**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Bedside Medication Storage, the facility failed to ensure unauthorized medications were not stored at the bedside for one of 40 sampled residents (R) (R10). This deficient practice had the potential to place R10 at risk of the use of unauthorized medications in an unsafe manner. Findings Include: A review of the facility's policy titled, Bedside Medication Storage, revision date 8/2020, revealed the Policy section stated, Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent). The Procedures section included 1. A written order for the bedside storage of medication is present in the resident's medical record. 2. Bedside storage of medications is indicated on the resident Medication Administration Record (MAR) and in the care plan for the appropriate medications. 6. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. A review of R10's electronic medical record (EMR) revealed an admission date of 10/16/2024 with diagnoses including, but not limited to, hypo-osmolality and hyponatremia, cardiomegaly, essential (primary) hypertension, and muscle weakness. A review of R10's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment) and Section GG (Functional Abilities and Goals) documented R10 required assistance with activities of daily living (ADLs). A review of R10's care plan revealed no care plan area for self-administration of medication. A review of R10's Physician Orders revealed no order for self-administration of medications. Further review revealed there was no physician's order for Gold Multi + Vita -Lea with Vitamin K. An observation and interview on 12/3/2024 at 11:05 am with R10 revealed a bottle labeled Gold Multi + Vita -Lea with Vitamin K 120 capsules on her bedside table. R10 revealed she had been taking the vitamins before she was admitted to the facility and had continued to take them at the facility. R10 stated the staff knew she had the vitamins. An observation on 12/4/2024 at 10:01 am revealed one bottle of Gold Multi + Vita -Lea with Vitamin K 120 capsules was seen on her bedside table. In an interview on 12/4/2024 at 12:02 pm, Certified Nursing Assistant (CNA) BB confirmed R10 was not allowed to have any medications at the bedside. In an interview on 12/4/2024 at 12:21 pm, Licensed Practical Nurse (LPN) CC confirmed that medications are not allowed at the bedside unless specifically authorized by the physician. LPN CC confirmed the medications at R10's bedside and removed the medications. LPN CC stated staff members should be vigilant about medications at the bedside and notify the charge nurse immediately if any were found. In an interview on 12/4/2024 at 11:50 am, the Director of Nursing (DON) revealed there should never be any medications at the bedside. The DON stated there was a risk of overdose if medications were left at the bedside. The DON further stated if a resident wished to take vitamins or other supplements, the physician should be contacted, and the appropriate protocol should be followed. In an interview on 12/4/2024 at 12:36 pm, the Administrator confirmed residents were not allowed to have medications at the bedside table. The Administrator stated allowing medications at the bedside posed a risk, and various negative outcomes could occur. The Administrator stated staff members were expected to remove medications they observed at the bedside to ensure the safety of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, Bed Hold Policy, the facility failed to provide written bed hold notices for one of three residents (R) (R201) reviewed for hospitalization. This failure had the potential to place R201 at risk of possible denial of re-admission and loss of their room following a transfer to the hospital. Findings include: Review of the facility's undated policy titled, Bed Hold Policy revealed, There will be times that the resident is out of the facility overnight, whether due to a hospital stay. Should any events occur there are clear guidelines regarding payment source to maintain, or hold the resident's bed in the facility. Review of R201's admission Record revealed R201 was admitted to the facility on [DATE]. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Section A (Identification Information) documented R201 was discharged to a short-term hospital with an anticipated return. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Section A (Identification Information) documented R201 was discharged to a short-term hospital with an anticipated return. Review of the Nurse's Notes revealed an entry dated 7/24/2024 at 12:21 pm of Resident was transferred Hospital. [sic] The reason for transfer is an immediate transfer or discharge is required by the resident's urgent medical needs . At the time of transfer, the resident was Alert, disoriented, but can follow simple instructions. Review of the Nurse's Notes revealed an entry dated 8/4/2024 at 12:37 am of .Resident had abnormal breathing . SN [Skilled Nurse] called PCP [Primary Care Physician]. PCP stated sent to the ER [emergency room]. SN called EMS [emergency medical services]. They arrived around 0020. SN gave report to ER nurse and updated resident brother. In an interview on 12/5/2024 at 3:30 pm, the Business Office Manager (BOM) and Administrator verified there was not a bed hold notice provided for R210 for 7/23/2024 and 8/4/2024. The Administrator stated the families were made aware of the bed hold policy at admission, and it is a part of their admission packet. The BOM confirmed she does not provide a bed hold policy when a resident is transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's status at the time of the assessment for one of 40 sampled residents (R) (R42). This deficient practice had the potential to affect the assessment of R42's care needs. Findings Include: A review of R42's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. A review of R42's Annual MDS dated [DATE] revealed Section A (Identification Information) documented the resident had not been evaluated by Level II PASRR [Preadmission Screening and Resident Review] and determined to have a serious mental illness and/or mental retardation or a related condition. Review of R42's EMR revealed a PASRR Level II dated 9/21/2023. In an interview on 12/5/2204 at 10:42 am, the MDS Coordinator verified R42 had a PASRR Level II dated 9/21/2023, and it was not coded accurately on the MDS assessment dated [DATE]. In an interview on 12/05/24 at 2:05 pm, Registered Nurse (RN) GG stated she signed the MDS assessments confirming completion by the required date. She further stated she does not check the MDS for accuracy. In an interview on 12/5/2024 at 2:21 pm, the Administrator stated RN GG's role in the MDS process was to sign off to confirm the MDS was complete. The Administrator further stated her expectation was for the MDS assessment information to be accurate. She acknowledged that a possible negative outcome of inaccurate MDS information could be that the facility could be submitting inaccurate assessments and compromise resident care. In an interview on 12/6/2024 at 11:55 am, the Administrator confirmed that the facility did not have a specific MDS policy but followed the Resident Assessment Instrument (RAI) guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R2's admission Record revealed diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adult failure to thrive, muscle weakness, and contracture of muscle in the left forearm, left hand, right forearm, right hand, and right upper arm. Review of R2's Annual MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS of 15 (indicating no cognitive deficit), and Section GG (Functional Abilities and Goals) documented R2 had an impairment on both upper extremities and was dependent on a helper for assistance with all ADLs. Review of R2's care plan dated 3/28/2023 revealed a Focus of total assistance for bathing, dressing, and grooming. Interventions include R11 is total care for oral care every shift and as needed, and staff to provide ADL care daily to make sure his daily needs are met. An observation and interview on 12/4/2024 at 9:15 am in R2's room revealed that R2 had a foul odor from his mouth. In an interview, R2 stated that it had been over two weeks since he had assistance with brushing his teeth. In an interview on 12/6/2024 at 10:15 am, R2 revealed staff had not assisted him with oral care this week. He stated that the staff did not help him with brushing his teeth. He further stated staff helps with using mouthwash, but he would like help brushing his teeth. In an interview on 12/6/2024 at 1:06 pm, CNA RR revealed that R2 needed total assistance with ADL care, including oral care. She further stated that she provided R2 with mouthwash but had not offered to help with brushing his teeth. In an interview on 12/6/2024 at 12:01 pm, the DON stated she expected staff to provide ADL care for dependent residents as often and as needed, including brushing their teeth daily in the morning and anytime it is needed. Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to ensure activities of daily living care, specifically fingernail care and oral hygiene, were provided for two of 40 sampled residents (R) (R11 and R2). The deficient practice had the potential to place R11 and R2 at risk for unmet needs and a diminished quality of life. Findings include: Review of the facility's policy titled, Activities of Daily Living, dated 10/17/2022, revealed the Policy section stated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate. The Policy Explanation and Compliance Guidelines section included .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. 1. Review of R11's admission Record revealed diagnoses including, but not limited to, cerebrovascular disease, Parkinson's disease, vascular dementia, age-related nuclear cataract, and type 2 diabetes. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 3 (indicating severe cognitive impairment), Section GG (Functional Abilities and Goals) documented R11 required substantial to maximal assistance with ADLs. Review of R11's care plan dated 1/2/2024 included a Focus of total care for dressing/grooming. Interventions included staff to provide ADL care daily to make sure all his daily needs are met. During observation and interview on 12/4/2024 at 12:45 pm with R11 in his room, observation revealed his fingernails were long and had a dark substance underneath them. R11 stated he did not like his nails long. He stated it had been a month since they were cut. Observation on 12/5/2024 at 8:35 am revealed R11 was sitting in the day room watching television. Further observation revealed his fingernails were long with a dark substance underneath. In an interview on 12/5/2024 at 8:45 am, Certified Nurse Assistant (CNA) BB stated R11 required total assistance with ADL care. She stated she did not cut fingernails often, but if they were dirty or needed clipping, she would. She confirmed R11's nails were long with a dark substance underneath them and needed cleaning and trimming. In an interview on 12/5/2024 at 4:57 pm, the Director of Nursing (DON) stated she expected staff to check residents' nails and attend to them when providing care. She stated nail care was included in ADL care.

Based on observations, staff interviews, and review of the facility's policy titled, Controlled Substance Prescriptions, the facility failed to ensure controlled medication shift counts were documented with nurse signatures on one of four medication carts (D Hall Medication Cart). This deficient practice had the potential to affect the availability of residents' controlled medications. Findings include: Review of the facility's policy titled, Controlled Substance Prescriptions, revised 8/2020, revealed the Policy section stated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and record-keeping requirements in the facility, in accordance with federal and state laws and regulations. Observation on 12/4/2024 at 10:25 am of the controlled-substance document titled Narcotic Sign Off Form on the D Hall Medication Cart revealed 28 missing signatures of 112 opportunities for controlled-substance shift counts for incoming and outgoing nurses between 9/29/2024 through 10/27/2024. The dates of missing nurses' signatures were 9/29/2024 (two missing signatures), 10/5/2024 (two missing signatures), 10/6/2024 (two missing signatures), 10/7/2024 (two missing signatures), 10/12/2024 (one missing signature), 10/13/2024 (two missing signatures), 10/14/2024 (one missing signature), 10/15/2024 (two missing signatures), 10/16/2024 (one missing signature), 10/19/2024 (two missing signatures), 10/20/2024 (two missing signatures), 10/21/2024 (two missing signatures), 10/22/2024 (two missing signatures), 10/24/2204 (two missing signatures), 10/26/2024 (one missing signature), and 10/27/2024 (two missing signatures). In an interview on 12/4/2024 at 4:14 pm, Nursing Supervisor (NS) EE stated her expectations were for the nurses to count the narcotics and document the count by signing the controlled substance sheet at the change of each shift. She stated if there was a discrepancy in the controlled medications counts, the residents may not receive their medications if the medications were missing. In an interview on 12/5/2024 at 5:50 pm, the Director of Nursing (DON) stated the controlled medications should be counted by the nurses at shift change and the controlled substance sheet shift change form should be signed by the oncoming and off-going nurse at each shift change to verify the accuracy of the controlled substance count.

Based on observations, staff interviews, and review of the facility's policy titled, Storage of Medications, the facility failed to ensure expired medications were removed from one of two medication storage rooms. The deficient practice placed residents at risk of receiving expired medications. The facility census was 97 residents. Findings include: Review of the facility's policy titled, Storage of Medications, revised 8/2020, revealed the Policy stated, Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The Procedures section included Expiration Dating (Beyond-Use Dating) . 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. Observation on 12/4/2024 at 3:07 pm of the Front Hall Medication Storage Room with Licensed Practical Nurse (LPN) DD revealed 14 blister-pack medications dated 7/2024 on the counter. Further observation revealed one bottle of vitamin D 250 microgram (mcg) with an expiration date of 10/2024 and one bottle of vitamin D 400 international units (IUs) with an expiration date of 11/2024 on the counter. LPN DD verified the expired medications and stated they should have been discarded. In an interview on 12/4/2024 at 3:15 pm, Nursing Supervisor (NS) EE confirmed there were 14 blister packs of three residents' medications dated 7/2024 on the counter in the Front Hall Medication Storage Room and stated they should not be on the counter but should be placed in a sealed bag and labeled for the pharmacy to pick up. NS EE stated her expectations were for the expired medications to be removed from the medication room and sent to the pharmacy. In an interview on 12/5/2024 at 5:50 pm, the Director of Nursing (DON) stated she expected the nurses to remove expired medications from the medication room because the residents could be adversely affected if they received expired medications.

Observation on 12/3/2024 at 10:00 am revealed an unpleasant odor on the D Hall. Observation on 12/4/2024 at 11:00 am and 5:20 pm revealed an odor of urine on the D Hall. The odor was strongest close to room D2 and between rooms D9 and D10. In an interview on 12/4/2024 at 5:34 pm, Certified Nursing Assistant (CNA) JJ confirmed the odor of urine on the D Hall and confirmed the odor was strongest close to room D2 and between rooms D9 and D10. She stated the D Hall usually had an unpleasant odor. She further stated there were bins in the hallway between rooms D9 and D10 which contained linen and incontinence pads, and they were usually emptied by the CNAs on the units. She confirmed the bins needed to be emptied. In an interview on 12/4/2024 at 5:43 pm, the Director of Nursing (DON) confirmed the D Hall had an unpleasant odor. She stated her expectations were for the hallways to be odor-free. She stated the outcome of unpleasant odors could negatively affect the residents. In an interview on 12/5/2024 at 11:20 am, Environmental Services Lead TT stated one of the two large black garbage bins in the D Hall contained incontinence trash of urine and feces, and the other one had dirty resident laundry. She stated she did not know why the D Hall was the only hall with those bins, but they had always been there. She further stated the CNAs would change the residents and often leave the soiled undergarments in the bins. She stated she believed the bins were the reason for the D Hall smelling bad. In an interview on 12/6/2024 at 11:00 am, the Administrator stated she expected the facility to not have unpleasant odors. She confirmed the D Hall had unpleasant odors and stated she expected unpleasant odors to be addressed quickly. Based on observations, staff interviews, and review of the facility policy titled, Environment, the facility failed to provide a safe, functional, sanitary, and comfortable environment on three of five halls and one of two shower rooms. These deficient practices had the potential to place residents at risk of living in an unsanitary living environment and a potential for diminished quality of life. The facility census was 97 residents. Findings include: Review of the facility policy titled, Environment, dated 12/5/2018, revealed the Policy section stated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The Policy Explanation and Compliance Guidelines section included . 9. General considerations: a. Minimize orders by disposing of soil linens properly and reporting lingering orders at bathrooms needing cleaning to housekeeping department. Observations on 12/3/2024 at 1:00 pm revealed patched walls at the end of A Hall and stained ceiling tiles on A Hall. Observations on 12/5/2024 at 3:31 pm revealed the Shower Room on C Hall had missing floor tiles, scuffed walls, and a foul odor. Further observation revealed stained ceiling tiles on C Hall. During a concurrent interview and observations on 12/6/2024 at 1:44 pm, the Administrator and Maintenance Director confirmed the patched walls at the end of A Hall and the missing floor tiles and scuffed walls in the C Hall Shower Room. They further confirmed stained ceiling tiles on A Hall and C Hall.

2. Review of the facility's policy titled, Legionella Surveillance, revised 11/20/2022, revealed the Policy section stated, It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. The Policy Explanation and Compliance Guidelines section included 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. A water management program policy was requested and not provided. In an interview on 12/5/2024 at 3:11 pm, the Maintenance Director and Environmental Services Director (ESD) revealed that both the Maintenance Director and ESD share the responsibility of overseeing the water management program for the facility. They stated the current Maintenance Director had been in his position for almost three months. They further stated the previous Maintenance Director had full responsibility for maintaining the water management program and took all the water management program documentation and information with him at the end of his employment. They stated that they were in the process of developing the water management program and confirmed there was no current water management program for the facility. Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Hand Hygiene and Legionella Surveillance, the facility failed to ensure staff performed proper infection control practices while serving meals to the residents on two of five halls (D Hall and E Hall). In addition, the facility failed to ensure an effective water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water system. The deficient practices had the potential to spread infection by cross-contamination and placed the residents at risk of waterborne illnesses, including Legionnaires disease. The facility census was 97 residents. Findings include: 1. Review of the facility's policy titled, Hand Hygiene, reviewed 6/25/2020, revealed the Policy section stated, Staff involved in direct resident contact will perform proper hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table section included Either Antimicrobial Soap and Water or Alcohol Based Hand Rub is to be used between resident contacts. Observation on 12/3/2024 at 12:50 pm, on D Hall revealed Certified Nursing Assistant (CNA) BB did not sanitize her hands after leaving a resident's room. Further observation revealed her to take a food tray into another resident's room and exited the room without sanitizing her hands upon entry or exit of the room. CNA BB was observed to place a meal tray on the meal cart, and did not sanitize her hands after handling the dirty tray. Observation on 12/3/2024 at 12:56 pm on E Hall revealed CNA HH serving meals to the residents. Observation revealed that she took the meal tray from the meal cart, went into the resident's room, exited the resident's room, returned to the meal cart for another resident's meal tray, and took it to the other resident's room. CNA HH did not sanitize her hands between serving the residents their meal trays. In an interview on 12/3/2024 at 12:54 pm, CNA BB confirmed she did not sanitize her hands after exiting the resident's room on the D Hall. She stated she should have sanitized her hands after exiting the resident's room, but she forgot. She further stated not sanitizing her hands between residents could expose residents to germs and infections. In an interview on 12/3/2024 at 1:00 pm, CNA HH confirmed she did not sanitize her hands while serving the residents' meals. She stated she should have sanitized her hands between serving meals to the residents, but she did not. She stated she was trying to get the residents' lunches to them as quickly as possible, so she did not sanitize her hands in between serving the residents. She further stated not sanitizing her hands between residents could cause germs to spread between residents and cause illness. In an interview on 12/5/2024 at 5:50 pm, the Director of Nursing (DON) stated her expectations were for all staff to sanitize their hands between contact with residents and before and after attending to a resident. She stated if staff didn't sanitize their hands between residents, infections could be spread to residents.

Based on observation, staff interviews, and review of the facility policies titled, Maintenance Inspection and Housekeeping Services, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in six of 61 resident rooms (rooms D4, D6, D8, D9, D12, and D13) on one of five hallways (D Hall) related to grime build-up on room air conditioner (AC) units, dust build-up on room AC unit filters, and an area of missing and uneven flooring. Findings include: Review of the facility policy titled, Maintenance Inspection revealed: 1. The Director of Maintenance Services will perform random and/or routine inspections using the Maintenance checklist. Last reviewed 11/21/2017. Review of the facility policy titled, Housekeeping Services revealed: 1. The Director of Housekeeping will perform random and/or routine inspections using the Environmental Room Attendants checklist. Last reviewed 11/21/2017. Observations on 7/28/2023 at 8:00 a.m. on the D-hall revealed: Rooms: D4 A/C unit had dark brown/black grime buildup on the unit and the unit had cracked slats with broken and jagged areas. D6 A/C unit had dirt and grime buildup on the A/C unit and vents, machine had cracked slats with broken and jagged areas. D8 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D9 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D12 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D13 A/C unit had dried brown/black grime and dust build up. An area on the D-hall near room D10 revealed a large area of flooring missing with uneven flooring and cement near a drainage pipe. Observations on 7/29/2023 at 12:40 p.m. on the D-hall revealed: Rooms: D4's A/C unit had dark brown/black grime buildup on the unit and the unit had cracked slats with broken and jagged areas. D6 A/C unit had dirt and grime buildup on the A/C unit and vents, machine had cracked slats with broken and jagged areas. D8 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D9 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D12 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D13 A/C unit had dried brown/black grime and dust build up. Interview on 7/29/2023 at 12:40 p.m. with the Administrator revealed they had a plumbing leak a few weeks ago and the plumber had to dig the floor up to remove a blockage in the drainage pipe. Interview and observation on 7/30/2023 at 8:49 a.m. with the Maintenance Supervisor and the Housekeeping Supervisor revealed maintenance was responsible for cleaning the A/C unit air filters and the housekeepers were to clean the unit itself. Maintenance indicated he does not have a schedule for cleaning the filters, but he tries to clean them monthly. The Housekeeper Supervisor indicated the housekeepers should be cleaning the A/C units during normal day cleaning. They both would expect them to be clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of facility policies titled, Restraints, Physical and Restraints, Consent For Use, the facility failed to ensure three of 27 sampled Residents (R) (R#7, R#18, and R#80) were free from the use of physical restraints. Specifically, geri-chairs (reclining, geriatric chair) with tray tables secured to the front of the chairs and wedges put underneath mattresses to raise them up were used, preventing R#7 and R#18 from getting up from the geri-chair and R#80 from getting out of the bed. Findings include: Review of facility policy titled, Restraints, Physical last update 3/16/2022 revealed: POLICY: Upon admission Residents and family is made aware that this facility strives to be Restraint Free. Our policy is in compliance with State and Federal regulations that the Resident has a right to be free from any physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the Residents medical symptoms. We will use restraint free methods such as: Low beds, low chairs, bean bag, door alarms, floor mats, cushions, and other adaptive devices as needed. PROCEDURE: If a Resident becomes physically abusive, which will cause harm to self or other, and Emergency physical restraint will be used at this time, only, until further measures can be obtained or met, (Soft Belt Restraint only). RESTRAINT= Vest, Soft Belt, Side Rails, and any other mechanism which limits/restricts movements of the Resident including Chemical Restraints. Review of facility policy titled, Restraints, Consent For Use last updated 3/16/2022 revealed: POLICY: It is the policy of this facility to maintain the residents as restraint free as possible. Written consent shall be obtained for application of physical restraints. PROCEDURE: 1. The attached form shall be completed by both nursing and the resident or responsible party. 2. Restraints will be applied only with a Physician's order and consent of the resident or responsible party EXCEPT when the situation warrants emergency application of a restraint for 'the safety and/or protection of the resident. In such instances, the physician shall be notified as soon as possible after application of the restraint to obtain appropriate orders. The responsible party shall be notified also. A consent will be obtained at that time. 3. The following restraint protocols shall be observed: a. the resident shall be checked every 30 minutes. b. the restraint shall be released every 2 hours for exercise or ROM. c. the residents will receive ongoing evaluations for entry into restraint free trial or restraint reduction by the Rehab Nurse. Review of the electronic medical record (EMR) revealed R#7 was admitted to the facility with diagnoses including but not limited to dementia, anxiety disorder, psychosis, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#7 did not use restraints. Observation on 7/28/2023 at 11:10 a.m. revealed R#7 sitting up in a geri-chair with tray table secured in place to geri-chair. Observation on 7/29/2023 at 9:10 a.m. revealed R#7 sitting in geri-chair with tray table secured in place to geri-chair. Observation on 7/29/2023 11:38 a.m. revealed R#7 sitting in geri-chair with tray table secured in place to geri-chair. Review of R#7's Physician Orders revealed no order in place for tray table over geri-chair. Review of R#7's EMR and physical chart revealed no consents from R#7's responsible party (RP) for restraint use and no restraint assessments. Review of R#7's care plan revealed a problem: R#7 is physically mobility impaired with h/o [history of] multiple falls prior to admission and remains at potential for falls/edema/pain/skin breakdown with dx [diagnosis] of dementia/Alzheimer's with actual falls on 12/23/2022, 12/25/2022, 12/30/2022 w/injury, 1/2/2023, and 3/24/2023 w/o injury noted with a wedge compression fracture to left vertebra during hospitalization, last revised on 5/1/2023 with an intervention that stated R#7 to be out of bed in geri-chair without lap tray [tray table] last revised on 2/18/2023. Interview on 7/29/2023 at 11:38 a.m. with Certified Nursing Assistant (CNA) EE revealed the tray table is used on R#7's geri-chair to make sure she does not fall out of the chair because she wiggles around a lot. CNA EE stated the tray table was used when R#7 was out of bed and removed when resident was put to bed. Interview on 7/29/2023 at 11:42 a.m. with the Director of Nursing (DON) revealed the facility has no residents with restraints. It was further revealed R#7 should not have a tray table over her except during meals. The DON confirmed R#7 does not have an order or assessment for restraint use. 2. Review of EMR revealed R#18 was admitted with diagnoses including but not limited to dementia and major depressive disorder. Review of quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of zero out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#18 did not use a restraint. Observation on 7/29/2023 at 12:25 p.m. revealed R#18 being pushed down the hall by a CNA in a geri-chair with tray table secured to the chair. An interview with CNA EE revealed the tray table is used to keep resident from falling out of chair or attempting to get out of chair on her own. Interview on 7/30/2023 at 12:27 p.m. with the DON revealed R#18 should not have the tray table in place. The DON stated the facility does not use restraints. The DON confirmed R#18 had a tray table secured in place and did not have an order, care plan, or assessment done. 3. Review of the EMR revealed R#80 was admitted with diagnoses that included but not limited to traumatic subdural hemorrhage with loss of consciousness of unspecified duration, and pressure ulcer of sacral region, stage 3. Review of R#80's quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of four indicating R#80 was severely cognitively impaired. R#80 had behaviors to include physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, and disruptive sounds. Behaviors of this type occurred daily. Further review revealed R#80 was not assessed for the use of a restraint. Review of care plans for R#80 revealed there was not a care plan to address the use of restraints. Observation 7/28/2023 at 7:55 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 9:26 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 11:00 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 12:15 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 2:00 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 7:45 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 9:30 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 10:15 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 11:47 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 12:50 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 1:55 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 2:30 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/30/2023 at 7:45 a.m. of R#80 lying in bed with eyes open. The bed was lowered to the floor. Blue wedges noted in a chair in the room. Observation 7/30/2023 at 8:20 a.m. of R#80 out of bed sitting in geri-chair in room. There was not a tray table over the geri-chair. Interview on 7/28/2023 at 9:25 a.m. with the Director of Nursing (DON) revealed the DON does not consider the wedges underneath R#80's mattress to be a restraint. She stated that it does not seem to be uncomfortable. DON stated that she did not lie on the mattress, but it did not seem to be uncomfortable. She stated that R#80 can move around in the bed. The DON stated that they tried everything to include checking on him every 30 minutes. The DON stated that R#80 was coming out of the bed. She stated they tried him on a low bed but that did not work out well because he was crawling on the floor and pulling down things like the curtains. She stated they put him back in a regular bed and placed the wedges underneath the mattress so that he could not get out of bed. She stated that you would have to get to know him and know his history. DON stated that they were trying to keep him safe by putting the wedges underneath the right side of his mattress. The DON again stated that R#80 cannot get out of bed while the wedges are underneath it. She stated that was why it was there because they did not want him to get out of bed. Interview on 7/29/2023 at 11:57 a.m. with Licensed Practical Nurse (LPN) BB revealed she was familiar with R#80 and his care. She stated that she was not sure if the wedges underneath the mattress were a restraint or not. She stated that she did what her DON told her to do. LPN BB stated that R#80 cannot get out of bed when the wedges are underneath it. She stated that because he had a lot of falls, they do not want him to get up. LPN BB stated that R#80 cannot remove the lap tray from the geri-chair. She stated he can push it forward, but he cannot remove it. Interview on 7/29/2023 at 1:46 p.m. with the DON revealed that she does not consider the lap tray over the geri-chair a restraint. She stated that she considers it an enabler. The DON stated that if the tray was not over the geri-chair, R#80 would get up. She stated that R#80 falls a lot, and the lap tray prevents him from falling. The DON stated that R#80 was not able to physically remove the lap tray. She stated that they do not want him to remove it. Interview on 7/30/2023 at 8:21 a.m. with Licensed Practical Nurse (LPN) GG revealed that she was familiar with R#80 and his care. LPN GG stated that she considers the geri-chair with the lap tray over it a restraint. She stated that she also considers the bed with the wedges under the right side of the mattress to be a restraint. LPN GG stated that R#80 cannot get out of the bed while it has the wedges underneath the mattress. She stated that R#80 cannot remove the lap tray from the geri-chair. LPN GG stated that R#80 can move around in the chair and in the bed. Interview on 7/30/2023 at 10:53 a.m. with the Administrator revealed she was not aware that there were restraints in the facility. She stated that she heard a conversation yesterday about restraints. She stated that they try to keep the residents safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to submit an application for a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 27 sampled residents (R) (R#73). Findings include: The facility does not have a policy on PASRR. Review of electronic medical records (EMR) for R#73 revealed diagnoses including but not limited to bi-polar disorder and anxiety disorder. Review of R#73's annual Minimum Data Set (MDS) dated [DATE] revealed: Section A-Identification 1500: no PASRR; Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 14 indicating R#73 was cognitively intact; Section D-Mood: score of two indicating minimal depression. Review of R#73's care plan dated 7/30/2023 revealed: Resident at risk for drug related side effects due to use of psychotropic drugs and indication for use for bi-polar disorder and anxiety. Resident has a mood/behavior impairment related to diagnosis of bi-polar disorder with noted episodes of greeting upset with staff when he cannot do things his way, cursing at staff, chronic complaints of medical concerns, and refusing care. Review of R#73's Physicians Orders include but not limited to: lithium carbonate oral tablet 300 milligrams (MG) give one (1) tablet by mouth (PO) 1 time a day (QD) for bi-polar disorder for seven (7) days. Start date 7/21/2023, seroquel oral tablet 100 MG give 1 tablet PO QD in a.m. related to bi-polar disorder, seroquel oral tablet 200 MG give 1 tablet PO at bedtime (HS) related to bi-polar disorder, and buspirone tablet 15 MG give 1 tablet PO two times a day (BID) related to bi-polar disorder. Review of R#73's Progress Notes revealed a note dated 7/19/2023 indicating the Physician visited R#73 and gave a new order for lithium 300 MG QD for 1 week then increase to BID. Ordered labs for lithium level and other labs in three (3) weeks. R#73 was not receiving psych services. Review of the admission PASRR Level 1 dated 8/29/2022, completed at the hospital prior to admission revealed no diagnosis of bipolar disorder. Interview on 7/29/2023 at 9:30 a.m. with the Social Services Director revealed that she had been employed at the facility for three months and had not had training on the process and procedure for submitting and or ensuring residents are screened for level II PASRR and was unsure of who was responsible for obtaining that information. During the interview it was revealed that the training received for the Social Worker position at the facility was and continues to be from the facility Administrator and the MDS Coordinator. There had not been any training on the PASRR process. Further interview also revealed that residents that were exhibiting any behaviors were discussed in the morning staffing meeting, daily. If residents were exhibiting behaviors, the Social Worker would assess the resident and try to determine the cause of the behaviors, whether it was medications that needed to be adjusted, any family concerns, or if the resident was in any pain that had not been addressed. Once the assessment is completed, the family and the Physician are notified, and the findings are documented under the Social Services note. Interview on 7/29/2023 at 9:45 a.m. with the MDS Coordinator revealed that she was not responsible for ensuring that residents have a level II PASRR on file and that it was the responsibility of the Social Worker. Further interview also revealed that if during a scheduled assessment it was noted that a resident was exhibiting behaviors with supporting diagnoses, then the Social Worker and Administrator would be notified so that the level II application could be submitted. Interview on 7/29/2023 at 9:50 a.m. with the Administrator revealed that there was no one in the facility at this time to ensure that residents that require a level II PASRR application are submitted to the appropriate state agency. Further interview also revealed that she was currently training the new Social Worker on her duties as the Social Services Director and had not educated her on PASRR level I and/or level II process and requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of facility's policy titled, Comprehensive Care Plan, the facility failed to follow the care for three of 27 sampled residents (R) (R#7, R#18, and R#80) related to the use of a restraint. Findings include: Review of facility policy titled, Comprehensive Care Plan implemented 12/6/2018 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of the electronic medical record (EMR) revealed R#7 was admitted with diagnoses including but not limited to dementia, anxiety disorder, psychosis, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R#7, section C-Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#7 did not use restraints. Review of R#7's care plan revealed a problem: R#7 is physical mobility impaired with h/o [history of] multiple falls prior to admission and remains at potential for falls/edema/pain/skin breakdown with dx [diagnosis] of dementia/Alzheimer's with actual falls on 12/23/2022, 12/25/2022, 12/30/2022 w [with]/injury, 1/2/2023 and 3/24/2023 w/o [without] injury noted with a wedge compression fracture to left vertebra during hospitalization, last revised on 5/1/2023, with an intervention that stated R#7 to be out of bed in geri-chair without lap tray, last revised on 2/18/2023. Observation on 7/28/2023 at 11:10 a.m. revealed R#7 sitting up in a geri-chair with a tray table secured in place to the geri-chair. Observation on 7/29/2023 at 9:10 a.m. revealed R#7 sitting in a geri-chair with a tray table secured in place to the geri-chair. Observation on 7/29/2023 11:38 a.m. revealed R#7 sitting in a geri-chair with a tray table secured in place to the geri-chair. Interview on 7/29/2023 at 11:42 a.m. with the Director of Nursing (DON) confirmed staff were not following R#7's care plan. 2. Review of EMR revealed R#18 was admitted with diagnoses including but not limited to dementia and major depressive disorder. Review of quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of zero out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#18 did not use a restraint. Observation on 7/29/2023 at 12:25 p.m. revealed R#18 being pushed down the hall by a CNA in a geri-chair with tray table secured to the chair. An interview with CNA EE revealed the tray table is used to keep resident from falling out of chair or attempting to get out of chair on her own. Review of the EMR revealed R#80 was admitted with diagnoses that included but not limited to traumatic subdural hemorrhage with loss of consciousness of unspecified duration, and pressure ulcer of sacral region, stage 3. 3. Review of R#80's quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of four indicating R#80 was severely cognitively impaired. R#80 had behaviors to include physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, and disruptive sounds. Behaviors of this type occurred daily. Further review revealed R#80 was not assessed for the use of a restraint. Review of care plans for R#80 revealed there was not a care plan to address the use of restraints. Observation 7/28/2023 at 7:55 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 9:26 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 11:00 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 12:15 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 2:00 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 7:45 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 9:30 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 10:15 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 11:47 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 12:50 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 1:55 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 2:30 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left.

Based on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of two residents (R) (R#74) reviewed for tracheostomy (trach) care. Specifically, the facility failed to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R#74's risk for compromised airway/respiratory distress. Findings include: Review of the facility-provided policy titled, Tracheostomy Care, dated 10/17/2022, revealed: Compliance Guidelines: Tracheostomy care will be provided according to the physician's orders, comprehensive assessment, and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include: a. Provide tracheostomy care at least twice daily. b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas [tracheostomy tubes], and a rescusitator bag [bag-valve mask for resuscitation] easily accessible for immediate emergency care. Review of the undated admission Record for R#74 located in the electronic medical record (EMR), revealed R#74 was admitted to the facility with multiple diagnoses including but not limited to tracheostomy status, aphasia, and diffuse traumatic brain injury (TBI) with loss of consciousness of unspecified duration. Review of the most recent quarterly Minimum Data Set (MDS) for R#74 dated 5/23/2023 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R#74 was unable to complete the interview due to cognitive deficits. Further review of the Physician Orders revealed no order for an emergency tracheostomy kit at the bedside. Review of R#74's care plan revealed R#74 had a tracheostomy related to impaired breathing mechanics with diagnoses of cerebral vascular accident (CVA). Observations made on 7/28/2023 at 8:34 a.m. revealed R#74 lying in bed with head of the bed elevated. R#74 was non-verbal. Tracheostomy was in place and secured with ties. Oxygen (O2) via trach collar at 2 liters (L)/minute (min). Observation revealed there was no same size trach or smaller size trach at the bedside. Review of Physician's Orders for R#74 in the EMR revealed the physician orders revealed no order for an emergency tracheostomy kit at the bedside. Review of Progress Notes dated 7/13/2023 revealed: Respiratory Therapist (RT) performed trach care this afternoon. No oral care kits on trach cart. RT will return tomorrow Friday, July 17, 2023. No one will come July 18-19,2023. RT will return Monday, July 17, 2023. Observation of the trach closet room on 7/29/2023 at 12:00 p.m. with Licensed Practical Nurse LPN BB revealed a supply of various sizes trach tubes and trach supplies. Interview on 7/28/2023 at 8:58 a.m. with Licensed Practical Nurse LPN AA revealed that she did not receive any training, in-service, or education relating to tracheostomy. LPN AA stated that she has provided trach care to R#74. She stated that she was uncomfortable while providing trach care. LPN AA stated that there was always another nurse present in the room when she provided trach care. LPN AA stated that there should be a rescusitator bag, suction, trach ties, and saline at bedside. When asked by surveyor if there was an obturator (trach guide) at the bedside, LPN AA stated that she did not know what an obturator was. When asked if R#74 had their trach size ordered and a trach one size smaller. LPN AA stated that there were trach supplies in the drawer located next to R#74's bed. LPN AA looked in the drawer and stated there were no trach kits in the drawer. LPN AA stated that there was a respiratory cart outside of R#74's room door with trach supplies. LPN AA exited the room and opened all drawers of the respiratory cart. LPN AA stated that there were no trach kits in the respiratory cart. When LPN AA was asked if R#74's trach came out, what would she do. LPN AA stated that they would be in big trouble because there was not a trach to put back in. Interview with the Director of Nursing (DON) on 7/28/2023 at 9:20 a.m. the DON stated that there was a trach cart in the hall outside R#74's room door. The DON went to the trach cart, opened all drawers, and verified that there were no trach kits in the trach cart. When asked by the surveyor if R#74's trach came out what would be the procedure, the DON stated that someone would go to the hospital and get a trach. The DON stated that the hospital would give them a trach. The DON stated that the hospital was five minutes away. When asked by the surveyor what would be done for R#74 while she waited for 15-20 minutes for someone to go to the hospital to get a trach, the DON stated that she guesses they would have to give her some O2. Interview on 7/29/2023 at 11:57 a.m. with Licensed Practical Nurse LPN BB revealed she received a trach in-service from a gentleman at the end of September of 2022. She stated that the gentleman showed them the different parts of a trach and how to care for a trach. LPN BB stated that she has been working with trachs for some years. LPN BB stated that there should be two trachs at the bedside, one the size that the resident uses, and one that is a size smaller. LPN BB stated that there was a trach cart in the hall outside of R#74's room door with trach supplies, and there was a trach closet down the hall with trach supplies in it. LPN BB took the surveyor to the trach closet. Observed in the trach closet were trach supplies to include but not limited to various sized trachs, trach cleaning kits, trach ties, and suction tubing. Observation on 7/29/2023 at 7:45 a.m. revealed at R#74's bedside a trach size 4 hanging in a plastic bag at the head of the bed. A trach size 4 was observed inside the top drawer next to R#74's bed. Interview on 7/29/2023 at 1:46 p.m. with the DON revealed there was a trach closet with trach supplies in it. When asked by the surveyor if she knew that there was a trach closet yesterday, she stated yes. When asked by the surveyor if she knew that there was a trach closet with trach supplies, why she stated to the surveyor that someone would go to the hospital to get a trach. The DON did not answer. Interview with on 7/30/2023 at 8:21 a.m. Licensed Practical Nurse LPN GG revealed she received trach in-service from the respiratory therapist that came out and did the training. LPN GG stated that she was comfortable working with a trach, but she was not an expert. LPN GG stated that at the bedside there should be suction, resuscitation bag, gauze, trach ties, inner canula, humidifier machine, and a trach. She stated that there was a trach closet down the hall with trach supplies. LPN GG stated that there was also a trach cart outside of R#74's room door.

Based on observations, staff interviews, and review of the facility policies titled, Sanitation Inspection and Date Marking for Food Safety, the facility failed to ensure that opened food items in the dry storage area were dated with the open date and expiration date, pots and pans were not facing outward, the dishwasher was free of spilled detergent, the freezer floor was free of rust, the stove was free of spills and stains, and the kitchen floor was clean. The deficient practice had the potential to affect 93 of 99 residents receiving an oral diet. Findings include: A review of the facility policy dated 8/20/2019 titled, Sanitation Inspection, revealed the food service area should be maintained in a clean and sanitary manner. Under policy revealed: All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. Review of the facility policy dated 8/20/2019 titled, Date Marking for Food Safety revealed it is the policy of this facility, as part of the department's sanitation to program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations and the facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for food safety. Initial walk through on 7/27/2023 at 8:42 a.m. of the kitchen with the Dietary Manager (DM) revealed the kitchen floor was dirty. Further observation in the dry storage area revealed a barrel containing rice, flour and sugar that were not dated with the open date and expiration date. The pots and pans by the three-compartment sink were hanging on the racks facing outward, making them vulnerable to dust and particles. Continued observation revealed the dishwasher had spilled detergent on top of the dishwasher, the freezer floor was rusted, and the back of the stove was filled with spills and stains. A follow up walk through on 7/29/2023 at 8:10 a.m. of the main kitchen revealed all previous observations: A barrel containing rice, flour and sugar that were not dated with the open date and expiration date, the pots and pans by the three-compartment sink were hanging on the racks facing outwards, and the spilled detergent on top of the dishwasher was cleaned but still had some residual detergent left on top of the dishwasher. Further observation revealed the freezer floor was rusted and the back of the stove was filled with spills and stains. Interview on 7/29/2023 at 8:15 a.m. with the DM, she acknowledged the containers of rice, flour, and sugar were not dated with the open and expiration dates, the pots and pans were facing outwards, the stains and spills behind the stove, and the kitchen floor was dirty. When asked how often the containers were cleaned, she stated daily. When asked about her expectations from the kitchen staff, she stated that she expected the staff to clean the kitchen floor and behind the stove every day.

Based on staff interviews, record review, and a review of the facility's policy titled, Medication Administration, review, the facility failed to ensure eye drops ordered for treatment of glaucoma were administered as ordered by the physician for 1of 2 sampled residents (R) (#3) reviewed for eye drop administration. Findings included: Review of a facility policy titled, Medication Administration, dated 10/17/2019, revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy also indicated the following: - 10. Review MAR (Medication Administration Record) to identify medication to be administered. - 14. Administer medication as ordered in accordance with manufacturer specifications. - 17. Sign MAR after administered. Record review of the most recent quarterly Minimum Data Set (MDS), for R#3 dated 02/14/2023, revealed Resident #3 had highly impaired vision. Record review of physician's orders for R#3's electronic medical record (EMR) revealed the following medications were ordered to treat the resident's diagnosis of glaucoma: - A physician's order dated 01/08/2023 indicated R#3 was to receive brimonidine tartrate solution 0.1%, instill one drop in both eyes one time daily. - A physician's order dated 11/17/2022 indicated R#3 was to receive netarsudil dimesylate solution 0.02%, instill one drop in both eyes daily. - A physician's order dated 07/26/2022 indicated R#3 was to receive dorzolamide hydrochloride (HCl)-timolol mal solution 22.3-6.8 milligrams per milliliter (mg/mL) three times a day. Record review of the Medication Administration Record (MAR) for R#3 dated January 2023 revealed nurses had documented their initials and a 9 which indicated the eye drops were not administered as scheduled on the following dates/times: - The netarsudil dimesylate solution was not administered on 01/21/2023 and 01/22/2023. - The brimonidine tartrate solution was not administered on 01/08/2023 at 2:00 p.m., 01/10/2023 at 6:00 a.m., 01/14/2023 at 2:00 p.m., 01/21/2023 at 10:00 p.m., 01/22/2023 at 2:00 p.m. and 10:00 p.m., 01/23/2023 at 2:00 p.m., 01/26/2023 at 2:00 p.m., and 01/28/2023 at 2:00 p.m. Record review of the MAR for R#3 dated February 2023 revealed nurses had documented their initials and a 9 which indicated the eye drops were not administered as scheduled on the following dates/times: - The netarsudil dimesylate solution was not administered on 02/13/2023 and 02/14/2023. - The dorzolamide HCl-timolol mal solution was not administered on 02/13/2023 at 8:00 p.m. and 02/14/2023 at 8:00 p.m. - The brimonidine tartrate solution was not administered on 02/01/2023 at 2:00 p.m., 02/06/2023 at 2:00 PM, 02/13/2023 at 10:00 p.m., and 02/14/2023 at 2:00 p.m. and 10:00 p.m. Record review of the MAR for R#3 dated March 2023 revealed nurses had documented their initials and a 9 which indicated the eye drops were not administered as scheduled on the following dates/times: - The netarsudil dimesylate solution was not administered on 03/09/2023 and 03/15/2023. - The dorzolamide HCl-timolol mal solution was not administered on 03/09/2023 at 8:00 p.m. and 03/15/2023 at 8:00 p.m. - The brimonidine tartrate solution was not administered on 03/04/2023 at 2:00 p.m., 03/06/2023 at 2:00 p.m., 03/09/2023 at 10:00 p.m., 10/11/2023 at 2:00 p.m., 03/14/2023 at 2:00 p.m., and 3/15/2023 at 2:00 p.m. and 10:00 p.m. During a telephone interview on 03/22/2023 at 6:15 p.m., Licensed Practical Nurse (LPN) #12 stated if she documented on the MAR that she did not administer R#3's eye drops, and it would have been because the medication was not available in the medication cart. LPN#12 further revealed if the medication was not in the medication cart, the nurse was supposed to reorder the medication directly from the MAR. She acknowledged she did not consistently follow that process. She stated if the process to reorder the medication was followed, the medication was usually available to administer within 24 hours from the time it was reordered. Interview on 03/22/2023 at 6:57 p.m., the Director of Nursing (DON) stated she was unaware that R#3 had not consistently been receiving the eye drops as ordered and indicated it was not acceptable to not give the ordered medications. The DON stated any medication could be obtained from the pharmacy provider within a few hours. The DON revealed the facility had a back-up pharmacy as well as a stat (immediate) pharmacy to ensure all medications could be administered as ordered. She indicated she expected nursing staff to reorder medications before the resident's supply ran out but no later than immediately after noting the medication was not available to administer at the scheduled time. The DON expected nursing staff to notify her when this occurred and to notify the physician when medications were not administered as ordered. Interview on 03/22/2023 at 7:01 p.m., the Administrator stated she was not aware R#3 had not been receiving the eye drops as ordered. The Administrator revealed that she expected all residents to be given their eye drops as ordered and expected the nursing staff to make sure all medications were available to administer as ordered.

Based on staff interviews, record review, and a review of the facility's policy titled, Catheter Care Policy, the facility failed to ensure an indwelling urinary catheter was changed at the frequency specified by the physician for 1 of 2 sampled residents (R) (#3) observed for indwelling urinary catheter care. Findings included: Review of a facility policy titled, Catheter Care Policy, dated 01/02/2019, revealed, Policy: It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. The policy did not address catheter changes. Record review of the admission Record for R#3 revealed the facility admitted the resident with diagnoses that included flaccid neuropathic bladder (bladder dysfunction caused by damage to the nervous system), and urinary tract infection (UTI). Record review of the most recent quarterly Minimum Data Set (MDS), for R#3 dated 02/14/2023, revealed the resident had an indwelling catheter and was always incontinent of bowel. The MDS indicated the resident had not had a UTI in the last 30 days. Record review of the care plan for R#3, revised on 01/20/2023, indicated the resident was incontinent of bladder with an indwelling catheter for bladder elimination and bowel related to diagnoses that included quadriplegia with a potential for hard stool and urinary tract infections. Interventions included for staff to change the resident's catheter monthly and as needed, and to provide catheter care every shift and as needed. Record review of Physician Orders, for R#3 dated 03/23/202, revealed to change the urinary catheter every 30 days and as needed (PRN) with a 16-French (Fr) catheter with a 10-cubic centimeter (cc) bulb. Record review of R#3's April 2022 Medication Administration Record (MAR) revealed Licensed Practical Nurse (LPN) #15 documented a 9 to indicate the resident's catheter was not changed as scheduled on 04/22/2022. There was no documentation that a catheter change was provided on any other date during the month of April 2022. Record review of the Progress Note, for R#3 dated 04/23/2022, revealed Licensed Practical Nurse (LPN) #15 documented she did not change the resident's urinary catheter due to being unable to locate. LPN #15 was unavailable for interview during the survey. Record review of the Progress Notes for R#3 dated 05/02/2022 at 7:55 p.m. revealed the resident continued to have muscle spasms, yellowish discharge from the urethra, and increased confusion. The family was at the bedside and requested the resident be seen by a doctor. The primary care physician (PCP) was notified and ordered that the resident be sent to the emergency room (ER) for evaluation and treatment. The resident refused to go, and the resident's family made an appointment at the Veteran's Administration (VA) clinic for the next day. Record review of the Progress Notes for R#3 Progress dated 05/05/2022 at 4:23 a.m., revealed the resident received orders from the VA clinic for Cipro 500 milligrams (mg) two times a day for a UTI. Interview on 03/21/2023 at 5:31 p.m., LPN #3 stated she was not aware that the catheter for R#3 was not changed as scheduled and indicated the catheter was to be changed monthly. She stated she had worked with the resident since December 2022 and had recently changed the resident's urine drainage bag. Interview on 03/22/2023 at 1:40 p.m., the Director of Nursing (DON) stated she was not aware that the catheter for R#3 was not changed as scheduled in April 2022. She indicated the resident's catheter was to be changed on the 15th of every month and as needed. The DON revealed that she expected the nursing staff to change the catheter as scheduled, and if the correct catheter was not available, they should order it and change the catheter as soon as possible. The DON stated indicated if the catheter was not changed as ordered, it could be a source of a UTI. Interview on 03/22/2023 at 7:01 p.m., the Administrator stated she could not speak to R#3's catheter not being changed but expected catheters to be changed as ordered by the physician. The Administrator stated if the correct catheter was not available in the building at the time a resident's catheter was supposed to be changed, the nurse should get the catheter as soon as possible and change it right away. She stated she was not aware of the potential negative outcome of not changing a catheter as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure one of three residents (R) R#466 was provided with a privacy bag for an indwelling catheter. The deficient practice had the potential to affect all residents currently utilizing indwelling catheters. Findings include: Record review revealed R#466 was admitted to facility on 7/30/2021. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) a Brief Interview of Mental Status Score (BIMS) score of 3 indicating resident had significant cognitive deficit. Section H- Bowel and Bladder documented that the resident had an indwelling catheter. Initial observation on 3/22/2022 at 11:21 a.m. revealed R#466 had catheter collection bag noted to be facing the door without a dignity bag. Second observation of R#466 on 3/23/2022 at 11:11 a.m. revealed the catheter collection bag was facing the door and was not inside a dignity bag. Interview on 3/24/2022 at 10:44 a.m. with Certified Nursing Assistant (CNA) FF confirmed that catheter was not in a dignity bag and revealed that it should be in the bag when on the right side of the bed facing the door. Interview on 3/24/2022 at 11:18 a.m. with Licensed Practical Nurse (LPN) GG revealed that residents that have a catheter should always have a dignity bag. LPN GG stated she did not check to see if R#466 had a dignity bag on her bed during a.m. medication administration. Facility staff did not provide requested policy information for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and review of the facility policy titled Restraint Free Environment the facility failed to ensure one resident (R) (R#44) had an ongoing assessment to determine if one physical device (a lap-tray located over the resident's Geri-chair) was the least restrictive alternative for the resident. The sample size was 28 residents. Findings include: Review of the Restraint Free Environment Policy dated 10/24/2020 revealed that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. It further explained using devices in conjunction with a chair, such as tray, tables, cushions, bars, or belts, that the resident cannot remove and prevents the resident from rising. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#44 had Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. Further review of this MDS revealed that a restraint was not used if the resident was out of bed or in a chair. Review of the Physician Order dated 10/3/2020 revealed that R# 44 may be up out of bed to Geri-chair with /without lap-tray as an enabler/positioning. Observations on 3/22/22 at 12:00 p.m. and 3/23/22 at 8:00 a.m. revealed R#44 sitting in a Geri-chair with the lap-tray attached in front of her. Observation on 3/22/22 at 1:27 p.m. R#44 was sitting in Geri-chair was trying to take the tray off unsuccessfully. Observation made on 3/24/22 from 8:00 a.m. till 10:00 a.m. resident was sitting in Geri-chair with lap-tray attached to her chair and she was trying to take the lap-tray off but was unable to do so. No staff came to check on her or to release the lap-tray. An interview with Certified Nursing Assistant (CNA) II on 3/23/22 at 10:00 a.m. revealed that when there is a shortage of staff, they don't get time to release the lap-tray off the resident and she has never seen R#44 take the lap-tray off her Geri-chair. An interview with Licensed Practical Nurse (LPN) KK on 3/23/22 at 12:00 p.m. revealed that she had never seen R#44 remove the lap-tray but was told by another nurse last week that R#44 took off the lap-tray and tried to throw it. During continued interview, LPN KK verified that there was information about the lap-tray use in the resident's chart for positioning, including the care plan, physician order and nurse's notes, but there is no evidence that a restraint assessment or re-assessment was done. She also revealed that restraints were defined as something that hindered a resident from doing something that they can normally do, such as a lap-tray preventing a resident from rising and the resident cant remove the restraint. An interview with Assistant Director of Nursing (ADON) on 3/23/22 at 1:30 p.m. revealed that R#44's lap tray would be considered a restraint because it limited access to her body. An interview with the Director of Nursing (DON) on 3/23/22 at 10:35 a.m. revealed that she was not sure if assessments were done related to use of potential restraints, including lap-trays. She also revealed that she wasn't sure if CNAs are supposed to do it and she thought that therapy department is supposed to assess for the lap-tray. She further stated that she has not asked therapy to re-evaluate the lap-tray for continued use. She stated that she was unsure of whether the resident could remove the lap-tray herself, but she did not think that she could.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review, the facility failed to follow the care plan for one of six residents (R) (R#7) related to oxygen administration. Finding include: Review of R#7's diagnoses included: (partial list) chronic obstructive pulmonary disease (COPD), hypertension, obesity, pneumonia, acute respiratory failure, history of COVID-19, diabetes, and heart failure. Review of R#7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 00 indicating resident was unable to participate in interview; Section G-Functional Status: resident was totally dependent for all Activities of Daily Living (ADL's); Section O-Special Treatments: resident was received oxygen therapy. Review of R#7's care plans revealed a plan in place for: Resident has potential for acquiring COVID-19 related to compromised immune system and underlying conditions .Oxygen therapy via nasal cannula at two liters per minute (lpm) as needed (PRN) for shortness of breath/wheezing or oxygen saturation rate of <90%. Resident is at risk for respiratory difficulties and infection related to diagnoses of COPD with oxygen and breathing treatments as ordered with history of smoking .Nurse to monitor resident for wearing oxygen as ordered every shift and document non-compliant episodes .Provide oxygen as ordered. Review of R#7's Physicians orders revealed: An order dated 6/12/20 for oxygen therapy via nasal cannula at 2 lpm PRN for shortness of breath/wheezing or saturation rate of <90%. Review of R#7's Medication Administration Record (MAR) and the Treatment Administration Record for 3/1/22 through 3/24/22 revealed no order for or documentation of the oxygen therapy received. An observation on 3/22/22 at 9:00 a.m., 3/23/22 at 8:34 a.m., and 3/24/22 at 8:21 a.m. revealed R#7's was receiving oxygen at 3 lpm via a nasal cannula and the oxygen concentrator was on and was set at 3 lpm. An interview on 3/24/22 at 8:40 a.m. the Director of Nursing (DON) revealed she would expect the nurses to follow the resident's care plan. An interview on 3/24/22 at 10:45 a.m. with the MDS Coordinator revealed she updates the care plans during comprehensive assessments and as needed when issues are discussed in meetings. She indicated she has not taken off irrelevant care plans. She would expect a care plan to reflect the residents' current needs and concerns. Cross refer to F695.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and review of the facility policy titled Policy for Administration of Oxygen the facility failed to ensure that one of six residents (R) (R#7) was administered oxygen therapy in accordance with the Physician's Order. Finding include: Review of the facility policy titled Policy for Administration of Oxygen revised 7/21/07, revealed: B. Rate of oxygen flow-liters per minute: 1. When ordered by a physician, administer as ordered. Review of R#7's diagnoses included: (partial list) chronic obstructive pulmonary disease (COPD), hypertension, obesity, pneumonia, acute respiratory failure, history of COVID-19, diabetes, and heart failure. Review of R#7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 00 indicating resident was unable to participate in interview; Section G-Functional Status: resident was totally dependent for all Activities of Daily Living (ADL's); Section O-Special Treatments: resident was received oxygen therapy. Review of R#7's Physicians Orders revealed: An order dated 6/12/20 for oxygen therapy via nasal cannula at 2 lpm (liters per minute) PRN (as needed) for shortness of breath/wheezing or saturation rate of <90%. Review of R#7's Medication Administration Record (MAR) and the Treatment Administration Record for 3/1/22 through 3/24/22 revealed no order for or documentation of the oxygen therapy received. An observation on 3/22/22 at 9:00 a.m., 3/23/22 at 8:34 a.m., and 3/24/22 at 8:21 a.m. revealed R#7's was receiving oxygen at 3 lpm via a nasal cannula and the oxygen concentrator was on and was set at 3 lpm. An observation and interview on 3/24/22 at 8:30 a.m. with the Licensed Practical Nurse (LPN) CC revealed the setting was at 3 lpm and it should be set at 2 lpm. She verified the residents Physician's Order and verified the order read to give oxygen at 2 lpm. She looked on the residents MAR and verified there was not an order for the oxygen at 2 lpm. She would have expected the oxygen order to be on the MAR. She indicated she checks the oxygen every shift but had not done it this morning. An interview on 3/24/22 at 8:40 a.m. with the Director of Nursing (DON) revealed she would expect the resident's oxygen order be on the MAR so the nurse would be able to document they checked the resident's oxygen concentrator for the correct lpm. She would also expect the oxygen be at the correct lpm. She would expect the nurses to check the oxygen concentrator at least every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to use appropriate hand hygiene during a wound treatment for one resident (R) (R#466) of three residents reviewed for pressure ulcers. Findings include: Record review for R#466 revealed resident was admitted to facility on 7/30/2021 with diagnoses including but not limited to sepsis, bacteremia, pressure ulcer of sacral region stage 3, anemia, hypokalemia, toxic encephalopathy, generalized muscle, lack of coordination, abnormal posture, chronic pain syndrome, moderate protein calorie malnutrition, major depressive disorder, anxiety disorder, and cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) BIMs score of 3 indicating R#466 had significant cognitive deficit. The resident had a stage three pressure ulcer that was present on admission. Review of treatment order dated 3/19/2022 revealed to change dressing to wound vac (vacuum assisted wound closure) every Tues/Fri, clean with normal saline then apply foam dressing. Wound care observation on 3/22/22 at 4:15 p.m. revealed the Assistant Director of Nursing (ADON) and Director of Nursing (DON) provided wound treatment for R#466. The ADON entered the room, washed hands and donned clean gloves. Resident was repositioned to the right side for removal of old dressing. ADON removed dressing and cleaned wound with normal saline and patted dry with clean gauze. Observation of wound base revealed area was beefy red with small amount of bleeding noted, wound edges were macerated and white in color. There was a foul odor noted during procedure coming from residents' wound. Further observation also revealed nurse changed gloves and did not wash hands or use sanitizer before applying clean dressing. Skin prep was applied to wound perimeter and transparent dressing strips were applied around the outside of the wound. The wound was measured with measurements as follows 10 centimeters (cm) x 9 cm x 1 cm, tunnel at 9 o'clock. Wound vac sponge was applied to wound base and covered with transparent dressing. During wound care observation there were no observations of nurse sanitizing or washing hands during wound vac change. Interview with Director of Nursing (DON) on 3/23/22 at 8:00 a.m. revealed wound vac dressing changes will only be completed by DON or ADON with the charge nurses ensuring that the wound vac is function properly while in operation. During interview it was disclosed there had not been any training provided to the staff on how to maintain or apply a wound vac. Continued interview also revealed that DON did not see any issues with nurse not washing and sanitizing hands during wound treatment. DON was present in residents' room during wound vac change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that care plan meetings were being conducted with designated disciplinary team and family members quarterly for two of 28 sampled residents (R) (R#466 and R#20). Findings include: Record review for R#466 revealed resident was admitted to facility on 7/30/2021 with diagnoses of sepsis, bacteremia, urinary tract infection, pressure ulcer of sacral region stage 3, anemia, narcolepsy, hypokalemia, toxic encephalopathy, generalized muscle , lack of coordination, abnormal posture, fibromyalgia, hypothyroidism, seizures, essential hypertension, chronic pain syndrome, moderate protein calorie malnutrition, major depressive disorder, anxiety disorder, cerebral infarction, diverting ostomy, and peg- placement. Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) a Brief Interview of Mental Status (BIMS) score of 3 indicating resident had significant cognitive deficit. Interview on 3/22/2022 at 12:08 p.m. with family of R#466 revealed that there had been one care plan that was attended which was conducted by the MDS Coordinator and that there were no other staff members in attendance. Further interview also revealed that there had not been any other care plan meetings attended. Interview with Social Services Director on 3/24/2022 at 8:00 a.m. revealed that care plan meetings are conducted by the MDS Coordinator by phone due to the pandemic. Further interview also revealed that Social Services is not involved in care plan meetings that are conducted quarterly, that the MDS Coordinator conducts the care plans with the families alone with no other disciplines in attendance. During interview there was no indication of why other disciplines including Social Services were not attending scheduled care plan meetings for residents. Interview with MDS Coordinator on 3/24/2022 at 8:30 a.m. revealed that family members are notified of scheduled care plan meetings by phone call and letters through regular mail prior to the meeting. Family members have the option to have meeting on the phone or they are allowed to come to facility for scheduled meeting. Continued interview also revealed that the staff that are to attend the care plan meeting are the Social Services Director, MDS Coordinator, Activities Director, and Dietary Manager. Further interview revealed that there is a care conference sheet that is signed by all staff including the family member that attends the conference. Continued interview confirmed that during review of care conference sheets for R#466 and R#20 that there were no other disciplines or resident representative signatures indicating their participation in care plan meeting conducted on 10/25/2021 and 1/12/2022 for R#466 and on 1/12/2022 for R#20. Record review for R#20 revealed resident was admitted to facility on 1/12/2022 with diagnoses of pneumonia, chronic cough, localized edema, non-pressure chronic ulcer of right heel, schizophrenia, asthma, shortness of breath, chronic obstructive pulmonary disease, bipolar disorder, gastroparesis, generalized edema, acquired absence of right foot, systemic lupus, major depressive disorder, Type 2 diabetes, Rheumatoid arthritis, anxiety disorder, heart failure, hypokalemia, weakness, essential hypertension. MDS admission assessment dated [DATE] Section C revealed BIMs score of 15 indicating resident is cognitive and able to make needs known. Interview with R#20 on 3/22/2022 at 9:55 a.m. revealed that there was a meeting with the MDS Coordinator after admission concerning their care but there were no other staff members present during the meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and review of facility Job Description, the facility failed to ensure the Director of Nursing (DON) had an active nursing license and failed to ensure that competent and trained staff provided wound care to residents in the facility. The census was 70. Findings include: 1. Review of Director of Nursing (DON) personnel file revealed her nursing licensed expired on [DATE]. Review of the Board of Nursing website revealed the DON's license had not been reinstated at time of survey. During interview on [DATE] at 1:35 p.m. with the DON revealed she did not renew her nursing license because she just forgot. She indicated she did not get anything in the mail or e-mail to remind her to renew her license. The DON stated she has contacted the Board of Nursing and was instructed to fill out a Reinstatement Form and it will take about 30 days after she turns the form in. Review of the undated Job Description and Performance Standards for the DON revealed the individual in this position is delegated to set resident care standards in accordance with accepted current standards of care . and to develop policies and procedures for nursing care of residents. 2. During wound care observation on [DATE] at 10:37 a.m. and [DATE] at 9:55 a.m. with Certified Nursing Assistant (CNA) AA revealed she was performing wound care independently without a licensed nurse overseeing the wound care. During interview on [DATE] at 9:00 a.m. with CNA AA revealed she has been doing wound treatments for thirty years at the facility and received a certificate from the former wound care physician. Continued interview also revealed treatments are usually completed without supervision from administrative staff or a charge nurse. CNA AA also stated she received a training certificate when she received wound care training. States she will provide the certificate to surveyor. During interview on [DATE] at 11:10 a.m. with Assistant Director of Nursing (ADON) revealed the CNA AA did not receive a wound care training certificate, however, she received education on wound care. During interview on [DATE] at 12:39 a.m. with CNA BB revealed that wound care is completed on the weekends by herself and another CNA that works the weekend. Continued interview also revealed there was no training conducted for wound management other than showing staff member how to complete the treatment. Review of education documentation provided revealed no education provided to CNAs on monitoring and treating wounds.