**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to develop a Baseline Care Plan (BCP) for one of 29 sampled residents (R) (R190). Specifically, the facility failed to develop a baseline care plan that included narcotic administration. The facility census was 34. Findings include: Review of the facility's policy titled Care Plan revised 7/27/2023 documented under Procedure: New admission Baseline Plan of Care: 1. Upon a new admission, a baseline care plan will be developed by admitting nurse/nurses in conjunction with other IDT, the patient/resident and /or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Review of Electronic Medical Records (EMR) revealed R190 was admitted on [DATE] with diagnoses including but not limited to chronic pain. Review of R190's Minimum Data Set (MDS) assessment dated [DATE] documented in Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 13, which indicated R190 had intact cognition, Section J (Health Condition) experiences pain frequently, Section N (Medications) receives opioids. Review of R190's care plan dated 11/8/2024 documented no focus areas for narcotic administration. Review of Physician Orders for R190 dated 11/7/2024 documented orders included but not limited to hydrocodone-acetaminophen - Schedule II tablet; 10-325 mg (milligrams); amt (amount): 1; oral Three Times A Day 08:00 AM, 12:00 PM, 08:00 PM for chronic pain. Neurontin (gabapentin) capsule; 400 mg; amt: 1; oral Three Times A Day 08:00 AM, 12:00 PM, 04:00 PM for chronic pain. Tizanidine tablet; 4 mg; amt: 1; oral Twice A Day - PRN (as needed) PRN 1, PRN 2 for chronic pain. Interview on 11/14/2024 at 9:26 am with R190 revealed she stated she was admitted to the facility on e week ago. She stated she had constant pain which started after having cervical surgery and chronic lumbar problems. She stated she fell and fractured her right hip and right leg, so she had constant chronic pain. She stated she needed pain medication round the clock and if she did not get it on schedule, her pain got out of control. She stated the staff gives her pain meds on schedule and as needed. Interview on 11/14/24 at 9:39 am with the MDS Director revealed the BCP is to be initiated within 24 hours. Five care areas are to be initiated by nursing staff which includes falls, pain, activities of daily living (ADLs), discharge planning and advance directives. The MDS Director confirmed the BCP was not done. He stated the BCP was an initial driver which showed the direction towards the resident's goals. Interview on 11/14/2024 at 11:50 am with Licensed Practical Nurse (LPN) DD revealed she stated anybody can initiate the care plan and update it. She stated the night nurses usually did it for admissions but if they did not, MDS would check and update it. She stated if a resident's care plan was not updated, the outcome would be inconsistent in the care of the resident. Interview on 11/14/2024 at 11:56 am with the Director of Health Services (DHS) revealed she stated the nurses usually initiated and updated care plans and MDS followed up to ensure it was done. She stated if MDS did not follow up, she would do it. She stated she did not do the BCP for R190. She stated her expectations were for the nurses to update the care plan. She further stated doctor's orders still have to be followed and the care plan was done based on doctor's orders so the resident would not benefit from the doctor's orders if the care plan was not updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to review and revise a comprehensive care plan for one of 29 sampled residents (R) (R5) related to oxygen (O2) therapy. The deficient practice had the potential to cause R5 to not receive the necessary treatment required to provide and meet her needs. Findings include: Review of facility's policy titled Care Plans revised 7/27/2023 documented under Care Plan Review and Update: 1. Care Plan updated/ reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Review of electronic medical records (EMR) revealed R5 was re-admitted to the facility on [DATE] with diagnoses including but not limited to pneumonia. Review of Minimum Data Set (MDS) dated [DATE] documented no information. Review of R5's care plan dated 10/7/2024 revealed no documentation for O2 administration since admission on [DATE] to survey date 11/13/2024. Review of Physician's orders dated 11/9/2024 documented included but not limited to Oxygen: Oxygen at 2-3 LPM (liters per minute) via NC (nasal cannula) to keep sats (oxygen saturation) 90% and above PRN (as needed) Every Shift Days 07:00 AM - 03:00 PM, Evenings 03:00 PM - 11:00 PM, Nights 11:00 PM - 07:00 AM. Review of Nurses Progress Notes dated 11/9/2024 documented Received nurse report on resident returning to facility with DX (diagnosis) Pneumonia and A-Fib (Atrial Fibrillation). New medications updated on MAR (Medication Administration Record) and Dr (doctor) notified. Interview on 11/14/2024 at 9:31 am with MDS Director revealed he stated the nurses initiated care plans on admission and he checked the care plans to ensure it was done. He confirmed the care plan for R5 did not include O2 administration since her readmission to the facility on [DATE]. He stated if the care plan was not updated, the outcome could be delay in care of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled, Controlled Substances for HealthCare Centers, the facility failed to maintain the correct narcotic count for one of 29 sampled residents (R) (R190). The deficient practice had the potential to cause drug-control issues and potentially cause negative effects for residents. The facility census was 34. Review of the facility's policy titled Policy Controlled Substances for HealthCare Centers revised 4/30/2024 documented under Policy Statement: . Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses . Under Accounting: 1. A physical inventory of all controlled substances is conducted at each shift change by the incoming and outgoing licensed professional nurses. 2. The inventory is documented on the Controlled Drug Shift Audit Sheet. Review of Electronic Medical Records (EMR) revealed R190 was admitted on [DATE] for diagnosis including but not limited to chronic pain. Review of R190's Minimum Data Set (MDS) assessment dated [DATE] documented in Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 13, which indicated R190 had intact cognition, Section J (Health Condition) experiences pain frequently, Section N (Medications) receives opioids. Review of R190's care plan dated 11/8/2024 documented no focus areas for narcotic administration. Review of Physician Orders dated 11/7/2024 documented orders included but not limited to hydrocodone-acetaminophen - Schedule II tablet; 10-325 mg (milligram); amt (amount): 1; oral Three Times A Day 08:00 AM, 12:00 PM, 08:00 PM for chronic pain. Neurontin (gabapentin) capsule; 400 mg; amt: 1; oral Three Times A Day 08:00 AM, 12:00 PM, 04:00 PM for chronic pain. Tizanidine tablet; 4 mg; amt: 1; oral Twice A Day - PRN PRN 1, PRN 2 for chronic pain. Observation and interview on 11/13/2024 at 12:50 pm revealed during medication administration Licensed Practical Nurse (LPN) AA checked doctor's orders and removed Hydrocodone/acetaminophen 10-325 mg 1 tablet from the medication card and administered it to R190. There were 45 tablets left on the medication card, but the narcotic book documented 46 tablets remaining. The discrepancy was pointed out to LPN AA who stated she was not aware of the discrepancy, and she recounted the tablets and checked the narcotics book again. She confirmed there were 45 tablets left on the medication card, but the narcotic book documented 46 tablets remaining. She stated she did not count the tablets on the medication card at change of shift that morning and she only signed the narcotics book. Interview with the Director of Health Services (DHS) revealed she confirmed there were 45 tablets left on the medication card, but the narcotic book documented 46 tablets remaining. She stated her expectation was that the nurses should count the narcotics and document each count at change of shifts in the Controlled Drug Record. Interview on 11/13/2024 at 5:25 pm with the Administrator revealed she stated her expectations were for the oncoming nurse to check off the narcotics with the outgoing nurse at change of shift. She stated the nurse should ensure the pill count was correct, and it matched the count documented in the narcotic controlled drug log. It was to be signed off by both nurses and if the count was off, the DHS was to be notified. She stated if the narcotics count was not correct, the outcome could be a potentially negative affect for the resident.

Based on observations, staff interviews, and review of the facility's policy titled, Medication Administration: Hand Hygiene, the facility failed to maintain infection control practices by not ensuring hand hygiene during two of three medication administration observations. This deficient practice had the potential to increase the potential for cross-contamination and spread of infection. The facility census was 34. Findings include: Review of the facility's policy titled, Medication Administration: Hand Hygiene, review date 10/14/2024, documented Policy Statement: It is the policy of (name of facility) Pharmacy Services that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. The Procedure section included 1. During medication administration, use hand hygiene before and after touching a patient . after touching a patient's immediate surroundings, and before and after glove removal. Observation on 11/13/2024 at 9:06 am revealed Licensed Practical Nurse (LPN) AA did not hand sanitize before and after administering medications to the residents during the medication pass. Observation on 11/13/2024 at 12:35 pm revealed LPN BB did not hand sanitize before and after administering medications to the residents during the medication pass. In an interview on 11/13/2024 at 1:27 pm, LPN AA confirmed she did not use hand sanitizer or wash her hands before and after administering medications to the residents. She stated she should have hand sanitized because it gets rid of germs and prevents germs from being carried to the residents or between them. In an interview on 11/13/2024 at 1:31 pm, LPN BB confirmed he did not sanitize his hands before and after administering medications to the residents. He stated he did not hand sanitize consistently, and sanitizing hands consistently was about infection control and preventing infection from person to person. He stated it was important to prevent residents from getting infections. In an interview on 11/13/2024 at 1:40 pm, the Director of Health Services (DHS) stated her expectations were for the staff to practice hand washing and sanitizing hands during the care of the residents and for the nurses to sanitize or wash their hands during medication administration. She stated the outcome of not performing hand hygiene could spread germs from one person to another.

Based on observation, staff interviews, and review of the facility policy titled, Food Ordering, Receiving, and Storage, the facility failed to ensure opened food items were dated. This deficient practice had the potential to affect residents receiving an oral diet. The census was 34. Findings include: Review of the facility policy titled, Food Ordering, Receiving, and Storage, reviewed 8/3/2017, revealed the Storage and Rotation Guideline section stated the facility must date and store all food items received on delivery day. During the initial Kitchen tour on 11/12/2024 at 9:50 am with the Dietary Manager (DM), observation of the walk-in freezer revealed an unlabeled and undated opened bag of frozen sweet potatoes. Observation of the walk-in refrigerator revealed an unlabeled and undated open block of Swiss cheese and one unlabeled and undated carton of heavy cream. During an interview on 11/13/2024 at 1:35 pm, the DM confirmed the unlabeled and undated food items and stated the Dietary [NAME] and Dietary Aides were responsible for labeling, dating, and proper storage of food. She further stated food items should be labeled with storage and opened dates when stored and opened. She stated labeling and dating food items was critical to maintaining food safety.

Based on staff interview, record review, review of the facility's policy titled, Care Plan, the facility failed to implement the care plan interventions for weekly weights and to consult with the registered dietician for one of eight Residents (R) (R#21) with a significant weight loss. Specifically, the facility failed to ensure that R#21 was assessed by the Registered Dietician for noted significant weight loss, and to ensure that the plan of care for R#21 addressed current weight status. Findings include: Review of the facility's policy titled, Care Plan dated 12/31/1996 indicated: Policy Statement-It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment. Review of the care plan initiated 2/17/2023, revealed that R#21 was at risk for alteration in nutrition/hydration related to dysphagia (difficulty swallowing) and being edentulous (toothless). Interventions to be implemented included monitoring and recording weight. Registered Dietician consults as needed. Interview on 6/4/2023 at 9:42 a.m. with the Director of Health Services (DHS) reviewed the weights for R#21. The DHS confirmed that there were inconsistencies with obtaining R#21's weights per the facility's policy. She also confirmed there were no nutritional assessments completed by the registered dietician for R#21's significant weight loss. Refer to F-tag 692.

**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, Smoke Free Policy, the facility failed to have a process in place to evaluate and monitor the use of a vaping device for one of one Resident (R) (#15). Findings include: Review of the facility's policy titled, Smoke Free Policy revised 10/12/2022 revealed the new smokeless cigarettes', including vapor devices, are not to be used in (inside) the healthcare center. These are to be used . as outlined in this policy for patients/ residents who are . permitted to smoke. Patients/ residents who are grandfathered in will be assessed for risks/hazards prior to smoking .During the assessment for the smoker, the assessor will ensure the grandfathered resident is able to demonstrate use of the smoking device (e-cigarettes' or vaping device) per manufacturers recommendations. An assessment . will be completed quarterly .After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident's care plan. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#15 had a Brief Interview for Mental Status (BIMS) score of 15 indicating R#15's cognition was intact. R#15 was independent with dressing, eating and personal hygiene. R#15 had diagnoses including progressive neurological condition, dementia, and Parkinson's disease. Review of the clinical record revealed no documented evidence that R#15 had an assessment or care plan related to using a vaping device. Observations on 6/2/2023 at 9:34 a.m. and 6/3/2023 at 2:10 p.m. revealed R#15 with a vaping device. R#15 was not observed using the vaping device at any time throughout the survey. Observation and interview on 6/4/2023 at 10:40 a.m. revealed R#15 was alert and oriented with no impairments to upper extremities. R#15 stated he did have a vaping device and the facility staff knew he had it and would help in any way needed related to the use of the vaping device. R#15 did not currently have a roommate. Interview on 6/4/2023 at 1:13 p.m. with Licensed Practical Nurse (LPN) CC revealed she did know that R#15 had a vape device. She was unsure of how a resident was evaluated for the ability to use a vape device. There was nothing that outlined the expectation of when residents need to utilize a vape. She said she had never seen R#15 vape inside. R#15 usually sat outside to use the vape device and staff had never witnessed him vaping in his room or inside the facility. Interview on 6/4/2023 at 1:57 p.m. with Regional [NAME] President (RVP) BB revealed R#15 was evaluated back in 2020 and denied smoking. She was unable to provide any evaluations, education, or any documentation related to R#15 using a vape device. Phone interview on 6/16/2023 at 2:00 p.m. with the Director of Nursing (DON) revealed that the facility identifies as a non-smoking facility. She stated that the facility does not have any residents in the facility who smoke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and review of the facility's policy titled, Weight Monitoring Program, the facility failed to provide evidence that a nutrition assessment was completed by the Registered Dietitian for one of eight Residents (R) (R#21) with a significant weight loss. Specifically, the facility failed to ensure that R#21 was assessed by the Registered Dietician for current weight loss status. Findings include: Review of the facility's policy titled, Weight Monitoring Program dated 6/13/2018 indicated: Policy Statement- It is the policy of the facility for each patient/resident to be weighed once a month unless otherwise ordered by the physician or contraindicated by patient/resident's medical condition. The Weight Team will review patient/resident weights monthly to determine risk of weight loss or weight gain. 3. Hospital Returns: A hospital return weight will be obtained and documented on the Yearly Weight Record Form within 24 hours and then the patient/resident will be weighed weekly times four weeks and/or until the weight is stable. 4. Significant Weight Loss: Patients/residents with a Significant Weight Loss will be weighed weekly and reviewed weekly for a minimum of four weeks until their weight is stable or increasing. All significant weight losses/gains will be addressed on the patient/resident's care plan. The care plan will be updated upon identification of the Significant Weight Loss or Significant Weight Gain. Review of the document titled, Position Description Job Title: Dietary Manager. Job Purpose: Plans, organizes, develops, and directs the overall operation of the Dietary Department in accordance with current federal, state, and local regulations governing the center and as directed by the Administrator. Key Responsibilities: 3. Prepares for visit from Registered Dietitian and comply with recommendations as outlined in company policies and procedures. Review of the document titled Position Description Job Title: Dietitian. Job Purpose: In collaboration with the Dietary Manager and Administrator, allocates department resources in an efficient and economic manner to ensure each resident receives food in amount, type, consistency, and frequency to maintain usual body weight and nutritional values. Key Responsibilities: 2. Completes appropriate clinical documentation in the medical record pertaining to the nutritional needs of the patient in accordance with the patient comprehensive assessment and care plan to comply with regulatory guidelines. 3. Completes and updates dietary assessments as part of the comprehensive resident assessment process. Review of the Face Sheet for R#21 revealed diagnoses of, but not limited to dysphagia, gastro-esophageal reflux, and constipation. Review of R#21's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 00 which indicated severe cognitive impairment. Section G-Functional Status revealed the resident requires supervision with meals. Section K-Swallowing/Nutritional Status revealed swallowing problems none. The resident height was 65 inches and weighs 237 pounds (lbs.). No weight loss or weight gain. Nutritional Status triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of R#21's quarterly MDS dated [DATE] revealed a BIMS was coded as 00 which indicated severe cognitive impairment. Section G revealed the resident requires supervision with meals. Section K revealed swallowing problems none. The resident height is 65 inches and weighs 204 pounds (lbs.). A weight loss not on prescribed weight loss regimen. Review of the care plan initiated 2/17/2023, revealed that R#21 is at risk for alteration in nutrition/hydration related to dysphagia (difficulty swallowing) and being edentulous (toothless). Interventions to be implemented included monitoring and recording weight. Registered Dietician consults as needed. Review of the Electronic Medical Record (EMR) Vital Signs: Weight results revealed the following weights: 11/2/2022-241 pounds (lbs.) 11/18/2022-237 lbs. 1/19/2023-217 lbs. 2/10/2023-215 lbs. 3/22/2023-211 lbs. 5/1/2023-204 lbs. There was no documented weights for December 2022 and April 2023. Review of the EMR revealed no documentation of any nutritional assessment for R#21 from a registered dietician. Observation on 6/3/2023 at 8:50 a.m. of R#21 Lying in bed with eyes closed and lightly snoring. R#21's untouched meal tray was in front of her. Observation on 6/3/2023 at 1:58 p.m. during mealtime of R#21 in bed with eyes closed. Interview on 6/3/2023 at 8:52 a.m. with Certified Nursing Assistant (CNA) EE who was in charge of the care for R#21 revealed R#21 needed assistance and prompts with meals. CNA EE stated she attempted several times to wake R#21 for breakfast and was unsuccessful. Interview on 6/3/2023 at 2:15 p.m. with CNA EE revealed R#21 did not eat breakfast or lunch today. Interview on 6/4/2023 at 9:42 a.m. with the Director of Health Services (DHS) confirmed there were no nutritional assessments completed by the registered dietician for R#21's significant weight loss. Phone interview on 6/4/2023 at 12:04 p.m. with Dietary Manager (DM) DD revealed it was her responsibility to make sure the registered dietician nutritional assessments were completed on the high-risk residents which include residents that return from the hospital and with significant weight loss. The DM stated she did not communicate with the registered dietician of R#21's hospital returns and significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to maintain a homelike environment related to disrepair of a ceiling on one hall and peeling/dirty wallpaper on three of three hallways (100, 200, and 300 halls). Findings include: Observation on 6/2/2023 at 11:00 a.m. revealed wallpaper peeling from the walls of the 100 hall. Specifically in the following areas: 1. Wallpaper peeling outside room [ROOM NUMBER] and between the therapy office. 2. Wallpaper peeling over the door of the oxygen storage room, janitor closet, and between the health clinic doors. Additionally, wallpaper was seen peeling in front of the nurses' station by the soiled linen room. .Observations on 6/2/2023 at 10:19 a.m. revealed peeling wallpaper from the walls on the 200 hall in the followings places: 1. Above the exit door at the end of the 200 hall. 2. Above room [ROOM NUMBER] door and above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 212. 3. Above room [ROOM NUMBER] door. 4. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 211. 5. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 208. 6. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 207. 7. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 206. 8. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 204. 9. Above room [ROOM NUMBER] door. There were also some discolored spots throughout on the wallpaper on the 200 hall. Observed disrepair of the ceiling in the hall off of the 200 hall past the exit door on the right. Observation on 6/2/2023 at 1:00 p.m. revealed wallpaper peeling beside and over the doors from rooms 301 to 306 on the 300 hall. Interview on 6/2/2023 at 1:30 p.m. with Staff Personnel AA revealed the facility was doing renovations next door at the Assisted Living building and that was where everything goes for the appearance of the buildings. She further stated that it would take forever to have renovations completed to this facility.