**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy titled, Advance Directives, the facility failed to ensure two of 30 residents (R) (R54 and R31) code status was accurately reflected in the electronic medical record (EMR). As a result, the residents' code status had the potential to not be honored in the event they would have coded. Findings include: Review of the facility's policy titled, Advance Directives with a review date of [DATE], stated, Each patient with decision making capacity has the right to make their own decisions related to their medical care .including the right to refuse or alter treatment plans, to accept or refuse medical or surgical treatment .and formulate advance directives. 1.Review of R54's EMR revealed she was coded as a Do Not Resuscitate (DNR) on the EMR's dashboard. R54 had a physician's order in the EMR under the Orders tab dated [DATE] for Allow Natural Death (AND) - Do Not Attempt Resuscitation (DNR). Review of a document titled Physician Orders for Life-Sustaining Treatment (POLST) signed by the responsible party and dated [DATE] and signed by the physician on [DATE] indicated Attempt Resuscitation (CPR) marked in section A of the form indicating the resident's wishes were to be resuscitated in the event they were nonresponsive. Interview on [DATE] at 3:41 pm, Licensed Practical Nurse (LPN)1 and Certified Medication Aide (CMA) 1 stated that if R54 was found nonresponsive or coded, they would check the EMR dashboard on the computer screen where it stated DNR, and they would not attempt CPR. Interview on [DATE] at 3:45 pm, Registered Nurse (RN) 1 stated that if R54 was found nonresponsive or were to code she would check the EMR dashboard on the computer screen where it stated DNR, and she would not attempt CPR. On [DATE] at 3:48 pm the information was reviewed with the Division Nurse Consultant (DNC), the Administrator, and the Director of Nursing (DON). The DON and DNC both checked the EMR and verified the above findings. The Social Worker (SW) was present during the interview, and she stated she spoke to the daughter and the daughter stated she wanted the facility staff to do CPR if her mother coded even though she was on hospice. Interview on [DATE] at 4:47 pm the DNC and Administrator stated they called the daughter, and she wanted her mother to be a DNR with her being on hospice. They stated the daughter was coming into the facility to sign the DNR paperwork. Interview on [DATE] at 5:32 pm, R54's daughter/ responsible party stated her mother wanted to be full code until today ([DATE]) when she arrived at the facility and signed the paperwork changing her mother from a full code to a DNR code status. She stated she decided to change the code status because her mom is now cognitively unable to make decisions, and declining in health. She does not want her mother to suffer if CPR were to be attempted. 2. Review of R31's EMR revealed admitted on [DATE] with diagnosis of acute and chronic respiratory failure with hypoxia. Review of the EMR revealed a document titled POLST located in the Advanced Directive tab of the EMR signed by the resident and the physician and dated [DATE]. Under section A Code Status of the document the resident marked Allow Natural Death (AND)-Do not Attempt Resuscitation. Review of the Dashboard of the EMR and the physician's orders with a start date of [DATE] indicated the resident was Full Code. The resident's care plan for Advanced Directive located in the care plan tab of the EMR stated Full Code Status with an onset date of [DATE]. Interview on [DATE] at 3:41 pm, LPN1 and CMA1 stated they would check the EMR, dashboard on the computer screen where it stated, Full Code and they would do CPR. Interview on [DATE] at 3:45 pm, RN1 stated for R31 if she coded, she would check the EMR, dashboard on the computer screen indicates Full Code she would start CPR. On [DATE] at 3:48 pm the information was reviewed with the DNC, the Administrator, and the DON. The DON and DNC both checked the EMR and verified the dashboard and physician's order should have been marked Allow Natural Death (AND)-Do not Attempt Resuscitation. After the information was shared the code status in the dashboard and the physician's orders were changed to reflect the resident's wishes to be a DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility policy review titled, Pharmacy Services Insulin Administration, and review of manufacturer's instructions, the facility did not ensure that one of one Licensed Practical Nurse (LPN)2 had primed an insulin pen prior to dialing the ordered dose for one of one (Resident (R)227). In addition, LPN2 did not keep the needles in R227's arm for 10 seconds. Not priming an insulin pen prior to dialing the ordered dose and the failure to keep the needle in the arm for 10 seconds has the potential to reduce the insulin dose which could have affected R227's blood glucose. Findings include: Review of the facility's policy Pharmacy Services Insulin Administration dated 2025 revealed, Prime the pen and clear air from the needle. Turn the dose knob at end of pen to 1 or 2 units. Hold the pen with needle upward. Press dose knob while watching for insulin drop or stream to appear. Repeat, if needed, until insulin is seen at tip. The dial should be back at zero after priming complete .Needle should remain in subcutaneous tissue for 10 seconds to allow all of the medication to be administered properly. Review of the manufacturer's Instructions for use Humalog ([NAME]-ma-log) KwikPen® (insulin lispro) revealed, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Observation on 2/13/2025 at 11:48 am revealed Licensed Practical Nurse (LPN) 2 retrieved R227's Humalog insulin pen from the medication cart. She dialed the pen to four units of insulin and then placed a new needle. She went ahead and injected the insulin in R227's left arm. She only left the needle in for approximately six seconds.] Interview on 2/13/2025 at 12:15 pm, LPN 2 stated that she was not aware that an insulin pen needle system should have been primed with two units prior to dialing the four units. LPN2 also acknowledge that she had not left the needle in the arm for the 10 seconds. Interview on 2/13/2025 at 1:00 pm with the Director of Nursing (DON) and the Divisonal Nurse Consultant, both stated that the nurses have all been educated on using the insulin pens and about priming the insulin pen first. Interview on 2/14/2025 at 9:00 am, Registered Nurse (RN) 1 revealed when giving insulin with an insulin pen it was required to prime the pen, after the needle unit had been placed, with two units of insulin. Priming the pen ensured the resident received the correct dose of insulin ordered.

Based on observation, interview, review of the facility's policy titled, Disinfecting Point of Care Devices and manufacturer's instructions, the facility did not ensure one of two nurses (Licensed Practical Nurse (LPN)4 sanitize the glucometer between (Residents (R)72, R227, and R228) use. The failure to ensure the glucometer had been disinfected between residents increased the risk of residents' contracting a blood borne disease. Findings include: Review of the facility's policy for Disinfecting Point of Care Devices dated 12/27/2024 revealed the center would ensure that reusable Point of Care devices, including glucose meters, were to have been cleaned and disinfected per manufacture's guidelines after each use. Review of the (Company Name) ProView Meter manufacturer's Caring for the Meter instructions indicated, Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients the meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. Observation on 2/13/2024 at 11:18 am. LPN4 removed the glucometer from the top drawer of the medication cart and placed the glucometer without sanitizing it on a clean tissue she had laid on top of the medication cart. Before she went into Resident (R)72's room she wiped the glucometer with an alcohol wipe and placed the glucometer back on the same tissue. LPN4 carried the glucometer into R72's room with the tissue wrapped around it and set it on R72's overbed table. She then used the glucometer to complete R72's accu chek. LPN4 brought the glucometer out of R72's room wrapped in the tissue, set the glucometer on the medication cart, took a clean tissue, and set the glucometer on that tissue without sanitizing the glucometer. LPN4 cleaned the glucometer with an alcohol wipe. LPN4 used the same glucometer for R227 and R228 and only wiped the glucometer with an alcohol wipe between residents' use of the glucometer. Review of R72's diagnoses under the Summary tab in her electronic medical record (EMR) revealed she did not have a communicable disease. Review of R72's February 2025 Medication Administration Record (MAR) revealed the order date for accu chek was 1/13/2025. Review of R227's diagnoses under the Summary tab in her EMR revealed she did not have a communicable disease. Review of R227's February 2025 MAR revealed the order date for accu chek was 2/06/2025. Review of R228's diagnoses under the Summary tab in her EMR revealed she did not have a communicable disease. Review of R228's February 2025 MAR revealed the order date for accu chek was 2/06/2025. Interview on 2/13/2025 at 11:55 am, LPN4 stated that she had not maintained the proper infection control procedures when she had used the glucometer between residents' use. She said she was told to use alcohol wipes to clean the glucometer between residents' use instead of the purple-top Santi-cloth wipes. Interview on 2/13/2025 at 1:00 pm with the Director of Nursing (DON) and the Divisional Nurse Consultant both stated that the glucometers were to be disinfected between residents with a purple-top Sani-cloth wipes. They agreed if the glucometer had been set on the medication cart and then on the clean barrier it would have contaminated the barrier. During a phone interview with the facility Medical Director (MD) on 2/14/2025 at 3:56 pm, the MD stated that he felt the alcohol swab and the antimicrobial cleaner could be interchangeable with the same sanitizing result. He stated, . as long as it was cleaned between residents and there are no communicable diseases in the building, I expect the outcomes would be the same with either cleaner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of policy titled Elopement the facility failed to ensure the doors leading into the attached vacant hospital were secured to prevent an elopement by one resident (R1) from a sample of six residents. Findings include: Review of the facility policy titled Elopement with a review date of 12/29/2023 revealed the following: The center implements mechanisms and procedures for monitoring and managing patients at risk for elopement to minimize the risk of a patient leaving a safe area without authorization and/or appropriate supervision. R1 was admitted to the facility on [DATE] with the following but not limited diagnoses: schizophrenia, other abnormalities of gait and mobility, muscle weakness, difficulty walking, anxiety disorder and unspecified dementia with other behavioral disturbance. The resident had a Quarterly Minimum Data Set (MDS) assessment completed on 10/15/2024 noted a Brief Interview for Mental Status (BIMS) of 0 indicating the resident had severely impaired cognition, had hallucinations, delusions, verbal behavioral symptoms directed towards others and rejection of care daily. The resident had a care plan since 7/18/2024 for elopement/risk for elopement as evidenced by the resident exited the facility on 10/27/2024, aimless wandering and/or exit seeking behavior since 7/21/2024 and the resident stated they would leave the center on 10/14/2024 with the following interventions: 1:1 supervision while outside, maintain close observation of patient's location, provide activities of interest, redirect as needed and talk to patient in a calm reassuring voice. The resident had an Elopement Risk Assessment completed on 6/27/2024 with a score of 21 indicating the resident above high risk for elopement. The Elopement Risk Assessment completed on 10/27/2024 with a score of 16 indicated the resident was moderate risk for elopement. Review of the 10/27/2024 Nurses Note revealed the resident was observed walking through by the Nursing Station around 6:50 pm going down the back hallway on Tulip Lane Hallway. The resident went all the way down toward the kitchen way through the double doors and the right side of the door was open. The resident went through the double doors through the kitchen area, then walked through the hospital area and the resident through the front doors of the hospital area. Registered Nurse (RN) AA noticed the resident did not come back down the hallway that went through the hospital area out through the front doors because all the other doors had to have a code put in. All the staff started searching through the kitchen area, hospital area, and through the nursing home area. Some of the staff started looking outside and spotted the resident over in the hospital parking lot walking in front of the hospital. The Certified Nursing Assistant (CNA) brought the resident back in safely. The resident was given a head-to-toe assessment, and the resident did not have any new areas noted on her body. The resident was alert and verbally responsive. No distress noted. No complaints of pain noted. The resident is now walking around doing her usual things. The resident's daughter was called around 8:10 pm and notified about the incident. The doctor was also called around 8:15 pm with no new orders. During an interview with RN AA on 10/30/2024 at 12:30 pm, she stated around 7:15 pm on 10/27/2024 she saw the resident walking up the hall going to the kitchen. She told the resident to come back. At the same time a visitor was at the front door, so she had to go let that person in. When she got back she noticed the resident had not come back so she walked up that way and met the Maintenance Supervisor and asked him to go with her to look for the resident and told the other staff to look for her as well. She stated the door to the hospital/kitchen was open. She stated the resident wasn't missing longer than 10 minutes when she was found in the parking lot across from the hospital entrance. When they walked through the hospital only one of the halls had light. She stated they could see but they had to use the lights on their cell phones. She stated the resident was walking all day long. She stated she has never known the resident to try and get out of the building. She usually just stays in the visitor's bathroom that is in the front of the building, or she is in the front lobby just looking out the window but has never tried to get out. She stated the resident also paces up and down the hallways and a few times has gone in other resident's rooms. She immediately called the Administrator and the DON. During an observation of the double doors leading to the kitchen area and the vacant hospital on [DATE] at 2:20 pm with the Business Office Manager (BOM), the doors were observed to be closed and locked and could only be opened after entering a code. The magnets which hold the double doors open had been removed causing the doors to close. The surveyor and the BOM then walked throughout the vacant hospital which consisted of old patients rooms, a nursing station, surgical rooms and surgical suite, a radiology area, offices and other empty rooms. Although equipment except for some patient beds and furniture had been removed, the majority of the vacant hospital was dark with only certain areas having lights on. The exit doors leaving the hospital were all locked except the main front entrance doors that were unlocked from the inside. During an interview with the BOM at that time, she stated apparently on 10/27/2024 staff did not close the doors once the meal carts were pushed through the double doors and the resident walked through the doors and entered the hospital. She stated they think the resident continued to walk straight through the hospital finding her way to the front main entrance of the hospital and went out the unlocked doors out to the hospital parking lot where she was found by staff. She stated the next morning, maintenance removed the magnets from the double doors so the doors could not be held open anymore. Review of the conclusion of the facility's investigation indicated the facility identified the root cause as a door that was held ajar to allow staff passage but was not re-secured. Interventions were put in place to prevent staff from propping secure doors open. Education had been provided to all associates regarding elopement risks and ensuring all exterior doors are securely shut when they enter/exit through them. An ADHOC QAPI meeting was held with the Medical Director regarding investigation findings and interventions and was in agreement with the facility's interventions. The facility will continue to assess residents routinely for elopement risk and implement interventions as appropriate to ensure safety. Routine plant inspections will continue and any safety risk will be addressed immediately upon identification. Review of the Allegation of Compliance that the facility developed following the elopement revealed the following actions were implemented: Beginning 10/27/2024 at 7:30 pm, an accounting for all residents was conducted by the Nurse Managers and charge nurses to ensure all residents were accounted for. 1. Education was provided to nursing staff on duty 10/27/2024 regarding resident's noted wandering and risk for elopement by the Charge Nurse. 2. Education was provided to all other staff by the Administrator for residents' risk for elopement related to wandering and ensuring all exterior doors close completely when entering and exiting the facility, including closure of doors on the hospital side to prevent access without code. 3. All exterior doors were tested to ensure they were closing properly without complication on 10/27/2024 by the maintenance director at 8:00 pm. 4. An Root Cause Analysis (RCA) of how the resident was able to exit the facility, obtained through interviews with staff who may have witnessed the incident, identified an unsecured right door left open to the closed hospital side. 5. Magnets were removed from the doors that lead to the kitchen area so doors would automatically close upon entry/exit and disabled from being braced open with the magnets by the Maintenance Director by 9:00 am on 10/28/2024. Systemic Changes 1. Education provided to staff to not leave doors open and to increase monitoring of patients with elopement risks. I. Review of elopement drills will be provided to associates actively working by the Administrator on 10/28/2024. Associates on leave will be provided education upon return to work duty. Newly hired associates will be provided upon hire. The facility does not utilize agency at this time. II. The DON will provide nursing staff with education on identifying behaviors that increase residents risk for elopement and completing behavior assessments and elopement risk assessments by 11/1/2024. III. By 11/1/2024, the facility will complete an elopement risk assessment on all residents to determine whether any changes in baseline have occurred that may warrant additional intervention. Review of the documentation revealed all residents had elopement assessments completed on 10/28/2024. IV. The facility Maintenance Director or designee will start conducting rounds on 10/28/2024 to ensure all exterior doors are secure with concerns every 2 hours x24 hours , every 4 hours x24 hours and then every 6 hours x 24 hours and report findings to the Administrator for QAPI tracking. V. Monitoring was implemented for resident for nursing staff to be aware of her location that included q 30 minute checks x7 hours initially, then tapered to hourly checks during the night from x4 hours. Monitoring was re-evaluated at 7:00 am on 10/28/24 and increased to q 15 minutes checks x8 hours, then q 30 minutes checks x12 hours, then hourly checks x12 hours. 2. The resident was assessed for any possible injury from noted wandering with no injury identified on 10/27/2024 by the Charge Nurse. 3. On 10/27/2024 around 8:00 pm the Charge Nurse notified the resident's daughter of resident wandering and high risk for elopement. Education on risk for injuries related elopement and review of care needs was discussed. 4. A new elopement assessment was conducted on the resident by the DON on 10/27/2024 to aid in identifying any additional behaviors that increase risk for elopement. 5. The elopement notebook at the nurses station was updated to reflect current high elopement risk residents. 6. On 10/27/2024 the charge nurse notified the resident's primary care provider of the wandering behaviors and risk for elopement. 7. The deficient practice door being unsecured leading to the kitchen was due to an associate not detaching the magnet from the right door to close it which allowed the resident to reach an unsecured area of the adjacent building. Magnets were detached from the doors leading to the kitchen area to prevent propping and increasing monitoring of residents with wandering behaviors were the interventions communicated with the Medical Director as part of Ad Hoc QAPI on 10/28/2024 and incorporated the facility's QAPI plan for continued monitoring of compliance and review with the Medical Director at least quarterly for maintenance of compliance standards. 8. The Administrator and Maintenance Director conducted rounds and identified secondary doors beyond the kitchen leading to the hospital side of the building that is not utilized by the facility. These doors have key coded magnet locking mechanisms and were activated and secondary doors secure to limit access to the hospital side of building. These doors are past the point of the doors that provide access to the kitchen side of the building. Utilization/activation of these doors was implemented by the Maintenance Director on 10/29/2024. A review of In-service sign in sheets, Elopement Risk Assessments/Clinical Assessment List, Patient Frequent Rounds for Increased Surveillance Related to Wandering Behaviors logs and Door Checks Logs and observations of the exit doors and double doors leading to the hospital revealed the facility's allegation of compliance was implemented with no additional deficient practice identified. The facility indicated that all tasks would be performed by 11/1/2024 but after review all tasks were confirmed to have been performed prior to surveyor entry to the facility on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assess a wound, obtain treatment orders on admission, and provide treatment as ordered for 1 (Resident #74) of 3 residents reviewed for skin issues. Specifically, Resident #74 was admitted on [DATE] with a wound to the left great toe. The facility failed to obtain treatment orders for the wound until 03/24/2023, two days after admission, and failed to provide the treatment during two days in March of 2023. Findings included: A review of Resident #74's Face Sheet revealed the facility admitted the resident on 03/22/2023 with diagnoses that included peripheral vascular disease (PVD), end stage renal disease (ESRD) dependent on hemodialysis (HD), and diabetes. A review of Resident #74's Nurses Note, dated 03/22/2023 at 4:20 PM, revealed the resident was newly admitted to the facility. The note indicated the resident had a wound to the left big toe with an intact dressing and a left groin wound due to a stent placement. A review of Resident #74's Comprehensive Nursing Assessment V4.0, dated 03/23/2023, revealed the resident had a left great toe wound and pain to the left foot. There was no documented description of the wound. A review of Resident #74's History and Physical revealed a nurse practitioner completed a telehealth visit on 03/24/2023. The note indicated the resident had been hospitalized after a fall at home and recently underwent a left leg angiogram endarterectomy (removal of plaque buildup in an artery) and stent placement on 03/15/2023. The note indicated the resident complained of left foot pain during the visit and per nursing, the resident had a wound present. The note indicated the resident had bilateral foot pain and the left great and second toe had a darkened area. The nurse practitioner's note indicated see skin assessment documentation; however, there was no evidence an assessment of the resident's left toe had been completed. A review of Resident #74's physician order Summary Report revealed a treatment was not ordered for the resident's left great toe until 03/24/2023, two days after admission to the facility. The order directed staff to clean the toe with normal saline, pat the area dry, apply a petroleum gauze, cover with a four-by-four dressing, and wrap with Kling (a [NAME] conforming bandage). Review of Resident #74's eTAR [electronic treatment administration record] for the month of March 2023 revealed left great toe treatments for Resident #74 were held on 03/28/2023 and 03/30/2023 without an explanation documented. During an interview with Licensed Practical Nurse (LPN) #2 on 04/25/2023 at 3:12 PM, she stated she was the admitting nurse for Resident #74 on 03/22/2023 and recalled the resident had a bandage on the left great toe. She stated she did not remove the bandage but verbally notified the Wound Treatment Nurse of the issue with the toe on 03/23/2023, the day after admission. LPN #2 stated if a newly admitted resident had a dressing intact, she did not usually remove the dressing. She stated she documented the location of the dressing and allowed the Wound Treatment Nurse to perform the initial assessment. She stated if the Wound Treatment Nurse was not in the building, then one of the Nurse Supervisors would complete the wound assessment. During an interview with the Wound Treatment Nurse on 04/27/2023 at 8:31 AM, she stated when Resident #74 was admitted , treatment orders for the left great toe were not provided. She stated she saw the resident on 03/24/2023, removed the dressing to assess the left great toe, and ordered a Vaseline gauze treatment. According to the Wound Treatment Nurse there should have been documentation of her initial assessment on 03/24/2023. Further interview with the Wound Treatment Nurse revealed the treatments were held on 03/28/2023 and 03/30/2023 because the resident was away for dialysis. She stated if a resident was out of the facility on the day of their scheduled treatment, the treatment would not be completed until the next scheduled day. The Wound Treatment Nurse stated the Nurse Supervisors were assigned to provide wound treatments when she was off or not in the building. Nurse Supervisor #1 was interviewed on 04/26/2023 at 10:46 AM. She stated if a resident was admitted with a skin issue, the nurse on duty should complete an assessment, and the Wound Treatment Nurse should conduct an in-depth wound assessment the next time she was available. Nurse Supervisor #1 indicated if the Wound Treatment Nurse could not look at the wound within two days, then she or the other Nurse Supervisor would do an in-depth assessment. Nurse Supervisor #1 stated the Wound Treatment Nurse measured wounds and ordered the treatments. She stated when the Wound Treatment Nurse was not available, the Nurse Supervisors provided wound treatments. Nurse Supervisor #1 stated bandages were removed upon admission on ly if the hospital ordered them to be removed. If there were not any orders/instructions for the wound on admission, the bandage would need to be taken off and assessed upon arrival at the facility. Further interview with Nurse Supervisor #1 revealed if a treatment was coded as Held, then there should have been a note with an explanation. The Director of Nursing (DON) was interviewed on 04/25/2023 at 2:51 PM. She stated Resident #74's left great toe did not look good when the resident was admitted , and it looked black the day after the resident arrived at the facility. The DON stated nursing staff should have documented a description of the left great toe upon admission, and the Wound Treatment Nurse should have also documented an assessment of the wound. The DON stated documentation of the wound should have included the location; a description, including color/drainage; and the type of wound (arterial/ulcer). During a follow-up interview with the DON on 04/27/2023 at 10:16 AM, she stated nursing staff should not have taken off Resident #74's dressing unless they were told to remove it during a report from the hospital, or orders from the hospital to remove the dressing were provided. She indicated LPN #2 should have documented dressing to left great toe, clean and dry. The Wound Treatment Nurse would have then taken off the bandage and assessed the wound to determine the plan of treatment. The DON indicated she expected the Wound Treatment Nurse to have assessed Resident #74's left great toe wound within 24 hours of admission and the assessment should have been documented in the weekly wound report. The DON stated documentation should have included size, color, and drainage. She further stated that nursing staff were expected to follow the physician orders for dressing changes. If Resident #74 was out of the building, then staff should have documented the treatment was deferred and postponed to the next scheduled dressing change. However, the DON also stated she expected the nurse on duty to have assessed Resident #74's wound on 03/28/2023 and 03/30/2023 to determine if the resident needed a dressing change on those dates. The DON stated if the nurse on duty could not complete the dressing change on the date assigned, they should have notified the Wound Treatment Nurse or the DON. The Administrator was interviewed on 04/27/2023 at 12:06 PM. He stated he did not have the appropriate training to answer clinical questions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy titled Dental Services/Oral Assessment, it was determined that the facility failed to assist residents in obtaining necessary dental care for 1 (Resident #43) of 1 resident reviewed for dental services. The facility census was 76 residents. Findings included: A review of the facility policy titled, Dental Services/Oral Assessments, with a review date of 12/30/2022, revealed the facility will promptly refer patients who have lost or damaged dentures within three (3) business days for dental services. The policy indicated, In the case of damage or loss to a patient's dentures, the center will investigate the circumstances of what happened to the dentures. In the event it is determined that the center/center associate was responsible for the loss or damage, the center will assume the financial responsibility for repairing or replacing the dentures. A review of Resident #43's Face Sheet revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and need for assistance with personal care. A review of Resident #43's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2023, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS indicated Resident #43 was totally dependent on staff for transfers, locomotion on and off unit, dressing, and toilet use. Resident #43 required extensive assistance from staff for bed mobility, eating, and personal hygiene. The MDS indicated Resident #43 did not have broken or loosely fitting full or partial dentures. A review of Resident #43's Care Plan, with a most recent review date of 02/09/2023, revealed Resident #43 required assistance to clean teeth or dentures and included an intervention that instructed staff to assist with activities of daily living (ADLs) as needed. The Care Plan indicated the resident elected to receive a regular diet with chopped meats. The Care Plan did not mention or address missing or broken dentures. A review of a Comprehensive Nursing Assessment, dated 02/03/2023, revealed Resident #43 had no visible problems to the mouth. The assessment indicated Resident #43 needed assistance to clean teeth or dentures but did not mention broken or missing dentures. A review of a Comprehensive Nursing Assessment, dated 04/14/2023, revealed Resident #43 had broken, loose, or missing teeth. The assessment indicated Resident #43 needed assistance to clean teeth or dentures but did not mention broken or missing dentures. In an interview on 04/26/2023 at 9:07 AM, Resident #43 said they had dentures when they admitted to the facility but did not currently have their dentures. Resident #43 said they had told the Social Service Director (SSD) about the missing dentures. In an interview on 04/26/2023 at 8:50 AM, Licensed Practical Nurse (LPN) #1 said she knew Resident #43 had upper dentures but was not sure about bottom dentures. She said she was unaware of any problems with Resident #43's dentures. LPN #1 said if a resident had dental issues, including missing or broken dentures, the physician would be notified, and social services would help as needed. LPN #1 said if an item was missing, staff would look for it and talk with the family as needed. In an interview on 04/26/2023 at 9:17 AM, Certified Nursing Assistant (CNA) #3 said Resident #43 had broken their dentures about a month previously. CNA #3 said Resident #43 told CNA #3 the resident had dropped the dentures. CNA #3 said she told the SSD about the broken dentures and that CNA #3 had put them in a cup in the resident's bathroom if the family wanted to do anything with them. CNA #3 showed the surveyor the broken dentures in a cup in Resident #43's bathroom. In an interview on 04/26/2023 at 9:42 AM, the SSD said Resident #43 did not have dentures when they were admitted to the facility, and Resident #43 could not say where the dentures were. The SSD said she did not remember anyone telling her about Resident #43 breaking their dentures. The SSD said if a resident loses or breaks their dentures, she would notify the Administrator. She said that if it was the facility's fault, the facility would make any necessary appointments and replace them or let the family know they were missing. In an interview on 04/26/2023 at 9:53 AM, the Director of Nursing (DON) said her expectation was that if a resident reported anything missing, the charge nurse should be notified, as well as the SSD, and the facility would investigate. She said she had not heard about Resident #43's denture issues. In an interview on 04/26/2023 at 11:58 AM, the Administrator said that if a resident loses something, the family would be notified. He said that if a CNA was told, the CNA would look for the item, and if not found, the SSD would be notified and begin an investigation. He said the facility would search, notify the family, and replace the item if not found. The Administrator said he had not heard about Resident #43's missing dentures. He said Resident #43 did not have dentures on admission.

Based on observation and staff interviews, the facility failed to serve food, monitor food and drink expiration dates, and maintain cooking equipment in a manner to prevent potential food safety issues. Specifically, the facility failed to: 1. allow 77 plate covers to air dry prior to assemblage and stacking in preparation for use during 1 of 2 meal observations; and 2. discard expired perishable foods and milk from 1 of 1 walk-in refrigerators; and 3. clean the convection oven weekly. These practices had the potential to affect 72 of 76 residents who received meals from the kitchen. Findings included: Reference: As viewed on 05/04/2023, FDA Food Code | FDA indicated, in part, under 4-903 Storing, (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. Under 4-602.12 Cooking and Baking Equipment, the food code indicated, in part, Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. Under 4-602.13 Nonfood-Contact Surfaces, the food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Under 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking and 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, the food code indicated, Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microbes and Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 1. During an observation of the kitchen on 04/24/2023 at 9:07 AM, 77 plate covers were stacked wet and ready for use on the tray line. At that time, the Dietary Manager (DM) stated the plate covers should not be wet nested (the stacking of wet items such as pans, preventing them from drying and allowing an environment where microorganisms could begin to grow) but, instead, should be left to air dry before usage. She indicated Dietary Aide (DA) #1 was responsible to ensure all dishes were allowed to air dry. During an interview on 04/24/2023 at 9:12 AM, DA #1 revealed she loaded and unloaded the dish machine that morning but did not allow the plate covers to air dry due to being in a rush to finish everything. She stated she had previously received training regarding wet nesting. During an interview on 04/27/2023 at 12:00 PM, the Administrator revealed the plate covers in question should not have been wet before usage but, instead, should have been air dried. 2. During an observation of the kitchen on 04/24/2023 at 9:16 AM, the following expired food items were identified in the walk-in refrigerator: one sealable plastic bag of sliced turkey (expiration date of 04/23/2023), one sealable plastic bag of sliced ham (expiration date of 04/23/2023), one sealable plastic bag of parmesan cheese (expiration date of 04/14/2023), and 21 whole milk cartons (expiration date of 04/23/2023). Additionally, a sealable plastic bag of sliced cheese was found unlabeled and undated. At that time, the Dietary Manager (DM) stated that all outdated food and milk items should be discarded before the expiration date. During an interview on 04/27/2023 at 12:00 PM, the Administrator noted food in the refrigerator should be labeled, dated, and discarded by the expiration date. 3. During an observation of the kitchen on 04/24/2023 at 9:39 AM, the bottom of the convection oven had a thick, black substance and the glass doors were covered with a thick layer of brown grease that obstructed visualization of the interior of the oven. During an interview on 04/24/2023 at 9:40 AM, [NAME] #1 revealed the oven had not been cleaned in two months. She stated the convection oven should be cleaned weekly, but she did not have the time to do so due to the absence of an Assistant Manager. During an interview on 04/24/2023 at 9:10 AM, the Dietary Manager (DM) stated the Assistant Manager had been out for the prior two months. On 04/24/2023 at 9:42 AM, the DM revealed the oven was not cleaned because staff did not have enough time due to a full census in the facility. During an interview on 04/27/2023 at 12:00 PM, the Administrator revealed all kitchen equipment should be cleaned prior to usage if soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of facility policy titled Patient's Plan of Care, the facility failed to develop a comprehensive person-centered care plan for three residents (R) R#35 related to anticoagulant use, R#8 for diagnosis related to pain, and R#11 related to a diagnosis of diabetes mellitus type 2) of 26 sampled residents. Findings include: Review of facility policy titled Patient's Plan of Care (dated 2020) revealed Intent: Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. 1. Record review revealed R#35 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction and coronary artery disease. Review of R#35 admission Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. Section N (medications) of the MDS revealed resident received three days of anticoagulant therapy. Review of physician orders for R#35 revealed orders for apixaban 5 milligrams (mg) by mouth two times per day and clopidogrel bisulfate 75 mg by mouth one time per day. Record review revealed no person-centered care plan to address residents need for anticoagulant therapy. During interview on 10/21/21 at 10:12 a.m. with the Director of Nursing DON), she confirmed there was no care plan to address R#35's need for anticoagulant therapy. DON stated that she expected residents diagnoses to be addressed on the care plan. Care plan was created for anticoagulant use after surveyor brought to attention of DON there was not one. 2. Record review revealed R#8 was admitted to the facility on [DATE] with diagnoses including but not limited to osteoarthritis of the hip and unspecified lump in unspecified breast. Review of admission MDS dated [DATE] for R#8 revealed a BIMS score of 0, indicating severe cognitive decline. Section J (health conditions) of the MDS revealed resident received as needed medication for pain, vocalized pain, and protective body movements/posture. Review of the physician orders for R#8 revealed orders for meloxicam 15 mg by mouth as needed for moderate pain and tramadol hcl 50 mg by mouth every six hours as needed for moderate pain. Record review revealed no person-centered care plan to address resident's pain. During interview on 10/21/21 at 10:15 a.m. with the DON she confirmed there was not a care plan to address resident's pain. Stated that she expected residents to have care plans to address pain. 3. Record review revealed Resident # 11 was an [AGE] year-old female, admitted on [DATE], no BIMS score, and Full code status. Diagnoses included but not limited to, Diabetes Mellitus. Review of physician orders titled, Resident's Consolidated Order, revealed the following current orders that included but not limited to: Lab (Laboratory) dated 2/22/21: Hemoglobin A1C every 13 weeks (4 times per year) monitoring of blood glucose levels and symptoms of hyper/hypoglycemia. Glucometers and insulin dated 2/2/21: Levemir U-100 insulin 100 units/milliliter (units/ml) subcutaneous (sq) solution (Insulin Detemir) 20 units sq 2 times a day (bid), Do not mix with other insulins, expires 42 days after 1st use. Humulin R Regular U-100 insulin 100 units/ml injection solution (insulin Regular, Human) Units per sliding scale sq before meals and at bedtime (ACHS), expires 28 days from 1st use. Supplement dated 9/24/21: Boost Glucose control oral liquid, 1 carton by mouth 1 time per day (qd). Further review of the Consolidated Orders revealed on page 3/3, the second diagnosis on the list was Type 2 diabetes mellitus with diabetic neuropathy, unspecified. Review of the MDS Quarterly assessment dated [DATE] revealed Section I (active diagnoses) included Diabetes Mellitus; Section N- medications reported insulin injections on seven out of seven (7/7) days in the look back period. Further review of the MDS schedule revealed a comprehensive Entry tracking/5-day assessment dated [DATE], a significant change assessment dated [DATE] and 6/17/21, with Diabetes Mellitus listed under Section I, as an active diagnosis, for all of these assessments. Record review revealed no person-centered comprehensive care plan was developed, with interventions implemented to meet the resident's medical needs related to the diagnoses of diabetes mellitus, including monitoring for symptoms of hypo and hyperglycemia, for a resident with severe-moderate cognitive impairment. During an interview, and review of the care plan, on 10/21/21 at 1:05 p.m. with the DON, she confirmed there was no care plan for Diabetes Mellitus. DON then stated there should be a care plan for diabetes but felt the reason why there was not, was because the nurses failed to develop one or report to the MDS staff. The DON revealed that nurses can implement and update care plans for new diagnoses, new orders, new problem areas, new interventions, change in condition, etc., or they must report to MDS, the Assistant Director of Nursing (ADON) or the DON, so they can develop and implement an individualized care plan. DON expressed that her expectation was that the care plan should include Diabetes Mellitus, with goals, and interventions that included performing finger stick blood sugar (FSBS) checks, administration of insulin and monitoring for hypo and hyperglycemia.

Based on record review and staff interview, the facility failed to provide the skilled Notice of Medicare Non-Coverage Form CMS (Center for Medicare and Medicaid Services) 10123-(NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two of three residents (R) R#18 and R#38) reviewed that were discharged from Medicare Part A coverage. Findings Include: Review of facility policy titled Financial Liability Notices (updated January 2020) revealed It is the intent of this nursing center to issue all required Financial Liability Notices in compliance of CMS (Centers for Medicaid and Medicare Services) or other payer regulations. 1. R#18 was discharged from Medicare Part A services on 5/29/21 and remained in the facility. However, the only notice provided to the resident was the Notice of Medicare Non - Coverage (NOMNC) (Form CMS-10123). There was no evidence that the facility had Issued the SNF ABN to R#18 or his responsible party, providing the opportunity to continue with skilled services, at his cost if Medicare did not reimburse. 2. R#38 was discharged from Medicare part A services on 7/9/21 and remained in the facility. However, the only notice provided to the resident was the Notice of Medicare Non - Coverage (NOMNC) (Form CMS-10123). There was no evidence that the facility had issued an SNF ABN (Form CMS -10055) to R#38 or his responsible party, providing the opportunity to continue with skilled services, at his cost if Medicare did not reimburse. During interview on 10/20/2021 at 1:30 p.m. with the Administrator she confirmed that R#38, and R#18 had not been issued the SNF ABN (Form CMS-10055). Interview on 10/21/2021 at 2:30 p.m. with the Admissions Coordinator who revealed that she was responsible for providing the Beneficiary Protection Notifications to residents prior to discharge from skilled services. She acknowledged that the facility provided her with training in April 2021 on what notices to provide but she still has failed to provide the correct notices.