**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and the facility's policy titled, Safe and Homelike Environment, the facility failed to ensure the residents' living area was safe, clean, and comfortable in four of 165 rooms (Rm 515, RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER]). The facility also failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit filters were free of buildup and debris and failed to ensure that a broken mirror was not stored on the floor in one of six Central bath areas. Findings include: Review of the facility's undated policy titled, Safe and Homelike Environment, revealed under Policy Explanation and Compliance Guidelines: 1. The facility will create and maintain, to the extent possible, a homelike environment that emphasizes the institutional character of the setting. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Initial screening observation on 5/27/2025 at 8:10 am in room [ROOM NUMBER] revealed a small black oscillating fan blowing on bed A near window with fuzzy grayish substance on its fan vents. Initial screening observations on 5/27/2025 at 11:44 am and 1:04 pm in rooms 624, 702, 703 revealed PTAC unit front spongy filters dirty with thick gray fluffy substances. Observations on 5/28/2025 at 12:55 pm in room [ROOM NUMBER] revealed a small black oscillating fan blowing on bed A with fuzzy grayish substance on its fan vents. Observations on 5/28/2025 at 1:19 pm in rooms 624, 702, 703 revealed PTAC unit front spongy filters dirty with thick gray fluffy substances. Observation on 5/28/2025 at 3:30 pm revealed third floor shower room with a shattered broken wall mirror lying on the floor and wheelchair's leg rests lying on top of the PTAC unit. Observation on 5/29/2025 at 9:55 am revealed third floor shower room with a shattered broken wall mirror lying on the floor and wheelchair's leg rests lying on top of the PTAC unit. Interview walking rounds on 5/29/2025 at 10:25 am with Regional Maintenance Director (RMD) OO confirmed dirty personal fans, broken shattered wall mirror lying on the floor and wheelchair's leg rests on top of PTAC unit in the shower room, and dirty damaged PTAC units. Staff member stated his expectation was for environmental issues to be taken care of as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed R75 was admitted to the facility with diagnosis of but not limited to paranoid schizophrenia, mood disorder due to known physiological condition with mixed features, and major depressive disorder, recurrent. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C that R75 had a BIMS score of ten indicating the resident has moderate cognitive impairment. Section O revealed R75 has not received psychological therapy. Review of R75's care plan with revision date of 7/23/2020 revealed resident has past medical history of schizophrenia. Interventions to care include administer medications as ordered, assist and provide resident with a program of activities that are meaningful, and behavioral health consults as needed. Interview on 5/28/2025 at 2:47 pm with the Licensed Practical Nurse (LPN) VV revealed the process for identifying residents with possible mental disorders is checking the chart to see if they have any diagnoses of mental disorders. It was revealed the psychiatric doctor comes in to check for mental disorders. LPN VV stated the social worker is responsible for sending a PASARR referral to the appropriate agency. LPN VV confirmed R75 had a diagnosis of mental disorders without a PASARR II in the system. Interview on 5/29/2025 at 11:46 am with Social Worker WW revealed the facility's process for identifying residents with possible mental disorders prior to admission is to look at the PASARR Level I to identify if a resident is triggered for a PASARR Level II. It was revealed if a resident is triggered, a referral for PASARR Level II will be submitted. The social workers are responsible for making the referral if diagnoses occur in the facility. The Social Worker confirmed that R75 did not have a Level II on file and it was submitted for approval on 5/28/2025 during the survey. Interview on 5/29/2025 at 2:00 pm with the Administrator revealed her expectation is for the facility to be in compliance with the PASARR Level II audits and screenings. Interview on 5/29/2025 at 2:00 pm with the Administrator revealed her expectation is for the facility to be in compliance with the PASARR Level II audits and screenings. Based on resident and staff interviews, record review, and review of the facility's policy titled Coordination with PASAAR Program, the facility failed to provide Preadmission Screening and Resident Review (PASARR) Level II for two of six residents (R) (R54 and R75) with qualifying diagnoses. Findings include: Review of the facility undated policy titled, Coordination with PASAAR Program revealed under Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serios mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 5b. The Level II resident review must be completed within 40 calendar days of admission. Record Review revealed R54 was admitted to the facility with a diagnosis of but not limited to bipolar disorder current episode, aphasia, major depressive disorder, epilepsy, anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R54 has Brief Interview for Mental Status (BIMS) score of five indicated the resident has severe cognitive impairment. Record review of the care plan revealed R54 has focus to use anti-psychotic medication to manage bipolar disorder. R54 goals are to remain free of drug related complication through the review date. Interventions are to use medication as ordered and monitor for side effects and effectiveness. Interview on 5/29/2025 at 11:46 am with Social Worker WW described the process used to identify potential mental health concerns prior to admission. Continued interview revealed that the PASARR level I screening is reviewed to determine if a referral for PASARR Level II is required. If a resident is triggered a referral for a PASARR Level II will be submitted. SW WW expressed that the hospital makes a referral to the agency if a resident has a mental health diagnosis prior to admission. During the interview it was disclosed that if a resident has a diagnosis in the facility, then the social workers will do the referral. She confirmed a PASSAR Level II was not submitted for the R54 until 5/27/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for three of 59 sampled residents (R) (R36, R61, and R75) related to not receiving showers/baths, fingernails care and ADLs care. Findings include: Review of the facility's undated policy titled Activities of Daily Living (ADLs) indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. 1. Review of R36's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. Section GG (Functional Abilities and Goals) documented that R36 was dependent for showering/bathing and required substantial/maximal assistance with personal hygiene. Record review of the care plan revealed R36 has a focus of required assistance with ADLs due to generalized weakness and highly impaired mobility. R36 has a goal of being kept clean, dry, well-groomed, and appropriately dressed throughout the next review. R36 had interventions to assess ADL status and provide care/assistance as needed, and two staff members to assist the resident with ADL activities. Record review of the clinical record revealed R36 was admitted to the facility on [DATE] with diagnoses, including but not limited to, type 2 diabetes mellitus without complications other reduced mobility, schizoaffective disorder unspecified, major depressive disorder, hypertensive heart disease with heart failure, and unspecified diastolic (congestive) heart failure. Observation and interview on 5/27/2025 at 11:38 am with R36 revealed she was told by staff that the reason she could not receive a shower was that their shower bed had been broken for a long time. She stated she had to receive bed baths, but the staff do not wash her entire body. She stated, I am tired of my legs, feet, arms, back, and hair not being cleaned. I just get my chest and private area washed. Please tell me what lady you know only wants a few parts of her body washed? 2. Review of R61's Quarterly MDS, dated 3/272025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident had moderate cognitive impairment. Section GG (Functional Abilities and Goals) documented that R61 required substantial/maximal assistance for showering/bathing and required partial assistance with personal hygiene. Record review of the care plan revealed R61 has a focus of self-care deficit related to hemorrhagic stroke of cerebrovascular accident (CVA) resulting in chronic right-side hemiparesis, seizure disorder, and high blood pressure (HTN). R61 has a goal of ADL needs that will be observed and addressed to ensure his needs are met as needed through the next review. R61 has an intervention to observe ADL status and provide care/assistance as needed. Record review of the clinical record revealed R61 was admitted to the facility on [DATE] with diagnoses, including but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysarthria following cerebral infarction, other seizures, essential (primary) hypertension, hyperlipidemia, and unspecified insomnia. Observation on 5/27/2025 at 3:54 pm revealed R61's fingernails were untrimmed, jagged, and dirty with dark brownish and black substances underneath the fingernails. Observation on 5/28/2025 at 10:43 am revealed R61 sitting in the common area watching television with other residents, with fingernails untrimmed, jagged, and dirty with dark brownish and black substances underneath fingernails. In an interview on 5/28/2025 at 1:10 pm, Certified Nursing Assistant (CNA) MM stated there were no broken shower beds. She stated ADL care was provided for all residents, and showers were given every day. She stated each resident had two scheduled shower days, and on the other days, they provided bed baths. She stated that normally she does extensive grooming, like trimming fingernails, on shower days, because the nails were clean and softer to manage. She stated she had not noticed R61's nails being long and further stated the evening shift gave him his showers. In an interview on 5/28/2025 at 1:20 pm, Licensed Practical Nurse (LPN) NN confirmed R36's showers were scheduled on Mondays and Thursdays during the day shift. She stated, according to their shower sheets for the months of April and May, R36 only had a shower on 5/8/2025. She confirmed R36 only refused a shower on 5/12/2025 but received a bed bath. LPN NN further stated R61 shower days were scheduled on Tuesdays and Fridays at night. She stated that he should have received a shower last night, and all his grooming, including trimming of fingernails, should have been done. She confirmed that R61's fingernails were untrimmed, jagged, and dirty with dark brownish and black substances. She further confirmed that R61 did not receive a bath on his scheduled day, which was last night. In an interview on 5/29/2025 at 8:33 am, the Director of Nursing (DON) revealed her expectation was for staff to provide grooming care needs every day during their shower and bed bath time. She stated the facility's process for nail care was for it to be done when anyone has dirty fingernails, by trimming and cleaning as needed. She stated she expected staff to give residents showers on their scheduled weekly shower days. She stated that if they do not want a shower but a bed bath, then that is their preference as well. She confirmed the facility has not had any broken shower/bath beds. She stated the CNAs are required to document all showers and bed baths information on their shower sheet, that are kept in a binder at the nursing station. She confirmed on all the April and May shower/bath sheets that there was only one shower sheet showing R36 had a shower. 3. Review of R75's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of ten, indicating the resident has moderate cognitive impairment. Section GG (Functional Abilities and Goals) documented impairment on both sides of his lower extremities, and dependence for bathing, dressing, personal hygiene, and transfers. Review of R75's care plan, with revision date of 7/23/2020, revealed the resident needs assistance with ADL functions related to debility stroke. Interventions to care include assessing ADL status and providing care as needed, assisting the resident with ADLs, and cueing and guiding the resident in the performance of ADL activities. Record review revealed R75 was admitted to the facility on [DATE] with a diagnosis of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, paranoid schizophrenia, mood disorder due to a known physiological condition with mixed features, and major depressive disorder, recurrent, unspecified. Observation and interview on 5/28/2025 at 1:38 pm revealed the resident lying in bed. R75 revealed he missed church every time it was held due to the staff not getting him out of bed. R75 also revealed that he missed bingo activities. R75 revealed he has addressed the concerns with the staff, and they told him they will get him up for the next activity. R75 stated that the staff does not get him up for the activities. Observations on 5/28/2025 at 2:30 pm revealed residents attending church, and R75 was not in attendance. In an interview on 5/28/2025 at 2:47 pm, LPN VV confirmed R75 missed church on 5/28/2025 due to not being dressed and out of bed, and that R75 was care planned for attending church along with other activities. In an interview on 5/29/2025 at 11:15 am with the Certified Nursing Assistant (CNA) UU revealed she was familiar with R75's care plan and that he was care planned for participating in activities he enjoys. In an interview on 5/29/2025 at 2:00 pm, the Administrator revealed her expectation was for the facility staff to ensure the residents were well-groomed, dressed, out of bed, and for residents to participate in desired activities if requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policies titled, Resident Self-Administration of Medications and Medication Storage, the facility failed to adequately assess two of 59 sampled residents (R) (R56 and R515) for self-administration of medication; failed to ensure one room was free from accident hazards. Specifically, medication was found in an unoccupied room (room [ROOM NUMBER]) on the second floor. The deficient practice had the potential to cause serious safety issues for residents, staff and visitors. Findings include: Review of the undated facility's policy titled Resident Self-Administration of Medications documented under the Policy Explanation and Compliance Guidelines section revealed, 1. Each resident if offered the opportunity to self-administer medication during the routine assessment by the facility's interdisciplinary team (IDT). 2. Resident's preference will be documented on the appropriate form and placed in the medical chat. 3. When determining if self-administration is clinically appropriate, the IDT should at a minimum consider the following: a. The medication appropriate and safe for self-administration. b. The 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 medication 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. The resident comprehension of instructions for the medication they are taking including 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 the medication is stored safely and securely. Review of the facility's undated policy titled Medication Storage under section one, subsection c, revealed, During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. Review of the electronic medical record (EMR) revealed R56 was admitted to the facility with a diagnoses of but not limited to unspecified mood affective disorder and major depressive disorder, single episode. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed R56 had a Brief Interview for Mental Status score of 15, indicating intact cognition. Review of physician orders for R56 revealed no orders were found for [Name] (pain reliever) gel liquid oral tablets. Review of physician orders for R56 revealed no orders were found for melatonin (sleep rhythm) 10 milligrams (mg). Review of R56's EMR revealed no self-administration order for self-medication assessment. During an observation on 5/27/2025 at 12:06 pm and on 5/28/2025 at 11:52 am revealed [Name] (pain reliever) gel liquid oral tablets and melatonin at R56's bedside dresser. During an observation and interview on 5/28/2025 at 11:55 am with Licensed Practical Nurse (LPN) CC confirmed R56 was not assessed for self-administration of medication and those items should not be in her possession. During an interview on 5/29/2025 at 2:29 pm with the Director of Nursing (DON) revealed she did not expect medication to be at the resident bedside unless they were clinically assessed, and medication was stored and locked appropriately. She continued to reveal everyone was responsible for ensuring these situations were reported to ensure safety for the residents. 2. Review of the EMR revealed R515 was admitted to the facility with diagnoses including but not limited to cerebral infarction, unspecified, viral infection, unspecified, type 2 diabetes mellitus, schizoid personality disorder. Review of R515's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicates R515 has moderate cognitive impairment. Section GG, functional status, revealed R515 required partial/moderate assistance for activities of daily living (ADLs). Review of the Physician's Orders for R515 included but was not limited to: Order dated 5/21/2025 Clopidogrel Bisulfate Tablet 75 MG (milligram); Order dated 5/21/2025 Sulfamethoxazole-Trimethoprim Oral Tablet 400-80 MG (Sulfamethoxazole-Trimethoprim); Order dated 5/21/2025 valganciclovir HCl Oral Tablet 450 MG (Valganciclovir HCl). Observation and interview on 5/27/2025 at 11:04 am revealed R515 was not in his shared room. The bedside table between R515's bed and his roommate's bed had one pill in applesauce sitting on it. R515 entered the room at 11:19 am in a manual wheelchair and confirmed that the bedside table and the pill belonged to him. R515 revealed, I have been here maybe three weeks. I take my pills in applesauce. I took all of them except for one. Observation and interview on 5/28/2025 at 10:40 am revealed R515 lying on the bed. R515 stated, They bring me pills in a small cup with applesauce and I eat them. They usually stand here and make sure I take them all. They will usually tell me if a pill is left in the cup, and I take it. Maybe I missed one of my pills yesterday. An interview on 5/27/2025 at 2:10 pm with the Administrator and the Unit Manager of the seventh floor confirmed that medications should not be left at the bedside. An interview on 5/29/2025 at 9:48 am with LPN RR confirmed that there was no self-medication at this facility. She also stated, I stay in the room to ensure all meds are given. If they refuse, I encourage them to take the medications. If they still refuse, I dispose of it and document refusal. 3. Observation made on 5/27/2025 at 12:19 pm in room [ROOM NUMBER]B revealed a single pill lying on top of a bare, unassigned bed. No staff were present in the room at the time of the observation, and the pill was unsecured and unattended. Interview with LPN DD on 5/27/2025 at 12:22 pm confirmed the presence of the pill on the unassigned bed. LPN DD removed the pill and stated she could not identify the pill or determine which resident it may have belonged to. LPN DD further acknowledged that had the pill been a narcotic, it would have posed a serious safety concern, as a resident or family member could have entered the room and ingested it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff, resident, and resident family interviews, record review, and review of the facility's policy titled, Oxygen Concentrator, the facility failed to ensure physician orders for oxygen (O2) therapy were followed for two of eight residents (R) (R43 and R564) receiving oxygen. The deficient practice had the potential to cause abnormal respiratory function and adverse clinical outcomes. Findings include: Review of the undated facility's policy titled Oxygen Concentrator revealed under Section four, Use of Concentrator, subsection (a) The nurse shall verify the physician's orders for the rate of flow and route of administration of oxygen (e.g., mask, nasal cannula). Subsection (g) Plug in the unit, turn it on to the prescribed flow rate, and assess for proper functioning. 1. Review of the electronic medical record (EMR) revealed R43 was admitted to the facility with pertinent diagnoses including, but not limited to COVID-19, chronic pulmonary edema, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD)-unspecified, and unspecified diastolic (congestive) heart failure. Review of R43's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of R43 care plan dated 5/1/2025 revealed no documented interventions or goals related to O2 therapy or management. The care plan did not address the physician's order for O2 administration or monitoring. Review of the physician's orders for R43 revealed an order dated 5/12/2025 for oxygen two liters via nasal cannula (NC) to maintain oxygen saturation of 90% (percent). Observation and interview on 5/27/2025 at 1:09 pm with R43 revealed the resident was receiving O2 via NC from a concentrator set to three liters per minute (LPM), which was not consistent with the physician's order. R43 reported experiencing a persistent cough that comes and goes, often lasting a while. He stated that the coughing fits tire him out to the point that he needs to lie down and rest in bed afterward. Observation on 5/28/2025 at 1:02 pm revealed the O2 concentrator for R43 remained set at three LPM by NC. Observation on 5/28/2025 at 1:04 pm with R43 revealed the O2 concentrator set at three LPM and R43 lying in bed and stated that he continued to experience coughing fits. Interview on 5/28/2025 at 1:05 pm, Licensed Practical Nurse (LPN) EE confirmed that R43 was receiving three LPM of O2 and acknowledged this was inconsistent with the physician's order and adjusted the flow to two LPM and filled the humidifier with distilled water as it was empty. LPN EE further revealed that she had not checked any of the concentrators for flow rate that shift and should be verifying them at least three times per shift. She further stated she had not received any training on O2 concentrator use at the facility and that her knowledge came from previous experience. LPN EE viewed the flow rate from a standing position, not at eye level. An interview on 5/29/2025 at 2:05 pm with the Director of Nursing (DON) revealed that her expectations for nursing staff include verifying O2 concentrator settings at the beginning of each shift, ensuring the O2 flow rate matched the physician's order, and confirming that residents were wearing NC's as prescribed. She emphasized that staff should check the concentrator's flow rate at eye level and take a proactive approach in monitoring residents receiving O2 therapy. The DON stated that any discrepancy in O2 flow, whether too high or too low, required immediate notification of the physician. She acknowledged that failure to follow prescribed O2 levels could result in abnormal respiratory function and potentially serious clinical complications. Review of staff education records for the past year revealed no documented training or in-service on O2 administration or use of O2 concentrators. Clinical training related to O2 management was conducted during a three-day unit orientation, during which new staff shadow a nurse and complete checklists. There was no structured or formal instruction specific to O2 therapy or equipment use documented. 2. Review of EMR revealed R564 was admitted to the facility with pertinent diagnoses including, but not limited to: COVID-19, Alzheimer's Disease, aftercare following joint replacement surgery, fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, and chronic kidney disease-stage three A. Review of the R564 admission MDS dated [DATE] revealed a BIMS score of 8, indicating moderate cognitive impairment. Review of R564's care plan dated 5/27/2025, with focus on O2 therapy, included the goal that the resident will have no signs or symptoms of poor oxygen absorption through the review date of 8/1/2025. Interventions included but not limited to medication administration as ordered, monitoring for respiratory distress symptoms. Oxygen settings were documented as two liters per minute via nasal cannula per physician orders, with positioning recommendations to optimize ventilation. Review of the physician's orders for R564 revealed an order dated 5/1/2025 for oxygen via nasal cannula at two liters per minute continuously every shift. Observation and interview on 5/27/2025 at 11:23 am with R564 revealed the resident was wearing a NC, however, the O2 concentrator was turned off, and next to R564's nightstand was an O2 tank, free standing, not placed in holder or on a cart. Observation and interview on 5/28/2025 at 1:10 pm with R564 revealed the resident was in her room eating lunch without wearing the NC. The O2 concentrator was set at one and one-half LPM. Interview on 5/28/2025 at 1:13 pm with LPN EE confirmed and acknowledged R564 was not wearing the NC, and the O2 concentrator was set below the ordered flow rate which was inconsistent with the physician's order. LPN EE assisted the resident with placement of the NC and adjusted the O2 concentrator to deliver the prescribed dose of two LPM of O2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Pain Management, the facility failed to ensure adequate pain management for two of 59 sampled residents (R) (R371 and R43). Findings include: Review of the facility's undated policy titled Pain Management revealed the Policy stated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The Pain Assessment section included, 2. c. Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident. 1. Review of R371's admission Record revealed R371 was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified fracture of shaft or tight femur (thigh bone), fracture of right pubis (pelvis bone), fracture of sacrum (buttock bone), and personal injury in unspecified motor-vehicle accident. Review of R371's admission Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section J (Health Conditions) documented that the resident was on a scheduled pain medication regimen, received as-needed pain medication, and had frequent pain that was severe. Review of R371's Clinical Physician Orders revealed an order dated 5/12/2025 and discontinued on 5/18/2025 for oxycodone-acetaminophen oral tablet 5-325 milligram (mg) (a medication used to treat moderate to severe pain), one tablet by mouth every four hours as needed for severe pain. Further review revealed an order dated 5/12/2025 for oxycodone-acetaminophen oral tablet 5-325 mg, one tablet by mouth every four hours as needed for moderate pain. Continued review revealed an order dated 5/18/2025 for oxycodone-acetaminophen oral tablet 5-325 mg, give two tablets every four hours as needed for severe pain, alternate one and two with previous dose. An order dated 5/12/2025 revealed to record the numeric value of pain using the following: 0-10 (0=No Pain; 3=Mild; 6=moderate;10=Excruciating). Review of R371's Medication Administration Record (MAR) dated May 2025 revealed the following: 5/15/2025: oxycodone-acetaminophen 5-325 mg one tablet at 9:25 am with a pain level of 9. 5/15/2025: oxycodone-acetaminophen 5-325 mg one tablet at 1:30 pm with a pain level of 9. 5/16/2025: oxycodone-acetaminophen 5-325 mg one tablet at 8:45 am with a pain level of 9. 5/21/2025: oxycodone-acetaminophen 5-325 mg two tablets at 11:15 am with a pain level of 8. 5/21/2025: oxycodone-acetaminophen 5-325 mg one tablet at 3:52 pm with a pain level of 8. 5/22/2025: oxycodone-acetaminophen 5-325 mg two tablets at 12:48 am with a pain level of 8. 5/22/2025: oxycodone-acetaminophen 5-325 mg one tablet at 9:32 am with a pain level of 8. 5/22/2025: oxycodone-acetaminophen 5-325 mg one tablet at 4:57 pm with a pain level of 8. 5/23/2025: oxycodone-acetaminophen 5-325 mg two tablets at 9:49 am with a pain level of 8. 5/23/2025: oxycodone-acetaminophen 5-325 mg one tablet at 1:43 pm with a pain level of 8. 5/24/2025: oxycodone-acetaminophen 5-325 mg two tablets at 1:58 pm with a pain level of 8. 5/24/2025: oxycodone-acetaminophen 5-325 mg one tablet at 6:20 pm with a pain level of 8. 5/25/2025: oxycodone-acetaminophen 5-325 mg one tablet at 10:00 am with a pain level of 8. 5/25/2025: oxycodone-acetaminophen 5-325 mg two tablets at 2:14 pm with a pain level of 8. 5/27/2025: oxycodone-acetaminophen 5-325 mg one tablet at 10:19 am with a pain level of 8. 5/27/2025: oxycodone-acetaminophen 5-325 mg two tablets at 1:40 pm with a pain level of 8. 5/27/2025: oxycodone-acetaminophen 5-325 mg two tablets at 5:53 pm with a pain level of 10. During an interview on 5/27/2025 at 11:56 am, R371 revealed she was always in pain and had expressed to the nurses her current medication dosage for her pain levels was not strong enough. During an interview on 5/29/2025 at 1:06 pm, Licensed Practical Nurse (LPN) AA stated that when she administered pain medication to a resident, she asked about the pain levels, assessed them, and asked where the pain was. LPN AA reviewed R371's MAR and confirmed, based on the physician's orders and medication administered, R371 was not receiving an adequate medication dosage for her pain levels. During an interview on 5/29/2025 at 1:13 pm, LPN BB stated R371 was not receiving the corrected pain medication based on her pain scale. During an interview on 5/29/2025 at 2:29 pm, the Director of Nursing (DON) stated the nurses were expected to ask the resident how they feel, what their pain level is, and should administer medications based on their scale and proceed to follow the order as written. 2. Review of R43's electronic medical record (EMR) revealed R43 was admitted to the facility on [DATE] with diagnoses including, but not limited to, unstable burst fracture of the third thoracic vertebra, displaced intertrochanteric fracture of the left femur, fracture of one rib-right side, and unspecified fracture of the sternum. Review of R43's admission Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment). Section J (Health Conditions) documented R43 received scheduled and as needed pain medication, and had frequent pain. Review of R43's Physician Order Summary revealed an order dated 4/30/2025 for morphine sulfate ER (extended release) 15 mg, one tablet by mouth every 12 hours for chronic pain. Further review revealed an order dated 4/30/2025 for oxycodone HCl (hydrochloride) 5 milligram (mg) (a medication used to treat moderate to severe pain), give one tablet by mouth every six hours as needed for breakthrough pain. Review of R43's Medication Administration Record (MAR), dated 5/2025, revealed the scheduled morphine sulfate was not documented as administered on 5/1/2025, 5/8/2025, 5/15/2025, 5/16/2025, 5/23/2025, and 5/24/2025. The missed medications were documented with a coded note indicating 14 = Pharmacy Pending. In an observation and interview on 5/27/2025 at 1:09 pm, R43 stated he had not received his pain medication regularly. He stated the medication was not available for two days in a row and on other days. R43 stated that the medication prescribed for breakthrough pain was not effective in managing his discomfort and emphasized the need for regular pain medication. In an observation and interview on 5/29/2025 at 11:05 am, R43 stated that on the days he did not get his scheduled pain medication, he experienced pain at a level of 10 out of 10, was unable to sleep, and avoided movement. In an interview on 5/28/2025 at 1:04 pm, LPN EE revealed that the pharmacy often fails to deliver medications in a timely manner, and staff frequently needed to call in medication reorders. When asked about the process for managing missing medications, particularly pain medications, LPN EE did not describe a clear procedure or mention the use of an emergency supply or timely physician notification. In an interview on 5/28/2025 at 9:58 am, the Unit Manager LPN FF stated that there were ongoing issues with timely medication delivery from the pharmacy. She explained that delays often occur with narcotic prescriptions due to insurance verification processes and the absence of automatic physician communication for renewals. She further stated that medications were ordered based on insurance coverage, and delivery depended on what was approved and when. She did not identify any alternative procedures, such as the use of an emergency drug supply, or provide details on how residents' pain is managed in the interim. In an interview on 5/29/2025 at 2:05 pm, the DON revealed that it was never acceptable for a resident to be left in pain. The DON stated that if a resident's prescribed pain medication has been exhausted, nursing staff are expected to utilize the emergency supply as an interim measure. She stated that this expectation applies to all nursing staff, including agency nurses, and that they are to seek assistance from the on-duty supervisor when needed. The DON further explained that nurses were responsible for monitoring medication supplies, identifying medications that are low or due for reorder, and submitting reorders through the facility's electronic health record system. The DON acknowledged ongoing issues with the pharmacy, particularly delays related to the refill of narcotic medications. She stated that narcotic prescriptions require physician approval, but the pharmacy does not initiate contact with the physician to obtain this approval. As a result, there are instances where medications are not refilled in a timely manner.

Based on observations, record review, staff interviews, and review of the facility's policies titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. There were five errors from 40 opportunities observed for a medication error rate of 7.5 percent. This deficient practice had the potential to place resident (R) R12 at risk of medical complications and a diminished quality of life. Findings Include: Review of the facility's undated policy titled Medication Administration, revealed the Policy section included, 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. Observation on 5/28/2025 at 9:36 am of medication pass with Registered Nurse (RN) GG revealed R12's prescribed medications included losartan potassium 50 milligrams (mg)(a medication used to treat high blood pressure), Flonase 50 micrograms (mcg) (a medication used to treat nasal allergies), and Icy Hot patch five percent (a medication used to relive minor muscle and joint pain) were not administered due to being unavailable. In an interview on 5/28/2025 at 9:36 am, RN GG confirmed that R12 medications were not available and had not yet been refilled by the pharmacy. She reported submitting refill requests, but no further action was taken to procure the medications. In an interview on 5/29/2025 at 2:05 pm, the Director of Nursing (DON) revealed that all nursing staff are expected to verify the availability of scheduled medications before each pass and to administer medications as ordered. She further confirmed that medications not available from the pharmacy should be obtained through the emergency drug supply if they were available, and further stated that pharmacy orders normally took two days for delivery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review and review of the facility's policy titled, Residents' Rights & Responsibilities, the facility failed to ensure call lights were answered and care provided for one of three residents (R) (R1). Specifically, the facility failed to ensure R1 care needs were met after the initiation of the call light system. Findings include: Review of the facility's policy titled, Residents' Rights & Responsibilities dated September 28, 2023, under the Purpose statement revealed, [Facility Name] respects the rights of the patients / residents; recognizes that each patient / resident is an individual with unique healthcare needs, values, and cultural perspectives; and because of the importance of respecting each patient's / resident's personal dignity, provide considerate, respectful care focused on the patient's / resident's needs. Review of R1's admission Record revealed diagnoses of but not limited to unspecified osteoarthritis, other chronic pain, asthma, morbid (severe) obesity due to excess calories, abnormal posture, pain in right knee, presence of right artificial knee joint, other symptoms and signs involving the musculoskeletal system, muscle weakness (generalized), and difficulty in walking. Review of R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 15, which indicated little to no cognitive impairment; Section GG (Functional Abilities and Goals) revealed, the resident required staff assistance with showering, dressing, toileting/bedpan, and personal hygiene. Review of R1's care plan with date initiated on 5/17/2024 revealed R1 has ADL (Activities of Daily Living)/self-care deficit related ot Stage IV Ovarian Cancer with interventions that included but not limited to: assess ADL status and provide care/assistance as needed, bath/shower as scheduled and as needed; provide assistance with dressing, grooming, personal hygiene, and bathing; and Transfers: resident requires one person assist with transfers (date initiated 1/6/2024). Interview on 10/25/2024 at 2:01 pm with R1 revealed, staff would ignore her call light, walk by or would answer the light and leave without assisting, which resulted in episodes of incontinence of urine and feces. Interview on 10/28/2024 at 10:20 am with the Administrator, Director of Nursing (DON), and R1 revealed resident was asked if any of staff members tell you to use the restroom on yourself when you ask to be toileted, and they will come back to clean you up? R1 stated, Yes, they do that, and I don't want to poop on myself, and I really hate peeing on myself, but I don't have a choice. Observation on 10/28/2024 at 11:15 am of R1's head-to-toe assessment, with Registered Nurse (RN) DD revealed R1 had a towel wrapped around their pelvis and was triple diapered and the brief was full of urine. During this time an interview was conducted with RN DD, who was asked was this normal peri care protocol and RN DD responded with, No, some of the CNA's are really telling on themselves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Residents' Rights & Responsibilities, the facility failed to ensure one of three residents (R) (R1) the choice of time and preference for showers. Findings include: Review of the facility's policy titled, Residents' Rights & Responsibilities dated September 28, 2023, under the Purpose statement revealed, [Facility Name] respects the rights of the patients / residents; recognizes that each patient / resident is an individual with unique healthcare needs, values, and cultural perspectives; and because of the importance of respecting each patient's / resident's personal dignity, provide considerate, respectful care focused on the patient's / resident's needs. Under the section titled, Patients / Residents of [Facility Name] are entitled to the rights listed below revealed, number 10. Make informed decisions regarding his / her care. Review of R1's admission Record revealed diagnoses of but not limited to unspecified osteoarthritis, other chronic pain, asthma, morbid (severe) obesity due to excess calories, abnormal posture, pain in right knee, presence of right artificial knee joint, other symptoms and signs involving the musculoskeletal system, muscle weakness (generalized), and difficulty in walking. Review of R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 15, which indicated little or no cognitive impairment; Section GG (Functional Abilities and Goals) revealed, the resident required staff assistance with showering, dressing, toileting/bedpan, and personal hygiene. Review of R1's care plan with date initiated on 5/17/2024 revealed R1 has ADL (Activities of Daily Living)/self-care deficit related ot Stage IV Ovarian Cancer with interventions that included but not limited to: assess ADL status and provide care/assistance as needed, bath/shower as scheduled and as needed; honor resident's wishes to have her showers in the evening; provide assistance with dressing, grooming, personal hygiene, and bathing. Interview on 10/23/2024 at 11:46 am with R1 revealed, that the night Certified Nursing Assistants (CNAs) would not always honor the late shower times that they preferred, between 11:00 pm - 12:00 am. R1 stated, the night CNA was unwilling to give them a shower or bed bath the night before surveyor entered the facility on 10/23/2024. R1 stated CNA's complained about going through the process of transferring R1 with the Hoyer lift and would typically only offer a bed bath. Review of the Shower Schedule posted at Nurse's Station revealed night showers on Tuesday and Friday for R1. Shower Sheet's for R1 revealed only three documented showers out of seven possible showers for the month of October prior to the surveyor's entry. The three showers documented were dated on 10/1/2024,10/8/2024, and 10/15/2024. There was no documentation noting the reasons for R1's missed showers for the other scheduled days. Interview on 10/24/2024 at 10:00 am with Registered Nurse (RN) CC, Unit Manager stated CNAs are expected to document the reasons for missed showers on the Shower Sheet's and report them to the Unit Manager for rescheduling.

Based on observation, staff interviews, record review, and review of the facility's policy titled, Medication Administration, the facility failed to follow professional standards of care for one of 26 Residents (R) (R134). Specifically, the facility failed to transfer a physician ordered medication to the Electronic Medical Record (EMR) system and to the Medication Administration Record (MAR). Findings included: Review of the facility's policy titled, Medication Administration dated September 28, 2023, revealed under Purpose revealed, Medications are administered as ordered 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. Further review, under the Policy Explanation and Compliance Guidelines revealed, Number 17. Sign MAR after administered . Review of R134's undated admission record located in the resident's EMR under the Profile tab revealed R134 was admitted with diagnosis of chronic obstructive pulmonary disease (COPD). Review of R134's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/2023, located in the resident's EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R134 was cognitively intact. During a medication administration observation on 12/20/2023 at 9:00 am, R134 stated she was supposed to receive a Trelegy inhaler (inhalation medication to treat COPD) once a day. Review of R134's hospital Discharge Report, dated 12/3/2023, provided by the facility, revealed the following order: Trelegy Ellipta 100-62.5-25 mcg (microgram) - inhale 1 puff into the lungs daily. Review of R134's MAR for the month of December 2023 revealed the Trelegy inhaler had not been added to the EMR system nor the December 2023 MAR. During an interview on 12/20/2023 at 11:01 am, Licensed Practical Nurse (LPN)1 stated that she transferred R134's medications from the discharge report on 12/4/2023, but inadvertently did not transfer the Trelegy inhaler to the EMR system or the MAR. During an interview on 12/20/2023 at 1:41 pm, the Director of Nursing (DON) confirmed all orders should be placed in the EMR system so that it would generate on the MAR.

Based on interviews, record review, and review of the facility's policy titled, Physician Verbal Orders, the facility failed to ensure a telephone order for one of 31 sampled Residents (R) (R290) were transcribed into the Electronic Medication Administration Record (EMAR) system which resulted in R290 not receiving the physician ordered medication. Findings include: Review of the facility's policy titled, Physician Verbal Orders, dated 9/28/2023, under the Policy Explanation and Compliance Guidelines revealed, Number three Enter the order into the medical record electronically. Review of R290's undated admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed R290 was admitted with diagnosis that included dementia. Review of the admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/11/2023 revealed R290 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated severe cognitive impairment. Review of the Consultation Initial Visit note located in the EMR under the Progress Notes tab, dated 12/11/2023, revealed GERD [gastro-esophageal reflux disease], Added Famotidine (medication to treat GERD, generic for Pepcid) 20 mg [milligram] BID [twice daily]. Review of the EMR Orders tab for 12/2023, revealed no current or discontinued orders for Famotidine. During an interview on 12/18/2023 at 10:51 am, R290's Family (F)1 stated that the resident was not getting the medications ordered by the physician. She stated he was supposed to receive Prilosec (medication that reduces gastric acid secretion) twice a day and had still not received it. During an interview on 12/20/2023 at 10:10 am, the Licensed Practical Nurse (LPN) 1 stated she was the unit manager and that orders depended on the physician. She stated some of the physicians were able to add orders directly into the electronic system and others had handwritten orders. She stated she located R290's handwritten order, dated 12/11/2023, for the GERD medication and she confirmed that she had signed off on the order, however, she confirmed she did not add the order to the (EMAR). She stated orders should have been implemented as soon as possible. During an interview on 12/20/2023 at 3:17 pm, the Director of Nursing (DON) confirmed that it was missed for this resident.

Based on staff interviews, record review, and review of the facility's policies titled, Fall Prevention and Fall Management, the facility failed to ensure a resident that required two-person assistance received adequate supervision during activities of daily living (ADL) care for one of four Residents (R) (R231) reviewed for accidents. This failure resulted in R231 falling from bed to the floor, sustaining neck pain and being transferred to the hospital. Findings include: Review of the facility policy titled, Fall Prevention dated 9/28/2023, provided by the facility, stated, . Ensure that the resident's care plan addresses her [sic] fall risk . Review of the facility policy titled, Fall Management dated 9/28/2023, provided by the facility, stated, . If you're with a resident as he [sic] falls, try to break his fall with your body and gently guide him to the floor . Review of the Progress Notes dated 10/28/2023, located in the Electronic Medical Record (EMR) under the Progress Notes tab revealed, CNA [certified nurses' aide] called writer to the room Upon arrival writer noted resident on the floor lying on her back. Resident alert and responsive. Action: . Resident complained of neck pain. Supervisor called. 911 called and resident taken to the hospital. Review of the facility investigation revealed the Administrator was notified of the incident on 10/28/2023. The investigation included a timeline created by the facility revealed three CNAs were providing care by 6:40 am .at 6:43 am CNA 2 and CNA 4 exited the room . speaking loudly to each and exited the room . 6:45 am nurse heard CNA 1 calling for help . Nurse arrived and noted resident on the floor on her back. Assessment initiated . 7:30 am Paramedics arrived . 8:15 am Patient left facility to ER [emergency room] . Review of 5-Day Follow-Up Report to the State Survey Agency, provided by the facility, revealed CNA1 was finishing ADL care and R231 told her I'm falling. CNA1 went to the other side of the bed to assist her to the floor. She was not able to catch R231 but was able to prevent R231's head from hitting the floor. R231 complained of neck pain and the paramedics were called. Review of the admission Record located under the Profile tab of the EMR revealed R231 was admitted with diagnoses that included osteomyelitis of the left and right ankle and foot, thrombosis of unspecified deep veins of bilateral lower extremity, muscle weakness, abnormal posture, spinal stenosis, and history of falling. Review of the Annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 8/20/2023 revealed R231 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R231 was cognitively intact. Review of the Care Plan located in the Care Plan tab of the EMR revealed R231 required assistance with ADLs and one of the interventions stated, Resident requires two person assist for transfers & ADL care. Review of the Fall Risk Assessment dated 9/20/2023 located in the Assessments tab of the EMR revealed R231 a score of nine. During an interview on 12/21/2023 at 2:05 pm, the Director of Nursing (DON) stated that a score of nine indicated R231 was a moderate risk for falls. During a telephone interview on 12/19/2023 at 2:28 pm, CNA4 confirmed she was assisting CNA1 and CNA2 with providing ADL care to R231. She stated she left the room towards the end of the care being provided and did not know anything else. Interview on 12/21/2023 at 10:54 am with the DON revealed CNA1, CNA2, and CNA4 were providing ADL care to R231 and CNA2 and CNA4 left the room prior to care being completed and sustained a fall. The DON stated he expected the three CNAs to remain in the room until ADL care was completed, and the resident was positioned safely in the bed. The DON confirmed R231 was a two-person assist during ADL care.

Based on observation, staff interview, record review and review of the facility's policy titled, Oxygen Management, the facility staff failed to maintain proper storage of a CPAP (continuous positive airway pressure) mask when not in use for one of one Resident (R) (R134) reviewed for oxygen use. Findings include: Review of the facility's policy titled, Oxygen Management, dated September 28, 2023, under the Policy Explanation and Compliance Guidelines revealed, Number 5. (e) Keep delivery devices covered in plastic bag when not in use. Review of R134's undated admission record located in the resident's Electronic Medical Record (EMR) under the Profile tab revealed R134 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. Review of R134's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/2023, located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R134 was cognitively intact. Review of the Physician Orders located in the EMR under the Orders tab revealed an order dated 12/7/2023 which indicated, CPAP apply at HS [at bedtime]. Observation on 12/20/2023 at 9:25 am revealed R134's CPAP mask was lying on the bedside table not stored in a plastic bag. Interview on 12/20/2023 at 9:29 am with Licensed Practical Nurse (LPN)1 stated, All respiratory items are to be stored in a plastic bag. LPN1 confirmed the CPAP mask was unbagged.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage Rooms and Medication Carts, the facility staff failed to store physician ordered medications in a locked compartment when unattended for two of six medication carts in the facility. The facility census was 118. Findings include: Review of the facility's policy titled Medication Storage Rooms and Medication Carts dated September 28, 2023, revealed [Name of Facility] does not have medication storage rooms nor does the facility use medication carts on post-acute floors (6, and 7); however, it does use medication carts on long-term care floors (3 and 5). The facility has Omnicell cabinets which are the facility's automated medication dispensing system . During an observation on 12/21/2023 at 12:57 am, the sixth-floor medication cart was observed to have the following medications in unlocked drawers: Lactulose one (1) grams/(per) 15 ml (milliliter); 11 lancets used to perform fingerstick for blood sugars; and three Admelog (fast acting insulin) 100 units/ml and insulin syringe filled with 15 units of clear liquid. During an interview on 12/21/2023 at 1:00 pm, Licensed Practical Nurse (LPN)5 stated, I should have moved these to another place because these carts don't lock. During an observation on 12/21/2023 at 1:04 pm, the following medications were observed to be in unlocked drawers in the seventh-floor medication cart: Latanoprost 0.005% eye drops, Atropine 1% eye drops, and Prednisolone 1% eye drops; Anoro Ellipta 62.5 mcg (microgram)/25 mcg inhaler, Artificial Tear eye drops and Triamcinolone 0.1% Cream; MiraLax packet and Carvedilol 3.125 mg (milligram) tablet; Novolog insulin 100 units/ml and Lantus insulin 100 units/ml; Levetiracetam100 mg /ml. During an interview on 12/21/2023 at 1:15 pm, LPN6 stated, I guess I should have placed these somewhere else. LPN6 confirmed the medications should have been kept in a locked container. During an interview on 12/21/2023 at 1:20 pm, Director of Nursing (DON)stated, Those carts are called Savvy carts. They do have a feature to be locked but we use those for medication transport only. The DON confirmed the medications should have been kept in a locked container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interviews, the facility failed to ensure a care plan was developed for ostomy care for one resident (R) B of 22 sampled residents. The findings include: Review of the clinical record revealed that R B was admitted to the facility on [DATE] diagnoses including history of a small bowel obstruction and ostomy, decreased mobility post cervical surgery and infection, and Parkinson's Disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident was assessed with an ostomy in Section H-Bowel, and for a [NAME] Catheter for Intravenous (IV) antibiotic infusion. Review of the resident's care plan revised 8/1/2023 revealed there was no evidence of development for focus areas addressing resident's colostomy or the [NAME] catheter. Interview on 9/26/2023 at 11:15 a.m. with R B revealed the resident was in bed, with a neck brace in place, the [NAME] Catheter was visible on the resident's right chest, and a private care giver was at bedside with the resident. The resident and the care giver stated that the nurses or Certified Nursing Assistants (CNAs) do not check the ostomy or perform care for it rather the resident and the care giver provided the care. This was the routine before the fall and was continued in the facility. Interview on 9/28/2023 at 10:14 a.m. with MDS Coordinator/Registered Nurse (RN) OO revealed that the nurses completed the baseline care plan and once the admission assessment was completed the care plan was developed. Review of the care plan revealed there was no problem area for the ostomy which he/she could not explain. Review of the baseline care plan also did not mention the resident's ostomy or care for it. Interview on 9/28/2023 at 10:40 a.m. with RN GG stated that staff do perform care for the resident's ostomy but could not provide documentation. Review of the care plan revealed there was now an ostomy care plan which had just been entered into the system. Interview on 9/29/2023 at 9:15 a.m. with the Director of Nursing (DON) revealed that there was a glitch in the software which caused the ostomy care plan to be missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to ensure that allegations of abuse were reported to the State Survey Agency (SSA) for three of 11 sampled residents (R) (R A, R5, and R12). The findings include: 1. Review of clinical record for R A revealed resident was admitted to the facility on [DATE] with multiple diagnoses including cerebral vascular accident (CVA) with left sided hemiplegia, chronic urinary tract infections (UTI), dementia, anxiety, depression, seizure disorder, chronic pain syndrome and borderline personality disorder. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Resident was dependent on staff for all activities of daily living (ADLs) care and always incontinent of bowel and bladder. The resident was assessed on admission with a feeding tube, at risk for development of pressure ulcers, although with no current wounds, and received anti-depressant medication daily. A telephone interview with R A on 9/26/2023 at 6:50 pm revealed the resident felt her stay at the facility was the worst, most horrifying experience of her life. The resident expressed being abused, verbally and physically by staff, that staff did not listen to her, stated that staff would talk about the resident in the hallway, stated one Certified Nursing Assistant (CNA) went into the resident's rectum and vagina and caused pain. R A stated this forced her to stay in a hostile environment. She stated she had urinary tract infections (UTIs) from being left wet all the time, and that she'd had weight loss, but was only weighed once during this stay. The resident stated the facility changed her room at their convenience and the heat was turned up high for her roommate, which left the resident feeling miserable. The resident expressed filing grievances but did not believe they were written down or investigated. Review of the Grievance Logs revealed R A had filed, in 2023, eight grievances during the month of May, three grievances in June, two in July and eight in August. a. Review of the facility Complaint Form dated 5/28/2023 revealed the resident's family called reporting the resident had been complaining of pain since 10:00 am and had complained three times to the tech and was told she would notify the nurse. Action Taken: Resident was asleep then pain medication was (sic) given at 2:15 pm Education provided to the tech, advised to report pain to the nurse every time a complaint is received. b. Review of the facility Complaint Form dated 5/31/2023 revealed the resident's complaint was related to: 1.) a specific nurse who was very rude and nasty toward her; 2.) the resident did not receive a shower on the assigned shower day, because she was assessed as needing one person to assist and although the resident needed additional assistance, staff would not help; 3.) the resident was unable to be changed until after lunch even though she was wet. Feedback given to the resident: The resident should ask to be changed prior to lunch service. Staff were instructed to call for the nurse whenever this happened. c. Review of the Complaint Form dated 6/28/2023 related to not being cleaned or changed after being put back to bed after an appointment, leaving the resident wet. Action taken: It was the end of the CNA's shift, and the next shift would clean the resident up. The report did not include a time frame when this complaint occurred. d. Review of the Complaint Form dated 8/16/2023 revealed the resident asked a specific CNA to call dietary because her meal was incorrect. The CNA stated that she was passing meal trays and walked out of the room. The resident called after the CNA who returned to the room, put the telephone next to the resident and said to call herself. The resident was unable to hold this phone and it fell to the floor. The CNA accused the resident of throwing the phone at him/her. Action Taken: requested tray received, after family member called, and resident was spoken to about throwing things at staff. e. Review of the Complaint Form dated 8/16/2023 stated that CNA NN responded to the call light saying, what do you want? The resident asked CNA NN to please remove her meal tray and was told the earlier shift should have done that so I will leave it too but moved it to the clothes hamper. The resident asked CNA NN to move her bedside table closer to the bed, but CNA NN answered, I have to get out of here and did not move the bedside table close to the resident. Action Taken: Due to several complaints, is abrupt in communications of CNA NN, the CNA received a written warning notice for violation of acceptable standards of respect and courtesy. f. Review of the Complaint Form dated 8/23/2023 revealed the resident's call light was not answered (initiated at 2:30 pm) after an incontinent episode and it took two hours for someone to response. [sic] The resident was upset that it took so long and left the resident soiled. Action Taken: stated the resident was being cleaned at 4:52 pm when the nurse checked after the resident's family member called. g. Review of the Complaint Form dated 8/24/2023 revealed a complaint that the resident's foot was injured during a shower yesterday. The resident revealed screaming and the staff would not listen. Investigation/Action Taken: The resident did not report the injury for 24 hours and then reported to the Physician only. The facility investigated and decided the event did not occur. A SBAR (Situation, Background, Assessment, Recommendation) was completed on 8/24/2023. The resident was complaining of pain at a level six stated is chronic pain. No swelling or change in appearance. The Physician assessed the resident when the incident was reported, and the Director of Nursing (DON) was notified. An X-ray was ordered and revealed osteopenia and no acute fracture. h. Review of the Complaint Form dated 8/28/2023 revealed the resident asked a specific CNA to get the resident up to attend the Resident Council Meeting and CNA said he/she did not have time to get the resident up. The Resident did not feel she was cleaned appropriately, and the CNA responded that the resident should turn over if the resident wanted to be cleaned. The resident felt the CNA was disrespectful and rude. The Action Taken: customer service training for the CNA. i. Review of the Complaint Form dated 8/30/2023 revealed the resident complained that a specific CNA came in to change her brief at 6:45 am and only removed an insert in the brief. When the resident asked to be cleaned and changed, the CNA stated I don't have time for this and refused. The Investigation/Action Taken revealed the CNA stated she did take care of the resident. 2. Review of the clinical record for R#5 revealed she was admitted to the facility on [DATE] and discharged on 8/14/2023 with diagnoses which included type 2 diabetes mellitus, congestive heart failure (CHF), depression, end-stage renal disease (ESRD) with dependence on renal dialysis, hypotension, and anemia. Review of R#5's admission MDS dated [DATE] revealed BIMS was coded as 13, which indicated no cognitive impairment. The resident did not exhibit any behavior during the assessment period. Resident was assessed as requiring extensive physical assistance of one person for bed mobility and transfers; total physical assistance of one person for dressing, and toilet use; independent with set-up help only for eating; limited physical assistance of one staff for personal hygiene and physical help limited to transfer only of one for bathing. The resident was assessed as frequently incontinent of bladder and always incontinent of bowel. Review of Resident #5's Care Area assessment dated [DATE] revealed the following areas that were addressed: urinary incontinence and indwelling catheter, ADL functional/rehabilitation potential, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer/injury, psychotropic drug use, and pain. Review of the Complaint Form dated 8/2/2023 revealed Complaint: Res. [resident] reports nurse brought medication @ [at] wrong time and administered medication too fast and stated He shoved them down my throat! Investigation/Action Taken: Nurse reports that resident refused meds [medications] initially, then spit meds out after she attempted to take them, nurse gave meds @ scheduled time and nurse put resident meds in hand, meds were not shoved down her throat. Further review revealed the initial allegation of abuse was not reported. 3. Review of the clinical record for R#12 revealed she was readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension (HTN), anxiety disorder, major depressive disorder, and contractures of right and left thighs. Review of the Significant Change MDS dated [DATE] revealed a BIMS score of 15 which indicated she had no cognitive impairment. The functional assessment indicated R#12 required total care from one care giver, was always incontinent of urine and had a colostomy for stool elimination. Review of Complaint Form dated 8/22/2022 indicated that R#12 reported that the CNA (name unknown) was rude and told her to shut up. Documentation dated 8/24/2022 indicated nine staff members received education that included customer service as one of the topics. Review of monthly Resident Council Meeting Minutes dated 9/26/2022 through 8/28/2023 revealed residents complained of staff being rude and yelling at them. Interview on 9/26/2023 at 12:20 p.m., R#12 stated that staff change frequently and some of the staff yells and screams at her when she asked for help. R#12 stated that she complained in the past and the staff is much better but there are still a few who are very rude. Interview on 9/28/2023 at 8:45 am with the Director of Nursing (DON) revealed that only willful allegations of abuse were reported to the State Survey Agency (SSA). The DON stated she did not feel any of the complaints were willful, although the DON was unaware of the clarification and the updated regulatory requirements in 2017. The DON was not aware that allegations of abuse, physical or verbal, should be reported to the SSA even if they were not willful actions. Interview on 9/28/2023 at 3:00 pm the DON revealed that after reviewing the updated guidance she had a better understanding of what should be reported to the SSA and was unaware the Regulatory Guidance had been updated in 2017. The DON explained that all Abuse training had been conducted based on the previous Regulatory Guidance for the Centers for Medicare & Medicaid Services (CMS). Cross reference to F607, F835 and F867.

Based on record review, review of the policy titled Reporting Abuse Allegations and staff interviews, the facility failed to ensure that the Abuse Policy and Procedures were current and implemented, which had the potential to affect all residents. Substandard Quality of Care was identified related to Develop/Implement Abuse/Neglect Policies.The census was 115. The findings include: Review of the facility policy titled, Reporting Abuse Allegations effective 11/28/2016 revealed that POLICY: The facility shall ensure that all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property, are reported to the facility's administrator AND to the State Survey Agency (SSA) immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. [sic] The Regulatory guidance provided by the Director of Nursing (DON) on 9/27/2023 contained reference to an old regulatory set with F223 as the guidance. Review of the updated regulatory guidance included a clarification of Willful in definition of abuse and means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm. Review of the Grievance Log revealed 11 occurrences of allegations of abuse for three (3) residents which were not reported to the State Survey Agency (SSA). An interview with the DON on 9/28/2023 at 8:45 am revealed the F223 regulation was the most updated guidance implemented and followed by the facility. The DON was unaware that the regulatory guidance had been updated in 2017 which included new regulation numbers. He stated that allegations of abuse or neglect were not reported to the State Survey Agency unless there was willful intent. The DON stated he was involved in investigations of abuse. He further stated the grievances were investigated and some had outcomes for staff who have Customer Service Training and/or received written disciplinary actions, although none of those incidents were reported to the State Survey Agency (SSA). The DON revealed that the Administrator was the Abuse Coordinator, however, the Administrator was out of the country and unavailable. The DON further stated that all abuse training had been based on outdated abuse regulations. The DON revealed that the policies were reviewed annually, but somehow they missed this regulatory change. Cross reference to F609, F835 and F867.

Based record review, staff interview, review of the Administrator Job Description, review of grievance files and Resident Council meeting minutes for 2023, facility Administration failed to ensure there was an up-to-date and effective Abuse Prevention Program, that consistently reported allegations of abuse by residents to the State Survey Agency (SSA) and that all staff were educated utilizing the most current Center for Medicare & Medicaid Service (CMS) regulations. The census was 115. The findings include: Review of the job description titled Administrator with a revision date of 1/2021 revealed Resident Rights the Administrator should know and respects patient's rights, report allegations of patient abuse, neglect and/or misappropriation of patient property. Staff Development communicates new Policy and Procedures and regulations to staff to ensure compliance. Administrator Responsibilities ensures that facility operations comply with local, state, and federal standards, laws and licensing and certifying bodies. Oversee completion of forms, reports, etc. including State licensure reports, monthly financial reports, Public Health or Department of Labor surveys, plans of correction, responses to corporate request, replies to patient council, and others as needed. Develops all facility policies consistent with corporate guidelines. Interview on 9/26/2023 at 8:50 am the Director of Nursing (DON) revealed the Administrator was not in the building during the survey due to a prior leave request. Interview on 9/28/2023 at 8:45 am DON stated the F223 regulation was the most updated guidance implemented and followed by the facility for abuse reporting. The DON revealed he was unaware the regulatory guidance had been updated in 2017, which included new regulation numbers and guidance for abuse. He stated that allegations of abuse or neglect were not reported to the State Survey Agency unless there was willful intent on the part of the perpetrator. During further interview, DON revealed being involved during investigations of abuse. He stated the grievances were investigated with some staff who were undergoing Customer Service Training and/or written disciplinary actions, although none were reported to the SSA. The DON revealed that the Administrator was the Abuse Coordinator, however, the Administrator was out of the country and unavailable. The DON further stated that all abuse training had been based on outdated abuse regulations and guidance. The DON revealed that the policies were reviewed annually, but they somehow missed this regulatory change. Cross reference to F607, F609 and F867.

Based on interview and review of the policy titled Quality Assurance and Performance Improvement Plan (QAPI) and QAPI minutes, the facility failed to have a Quality Assessment and Assurance (QAA) committee that effectively identified, developed, implemented, and monitored corrective action plans related to Abuse Prevention Policy and Procedure and to ensure that allegations of abuse were reported to the State Survey Agency (SSA). The census was 115. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan (QAPI) policy, revised 5/1/23, revealed Policy Explanation and Compliance Guidelines: 3. Data analysis-a. The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate. This data is reported to the QAPI Committee. An interview and discussion with the Director of Nursing (DON) on 9/29/23 at 12:10 p.m. revealed that the QAPI committee meets monthly and included the Administrator, DON, Director of Therapy, Director of Environmental Services, Director of Activities, Director of Social Services, Director of Admissions, Facility Management Lead, Pharmacy Manager, Minimum Data Set (MDS) Coordinator, Director of Human Resources, Dietitian, Acting Dietary Manager and Medical Director. The DON was unaware of when the Policy and Procedures were reviewed to ensure they met regulatory requirements. Review of the QAPI meeting minutes for 8/17/23 and 9/14/23 revealed concerns and grievances were not identified as concerns for the QAPI committee, although 26 total concerns had been noted at the September meeting and 13 total concerns identified in August. There were no actions noted to address these concerns for abuse or customer service concerns. Cross reference to F607, F609, and F835

Based on record reviews, observations, interviews, and review of the facility poicy titled Medication Self-Administration, the facility failed to assess and determine if a resident was safe to self-administer medication for one of five sampled residents (R) (R #184) reviewed for medication administration. Findings included: A review of facility policy titled Medication Self-Administration, dated 11/28/16, revealed The interpretive guidelines in the SOM [State Operations Manual] stated that if a resident requests to self-administer drugs, the interdisciplinary team is responsible for determining whether it's safe for the resident do so before he may exercise that right. The interdisciplinary team must also determine who will be responsible (the resident or the nursing staff) for storing and documenting administration of drugs as well as site of drug administration (for example, in the resident's room, at the nurses' station, or in the activities room). You should document these determinations in the resident's care plan. A review of R#184's electronic health record (EHR) revealed the comprehensive admission Minimum Data Set (MDS) had not been completed due to the resident's admission date of 7/12/22 and within the assessment look back period. A review of the resident's admission Assessment, dated 7/12/22, revealed documentation of the resident being assessed as alert and oriented to person, place, time, and situation. A review of the resident's Baseline Care Plan, dated 7/12/22, revealed there was no documentation on the baseline care plan that would indicate the resident had been assessed to safely self-administer medication. An observation on 7/18/22 at 2:15 p.m. of the over the bed table that was placed within reach of R#184 revealed a six-ounce bottle of Chloraseptic (oral analgesic) throat spray. During an interview at the same time of the observation, R#184 stated they used the throat spray throughout the day when their throat got dry. An observation on 7/19/22 at 2:41 p.m. revealed that the six-ounce bottle of Chloraseptic throat spray remained on the resident's over the bed table. Interview on 7/19/22 at 2:56 p.m., Registered Nurse (RN) VV confirmed the resident had not been assessed to self-administer medication. The nurse stated the resident had several medications brought in from home that were kept on the medication cart. She further added the family came in daily, and she was not sure if the family brought in the Chloraseptic. She satted she was not aware there was a bottle of Chlorasepctic at the resident's bedside. A follow up interview conducted 7/19/22 at 3:01 p.m., RN VV stated she went to the resident's room and asked the resident where the Chloraseptic came from, and the resident stated their family brought it to them. Interview conducted on 7/19/22 at 3:03 p.m., Unit Manager (UM) TT stated the family had brought medications to the resident before. She explained to the family that medication could not be left at the bedside and she would call the family again to provide re-education. She confirmed that the resident did not have orders for self-administration of medication and the resident had not been assessed for self-administration of medication. Interview conducted on 7/19/22 at 3:11 p.m. the Director of Nursing (DON) stated he was not aware of R#184 having medication at their bedside. He further stated there should be no medication at the bedside unless determined by the physician the resident was safe to administer the medication. Interview on 7/22/22 at 11:20 a.m. the Administrator stated he expected any resident wishing to self-administer medication to be assessed and approved to keep medications at the bedside.

Based on interviews, and review of the facility's policy titled Visitation, the facility failed to ensure a resident was allowed to have a visitor of his/her choosing at the time of his/her choosing for one of one sampled resident ((R) R #186) reviewed for visitation. Findings included: A review of the facility policy titled Visitation dated 1/27/22, revealed Patients/Residents have the right to have their visitors on a 24-hour basis. These visitors include, but are not limited to, spouses (including same-sex spouse), domestic partners (including same-sex domestic partners), and other family members or friends. During an interview with R#186's family member on 7/21/22 at 9:10 a.m., the family member explained that on the evening of 5/7/22, he/she had arranged for someone to sit with R#186 overnight, because the resident got extremely anxious when alone at night. The family member stated they had arranged for a sitter, who was also a family friend, to stay with the resident for four nights, prior to 5/7/22. The family member stated the resident was in a private room during his stay at the facility. The family member indicated that at around 9:00 p.m., the sitter was approached by Unit Manager (UM) UU, who was assigned to care for the resident. UM UU instructed the friend/sitter to leave the facility and informed him/her that visits were allowed, but overnight stays were against the facility policy. The family member added that after the sitter relayed this information to him/her, the family member called the facility to clarify, and the nurse stated that overnight visitors were not allowed and that the sitter must leave the facility. During an interview on 7/21/22 at 10:00 a.m., UM UU stated she was working the night of 5/7/22 and remembered a sitter for R#186 being in the facility that evening. She stated residents could have visitors at any time, but all visitors had to leave when the lobby doors were locked in the evening. When asked about overnight stays, UM UU indicated she instructed all family members about the facility rule of no overnight guests if she noticed anyone in a resident room late at night. She added that anyone being used as a sitter would have a contract with the facility. She stated she felt like the family was not happy, so she reached out to the Administrator for confirmation. She indicated the Administrator confirmed she was correct in what she had told the sitter. During an an interview on 7/21/22 at 10:26 a.m., the Director of Nursing (DON) stated that family could come anytime but they were not allowed to spend the night. He indicated that if a supervisor was making rounds at night and noticed a visitor, the visitor was asked to leave. The DON stated this had been the facility policy for as long as he could remember and stated he had been in the position of Director of Nursing since January 2022. He added if the visit was medically related, visitation would not be limited. He also explained that some overnight stays had been allowed in some circumstances. The examples of the circumstances were explained as a blind resident had been allowed a sitter or for a resident who was a fall risk or receiving palliative care, overnight visitation was allowed. Additionally, the DON stated he was not aware of a sitter being asked to leave and indicated if the resident was in a private room, there was no reason to send the sitter home. During an interview on 7/21/22 at 1:56 p.m., the Administrator stated that the residents could have visits at any time; however, no overnight stays were allowed. He further added that a normal visit would not occur in the middle of the night. He explained he had this policy in place to protect the residents and staff who were in the facility, due to previous visits from people that occurred at 2:00 a.m. or after, and he did not feel that was a reasonable time. He explained that this came about due to having disruptive behaviors during some late night/early morning visits, and he did not want visits from people who had just stopped by after partying, et cetera. He indicated that his policy could state visitors were not allowed to stay overnight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, and review of the facility policy titled , Restraints, the facility failed to ensure physical restraints were used only when medically necessary for one resident (R) (R #22) of two sampled residents reviewed for restraint use. Specifically, the facility failed to: - ensure an assessment to identify the medical symptom that necessitated physical restraint use was conducted and documented for R#22. - evaluate the continued need for a physical restraint at least quarterly for R#22. - develop and implement interventions for reducing or eventually discontinuing the use of the restraint for R#22. Findings included: A review of the facility's policy titled, Restraint Use, dated 11/28/16, indicated, Anything that restricts freedom of movement is considered a restraint. Further review of the policy revealed Restraint use should be limited to the least restrictive method needed to address the resident's signs or symptoms and to help him attain or maintain his highest practicable level of physical and mental well-being. The resident requires continual assessment to ensure that his needs are met, and the restraint should be reduced or removed as soon as it's no longer needed. The policy also indicated, Document the facility's approach to reducing or eliminating physical restraint use, attempts to reduce or eliminate physical restraint use, and the results of those attempts. A review of an admission Record revealed R#22 had diagnoses including dementia, unspecified psychosis, anxiety, muscle weakness, history of falling, and repeated falls. A review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed R#22 had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. The resident required extensive assistance of one person for activities of daily living (ADLs), including bed mobility, transfer, and locomotion on and off the unit. According to the MDS, the resident used a chair that prevented rising daily. A review of a Care Plan, dated as revised 5/27/22, revealed the resident was at risk for falls and injury and required the use of a physical restraint related to dementia and anxiety, use of psychotropic medications, history of falls, impaired mobility, and poor safety awareness. The resident also had a focus area of physical restraint (geri chair) related to multiple falls with previous fracture. Interventions included: - Restraint assessment initially and with each quarterly, annual, or significant change assessment. - Obtain informative consent from the responsible party following education, once available. - Educate the resident and responsible party on the reasons for the restraint and the risks associated with restraint use, per request, and quarterly per interdisciplinary team (IDT) meeting. - Apply restraint in accordance with physician orders. - Resident up in a Geri-chair with tray table by 7:30 a.m. and release the tray table every two hours to reposition and toilet. - Reassess the need for the restraint and possible reduction/elimination quarterly and as needed (PRN). - Notify the physician of any restraint related issues including development of increased behavior or mood, development of contractures, development of skin issues. Notify the physician and responsible party of any changes in the resident's mental, physical, or psychosocial issues. A review of an Order Summary Report revealed R#22 had physician's orders dated 11/25/21 for a geri-chair with tray table for safety. The orders indicated when the resident was up in the geri-chair, the tray table was to be on at all times and was to be released every two hours to reposition the resident and provide incontinent care as needed. A review of the Pre-Restraining Evaluation dated 12/1/21, indicated the interdisciplinary team (IDT) evaluated the resident for restraint use six days after getting the order for the restraint and applying it. The form indicated the next evaluation would be completed on 3/1/22. A review of the resident's medical record revealed no further evaluations or follow-up reviews for the continued use of the restraint. A review of a Physical Restraint Consent revealed the form was not signed to allow consent for the restraint until 12/15/21, twenty days after the initiation of the restraint, and it did not indicate what medical symptoms the restraint was being used for. A review of the July 2022 Medication Administration Record (MAR) revealed the order to remove the tray on the geri-chair, reposition the resident, and provide incontinent was not signed off as being completed during the day shift on 7/3/22 from 10:00 a.m. through 10:00 p.m., on 7/4/22 from 10:00 a.m. through 6:00 p.m., on 7/13/22 at 12:00 p.m. and 6:00 p.m., and on 7/15/22 at 6:00 p.m Observation on 7/19/22 at 3:43 p.m. revealed R#22 sitting in the day room on the third floor of the facility. The resident was in a geri-chair with a tray table attached, and a pillow was behind the resident's back. R#22 was leaning up and pulling on the tray. Observation on 7/20/22 at 11:56 a.m. revealed R#22 sitting in the day room in a geri-chair. His/her legs were dangling, and the resident was crying. Observation on 7/21/22 at 7:43 a.m. revealed the resident was sitting in the day room in a geri-chair with a tray table attached. Observation on 7/21/22 at 9:02 a.m., the resident was sitting in a geri-chair in the day room with a breakfast tray on the tray table in front of her. Observation on 7/21/22 at 9:07 a.m., the resident continued sitting in the day room with a breakfast tray in front of him/her. Continued observation on 7/21/22 at 9:21 a.m., an unidentified staff member took the tray table off the geri-chair and pushed the resident up to the dining table. The staff member sat down and began to feed the resident. During an interview on 7/21/22 at 2:40 p.m., CNA OO stated a restraint was when something was used to hold the resident down or by putting something in front of them so they cannot get up. CNA OO stated R#22 used a geri-chair with a tray table in front of him/her to keep the resident in place when eating. She stated it was more to protect the resident, and she would not consider it a restraint because the resident would fall out of the chair without it. During an interview on 7/21/22 at 2:53 p.m., Licensed Practical Nurse (LPN) NN stated a restraint was anything that restricted a person from moving freely, and even a table could be a restraint. She stated an assessment needed to be done for restraint use, but she was unsure of what it included. She stated a restraint was monitored every two hours. She stated she was not able to comment on the restraint use for R#22 because she was not familiar with the resident except for seeing him/her up in the geri-chair with a tray on it in the day room. During an interview on 7/22/22 at 7:39 a.m., LPN QQ stated R#22 had a tray on the geri-chair to keep the resident from falling out of the chair. During an interview on 7/22/22 at 11:30 a.m., the Assistant Director of Nursing (ADON) stated a restraint was anything that was used to restrict a resident's movements, such as side rails, a table, geri-chair, or vest. She stated restraints should be removed and the resident repositioned according to physician orders. The ADON stated the facility staff made sure that everything else had failed before they tried a restraint, and they had a care plan meeting with the family to get their input. She stated she did not know if the use of the restraint was reassessed but indicated it should be done quarterly with the care plan. The ADON stated no formal assessment was done prior to using a restraint. They just monitored the use daily, and if the resident's condition changed, then they would adjust the use of the restraint. During an interview on 7/22/22 at 12:23 p.m., the Director of Nursing (DON) stated restraints could be anything that prevented the resident from doing what they would normally be able to do. The DON stated R#22 was the only person in the facility who had a restraint, and they had a consent signed and approved by the family for geri-chair and table. The DON stated the use of restraints should be re-evaluated every eight months to determine if they were still necessary. The DON stated the resident's family was really engaged with care and it was the family's request to keep the resident safe. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated the facility wanted to use the least restrictive devices for residents, and he thought assessing restraint use every eight months sounded realistic but also stated he could not comment because he was not a clinician.

Based on record review, interviews, and review of facility policy MDS (Minimum Data Set), the facility failed to complete a quarterly Minimum Data Set (MDS) no less than every three months for two of 32 residents (R) (R#4 and R#6) reviewed for timely MDS assessments. Findings included: A review of the facility's MDS (Minimum Data Set) policy dated 3/1/21, revealed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. According to the policy, the quarterly assessment was completed using an ARD [Assessment Reference Date] no [greater] than 92 days from the most recent prior quarterly or comprehensive assessment. 1. A review of R#4's admission Record revealed the resident had diagnoses of hypertensive heart, chronic kidney disease with heart failure, dementia, paranoid schizophrenia, and depression. A review of R#4's last completed quarterly MDS, with an assessment reference date (ARD) of 3/24/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognitive function. A review of R#4's quarterly MDS with ARD of 6/24/22, revealed the assessment was incomplete. 2. A review of R#6's admission Record revealed the resident had diagnoses of pulmonary embolism, Alzheimer's disease, atrial fibrillation, aortic aneurysm, and acute respiratory failure. A review of a R#6's completed quarterly MDS with an ARD of 3/29/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. A review of R#6's quarterly MDS with an ARD of 6/29/22 revealed the MDS was incomplete. During an interview on 7/20/22 at 4:13 p.m., the MDS Manager stated MDSs should be completed quarterly at a minimum unless there was a significant change in a resident's status. Once an MDS was initiated, it should be completed within 14 days. The MDS Manager further stated R#4 and R#6's quarterly MDSs were not completed because the facility was short staffed; subsequently, he and the MDS Coordinator were behind on completing residents' MDS assessments. The MDS Manager stated they needed another person to help complete MDS assessment to stay up to date. During an interview on 7/21/22 at 2:05 p.m., the Director of Nursing (DON) stated he expected MDSs to be completed and submitted on time to ensure patient care was provided and a care plan was in place. The DON stated they did not currently have the number of MDS staff that they used to. During an interview on 7/22/22 at 1:05 p.m., the Administrator stated he did not know what the expected timeline completion was for MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure treatment and services to maintain or improve a resident's ability to carry out activities of daily living (ADLs) were provided for one (Resident (R) #95) of four sampled residents reviewed for ADL decline. Specifically, the facility failed to follow through with therapy plans for a restorative nursing program for R#95. Findings include: A review of the facility's policy titled, Restorative Services, dated 10/1/16, indicated, It is the policy of Budd Terrace at [NAME] Woods to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The policy also indicated the following: - 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: Passive or active range of motion. Splint or brace assistance. Bed mobility training and skill practice. Training and skill practice in transfers or walking. Training and skill practice in dressing and/or grooming. Training and skill practice in eating and/or swallowing. - Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy or upon discharge from therapy. - When restorative nursing services are no longer warranted, or the resident is appropriate for being transferred to nursing assistants, the restorative aide, Restorative Nurse, and/or designated licensed nurse will train the appropriate nursing assistants on the maintenance care or activities that need to be provided on an ongoing basis. Review of an admission Record revealed R#95 had diagnoses including vascular dementia with behavioral disturbance, other seizures, and essential hypertension. Review of an Occupational Therapy (OT) Discharge Summary, dated 3/19/21, indicated the resident was able to sustain movements for self-feeding for five plus minutes with cues and was sitting up in the wheelchair for greater than an hour. The summary indicated staff was positioning the resident in the wheelchair to be up for meals and that further training was required to have staff cue the resident to maintain the resident's level of alertness in order to participate in self-feeding. The summary indicated the prognosis for the resident to maintain the current level of function was excellent with consistent staff support. The summary indicated to facilitate the resident maintaining the current level of performance and in order to prevent a decline, a restorative nursing program (RNP)/functional maintenance program (FMP) for bed mobility and passive range of motion (ROM) was developed and completed with the interdisciplinary team (IDT). A review of R#95's medical record revealed no documentation of the resident receiving any restorative services, and there was no documentation of the resident being screened by therapy since the resident was discharged from therapy in March 2021. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident required supervision with set up for eating; required extensive assistance of one person for transfers, toileting, and bathing; and required limited assistance of one person for locomotion on the unit. A review of the annual MDS dated [DATE] revealed R#95 had moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 10. The MDS indicated the resident did not receive therapy or restorative services during the assessment period. Additionally, the MDS indicated the resident had experienced ADL declines in the following areas, as compared with the 3/7/22 quarterly MDS: - The 6/6/22 MDS indicated the resident required limited assistance of one person for eating; this was a decline as compared with the 3/7/22 MDS which indicated the resident required only supervision and set-up for eating. - The 6/6/22 MDS indicated the resident required extensive assistance of one person for locomotion on the unit; this was a decline as compared with the 3/7/22 MDS which indicated the resident required limited assistance of one person. - The 6/6/22 MDS indicated the resident was totally dependent on one person for toileting and bathing; this was a decline as compared with the 3/7/22 MDS which indicated the resident required extensive assistance of one person. - The 6/6/22 MDS indicated the resident was totally dependent on two people for transfers; this was a decline as compared with the 3/7/22 MDS which indicated the resident required extensive assistance of one person. A review of a care plan dated 6/21/22, indicated R#95 was at risk for a self-care deficit related to impaired ADL function. Interventions included: - Assist with ADLs at the level needed.' - Encourage resident to participate with ADLs as much as possible/tolerated. - Prompting/cueing as needed. - Task segmentation as appropriate. - Therapy to evaluate and treat as indicated. Copies of restorative notes and therapy screens for R#95 were requested from the facility on 7/20/22 and were not received by the end of the survey. Observations on 7/20/22 at 11:41 a.m., revealed R#95 lying in bed with the head of the bed (HOB) up 90 degrees. The resident was resting with eyes closed. The resident's breakfast tray was on the over-the-bed (OTB) table in front of the resident. Observation on 7/20/22 at 1:15 p.m., the resident was in the same position but had a lunch meal tray in front of him/her on the OTB table. The resident was picking at the food on the lunch tray. There was no staff member prompting, encouraging, cueing, or assisting the resident to eat. Observation on 7/20/22 at 1:26 p.m., an unidentified staff member picked up the meal tray and did not assist the resident to eat. Observations on 7/21/22 at 9:01 a.m., revealed R#95 lying in bed with the HOB up 90 degrees. The OTB table was in front of them with the breakfast meal tray on the table. The resident was resting with their eyes closed and they had not touched the food. During an interview on 7/20/22 at 3:13 p.m. with the Director of Rehabilitation (DOR), he stated the resident was last on therapy services in March of 2021. He stated residents should be screened for a decline quarterly to determine if they needed therapy services. He stated he was not able to locate any screens for R#95, so he was not able to say if they were completed or not. During an interview on 7/21/22 at 2:40 p.m., Certified Nurse Assistant (CNA) OO stated she did not think the facility did restorative services and she did not provide any type of restorative. She stated she only turned and repositioned the residents if they needed it. CNA OO stated R#95 required extensive assistance for ADLs except for eating, for which the resident only needed to be awakened and reminded to eat. CNA OO also stated she had been coming to the facility for about two months and had not noticed any decline in the resident's status. CNA OO stated the resident would get out of bed and do better when he/she was out of bed but required a mechanical lift and two people to assist with transfers, so it did not always get done. During an interview on 7/21/22 at 2:53 p.m., Licensed Practical Nurse (LPN) NN stated she did not think the facility had a restorative program, but the CNAs should provide ROM with care. She also stated R#95 required total assistance for all ADLs except eating, and stated the resident could feed him/herself and just needed minimal set-up. She further stated that she did not believe R#95 was on any type of restorative program but had not seen a decline in the resident's status. During an interview on 7/22/22 at 7:39 a.m., LPN QQ stated he was not aware of the facility having a restorative program. During an interview on 7/22/22 at 11:30 a.m., the Assistant Director of Nursing (ADON) stated she had not seen a restorative program in the facility for a while, but it should be guided by therapy. She stated when staff noticed a change in the resident's condition, the nurse would request a screen from therapy, or if the resident/family requested it, then they would be screened by therapy. She stated she thought therapy kept track of the screens. The ADON stated screening residents routinely was important to make sure the residents were maintaining their level of function and did not have a decline. The ADON stated R#95 required total assistance for ADLs except eating. She stated the resident could feed him/herself. The ADON stated the resident had not had a decline in ADL function that she was aware of and was not receiving restorative services. During an interview on 7/22/22 at 12:23 p.m., the Director of Nursing (DON) stated the facility did not have a restorative program but was using a functional maintenance program (FMP) that was supposed to be run by therapy. He stated the program was not at the level they wanted it to be at due to staffing issues. The DON stated residents were screened for therapy if the nurse or a CNA sent a referral to therapy after a change of condition. He stated it was important to screen the residents for services to ensure residents were able to regain their strength and maximize their potential. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated the facility should explore all options for a resident to see if recommendations made from therapy for a restorative program or an FMP were viable, but they were only recommendations and not orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy titled Fall Prevention , the facility failed to provide a safe environment and proper supervision to prevent falls for one resident (R) (R#22) of four sampled residents reviewed for accidents. Specifically, the facility failed to ensure care planned interventions were consistently implemented to prevent further falls for R#22. Findings include: A review of the facility's policy titled, Fall Prevention, dated 11/28/16, indicated, Assess the resident's risk of falling on admission, at least every three months therefore [sic], and whenever her status changes. The policy also indicated the following: - If the resident is at risk, take steps to reduce the danger based on the factors creating the risk. - Ensure the resident's care plan addresses her fall risk. - Alert other caregivers to the resident's risk for falling and to the interventions planned and implemented. A review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated R#22 had severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 1. The resident required extensive assistance of one person for activities of daily living (ADLs) and had no falls since the previous assessment. A review of a care plan, last revised 5/27/22, indicated R#22 was at risk for fall/injury related to dementia and anxiety, daily use of psychotropic medications, a history of falls, impaired mobility, and poor safety awareness, as evidenced by the need for assistance with transfers and ambulating. Interventions included: - Wedge cushion for proper positioning and to establish boundaries, initiated 5/4/22. - Bed with upper and lower half rails up when in bed with a wedge in between the two rails as a border, initiated 12/2/21. - Bed against the wall. Place one side of bed against the wall to minimize ways resident can fall out of the bed, initiated 5/19/22. - Place mats at bedside, initiated 7/28/21. - Scoop mattress, initiated 8/27/21. - Keep bed in lowest position with brakes locked, initiated 8/30/21. - Mattress alarm on bed at all times, check every 12 hours to ensure alarm is on and working, initiated 11/11/21. - Use stuffed animal for redirection, initiated 5/4/22. A review of a Fall Risk Assessment, dated 6/17/22, indicated R#22's fall risk score was 13, which indicated the resident was at high risk for falls. A review of an Order Summary Report for active orders as of 7/22/22 indicated R#22 had the following physician's orders: - Geri-chair with tray table for safety. When resident is up in geri-chair the tray table must be on at all times. The tray table to be released every two hours to reposition the resident and provide incontinent care if needed. - Bed alarm: check functionality when in use and change battery on the 11:00 p.m. to 7:00 a.m. shift on the 15th of the month. A review of a Fall Incident Report, dated 5/4/22 at 11:45 p.m., indicated R#22 was found face down on the floor next to the bed with no injuries. No root cause was identified, and no new interventions were documented as being implemented. A review of a Nurse's Note, dated 5/5/22 at 2:00 a.m., indicated R#22 was observed lying face down on the floor next to the bed. The note indicated the resident was lifted off the floor with the Hoyer lift and two staff members and transferred the resident back into bed. The bed was placed in the lowest position with the floor mat in place and the bed sensor alarm on and functioning. The note indicated the call light was placed within the resident's reach and the staff was educated on fall prevention. A review of a Fall Incident Report, dated 5/20/22, indicated a nurse passing by R#22's room in the hallway observed the resident on the floor in front of the bed with no injuries. No predisposing factors were identified, and no new interventions were documented as being implemented. A review of a Nurse's Note, dated 5/20/22, indicated the resident was observed on the floor on the mat in front of the bed, with the bed in low position and side rails up. The note indicated the resident had no injuries, and the family and physician were notified. Observation on 7/18/22 at 3:54 p.m., revealed R#22's bed had side rails that were up, with the bed pushed against the wall, a lipped (scoop) mattress, and a bed alarm in place. Observation on 7/20/22 at 9:01 a.m., revealed R#22 was lying in bed resting with eyes closed. The head of bed (HOB) was up 90 degrees. The bed was up against the wall and both the upper and lower side rail were up on the side of the bed next to the wall. The upper side rail was up on the other side of the bed. The over-the-bed (OTB) table was over the foot of the bed where the lower side rail would be. The floor mat was folded up, leaning against the side of the closet across from the bed. The bed had a scoop mattress, and there was a bed alarm on the bed that was not turned on. The bed was at a normal height. The observations revealed the care planned interventions were not being consistently implemented. During an interview on 7/20/22 at 12:02 p.m., Certified Nurse Assistant (CNA) MM stated R#22 had side rails on the bed to keep him/her from falling out of the bed, and the tray on the geri-chair kept her from coming out of the chair. During an interview on 7/21/22 at 2:40 p.m., CNA OO stated when new interventions were put in place, the nurse would pass it along during report or the facility would have an in-service for it. She stated she did not know who updated the care plan after a fall. CNA OO also stated R#22 required total assistance with ADLs, and the side rails were used to keep her from wiggling out of the bed. She stated the resident would fall out of the geri-chair without the tray. During an interview on 7/21/22 at 2:53 p.m., Licensed Practical Nurse (LPN) NN stated after a fall, interventions to prevent further falls needed to be done right away, then the interdisciplinary team (IDT) reviewed them to see if they were effective. She stated interventions were communicated verbally to the staff and through an in-service. LPN NN stated the staff should also use the care plan to know what interventions were in place to prevent the resident from falling. During an interview on 7/22/2022 at 7:39 a.m., LPN QQ stated it was up to the physician to implement new interventions. LPN QQ stated the care plan should be updated with new interventions, but he was not sure who did it. During an interview on 7/22/22 at 11:30 a.m., the Assistant Director of Nursing (ADON) stated all falls went on a star report that went to the hospital fall committee that met quarterly. The ADON stated interventions were done by the nurse caring for the resident and they should update the care plan. The ADON stated they had meetings on the unit with the manager and nurses and they would verbally let the staff know of any new interventions. The ADON stated R#22 required total assistance with all ADLs, and the resident had falls out of bed and out of the chair. The ADON stated R#22 had fallen out of bed with the side rails up but had no injuries. She stated they tried multiple interventions, including the low bed, fall mat, scoop mattress, and alarm, and they did meet with the family and got the resident the geri-chair with the table to keep the resident from falling out of the chair. During an interview on 7/22/22 at 12:23 p.m., the Director of Nursing (DON) stated after a fall occurred, interventions should be put into place by the nurse who documented the fall and did the assessments. He stated the nurse should update the care plan, but it could also be done by the MDS Coordinator. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated after a fall occurred, an incident report needed to be completed to determine the cause of the fall, and the nurse needed to identify what interventions to implement and document accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of R#120's admission Minimum Data Set (MDS), dated [DATE], revealed the facility admitted the resident with diagnoses which included renal failure, heart failure, and atrial fibrillation. The MDS showed that the facility assessed the resident's mental status using the Brief Interview for Mental Status (BIMS), which identified the resident's score was 7 out of 15, indicating severe impairment in cognition. The resident was dependent on staff for completing activities of daily living (ADL) care and received dialysis. A review of resident's plan of care, dated 4/11/22 and last revised on 6/28/22, revealed no person-centered interventions to address R#120 receiving dialysis. An observation on 7/18/22 at 11:54 a.m. revealed R#120 sitting up in a geriatric chair in the hallway of the 500 Hall and appeared to be clean, dry, and well-groomed. During an interview with R#120 on 7/18/22 at 11:55 a.m. revealed the resident had no problems with dialysis and had never missed a dialysis appointment. During an interview on 7/21/22 at 1:47 p.m., UM TT revealed R#120 received hemodialysis. She stated the staff members used care plans as a guide to care for the resident safely and efficiently. R#120's care plan was not showing on her phone. UM TT revealed she had the Point Click Care program on her phone, and R#120's care plan was not showing on her phone. During an interview on 7/21/22 at 2:44 p.m. the MDS Manager revealed the staff members utilized the residents' plan of care for documentation as a guide that directed the staff members how to provide care to the residents. She stated that care plans were vital to ensure the staff members were providing the care that the residents needed. She reported that R#120 had a significant change in June 2022, and the MDS coordinators were responsible and failed to pull the dialysis problem over on the care plan. During the interview on 7/22/22 at 7:57 a.m., the Director of Nursing (DON) revealed that she expected the facility centered the plan of care for a resident who was receiving dialysis treatments around the resident's specific needs. During an interview on 7/22/22 at 11:04 a.m., the Administrator revealed he was not a clinician when asked if a resident on dialysis should have a comprehensive care plan. Based on record review, observations, interviews and review of the faciity policy titled Care Plan- Assessments and Quarterly Reviews, the facility failed to develop a comprehensive care plan that addressed each resident's individual care needs for four residents (R) (R#95, R#120, R#81, and R#6) of 32 sampled residents reviewed for care plans. Specifically, the facility failed to develop a care plan to address: - R#120's pre and post-dialysis care. - R#95's use of side rails. - R#81's diagnoses and treatment for diabetes and congestive heart failure. - R#81's and R#6's use of psychotropic medications. Findings include: A review of the facility's Care Plan - Assessments and Quarterly Reviews policy, dated 11/28/16, revealed, A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment. 1. A review of an annual Minimum Data Set (MDS) dated [DATE], revealed R#95 had moderate cognitive impairment based on a Brief Interview for Mental Status (BIMS) score of 10. The resident required extensive assistance of one person for bed mobility and locomotion on the unit. The resident was dependent on the assistance of two people for transfers. The resident was able to stabilize themselves only with the assistance of staff members during surface-to-surface transfers and had functional limitation in range of motion to both lower extremities. Further review of the MDS revealed the resident did not use the bed rails. Observation on 7/20/22 at 11:41 a.m., revealed R#95 lying in bed with the head of the bed up at 90 degrees. The bed was pushed up against the wall and the half-bedrail was up at the head of the bed on both sides. Observation on 7/21/21 at 9:01 a.m., revealed R#95 lying in bed with the head of the bed up at 90 degrees. The bed was pushed up against the wall and the half-bedrail was up at the head of the bed on both sides. A review of R#95's care plan, updated 7/4/22, revealed the care plan did not address the use of side rails. During an interview on 7/21/22 at 2:53 p.m., Licensed Practical Nurse (LPN) NN stated R#95 used the side rails for positioning. LPN NN stated the staff members used the care plan to direct a resident's care. She stated she did not know who was responsible for updating the care plans and ensuring they were accurate. During an interview on 7/22/22 at 7:39 a.m., LPN QQ stated R#95 used the side rails to keep him/herself from falling on the floor. LPN QQ stated he did not do anything with the care plan but would let the supervisor know if there needed to be an update or change to a care plan. During an interview on 7/22/22 at 9:49 a.m., with the MDS Manager and MDS Assistant, the MDS Manager stated when she was developing a care plan, the information she included in the care plan was based on the particulars of the resident and not every resident was the same. She stated the information she was to include in the care plan would depend on what the resident's assessment triggered and according to the unique care needs of the resident. She stated each member of the team was responsible for ensuring the accuracy of the care plan. The MDS Manager stated the facility should include the use of bedrails in the care plan when side bed rails were in use and if a bedrail assessment was completed. The MDS Assistant stated the use of side rails would only be included in the care plan if it was determined the bed rails were to be used as a restraint. During an interview on 7/22/22 at 12:23 p.m., the Director of Nursing (DON) stated the care plan should include the type of services the facility was providing that were tailored to the resident's care needs. The DON stated the facility should include the use of side rails in the care plan. He indicated that partial bed rails were used for increased mobility and if an assessment indicated they were required for safety. If so, then he stated the facility should document the need in the care plan and obtain a consent. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated that the staff should develop the plan of care accurately and his goal was that the facility identified and documented any care information that helped the staff to provide a higher level of care. He stated the facility needed to identify all areas so the facility could meet the residents' needs. 2. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated R#81 scored 15 on BIMS score, which indicated the resident had no cognitive impairment The resident required extensive assistance of one person for bed mobility and transfers did not occur during the assessment period. The MDS indicated the resident had active diagnoses including end stage renal disease (ESRD), heart disease and diabetes. Per the MDS, the resident received antipsychotic and antidepressant medications on seven out of seven days during the assessment period. A review of an Order Summary Report, with active orders as of 7/22/22, indicated R#81 had physician's orders for the following: - Cymbalta (an antidepressant) 60 milligrams (mg) give one capsule by mouth one time a day for sadness, ordered 2/25/22. - Seroquel (an antipsychotic) 300 mg give two tablets by mouth at bedtime for psychosis, ordered 3/22/22. - Basic metabolic profile (BMP) (a blood test) every Tuesday for congestive heart failure (CHF), ordered 4/11/22. - Lasix (a diuretic) 20 mg give one tablet by mouth one time a day for hypertension, ordered 4/12/22. A review of the plan of care revealed no care plan problem with specific goals and interventions related to the use of psychotropic medications. The use of psychotropic medications was mentioned in the fall risk care plan with an intervention to monitor for adverse side effects of the medications. The care plan also did not address the resident's diagnoses of diabetes with related insulin use, nor congestive heart failure with related diuretic use. During an interview on 7/21/22 at 2:53 p.m., Licensed Practical Nurse (LPN) NN stated staff members used the care plan to let staff know how to care for the resident specifically, but she did not know who was responsible for updating the care plan and who ensured its accuracy. LPN NN stated she was not familiar with R#81's care, but the facility should include use of psychotropic medications and diabetes in the care plan. During an interview on 7/22/22 at 7:39 a.m., LPN QQ stated he was not involved in the development of the care plans but would notify the supervisor if a change needed to be made to the care plan. During an interview on 7/22/22 at 9:49 a.m, with the MDS Manager and MDS Assistant, the MDS Manager stated when developing a care plan, it was based on the particulars of the resident and not every resident was the same. The contents of the care plan would depend on what the assessment triggered and what was unique to the resident. The MDS manager stated the use of psychotropic medications should be care planned, and a resident with diabetes should have a care plan that included monitoring the medications and observing for high or low blood sugars. The MDS Manager stated the use of psychotropic medications was included in the fall care plan for being at risk for side effects, and the diabetic care plan was covered under the nutrition care plan. He stated he had been writing care plans for 20 years and had always care planned these items this way. He stated if it was mentioned in the care plan somewhere, then it was addressed. During an interview on 7/22/22 at 11:30 a.m. the Assistant Director of Nursing (ADON) stated she would sit in care plan meetings sometimes and update care plans occasionally, if needed. She stated the use of psychotropic medications should be care planned and interventions should include monitoring for side effects and effectiveness of the medication to make sure it was doing what it was intended to do. During an interview on 7/22/22 at 12:23 p.m., the Director of Nursing (DON) stated the care plan should include the type of services the facility was providing and should include items like the resident's fall risk, if they were on dialysis, were on psychotropic medications, if they had a urinary catheter or had diabetes. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated care plans should be accurate and his goal was that anything that helped the staff to provide a higher level of care should be care planned. He stated all areas needed to be identified so they could meet the resident's needs. 4. A review of R#6's admission Record revealed the facility admitted the resident with diagnoses of pulmonary embolism, Alzheimer's, atrial fibrillation, and acute respiratory failure. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Further review revealed an antipsychotic medication was used during the seven days prior to the assessment, also known as the look-back period. A review of R#6's July 2022 Medication Administration Record (MAR) revealed a physician's order for Seroquel 25 milligram (mg) tablet one time a day (QD) for psychosis started on 6/23/22. A review of R#6's June MAR revealed a physician's order for Seroquel 12.5 mg QD related to psychosis, initiated on 3/20/22 and discontinued on 6/23/22. Further review revealed on 6/23/22, the facility increased the Seroquel from 12.5 mg to 25 mg QD due to psychosis. A review of R#6's care plan , last revised on 7/6/22, revealed the facility did not include the use of Seroquel in the care plan. During an interview on 7/19/22 at 4:22 p.m., the MDS Manager stated he expected to include psychotropic medications in the care plan. He stated that the facility initiated the Seroquel for R#6 in June 2022. He indicated the facility should have captured the Seroquel if the quarterly MDS, which the facility also initiated in June 2022, had been completed. The MDS Manager further stated it was important that the plan of care included the use of psychotropic medication, so the facility monitored for any adverse side effects or medication-related behaviors while the resident used the medication, as well as ensuring the facility included the correct diagnoses. The MDS Manager further stated it was important to have this monitoring in place to see if the clinical team was getting the desired outcome from the medication. During an interview on 7/19/22 at 4:28 p.m., UM EE stated a resident who was receiving psychotropics medications should have had a care plan in place. She further stated that she was not able to locate the Seroquel use in R#6's plan of care. UM EE stated the facility initiated the Seroquel at 12.5 milligrams (mg) daily in March 2022. The facility increased the Seroquel to 25 mg daily in June 2022. She explained that since the facility initiated the Seroquel in March 2022, there should have already been a care plan in place prior to increasing the dosage in June 2022. Unit Manager EE further stated it was important to have accurate care plans that captured psychotropic use so the staff members could monitor the effectiveness of the medication. During an interview on 7/21/22 at 2:05 p.m., the Director of Nursing (DON) stated it was important to ensure accurate care planning because it reflected the type of care the staff members were to provide to the resident. She added that the facility tried to make the care plans as accurate as possible. During an interview on 7/22/22 at 1:05 p.m., the Administrator stated he expected the staff members to develop care plans accurately so that the staff members could provide the highest level of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of a facility policy titled, Nail Care, dated 9/1/21, revealed, The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. The policy also indicated, Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. A review of an undated admission record revealed the facility re-admitted R#71 with diagnoses that included hemiplegia (paralysis) affecting the left non-dominant side, major depressive disorder, and gastrostomy (feeding tube) care. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R#71 had moderately impaired cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). Per the MDS, R#71 did not refuse care. The resident was totally dependent on one person for personal hygiene and totally dependent on two or more people for bathing. A review of R#71's care plan, dated as reviewed/revised on 6/10/22, revealed bathing and personal hygiene, including nail care, were not addressed on the care plan. A review of R#71's Task: Bathing New, flowsheet dated 6/23/22, revealed R#71 received a bed bath on Tuesday 7/12/22; Wednesday 7/13/22; Monday 7/18/22; and Tuesday 7/19/22. The flowsheets did not specify whether or not nail care was performed. A review of the July 2022 Medication Administration Record (MAR), and Treatment Administration Record (TAR), did not indicate whether nail care was provided. An observation on 7/18/22 at 11:14 a.m., revealed R#71 was in her room in bed. There was a dark colored, dry substance under the fingernails on the resident's left hand. An observation on 7/18/22 at 2:32 p.m., revealed R#71 was in her room in bed. There was a dark colored, dry substance under the fingernails on the resident's left hand. An observation on 7/19/22 at 2:02 p.m., revealed R#71 was in her room in bed. There was a dark colored, dry substance under the fingernails on the resident's left hand. During an interview on 7/19/22 at 2:27 p.m., Unit Manager (UM) TT indicated that R#71 received a shower twice a week, and nails were cleaned on shower days and as needed (PRN). UM TT stated the Certified Nurse Aides (CNAs) gave R#71's showers and cleaned the resident's nails. UM TT indicated R#71 nails could use some cleaning and stated she did not know what the dark substance was under R#71 nails. During an interview on 7/19/22 at 3:39 p.m., CNA FF revealed R#71 received showers twice a week, and nails were cleaned on shower days and every other day. CNA FF indicated R#71 scratched, dug, and rubbed him/herself and that residents should have clean nails due to sanitary and health reasons. During an interview on 7/22/22 at 7:57 a.m., the Director of Nursing, (DON) revealed that residents should not have a dark brown, dried substance under them due to infection control and dignity, and the expectation was for the staff to provide nail care accordingly. During an interview on 7/22/22 at 11:09 a.m., the Administrator stated residents' nails should be clean and without dark brown, dried substances under them. Based on record reviews, observations, interviews, and review of the facility policies titled, Resident Shwering and Bathing and Nail Care, the facility failed to consistently provide assistance with activities of daily living (ADLs) for three dependent residents (R) (R#67, R#71, and R#452) of six sampled residents reviewed for ADLs. Specifically, the facility failed to regularly provide showers for R#67 and R#452 and failed to regularly provide nailcare for R#71. The failure to provide showers and nailcare had the potential to affect all dependent residents in the facility. Findings include: A review of a facility policy titled, Resident Showering and Bathing, dated 10/1/19, revealed, Residents shall be provided showers as per request or as per facility schedule protocols and based upon resident safety. A resident may typically be offered two (2) showers per week if a preference is not provided by the resident. Partial baths and/or bed baths may be given in between regular shower schedules or in place of regular showers. 1. Review of an undated admission record revealed R#67 had diagnoses including heart failure, presence of artificial knee joint, and nondisplaced fractures of the shaft of the second and third metacarpal bones (the bones that connect the wrist to the fingers) in the left hand. A review of an annual Minimum Data Set (MDS), dated [DATE], revealed R#67 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident had no documented behaviors, including refusal of care. Per the MDS, the resident required extensive assistance for bed mobility and was totally dependent on staff for dressing, toilet use, bathing, and transfers. A review of the care plan, dated as revised 7/21/22, indicated the resident had a self-care deficit related to debility and morbid obesity. Interventions included: - Bath/shower as scheduled and as needed. - Honor resident's wishes to have showers in the evening. A review of the Order Summary Report for active orders as of 7/22/22 indicated R#67 had an order dated 7/20/22 for showers on Tuesday and Friday on the 7:00 p.m. to 7:00 a.m. shift. A review of R#67's record revealed no documentation of the resident receiving a bath or shower in June or July 2022. On 7/20/22, on a list provided to the facility's receptionist, the surveyor requested documentation of showers provided to R#67 for May, June, and July 2022. The facility provided a Medication Administration Record (MAR) for May 2022. Nothing was provided for June or July 2022. Review of the May 2022 MAR revealed the last documented shower for R#67 was on 5/17/22. During an interview on 7/18/22 at 3:33 p.m., R#67 stated she was not getting showers. During an interview on 7/21/22 at 2:40 p.m., Certified Nurse Assistant (CNA) OO stated she gave showers every day according to the schedule at the desk, which was based on the residents' room numbers. She stated she would give a bed bath or shower, depending on how the resident felt. She stated she encouraged the residents to take showers but if they refused, she would let the nurse know and the nurse would document it. During an interview on 07/21/2022 at 2:53 p.m., Licensed Practical Nurse (LPN) NN stated showers popped up on the MAR three times a week, and the CNAs had a schedule. LPN NN stated the showers came up on the MAR as a backup so the nurses could make sure the showers were getting done. She stated if a resident refused a shower, the CNA should try to encourage them and reapproach and educate. During an interview on 07/22/2022 at 7:39 a.m., LPN QQ stated showers were done according to the resident's preference and would come up on the MAR for the nurses to double-check and make sure they were done. He stated if the resident refused showers, then he would document it on the MAR and make a progress note. During an interview on 7/22/22 at 11:30 a.m., the Assistant Director of Nursing (ADON) stated showers were given twice a week on schedule and the residents could get showers in between also. The ADON stated the shower schedule was based on the room number, but the residents did get to choose evening or daytime showers. She stated if the resident refused a shower, the CNA should report to the nurse and let the nurse talk to the resident, and if they still refused, then the CNA should offer a bed bath. She stated if the resident still refused, they should notify social services to notify the family and document it. She stated showers were documented on the MAR so the nurse could ensure it was done. She stated they also had shower sheets for the CNA to fill out. These were not provided during the survey. During an interview on 7/22/22 at 12:23 p.m., the Director of Nursing (DON) stated showers were given two times a week and as needed or requested. He stated the shower schedule was based on room number, but the resident could request a specific day. The DON stated the showers should be documented on the shower sheet as done by the CNA and on the MAR for the nurse to check. He stated if a resident refused a shower, it should be documented on the MAR. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated showers should be offered to the residents two times a week, and if they requested more, they accommodated that, even if it was daily. He stated the resident may get a bed bath instead of a shower, depending on staffing. He said there were variable reasons why a resident may not get a shower, including refusing because they did not want to be bothered. 2. A review of an undated admission record revealed R#452 had diagnoses that included acute transverse myelitis in demyelinating disease of the nervous system (an inflammation of both sides of one section of the spinal cord) and hemiparesis (weakness on one side of the body) and hemiplegia (paralysis on one side of the body) affecting the left non-dominant side. R#452 no longer resided in the facility at the time of the survey. Review of an admission MDS dated [DATE] revealed R#452 required extensive assistance of two or more people with transfer and physical assistance of one person in part of the bathing activity. A review of R#452's January 2022 MAR revealed an order for staff to offer a shower on Tuesdays and Fridays during the day shift beginning on 1/11/22. Further review revealed the MAR was initialed to indicate showers were offered on three occasions (Tuesday 1/11/22, Tuesday 1/18/22, and Tuesday 1/25/22) from 1/11/22 to 1/31/22. Review of a quarterly MDS dated [DATE] revealed R#452 scored 13 on a Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. During an interview on 7/21/22 at 12:23 p.m., R#452 stated she was offered a shower only once a week and would like a shower twice a week. During an interview on 7/21/22 at 2:05 p.m., the Director of Nursing (DON) stated nursing staff offered residents showers twice per week and as needed (PRN). The DON further stated he did not know if he could find shower sheets for R#452. The DON indicated the showers on the MAR were signed off on a weekly basis as a double-check to ensure nursing staff offered showers. During an interview on 7/22/22 at 1:05 p.m., the Administrator stated nursing offered residents two showers per week and many residents often refused showers. The Administrator further stated if a resident refused a shower, nursing then offered them a bed bath to accommodate their needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policies, the facility failed to provide care and services according to accepted standards of nursing practice for three residents (R) (R#127, R#81, and R#22) of 13 residents whose physician orders were reviewed. Specifically, the facility failed to: - Perform neurological checks after an unwitnessed fall to monitor for potential head/brain injury for R#22. - Monitor blood glucose levels, administer insulin, and notify the physician of blood sugar results outside the ordered parameters to manage diabetes for R#81. - Obtain necessary laboratory testing to monitor potassium levels related to the use of diuretic medication for R#81. - Follow physician orders for weekly weights and compression stocking use to manage congestive heart failure for R#127. Findings include: 1. A review of a facility policy titled, Neurological Assessment, dated 11/28/16, indicated, Neurological assessment supplements the routine measurement of vital signs, such as temperature, pulse rate, blood pressure, and respirations, by evaluating a resident's level of consciousness (LOC), pupil activity, motor response, and orientation to time, place, and person. A neurological assessment is a simple, indispensable tool for quickly checking a resident's neurological status. You should perform a focused neurologic assessment after a resident falls and you suspect head injury. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated R#22 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of one. The resident required extensive assistance of one person for activities of daily living (ADLs) and had no falls since admission/reentry or the previous assessment. A review of a Fall Incident Report, dated 5/4/22 at 11:45 p.m., indicated R#22 was found face down on the floor next to the bed with no injuries. The report indicated a head-to-toe assessment was performed and the resident had no visible injury noted. Vital signs were within normal limits. There was no documentation that neurological checks were initiated at the time of the fall. A review of a Nurse's Note, dated 5/5/22 at 2:00 a.m., indicated R#22 was observed lying face down on the floor next to the bed. The note indicated a head-to-toe assessment was performed and neurological checks were initiated and within normal limits. A review of R#22's medical record revealed no documentation of the neurological checks. A copy of the neurological checks for the fall on 5/4/22 was requested from the facility on 7/20/22 and was not received by the end of the survey. During an interview on 7/21/22 at 2:53 p.m., Licensed Practical Nurse (LPN) NN stated neurological checks were documented on a paper form and then put in the chart. She stated neurological checks were done if the resident hit their head or if the fall was unwitnessed. She stated it was important to do neurological checks to monitor for a change in the level of consciousness (LOC) that would indicate a brain injury. During an interview on 7/22/22 at 7:39 a.m., LPN QQ stated neurological checks were done with any fall and were documented under the assessment tab in the computer, but he stated he had not had to do any since he had been working here. He stated neurological checks were needed to assess for a change of condition (COC). During an interview on 7/22/22 at 11:30 a.m., the Assistant Director of Nursing (ADON) stated neurological checks were done when a resident had an unwitnessed fall or if they could tell you they hit their head. She stated the neurological checks were documented on the neuro check sheet, which was kept at the nurse's station, and once complete, it was put into the chart. She stated neurological checks were important to monitor for a COC and change in LOC. During an interview on 7/22/22 at 12:23 p.m., the Director of Nursing (DON) stated neurological checks were done right after a fall occurred if the resident sustained any head injury or if it was unknown whether they hit their head. He stated the nurses documented the neurological checks on a form. He stated it was important to do neurological checks to know if there was a change in the resident's status and to catch a change in LOC. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated he would expect nursing to follow professional standards of practice. 2 a). A review of the facility's policy, titled, Diabetic Management, dated 11/28/16, indicated to Notify MD [medical doctor] through practitioner notification book if the patient/resident has glucose levels greater than 300: a. More than once in one day, b. On two consecutive days, or c. More than three times in a week.A review of an admission Record, indicated the facility admitted R#81 with diagnoses of type two diabetes with hyperglycemia and venous insufficiency. A review of a quarterly MDS, dated [DATE], indicated R#81 had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15. The MDS indicated the resident's active diagnoses included end stage renal disease (ESRD), heart disease, and diabetes. The MDS indicated R#81 received insulin injections and a diuretic seven out of seven days of the assessment period. A review of R#81's care plan revealed no plan of care to address the resident's diagnosis of diabetes. A review of the Order Summary Report for active orders as of 7/22/22 indicated R#81 had the following physician's orders: - Accu Check (test to check blood sugar) before meals and at bedtime, ordered 2/25/22. - Blood glucose/sugar (BG) over 400 call the physician (MD), nurse practitioner (NP) or physician assistant (PA) as needed (PRN), ordered 2/25/22. - For BG 50-70 give orange juice or milk. Do not give pre-meal insulin or oral hypoglycemic medication, ordered 2/25/22. - Admelog insulin (lispro) inject three units subcutaneously (SQ) three times a day, ordered 6/2/22. - Novolog insulin 100 units/milliliter (ml), inject as per sliding scale subcutaneously (sq) before meals and at bedtime: if 0-35 give glucagon 1 milligram (mg) intramuscularly (IM) and notify MD. Recheck in 20 minutes and report to MD; 36-60 = glucose gel as directed or four ounces of orange juice. Recheck in 20 minutes and call MD; 61-200 no insulin, 201-250 = two units, 251-300 = four units, 301 to 350 = six units, 351-400 = eight units, 401 -450 = 10 units, 451-1,000 = notify MD/NP/PA, ordered 3/1/22. - Glucagon Emergency Kit - inject one gram IM PRN for severe hypoglycemia (low blood sugar/glucose) of BG less than 39 or if resident is unresponsive. Recheck blood glucose in 20 minutes and report results to MD, NP, or PA, ordered 3/1/22. - Glucose Gel 40% give one application by mouth as needed for low blood sugar of 40-49. Recheck blood glucose in 20 minutes, ordered 2/25/22. A review of the June 2022 Medication Administration Record (MAR) revealed R#81's blood glucose was not checked as per the physician's order and the resident did not receive the Novolog sliding scale insulin as per the sliding scale orders on the following days: - 6/11/22 at 11:30 pm or 4:30 p.m. - 6/14/22 at 4:30 p.m - 6/15/22 at 6:30 a.m. - 6/19/22 at 6:30 a.m. - 6/20/22 at 4:30 a.m. - 6/27/22 at 6:30 a.m Further review of the June 2022 MAR revealed R#81's blood glucose was greater than 400 and there was no documentation the physician (MD), nurse practitioner (NP), or physician assistant (PA) were notified as per the order: - 6/1/22 at 4:30 p.m. blood glucose was 440. - 6/5/22 at 11:30 p.m. blood glucose was 414. - 6/10/22 at 4:30 p.m. blood glucose was 444. - 6/12/22 at 6:30 a.m. blood glucose was 477. - 6/22/22 at 9:00 p.m. blood glucose was 433. - 6/24/22 at 9:00 p.m. blood glucose was 412. Review of the June 2022 MAR also revealed R#81 did not receive the Admelog insulin six units as ordered on 6/11/22 at 12:00 p.m. or on 6/20/22 at 5:00 p.m A review of the July 2022 MAR revealed R#81's blood glucose was not checked as per the order and the resident did not receive Novolog insulin if needed on 7/18/22 at 6:30 a.m Further review of the July 2022 MAR indicated R#81's blood glucose was greater than 400 and there was no documentation the MD, NP, or PA was notified as per the order on: - 7/3/22 at 11:30 a.m. for a blood glucose of 448. - 7/15/22 at 9:00 p.m. for a blood glucose of 403. During an interview on 7/21/22 at 2:53 p.m., LPN NN stated blood sugars out of parameters should be reported to the provider. It was usually anything over 400, but she followed whatever the physician order said. She stated if a blood sugar was out of parameters, she would do an SBAR (Situation, Background, Assessment, Report) since it was a change of condition. She stated she would also do a progress note. During an interview on 7/22/22 at 7:39 a.m., LPN QQ stated the parameters for when to notify a physician of a resident's blood sugar result were usually on the MAR and depended on the resident. He stated he would write a notification for the provider and put it in their folder, then put it in a progress note. He indicated the provider had a folder at each nurse's station that was reviewed daily when they came in. He stated the nurses would put any concerns or residents with a change of condition (COC) or other issues in the folder for the provider to review. If it was a weekend, he would call the on-call provider instead of waiting until Monday when the provider came in. During an interview on 7/22/22 at 11:30 a.m., the ADON stated the nurse should report blood sugars if they were too low or too high, and the order for sliding scale insulin usually gave parameters. She stated if the physician was notified, it was documented in a progress note or on the MAR, where it would say to see the nurses note. During an interview on 7/22/22 at 12:23 p.m., the DON stated the nurses should report when a blood sugar was out of parameters. If there were no parameters listed, then the nurse should use their nursing judgement. The DON stated there were two places to document the notification to the provider on the MAR, which gave you an option to make additional notes. He stated the nurse could also document in the physician's book as a back up to notifying the physician. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated he could not answer questions related to nursing services. 2.b) A review of the facility's policy titled, Laboratory Services, dated 11/28/16, indicated, Laboratory staff are on-site daily to conduct physician-ordered blood draws and specimen collections. Laboratory results are promptly transmitted to the medical staff (physicians and extenders) by way of electronic chart uploads, faxes to the appropriate nursing unit, and phone calls to the appropriate nursing units when necessary. A review of R#81's care plan revealed no plan of care to address the resident's diagnosis of congestive heart failure and use of a diuretic which caused fluctuating potassium levels. A review of an Order Summary Report for active orders as of 7/22/22 indicated R#81 had the following physician's orders: - Basic Metabolic Profile (BMP) (a blood test) every Tuesday for congestive heart failure (CHF), ordered 4/11/22. - Lasix 20 milligrams (mg) give one tablet by mouth one time a day for hypertension, ordered 4/12/22. - Potassium chloride ER (extended release) 10 milliequivalent (meq) give one tablet by mouth one time a day for low potassium, ordered 6/10/22. A review of the June 2022 MAR revealed the order for the BMP was scheduled every Tuesday at 7:00 a.m It was signed off as being completed every Tuesday of June 2022, on 6/7/22, 6/14/22, 6/21/22, and 6/28/22. A review of R#81's medical record revealed laboratory results dated [DATE] with results that included: - Potassium level was low at 3.3 millimole per liter (mmol/L), normal range is 3.5-5.1 mmol/L. - Blood Urea Nitrogen (BUN) was high at 33 milligrams per deciliter (mg/dl), normal range is 7-25 mg/dl. Further review of R#81's medical record revealed laboratory results dated [DATE] with results that included: - Potassium level was low at 3.0 mmol/L. - BUN was high at 31 mg/dl. Review of the June 2022 MAR revealed R#81's potassium chloride ER was increased to 40 meq for two days on 6/9/22 and 6/10/22 and then was decreased back to 10 meq daily. Further review of R#81's medical record revealed no further BMP tests were conducted after 6/8/22. A copy of the laboratory results for the weekly BMP ordered by the physician was requested from the facility on 7/22/22, and no laboratory reports after 6/8/22 were received from the facility by the end of the survey. During an interview on 7/21/22 at 2:53 p.m., LPN NN stated R#81's laboratory test was ordered weekly. She assumed the Unit Manager was filling out the laboratory requisitions and that it was being done and followed up by the Unit Manager. She indicated that was why she was signing it off on the MAR as being completed. She stated she assumed it was being done and did not verify it. During an interview on 7/22/22 at 11:30 a.m., the ADON stated the labs for R#81 got missed. She stated the resident did not refuse to have the labs drawn. She stated the nurse or the Unit Manager was responsible for filling out the lab requisition when an order for a laboratory test was received. She stated if it was a routine laboratory test, the Nurse Manager should fill out the laboratory requisition to ensure the laboratory test was obtained. The laboratory technician came to the facility on a different day of the week for each floor. She stated R#81's laboratory day was Wednesday. During an interview on 7/22/22 at 12:23 p.m., the DON stated when an order was received for laboratory tests, if the order was for weekly labs, the Unit Manager would fill out the requisition, and if it was a one-time order, the nurse on the floor would fill out the requisition. The DON stated he was unaware that R#81's labs were not being completed as ordered. During an interview on 7/22/22 at 1:10 p.m., the Administrator stated he could not answer questions related to nursing services. 3. A review of R#127's admission Record revealed the resident had diagnoses of hemiplegia and hemiparesis of the right dominant hand, stroke sarcopenia (loss of muscle mass and function), diabetes, hyperlipidemia, and hypertension. A review of R#127's quarterly MDS, dated [DATE], BIMS score of 15, indicating intact cognition. According to the MDS, R#127 did not reject care and was totally dependent/required extensive assistance from staff for activities of daily living, including dressing, transferring, and bed mobility. Further review of the MDS revealed R#127 received a diuretic (removes fluid from the body). According to the MDS, the resident weighed 208 pounds. A review of R#127's care plan initiated on 12/24/21 revealed the resident had a history of congestive heart failure (CHF). The facility developed interventions that included ensuring the CHF order set had been completed by the physician and to monitor for shortness of breath, chest pain, altered mental status, increased fatigue, or activity intolerance. 3.a) A review of R#127's July 2022 MAR revealed an order to apply compression stockings 20-30 millimeters of mercury (mm/hg), every day at 9:00 a.m. and remove them every night at 9:00 p.m. for lower extremity swelling beginning 7/14/22. A review of R#127's progress notes, dated 7/11/22, revealed bilateral leg and pedal edema. Further review revealed a diagnoses of heart failure that has improved but still has persistent leg edema. An intervention listed included compression hose. An observation on 7/18/22 at 10:03 a.m., revealed R#127 lying in bed. The resident's feet were observed to be swollen but were not elevated. An observation on 7/19/22 at 3:45 p.m., revealed R#127 lying in bed. The resident's feet were swollen, the resident's feet were not elevated, and the resident was not wearing compression stockings. During an interview on 7/18/22 at 10:03 a.m., R#127 stated the resident was taking medication to treat swelling. The resident stated the swelling went down at times, but the swelling to the feet returned. R#127 further stated they did not know why their feet kept swelling. During an interview on 7/19/22 at 3:45 p.m., R#127 revealed the resident had not worn compression stocking for a couple of weeks. The resident stated staff took them off and the next day they were gone. The resident stated his/her physician wanted the resident to wear the stockings. Without the stockings, R#127 was worried their feet would swell so big the resident's feet would have to be amputated. During an interview on 7/20/22 at 11:15 a.m., Certified Nurse Assistant (CNA) CC stated R#127 required total care from staff and had never refused care. CNA CC further stated the resident's compression stockings were not put on that morning because they only put them on when the resident got out of bed. CNA CC removed a pair of compression stockings from R#127's dresser and laid them out. During an interview on 7/20/22 at 11:26 a.m., LPN DD stated the CNA was responsible for putting on R#127's compression stockings. LPN DD stated that it was believed that the resident was wearing them and had documented the stockings were on, and that staff were putting the stockings on R#127 as ordered. LPN DD further stated that had never notified the physician that R#127 was not wearing compression stockings. LPN DD stated it was important to wear compression stockings because the stockings helped reduce the swelling, During an interview on 7/20/22 at 11:40 a.m., R#127's Physician stated R#127 had a history of heart failure and should wear compression stockings when out of bed. The physician stated she would be fine with the resident not wearing compression stockings in bed if the resident's feet were elevated. The physician stated R#127's compression stockings may have not been applied due to short staffing issues at the facility. The physician further stated staff should not have documented that compression stockings were on if they were never applied. If R#127 complained of lower extremity swelling, the resident's feet should be elevated while in bed. According to the physician, compression stockings were just ordered for the resident on 7/14/22, for neurovascular purposes. A follow up interview with the physician on 7/20/22 at 3:05 p.m., revealed nursing staff should have reported that R#127 was not getting TED hose or compression stockings. Futher interview on 7/21/22 at 2:05 p.m., revealed the DON expected physician's orders to be followed through so proper care was provided to residents and care could be measured. During an interview on 7/22/22 at 1:05 p.m., the Administrator stated he expected nursing to follow physician orders, and to document and notify the physician if orders were not followed. 3.b) A review of R#127's July MAR revealed beginning 5/2/22, staff were required to weigh the resident weekly on Monday and were required to notify the resident's provider if the resident had greater than three-pound weight gain. Further review of the MAR revealed staff documented 0 for 7/4/22, 7/11/22, and 7/18/22. A review of R#127's medical record revealed the following weights were documented for the resident: 6/2/22: 208.2 pounds 5/9/22: 211.3 pounds 5/6/22: 213.3 pounds 3/9/22: 202.8 pounds 2/7/22: 201.9 pounds 1/4/22: 194.2 pounds Further review of R#127's care plan revealed the resident weighed 208 pounds on 6/17/22, which was the last documented weight found for the resident. During an interview with R#127 on 7/20/22 at 11:22 a.m., revealed the resident was probably weighed once a month and had never refused a weight. During an interview on 7/20/22 at 11:15 a.m., CNA CC stated R#127 required total care. The CNA was not assigned to care for the resident often. CNA CC stated the facility had restorative aides and they were responsible for obtaining residents' weekly/monthly weights. The CNA stated if the restorative aide was not working, the facility would ask other staff to obtain weights. During an interview on 7/20/22 at 11:26 a.m., LPN DD stated R#127 sometimes refused to allow staff to weigh the resident but had never refused any care she attempted to provide, including medication. The LPN stated the resident was supposed to be weighed weekly. During an interview with R#127's physician on 7/20/22 at 11:40 a.m., revealed the order for weekly weights was probably carried over from admission. According to the physician, the last person who obtained residents' weights left and the facility had not been able to rehire anyone. The physician stated she thought the resident had refused to be weighed in the past, but it was not routine for the resident to refuse. During a follow-up interview on 7/20/22 at 3:05 p.m., R#127's physician stated because of the staffing shortage, the facility had not been pushing to ensure residents' weight were obtained. According to the physician, she had to increase R#127's Lasix (diuretic medication) the week before due to swelling. During an interview on 7/20/22 at 10:50 a.m., the Administrator stated R#127 refused care often and nurses did not have to document every time R#127 refused care because it was care planned. During an interview with the DON on 7/21/22 at 2:05 p.m., revealed that the expectation is that physician's orders are to be followed. During an interview with the DON on 7/22/22 at 1:04 p.m., revealed the registered dietitian had brought to their attention that resident weights were not being obtained. During an interview with the Administrator on 7/22/22 at 1:05 p.m., revealed it was expected physician's orders are to be followed.

Based on record review, observations, interviews, and review of the facility policy titled, Food and Nutrition Department Staffing Model, the facility failed to employ sufficient kitchen staff to ensure resident meals were served on dishware. Specifically, the facility failed to ensure there were suficient staff to wash dishes, resulting in the facility serving meals on disposable dishware. Findings include: A review of the facility's Food and Nutrition Department Staffing Model, dated 9/1/15, revealed The following staffing model is the plan by which the department utilizes to provide its services to residents and patients. Unforeseen circumstances may prevent the staff model from being optimal, but department leadership shall demonstrate every effort to reach the department's staffing goals. Review of the staffing model gird revealed the morning shift (5:30 a.m. to 2:30 p.m.) should be staffed with one supervisor, one cook, three dietary aides, and one dishwasher. The evening shift (12:00 p.m. to 8:30 p.m.) should be staffed with one supervisor, one cook, two dietary aides, and one dishwasher. Observation on 7/18/22 at 9:00 a.m. revealed breakfast was being served on disposable dishware. Observation on 7/20/22 at 1:40 p.m. revealed one cook, two dietary aides, and Assistant Food Service Director (AFSD) AA were working in the kitchen. During an interview on 7/18/22 at 9:00 a.m., AFSD AA stated they were using disposable dishware for meals because they were short staffed in the kitchen and did not have anyone to wash the dishes. During an interview on 7/20/22 at 3:45 p.m., AFSD BB stated the kitchen should be staffed with one cook, one dishwasher, two dietary aides, and the AFSD on duty for two shifts each day. AFSD BB stated the kitchen was not fully staffed that morning, so the supervisor on duty had to fill in where the kitchen staff was short. When the kitchen was short-staffed, the kitchen did not have a staff member available to wash dishes, so they used disposable dishware for meal service. AFSD BB indicated if there were four to five staff in the kitchen, they used regular dishware. During an interview on 7/20/22 at 4:00 p.m., the Registered Dietitian (RD) stated the kitchen was short two to three positions. If the kitchen did not have someone to wash dishes, the kitchen used disposable dishware for meal service. The RD indicated the Administrator had sent a letter notifying residents and families that the kitchen was short-staffed and would be using disposables as needed. A review of the facility letter dated 4/4/22 during the interview, revealed it acknowledged that many of the residents had voiced concerns regarding the facility's use of disposable dishware. The letter indicated staff shortages had necessitated process changes, including the use of disposables but that the facility was working diligently to fill vacant positions and bring all service delivery back to acceptable operating levels within the next 60 days. During an interview on 7/21/22 at 2:05 p.m., the Director of Nursing (DON) stated if the kitchen did not have staff to wash dishes, they used disposable dishware in place of regular dishes. The DON further stated he expected meals to be served on regular dishes to maintain food temperature and food quality. During an interview on 7/22/22 at 1:05 p.m., the Administrator stated he expected the kitchen to only use disposable dishware if that was their only option. During further interview, he stated if the kitchen did not have staff to wash dishes, they used disposables in place of regular dishes. The Administrator further stated the kitchen was short two full time equivalent staff. QA'd LMM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the quarterly Minimum Data Set (MDS), dated [DATE] , revealed the facility assessed R#71's mental status using the Staff Assessment for Mental Status, which indicated the resident was moderately impaired (score of 2 of 3) in cognitive skills for daily decision-making. Further review of the MDS indicated the resident did not refuse care, was dependent on two-person physical assistance with transfers and toilet use, was dependent on one-person physical assistance for eating and personal hygiene, had an indwelling urinary catheter, and was always incontinent of bowel. A review of the care plan, revised on 6/10/22, revealed the resident was at risk for infection related to the presence of an indwelling catheter. The care plan indicated staff members were to keep the indwelling urinary catheter tubing free of kinks and ensure the drainage bag was always below the bladder and in a privacy bag. Observation on 7/18/22 at 11:10 a.m., R#71 was in her room lying in bed with an indwelling urinary catheter bag on the floor directly under her waist. Observation on 7/19/22 at 2:00 p.m., R#71 was in her room lying in bed with approximately 6 inches of urinary catheter tubing on the floor under the bed. During an interview on 7/19/22 at 2:27 p.m., UM TT confirmed that R#71's indwelling urinary catheter tubing was touching the floor. UM TT indicated that the indwelling urinary catheter tubing on the floor was an infection control issue and that all nursing staff were responsible for ensuring urinary catheter bags and tubing were not on the floors. During an interview on 7/19/22 at 3:30 p.m., CNA FF indicated that indwelling urinary catheter bags and indwelling urinary catheter tubing on the floor was an infection control issue and that the whole team was responsible for ensuring urinary catheter bags and tubing were not on the floors. During an interview on 7/22/22 at 7:57 a.m., the DON indicated the staff members should keep indwelling urinary catheter bags and tubing contained and off the floor to prevent infection and to maintain the residents' dignity. The DON revealed his expectation of his staff was to ensure that indwelling urinary catheter bags and tubing were in a privacy bag and not touching the floor. During an interview on 7/22/22 at 10:50 a.m., the Assistant Director of Nursing (ADON) revealed the reason the staff members need to keep urinary catheter bags and tubing off the floor was to prevent infection. During an interview on 7/22/22 at 11:09 a.m., the Administrator revealed that he was not a clinician, but stated that the staff members should keep residents' indwelling urinary catheter drainage bags and tubing off the floor. Based on record review, observations, interviews, and review of current Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff followed CDC guidance regarding the use of personal protective equipment (PPE) while on the facility's COVID-19 unit for two of six staff members observed entering/exiting the unit. The facility also failed to ensure an indwelling urinary catheter drainage bag and tubing was kept off the floor for one Resident ((R) (R#71) of two sampled residents who had an indwelling urinary catheter. Findings include: 1. A review of the CDC guidance titled, Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC updated 2/2/22, revealed, Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection. Personal Protective Equipment. HCP [healthcare personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health]-approved N-95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e. [such as], goggles or a face shield that covers the front and sides of the face). Observation on 7/18/22 at 10:05 a.m., revealed the COVID-19 unit (the area of the facility designated for COVID-19-positive residents) was located on one end of the sixth floor of the facility. The plastic partition the facility had placed to separate the section of the hallway from the rest of the floor had a zipper to open and close the plastic when entering and exiting the COVID-19 unit. Housekeeper XX exited the COVID-19 unit through the zippered opening wearing only a mask. Observation on 7/22/22 at 6:15 a.m., revealed Certified Nursing Assistant (CNA) YY exiting the COVID-19 unit on the sixth floor. She removed her PPE prior to exiting the unit but had on four layers of surgical masks. During an interview at this time, CNA YY indicated she wore surgical masks in layers because the N-95 masks cut her face. During an interview on 7/18/22 at 11:15 a.m., Housekeeper XX stated that when staff members entered the COVID-19 unit, the facility did not require that full PPE be worn unless they would be entering into a resident's room. During an interview on 7/18/22 at 11:25 a.m., Unit Manager (UM) UU explained that staff members should wear full PPE anytime they entered the COVID-19 unit. She added that staff members were to remove the used PPE prior to exiting the COVID-19 unit. During an interview on 7/22/22 at 7:30 a.m., the Director of Nursing (DON) indicated the facility followed the most recent CDC recommendations regarding the type of PPE that staff members should wear while on the COVID-19 unit. During a follow-up interview on 7/22/22 at 7:58 a.m., the DON indicated the facility required the staff members to wear a gown, N-95 mask, eye protection or face shield, and gloves while on the COVID-19 unit. During an interview with the Administrator on 7/22/22 at 11:41 a.m., he stated he expected the staff members to follow the current CDC recommendations related to the use of PPE.