - 0.5 mg tablets of Bumetanide (Bumex) from the facility's electronic medication dispensary. The resident was administered the 2 tablets. A review of the Resident #70's July 2023 MAR identified that the resident's Isosorbide and Jardiance was scheduled for 8:00 a.m. The progress notes, dated 7/11/23, did not indicate the physician was notified of the late medications. On 7/13/23 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). The DON reviewed Resident #45's MAR and confirmed that staff were administering Atenolol despite the parameters. The DON stated the expectation for late meds was for the doctor and family to be notified and (receive) instructions on how to proceed. If okay to give (medication) and if it was a medication ordered for twice a day the second dose should be adjusted. The policy titled, Medication Administration, implemented on 3/24/23, revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The compliance guidelines instructed staff to Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. The guidelines continued to indicate that staff were to Review MAR to identify medication to be administered and If any medication is not available, or the possibility of late administration, the nurse will contact the Attending Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An observation was made on 7/10/23 at 10:00 a.m. in the bathroom of Resident room [ROOM NUMBER]. The bathroom toilet had a brown stain in the toilet bowl. The screws for the bowl base were rusted and dusty. An observation was made on 7/10/23 at 10:04 a.m. in the bathroom of Resident room [ROOM NUMBER]. The bathroom toilet had a buildup of dirt and dust in the corner of the wall next to the toilet. On the floor behind the toilet was significant dirt buildup, a dried piece of toilet tissue and dead bugs. The screws for the bowl base were rusted and dusty. An observation was made on 7/10/23 at 10:10 a.m. in the bathroom of Resident room [ROOM NUMBER]. The bathroom door frame had a hole at the bottom of the frame near the floor inside the bathroom where it was rusted out. The rust pieces were on the floor. (Photographic Evidence Obtained) An observation was made on 7/10/23 at 10:20 a.m. in the bathroom of Resident room [ROOM NUMBER]. The floor had dirt build up near the edges of the floor and wall. Bathroom walls near the toilet had a light black substance splattered on the wall. The foot tips of the shower bench had a black shiny bio growth on them. The grout of the shower floor, near where it meets the bathroom floor had black bio growth in the tile grout line. In the room closet a buildup of dirt and dust was in the corners. The base of the wall in the room closest to the floor had a black substance going up the wall. (Photographic Evidence Obtained) An observation was made on 7/10/23 at 10:25 a.m. in the bathroom of Resident room [ROOM NUMBER]. The wall next to the sink had an unpainted area, leaving the drywall exposed. The bathroom toilet had dirt and dust built up around the toilet. (Photographic Evidence Obtained) An observation was made on 7/10/23 at 10:30 a.m., in Resident room [ROOM NUMBER] and the bathroom. The floor had dirt build up near the edges of the floor in the bathroom. The foot tips of the shower bench had a black shiny bio growth on them. The corner of the shower nearest the sink had holes and tile missing. (Photographic Evidence Obtained) On 7/12/23 at 9:45 a.m. an interview was conducted with Staff N, Housekeeping Aide. Staff N stated she cleans the residents' rooms and bathrooms. Staff N stated she must have missed the dust and the equipment is not for housekeeping to clean. If I see soiled equipment, I do try to clean it. If a repair is needed of something, an entry is placed in the maintenance logbook for follow up. On 7/13/23 at 3:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA), regarding the environmental concerns, the photographic evidence was reviewed. The pictures of the rusted out bathroom doorframes were reviewed and the NHA stated that just requires some paint. The NHA continued to state, there is a lot of maintenance that is needed here, we have a lot to do. 2. A tour of the facility kitchen was conducted on 7/10/2023 at 9:41 a.m. During this tour, the ceiling was observed to have cracks/holes in the plaster and a black substance surrounding the condensation vents as well as spotted in areas on the ceiling. (Photographic Evidence Obtained) These findings were confirmed and discussed during an interview with the facility's Maintenance Director on 7/10/2023 at 9:46 a.m. During this interview the Maintenance Director stated, Yes, we got a lot of rain last night and it appears that we got a leak in the roof. I got a call out for someone to come and take a look at the roof. Once we get that taken care of , I will fix the drywall. Based on observations, record reviews, and interviews the facility failed to provide an environment that was clean, sanitary, and well-maintained related to lack of housekeeping three halls (100, 400 and 600) of six halls affecting 12 resident rooms (604, 609, 101, 103, 102, 104, 400, 404, 406, 408, 411, 412 ), two storage areas (600-hall oxygen room, clean utility room) and broken handrails located in the hallway across from the therapy room and the dining room, and failed to ensure the ceiling was free and a black like substance and in good repair in one of one kitchen. Findings included: 1. An observation on 7/10/23 at 9:53 a.m. of the 600-hall oxygen room revealed under an empty oxygen rack dirt and mulch-looking material and behind the door was piles of dead ants intermixed with dust. On 7/10/23 at 10:01 a.m., an observation was conducted in the bathroom for Resident room [ROOM NUMBER]. The observation revealed a black biofilm along the floor and in the corner of the shower, the light above the shower was not working, and the room was very warm as the exhaust fan was not working. On 7/10/23 at 10:12 a.m., an observation was made of the bedside refrigerator in Resident room [ROOM NUMBER], inside the refrigerator was three dead bugs on the bottom and one on a door shelf. The bathroom of the room was very warm and the exhaust fan was not working. On 7/10/23 at 11:24 a.m., on a metal shelf inside the clean utility room was a pump with residual of enteral nutrition dried to it, Staff H, Licensed Practical Nurse (LPN), confirmed the findings. On 7/10/23 at 2:00 p.m., the vanity inside Resident room [ROOM NUMBER]'s bathroom was missing a drawer front and with deteriorated manufactured wood. (Photographic Evidence Obtained) On 7/10/23 at 2:13 p.m. the inside of a refrigerator in Resident room [ROOM NUMBER] was observed the plastic interior of the refrigerator was chipped and not intact. (Photographic Evidence Obtained) On 7/10/23 at 2:22 p.m. an observation was conducted of Resident room [ROOM NUMBER]'s toilet. The toilet bowl had an overall brown residual around the sides. (Photographic Evidence Obtained) On 7/11/23 at 10:34 a.m. an observation was made of the bathroom of Resident room [ROOM NUMBER]. The toilet pedestal was unclean, a plunger labeled sink only was sitting beside the toilet on a brown paper towel, and a water basin was under the toilet's water valve with dried water stains. On 7/11/23 at 5:57 p.m. an observation was conducted of a broken handrail attached to the wall across from the therapy room, above the handrail was unpatched drywall that had been painted the same color as the wall. (Photographic Evidence Obtained) On 7/10/23 at 10:29 a.m., Staff R, Laundry Aide stated they only clean refrigerators in resident rooms if the resident requests, not supposed to go in their refrigerators. On 7/12/23 at 11:25 a.m. the Maintenance Director observed the 600-hall oxygen room and reported not knowing who was supposed to be cleaning the room and the material under the oxygen rack was mulch. On 7/13/23 at 12:39 p.m., the Housekeeping Manager stated housekeeping staff were responsible for cleaning resident rooms, common areas, dining room, clean and soiled utility rooms, oxygen room, and all offices. The Housekeeping Manager reported the facility was fully staffed with 10 housekeeping staff. The Housekeeping Manager stated housekeeping staff were supposed to clean refrigerators inside resident rooms, the cobwebs at the end of the 600-hall were supposed to be cleaned daily, dead ants were to be cleaned off surfaces, the bugs inside Resident room [ROOM NUMBER]'s refrigerator should have been cleaned along with the toilet bases. The Housekeeping Manager confirmed the black biofilm on the shower chair in Resident room [ROOM NUMBER]. On 7/13/23 at 12:59 p.m., a tour of the facility was completed with the Regional Maintenance Director (RMD). The RMD confirmed the broken handrail next to the dining room. The RMD acknowledged the exhaust fan in the bathroom of Resident room [ROOM NUMBER] and confirmed the exhaust fan was not working and the room was very muggy. The RMD stated the HVAC (Heating, Ventilation, and Air Conditioning) company will need to come back to the facility. The RMD stated the facility did have a [electronic maintenance system] but did not know if staff had access to it and there was also maintenance books at each unit. A review of the policy titled, Resident Refrigerators, implemented 5/2022 and revised 2/2023, revealed: This facility does not provide a refrigerator in a resident's room. However, it the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. The policy explanation and guidelines showed the dormitory-sized refrigerator are allowed in a resident's room under the following conditions, which included: the refrigerator is inspected by maintenance personnel and deemed safe prior to use and upon routine inspections, and identified that nursing/housekeeping staff shall clean the refrigerator and discard any foods that are out of compliance. The policy showed the Accommodations shall be made for the resident to be present for temperature checks, observing food for sanitary storage, and cleaning of the refrigerator, if so desired by the resident. The policy titled, Routine Cleaning and Disinfection, implemented 5/2022 and revised 2/2023, revealed the policy of the facility was to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to be extent possible. The guideline indicated that Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. The routine cleaning will focus on visibly soiled surfaces and high touch areas not limited to toilet handles, bed rails, tray tables, call buttons, TV remote, telephones, toilet seats, and monitor control panels, touch screens and cables, sinks and faucets, and door knobs and levers. The policy titled, Preventative Maintenance Program, implemented 5/2022 and revised 2/2023, revealed, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility 1) failed to ensure staff appropriately donned Personal Protective Equipment (PPE) prior to entering isolation rooms for two residents (#74 and #561) out of two residents on Contact Precautions, and 2) failed to ensure staff were educated on Enhanced Barrier Precautions (EBP) on two hallways (400 and 100) out of six hallways in the facility, 3) failed to implement proper PPE during wound care for one resident (#105) out of one wound care observation, and 4) failed to ensure staff followed proper infection control practices related to nail care during medication administration. Findings included: 1) On 7/12/2023 at 10:30 a.m. an Enhanced Barrier Precautions sign was observed on Resident #74's room door and no PPE caddy available to staff. (Photographic Evidence Obtained) On 07/12/23 at 11:06 a.m. an interview was conducted with Staff H, Licensed Practical Nurse (LPN). Staff H, LPN stated she was informed during her nurse-to-nurse communication from last night an order was received to test Resident #74 for Clostridium Difficile Colitis (C. Diff). Staff H, LPN proceeded to state the nurse from the night shift should have placed Resident #74 on Contact Isolation, when she received the order. Staff H, LPN validated there was no order and no sign on the door for Contact Isolation. On 7/12/23 at 11:15 a.m. Staff N, housekeeping aide (HA) was observed entering Resident #74's room without PPE in place. Staff N, HA proceeded with her normal cleaning duties including dusting, wiping of resident areas, bathroom cleaning and mopping. Staff N, HA exited the room and proceeded to clean the next resident room. An interview was conducted on 7/12/2023 at 11:30 p.m. with Staff P, LPN. She stated Resident #74 should have a Contact Isolation sign on the door. Staff P, LPN retrieved and placed an isolation caddy outside of the door. A review of the Physician orders for Resident #74 revealed an order for Contact Isolation for C. Diff was written at 12:28 p.m. on 7/12/23. An observation of Resident #74's door on 7/12/23 at 12:45 p.m. revealed an EBP sign on the door. Staff M, Certified Nursing Assistant (CNA) was in the resident's room delivering the lunch tray. She was observed without PPE in place. Staff M was observed touching the over bed table with her scrubs while delivering the resident lunch tray. An observation and interview was conducted on 7/12/23 at 1:30 p.m. with Staff P, LPN. She stated a Contact Isolation sign had not been placed on the door for Resident #74 and the EBP sign was still in place. Staff P, LPN proceeded to place the Contact Isolation sign on Resident #74's door according to the physician order. An interview was conducted on 07/12/23 at 11:00 a.m. with the Director of Nursing (DON) and the Infection Preventionist (IP). They stated the process with C. Diff is to place the resident on Contact Isolation as soon as the order is received. The nurse receiving the order would place the signage and PPE on the door to inform staff of the change. A review of the Medical Record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses to include: Metabolic encephalopathy, Obstructive Sleep Apnea, Chronic Pulmonary edema, Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Chronic Diastolic (Congestive) Heart Failure and History of Covid-19. A review of Resident #74's Physician orders revealed the following orders: 6/14/23 EBP related to wounds. 7/1/23 Droplet precautions for 10 days due to Covid 19 positive. 7/11/23 at 6:46 p.m. C. Diff laboratory for diarrhea. On 7/10/2023 at 10:55 a.m. an observation of Resident #561's room door revealed signage indicating the resident was under Contact Isolation Precautions. A caddy with various PPE items was hanging on the door. Staff I, Occupational Therapist (OT) was observed exiting Resident #561's room with a walker and two small hand weights in her hands. Staff I, OT stated Resident #561 was on Contact Precautions for an infection of a wound and was on intravenous antibiotics. Staff I, OT stated Contact Precautions meant she needed to wear a gown and gloves to enter the resident's room. Staff I, OT stated the equipment was not cleaned prior to exiting the resident room. The equipment would be taken back through the hallways with her ungloved hands to the therapy gym for appropriate cleaning with germicidal wipes. On 7/10/23 at 11:00 a.m. Staff G, CNA was observed entering and exiting Resident 561's room without donning or doffing any PPE. When Staff G, CNA exited the room, she did not utilize any ABHS (alcohol-based hand sanitizer). On 7/10/23 at 12:49 p.m. Staff J, CNA was observed entering Resident #561's room without donning/doffing of PPE. Staff J exited the room and went directly to the next room without utilizing ABHS. A review of the Medical Record revealed Resident #561 was admitted to the facility on [DATE] with a diagnosis of a wound to a lower extremity with Methicillin-Resistant Staphylococcus Aureus (MRSA) with orders for Contact Isolation. 2) A tour was conducted on 7/10/23 at 10:58 a.m. of the 400 unit in the facility. An observation was made of Staff G, Certified Nursing Assistant (CNA) in room [ROOM NUMBER]-A changing bed linen and making the bed. There was a sign on the door to room [ROOM NUMBER] that revealed Enhanced Barrier Precautions (EBP) were in place. The sign indicated use of a gown and gloves were required when providing direct care. Staff G, CNA was observed with no gown or gloves on while changing the linen. An interview was conducted with Staff G, CNA on 7/10/2023 at 10:58 a.m. Staff G stated EBP meant she only had to wear gown and gloves when providing patient care. Staff G, CNA stated she did not think changing dirty linen was direct patient care. An interview was conducted on 7/10/23 at 12:35 p.m. with Staff H, Licensed Practical Nurse (LPN). Staff H, LPN stated EBP meant just normal Universal Precautions of a gown and gloves being worn when caring for residents. She continued to explain Contact Precautions require a gown and gloves whenever entering a room for any reason. An interview was conducted on 7/10/2023 at 12:55 p.m. with Staff K, CNA. Staff K, CNA stated EBP is used for Covid residents and requires use of a gown, mask, eye protection and gloves. Staff K, CNA continued to explain Contact Isolation is for everything else, and she wears a gown and gloves when providing resident care. Multiple observations were conducted on 7/10/23 throughout the day on the 400 unit of the facility. room [ROOM NUMBER] was the only room with EBP signage on the door. rooms [ROOM NUMBERS] had signage on the doors indicating Contact Isolation. PPE caddies were observed on all three doors in the hallway. On 7/11/23 at 9:00 a.m. an observation of the 400 unit of the facility was conducted. Multiple rooms including, 411, 409, 407, 406, and 403 were observed with EBP signs on the door. No PPE caddies or carts were next to the EBP rooms. room [ROOM NUMBER] was observed to have a Contact Isolation sign on the door. On 7/11/23 at 9:05 a.m. Staff H, LPN was interviewed. Staff H, LPN stated she was caring for the resident in room [ROOM NUMBER]. Staff H, LPN stated the room was not on any isolation precautions on 7/10/2023, and last night management placed EBP signs on resident's door if they had an increased risk of acquiring a Multiple Drug Resistant Organism (MDRO). Staff H, LPN stated signs for EBP were now on four additional rooms, although the resident's conditions remained the same. Staff H, LPN stated she had not seen any different education or materials related to the changes other than the signs should have been on the rooms all along. A review of the facility policy titled Management of C. Difficile Infection implemented: 5/2022 revealed the following: Policy the facility implements facility-wide strategies for the prevention and spread of Clostridioides Difficile (C. Diff) infections. The policy also revealed under explanations and compliance guidance that nurses may implement preemptive contact precautions when C. difficile infection is suspected, pending results of testing. General principles relating to contact precautions for C. difficile: all staff are to wear gloves and a gown upon entry into the resident's room and while providing care for the resident with C. difficile infection. Hand hygiene shall be performed by handwashing with soap and water in accordance with the facility policy for hand hygiene. Maintain on contact precautions for duration of illness, but no less than 48 hours after diarrhea has resolved. Encourage/assist residents to wash hands frequently. Bathe daily with soap and water. Use disposable equipment whenever possible. 6) During an interview, on 07/10/23 at 12:25 p.m., Staff F, LPN stated the Enhanced Barrier Precaution (EBP) signs are tricky. Staff F, LPN stated the EBP signs were originally placed to let staff know the resident had a catheter, wounds, feeding tube, or on dialysis to give staff an idea there was something about the resident to be careful with. LPN F stated the facility just put Personal Protective Equipment (PPE) outside some doors with EBP signs while other doors with EBP signs still do not have PPE. Staff F, LPN stated, Now what do I do. There is nothing clear about the designated EBP rooms now. There seemed to be no set guidelines, so we don't know, should we don PPE or not? During an interview, on 07/10/23 at 12:30 p.m., Staff A, LPN stated the EBP signs were used to identify a resident with catheters, wounds, a feeding tube or was on dialysis. Staff A, LPN stated, The facility just went around placing PPE bins outside of some of the EBP rooms so right now I am confused. It's just not clear as to what EBP room PPE should be worn. A review of the facility's policy titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to prevent spread of Multidrug Resistant Organisms (MDROs), dated 07/12/22, revealed the following: Enhanced Barrier Precautions- Nursing home residence with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply. The Enhanced Barrier Precautions high contact resident care activities included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens and Changing briefs or assisting with toileting. 3) On 7/12/23 at 2:36 p.m., an observation was conducted with Staff H, Licensed Practical Nurse (LPN) of wound care for Resident #105. The staff member was assisted by Staff G, Certified Nursing Assistant (CNA) and Staff Q, LPN. The resident's room was posted for staff to observe Enhanced Barrier Precautions (EBP) which instructed providers and staff to wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. Staff G, CNA was observed standing on the far side of Resident #105's bed wearing gloves and no gown, the residents' linens were touching the clothing of the staff member. Staff H, LPN entered the room, without donning a gown, and cleaned the over-bed table. Staff Q, LPN who was not wearing Personal Protective Equipment (PPE) stood next to the resident bed and handed Staff G the urinary drainage bag who placed it on the side of the bed next to the wall. Staff H placed barrier on over-bed table, went into the hallway where the treatment cart was parked next to the PPE storage chest. The staff member removed wound care supplies and re-entered the room. Staff G and Staff Q were standing on the same side of the bed. Staff Q moved to the interior side of bed and assisted with removal of the resident's incontinency brief and provided hygiene care. Staff H was observed cutting the alginate pad with scissors that had not been observed to be cleaned prior. The staff member performed wound care without donning a gown, Staff G and Q assisted with positioning the resident without wearing PPE gowns. Immediately following the observation of the wound care for Resident #105, while standing at the treatment cart in the hallway outside of the residents' room, Staff H reported not noticing the EBP sign or the PPE caddy and stated she should have been dressed (in PPE) but would have to check it. On 7/12/23 at 3:24 p.m., the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) were notified of the observation of wound care for Resident #105. The RDCS stated Enhanced [NAME] to my existence. 4) On 7/13/23 at 6:48 a.m., an observation was conducted on the 100 hallway of the facility. rooms [ROOM NUMBERS] were observed with EBP signage on the doors. No PPE caddies were observed in the hallway available for use by staff or visitors. Staff F, Licensed Practical Nurse (LPN), reported on 7/10/23 at 10:53 a.m., of not knowing why they have EBP posted, There is no COVID. The staff member stated the previous DON had started it and the facility hadn't taken the signs down. Two rooms on the 100-hall were posted with EBP and stated PPE was available in a room and pointed toward the nursing station where staff could get PPE from Central Supply. Staff F stated PPE could be worn in the EBP rooms If you feel safer. On 7/10/23 at 11:53 a.m. the DON stated staff were to use PPE when doing direct care with residents under EBP, which included linen changes. She then stated staff do not need to use PPE in an EBP for linen changes. The EBP signs posted on the units instructed staff and providers to wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. 5) On 7/11/23 at 8:41 a.m., an observation was conducted of Staff O, LPN during the task of medication administration. Staff O, LPN fingernails were painted a dark teal color, extended approximately 1 inch past the tip of the finger, and pointed. The staff member responded Don't start with me in regard to the color of the fingernails. The facility Dress Code and Personal Hygiene policy indicated the following: To maximize our residents' well-being, fingernails must be clean and clipped short, and chin-length or longer hair must be secured away from the face in a clean looking fashion, if you provide direct care to residents. The Center of Disease Control and Prevention (CDC), located at https://www.cdc.gov/handhygiene/download/hand_hygiene_core.pdf, indicated that fingernail length can often harbor potential pathogens even with careful handwashing. Natural nail tips should be kept to 1/4 inch in length. and gram-negative pathogens are more likely to be harbored with healthcare workers who wear artificial nails and should not be worn when having direct contact with high-risk patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and facility policy review, the facility failed to ensure an effective pest control system was in place in four halls (100, 200, 400 and 600) of six halls and one resident (#60) who resided in one of the affected halls. Findings included: A review of a facility policy titled, Pest Control, revised date: 2/2023, revealed: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). During multiple facility tours, observations were made of live and dead pests and flying insects in resident rooms and storage areas as follows: 1. On 7/10/23 at 10:04 a.m. in the bathroom of Resident room [ROOM NUMBER] an observation revealed dead and live cockroaches near the toilet and shower drain. On 7/10/23 at 10:10 a.m. in the bathroom of Resident room [ROOM NUMBER] an observation was made of small ants in the resident's bathroom sink, both dead and alive. (Photographic Evidence Obtained) On 7/12/23 at 9:44 a.m. an interview was conducted with Staff N, Housekeeping Aide. She stated she had been at the facility for a year. She said, Yes, I have seen roaches, and ants. I just spray them away if they are in bathroom with my cleaning spray. She stated she notifies someone such her supervisor. Review of the Pest Sighting Log Sheet showed recent sightings as follows: 6/23/23 in room [ROOM NUMBER] B a pest was seen. There was no acknowledgement by staff of the pest sightings noted on the sheet. 6/25/23 in room [ROOM NUMBER] A multiple pests were seen. There was no acknowledgement by staff of the pest sightings noted on the sheet. There were no sightings reported after 6/25/23, until 7/10/23. 3. An observation on 07/10/2023 at 10:00 a.m., revealed Resident #60 sleeping in her bed with her mouth open and her covers partially pulled over her. Flies were seen flying around her mouth, on her face, and on her neck. A review of Resident #60's admission Record revealed she was admitted to the facility on [DATE], with diagnoses to include but not limited to major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 99, indicating that Resident #60 was unable to complete the interview. A review of the care plan initiated on 01/18/2022 and revised on 1/18/2022, showed that Resident #60 has an ADL (activities of daily living) self-care performance deficit related to (r/t) dementia. Further review showed an intervention initiated on 01/18/2022, showing that Resident #60 is totally dependent on one to two staff for repositioning and turning in bed as necessary and for dressing toileting and transferring. In addition, Resident #60 was totally dependent on one staff for eating. 2. An observation on 7/10/23 at 9:53 a.m. of the 600-hall oxygen room revealed under an empty oxygen rack dirt and mulch-looking material and behind the door was piles of dead ants intermixed with dust. On 7/10/23 at 10:12 a.m., an observation was made of the bedside refrigerator in Resident room [ROOM NUMBER], inside the refrigerator was three dead bugs on the bottom and one on a door shelf. On 7/10/23 at 10:29 a.m., Staff R, Laundry Aide stated they only clean refrigerators in resident rooms if the resident requests, not supposed to go in their refrigerators. On 7/10/23 at 12:18 p.m., the exit door at the end of the 600-hall was framed with cobwebs that had dead ants in them. The door bar had dead ants lying on it and in the corners on each side of the hall was cobwebs with dead ants. (Photographic Evidence Obtained) On 7/10/23 at 2:25 p.m., an observation was made of the vanity top in the bathroom of Resident room [ROOM NUMBER]. The observation identified numerous dead ants next to the sink. On 7/13/23 at 12:39 p.m., a tour was conducted with the Housekeeping Manager. The tour included an observation of the bathroom for Resident room [ROOM NUMBER]. One of the resident's in the room stated, While you're in there step on the roaches. During the observation a live roach came out from the shower and moved towards the door. The Housekeeping Manager chased it back into the shower area and killed it. On 7/13/23 at 12:39 p.m., the Housekeeping Manager stated housekeeping staff were responsible for cleaning resident rooms, common areas, dining room, clean and soiled utility rooms, oxygen room, and all offices. The Housekeeping Manager reported the facility was fully staffed with 10 housekeeping staff. The Housekeeping Manager stated housekeeping staff were supposed to clean refrigerators inside resident rooms, the cobwebs at the end of the 600-hall were supposed to be cleaned daily, dead ants were to be cleaned off surfaces, the bugs inside Resident room [ROOM NUMBER]'s refrigerator should have been cleaned along with the toilet bases. A review of the policy titled, Resident Refrigerators, implemented 5/2022 and revised 2/2023, revealed: This facility does not provide a refrigerator in a resident's room. However, it the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. The policy explanation and guidelines showed the dormitory-sized refrigerator are allowed in a resident's room under the following conditions, which included: the refrigerator is inspected by maintenance personnel and deemed safe prior to use and upon routine inspections, and identified that nursing/housekeeping staff shall clean the refrigerator and discard any foods that are out of compliance. The policy showed the Accommodations shall be made for the resident to be present for temperature checks, observing food for sanitary storage, and cleaning of the refrigerator, if so desired by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide a clean and homelike environment for 2 of 31 (#19, #27) sampled residents. Findings included: 1. Review of Resident #19's record revealed that this resident was admitted to the facility on [DATE] and has diagnosis that included hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side and receives nutrition via tube feed. Observations of Resident #19 on 6/28/21 at 12:05 PM revealed that the resident was lying in her bed with the head of her bed elevated and her tube feeding hanging. Inspection of the residents room surrounding her bed revealed that there was a puddle of a light brown substance pooled on the floor located in the area beneath the tube feed formula, on the tube feed pole and on the floor mat next to the bed. (Photgraphic Evidence Obtained) Observations of Resident #19 on 6/29/21 at 10:03 AM revealed that the resident was lying in her bed with the head of her bed elevated and her tube feeding hanging. Inspection of the residents room surrounding her bed revealed that there was a puddle of a light brown substance pooled on the floor located in the area beneath the tube feed formula, on the tube feed pole and on the floor mat next to the bed. (Photgraphic Evidence Obtained) Interview on 6/29/21 at 3:05 PM with Staff G, Licensed Practical Nurse (LPN) revealed if there is a tube feed spill the aides or anyone else who sees the spill should clean it up, She reported that she hung this resident's tube feed today at 2:00 PM with no concerns and did not see the spill. Interview on 6/29/21 at 3:08 PM with Staff B, Registered Nurse (RN), Unit Manager revealed that if aides or anyone sees a spill in a residents room they should call housekeeping to clean room. She reported that housekeeping cleans rooms daily. Interview on 6/29/21 at 3:10 PM with Staff H, Housekeeper revealed that she is assigned to Resident #19's room today and that she has already cleaned the room today. Inspection of the room at this time with Staff B, Staff G and Staff H present, revealed that the spill identified on 6/28/21 and 6/29/21 was still present on the floor of Resident #19's room. Staff B, RN reported that this spill should have been cleaned up right away and should not have been there for 2 days. At this time Staff G, LPN reported that she is responsible for this issue and that she should have noticed spill before now. Interview on 6/29/21 at 3:22 PM with the Housekeeping Manager revealed that at this time she has 3 housekeepers and that the housekeepers clean resident rooms everyday, which includes cleaning up spills, She reported that spills should never be there for more than a day. She reported that the housekeeper needed to scrap the spill and that she did not do her job. 2. Review of Resident #27's record revealed that this resident was admitted to the facility on [DATE] and has diagnosis that includes Muscle wasting and atrophy, and need for assistance with personal care, and has a Brief Interview For Mental Status dated 5/6/21 with a score of 13 (Cognitively intact). Observation of Resident #27s room on 6/28/21 at 12:28 PM revealed that there was a bookcase located in the residents room to the left of her bed. It was noted that the shelf of the bookcase was broken and on the floor and that the residents belonging were lying on the floor. (Photgraphic Evidence Obtained). An interview with Resident #27 was conducted at this time and the resident reported the aides are aware of the broken bookcase and that it has been that way for about 3 weeks and no one has fixed it. Observation of Resident #27s room on 6/29/21 at 10:09 AM revealed the bookcase located in the residents room to the left of her bed, was still broken withthe shelf located on the floor and that the residents belonging were still lying on the floor. Observation on 6/29/21 at 3:00 PM of Resident #27's room revealed that the bookcase in her room was now fixed and all of her belongings were appropriately stored. Interview with Resident #27 revealed that Staff I fixed the bookcase and arranged her belongings without me even asking her to. Interview on 6/29/21 at 3:05 PM with Staff I, Certified Nursing Assistant (CNA) revealed that she did not work yesterday but worked today and was assigned to Resident #27 and found the book shelf broken with items on the floor so picked it up and fixed everything. An interview on 6/29/21 at 3:08 PM with Staff B, RN revealed the aide or anyone else could have assisted and cleaned up the resident's bookshelf and belongings on the floor. 3. Review of the facility policy titled Daily Patient Room Cleaning with a revised date of 9/05/2017 revealed the following: -B, Do quick straighten up. -C-4) Dust mop floor. Use dust mop to gather all trash and debris on floor. Sweep to the door, pick up with dust pan. -C-5) Damp mop floor with germicide solution damp mop floor working from back corner to door

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, observation, and policy review the facility failed to ensure a grievance was acted upon for one resident (#46) of fifteen sampled residents. Findings included: Resident #46 was admitted to the facility with a diagnosis of perforated intestine, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment in the medical record, dated 5/28/21, reflected a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #46's cognition was intact. On 6/28/21 at 10:39 AM an interview was conducted with Resident #46. She said the man that lives next door [Resident #16] is verbally abusive to the staff. He is obnoxious. He screams. He is vulgar. He wanders everywhere. She said he has not come in her room or spoke to her, but it's really a bother, and the staff aren't allowed to do anything about it. She has reported it to the ARNP [Advanced Registered Nurse Practitioner] and the DON [Director of Nursing]. Resident #46 also said that it takes thirty minutes to an hour for anyone to answer the call light on the eleven to seven shift [night shift]. They are so busy chasing that man around to keep everybody safe. Review of the complaint/grievance report, dated 6/24/21, reflected the following findings: Communicated by: Resident #46, pertaining to: Resident #16. Communicated to the SSD [Social Services Director]. Concern Resident #46 reports that Resident #16 is very disruptive at night, yelling profanities and slamming doors and is disturbing her sleep. Plan to resolve complaint/grievance: Resident offered a room change and declined. Resident made aware that ARNP would be made aware of Resident #46's behaviors. Results of action taken: SS [Social Services] and DON met with Resident #46 to discuss concern and plan to resolve concern. Resident told us to leave family room because her family was coming for a visit. Resolution Complaint/grievance resolved? Yes Will follow up as needed. Is complainant satisfied? the answers were blank (yes, no). Complainant remarks: We will see. Resident #46 encouraged to voice any other concerns that she may have. 6/25/21 Resident #16 was admitted to the facility with diagnoses of schizophrenia and bipolar disorder, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE], reflected a BIMS of 15, indicating an intact cognition. Further review of the assessment revealed the following information: Section G, functional status, locomotion on unit was marked supervision of one person. Section E, behaviors, verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) was marked 'behavior of this type occurred daily'. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) was marked 'behavior of this type occurred daily'. Under 'wandering presence and frequency', the choice was marked 'behavior of this type occurred daily'. On 7/01/21 at 10:23 AM an interview was conducted with the Social Services Director (SSD), who was the grievance coordinator at the facility. She said the DON and herself met with Resident #46 in the family room. Resident #46 had concerns with Resident #16 regarding him not sleeping at night, yelling, slamming doors, and profanity, and it was keeping her awake. They offered her a room on the other unit. She did not want that. She asked what would be done. We said we would talk to the ARNP. She asked what she would do about it. We said we could not share that because it would violate privacy rights. The SSD said she let the ARNP know about the behaviors. There have been no further complaints from Resident #46. I have not heard that he isn't sleeping at night. The SSD said she did not ask Resident #46 if she is still having concerns about Resident #16. I talk to her everyday about her discharge plan and she has not voiced anything about him. On 6/30/21 at 10:33 AM an interview was conducted with Resident #16's CNA (Certified Nursing Assistant), Staff C. Staff C, CNA said Resident #16 does have behaviors. He takes all his clothes out and puts them on the bed, even the dirty ones from his basket. He puts food in the toilet and clogs it a lot. There has been no aggression on her shift. He does yell, but she has never seen him do anything to anyone else. 06/30/21 at 10:43 AM an observation was conducted. Resident #16 was walking through the hallway on the nursing unit with the use of a walker, pleasant and asking for coffee. On 6/30/21 at 10:59 AM an interview was conducted with Staff B, RN (Registered Nurse), Unit Manager. Staff B, RN said the ARNP with psychiatric services visits every Friday. She is managing Resident #16 's medications. Sometimes he refuses medications. He went to the hospital Saturday early in the morning for aggressive behavior. Normally somebody goes and talks to him, or he goes and talks to social services. On 7/01/21 at 1:18 PM a follow up interview was conducted with the DON. She said Resident #46 had a grievance and we wrote it up. We could not give her a lot of information because of HIPAA [Health Insurance Portability and Accountability Act] violation. We offered a room change, but she did not want it. She started getting upset and asked us to leave because her family was coming, and she did not want to be upset for the visit. We left because she asked us too; it wasn't quite resolved. She was upset that we offered her to move. She did not feel she had to move when she wasn't the problem. We tried to explain that we offer to move the person who has the concern, but that is when she asked us to leave. I have not followed up with her. The SSD usually goes back and follows up with them. We should have followed up with her. Review of the policy, Complaint/Grievance, dated 8/9/18, revealed the following: Overview: The intent of this guideline is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, loss clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the center actively seek a resolution for resident appropriately apprised of its progress toward resolution. Prompt efforts by the center to resolve grievances the resident may have, including those with respect to the behavior of other residents. Grievances will be reviewed by the quality assurance performance improvement committee. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. Purpose To support each resident's right to voice grievances resulting in a follow up and resolution while keeping the resident apprised of its progress toward resolution. Process An employee receiving a complaint/grievance from a resident, family member and/or visitor shall initiate a complaint/grievance form or electronic equivalent. The grievance officer/designee shall act on the grievance and begin follow up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable timeframe; this should not exceed 14 days. The findings of the grievance shall be recorded on the complaint/grievance form or electronic equivalent. The individual voicing the grievance shall receive a follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review the facility failed to ensure the necessary information was provided to the receiving facility during a transfer to the hospital for one resident (#16) of three residents sampled for a hospital transfer. Findings included: Resident #16 was admitted to the facility with diagnoses of schizophrenia and bipolar disorder, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) of 15, indicating an intact cognition. Further review of the assessment revealed the following information: Section G, functional status, locomotion on unit was marked supervision of one person. Section E, behaviors, verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) was marked 'behavior of this type occurred daily'. Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) was marked 'behavior of this type occurred daily'. Under 'wandering presence and frequency', the choice was marked 'behavior of this type occurred daily'. Review of a telephone order in Resident #16's record reflected a physician's order dated 5/21/21 for ABH (Ativan, Benadryl, Haldol) gel 0.5 milligrams (mg)-12.5 mg-0.5 mg, apply 1 milliliter (ml) topically [on the skin] to the neck, every 6 hours as needed for agitation. Review of a physician's order in the medical record dated 6/26/21 reflected transfer to hospital via 911 for altered mental status and aggression. Review of the nurse's notes in the Resident's medical record revealed the following findings: 6/26/21 2:38 p.m. Resident verbally aggressive, yelling and cursing throughout unit and difficult to redirect. Resident banging on windows and repeatedly slamming doors. Resident threatening staff and becoming physically aggressive towards staff. MD [medical doctor] made aware and prn (as needed) dose of Ativan administered per MD orders. Resident responsible party made aware of altered mental status and aggression. Continue to monitor. 6/26/21 3:43 p.m. Resident transferred via 911 for altered mental status and aggression towards staff for eval and treat per MD. Resident's daughter made aware. 6/26/21 10:33 p.m. Resident returned from the hospital via stretcher. Further review of Resident #16's record revealed there was no other information regarding Resident #16's transfer. On 7/01/21 at 10:23 AM an interview was conducted with the Social Services Director (SSD). She said, he went to the hospital on Saturday, and the doctor did more medication changes on Saturday. I was not here Saturday. The DON sent him out. On 6/30/21 at 10:59 AM an interview was conducted with Staff B, RN (Registered Nurse), Unit Manager. Staff B, RN said he went to the hospital Saturday early in the morning for aggressive behavior. The doctor gave the order. The DON called the physician, and he gave an order to send Resident #16 out for evaluation and treatment with a 911 pick-up. He was aggressive with the staff on night and morning shift. The weekend supervisor called the DON. Normally somebody goes and talks to him or he goes and talks to social services. He refused the medications. He doesn't normally have a problem with the day or night shift. On 6/30/21 at 4:20 PM an interview was conducted with the DON. She said he was getting aggressive, altered mental status. We called the doctor and he wanted him sent out. The hospital evaluated him and sent him back. He didn't come back with any new orders. He was cursing, walking up to staff aggressively. He says inappropriate words. He was being loud. I have never seen aggression toward residents, just staff. A lot of times he won't take his medications so he may not have allowed them to put it (the ABH gel) on. It is listed under 'other', which is why it is probably not showing up for them. Review of the June 2021 MAR (medication administration record) revealed that the ABH gel had never been administered. On 7/01/21 at 12:35 PM an interview was conducted with the DON, who confirmed there wasn't a transfer form in Resident #16's record. On 7/01/21 at 1:18 PM a follow up interview was conducted with the DON. She said I don't know why they didn't do the transfer form. Whether it's a [NAME] Act or not, the transfer form still should be completed. We sent him out for an evaluation. He normally walks around talking loud. That day he was louder than usual and verbally inappropriate. We tried redirecting him. He has PRNs, but once he has at a certain level he isn't going to take anything. The hospital evaluated him and sent him back. Review of the policy, Transfer/Discharge Notification and Right to Appeal, dated 3/26/18 reflected the following: Policy: Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. Procedure: The center must permit each resident to remain in the center, and not transfer or discharge the resident from the center unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs can't be met at the center unless: b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the center; c. The safety of individuals in the center is endangered due to clinical or behavioral status of the resident; d. The health of individuals in the center would otherwise be endangered; Documentation: When the center transfers or discharges a resident under any of the circumstances listed above the facility will ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation in the medical record to include: the basis for the transfer; In case of inability to meet resident's needs (as per above); the specific needs can not be met, The facility's attempts to meet the resident's needs, And the service available at the receiving facility to meet those needs The documentation must be made by: A physician when transfer or discharge is necessary due to: The safety of individuals in the center is endangered due to clinical or behavioral status of the resident; The health of individuals in the center would otherwise be endangered. Information provided to the receiving provider must include but is not limited to: Contact information of the practitioner responsible for the care of the resident. Resident representative information including contact information Advance Directives Special care instructions or precautions for ongoing care as indicated Comprehensive care plan goals All other necessary information, including copies of the resident's discharge summary and other documentation, as applicable to ensure safe and effective transition of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to obtain documentation from a hospice provider to ensure coordination of services for 1 of 2 (#17) residents receiving hospice services. Findings included: Review of the facility policy titled Hospice Care with an effective date of 11/30/14, and a revision date of 9/20/17 revealed the following: To ensure continuity of care between the center and the hospice provider, the Director of Nursing will designate a clinical member of the interdisciplinary team to work with the hospice including the following: Coordination of care plan process between the hospice and the center Communication with hospice representatives, hospice medical director and the patient/residence attending physician to ensure coordination of care. Ensure the following information is obtained from the Hospice: Most recent hospice plan of care A review of the Minimum Data Set (MDS) dated [DATE] indicates that Resident #17 is currently receiving hospice care. Review of the current physician orders revealed that the resident has a current order for hospice services dated 5/14/21. A review of Resident #17's electronic record and the paper record revealed that there was no documentation in the record that would identify what disciplines or services this resident would be receiving from the hospice provider, additionally there was no hospice assessment, no hospice care plan and no hospice ongoing notes that would indicate what needs the resident had and what is actually being provided. An interview on 6/30/21 at 9:46 AM with Staff J, Licensed Practical Nurse (LPN) revealed that if there are any changes with the resident, they notify the hospice team as well as the physician. She reported that the hospice nurse probably comes in once a week but that she has not seen that person and maybe they come on a different shift. She reported the hospice notes should be in the resident chart. An interview on 6/30/21 at 2:35 PM with the Director of Nursing (DON) revealed she is not sure how often hospice comes in to provide services for Resident #17, and that she is not sure of what the residents hospice plan of care is. She reported that she did investigate and found there is no documentation in the record from hospice. She reported she is unsure as to why there is no hospice plan of care or any other hospice documentation in the record. A phone interview on 6/30/21 at 3:05 PM with Staff K, Hospice Registered Nurse (RN), reported that that there are 2 hospice nurses on this team and the other nurse works weekends and visits the facility to see this resident on the weekends. She reported per the documentation the nurse has completed all visits and has faxed documentation including the plan of care to the facility. She reported as far as she knows the facility has not reported they have not received any documentation, but they have requested the plan of care today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to provide care and services consistent with professional standards of practice related to communication with the dialysis facility, as evidenced by a failure of monitoring resident status pre and post dialysis for one resident (#25) of four residents receiving dialysis. Findings included: A review of the medical record for Resident #25 revealed diagnoses that included type II diabetes, end stage renal disease, and dependence on renal dialysis, and anemia. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review physician's orders revealed: -An order dated 2/23/2021 for Hemodialysis M/W/F (Monday, Wednesday, Friday) with pick up at 9:30 a.m., dialysis time 10:30 a.m. -An order dated 2/23/21 to assess dialysis port site on the left upper chest for bruising/bleeding/symptoms of infection. A review of Resident # 25's care plan dated 05/05/21 revealed a focused area for renal dialysis related to renal failure and chronic kidney disease (CKD), with interventions that included check and change dressing daily, dialysis M/W/F, monitor for signs and symptoms (s/s) infection to access site, monitor/document and report s/s peripheral edema, bleeding, hemorrhage, or sepsis. A review of the medication administration record (MAR) and treatment administration record (TAR) for February 2021 through June 2021 revealed no documentation related to checking and/or changing the dressing on the dialysis site. An interview was conducted with Resident #25 on 06/30/2021 at 9:02 a.m. Resident #25 confirmed that she receives dialysis Monday/ Wednesday/Friday (M/W/F) at an outpatient facility. Resident #25 also confirmed that she does not take a dialysis binder with her to dialysis, but that if there are any papers she needs to bring back, the dialysis staff give her an envelope to give to the staff in the nursing home. An interview was conducted on 06/30/2021 at 9:10 a.m. with the Director of Nursing (DON) who revealed because of COVID-19, some dialysis facilities stopped using the resident binder for communication, but staff should check the resident vitals prior to transport. The DON also stated if there are any changes or issues during dialysis that the nursing home would receive a call from the dialysis facility. She confirmed all communication should be documented in the resident's medical record. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 06/30/2021 at 9:20 a.m. who stated she does take resident vital signs prior to transport for dialysis, and when the resident returns to the facility she was not aware of a dialysis binder, or a Dialysis Communication form. An interview was conducted with Staff B, Registered Nurse (RN), Unit Manager 06/30/21 at 12:20 p.m. Staff B, RN stated the nurse should be assessing the dialysis site every shift. Staff B, RN also stated that the Dialysis Communication form should be completed by the nursing staff prior to the resident being transported to the dialysis center, the form should be sent with the resident and facility staff should also complete the Dialysis Communication Record form on the resident's return. Staff B, RN confirmed that there was no documentation related to observation of the dialysis site in Resident #25's record. The Dialysis Communication form for 06/09/2021 was reviewed and the assessment area pre and post dialysis were not completed. No other Dialysis Communication forms were identified in Resident #25's record. A review of the facility policy titled, Coordination of Hemodialysis Services, last revised on 07/02/2019 revealed under the section titled 'Procedure': - The Dialysis Communication form will be initiated by the facility for any resident going to an End Stage Renal Disease (ESRD) center for hemodialysis. - Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center or the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. - Nursing will complete the post dialysis information and the Dialysis Communication form and file the form in the Resident's Clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview it was determined that the facility failed to provide Quality Assessment and Assurance (QAA) practice that demonstrated implementation of an effective action plan to correct the previously cited deficient practice at F584 related to providing a clean and sanitary environment for one resident (#17) out of three residents who received nutrition through enteral feeding. Findings included: A review of the facility policy titled, Performance Improvement Committee, effective 11/30/2014 and revised 8/19/2020, identified that The committee will assure QAPI activities have indicators and standards/thresholds for evaluation, that appropriate actions are implemented, and that such correction has been evaluated by subsequent monitoring. Review of the admission Record for Resident #17 revealed the resident was admitted to the facility on [DATE] with readmission on [DATE] and the diagnoses included personal history of transient ischemic attack and cerebral infarction, cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, encounter for attention to gastrostomy and encounter for palliative care. Review of the September 2021 physician orders revealed an order ,dated 8/5/21, for Enteral Feed Order every shift for Nutrition, Enteral Tube Feeding Jevity 1.2 at 55 ml/hr (milliliters per hour) x 20 hours. An observation of Resident #17, on 9/8/21 at 9:23 a.m. revealed the resident lying in her bed with the head of her bed elevated and her enteral feed container hanging from a pole next to her bed. Inspection of the resident's room surrounding her bed revealed a puddle of a light brown substance pooled on the floor located in the area beneath the tube feed formula. In addition, there were spatters of the light brown substance extending from under the pole out approximately two feet. ( Photographic Evidence Obtained) An observation of Resident #17 on 9/8/21 at 10: 41 a.m. revealed the resident lying in her bed with the head of her bed elevated and her enteral feeding container hanging from a pole. The observation revealed the puddle of light brown substance and the spatters of the light brown substance were still present. ( Photographic Evidence Obtained) An interview was conducted on 9/8/21 at 10: 45 a.m. with a person who identified herself as a Housekeeping Manager who was assisting from another facility. She stated the facility's Housekeeping Manager was on vacation. She stated there are four housekeepers out with COVID -19 and she has other housekeepers from other places helping. She was asked if the 200 hallway rooms had been cleaned by housekeeping today. She stated that on the left side of the hallway; the rooms had been cleaned. (Resident # 17 resides in a room on the left side of the hallway.) An observation with the Housekeeping Manager on 9/8/21 at 10:45 a.m. revealed the puddle of a light brown substance and the spatters of the light brown substance were still present. She stated that the housekeeping staff who cleaned the room should have cleaned the spill. She called a staff member to come in the room. The staff member stated he was the floor tech and he had cleaned the room this morning. He looked at the spillage and stated that when he cleaned the room someone was over there, so he couldn't clean and he had planned to come back, and clean that side of the room. He stated he was not aware of the spillage. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 9/8/21 at approximately 12:33 p.m. She stated she was the assigned nurse for Resident #17 for this day. She stated when she came in at 7:00 a.m. the tube feeding was hung and running. She stated she provided care for Resident #17 this morning, administered medication and ensured positioning but did not look down at the floor. She stated she was unaware of the spillage. She stated she did not know why it was on the floor and housekeeping should have cleaned it up. An interview was conducted with Staff B, Certified Nursing Assistant (CNA) on 9/8/21 at 2:17 p.m. She stated she was the assigned CNA for the day shift today for Resident #17. She stated she provided care for Resident #17 several times today but, I don't' look at the floor. She stated she did not notice the spillage. An interview was held with the Director of Nursing (DON) on 9/8/21 at 6:50 p.m. regarding the substance on the floor in Resident 17's room. She stated she heard there were some drips and housekeeping cleaned it up. She stated, Anyone can clean up the floor, and her expectation was if someone spilled something they should clean it up. Review of a policy titled, Cleaning and Disinfecting Resident's Rooms, revised August 2013, revealed: Purpose : The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident's rooms. General Guidelines: 1. Housekeeping surfaces (e.g floors, tabletops) will be cleaned on a regular basis,when spills occur, and when these surfaces are visibly soiled.

Based on observation, interview, and record review the facility failed to maintain the kitchen in a safe and sanitary manner related to ensuring the range hood was free from dust. Findings included: Observations during the initial tour of the facility's kitchen on 6/28/21 at 10:30 AM revealed that the kitchen housed a range hood which was located over the stove and steam oven. Closer observation of the range hood revealed the light covers and piping were covered in dust particles. Closer observation of the range hood revealed the sealants had become dislodged from the seams of the range hood and was noted to be blowing back and forth over the stove and steamer. (Photographic Evidence Obtained) An interview at this time with the Certified Dietary Manager (CDM), who was present in the kitchen at the time of the initial tour revealed she was unsure as to when the range hood was last cleaned. An interview on 6/28/21 at 10:42 AM with the Maintenance Director revealed the vendor who cleans the hood is due to come tomorrow. They come every 3 months and in between visits the Maintenance Director and dietary staff are responsible to keep it clean. An interview on 6/28/21 at 1:39 PM with the Maintenance Director revealed the facility does not have a contract with the range hood vendor and does not have a policy related to the range hood, or its maintenance/cleaning.