**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R26's Face Sheet, located under the Profile tab in the EMR revealed R26 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of R26's Attachment J Advance Directives Acknowledgment, located under the MISC tab in the EMR, dated 04/22/21, and signed by the resident representative, indicated R26 had not executed an Advance Directive. There was no documentation located that the resident and/or resident representative was provided with written information concerning how to formulate an Advance Directive if R26 and/or the resident representative wished to formulate one. 3. Review of R41's Face Sheet, located under the Profile tab in the EMR, revealed R41 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and left bundle-branch block. Review of R41's Attachment J Advance Directives Acknowledgment, located under the MISC tab in the EMR, dated 07/14/23, and signed by the resident representative, indicated R41 had not executed an Advance Directive. There was no documentation that the resident and/or resident representative was provided with written information concerning how to formulate an Advance Directive if R41 and/or the resident representative wished to formulate one. 4. Review of R14's Face Sheet, located under the Profile tab in the EMR, revealed R14 was originally admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R14's Attachment J Advance Directives Acknowledgment, located under the MISC tab in the EMR, dated 07/25/16, and signed by the resident, indicated R14 had not executed an Advance Directive. There was no documentation that the resident was provided with written information concerning how to formulate an Advance Directive if R14 wished to formulate one. 5. Review of R15's Face Sheet, located under the Profile tab in the EMR, revealed R15 was originally admitted to the facility on [DATE] with diagnoses that included cerebral infarction. Review of R15's Attachment J Advance Directives Acknowledgment, located under the MISC tab in the EMR, dated 12/11/17, and signed by the resident representative, indicated R15 had not executed an Advance Directive. There was no documentation that the resident and/or resident representative was provided with written information concerning how to formulate an Advance Directive if R15 and/or the resident representative wished to formulate one. During an interview on 04/28/25 at 1:23 PM, the Admissions/Marketing Director (AD) was asked if she provided written information to the resident and/or resident representative on how to formulate an Advance Directive. The AD stated, No, I do not. I only give them the POLST (Physician Orders for Life Sustaining Treatment) form in order to make their choices. During an interview on 04/28/25 at 3:35 PM, the Administrator stated, We didn't know that the POLST was not their Advance Directive. We will do whatever we need to do to correct this. On 04/28/25 at 1:00 PM, the Director of Nursing was asked to provide the facility's policy related to Advance Directives. On 04/28/25 at 3:30 pm, the AD was asked to provide the policy. On 04/28/25 at 3:35 PM, the Administrator was asked to provide the policy. The facility failed to provide the policy to the survey team prior to exit. Based on staff interviews and record review, the facility failed to provide the residents and/or their representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for five of 23 sampled residents (Resident (R) 48, R26, R41, R14, and R15) reviewed for Advanced Directives. This failure created the potential the resident wishes to not be followed if the residents were unable to speak for themselves. Findings include: 1. Review of R48's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R48 was admitted to the facility on [DATE]. Review of R48's EMR revealed no documentation that R48 had an Advance Directive or that the facility provided written information to the resident or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an Advance Directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R26's Face Sheet, located under the Profile tab in the EMR, indicated R26 was admitted to the facility on [DATE] with diagnoses that included epilepsy. Review of R26's Nursing Progress Notes, dated 12/25/24 at 10:32 AM and located under the Progress Note tab in the EMR, revealed, I [name of registered nurse] was summoned to resident's room. Resident appeared actively seizing at the time of entrance, which lasted one minute. Resident was noted in his bed and all safety precautions were taken, resident was not harmed during the seizure. V/S [vital signs] were taken at this time, BP [Blood Pressure] 197/149, P [pulse] 126, R [respirations] 18, T [temperature] 98.4. [Name of Nurse Practitioner] notified of resident's change in condition and gave new order for hospital transport. Resident transported to hospital . Review of R26's EMR revealed no documented evidence that a written transfer notice was provided to R26 or the resident's representative. During an interview on 04/29/25 at 10:15 AM, the Administrator stated, We let the resident representative [RP] know verbally that the resident is being sent out, the reason, and where they are going. We don't hand them a letter. During an interview on 04/30/25 at 11:30 AM, the Director of Nursing (DON) confirmed that a transfer notice was not sent or given to the resident and/or RP stating the reason for the transfer that was written and was easily understood by the resident and/or RP. The DON stated, We send the transfer form that we fill out with the resident to the hospital. Based on record review, staff interviews, and facility policy review, the facility failed to provide written transfer/discharge notices that stated the reason for transfer, the place of transfer, and other information regarding the transfer to three of 23 sampled residents (Resident (R) 48, R29, and R26) reviewed for discharge to the hospital. This failure had the potential to affect the residents by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Transfer and/or Discharge, Including Against Medical Advice (AMA), Discharge Notification (622, old F623), reviewed April 2025, revealed, . This community has established transfer and discharge criteria based upon applicable federal requirements . The resident, and/or representative (sponsor) will be provided with the following information within the notice, in writing and language and manner they understand, prior to transfer. a. The reason for the transfer or discharge, and the reasons for the move in writing and in the language and manner they understand. b. The effective date of the transfer or discharge. C. The specific location (such as the new provider or description and/or address if the location is a location) to which the resident is being transferred or discharged . 1. Review of R48's admission Record. located under the Profile tab of the electronic medical record (EMR), revealed R48 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, monoplegia of upper arm affecting unspecified side, and other iron deficiency anemia Review of R48's Progress Notes, dated 01/14/25 at 6:52 PM and located under the Progress Notes tab of the EMR, revealed R48 had critical lab values, and the physician ordered for the resident to be transferred to the hospital. Review of R48's EMR revealed no documentation that a written transfer notice was provided to R48 or the resident's representative. 2. Review of R29's admission Record, located under the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, rheumatoid arthritis, and generalized anxiety disorder. Review of R29's Progress Notes, dated 04/24/25 at 4:22 PM and located under the Progress Notes tab of the EMR, revealed R29 a decrease in appetite and had an overall decline. The physician was notified and ordered for the resident to be transferred to the hospital. It was recorded that the resident's family member was at the bedside. Review of R29's EMR revealed no documentation that a written transfer notice was provided to R29 or the resident's representative (RP).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one of 23 sampled residents (Resident (R)11) reviewed for Preadmission Screening and Resident Review (PASARR) and one of 23 sampled residents (R11) reviewed for unnecessary medications. This failure placed the resident at risk of having unmet care needs and services. Findings include: Review of the facility's policy titled, Comprehensive Assessment, dated 03/2025, indicated, . Residents will receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline . Review of the Resident Assessment Instrument (RAI) Manual 3.0, dated 10/2019, revealed .If a Minimum Data Set (MDS) assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . 1. Review of R11's admission Record, found under the Profile tab of the electronic medical record (EMR), revealed R11 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, depressive type. Review of R11's annual MDS assessment, located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 12/18/24, indicated R11 had an active diagnosis of schizophrenia and was currently not considered by the State Level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 04/28/25 at 1:43 PM, the facility's Business Office Manager (BOM) stated R11was previously evaluated by the State Level II PASARR on 06/05/23. The BOM provided a copy of R11's PASARR Level II evaluation. Review R11's Level II PASARR evaluation, dated 06/05/23, provided by the BOM, specified R11 had a serious mental illness and specialized behavioral health services was recommended. During an interview on 04/28/25 at 2:27 PM, the MDS Coordinator (MDSC) stated she completed the PASARR section on R11's 12/18/24 annual MDS. The MDSC reviewed R11's EMR and confirmed R11's annual MDS of 12/18/24 inaccurately assessed the resident's PASARR status. The MDSC stated she would correct R11's annual MDS assessment to reflect the resident had a PASARR Level II evaluation completed which specified she had a serious mental illness. Review of R11's annual MDS assessment, located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 12/18/24, indicated R11 had an active diagnosis of schizophrenia and was taking an antidepressant medication. Review of R11's December 2024 Medication Administration Record (MAR), located in the Orders tab of the EMR, revealed the resident did not receive an antidepressant medication during this month. During an interview on 04/30/25 at 11:30 AM, the MDSC stated she completed the medication section on R11's 12/18/24 annual MDS. The MDSC reviewed R11's EMR and confirmed R11's annual MDS of 12/18/24 inaccurately assessed the resident as taking an antidepressant medication. The MDSC stated she would correct R11's 12/18/24 annual MDS assessment to reflect the resident was not taking an antidepressant medication at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and facility policy review, the facility failed to follow professional standards of practice when they did not clarify medication orders for two of 23 sampled residents (Resident (R) 11 and R25). Staff did not clarify a physician's order for discontinuing an antidepressant abruptly for R11 and did not clarify R25's physician order for an antipsychotic medication that contained two different frequencies for administration. This had the potential to cause the residents to suffer adverse consequences. Findings include: 1. Review of the facility's policy titled, Administering Medications, dated 10/2024, indicated, Policy Medications should be administered in a safe and timely manner, and as prescribed . 5. If a dosage is believed to be inappropriate of excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associate with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. Review of the facility's policy titled, Administering Medications F760, revealed, . The individual administering the medication must check THREE [sic] (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication . Review of Preventing Medication Errors in Nursing, located at https://www.nursingcenter.com/clinical-resources/nursing-drug-handbook/medication-errors/prevention, revealed, . Reducing medication errors is critical. In addition to recognizing common medication error risk factors, nurses must implement workplace strategies to prevent adverse drug events . Clarify drug, dosage, frequency and other details with the pharmacist or prescribing healthcare provider if there is any uncertainty . Review of R11's admission Record, located under the profile tab in the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder depressive type, epilepsy, anxiety disorder, and delusional disorders. Review of R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/24, located in the resident's EMR under the MDS tab, revealed the resident was receiving an antidepressant medication and had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated she was moderately cognitively impaired. Review of R11's current care plan, located under the Care Plan tab of the EMR, revealed a Focus area, with a creation date of 03/31/16, which identified R11 as having behavior problems with a diagnosis of schizoaffective disorder. A care plan intervention indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of R11's September 2024 Order Summary Report, located in the Misc [Miscellaneous] tab of the EMR, revealed an order for Duloxetine HCL [an antidepressant medication] Capsule Delayed Release Particles 30 MG [milligrams] Give 1 capsule by mouth two times per day related to schizoaffective disorder, depressive type. This medication order had a start date of 05/31/22. Review of R11's Physician orders, located under the Orders tab of the EMR, revealed an order written on 09/26/24 to discontinue the order for Duloxetine HCL Capsule Delayed Release Particles 30 MG [milligrams] Give 1 capsule by mouth two times per day. Further review of R11's physician orders revealed no orders were written for R11 to receive duloxetine after the medication was discontinued on 09/26/24. Review of R11's Progress Notes tab of the EMR revealed no documented evidence staff had attempted to clarify with the physician why R11's duloxetine had been abruptly discontinued. During an interview on 04/29/25 at 9:15 AM, the Director of Nursing (DON) stated R11's duloxetine was mistakenly discontinued on 09/26/24 by the facility's prior Medical Director. The DON explained that the error was not discovered until 03/24/25 when the facility's consultant pharmacist discovered the error during her monthly review of R11's medications. The DON stated the resident did not receive duloxetine from 09/27/24 until present because a new order was not written to restart the medication. During an interview on 04/29/25 at 9:15 AM, the Administrator stated the physician who made the error in discontinuing R11's duloxetine on 09/26/24 was no longer employed by the facility. During an interview on 04/29/25 at 12:29 PM, the facility's current Medical Director stated that R11's duloxetine should not be discontinued cold turkey because a resident needs to be weaned off the medication because there were side effects that could occur with it being discontinued abruptly. Review of a facility Medication Related Incident Report, dated 03/24/25, provided by the facility, indicated, Incident Description: Pharmacy consultant questioned why medication [duloxetine] was no longer active on eMAR [electronic Medication Administration Record] . Description: It was founded that the medical director mistakenly discontinued medication and failed to notify facility. Provider was immediately notified of occurrence. No recommendation. Resident was assessed and no abnormalities were observed. Resident was pleasant. Name of provider behavioral services notified of occurrence. During an interview on 04/29/25 at 11:41 AM, the Pharmacist Supervisor (RPHS) stated duloxetine should not be stopped abruptly because a resident could experience side effects including nausea, vomiting, dizziness, and other effects as noted on the medication's information insert. Review of R11's behavioral health notes, located in the EMR under the Prog [Progress] Note tab revealed behavioral notes written on 10/24/24, 11/08/24, 11/29/24, 12/05/24, 12/19/24, 01/16/25, 01/30/25, 02/13/25, and 02/28/25 specified R11 continued to receive duloxetine HCL and that it was helping to control her symptoms of despair and sadness even though the medication had been discontinued on 09/26/24. R11's behavioral health note dated 04/25/25 [noted as a late entry] specified, Depression is stable. Her Duloxetine was accidentally discontinued by another staff member and never added back. She tolerated the discontinuation well and we will monitor for any changes in her mood or behavior. No feelings of sadness or dread are noted. During an interview on 04/29/25 at 12:34 PM, the Mental Health Nurse Practitioner (MHNP), stated he had worked with R11 for years and was not aware that R11's Duloxetine medication was discontinued on 09/26/24 until March 2025. The MHNP stated after R11's duloxetine medication was discontinued he continued to erroneously document in the resident's behavior notes that she was receiving this medication and that it was helping to control her symptoms of depression. The MHNP stated it would have been prudent of him to review R11's medications at each of his visits to see what medications the resident was receiving. The MHNP stated he would have expected staff to inform him that R11's antidepressant medication was discontinued, but it was his responsibility to review the residents' medications as part of his evaluation. The MHNP stated that R11's duloxetine was stopped abruptly, which was not advisable. The MHNP explained that R11 should have been weaned off her duloxetine medication slowly to prevent any potential side effects when discontinuing this medication. The MHNP stated he had not noticed a change in R11's mood or an increase in her depression during the past months. During an interview on 04/29/25 at 1:15 PM, R11 stated over the past months she had felt a little more tired than normal but had not experienced an increase in depression or sadness. During an interview on 04/30/25 at 1:40 PM, The DON stated she would expect facility nurses to clarify any questionable physician order, which included when a physician discontinued a resident's antidepressant medication abruptly. The DON stated when an order was questionable the nurse should call the Physician for clarification to ensure the order is what the physician wants to implement. The DON stated since it was discovered that R11's antidepressant medication was discontinued abruptly in error by the physician the nursing staff had received additional training on clarifying physician orders. During an interview on 04/29/25 at 5:19 PM, R11's Physician stated, If I wanted to decrease Cymbalta [duloxetine] from 30 mg to completely taking her [R11] off of the medication, I would not stop it [duloxetine] abruptly. I would have tapered her [R11] off of it [duloxetine] by decreasing the dosage to 30 mg every other day for a month, then 15 mg every other day for a month and assess how she was doing with the taper and adjust as I would need to so she would not have withdrawals. I was not made aware of this until six months later, that the mistake was made by another doctor that mistakenly discontinued it [duloxetine]. 2. Review of R25's Face Sheet, located under the Profile tab in the EMR, indicated R25 was originally admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (COPD). Review of R25's quarterly MDS located under the MDS tab in the EMR and with an ARD of 09/07/24, revealed R25 had a BIMS score of 10 out of 15, which indicated R25 was moderately cognitively impaired. R25 was coded as receiving antipsychotic medications while a resident at the facility. Review of R25's Care Plan, located under the Care Plan tab in the EMR and dated 09/20/23, revealed, . [R25] is easily angered\annoyed [sic] by others, uses profanity, demanding, inpatient, behaviors not always altered. Has dx of brief psychotic disorder, vascular dementia with behavioral problems, drug seeking behaviors [sic]. Non compliant [sic] with care/tx [treatment]. Interventions were, . Allow him [R25] to make decisions in his care, give choices and honor preferences. Explain what you are doing prior to doing it. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's [sic] understanding of the situation. Allow time for the resident to express self and feelings towards the situation . Review of R25's Physician's Orders, located under the Orders tab in the EMR, indicated an order dated 09/09/24 for ziprasidone [Geodon, an antipsychotic medication] HCL Oral Capsule 20 mg [milligram] Give one capsule by mouth two times a day for F19.14 [sic] Give one capsule by mouth three times a day related to Other PSYCHSOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD DISORDER (F19.14) [sic]. Review of R25's Medication Administration Records (MARs), dated 09/09/24 through 12/01/24, revealed R25 received ziprasidone twice daily. Review of R25's Progress Notes and Orders tabs of the EMR revealed no documented evidence staff attempted to clarify the 09/09/24 physician's order until 12/02/24, when a new order was received to give ziprasidone 20 mg three times a day. During an interview on 04/30/25 at 5:00 PM, the Director of Nursing (DON) stated the resident had the right to receive the right frequency of medication. The DON stated the nursing staff did not ensure this right. The DON stated, They should have called the doctor to clarify the order. There were 2 times listed to give this medication. During an interview on 04/30/24 at 4:30 PM, the Regional Director of Clinical Services confirmed the nurses administering ziprasidone should have called the doctor to clarify the frequency in which the medication was to be given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and facility policy review, the facility failed to ensure nail care and/or showers were provided for three of 23 sampled residents (Resident (R) 49, R24 and R37) reviewed for activities of daily living (ADLs). This failure had the potential to cause R49, R24, and R37 to have unmet care needs. Findings include: Review of the facility's policy titled, Quality of Life-Activities of Daily Living F676, F677, revised 04/2025, revealed, . Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene . 1. Review of R49's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R49 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of brain, unspecified epilepsy, and repeated falls. Review of R49's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/25 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed R49 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated R85 had severe impaired cognition. Review of R49's Care Plan, located in the EMR under the Care Plan tab and last revised 02/27/25, revealed R49 . Requires mod-max [moderate to maximum] assist from staff with baths, prefer showers on Tuesdays and Thursdays, bed bath on alt. [alternate] days . During an observation and interview on 04/27/25 at 10:50 AM, R49 was observed sitting in her room. R49's fingernails were noted to be greater than a quarter an inch over her fingertips. [NAME] debris was noted under the nails. When asked if she preferred her fingernails to be this long and unclean, R49 stated, No I really want them trimmed. During an observation on 04/28/25 at 9:30 AM, R49's nails remained greater than a quarter of an inch over her fingertips with brown debris under her nails. 2. Review of R24's Face Sheet, located under the Profile tab of the EMR, revealed R24 was admitted to the facility on [DATE] with diagnoses which included hypertension, paroxysmal atrial fibrillation, and legal blindness. Review of R24's significant change MDS, with an ARD of 04/02/25 and located under the RAI tab of the EMR, revealed R24 had a BIMS score of eight out of 15, which indicated R24 had moderate impaired cognition. Review of R24's Care Plan, located in the EMR under the Care Plan tab and last revised 03/27/25, revealed, . Resident has difficulty in performing tasks of daily living such as feeding self, dressing, bathing, toileting . During an observation and interview on 04/27/25 at 10:40 AM, R24 had fingernails that were greater than one half inch over her fingertips. [NAME] debris was noted under her nails. R24 stated, I don't get a regular bath, I have to wipe up, I haven't refused my bath. During an observation 04/28/25 at 12:24 PM, R24 continued to have fingernails that were greater than one half inch over her fingertips, and brown debris was noted underneath her nails. 3. Review of R37's Face Sheet, located under the Profile tab of the EMR, revealed R37 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, venous insufficiency, and hypertension. Review of R37's quarterly MDS, with an ARD of 03/30/25 and located under the RAI tab of the EMR, revealed R37 had a BIMS score of 14 out of 15, which indicated R37 had intact cognition. Review of R37's Care Plan, located in the EMR under the Care Plan tab and last revised 03/07/23, revealed, . Resident requires assist with adl's, non-compliant with allowing staff to assist, believes he is more capable of doing more for himself than he is able . Prefers to have showers on Mondays and Thursdays on 7a-7p (7:00 am to 7:00 pm) shift, bed bath on other days on 7a-7p shift . date initiated: 06/29/2023, no revision . During an observation on 04/27/25 at 12:19 PM, R37 stated, I'm lucky to get one shower a week. R37 stated, I have not refused a shower or bath. During an observation 04/28/25 at 1:00 PM, R37 stated, I still haven't had a shower. During an interview on 04/29/25 at 3:30 PM, Certified Nursing Assistant (CNA) 9 was asked who was responsible for trimming residents' fingernails and toenails. She stated CNA's during the residents' shower and anytime it is needed. She stated R49's daughters trim and clean her nails. She was asked who was responsible if the family was not there to provide the care. CNA 9 stated, I guess we are. She stated, CNAs are supposed to make sure each resident was bathed/showered unless they refuse and then the nurse would be notified CNA9 was asked if R37 had refused. She stated, Not that I know of. CNA9 stated she did not assist R37 with showers. She stated the resident bathed himself at the sink. During an interview on 04/29/25 at 3:45 PM, CNA4 was asked who was responsible for trimming and cleaning residents' fingernails. She stated, CNAs during their [the residents] shower and anytime it's needed, unless the resident is diabetic then the nurse would trim the resident's nails. CNA4 stated, CNAs are supposed to make sure each resident is bathed/showered unless they refuse and then the nurse would be notified. CNA4 was asked if R37 had refused showers. She stated, Not that I know of. CNA4 stated she did not assist R37 with showers. She stated the resident bathed himself at the sink. During an interview on 04/29/25 at 4:15 PM, CNA3 was asked who was responsible for trimming residents' fingernails and toenails. She stated, CNAs during their shower, and anytime it's needed, unless the resident is diabetic then the nurse would trim the resident's nails. CNA3 stated CNAs were supposed to make sure each resident was bathed/showered unless they refused and then the nurse would be notified. CNA3 was asked if R37 had refused showers. She stated, Not that I know of. We let him wash up. During an interview on 04/29/25 at 4:20 PM, CNA2 was asked who was responsible for trimming residents' fingernails and toenails. She stated, CNAs during their shower, and anytime it's needed, unless the resident is diabetic and then the nurse would trim the resident's nails. CNA2 stated CNAs were supposed to make sure each resident was bathed/showered unless they refused, and then the nurse would be notified. CNA2 was asked if R37 had refused showers. She stated, I'm not sure. CNA2 stated she did not assist R37 with showers. She stated the resident bathed himself at the sink. During an interview on 04/29/25 at 4:25 PM, Licensed Practical Nurse (LPN) 6 was asked who was responsible for trimming and cleaning resident's fingernails, she stated, CNA's during their shower, and anytime it's needed, unless the resident was diabetic then the nurse trims the resident's nails. LPN6 was asked if residents are not bathed/showered are you made aware, she stated yes, the CNAs are supposed to let us know, I don't know of R37 refusing a shower. During an interview on 04/29/25 at 4:30 PM, Licensed Practical Nurse (LPN) 4 was asked who was responsible for trimming and cleaning resident's fingernails. She stated, CNAs during their shower, and anytime it's needed, unless the resident is diabetic. Then one of nurses would trim the resident's nails. LPN4 was asked if she was made aware if residents were not bathed/showered. She stated, Yes, the CNAs are supposed to let us know. LPN4 was asked if she was aware R37 had not received his showers. She stated, I didn't know he had not gotten a shower, I'll see what I can get done. During an observation and interview on 04/30/25 at 10:45 AM, the Director of Nursing (DON) observed R49 and R24's nails and confirmed they needed to be cleaned and trimmed. The DON was asked who was responsible for trimming residents' fingernails and toenails. She stated primarily the CNAs during showers, but everyone there should assist the residents with their needs. She was asked what the expectation was regarding baths/showers for residents. She stated, The care plan should be followed and the resident offered and given their showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and policy review, the facility failed to store a Trilogy (a noninvasive ventilator device used to assist breathing for patients with respiratory issues) mask in a manner to prevent contamination for one of 23 sampled residents (Resident (R)156) reviewed for respiratory services. This failure increased the risk of respiratory infection. Findings include: Review of the facility's policy titled, Administrating Medications through a Small Volume (Handheld) Nebulizer dated 10/2024, revealed, . When equipment is completely dry, store in a plastic bag with the resident's name and date on it . Review of R156's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R156 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypercapnia (elevated carbon dioxide levels in the blood). Review of R156's admission Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 04/18/25, indicated R156 had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated R156 was severely cognitively impaired. R156 was coded as requiring continuous oxygen therapy and a non-invasive mechanical ventilator. Review of R156's Care Plan, dated 04/14/25 and located under the Care Plan tab in the EMR, revealed, [R156] is on a non-invasive ventilator during hs [hour of sleep], O2 [oxygen] via [by] n/c [nasal cannula] during the day. Interventions were, Assess for s/sx [signs/symptoms] of hypoxia: altered level of consciousness, irritability, listlessness, cyanosis [sic]. Keep head of bed elevated above 30 degrees unless providing care or resident request . Maintain ventilator settings as ordered md [sic] for settings . During observations on 04/27/25 at 10:30 AM and on 04/28/25 at 11:15 AM, the Trilogy non-invasive mechanical ventilator mask was stored on the top of the bedside table and not being stored in a plastic bag when not in use. During an observation and interview on 04/28/25 at 2:06 PM, Licensed Practical Nurse (LPN)2 accompanied the surveyor to R156's room, and the resident's mask was not stored in a plastic bag. LPN2 stated, That mask should be in a bag. Let me go get her [R156] a new mask and a plastic bag to put it in. During an interview on 04/28/25 at 2:09 PM, the Infection Preventionist (IP) stated, It [Trilogy mask] is supposed to be stored in a bag. The IP was asked to provide the facility's policy on the storage of masks when they were not in use. The IP brought a policy and explained this policy did not specifically address Trilogy masks. The IP stated, But it is what we would expect the staff to follow for this mask.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R25's Face Sheet, located under the Profile tab in the EMR, revealed R25 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of R25's quarterly MDS, located under the MDS tab in the EMR and with an ARD of 9/07/2024, revealed R25 had a BIMS score of 10 out of 15, which indicated R25 was moderately cognitively impaired. R25 was coded as receiving antipsychotic medications while a resident at the facility. Review of R25's Care Plan, located under the Care Plan tab in the EMR and dated 09/20/23, revealed a focus of, [R25] is easily angered\annoyed [sic] by others, uses profanity, demanding, inpatient, behaviors not always altered. Has dx [diagnosis] of brief psychotic disorder, vascular dementia with behavioral problems, drug seeking behaviors [sic]. Non compliant [sic] with care/tx [treatment]. Interventions were Allow him [R25] to make decisions in his care, give choices and honor preferences. Explain what you are doing prior to doing it. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's [sic] understanding of the situation. Allow time for the resident to express self and feelings towards the situation . Review of R25's Physician's Orders, located under the Orders tab in the EMR, revealed an order dated 09/09/24 for ziprasidone [Geodon, an antipsychotic medication] HCL Oral Capsule 20 mg Give one capsule by mouth two times a day for F19.14 [sic] Give one capsule by mouth three times a day related to Other Psychsoactive Substance Abuse With Psychoactive Substance-Induced Mood Disorder (F19.14) [sic]. Review of R25's Medication Administration Record (MAR), located under the Orders tab in the EMR, indicated R25's order for ziprasidone was written in the same manner which the order for 9/9/2024 recorded. Review of R25's MAR for the months of September through November 2024 indicated R25 was administered ziprasidone two times a day at 8:00 am and 4:00 pm. Review of R25's Consultation Report, provided by the facility and dated 10/23/2024 and 11/20/2024, revealed, Clinical Priority Recommendation. Prompt Response Requested. [R25's] order for Ziprasidone 20 mg was TID [three times per day] but on 9/9/2024, the directions in , the EMR were changed to Give 1 [sic] capsule by mouth two times a day for F19.14 Give 1 [sic] capsule by mouth three times a day. These reports had the Director of Nursing (DON) name under the signature line. Neither report was signed nor dated by the DON. Review of R25's Physician Orders, dated 12/02/24 and located under the Orders tab of the EMR, revealed an order to give ziprasidone 20 mg three times a day. During an interview on 4/30/2025 at 3:30 pm, the DON stated, This order was clarified with the doctor on 12/2/2024. The DON was asked why the pharmacy recommendations were not acted upon until 12/2/2024. The DON stated, I cannot answer that. The ADON [Assistant Director of Nursing] was responsible for doing those, and she no longer works here. The DON was asked if she had checked behind the ADON to see that the pharmacy recommendations were completed and acted upon. The DON stated, No, I didn't check behind her. The DON confirmed the pharmacy recommendations should have been completed when the 10/23/2024 pharmacy request for clarification of the order was received. During an interview on 4/30/2024 at 4:30 pm, the Regional Director of Clinical Services confirmed the pharmacy recommendations received on 10/23/2024 should have been acted upon by nursing as soon as they had received the consultation report and staff should not have waited until 12/2/2024 for the order to be clarified. Based on staff interviews, record review, policy review, and review of the National Library of Medicine, the facility failed to ensure the Consultant Registered Pharmacist (CRPH) identified an irregularity when performing monthly medication regimen reviews regarding the discontinuation of a resident's duloxetine (Cymbalta, antidepressant medication) and/or failed to ensure pharmacist recommendations regarding antipsychotic medications in a timely manner for two of five residents (Resident (R)11 and R25) reviewed for unnecessary medications out of a total sample of 23 residents. Failures to identify irregularities in medication regimens and to act upon pharmacist recommendations placed residents had increased risk of adverse reactions and medication administration errors. Findings include: Review of the facility's policy titled, Medication Regimen Review, dated 2/2025, indicated, Procedure The consultant pharmacist will conduct MRRs [medication regimen reviews] if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the residents' health record . 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. Review of the National Library of Medicine article titled, Symptoms following abrupt discontinuation of duloxetine treatment in patients with major depress disorder, located at https://pubmed.ncbi.nlm.nih.gov/16266753/, revealed, . Abrupt discontinuation of duloxetine is associated with a DEAE [discontinuation-emergent adverse events] profile similar to that seen with other selective serotonin reuptake inhibitor (SSRI) and selective serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants. It is recommended that, whenever possible, clinicians gradually reduce the dose no less than 2 weeks before discontinuation of duloxetine treatment. 1. Review of R11's admission Record, located under the profile tab in the electronic medical record (EMR), revealed R11 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder depressive type, epilepsy, anxiety disorder, and delusional disorders. Review of R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/18/2024 and located in the resident's EMR under the MDS tab, revealed the resident was receiving an antidepressant medication and had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated she was moderately cognitively impaired. Review of R11's current care plan, located under the Care Plan tab of the EMR, revealed a Focus area, with a creation date of 3/31/2016, of having behavior problems with a diagnosis of schizoaffective disorder. A care plan intervention indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness. Review of R11's August 2024 Order Summary Report, located in the Misc [Miscellaneous] tab of the EMR, revealed an order for Duloxetine HCL Capsule Delayed Release Particles 30 MG [milligrams] Give 1 capsule by mouth two times per day related to schizoaffective disorder, depressive type. This medication order had a start date of 5/31/2022. Review of R11's September 2024 Order Summary Report, located in the Misc tab of the EMR, revealed the order for Duloxetine HCL Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times per day related to schizoaffective disorder, depressive type continued as an active order. Review of R11's Physician Orders, located under the Orders tab of the EMR, revealed an order was written on 9/26/2024 to discontinue the resident's order for Duloxetine HCL Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times per day. Further review of R11's physician orders revealed there was no new order written for R11 to receive Duloxetine medication after the medication was discontinued on 9/26/2024. There was no order to taper the use of the medication. Review of R11's September 2024 monthly Medication Administration Record (MAR), provided by the facility, revealed the resident last received duloxetine HCL on 9/26/2024. Review of R11's monthly October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, and April 2025 MARs, provided by the facility, revealed that R11 had not received duloxetine medication since 9/26/2024. During an interview on 4/29/2025 at 9:15 am, the Director of Nursing (DON) stated R11's duloxetine was mistakenly discontinued on 9/26/2024 by the facility's prior Medical Director. The DON explained that the error was not discovered until 3/24/2025 when the facility's consultant pharmacist discovered the error during her monthly review of R11's medications. The DON stated the resident did not receive duloxetine from 9/27/2024 until present because a new order was not written to restart the medication. Review of the monthly pharmacy Consultation Reports, provided by the facility, revealed on 10/23/2024, 11/20/2024, 12/22/2024, 1/31/2025, and 2/24/2025, the CRPH reviewed R11's drug regimen and did not identify any medication irregularities. During an interview on 4/29/2025 at 9:45 am, the facility's CRPH confirmed that R11's duloxetine medication was discontinued on 9/26/2024. The CRPH stated she performed monthly medication reviews after the physician discontinued R11's duloxetine on 9/26/2024. She confirmed she did not note any irregularities on her monthly reviews until she completed the resident's review in March 2025 and informed the facility of the error. During an interview on 4/29/2025 at 11:41 am, the Pharmacist Supervisor stated duloxetine should not be stopped abruptly because a resident could experience side effects including nausea, vomiting, dizziness, and other effects as noted on the medication's information insert.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility document review, the facility failed to have a complete and accurate medical record regarding documentation of a change in condition for one of 23 sample residents (Resident (R)15). This failure had the potential for the following shifts not to be completely informed of the resident's status. Findings include: Review of the facility's policy Documentation Guidelines F583, F755, F842 dated 04/2024 revealed, . Services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record . Review of R15's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R15 was admitted to the facility on [DATE] with the diagnosis of cerebral infarction. Review of R15's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 03/22/24, indicated R15 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R15 was severely cognitively impaired. Review of R15's Care Plan, located under the Care Plan tab in the EMR and dated 12/31/17, revealed, . [R15] has dx [diagnosis] and cva [sic] [Cerebral Vascular Accident] with hemiplegia . Interventions were Notify md [Medical Doctor] if blood pressure is outside perimeters. Give cardiac/antihypertensive meds [medications] as ordered, monitor for effectiveness and adverse effects. Monitor blood pressure as scheduled and as needed. Monitor for and document any edema. Notify MD . Review of R15's Nursing Progress Notes, located under the Progress Note tab in the EMR indicated documentation and dated 06/01/24 at 8:24 AM, revealed, . Received report that resident vomited throughout the night. [Name of Certified Nursing Assistant (CNA)] reported to [Name of Licensed Practical Nurse (LPN)2] that the resident did not look like herself. Upon further evaluation, we discovered the resident has left sided facial droopiness. She [R15] is also not alert and responding at this time. MD notified of situation and instructed us to send her [R15] out . During an interview on 04/30/25 at 11:00 AM, LPN1 stated, If I was working on her [R15] hallway and she [R15] had a change in condition that I was aware of, I would document the change and the assessment if I had to perform one. I can't remember back that far if I worked with her [R15] or not. During an interview on 04/30/25 at 11:15 AM, LPN2 stated, I remember working with another nurse that day. I can't remember who told me about her [R15] not acting like herself but as soon I was told, I went and assessed her [R15] and told the other nurse that I was working with that day, and we worked together getting her [R15] out of the facility. LPN2 was asked if the assessment would be something that LPN2 would have documented. LPN2 stated, Yes, I would have documented it. LPN2 was notified the only documentation on 06/01/24 was from another nurse and not LPN2. LPN2 was asked if she should have documented this assessment. LPN2 stated, Yes. During an interview on 04/30/25 at 12:09 PM, Registered Nurse (RN)1 stated, I remember someone said she [R15] had a little vomiting the night before she [R15] was transferred to the hospital the day after that. Further review of R15's Nursing Progress Notes revealed no documentation on 05/31/25 that R15 had been vomiting that shift. During an interview on 04/30/25 at 3:30 PM, the Director of Nursing (DON) stated, If a resident has a change in condition, the nurse is to do an assessment and document the findings in PCC [Point Click Care, electronic medical record].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, policy review, and review of McGeer criteria (a tool designed to support facility healthcare-associated infection surveillance), the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for three of 23 sampled residents (Resident (R) 33, R42, and R8) reviewed for antibiotic stewardship. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary. Findings included: Review of the facility's policy titled, Infection Control Program - Antibiotic Stewardship F881, dated 10/2024, revealed, . After an order has been received, the Infection Control Coordinator or designee should complete the surveillance document, utilizing the McGeer criteria, noting evidence for the infection. If the antibiotic does not fit criteria, the physician will be contacted. Review of the McGeer's Criteria (11/5/24) revealed, Table 1. Constitutional Criteria for Infection Fever, Leukocytosis, Acute Mental Status Change, Acute Functional Decline . Table 2. Urinary Tract Infection (UTI) Surveillance Definitions Syndrome: UTI without indwelling catheter Criteria: 1. At least one of the following sign or symptom: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and one or more of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency If no fever or leukocytosis, then greater than 2 of the following: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency 2. At least one of the following microbiologic criteria greater than or equal to 100,000 Colony Forming Units (CFU) per milliliter (mL) of no more than 2 species of organisms in a voided urine sample greater than or equal to 100 of any organism(s) in a specimen collected by an in-and-out catheter . Selected Comments: The following two comments apply to both UTI with or without catheter: UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection In the absence of a clear alternate source of infection, fever, or rigors with a positive urine culture resulting in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source. Urine specimens for culture should be processed as soon as possible, preferably within 1-2 hours If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated and used for culture within 24 hours. 1. Review of R33's Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed R33 was admitted to the facility on [DATE] with diagnoses of but not limited to urinary tract infection and dementia. Review of R33's Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed a note dated 01/09/25 at 3:11 PM which indicated, This nurse spoke with resident about getting a urine sample after staff had mentioned some confusion. She agreed to [sic] due to having lower back pain that comes and goes and urinary urgency, Urine will be sent to [name of laboratory] for testing after collection. Further review of the nursing progress notes indicated no documentation of R33 experiencing low back pain with urinary urgency before the nursing note that was documented on 01/09/25 or having malaise and confusion before 01/09/25. Review of R33's Physician's Orders, dated 01/09/25 and located under the Orders tab in the EMR, revealed a physician's order to obtain a urinalysis with culture and sensitivity for malaise and confusion. Review of R33's Urinalysis lab report, provided by the facility and with a collection date of 01/15/25 and a reported date of 01/18/25, revealed the urinalysis was for microscopic only and not a complete urinalysis. Review of R33's Urine Culture lab report, provided by the facility and dated 01/18/25, revealed results of the organism being Escherichia coli greater than 100,000 colonies. Review of R33's Physician's Orders, located under the Orders tab in the EMR, revealed an order dated 01/21/25 for Levaquin (an antibiotic) 500 mg (milligram) Give one tablet by mouth one time a day for UTI (Urinary Tract Infection) for 10 days. Review of R33's Infection Screening Evaluation, provided by the facility and dated 01/21/25, indicated R33 did not have a fever, and the symptom being experienced by R33 was urinary incontinence. Under the Infection Analysis section of the screening, it was indicated, McGeer's Criteria: Suspected UTI without indwelling catheter. During an interview on 04/30/25 at 11:27 AM, the Infection Preventionist (IP) stated, We were told in an in-service with the lab we could only order UA [urinalysis] microscopic. The IP confirmed that a complete urinalysis should have been obtained from the lab instead of the microscopic only. The IP confirmed that the order for the antibiotic did not meet McGeer's Criteria due to the resident having confusion and malaise and there were no urine results that showed the presence of leukocytes (organisms that can indicate infection). 2. Review of R42's Face Sheet, located under the Profile tab in the EMR, revealed R42 was admitted to the facility on [DATE] with the diagnosis of cerebral infarction and diabetes mellitus. Review of R42's Physician's Orders, located under the Orders tab in the EMR, indicated an order dated 08/18/24 for Urinalysis one time only for lethargic, change in mental status. Review of R42's Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed no documented evidence that the resident was experiencing lethargic or altered mental changes. Review of R42's Urinalysis lab report, provided by the facility and with a collection date of 08/21/24 and a resulted date of 08/22/24, revealed a urinalysis-microscopic only was performed. Review of R42's Urine Culture lab report, provided by the facility and dated 08/24/24, indicated the organism in the urine was Providencia stuartii, greater than 100,000 colonies. Review of R42's Physician Orders, dated 08/29/24 and located under the Orders tab of the EMR, revealed an order dated 08/29/24 for Cipro (an antibiotic) 500 mg Give one tablet by mouth two times a day for UTI for 10 days. Review of the Infection Screening Evaluation, dated 08/30/24 and provided by the facility, revealed R33 did not have a fever, had acute pain, swelling, or tenderness of the testes, epididymis or prostate, was experiencing abdominal pain/tenderness, and urinary urgency. R33 was a female. Under the Infection Analysis section of the screening, it was indicated McGeer's Criteria Met: Gastroenteritis. During an interview on 04/30/25 at 11:27 AM, the IP stated, The RN [Registered Nurse] would round with the doctors and write these orders. She did not document anything on this resident except to order the urinalysis with culture and sensitivity. There was no documentation from nursing on any of these symptoms. The IP also confirmed the urinalysis performed should have been for a complete urinalysis and this did not meet McGeer's Criteria for a UTI. The IP stated, I will put in the information into the EMR but not necessarily what is in the nurses' notes, but from what I know from what they have reported to me about this antibiotic order. 3. Review of R8's Face Sheet, located under the Profile tab in the EMR, revealed R8 was admitted to the facility on [DATE] with the diagnosis of seizures. Review of R8's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 01/12/24 for Macrobid (an antibiotic) 100 mg one tab twice a day for seven days. There was also an order dated 01/12/24 to collect urine due to recent behaviors. Review of R8's Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed no documentation of R8 having any behaviors. Review of R8's Urinalysis Results lab report, provided by the facility and dated 01/12/24, revealed the abnormal results for Leukocytes 75 High and [NAME] Blood Cells 5-10 High. There was no culture results noted prior to the start of the antibiotic Macrobid. Review of the Infection Screening Evaluation, dated 01/12/24 and provided by the facility, revealed R8 did not have a fever, had acute dysuria, delirium, new onset of confusion, and supra (around) pubic tenderness. Under the Infection Analysis section of the screening indicated McGeer's Criteria: Suspected UTI without indwelling catheter. During an interview on 04/30/25 at 11:27 AM, the IP confirmed after reviewing the nursing progress notes and the behavioral monitoring for R8, that there was no documentation of symptoms or behaviors to support what was recorded on the 01/12/24 screening. The IP also confirmed after reviewing the documentation with the surveyor that this did not meet McGeer's Criteria due to the doctor prescribing an antibiotic prior obtaining the urine culture on R8. During an interview on 04/30/25 at 12:10 PM, the Regional Director of Clinical Services confirmed that R33, R42, and R8 did not meet McGeer's Criteria for antibiotic usage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to provide a pneumococcal vaccine once the resident's responsible (RP) had signed the consent form for one of 23 sampled residents (Resident (R) 24) reviewed for immunizations. This failure had the potential to increase the resident's risk of developing pneumonia. Findings include: Review of the facility's policy Pneumococcal Vaccine F883, dated 02/2025 and provided by the facility, revealed, . Residents will be offered the pneumococcal vaccine to aid in preventing pneumococcal infections (e.g., pneumonia) . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccine unless medically contraindicated or the resident has already been vaccinated. Assessments of the pneumococcal vaccination unless medically contraindicated within five (5) days of the resident's admission if not conducted prior to admission . Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give one dose of PCV20 [pneumococcal conjugate vaccines] or PCV21 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 or PCV21 is used, Give a dose of PCV15 at least one year later . For adults 65 years or older who have only received a PPSV23, CDC recommends you . May give one dose of PCV20 or PCV21 . The PCV20 or PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13, Give one dose of PCV20 or PCV21 or PPSV23 to be administered at least a year later. If PCV20 and PCV21 are used, their pneumococcal vaccinations are complete . Review of R24's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R24 was admitted to the facility on [DATE] with diagnoses that included heart failure and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R24 was currently over [AGE] years old. Review of R24's Immunizations, located under the Immunizations tab in the EMR, revealed R24 had not received a pneumococcal vaccine since being admitted to the facility on [DATE]. There was no documentation of historical administration or refusal of any pneumococcal vaccine for R49. During an interview on 04/30/25 at 4:30 PM, the Infection Preventionist (IP) stated, The resident's RP signed her consents for [R24] to receive the pneumococcal vaccine, but I have not ordered the vaccine for her yet. Review of R24'sInformed Consent for Pneumococcal Vaccine PCV-15 or PCV-20 (Pneumococcal Conjugate) and PPSV23 (Pneumococcal Polysaccharide), provided by the facility, revealed PCV-20 was marked the section You are being offered the following vaccine. The section I have received information about the vaccine and understand the risk and benefits of receiving this vaccine. I CONSENT to receiving the vaccine by signing below was signed by the resident's RP, dated 10/08/24, and was witnessed by the IP. During an interview on 04/30/24 at 4:40 PM, the DON confirmed R24 should had been given the pneumococcal vaccine when the consent was signed by the RP in 2024 or soon after.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to serve food that was palatable and hot to three of 23 sampled residents (Resident (R) 8, R11, and R13) reviewed for food palatability. This failure had the potential to affect all 51 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Food Preparation and Appearance, revised 10/2024, specified, . Residents are provided meals that are prepared by methods that conserve value, flavor, and appearance. Residents are provided with food and drink that is palatable, attractive and at a safe and appetizing temperature . 1. Review of R8's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/25 and located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. During an interview on 04/27/25 at 1:04 PM, R8 stated the food served at the facility could be improved. R8 specified the food served at meals did not always taste good and was not always hot. 2. Review of R11's quarterly MDS, with an ARD of 03/20/25 and located in the EMR under the MDS tab, revealed a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. During an interview on 04/27/25 at 11:12 AM, R11 stated she ate her meals in her room and most of the time her food was not hot when served at mealtime. 3. Review of R13's significant change MDS, with an ARD of 01/18/25 and located in the EMR under the MDS tab, revealed a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. During an interview on 04/27/25 at 1:32 PM, R13 stated the food served at meals was not always hot. 4. In response to resident complaints about food, a test tray was requested to be sent to the facility's 300 hallway during the evening meal on 04/29/25. Observation revealed before the meal cart, which contained the test tray, left the kitchen at 5:27 PM, resident meals were observed being served on unheated plates and food temperatures were at acceptable levels of 140 degrees Fahrenheit (F) and above when being served from the kitchen's tray line. The meal trays were placed on an enclosed tray cart with no heating element and were delivered to the 300 hallway at 5:29 PM. Observation revealed the last resident's evening meal tray was served on the 300 hallway on 04/29/25 at 5:44 PM. At this time, the foods and beverages were sampled in the presence of the facility's Consultant Registered Dietitian (RD). The RD utilized a calibrated facility thermometer to obtain temperatures of the food served on the test tray. The RD also tasted the food served on the requested test tray with the surveyor. Temperature checks and tasting of the food served on the test tray revealed the following: a. The spaghetti with meat sauce served on the test tray registered 125 degrees F and was warm when tasted. The RD also tasted the spaghetti with meat sauce and confirmed it was warm and needed to be hotter. b. The peas and carrots served on the test tray registered 126 degrees F and were warm when tasted. The RD also tasted the peas and carrots confirmed it was warm and needed to be hotter. During an interview on 04/29/25 at 5:44 PM, the RD stated the spaghetti with meat sauce and peas and carrots should be hot when served to residents.

Based on observations, staff interviews, and facility policy review, the facility failed to discard food with expired use by dates and cover and date food stored in kitchen refrigeration units. The facility failed to ensure the kitchen's electric slicer and knives were clean prior to being stored for use. These failures had the potential to create an environment for food-borne illnesses which could affect 51 residents who consumed food prepared from the facility's kitchen. Findings Include: Review of the facility's policy titled, Food Safety Requirements, revised on 10/2022, specified, . Food shall be received and stored in a manner that complies with safe food handling practices . 8. All food stored in the refrigerator or freezer will be covered, labeled, and dated . Review of the facility's policy titled, Sanitation, revised on 10/2022, specified, . The food service area shall be maintained in a clean and sanitary manner. Guidelines . 2. Utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair . 3. Equipment, food contact services, and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . 1. Observation during the initial kitchen inspection on 04/27/25 from 8:20 AM to 8:50 AM, with the Dietary Manager (DM) present, revealed the following food stored in the kitchen's reach in refrigerators: six dozen hard boiled eggs with expired use by dates of 04/10/25, one five pound container of cottage cheese with an expired use by date of 04/12/25, one opened and undated 46 ounce container of thickened orange juice, one large uncovered container of shredded cheese, and one large plastic zip lock bag that contained cheese slices was stored open to air. During an interview on 04/27/25 at 8:50 AM, the DM confirmed the expired, undated, and/or uncovered food stored in the kitchen's reach in refrigerators. The DM stated food should be dated and closed when stored and food with expired use by dates should be discarded by kitchen staff. 2. Observation during the initial kitchen inspection on 04/27/25 from 8:20 AM to 8:50 AM, with the DM present, revealed the following unclean food preparation and service equipment that was stored and ready for use: the kitchen's electric slicer was unclean with grease and food residues on the front and back of its' slicing blade and control board, and three large knives, stored in a kitchen drawer, were unclean with a greasy residue on their cutting blade. During an interview on 04/27/25 at 8:50 AM, the DM confirmed the kitchen's stored electric slicer and three knives were not clean. The DM stated the slicer and knives should be cleaned by staff prior to being stored for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, Transfer and/or Discharge, Including Against Medical Advice (AMA). The facility failed to ensure two of two residents and/or their representatives (Residents (R) 35 and R54) were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer or appeal information. In addition, the facility failed to send the transfer/discharge notices to the State Long Term Care Ombudsman's office. This failure has the potential to affect any resident or Resident Representative (RR) in having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer if the resident or RR desired. In addition, the Long-Term Care Ombudsman's office was not aware of facility-initiated transfers from this facility. Findings include: Review of the facility's policy titled, Transfer and/or Discharge, Including Against Medical Advice (AMA) dated 10/2022 revealed, .11. The resident and/or representative will be provided with the following information within the notice, in writing .prior to transfer. A. The reason for the transfer .b. Send a copy of the notices to the State Long Term Care Ombudsman, note in record. c. the date of the transfer .e. The specific location .f. A statement of the resident's appeal rights .g. The name, address, and telephone number of the State Long Term Care Ombudsman .h. The name address and phone number of the agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals and i. The name, address mailing and email address and telephone number of the state health department .15. The above transferor discharge information will be documented in the resident's chart . 1. Review of the Electronic Medical Record (EMR) Progress Notes in the Progress Notes tab revealed on 12/10/2022, R35 was found on the floor in his room complaining of pain to right leg and unable to move and extend his leg. R35 was transferred to the emergency room (ER). Review of R35's EMR Progress Notes in the tab Progress Notes revealed on 3/30/2023, R35 was transferred to the ER due to change of condition and difficulty breathing. Review of R35's EMR revealed that there was no documentation that the resident and/or representative was provided a written transfer/discharge notice for either the 12/10/2022 or 3/30/2023 transfers to the ER. During an interview on 5/25/2023 at 3:00 p.m., the Admitting/Marketing Coordinator stated that the nurses send the transfer/discharge notice with the Emergency Medical Services (EMS) packet to the hospital. A copy of the transfer/discharge notice would be made, scanned, and uploaded to the EMR. The Admitting/ Marketing Coordinator confirmed there was no documentation in the EMR that the transfer/discharge notice had been scanned and uploaded to the EMR. In addition, the Admitting/Marketing Coordinator confirmed there was no evidence that the resident and/or representative had been provided with a copy of the transfer/discharge notice. During the interview on 5/25/2023 at 3:00 p.m., the Social Service Director (SSD) confirmed that the Ombudsman did not receive the transfer/discharge notice for either of R35's transfer to the ER. The SSD stated that she was told by the Ombudsman that the facility only had to send the involuntary discharge transfer notices to the Ombudsman. 2. Review of resident (R)54's Face Sheet located in the Resident tab in the electronic medical record (EMR) revealed R54 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR with an assessment reference date (ARD) 3/27/2023 revealed that R54 had a Brief Interview of mental status (BIMS) score of 11 which indicated the resident was mildly cognitively impaired. Review of the 3/28/2023 3:04 p.m. Progress Notes in the Progress Notes tab in the EMR revealed that R54 had been due for an antibiotic but was transferred out to the hospital for evaluation. Review of the 3/28/2023 Resident Documents under the Resident Documents tab on 5/24/2023 showed that there were no documents attached to the resident's chart reflecting a transfer notice given to the resident or the resident representative. Review of Progress Notes in the Progress Note tab revealed there was not a progress note on 5/24/2023 which documented a bed hold notice being given to the resident or the resident representative by the nursing staff or social worker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policies titled, Transfer and/or Discharge, Including Against Medical Advice (AMA) and Bed Hold. The facility failed to ensure two of two residents (Resident (R) 35 and R54) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 21 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the facility's policy titled, Transfer and/or Discharge, Including Against Medical Advice (AMA) dated 10/2022 revealed, .13. Prior to transfer to the hospital .will provide the bed hold policy in writing to the resident or their representative . Review of the facility's policy titled, Bed Hold dated 8/2022 revealed, Guidelines .2. When emergency transfers are necessary, the facility will provide the resident and the resident representative with information concerning our bed-hold policy . 1. Review of R35's Electronic Medical Record (EMR) Progress Notes in the Progress Notes tab revealed on 12/10/2022, R35 was found on the floor in his room complaining of pain to right leg and unable to move and extend his leg. R35 was transferred to the emergency room (ER). Review of R35's EMR Progress Notes in the tab Progress Notes revealed on 3/30/2023, R35 was transferred to the ER due to change of condition and difficulty breathing. Review of R35's EMR revealed that there was no documentation that the resident and/or representative provided the bed hold policy for either the 12/10/2022 or 3/30/2023 transfers to the ER. During an interview on 5/25/2023 at 3:00 p.m., the Admitting/Marketing Coordinator stated that the nurses send the bed hold policy with the Emergency Medical Services (EMS) packet to the hospital. A copy of the bed hold policy was supposed to be made, scanned, and uploaded to the EMR. The Admitting/ Marketing Coordinator confirmed that there was no documentation in the EMR that the bed hold policy had been scanned and uploaded to the EMR. In addition, the Admitting/Marketing Coordinator confirmed that there was no evidence that the resident and/or representative had been provided a copy of the bed hold policy. 2. Review of R54's Face Sheet located in the Resident tab in the EMR revealed R54 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) 3/27/2023 revealed that R54 had a BIMS score of 11 out of 15 which indicated the resident was mildly cognitively impaired. Review of the 3/28/2023 3:04 p.m. Progress Notes in the Progress Notes tab in the EMR revealed that R54 had been due for an antibiotic but was transferred out to the hospital for evaluation. Review of the 3/28/2023 resident documents under the Resident Documents tab on 5/24/2023 showed that there were no documents attached to the resident's chart reflecting a transfer notice given to the resident or the resident representative. Review of Progress Notes in the Progress Note tab revealed there was no progress note on 5/24/2023 documented of a bed hold notice given to the resident or the resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR) the facility failed to ensure one of three residents (Resident (R) 1) reviewed for the PASRR process, who was admitted with a mental health diagnosis, was referred for a Level II screening. This failure increases the risk for a resident with a mental illness diagnosis from not receiving specialized services. Findings include: Review of the facility's policy titled Pre-admission Screening and Resident Review (PASRR) dated 11/2016 revealed, Policy Statement . will coordinate assessment with the preadmission screening and resident review (PASARR) program .Policy Interpretation and Implementation 1. Upon admission, the Social Worked .the recommendations of the PASARR level II . Review of R1's admission Record from the Electronic Medical Record (EMR) Profile tab showed an admission date of 10/02/2017 with medical diagnoses that included schizophrenia, bipolar disorder, and generalized anxiety disorder. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/22/2022 located in the EMR under the MDS tab indicated diagnoses of bipolar disorder, anxiety, and schizophrenia. During an interview on 5/23/2023 at 4:38 p.m., the Admitting/Marketing Coordinator stated that she was unable to locate for R1 that a PASRR II was completed. During the interview, the Admitting/Marketing Coordinator confirmed that R1's had mental illness diagnoses on admission to the facility on [DATE] and that documentation for a PASRR II evaluation to be completed had not been submitted. Review of the PASRR [another acronym for PASARR) form AHCA MedServD Form 004 Part A, March 2017 (lncorporated by reference in Rule 59G-1.040, F.A.C.) revealed, on Page 4 of 5 that, A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR Evaluator in accordance with 42 CFR 483.128(m)(2)(i) or 42 CFR 483.128 (m)(2)(ii).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Care Plans-Baseline. The facility failed to develop a baseline care plan within 48 hours of the resident's admission that included resident-specific health concerns, intervention, services, and treatment to be administered by facility personnel to properly care for the resident immediately upon their admission. In addition, the facility failed to provide the residents and their representative with a summary of the baseline care plan for three of three residents (R) 107, R106 and R34) reviewed for new admission to the facility. Findings include: Review of the facility's policy titled Care Plans-Baseline dated 11/2017 revealed, Policy Interpretation and Implementation 1. A baseline care plan will be developed within forty-eight hours. Include baseline information .b. physician orders; therapy services .g. within 48 hours the summary of the baseline care plan should be presented to the resident and/or their representative in writing .the summary must include: a. initial goals .c. Services and treatments to be administered by the facility and personnel .7. Document evidence of the summary to the resident or their representative in the medical record. 1. Review of R107's Electronic Medical Record (EMR) admission Record in the Profile tab revealed R107 was admitted on [DATE]. Review of R107s Baseline Care Plan in the EMR under Misc. tab revealed that the base line care plan did not address R107's preferences regarding bathing, eating or the time of day he prefers to go to bed or rise in the morning. During an interview on 5/23/2023 at 9:30 a.m., licensed practical nurse (LPN) 3 told the surveyor that the resident was diabetic and wanted to eat all of the time. LPN3 also indicated that the resident begs for food. Interview on 5/23/2023 at 11:05 a.m., the Minimum Data Set (MDS) Coordinator confirmed the base line care plan was completed on the day R107 was admitted to the facility. The MDS Coordinator confirmed that the baseline care plan did not address that the resident was diabetic, that the resident begs for food and eats everything. 2. Review of R106's EMR admission Record in the Profile tab revealed R106 was admitted to the facility on [DATE]. Review of R106's Baseline Care Plan in the EMR under Misc. tab revealed that the base line care plan did not address R106's amputation of right great toe surgery site treatment, diabetic ulcer to left great toe treatment, receiving physical and occupational therapy services and the use of a walker for ambulation. Interview on 5/23/2023 at 11:05 a.m., the MDS Coordinator confirmed that R106's baseline care plan did not address that he was receiving physical and occupation therapy; the surgery to his right toe and treatment; the diabetic ulcer to his left toe and treatment; that R106's used a walker for ambulation and that R106 could take himself to the bathroom after nursing staff applied his yellow slip resistant socks. During the interview on 5/23/2023 at 11:05 a.m., the MDS Coordinator confirmed that there was no documentation in R106 or R107's EMR that the resident or resident's representative had received a summary of the base line care plan. 3. Review of R34's admission Record found in the electronic medical record (EMR) under the Profile tab, revealed R34 was admitted on [DATE] with a primary diagnosis of encounter for orthopedic aftercare following surgical amputation. Review of R34's admission MDS with an ARD date of 4/11/2023 revealed a BIMS score of 14 out of 15 indicating the resident was cognitively intact. Active diagnoses included amputation, anemia, heart failure, hypertension, benign prosthetic hyperplasia, diabetes, hyperlipidemia, respiratory conditions, and respiratory failure. Review of R34's Nursing: Baseline Care Plan- V 9 indicated the baseline care plan was not completed until 4/15/2023. During an interview on 5/24/2023 at 12:21 p.m. with the Social Services Director (SSD) she confirmed that R34 was admitted to the facility on [DATE], and R34's baseline care plan should have been completed by 4/9/2023 but was not completed until 4/15/2023. During an interview on 5/25/2023 at 5:02 p.m. with the MDS Coordinator she confirmed that R34 was admitted to the facility on [DATE], and his baseline care plan should have been completed by 4/9/2023 but was not completed until 4/15/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of the facility policy titled, Quality of Life-Activities of Daily Living . The facility failed to assist with activities of daily living (ADL), specifically bathing and shaving for one (Resident (R) 35) for ADL care out of a total sample of 21 residents This failure had the potential to affect the residents' comfort, body image and increases the risk for infections. Findings include: Review of the facility's policy titled, Quality of Life-Activities of Daily Living dated 11/2017 revealed, Policy Statement .Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good .grooming .1. Resident are provided with appropriate care and services including a. hygiene . Review of R35's Electronic Medical Record (EMR) undated admission Record, located under the Profile tab, indicated R35 was admitted to the facility on [DATE] with a diagnosis of dementia and depression. Observation on 5/22/2023 at 4:40 p.m., R35 had approximately half inch of facial hair. An interview with R35 at this time revealed that he doesn't like facial hair and wants it to be shaved off. Observation on 5/24/2023 at 11:08 a.m., R35 had facial hair approximately half inch long. Interview with the R35's Family member (F) 35 revealed that R35 likes to be shaved. Interview with R35 at this time revealed that he could not remember when had his last bath/shower. F35 stated that if they gave him a shower or bath, would they not have shaved him. Review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD of 10/23/2022 indicated a Brief Interview for Mental Status (BIMS) and score of seven out of 15 which indicated R35 was severely cognitively impaired. This MDS assessment indicated R35 requires supervision and oversite of one person only for bathing. The MDS indicated that for R35 it was somewhat important for him to choose baths or showers. The quarterly MDS with an ARD of 3/20/2023 indicated R35's BIMS score was five of 15 which indicated R35 was severely cognitively impaired and showed no rejection of care. The MDS indicated that R35 required physical help with bathing activity. Interview on 5/24/2023 at 3:19 PM, Certified Nurse Aide/Certified Medication Aide (CNA/CMA) 1 stated that there is a schedule at the nurses' station which identified for each day which residents are to receive a shower, bed bath. The CNAs then mark in the EMR if the shower was done, bed bath done, or refused. CNA/CMA1 stated that shaving is a part of the shower or bed bath, but there is nowhere in the EMR to mark that the resident was shaved. Review of R35's EMR Task tab ADL resident request showers on Thursday document indicated R35 had a bath on 5/19/2023, 5/20/2023 and 5/21/2023 and no baths on 5/23/2023 and 5/24/2023. According to the document R35 requests showers on Thursdays and that his bathing preference is on the 7a-7p shift. Review of R35's Care Plan found in the EMR under the Care Plan tab revealed that ADLs, specifically to include bathing and shaving, were not addressed on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Staff interview, record review, and review of the facility bowel protocol, the facility failed to implement the facility's bowel protocol for one of one resident (Resident (R) 35). Specifically, the facility failed to ensure that R35 received medication for constipation as outlined in the facility's Criteria for Bowel Movement Protocol. Findings include: Review of the facility's undated Criteria for Bowel Movement Protocol revealed, The nurses are required to monitor clinical alerts every shift for residents that have not had a bowel movement within 3 days. For the residents that have not had a bowel movement within 3 days, the nurse will complete a progress note and initiate the bowel movement protocol. 1. Give MOM [Milk of Magnesium] [laxative medication] 30 ml [milliliter] . Review of R35's Electronic Medical Record (EMR) undated admission Record, located under the Profile tab, indicated R35 was admitted to the facility on [DATE] with diagnoses of dementia and depression. Review of R35's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/20/2023 indicated R35's Brief Interview of Mental Status (BIMS) score was five of 15 which indicated R35 was severely cognitively impaired and showed no rejection of care. Review of R35's Progress Notes in the EMR under the Progress Notes tab revealed on 4/03/2023, R35's family member, (F35) was concerned that R35 was severely impacted upon arrival to hospital, and they used enemas to clean him out. F35 asked that we monitor him closely so that will not happen again. During an interview on 5/22/2023 at 5:02 p.m., R35 told the surveyor that he needed something for constipation. Immediately after leaving R35's room, the surveyor informed Certified Nurse Aide/Certified Medication Aide (CNA/CMA) 2 that R35 requested something for constipation. Review of R35's Physician Order in the EMR under the Order tab revealed GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for constipation (in Liquid) dated 4/4/2023. Review of the R35's BM (Bowel Movement) report provided by the Director of Nursing (DON) dated 5/18/2023 to 5/24/2023 revealed that R35 did not have a BM on 5/20/2023, 5/21/2023 and 5/22/2023. Interview on 5/24/2023 at 4:05 p.m., the DON provided the surveyor with the facility's bowel protocol which indicated the resident should have received 30 ml of MOM. The DON confirmed after review of R35's Medication Administration Record (MAR) that R35 did not receive the MOM only his routine MiraLAX medication (medication used to soften stool and relieve constipation). Review of R25's Care Plan in the EMR under the Care Plan tab revealed the problem of constipation was not addressed on care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and review of the facility policy titled, Weight Assessment and Intervention. The facility failed to assess nutritional status for weight loss and tube feeding for two of four residents (Resident (R) 50, and R10). Specifically, the facility failed to ensure that R50 and R10 were evaluated by the Registered Dietician (RD) monthly for weight loss. Findings include: Review of facility policy titled, Weight Assessment and Intervention F 692, revised 10/2022 stated, The Interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain for our residents. Each resident is weighed upon admission and re-admission and weekly x 4 and unless indicated otherwise, monthly thereafter . The RD (Registered Dietitian) will review the communities Weight Record of the month to follow individual weight trends over time .The threshold for significant unplanned and undesired weight change will be based on the following criteria [where percentage of body weight loss= (usual weight-actual weight/ (usual weight) x 100]: a. 1 month- 5% weight change is significant: greater than 5% is severe, 3 months- 7.5% weight change is significant; greater than 7.5% is severe. 6 months- 10% weight change is significant; greater than 10% is severe . Review of the facility's contract with the Registered Dietitian (RD), titled, Dietary Consultant Agreement dated 8/01/2022, indicated that the RD would perform consultation duties one to two days per month, make recommendations to nursing staff, dietary staff, and rehab staff regarding nutritional needs of resident. 1.Review of R50's admission Record found in the electronic medical record (EMR) under the Profile tab, revealed R50 was admitted on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Comorbidities included type two diabetes, gastro-esophageal reflux disease, polyphagia, and major depressive disorder. Review of R50's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 3/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident was moderately cognitively impaired. Active diagnoses included stroke, hypertension, gastro-esophageal reflux disease, diabetes mellitus, hyperlipidemia, arthritis, and hemiplegia. Review of R50's Care Plan located in the EMR under the Care Plan tab stated he was at risk for altered nutritional/hydration status related to diuretic use and inadequate oral intake as of 3/28/2023. Interventions included house supplements as ordered, staff assistance to feed him, recording/monitoring of meal intakes, monitor/record/report to physician as needed signs and symptoms of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss: 3 pounds in one week, greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months, and Registered Dietitian to evaluate and make recommendations as needed. Review of R50's Weights located in the EMR under the Wts. /Vitals tab revealed the resident weighed 194.2 pounds on 3/21/2023, 178.2 pounds on 4/25/2023, and 172 pounds on 5/24/2023. Review of R50's Physician Orders located in the EMR under the Orders tab included house supplement shake on 3/31/2023, carbohydrate-controlled diet on 3/30/2023, Lasix (diuretic) 40 mg (milligram) by mouth twice daily for edema on 4/27/2023, call physician for any change in condition, dietary supplements as of 3/21/2023, and monthly weights; contact physician if gain or loss of 5% in one month or 10% in six months. Review of R50's Nutrition: Dietary Manager Initial (Admission) Evaluation- V 5 provided by the facility, dated 3/28/2023 indicated the resident's current weight as of 3/29/2023 was 185.6 pounds. Review of R50's Nutrition: RD (Registered Dietitian) admission (Initial) Assessment- V 5 located in the EMR under the Assessment tab dated 3/28/2023 indicated the resident's current weight as of 3/28/2023 was 194.2 pounds, had poor intake eating less than 50% of meals, was eating independently, had inadequate oral intake, had a nutrition problem, and that he was at risk for altered nutritional/hydration status related to diuretic use and inadequate oral intake. Recommendations included liberalization of diet, add/change supplements, carbohydrate-controlled diet due to history of diabetes mellitus, and additionally house shakes twice daily with meals. Review of R50's food intake located in the EMR under the Tasks tab indicated that the resident typically refused breakfast and consumed approximately zero to 50% of lunch and dinner meals. Review of R50's Progress Notes located in the EMR under the Progress Notes tab, dated 4/25/2023 indicated there was an 8.2% weight loss over the past 30 days. Review of R50's Progress Notes located in the EMR under the Progress Notes tab dated 5/11/2023 indicated the resident needed total assistance with meals. Review of the Consultant Dietitian's Report for March -May 2023, provided by the facility, confirmed that R50 was assessed on 3/28/2023, and no other dates. During an interview on 5/24/2023 at 11:37 a.m. with Certified Nursing Assistant (CNA) 2 confirmed that the resident required assistance with feeding himself, and that he typically eats about 25% of meals. During an interview on 5/25/2023 at 10:26 a.m. with the Dietary Manager (DM) stated that R50 typically eats less than 50% of his meals, and usually does not eat breakfast. She runs numbers on a weekly basis for any weight loss and high-risk residents, she then notifies the Registered Dietitian (RD) when an assessment needs to be done. The DM provided a copy of an email that she sent to the RD dated 4/18/2023 requesting that R50 be looked at. The DM stated that she did not receive a response and did not follow-up with her. During an interview on 5/25/2023 at 11:06 a.m. with Nurse Practitioner (NP), he stated the resident was currently being seen for depression and was being treated with Wellbutrin (antidepressant) and Trazodone (antidepressant) both of which would not contribute to weight loss, but rather should help with weight gain. The NP stated he was aware that the resident was experiencing weight loss, and poor appetite, as of 5/11/2023 he noted a 19-pound weight loss and recommended re-evaluation in two weeks. The NP stated he had not discussed weight loss with the physician but would speak with him today to recommend an appetite stimulant. During an interview on 5/25/2023 at 2:30 p.m. with the Director of Nursing (DON) she stated she was aware of R50's weight loss, and that the weight loss had been discussed during the weekly meetings for Patients at Risk (PAR). The DON confirmed that R50 weighed 194.2 pounds on 3/21/2023, 189 pounds on 4/14/2023, and 189 pounds on 5/18/2023. Review of R50's progress notes confirmed that she was not able to confirm that staff had notified the Medical Director of R50's weight loss. During an interview on 5/25/2023 at 3:00 p.m. with the Medical Director, he stated he was aware that R50 had stopped eating at one point, the RD had assessed him, added supplemental shakes, and the resident did not want to drink them. Additionally, the Medical Director stated that the Nurse Practitioner that visited with R50 today notified him of a 22-pound weight loss since admission. The Medical Director was also not aware that the RD had not followed-up on the weight loss since admission but should have due to the amount of weight lost. During an interview on 5/25/2023 at 4:20 p.m. with the Registered Dietitian (RD) stated she visited the facility once monthly to inspect the kitchen and perform assessments on any residents with weight loss, feeding tube status, and pressure ulcers. Her role was to inspect the kitchen, perform patient assessments, perform follow-ups as necessary, and make recommendations to the physician. Typically, she receives a list from the MDS coordinator for any quarterly or annual reviews that are due, and the Dietary Manager will notify her via email any residents with weight loss that needed to be assessed. Parameters for weight loss that she considered severe were any weight loss that was greater than 5% in one month, and 10% or more in six months. The RD confirmed that she received an email from the Dietary Manager (DM) on 4/28/2023 that indicated R50 needed to be looked at. The RD stated that she accidentally moved the email to her delete folder and the resident was not assessed. Again on 5/25/2023, she received another email indicating that R50 had lost more than 5% in March (weight upon admission 194.2#, then on 4/25/2023 weighed 178.2# which was a 8.2% loss from March to April 2023), and a 3.4% loss from April to May 2023 (178.2# on 4/25/2023 and 172# on 5/24/2023). She stated the list that the MDS Coordinator sent her for April 2023 did not include R50. Additionally, the RD stated that she was not aware of R50's weight loss due to accidentally deleting the email from the DM. 2. Review of R10's admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R10 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, anemia, severe protein malnutrition, Parkinson disease and aphasia. Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 3/29/2023 indicated the Brief Interview of Mental Status (BIMS) could not be conducted due to R10's short-and long-term memory loss and severe impaired cognitive skills. Review of R10's weights in the Weights/Vital signs tab in the EMR revealed the following: 5/18/2023-116.4 pounds (Lbs.) 5/10/2023-119.6 Lbs. 5/04/2023-120.6 Lbs. 4/25/2023-119.2 Lbs. 4/18/2023-120.0 Lbs. 4/12/2023-122.2 Lbs. 4/03/2023-121.6 Lbs. 3/29/2023-120.8 Lbs. 3/22/2023-122.0 Lbs. 3/14/2023-124.8 Lbs. 3/09/2023-124.4 Lbs. 3/08/2023-126.8 Lbs. 3/01/2023-124.4 Lbs. 2/21/2023-126.6 Lbs. 2/14/2023-123.6 Lbs. 2/08/2023-124.4 Lbs. 2/07/2023-119.6 Lbs. 2/1/2023-121.6 Lbs. 1/25/2023-121.8 Lbs. 1/25/2023-121.2 Lbs. 1/17/2023-126.6 Lbs. 1/11/2023-125.8 Lbs. 1/08/2023-123.8 Lbs. 1/06/2023-123.8 Lbs. 12/28/2022-128.6 Lbs. 12/21/2022-123.2 Lbs. 12/13/2022-119.4 Lbs. 12/08/2022-125.4 Lbs. 12/06/2022-125.4 Lbs. Review of R10's Physician Orders in the EMR under the Orders tab revealed an order for NPO (nothing by mouth) and Jevity 1.5 cal. (calorie). Give formula at 50 cc x 22 hrs. (hours) daily, provided 1210 ml (milliliter) total volume, 1800 calories, dated 5/24/23. Review of the Medication Administration Record (MAR) dated May 2023 revealed that the MAR did not indicate what time the formula was started or discontinued to ensure the physician's order for the formula to infuse 22 hours per day was being implemented. In addition, the MAR did not indicate the amount of formula infused per day. The MAR date 5/2023 indicated check marks for 0000 (midnight), 0400 (4:00 a.m.), 0800 (8:00 a.m.), 1200 (12:00 PM), 1600 (4:00 p.m.), and 2000 (8:00 p.m.). Interview on 5/24/2023 at 2:00 p.m., the Director of Nursing (DON) reviewed R10's MAR and stated that the MAR only indicates that the tube feeding was checked at midnight, 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. The DON confirmed that the MAR does not indicate when the tube feeding was started each day and ended each day to comply with the physician's order for the tube feeding to infuse 22 hours per day. The DON also confirmed the MAR did not indicate how much tube feeding formula R10 received per day. Review of the RD [Registered Dietician] Review dated 3/24/2023 revealed in section C, Enteral order, Jevity 1.5 at 45 ml/hr. x 23 hrs./day, calories 1553. Comments: Given wt. decrease suggest increasing TF to Jevity 1.5 at 50 cc/hr. x 23 hr./day to provide 1725 calories . RD will f/u [follow-up] monthly with TF. Review of the RD's summary of residents reviewed per month document revealed that R10 was not listed as being assessed by the RD for either April 2023 or May 2023. Interview on 5/24/2023 at 5:06 p.m., the Dietary Manager (DM) provided the surveyor with the last RD note for R10 which was dated 3/24/2023. The DM stated the RD stated that she did not see the resident in April or May 2023. The DM confirmed that the RD has not seen the resident for over 60 days, even though the RD's last review dated 3/24/2023 indicated that the RD would follow-up with R10's tube feeding monthly. Review of R10's EMR Physician Orders in the Orders tab of the EMR indicated the R10's Enteral Feeding was changed on 5/24/2023 to Jevity 1.5 Cal: Give formula at 50 ml/hr. x 22 hrs. daily via G-tube. Feeding Provides: 1210 ml total volume, 1800 calories. Interview on 5/25/2023 at 4:30 p.m., the RD stated that she was not aware that her recommendation of 3/24/2023 to increase R10's tube feeding rate to 50cc hour was not implemented until 5/24/2023. The RD stated that she was not aware that nursing staff were not documenting on the MAR when the tube feeding was started and ended each day or how much tube feeding formula the resident received per 22 hours/day. The RD stated that she had no excuse why the resident was not assessed in April and May especially since her March note indicated to follow up monthly regarding the tube feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and review of the facility policy titled, Gastric Tube Feeding Via Continuous Pump. The facility failed to accurately implement one of three resident's (R )10 physician order regarding the amount of tube feeding to receive and failed to accurately document the time the tube feeding was started and ended and the amount the resident received of tube feeding formula per day. Findings included: Review of the facility's policy titled, Gastric Tube Feeding Via Continuous Pump dated 6/2021 revealed, Documentation, the person performing the procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed .3. The Amount and type of enteral feeding . Observation on 5/23/2023 10:01 a.m., R10 was in bed with the tube feeding infusing through the Gastrostomy (G-Tube) at 50cc/hour (hr.). The tube feeding formula bag was labeled 5/22 8 a.m., infuse the formula at 40 cc (cubic centimeters) per hour. Interview on 5/23/2023 at 10:30 a.m., Licensed Practical Nurse (LPN)3 observed R10's tube feeding formula bag and stated that the night shift nurse should have changed out the bag last night. LPN3 confirmed that R10's tube feeding bag was dated 5/22 at 8 a.m., that the rate was incorrect, that the rate had been increased to 50cc hour. Review of R10's admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R10 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, anemia, sever protein malnutrition, Parkinson disease and aphasia. Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 3/29/2023 indicated the Brief Interview of Mental Status (BIMS) could not be conducted due to R10's short-and long-term memory loss and severe impaired cognitive skills. Review of R10's Physician Orders in the EMR under the Orders tab revealed an order for NPO (nothing by mouth) and Jevity 1.5 cal (calorie). Give formula at 50 cc x 22 hrs. (hours) daily, provided 1210 ml (milliliter) total volume, 1800 calories, dated 5/24/2023. Review of the Medication Administration Record (MAR) dated May 2023 revealed that the MAR did not indicate what time the formula was started or discontinued to ensure the physician's order for the formula to infuse 22 hours per day was being implemented. In addition, the MAR did not indicate the amount of formula infused per day. The MAR date 5/23 indicated check marks for 0000 (midnight), 0400 (4:00 a.m.), 0800 (8:00 a.m.), 1200 (12:00 p.m.), 1600 (4:00 p.m.), and 2000 (8:00 p.m.). Interview on 5/24/2023 at 2:00 p.m., the Director of Nursing (DON) reviewed R10's MAR and stated that the MAR only indicates that the tube feeding was checked at midnight, 4:00 a.m., 8:00 a.m, 12:00 p.m, 4:00 p.m, and 8:00 p.m. The DON confirmed that the MAR does not indicate when the tube feeding was started each day and ended each day to comply with the physician's order for the tube feeding to infuse 22 hours per day. The DON also confirmed the MAR did not indicate how much tube feeding formula R10 received per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and review of the facility policies titled, Medication Administration Schedule and Physician Medication Orders,. The facility failed to administer medication per physician's orders for one of eight residents (Resident (R) 34). Specifically, the facility failed to ensure that R34 received nicotine patches as ordered by physician for smoking cessation. Findings include: Review of the facility's policy titled, Medication Administration Schedule, revised 5/2022, stated, .Medications are administered according to community protocol . Review of the facility's policy titled, Physician Medication Orders, revised on 5/2022, stated, . The Charge Nurse or the Director of Nursing Services shall call-in the order for all prescribed medications . Review of R34's admission Record found in the electronic medical record (EMR) under the Profile tab, revealed R34 was admitted on [DATE] with a primary diagnosis of encounter for orthopedic aftercare following surgical amputation. Review of R34's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 4/11/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the resident was cognitively intact. Active diagnoses included amputation, anemia, heart failure, hypertension, benign prosthetic hyperplasia, diabetes, hyperlipidemia, respiratory conditions, and respiratory failure. Review of R34's Baseline Care Plan located in the EMR under the Care Plan tab, dated 4/15/2023 did not include smoking status or need for assistance with smoking cessation. Review of R34's Orders located in the EMR under the Orders tab included nicotine transdermal patch 21mg trans dermally every morning for cigarette cessation. Review of medical supply order on 5/03/2023 revealed an order was placed for nicotine patches that was ordered. Review of R34's Medication Administration Record (MAR) located in the EMR under the Orders tab revealed R34 did not receive nicotine patches for eight days in April 2023, and no doses from 5/01/2023-5/22/2023. During an interview on 5/24/2023 at 9:04 a.m. with Licensed Practical Nurse (LPN1) stated that she recalled an incident where the resident went to a physician appointment and returned to the facility with a pack of cigarettes; staff took the cigarettes from him due to the facility being a non-smoking facility, the resident's son was notified, as was the Administrator. Additionally, LPN1 stated that R34 gets a nicotine patch daily at 6:00 a.m. and she was unaware that he had not been getting his nicotine patches on a routine basis in April 2023, or at all in May 2023. During an interview on 5/24/2023 at 11:37 a.m. with Certified Nursing Assistant (CNA2) stated that R34 is very short tempered and yells at the staff, she was not aware of him being a previous smoker. During an interview on 5/24/2023 at 12:21 p.m. with the Social Services Director (SSD) stated that she was not aware of R34 not receiving his nicotine patches until Monday night, when one of the nurses informed her that R34 and another resident were out of nicotine patches. During an interview on 5/24/2023 at 4:07 p.m. with LPN1 confirmed that R34's MAR for April and May 2023 had multiple dates indicating 3 for administration of nicotine patches. LPN1 stated the code was to indicate the medication was not administered, and it was on order. LPN1 confirmed that R34 missed 12 doses in April 2023, and all doses from 5/01/2023-5/23/2023. During an interview on 5/24/2023 at 4:40 p.m. with Medical Records/Supplies (MR/SUP) stated a few weeks ago she was notified of R34 and another resident being out of nicotine patches, she went to the store and purchased a box of nicotine patches and also ordered nicotine patches from medical supplier on 5/3/2023. During an interview on 5/24/2023 at 7:15 p.m. with the Administrator indicated the facility had ordered nicotine patches on 5/03/2023; she also notified the pharmacy, and she was not sure why the pharmacy had not delivered the patches. The Administrator stated she was not aware that R34 had not been receiving his nicotine patches until 5/22/2023 when one of the nurses notified her. During an interview on 5/25/2023 at 2:30 p.m. with the Director of Nursing (DON) stated she was not aware of R34 missing multiple doses of nicotine patches and that the facility protocol was for the nurses to either order the medication from the pharmacy or to the let administrative staff know that over-the-counter medication needed to be ordered or purchased so the resident would not miss any doses. Additionally, either herself or the Administrator would notify Omnicare Pharmacy of the need for medication delivery, and if that was not possible, then one of them would purchase from local pharmacy/store. Typically, if the medication was not available for more than 48 hours, the nurse should notify the physician. In this case, she could not confirm that nursing staff had notified the physician. During an interview on 5/25/2023 at 4:10 p.m. with the Medical Director stated he was not aware of R34 missing multiple doses of his nicotine patches in April and May 2023. His concern of R34 not receiving the patches would be for the resident experiencing increased anxiety/agitation due to nicotine withdrawal. Typically, a resident would be on nicotine patches for six to eighteen weeks while staff monitored for withdrawal or agitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Resident/Family Participation-Assessment/Care Plans. The facility failed to ensure three residents (Resident's (R) 31, R9 and R37) were receiving timely care plan conferences. Findings Include: Review of the facility's policy titled, Resident/Family Participation-Assessment/Care Plans dated 11/2018 revealed, Policy Interpretation and Implementation, 1. The resident and /or representative are invited to attend and participate in the care plan conference. Notice shall be made by mail, electronic mail and/or telephone . 1. Review of R31's admission Record found in the EMR under the Profile tab, revealed R31 was admitted on [DATE] with a primary diagnosis of cardiac arrhythmias. Review of R31's quarterly Minimum Data set MDS with an Assessment Reference Date (ARD) date of 4/11/2023 revealed a Brief Interview of Mental Status BIMS score of 12 out of 15 indicating the resident was moderately cognitively impaired. Active diagnoses included medically complex conditions, anemia, atrial fibrillation, heart failure, hypertension, benign prostatic hyperplasia, dementia, malnutrition, depression, psychotic disorder, and respiratory failure. Review of R31's Baseline Care Plan-V 5 located in the EMR under the Assessments tab indicated a baseline care conference was held on 1/5/2022. Review of R31's Care Plan Conference Summary- V 4 located in the EMR under the Assessments tab indicated a care conference was held on 6/3/2022; no other care conferences were able to be located. During an interview on 5/24/2023 at 12:13 p.m. with the Social Services Director (SSD), she confirmed that R31 was admitted on [DATE], had a baseline care conference held on 1/5/2022, and had a quarterly care conference that was held on 6/3/2022. The SSD stated that normally the EMR would trigger an assessment, however, many residents, including R31, were not triggering for her to be alerted that the resident was due for a care conference. SSD confirmed that R31 was not having quarterly care conferences but should have been. 2. Review of R9 admission Record in the EMR under the Profile tab revealed R9 was admitted to the facility on [DATE]. During an interview on 5/22/2023 at 12:12 p.m., with R35 when asked if she had attended her care plan conferences since admission to the facility, R35 stated, I don't know what they are. The surveyor explained that the care plan conference was a meeting in which the resident and members of the Interdisciplinary team (IDT) team discussed her care needs and interventions, R35 stated that she had not attended a meeting like that in which her care was discussed. Review of the admission MDS for R9 with an ARD date of 10/18/2022, the quarterly MDS with ARD of 1/18/2023 and the quarterly MDS with ARD of 3/18/2023 in the EMR under the MDS tab revealed a BIMS score of 15 of 15 which indicated the resident was cognitively intact. The MDS indicated that R9 had no issues with short- or long-term memory. During an interview on 5/23/2023 at 10:39 a.m., the SSD stated that there was no documentation in the EMR that a care plan conference was held with the resident and IDT staff. The SSD stated that R9 should have had a care plan conference in January 2023 then April 2023. 3. Review of R37's admission Record in the EMR under the Profile tab revealed R37 was admitted to the facility on [DATE]. Review of the admission MDS for R37 with an ARD date of 9/6/2022, the quarterly MDS with an ARD date of 12/29/2022 and the quarterly MDS with an ARD date of 3/30/2023 revealed a BIMS score of 15 of 15 which indicated the resident was cognitively intact. During an interview on 5/22/2023 at 3:08 p.m., R37 stated that he has not attended a care plan meeting to discuss his care since admission to the facility. During an interview on 5/23/2023 at 10:29 a.m., the SSD stated that she can't find any evidence in the EMR that R37 was invited and attended his care plan meeting with the IDT team. The SSD stated the problem she has is the EMR does not always trigger when it was time to conduct the residents' care plan meetings. The SSD stated that if the system did not trigger the meeting, then those residents would fall through the cracks and a care plan meeting was not conducted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident interview, and review of the facility policy titled, Hospice Program F684, F849, F552, the facility failed to ensure the plan of care was comprehensive for residents receiving hospice services for three of five residents (Resident (R) 31, R37, and R10). Findings include: Review of the facility's policy titled, Hospice Program F684, F849, F552, revised 4/2023, stated, 1. Identify in writing the services that the Hospice will be providing and address in the resident's person-centered care plan . 7. Identify a member of the IDT (Interdisciplinary Team) who is responsible for working with the hospice representative. This person must have a clinical background and have the ability to assess the resident within state scope of practice or have access to someone who can complete that function. This person's responsibilities include a. Collaboration and coordination of hospice care; b. Communication with hospice representatives and other health care providers participating in the hospice care; d. Ensuring the appropriate documents are readily available. The Hospice providers may have access and can document in PCC/POC (Point Click Care/Point of Care) to documents [sic] the care provided. A nursing progress note stating hospice saw the resident saw the resident and notes to follow etc. should be documented in the progress notes. If the Hospice does not document in PCC/POC, community may include selecting one personal [sic] to scan and upload hospice documents to the resident's electronic medical record no more than 5 days after documents are received as outlined below), to include: i. Most recent hospice plan of care ii. Hospice election form iii. Physician certification for terminal illness iv. Names and contact information of hospice personnel involved for each resident; v. Instructions for the 24 hour on call system; vi. Hospice medication and supplies specific to each resident 10. To promote continuity of care, collaborate with the hospice, nursing home and resident/representative on a coordinated care plan noted in the medical record. Review of the facility's contract with the Hospice company revealed it was the obligation of the hospice company to provide a copy of the Patient's Plan of Care to the facility at the time of admission, which specifies which services hospice was to provide and what services the facility was responsible for . All communications between the Hospice and SNF (skilled nursing facility) pertaining to the care and services provided to the Patient shall be documented in the Patient's clinical record . Hospice shall identify an individual (Hospice Designee) who is a member of the IDT, responsible for the implementation of the provisions of this Agreement, and any amendments thereto, in conjunction with the SNF Designee . SNF shall identify a SNF Designee within the SNF. The name of the SNF Designee shall be communicated to Hospice, in writing, at the time of admission of a Patient to the SNF, or as soon thereafter as possible. The SNF Designee shall be responsible for: (a) collaborating with Hospice representatives and coordinating SNF staff participation in the Hospice care planning process; . SNF shall permit IDT members identified in the Plan of Care for a given Patient to attend, counsel, and serve such Patient to exercise the professional management responsibility for the provision of SNF Services . 1.Review of R31's admission Record found in the electronic medical record (EMR) under the Profile tab, revealed R31 was admitted on [DATE] with a primary diagnosis of cardiac arrhythmias. Review of R31's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 4/11/2023 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident was moderately cognitively impaired. Active diagnoses included medically complex conditions, anemia, atrial fibrillation, heart failure, hypertension, benign prostatic hyperplasia, dementia, malnutrition, depression, psychotic disorder, and respiratory failure. The MDS also indicated the resident was on hospice services. Review of R31's Physician Orders located in the EMR under the Orders tab included orders for hospice services as of 1/19/2023. Review of R31's Care Plan revised on 1/12/2023, indicated he was receiving hospice services and that staff were to provide assistance with activities of daily living, monitor symptoms and communicate to practitioner on an as need [sic] basis .nursing home staff and hospice staff work cooperatively to provide maximum comfort and ensure her [sic] spiritual, intellectual, physical and social needs are being met . Review of R31's Care Plan Conference Summary- V 4 located in the EMR under the Assessments tab indicated a care conference was held on 6/03/2022; no other care conferences were able to be located. Review of R31's Physician Progress Note located in the EMR under the Progress Note tab and dated 3/29/2023 indicated that the resident reported pain to the physician and the plan was, He has been advised to contact Hospice for pain management. Review of R31's Physician Progress Note located in the EMR under the Progress Note tab and dated 4/26/2023 indicated that the resident reported pain to the physician and the plan was, Pain management by hospice. Review of R31's EMR did not include any progress notes or plan of care from the hospice company. During an interview on 5/22/2023 at 1:31 p.m. with R31 stated he had chronic left hip/leg pain and was currently being treated with hydrocodone (narcotic pain medication) which was not strong enough, had told the damn doctor, but [expletive] he won't even listen. R31 confirmed he was receiving hospice services but did not elaborate on what services were provided to him. During an interview on 5/23/2023 at 1:22 p.m. with the Hospice Nurse, she confirmed that R31 had been receiving hospice services with the current company since 1/19/2023. The typical protocol was for the Hospice Nurse to document their assessment/visit findings, then someone at the hospice office prints out the documents, and then someone brings a copy to the nursing home and then the nursing home scans and uploads the documents to the resident's electronic chart. Typically, she had been getting reports from the floor nurse on the resident's status, and then she charted that information in her nursing progress notes which she reported at the hospice IDG (Interdisciplinary Group) meetings. Previously, one of the retired nurses would bring over the hospice documents, but that nurse retired, and she was not sure who was responsible for the documents currently. The Hospice Nurse stated she had never been informed of any care conferences or coordination of care meetings since January 2023 when she started seeing him. During an interview on 5/25/2023 at 1:42 p.m. with the Hospice Director of Operations she stated she was not aware that the facility was not receiving progress notes, plan of care, or recertifications; she stated all documents should be printed off at the hospice office, and the nurse should be taking them to the facility on a weekly basis. Additionally, it was her expectation that the hospice case manager or the hospice social worker, should be attending care plan meetings at the facility, however, she was not aware of any meetings being held. During an interview on 5/24/2023 at 4:56 p.m. with the MDS Coordinator confirmed that a hospice representative should be invited to attend care conferences, but she was not sure what the process was for ensuring the hospice nurse/social worker was notified. The MDS Nurse also confirmed that no care conferences were held for R31 since 6/03/2022. During an interview on 5/24/2023 at 5:05 p.m. with the Social Services Director (SSD) she stated she had overlooked inviting the hospice case manager to the care conference meetings, but they should be invited. Additionally, no care conferences were held for R31 since 6/3/2022. 2. Review of R37's admission Record in the EMR under the Profile tab revealed R37 was admitted to the facility on [DATE] with diagnosis of multi-system degeneration of the autonomic nervous system. Review of R37's EMR under the MDS tab revealed a quarterly MDS with an ARD date of 3/30/2023 revealed that R37's BIMS score was 15 of 15 which indicated R37 was cognitively intact. Review of R37's Care Plan in the EMR under the Care Plan tab revealed that R37's care plan did not include the collaboration with hospice as to what services, interventions, and medications that hospice would provide. During an interview on 5/23/2023 at 10 a.m., the Hospice nurse confirmed that R37 was receiving Hospice services from her agency. The Hospice Nurse showed the surveyor the hospice Care Plan on her tablet. The Hospice nurse stated that she has not been invited to R37's care plan meetings. During an interview on 5/24/2023 at 5:05 p.m., the Social Services Director (SSD) confirmed that Hospice staff have not been invited to care plan meetings and that the facility has not received the Hospice care plan so that there can be a collaboration of services. 3. Review of R10's admission Record in the EMR under the Profile tab revealed R10 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, anemia, sever protein malnutrition, Parkinson disease and aphasia. Review of R10's quarterly MDS with an ARD date of 3/29/2023 indicated the BIMS could not be conducted due to R10's short-and long-term memory loss and severe impaired cognitive skills. R10's MDS was coded for hospice services. Review of R10's Physician Orders in the EMR under the Orders tab revealed Hospice services began on 5/26/2022. Review of the Care Plan tab of the EMR revealed that R10's care plan did not include the collaboration with hospice as to what services, interventions, and medications that hospice would provide. During an interview on 5/23/2023 at 4:15 p.m., the Hospice nurse showed the surveyor, R10's hospice Care Plan on her tablet. The Hospice nurse confirmed that a previous nurse of the Hospice agency used to bring the Hospice care plan to the facility. However, since this employee no longer works for the Hospice agency, she was not aware of anyone bringing the Hospice care plan to the facility. Interview on 5/24/2023 at 4:42 p.m., the SSD and Medical Records were asked whether the facility received the hospice care plan from the Hospice agency. Both stated that they have not received Hospice care plans since the previous Hospice nurse used to bring the Hospice care plan to the facility. Review of R10's Care Plan with the SSD revealed that the Hospice care plan was not incorporated into R10's overall care plan to ensure collaboration of services.

Based on observation, staff interview, and Review of the facility policies titled, Refrigerator and Freezers, Food Safety Requirement, Sanitation, and Food Preparation and Service. The facility failed to ensure that expired foods were removed from the cooler; all food items in the coolers, refrigerator or freezers were labeled and included the date the item was placed in the cooler, refrigerator or freezer; failed to label and date chicken that was thawing in the cooler; failed to ensure that shelves used to store clean pots and pans was free from white powder and failed to ensure that the inside of the freezer was free of frost build-up. This deficient practice had the potential to affect 52 of 55 residents receiving an oral diet. Findings include: Review of the facility's policy titled, Refrigerator and Freezers dated 10/2022 revealed, Guidelines .6. All foods shall be appropriately dated to ensure proper rotation by expiration dates.8. The food shall be labeled and clearly marked to indicate the date or day by which the food shall be consumed or discarded. Review of the facility's policy titled, Food Safety Requirement dated 10/2022 revealed, Guidelines .8. All Foods stored in the refrigerator or freezer, will be covered, labeled, and dated . Review of the facility's policy titled, Food Preparation and Service dated 9/2022 revealed, Thawing Frozen Food .a. thawing in the refrigerator in a drip proof container . Review of the facility's policy titled, Sanitation dated 10/2022 revealed, guidelines .2. Utensils, countertops, shelves .shall be kept clean . Observation on 5/22/2023 at 9:27 a.m., of the dietary department, with the Administrator since the Dietary Manager was not at the facility, revealed: 1.Inside the milk cooler, on the top shelf were six gallons of milk and none were expired. On the second shelf were five gallons of milk and one gallon of milk had an expiration date of 5/18/2023. The Administrator confirmed the milk was expired and should have been disposed of prior to today. 2. Inside the juice cooler on the shelf was an uncovered, unlabeled, undated sheet cake. Also, on the bottom shelf was an unlabeled, undated large plastic container of what appeared to be chicken parts and a plastic bag sitting in bloody red liquid. The container did not have a date when the chicken was placed in the plastic container. Interview on 5/22/2023 at 9:45 a.m., the cook stated that someone must have thawed the chicken yesterday because she didn't do it and it was there when she came to work today. The Administrator stated that the chicken would be thrown out since no one knows when the chicken was placed in the juice cooler for thawing. 3. The bottom shelf of a cabinet, where clean pots and pans were stored, revealed a shelf that had three large pots and a white powdery substance on the shelf. The Administrator confirmed the shelf was for the storage of clean pots and pans and that the shelf should be free of powder. 4. The vegetable freezer had a build-up of frost around the inside of the door. 5. The ice cream chest freezer had an unlabeled bag of what appeared to be hash browns dated 4/03/2023 and an unlabeled bag of what appeared to be French fries dated 5/17/2023. The Administrator confirmed that both items were unlabeled.

Based on documentation review, Staff interview, and review of the facility policy titled, Surveillance for Healthcare-Associated Infections, the facility failed to develop an effective Antibiotic Stewardship Program (ASP) to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use which has the potential to affect all residents. Specifically, three (Residents (R) 9, R37, and R4) were prescribed an antibiotic (s) without diagnostic testing that identified an organism and documented symptomology to support the continued use of an antibiotic. Findings include: Review of the facility's policy titled, Surveillance for Healthcare-Associated Infections dated 5/2023 revealed, Definitions, Outcome Surveillance- Collecting and documenting data on individual resident case and comparing the collected data to standard written (criteria) of infections. Guidance, The Surveillance of Infections, 2. The criteria for such infections are based on the current standard definitions of infections. 3. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections. Gathering Surveillance Data, 3. The surveillance should include a review of infections utilizing the Mc Geer criteria h. antibiotic review. Review of the April 2022 through April 2023 Stewardship Tracking and Analysis logs provided by the Infection Preventionist (IP) revealed the logs had inconsistent documentation that identified the diagnostic testing and the symptomology exhibited for the use of the antibiotic. Review of the April 2023 Antibiotic Stewardship Meeting Report did not consistently indicate the symptoms exhibited and laboratory results. The April log indicated that 10 antibiotics were ordered. One of the 10 antibiotics met the McGeer Criteria (used for retrospectively counting true infections) and six antibiotics did not meet either criterion. R9's entry on the April 2023 Infection Control Log indicated on 4/12/2023 the DX (diagnosis) for the ABT (Antibiotic) was URI (Upper Respiratory Infection. R9's antibiotic use was documented did not meet the criteria. R9 received the antibiotic, Levaquin 500 mg (milligrams) x (times) seven days. Interview with Infection Preventionist (IP) on 5/24/2023 at 10:14 a.m., revealed that. R9 went out with her family on 4/9/2023. R9 had no document evidence of complaints of sore throat, elevated temperature, or cough on 4/9/2023, 4/10/2023, and 4/11/2023. On 4/12/2023, R9 requested to see the Medical Director (MD) and informed the MD that she had a sore throat. The MD ordered the antibiotic Levaquin for 7 days. The IP confirmed that R9 did not meet the criteria for the use of an antibiotic. Review of the March 2023 Antibiotic Stewardship Meeting Report did not consistently indicate the symptoms exhibited and laboratory results. The March 2023 log indicated that eight antibiotics were ordered. Six of the eight antibiotics met the Loeb and McGeer Criteria, and two antibiotics did not meet either criterion. Interview with the IP on 5/24/2023 at 10:14 a.m., the IP stated that R4 had gall bladder surgery in October 2023 and since then has had a wound at the surgery site. The IP stated that R4 sees the Wound Clinic one time per week and that the Wound Clinic staff perform the wound treatment and the remaining days of the week, the facility's nursing staff perform the treatment. The IP stated that on 3/14/2023 the Wound Clinic ordered Tetracycline 500 mg x seven days. The IP confirmed that the Wound Clinic did not culture the wound prior to the initiation of the antibiotic. The IP confirmed that R4 has received antibiotics in February 2023. On 2/4/2023 and 2/13/2023, R4 was ordered Bactrim x seven days for each time it was ordered and then on 2/21/2023 received Tetracycline 500 mg x 10 days. Prior to the Tetracycline being ordered a culture was done on 2/16/2023 and the results returned on 2/20/2023 which indicated Staphylococcus epidermidis. The February 2023 Infection Control Log indicated that a re- culture was not completed after the completion of the antibiotic on 3/2/2023. Review of the February 2023 Antibiotic Stewardship Meeting Report did not consistently indicate the symptoms exhibited and laboratory results. The February 2023 log indicated that 15 antibiotics were ordered. Ten of the 15 antibiotics met the Loeb and McGeer Criteria, and five antibiotics did not meet either criterion. Interview with the IP on 5/24/2023 at 10:14 a.m., the IP stated according to the February 2023 Infection Control Log R4 had a Urinary Tract Infection (UTI). The IP stated that R4 did not display any symptoms other than he had a behavior change of wandering. The IP stated that the MD ordered a urinalysis with a follow up culture and sensitivity. The results of the urinalysis indicated that the urine was contaminated. The IP stated that another urinalysis was not obtained. The MD ordered the antibiotic Amoxicillin x seven days. Further interview, the IP stated that on 2/3/2023, R37 complained of a tooth abscess to the Physician, who ordered Amoxicillin 5000 mg x seven days. The IP stated that R37 canceled both of his dental appointments which were scheduled for assessment and treatment of the tooth abscess. The IP stated that R37 has not complained anymore about the tooth. The IP confirmed that there is no documentation from 2/1/2023 through 2/11/2023, in the R37's Electronic Medical Record (EMR), of tooth pain. Review of the January 2023 Antibiotic Stewardship Meeting Report did not consistently indicate the symptoms exhibited and laboratory results. The January 2023 log indicated that eight antibiotics were ordered. Six of the eight antibiotics met the Loeb and McGeer Criteria, and two antibiotics did not meet either criterion. Interview with the IP on 5/24/2023 at 10:14 a.m., the IP stated that R4 was prescribed an antibiotic on 1/5/2023 of Cipro 500 mg x seven days for the gall bladder wound infection. The IP confirmed that a culture was not obtained prior to the ordering of the antibiotic. The IP provided the Antibiotic Stewardship data for April 2022 through December 2022 revealed the following: April 2022, 15 antibiotics were ordered, 13 of the 15 antibiotics were ordered without clinical symptoms or diagnostic testing. May 2022, 12 antibiotics were ordered, six of the 12 antibiotics were ordered without clinical symptoms or diagnostic testing. June 2022, 11 antibiotics were ordered, eight of the 11 antibiotics were ordered without clinical symptoms or diagnostic testing. July 2022, 12 antibiotics were ordered, five of the 12 antibiotics were ordered without clinical symptoms or diagnostic testing. August 2022, 12 antibiotics were ordered, nine of the 12 antibiotics were ordered without clinical symptoms or diagnostic testing. September 2022, 13 antibiotics were ordered, eight of the 13 antibiotics were ordered without clinical symptoms or diagnostic testing. October 2022, seven antibiotics were ordered, four of the seven antibiotics were ordered without clinical symptoms or diagnostic testing. November 2022, 17 antibiotics were ordered, five of the 17 antibiotics were ordered without clinical symptoms or diagnostic testing. December 2022, 13 antibiotics were ordered, seven of the 13 antibiotics were ordered without clinical symptoms or diagnostic testing. During an interview with the IP on 5/24/2023 at 10:14 a.m., the IP stated she maintains a monthly log of residents who receive antibiotics, and the log identifies if the antibiotics were ordered according to the LOEB or McGeer criteria. The IP stated that she discussed the data collected for the month regarding residents who received antibiotics that met the criteria and residents that did not meet the criteria at the facility's monthly Quality Assurance and Performance Improvement (QAPI) meeting. The IP stated the information she provides at the QAPI meeting is how many antibiotics ordered met criteria and how many antibiotics did not. Other than providing this information at the QAPI meeting, the IP did not have any further documentation that the members of the QAPI meeting analyzed the data for clusters, trends, or compliance with the criteria. During the interview and review of the January 2023 through April 2023 Antibiotic Stewardship Meeting Report, the IP confirmed that for the question on each meeting report, What was done about them [antibiotics that were ordered without meeting the criteria] the IP confirmed that there was discussion or suggestions of interventions during the meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop a care plan to address hypoxemia for one of five residents (R#13) receiving oxygen therapy. Findings include: 1. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that R#13 had a diagnosis of hypoxemia. Observations on 1/22/2022 at 1/25/2022 at 2:07 p.m., 1/26/2022 1:14 p.m., and on 1/25/2022 at 4:29 p.m. on 1/23/2022 at 7:10 a.m., and 1/23/2022 at 7:37 a.m. revealed R#13 was receiving oxygen therapy via nasal cannula ranging at 3/LPM (liters per minute). During an interview and observation on 1/27/22 9:34 a.m. Licensed Practical Nurse (LPN) AA confirmed that R#13 was currently receiving oxygen at 3 LPM. However, when the order was checked LPN AA revealed an order for oxygen had not been entered into the system. During an interview on 1/27/22 at 9:47 a.m. with the Director of Nursing (DON), revealed that although the facility can place the resident on oxygen via NC at 2LPM without orders, there should have been an order written for R#13 for oxygen for 3LPM via NC. The DON revealed normally this would have been caught during the 24-hour chart-check, which is done within 24-hours after a resident is admitted into this facility. The facility currently has five residents on oxygen therapy. The DON revealed she couldn't understand why this was missed.

Based on observations and staff interviews the facility failed to maintain an environment that was free from peeling and chipped paint on two of four halls with 23 of 50 rooms affected. Findings include: During observations on 1/25/2022 at 9:34 a.m. revealed chipped, missing, and peeling paint on the doorframes of rooms 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, and 212. Several locations on the 200 hall also revealed missing, peeling, and chipped paint in the hallway. During observation on 1/25/2022 at 9:46 a.m. revealed chipped, missing, and peeling paint on the doorframes of rooms 301, 302, 303, 304, 305, 307, 308, 309, 310, 311, and 312. Several locations on the 300 hall also revealed missing, peeling, and chipped paint in the hallway. During an interview on 1/27/2022 at 10:45 a.m. with Maintenance Director revealed, he is aware of the need for paint on the 200 and 300 halls, including the doorframes of the rooms. Stated he does not have assistance at this time to complete the painting and is unable to complete all the work alone. During an interview on 1/27/2022 at 11:05 a.m. with Regional Director of Operations (filling in for the Administrator who is out sick) revealed she is aware of the need for the 200 and 300 halls to be painted including door frames.